El error médico y la seguridad del paciente en Oftalmología / Medical errors and patient safety in Ophthalmology

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Cuerpo extraño enclavado en iris después de cirugía de catarata / Foreign body embedded in the iris after cataract surgery

CASO CLÍNICO: Mujer de 75 años intervenida de catarata en ojo izquierdo, que presentaba a las 24 h una agudeza visual de 0,8. En la biomicroscopia destacaba un cuerpo extraño anclado al iris en sector nasal coincidente con la incisión principal de la facoemulsificación, que fue retirado en un segundo acto quirúrgico. Fue analizado e informado como estructura inerte de naturaleza plástica. DISCUSIÓN: Planteamos el posible origen de la presencia del resto plástico en el postoperatorio de la cirugía de la catarata. En este caso su naturaleza inerte no desencadenó mayor inflamación intraocular. Además, la estructura rígida favoreció su anclaje al iris evitando otras complicaciones. Deben extremarse las medidas preventivas en la cirugía de la catarata revisando incluso los instrumentos y accesorios al terminar la cirugía

CASE REPORT: a 75-year old woman who had had cataract surgery in her left eye and showed a visual acuity of 0.8 twenty-four hours post-surgery. Biomicroscopy revealed a foreign body attached to the iris in the nasal sector that coincided with the main incision of the phacoemulsification, which was then removed in a second surgical procedure. It was analysed and described as an inert structure made of plastic. DISCUSSION: The possible origin of the presence of a fragment of plastic in the postoperative period following cataract surgery is established. In this case, its inert nature did not cause any further intraocular inflammation. Its rigid structure also favoured its attachment to the iris, thus avoiding any other complications. There must be greater preventative measures during cataract surgery, including checking the instruments and accessories before and after the surgical procedure

Establishment of a Registry to Monitor Trends in Cataract Surgical Procedures and Outcomes in Israel, 1990-2014.

BACKGROUND: Cataract extraction is the most commonly performed ophthalmic surgical procedure. There is no registry for documenting cataract surgical procedures and the overall risk of its complications overtime in Israel. OBJECTIVES: To present trends in the number and type of selected parameters associated with cataract surgical procedures in Israel between 1990 and 2014. METHODS: Questionnaires had been sent annually to all surgical centers in which cataract surgery was performed in Israel during the study period. The trends that were investigated included annual rates, surgical sites, surgical techniques, use of an intraocular lens (IOL), and type and rates of postoperative endophthalmitis (POE). RESULTS: A total of 812,112 cataract surgical procedures were reported during the 25 year study period. Responses to the questionnaire increased from 75% in 1990 to 100% in 2006 onwards. The annual number of reported cataract surgical procedures increased from 16,841 (3.5 per 1000) in 1990 to 57,419 in 2014 (6.9 per 1000), representing an increase of 197%. There was a shift from performing the surgery in the public health system to private medical centers. The surgical technique changed from predominantly manual extracapsular cataract extraction (56% in 1999) to predominantly phacoemulsification (98.7% in 2014). POE rates decreased from 0.25% in 2002 to 0.028% in 2014. CONCLUSIONS: There was a continuous increase in the rate of surgical cataract procedures, and more were performed in private medical facilities. There was also a major shift towards advanced cataract procedures and a decreased rate of POE.

The phaco machine: analysing new technology.

PURPOSE OF REVIEW: The phaco machine is frequently overlooked as the crucial surgical instrument it is. Understanding how to set parameters is initiated by understanding fundamental concepts of machine function. RECENT FINDINGS: This study analyses the critical concepts of partial occlusion phaco, occlusion phaco and pump technology. In addition, phaco energy categories as well as variations of phaco energy production are explored. SUMMARY: Contemporary power modulations and pump controls allow for the enhancement of partial occlusion phacoemulsification. These significant changes in the anterior chamber dynamics produce a balanced environment for phaco; less complications; and improved patient outcomes.

