RESUMEN
BACKGROUND: Older age is commonly associated with an increased risk of surgical complications and comparatively poor outcomes. PURPOSE: To report cataract surgery outcomes and risk indicators for patients aged 90 years and older. METHODS: Data collected as part of routine cataract care in 34 centres contributing to the United Kingdom Royal College of Ophthalmologists' National Ophthalmology Database (NOD) were analysed. Very elderly people undergoing cataract surgery were profiled in terms of demographics, pre- and postoperative best-measured visual acuity (VA), ocular co-morbidities, intraoperative posterior capsule rupture (PCR) or vitreous loss or both, and risk indicators for operative PCR and adverse VA outcome. RESULTS: 25,856 cataract operations in 19,166 people of 90 years or older between 2000 and 2014 are reported. Preoperative VA was available for 82.4% eyes, being 0.30 LogMAR or better in 21.5%. Postoperative VA was available for 61.8% eyes, being 0.30 LogMAR or better in 74.4%. For those without ocular co-morbidity, postoperative VA was 0.30 LogMAR or better in 84.7%. Various co-morbidities were present in 49% and contributed to an adverse VA outcome. PCR data were available for all operations and occurred in 2.7%. Significant risk indicators for PCR included pseudoexfoliation/phakodonesis, mature cataract, smaller pupil and worse preoperative VA. CONCLUSIONS: Slightly poorer cataract surgery outcome results were noted in patients of 90 years or older, more so in patients with ocular co-morbidity which was highly prevalent. However, surgeons should not be deterred from offering cataract surgery to the very elderly as successful visual rehabilitation remains achievable.
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Extracción de Catarata/efectos adversos , Complicaciones Intraoperatorias , Oftalmología/estadística & datos numéricos , Ruptura de la Cápsula Posterior del Ojo/epidemiología , Medición de Riesgo/métodos , Sociedades Médicas/estadística & datos numéricos , Agudeza Visual , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Ruptura de la Cápsula Posterior del Ojo/etiología , Pronóstico , Factores de Riesgo , Reino Unido/epidemiologíaRESUMEN
PURPOSE: To determine if donor age and preoperative endothelial cell density (ECD) affect corneal endothelial failure following penetrating keratoplasty (PK). METHODS: Preoperative and postoperative data for PKs performed in the UK between April 1999 and March 2012 were analysed. Donor age was split into three groups (0-60, 61-75 and >75â years) and donor ECD was split into three groups (≤2400, 2401-2600 and >2600 cells/mm2). Cox proportional hazards regression was used to determine whether the selected subgroups of donor age and donor ECD have an impact on endothelial failure and a systematic analysis of the interaction between donor ECD and donor age was conducted. The analysis was stratified for primary corneal diagnosis (Fuchs endothelial dystrophy (FED), pseudophakic bullous keratopathy (PBK) and other) and corrected for potentially confounding factors (human leukocyte antigen matching, donor trephine diameter, deep vascularisation, the occurrence of reversible rejection episodes and receipt of systemic antiviral medication, long-term steroids or other immunosuppressive agents). RESULTS: A total of 9415 patients, from the National Health Service Blood and Transplant UK Transplant Registry, who received their first PK for visual reasons were included in this study. The overall 5-year graft survival rate due to endothelial failure was 89%. Survival rates in recipients with FED, PBK and 'all other indications' were 95%, 83% and 89%, respectively. Our analysis shows that donor ECD did not affect outcome following corneal graft within the preselected categories, irrespective of diagnosis and after allowing for any potential confounding factors. Furthermore, HRs for each level of donor ECD, relative to >2600 cells/mm2, for each combination of age group and indication, were not statistically significant. CONCLUSIONS: We were unable to detect a significant effect of donor age, up to 90â years, and preoperative donor ECD, above the lower limit of 2200 cells/mm2, on endothelial failure at 5â years following PK.
