Confidence of UK Ophthalmology Registrars in Managing Posterior Capsular Rupture: Results from a National Trainee Survey.

INTRODUCTION: To establish the level of confidence amongst UK ophthalmology specialist registrars (residents) in managing posterior capsule rupture (PCR) during cataract surgery. METHODS: An online nine-item questionnaire was distributed to all registrars, recruited nationwide via regional representatives. Data collected included stage of training, number of completed cataract operations, cumulative PCR rate, number of PCRs independently managed, understanding of vitrectomy settings and fluidic parameters and access to simulation. Respondents self-evaluated their confidence in managing PCR with vitreous loss. RESULTS: Complete responses were obtained from 248 registrars (35% response rate). Mean number of phacoemulsification procedures performed was 386. For senior registrars (OST 6-7), 35 out of 70 (50%) felt confident to manage PCR independently and 55 out of 70 (78.6%) were either quite confident or very confident at deciding when to implant an intraocular lens during PCR management. Lower confidence levels were noted for junior trainees (OST 1-2). Over 65% of survey respondents had access to relevant simulation. CONCLUSIONS: Our results represent the largest UK survey analysing the confidence of PCR management amongst registrars. Confidence improves with duration of training and increased exposure to management of PCR. However, 50% of senior registrars still lacked confidence to independently manage PCR and vitreous loss. A specific competency-based framework, potentially using a simulator or simulating a PCR event, incorporated into the curriculum may be desirable.

PIMASERTIB AND SEROUS RETINAL DETACHMENTS.

PURPOSE: To report a case of multifocal serous retinal detachments associated with pimasertib. METHODS: The authors report a 26-year-old patient who developed bilateral multifocal serous retinal detachments appearing 2 days after starting pimasertib (as part of a clinical trial investigating its use in low-grade metastatic ovarian cancer) and rapidly resolving 3 days after stopping it. CONCLUSION: The mechanism of MEK inhibitor induced visual toxicity remains unclear. The pathophysiology of multifocal serous retinal detachments as a complication of pimasertib is still poorly understood.

Tectonic lamellar keratoplasty: simplified management of corneal perforations with an automated microkeratome.

OBJECTIVE: To describe a simplified tectonic lamellar keratoplasty (LK) technique, which can be used to manage full-thickness corneal perforations. DESIGN: Case series demonstrating a new surgical technique. PARTICIPANTS: A 69-year-old female with rosacea keratitis and peripheral corneal perforation; a 49-year-old male with keratoconus, ipsilateral herpes simplex keratitis and an inferonasal corneal perforation; and a 12-year-old female with an apparently spontaneous central corneal perforation. RESULTS: These 3 patients with full-thickness corneal perforations were successfully managed with this automated tectonic LK technique. CONCLUSIONS: Tectonic LK has benefits relative to tectonic penetrating keratoplasty but remains unpopular because it is technically difficult to prepare the host and donor corneas. This tectonic LK technique negates the need for challenging free-hand dissection and gives an excellent donor fit to the host bed. This provides an easier and more effective way to manage corneal perforations.

Intraocular lens opacification after corneal endothelial keratoplasty: electron microscopy and x-ray element spectroscopy analysis.

PURPOSE: To assess a newly recognized long-term complication of Descemet-stripping automated endothelial keratoplasty (DSAEK). SETTING: Plymouth Royal Eye Infirmary and Plymouth Electron Microscope Centre, Plymouth, United Kingdom. DESIGN: Retrospective case series. METHODS: This study evaluated cases of intraocular lens (IOL) opacification that developed after uneventful DSAEK. None of the IOLs was previously known to opacify. In 1 case, the opacified IOL was explanted and analyzed using detailed light microscopy, scanning electron microscopic (SEM) analysis, and element x-ray spectroscopy. RESULTS: In all 5 cases, the IOL was hydrophilic acrylic and the eye developed IOL anterior surface opacification 4 to 12 months after DSAEK. In 1 eye, the opacification was symptomatic; thus, an IOL exchange was performed. Light microscopy and SEM analysis of the explanted IOL confirmed opacification on the anterior surface and subsurface areas. X-ray element spectroscopy showed the granules were composed of calcium and phosphorous. CONCLUSIONS: These cases indicate that IOL opacification after DSAEK is a late, although newly recognized, complication of endothelial keratoplasty. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

A prospective and nationwide study investigating endophthalmitis following pars plana vitrectomy: incidence and risk factors.

