Prevention, diagnosis, and management of acute postoperative bacterial endophthalmitis.

This distillation of the peer-reviewed scientific literature on infection after cataract surgery summarizes background material on epidemiology, etiology, and pathogenesis, describes the roles of surgical technique and antibiotic prophylaxis in prevention, and discusses diagnostic and therapeutic interventions in cases of suspected endophthalmitis.

Causes of cataract surgery malpractice claims in England 1995-2008.

AIMS: To analyse the causes of malpractice claims related specifically to cataract surgery in the National Health Service in England from 1995 to 2008. METHODS: All the malpractice claims related to cataract surgery from 1995 to 2008 from the National Health Service Litigation Authority were analysed. Claims were classified according to causative problem. Total numbers of claims, total value of damages, mean level damages and paid:closed ratio (a measure of the likelihood of a claim resulting in payment of damages) were determined for each cause. RESULTS: Over the 14-year period, there were 324 cataract surgery claims with total damages of £ 1.97 million and mean damages for a paid claim of £ 19,900. Negligent surgery (including posterior capsule tear and dropped nucleus) was the most frequent cause for claims, while reduced vision accounted for the highest total and mean damages. Claims relating to biometry errors/wrong intraocular lens power were the second most frequent cause of claims and result in payment of damages in 62% of closed cases. The claims with the highest paid:closed ratio were inadequate anaesthetic (75%) and complications of anaesthetic injections including globe perforation (67%). CONCLUSIONS: Claims from cataract surgery in the NHS are extremely infrequent. Consent, though essential, may not prevent a claim arising or resulting in damages. Refractive accuracy has significant medicolegal impact. Endophthalmitis can lead to successful claims if there is delay in diagnosis. Claims relating to inadequate anaesthesia or anaesthetic injection complications are particularly hard to defend.

Use of low-cost video recording device in reflective practice in cataract surgery.

Reflective surgical practice is invaluable for surgeons at all levels of experience. For trainees in particular, every surgical opportunity must be optimized for its learning potential. Recording and reviewing cataract surgery is an invaluable tool. We describe a video recording device that has the advantages of ease of use; low cost; portability; and ease of review, editing, and dissemination, all of which encourage regular use and reflective surgical practice.

Complications of sulcus placement of single-piece acrylic intraocular lenses: recommendations for backup IOL implantation following posterior capsule rupture.

PURPOSE: To describe complications arising from sulcus placement of single-piece acrylic (SPA) intraocular lenses (IOLs), evaluate IOL options for eyes that lack adequate capsule support, and examine the appropriateness of various IOL designs for sulcus placement. SETTING: University and private anterior segment surgery practices. METHODS: Patients referred for complications of SPA IOLs in the ciliary sulcus from 2006 and 2008 were identified. Demographic information, examination findings, and complications of the initial surgery were recorded. Details of surgical interventions and the most recent corrected distance visual acuity (CDVA) were noted. A thorough review of the literature was undertaken to analyze options for IOL placement. RESULTS: Complications of sulcus SPA IOLs included pigment dispersion, iris transillumination defects, dysphotopsia, elevated intraocular pressure, intraocular hemorrhage, and cystoid macular edema. Two patients in the series of 30 patients experienced 1 complication; 8 experienced 2 complications; 13 experienced 3 complications; 4 experienced 4 complications; and 2 experienced 5 complications. Twenty-eight eyes (93%) required surgical intervention; IOL exchange was performed in 25 (83%). Postoperatively, the mean CDVA improved, with most eyes attaining 20/20. CONCLUSIONS: Intraocular lenses designed solely for the capsular bag should not be placed in the ciliary sulcus. Backup IOLs in appropriate powers, sizes, and designs should be available for every cataract procedure. The development, investigation, and supply of IOLs specifically designed for placement in eyes that lack adequate capsule support represent clinically important endeavors for ophthalmology and the ophthalmic industry.

Anterior chamber instability caused by incisional leakage in coaxial phacoemulsification.

