Vitreo-retinal surgery in sickle cell disease [abstract]

Sickle cell disease is the commonest haemo-globinopathy. The gene is present in about 8 percent of Afro-American and 10 percent of Afro-Jamaican. Severe ocular complications of this condition include proliferative retinopathy, vitreous haemorrhages, and retinal detachment ultimately leading to blindness in a number of cases. There are not many reports of vitreo-retinal surgery in the literature dealing with cases. This is a report of 28 vitero-retinal surgeries in 20 eyes of 19 patients with sickle cell eye disease. Four eyes had surgery for viterous haemorrage, 16 for retinal detachment. All four eyes with vitreous haemorrage had successful pars plana vitrectomy (PPV) with full restoration of full potential vision. Eight of 16 eyes had successful retinal detachment surgery. Four eyes had pneumatic retinopexy with one unsuccessful result. Five eyes had scleral buckles with four having successful results, and six had bad results and one was unchanged. Six of ten eyes that had pars plana virectomy for retinal detachment had bad results. The unsuccessful cases were difficult ones with extensive proliferative vitero-retinopathy and long-standing retinal detachment. (AU)

Avoiding burn out [abstract]

Burn-out is a term applied to the boredom with day-to-day practice and a desire to do something else. These symptoms are fairly common and are experienced after a number of years in practice doing tasks that have lost their challenge. It is more common in industry but less so in highly skilled workers. I have avoided these more by fortuitousness than design and the strategies I am outlining are what I believe happened in my case rather than a result of scientific study. These strategies therefore are subjective rather than objective, speculative rather than definitive and possibly may be of anecdotal value only. The strategies are as follows: -Keep current with new treatment modalities; -Constantly think of new methods of improving your current techniques; -Argue with yourself the pros and the cons of your methodology; -Take on new problems as soon as you have established reliable competence in your regular fields eg refractive surgery is a new area and prime one for this sort of exploration; -Participate in CME activities as a presenter regularly. (AU)

Understanding your account [abstract]

Accounting is a specific discipline with its own technical definitions and terminology. Terms used in common parlance have very different and specific meanings when used in a accounting context. This presentation explains the business cycle and its terms, and explains and emphasizes the differences in meanings of terms used in the accounting contest from their use in the non-accounting context. Accounting is a system of keeping tract of who owns what in a business, and of the transactions of the business. An account is a structured list in a table form with a right hand side called credit and a left hand side called debit. A debit is not a reduction in the amount in an account and a credit is not an increase in the amount in an account. Both terms can be addition or reduction in the amount in an account depending on the type of account. Assets are properties of a business. The rights to these assets are caled Equities. If these rights belong to the owners of the business they are called Owner's Equity, if these belong to non-owners of the business they are called Liabilities. Owner's equity is often simply referred to as equity. The accounting equation is: Assets = Liabilities + Assets + (Revenue - Expenses). The terms trial balance, income statement of cash flows, the difference between a cash based accounting system and an accrual based accounting system, and the double entry system are explained. (AU)

The black eye

PURPOSE: The paper highlights the differences in appearance of the normal and diseased states and frequency and nature of disease processes as they occur in the eye of persons of African descent compared with the Caucasian. METHODS: The observations of an opthalmologist who has practised in a racially mixed population, but predominantly among individuals of African descent for over 20 years, have been catalogued and compared with his experience in a predominantly Cacucasian community. Photographic images of these differences are presented. RESULTS AND CONCLUSIONS: Significant differences in both the normal apperance and clinical features of important ocular diseases occur between patients of predominantly African origin and Caucasians. It is important that ophthalmologists practicising among these racial groups be aware of the differences.(AU)

