Rajen Gupta

Measuring the benefit of 4 years of intravitreal ranibizumab treatment for neovascular age-related macular degeneration

Aim To analyse the benefit of intravitreal ranibizumab over 4u2005years for patients with neovascular age-related macular degeneration (AMD). Methods A retrospective case note review of all patients who started treatment between August 2007 and September 2009 in our unit, minimum follow-up 2u2005years, maximum 4u2005years. The main outcome measures were: numbers of patients with different levels of vision, changes in visual acuity, number of treatments and numbers remaining under follow-up. Results 1086 eyes of 1017 patients received treatment. Numbers of patients remaining under follow-up were 892/1017 (87.71%) at 12u2005months, 730/1017 (71.78%) at 24u2005months, 468/730 (64.11%) at 36u2005months and 110/217 (50.69%) at48u2005months. The main reasons for patients no longer being under follow-up were the consequences of old age or transfer of care. 50% of patients had 6/18 or better over 4u2005years. Patients received on average 5.79±2.53, 9.15±3.79, 11.22±4.92 and 13.7±7.84 injections by 12, 24, 36 and 48u2005months, respectively. Conclusions We suggest that the numbers of patients with a particular level of vision may best reflect the actual benefit of AMD treatment provided by a service. Long-term follow-up is required as only 72/730 (10%) had been discharged at 36u2005months, half of whom had good vision of greater than 60 letters. 83% and 65% of patients needed treatment in the third and fourth year. Follow-up may be for the rest of the patients’ life or at some point they may no longer be well enough to attend.

Choroidal detachment following extracapsular cataract extraction in a patient treated with latanoprost

Editor,—Adverse reactions associated with the topical administration of the synthetic prostaglandin F2αanalogue latanoprost have been described.1 We would like to report a case of choroidal detachment following extracapsular cataract extraction in a patient treated with topical latanoprost.nn### CASE REPORTnnA 78 year old man initially presented with primary open angle glaucoma in 1981. This was well controlled on timoptol and ophthalmic follow up was uneventful except for the development of left age related maculopathy in 1995 reducing the vision to 6/9. In November 1999 the intraocular pressure (IOP) became uncontrolled and a left sided cataract noted. Latanoprost was substituted with subsequent control of the IOP.nnHe underwent an uneventful left extracapsular cataract extraction by a traditional, non-phacoemulsification technique at another facility in January 2000 (the operating surgeon did not perform phacoemulsification on any …

Debulking of Lens Fragments

When novice surgeons perform nucleus disassembly, the lens fragments are often of an irregular size and shape. It is more technically demanding to remove larger sized fragments, as it requires additional bimanual manipulation and the surgeon must exert better phaco probe control. This chapter will introduce a technique of breaking down large fragments (or even medium sized fragments) into smaller pieces. This is a fundamental skill and it is recommended that novice surgeons gain experience in performing it before taking on whole lens removal.

Phacoemulsification: Grooving and Cracking

Two key surgical phacoemulsification skills to acquire are the ability to form a trench in the lens nucleus (referred to as grooving or sculpting), and the ability to apply pressure to the walls of the trench, dividing the lens nucleus into two smaller segments (cracking). Lens grooving and lens cracking form the basis for one method of disassembling the lens nucleus.

Phacoemulsification: An Easy Stop, Chop and Crack Technique

The technique of ‘groove-and-crack’, coupled with the ability to debulk large fragments, is a useful method for tackling the majority of cataracts. However, as training progresses, surgeons may wish to develop the nucleus chopping method of creating fragments. A chop technique requires the phaco tip to be embedded the into the lens nucleus whilst the second instrument cleaves the lens nucleus apart. The original chop [1] has been adapted and refined into two chopping techniques, vertical and horizontal [2]. The vertical and horizontal phaco chop are advanced techniques, best attempted once Trainee surgeons have become highly skilled in standard methods.

The Paracentesis Incision

The main corneal and side-port paracentesis incisions are the last modules for the Trainee to learn before combining all the cataract steps to perform whole case surgery. This chapter discusses the paracentesis incision whilst Chap. 14 deals with the main incision. Rear-ended modular training provides Trainees with the opportunity to observe many corneal side port paracentesis incisions before their first attempt. However, it is only natural to remain hesitant about holding a blade near the eye and creating an incision. The paracentesis step can be learnt as a separate step to the main incision providing the opportunity to quickly overcome this anxiety.

How to Palm an Instrument

Palming an instrument is a technique that experienced surgeons use subconsciously. The technique requires the surgeon to reposition and retain an instrument within the grasp of one hand, at the same time freeing up fingers of the same hand to perform other tasks. The reverse technique (i.e. “un-palming” an instrument) is used to reposition and grip the same instrument so that it is ready to use again or hand back to the assistant. Most novice surgeons are not formally taught how to palm, and the skill ends up being self-acquired.

The Main Corneal Incision

Over time, experienced surgeons will develop a preferred technique for creating the corneal wound. This will automatically take account of several factors: available access to the corneal surface, corneal astigmatism, anterior chamber depth, ocular movement and ocular co-pathologies.

Soft Lens Material Removal

Irrigation/aspiration (IA) of residual soft lens cortical material is required to clean the inner surface of the capsule bag before placement of the intra ocular lens (IOL).

Intraocular Lens Insertion

Following the removal of any residual soft lens material, the artificial intraocular lens (IOL) implant is inserted into the empty capsule bag. Common practice is to use a pre-loaded injector system to insert the IOL into the eye. There are many injectable systems on the market, and each manufacture has their own lens and injector design. Thus, each device system will have a recommended IOL preparation and implantation technique. Novice surgeons will need to be familiar with the injection device and implant used in their unit. Trainer and Trainee should discuss the precise specifics before surgery.