Parul Desai

National cataract surgery survey 1997–8: a report of the results of the clinical outcomes

AIMS A national survey of over 100 hospitals in the UK was carried out to collect routine clinical information on the outcomes of cataract surgery. The clinical outcomes of interest were: visual acuity at time of discharge from postoperative hospital follow up, visual acuity at time of final refraction; complications related to surgery occurring during the operation, within 48 hours of surgery, and within 3 months of surgery. In addition, information on age and comorbidity was obtained. This article reports on the findings of the experience of approximately 18 000 patients who had cataract surgery in the hospital eye service of the NHS. RESULTS Of those with no ocular comorbidity, 85% achieved a visual acuity of 6/12 or better on discharge from postoperative hospital follow up, while 65% of patients with a serious co-existing eye disease achieved this level of acuity at this time. At final refraction, 92% of patients without ocular comorbidity and 77% of patients with ocular comorbidity achieved 6/12 or better visual acuity. The following main risk indicators were associated with visual outcomes and complications related to surgery: age, other eye diseases, diabetes and stroke, type of surgical procedure, and grade of surgeon. CONCLUSIONS The acceptability of these findings could fruitfully be the subject of discussion within the ophthalmic community and hopefully issues arising out of the study can lead to research, especially in-depth studies of the outcomes of cataract surgery in those patients with co-existing serious eye conditions.

Gains from cataract surgery: visual function and quality of life.

AIMS: To describe the impact of cataract surgery in terms of visual function (functioning in everyday life with respect to vision dependent activities) and health related quality of life. METHODS: An observational, longitudinal study of patients undergoing cataract surgery was carried out at three district general hospitals in outer London districts of North Thames Region with follow up at 4 and 12 months postoperatively for a clinical assessment and a standardised administered interview. Patients were admitted for surgery to the first eye for age-related cataract between 1 May 1993 and 31 August 1994. Visual functioning was assessed by the VF-14, health related quality of life was assessed by the sickness impact profile (SIP), and vision related quality of life was assessed by VR-SIP (a modification of the generic SIP). RESULTS: Significant gains in all the outcome measures were demonstrated at 4 months postoperatively. No significant change (gain or loss) was observed between 4 and 12 months after surgery to the first eye. Postoperatively, the mean visual function (VF-14) scores, and health related (SIP) and vision related (VR-SIP) quality of life scores, indicated less reported trouble with vision dependent activities and better perceived quality of life, respectively. The average gains in visual function and quality of life (health and vision related) were apparent in groups with good visual outcome and poor visual outcome. Significant additional gains were seen at 1 year in patients who had second eye surgery in the interval between the postoperative assessments. CONCLUSIONS: Gains in visual functioning and quality of life (health and vision related) have been demonstrated following cataract surgery. These gains were sustained at 1 year after surgery to the first eye, with additional gains being conferred if second eye surgery had been performed. Assessment of the outcomes of cataract surgery by clinical indicators alone may underestimate the overall benefits of surgery, particularly in patients with poor visual outcome.

Extracapsular cataract extraction compared with small incision surgery by phacoemulsification: a randomised trial

BACKGROUND Cataract extraction constitutes the largest surgical workload in ophthalmic units throughout the world. Extracapsular cataract extraction (ECCE), through a large incision, with insertion of an intraocular lens has been the most widely used method from 1982 until recently. Technological advances have led to the increasing use of phacoemulsification (Phako) to emulsify and remove the lens The technique requires a smaller incision, but requires substantial capital investment in theatre equipment. In this randomised trial we assessed the clinical outcomes and carried out an economic evaluation of the two procedures. METHODS In this two centre randomised trial, 232 patients with age related cataract received ECCE, and 244 received small incision surgery by Phako. The main comparative outcomes were visual acuity, refraction, and complication rates. Resource use was monitored in the two trial centres and in an independent comparator centre. Costs calculated included average cost per procedure, at each stage of follow up. RESULTS Phako was found to be clinically superior. Surgical complications and capsule opacity within 1 year after surgery were significantly less frequent, and a higher proportion achieved an unaided visual acuity of 6/9 or better (<0.2 logMAR) in the Phako group. Postoperative astigmatism was more stable in Phako. The average cost of a cataract operation and postoperative care within the trial was similar for the two procedures. With the input of additional spectacles for corrected vision at 6 months after surgery, the average cost per procedure was £359.89 for Phako and £367.57 for ECCE. CONCLUSION Phako is clinically superior to ECCE and is cost effective.

