Trends in serious ocular trauma in Scotland.

PURPOSE: To report trends in serious, sight-threatening ocular trauma in Scotland. METHODS: A prospective, population-based, observational study of patients with ocular trauma admitted to hospital in Scotland during a 12-month period (2008-2009), conducted through the British Ophthalmic Surveillance Unit. Data on circumstances of the injuries and visual outcomes were collected using protocols standardised to those from an earlier study (1991-1992) to allow direct comparisons over time. RESULTS: In all, 0.3% of all emergency admissions in Scotland were for ocular trauma. Significant differences were observed between the time periods in where an injury occurred (P=0.009): a reduction of those occurring in a sports/leisure facility (8.2%) and an increase in those occurring on the street (21.4%). Assaults remained the most common cause of injury (31%). Gender differences persisted with females more likely to have an injury from falls (OR=8.67; 95% CI: 2.41-31.49; P=0.002), or in the home (OR=5.40; 95% CI: 1.69-17.16; P=0.009 ), and less likely to have one in the workplace (P=0.06). Poor visual outcome was associated with injuries occurring in the home (OR=4.33, P=0.047), in a public place (OR=6.25, P=0.047), and those caused by a fall (OR 42.75, P<0.001); or assault (OR 7.29, P=0.019). Half of those with a poor outcome have no perception of light. CONCLUSION: Serious ocular trauma remains an infrequent, sight-threatening event, associated with significant monocular visual morbidity. The findings suggest a shift from corporate to personal responsibility for risk awareness, health, and safety.

The incidence of serious eye injury in Scotland: a prospective study.

PURPOSE: Ocular trauma remains an important cause of visual morbidity worldwide. A previous population-based study in Scotland reported a 1-year cumulative incidence of 8.14 per 100 000 population. The purpose of this study was to identify any change in the incidence and pattern of serious ocular trauma in Scotland. METHODS: This study was a 1-year prospective observational study using the British Ophthalmological Surveillance Unit reporting scheme among Scottish ophthalmologists. Serious ocular trauma was defined as requiring hospital admission. Data were collected using two questionnaires for each patient 1 year apart. RESULTS: The response rate from ophthalmologists was 77.1%. There were 102 patients reported with complete data giving an incidence of 1.96 per 100 000 population, four times less than in 1992. In patients younger than 65 years, the age-adjusted incidence ratio (males/females) indicated a ninefold higher risk of trauma in males. In 25 patients (27.2%), the injured eye was blind (final visual acuities (FVA) <6/60), 24 being attributable to the eye injury. Standardised morbidity ratios suggested a threefold decrease in risk of poor visual outcome in 2009 compared with 1992. CONCLUSIONS: The incidence of serious ocular trauma has fallen; this study has shown hospital admission for serious eye injury in Scotland has decreased fourfold in 17 years. Young adult males continue to be at highest risk, which needs to be specifically addressed in future health-prevention strategies. This study also observed a reduction in visual loss from serious ocular injuries, although the reasons for this require further exploration.

Prevalence of diabetic macular oedema and related health and social care resource use in England.

AIMS: To address the absence from the public health ophthalmology literature of age- and sex-specific prevalence and related resource use for diabetic macular oedema (DMO) in England, UK. METHODS: Calculation of age- and sex-specific rates from primary source clinical data, and application to the demographic structure of England to estimate the number of cases affected by DMO. A public health commissioner and provider of social care perspective was adopted in a standard cost of illness study. RESULTS: The number of people with diabetes in England in 2010 was estimated at 2,342,951 of which 2,334,550 were aged ≥ 12 years. An estimated 166,325 (7.12%) had DMO in one or both eyes, and of these, 64,725 individuals had clinically significant DMO reducing the visual acuity to poorer than 6/6 in at least one eye. The overall health and social care costs in 2010, on the pathway from screening to rehabilitation and care in the home, are estimated at £116,296,038. CONCLUSIONS: The outcomes of this study should alert public health commissioners and clinical providers to the burden of DMO. The methods employed should also encourage the use of clinical ophthalmic data at the interface between local population and hospital-based recording systems.

