Latanoprost for open-angle glaucoma (UKGTS): a randomised, multicentre, placebo-controlled trial.

BACKGROUND: Treatments for open-angle glaucoma aim to prevent vision loss through lowering of intraocular pressure, but to our knowledge no placebo-controlled trials have assessed visual function preservation, and the observation periods of previous (unmasked) trials have typically been at least 5 years. We assessed vision preservation in patients given latanoprost compared with those given placebo. METHODS: In this randomised, triple-masked, placebo-controlled trial, we enrolled patients with newly diagnosed open-angle glaucoma at ten UK centres (tertiary referral centres, teaching hospitals, and district general hospitals). Eligible patients were randomly allocated (1:1) with a website-generated randomisation schedule, stratified by centre and with a permuted block design, to receive either latanoprost 0·005% (intervention group) or placebo (control group) eye drops. Drops were administered from identical bottles, once a day, to both eyes. The primary outcome was time to visual field deterioration within 24 months. Analyses were done in all individuals with follow-up data. The Data and Safety Monitoring Committee (DSMC) recommended stopping the trial on Jan 6, 2011 (last patient visit July, 2011), after an interim analysis, and suggested a change in primary outcome from the difference in proportions of patients with incident progression between groups to time to visual field deterioration within 24 months. This trial is registered, number ISRCTN96423140. FINDINGS: We enrolled 516 individuals between Dec 1, 2006, and March 16, 2010. Baseline mean intraocular pressure was 19·6 mm Hg (SD 4·6) in 258 patients in the latanoprost group and 20·1 mm Hg (4·8) in 258 controls. At 24 months, mean reduction in intraocular pressure was 3·8 mm Hg (4·0) in 231 patients assessed in the latanoprost group and 0·9 mm Hg (3·8) in 230 patients assessed in the placebo group. Visual field preservation was significantly longer in the latanoprost group than in the placebo group: adjusted hazard ratio (HR) 0·44 (95% CI 0·28-0·69; p=0·0003). We noted 18 serious adverse events, none attributable to the study drug. INTERPRETATION: This is the first randomised placebo-controlled trial to show preservation of the visual field with an intraocular-pressure-lowering drug in patients with open-angle glaucoma. The study design enabled significant differences in vision to be assessed in a relatively short observation period. FUNDING: Pfizer, UK National Institute for Health Research Biomedical Research Centre.

Interventions to increase clinical incident reporting in health care.

BACKGROUND: Reporting of adverse clinical events is thought to be an effective method of improving the safety of healthcare. Underreporting of these adverse events is often said to occur with consequence of missing of opportunities to learn from these incidents. A clinical incident can be defined as any occurrence which is not consistent with the routine care of the patient or the routine operation of the institution. OBJECTIVES: To assess the effects of interventions designed to increase clinical incident reporting in healthcare settings. SEARCH METHODS: We searched the the following databases: Cochrane Effective Practice and Organisation of Care Group Specialised Register, the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), CINAHL (EBSCO), Social Science Citation Index and Science Citation Index (Web of Knowledge), Healthstar (OVID), INSPEC, DHSS-DATA, SIGLE, ISI Conference Proceedings, Web of Science Conference Proceedings Citation Index (Science), Database of Abstracts of Reviews of Effectiveness (DARE). SELECTION CRITERIA: Randomised controlled trials (RCT), controlled before-after studies (CBA) and interrupted time series (ITS) of interventions designed to increase clinical incident reporting in healthcare. DATA COLLECTION AND ANALYSIS: At least two review authors assessed the eligibility of potentially relevant studies, extracted the data and assessed the quality of included studies. MAIN RESULTS: Four studies (one CBA and three ITS studies) met our inclusion criteria and were included in the review. The CBA study showed a significant improvement in incident reporting rates after the introduction of the new reporting system. Just one of the ITS studies showed a statistically significant improved effectiveness of the new reporting system from nine months. The other two studies reported no statistically significant improvements. AUTHORS' CONCLUSIONS: Because of the limitations of the studies it is not possible to draw conclusions for clinical practice. Anyone introducing a system into practice should give careful consideration to conducting an evaluation using a robust design.

