Practice styles and preferences of ASCRS members--1993 survey

Dysphotopsias or Unwanted Visual Phenomena after Cataract Surgery

Dysphotopsias are unwanted visual phenomena that occur after cataract surgery. They represent some of the most common reasons for patient dissatisfaction after uncomplicated surgery for cataract phacoemulsification with in-the-bag intraocular lens (IOL) implantation. Depending on the form of the optical phenomenon and the effect it poses on vision, dysphotopsias are divided into positive and negative type. Positive dysphotopsias are usually described by patients as glare, light streaks, starbursts, light arcs, rings, haloes, or flashes of light. Negative dysphotopsias are manifested as an arc-shaped shadow or line usually located in the temporal part of the visual field, similar to a temporal scotoma. In addition to their different clinical manifestations, positive and negative dysphotopsia also have different risk factors. Even though up to 67% of patients may experience positive dysphotopsia immediately after surgery, only 2.2% of the cases have persistent symptoms up to a year postoperatively. Surgical intervention may be indicated in 0.07% of cases. The incidence of negative dysphotopsias is up to 26% of all patients; however, by one year postoperatively, the symptoms usually persist in 0.13 to 3% of patients. For both types of dysphotopsia, preoperative patients' education, accurate preoperative diagnostics, and use of an appropriate IOL design and material is mandatory. Despite all these measures, dysphotopsias may occur, and when noninvasive measures fail to improve symptoms, a surgical approach may be considered.

Retained lens fragments after cataract surgery: outcomes of same-day versus later pars plana vitrectomy

PURPOSE

To compare visual acuity outcomes and adverse events in patients with retained lens fragments who underwent same-day versus later pars plana vitrectomy (PPV).

DESIGN

Retrospective, interventional case series.

METHODS

Single-center study evaluating all patients with retained lens fragments that underwent PPV over a 22-year period (1990 through 2011).

RESULTS

The study included 569 eyes of 568 patients with a mean age of 74.6 years and a median follow-up of 8 months (range, 1 week to 100 months). One hundred seventeen patients (22%) underwent same-day vitrectomy, 131 patients (23%) underwent PPV within 1 week, and 321 patients (57%) underwent PPV more than 1 week later. Median time to vitrectomy in the same week group was 5 days, compared with 22 days in the delayed group. At the last examination, 61%, 63%, and 56% of patients undergoing PPV on the same day, within 1 week, and more than 1 week later, respectively, achieved best-corrected visual acuity (BCVA) of 20/40 or better (P = .35), and 16%, 15%, and 21%, respectively, had BCVA of 20/200 or worse (P = .29). There were no differences between groups when assessing cystoid macular edema (P = .96), retinal detachment (P = .096), elevated intraocular pressure (P = .88), or suprachoroidal hemorrhage (P = .26).

CONCLUSIONS

Patients undergoing same-day versus a later PPV (within 1 week or more than 1 week later) for retained lens fragments had similar visual acuity outcomes and complication rates. Although same-day surgery may be attractive logistically in many cases, our retrospective data suggest equivalent outcomes for surgical timing.

Intraocular lens power calculation after corneal refractive surgery

Cataract surgery after corneal refractive surgery can be challenging for the ocular surgeon due to the difficulty with accurate intraocular lens (IOL) power determination and unexpected refractive surprises. As clinicians have done more work, a number of error sources have been determined. Furthermore, an increasing number of methods to avoid these refractive surprises have been proposed. The combination of this work has resulted in recommendations for the modification of standard IOL power calculations to improve outcomes. The following article includes a brief on, and by no means, inclusive, error sources and ways to compensate for them.

Patients' expectation and experience of visual sensations during phacoemulsification under topical anaesthesia

PURPOSE

To describe what patients expect to see and the visual sensations they actually experience during phacoemulsification under topical anaesthesia. We also sought to determine if patients find their intraoperative visual experience frightening and the factors associated with this.

MATERIALS AND METHODS

Ninety-eight patients who underwent phacoemulsification and intraocular lens implantation under topical anaesthesia were interviewed preoperatively on what they expected to see with their operated eye during surgery and again postoperatively on what they actually saw. No patient received counselling about possible intraoperative visual sensations. A logistic (multivariate) regression model was used for statistical analysis.

RESULTS

Preoperatively, 36 patients (36.7%) expected at least light perception, 38 (38.8%) expected no light perception, and 24 (24.5%) were unsure what to expect. Some patients also expected a variety of different visual sensations. Postoperatively, all patients (100%) reported seeing light intraoperatively and many experienced various other visual sensations. Nineteen patients (19.4%) found their visual experience frightening. The following factors were statistically associated with a frightening visual experience: preoperative anxiety, previous cataract surgery in the fellow eye, experiencing an intraoperative increase in clarity, not seeing movement intraoperatively, and not knowing what to expect.

CONCLUSIONS

The majority of patients in this study either expected that they would see nothing at all during the surgery or were unsure of what to expect. All patients subsequently saw at least some light, and many perceived various other visual sensations that were frightening to nearly one in five patients. Preoperative counselling should inform about possible intraoperative visual experience.

