Erica Darian‐Smith

Femtosecond laser-assisted cataract surgery versus standard phacoemulsification cataract surgery: Outcomes and safety in more than 4000 cases at a single center

Purpose To compare the intraoperative complications and safety of femtosecond laser–assisted cataract surgery and conventional phacoemulsification cataract surgery. Setting Single center. Design Prospective consecutive comparative cohort case series. Methods Eyes had femtosecond laser–assisted cataract surgery (study group) or phacoemulsification (control group) by 1 of 5 surgeons. The technique comprised manual corneal incisions and capsulorhexis or laser–assisted anterior capsulotomy, lens fragmentation, corneal incisions, phacoemulsification, and intraocular lens implantation. Results The study group comprised 1852 eyes and the control group, 2228 eyes. Patient demographics were similar between groups. There was a significant improvement in vacuum/docking attempts, surface recognition adjustments, treatment, and vacuum time during the laser procedure in the study group. Anterior capsule tears occurred in 1.84% of eyes in the study group and 0.22% of eyes in the control group (P < .0001). There was no difference in the incidence of anterior capsule tears between the first half and second half of laser‐assisted cases. Anterior capsulotomy tags occurred in 1.62% study group eyes. There was no significant difference in posterior capsule tears between the 2 groups (0.43% versus 0.18%). The incidence of significant intraoperative corneal haze and miosis was higher and the effective phacoemulsification time significantly lower in the study group (P < .001). Conclusions Significant intraoperative complications likely to affect refractive outcomes and patient satisfaction were low overall. The 2 cataract surgery techniques appear to be equally safe. Although anterior capsule tears remain a concern, the safety of femtosecond‐assisted cataract surgery in terms of posterior capsule complications was equal to that of phacoemulsification. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Effect of biologic therapy on radiological progression in rheumatoid arthritis: what does it add to methotrexate?

There have been substantial advances in the treatment of rheumatoid arthritis in recent years. Traditional disease-modifying antirheumatic drugs (DMARDs) have been shown to have small effects on the progression of radiographic damage. This quantitative overview summarizes the evidence for biologic DMARDs and radiographic damage either alone or in combination with methotrexate. Two outcomes were used (standardized mean difference and odds of progression). A total of 21 trials were identified of which 18 had useable data. For biologic monotherapy, tocilizumab, adalimumab, and etanercept were significantly better than methotrexate, with tocilizumab ranking first in both outcomes while golimumab was ineffective in both outcomes. For a biologic in combination with methotrexate compared with methotrexate alone, most therapies studied (etanercept, adalimumab, infliximab, certolizumab, tocilizumab, and rituximab) were effective at slowing X-ray progression using either outcome, with infliximab ranking first in both outcomes. The exceptions to this were golimumab (no effect on standardized mean difference) and abatacept (no effect on odds of progression). This effect was additional to methotrexate; thus, the overall benefit is moderate to large in magnitude, which is clearly of major clinical significance for sufferers of rheumatoid arthritis and supports the use of biologic DMARDs in those with a poor disease prognosis.

Intraocular pressure during femtosecond laser pretreatment: Comparison of glaucomatous eyes and nonglaucomatous eyes

Purpose To compare changes in intraocular pressure (IOP) during femtosecond laser pretreatment of cataract between glaucomatous eyes and nonglaucomatous eyes. Setting Launceston Eye Institute and Launceston Eye Hospital, Launceston, Australia. Design Nonrandomized interventional prospective case series. Methods Patients with clinically stable primary open‐angle glaucoma (POAG) having femtosecond laser pretreatment were compared with a concurrent cohort of patients with healthy eyes having the same procedure. Pretreatment was performed using a fluid‐filled optical docking system (Liquid Optics Interface). With the patient supine, the IOP was measured at 4 time points using a rebound tonometer (Icare Pro). Results The study comprised 143 eyes of 97 patients. Forty‐three eyes (30.1%) had documented glaucoma. The mean baseline IOP was 20.2 mm Hg ± 4.2 (SD) in glaucomatous eyes and 18.9 ± 4.0 mm Hg in nonglaucomatous eyes (P = .06). The mean change in IOP values between each time frame and baseline was as follows: vacuum‐on, 13.8 ± 9.9 mm Hg and 11.1 ± 6.9 mm Hg, respectively (P = .06); after treatment, 17.4 ± 7.4 mm Hg and 14.1 ± 7.2 mm Hg, respectively (P = .014); after undocking of vacuum, 9.9 ± 5.4 mm Hg and 8.7 ± 5.7 mm Hg, respectively (P = .24). Conclusions Femtosecond pretreatment caused a greater transient rise in IOP after treatment and a higher residual IOP after vacuum undocking in glaucomatous eyes than in nonglaucomatous eyes. This is well tolerated short term; however, long‐term implications for eyes with glaucoma are unknown at present. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Whole population incidences of patients presenting with rhegmatogenous retinal detachments within Tasmania, Australia

