Paul H.J. Donachie

The Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: report 1, visual outcomes and complications

AimsTo describe the outcomes of cataract surgery in the United Kingdom.MethodsAnonymised data on 180 114 eyes from 127 685 patients undergoing cataract surgery between August 2006 and November 2010 were collected prospectively from 28 sites. Outcome measures included intraoperative and postoperative complication rates, and preoperative and postoperative visual acuities.ResultsMedian age at first eye surgery was 77.1 years, 36.9% cases had ocular co-pathology and 41.0% patients underwent cataract surgery on both eyes. Preoperative visual acuity was 0.30 logMAR or better in 32.0% first eyes and 47.7% second eyes. Postoperative best-measured visual acuity was 0.00 and 0.30 logMAR or better in 50.8 and 94.6% eyes without ocular co-pathology, and 32.5 and 79.9% in eyes with co-pathology. For eyes without co-pathology, postoperative uncorrected distance visual acuity was 0.00 and 0.30 logMAR or better in 27.3 and 80.9% eyes. Posterior capsule rupture or vitreous loss or both occurred in 1.95% cases, and was associated with a 42 times higher risk of retinal detachment surgery within 3 months and an eight times higher risk of endophthalmitis.ConclusionThese results provide updated data for the benchmarking of cataract surgery. Visual outcomes, and the rate of posterior capsule rupture or vitreous loss or both appear stable over the past decade.

United Kingdom National Ophthalmology Database Study of Vitreoretinal Surgery: Report 1; Case mix, complications, and cataract

AimTo report the vitreoretinal (VR) surgical case mix in the United Kingdom, the intraoperative complication rate of pars plana vitrectomy (PPV), and the incidence of post-vitrectomy cataract extraction.MethodsParticipating hospitals prospectively collected ophthalmic data using a single electronic medical record system, with automatic extraction of anonymised data to a national database. This study included the subset of 11 618 VR operations undertaken on 9619 eyes, of 8741 patients, over 8 years, from 27 sites. Surgical data included the indication for surgery, all procedure elements, and whether or not an intraoperative complication occurred. Post-vitrectomy cataract data were also analysed. The main outcome measures were a description of the indications for surgery, intraoperative PPV complication rate, and percentage of eyes undergoing post-vitrectomy cataract surgery (PVCS).ResultsThe most common indications for VR intervention were retinal breaks and rhegmatogenous retinal detachment (48.5%), macular hole (9.8%), epiretinal membrane (9.6%), and diabetic eye disease (7.3%). Overall, 7.8% of PPVs had at least one intraoperative complication—the most common were iatrogenic retinal breaks (3.2%), and lens touch (1.2–1.6% of phakic eyes). PVCS occurred in 50.2, 68.7, and 74.0% of eyes at 1, 2, and 3 years, respectively.ConclusionVR surgery is undertaken for a wide range of conditions, but a small number of diagnoses encompass the majority of cases. Intraoperative PPV complications are not uncommon, and post-vitrectomy cataract is to be expected in most phakic eyes.

United Kingdom National Ophthalmology Database study of vitreoretinal surgery: report 2, macular hole.

PURPOSE To study macular hole (MH) surgery in terms of baseline demographics, intraoperative complications, post-vitrectomy cataract, reoperation, and visual outcome. DESIGN National Ophthalmology Database study. PARTICIPANTS A total of 1078 eyes from 1045 patients undergoing primary MH surgery. METHODS Participating centers prospectively collected clinical data using a single electronic medical record (EMR) system, with automatic extraction of anonymized data to a national database, over 8 years. The following data were extracted for eyes undergoing MH surgery: demographics, procedure elements, intraoperative complications, visual acuity (VA), and further surgery. MAIN OUTCOME MEASURES Description of the primary procedures performed, intraoperative complication rate, change in VA, proportion of eyes undergoing subsequent surgery for persisting MH, cataract, or retinal detachment. RESULTS The median age was 70.3 years, with a 2.2:1 female preponderance. All operations included a pars plana vitrectomy (PPV)-41.1% with hexafluoroethane (C2F6), 25.6% with perfluoropropane (C3F8), 24.5% with sulfahexafluoride (SF6), 2.2% with air, and 0.4% with silicone oil. A PPV was combined with internal limiting membrane (ILM) peel in 94.1% and cataract surgery in 40.5%. One or more intraoperative complications occurred in 12.4%. The median presenting logarithm of the minimum angle of resolution (logMAR) VA improved from 0.80 to 0.50 after a median follow-up of 0.6 years; 57.8% of eyes improved ≥0.30 logMAR units (∼2 Snellen lines). The choice of gas tamponade did not significantly influence the visual outcome, but eyes undergoing ILM peel were significantly more likely to gain ≥0.30 logMAR units, as were eyes with poor presenting VA. Subsequently, 4.2% of eyes underwent repeat surgery for MH and 2.4% for retinal detachment, and, excluding pseudophakic eyes, 64.6% underwent cataract surgery within 1 year. CONCLUSIONS This study provides pooled, anonymized data on the demographics, complications, and visual outcome of MH surgery. This may enable vitreoretinal surgeons to benchmark their case-mix and outcomes, and facilitate risk-benefit and cost-benefit analyses.