Bloqueo sinoauricular en el postoperatorio inmediato de cirugía de cataratas ¿Casualidad o causalidad? / Sino-auricular block immediately after cataract surgery. Casualty or causality?

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Profilaxis de la endoftalmitis postquirúrgica con cefuroxima intracamerular: experiencia de cinco años / Prophylaxis of postoperative endophthalmitis whit intracameral cefuroxime: A five years' Experience

Propósito: Mostrar los resultados de la profilaxis de endoftalmitis postquirúrgica (EPQ) tras cirugía de catarata con Cefuroxima intracamerular. Método: Se realizó un estudio retrospectivo con4.281 ojos intervenidos de catarata de octubre de2003 a septiembre de 2008. Todos los pacientes fueron intervenidos con técnica de facoemulsificación. Todos los casos recibieron una inyección de Cefuroxima: 0,1 ml (1 mg) en cámara anterior al finalizar la cirugía, a excepción de los pacientes con alergia a penicilinas y cefalosporinas hasta septiembre de 2007 y después de esta fecha solo aquellos con alergia demostrada a cefuroxima. Resultados: La incidencia de EPQ fue de 0,11% (5casos). Cuatro de ellos fueron cultivo positivo. No se detectó ningún signo clínico de toxicidad ocular. Conclusiones: La profilaxis de EPQ con Cefuroxima intracamerular es muy eficaz para reducir la incidencia de endoftalmitis postoperatoria, parece segura y es fácil de preparar (AU)

Purpose: To present the outcomes of prophylaxisof postoperative endophthalmitis following cataractsurgery with intracameral Cefuroxime.Method: A retrospective study was done on 4281eyes that underwent cataract surgery from October2003 to September 2008. All patients underwentphacoemulsification cataract surgery. All casesreceived an injection of 0.1 ml intracameral Cefuroxime(1 mg) at the end of surgery except thosepatients allergic to penicillin and cephalosporinuntil September 2007 and thereafter only those withdemonstrated allergy to cefuroxime.Results: The rate of postoperative endophthalmitiswas 0.11% (5 cases). Four of them had a positiveculture. We found no evidence of clinical oculartoxicity.Conclusions: Intracameral cefuroxime works verywell for reducing the incidence of postoperativeendophthalmitis. It appears safe to use and is easy toprepare(AU)

Vitrectomía pars plana, facoemulsificación e implante de lente intraocular para el manejo de catarata y retinopatía diabética proliferativa: comparación de técnica quirúrgica combinada versus en dos tiempos / Pars plana vitrectomy, phacoemulsification and intraocular lens implantation for the management of cataract and proliferative diabetic retinopathy: comparison of a combined versus two-step surgical approach

Propósito: Describir las complicaciones intra- y postoperatorias y los resultados visuales en vitrectomía vía pars plana (VPP), facoemulsificación e implante de lente intraocular (LIO) en pacientes con catarata y retinopatía diabética proliferativa (RDP). Se realizo una comparación de la técnica combinada versus en dos tiempos quirúrgicos. Método: Ensayo clínico intervencional retrospectivo no controlado. Se incluyeron 48 ojos de 48 pacientes consecutivos con RDP. Se analizaron 28 (58,3%) ojos con cirugía combinada y 20 ojos (41,7%) con cirugía secuencial. Resultados: El tiempo de seguimiento postoperatorio fue entre 6 y 63 meses (promedio: 18 meses). 1) Cirugía combinada: Agudeza visual mejor corregida preoperatoria (AVMC) estaba entre 20/200 a movimiento de manos, y AVMC postoperatoria se encontró entre 20/30 a movimiento de manos. En diecisiete (60,7%) ojos la AVMC mejoró, en 7 (25%) ojos no hubo cambios ≥ 2 líneas ETDRS) en la AV y en 4 (14,3%) ojos la AVMC se redujo. Las complicaciones postoperatorias incluyeron hemorragia vítrea (HV) en 10 ojos (35,7%), y exudación fibrinosa en nueve ojos (32,1%). 2) Cirugía en dos tiempos: AVMC preoperatoria entre 10/200 a percepción de luz, y de 20/40 a percepción de luz en el período postoperatorio. La agudeza visual mejor corregida mejoró en 15 (75%) ojos, permaneció igual en cuatro (20%) ojos, y se redujo en un (5%) ojo. Las complicaciones postoperatorias incluyeron exudación fibrinosa en seis (30%) ojos, y HV en tres (15%) ojos. Conclusión: Tanto la cirugía combinada de VPP, facoemulsificación e implante de LIO como el procedimiento en dos tiempos son seguras y efectivas para el manejo de catarata en RDP. La cirugía secuencial podría ser ventajosa para los resultados de AVMC al disminuir la posibilidad de HV postoperatoria, que parece ser más frecuente después de la cirugía combinada

