Training in cataract surgery in Spain: analysis of the results of a survey of the European Board of Ophthalmology in a Spanish cohort.

INTRODUCTION: A survey conducted by the European Board of Ophthalmology (EBO) revealed significant differences in the surgical training of the ophthalmology residents in Europe, including a disparity between the sexes and a variation in the experience on cataract surgery (CC) between them. This study is about the Spanish sub-cohort of the survey, and its objective is to present and analyse the peculiarities of ophthalmology training in Spain within the European context, as well as discussing ways to harmonise and improve that training throughout the EU. METHODS: We analyse data of the Spanish participants in the EBO exams, defining subgroups by the Autonomous Communities existing in Spain. RESULTS: 93 of 135 requested participants (68.9%) responded. A 60.2% passed the EBO exam between 2021-2022, being mostly women (65.59%) aged 31 years old on average. The 91.4% were right-handed, coming from 13 of the 17 Spanish autonomous communities, although mostly from the Community of Valencia, Madrid and Catalonia. Respectively, 16.1%, 3.2% and 8.7% of the respondents said they have completed 10 or more training sessions on animal eyes, synthetic eyes and through the virtual reality simulator. This training was correlated with greater self-confidence in the management of a posterior capsular tear during surgery (p .025). All respondents manifested to have already performed stages of the CC. The average number of operations reported was 181.6 with regional disparities. A significant difference is observed between the sexes against women (-28.3%, p 0.03). DISCUSSION: Ophthalmologists in Spain, much more than other European countries, have greater opportunities for surgical training, with surgical procedures during the residency, that nearly triples those made by the others. Spanish women refer, like their European colleagues, to be in disadvantage in learning opportunities about cataract surgery. The Simulation Based Medical Education (SBME) allows to respond to the training deficit and complements the training on the patient. Although we demonstrate a significant correlation between the number of procedures carried out and self-confidence to operate simple cases, the SBME would be a complementary tool in self-confidence in front of a complication like capsular rupture. CONCLUSION: Spain massively adopts the model named by us "surgery for all", despite the underrepresentation of women in this area, emphasising a need for cultural change that the SBME could facilitate.

Mean intraocular pressure and progression based on corneal thickness in patients with ocular hypertension.

PURPOSE: To determine the incidence of glaucomatous progression at mean intraocular pressure (IOP) levels in patients with ocular hypertension (OHT). METHODS: A retrospective, multicentre, cohort analysis of 230 OHT patients with 5 years of follow-up evaluated for risk factors associated with progressive optic disc and visual field loss to determine the incidence of glaucomatous progression. RESULTS: Forty percent of patients with IOPs > or = 24 mmHg, 18% of patients with IOPs of 21-23 mmHg, 11% of patients with IOPs with 18-20 mmHg, and 3% of patients with IOPs of < or = 17 mmHg progressed to glaucoma. The mean IOP was 19.8+/-2.4 mmHg in the stable group and 21.7+/-2.6 mmHg in the progressed group (P=0.0004). The highest average peak IOP was 23.4+/-4.0 mmHg in the stable group and 25.2+/-3.1 mmHg in the progressed group (P=0.006). Based on the pachymetry values for central corneal thickness, patients with thinner corneas more often progressed to glaucoma (P<0.0001). A multivariant regression analysis to determine risk factors for progression was positive primarily for higher peak IOPs, older age, male gender, argon laser trabeculoplasty, visual acuity > or = 20/50, and no topical medical therapy or beta-blocker therapy prior to the study. CONCLUSIONS: IOP reduction within the normal range over 5 years of follow-up reduces the chance of progression to primary open-angle glaucoma in OHT patients.

Diagnostic accuracy of the Moorfields Regression Analysis using the Heidelberg Retina Tomograph in glaucoma patients with visual field defects.

PURPOSE: This study was designed to determine the specificity and sensitivity of the Heidelberg Retina Tomograph I (HRT) using the Moorfields Regression Analysis (MRA) in differentiating healthy from glaucomatous eyes. METHODS: In this cross-sectional study, 74 eyes of 37 healthy subjects and 87 eyes of 47 glaucoma patients were examined with Octopus standard automated perimetry and HRT. Only one eye per patient was used for statistical analysis. According to visual field index mean defect (MD) glaucoma patients were divided into three groups with early (MD < 6 dB), moderate (6 dB < MD < 12 dB), and advanced visual field loss (MD > 12 dB). The sensitivity and specificity of optic nerve head examinations using the MRA of HRT were evaluated by two criteria (criteria 1, as diseased if classified by MRA as outside normal limits; criteria 2, as diseased if classified by MRA as borderline). The correlations between the topographic parameters and visual field index MD were measured by correlation coefficient and presented by scatter plot. RESULTS: The specificity and sensitivity of HRT-MRA examination were, respectively, 100% and 68.1% when borderline cases were considered normal (criteria 1) and 97.3% and 85.1% when borderline cases were considered glaucomatous (criteria 2). The sensitivity of the MRA in eyes with different stages of visual field loss was 59.1% for early, 54.5% for moderate, and 92.8% for advanced visual field loss with criteria 1; the figures were, respectively, 81.8%, 72.7%, and 100% with criteria 2. The statistically significant correlations with moderate strength of association (r = 0.40-0.59) were found for rim area, rim volume, cup to disc area ratio, mean retinal nerve fiber layer (RNFL) thickness, and RNFL cross-sectional area. CONCLUSIONS: The MRA showed an excellent specificity and good sensitivity using criteria 2 including as glaucomatous optic discs those classified by MRA as borderline. Although correlations of moderate strength were found between rim area, rim volume, mean RNFL thickness, RNFL cross-sectional area, and visual field index MD, great interindividual variation limits the prediction of one parameter from the other. Therefore, in clinical practice both structural and functional examinations should be performed in order to characterize glaucomatous damage.

