Binocular Visual Function in a Pre-Presbyopic Patient with Uniocular Cataract Undergoing Cataract Surgery with a Multifocal Intraocular Lens.

BACKGROUND/AIM: An increasing number of pre-presbyopic patients are undergoing uniocular cataract extraction. We aim to compare the binocular status of subjects with uniocular cataracts, implanted either with a multifocal or a monofocal intraocular lens (IOL). MATERIALS AND METHODS: Subjects were recruited from outpatient ophthalmology clinics and randomized to an IOL type. Corrected and uncorrected LogMAR distance visual acuity (VA) and near and intermediate VA using the Radner reading test were completed. The binocular tests included the Worth Four Dot Test, fixation disparity, TNO stereoacuity and foveal suppression assessment. In addition to the near activity vision questionnaire. The trial was closed early because the chosen multifocal lens had been superseded by newer models. We report two subjects, one receiving the multifocal IOL and a monofocal IOL control with the most comparable baseline characteristics. RESULTS: Both subjects experienced uncomplicated cataract surgery, showing clinically significant improved corrected distance VA, 0.06 LogMAR and -0.16 LogMAR in the monofocal and multifocal IOL, respectively. The multifocal subject had 30 seconds of arc stereoacuity indicating normal binocular vision. Only gross binocular single vision with no stereopsis was found in the monofocal IOL subject. The latter subject also had reduced near vision quality-of-life questionnaire results. CONCLUSION: This two-patient case series demonstrates greater binocular near ability, with the multifocal IOL, in the pre-presbyopic patient undergoing uniocular cataract surgery. The case series highlights the need, and methodology for investigating further the functional and quality-of-life benefits of implanting multifocal IOLs in pre-presbyopic patients, those in their twenties and thirties, undergoing uniocular cataract surgery.

Quantifying the real-world cost saving from using surgical adjuncts to prevent complications during cataract surgery.

INTRODUCTION: Surgical adjuncts in cataract surgery are often perceived as sometimes necessary, always expensive, particularly in the "lean" cost-saving era. However, prevention of a surgical complication, rather than subsequent management, should always be the preferred strategy. We wished to model real-world costs associated with surgical adjuncts use and test the maxim for cataract surgery-"if you think of it, use it". METHODS: We compared UK list prices for equipment and related costs of preventing vitreous loss (VL) via use of surgical adjuncts vs its subsequent management in a hypothetical cataract surgery scenario of a white swollen cataract with a moderately dilated pupil. RESULTS: The original surgery costs for the "cautious with adjuncts, no complications" approach was £943.54, including adjuncts costing £137.47. In the "minimalist, no adjunct" scenario, management of VL using the Anterior Vitrectomy Kit cost £142.45, and additional management and follow-up costs resulted in total cost of £1178.20 (£234.66 (25%) more expensive). If left aphakic, an additional operation for secondary iris clip IOL insertion and further follow-up to address the impact of the complication ultimately cost £2124.67 overall. An additional initial spend on surgical adjuncts of £137.47 could potentially prevent £1293.60 (9× increase) in direct costs in this scenario. CONCLUSIONS: Through simple scenario modelling, we have demonstrated the cost benefits provided by the use of precautionary surgical adjuncts during cataract surgery. VL costs significantly more in terms of complication management and follow-up. This supports the cataract surgeon's maxim-"if you think of it, use it".

Outcomes of Pediatric Cataract Surgery in the Copperbelt Province of Zambia.

PURPOSE: To study the outcomes of pediatric cataract surgeries in children operated on in the Copperbelt Province of Zambia and the barriers to accessing surgery. METHODS: All children who had congenital, developmental, and traumatic cataracts operated on by lens aspiration, primary posterior capsulotomy, and anterior vitrectomy with posterior chamber intraocular lens implantation from 2012 to 2013 and followed up beyond 6 months were studied. Each child underwent a comprehensive preoperative evaluation. An active, assisted follow-up was done and parents were asked about reasons for delay between presentation and surgery. RESULTS: One hundred two eyes of 70 children met the inclusion criteria of the study. Preoperatively, 76 of 77 (98.7%) eyes in the congenital and developmental cataract group had presenting visual acuity of worse than 6/60. This improved postoperatively, with 19 (29.7%) eyes having best corrected visual acuity (BCVA) of better than 6/18, 23 (35.9%) having BCVA of 6/24 to 6/60, and 22 (34.4%) having BCVA of worse than 6/60. Older age (P = .005), better preoperative vision (P = .045) at presentation, unilaterality (P = .012), and delay between presentation and surgery (P = .004) were predictors of a better postoperative outcome. On multivariate analysis, only age was significant (P = .025). Distance and cost of travel and surgery were the causes of delay in presentation. In the patients with traumatic cataracts, 17 of 25 (68%) had BCVA of better than 6/18, 6 (24%) had BCVA between 6/24 and 6/60, and 2 (8%) had BCVA of worse than 6/60 at the 6-month follow-up. The most common causes of injury were being struck by sticks and stones (10 children, 25%). CONCLUSIONS: Visual outcomes after pediatric cataract surgery in Zambia were comparable and satisfactory. Cost of treatment was a barrier, but delay did not adversely affect outcome. [J Pediatr Ophthalmol Strabismus. 2016;53(5):311-317.].

