Comparison of results and risk factors of cardiac surgery in two 3-year time periods in the 1990s.

With the increasing number of treatment options for heart disease, decision-making requires profiles of risk for conventional cardiac surgery. Refinements in techniques and clinical practices seem to have reduced surgical risk. This study was performed to determine current risk factors. From July 1, 1990, to June 30, 1996, 1,036 consecutive patients underwent 1,042 heart operations using standard incisions and cardiopulmonary bypass with cardioplegia. Univariate and multivariate analyses using a logistic regression model were performed to determine factors significant for combined 30-day and hospital mortality. To determine if there were trends in the results and the risk factors, the last 500 consecutive cases in the series were analyzed separately. Overall, 30-day mortality was 17 of 1,042 (1.6%) and combined 30-day and hospital mortality was 27 of 1,042 (2.6%). Significant risk factors for combined 30-day and hospital mortality by multivariate analyses were: emergent/resuscitative status, preoperative dialysis, left ventricular ejection fraction < or = 30%, valve operation, and creatinine > or = 1.5 mg/dl. Comparison with baseline characteristics of the patients undergoing the last 500 consecutive operations to the earlier 542 operations in the study group showed that risk factors had a very similar profile for the 2 groups. The overall 30-day mortality for the last 500 consecutive operations was 5 of 500 (1.0%) and combined 30-day and hospital mortality was 8 of 500 (1.6%). The significant risk factors by multivariate analyses were reduced to left ventricular ejection fraction < or = 30% and creatinine > or = 1.5 mg/dl. These results indicate that modern techniques and clinical practices have mitigated well-recognized risk factors in conventional cardiac surgery and this trend is ongoing.

Multifocal intraocular lenses.

It has been 10 years since I implanted the first multifocal intraocular lens (IOL). Unfortunately, there has been a gradual lessening of commitment to this modality by the ophthalmic community. The most important single factor for this lack of interest despite the more than adequate available clinical data is the repeated moving of "goal posts" by the American FDA when a multifocal lens style nears premarket approval. The refractive multifocal lens styles of iolab (Claremont, CA), Stortz Ophthalmics (St. Louis, MO), Domilens (Lyon, France), and Amo with the diffractive multifocals of 3M (St. Louis, MO), and Pharmacia (Kalamazoo, MI) and their recent modifications are reviewed. Reports show that they generally give excellent visual results depending on whether a near or distance dominant lens is indicated. The foldable Amo Array SA40N provides a good distance dominant foldable lens for the surgeon performing small incisions and has a small but dedicated surgical following. Loss of contrast sensitivity at low-light levels remains a source of concern in certain professions and with certain lifestyles, and a report suggesting that many monofocal and multifocal patients do not achieve the standards set for night driving by the German Ophthalmic Society warrants further consideration. Development of a new accommodative IOL for small incision surgery is the only really new concept, and it will be interesting to see the results of independent reports. Spectacle dependence is considerably reduced with all the current multifocals when compared to monofocals, and for patients there are ample multifocal lens styles from which to choose. It is the author's opinion that more than 60% of the cataract population is currently suitable for multifocals if small incision surgery is performed. More multifocals would be used if price disparity with monofocals was reduced.

Multifocal intraocular lenses.

Since the publication of my last article in Current Opinion in Ophthalmology in 1991 (2:33-34), the use of multifocal intraocular lenses (IOLs) has not gained general acceptance among ophthalmologists. Despite this situation, major IOL companies have continued to invest in clinical trials of new designs. Recently, large optic multifocal lenses used mainly with extracapsular extraction provided good results, with 94% to 100% of best-corrected cases having distance correction of 20/40 vision or better; 77% to 100% similarly had J3 near vision or better, and approximately 52% to 63% of patients became eyeglass independent. Between 50% to 80% of eyes in which 20/40 vision or better was obtained and in which J2 or better resulted were unaided. However, all multifocal lens designs showed some reduction in contrast sensitivity compared with monofocal designs using Regan charts and Vistech 6500 tests. Contrast sensitivity loss was probably only significant when reading very small print or in low-contrast light. Small-incision surgery with phacoemulsification and more accurate IOL power calculations have made the goal of emmetropia more possible. Also, less eyeglass dependence with the use of multifocal IOLs is a more realistic expectation.

Simultaneous bilateral cataract extraction in the UK.

