Factors affecting anatomical and visual outcome after macular hole surgery: findings from a large prospective UK cohort.

OBJECTIVES: To reassess the definition of a large macular hole, factors predicting hole closure and post-surgery visual recovery. DESIGN: Database study of 1483 primary macular hole operations. Eligible operations were primary MH operations treated with a vitrectomy and a gas or air tamponade. Excluded were eyes with a history of retinal detachment, high myopia, previous vitrectomy or trauma. RESULTS: A higher proportion of operations were performed in eyes from females (71.1%) who were 'on average' younger (p < 0.001), with slightly larger holes (p < 0.001) than male patients. Sulfur hexafluoride gas was generally used for smaller holes (p < 0.001). From 1253 operations with a known surgical outcome, successful hole closure was achieved in 1199 (96%) and influenced by smaller holes and complete ILM peeling (p < 0.001), but not post-surgery positioning (p = 0.072). A minimum linear diameter of ~500 µm marked the threshold where the success rate started to decline. From the 1056 successfully closed operations eligible for visual outcome analysis, visual success (defined as visual acuity of 0.30 or better logMAR) was achieved in 488 (46.2%) eyes. At the multivariate level, the factors predicting visual success were better pre-operative VA, smaller hole size, shorter duration of symptoms and the absence of AMD. CONCLUSIONS: Females undergoing primary macular hole surgery tend to be younger and have larger holes than male patients. The definition of a large hole should be changed to around 500 µm, and patients should be operated on early to help achieve a good post-operative VA.

Real world outcomes of ocriplasmin use by members of the British and Eire Association of Vitreoretinal Surgeons.

PurposeTo describe a survey of the use of ocriplasmin by members of the British and Eire Association of VitreoRetinal Surgeons (BEAVRS) for VitreoMacular Traction (VMT) and Full Thickness Macular Hole (FTMH) and compare it to published MIVI TRUST trial data.MethodsAll 173 BEAVRS members were contacted by email in October 2014 requesting data on all cases treated with ocriplasmin up to that date. The total number of cases, FTMH closure rate, VMT release rate and the frequency of adverse events were recorded. Results were compared with trial data.Results48 members responded reporting results from 241 eyes. The respective BEAVRS and MIVI TRUST trial closure rates for small FTMHs were 42.1 and 58.3% (P=0.09) and for medium FTMH 12.7 and 36.7% (P=0.01). The respective VMT release rates were 34.1 and 37.4% (P=NS). Retinal detachment was observed in 3.3% of the BEAVRS cohort compared with 0.4% in MIVI TRUST. Reduction in visual acuity to <6/60 was observed in 5.8% of the BEAVRS cohort and 0.6% in MIVI TRUST. Other complications not reported in the MIVI TRUST trial included an increase in FTMH basal diameter following unsuccessful ocriplasmin use in 46.9% of BEAVRS cases and zonular instability at the time of subsequent phacoemulsification in 2.4%.ConclusionMacular hole closure rates were lower in the BEAVRS survey than published in the MIVI TRUST trial data. The incidence of adverse events was greater than previously reported. The reasons for these disparities are unknown but could include positive reporting bias inherent to retrospective surveys, treatment and population differences.

Interventions for trachoma trichiasis.

