Training in cataract surgery in Spain: analysis of the results of a survey of the European Board of Ophthalmology in a Spanish cohort.

INTRODUCTION: A survey conducted by the European Board of Ophthalmology (EBO) revealed significant differences in the surgical training of the ophthalmology residents in Europe, including a disparity between the sexes and a variation in the experience on cataract surgery (CC) between them. This study is about the Spanish sub-cohort of the survey, and its objective is to present and analyse the peculiarities of ophthalmology training in Spain within the European context, as well as discussing ways to harmonise and improve that training throughout the EU. METHODS: We analyse data of the Spanish participants in the EBO exams, defining subgroups by the Autonomous Communities existing in Spain. RESULTS: 93 of 135 requested participants (68.9%) responded. A 60.2% passed the EBO exam between 2021 and 2022, being mostly women (65.59%) aged 31 years old on average. The 91.4% were right-handed, coming from 13 of the 17 Spanish autonomous communities, although mostly from the Community of Valencia, Madrid and Catalonia. Respectively, 16.1%, 3.2% and 8.7% of the respondents said they have completed 10 or more training sessions on animal eyes, synthetic eyes and through the virtual reality simulator. This training was correlated with greater self-confidence in the management of a posterior capsular tear during surgery (p .025). All respondents manifested to have already performed stages of the CC. The average number of operations reported was 181.6 with regional disparities. A significant difference is observed between the sexes against women (-28.3%, p 0.03). DISCUSSION: Ophthalmologists in Spain, much more than other European countries, have greater opportunities for surgical training, with surgical procedures during the residency, that nearly triples those made by the others. Spanish women refer, like their European colleagues, to be in disadvantage in learning opportunities about cataract surgery. The Simulation Based Medical Education (SBME) allows to respond to the training deficit and complements the training on the patient. Although we demonstrate a significant correlation between the number of procedures carried out and self-confidence to operate simple cases, the SBME would be a complementary tool in self-confidence in front of a complication like capsular rupture. CONCLUSION: Spain massively adopts the model named by us "surgery for all", despite the underrepresentation of women in this area, emphasising a need for cultural change that the SBME could facilitate.

Biocompatibility of a fish scale-derived artificial cornea: Cytotoxicity, cellular adhesion and phenotype, and in vivo immunogenicity.

PURPOSE: To determine whether a fish scale-derived collagen matrix (FSCM) meets the basic criteria to serve as an artificial cornea, as determined with in vitro and in vivo tests. METHODS: Primary corneal epithelial and stromal cells were obtained from human donor corneas and used to examine the (in)direct cytotoxicity effects of the scaffold. Cytotoxicity was assessed by an MTT assay, while cellular proliferation, corneal cell phenotype and adhesion markers were assessed using an EdU-assay and immunofluorescence. For in vivo-testing, FSCMs were implanted subcutaneously in rats. Ologen(®) Collagen Matrices were used as controls. A second implant was implanted as an immunological challenge. The FSCM was implanted in a corneal pocket of seven New Zealand White rabbits, and compared to sham surgery. RESULTS: The FSCM was used as a scaffold to grow corneal epithelial and stromal cells, and displayed no cytotoxicity to these cells. Corneal epithelial cells displayed their normal phenotypical markers (CK3/12 and E-cadherin), as well as cell-matrix adhesion molecules: integrin-α6 and ß4, laminin 332, and hemi-desmosomes. Corneal stromal cells similarly expressed adhesion molecules (integrin-α6 and ß1). A subcutaneous implant of the FSCM in rats did not induce inflammation or sensitization; the response was comparable to the response against the Ologen(®) Collagen Matrix. Implantation of the FSCM in a corneal stromal pocket in rabbits led to a transparent cornea, healthy epithelium, and, on histology, hardly any infiltrating immune cells. CONCLUSION: The FSCM allows excellent cell growth, is not immunogenic and is well-tolerated in the cornea, and thus meets the basic criteria to serve as a scaffold to reconstitute the cornea.

Outcome after multifocal intraocular lens exchange because of severely impaired quality of vision.