The antimalarial ferroquine: from bench to clinic.

Ferroquine (FQ, SSR97193) is currently the most advanced organo-metallic drug candidate and about to complete phase II clinical trials as a treatment for uncomplicated malaria. This ferrocene-containing compound is active against both chloroquine-susceptible and chloroquine-resistant Plasmodium falciparum and P. vivax strains and/or isolates. This article focuses on the discovery of FQ, its antimalarial activity, the hypothesis of its mode of action, the current absence of resistance in vitro and recent clinical trials.

Risk factors for microbial keratitis with contemporary contact lenses: a case-control study.

OBJECTIVE: To assess the relative risks (RR) of microbial keratitis (MK) for contemporary contact lens (CL) types and wearing schedules. DESIGN: A 2-year prospective case-control study begun in December 2003. PARTICIPANTS: Cases were 367 CL wearers attending Moorfields Eye Hospital with proven or presumed MK. Controls were 1069 hospital controls, who were CL wearers with a disorder unrelated to CL wear, and 639 population-based controls who were CL wearers randomly selected from the Moorfields catchment area. Hospital patients completed a self-administered questionnaire; population-based controls were interviewed by telephone. TESTING: Multivariate analysis was done both for all cases of MK, and for the moderate and severe MK subgroups alone. MAIN OUTCOME MEASURES: The RR for developing MK, and vision loss, for all lens types compared with planned replacement soft lenses (the referent). RESULTS: Compared with planned replacement soft lenses (the referent), the RR of MK was significantly increased with daily disposable (DD) CLs (RR, 1.56x [95% confidence interval (CI), 1.1-2.1]; P = 0.009) and differed between different brands of DD lens, was reduced for rigid lenses (RR, 0.16x [95% CI, 0.06-0.4]; P<0.001), and no different for silicone hydrogel or other types of soft lens. Although the risk of MK was higher overall among DD lens users, the risk of vision loss was less than for planned replacement soft CL users (P = 0.05); no DD lens users lost vision to the level of >or=20/40. The RR for overnight wear, for any lens type, was 5.4 times higher (95% CI, 3.3-10.9; P<0.001). Comparison of the DD soft CL types with planned replacement soft lenses (the referent), showed significant differences between brands for the risk of MK. CONCLUSIONS: The risk of MK has not been reduced in users of DD and silicone hydrogel CLs. However, vision loss is less likely to occur in DD than in reusable soft CL users. Different brands of CL may be associated with significantly different risks of keratitis; understanding these differences should lead to the development of safer soft lenses. These findings suggest that lens/ocular surface interactions may be more important in the development of corneal infection than oxygen levels and CL case contamination.

Unmet needs for cataract surgery in Spain according to indication criteria. Evaluation through a simulation model.

AIMS: Despite the increase in cataract surgery rates, the volume of unmet needs for this type of surgery in the population is substantial due to ageing and widening of the indication criteria. Our objective was to assess future trends in needs for cataract surgery according to different scenarios of indication criteria. METHODS: A discrete-event simulation model was built for the population aged 50 years or older in five regions of Spain (45.7% of the population). Different scenarios of worse eye visual acuity thresholds for indication criteria were compared. Data from the North London Eye Study were used to project the baseline needs for surgery onto the study population. The surgery rate of each region was calculated using the Minimum Data Set. The model used data for the year 2003 and the simulation horizon was 5 years. RESULTS: The volume of need predicted for the year 2008 when scenarios of 0.5 (20/40) and 0.4 (20/50) visual acuity thresholds were used was 69,214 and 51,315 surgeries needed per million inhabitants, respectively. However, unmet needs decreased when a 0.3 (20/70) threshold was used. The increment in the cataract surgery rate needed to prevent the cataract backlog from increasing was 60% for a 0.5 threshold and 50% for a 0.4 threshold. CONCLUSION: Application of indication criteria following current guidelines would substantially increase unmet needs for surgery in the next 5 years.

Acanthamoeba keratitis in England and Wales: incidence, outcome, and risk factors.