Sulcus-fixated intraocular lens implantation for the management of negative dysphotopsia.

PURPOSE: To determine whether intraocular lens (IOL) exchange with insertion of a sulcus-fixated IOL is an effective treatment for the management of pseudophakic negative dysphotopsia. SETTING: Department of Ophthalmology, Stoke Mandeville Hospital, Buckinghamshire, United Kingdom. DESIGN: Case series. METHODS: Participants in the study were recruited prospectively from the clinic at the time of diagnosis or retrospectively from the operating room logs by identifying all patients who had IOL exchanges over a 4-year period (2009 to 2012). RESULTS: Five eyes of 5 women with negative dysphotopsia were treated with IOL exchange and replacement with a 3-piece IOL (Acrysof MA60AC) inserted in the ciliary sulcus. All patients had a resolution of the negative dysphotopsia symptoms. One patient had primary insertion of a sulcus IOL in the fellow eye and did not develop negative dysphotopsia symptoms. CONCLUSION: Intraocular lens exchange with insertion of a 3-piece IOL in the ciliary sulcus appears to be a safe and effective treatment for the management of pseudophakic negative dysphotopsia. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.

Neisseria meningitidis endogenous endophthalmitis with meningitis in an immunocompetent child.

Neisseria meningitidis is a major cause of childhood morbidity and mortality worldwide. We describe an exceptional case of an immunocompetent 15-month-old child presenting with a unilateral anterior uveitis, hypopyon, and sepsis. Anterior chamber aspirate demonstrated gram-negative cocci before Neisseria meningitidis was identified in blood and cerebrospinal fluid. Meningococcal endophthalmitis presents variably with sepsis, meningitis, or isolated ocular symptoms. Diagnosis is a clinical challenge, requiring diagnostic sampling and treatment from both pediatricians and ophthalmologists. Delayed or incorrect treatment risks blindness, disability, or death. Simultaneous invasion of meningococcus across intact blood-brain and blood-ocular barriers in this child suggests antigenic correlates between meningeal and ocular endothelial interfaces. Meningococcus is an exclusively human pathogen; research is hampered by the lack of animal models. This clinical observation suggests the potential of a novel in vitro experimental approach of using ocular tissue from eye banks to further elucidate the meningococcal-endothelial interaction that underpins meningococcal disease.

Phacoemulsification skills training and assessment.

BACKGROUND The quality of ophthalmic surgical training is increasingly challenged by an untimely convergence of several factors. This article reviews the tools currently available for training and assessment in phacoemulsification surgery. METHODS Medline searches were performed to identify articles with combinations of the following words: phacoemulsification, training, curriculum, virtual reality and assessment. Further articles were obtained by manually searching the reference lists of identified papers. RESULTS Thus far phacoemulsification training outside the operating room include wet labs and micro-surgical skills courses. These methods have been criticised for being unrealistic, inaccurate and inconsistent. Virtual reality simulators have the ability to teach phacoemulsification psychomotor skills, as well as to carry out objective assessment. Other ophthalmic surgical skill assessment tools such as Objective Assessment of Skills in Intraocular Surgery (OASIS) and Global Rating Assessment of Skills in Intraocular Surgery (GRASIS) are emerging. Assessor bias is minimised by using video-based assessments, which have been shown to reduce subjectivity. Dexterity analysis technology such as the Imperial College Surgical Assessment Device (ICSAD) and virtual reality simulators can be used as objective assessment devices. CONCLUSION Improvements in technology can be utilised in ophthalmology and will help to address the increasingly limited opportunities for training and assessment during training and throughout a subsequent career (re-training and re-validation). This will inevitably translate into enhanced patient care.

Symptomatic dynamic vitreomacular traction during accommodation and head-down posture preceding definitive vitreomacular traction syndrome.