Hyperopic laser in situ keratomileusis in eyes with previous radial keratotomy

PURPOSE

To assess the safety and efficacy of hyperopic laser in situ keratomileusis (LASIK) in eyes with previous radial keratotomy (RK).

SETTING

Zale Lipshy University Hospital Laser Center for Vision, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

METHODS

Thirty-eight eyes of 25 patients were treated with LASIK for secondary hyperopia after RK using a Visx Star S2, S3, S4, or LADARVision excimer laser. Retreatment was done in 7 eyes. The main outcome measures were manifest refraction spherical equivalent (MRSE), uncorrected visual acuity (UCVA), best spectacle corrected visual acuity (BSCVA), predictability of treatment, and complications.

RESULTS

Preoperative mean MRSE was +2.39 diopters (D) +/- 1.28 (SD) (range +0.87 to +6.00 D). At the last visit (25 eyes with minimum follow-up of 12 months, including retreatments), the mean follow-up was 23.3 +/- 7.3 months (range 12 to 34 months), the mean MRSE was +0.11 +/- 0.71 D, and the UCVA was 20/40 or better in 24 eyes (96%). Although no significant change in the mean MRSE was observed, the postoperative mean refractive cylinder showed a gradual increase over the follow-up period. No eye lost more than 2 lines of BSCVA.

CONCLUSIONS

Laser in situ keratomileusis was a safe and effective treatment with good predictability for the correction of consecutive hyperopia after RK. Cylindrical errors were difficult to correct, and astigmatic correction tended to regress over time. Retreatments are safe when old flaps were relifted.

Intraocular lens power calculation after corneal refractive surgery

PURPOSE OF REVIEW

Keratorefractive procedures designed to decrease refractive errors have gained enormous popularity among ophthalmologists and patients. As the post-refractive surgery patient population ages, visually significant cataracts will develop. With advances in techniques for cataract extraction and intraocular lens implantation, cataract surgery has evolved into a refractive surgical procedure as well as an operation to improve best corrected visual acuity. This raises expectations in terms of desired postoperative refractive status and uncorrected visual acuity. Although performing modern cataract surgery in post-refractive surgery eyes is technically no more complicated than operating on virgin eyes, the calculation of intraocular lens power for a desired refractive target can be challenging and complicated. This has become increasingly apparent as case reports of "refractive surprises" after cataract surgery appear in the literature more frequently.

RECENT FINDINGS

This paper reviews the current clinical experience with intraocular lens power determination after cataract surgery in post-keratorefractive patients, provides an overview of possible sources of error in intraocular lens power calculation in these patients, and analyzes methods to minimize intraocular lens power errors.

SUMMARY

The clinical and routine methods of intraocular lens power determination after keratorefractive surgery need to be modified to improve accuracy. Our knowledge of this subject is still evolving. Given the enormous impact of this problem on clinical practice, awareness of the shortcomings and suggested methods to improve accuracy can be valuable to clinicians.

Practice styles and preferences of ASCRS members--2003 survey

A survey of the members of the American Society of Cataract and Refractive Surgery (ASCRS) with a United States ZIP code was performed in July 2003. Approximately 15.5% (985) of the 6350 questionnaires were returned for analysis. Three main profile questions were used in the cross-tabulation: age of the respondent, geographic location, and volume of cataract surgery per month. The refractive surgical questions were cross-tabulated for the volume of laser in situ keratomileusis. Results of the survey were compared with those in previous surveys of ASCRS members.

Practice styles and preferences of ASCRS members--2002 survey

A survey of the practice styles and preferences of members of the American Society of Cataract and Refractive Surgery (ASCRS) with a United States ZIP code was performed in August 2002. Approximately 18% (1056) of the 5816 questionnaires mailed were returned. Three profile questions were used to cross-tabulate: age of the respondent, geographic location, and volume of cataract surgery per month. The refractive surgical questions were cross-tabulated for the volume of laser in situ keratomileusis (LASIK). Data in this survey were compared with those in previous surveys of ASCRS members.

Practice styles and preferences of ASCRS members--2001 survey

A survey of the practice styles and preferences of members of the American Society of Cataract and Refractive Surgery (ASCRS) with a United States ZIP code was performed in August 2001. Approximately 20% (1130) of the 5686 questionnaires mailed were returned before the November cutoff date. The response rate was undoubtedly negatively affected by the September 11 attack on the World Trade Center in New York. Three profile questions were used to cross-tabulate: age of the ophthalmologist, geographic location, and volume of cataract surgery per month. Data in this survey were compared with those in previous surveys of ASCRS members.

Practice styles and preferences of ASCRS members--2000 survey. American Society of Cataract and Refractive Surgery

A survey of the practice styles and preferences of members of the American Society of Cataract and Refractive Surgery with a United States ZIP code was performed in August 2000. Approximately 26% (1400) of 5342 questionnaires mailed were returned prior to the november cutoff date. Three profile questions were used to cross-tabulate: age of the ophthalmologist, geographic location, and volume of cataract surgery per month. Current data were compared with data in previous surveys.