PURPOSE: To establish the percentage of fluid loss through incisions during coaxial phacoemulsification and analyze whether simple measures can reduce it. SETTING: Department of Ophthalmology, Royal Free Hospital, London, United Kingdom. METHODS: This prospective study comprised consecutive patients having routine uneventful cataract surgery. Surgeons used their standard techniques. Incisional leakage was defined by the difference between the total volume of irrigation fluid used and the volume aspirated by the phacoemulsification machine. Nonparametric statistical tests were used to compare phaco-chop techniques performed by consultants, differing only by the duration of the chopper in situ. In 1 technique, the chopper was removed after all the segments were chopped. The other technique required the chopper to be in situ throughout the phacoemulsification stage. RESULTS: The study evaluated 105 patients. The mean incisional leakage was 127 mL +/- 60 (SD) (range 10 to 300 mL), with a significant positive correlation with operation duration and actual phaco time (P<.0001). The mean percentage of incisional leakage was 67% +/- 11% (range 20% to 89%). The mean fluid loss through incisions was 75% in operations performed with the chopper in situ throughout the phacoemulsification stage and 59% when the chopper was removed after all segments were chopped (P<.005). CONCLUSIONS: Significant intraoperative fluid leakage occurred through the incisions. Removal of the chopper after chopping led to a significant reduction in fluid loss and improved chamber stability.

United Kingdom survey of antibiotic prophylaxis practice after publication of the ESCRS Endophthalmitis Study.

The European Society of Cataract & Refractive Surgeons Endophthalmitis Study published preliminary results in 2006 showing a near 5-fold decrease in the rates of postoperative endophthalmitis with the use of intracameral cefuroxime. The study findings have generated considerable controversy, and 1 year later its recommendations had been heeded by only 6% of American Society of Cataract and Refractive Surgery (ASCRS) members. This poll sought to gauge the uptake among surgeons in the United Kingdom and survey their response to its findings. Fifty-five percent of respondents were using intracameral cefuroxime; 48% had switched after publication of the ESCRS study. Of those remaining, 68% reported their main concern was the risk for dilution errors in the absence of a commercially preformulated preparation, with 67% stating they would switch if such a product became available. Sixty-eight percent considered the lack of a subconjunctival cefuroxime treatment arm within the study a major methodology flaw. Sixty-seven percent said they do not consider penicillin allergy a contraindication to intracameral cefuroxime use, with the remaining 33% opting for alternative antibiotic prophylaxis. The majority of United Kingdom and Ireland Society of Cataract and Refractive Surgeons members have switched to intracameral cefuroxime, despite the absence of previously preferred practice in the study design. The major barrier to its further use appears to be the lack of a commercially available preformulated preparation.

Conjunctival sweeping with a squint hook to reduce chemosis.

We describe a simple technique for reducing surgical chemosis. The conjunctival sweeping technique uses a squint hook and tissue scissors and can be used effectively by surgeons at all levels of experience.

Little capsulorhexis tear-out rescue.

Backward traction on the capsule flap forms the basis of a predictable technique for rescuing the capsulorhexis from a radial tear-out.

Removal of a capsular tension ring from the anterior chamber angle.

A 75-year-old woman presented with unexplained ocular hypertension 4 weeks after phacoemulsification. Steroid response was diagnosed initially until a misplaced capsular tension ring (CTR) was identified in the drainage angle. We describe the technique used to successfully remove the CTR from the drainage angle with minimal trauma. This case illustrates the importance of the initial surgical technique used for CTR insertion and emphasizes the role of gonioscopy in such a case.

Efficacy of anterior chamber decompression in controlling early intraocular pressure spikes after uneventful phacoemulsification.

PURPOSE: To determine the efficacy of anterior chamber decompression in the management of intraocular pressure (IOP) spikes in the early period after uneventful phacoemulsification. SETTING: Royal Free Hospital, Department of Ophthalmology, Royal Free and University College London Medical School, London, United Kingdom. METHODS: This prospective case series comprised 11 consecutive patients with otherwise healthy eyes who an IOP of at least 40 mm Hg 4 to 6 hours after phacoemulsification. After anterior chamber decompression, the IOP was measured at 0, 15, 30, 45, and 60 minutes or until it exceeded 40 mm Hg. RESULTS: The mean IOP 4 to 6 hours postoperatively was 47.09 mm Hg +/- 7.92 (SD) (range 40 to 68 mm Hg). After decompression, the IOP dropped significantly to a mean of 4.73 +/- 3.00 mm Hg at 0 minutes (P<.001) and then increased progressively to 23.36 +/- 10.80 mm Hg at 15 minutes (P<.001), 33.82 +/- 11.74 mm Hg at 30 minutes (P=.005), 35.00 +/- 6.53 mm Hg at 45 minutes (P=.015), and 38.50 +/- 2.51 mm Hg at 60 minutes (P=.041). CONCLUSIONS: Marked IOP spikes developed in eyes without glaucoma or ocular hypertension after uneventful phacoemulsification. Anterior chamber decompression immediately lowered IOP, but the effect was transient.