PURPOSE: To evaluate the surgical outcome after intraocular lens exchange in patients implanted with a multifocal intraocular lens (MIOL) who presented impairing visual complaints SETTING: Department of Ophthalmology, Antwerp University Hospital, Belgium. METHODS: 25 eyes of 17 consecutive patients underwent IOL exchange. Pre- and postoperative evaluation consisted of: determining patient's complaints, type of IOL before and after IOL exchange, degree of glare and aberrometry (mainly preoperative data), pre and postoperative DCVA and NCVA. RESULTS: Diffractive MIOL were more frequently exchanged than refractive MIOLs and were exchanged when possible by a bag-in-lens IOL. DCVA, NCVA and postoperative subjective complaints improved significantly postoperatively. Eyes with prior Nd:YAG laser capsulotomy needed anterior vitrectomy during MIOL exchange procedure due to the presence of a ruptured anterior vitreous face by the laser treatment. CONCLUSION: MIOL exchange can be performed safely and with very good visual outcome in patients with severe postoperative visual complaints related to decentered MIOL. Although, patient's postoperative quality of vision remained poor in 7 eyes out of the 25 in this series.

UVA/riboflavin crosslinking as treatment for corneal melting.

PURPOSE: To demonstrate that UVA/riboflavin crosslinking (CXL) can stop corneal melting in therapy resistant infectious corneal ulceration. METHODS: We will present a case report on a 70-year-old female patient referred for severe infectious ulcerative keratitis caused by Pseudomonas aeruginosa. After intensive treatment with fortified antibiotics, corneal melting developed. CXL was performed to avoid imminent corneal perforation. RESULTS: The CXL treatment was successful: the corneal melting was stopped and the lesion cicatrized, thereby avoiding emergency keratoplasty. CONCLUSION: This case report highlights that CXL may be a valuable addition to our therapeutic armamentarium in the treatment of corneal melts.

Comparison of various spherical aberration compensation methods in pseudophakic eyes.

PURPOSE: To provide a numerical comparison of the efficiency of spherical aberration (SA) compensation methods commonly used in commercial aspheric intraocular lenses (IOLs). METHODS: Numerical simulations were performed using the wavefront data of 139 right eyes implanted with a spherical Morcher 89A ("Bag-in-the-Lens") IOL. Simulations were done for spherical, constant aspherical and SA-free IOLs, as well as for the customized selection method. RESULTS: Constant aspherical IOLs bought 49.6% of the eyes to a targeted postoperative SA value +/- 0.05 microm, while zero-SA IOLs brought 61.2% of the eyes to this range. However with customized selection 95% of the eyes could be brought to this target, resulting in more control over the postoperative spherical aberration. If no aspherical correction was used, only 8.6% of the eyes could reach the set target. CONCLUSION: These numerical results suggest that IOLs with an asphericity as a function of IOL power, supplemented by a customized selection from a number of fixed SA values according to preoperative corneal SA, may provide sufficient control over the postoperative SA. Given the surgeon centration possibility of the Bag-in-the-Lens IOL used in this study, as well as its centration stability, this is an ideal lens to implement the customized selection method.

[Advantages of the bag-in-the-lens intraocular lens in pediatric cataract surgery]. / Intérêt de l'implant "bag-in-the-lens" dans la chirurgie de la cataracte de l'enfant.

OBJECTIVE: Evaluate the advantages of the bag-in-the-lens intraocular lens in children undergoing cataract surgery. PATIENTS AND METHODS: This prospective study included 54 eyes of 37 children and babies (age, 2 months to 14 years), consecutively operated on between December 1999 and January 2008 for unilateral or bilateral cataract using the "bag-in-the-lens" intraocular lens. Slit-lamp examination, intraocular pressure, visual acuity, and refraction were followed to the best possible degree over time. RESULTS: The mean age of the 37 children at the last consultation visit was 8.3+/-4.9 years. The mean visual acuity improved from 0.2+/-0.1 to 0.8+/-0.3. On the other hand, visual acuity improvement in children presenting hyperplastic persistence of the vitreous was less favorable with a postoperative average visual acuity of 0.14+/-0.18. The mean postoperative refraction in 13 children (26 eyes) operated on for bilateral cataract was 0.5+/-1.5 D for eyes showing axial lengths with substantial variation. The refraction was stable over time in children over 2 years of age. Once the implant was positioned correctly, the remaining epithelial cells of the lens did not migrate toward the visual axis, which was the case in 93.8% of all eyes and in 100% of children over 1 year of age. CONCLUSIONS: The "bag-in-the-lens" implant is particularly indicated in children in whom posterior rhexis and optic capture have been recommended since 1994. The implantation minimizes the use of anterior vitrectomy in pediatric cataract surgery, limiting it to those eyes presenting a proliferative hyperplastic vitreous.