We report the first whole population study within Australia to investigate the incidence of rhegmatogenous retinal detachment (RRD). All cases of RRD treated in Tasmania were identified between March 2005 and March 2010. During this period, the senior author (BJV) was the only vitreoretinal surgeon in Tasmania; therefore, accurate whole population data could be reported. For analysis of incidence data, a standardized 5-year period with whole year analysis was performed to minimize bias. This study was approved by The Tasmanian Health andMedical Human Research Ethics Committee (REF H0014540) and complies with the tenets of the Declaration of Helsinki. All primary RRDs in Tasmanian residents including non-operative cases were included, and bilateral RRDs were included as separate cases. Preoperative and operative factors were analysed including proliferative vitreoretinopathy (PVR) graded as previously defined by the Silicone Oil Study and subsequent revisions. Exclusion criteria included combined tractional/rhegmatogenous detachments, exudative retinal detachments, prior RRD in the affected eye, retinal tears without evidence of detachment, prior history of posterior segment surgery and a history of penetrating ocular trauma. Subjects not residing in Tasmania but having their detachment managed in Tasmania were also excluded. After exclusion criteria were applied, 231 RRD cases were included for the 5-year-incidence analysis. The overall incidence of primary RRD in Tasmania was 9.7 per 100000 persons per year. This is the first investigation to report the RRD incidence within Australia. Annual incidences, incidences relating to known risk factors and incidence ratios of men versus women are shown in Table 1 with peak incidences relating to risk factors shown in Table 2. The mean age of presentation was 61.6years (+/ 14.2years; range 13–92years). The peak incidence of RRD by age, gender and lens status is demonstrated in Figure 1. Men were more likely to be affected with an incidence ratio of 1.44:1 (P=0.006). The right eye was predominantly affected in 54.0% of cases with a trend to right eye predominance in women (P=0.07). Peak decade of RRD was 60–69years old, with men presenting slightly younger with a mean age of 60.4years compared with 63.5years (P=0.05). Overall, 37.8% of patients were pseudophakic; 9% had a history of blunt trauma, and 8.6%weremyopic greater than 5dioptres. At presentation, the macula was detached in 202 (62.0%) of cases. PVR at presentation was present in 39 eyes (12.0%) with grade B and 26 (8.0%) with grade C PVR. The overall incidence of RRD is similar to that demonstrated bymost studies,which have variably reported incidences between 9 and 13 per 100000. Peak ages, gender distribution, the predominance of right eye detachment and the rates of pseudophakia/trauma/high myopia were also congruent. The higher incidence in men was only partially explained by differences in trauma/pseudophakia/high myopia. Of the 37.4% (n=122) of pseudophakic patients, 11.8% (n=14) provided a history of complicated cataract operation. Given a large Western Australian audit reported a cataract operation complication rate of 1.6%, this supports the hypothesis that complicated cataract surgery increases the risk of RRD. Nine per cent of patients had a background of ocular trauma and presented with a mean age of 12years younger at presentation (P=0.009), confirming trauma as a risk factor for RRD at a younger age. The incidence ratio of trauma-related detachment for men versus women was 1.7:1. A high proportion (13.7%) of phakic patients in this study were myopic greater than 5dioptres, more than double the population rate (4.4%) reported by a Victorian series of 4744 subjects in Victoria, Australia. The incidence ratio of high myopia-related RRD for men versus women was 1.9:1. This cohort was more likely to present without macular detachment (35.7% vs. 61.7%, P=0.006). This has not been reported previously but possibly represents greater awareness of warning symptoms within this group of patients, because of counselling by primary eye services regarding warning symptoms at routine ocular reviews. Patients had a fellow eye detachment in 8.3% of cases (n=28), and 4% had a first degree family history of RRD. Given the incidence of 9.7 per 100000 per year, these proportions are higher than would be expected within the population. Advantages of this study are the well-defined geographic area and population data, covering a whole island. As there was only one vitreoretinal surgeon during the period under investigation, all patients with retinal detachment within the state were

Tasmanian macular hole study: whole population based incidence of full thickness macular hole

To determine the incidence of full thickness macular hole in the Tasmanian population.

Corneal decompensation following bleb needling with 0.01% mitomycin C: a case study.