The efficacy and safety of timolol maleate versus brinzolamide each given twice daily added to travoprost in patients with ocular hypertension or primary open-angle glaucoma.

PURPOSE: To compare the efficacy and safety of timolol maleate 0.5% versus brinzolamide 1% when added to travoprost 0.004% in patients with ocular hypertension or primary open-angle glaucoma. DESIGN: A prospective, double-masked, randomized, active-controlled, parallel comparison. METHODS: Qualified patients at Visit 1 were placed on travoprost dosed every evening for 4 weeks and then were randomized at baseline (Visit 2) to the addition of timolol maleate or brinzolamide each given twice daily. Patients returned to clinic at Week 4 (Visit 3) for a safety visit and Week 12 (Visit 4) for an efficacy visit. At Visits 2 and 4 the intraocular pressure (IOP) was measured at 08:00, 12:00, and 16:00 hours. RESULTS: Ninety-seven patients on brinzolamide had a baseline diurnal IOP of 21.5+/-2.2 mmHg and 95 on timolol maleate had 21.3+/-2.5 mmHg, each added to travoprost. The diurnal mean IOP at Week 12 was 18.1+/-2.7 mmHg for brinzolamide and 18.1+/-3.0 mmHg for timolol maleate (p=0.96). There was no statistical difference found between treatment groups in the absolute level of pressure, or in the reduction in IOP from baseline, at each time point or for the diurnal curve (p>0.05). There was no significant difference for any adverse event between groups (p>0.05), with the most common side effect being conjunctival hyperemia in 15/97 (16%) brinzolamide and 6/95 (6%) timolol treated patients (p=0.06). CONCLUSIONS: This study showed that brinzolamide provides similar safety and efficacy compared to timolol maleate when added to travoprost.

Conjunctival epithelium expression of HLA-DR in glaucoma patients and its influence on the outcome of filtration surgery.

AIMS: To analyse the expression of HLA-DR on conjunctival epithelial cells in patients with glaucoma taking topical antiglaucoma therapy. METHODS: 10 patients taking no topical medication and 30 patients with uncontrolled glaucoma taking medical therapy participated in the study. The specimens were obtained by impression cytology preoperatively, 3 months, and 6 months after filtration surgery. The expression of HLA-DR on T lymphocytes and epithelial cells was analysed by flow cytometry. RESULTS: A significant increase in HLA-DR on epithelial cells was found preoperatively in patients with glaucoma. A significant increased expression of HLA-DR on epithelial cells was detected 3 months and 6 months after surgery. CONCLUSIONS: The increased expression of HLA-DR on conjunctival epithelial cells still present 6 months after surgery indicates the increased ability of epithelial cells to induce immune inflammation with subsequent fibrosis.

Conjunctival scrapings and impression cytology in chronic conjunctivitis. Correlation with microbiology.

To assess the utility of exfoliative cytology in the diagnosis of chronic conjunctivitis, we compared its findings with microbiological examination and established the correlation between cytology and microbiology in 32 patients with conjunctivitis lasting four weeks or more, with a nonspecific clinical picture. The material for cytology was collected by scraping and by imprint of the ocular surface on Millipore filter paper. The specimens were stained with Giemsa. Material for bacterial culture and fluorescent antibody test for viruses and Chlamydia were obtained at the same time. In 12 patients neutrophils predominated in cytology, in six eosinophils were found and in four there were more lymphocytes. One patient had a basophilic intracytoplasmic inclusion specific for Chlamydia infection. In eight patients coagulase-negative Staphylococcus species and in one Staphylococcus aureus were isolated, in two the fluorescent antibody test for Chlamydia was positive and in three for viruses. In all patients with a positive bacterial culture, a predominance of neutrophils was observed. All patients with a positive test for viruses had lymphocytosis in conjunctival scrapings. In two patients microbiology detected Chlamydia, but characteristic intracytoplasmic inclusions were observed only in one. Scrapings gave more specific results, that correlated well with microbiology in bacterial and viral infection, whereas the results of impression cytology showed minor metaplastic changes of epithelial cells that were nonspecific for the type of inflammation. Cytology remains a useful non-invasive tool and is an adjunct to clinical and microbiological examination. It proved especially helpful in allergic conjunctivitis.

Transmission electron microscopic analysis of trabecular meshwork in secondary glaucoma after intravitreal silicone oil injection.

PURPOSE: We analyzed morphological changes in trabecular meshwork in glaucoma developing after intravitreal silicone oil injection with transmission electron microscopy (TEM). METHODS: Specimens obtained from 2 patients after surgical trabeculectomy were fixed in McDowell fixative in one patient and in buffered formaldehyde in the other, dehydrated and embedded in Epon. Ultrathin sections were made and stained with lead citrate and uranyl acetate for TEM. RESULTS: In specimens mainly connective tissue sheets with disorganized and narrowed intertrabecular spaces were observed. At higher magnification the collagen sheets were composed of interstitial collagen and some of them were covered by amorphous basal membrane structures resembling material. Cellular remnants were present along the intertrabecular spaces. No other cells or clearly evident silicone oil were noted. CONCLUSION: Changes such as decrease in cell content, fibrosis and build-up of basement membrane-like material have been described by other authors. They are not specific and can be seen in many secondary glaucomas. No macrophages and foreign-body granulomas in response to silicone oil were present. The pathological changes in angle structures are probably caused by other mechanisms and are not induced by silicone oil itself.