United Kingdom National Ophthalmology Database Study: Diabetic Retinopathy; Report 1: prevalence of centre-involving diabetic macular oedema and other grades of maculopathy and retinopathy in hospital eye services

AimsTo report estimates of the prevalence of diabetic retinopathy (DR) and maculopathy grades for a large cohort of patients managed by the UK hospital eye service (HES).MethodsAnonymised data were extracted from 30 UK NHS hospital trusts using a single ophthalmic electronic medical record (EMR) for the period from April 2000 to November 2010 to create the National Ophthalmology Database (NOD). From 2007, the EMR facilitated capture of a nationally agreed-upon standardised data set (DR Structured Assessment) relating to the presence or absence of clinical signs of DR and maculopathy. An algorithm in the software automatically calculated the Early Treatment of Diabetic Retinopathy Study grades of retinopathy and maculopathy.ResultsBetween 2007 and 2010, 307 538 patients had data on the NOD, with 76 127 (24.8%) patients having been recorded as having diabetes. The proportion of patients with diabetes who had a structured assessment increased from 50.7% (2007) to 86.8% (2010). In each NHS year, 12.6–20.6% of eyes with structured assessments had no DR; 59.6–67.3% had non-proliferative DR; and 18.3–20.9% had active or regressed proliferative DR. Clinically significant macular oedema was present in 15.8–18.1% of eyes, and in 8.7–10.0% of eyes, this involved the central macula.ConclusionThis study provides contemporary estimates of the prevalence of retinopathy and maculopathy grades in a large cohort of patients with diabetes managed by the UK HES. Centre-involving diabetic macular oedema, potentially amenable to anti-VEGF therapy, is present in the eyes of almost 10% of these patients. This information is useful for clinicians, health-care economists, and commissioners involved in planning and delivering diabetic eye services.

Which visual acuity measurements define high-quality care for patients with neovascular age-related macular degeneration treated with ranibizumab?

PurposeThe purpose of this study is to define which visual acuity (VA) measurements are the best indicators of high-quality care for patients receiving intravitreal ranibizumab for neovascular age-related macular degeneration (nAMD).MethodsAnalysis of prospectively collected data recorded within an electronic medical record system on treatment-naive, first-eligible eyes with nAMD, treated with ranibizumab using an as-needed treatment regimen with a minimum follow-up of 1 year. Data collection included the following: age, gender, laterality, type of nAMD, VA, central 1 mm OCT retinal thickness, number of intravitreal injections, and number of follow-up assessments.ResultsData were available on the first-treated eye from 406 patients with at least 1 year follow-up; of these, 198 had data at 2 years. The mean baseline VA of 54.4 Early Treatment Diabetic Retinopathy Study letters improved to 58.5 letters at 12 months and to 56.8 letters at 24 months. The mean VA changes from baseline to 1 year were +6.5, +7.5, +1.7, and −1.5 letters, respectively, for baseline VA categories of 23–35, 36–55, 56–70, and >70 letters. Change in mean VA from the end of the loading phase to year 1 ranged from −2.9 to +1.4 letters for the different baseline VA categories. The mean number of injections were similar across baseline VA categories ranging from 5.7 to 6.0 injections in year 1 and from 3.3 to 3.8 in year 2.ConclusionsThis large, real-world series demonstrates that mean change in VA is largely a function of selection criteria and baseline VA. The quality of a service is therefore better judged by actual VA outcomes and maintenance of vision after the loading phase.