Anesthesia modalities for cataract surgery

Modern cataract surgery represents an amalgam of new technologists which may include phacoemulsification, foldable intraocular lenses and, in many instances, clear corneal incision. The fusion of newer techniques has allowed for a re-evaluation of the anesthetic needs for cataract surgery. These minimally incisive surgical procedures have allowed us to reintroduce a very old technique: topical anesthesia into cataract surgery. This article reviews the present day techniques that are available from the use of general anesthesia to the use of injection technique as well as topical.

Clinical outcomes and costs of cataract surgery performed by planned ECCE and phacoemulsification

PURPOSE

To compare clinical outcomes and costs of cataract surgery between patients operated with standard extracapsular extraction (ECCE) and those undergoing phacoemulsification.

SETTING

Patients from the Ophthalmology Department of a teaching hospital in Barcelona (Spain) scheduled for cataract surgery, not combined with any other ophthalmic procedure.

METHODS

A retrospective analysis has been performed on a database of 1046 patients undergoing ECCE and phacoemulsification. The outcome measures used were: surgical complications, visual acuity and costs of surgery and of follow-up. Overall rate of all complications and postoperative visual acuity were compared between the two groups, adjusting for age, preoperative visual acuity, medical and ocular comorbidity.

RESULTS

31.9% of the patients (334) underwent phacoemulsification, and 68.1% (712) underwent ECCE. Patients undergoing phacoemulsification presented a frequency of intra- and postoperative complications lower than those undergoing ECCE (odds ratio 0.57, 95%CI 0.37-0.87 and 0.66, 95%CI 0.46-0.96, respectively), specifically for intraoperative iris trauma (3.1% vs 0.3%, p = 0.004), residual posterior capsular opacity (2% vs 0.3%, p = 0.035) and postoperative corneal edema (7.4% vs 3.6%, p = 0.016). Costs of intervention and follow-up were lower for phacoemulsification compared with ECCE (23.9% and 14%, respectively). But global costs were slightly higher for phacoemulsification (4.87%), due to supply costs, which were more than twice those of ECCE.

CONCLUSIONS

Phacoemulsification, when performed by an experienced surgeon, has better clinical outcomes than planned extracapsular extraction, and costs may be lower since supply costs are expected to decrease as the phacoemulsification technique becomes more widespread.

Practice styles and preferences of ASCRS members--1999 survey

A survey of the practice styles and preferences of members of the American Society of Cataract and Refractive Surgery with United States ZIP codes was performed in September 1999. Approximately 27% (1342) of 4932 questionnaires mailed were returned before the November cutoff. Three profile questions were used to cross-tabulate: age of the opthalmologist, geographic location, and volume of cataract surgery per month. Current data were compared with data of previous surveys.

Dysphotopsia in phakic and pseudophakic patients: incidence and relation to intraocular lens type(2)

PURPOSE

To determine the relationship between various intraocular lens (IOL) types and the incidence of unwanted light images.

SETTING

The Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.

METHODS

A telephone questionnaire was administered to 302 postoperative patients who had received 1 of 6 commonly used IOLs between January and September 1998. Patients were included only if they had uneventful cataract surgery, no additional ocular pathology, and a postoperative best corrected visual acuity of 20/25 or better. A control group of 50 patients with the diagnosis of presbyopia only also participated in the questionnaire. Patients reported on incidence of glare, light sensitivity, and unwanted images. The data were analyzed for statistically significant relationships between incidence of photopsias and IOL type.

RESULTS

The AcrySof 5.5 mm, AcrySof 6.0 mm, and SI-40 groups reported significantly more unwanted images than the control group (P =.0014). The 2 AcrySof groups also reported a greater incidence of light to the side causing a central flash, and the SI-40 group, a higher incidence of glare. The control group was more likely to experience symptoms of glare than any pseudophakic group. Overall, a mean of 49% of patients reported some light-related phenomenon postoperatively. The majority in all groups reported being satisfied with their eyesight despite the light-related problems.

CONCLUSIONS

A significant number of pseudophakic patients reported symptoms of dysphotopsia. Patients who received an acrylic IOL with flattened edges were at increased risk of experiencing images associated with edge reflections. The SI-40 lens group, although less than the AcrySof groups, reported a higher incidence of glare than the non-AcrySof groups; however, it also had the highest number of patients still driving at night. The phakic population commonly experienced glare reported as more severe than several of the IOL groups.

Outpatient ophthalmic plastic surgery: outcomes and patient satisfaction using initial postoperative telephone call follow-up

PURPOSE

To evaluate the safety and efficacy of using a telephone call within 24 hours as the initial follow-up after outpatient ophthalmic plastic surgery, deferring the first postoperative visit 4 to 7 days.

METHODS

We prospectively evaluated clinical outcomes, including complications and patient satisfaction, after 469 outpatient eyelid, lacrimal and anterior orbital procedures. Patient satisfaction was assessed with a 13-item questionnaire.

RESULTS

Response to the questionnaire was 282 of 469 (60%) patients. Essentially, all patients responding to the questionnaire who received a telephone call believed that it was helpful and their questions and concerned were adequately addressed. Only 4 of 274 (1%) patients without a planned 24-hour visit indicated that they would have preferred being seen in the office. Complications of a minor nature were noted in 12 of 469 (3%) patients, none of which adversely affected clinical outcomes.