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Pérdida de Celulas Endoteliales de la Córnea/diagnóstico , Endotelio Corneal/patología , Distrofia Endotelial de Fuchs/cirugía , Supervivencia de Injerto , Queratoplastia Penetrante/efectos adversos , Donantes de Tejidos , Adolescente , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Recuento de Células , Niño , Preescolar , Pérdida de Celulas Endoteliales de la Córnea/epidemiología , Pérdida de Celulas Endoteliales de la Córnea/etiología , Femenino , Distrofia Endotelial de Fuchs/diagnóstico , Humanos , Incidencia , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Pronóstico , Reino Unido/epidemiología , Adulto JovenRESUMEN
PURPOSE: To assess the effect of antiviral treatment on corneal graft survival following penetrating keratoplasty for herpetic keratitis. METHODS: Retrospective cohort study of 454 patients receiving primary penetrating keratoplasties (PKs) for viral infection reported to NHS Blood and Transplant (NHSBT) between April 1999 and June 2005. Follow-up data were available on 403 PKs. Kaplan-Meier survival estimates were used to determine graft survival for the three treatment groups: no medication, topical antiviral, and oral antiviral medication. A Cox regression model was used to investigate the combined effects of all additional factors on graft failure. The model was fitted using all pre-operative factors first and then post-operative factors including type of antiviral medication were included. RESULTS: Patients who received oral antiviral medication post-operatively had consistently better graft survival than those receiving no medication or only topical medication. Patients receiving oral antivirals were less than a third as likely to have a failed graft at 5 years compared with those on no antiviral medication (relative risk (RR) 0.3, CI: 0.2-0.7, P=0.002). Other factors that were found to influence the risk of graft failure were the presence of deep corneal vascularisation (P=0.009), PK performed for therapeutic reasons (P=0.03), large diameter grafts (P=0.04), and experiencing a rejection episode (P=0.003). CONCLUSION: Oral antiviral treatment reduces the risk of graft failure in patients undergoing primary PK for herpetic keratitis and should be routinely used in this group of patients post-operatively unless contra-indicated.
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Antivirales/uso terapéutico , Supervivencia de Injerto , Queratitis Herpética/tratamiento farmacológico , Queratoplastia Penetrante , Complicaciones Posoperatorias/prevención & control , Administración Oral , Administración Tópica , Anciano , Estudios de Cohortes , Femenino , Humanos , Estimación de Kaplan-Meier , Queratitis Herpética/cirugía , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
PURPOSE: Hydroview intraocular lenses (IOLs) have been associated with symptomatic opacification of the optic necessitating IOL exchange. Glare and misty vision have been noted as common presenting symptoms. This study's purpose was to investigate the impact of IOL opacification on objective measurements of visual function, including glare, and on vision-related quality of life. METHODS: All patients who underwent Hydroview IOL implantation at Bristol Eye Hospital between December 2000 and the end of February 2001 were invited for assessment along with patients found to have Hydroview IOL opacification in routine ophthalmic clinics. Glare, visual acuity, contrast sensitivity, visual field, and colour vision were assessed. Vision-related quality of life and subject's symptoms were determined by questionnaire. IOL opacification was assessed by slit lamp bio-microscopy and anterior segment photography. RESULTS: Data from 129 patients were analysed. Fifty subjects had opacified IOLs and 79 clear IOLs. Subjects with opacified IOLs showed dramatically higher levels of glare (adjusted mean difference of 0.63 log units 95% CI, 0.45-0.82; P<0.001) with only mildly reduced visual acuity (adjusted mean difference of 0.09 logMAR units 95% CI, 0.03-0.15; P=0.002). Opacification was associated with poorer contrast sensitivity (P<0.001), visual field (P<0.001), and with lower vision-related quality of life (P<0.001). CONCLUSIONS: This study highlights the significant impact IOL opacification has on visual performance and experience, in particular glare and consequent impact on quality of life. The study shows that to quantify accurately the effect of IOL opacification on vision glare must be assessed.
