Recurring themes during cataract assessment and surgery.

The aim of this review was to discuss frequently encountered themes such as cataract surgery in presence of age-related macular degeneration (AMD), dementia, Immediate Sequential Bilateral Cataract Surgery (ISBCS), discussing non-standard intraocular lens (IOL) options during consultation in the National Health Services (NHS) and the choice of the biometric formulae based on axial length. Individual groups of authors worked independently on each topic. We found that cataract surgery does improve visual acuity in AMD patients but the need for cataract surgery should be individualised. In patients with dementia, cataract surgery should be considered 'sooner rather than later' as progression may prevent individuals presenting for surgery. This should be planned after discussion of patients' best interests with any carers; multifocal IOLs are not proven to be the best option in these patients. ISBCS gives comparable outcomes to delayed sequential surgeries with a low risk of bilateral endophthalmitis and it can be cost-saving and efficient. Patients are entitled to know all suitable IOL options that can improve their quality of life. Deliberately withholding this information or pressuring patients to choose a non-standard IOL is inappropriate. However, one should be mindful of the not spending inappropriate amounts of time discussing these in the NHS setting which may affect care of other NHS patients. Evidence suggests Hoffer Q, Haigis, Hill-RBF and Kane formulae for shorter eyes; Barrett Universal II (BU II), Holladay II, Haigis and Kane formulae for longer eyes and BU II, Hill-RBF and Kane formulae for medium axial length eyes.

Primary low-risk trabeculectomy augmented with low-dose mitomycin-C.

PURPOSE: To present outcome data on low risk primary trabeculectomy augmented with low dose peroperative (0.1 mg/mL for 1 minute) mitomycin-C (MMC). METHODS: Retrospective case note review. All cases of trabeculectomy utilizing MMC augmentation at a concentration of 0.1 mg/mL with an application time of 1 minute and at least 1 year follow-up during the study period were included. Only first eyes were included. Patient demographics and postoperative course including complications, interventions, and outcomes were documented and analyzed. RESULTS: Fifty-nine trabeculectomies that met the inclusion criteria were identified. Mean age of cases was 70.8 years. Mean follow-up time was 19.3 months. Bleb leaks occurred in 16 (27.1%) cases. Only one case required surgical intervention in the form of resuturing after 14 days. At 1 year, there was a reduction in mean number of topical medications from 2.70 to a mean of 0.07. Unqualified success (intraocular pressure [IOP] at 1 year of less than 16 mmHg without medication) was achieved in 49 cases (83.1%). Mean IOP was reduced from the preoperative value of 23.1 mmHg (SD 5.8) to 13.5 mmHg (SD 5.0) (p<0.001). CONCLUSIONS: Our data suggest that a primary trabeculectomy augmented with a low dose of MMC is a safe and effective procedure for IOP reduction in patients with a low risk of trabeculectomy failure.

Predictive value of early IOP in mitomycin-C augmented trabeculectomy.

PURPOSE: To determine whether early intraocular pressure (IOP) after mitomycin-C (MMC) augmented trabeculectomy has any predictive value for intermediate IOP outcome. METHODS: Retrospective case note review. All cases of trabeculectomy using MMC augmentation and at least 1-year follow-up during the study period were included. Cases where a bleb leak occurred were excluded from the analysis. Only first eyes operated upon during the study period were included. Patient demographics and postoperative course were documented and analyzed. Early IOP measurements at day 1, day 7, and month 1 postoperatively were correlated to IOP at 1 year or final follow-up. RESULTS: One hundred nineteen trabeculectomies were identified. Of these 27 (22.7%) had an early bleb leak and were excluded. Further analysis was carried out on the remaining 92 cases. Mean age of cases was 70.8 years. Nine cases (9.8%) were repeat trabeculectomies. Mean follow-up time was 18.5 months (range 12 to 60 mo). Patients with a final IOP of < or =16 mm Hg (without drops or further surgery) (unqualified successes) had a mean day 1 IOP of 12.5 mm Hg compared with 17.4 mm Hg in those with an IOP more than 16 mm Hg at final follow-up (P=0.02). Patients with a final IOP of < or =16 mm Hg (with or without drops) (qualified successes) had mean day 1 IOP of 13.3 mm Hg compared with 17.1 mm Hg in those with an IOP of >16 mm Hg at final follow-up (P=0.06). At 1 month the mean IOPs were 10.7 mm Hg and 19.5 mm Hg, respectively (P<0.001). By logistic regression analysis at final recorded visit those cases in the lowest IOP quartile at 1 month were 14 times more likely to have an IOP < or =16 mm Hg without treatment than those in the highest quartile at 1 month. CONCLUSIONS: Our data suggests that a low early postoperative IOP measurement is a predictive factor for IOP value and success after intermediate length follow-up in patients undergoing trabeculectomy surgery augmented with MMC.

