Randomized double-masked controlled trial comparing pain scores with and without the use of supplementary 2% lidocaine gel in LASIK

PURPOSE

To compare pain scores with and without supplementary topical 2% lidocaine gel in patients undergoing simultaneous bilateral laser-assisted in situ keratomileusis (LASIK) under topical anesthesia using 0.5% proparacaine eye drops.

DESIGN

Randomized double-masked placebo-controlled trial.

METHODS

Fifty-one Chinese subjects (102 eyes, with 51 eyes in each arm) were included. One eye was randomly allocated to have supplementary 2% lidocaine gel while the other eye received carbomer gel as control, in addition to topical 0.5% proparacaine. The pain scores for each eye during microkeratome flap creation, during laser ablation, and at 15, 30, and 45 minutes after LASIK were assessed. An overall pain score of the LASIK procedure was also obtained. Primary outcome measures were pain scores during and after LASIK. Secondary outcomes included need for additional topical anesthesia, patient cooperation score, and duration and complications of surgery.

RESULTS

In the 2% lidocaine gel-treated group, the pain scores were significantly lower during microkeratome flap creation and laser ablation, and postoperatively at 30 and 45 minutes (P<.05 for all). Patients in the lidocaine gel group required less additional topical anesthesia (P=.0004) and were more cooperative (P=.019) as compared to the carbomer gel group. No surgical or postoperative complications were observed.

CONCLUSIONS

The use of supplementary 2% lidocaine gel in LASIK is effective in lowering the pain experienced during and up to 45 minutes after LASIK.

Preoperative Antisepsis With Povidone-Iodine 5% in Cataract Surgery

PURPOSE

This study aimed to evaluate the efficacy of povidone-iodine (PI) 5% as the only preoperative antiseptic in cataract surgery.

DESIGN

Prospective interventional case series.

METHODS

Fifty patients undergoing phacoemulsification under topical anesthesia in an outpatient surgery setting in a teaching hospital participated in the study. The preoperative antiseptic regimen consisted of instillation into the conjunctival sac and periorbital scrub with PI 5%. No topical antibiotic was given. Eyelid margin swabs were obtained for bacteriological culture before and after PI antisepsis and at the conclusion of surgery. The number of bacterial species isolated was compared with the Wilcoxon test. Anterior chamber aspirates were taken immediately before and after surgery to determine the rate of contamination.

RESULTS

Bacteria were isolated from the eyelid margins of 48 patients (96%; 95% exact confidence interval, 86.3%-99.5%) before surgery, from the eyelid margins of 28 patients (56%) after antisepsis with PI 5%, and from the eyelid margins of 26 patients (56%; 95% exact confidence interval, 41.3%-70.0%) at the conclusion of surgery. The reduction of positive eyelid margin culture was statistically significant (P < 0.0001). Anterior chamber aspirates were positive in 3 patients. One patient with negative growth from anterior chamber aspirates developed culture-negative postoperative endophthalmitis.

CONCLUSIONS

Because 56% of eyelids still have positive culture after PI 5% antisepsis, it might not be relied on as the sole preoperative antiseptic measure. Meticulous surgical technique, together with other modalities of preoperative and intraoperative antisepsis, should be used to prevent postoperative endophthalmitis.

Effectiveness of diode laser trans-scleral cyclophotocoagulation in patients following silicone oil-induced ocular hypertension in Chinese eyes

We evaluated the effectiveness of diode laser trans-scleral cyclophotocoagulation (TSCPC) on intraocular pressure (IOP) in nine patients having raised IOP following use of silicone oil (SO) for retinal detachment (RD) surgery in a retrospective observational case series. Diode laser TSCPC was applied at a power setting of 1.75 to 2.5 watts, for two sec with a maximum of 30 applications. The patients were followed up for 40 to 312 weeks. The mean pre-laser IOP was 32.06 mm Hg (SD 7.32). The mean post-laser IOP at one month, three months and six months was 17.89 mm Hg (SD 8.23), 21.89 mm Hg (SD 8.16) and 21.67 mm Hg (SD 7.55) respectively. The final IOP (at the last follow-up) was 19.56 mm Hg (SD 7.85) (P=0.021). Seven of them had undergone SO removal. In our observation, effectiveness of TSCPC in long-term control of SO-induced ocular hypertension was limited as compared to short-term control of IOP.