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Catarata/fisiopatología , Lentes Intraoculares/efectos adversos , Falla de Prótesis , Adulto , Anciano , Anciano de 80 o más Años , Sensibilidad de Contraste , Estudios Transversales , Femenino , Deslumbramiento , Humanos , Masculino , Persona de Mediana Edad , Calidad de Vida , Agudeza Visual/fisiología , Adulto JovenRESUMEN
PURPOSE: Calculation of intraocular lens (IOL) power for implantation during cataract surgery depends on ocular biometric measurements. The aim of this study was to characterise the normal range of intra- and interindividual variation in axial length (AL) and corneal power (K) when IOLMaster measurements were possible and to derive recommendations as to which outlying measurements merit verification before acceptance. METHODS: The Medisoft electronic patient database contains prospectively collected data conforming to the United Kingdom (UK) Cataract National Dataset on 55,567 cataract operations. From this AL and K information on the 32,556 eyes (14,016 paired) of patients older than 25 years, without corneal pathology, history of intraocular surgery and who had all biometric measurements taken with the Zeiss IOLMaster (Carl Zeiss Meditec) were extracted. R 2.8.1 (R Foundation for Statistical Computing) was used for statistical analysis. RESULTS: Mean age was 76.4 years and 62.0% were female. Mean (95% confidence interval) values for AL, mean K and corneal astigmatism were 23.40 (21.27-26.59) mm, 43.90 (40.94-47.01) D and 1.04 (<2.50) D. Nearly all astigmatism was either with or against the rule. Differences between paired eyes were not statistically significant. 95% individuals had asymmetry of AL and mean K<0.70 mm and 0.92 D, respectively. CONCLUSIONS: On the basis of approximation of the 95% CI above, it is suggested that AL, mean K and keratometric astigmatism measurements outside the ranges 21.30-26.60 mm, 41.00-47.00 D and >2.50 D, respectively, and intraindividual asymmetry of AL >0.70 mm or mean K>0.90 D should be verified before acceptance.
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Extracción de Catarata , Implantación de Lentes Intraoculares , Lentes Intraoculares , Refracción Ocular , Anciano , Anciano de 80 o más Años , Astigmatismo/etiología , Longitud Axial del Ojo , Biometría , Auditoría Clínica , Córnea/anatomía & histología , Femenino , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Reino UnidoAsunto(s)
Anticuerpos Monoclonales/uso terapéutico , Enfermedades Autoinmunes/tratamiento farmacológico , Conjuntivitis/tratamiento farmacológico , Inmunosupresores/uso terapéutico , Penfigoide Benigno de la Membrana Mucosa/tratamiento farmacológico , Adulto , Anticuerpos Monoclonales de Origen Murino , Enfermedades Autoinmunes/diagnóstico , Enfermedad Crónica , Conjuntivitis/diagnóstico , Humanos , Masculino , Penfigoide Benigno de la Membrana Mucosa/diagnóstico , RituximabRESUMEN
PURPOSE: The aim of this study was to investigate the visual and refractive outcome of combined penetrating keratoplasty, cataract extraction, and intraocular lens insertion (triple procedure) compared with cataract surgery following penetrating keratoplasty (sequential surgery). METHODS: Retrospective cohort study of 1256 first penetrating keratoplasty for Fuchs' dystrophy performed between April 1999 and December 2005. In all, 1202 triple and 54 sequential procedures were reviewed. At 1 year, refractive outcomes were available for 499 triple procedure and 26 sequential surgery eyes. At 2 years, data were available for 264 triple procedure and 10 sequential surgery eyes. At 1 and 2 years postoperatively, graft survival, best-corrected visual acuity (BCVA), spherical equivalent, and cylindrical error were recorded. chi(2)-Tests were used to compare visual outcomes between the two groups. RESULTS: At 1 year after triple procedure surgery, 61% of eyes attained BCVA of >or=6/12, with 47% of eyes within+/-2 D of emmetropia. After sequential surgery, 59% achieved BCVA of >or=6/12 with 67% of eyes within+/-2 D of emmetropia (=0.05). Mean spherical equivalent (MSE) at 1 and 2 years after triple procedure was +1.20 D (SD 5.45) and +0.15 D (SD 3.58), respectively. MSE following sequential surgery at 1 and 2 years was +0.08 D (SD 3.06) and -1.50 D (SD 3.14), respectively. Mean refractive cylinder after combined surgery was +4.16 D (SD 5.11) and +3.91 D (SD 2.79) at 1 and 2 years, respectively, compared with +3.65 D (SD 2.24) and +3.70 D (SD 2.06) after sequential surgery. In all, 29% of triple procedure and 27% sequential surgery eyes had an astigmatic error >or=5.0 D after 1 year (P=0.64), which increased to 34 and 30%, respectively, by the second year. The 5-year graft survival was 85% in both groups. There were no differences in graft survival, visual or refractive outcomes between triple procedure, and sequential surgery techniques. CONCLUSIONS: This analysis provided no evidence of improved visual or refractive outcome after sequential surgery compared with triple procedure.
