Surgical management of coexisting pseudophakic bullous keratopathy and glaucoma.

This technique is a 1-step surgical management approach for patients with pseudophakic bullous keratopathy, glaucoma, and an unsatisfactory intraocular lens (IOL). The outcome of 4 consecutive patients who had penetrating keratoplasty, IOL removal, vitrectomy, transscleral sutured IOL implantation, and trabeculectomy by the same surgeon were reviewed. All patients had had intracapsular cataract extraction with anterior chamber IOL implantation and were on antiglaucoma therapy. Main outcome measures were Snellen visual acuity and intraocular pressure. A 1-stage quintuple procedure can achieve relatively rapid visual rehabilitation in these high-risk eyes. The role of filtration surgery is controversial, but it was partially successful in controlling postoperative intraocular pressure.

Topical anesthesia: Proxymetacaine versus Amethocaine for clear corneal phacoemulsification.

PURPOSE: To evaluate the use of proparacaine (Proxymetacaine) versus tetracaine (Amethocaine) as the topical anesthetic agent for phacoemulsification cataract surgery using a 3.5 mm clear corneal sutureless incision. SETTING: Harold Wood Hospital, Romford, Essex, United Kingdom. METHODS: This prospective study comprised 40 randomly selected patients. Twenty were given Proxymetacaine and 20, Amethocaine. The level of discomfort experienced during delivery of the topical anesthetic agent and during and immediately after surgery was measured using a pain score. During surgery, topical anesthesia was supplemented by intracameral lignocaine 1%. RESULTS: Patients given Proxymetacaine experienced no stinging sensation during its administration; those given Amethocaine reported varying degrees of discomfort. The difference between groups was statistically significant (P < .01). There was no difference between groups in the amount of discomfort experienced intraoperatively or postoperatively. CONCLUSION: Proxymetacaine is the topical analgesic of choice for phacoemulsification because it produced no discomfort on administration yet had the same analgesic properties as Amethocaine.

Topical versus peribulbar anesthesia, without sedation, for clear corneal phacoemulsification.

PURPOSE: To investigate patient and surgeon acceptance of topical anesthesia as an alternative to peribulbar anesthesia for clear corneal phacoemulsification. SETTING: Department of Ophthalmology, Whipps Cross Hospital, London, England. METHODS: All cataract surgery was performed using a temporal clear corneal approach, bimanual phacoemulsification, and in-the-bag intraocular lens implantation. The results of 51 patients having surgery under topical anesthesia (amethocaine) were compared with those of 30 patients having peribulbar anesthesia (50:50 mixture of lignocaine 2% and bupivacaine 0.5% with hyaluronidase). No sedation was used in either group. Pain perception on administration of the anesthetic, perioperatively (period immediately surrounding and during surgery), and postoperatively was assessed using a visual analog scale from 0 to 10 (0 = no pain: 10 = worst pain imaginable). A questionnaire was used to assess the degree of patient and surgeon satisfaction. RESULTS: Administration of topical amethocaine was significantly less painful than peribulbar bupivacaine (P = .03). Perioperative pain showed a trend toward being worse in the topical anesthesia group but did not reach statistical significance. There was no difference in the postoperative pain scores of the two groups. The surgical experience was rated very satisfactory by 67% in the topical group and 73% in the peribulbar group. The surgeons reported no difficulties or complications. CONCLUSION: Topical anesthesia was safe and effective for clear corneal phacoemulsification and was well tolerated by patients. The slightly greater awareness of ocular discomfort in the topical group perioperatively did not alter patient satisfaction with the surgical experience when compared with the peribulbar group.

Topical anaesthesia for cataract surgery.

First, do no harm. We believe that the analgesia provided by topical anaesthetic is adequate for small-incision cataract surgery and does not compromise the safety of the surgery. In addition, the lack of amaurosis is ideal for day-case surgery, which itself is increasingly popular. If preventable, why not prevented? The greatest attraction of topical anaesthesia is its complete absence of the complications described for injectional local anaesthetic techniques. We therefore recommend that our colleagues consider topical anaesthetic for patients undergoing small-incision cataract surgery under local anaesthesia. Our policy for the past 3 years has been to use only topical or general anaesthetics for cataract surgery.

Why are new patients coming to the eye clinic? An analysis of the relative frequencies of ophthalmic disease amongst new patients attending hospital eye clinics in two separate locations.