Ophthalmic complications after functional endoscopic sinus surgery (FESS).

The purpose of this paper is to inform the ophthalmologist about the occurrence of ophthalmological complications after functional endoscopic sinus surgery (FESS). Due to the close anatomical relationship between the paranasal sinuses and the orbit, involvement and/or injury of the orbit from processes primarily located in the paranasal sinuses, may occur. The orbit, the extra-ocular muscles, the optic nerve and the lacrimal drainage system can be damaged during FESS. The risk of injury is correlated to the anatomical variations, the history of previous surgery, the extent and the gravity of the disease and the skill of the surgeon. We hereby present three cases, each showing a different ophthalmologic complication after FESS.

[Treatment for combined hypermetropia and presbyopia with a gaussian broad beam Excimer Laser]. / Traitement combiné de l'hypermétropie et de la presbytie par un Laser Excimer à faisceau large gaussien.

AIM: To analyze the performances of the Inpro-Gauss Excimer laser in the treatment of hyperopia and combined hypermetropia-presbyopia. METHODS: The hypermetropic treatment consisted in making 12 confluent ablation spots of 3.3+/-0.1 mm at 4.5 mm from the corneal apex. The surgical parameters were simulated by a computer model of the corneal profile. The combined hypermetropic-presbyopic treatment was achieved by adding 4 spots of +2 D in the infero-nasal quadrant. Our series included forty eyes of which eleven were treated for hyperopia only and twenty nine were treated both for hyperopia and presbyopia. RESULTS: The uncorrected postoperative visual acuity was equivalent or better than the preoperative corrected visual acuity in 82% of cases. The averaged postoperative spherical equivalent was -0.2+/-0.5 D. Near uncorrected visual acuity was one line better (in decimal notation) for the group treated for both hyperopia and presbyopia than in the single hyperopia group. CONCLUSION: Surface laser treatment of hyperopia and presbyopia with a gaussian broad beam laser is safe, accurate and reproducible.

Effect of refractive surgery on binocular vision and ocular alignment in patients with manifest or intermittent strabismus.

OBJECTIVE: To evaluate the effect of refractive surgery on binocular vision and ocular alignment in patients with manifest or intermittent strabismus, with or without vertical component. SETTING: University Hospital Antwerp, Edegem, Belgium. PATIENTS AND METHODS: 13 patients (22 eyes) with strabismus underwent refractive surgery. Five of these patients presented with an esotropia and four of them with a small vertical deviation. Five patients had a manifest exotropia, of whom two presented with a small vertical deviation. Two patients had an intermittent exotropia with binocular vision, of whom one patient had a vertical deviation. One patient had a hypertropia with a dissociated vertical deviation. RESULTS: Ocular alignment and binocular function remained unchanged postoperatively in all except two patients with high anisometropia who experienced an improvement in binocular function. In these patients, the preoperative manifest deviation became intermittent or latent after surgery, allowing fusion and stereopsis. Vertical deviation was found preoperatively in 8 of the 13 patients. This vertical deviation remained unchanged postoperatively, but improved in one patient with anisometropia. CONCLUSION: Preoperative intermittent or manifest strabismus is not a contraindication for refractive surgery provided some specific recommendations are taken into account, such as an adequate preoperative orthoptic examination and aiming at emmetropia for both eyes.

Searching the way out for posterior capsule opacification.

Searching the way out for posterior capsule opacification was one of our goals in improving current cataract surgery techniques. The second goals was restoring accommodation but this goal prooved to remain unsolved. The bag-in-the-lens concept of IOL and implantation technique has been used in 271 patients of which 15 children. These patients have a follow-up of one month to 5 years. The optical axis of all these patients remained crystal clear, which allows us to conclude that the problem of PCO is solved by the bag-in-the-lens implantation concept. These very encouraging results inspired us to new ideas, which will receive priority in our research: accommodation and optimising the quality of vision by compensating for the ocular aberrations.

Clinical, epidemiological and cost aspects of contact lens related infectious keratitis in Belgium: results of a seven-year retrospective study.

