Ravjit Singh

Comparison of macular morphology between femtosecond laser–assisted and traditional cataract surgery

Comparison of macular morphology between femtosecond laser–assisted and traditional cataract surgery After reading the article by Nagy et al. on femtosecond laser–assisted cataract surgery technology, we have significant methodological concerns about the risk for postoperative cystoid macular edema (CME). These render the conclusions drawn by the authors difficult to support. The incidence of CME following cataract surgery is variable. Differing definitions of CME make it difficult to determine accurately its incidence; a recent review reported the incidence as 0.1% to 2.5%. It is essential to differentiate clinical CME, in which visual impairment is present, from angiographic or subclinical macular edema, in which visual acuity is not impaired. Flach identified 20 factors that could affect the reported incidence of postoperative CME. These factors relate to the patient (underlying vascular diseases such as diabetes mellitus, hypertension, and chronic kidney disease), research methodology, and surgical technique. The numerous shortcomings we find in the Nagy et al. study methodology are as follows. 1. Relevance of subclinical macular edema. The authors state that the incidence of subclinical macular edema after uneventful cataract surgery has become an issue of safety. This is in fact not the case. Subclinical macular edema is defined and diagnosed using fundus fluorescein angiography. It is considered a precursor process that might predispose to CME. The major objective outcome parameter after cataract surgery remains corrected distance visual acuity (CDVA). While macular edema is a critical determinant of surgical success, it is only so when it is clinically significant and results in an adverse effect on CDVA. The authors suggest that the mean CDVA was similar in the traditional phacoemulsification group and the femtosecond laser–assisted cataract surgery group, but no statistical analysis was performed. 2. Methodological bias. Specific patient factors such as age, sex, and refractive error were accounted for, but systemic illnesses (cited above) known to affect the risk for CME were not documented. Despite the study being documented as a prospective case-control series, the criteria for allocation to the traditional phacoemulsification cohort versus the femtosecond laser–assisted cataract surgery cohort were not addressed. There was no record of masking the observers during follow-up and optical coherence tomography (OCT). The mean follow-up was stated to be similar in the 2 cohorts, but there was no statistical

Factors Influencing the Incidence of Postoperative Endophthalmitis

EDITOR: HAVING READ THE ARTICLE BY WYKOFF AND ASSOCIATES, we were impressed to read that the endophthalmitis rate at the Bascom Palmer Eye Institute (BPEI) was 2.8 per 10 000 for cataract surgery. 1 Although there is a range in the endophthalmitis rate reported in the literature, the currently accepted rate around the developed world is approximately 1 per 1000, or 1 per 2000 after intracameral antibiotics. 2,3 This suggests that BPEI may have an endophthalmitis rate of one quarter of rest of the developed world. Unfortunately, in New South Wales, Australia, the rate recently was shown to be more than 8 per 1000. 4 Perhaps in Australia something is very different from the sunny, healthy clime of Florida. Herein we raise some questions in relation to the study by Wykoff and associates. The authors stated that it is unlikely that any cases were missed in their 6-week follow-up in the light of the requirements of their Quality Assurance Committee. However, this assertion may not be able to be validated. Moreover, the patients in whom endophthalmitis developed may not have returned to BPEI for treatment. It was stated that the cataract surgery was being converted from subconjunctival or scleral incisions to unsutured clear corneal incisions during the period of the study. However, there was no documentation of the incision types, wound sizes, the frequency of wound suturing, or the level of experience of the surgeon, all of which are known to affect the incidence rate of endophthalmitis. Some studies have collected cases of endophthalmitis based on self-reporting of the complication by surgeons. 5 This type of reporting is known to be unreliable. Furthermore, a recent British study documented definitively that studies with positive results are more likely to be reported and published than those with negative results. 6

Fine central macular dots associated with childhood‐onset Stargardt Disease

Booij JC, Baas DC, Beisekeeva J, Gorgels TG & Bergen AA (2010): The dynamic nature of Bruch’s membrane. Prog Retin Eye Res 29: 1–18. Finger RP, Charbel Issa P, Schmitz-Valckenberg S, Holz FG & Scholl HN (2011): Longterm effectiveness of intravitreal bevacizumab for choroidal neovascularization secondary to angioid streaks in pseudoxanthoma elasticum. Retina 31: 1268–1278. Gliem M, De Zeaytijd J, Finger RP, Holz FG, Leroy BP& Issa PC (2013): An update on the ocular phenotype in patients with pseudoxanthoma elasticum. Front Genet 4: 14. Tr elohan A, Martin L, Milea D, Bonicel P & Ebran JM (2011): Retinal lesions in pseudoxanthoma elasticum: 51 patients. J Fr Ophtalmol 34: 456–467. Wang M, Sander B, la Cour M & Larsen M (2005): Clinical characteristics of subretinal deposits in central serous chorioretinopathy. Acta Ophthalmol Scand 83: 691–696.