AIM: To determine the incidence, regional variation in frequency, outcome, and risk factors for acanthamoeba keratitis (AK) in England and Wales. METHODS: AK cases presenting from 1 October 1997 to 30 September 1999 were identified by the British Ophthalmic Surveillance Unit active reporting system. Clinical and patient postal questionnaire data were analysed. RESULTS: 106 reported cases met study criteria. The annual incidence for the 2 years was 1.26 and 1.13 per million adults and, for contact lens (CL) wearers, 21.14 and 17.53 per million. There was marked regional variation in incidence (0 to 85.13 per million adult CL wearers), with CL wearers in the south having a ninefold increased risk of AK compared with those resident in the north (95% confidence limits: 2.2-38.9, p<0.0001), and a threefold increased risk with hard as opposed to soft domestic water (95% confidence limits: 1.73 to 6.58, p<0.001). Treatment and outcome data were similar to those previously reported. 93/106 (88%) patients were CL wearers. Among these, 46/77 (60%) were disinfecting irregularly, and 20/63 (32%) had been swimming in CLs. One step hydrogen peroxide and chlorine release soft CL (SCL) disinfection systems were significantly over-represented among the cases. Among SCL users, one or more previously established risk factors for AK were identified in 50/55 (91%) patients. CONCLUSIONS: The incidence was considerably higher than most previous estimates, and was static. The geographical variation in incidence may be partly related to the increase in risk associated with hard water. The fact that water quality can have such an effect on the risk of AK suggests that many CL wearers must be letting tapwater come into contact with their lenses or storage cases. Improved education for CL wearers and practitioners about hygiene practice and the variable efficacy of contact lens systems could be expected to reduce the incidence of this disease.

Childbearing and risk of cataract in young women: an epidemiological study in central India.

BACKGROUND/AIMS: Observations in central India, over a period of more than a decade, suggested that the frequency of sight restoring cataract surgery was substantially higher in women of childbearing age compared to men of the same age. Formal surveys in the subcontinent of India have confirmed a higher prevalence of cataract in women. The present study was conducted to explore possible effects of childbearing and associated adverse factors on cataract risk. METHODS: A case-control study design was used. Cases were mothers aged 35-45 with bilateral "senile" cataract. Controls were mothers of the same age but with clear lenses, attending the hospital services with other, mostly minor, complaints. RESULTS: A significant association was found between childbearing and risk of sight impairing cataract in mothers. Having more than three babies doubled the risk (adjusted odds ratio 2.0, p=0.012), and the risk increased by an estimated 20% for each additional birth. The birth effect was independent of age, socioeconomic status (occupation and income level), body mass index, and multiple episodes of severe dehydration, all regarded as putative risk factors for cataract. CONCLUSIONS: Having more than three babies may substantially increase the risk of sight impairing cataract in mothers of childbearing age in central India. The findings open new research challenges to identify cataract risk factors to which mothers may be exposed during pregnancy and childbirth, particularly under poor socioeconomic conditions.

Increased mortality in women with cataract: a population based follow up of the North London Eye Study.

BACKGROUND/AIMS: In diabetics, cataract is associated with higher risk of death. In non-diabetics the data are conflicting, but some indicate an association between one type of cataract (nuclear) and increased mortality. The aim of this study was to estimate and compare age and sex specific mortality for elderly people with and without cataract in a population based cohort. METHODS: A random sample drawn from a defined population of elderly people (age 65 and older) registered with 17 general practice groups in north London formed the study cohort and were followed up for 4 years. The age and sex specific mortality from various causes was estimated and compared in those with and without cataract. RESULTS: In non-diabetics (n=1318), cataract (lens opacity at baseline) was significantly associated with higher mortality in women. The age standardised death rate per 1000 was 39.8 and 24.8 in women with and without cataract, respectively (age adjusted hazard ratio 1.7, confidence limits 1.1 to 2.7, p=0.032). This was not the case in non-diabetic men (hazard ratio 0.9, confidence limits 0.6 to 1.5, p=0.782). The excess mortality in women with cataract was consistent for cardiovascular, respiratory, and other non-cancer causes of death. There was no association between cataract and mortality from cancer. CONCLUSIONS: This study has shown, for the first time, that cataract is associated with higher mortality in women but not in men, among the non-diabetic population. This sex effect suggests that women may be exposed to risk factors that increase both the risk of cataract and mortality, and that men may have little or no exposure to these "sex specific" factors. Possible risk factors that warrant further investigation may be those associated with some pregnancy and childbearing experience.