AIMS/BACKGROUND: Simultaneous bilateral extracapsular cataract extraction (SBCE) is not routinely performed in the developed world. This study investigated the safety and efficacy of this procedure as performed in the UK. METHODS: A review of 319 consecutive patients (638 eyes) who underwent SBCE with posterior chamber intraocular lens implantation is presented. RESULTS: The incidence of intraoperative complications was 7.7%. These included posterior capsule rupture (0.8%) and vitreous loss (0.3%). Postoperative complications were seen in 8.7% of operated eyes and included iris prolapse (0.3%) and raised intraocular pressure (3.0%). Endophthalmitis occurred in one eye (0.15%). There were no major bilateral complications, and, in particular, no cases of bilateral endophthalmitis. Final visual acuities compared favourably with reports for unilateral surgery. Eighty two per cent achieved a final visual acuity of 6/12 or better, and 41% tested 6/6 or better. CONCLUSION: This study illustrates that SBCE is not associated with an increased incidence of complications and that the visual results are good. Where indicated, and under strict surgical protocol, this procedure is safe.

Intraocular lenses.

In reviewing the 1990 literature on intraocular lenses, it is evident that the increased popularity of phacoemulsification in North America has stimulated interest in lens designs that can be inserted through small incisions, and various methods for folding soft lenses. Critical evaluation of various multifocal lenses has now resulted in greater understanding of their advantages and drawbacks, and it is becoming apparent that there are guidelines of suitable candidates for such lenses. Use of multifocals has stimulated interest in contrast sensitivity testing, and new more accurate lens power formulas. Heparin surface modification of polymethylmethacrylate lenses now seems to be accepted as having value in reducing pigment deposits after surgery. Clinical trials of lenses for patients suffering from age-related macular degeneration hold some promise for this large group of unhappy patients. However, the use of anterior chamber lenses to correct high myopia in phakic eyes is now on hold because of reports of progressive endothelial cell loss in some eyes. More reports are available on the technique and results of suturing posterior chamber lenses to the sclera where there is absent or insufficient capsule to support a conventional sulcus fixated posterior chamber lens. Intraocular lenses remain alive and well in 1990 with increased usage worldwide.

Topical use of indomethacin on the day of cataract surgery.

The use of topical indomethacin in the prevention of surgically induced miosis has been documented. However, in these previous prospective trials this prostaglandin synthetase inhibitor was administered the day before surgery. With the frequency of 'day case' cataract surgery increasing, an efficient preoperative mydriatic regimen is important. In this study we considered the use of topical indomethacin as an addition to a regimen already implemented. One hundred and fourteen eyes underwent intercapsular cataract surgery, of which 64 were randomised to receive topical aqueous indomethacin one hour beforehand, and 50 eyes, which did not receive indomethacin formed the comparison group. Topical indomethacin reduced the miosis which occurs during cataract surgery whether performed under local or general anaesthesia. The operating time was shorter for eyes with less surgically induced miosis.

Intercapsular versus extracapsular cataract extraction.

Forty-five eyes that have undergone routine extracapsular cataract extraction with insertion of a posterior chamber intraocular lens were compared with a similar group of eyes that had undergone intercapsular extraction. Capsular fixation was more predictable following intercapsular (78%) than it was following extracapsular extraction (22%). Gonioscopy revealed prominence of the lens haptic in 22% of the intercapsular group, with peripheral anterior synechiae (PAS) in 18%; haptics were prominent in 78% of the extracapsular group, with synechiae in 55%. Lens eccentricity of 2 mm or more was seen in 2 patients (4%) following intercapsular and in 10 (22%) following extracapsular extraction. Pupil irregularities were noted in three of the intercapsular group (7%) and in eight of the extracapsular group, (13%) with peripheral iris tucking alone in three. These data strongly support the view that intercapsular is superior to extracapsular cataract surgery in terms of facilitating capsular fixation of posterior chamber intraocular lenses.

A new cannula for nucleus hydrodissection.

This disposable 25-gauge cannula has a specially designed distal segment which facilitates crystalline lens nucleus hydrodissection or viscodissection. The injection of a fluid or viscous material creates a cleavage plane between the nucleus and cortex or capsule, thus facilitating extraction of the nucleus. The flattened, smooth, cannulated tip allows easier insertion and manipulation under the capsule.

Day-case cataract surgery.