BACKGROUND: Trachoma is a leading cause of avoidable blindness. The World Health Organization recommends eliminating trachoma blindness by the SAFE strategy incorporating Surgery, Antibiotic treatment, Facial cleanliness and Environmental hygiene. OBJECTIVES: This review examined the evidence for the effectiveness of different interventions for trachoma trichiasis. SEARCH STRATEGY: We identified trials from the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (2005, Issue 3), MEDLINE (1966 to September 2005) PubMed (searched on 21-09-06; last 90 days), EMBASE (1980 to September 2005), LILACS (March 2004) and the reference lists of included studies. We also contacted authors for details of other relevant studies. SELECTION CRITERIA: We included randomised trials of any intervention intended to treat trachoma trichiasis and trials comparing different methods of delivering the same intervention. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials. We contacted trial authors for missing data when necessary. MAIN RESULTS: Seven studies met the inclusion criteria. Three studies compared different surgical interventions. These trials suggest the most effective surgery is full-thickness incision of the tarsal plate and rotation of the terminal tarsal strip 180 degrees. One study showed that bilamellar rotation was more effective than unilamellar rotation but the other two studies did not. One trial found double-sided sticking plaster more effective than epilation for the immediate management of trichiasis but required frequent replacement (odds ratio (OR) 0.01, 95% confidence interval (CI) 0.00 to 0.22). Another trial found community-based surgery increased convenience for patients without increasing the risk of complications or recurrence when compared to health centres. One trial found no difference between trichiasis surgery performed by ophthalmologists and integrated eye workers (OR 1.32, 95% CI 0.83 to 2.11). A trial comparing trichiasis surgery with and without concurrent administration of azithromycin found no difference in success rates at one year (OR 0.99, 95% CI 0.67 to 1.46). AUTHORS' CONCLUSIONS: No trials show interventions for trichiasis prevent blindness. Certain interventions have been shown to be more effective at eliminating trichiasis. Full thickness incision of the tarsal plate and rotation of the lash-bearing lid margin through 180 degrees is probably the best technique and is preferably delivered in the community. The use of double-sided sticking plaster is more effective than epilation as a temporary measure. Surgery may be carried out by an ophthalmologist or a trained ophthalmic assistant. The addition of azithromycin treatment at the time of surgery does not appear to improve outcomes.

Vitrectomy with subretinal tissue plasminogen activator and ranibizumab for submacular haemorrhages secondary to age-related macular degeneration: retrospective case series of 45 consecutive cases.

PurposeTo assess the efficacy of small-gauge vitrectomy with subretinal recombinant tissue plasminogen activator (rtPA) and ranibizumab for submacular haemorrhages secondary to neovascular age-related macular degeneration (nAMD), and to identify the factors associated with visual outcome.MethodsA retrospective case series was performed, including all patients who had small-gauge vitrectomy with subretinal rtPA and ranibizumab for submacular haemorrhages secondary to nAMD. All patients received three consecutive monthly injections of ranibizumab after the surgery, and were reviewed monthly and treated on a pro re nata regime.ResultsA total of 45 eyes of 45 patients were included in the study. Mean age was 77.07±9.67 years, and 32 of 45 patients (71.1%) were women. Surgery was performed on average 6.98±5.70 days after the onset of symptoms, and patients were observed for a follow-up period of 12.9±10.8 months. On average, visual acuity improved -0.59±0.61 LogMAR between presentation and last follow-up. Visual acuity improved in 33 patients (73.3%), remained unchanged in 10 patients (22.2%), and worsened in 2 patients (4.4%). Multiple linear regression showed that patients with smaller haemorrhages (P=0.012) and prompt surgery (P=0.008) had better final visual acuities. A haemorrhage area of ≤30 mm(2) had 91.3% sensitivity and 73.3% specificity for predicting a final visual acuity ≥6/60.ConclusionSmall-gauge vitrectomy with subretinal rtPA and ranibizumab is effective for improving visual acuity in patients with submacular haemorrhages secondary to nAMD. Small haemorrhage area and prompt surgery are associated with better final visual acuity.

Corneal ulceration in Tanzanian children: relationship between measles and vitamin A deficiency.

Two 3-year prospective studies from 1982-1984 and 1986-1988 in Tanzania identified 189 children with corneal ulceration, of whom 31 (16.4%) were due to vitamin A deficiency. In 1982-1984, vitamin A deficiency was responsible for 23.4% of corneal ulcers (25 of 107) compared with 7.3% (6 of 82) from 1986-1988 (P = 0.006). It is postulated that the decrease in corneal ulceration due to vitamin A deficiency can be attributed to improved measles immunization coverage.

Corneal ulceration in Tanzanian children: relationship between malaria and herpes simplex keratitis.

Two 3-year prospective studies from 1982-1984 and 1986-1988 in Tanzania identified 189 children with corneal ulceration, of whom 92 (48.7%) were due to herpes simplex keratitis. In 1982-1984 herpes simplex keratitis was responsible for 35.5% of corneal ulcers (38 of 107), compared with 65.8% (54 of 82) in 1986-1988 (P = 0.00006). It is postulated that the increase in corneal ulceration due to herpes simplex keratitis can be attributed to an increase in the incidence and severity of malaria infection.