Randomized controlled trial on the safety of intracameral cephalosporins in cataract surgery

Objective:

To compare the safety profiles of intracameral cephalosporins in cataract surgery.

Patients and methods:

In this controlled trial, 129 patients were randomized to one of four groups to receive 1 mg of one of three cephalosporins – cefazolin, cefuroxime, or ceftazidime, or normal saline – given intracamerally during cataract surgery. Central endothelial cell density (ECD) and retinal center point thickness (CPT) were determined by specular microscopy and ocular coherence tomography, respectively, before and at 3 months after surgery.

Results:

There were no statistical significant differences in the changes of ECD and CPT between eyes receiving intracameral cephalosporin and control.

Conclusion:

The use of intracameral cefazolin, cefuroxime, or ceftazidime (1 mg in 0.1-mL solution) at the time of cataract surgery had no significant effect on ECD and CPT postoperatively.

Central serous chorioretinopathy after sequential argon-neodymium: YAG laser iridotomies

Laser peripheral iridotomy is the standard treatment for acute angle-closure glaucoma. A patient with acute angle-closure glaucoma who developed central serous chorioretinopathy after uneventful laser iridotomies is described. Central serous chorioretinopathy occurring after sequential argon-neodymium:YAG laser peripheral iridotomy is a novel complication in the English literature and is related to the stress induced by both the initial disease and the subsequent procedure, particularly in psychologically susceptible individuals.

Unilateral ptosis correction with mersilene mesh frontalis sling in infants: thirteen-year follow-up report

PURPOSE

To assess surgical, visual, refractive, and aesthetic outcomes 13 years after mersilene mesh frontalis sling (MMFS) operation for severe unilateral congenital ptosis performed in 10 infants before 1 year of age.

METHODS

Longitudinal follow-up of an interventional case series by structured ocular examinations, external photographs, and questionnaire-based interviews.

RESULTS

Mean age at surgery was 6.9+/-2.7 months. After a mean follow-up of 13.0+/-0.6 years, one patient (10%) had recurrent ptosis with the upper lid 2 mm below the superior limbus at 3 months postoperatively. Best-corrected visual acuities were within two Snellen lines between the two eyes in all patients. Astigmatic errors were 1.20+/-1.00 D and 1.10+/-1.70 D between operated and unoperated eyes. Four patients had 2 mm lid lag on down-gaze and one of them had 2 mm lagophthalmos. Mean satisfaction scores (scale of 1 to 100) for lid position, cosmesis, function, and to the procedure were 83.3+/-11.8, 77.0+/-22.9, 89.4+/-5.5, and 86.8+/-6.3, respectively. No case of overcorrection, sling extrusion, stitch granuloma, or exposure keratopathy was noted.

CONCLUSIONS

In view of the low recurrence rate (10%) and absence of serious complication or need for revision after 13 years, the use of MMFS seems effective and feasible in infants less than 1 year old. Achieving compatible long-term stability, satisfactory aesthetic, and visual outcomes, MMFS may offer an alternative to delaying operations for autogenous fascia lata harvesting in infants requiring early ptosis correction.

Retrocapsular lens matter in uneventful phacoemulsification: does it really exist?

PURPOSE

To have the first cytopathological evaluation of any lens matter fragments within retrocapsular anterior vitreous in those patients undergone uneventful phacoemulsification in Prince of Wales Hospital, Department of Ophthalmology and Visual Sciences, the Chinese University of Hong Kong, Hong Kong.