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Extracción de Catarata/métodos , Queratoplastia Penetrante/métodos , Implantación de Lentes Intraoculares , Anciano , Estudios de Cohortes , Femenino , Supervivencia de Injerto , Humanos , Masculino , Refracción Ocular , Estudios Retrospectivos , Resultado del Tratamiento , Agudeza VisualRESUMEN
PURPOSE: The primary aim of this study was to detail anaesthetic techniques and complications for cataract surgery in the UK. METHODS: The Cataract National Dataset was extracted from 12 National Health Service Trusts that used the same electronic patient record system between November 2001 and July 2006 on a total of 55,567 cataract operations. RESULTS: Anaesthesia was administered by an ophthalmologist in 56.7% of the cases, a career anaesthetist in 42.1% of the cases, a clinical assistant anaesthetist in 0.3% of the cases, and staff were not recorded in 0.9% of the cases. Local anaesthesia (LA) was used in 95.5%, with topical anaesthesia alone in 22.3% (range by site, 0-99.8%), topical and intracameral in 4.7% (range, 0-24.1%), subtenons in 46.9% (range, 0-81.8%), peribulbar in 19.5% (range, 0-63.4%), and retrobulbar in 0.5% (range, 0-5.3%). One or more minor complications occurred in 4.3% of 38,058 local blocks administered by either sharp needle or subtenons (blunt) cannula. Minor complications were 2.3 times more common with subtenons blocks (P<0.001). Serious complications, defined as sight or life threatening occurred in 25 eyes, 0.066%, undergoing sharp needle or subtenons cannula blocks. Sharp needle techniques had a 2.5-fold increased risk of serious complications compared with subtenons cannula techniques (P=0.026). CONCLUSION: Subtenons anaesthesia was the most widely used anaesthetic technique for cataract surgery but wide variation existed by site. There was a low rate of reported LA complications. There was a statistically significant increased risk of serious complications with sharp needle anaesthesia compared with subtenons technique.
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Anestesia Local/métodos , Extracción de Catarata/métodos , Procedimientos Quirúrgicos Ambulatorios/normas , Anestesia Local/efectos adversos , Anestesia Local/estadística & datos numéricos , Anestesiología/normas , Anestesiología/estadística & datos numéricos , Extracción de Catarata/efectos adversos , Extracción de Catarata/estadística & datos numéricos , Humanos , Auditoría Médica , Oftalmología/normas , Oftalmología/estadística & datos numéricos , Estándares de Referencia , Reino UnidoRESUMEN
AIMS: To compare the quality of referrals and listing rates of direct optometric referrals vs traditional GP referrals for cataract surgery. METHODS: A retrospective cohort of 124 patients referred for cataract surgery was identified (62 via optometric pathway and 62 via GP pathway). The quality of the referral was assessed by establishing if it contained adequate information relating to the College of Optometrists' referral framework document. Age, sex, drug history, listing rate, operative rate, and visual acuity (best corrected) at referral and at the postoperative visit were recorded and compared between the two referral pathways using the Fisher's exact test. RESULTS: Optometric referrals, relative to GP referrals, were more likely to include information relating to objective visual loss (100 vs 87%, P=0.0061) and to counsel the patient (97 vs 18%, P=0.0001). GP referrals, relative to optometric referrals, were more likely to comment on personal circumstances (32 vs 3%, P=0.0001), past medical history (95 vs 68%, P=0.0001), and drug history (94 vs 69%, P=0.0009). Operative rates were higher for the optometric direct referrals relative to GP referrals (87 vs 69%, P=0.0284). There was no difference in the visual acuity before or after surgery between the pathways. CONCLUSIONS: Optometric direct cataract referrals provide better information on objectively measured vision and better delivery of preoperative counselling. Traditional GP referrals contain better medical history, drug information, and details of personal circumstances. Rates of surgery were slightly higher with optometric referrals.