CONCLUSION

We conclude that a telephone call on the initial postoperative day, deferring the first visit 4 to 7 days, is a safe, cost-effective strategy with high patient acceptance for most types of eyelid and lacrimal surgery, as well as some types of orbital surgery.

The National Survey of Local Anaesthesia for Ocular Surgery. II. Safety profiles of local anaesthesia techniques

PURPOSE

To describe the adverse events associated with local anaesthesia (LA) for intraocular surgery.

METHODS

An observational study of practice of LA in the whole of the United Kingdom was conducted over 3 months in late 1996. Staff in all ophthalmology theatres in the National Health Service were invited to report every LA given for the purpose of intraocular surgery during the first week, and thereafter to report adverse events only.

RESULTS

During the first week, the reported incidence of all adverse events within the orbit was 2.7%, and for 'systemic' adverse events it was 0.9%. Serious adverse events were reported in association with all LA techniques. In 3 months, 18 events were described as 'life-threatening' by respondents, and further patients were reported to have had epileptic fits or were transferred directly from the operating theatre to an intensive care unit. The voluntary nature of the survey introduces some bias from under-reporting, making the incidence of these severe events difficult to assess. Reported incidence of severe 'systemic' adverse events was similar for all LA techniques.

CONCLUSIONS

Serious adverse events were reported in association with with all LA techniques. This implies that we should be prepared for such events in all patients who have intraocular surgery.

The National Survey of Local Anaesthesia for Ocular Surgery. I. Survey methodology and current practice

PURPOSE

To describe the current usage of the various techniques of local anaesthesia (LA) in the United Kingdom, and safety precautions taken.

METHODS

An observational study of practice of LA in the whole of the United Kingdom was carried out over 3 months in late 1996. Staff in all ophthalmology theatres in the National Health Service were invited to report every LA given for the purpose of intraocular surgery during the first week, and thereafter to report adverse events only.

RESULTS

Participation during the first week was calculated to be 72.8% overall. Anaesthesia techniques for intraocular surgery were: 70% LA alone, 5.8% LA with sedation and 24.2% general anaesthesia. LA techniques were: 65.6% peribulbar, 16.9% retrobulbar, 6.7% sub-Tenon's, 4.4% subconjunctival, 2.9% topical and 2.3% combinations. Of patients who were given LA, 96% were monitored, 84% had an anaesthetist available in theatres in case of a problem and intravenous access was established in 60%.

CONCLUSION

Local anaesthesia is frequently used for intraocular surgery in the United Kingdom. A variety of techniques are used, and safety precautions are taken in most cases.

Combined surgery for cataract and glaucoma: phacoemulsification and deep sclerectomy compared with phacoemulsification and trabeculectomy

PURPOSE

To compare the outcome of phacoemulsification-intraocular lens (IOL) implantation combined with nonperforating deep sclerectomy (P-DS) with that of phacoemulsification-IOL implantation combined with trabeculectomy (P-T).

SETTING

Glaucoma Unit, Department of Ophthalmology, University of Lausanne, Switzerland.

METHODS

This prospective study involved 60 eyes of 60 patients with cataract and various types of open-angle glaucoma. Thirty eyes had P-DS and 30, P-T. Follow-up was performed at regular intervals for up to 18 months.

RESULTS

Mean follow-up was 12.5 months +/- 6.5 (SD) and 12.6 +/- 4.9 months for the P-DS and P-T groups, respectively. Mean preoperative intraocular pressure (IOP) was similar in both groups (24.8 +/- 5.9 mm Hg in the P-DS group and 24.6 +/- 7.2 mm Hg in the P-T group). There was no statistically significant difference in IOP decrease (14.2 +/- 4.0 mm Hg in the P-DS group and 15.2 +/- 2.8 mm Hg in the P-T group). Visual outcome was similar in both groups. The P-DS group experienced significantly less inflammation (40.0% versus 83.0%; P = .0012) and hyphema (6.7% versus 36.7%; P = .010) than the P-T group.

CONCLUSION

Deep sclerectomy combined with cataract surgery resulted in an IOP reduction similar to that with phacotrabeculectomy with the same visual outcome, but the lower complication rate makes ambulatory care easier.

A randomized clinical trial of combined topical-intracameral anesthesia in cataract surgery

OBJECTIVE

To evaluate the level of patient discomfort during phacoemulsification and implantation of a foldable intraocular lens (IOL) while under topical lidocaine, alone or in combination with intracameral lidocaine.

DESIGN

A prospective, randomized, controlled trial.

PARTICIPANTS

Between January and July 1997, a total of 162 patients (162 eyes) scheduled for cataract surgery were randomly assigned to either the placebo group (topical anesthesia with intracameral balanced salt solution [group 1, n = 81]) or the interventional group (combined topical-intracameral anesthesia [group 2, n = 81]).

INTERVENTIONS

All patients underwent temporal clear corneal phacoemulsification and implantation of a foldable silicone IOL. All patients received a minimum total of five doses (two drops per dose) of 2% topical lidocaine hydrochloride. Three doses were administered before surgery into the superior and inferior cul-de-sac at 10 minutes, 5 minutes, and immediately before the initial corneal incision. One dose was administered before the commencement of phacoemulsification and another dose before implantation of the IOL. In addition, all patients received an intracameral injection immediately after entrance into the anterior chamber. Patients in group 1 received a 0.5-ml injection of balanced salt solution, and those in group 2 received a 0.5-ml injection of 1% lidocaine.