METHODS

Thirty patients with cataracts and various vitreoretinal conditions that required combined surgery were recruited. After the uneventful clear corneal phacoemulsification, three sclerotomies including infusion port were created with cautions against any inadvertent leakage of vitreal content. The anterior vitreous at retrocapsular space was harvested by a special 'round-the-clock' dry vitrectomy into a special specimen reservoir hub and syringe. The aspirate was immediately fixed in 50% ethanol and together with a masked positive control sent for cytocentrifugation processing. The microscope slides of the anterior vitreal content and control were stained with haematoxylin and eosin and papanicolaou. Positive controls were collected from the effluent fluid of the phaco cassettes right after the phacoemulsification. The samples were masked and examined by an experienced pathologist for any cytopathological evidence of lens matter.

RESULTS

Out of 30 patients, three suspicious cases of retrocapsular lens fragment were noted by retroillumination on the operating table. However, all the anterior vitreous specimens were negative for lens matter whereas all the controls were positive after cytopathological verification.

CONCLUSIONS

This is the first cytopathological study objectively indicating low likelihood of the postulation that retrocapsular lens matter occurred after uneventful phacoemulsification.

Photographic essay. Anterior segment optical coherence tomography findings of early capsular block syndrome

Capsular block syndrome (CBS) or capsular bag distension syndrome is characterized by distension of the capsular bag after uneventful phacoemulsification and endocapsular intraocular lens implantation. The syndrome has also been reported after extracapsular cataract extraction and intraocular lens placed in the sulcus. We report the anterior segment optical coherence tomographic findings in a case of early postoperative CBS. Anterior segment optical coherence tomographic aids in the diagnosis and management of CBS.

Retention of silicone oil droplets from ophthalmic viscosurgical devices in the drainage angle of 2 eyes

We report the outcome in 2 eyes of 2 patients with retained silicone oil droplets in the anterior chamber drainage angle after the use of an ophthalmic viscosurgical device (OVD) during cataract surgery. Silicone oil droplets were observed when the OVD was injected into the anterior chamber during phacoemulsification. Despite removal by irrigation and aspiration, droplets were observed in the anterior chamber during the immediate postoperative period. At 15 months, they were observed in the drainage angle. The retained silicone did not produce untoward side effects in the eyes. Silicone oil is a common contaminant in OVDs but appears to be inert and harmless when retained in small amounts in the anterior chamber drainage angle.

Topical anesthesia-induced keratopathy after laser-assisted subepithelial keratectomy

A 42-year-old woman had uneventful bilateral laser-assisted subepithelial keratectomy (LASEK) to correct myopia. She experienced intense pain in the first postoperative week and obtained topical oxybuprocaine for pain relief. Subsequently, she developed bilateral persistent corneal epithelial defects, epithelial edema, and bullae that failed to heal with bandage contact lens and topical lubricants. Over the next 4 months, there was progressive corneal stromal thinning and descemetocele formation in 1 eye, requiring application of cyanoacrylate glue, and stromal edema and scarring in the other eye, which resulted in a visual acuity of counting fingers. Investigations did not reveal associated infection or an underlying immunological disorder; however, the patient admitted to excessive use of topical anesthetic eyedrops in the post-LASEK period. She subsequently had penetrating keratoplasty and lens extraction with IOL implantation in the right eye. The left eye healed with central corneal scarring. This case illustrates that serious sight-threatening complications may occur after LASEK due to abuse of topical anesthetic agents.

Unusual eye signs in Wegener's granulomatosis

Wegener's granulomatosis is a rare necrotising vasculitis not easily diagnosed due to the obscurity of its diverse clinical features. Despite its comparatively low incidence, the unusual ophthalmic manifestations seen in this disease warrant extra caution from attending rheumatologists. In this case, bilateral peripheral ulcerative keratitis preceded any systemic symptoms. Timely recognition of the significance of this ophthalmic complaint and prompt ophthalmological consultation can help achieve early diagnosis and treatment of this potentially fatal rheumatological disease.