Eye injuries in children: the current picture

AIMS To investigate the current causes and outcomes of paediatric ocular trauma. METHODS A prospective observational study of all children admitted to hospital with ocular trauma in Scotland over a 1 year period. RESULTS The commonest mechanism of injury was blunt trauma, accounting for 65% of the total. 60% of the patients were admitted with a hyphaema. Injuries necessitating admission occurred most frequently at home (51%). Sporting activities were the commonest cause of injury in the 5–14 age group. There were no injuries caused by road traffic accidents or fireworks. Patients were admitted to hospital for a mean of 4.2 days (range 1–25 days). One (1%) child had an acuity in the “visually impaired” range (6/18–6/60) and one (1%) was “blind” (6/60) in the affected eye. No child was bilaterally blinded by injury and none required blind or partial sight registration. CONCLUSION This study has shown that the incidence of eye injuries affecting children has fallen. The outcome of ocular trauma has improved significantly, and for the first time paediatric injuries appear to have a better prognosis than injuries affecting adults.

Incidence of cases of ocular trauma admitted to hospital and incidence of blinding outcome.

AIMS: To provide epidemiological data on the current burden of serious eye injuries utilising the hospital eye service, to inform the planning and provision of eye health care, and health and safety strategies for the prevention of ocular injuries. METHODS: A prospective observational study was carried out of all patients with ocular trauma admitted to hospitals in Scotland, under the care of a consultant ophthalmologist, during a 1 year period. The population of Scotland represented the population at risk of injury. Visual outcome (Snellen visual acuity in the injured eye) was measured at the time of final discharge from ophthalmic care and at follow up. RESULTS: All ophthalmic departments in Scotland participated and a total of 415 residents of Scotland were admitted. The 1 year cumulative incidence of ocular trauma necessitating admission to hospital is estimated to be 8.14 per 100 000 population (95% CI 7.38 to 8.97). Some 13.2% (n = 26/197) of patients discharged from follow up had a poor visual outcome with a visual acuity less than 6/12 in the injured eye. Some 10.7% (21/197) patients at this time had a blinding outcome in the injured eye (visual acuity less than 6/60). No patient was registered blind or partially sighted during the study period. The home was the single most frequent place for blinding injuries to occur (52%, n = 11/21), followed by the workplace 24% (n = 5/21). The 1 year cumulative incidence of blinding outcome from serious ocular trauma is estimated to be 0.41 per 100 000 population per year (95% CI 0.26 to 0.64). CONCLUSION: The current burden of serious ocular trauma presenting to the hospital eye service has been quantified from this population based study, and for the first time, a direct estimate of the incidence of the subsequent blinding outcome from these injuries has been provided. Ocular trauma remains an important cause of avoidable and, predominantly, monocular visual morbidity (visual impairment and blindness), with over half of the blinding injuries now occurring in the home. Health education and safety strategies should now consider targeting the home for the prevention of the serious eye injuries in addition to the traditional work, sports, and leisure environments and their related activities.

Profile of patients presenting for cataract surgery in the UK: national data collection

AIMS/METHODS A national data collection exercise was carried out in more than 100 hospital eye service units within the UK to provide clinical and administrative information on patients undergoing cataract surgery. This included patient clinical data such as visual acuity at the time of wait listing and at the time of admission for surgery, presence of other eye disorders, other serious medical disorders, and data on waiting time and type of admission. RESULTS The profiles of the 18 454 patients aged 50 years or older are reported. Findings of particular note were as follows. At the time of wait listing for cataract surgery 31% had visual acuity of 6/12 or better, 54% had visual acuity between 6/18 and 6/60, and 15% had less than 6/60 vision. Considering those who had visual acuity of 6/12 or better at the time of wait listing, by the time of admission for surgery, the vision deteriorated to 6/18–6/60 in 33% and in a further 3% the vision deteriorated to below 6/60. In patients with moderately poor visual acuity (<6/12–6/60) at the time of wait listing, 13% had less than 6/60 vision by the time of admission for surgery. CONCLUSION This type of data collection and reporting exercise provides new material that can be used in the planning and provision of cataract surgery services in the UK.

The deficit in cataract surgery in England and Wales and the escalating problem of visual impairment: epidemiological modelling of the population dynamics of cataract

BACKGROUND The pool of old cases of cataract, the expected new cases, and the shortfall in cataract surgery and consequently the numbers dying with poor vision without the benefit of cataract surgery are regarded as escalating problems worldwide. Successive governments and the professional ophthalmic bodies have not had the wherewithal to estimate the magnitude or interaction of these elements in the population of the UK. This study has collected and applied the best available epidemiological data on cataract prevalence, incidence and service utilisation, and demography to address the problem of control of the cataract pool in the population of England and Wales. METHODS Data from recent surveys undertaken by the authors, both on prevalence of vision impairing cataract and on patterns of cataract surgery, were used together with demographic and service utilisation information obtained from government departments. These were integrated within a holistic model, which was run under varied assumed levels and patterns of service provision. RESULTS The study shows that there is a serious pool of unoperated vision impairing cataract in the population aged 65 and older, reflecting a shortfall in cataract surgery. Continuing with the present level and pattern of service provision, the pool will increase to over 2.5 million by the year 2001. In addition, more than 700 000 will die with unoperated impaired vision. CONCLUSIONS Targeting of existing or new additional operations to those below the visual acuity of 6/12 will have relatively little effect on numbers dying without surgery, but should have a substantial controlling effect on the pool of vision impairing cataract in the population.