Purpose: To report the intra-and postoperative complications and visual acuity outcomes in pars plana vitrectomy (PPV), phacoemulsification and intraocular lens (IOL) implantation in patients with cataract and proliferative diabetic retinopathy (PDR). A comparison of the combined versus two-step surgical approach is given. Method: Retrospective uncontrolled interventional clinical trial. Forty-eight eyes of 48 consecutive patients with PDR were included. Twenty-eight (58.3%) eyes with combined surgery and 20 (41.7%) eyes with sequential surgery were analyzed. Results: Postoperative follow-up time was between 6 and 63 months (mean: 18 months). 1) Combined surgery: Preoperative best-corrected visual acuity (BCVA) ranged from 20/200 to hand motions, and postoperative BCVA ranged from 20/30 to hand motions. BCVA improved in 17 eyes (60.7%), while in 7 (25%) eyes there was no change ≥ 2 ETDRS lines) in VA, and in 4 (14.3%) eyes BCVA decreased. Postoperative complications included vitreous hemorrhage (VH) in 10 (35.7%) eyes, and fibrinous exudation in 9 (32.1%) eyes. 2) Two-step surgery: Preoperative BCVA ranged from 10/200 to light perception, and from 20/40 to light perception in the postoperative period. Best-corrected visual acuity improved in 15 (75%) eyes, remained the same in 4 (20%) eyes, and decreased in 1 (5%) eye. Postoperative complications included fibrinous exudation in 6 (30%) eyes, and VH in 3 (15%) eyes. Conclusion: Combined PPV, phacoemulsification and IOL implantation as well as the two-step procedure are safe and effective for the management of cataract in PDR. Sequential surgery could be advantageous to BCVA outcomes by minimizing postoperative VH, which is significantly more frequent after combined surgery (Arch Soc Esp Oftalmol 2009; 84: 31-38)

Síndrome de Brown-McLean con lente intraocular de cámara anterior: descripción de un caso / Brown-McLean syndrome after insertion of an anterior chamber intraocular lens: description of one case

Caso clínico: Se presenta un caso de síndrome de Brown-McLean. Discusión: Un varón de 71 años de edad desarrolló un síndrome de Brown-McLean tras el implante de una lente de cámara anterior en un ojo afáquico. Se realizó facoemulsificación en el ojo contralateral sin desarrollo de alteraciones en la transparencia corneal. El síndrome de Brown-McLean tiene un origen incierto todavía. Probablemente, se desarrolle en ojos con predisposición genética expuestos a ciertas condiciones, como por ejemplo lentes de cámara anterior

Case report: We report one case of Brown-McLean syndrome. Discussion: In this case, a 71-year-old male developed a Brown-McLean syndrome after implantation of an anterior chamber lens in one aphakic eye. A phacoemulsification procedure was performed in the other eye without development of corneal clearance alterations in the next 7 years. The cause of Brown-McLean syndrome is still unexplained. It is possible that it could develop in eyes with a genetic predisposition when these eyes are exposed to certain conditions, such as insertion of an anterior chamber lens

Surgical techniques in phacoemulsification.