Cutaneous anthrax leading to corneal scarring from cicatricial ectropion.

Eleven patients with cutaneous anthrax of the eyelids are presented. The complications were cicatricial ectropion (eight patients), resulting in corneal scarring (three patients). The ectropion was corrected by full thickness postauricular skin grafts, with good results. The predilection of this infection for the eyelids of young children and a seasonal variation suggest that a vector may be involved in transmission.

Herpetic keratitis in Tanzania: association with malaria.

Of 103 patients who presented to a rural clinic in Africa with corneal ulceration, 62 (60.2%) had corneal ulcers which on clinical diagnosis were attributable to herpes simplex virus. There was a strong association between herpetic ulceration and a history of recent malaria; 37 of 62 (59.7%) herpetic ulcers occurred in the 3 month period from April to June which corresponds to the end of the peak season for malaria compared with 14 of 41 (34%) of the non-herpetic ulcers. Fifty per cent of herpetic ulcers had a geographic morphology, 27.4% were dendritic, and 22.6% presumed herpetic ulcers were stromal: 38.7% of herpetic ulcers occurred in children under 5 years of age. Bilateral herpetic ulcers occurred in 16.1% of patients but were more common in children under 2 years of age. Geographic and stromal ulcers tended to heal more slowly than dendritic ulcers (mean time to healing 12.6, 12.2, and 6.6 days respectively), and were more likely to result in severe corneal scarring (45%, 29%, and 0% respectively). Herpes simplex keratitis is a major cause of corneal scarring in Africa. It is often seen in children, may be bilateral, commonly is geographic in morphology, and has a strong association with malaria infection. Because it is not easily preventable, more effort must be made to ensure early diagnosis and prompt, effective treatment in order to prevent severe scarring and visual loss.

Audit of extracapsular cataract extraction and posterior chamber lens implantation as a routine treatment for age related cataract in east Africa.

AIMS: To evaluate the outcome of extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens implantation (PC-IOL) in an African eye clinic during the transition from intracapsular cataract extraction to ECCE and PC-IOL. METHODS: A retrospective survey of 461 consecutive operations for age related cataract with a mean follow up of 52.9 weeks (range 0-275) and a minimum follow up of 4 weeks in 87.9% of eyes. RESULTS: A best corrected vision of 6/18 or better was obtained in 94.3% of eyes, and an uncorrected vision of 6/18 or better in 78.2% of eyes. Six eyes (1.5%) had a best corrected vision of less than 6/60. The visual acuity at 2 months was strongly predictive of the vision at 1 year or more after surgery. Preoperative biometry and IOL power calculation increased the proportion of eyes obtaining an uncorrected vision of 6/18 or better from 73.8% to 81.3%. Four eyes developed visually significant posterior capsule opacity. CONCLUSION: ECCE and PC-IOL can give very good results in an African setting. A better visual outcome should lead to increased demand for cataract surgery, which will eventually reduce the number of cataract blind people in Africa.

Penetrating keratoplasty in Africa: graft survival and visual outcome.

AIM: To study the survival and visual outcome of penetrating keratoplasty in an African setting. METHODS: A retrospective analysis of 216 corneal grafts, performed on 203 eyes of 186 patients, at Kikuyu Hospital, Kenya over a 5 year period. RESULTS: Half of the transplants were carried out for keratoconus with only 5% of the grafts being undertaken for corneal scarring caused by trachoma or measles. The average follow up was 27.3 months. The probability of graft survival at 2 years was 87.4% (95% CI 80.6%-94.3%) for keratoconus and 64.7% (95% CI 54.8%-74.6%) for other corneal pathologies. Forty seven grafts (21.8%) in 36 patients (17.7%) are known to have become opaque. The commonest causes of graft opacification were bacterial keratitis (6.0%), endothelial failure (6.0%), and graft rejection (5.1%). Preoperatively 55% of keratoconus eyes and 75.7% of non-keratoconus eyes were blind. Postoperatively, 5% of keratoconus eyes and 41.7% of the non-keratoconus eyes were blind. Normal vision was achieved in 53.7% of operated eyes. Grafts carried out for keratoconus had a better visual outcome than grafts performed for other corneal pathologies. Preoperatively, 12.4% of keratoconus and 48.5% of non-keratoconus patients were blind in their better eye. Postoperatively, 1.1% of keratoconus patients and 25.7% of non-keratoconus patients were blind. The number of patients with normal vision in the better eye increased from 32 (17.2%) to 106 (57.0%). Sight was restored to 34 blind patients, but two patients with severe visual impairment preoperatively were blind at their last follow up. There was therefore a net reduction of 32 in the number of blind patients after 216 keratoplasties. CONCLUSIONS: Penetrating keratoplasty can be successful in Africa, particularly for keratoconus and other corneal dystrophies. However, penetrating keratoplasty has a limited role in the treatment of blindness from corneal scarring due to trachoma, measles, and vitamin A deficiency for which community based preventive measures must remain the priority.