Role of intraocular pressure measurement on the day of phacoemulsification cataract surgery.

PURPOSE: To determine whether measurement of intraocular pressure (IOP) preoperatively or in the early postoperative period is an accurate predictor of raised IOP 24 hours after cataract surgery. SETTING: Department of Ophthalmology, Queen's Medical Centre, Nottingham, United Kingdom. METHODS: This prospective study comprised 101 eyes of 101 patients having phacoemulsification cataract surgery. The IOP was measured by Goldmann applanation tonometry preoperatively and 2 to 3 hours, 6 to 8 hours, and 22 to 24 hours postoperatively. The relationship between the same-day and next-day IOP readings was examined. RESULTS: One hundred patients completed the study. The IOP at 22 to 24 hours was significantly correlated with the IOP preoperatively (correlation coefficient [r] 0.54; 95% confidence interval [CI], 0.38-0.67) and at 6 to 8 hours (r = 0.56; 95% CI, 0.41-0.68). In contrast, the IOP measurement at 2 to 3 hours correlated relatively poorly with the next-day IOP (r = 0.33; 95% CI, 0.14-0.49). Twelve patients had an IOP of 26 mm Hg or higher at 22 to 24 hours. The risk of this outcome increased significantly with higher IOP values preoperatively and, to a lesser extent, with a raised IOP at 6 to 8 hours. Glaucoma and ocular hypertension were associated with a 2.9-fold increased risk (95% CI, 0.67-12.8) of a next-day IOP of 26 mm Hg or higher. CONCLUSIONS: Preoperative IOP or a diagnosis of glaucoma or ocular hypertension were significant risk factors for raised next-day IOP after small-incision phacoemulsification. It may be possible to select patients at greater risk of prolonged ocular hypertension before surgery for prophylactic IOP-lowering treatment. This would minimize patient morbidity and reduce the number of patients requiring next-day review, resulting in significant health economic savings.

Effect of hyaluronidase on ocular motility in sub-Tenon's anesthesia: randomized controlled trial.

PURPOSE: To assess the effect of hyaluronidase additive on the onset and degree of ocular akinesia in sub-Tenon's anesthesia for cataract surgery. SETTING: Routine cataract operating list. METHOD: This double-blind randomized controlled study comprised 100 patients who had phacoemulsification cataract surgery. Patients were randomized to 1 of 2 groups. For sub-Tenon's anesthesia, Group A received 5 mL lignocaine 2% with sodium hyaluronidase 150 IU/mL and Group B, 5 mL plain lignocaine 2%. Akinesia was assessed by scoring movement in the 6 positions of gaze. Scores ranged from 0 (complete akinesia) to 3 (no akinesia). Movements were measured at 30 seconds and 1, 3, 5, and 10 minutes. Changes in motility scores were compared by the Mann-Whitney U test. RESULTS: There was no significant difference in akinesia between the 2 groups 30 seconds after the injection (P =.224); however, at 1 and 3 minutes, Group A achieved significantly better akinesia than Group B (P =.003 and P =.023, respectively). The median score after 3 minutes was 3.5 (interquartile range 0 to 7.5) in Group A and 7.0 (interquartile range 2.5 to 10.0) in Group B. There was no significant difference between the groups at 5 and 10 minutes (P =.225 and P =.831, respectively). CONCLUSIONS: The addition of hyaluronidase in sub-Tenon's anesthesia significantly improved the rapidity of the onset of akinesia. This benefit disappeared over time; after 5 minutes the akinesia observed in the group receiving hyaluronidase was similar to that in the group receiving lignocaine alone. Thus, there appears to be no benefit to adding hyaluronidase to the anesthetic solution in terms of final ocular akinesia.