MAIN OUTCOME MEASURE

A 10-point visual analogue scale was used immediately after the surgery to assess each patient's overall severity of pain intraoperatively.

RESULTS

Ninety percent of patients in group 1 and 95% in group 2 assigned a score of 0 or 1 to the level of intraoperative discomfort. The mean pain score +/- 1 standard deviation for group 1 was 0.63 +/- 0.68 and for group 2 was 0.37 +/- 0.58. The difference between the pain scores for the two groups was statistically significant (P = 0.0053). A small but significant proportion (15%) of patients in group 1 expressed distress when the ciliary body was stretched or the iris was manipulated with instruments.

CONCLUSION

Although topical lidocaine alone provides adequate anesthesia for phacoemulsification and implantation of a foldable IOL, combined topical and intracameral administration of lidocaine can further minimize intraoperative discomfort.

Effectiveness of cataract surgery in Barcelona, Spain site results of an international study. Barcelona I-PORT investigators. International Patient Outcomes Research Team

OBJECTIVES

To describe the impact of cataract surgery on visual function and health status in terms of clinical indicators as well as perceived health and functional capacity, and to identify patient characteristics and differences in clinical management that might affect outcomes.

SUBJECTS AND METHODS

Observational longitudinal study of a cohort of 218 patients aged 50 or older undergoing first eye cataract surgery. Patients were evaluated pre- and postoperatively by clinical examinations (visual acuity [VA], ocular and medical comorbidity) and standardized telephone interviews. Main outcome measures included: the VF-14 Visual Function Index, the Cataract Symptom Score (CSS), the Sickness Impact Profile (SIP), and global measures of patients' trouble and satisfaction with vision.

RESULTS

Significant improvement in all outcomes measures were observed at 4 months postoperatively (P < 0.001). However, the proportion of improved patients varied according to the outcome considered: VA (87%), CSS (72%), VF-14 (62%), and SIP (38%). Patient characteristics associated with higher a level of improvement were: worse preoperative visual function (VA, CSS, VF-14) (P < 0.001), less ocular comorbidity (P < 0.05), less postoperative complications (P < 0.05) and better preoperative general health status (SIP) (P < 0.01). The differences in clinical management were not associated with the outcomes (effectiveness) of surgery.

CONCLUSIONS

A large proportion of patients benefit from cataract surgery, the greatest gain corresponding to visual function rather than to general health status. Since effectiveness of surgery is unrelated to operative procedures, less costly practices (i.e., day case surgery and loco-regional anesthesia) should be promoted.

Practice styles and preferences of ASCRS members--1997 survey

A survey of the practice styles and preferences of members of the American Society of Cataract and Refractive Surgery with a United States ZIP code was performed in September 1997. Approximately 29% (1441) of the 5000 questionnaires mailed were returned by the November cut-off date. Three main profile questions were used to cross-tabulate data: age of the ophthalmologist, geographic location, and volume of cataract surgery per month. Current data were compared with data in previous annual surveys.

Phacoemulsification at King Khaled Eye Specialist Hospital--the experience of the past

OBJECTIVE

To study the outcome of phacoemulsification (PE) compared to standard extracapsular surgery before the introduction of state-of-the-art techniques (capsulorhexis, hydrodissection, nuclear cracking, nuclear chopping, sutureless incisions) and sophisticated equipment.

STUDY DESIGN

Charts from 375 patients (453 eyes) undergoing PE between 1984 and 1989 were randomly selected and studied retrospectively. A minimum age of 35 years, and a minimum follow-up of three months were required.

SETTING

A large eye hospital in the Kingdom of Saudi Arabia staffed with an international faculty of ophthalmic surgeons.

PATIENTS

Patients over 35 years of age undergoing PE for immature, mature and traumatic cataract.

MAIN OUTCOME MEASURES

Postoperative visual acuity, and rate or frequency of intraoperative complications.

RESULTS

66.5% achieved visual acuity of 20/40 or better, which compares favourably with the 36.5% of eyes reaching this level of visual acuity after mainly standard extracapsular cataract surgery in another study at our hospital. Posterior capsule ruptures occurred in 7.5% and vitreous loss in 5.5%. Other ocular disease (odds ratio 7.51 confidence interval 4.43-12.7) and intraoperative complications (odds ratio 2.97 confidence interval 1.38-6.42) were statistically significant predictors for final visual acuity of under 20/40 (p = < 0.001 and 0.005 respectively).

CONCLUSION

The outcome of PE was better than that of standard extracapsular cataract extraction in the same setting. However, since PE appeared to be used selectively, no clear advantage compared to extracapsular cataract extraction is evident in the period before the introduction of modern state-of-the-art PE-techniques.

Corneal endothelial toxicity of topical anesthesia

PURPOSE

To determine the relative corneal endothelial toxicities of the following topical anesthetic agents: bupivacaine HCl 0.75%, unpreserved lidocaine HCl 4%, proparacaine HCl 0.5%, and tetracaine HCl 0.5%.

