Perioperative glycaemic control in diabetic patients undergoing cataract surgery under local anaesthesia: a survey of practices of Singapore ophthalmologists and anaesthesiologists

<p><b>INTRODUCTION</b>Perioperative glycaemic control is an important aspect of clinical management in diabetic patients undergoing cataract surgery under local anaesthesia. While poor long-term glycaemic control has significant implications for surgery, perioperative hypoglycaemia or hyperglycaemia may also compromise patient safety and surgical outcomes. We aimed to survey ophthalmologists and anaesthesiologists on their approach and to identify the prevalent practice patterns in Singapore.</p><p><b>METHODS</b>This was a cross-sectional questionnaire-based survey conducted in four public hospitals in Singapore with established ophthalmology and anaesthesia units. Respondents were approached individually, and the self-administered questionnaires comprised questions related to practice patterns, clinical scenarios and awareness of pre-existing guidelines.</p><p><b>RESULTS</b>A total of 129 doctors responded to the questionnaire survey. 76 (58.9%) were from ophthalmology departments and 53 (41.1%) were from anaesthesia departments. The majority chose to withhold oral hypoglycaemic agents (82.9%) and/or insulin (69.8%), and keep the patient fasted preoperatively. A blood glucose level ≥ 17 mmol/L prompted 86.0%-93.8% of respondents to adopt a treat-and-defer strategy, while a level ≥ 23 mmol/L prompted 86.0%-96.9% of respondents to cancel the cataract surgery. The respondents were consistently more concerned about perioperative hyperglycaemia (n = 99, 76.7%) than intraoperative hypoglycaemia (n = 83, 64.3%).</p><p><b>CONCLUSION</b>The current study presented the prevalent practice patterns of ophthalmologists and anaesthesiologists in the perioperative management of diabetic patients undergoing cataract surgery in four public hospitals in Singapore. Further research in this field is required, and may be useful for the future formulation of formal guidelines and protocols.</p>

Health Promotion Board-Ministry of Health Clinical Practice Guidelines: Falls Prevention among Older Adults Living in the Community

The Health Promotion Board (HPB) has developed the Clinical Practice Guidelines (CPG) on Falls Prevention among Older Adults Living in the Community to provide health professionals in Singapore with recommendations for evidence-based assessments and interventions for falls prevention. This article reproduces the introduction and executive summary of the key recommendations from the HPB-MOH CPG on Falls Prevention among Older Adults Living in the Community for the information of SMJ readers. The chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Health Promotion Board website: http://www.hpb.gov. sg/cpg-falls-prevention. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Spontaneous closure of traumatic macular hole

Macular hole formation is a well-known complication following ocular trauma. Less commonly recognised is the spontaneous closure of such holes. A 27-year-old man presented with a history of blunt trauma to his left eye. Eye evaluation showed conjunctiva! laceration, diffuse retinal oedema and multiple retinal haemorrhages in that eye. A month later, he developed a full thickness macular hole. Two months later, there was spontaneous complete closure of the full-thickness macular hole in the left eye as confirmed on optical coherence tomography. Spontaneous closure of hole is not uncommon. Observation for a period of up to 12 months is a reasonable management option. Macular hole surgery for traumatic macular holes may be delayed in such cases

Pars plana vitrectomy and internal limiting membrane peeling for macular oedema secondary to retinal vein occlusion: a pilot study

<p><b>INTRODUCTION</b>Macular oedema is the main cause of visual impairment following retinal vein occlusion. The purpose of this study was to evaluate the anatomical and functional outcome of pars plana vitrectomy and internal limited membrane (ILM) peeling for macular oedema secondary to retinal vein occlusion.</p><p><b>CLINICAL PICTURE</b>This pilot study is a prospective nonrandomised series of 11 eyes of 11 patients with macular oedema secondary to retinal vein occlusion. The best-corrected visual acuity (BCVA), foveal thickness on optical coherence tomography, fundus fluorescein angiography (FFA) and multifocal electroretinography were evaluated.</p><p><b>TREATMENT AND OUTCOME</b>All 11 patients underwent pars plana vitrectomy with ILM peeling. The mean postoperative follow-up was 13.5 months (range, 1.5 to 24). The mean thickness at the foveal centre decreased from 794 +/- 276 microm preoperatively to 373 +/- 150 microm, 302 +/- 119 microm, 249 +/- 203 microm and 185 +/- 66 microm at 1 week, 1 month, 3 months and the final visit postoperatively, respectively (all P <0.001, paired t- test, compared to preoperative thickness). Postoperative FFA demonstrated markedly reduced leakage in the macular region. At the final visit, BCVA improved 2 lines or more in 72.7% (8/11) of patients and was unchanged in 27.3% (3/11) patients. Complications included cataract in 7 patients and vitreous haemorrhage, recurrence of macular oedema and visual field defect in 1 case each.</p><p><b>CONCLUSION</b>Pars plana vitrectomy and ILM peeling rapidly reduced the macular oedema caused by retinal vein occlusion, with improvement in BCVA.</p>