Phaco-emulsification vs extracapsular cataract extraction: a cost analysis

Phaco-emulsification is a technically sophisticated method of cataract extraction. It is the "state of the art" method of cataract extraction that is in routine use for uncomplicated cataracts. Its advantages include: a) early restoration of vision; b) minimal surgically induced astigmatism; and c) the public relations value of using a modern state of the art technique. High cost is usually listed among its disadvantages, but the essential question to be addressed is whether the benefits of phaco-emulisification justify its cost. This is an analysis of the costs of phaco-emulsification (PHACO), small incision extracapsular cataract extraction and extracapsular cataract extraction (ECCE). In this analysis activity based costing is used: a portion of the purchase price of the PHACO machine may be charged to each patient who has phaco-surgery. Alternatively, a levy may be placed on each patient in the practice to cover the cost of the machine, ie, treating the PHACO machine as an overhead cost. However, activity base costing is more accurate than overhead based costing. It is also more desirable because if the fixed cost of the PHACO machine is treated as an overhead, the cost of patients who have PHACO will be subsided by those who do not. Patient who have PHACO will be charged less than their real cost, and non-PHACO patients will be charged more than the cost they actually incur. If the surgical fee is the same for cataract surgey regardless of the method of cataract extraction, the surgeon who does ECCE will realise the largest profits. The decision as to whether the advantages of PHACO are worth the extra cost is a judgement to be made by the surgeon and an informed patient. My own position since doing this analysis is to do a mixture of PHACO without flexible IOL, and ECCE. The choice of technique is determined by the estimate of the toughness of the lens. If I estimate the lens to be very tough I will do a small incision ECCE, and if the cataract appears to be suitable then I will do PHACO. I err on the side of ECCE. I hope that flexible IOL prices will decreases to more acceptable levels in the near future.(AU)

Itinerant Surgery: its effect on local development

The cost of any goods or service is the amount of resources given up in order to obtain it. A service is considered free when the recipient does not give up any resource in exchange for obtaining it, but is free only to the recipient, because someone else pays for it. Itinerant surgery is often justified on the grounds that it is free to the recipient, and this is considered good. But compromises in standards often appear acceptable because the service is free and, after all. "beggars can't be choosers". A discussion of monetary matters borders on the unethical and is traditionally avoided when medical issues are considered, but cost is probably the most limiting factor in the provision of health care in the West Indies. If the itinerant surgeons provides the cost of the surgery it aids the community economically in the short run. In the long run the community will be better able to support its need for surgery and will be more developed if it has its own surgeon. "Give a man fish and he'll eat for a day; teach a man to fish and he'll eat for longtime."(AU) [truncated]

Trabeculectomy - the Watson Cairns operation

Trabeclectomy was invented by John Cairns in 1968. Its success and reliability made it the operation of choice in glaucoma surgery until today. Modification of any surgical procedure is inevitable, and has led to many completely different surgical procedures being called trabeculectomy. In many of these failure led to the use of cytotoxic agents, eg 5 fluouracil and mitomycin C. This presentation shows Peter Watson's modification of the Cairns operation, which I find makes the use of anti-metabolites unnecessary. A conjunctival flap is fashioned. This may be fornix or limbal based. A superficial scleral flap about 4.5 to 5 mm square hinged on the cornea is dissected. A deep scleral flap is excised about a millimeter inside the edge of the superficial flap, extending into clear cornea beyond Schwalbe's line. The adhesions between the trabecular meshwork to the iris and ciliary body are severed by blunt dissection or by cutting through taut fibres held on the stretch. The excised block of tissue contains cornea, Schwalbe's line, trabecular meshwork, scleral spur and a large piece of sclera. Its dimensions are about 3 mm wide by 4 mm antero-posteriorly. A peripheral iridectomy is done with deWecker's scissors. The superficial scleral flap is sutured with two interrupted nylon sutures to the apices. Often the conjunctiva is not sutured. Sometimes it is closed with two interrupted sutures in a hood flap. I often find it unnecessary to reform the anterior chamber but, if it seems a little shallow at the end of the procedure, I may reform it by introducing a small air bubble under the scleral flap and gently stroking it into the anterior chamber. The most frequent undesirable finding is a small hyphaema post operatively, which clears without treatment in a day or two. In combined cataract extraction and trabeculectomy, I do a fornix based conjunctival flap, make the scleral flap a little smaller and extend the lateral sides of the incision at the limbus to make it wide enough for a removal of the nucleus and insertion of an intraocular lens. I have found these procedures relatively complication free, but have experienced one case of ciliary block glaucoma, and two of persistent flat chambers (AU)