Interventions for acute non-arteritic central retinal artery occlusion.

BACKGROUND: Acute central retinal artery occlusion (CRAO) occurs as a sudden interruption of the blood supply to the retina and results in an almost complete loss of vision in the affected eye. There is no generally agreed treatment regimen although a number of therapeutic interventions have been proposed. OBJECTIVES: The objective of this review was to examine the effects of treatments used for acute non-arteritic CRAO. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library, Issue 3, 2008), MEDLINE (January 1966 to September 2008), EMBASE (January 1980 to September 2008) and the reference lists of relevant papers. SELECTION CRITERIA: We included randomised controlled trials (RCTs) only in which one treatment aimed to re-establish blood supply to the retina in people with acute CRAO was compared to another treatment. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the search results for relevant trials. Discrepancies were resolved by discussion. MAIN RESULTS: We found two RCTs that met our inclusion criteria. AUTHORS' CONCLUSIONS: The included studies in this review were small and from single centres. Neither study was completely clear about it's method of treatment allocation. One study described the use of pentoxifylline tablets (three 600 mg tablets daily) and the other the use of enhanced external counterpulsation (EECP) combined with haemodilution. Both studies indicated improved retinal perfusion in the non-control group but neither showed an improvement in vision. Large, well-designed RCTs are still required to establish the most effective treatment for acute CRAO. These studies should be looking at factors important to the patient i.e. improved vision with acceptable risk/side-effects.

A review of anterior segment dysgeneses.

The anterior segment dysgeneses are an ill-defined group of ocular developmental abnormalities that share some common features and have a high prevalence of glaucoma. Current classification of what are and what are not anterior segment dysgeneses seems to vary and our knowledge of them is incomplete. As the limits of classical clinical medicine based on evaluation of signs and symptoms are reached, further advancements increasingly will come from molecular medicine and genetics. In this article we review the normal and abnormal development of the anterior segment (concentrating primarily upon neural crest derived dysgeneses), describe the various clinical entities produced and their diagnosis, and discuss the current knowledge of the genetics of these disorders. We also suggest a new approach to the classification of anterior segment dysgeneses, based upon the embryological contribution to the formation of the anterior segment of the eye.

Hospital Episode Statistics and trends in ophthalmic surgery 1998-2004.

BACKGROUND: Hospital episode statistics (HES) is a UK national database for the National Health Service (NHS), now available online. The purpose of this study was to observe trends in ophthalmic operations performed during the period from 1998 to 2004, using this data. METHODS: From the 'Main Operation' codes within the 'Free data' section of the HES website we analysed data in regard to 28 specific ophthalmic operations. These represented each sub speciality within ophthalmology. RESULTS: The figures show a change in the total number and proportions of operations performed for many of the procedures. For example, there was an increase in numbers of orbital decompressions, but a decrease in numbers of glaucoma filtering operations. Changing trends could be seen in different surgical areas such as the change in operations used for corneal grafting and in retinal surgery. CONCLUSION: The HES database represents an important, potentially useful source of information. There are imitations in interpretation of and validity of such data related to coding inconsistencies. We suggest the benefit of the data comes from observing trends rather than exact numbers. As other studies using this data have suggested, it is important that clinicians are involved in improving the quality of this data.

Acute red eye and back pain as a presentation for systemic illness: case report.

BACKGROUND: Acute red eye is a common presentation in both primary and secondary care. Presentation in combination with other systemic symptoms can indicate serious underlying pathology. CASE PRESENTATION: 73-year-old lady presenting with endogenous endophthalmitis and thoracic discitis secondary to sub-acute bacterial endocarditis. CONCLUSION: Acute red eye in combination with systemic symptoms requires immediate investigation. If endogenous endophthalmitis is diagnosed, a source of sepsis should be comprehensively investigated and referral made to individual specialties if necessary.