Visual perception during phacoemulsification cataract surgery under topical and regional anaesthesia.

PURPOSE: To compare the subjective visual experiences of patients during phacoemulsification and intraocular lens (IOL) implantation using regional and topical anaesthesia. DESIGN: A prospective, cohort, questionnaire-based study. METHODS: The study cohort consisted of 247 patients without pre-existing ocular pathology who underwent routine phacoemulsification and IOL implantation. The mean age of the subjects was 75.4 +/- 9.4 years and 34.5% of them had a history of cataract surgery. Three different methods of local anaesthesia were used: 66 (26.7%) of the patients were given topical anaesthesia (TA); 74 (30.0%) were given sub-Tenon's anaesthesia (SA), and 107(43.3%) were given peribulbar anaesthesia (PA). The patients were interviewed immediately after surgery by theatre staff using a standardized questionnaire that investigated their intraoperative visual experiences. RESULTS: There was no significant difference between the three methods of anaesthesia regarding light perception during the surgery. However, patients undergoing surgery under TA experienced brighter light intensity levels (78.3%) than those given SA (50.0%) and PA (55.7%) (p = 0.02). A total of 69.6% of subjects who received TA reported visual perception of colours during surgery, as opposed to 56.8% of SA recipients and 49.0% of PA recipients (p = 0.02). In addition, patients under TA were more aware of surgical instruments (26.1%) than those under SA (10.8%) and PA (15.9%) (p = 0.08). The vast majority of patients in all three groups found the visual experience to be non-frightening. There were no associations between intraoperative visual impression and age or sex. Although not statistically significant (p = 0.06), prior cataract surgery appeared to alleviate some of the anxiety associated with the visual experience. CONCLUSION: Patients undergoing regional and topical anaesthesia experience a wide variety of visual sensations during surgery. The differences in visual impressions between the groups may reflect the varying degrees of optic nerve blockade that result from the different anaesthetics.

Same-day versus first-day review of intraocular pressure after uneventful phacoemulsification.

PURPOSE: To compare the incidence and the spectrum of postoperative complications detected when the intraocular pressure (IOP) is reviewed 4 to 6 hours or the day after uneventful phacoemulsification cataract extraction and intraocular lens (IOL) implantation. SETTING: Royal Free Hospital, London, United Kingdom. METHODS: The study cohort consisted of 141 patients who had uneventful phacoemulsification and IOL implantation under regional (peribulbar/topical) or general anesthesia. Postoperative evaluation of the patients was performed by an ophthalmologist using a standard form at 4 to 6 hours or 24 hours. RESULTS: The mean IOP at 4 to 6 hours and 24 hours was 22.85 mm Hg +/- 9.56 (SD) and 19.44 +/- 7.04 mm Hg, respectively. The IOP was more likely to be greater than 30 mm Hg when measured on the same day, resulting in a significantly higher intervention rate than on the first day (P =.037). The best corrected visual acuity was significantly better at 24 hours than at the same-day review (P <.001). There was no significant difference in the extent of anterior chamber activity, patient comfort, or state of the wound between the same- or next-day follow-up. All patients attended a follow-up appointment 3 weeks after surgery, had an IOP of 21 mm Hg or less, and were subsequently discharged. CONCLUSIONS: The results indicate that moderate IOP spikes (<40 mm Hg) can be left untreated if they are not associated with corneal edema or patient discomfort as they decline spontaneously. Before they are discharged, patients with compromised optic discs or predisposed to retinal or optic nerve pathology should be carefully evaluated the day after surgery to treat IOP elevations.