Acyclovir-induced nephrotoxicity in a patient with acute retinal necrosis

A 50-year-old woman developed rapidly progressive acute renal failure on the first day after the administration of intravenous acyclovir for acute left retinal necrosis. Intravenous acyclovir was stopped and replaced with intravitreal injections of ganciclovir sodium (2 mg/0.05 mL) and foscarnet (1.2 mg/0.05 mL) 3 times per week for 4 weeks. Acyclovir-induced renal impairment can be reversed if recognised early and treated with careful, timely body fluid replacement. The necrotising retinitis responded well to intravitreal antiviral agents. No complications were seen at the 6 months' follow-up. Constant vigilance is essential for avoiding acute renal failure when treating ophthalmic conditions with intravenous acyclovir. Systematic monitoring of renal function, urine output, and characteristic symptoms like loin pain is warranted.

Safety and Efficacy of Micro-Incisional Cataract Surgery with Bimanual Phacoemulsification for White Mature Cataract

BACKGROUND

To evaluate the safety and efficacy of micro-incisional cataract surgery (MICS) with bimanual phacoemulsification for the management of white mature cataract.

METHODS

Twenty-five eyes in 25 patients with mature cataract were prospectively recruited to undergo MICS with bimanual phacoemulsification. Serial changes in best-corrected visual acuity (BCVA), central corneal thickness (CCT) and endothelial cell density (ECD) were compared using the Wilcoxon signed-rank test.

RESULTS

MICS was successfully performed in 24 (96%) of the 25 eyes, with 1 eye requiring conversion to extracapsular cataract extraction due to radial tear during continuous curvilinear capsulorhexis. The median preoperative BCVA was hand movement. On day 1 postoperatively, the median BCVA improved to 0.6 (p < 0.001 compared with baseline). All patients had BCVA of 0.6 or better at 3 months after surgery (p < 0.001 compared with baseline). The mean increase in CCT at day 1 and week 1 postoperatively was 11.5 and 7.1%, respectively. The change in mean CCT was no longer significant at month 3 postoperatively (p = 0.82). The mean reduction in ECD at 3 months postoperatively was 7.8% (p = 0.037). None of the patients developed any postoperative complications.

CONCLUSIONS

MICS with bimanual phacoemulsification appeared to be a promising alterative for the management of white mature cataract.

Prioritization of cataract surgery: visual analogue scale versus scoring system

BACKGROUND

The purpose of the present paper was to evaluate the variability of using a visual analogue scale (VAS) and to assess the feasibility of a priority-setting scoring system for prioritizing elective cataract surgery.

METHODS

Consecutive cases listed for cataract surgery were prospectively recruited. Ophthalmologists listed patients to undergo early or normal surgery and were asked to rate the urgency of surgery using a VAS. Patients were then reassessed and a cataract surgery prioritization (CSP) score was calculated based on the New Zealand priority criteria for cataract surgery. Correlation coefficients between VAS and CSP scores were calculated to determine the variability among ophthalmologists in using the VAS in prioritizing surgery. Further analyses were performed to assess the potential impact of implementing the CSP system.

RESULTS

A total of 326 patients were recruited. There was a positive correlation between VAS and CSP scores (Spearman rho= 0.407, P < 0.001). A high degree of variation among ophthalmologists in the use of VAS was found. Patients with poor binocular vision were not listed as early, whereas patients with poor vision in the eye listed for cataract surgery but good vision in the fellow eye were more likely to be prioritized to have early operation. These findings suggest that patients with severe impairment in binocular visual function were not adequately accounted for during cataract surgery listing.

CONCLUSIONS

The use of a VAS for prioritizing cataract surgery may be suboptimal due to high subjectivity. Adoption of an objective criteria-validated priority-setting scoring system may allow better stratification of patients to ensure better service provision.

A prospective study on trypan blue capsule staining under air vs under viscoelastic

AIM

To compare the safety and effectiveness of trypan blue capsule staining under air vs under viscoelastic.