METHODS

The experiment was conducted using pigmented rabbits. Approximately nine animals each were randomly assigned to eight groups. Right eyes received injections of 0.2 ml of one of the four anesthetic agents at one of two concentrations and left eyes received injections of 0.2 ml of balanced salt solution. Corneal thickness and clarity were measured before surgery and on postoperative days 1, 3, and 7.

RESULTS

A statistically significant increase (P < 0.05) in corneal thickness and opacification over preoperative measurements was noted with injections of bupivacaine, lidocaine, and proparacaine, controlling for changes occurring in control eyes from surgery alone. Proparacaine was statistically more toxic than were the others. The toxicity of tetracaine was statistically indistinguishable from balanced salt solution, although mild toxicity was evident clinically. Injection of 1:10 dilutions of the same anesthetic agents failed to produce a statistically significant increase in corneal thickness or opacification on any postoperative examination.

CONCLUSIONS

Anterior chamber injection of bupivacaine HCl 0.75%, unpreserved lidocaine HCl 4%, and proparacaine HCl 0.5% produces corneal thickening and opacification that is clinically and statistically significant. Tetracaine HCl 0.5% injection produces corneal thickening and opacification that is clinically apparent in some eyes but statistically insignificant. Ophthalmic surgeons should be aware of the potential for endothelial cell injury if anesthetic agents enter or are injected into the eye during cataract surgery in the concentrations supplied commercially.

The Suction Bridge for Radial Keratotomy May Avoid Late Hyperopic Shift

BACKGROUND

Radial keratotomy may induce late hyperopic shift. We present data on 140 consecutive eyes with a follow-up of up to 3 years that underwent radial keratotomy with the RK suction bridge.

METHODS

We conducted a retrospective study of 140 consecutive eyes that had radial keratotomy between 1987 and 1994. Mean preoperative spherical equivalent was -5.21 D (range -2.00 to -9.75 D). All operations were performed by one surgeon (JHK) with the RK suction bridge. A suction ring maintaining physiological intraocular pressure immobilized the eye and left a peripheral rim of uncut cornea. The ring incorporated an eccentric bridge that guided the radial keratotomy knife. The knife setting was 90% of the central corneal thickness, measured by pachymetry. Spherical equivalent refraction and spectacle corrected visual acuity were measured at 1 week, 1, 3, 6 months, 1 year, and 3 years after radial keratotomy.

RESULTS

The mean preoperative spherical equivalent refraction of -5.21 D dropped to -0.43 D at 1 week (n = 136), -0.71D at 1 month (n = 120), -0.85 D at 3 months (n = 95), -0.74 D at 6 months (n = 73), -0.77 D at 12 months (n = 79), and -0.85 D at 3 years (n = 67). Compared to 1 month spherical equivalent, at 3 years three eyes (4.4%) had moved > = or 1.00 D toward hyperopia. One eye (1.4%) shifted by 1.25 D. Paired t-tests of mean spherical equivalent refraction did not reveal significant shifts toward hyperopia. Mean preoperative spectacle-corrected visual acuity was slightly diminished at 1 week and was equal or better thereafter.

CONCLUSIONS

Our 3-year data suggest that a late hyperopic shift following radial keratotomy may be prevented if an intact peripheral rim is maintained and cutting depth does not exceed 90% of the lowest corneal thickness.

Practice styles and preferences of ASCRS members--1996 survey

A survey of the practice styles and preferences of members of the American Society of Cataract and Refractive Surgery with a United States ZIP code was performed in September 1996. Approximately 26% (1440) of the 5520 questionnaires mailed were returned by the November cutoff date. Three main profile questions were used to cross-tabulate data: age of the ophthalmologist, geographic location, and volume of cataract surgery per month. Current data were compared with data in previous annual surveys.

Mitomycin-C supplemented trabeculectomy, phacoemulsification, and foldable lens implantation

PURPOSE

To evaluate the outcome of combined mitomycin-C filtering surgery, phacoemulsification, and foldable intraocular lens (IOL) implantation.

SETTING

Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

METHODS

This retrospective study evaluated 182 eyes of 174 patients who had combined mitomycin-C trabeculectomy, phacoemulsification, and insertion of a foldable IOL through a 3.5 mm incision. Success of the combined procedure was defined as intraocular pressure (IOP) below 21 mm Hg, with or without medications, and no serious complication. Success rates were calculated using the Kaplan-Meier actuarial method.

RESULTS

Mean follow-up was 16.7 months +/- 5.4 (SD). The probability of success at 6, 12, 18, and 24 months was 98.3, 95.6, 90.6, and 88.0%, respectively. When compared with preoperatively, visual acuity improved one or more lines in 148 eyes (81.3%) and worsened one or more lines in 15 (8.2%); 111 eyes (61.0%) achieved visual acuity of 20/40 or better. The most frequent complication was posterior capsule opacification requiring capsulotomy, which occurred in 22 cases (12.0%).

CONCLUSION

The 1 year and 2 year IOP control rate of combined mitomycin-C filtering procedures and phacoemulsification in glaucoma patients was high.