Escherichia coli O157 and Salmonella infections associated with sprouts in California, 1996-1998.

BACKGROUND: In California, from 1996 through 1998, more than 50% of multicounty outbreaks with confirmed food vehicles were related to alfalfa or clover sprouts. OBJECTIVE: To summarize investigations of sprout-associated outbreaks. DESIGN: Matched case-control studies. SETTING: California. PATIENTS: Outbreak-associated patients and matched population controls. MEASUREMENTS: Matched odds ratios and 95% CIs; traceback and environmental investigations of sprout and seed growers; and pulsed-field gel electrophoresis of isolates from patients, sprouts, and seeds. RESULTS: Five sprout-associated outbreaks of salmonellosis and one outbreak of infection with nonmotile Shiga toxin-producing Escherichia coli O157 occurred. Six hundred patients had culture-confirmed disease, and two died. It is estimated that these outbreaks caused 22 800 cases of gastrointestinal illness or urinary tract infection. In the case-control studies, odds ratios for the association between illness and alfalfa sprout consumption ranged from 5.0 to infinity (all were statistically significant). Three sprout growers were implicated, and each was associated with two outbreaks. Outbreak strains of Salmonella were isolated from sprouts supplied by two sprout growers and from seeds used by the third sprout grower. CONCLUSIONS: As currently produced, sprouts can be a hazardous food. Seeds can be contaminated before sprouting, and no method can eliminate all pathogens from seeds. Seed and sprout growers should implement measures to decrease contamination. The general public should recognize the risks of eating sprouts, and populations at high risk for complications from salmonellosis or E. coli O157 infection should avoid sprout consumption.

Extracapsular cataract extraction compared with small incision surgery by phacoemulsification: a randomised trial.

BACKGROUND: Cataract extraction constitutes the largest surgical workload in ophthalmic units throughout the world. Extracapsular cataract extraction (ECCE), through a large incision, with insertion of an intraocular lens has been the most widely used method from 1982 until recently. Technological advances have led to the increasing use of phacoemulsification (Phako) to emulsify and remove the lens The technique requires a smaller incision, but requires substantial capital investment in theatre equipment. In this randomised trial we assessed the clinical outcomes and carried out an economic evaluation of the two procedures. METHODS: In this two centre randomised trial, 232 patients with age related cataract received ECCE, and 244 received small incision surgery by Phako. The main comparative outcomes were visual acuity, refraction, and complication rates. Resource use was monitored in the two trial centres and in an independent comparator centre. Costs calculated included average cost per procedure, at each stage of follow up. RESULTS: Phako was found to be clinically superior. Surgical complications and capsule opacity within 1 year after surgery were significantly less frequent, and a higher proportion achieved an unaided visual acuity of 6/9 or better (<0.2 logMAR) in the Phako group. Postoperative astigmatism was more stable in Phako. The average cost of a cataract operation and postoperative care within the trial was similar for the two procedures. With the input of additional spectacles for corrected vision at 6 months after surgery, the average cost per procedure was pound359.89 for Phako and pound367.57 for ECCE. CONCLUSION: Phako is clinically superior to ECCE and is cost effective.

Visual outcome following posterior capsule rupture during cataract surgery.

AIM: To determine the relative risk of a poor visual outcome following posterior capsule rupture during cataract surgery. METHODS: Prospective data were collected on consecutive eyes undergoing cataract extraction. The patient's age, preoperative visual acuity, ocular comorbidity, grade of surgeon, and operative complications were documented. The best spectacle corrected visual acuity was recorded at discharge from the hospital service. RESULTS: From a total of 1533 cases, 1420 (92.6%) eyes had complete follow up data. Posterior capsule rupture occurred in 59 (4.1%) cases. Eyes with posterior capsule rupture were 3.8 times more likely to have a final best spectacle corrected visual acuity less than 6/12. CONCLUSIONS: Eyes having posterior capsule rupture during cataract surgery have a significant risk of reduced visual acuity.