PURPOSE OF REVIEW: Recent advances in cataract surgical techniques are described, focusing on the evolution towards less traumatic surgery. RECENT FINDINGS: Smaller incisions, split infusion, astigmatic management, and techniques of managing floppy iris syndrome are significant changes in the cataract surgical technique within the last 12-24 months. SUMMARY: Surgeons need to learn the new techniques and instrumentation as cataract surgery moves towards less invasive surgery, with smaller incisions, more precise refractive outcomes, and fewer complications.

Innovations in phacoemulsification technology.

PURPOSE OF REVIEW: A working knowledge of the principles guiding recent technologic upgrades in phacoemulsification units will help the surgeon to maximize clinical benefits from the latest machines. RECENT FINDINGS: Reduced thermal energy combined with more efficient emulsification resulting from microfractionation of ultrasound energy, and improved chamber stability from automatic fluidic adjustments are achievable with the recent technological advances. SUMMARY: Improved safety and efficiency can be achieved with the most current advances in phacoemulsification technology.

[Tendencies of cataract surgery in Lithuania]. / Kataraktos chirurgijos tendencijos Lietuvoje.

OBJECTIVE: To review the tendencies of cataract surgery in Lithuania. MATERIALS AND METHODS: More than ten years the data are collected from all medical institutions in Lithuania, where cataract surgery is performed. Each year from 1994 standardized questionnaires are sent to all centers of the cataract surgery and afterwards collected in the database. The questionnaires contain questions regarding the incidence of cataract surgery, operation methods, the rate of applied intraocular lenses, their models, etc. RESULTS: A total of 74,954 cataract operations were performed in Lithuania from 1994 till 2004. Phacoemulsification for the first was used in Lithuania in 1996. Since that time, 18,393 phacoemulsification operations have been performed. The first foldable intraocular lens was implanted in Lithuania in 1998. A total of 5,140 foldable intraocular lenses were implanted till 2005. It makes up 7.36% from total number of implanted intraocular lenses during the period under review. CONCLUSIONS: We have been observing a great quantitative and qualitative increase in the amount of cataract surgeries for last ten years. This is due to the newest cataract surgery methods (manual small incision cataract surgery, phacoemulsification), introduction of viscoelastic agents, new generation lenses (foldable: acrylic, silicone), and modern phacoemulsificators to clinical practice.

Time series analysis of age related cataract hospitalizations and phacoemulsification.

BACKGROUND: Cataract surgery remains a commonly performed elective surgical procedure in the aging and the elderly. The purpose of this study was to utilize time series methodology to determine the temporal and seasonal variations and the strength of the seasonality in age-related (senile) cataract hospitalizations and phacoemulsification surgeries. METHODS: A retrospective, cross-sectional time series analysis was used to assess the presence and strength of seasonal and temporal patterns of age-related cataract hospitalizations and phacoemulsification surgeries from April 1, 1991 to March 31, 2002. Hospital admission rates for senile cataract (n = 70,281) and phacoemulsification (n = 556,431) were examined to determine monthly rates of hospitalization per 100,000 population. Time series methodology was then applied to the monthly aggregates. RESULTS: During the study period, age-related cataract hospitalizations in Ontario have declined from approximately 40 per 100,000 to only one per 100,000. Meanwhile, the use of phacoemulsification procedures has risen dramatically. The study found evidence of biannual peaks in both procedures during the spring and autumn months, and summer and winter troughs. Statistical analysis revealed significant overall seasonal patterns for both age-related cataract hospitalizations and phacoemulsifications (p < 0.01). CONCLUSION: This study illustrates the decline in age-related cataract hospitalizations in Ontario resulting from the shift to outpatient phacoemulsification surgery, and demonstrates the presence of biannual peaks (a characteristic indicative of seasonality), in hospitalization and phacoemulsification during the spring and autumn throughout the study period.