PURPOSE: To report a case of progressive vitreomacular traction, definitive optical coherence tomography evidence of established vitreomacular traction, and subsequent spontaneous resolution with posterior vitreous detachment occurrence. METHODS: Case report and literature review. This study involved a patient presenting to the Retina Clinic at Stoke Mandeville Hospital. RESULTS: Symptomatic improvement after posterior vitreous detachment. CONCLUSION: Dynamic vitreomacular traction should be suspected in cases of fluctuating central visual disturbance, particularly when associated with accommodation and downward head posture. The authors discuss the possible influence of accommodation and head position.

Postoperative rotation of a 3-piece loop-haptic acrylic intraocular lens.

PURPOSE: To assess the rotational stability of the AcrySof MA60BM acrylic intraocular lens (IOL) with and without aspiration of residual lens epithelial cells (LECs). SETTING: Stoke Mandeville Hospital, Aylesbury, United Kingdom. METHODS: Routine phacoemulsification was performed with (Group A) or without (Group B) aspiration of residual LECs (random allocation). The baseline position of the IOL was determined from a video frame acquired at the conclusion of surgery. Postoperative IOL position was documented using digital retroillumination images at 2 weeks and 3 months. Early IOL rotation (surgery to 2 weeks postoperatively) was graded as mild (<10 degrees), moderate (10 to 30 degrees), or severe (>30 degrees) by semiobjective comparison of the images. Late IOL rotation (2 weeks to 3 months) was measured more precisely using purpose-designed software. RESULTS: Group A had incomplete aspiration of residual LECs. The only between-group demographic difference was significantly more men in Group A than in Group B (P<.05). There were no cases of severe early IOL rotation. Mild and moderate early rotation occurred in 91.5% of eyes and 8.5% of eyes, respectively. The mean late rotation was 0.03 degrees +/- 3.06 (SD) (range 7.8 to -8.7 degrees). Aspiration of residual LECs made no statistical difference in early or late rotation (P>.05). Between 2 weeks and 3 months, counterclockwise rotation occurred in 50% of all cases. CONCLUSIONS: Postoperative rotation of the loop-haptic IOL was stable; LEC clearance did not adversely affect performance. The tendency toward counterclockwise rotation would not preclude good performance of a toric model of the IOL.

Optimizing microsurgical skills with EEG neurofeedback.

BACKGROUND: By enabling individuals to self-regulate their brainwave activity in the field of optimal performance in healthy individuals, neurofeedback has been found to improve cognitive and artistic performance. Here we assessed whether two distinct EEG neurofeedback protocols could develop surgical skill, given the important role this skill plays in medicine. RESULTS: National Health Service trainee ophthalmic microsurgeons (N = 20) were randomly assigned to either Sensory Motor Rhythm-Theta (SMR) or Alpha-Theta (AT) groups, a randomized subset of which were also part of a wait-list 'no-treatment' control group (N = 8). Neurofeedback groups received eight 30-minute sessions of EEG training. Pre-post assessment included a skills lab surgical procedure with timed measures and expert ratings from video-recordings by consultant surgeons, together with state/trait anxiety self-reports. SMR training demonstrated advantages absent in the control group, with improvements in surgical skill according to 1) the expert ratings: overall technique (d = 0.6, p < 0.03) and suture task (d = 0.9, p < 0.02) (judges' intraclass correlation coefficient = 0.85); and 2) with overall time on task (d = 0.5, p = 0.02), while everyday anxiety (trait) decreased (d = 0.5, p < 0.02). Importantly the decrease in surgical task time was strongly associated with SMR EEG training changes (p < 0.01), especially with continued reduction of theta (4-7 Hz) power. AT training produced marginal improvements in technique and overall performance time, which were accompanied by a standard error indicative of large individual differences. Notwithstanding, successful within session elevation of the theta-alpha ratio correlated positively with improvements in overall technique (r = 0.64, p = 0.047). CONCLUSION: SMR-Theta neurofeedback training provided significant improvement in surgical technique whilst considerably reducing time on task by 26%. There was also evidence that AT training marginally reduced total surgery time, despite suboptimal training efficacies. Overall, the data set provides encouraging evidence of optimised learning of a complex medical specialty via neurofeedback training.

Skills acquisition and assessment after a microsurgical skills course for ophthalmology residents.