Effect of age on visual outcome following cataract extraction.

AIM: To determine the effect of age on final corrected visual acuity following cataract extraction. METHODS: A case series of 880 patients aged 60 years and older undergoing cataract extraction between 1996 and 1999 was studied. The best corrected visual acuity was assessed at discharge from the service and the proportion of patients who achieved a postoperative acuity of > or = 6/12 was determined for different age groups. Analysis was also performed after exclusion of patients identified preoperatively as having ocular comorbidity that was thought to limit their final corrected acuity. The odds ratios for visual outcome were calculated for age using multiple logistic regression analysis to adjust for other prognostic factors. RESULTS: A significant age effect was observed, with the proportion of patients who had no ocular comorbidity identified preoperatively and who achieved a visual acuity of > or = 6/12 at discharge decreasing with age (p<0.001). In patients with no comorbidity the odds of achieving an acuity of > or = 6/12 were 4.6 times higher in the 60-69 year age group than in the oldest age group (80+ years). CONCLUSIONS: Age is a significant determinant of visual outcome. This has implications if a points system incorporating an assessment of visual acuity or if visual acuity alone is used to determine the threshold for eligibility for cataract surgery.

Evaluation of a national eye care programme: re-survey after 10 years.

AIM: To re-survey the Gambia after an interval of 10 years to assess the impact of a national eye care programme (NECP) on the prevalence of blindness and low vision. METHOD: Comparison of two multistage cluster random sample surveys taking into account the marked increase in population in the Gambia, west Africa. Samples of the whole population in 1986 and 1996 were taken. The definition of blindness is presenting vision less than 3/60 in the better eye, or visual fields constricted to less than 10 degrees from fixation. Low vision is less than 6/18 but 3/60 or better. Causes of blindness were determined clinically by three ophthalmologists. RESULTS: The crude prevalence of blindness fell from 0.70% to 0.42%, a relative reduction of 40%. During the same 10 year period, the population increased by 51% from 775 000 to 1 169 000. When the results were standardised for age, a west to east gradient was found for changes in risk of blindness over the 10 year period. This matched the phased west to east introduction of the NECP interventions. There was a modest but significant increase in the risk of low vision across the whole country. CONCLUSIONS: The overall reduction in risk of blindness, in those areas where the NECP has been active, appears to justify the programme and the support of donor organisations. The low vision cases due to cataract must now be addressed.

Anterior chamber flare after trabeculectomy and after phacoemulsification.

AIMS: To evaluate and compare prospectively the anterior chamber inflammatory response after phacoemulsification cataract surgery and after trabeculectomy with peripheral iridectomy. METHODS: Anterior chamber inflammation was measured using the Kowa FM-500 laser flare meter in 131 patients undergoing trabeculectomy and 148 patients undergoing phacoemulsification cataract extraction with intraocular lens implantation. Flare was measured before surgery and on each postoperative visit up to 12 months. RESULTS: Before surgery there was no significant difference in flare readings between the two groups. Following trabeculectomy flare returned to baseline levels 4 weeks after surgery, while following phacoemulsification cataract extraction it remained significantly higher at week 6 (p<0.006) and month 3 (p<0.05). CONCLUSIONS: Anterior chamber inflammation is more prolonged after cataract surgery than after trabeculectomy. This may have implications for the timing of trabeculectomy in relation to cataract surgery.

Utility of predictive equations for estimating the prevalence and incidence of primary open angle glaucoma in the UK.