The outcome of 2.3 mm incision combined phacoemulsification, trabeculectomy and lens implantation of non-foldable intraocular lenses

We report the results of 100 eyes in 88 patients that underwent combined phacoemulsification and implantation of non-foldable intraocular lenses (IOLs) following enlargement of the initial 2.3 mm opening and trabeculectomy. Intraocular pressure (IOP) control (< 21 mmHg) was attained in 96% of the eyes. Visual acuity of 6/12 or better was attained in 76% of the eyes. A filtering bleb was absent in only 11% of the eyes. All these outcomes were favourable compared with previously reported series in which foldable IOLs were inserted without enlargement of the initial trabeculectomy openings. We conclude that the combination of small-incision cataract surgery and trabeculectomy with implantation of non-foldable IOLs is a successful surgical approach for visual rehabilitation and glaucoma control in patients with concurrent cataract and glaucoma.

Site of service, anesthesia, and postoperative practice patterns for oculoplastic and orbital surgeries

PURPOSE

Variations in physician practice patterns, particularly with reference to cost-intensive resource utilization, are increasingly being scrutinized. However, little information is currently available regarding physician practice patterns for oculoplastic surgery.

METHODS

The authors surveyed members of the American Society of Ophthalmic Plastic and Reconstructive Surgery regarding their most common site of service, type of anesthesia, and first postoperative week of follow-up for 15 selected eyelid, lacrimal, and orbital procedures.

RESULTS

The majority of eyelid and lacrimal surgeries are currently performed on an out-patient basis (hospital out-patient, ambulatory surgery center, or office), typically using local anesthesia, with or without sedation. Regional differences were noted. Physicians in western states showed a greater tendency toward office-based surgery for procedures such as blepharoplasty and ptosis repair. Orbital procedures were performed more frequently as a hospital inpatient surgery, under general anesthesia. Patterns of follow-up within the first postoperative week varied considerably for most procedures. Compared with admitting practices in 1987, an obvious trend toward out-patient surgery was noted.

CONCLUSION

Variations in practice patterns will assume greater importance as the pressure for cost-containment increases. Total costs are affected by physician choices for site of service and type of anesthesia. This study allows surgeons who perform oculoplastic procedures to compare their practices with a national group specializing in such surgery. Further outcome-oriented studies are needed to develop practice guidelines for "preferred patterns" of care.

Practice styles and preferences of ASCRS members--1995 survey

A survey of the practice styles and preferences of the 1995 members of the American Society of Cataract and Refractive Surgery with a U.S. ZIP code was performed in September 1995. Approximately 27% (1500) of the 5500 questionnaires mailed were returned by the December cutoff date. Four main profile questions were used to cross-tabulate data: age of the ophthalmologist, geographic location, volume of cataract surgery per month, and volume of refractive surgery per month. Current data were compared with data in previous annual surveys.

No-stitch phacotrabeculectomy

PURPOSE

To describe and evaluate no-stitch trabeculectomy combined with phacoemulsification and intraocular lens implantation.

SETTING

Arnold Cataract Center, Springfield, Missouri.

METHODS

Results of two groups that had combined phacoemulsification/trabeculectomy were compared. One group had a standard, "two-stitch" phacotrabeculectomy in which the scleral tunnel incision was secured with sutures. In the no-stitch group, no scleral "flap" was created. The scleral tunnel (pocket) was left intact over the trabeculectomy, and no sutures were used to close the scleral incision. One episcleral suture was used to secure the conjunctiva at the limbus.

RESULTS

Mean intraocular pressure (IOP) reduction in the no-stitch group (n = 66) was 9.7 mm Hg; 88% of eyes required no glaucoma medication after a mean of 13.2 months. At the last examination, 95% had an IOP of 21 mm Hg or less and 73%, 16 mm Hg or less. A detectable bleb was present in 92%. These results, comparable to those of the two-stitch group, were consistent in eyes followed over 2 years.

CONCLUSION

No-stitch phacotrabeculectomy is a simple, safe, effective way to combine phacoemulsification and trabeculectomy that might lead to better filtration without the risks of other techniques (e.g. releasable sutures, suturelysis, antimetabolite therapy.

Practices styles and preference of Danish cataract surgeons--1995 survey

A survey of the practice styles and preferences of the 348 members of the Danish Ophthalmological Society with address in Denmark was performed in January 1995, 51.4 percent (179) of the questionnaires were returned. The low percentage of returned answers is mainly due to non-response from ophthalmologists not performing cataract surgery. The data from the questionnaire were compared to similar reports from Sweden and the US.

Prospective study of the SI-40NB foldable silicone intraocular lens

PURPOSE

To evaluate the surgical performance and postoperative outcomes of 100 consecutive implantations of the new AMO PhacoFlex SI-40NB foldable intraocular lens (IOL).

SETTING

Concord Hospital and Dalcross Private Hospital, Sydney, Australia.

METHODS

This prospective study comprised 100 consecutive patients who had endocapsular phacoemulsification cataract surgery with implantation of the AMO SI-40NB IOL, which has a silicone optic and poly(methyl methacrylate) (PMMA) haptics. Patients were excluded if trabeculectomy was performed concomitantly. The main outcome measures were control of folding, ease of implantation, centration, intraoperative and postoperative complications, and visual acuity. A minimum of 4 months follow-up was planned.

