Philip Bloom

Raising the benchmark for the 21st century—the 1000 cataract operations audit and survey: outcomes, Consultant-supervised training and sourcing NHS choice

Purpose: Clinical outcomes for phacoemulsification surgery are still compared with the almost 10-year-old benchmark of the 1997–98 National Cataract Surgery Survey (NCSS) published in this journal. Extraneous to the peer-reviewed research literature, more recent databases suggest much better results may be being obtained. This offered the rare opportunity to perform an audit as research investigating if this was indeed the case and a new benchmark is needed, with the additional standard of rigorous study peer review by independent senior ophthalmologists. At this pilot centre for Patient Choice provision, all cataract surgery was performed on Consultant-supervised training lists, a novel extension in-sourcing care using public resources rather than to an independent sector that may not be supervised by NHS Consultants. Patient satisfaction was also surveyed. We asked whether the NCSS is out-of-date, and whether good outcomes on Choice schemes are compatible with Consultant-led training within the National Health Service? Methods: An audit of 1000 consecutive patients undergoing cataract surgery on Patient Choice at the Western Eye Hospital between October 2002 and September 2004. All subjects were scheduled for phacoemulsification. A novel policy was extending “choice” onto training list slots for this period. A validated questionnaire assessed patient satisfaction. Results: A best corrected visual acuity of 6/12 or better was obtained in 93% of cases. Over 80% of cases were ±1 D of target refraction (65.7% within 0.5 D). The total incidence of complications was 8.7%. Overall incidence of major complications was 2.4%. Incidence of vitreous loss was 1.1% and that of endophthalmitis 0.1%. Complications rates were lowest for consultants (less than 1%). User satisfaction with having cataract surgery on “patient choice” was high. Conclusions: Cataract surgery under patient choice on supervised training lists is associated with a visual outcome and an incidence of complications at least as good as the published national average. User satisfaction is high. Cataract surgery under patient choice is compatible with training activity in receiving hospitals. The improvement in outcomes since the 1997–98 NCSS suggest that the accepted standards for complication rates should be updated to reflect the fact that phacoemulsification has become an established procedure.

Treatment failure in a case of fungal keratitis caused by Pseudallescheria boydii.

A case is presented of Pseudallescheria boydii fungal keratitis in an agricultural welder. Treatment with azole antifungal drugs (miconazole and itraconazole) and with penetrating keratoplasty was unsuccessful in eradicating the infection, and eventually the eye was eviscerated.

Delayed suprachoroidal haemorrhage following trabeculectomy bleb needling

Editor,—Transconjunctival needling of trabeculectomy blebs is a relatively safe, simple outpatient procedure that can successfully re-establish aqueous flow in failed trabeculectomies.1 2 We report a severe delayed suprachoroidal haemorrhage occurring secondary to this procedure in an aphakic patient receiving aspirin therapy. ### CASE REPORT Fifteen years previously a 75 year old myopic man underwent bilateral intracapsular cataract extractions. He developed secondary open angle glaucoma but was intolerant of topical β blockers because of bradycardia. He was managed on pilocarpine drops 4% four times daily but control of intraocular pressure (IOP) was inadequate with deterioration in visual fields. Twelve years after the cataract extractions he underwent bilateral trabeculectomies with postoperative 5-fluorouracil. Three years later the left visual acuity was 6/18 with an IOP of 22 mm Hg despite pilocarpine. In view of progressive cupping of the left optic …

Trabeculectomy with intraoperative sponge 5-fluorouracil in Afro-Caribbeans

AIM To study the efficacy and safety of intraoperative 5-fluorouracil (5-FU) in Afro-Caribbean patients. METHODS The results of trabeculectomy in 18 eyes of 18 Afro-Caribbean patients in whom a sponge soaked in 25 mg/ml solution of 5-FU was applied between Tenon’s capsule and sclera for 5 minutes before excision of the trabecula were compared with 16 eyes of 16 Afro-Caribbean patients matched for age, quantity, and duration of preoperative medications, who underwent trabeculectomy without 5-FU. RESULTS The mean postoperative intraocular pressure (IOP) at 1 month was 15.6 (SD 6.1) mm Hg in the 5-FU group and 18.0 (5.2) mm Hg in the control group (p=0.15). There was no significant difference in the IOP at 6, 12, 15, 18, and 24 months in the two groups. Success rate at 18 months defined as an IOP less than or equal to 21 mm Hg with no adjunctive medication was 56% in the 5-FU group and 55% in the control group. No major complications were noted in either group. CONCLUSION Intraoperative sponge 5-FU alone is safe but does not appear to decrease the risk of failure of trabeculectomy in Afro-Caribbeans.

Quantification of melanin and iron content in uveal malignant melanomas and correlation with magnetic resonance image.