Long-term outcomes of intravitreal ranibizumab for neovascular age-related macular degeneration in a well defined region of the UK

Aims To study long-term, whole population ‘real-world’ clinical outcomes of ranibizumab therapy in treatment-naïve eyes for neovascular age-related macular degeneration. Methods Data collected prospectively from a single centre serving a defined population using an electronic medical record included: demographics, Early Treatment Diabetic Retinopathy Study visual acuity (ETDRS VA) at all visits, injection dates, central 1 mm retinal thickness, and operative and postoperative complications. Results 1483 eyes from 1278 patients were included in this study. The median age at the time of the patients first injection was 82.5 years, 64.9% of patients were female, and another ocular pathology was present in 7.3% eyes. The baseline VA was 23–39, 40–54, 55–70 and >70 ETDRS letters for 17.3%, 23.1%, 42.7% and 16.9% of eyes, respectively. The median VA in all baseline VA groups improved after the loading phase but declined back to the baseline level by 2–5 years. The rate of endophthalmitis following intravitreal injection was 1 in 2124 injections. Conclusions These long-term real-world data demonstrate that in general VA increases during the loading phase but returns to near baseline levels after 2–5 years of treatment for each baseline VA category. Patients should be identified and treated as early as possible, since presenting VA predicts the VA maintained after 5 years of treatment. National Institute of Health and Care Excellence guidance advising treatment only for eyes with vision below 70 letters does not promote best long-term VA outcomes for patients.

ELECTRONIC MEDICAL RECORD DATABASE STUDY OF VITRECTOMY AND OBSERVATION FOR VITREOMACULAR TRACTION.

Purpose: To audit the natural history of vitreomacular traction, and the risks and benefits of surgery. Methods: Database study of 1,254 patients (1,399 eyes) with vitreomacular traction from 16 UK vitreoretinal units. Results: The median age was 75 years, with 36.2% of patients diagnosed as diabetic. In 986 (70.5%) eyes managed conservatively, the median presenting logarithm of the minimum angle of resolution visual acuity of 0.30 (Snellen 20/40) was unchanged over follow-up. Of 413 eyes (29.5%) that required pars plana vitrectomy, the median preoperative visual acuity improved from 0.60 to 0.50 (20/80–20/63), 6 months to 12 months after surgery, with 33% gaining at least 0.3 units (approximately 2 Snellen lines). Vitrectomy was combined with internal limiting membrane peel in 43.8%, epiretinal membrane peel in 42.4%, gas/air tamponade in 46.2%, and cataract surgery in 27.9%. One or more intraoperative complications occurred in 12.6%; most commonly retinal breaks (8.0%), retinal trauma (1.9%), and retinal hemorrhage (1.0%). Postoperative retinal detachment occurred in 2.7% and macular hole in 2.2%. The 1, 2, and 3 year rates of postvitrectomy cataract surgery were 28.2%, 38.2%, and 42.7%, respectively. Conclusion: Many eyes with vitreomacular traction have stable visual acuity. Those progressing to vitrectomy have relatively modest visual acuity gains, and complications are not infrequent.

The Royal College of Ophthalmologists’ National Ophthalmology Database Study of vitreoretinal surgery: report 5, anaesthetic techniques