The results of a series of 40 cataract extractions with lens implantation performed on day-case patients under local anaesthesia are reported. The ways in which modern surgical techniques have rendered this a safe procedure are described, and the potential benefits of day-case intraocular surgery are discussed.

Implantation of a disc lens in the capsular bag.

We report a series of 65 cataract extractions with implantation of a rigid, posteriorly vaulted, disc-shaped lens in the capsular bag. Eight-nine percent achieved 20/40 vision or better, and 54% achieved 20/20 vision or better. The lens remained well centered in all cases. The method is described, and the practical and theoretical advantages of implantation of a lens approaching a natural shape are discussed.

Clinical results of the multifocal lens.

The multifocal posterior chamber intraocular lens was implanted in 46 eyes of 38 patients as part of the first clinical trial of this target-type implant. No major complications were reported. Visual acuity results for distance and near vision were excellent, with best case visual acuities better than 20/40 in over 95% of eyes in the first three months.

Modern cataract surgery in a highly myopic population.

A retrospective series of 117 highly myopic eyes with extracapsular cataract extractions and posterior chamber lens implants is presented. The results are analysed with reference to the current understanding of the complications anticipated. Of particular note is the use of low-powered posteriorly vaulted posterior chamber implants, with and without primary posterior capsulotomy. The results show a low retinal detachment rate (one eye, mean follow-up 12 months); low induced astigmatism (average 0.86 D); low myopic postoperative refraction (median -1.0 D); and high patient satisfaction.

Retrospective study of 67 cases of secondary pars plana posterior capsulotomy.

A technique of late pars plana posterior capsulotomy following extracapsular cataract extraction and posterior chamber lens implantation is described. The results and complications of 67 cases with an average follow-up period of approximately 14 months are reported. The incidence of cystoid macular oedema following this procedure was 2.9%, with no incidence of retinal detachment. The procedure appears to be an acceptable method of treating a thickened posterior capsule, and in the absence of a neodymium YAG laser and in a small unit it could prove to be a reasonable substitute.

Current state of posterior chamber intraocular lenses after intracapsular and extracapsular cataract surgery.

The current posterior chamber lenses available for use after intracapsular and extracapsular cataract extraction, including the iris-centred and supported lenses, are reviewed. The relative advantages of rigid and flexible loop posterior chamber lenses used after extracapsular extraction are compared and it is concluded that there is little difference in the immediate visual results. The flexible posterior chamber lens is more difficult to insert in a collapsed anterior chamber and small pupil; conversely, capsular-fixed posterior chamber lenses face the problem of anterior capsular fibrosis and optic decentration if inaccurately placed.

Pearce-style posterior chamber lenses.

The Pearce-style iris suture and sutureless lenses are described. Insertion of these lenses in 439 eyes yielded good visual results with a high degree of patient satisfaction. With the exception of forty (9.1%) eyes which required discissions, the complication rate was low. The absence of pupillary block glaucoma indicates that peripheral iridectomies are not necessary with Pearce lens styles. Use of the sutureless lens simplifies implant surgery, however, only time will show if it also reduces the complication rate.

Modern simple extracapsular surgery.

A series of 444 aphakic eyes is reviewed in which extracapsular extraction was performed by modern simple instrumentation followed by the insertion of a posterior chamber lens. The visual results of 93.5 per cent seeing 6/12 (20/40) or better in an age group of 70 years plus is satisfactory. The hospitalization is short and visual recovery rapid. Complications have been few and it has been shown that peripheral iridectomy is not required in most cases as they are not subject to pupil-block glaucoma. The main problem with extracapsular extraction is the incidence of needlings of 9 per cent rising to 16 per cent with longer follow-up. Despite this it is felt that the advantages of extracapsular extraction, with rapid visual rehabilitation and a lower incidence of cystoid macular oedema and retinal detachment, outweigh the disadvantages.

Long-term results of the Choyce anterior chamber lens implants Marks V, VII, and VIII.

68 eyes in which Choyce Mark VIII anterior chamber lenses had been implanted were examined, all surgery having been performed by Mr. Choyce. The average time since implantation was 5-5 years aand in 85 per cent. of eyes the corrected visual acuity was 6/12 or better. Bullous keratopathy, corneal epithelial oedema, and peripheral anterior synechiae giving rise to glaucoma were the most serious complications. Visual result, binocular function, and patient satisfaction were generally very good.