Blindness in sickle cell retinopathy: a clinician's perspective

Sickle cell retinopathy is a well recognized cause of blindness. However, in Jamaica it is not a very common cause of blindness, and the incidence of blindness in sickle cell disease is not accurately known. Most of the published work on sickle cell disease comes out of special research units which differ from the experience of clinicians in general ophthalmic practice. The study was undertaken to determine the causes and prevalence of blindness among sickle cell patients attending a general ophthalmology practice. Patients with sickle cell disease who attend with ocular complaints are listed, and a record of their complaints and examination findings are recorded. These records were pulled and examined for visual acuity, presence and type of sickle cell retinopathy. 74 patients presenting with ocular complaints attributable to sickle cell disease were found. One patient with homozygous sickle cell (SS) disease was blind in one eye. 3 patients with sickle cell trait were blind in one eye from sickle cell retinopathy. 27 (81 percent) of 33 patients with sickle cell-HbC (SC) disease had proliferative retinopathy, including 21 (63.6 percent) who were blind in at least one eye at the time of presentation. Of patients with SC who had proliferative retinopathy 77.7 percent were blind at the time of initial presentation. Only 8 (24 percent) patients with SC had 20/20 vision in both eyes. The age range was 5 to 55 years at the time of presentation. Of the blind eyes, one spontaneously regained sight, and four had sight restored surgically. Two patients who were blind in one eye at the time of presentation went on to become blind in the other eye despite surgical intervention and became permanently and bilaterally blind. Sickle cell disease is a significant cause of blindness. Sickle cell patients, particularly those with SC disease, need careful monitoring for the early detection and treatment of eye disease. More public education is needed on this matter.(AU)

Central retinal vein occlusion: an important cause of blindness in glaucoma in the Negro

This study was designed to determine the frequency of central retinal vein occlusion as a cause of blindness in glaucoma. Glaucoma patients attending the author's practice over a four month period were examined specifically for evidence of central retinal vein occlusion (CRVO) and their visual acuity recorded. Evidence of CRVO was taken as the following: tortuous anastamotic vessels on the disc; scattered retinal haemorrhages; and telangiectatic retinal vessels or scattered cotton wool spots in the retina in the absence of other retinal disease, eg. diabetic retinopathy. Blindness was accepted as a best corrected visual acuity of 20/200 or worse. The cause of blindness was recorded. 74 blind eyes were recorded, with 44 (60 percent) blind from glaucoma, 22 (30 percent) blind from CRVO. All patients were predominantly Negro. Central retinal vein occlusion is a common cause of blindness in glaucoma patients who are black. This is an important and previously unrecognized fact. In this study approximately one-third of glaucoma patients were blind from CRVO and not glaucoma itself. Essential hypertension and glaucoma are associated factors in CRVO, and each of them has a high incidence in Negroes, and they may be acting synergistically to produce the high incidence of blindness due to CRVO found in this study. This also explains the increase severity of glaucoma in the Negro. Tissue under-perfusion in both diseases may be the underlying explanation.(AU)

Eye complications of diabetic pregnancy

Pregnancies complicates the state of diabetic control. The presence of diabetes mellitus complicates pregnancy by increasing the risk of almost all the complications of pregnancy, including the risk of visual loss. The risk of vision is dependent on the presence and the extent of diabetic retinopathy. All diabetics contemplating pregnancy should have an ophthalmic evaluation; those who are already pregnant should have this evaluation done as soon as possible. As pregnancy progresses ophthalmic re-evaluation should be done with a minimum of at least one visit per trimester. Their management depends on the findings of these evaluations. Background diabetic retinopathy is not a threat neither to mother nor foetus, unless there is macular involvement; it is present in about 10 percent of diabetic pregnancies. If clinically significant macula oedema is present then this represents a risk to maternal vision and photocoagulation is indicated to reduce this risk. In the presence of pre-porliferative retinopathy, consideration should be given to photocoagulation of the retina. Proliferation retinopathy will develop in about 4 percent of diabetics with background diabetic retinopathy at the onset of pregnancy. If proliferative retinopathy is present, then pan-retinal photocoagulation is indicated and re-evaluation after 4-6 weeks. Failure of proliferative retinopathy to respond to laser pan-retinal photocoagulation may be considered as an indication for termination of the pregnancy. In the non-pregnant state, if proliferative retinopathy fails to respond favourably to pan-retinal photocoagulation then pregnancy is contraindicated (AU)

Xenon photocoagulation - an alternative to laser therapy in diabetic retinopathy

Diabetic retinopathy is a frequent cause of blindness. The treatment of choice is photo-coagulation for both diabetic maculopathy and proliferative retinopathy. Effective photo-coagulation can be with the Xenon Arc photo-coagulator. this is much cheaper than an Argon laser. It requires no maintenance. In areas in which laser s unavailable the Xenon Arc photo-coagulator is a safe and practical form of treatment. (Summary)

Cupping of the optic disc in the Jamaican population

The cup/disc of the optic nerves of 289 normal eyes of 145 persons were studied. The frequency of wide physiological cups in a Jamaican group was compared with eight other groups. The Jamaican group had an incidence of wide physiological cups that exceeded that of the others by two or three times. This high incidence of wide cups in the normal Jamaican population has profound implications for the management of glaucoma in Jamaica. The high incidence of wide, non-glaucomatous, cupping can be explained on the basis of racial factors (AU)