Aims To explore trends over time and variation in the use of anaesthetic techniques for vitreoretinal (VR) surgery in the UK. Methods Prospectively collected data from 13 centres contributing >50 VR operations, including either pars plana vitrectomy (PPV) or scleral buckle (SB), between May 2000 and November 2010 were retrospectively analysed. Anaesthesia was categorised as general anaesthesia (GA) or local anaesthesia (LA) and results were reported by year, centre, grade of surgeon and type of operation. Results 160 surgeons performed 12 124 operations on 10 405 eyes (9935 patients); 6054 (49.9%) under GA and 6070 (50.1%) under LA. The percentage performed under GA decreased from 95.3% in 2001 to 40.9% in 2010. Within LA techniques, peribulbar or retrobulbar injection was used in 2783 (45.8%) operations and sub-Tenons cannula in 3287 (54.2%). The proportions of operations performed under GA or LA were similar for consultants and trainees. Primary SB, primary combined PPV and SB for retinal detachment (RD), repeat RD surgery and complex vitrectomy surgery were more commonly performed under GA (85.8%, 67.0%, 63.5% and 69.4%, respectively), while primary PPV for RD, simple vitrectomy surgery and macular surgery were more commonly performed under LA (58.1%, 53.7% and 58.2%, respectively). Marked intercentre variation existed with the extremes being one centre with 100% of operations performed under GA and one centre with 98.3% under LA. Conclusions LA for VR surgery has steadily increased over the last decade in the UK but marked intercentre variation exists.

The Royal College Of Ophthalmologists' National Ophthalmology Database Study Of Vitreoretinal Surgery: Report 4, Epiretinal Membrane

Purpose: To report pragmatic outcomes from a database study of epiretinal membrane surgery. Methods: Prospective anonymized clinical audit data from electronic medical records were pooled over 10 years into a national database, from 1,131 primary epiretinal membrane operations, by 69 surgeons, in 16 U.K. vitreoretinal units. Results: The median age of 1,131 patients was 71.6 years. A pars plana vitrectomy and epiretinal membrane peel were combined with internal limiting membrane peel in 17.0% of operations, and cataract surgery in 49.9%. Use of general anesthesia declined from 94.1% in 2001 to 28.9% in 2010. One or more intraoperative complication occurred in 9.8% (8.1% excluding cataract surgery complications). The median preoperative logarithm of the minimum angle of resolution (logMAR) visual acuity improved from 0.60 to 0.30 (Snellen 20/80–20/40) after a median follow-up of 7.0 months; 41.7% of eyes improved ≥0.30 logMAR units (approximately 2 Snellens lines). The percentages of eyes undergoing subsequent surgery were 3.3%, 1.0%, 0.4%, and 0.8% for epiretinal membrane, retinal detachment, macular hole, and other vitreoretinal indications, respectively. Excluding pseudophakic eyes, 51.7%, 73.2%, and 76.2% of eyes underwent cataract surgery within 1 year, 2 year, and 3 years respectively. Conclusion: These results may help vitreoretinal surgeons to benchmark their surgical outcomes, and patients to assess the risks and benefits of surgery.

Agreement between photographic screening and hospital biomicroscopy grading of diabetic retinopathy and maculopathy.

Purpose To examine the level of agreement and reasons for disagreement between grading of diabetic retinopathy and maculopathy using mydriatic digital photographs in a diabetic retinopathy screening service (DRSS) and hospital eye service (HES). Methods English NHS Diabetic Eye Screening Programme grades for diabetic retinopathy prospectively recorded on a hospital electronic medical record were compared to the grades from the DRSS event that prompted referral. In cases of disagreement, images were reviewed. Results Data for 1,501 patients (3,002 eyes) referred between 2008 and 2011 were analyzed. The HES retinopathy grades were R0 (no retinopathy) in 341 eyes, R1 (background retinopathy) in 1,712 eyes, R2 (pre-proliferative retinopathy) in 821 eyes, and R3 (proliferative retinopathy) in 128 eyes. The DRSS grades were in agreement in 2,309 eyes (76.9%), recorded a lower grade in 227 eyes, and recorded a higher grade in 466 eyes. Agreement was substantial (κ = 0.65). The commonest cause for disagreement was overgrading of R1 as R2 by hospital clinicians. The HES maculopathy grades were M0 (no maculopathy) in 2,267 eyes and M1 (maculopathy) in 735 eyes. The DRSS were in agreement in 2,111 eyes (70.2%), recorded a lower grade in 106 eyes, and recorded a higher grade in 785 eyes. Agreement was fair (κ = 0.39). The commonest cause for disagreement was hospital clinicians missing fine exudates. Conclusions This study establishes a benchmark standard for agreement between HES and DRSS grading. Review of DRSS and grading reports images for newly referred patients is likely to improve levels of agreement, particularly for diabetic retinopathy, and should be strongly encouraged.