A nationwide survey on the knowledge and attitudes of Malaysian optometry students on patients' visual experiences during cataract surgery

<p><b>INTRODUCTION</b>During cataract surgery under regional (retrobulbar, peribulbar or sub- Tenon's) or topical anaesthesia, many patients experience a variety of visual sensations in their operated eye intraoperatively. Between 3% and 16.2% of patients are frightened by their intraoperative visual experiences, which may increase the risk of intraoperative complications and affect patients' satisfaction with the surgery. This study aims to determine optometry students' beliefs and knowledge of visual sensations experienced by patients during cataract surgery under regional and topical anaesthesia.</p><p><b>MATERIALS AND METHODS</b>A nationwide survey of all Malaysian optometry students using a standardised, self-administered questionnaire.</p><p><b>RESULTS</b>All 129 optometry students participated in the survey, giving a 100% response rate. Overall, 26.4% and 29.5% of the students believed that patients undergoing cataract surgery under regional and topical anaesthesia, respectively, may experience no light perception, while 78.3% and 72.9%, respectively, thought that patients would experience light perception. Many respondents also believed that patients might experience a variety of other visual sensations. Of all respondents, 70.5% and 74.4% of students believed that patients undergoing cataract surgery under regional and topical anaesthesia, respectively, may be frightened by their visual experience and 93.0% and 85.3%, respectively, felt that preoperative counselling might help to alleviate this fear.</p><p><b>CONCLUSION</b>Many optometry students are aware that patients might encounter a variety of visual sensations during cataract surgery under local anaesthesia. A high proportion of students believe that patients may experience fear as a result of the intraoperative visual sensations and felt that preoperative counselling would be helpful.</p>

Surgically-induced corneal changes following macular translocation with punctate retinotomies and chorioscleral infolding (limited macular translocation)

<p><b>INTRODUCTION</b>To report the sequential changes in corneal topography and astigmatism following limited macular translocation. CLINICAL PICTURE AND TREATMENT: A 45-year-old-man who underwent limited macular translocation for idiopathic subfoveal choroidal neovascularisation in the right eye was evaluated by corneal topography and manifest refraction preoperatively and serially for 1 year postoperatively.</p><p><b>OUTCOME</b>An increase in astigmatism with corneal steepening along meridians corresponding to the area of chorioscleral infolding was observed and this persisted for 1 year after surgery. Vector-analysed astigmatic change showed significant surgically induced astigmatism of 2.18 dioptres (D) X 52.9 degrees, 2.17 D X 57.8 degrees and 2.56 D X 59.1 degrees at 2, 5 and 12 months after surgery respectively.</p><p><b>CONCLUSION</b>Surgically induced corneal changes are evident after limited macular translocation and may remain up to 1 year after surgery.</p>

Rates of posterior capsule rupture during cataract surgery among different races in Singapore

<p><b>INTRODUCTION</b>The aim of this study was to determine if racial differences exist in the rate of posterior capsule rupture (PCR) during cataract surgery in Singapore.</p><p><b>MATERIALS AND METHODS</b>All intraoperative complications during cataract surgery were prospectively reported as part of a clinical audit programme. A retrospective review of all patients who sustained a PCR during cataract surgery between July 1995 and December 1998 was performed.</p><p><b>RESULTS</b>Of 8230 consecutive eyes which underwent cataract surgery, 6951 (84.5%) were Chinese, 597 (7.3%) were Malay, 524 (6.4%) were Indian, and 158 (1.9%) were of other races. The overall incidence of PCR was 1.9%. The PCR rates were 1.8% [125 of 6951; 95% confidence interval (CI), 1.49 to 2.11] in Chinese, 2.0% (12 of 597; 95% CI, 1.01 to 3.57) in Malay, 2.7% (14 of 524; 95% CI, 1.13 to 3.56) in Indian, and 2.5% (4 of 158; 95% CI, 0.00 to 4.98) in other races. There was no statistical difference between the PCR rates (P = 0.62, chi-square test).</p><p><b>CONCLUSION</b>Racial differences in Singapore do not have an effect on the rates of PCR during cataract surgery.</p>

Macular carotenoids and age-related maculopathy

Lutein (L) and zeaxanthin (Z) are concentrated at the macula, where they are collectively known as macular pigment (MP), and where they are believed to play a major role in protecting retinal tissues against oxidative stress. Whilst the exact pathogenesis of age-related maculopathy (ARM) remains unknown, the disruption of cellular processes by oxidative stress may play an important role. Manipulation of dietary intake of L and Z has been shown to augment MP, thereby raising hopes that dietary supplementation with these carotenoids might prevent, delay, or modify the course of ARM. This article discusses the scientific rationale supporting the hypothesis that L and Z are protective against ARM, and presents the recent evidence germane to this theory.