RESULTS

Mean follow-up was 4.3 months +/- 2.1 (SD) (range 1 to 12 months). The lens permitted excellent control of folding and insertion, as well as excellent centration at surgery and 4 months. There was one lens-related intraoperative complication because of crimping of the trailing lens haptic. Postoperative complications were minimal, and 92% of patients achieved a visual acuity of 20/20 or better at 1 and 4 months. Excluding the eyes with retinal pathology, 100% achieved 20/20 or better at 4 months.

CONCLUSION

The AMO SI-40NB three-piece silicone IOL with PMMA haptics provided excellent operative control, centration, and visual outcome and is suitable for small incision cataract surgery.

Calculation of intraocular lens power after radial keratotomy with computerized videokeratography

PURPOSE

Because standard methods to determine intraocular lens power are not adequate in eyes that have had radial keratotomy, we undertook this study to evaluate the corneal power derived from computerized videokeratography for use in intraocular lens power calculations.

METHODS

We examined four eyes of three patients who had radial keratotomy and who underwent phacoemulsification cataract surgery with implantation of a posterior chamber intraocular lens. We used a computerized videokeratography-derived corneal curvature value in the Holladay formula for intraocular lens calculations. We determined the ideal intraocular lens power and the keratometric value that would have led to the ideal intraocular lens power from the postoperative refraction at 6.1 +/- 1.1 months after cataract extraction. The ideal keratometric value was compared with the keratometric values derived from computerized videokeratography, standard keratometry, contact lens overrefraction, and refractions before and after radial keratotomy.

RESULTS

The postoperative refraction at approximately six months averaged -0.32 +/- 0.63 diopter (range, -0.88 to +0.75 diopter) different than the aim. The mean power in ring 3, which was the closest keratometric value to the ideal, disclosed only 0.09 +/- 0.73 diopter and -0.10 +/- 0.72 diopter of deviation from the ideal keratometric and intraocular lens powers, respectively. One to two weeks after phacoemulsification cataract surgery with implantation of a posterior chamber intraocular lens, the videokeratographic differential map disclosed steepening at the wound site with variable regression by six months in all patients.

CONCLUSION

Results suggest that, after radial keratotomy, using the keratometric value derived from computerized videokeratography in intraocular lens calculations is more accurate than using keratometric values measured by routine methods.

Deep, topical, nerve-block anesthesia

Retrobulbar anesthesia produces profound anesthesia but involves risks such as hemorrhage and ocular tissue damage. Simple topical anesthesia is safer but does not produce the same depth of anesthesia. I have developed a technique that places a lidocaine-soaked sponge deep in the conjunctival fornices. This deep, topical, "nerve-block" technique produces a level of anesthesia previously seen only with injection techniques. I present the results of using this technique in 81 cataract extraction and intraocular lens implantation procedures. Supplemental injection was used in only two patients. The technique has advantages over injection and topical methods of anesthesia and is applicable to a variety of surgical procedures.

Practice styles and preferences of ASCRS members--1994 survey

A survey of the practice styles and preferences of the 1994 members of the American Society of Cataract and Refractive Surgery who had a U.S. ZIP code was performed in September 1994. Approximately 32% (1569) of the 4849 questionnaires mailed out were returned by the November cutoff date. Four main profile questions were used to cross-tabulate: age of the ophthalmologist, geographic location, volume of cataract surgery per month, and volume of refractive surgery per month. This report also compared the data with previously published surveys.

Long-term decentration of intraocular lenses implanted with envelope capsulotomy and continuous curvilinear capsulotomy: a comparative study

Intraocular lens (IOL) decentration was studied in a series of 569 consecutive eyes that had extracapsular cataract extraction (ECCE) and posterior chamber IOL implantation. In 383 of the eyes, an envelope capsulotomy (EC) was performed; in 186, a continuous curvilinear capsulotomy (CCC). In 33 eyes, the anterior capsule had one radial tear that reached the lens equator. In all eyes, IOL decentration was determined more than six months after surgery. Mean IOL decentration was 0.42 +/- 0.02 mm in the EC eyes and 0.27 +/- 0.01 mm in the CCC eyes (P < .001). In the CCC eyes, mean IOL decentration was 0.23 +/- 0.02 mm when the anterior capsule had no tears and 0.42 +/- 0.06 mm when it had one radial tear (P < .01). In the EC eyes, mean decentration was less with lenses with a total diameter of 11.0 mm or less and 360 degree circular loops (compressible disc and circular open-loop lenses) than with C- and J-loop lenses with a total length of 13.5 mm to 14.0 mm. With the C- and J-loop lenses in all three capsulotomy groups, mean decentration was related to the presence and number of tears in the anterior capsule: 0.58 mm in the EC eyes, 0.41 mm in the CCC with tear eyes, and 0.23 mm in the CCC without tear eyes. A similar relationship was seen with the bag-implanted lenses: 0.48 mm in the EC eyes, 0.28 mm in the CCC with tear eyes; 0.22 mm in the CCC without tear eyes.