Results of cataract surgery in young children in east Africa.

BACKGROUND: Cataract is the leading cause of blindness in children in east Africa. The results of surgery are poor, partly because of inadequate correction of aphakia. METHODS: A retrospective survey of 118 eyes in 71 children with bilateral cataract. All eyes had implantation of an IOL at the time of cataract surgery. The average age at surgery was 3.5 years. 28 patients(39%) were less than 2 years old at the time of surgery on their first eye. RESULTS: Preoperatively, 75.4% of eyes and 76.1% of patients were blind. A follow up of at least 3 months was available in 91 (77.1%) eyes. In these eyes, 44% had a latest corrected vision of 6/18 or better and 91.2% had a latest corrected vision of 6/60 or better. Eyes with zonular cataract, and eyes operated after the age of 2 years were more likely to obtain a vision of 6/18 or better. 3.3% of eyes and 1.8% of patients had an acuity of less than 3/60. Nystagmus was present in 42.3% of patients before surgery. In those patients followed up for a minimum of 6 months, 10.2% still had nystagmus. The most frequent complication was severe fibrinous uveitis, which occurred in 36 (30.5%) eyes. 62 (52.5%) eyes had a posterior capsulotomy at the time of cataract extraction. Of the remaining 56 eyes, 20 (35.7%) had so far required a posterior capsulotomy. The leading cause of poor visual outcome was amblyopia. Two patients developed severe complications related to the intraocular lens. CONCLUSIONS: Insertion of a lens implant at the time of cataract extraction appears to be well tolerated in the short term, and may offer significant advantages in an African setting.

A randomised trial of the effect of intraoperative 5-FU on the outcome of trabeculectomy in east Africa.

AIMS: To determine if intraoperative application of 5-fluorouracil (5-FU) improves the prognosis for trabeculectomy in east Africa. METHODS: 68 eyes with chronic open angle glaucoma were included in a randomised trial of intraoperative 5-FU versus placebo. Main outcome measures were intraocular pressures at 6 months and probability of failure at 2 years. RESULTS: 180 days after surgery the mean intraocular pressure (IOP) was 17.4 (SD 6.1) mm Hg in the placebo group and 16.9 (5.8) mm Hg in the 5-FU group. By 2 years after trabeculectomy, the probability of successful IOP control was 70.6% in the placebo group, and 88.8% in the 5-FU group. The placebo group was 2.18 times (95% CI 0.67 to 7.15) more likely to require additional IOP lowering procedures than the 5-FU group. Among patients followed for 2 years, 30% lost 0.3 logMAR units of visual acuity. CONCLUSIONS: Trabeculectomy in Africa has an acceptable success rate which may be enhanced by the use of intraoperative 5-FU. It is estimated that this would cost approximately 1.25 pounds sterling per trabeculectomy failure prevented.

Results of community-based eyelid surgery for trichiasis due to trachoma.

In many parts of Africa patients with upper-lid trichiasis due to trachoma have very limited access to ophthalmologists or hospital facilities. In order to reach these patients it is necessary for trained paramedical eye workers to operate on patients close to where they live. The results of trichiasis surgery performed by an ophthalmic nurse in Tanzania were evaluated. A total of 156 operations were performed on 94 patients over a 2 year period by an eye nurse in central Tanzania. One hundred and forty four eyes in 86 patients were followed for a minimum of 9 months (range 9-36; mean 25.5 months). One eye developed a wound infection and nine eyes developed minimal central notching of the upper eyelid, but without corneal exposure. Survival time analysis showed a probability of survival without recurrent trichiasis of 81% at 24 months (95% CI 74% to 88%) and 79% at 36 months (95% CI 71% to 87%). It is concluded that trichiasis surgery may be safely and effectively performed in the community by a trained ophthalmic nurse.