The use of a pre-operative scoring system for the prediction of phacoemulsification case difficulty and the selection of appropriate cases to be performed by trainees.

BACKGROUND: To establish whether a previously validated scoring system (Habib) for the prediction of risk or likelihood of posterior capsule rupture during phacoemulsification surgery could be used to: 1. Predict the difficulty of a phacoemulsification case, and 2. Select appropriate phacoemulsification cases for trainees. METHODS: The study sample was consecutive phacoemulsification cases undertaken by senior surgeons at a single ophthalmic unit over a three-week period (170 cases). Each case was scored using a potential difficulty scoring system. Immediately post-operatively, each case was given two scores by the operating surgeon (who was masked with regard to the potential complication score). The first score indicated the perceived difficulty of the case, and the second score, the degree of experience that they thought a trainee would require in order to have performed the same case without complication. RESULTS: Using Cuzick's non-parametric test for trend, there was evidence for a trend of increasing perceived difficulty with increasing potential difficulty score (p = 0.05), and of increasing experience required with increasing potential difficulty score (p < 0.001) CONCLUSION: The authors advocate that Habib's potential difficulty scoring system can be used to inform the surgeon of the likely difficulty of a phacoemulsification case and to aid selection of appropriate cases for trainees prior to surgery.

Do variations in the theatre team have an impact on the incidence of complications?

BACKGROUND: To examine whether variations in non-medical personnel influence the incidence of complications in a cataract theatre. METHODS: A retrospective Case-Control study was undertaken in a single-site, designated cataract theatre. Staffing variations within theatre were examined and the incidence of cataract complications was assessed. RESULTS: 100 complicated lists and 200 uncomplicated control lists were chosen. At least 7 nurses were present for every list. Mean experience of the nurses was 6.4 years for case lists and 6.5 years for control lists. Average scrub nurse experience in years was 7.6 years for complicated lists and 8.0 years for controls. 26% of complicated case lists were affected by unplanned leave and 17% in control lists. Odds ratio 1.7 (1.0 to 3.1) 95% CI. CONCLUSION: Unplanned leave can have a detrimental effect on the operating list. The impact of this may be modifiable with careful planning.

Is post-trabeculectomy hypotony a risk factor for subsequent failure? A case control study.

BACKGROUND: Ocular hypotony results in an increased break down of the blood-aqueous barrier and an increase in inflammatory mediator release. We postulate that this release may lead to an increased risk of trabeculectomy failure through increased bleb scarring. This study was designed to try to address the question if hypotony within one month of trabeculectomy for Primary Open Angle Glaucoma (POAG), is a risk factor for future failure of the filter. METHODS: We performed a retrospective, case notes review, of patients who underwent trabeculectomy for POAG between Jan 1995 and Jan 1996 at our hospital. We identified those with postoperative hypotony within 1 month of surgery. Hypotony was defined as an intraocular pressure (IOP) < 8 mmHg or an IOP of less than 10 mmHg with choroidal detachment or a shallow anterior chamber. We compared the survival times of the surgery in this group with a control group (who did not suffer hypotony as described above), over a 5 year period. Failure of trabeculectomy was defined as IOP > 21 mmHg, or commencement of topical antihypertensives or repeat surgery. RESULTS: 97 cases matched our inclusion criteria, of these 38 (39%) experienced hypotony within 1 month of surgery. We compared the survival times in those patients who developed hypotony with those who did not using the log-rank test. This data provided evidence of a difference (P = 0.0492) with patients in the hypotony group failing more rapidly than the control group. CONCLUSION: Early post-trabeculectomy hypotony (within 1 month) is associated with reduced survival time of blebs.

Comparative study of first-day postoperative cataract review methods.