OBJECTIVE: To assess the impact of a skills course on microsurgical skills acquisition and to investigate the validity of a video-based modified Objective Structured Assessment of Technical Skill (OSATS) assessment tool that has not previously been applied to ophthalmic surgery. DESIGN: Prospective longitudinal cohort study. PARTICIPANTS: Fourteen residents were recruited from 20 attendees at the Moorfields Eye Hospital microsurgical skills course for residents. METHODS: Each resident performed a standardized microsurgical task consisting of the placement of a 10-0 nylon corneal suture into a model eye using an operating microscope with standardized equipment in a standardized environment. Objective measurements were made using the Imperial College Surgical Assessment Device (ICSAD). This is a motion-tracking device returning 3 parameters for economy of movement: total path length, time, and number of individual hand movements. A concurrent video recording was made of each task by 2 independent observers who were masked to the time of the recording relative to the course and the identity of the resident. Video footage was marked in accordance with the OSATS video scoring template. MAIN OUTCOME MEASURES: Each resident had motion-tracking analysis performed during corneal suturing before and after the course (total path length, time, and number of individual hand movements), along with concurrent OSATS video scores. RESULTS: Skills improvement after the course was found to be statistically significant for all 3 ICSAD economy of movement parameters: path length, P = 0.001; hand movements, P = 0.012; and time, P = 0.009. Differences in the combined OSATS scores of the 2 raters before and after the course were found to be significant (P = 0.039). Interrater reliability of OSATS scorers was 0.78 (alpha Cronbach). Correlations between the OSATS scores and each of the ICSAD parameters were found to be significant (P<0.001). CONCLUSIONS: A video-based OSATS scoring system has significant correlation with the ICSAD motion-tracking parameters, demonstrating concurrent validity between the 2 assessment tools. These data also demonstrate that surgical skill, as measured by a validated motion-tracking system, is significantly improved after a 1-day microsurgical skills course. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Objective structured assessment of cataract surgical skill.

OBJECTIVE: To evaluate the Objective Structured Assessment of Cataract Surgical Skill scoring system. METHODS: An objective performance rating tool was devised. This instrument is comprised of standardized criteria with global rating and operation-specific components, each rated on a 5-point Likert scale. The total potential score was 100. Complete phacoemulsification cataract extraction operations were recorded through the operating microscope of surgeons with a range of experience (group A, <50 procedures; group B, 50-249 procedures; group C, 250-500 procedures, and group D, >500 procedures). These were then scored by independent expert reviewers masked to the grades of the surgeons. The U test was used to evaluate statistical significance. RESULTS: We evaluated 38 surgical videotapes of 38 surgeons (group A, 11 surgeons; group B, 10 surgeons; group C, 5 surgeons; and group D, 12 surgeons). Mean +/- SD overall scores were as follows: group A, 32.0 +/- 5.3; group B, 55.0 +/- 12.6; group C, 89.0 +/- 4.7; and group D, 90.0 +/- 11.1. Statistically significant differences were found between groups A and B (P = .002) and groups B and C (P = .003), but not between groups C and D (P>.99). CONCLUSION: The Objective Structured Assessment of Cataract Surgical Skill scoring system seems to have construct validity with cataract surgery and, thus, may be valuable for assessing the surgical skills of junior trainees.

Effect of lens epithelial cell aspiration on postoperative capsulorhexis contraction with the use of the AcrySof intraocular lens: randomized clinical trial.

PURPOSE: To determine whether aspiration of lens epithelial cells (LECs) from under the anterior capsule reduces postoperative contraction of the capsulorhexis aperture. SETTING: Stoke Mandeville Hospital, Aylesbury, Buckinghamshire, United Kingdom. METHODS: This prospective randomized observer-masked study comprised 100 patients who had routine phacoemulsification by the same surgeon at a district general hospital in the United Kingdom. The postoperative changes in capsulorhexis apertures and anterior capsule opacification (ACO) between Group A (aspiration of LECs) and Group B (control) were compared. Digital retroillumination images of the capsulorhexis aperture were taken 1 week and 3 months postoperatively. The area of capsulorhexis aperture was determined with computer software, and capsule opacification was graded subjectively. RESULTS: Three months postoperatively, the mean decrease in capsulorhexis aperture was 1.9% in Group A and 5.6% in Group B (P = .02). The ACO at 3 months was grade 2 in 44% of eyes in Group A and in 61% in Group B (P = .13). CONCLUSION: Aspiration of LECs from the anterior capsule was a safe procedure that reduced capsulorhexis aperture contraction 3 months after cataract surgery.

Selection, teaching and training in ophthalmology.

This article examines the training requirements for ophthalmic surgical training, and the selection, assessment and training methodologies used for trainees, and also comments on the role of the surgical trainers. As an introduction to the article, a brief description of the current scheme in the UK is given.