Does prospective monitoring improve cataract surgery outcomes in Africa?

AIMS: To determine if prospective monitoring influences cataract surgical outcomes in east Africa. METHODS: A prospective observational study of all routine extracapsular cataract extractions with posterior chamber lens implants carried out at Kikuyu Eye Unit, Kenya, between 1 January 1999 and 31 December 1999. RESULTS: Out of 1845 eligible eyes 1800 were included in the study. Two months' follow up was available in 67.2% of patients. The proportion achieving a good outcome increased steadily from 77.1% in the first quarter to 89.4% in the fourth quarter (chi(2) for trend, p<0.001). There was no change in the incidence of operative complications; however, the proportion of patients achieving a good visual outcome following vitreous loss increased from 47.2% in the first 6 months to 71.0% in the last 6 months (chi(2) p<0.05). Of the eyes with poor outcome (best corrected acuity <6/60 at 2 months) half were due to pre-existing eye diseases. The proportion of patients with known ocular comorbidity decreased from 10.2% in the first quarter to 5.9% in the fourth quarter (chi(2) for trend, p<0.05). Poor outcome was associated with age over 80 years, known diabetes, preoperative bilateral blindness, any ocular comorbidity, and intraoperative vitreous loss. CONCLUSIONS: This study demonstrates improvement in visual outcome results after cataract surgery over a 1 year period. Monitoring of outcomes appears to be associated with a change in surgeons' attitudes, leading to greater emphasis on appropriate case selection, better management of surgical complications, and improved visual outcomes.

Sutureless cataract surgery with nucleus extraction: outcome of a prospective study in Nepal.

AIM: To report the short and medium term outcome of a prospective series of sutureless manual extracapsular cataract extractions (ECCE) at a high volume surgical centre in Nepal. METHODS: Cataract surgery was carried out, on eyes with no co-existing diseases, in 500 consecutive patients who were likely to return for follow up. The technique involved sclerocorneal tunnel, capsulotomy, hydrodissection, nucleus extraction with a bent needle tip hook, and posterior chamber intraocular lens (PC-IOL) implantation according to biometry findings. Surgical complications, visual acuity at discharge, 6 weeks, and 1 year follow up, and surgically induced astigmatism are reported. RESULTS: The uncorrected visual acuity at discharge was 6/18 or better in 76.8% of eyes, and declined to 70.5% at 6 weeks' follow up, and 64.9% at 1 year. The best corrected visual acuity was 6/18 or better in 96.2% of eyes at 6 weeks and in 95.9% at 1 year. Poor visual outcome (<6/60) occurred in less than 2%. Intraoperative complications included 47 (9.4%) eyes with hyphaema, and one eye (0.2%) with posterior capsule rupture and vitreous in the anterior chamber. Surgery led to an increase in against the rule astigmatism, which was the major cause of uncorrected visual acuity less than 6/18. Six weeks postoperatively, 85.5% of eyes had against the rule astigmatism, with a mean induced cylinder of 1.41 D (SD 0.8). There was a further small increase in against the rule astigmatism of 0.66 D (SD 0.41) between 6 weeks and 1 year. The mean duration of surgery was 4 minutes and the average cost of consumables, including the IOL, was less than $10. CONCLUSION: Rapid recovery of good vision can be achieved with sutureless manual ECCE at low cost in areas where there is a need for high volume cataract surgery. Further work is required to reduce significant postoperative astigmatism, which was the major cause of uncorrected acuity less than 6/18.

Traumatic wound rupture after penetrating keratoplasty in Africa.