Epidemiology and implications of ocular trauma admitted to hospital in Scotland.

OBJECTIVES: To describe the current epidemiology of serious ocular trauma which necessitates admission to hospital so that health and safety strategies for the prevention of ocular injuries and their role within the national health strategy, The Health of the Nation, can be better informed. DESIGN: A prospective observational study of all patients with ocular trauma admitted to hospital under the care of a consultant ophthalmologist between 1 November 1991 and 31 October 1992. SETTING: All ophthalmic department in Scotland. SUBJECTS: All patients with ocular trauma admitted to hospital in Scotland. The population of Scotland represented the population at risk of injury. MEASURES AND MAIN RESULTS: Measures included the type and cause of injury, the place where it occurred, and awareness of risk and safety. All ophthalmic departments in Scotland participated and 428 admissions were reported. The home was the most common place for a serious injury to occur (30.2%), followed by the workplace (19.6%) and a sports or leisure facility (15.8%). The home was the single most frequent place of injury for the 0-15 year and 65 year and over age groups. Tools or machinery, either at home (13.9%) or at work (10.3%), were collectively (24.2%) the most frequent cause of injury, followed by assault (21.8%) and sports-related activities (12.5%). The most frequent type of injury was a blunt injury (54.4%). Six per cent (n = 25) of all injuries were bilateral. Only 13.2% of patients were aware of any risk of injury, with 5.6% aware of any risk at home. When applicable, protective eye wear was only available to 48.6% of patients and only 19.4% of these used it. CONCLUSION: Serious ocular trauma frequently occurs at home and the young and the elderly are particularly at risk. This represents a significant change in the epidemiology of serious ocular trauma and has important implications for prevention. Health and safety strategies specifically aimed at preventing eye injury should now include the home as a high risk environment in addition to the work-place and sports/leisure facilities. The target groups for accident prevention in The Health of the Nation strategy include those at risk of serious ocular trauma with potentially sight threatening sequelae. Those involved in implementing the national accident prevention strategy should be aware of this, for in this process it is possible that some serious eye injuries may also be prevented.

Modelling the prevalence of age-related macular degeneration (2010–2020) in the UK: expected impact of anti-vascular endothelial growth factor (VEGF) therapy

Aims To project the number of cases with age-related macular degeneration (AMD) and the numbers with attributable sight loss in the UK in 2010–2020, taking into account the expected beneficial effect of the new anti-vascular endothelial growth factor (VEGF) therapies. Methods A ‘system dynamics’ approach was used in constructing the model to simulate the dynamics of the disease in large populations. The model computed the pool of affected cases over the simulation period, taking into account the expected demographic changes. Other determinants taken into account included: prevalence; incidence; mortality; and the expected efficacy and coverage of anti-VEGF treatment. Results In the UK, 608 213 persons in 2010 are estimated to have AMD, and this is expected to increase to 755 867 by the end of the decade. Numbers with sight loss from AMD are expected to rise from 223 224 in 2010 to 291 982 by 2020. Cases with sight loss due to neovascular AMD are expected to increase from 145 697 to 189 890 by the end of the decade. Conclusions The model predicts that the beneficial effects of the treatment would be outweighed by the strong anticipated demographic ‘ageing’ effect. This reaffirms the importance of continuing efforts to develop more effective and more broadly applicable therapies for AMD.

Ocular sports injuries: the current picture

Objectives—To determine the recent incidence of eye injury due to sport in Scotland, identify any trend, and establish which sports are responsible for most injury? The type of injury and final visual outcome is also evaluated. Methods—A prospective observational study of ocular injuries sustained during sport was performed over a one year period. Only patients requiring hospital admission were included. Data were collected on a standardised proforma and entered into a central database. Patients were followed up for at least three months. Results—Of 416 patients admitted because of ocular injury, 52 (12.5%) resulted from playing a sport. Although all racquet sports together accounted for 47.5% of these injuries, football was the single most common sport associated with ocular trauma, being responsible for 32.5% of cases. The most common clinical finding was macroscopic hyphaema occurring in 87.5% of patients. Overall the final visual acuity was 6/6 in 92.5% of patients. Conclusions—The incidence of eye injury due to sport at 12.5% is lower than previously reported, suggesting a change in the pattern of ocular trauma. Football is the single most common cause of ocular injury from sport in Scotland, but the wearing of protective headgear would be difficult to instigate. The incidence of hyphaema in sport related ocular trauma (87.5%) is almost double that of all ocular injury (47.8%), so the potential for serious visual loss as the result of a sports injury should not be underrated. Ophthalmologists have a role in protecting this young population at risk by actively encouraging the design and use of protective eyewear.