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Extracción de Catarata , Medicina Familiar y Comunitaria/organización & administración , Optometría/organización & administración , Derivación y Consulta/organización & administración , Anciano , Anciano de 80 o más Años , Catarata/complicaciones , Catarata/fisiopatología , Extracción de Catarata/estadística & datos numéricos , Vías Clínicas/organización & administración , Femenino , Humanos , Masculino , Registros Médicos/normas , Persona de Mediana Edad , Estudios Retrospectivos , Trastornos de la Visión/diagnóstico , Trastornos de la Visión/etiología , Agudeza VisualRESUMEN
AIMS: To identify and quantify risk factors for posterior capsule rupture or vitreous loss or both (PCR or VL or both) during cataract surgery and provide a method of composite risk assessment for individual operations. METHODS: The Cataract National Dataset was extracted on 55,567 operations from 12 National Health Service (NHS) Trusts using an electronic patient record (EPR) system between November 2001 and July 2006. Risk indicators for variations in the rate of 'PCR or VL or both' were identified by univariate and multivariate analyses. Adjusted odds ratios (ORs) were used to formulate a composite 'bespoke' risk for individual cases. RESULTS: Overall 'PCR or VL or both' rate was 1.92% (95% CI=1.81-2.04%). Risk indicators for this complication were increasing age, male gender, presence of glaucoma, diabetic retinopathy, brunescent/white cataract, no fundal view/vitreous opacities, pseudo-exfoliation/phacodonesis, reducing pupil size, axial length > or = 26.0 mm, the use of the alpha-blocker doxazosin, inability to lie flat and trainee surgeons performing operations. Adjusted ORs for these variables are used to estimate overall composite risk across multiple risk indicators in the form of a predicted probability of PCR or VL or both. Predicted probability for this complication ranged from less than 0.75% to more than 75%, depending on risk profile of individual operations. CONCLUSIONS: Higher-risk cases can be predicted, thus better informing the consent process and allowing surgeons to take appropriate precautions. Case-mix is a major determinant of the probability of an intraoperative complication. A simple composite risk estimation system has been developed.