AIM: Evaluation of the clinical, epidemiological and cost aspects of contact lens related infectious corneal ulcers requiring hospitalisation. METHODS: A retrospective analysis was performed on the files of patients hospitalised for contact lens induced corneal ulcer in the eight Belgian University Hospitals over a seven-year period (January 1997 until December 2003). For all hospitalised patients registration of the diagnosis is compulsory using the International Code of Diagnostics (ICD-9). RESULTS: 107 patients with contact lens related corneal ulcer were included. The great majority, 99 subjects, used soft contact lenses, of which 9 were disposables, 73 planned replacement and 17 conventional lenses. Only 6 patients were night and day wearers. Three patients used daily disposable lenses. The most frequently cultured organisms were Pseudomonas and other Gram-negative germs (70%) and Acanthamoeba (16%). The majority (77%) of the corneal ulcerations were localised centrally which resulted in an average visual loss of 4 lines. In 16 patients a corneal graft was performed and one eye had to be eviscerated. CONCLUSION: Despite important technological improvements in contact lens materials and care systems, the problem of infectious ulceration has all but disappeared. On the contrary, during the study period, the number of patients hospitalised increased from 5 in 1997 to 22 in 2003, which is only partially explained by the increasing prevalence of lens wearers: 3,5% of the Belgian population in 1995 and 6,5% in 2003.

Gaussian broad-beam excimer laser: clinical and experimental results.

PURPOSE: To evaluate the mid-term (1-3 years) results of the Gaussian broad-beam excimer laser Delivery System (DS) after single treatment for the correction of myopia. To study the corneal surface with scanning electron microscopy (SEM) after excimer laser ablation using a flying spot delivery system (Bausch & Lomb) and a Gaussian Delivery System (GDS) (InPro). METHODS: The 1035 consecutive eyes studied were split in four groups with respect to the treated myopia, expressed in spherical equivalent: low myopia up to -3.00 D (183 eyes), moderate myopia from -3.25 D to -6.00 D (540 eyes), high myopia from -6.25 D to -10.00 D (210 eyes) and very high myopia from -10.25 D to -20.00 D (102 eyes). Four post-mortem eyes of two donors were treated using the flying spot DS on one eye and the GDS on the other eye. RESULTS: We achieved postoperative spheriqual equivalent within +/- 1 D of emmetropia in respectively 99.1%, 98.9%, 83% and 21% of the eyes of group 1, 2, 3 and 4. UCVA was 10/10 or better in respectively 65%, 51% and 19% of group 1, 2 and 3. UCVA was 5/10 or better in respectively 86% and 75% of group 3 and 4. The defocus equivalent refraction was 1.0 or less in respectively 98%, 93%, 62%, and 7% of the four groups. On SEM, the corneal surface presented a smooth and polished profile for the GDS. CONCLUSIONS: The Gaussian Delivery System gives comparable results to the flying spot laser system for surface laser ablation in myopic eyes up to -10 D. Advantages of this system are: smooth ablation surface, short treatment time, low haze rate, high reliability and easy maintenance of the device due to the optical DS. It is an interesting alternative for the more complex mechanical DS.

Intraocular lens exchange for late-onset opacification.

PURPOSE: To report on the clinical, light microscopic and spectroscopic analyses of Hydroview intraocular lenses (IOLs) explanted for late postoperative IOL opacification. MATERIAL AND METHODS: Retrospective study of all cases with secondary lens implantation performed at the University Hospital of Antwerp during a period of one year (2002-2003) for postoperative opacification of Hydroview IOLs. Further analyses on some of the explanted IOLs included gross and light microscopic evaluation and RAMAN spectroscopy. RESULTS: Lens exchange for late-onset IOL opacification was needed in seven eyes of six patients. IOL opacification became apparent between 15 and 25 months after uneventful phacoemulsification and lens implantation. Visual acuity varied from < 0.05 to 0.6 before explantation. In almost all cases postoperative visual acuity improved to the pre-opacification level. Light microscopic and spectroscopic analyses showed that the opacification was mainly located in the anterior portion of the IOL optic as a layer of irregular granular deposits composed of calcium phosphate. CONCLUSION: Late postoperative opacification of Hydroview IOLs may cause severe visual impairment, requiring explantation. Calcium phosphate is involved in the formation of these opacifications. Reporting on this type of complications is mandatory according to the Belgian and European directives for medical devices.

LASIK and arcuate incisions for the treatment of post-penetrating keratoplasty anisometropia and/or astigmatism.