AIM: To investigate risk factors, visual outcome, and graft survival for traumatic wound rupture after penetrating keratoplasty. METHODS: A retrospective analysis of 336 patients who underwent penetrating keratoplasty from 1988 to 1995. RESULTS: 19 patients (5.7%) suffered traumatic postoperative wound rupture requiring surgical repair. They were younger (mean age 16.6 years, 95% CI 13.2-20.6) and more frequently keratoconic (p = 0.01) than other patients (mean age 28.9 years, 95% CI 26.-31.0). Mean postoperative follow up was 37.7 (SD 22.9) months and 24.5 (18.9) months for the rupture and non-rupture patients. Mean interval between keratoplasty and rupture was 18 (21) weeks. The lens was damaged and removed in 37% of ruptured eyes. For keratoconics, the probability of graft survival at 5 years was lower (p = 0.03) in the ruptured eyes (75%) than in the non-ruptured eyes (90%). Endothelial failure was a more common (p <0.05) cause of graft opacification in ruptured grafts than in intact grafts. Of the ruptured eyes, 53% achieved a final corrected acuity of at least 6/18 and 63% achieved at least 6/60 compared with 48% and 71% of the intact eyes respectively (both p >0.1). The proportion of keratoconic eyes which achieved at least 6/60 was lower (p = 0.02) in the ruptured eyes (67%) than the non-ruptured eyes (87%). Eyes with wound ruptures of 5 clock hours or greater were less likely (p <0.05) to achieve an acuity of 6/18 and were more likely (p <0.05) to have an associated lens injury. CONCLUSIONS: Graft rupture is relatively common in African practice, particularly in young keratoconics. Visual outcome and graft survival are not significantly worse than for other grafted eyes, but are significantly worse than for other grafted keratoconic eyes.

Intraocular lens implantation for traumatic cataract in children in East Africa.

PURPOSE: To review the visual outcomes and complications after intraocular lens (IOL) implantation in children with traumatic cataract in sub-Saharan Africa, where contact lenses for unilateral aphakia are impractical in most patients. SETTING: PCEA Kikuyu Eye Unit, Nairobi, Kenya, East Africa. METHODS: All children younger than 16 years having IOL implantation for traumatic cataract between February 1993 and December 1998 (215 eyes) were retrospectively reviewed. Complications and visual outcomes were evaluated. RESULTS: The study group comprised 147 boys and 68 girls. The median interval between injury and cataract surgery was 8 weeks. The most common causes of injury were stick (36.3%) and thorn (10.7%). Extracapsular cataract extraction with IOL implantation was performed in all patients. The most frequent early complication was fibrinous uveitis in 110 eyes (51.2%). One hundred sixty-seven eyes (77.7%) had 1 month or more follow-up. Of those, 108 eyes (64.7%) had a best corrected visual acuity of 20/60 or better. Twenty-one eyes (12.6%) had a visual acuity of worse than 20/200, with the most common causes being amblyopia (9/21) and retinal detachment (5/21). Amblyopia was found in 42 of 108 (38.9%) children aged 8 years or less at the time of injury. Eyes with the IOL in the capsular bag were significantly less likely to require subsequent capsulotomy (P <.01) during the 2-year follow-up. CONCLUSION: The results indicate that posterior chamber IOLs can be safely implanted by experienced surgeons in most children older than 2 years with traumatic cataract and should be the standard of care throughout the world.

Incidence of ocular injuries from road traffic accidents after introduction of seat belt legislation.

A prospective study was performed to characterize any change in the pattern of ocular injuries following the introduction of compulsory front seat belt wear on 1 February 1983. During a 24-week period in 1981 (1 February to 31 July), 24 patients with eye and adnexal injuries as a result of motor car road traffic accidents (RTAs) were seen at the Bristol Eye Hospital: 12 of these patients required emergency surgery. In the identical period two years later (1 February to 31 July 1983), only 6 patients suffered ocular injury from RTAs: 3 of these required emergency surgery. All patients in the latter series obeying the legislation on seat belt use were injured by flying glass, indicating a possible change in pattern of injury. The decrease in incidence of ocular injuries from RTAs between the two series was shown to be statistically significant. The compulsory fitting of laminated glass to all new cars in Great Britain and Europe is strongly advised.

An unusual uveitis in Tanzanian children.

In 1982-7, 254 children with panuveitis were seen at Mvumi Hospital, Tanzania, representing 56% of all cases of uveitis seen. Half were aged under 2. No consistent abnormality accounted for the uveitis and it resolved spontaneously over 6-12 weeks. A trial of prednisolone was performed in 30 children: 18 showed improvement by four weeks compared with 20 of 35 controls given only topical steroids and mydriatics.