BACKGROUND/AIMS: This is the first nationwide prospective study to investigate the incidence and risk factors of endophthalmitis following pars plana vitrectomy (PPV). METHODS: This was a prospective, nationwide case-control study. Cases of presumed infectious endophthalmitis within 6 weeks of PPV were reported via the established British Ophthalmological Surveillance Unit. The surveillance period was 2 years. Controls (patients who had PPV but no endophthalmitis) were recruited from nine randomly selected UK centres. RESULTS: 37 reports were received and 28 cases met the diagnostic criteria for presumed infectious endophthalmitis following PPV. The incidence of endophthalmitis following PPV was 28 cases per 48 433 PPVs (1 in 1730 with a 95% CI of 1 in 1263 to 1 in 2747). 272 controls were randomly recruited from nine UK centres. Smaller gauge port sizes were not found to be a risk. Immunosuppression (OR 19.0, p=0.001) and preoperative topical steroids (OR 131.4, p<0.001) increased the endophthalmitis risk. Operating for retinal detachment was associated with a reduced risk of endophthalmitis (OR 0.10, p=0.005). CONCLUSIONS: Endophthalmitis following PPV is rare. Operating with smaller gauge port sizes does not increase the risk of endophthalmitis.

A prospective and nationwide study investigating endophthalmitis following pars plana vitrectomy: clinical presentation, microbiology, management and outcome.

BACKGROUND/AIMS: This is the first prospective and nationwide study aiming to provide epidemiological data relating to presentation, microbiology, management and outcome of endophthalmitis following vitrectomy. METHODS: Two years of prospective and nationwide surveillance for cases of presumed infectious endophthalmitis within 6 weeks of pars plana vitrectomy was completed. The study obtained case reports via the established British Ophthalmological Surveillance Unit (BOSU) system. RESULTS: Thirty-seven cases were reported and 28 met the diagnostic criteria for presumed infectious endophthalmitis following vitrectomy. Mean age was 61 years and 67% were male. Nineteen cases were 23/25 gauge and 9 cases were 20 gauge. Mean time from surgery to endophthalmitis was 5 days. Blurred vision (85.2%), pain (77.8%) and a hypopyon (77.8%) were the commonest presenting symptoms and signs. Seventeen cases (60.7%) had a positive culture. Culture-positive endophthalmitis, relative to culture-negative endophthalmitis, was no different with respect to time to presentation, symptoms, signs or outcome. Outcome was poor, with 29.6% of eyes being eviscerated or having no perception of light or perception of light. CONCLUSIONS: This study helps surgeons promptly identify cases of endophthalmitis following vitrectomy and informs them about the various management options currently used and the likely outcome of this devastating complication.

Early spontaneous closure after reopening of a previously repaired macular hole.

PURPOSE: To describe a case of early spontaneous closure of macular hole after reopening after previous successful surgical repair. METHODS: A 72-year-old female patient was treated for stage 2 idiopathic macular hole in the right eye. The hole remained anatomically closed for 2 months postoperatively, before reopening 1 month later. RESULTS: The patient was listed for revision surgery; however, on the day of the operation, which was 2 months after the reopening, the hole seemed to have closed spontaneously. Two years later, the macular hole remains closed with best-corrected visual acuity of 6/9. CONCLUSION: Spontaneous closure of macular holes after reopening is a rare phenomenon. The case presented here demonstrates that for early reopening of macular holes, a period of observation with serial optical coherence tomography may allow the hole to close spontaneously before proceeding with further surgical intervention.

Can vertebroplasty restore normal load-bearing to fractured vertebrae?

STUDY DESIGN: Cadaver motion segments were used to evaluate the effects of vertebroplasty on spinal loading following vertebral fracture. OBJECTIVES: To determine if vertebroplasty reverses fracture-induced changes in the distribution of compressive stress in cadaver motion segments. SUMMARY OF BACKGROUND DATA: Vertebroplasty involves reinforcement of vertebrae by injection of cement and is now being used increasingly to treat osteoporotic vertebral fractures. However, its effects on spinal load-bearing are largely unknown. We hypothesize that vertebroplasty, following vertebral fracture, helps to equalize stress acting on the intervertebral disc and adjacent vertebral bodies. METHODS: Nineteen cadaver thoracolumbar motion segments (age 64-90 years) were induced to fracture by compressive overload. Specimens were then subjected to vertebroplasty, and subsequently creep loaded for 1 hour at 1.5 kN. The compressive stress acting on the intervertebral disc was measured before and after fracture, after vertebroplasty, and after creep, by pulling a pressure transducer mounted in a 1.3-mm needle across the disc's midsagittal diameter. This information was then used to calculate neural arch load-bearing. At each time point, measurements were also made of compressive stiffness. RESULTS: Vertebral fracture reduced motion segment compressive stiffness, decompressed the adjacent nucleus, increased stress concentrations in the posterior anulus, and increased neural arch load-bearing, all by a significant amount. Vertebroplasty partially, but significantly, reversed all of these fracture-induced changes. CONCLUSIONS: Vertebroplasty reduces stress concentrations in the anulus and neural arch resulting in a more even distribution of compressive stress on the intervertebral disc and adjacent vertebral bodies.