PURPOSE: To study the efficacy of Laser In Situ Keratomileusis (LASIK) and Arcuate Keratotomy (AK) for the treatment of anisometropia and/or astigmatism after Penetrating Keratoplasty (PKP) in an attempt to optimize binocular vision. MATERIAL AND METHODS: Correction of post-PKP anisometropia and/or astigmatism was considered only when stable refraction was achieved for at least 6 months. Four eyes were treated for anisometropia and astigmatism using the LASIK technique (IN-PRO Gauss Excimer Laser and SKBM Microkeratome). Five eyes were treated with AK to correct post-PKP astigmatism only. The results were evaluated using the following parameters: uncorrected visual acuity (UCVA), best subjective spectacle correction (BSC-VA), corneal uniformity (CU) index and predictive corneal (PC) acuity from the Holladay Diagnostic Summary (HDS) analysis. RESULTS: Post-PKP anisometropia and astigmatism were treated successfully after primary LASIK in three out of the four cases. One eye needed an additional diode thermal keratoplasty (DTK). Astigmatism post-PKP was treated successfully after primary AK in four of the five cases. One eye needed an additional LASIK. CONCLUSION: AK can be used successfully in cases of low-grade post-PKP astigmatism. LASIK gives better results in cases of post-PKP anisometropia and astigmatism. In order to affine the final results a combination with other refractive techniques such as DTK can be proposed. CU index and PC acuity (EyeSys-HDS analysis) are poor predictive parameters for visual outcome in cases of irregular corneal surfaces as it is often the case after PKP.

Lasek for myopia: first results.

PURPOSE: To evaluate the efficacy and safety of laser-assisted subepithelial keratectomy (LASEK) for the treatment of myopia and astigmatism (low, moderate and high). MATERIAL AND METHODS: Laser-assisted subepithelial keratectomy was performed by 3 surgeons in 45 eyes using an INPRO Gauss Excimer laser (31 eyes) or a NIDEK EC-5000 Excimer Laser (14 eyes). The mean follow-up is 9 months (3-15 months). Preoperative best-corrected visual acuity (BCVA) and corneal topography were measured. The postoperative parameters were: uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), spherical equivalent refraction (SER), defocus equivalent refraction (DER), and corneal topography. RESULTS: The mean preoperative sphere and cylinder were -4.09 diopters (D) +/- 1.94 D (range -1.25 D to -9.75 D) and -0.67 D +/- 0.55 D (range 0 D to -2.50 D) respectively. No eye lost 2 or more lines of BCVA. The UCVA was > or = to 20/20 in 56% of the cases and 20/40 or better in 100% of the cases. No eye developed corneal haze that affected visual acuity. No major complications were recorded. CONCLUSIONS: LASEK treatment is a safe and effective technique for treatment of low to high myopia. This surgical technique is less invasive and more effective than LASIK because of the lack of flap- and microkeratome-related complications.

[PRK with InPro-Gauss excimer laser: statistical analysis of results]. / PRK avec le laser excimer InPro-Gauss: analyse statistique des rèsultats.

PURPOSE: To analyse retrospectively the pre- and postoperative refraction and visual acuity according to Standard Graphs proposed by Waring for refractive surgery. METHODS: Ninety-three eyes with myopia ranging from -1.50 to -8 diopters (D) and/or with astigmatism ranging from 0.75 to 3 D were treated between July 1998 and June 2001. The laser delivers a broad beam with a regular gaussian energy repartition obtained by means of a plate containing an array of diffractive micro-lenses. RESULTS: The coefficient of linear correlation between the attempted and achieved spherical equivalent refraction was 0.97. A postoperative spherical equivalent refraction between -0.50 and +0.50 D was found in 92.3% of eyes. The defocus equivalent refraction (spherical refraction added to one-half of the cylindrical component, ignoring the sign) represents more accurately the reality of the refractive state, and in our study was within +/- 0.50 D for 86.4% of the eyes. A preoperative best corrected visual acuity of 10/10 was found in 78% of eyes and 64% achieved postoperatively an uncorrected visual acuity of 10/10. CONCLUSION: The InPro-Gauss excimer laser gives good refractive results. The Gauss profile delivery system provides reliability and quality of the ablated surface of cornea.

Combined fourth and sixth cranial nerve palsy after lumbar puncture: a rare complication. A case report.

Palsies of cranial nerves are well-known complications after lumbar puncture. Sixth nerve palsies are the most common. They normally occur 4 to 14 days after the lumbar puncture and spontaneously recover in a few weeks or months. The occurrence of a fourth nerve palsy following lumbar puncture however is extremely rare. We report on a patient who developed a combined contralateral fourth and sixth nerve palsy after lumbar puncture (Syndrome of Intracranial Hypotension), requiring surgical correction for secondary diplopia.