Arijit Mitra

Human Reliability Analysis of Cataract Surgery

OBJECTIVE To evaluate the use of the Human Reliability Analysis of Cataract Surgery tool to identify the frequency and pattern of technical errors observed during phacoemulsification cataract extraction by surgeons with varying levels of experience. DESIGN Observational cohort study. Thirty-three consecutive phacoemulsification cataract operations were performed by 33 different ophthalmic surgeons with varying levels of operative experience: group 1, fewer than 50 procedures; group 2, between 50 and 250 procedures; and group 3, more than 250 procedures. Face and content validity were surveyed by a panel of senior cataract surgeons. The tool was applied to the 33 randomized and anonymous videos by 2 independent assessors trained in error identification and correct tool use. Task analysis using 10 well-defined end points and error identification using 10 external error modes were performed for each case. The main outcome measures were number of errors performed per task, nature of performed errors (executional or procedural), and surgical experience of operating surgeon. RESULTS Analysis of 330 constituent steps of 33 operations identified 228 errors, of which 151 (66.2%) were executional and 77 (33.8%) were procedural. The overall highest error probability was associated with sculpting, followed by fragmentation of the nucleus; this was most evident in group 1. Surgeons in group 3 proportionally performed more errors during removal of soft lens matter than those in group 1 or 2. Surgical experience had a significant effect on the number of errors, with a statistically significant difference among the 3 groups (P < .001). CONCLUSIONS The Human Reliability Analysis of Cataract Surgery tool is useful for identifying where technical errors occur during phacoemulsification cataract surgery. The study findings, including the high executional error rate, could be used to enhance and structure resident surgical training and future assessment tools. Face, content, and construct validity of the tool were demonstrated.

Prophylactic subconjunctival cefuroxime during cataract surgery in patients with a penicillin allergy

The incidence of cross-reaction after subconjunctival cefuroxime following cataract surgery in penicillin allergy patients is not common and therefore cefuroxime with its better spectrum of action and lower toxicity is probably a better choice than gentamycin.

Orbital cellulits following cataract surgery under peribulbar anaesthesia

Introduction: Orbital cellulits following cataract surgery is extremely rare. We describe a case of orbital and facial cellulitis that occurred after routine cataract operation with peribulbar anaesthesia. There were no preoperative systemic or ocular risk factors for postoperative infection. Case description: An 89-year-old man presented to eye casualty, the day after he underwent an uneventful phacoemulsification and posterior chamber lens implantation in the left eye under peribulabr anaesthesia, with soreness, swelling and reduced visual acuity (6/18) in the operated eye. On initial presentation periorbital swelling was noted, the eye was minimally tender, intraocular pressure was raised at 28 mHg and fundoscopy was limited due to a hazy cornea. The patient was discharged on topical medication with a diagnosis of allergic reaction to postoperative drops. The following day, the patient re-presented with worsening orbital swelling involving the left cheek. Ocular findings remained unchanged. CT scan revealed left orbit soft tissue swelling and a locule of air medial to the medial rectus. There were no signs of sinus infection or periosteal inflammation. A diagnosis of left orbital and facial cellulitis was made and the patient was treated with intravenous antibiotics. Discussion: Our patient did not have any predisposing risk factors, therefore most likely cause of cellulitis is surgical trauma during administration of the peribulbar block. This case illustrates the need for adequate skin preparation before the administration of peribulbar anaesthesia and minimal tissue trauma during the procedure.

Occult giant cell arteritis and steroid therapy how urgent is urgent

Case ReportWe report two cases of sudden loss of vision in the second eye, within a few hours of loss of vision in the first, in association with occult giant cell arteritis. Both cases presented with bilateral disc edema. The importance of starting steroid therapy to prevent sight- or life-threatening complications, as soon as a diagnosis is suspected is emphasized.