AIMS: To assess the Tuck-Crick and the Quigley-Vitale predictive regression equations against fresh independent real world data for estimating the prevalence of primary open angle glaucoma (POAG) in the UK. To apply the equations to the elderly population of England and Wales, for which there is sample survey data on glaucoma, and demographic data. METHODS: Directly measured actual prevalence of POAG in a population sample of 1530 people was compared with the predicted prevalence derived by applying the Tuck-Crick and the Quigley-Vitale equations to the sample data. The two equations were applied to the demographic data of the population to project POAG prevalence and to derive 5 year cumulative incidence for the elderly population. These were compared with estimates derived from the local survey data. RESULTS: The actual directly measured prevalence of POAG in the local sample was 3.01%. The Tuck-Crick estimate was 2. 74% (difference 0.27%), and the Quigley-Vitale was 3.50% (difference -0.49%). The three methods-projection from local survey data, Tuck-Crick, and Quigley-Vitale-gave point estimates of 2.85% (228 526 cases), 2.71% (217 375 cases), and 3.50% (280 364 cases) respectively for the prevalence of POAG in the elderly population of England and Wales (8 008 705 people aged 65 or older). Calculation of incidence from age specific prevalence gave the following results: the numbers of new cases of POAG expected (5 year cumulative incidence) in the elderly population were 71 146 and 94 485 for methods 2 and 3 respectively. CONCLUSIONS: The Tuck-Crick predictive equation performed well when applied to fresh (independent) actual data from a local sample survey using a particular definition for POAG, and its usefulness for estimation of prevalence of POAG in England and Wales has been demonstrated. The work on development of predictive equations has been very promising and further refinements could be made when more fresh survey data become available.

The deficit in cataract surgery in England and Wales and the escalating problem of visual impairment: epidemiological modelling of the population dynamics of cataract.

BACKGROUND: The pool of old cases of cataract, the expected new cases, and the shortfall in cataract surgery and consequently the numbers dying with poor vision without the benefit of cataract surgery are regarded as escalating problems worldwide. Successive governments and the professional ophthalmic bodies have not had the wherewithal to estimate the magnitude or interaction of these elements in the population of the UK. This study has collected and applied the best available epidemiological data on cataract prevalence, incidence and service utilisation, and demography to address the problem of control of the cataract pool in the population of England and Wales. METHODS: Data from recent surveys undertaken by the authors, both on prevalence of vision impairing cataract and on patterns of cataract surgery, were used together with demographic and service utilisation information obtained from government departments. These were integrated within a holistic model, which was run under varied assumed levels and patterns of service provision. RESULTS: The study shows that there is a serious pool of unoperated vision impairing cataract in the population aged 65 and older, reflecting a shortfall in cataract surgery. Continuing with the present level and pattern of service provision, the pool will increase to over 2.5 million by the year 2001. In addition, more than 700 000 will die with unoperated impaired vision. CONCLUSIONS: Targeting of existing or new additional operations to those below the visual acuity of 6/12 will have relatively little effect on numbers dying without surgery, but should have a substantial controlling effect on the pool of vision impairing cataract in the population.

National cataract surgery survey 1997-8: a report of the results of the clinical outcomes.

AIMS: A national survey of over 100 hospitals in the UK was carried out to collect routine clinical information on the outcomes of cataract surgery. The clinical outcomes of interest were: visual acuity at time of discharge from postoperative hospital follow up, visual acuity at time of final refraction; complications related to surgery occurring during the operation, within 48 hours of surgery, and within 3 months of surgery. In addition, information on age and comorbidity was obtained. This article reports on the findings of the experience of approximately 18 000 patients who had cataract surgery in the hospital eye service of the NHS. RESULTS: Of those with no ocular comorbidity, 85% achieved a visual acuity of 6/12 or better on discharge from postoperative hospital follow up, while 65% of patients with a serious co-existing eye disease achieved this level of acuity at this time. At final refraction, 92% of patients without ocular comorbidity and 77% of patients with ocular comorbidity achieved 6/12 or better visual acuity. The following main risk indicators were associated with visual outcomes and complications related to surgery: age, other eye diseases, diabetes and stroke, type of surgical procedure, and grade of surgeon. CONCLUSIONS: The acceptability of these findings could fruitfully be the subject of discussion within the ophthalmic community and hopefully issues arising out of the study can lead to research, especially in-depth studies of the outcomes of cataract surgery in those patients with co-existing serious eye conditions.