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Extracción de Catarata/efectos adversos , Cápsula del Cristalino/lesiones , Implantación de Lentes Intraoculares/efectos adversos , Cuerpo Vítreo/lesiones , Adulto , Anciano , Anciano de 80 o más Años , Extracción de Catarata/estadística & datos numéricos , Métodos Epidemiológicos , Femenino , Humanos , Masculino , Persona de Mediana Edad , RoturaRESUMEN
AIMS: To pilot the use of the Cataract National Dataset (CND) using multi-centre data from Electronic Patient Record (EPR) systems and to demonstrate the ability of the CND to deliver certain of its intended benefits, including detailed preoperative profiling of cataract surgery patients and updating of benchmark standards of care in the NHS and beyond. METHODS: NHS departments using EPR systems to collect a minimum preoperative, anaesthetic, operative and postoperative data set, the CND, were invited to submit data, which were remotely extracted, anonymised, assessed for conformity and completeness, and analysed. RESULTS: Four-hundred and six surgeons from 12 NHS Trusts submitted data on 55,567 cataract operations between November 2001 and July 2006 (86% from January 2004). Mean age (SD) was 75.4 (10.4) years, 62.0% female. Surgery was for first eyes in 58.5%, under local anaesthesia in 95.5% and by phacoemulsification in 99.7%. Trainees performed 33.9% of operations. Preoperative visual acuity (VA) was 6/12 or better in 42.9% eyes overall, in 35.3% first eyes and in 55.3% second eyes. Complication rates included the following: posterior capsule rupture and/or vitreous loss of 1.92%, simple zonule dialysis of 0.46% and retained lens fragments of 0.18%. Postoperative VA of 6/12 or better (and 6/6 or better) was achieved for 91.0% (45.9%) of all eyes, 94.7% (51.0%) of eyes with no co-pathologies and 79.9% (30.2%) of eyes with one or more co-pathologies respectively. CONCLUSIONS: The CND is fit for purpose, is able to deliver useful benefits and can be collected as part of routine clinical care via EPR systems. This survey confirms shifts in practice since the 1997-1998 UK National Survey with full conversion to phacoemulsification, better preoperative acuity, a halving of the surgical 'index' benchmark complication of posterior capsule rupture and/or vitreous loss, and improved VA outcomes.
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Extracción de Catarata/normas , Catarata/fisiopatología , Anciano , Anestesia/estadística & datos numéricos , Extracción de Catarata/estadística & datos numéricos , Bases de Datos Factuales/estadística & datos numéricos , Femenino , Humanos , Masculino , Auditoría Médica , Oftalmología/estadística & datos numéricos , Cuidados Preoperatorios , Estándares de Referencia , Reino Unido , Trastornos de la Visión/fisiopatología , Agudeza Visual/fisiologíaRESUMEN
A case of branch retinal vein occlusion associated with fluoxetine-induced secondary hypertension is described. Although an infrequent complication of selective serotonin reuptake inhibitor therapy, it is important that ophthalmologists are aware that these agents can cause hypertension because this class of drugs is widely prescribed.
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Fluoxetina/efectos adversos , Hipertensión/inducido químicamente , Hipertensión/complicaciones , Oclusión de la Vena Retiniana/etiología , Inhibidores Selectivos de la Recaptación de Serotonina/efectos adversos , Adulto , Femenino , Fondo de Ojo , Humanos , Oclusión de la Vena Retiniana/complicaciones , Oclusión de la Vena Retiniana/diagnóstico , Trastornos de la Visión/etiología , Trastornos de la Visión/fisiopatología , Agudeza VisualRESUMEN
PURPOSE: Rheumatoid keratolysis (RK) is a rare but a serious cause of ocular morbidity in rheumatoid patients. The aim of this study was to analyze the presenting features, the subsequent treatment, and the outcome of patients with RK in the authors' department. METHODS: A retrospective study was undertaken of all patients with a diagnosis of RK at Bristol Eye Hospital between January 1987 and June 2002. RESULTS: Forty eyes of 38 patients were identified in total. The mean age at presentation was 70 years. The mean duration of rheumatoid arthritis at presentation was 15 years. Most (22, 55%) ulcers were peripheral. Three patients (8%) developed RK within a month of cataract surgery. Out of the 19 patients who did not have a further RK, 11 were immunosuppressed. A total of 37 grafts were performed on 26 eyes. Twenty-two grafts (59%) failed. Immunosuppression increased the chance of anatomical success following penetrating keratoplasty. Infection was identified as a cause of graft failure for immunosuppressed patients in the postoperative period. Nine patients had reversible side effects from immunosuppressant treatment. Four eyes (10%) had to be surgically removed and a further 10 (25%) had severe visual loss (visual acuity less than 6/60). Eleven of the 38 patients subsequently died (29% mortality). CONCLUSIONS: Although the visual prognosis is often poor, surgical preservation of the eye can be achieved by penetrating keratoplasty and systemic immunosuppression. With careful observation and regular monitoring, immunosuppressive medication appears to be safely tolerated in this group of patients.