We have analysed 64,417 patient-attendances by 56,409 patients to a dedicated ophthalmic new patient service to assess the demographic and epidemiological parameters of this population. Forty-three point five per cent were male and 56.5% female. Nine per cent of patients were under 16 years of age while 27.5% were over 70 years. Comparison of patients attending an outreach new patient clinic with that at the main hospital showed that a higher proportion of patients under 16 years were seen at the outreach clinic (p < 0.001), whereas the main clinic saw a higher proportion of patients in the 16-69 year age group (p < 0.001).

Misdiagnosis of acute angle closure glaucoma.

When acute glaucoma presents in its classical form, the diagnosis is fairly simple to make. However, atypical presentations are not uncommon and the diagnosis can be missed. This inevitably leads to a delay in treatment which can permanently compromise visual function. We have studied which doctors are most likely to make a misdiagnosis and calculated the resulting delay in treatment. All patients with acute glaucoma attending Whipps Cross eye unit between 1991 and 1994 were identified and their notes obtained. Thirty-eight patients were found to have a had diagnosis of acute closed angle glaucoma. In only 39.5% was the diagnosis correctly made by the referring practitioner and a misdiagnosis resulted in a mean delay of treatment of 5.8 days. General practitioners were the most likely group to have difficulty making the diagnosis, while casualty officers were most likely to make the correct diagnosis. Because acute glaucoma can present without its typical features, there needs to be a high index of suspicion for this diagnosis. This diagnosis does not require expensive equipment or a high level of training--all our patients had a significant reduction in vision. Any patient who has a red eye and a subjective reduction in vision should be referred to an ophthalmologist the same day.

The spectrum of herpes simplex virus disease of the anterior segment in the 1990s.

We have sampled our clinic population in order to ascertain the proportion with herpetic eye disease of the anterior segment. The age, gender predominance, and incidence of bilateral disease amongst such patients has not changed over the past 20 years. The predominant disease type was stromal keratitis, with significant morbidity and visual handicap. Herpetic eye disease of the anterior segment utilizes only 1% of out-patient clinic resources overall, but 17% of specialist external disease clinic time. There was a statistically significant correlation between total length of follow-up and reduced visual acuity. It would seem that the prevalence of herpetic eye disease of the anterior segment appears to have halved since comparable reports were published. In addition, the prognosis of the disease, in terms of the prevalence of visual impairment, has worsened.

Resource management of cataract patients: effect of four contemporary incisions on postoperative visits required.

PURPOSE: To assess the effect of four contemporary cataract surgery incisions on the number of postoperative visits required. SETTING: Cataract service of a large free-standing eye hospital in a capital city. METHODS: This study comprised a prospective evaluation of three incisions for phacoemulsification and a retrospective assessment of age- and sex-matched patients having conventional corneal section extracapsular cataract extraction. All patients had age-related cataract. Main outcome measures were complications, best corrected and uncorrected visual acuities 6 weeks after surgery, and number of visits before discharge. Follow-up was at least 6 months. RESULTS: Patients who had small and scleral incisions had better uncorrected visual acuities 6 weeks postoperatively because they had less astigmatism. Patients who had small and scleral incisions required significantly fewer postoperative visits before discharge. CONCLUSION: A prospective assessment of the feasibility and acceptability of reduced postoperative follow-up after phacoemulsification using a scleral tunnel is required.

Resource management of cataract patients: can visual rehabilitation be achieved in three visits?

PURPOSE: To assess the feasibility and acceptability of reduced postoperative follow-up after phacoemulsification using a scleral tunnel technique. SETTING: Cataract service of a large free-standing eye hospital in a capital city. METHODS: In this pilot study, patients with age-related cataract requiring surgery were prospectively recruited to a standardized management protocol, the three-episode model, with assessment by an independent observer. Main outcome measures were number of postoperative visits, patient satisfaction, and refractive error at 2 and 6 weeks postoperatively. RESULTS: Almost 90% of patients could be managed within this model of care. Patient satisfaction was high; no patient requested further hospital visits. Mean change in refractive error between 2 and 6 weeks was 0.34 diopters (D), with a modal value of 0 D. Patients were able to obtain spectacles 2 weeks postoperatively because little change in refraction occurs over the next month. CONCLUSION: The three-episode model for the management of patients with cataract could result in significant financial savings. Such savings could be used to treat patients with cataract who otherwise would not have treatment or would have their surgery delayed.