Eleven patients with uveal malignant melanomas (MM) were studied by magnetic resonance (MR) imaging before enucleation. The MR appearances varied, but often were different from those previously reported to be characteristic of these tumours. Using an image analyser to assess quantitatively the melanin and iron content of each tumour, a wide range of tumour melanin concentrations was found, but universally low tumour iron concentrations. These values were compared with MR appearances that were quantified and expressed as contrast to noise ratios. The correlation between T1 and T2 shortening and increasing melanin content did not reach statistical significance. There was no correlation between MR appearances and iron content. The theories postulated to explain the diverse MR appearances of uveal MMs are discussed and variations in tumour melanin content and differences in scanner strengths are suggested as the most likely explanations.

Retinal detachment in AIDS-related cytomegalovirus retinitis.

Patients with acquired immune deficiency syndrome (AIDS) and cytomegalovirus retinitis (CMVR) are surviving longer due to the use of virostatic medicines and improved treatment of opportunistic infections. As a result, retinal detachment is likely to become an increasingly common cause of visual morbidity in these patients. The incidence and outcome of retinal detachment complicating CMVR was studied at two London AIDS centres. Patients with CMVR were identified prospectively and underwent standard treatment. Retinal detachments were diagnosed during regular follow-up. if retinal reattachment surgery was performed, a standard procedure of vitrectomy and silicone oil internal tamponade was employed. Of 147 patients with CMVR, 41 (28%) developed retinal detachments (47 eyes). Forty-three detachments were rhegmatogenous and 4 were exudative. Fifteen eyes of 9 patients with rhegmatogenous detachments underwent retinal reattachment surgery. Of these, visual acuity remained stable or improved in 12 eyes (80%) in the immediate post-operative period. At the last clinic visit, 8 eyes (53%) maintained a visual acuity of 6/60 or better. The visual results of surgery are good in selected patients, bearing in mind the progressive nature of the underlying disease and poor life expectancy.

Spontaneous development of retinal ischaemia and rubeosis in eyes with retinal racemose angioma

Two Cases are described of spontaneous vascular closure occuring in eyes with arteriovenous malformations, causing visual loss due to retinal ischaemia and rubcosis iridis.

Visual prognosis of AIDS patients with cytomegalovirus retinitis

A prospective study of visual acuity (VA) was performed in a cohort of 147 AIDS patients with cytomegalovirus retinitis (CMVR). Patients were treated according to standard regimes, and corrected VA was recorded at regular intervals from presentation until death. Follow-up was 6 weeks to 5 years (mean 30 weeks). Fifty patients (34%) had bilateral CMVR at initial presentation; at death 81 patients (55%) had bilateral disease. Thirty-one eyes initially uninfected developed CMVR during follow-up. Of 228 infected eyes, VA at presentation was 6/12 or better in 182 eyes (80%) and 6/60 or better in 215 eyes (94%) At death, VA was 6/12 or better in 112 eyes (49%) and 6/60 or better in 171 eyes (75%). VA in the better eye at death was 6/12 or better in 113 of 147 patients (77%), 6/24 or better in 135 patients (92%) and worse than 6/60 in only 7 patients (5%). Treatment of AIDS-related CMVR minimises loss of vision and may protect previously uninfected eyes, prolonging visual independence.

Appearances of choroidal osteomas with diagnostic imaging

The diagnostic imaging appearances of three choroidal osteomas (osseous choristomas) are presented. This rare, benign choroidal tumour is being recognized with increasing frequency, and is important to remember in the differential diagnosis of any unusual mass in the ocular fundus lest it be mistaken for a more sinister lesion. All three osteomas were demonstrated by ocular ultrasound (US), fluorescein angiography (FA) and computed tomography (CT) but none by plain radiography. None of the lesions was visible on magnetic resonance imaging (MRI); the reason for this is probably the bony nature of the tumours. The appearances of choroidal osteomas on US, FA, plain radiography and CT are discussed. To our knowledge this is the first report of a series of choroidal osteomas investigated by MR.

Subjective and Objective Diplopia Caused by Intraocular Lens Decentration

OBJECTIVES: (1) To describe a case in which subjective diplopia (and objective diplopia on fundus biomicroscopy) resulted from decentration of a posterior chamber intraocular lens (IOL) following extracapsular cataract extraction with IOL implantation. (2) To discuss ways of avoiding this complication. (3) To propose an optical explanation for this subjective and objective monocular diplopia. STUDY DESIGN: A case report and discussion. SETTING & PATIENTS: One patient attending the Outpatient Department of Bristol Eye Hospital. OUTCOME MEASURES: To stimulate discussion about this serious complication of IOL implantation. CONCLUSIONS: Lens decentration is a cause of monocular diplopia following extracapsular cataract extraction with posterior chamber IOL implant. Differences is surgical technique may influence the incidence of this complication.