Bleb needling with mitomycin C (MMC) is a routine, safe and successful technique used to resuscitate a failed filtration procedure. It is known that MMC is associated with corneal endothelial toxicity in humans at intraocular concentrations of 0.2 mg/mL. We report the rare case of corneal decompensation following bleb needling with MMC 0.1 mg/mL in a patient with normal corneal endothelium. A 69-year-old female patient, who presented with bilateral advanced primary open-angle glaucoma and visually significant cataracts, underwent bilateral combined phacoemulsification, intraocular lens implantation and trabeculectomy with MMC 0.04%. The left eye was uneventful. The right eye developed late bleb encystment at 12 months with poorly controlled intraocular pressure of 33 mmHg. This was treated with bleb needling with MMC 0.01%. There was no pre-existing corneal disease. Corneal decompensation was observed 5 days after the needling. Preoperatively, lignocaine gel 2% was applied over the surgical site and a sub-Tenon’s block was performed. A corneal traction suture was placed superiorly and a paracentesis temporally. The encysted bleb and the posterior edge of the scleral flap were needled using a bent 27G needle. A blob of viscoelastic Provisc (Alcon, Fort Worth, TX, USA) was injected just behind the sclera flap before 0.2 mL of MMC 0.01% was injected further posteriorly. The anterior chamber was then reformed with balanced salt solution and Provisc. Subconjunctival cephalothin and dexamthasone were placed inferiorly at the end of the surgery. Postoperatively, the patient was administered Gutt Prednefrin Forte 1% (Allergan, Irvine, CA, USA) every 2 waking hours, Gutt Chloramphenicol QID and Hycor 1% ointment nocte (Aspen Pharma, New South Wales, Australia). Day 1 postoperatively, the patient’s best-corrected visual acuity (BCVA) was 6/45 with an intraocular pressure of 3 mmHg. The anterior chamber was formed with Provisc, and no choroidal effusion occurred. On day 5 postoperatively, the patient presented unexpectedly with a BCVA of hand movements only. On examination, there was diffuse corneal haziness with stromal oedema, Descemet’s folds and epithelial microcysts (Fig. 1). The conjunctiva was mildly injected with no hypopyon. B-scan ultrasound showed clear vitreous humour and no posterior segment lesion. This was managed conservatively with continuation of the topical steroid and antibiotic. After 6 weeks, there was complete resolution of corneal decompensation with improvement of BCVA to 6/12. Informed consent was obtained, and the study was conducted in accordance with the declaration of Helsinki and its subsequent revisions. To our knowledge, corneal decompensation following bleb needling with a low MMC concentration of 0.01%, in eyes with previously healthy endothelium, has not been reported. In a large study containing 186 late needling procedures of flat filtering blebs with MMC (0.1 mL at a concentration of 0.08 mg/mL), there were no cases of corneal decompensation. Additionally, 92% of all needled blebs were restored demonstrating that late bleb needling is a safe and effective procedure. Despite these encouraging findings, we report the rare complication of corneal decompensation following bleb needling, performed utilizing a similar technique. There are possible explanations for this rare complication aside from the possible ocular toxicity of MMC. For instance, potential contamination of MMC preparation may have caused disruption of the corneal milieu. Toxic anterior segment syndrome describes a specific, non-infectious, anterior segment inflammatory process that appears in the immediate aftermath of intraocular surgery and resolves with topical steroids. A variant of TASS could have caused reduced vision, corneal oedema and endothelial cell loss; however, the delayed presentation and the poor steroid response make this less likely. In addition, the patient’s dramatic improvement in BCVA following conservative Competing/conflicts of interest: No stated conflict of interest.

The Incidence of Ocular Tuberculosis in Australia Over the Past 10 Years (2006-2015)

ABSTRACT Purpose: To determine the incidence and clinical phenotype of ocular tuberculosis in Australia based on the mandatory jurisdictional health notification records for TB. Methods: A whole population retrospective case series (Australia). Patients diagnosed with ocular tuberculosis were identified over the past 10 years (1 January 2006 to 31 December 2015) as recorded by individual Health Department jurisdictions per mandatory health notifications. The incidence rates were calculated based on the available Australian census data. Incidence rates were age and sex standardized. Results: A total of 162 cases of ocular tuberculosis were identified across Australia over a 10-year time period. Of these, 156 participants were overseas born. The 10-year Australian incidence of ocular tuberculosis was 0.77 per 100,000 people. While there has been a downward trend in overall TB annual incidence rates from 2010 to 2015, over the same period the annual incidence of ocular TB has increased compared to the 4 previous years. Descriptive clinical data regarding the ocular manifestations of TB was available in 73/157 patients. In these 73 patients the commonest manifestations of ocular TB were unspecified uveitis (50.1%), focal, multifocal or serpiginous choroiditis or chorioretinitis (12.3%) and retinal vasculitis (11.0%). Of patients with ocular TB, 4/162 (2.47%) had associated pulmonary TB and 8/162 (4.94%) had associated systemic (non-pulmonary) TB. Systemic anti-TB therapy was administered to 161 patients. Conclusions: The annual Australian incidence of ocular tuberculosis was 0.077 per 100,000 people. Increasing notifications in the past 6 years may demonstrate increased awareness and changing diagnostic criteria of the disease in the Australian population.

Ophthalmology education in Australian medical schools: a survey of Australian junior medical officers

Ophthalmic presentations to the emergency department are common, and junior doctors who are often the first to review these patients may be required to determine whether an ophthalmology referral is required.1, 2 In addition, at least 3% (estimated range 3–19%) of all primary care consultations involve eye‐related conditions,1, 3 and ocular manifestations of systemic disease are common. The average time spent learning ophthalmology in Australian medical schools takes up less than 2% of university curricula,3, 4 underrepresentative when considering the frequency of ophthalmology‐related presentations in all clinical settings.