Intravitreal Fluocinolone Acetonide (ILUVIEN) Implant for the Treatment of Refractory Cystoid Macular Oedema After Retinal Detachment Repair

Cystoid macular oedema (CMO) is one of the most frequent postoperative macular complications to cause partial visual recovery after successful retinal detachment (RD) repair. Refractory CMO is difficult to treat and many strategies have been employed with varying degrees of success. We report for the first time the use of ILUVIEN implant to treat refractory CMO after successful RD repair. A 65-year-old female presented with right eye full-thickness macular hole and underwent pars plana vitrectomy, internal limiting membrane peeling and cryotherapy with gas tamponade with 12% C3F8. She subsequently developed right eye macula-on RD and proliferative vitreoretinopathy and required multiple procedures for successful retinal reattachment. Later, she developed CMO that responded to intravitreal triamcinolone injections and intravitreal dexamethasone 0.7-mg implants but recurrence of CMO continued to be a problem. After receiving ILUVIEN intravitreal implant, her visual acuity improved and CMO resolved without recurrence for 13 months. Refractory CMO after RD repair is difficult to treat and in a quarter of cases will not improve without treatment. Our case shows that a single ILUVIEN implant maintained anatomical dry fovea and improved vision. This also demonstrates that ILUVIEN is an effective management strategy to reduce the need for repeated treatments.

Active iris vascular tufts bleeding successfully treated with argon laser photocoagulation

Purpose: Iris vascular tufts (IVT) are rare biomicroscopic capillary outgrowths from the pupillary margins. Patients are usually asymptomatic until presenting with blurred vision due to spontaneous hyphema or with raised intraocular pressure. Case report: A 61-year-old woman presented to eye casualty with left eye (LE) blurred vision and discomfort for 1 day. Her external ocular examination was unremarkable and visual acuity was 6/6 in the right eye (RE) and 6/9 in the LE. Biomicroscopic examination revealed a 2-mm hyphema in her LE and bilateral multiple small IVT and active bleeding from IVT at the pupillary margin of the LE at the 5 o’clock position. Diagnosis of LE active bleeding from IVT was made and she underwent argon laser photocoagulation directed at the source of bleeding. The bleeding stopped immediately after the second burn. She was followed up for 3 months; her visual acuity was 6/5 and 6/6 in the RE and LE, respectively, with no further problems. Conclusions: Iris vascular tufts are benign and recurrent hemorrhages are unlikely. Therefore, definitive argon laser photocoagulation or surgical treatment are reserved to arrest further episodes of hyphema. Our case demonstrates the effective use of argon laser photocoagulation to completely arrest active bleeding from IVT and excellent recovery of hyphema with no further problems for 5 years.

Improving delivery of laser pan retinal photocoagulation in treatment of proliferative diabetic retinopathy

Purpose – The purpose of this paper is to assess the benefits of introducing a laser room poster in improving delivery of laser pan retinal photocoagulation (PRP) in treatment of proliferative diabetic retinopathy (PDR).Design/methodology/approach – An audit was carried out to describe the practice prior to introducing laser room poster. A reaudit was conducted after its introduction to evaluate if the practice had improved.Findings – There was a 20 per cent increase (92 per cent in reaudit versus 72 per cent in audit) in total number of laser burns between 1,000‐2,500 burns during first session. In a completed PRP, an increase of 23 per cent was recorded (45 per cent versus 22 per cent) in total number of laser burns between 3,000‐6,000 burns. Retinal area ablated less than recommended by ETDRS fell by 21 per cent (18 versus 39). Not surprisingly the percentage of patients requiring re‐treatment after completed PRP fell from 30 per cent to 21 per cent, indicating an overall improvement in PRP treatment r...

Occult giant cell arteritis and steroid therapy: how urgent is urgent?

We report two cases of sudden loss of vision in the second eye, within few hours of loss of vision in the first, in association with occult giant cell arteritis. Both cases presented with bilateral disc edema. The importance of starting steroid therapy to prevent sight or life threatening complications, as soon as a diagnosis is suspected is emphasized.