METHODS

A total of 52 consecutive patients planned for phacoemulsification of white mature cataract were randomly assigned to trypan blue staining under air or under viscoelastic. Perioperative changes in best-corrected visual acuity (BCVA), central corneal thickness (CCT), and endothelial cell density (ECD) were compared between the two groups. The differences in operating and phacoemulsification times, staining pattern, and complications between the two groups were also recorded.

RESULTS

Phacoemulsification of white mature cataract was performed in 50 (96%) eyes. The median preoperative BCVA was hand movement. No significant differences in the baseline characteristics were found between the two groups. At 3 months after phacoemulsification, the median BCVA improved to 0.8. The mean CCT returned to preoperative level by 1 month postoperatively and the mean ECD loss was 11.9% 3 months postoperatively. No significant differences in median BCVA, mean phacoemulsification and operation times, mean CCT, and mean ECD were found between the two groups.

CONCLUSIONS

Trypan blue staining of the anterior lens capsule under air or under viscoelastic were similarly effective and safe methods for the phacoemulsification of white mature cataract.

Black diaphragm aniridia intraocular lens for aniridia and albinism

BACKGROUND

Our aim was to assess the safety and efficacy of primary and secondary implantation of a black diaphragm aniridia intraocular lens (IOL) in patients that lacked a complete iris diaphragm.

METHODS

This was a retrospective non-comparative study of six eyes in five patients with iris defects. The causes of such defects included congenital aniridia, traumatic aniridia, and oculocutaneous albinism. Three eyes underwent primary implantations of a black diaphragm IOL, and three eyes were given secondary implantations. The visual acuity, subjective severity of glare, postoperative anatomical outcome and any intraoperative or postoperative complications were reviewed.

RESULTS

The mean follow-up period was 20.6 months (range 3-29 months). All patients showed stable or improvement in best-corrected visual acuity postoperatively. Glare and photophobia had improved subjectively in all patients after implantation of the black diaphragm IOL. Intraoperative complication included one case of hyphaema and iris damage during insertion of the IOL. Postoperative complications included intraocular inflammation with choroidal detachment, secondary glaucoma, and persistent epithelial defect after surgery. None of the patients developed decentration of IOL after surgery.

CONCLUSION

The black diaphragm aniridia IOL is useful in the management of the condition in patients with iris deficiency including oculocutaneous albinism. Intraoperative and postoperative complications are not uncommon, and patients should be monitored carefully in the perioperative period.

Randomized clinical trial of the efficacy and safety of tropicamide and phenylephrine in preoperative mydriasis for phacoemulsification

PURPOSE

To compare the mydriatic effect and safety between different concentrations of tropicamide and phenyle-phrine in preoperative mydriasis for phaco-emulsification.

METHODS

Two hundred and seventeen consecutive eyes in the same number of Chinese patients undergoing phaco-emulsification under local or topical anaesthesia in a university-based eye hospital were analyzed. Patients were randomized into two groups by cluster randomization, each group receiving a different preoperative mydriatic regimen. Regimen A consisted of tropicamide 1.0% with phenylephrine 2.5%, and Regimen B consisted of tropicamide 0.5% with phenylephrine 0.5%. The main outcome measures were horizontal pupillary diameter, systolic, diastolic and pulse pressure and pulse rate.

RESULTS

The group who received Regimen A attained a mean horizontal pupillary diameter of 7.00 +/- 1.06 mm. Their pupils were significantly larger than those receiving Regimen B (6.61 +/- 1.03 mm, P = 0.007). No untoward cardiovascular effects were noted in either groups.

CONCLUSION

Regimen A attained better preoperative mydriasis for phacoemulsification than Regimen B. Both regimens were safe with regard to their cardiovascular effects. The combination of tropicamide 1.0% and phenylephrine 2.5% is recommended as preoperative mydriatic for phacoemulsification in Chinese patients who have darkly pigmented irides.