PURPOSE: To assess whether telephone review on the first day after uneventful phacoemulsification is as effective as postoperative review in a hospital or the patients' home by nursing staff. SETTING: Sunderland Eye Infirmary, Sunderland, United Kingdom. METHOD: This prospective study comprised 3 arms, each of which consisted of 100 patients who had uneventful phacoemulsification with intraocular lens implantation. Patients received the same postoperative medications and were given a questionnaire regarding their opinions on the method of postoperative review. The method of review was different for each arm as follows: (1) home review by a nurse, (2) return to the hospital for review by a nurse, and (3) telephone review by a nurse. Statistical analysis of relative frequencies was done; exact testing was applied throughout to test for differences in proportions and, where applicable, to construct 95% confidence intervals. RESULTS: There were no significant differences between the 3 groups in the degree to which patients understood the instructions and questions. The telephone group was significantly less reassured than the home-visit group, but there was no significant difference in the degree of reassurance between the telephone and hospital-visit groups. Seventy percent of patients in the telephone group listed telephone review as their preferred method of postoperative review. CONCLUSION: In cases of uneventful phacoemulsification, telephone review is safe, effective, and acceptable and is a reasonable alternative to other first-day review methods.

Visual and refractive outcome of one-site phacotrabeculectomy compared with temporal approach phacoemulsification.

BACKGROUND: We aimed to compare visual and refractive outcome following phacoemulsification and intraocular lens implant (IOL) and combined one-site phacotrabeculectomy. METHOD: We performed a retrospective study of case records of patients who had temporal incision phacoemulsification with IOL or one-site phacotrabeculectomy, between June 1997 and June 2001. The patients were matched for age group, operating list and IOL type. All patients were operated on under local anesthesia by the same surgeon. Each arm of the study had 90 patients, age range 60 to 75 years. We collected pre- and postoperative visual acuity, pre- and postoperative refraction within six months after surgery, and intended refraction. The intraocular pressure control was not recorded, as it was not the aim of our study. RESULTS: In the phacotrabeculectomy group, 76.6% of patients achieved aimed spherical equivalent, 15.5% of patients had against-the-rule (ATR) astigmatism induced by the surgery, and 90% of the patients had best corrected visual acuity (BCVA) more than 6/12. In the temporal incision phacoemulsification group, 81.1% of patients achieved aimed spherical equivalent, 10% of the patients had induced ATR by the surgery and 95.55% of patients achieved BCVA more than 6/12. CONCLUSION: In this study the visual outcome of the phacotrabeculectomy group did not differ significantly from the visual outcome of temporal approach phacoemulsification.

Cataract surgery and quality of life implications.

Cataract surgery in the developed world has undergone a revolution over the last 20 years. An operation which used to require a stay in hospital and long visual rehabilitation is now a quick day-case procedure with immediate benefits. As with any surgery there is an associated morbidity, but there is now the potential to provide cataract surgery at an earlier stage of cataract maturation and save patients from a period of severe visual impairment. This article reviews the new techniques available to measure the impact that cataracts have not only on a patient's visual acuity but also their general physical health, function, cognition, and emotional well-being. New research is described that takes into account these more holistic tests and how they can be used to judge the best time to refer and operate on a patient with cataracts.

The contribution to ophthalmic literature from different regions of the world.

PURPOSE: To compare the volume of ophthalmic literature from the developed and developing countries. METHODS: We performed a retrospective review of the five highest scoring impact factor journals in ophthalmology within the 3 year period 1998-2000 inclusive. Europe, North America, Australia, New Zealand and Japan were categorised as developed countries, all others were categorised as developing market economies. Correspondence, news articles and book reviews were excluded from our study. RESULTS: The developing world contributed to only 5.47% of the literature compared to the 92.19% from the developed world. The majority of the contribution to ophthalmic literature from the developing countries originated from Israel, S. America, China, Saudi Arabia, India, Singapore and Korea. 2.33% of literature was the result of collaborative research from the two groups. CONCLUSION: The developing countries account for 90.8% of world blindness, compared to 9.2% from the developed countries, there is therefore, an inverse relationship between the burden of world blindness and the contribution to the highest impact factor ophthalmic journals with the developed countries only contributing to 5% of this research.