Role of adequate wound closure in preventing acute postoperative bacterial endophthalmitis

Role of adequate wound closure in preventing acute postoperative bacterial endophthalmitis We were delighted to read the excellent review of the current knowledge of acute postoperative bacterial endophthalmitis by Packer et al. This timely review definitely provides “a foundation for future research, [enabling] surgeons to assess current options and practices.” While treatment of acute postoperative bacterial endophthalmitis is well established, emphasizing timely recognition and rapid “tap and inject,” the authors rightly note that prevention of acute postoperative bacterial endophthalmitis is characterized by a notable absence of conclusive evidence. They confirm that “the primary risk factor for endophthalmitis seems to be increased intraocular exposure to the patients own normal adnexal and ocular surface flora.” Thus, the primary issue in preventing acute postoperative bacterial endophthalmitis is likely to be the prevention of intracameral ingress of these pathogens. It is acknowledged that bacteria may enter the anterior chamber and be cultured from it following cataract surgery. Particulate and microscopic matter regularly enters the eye during surgery, yet we are uncertain why more patients do not develop acute postoperative bacterial endophthalmitis. A notable case from Australia found postoperative intracameral migration of topical chloramphenicol ointment, requiring removal from the anterior chamber 2 months after an uncomplicated operation. Intraoperatively, a large volume of circulating sterile balanced salt solution (BSS) may flush out potential pathogens. Hence, in acute postoperative bacterial endophthalmitis, pathogen ingress is probably more important in the postoperative period. Taban et al. report a low incidence of acute postoperative bacterial endophthalmitis until sutureless clear corneal incisions (CCIs) were introduced. Prior to CCIs, phacoemulsification wounds were rarely sutured with subconjunctival sclerocorneal tunnel incisions, in which conjunctiva effectively excluded the tear films postoperative bacterial load. By contrast, the external aspect of the CCI is continuously exposed to the tear-film contents and the blinking lid. Puvanachandra and Humphry reported a case of bilateral endophthalmitis following simultaneous bilateral cataract surgery. We demonstrated that the intracameral antibiosis used in this case was statistically unlikely to have been able to prevent this patients acute postoperative bacterial endophthalmitis (probability of 1 in 4 000 000). This case illustrates that intracameral antibiotics may have a limited preventive role in the development of acute postoperative

Technique to exclude temporal lash incursion in phacoemulsification surgery

&NA; We describe the use of a Steri‐Strip to exclude lashes in cataract surgery cases in which the lashes impinge on the operative field. The technique has been used in 25 cases and achieved uniformly successful lash exclusion. In 6 cases, the strip became partially dislodged and required repositioning intraoperatively, after which it achieved complete lash exclusion. No complications have been observed. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Assessment of adequate removal of ophthalmic viscoelastic device with irrigation/aspiration by quantifying intraocular lens ‘Judders’

To assess the efficacy of ‘Judders’ as a technique reflecting adequacy of removal of ophthalmic viscoelastic device in cataract surgery.

Longitudinal follow-up of siblings with a discordant Stargardt disease phenotype.

anterior segment have been reported after injection of intravitreal dexamethasone implants. Most case reports describe migration of the implant into the anterior chamber in eyes that had previous cataract surgery complicated by posterior capsule rupture. (Cronin et al. 2012; Pardo-L opez et al. 2012; Malcl es et al. 2013) Only one article reports a case similar to ours, describing cataract surgery after implant in the crystalline lens. (Koller et al. 2012) Several conclusions can be drawn from this case series. Regarding the intravitreal procedure: the 22-gauge injector has a relatively large diameter compared to 28or 30-gauge needles used for anti-VEGF treatment, and the injection technique requires a considerable pressure on the globe. In addition, the pain experienced by the patient may provoke inadvertent eye or head movements. Subconjunctival anesthesia can be used in an attempt to minimize this side-effect, even though the presence of fluid under the conjunctiva may interfere with a proper marking procedure. Secondly, when considering cataract extraction, a careful preoperative evaluation in order to identify the site and the extension of posterior capsular tear, is essential. Hydrodelineation procedures with the purpose of separating the nucleus from the epinucleus is mandatory, and when hydrodissection is planned, it must be performed very carefully. During phacoemulsification, machine parameters must be lowered and anterior vitrectomy must always be taken into consideration. Implant of a three piece IOL in the sulcus with optic plate in the bag is recommended in order to avoid stress on the already damaged capsular bag and is considered to provide the best stability in these cases. Lens damage can be a complication of dexamethasone implant. A careful cataract surgery can alleviate anatomical and functional damages.

Comparison between intraocular pressure spikes with water loading and postural change

To compare the agreement between peak intraocular pressures measured through the water drinking test and the supine test, in patients with primary open angle glaucoma.

Branch retinal artery occlusion secondary to prepapillary arterial loop.

PURPOSE To report a case of branch retinal artery occlusion and prepapillary loop in a 10-year-old girl. METHODS Case report with funduscopic and fluorescein angiography imaging. RESULTS A 10-year-old girl presented with a history of the sudden onset of a superior visual field defect in her right eye. Fundus findings were consistent with thrombosis in a prepapillary arterial loop causing an inferior branch retinal artery occlusion. CONCLUSION Bilateral congenital prepapillary vascular loops are rare, and are usually asymptomatic. However, they can be complicated by vitreous hemorrhage and thrombosis. Such thrombotic events may be precipitated by hemodynamic or intravascular changes associated with exercise.

Iris floculli: elevated intraocular pressure or threat to life?

reports and the fact that the size and surface anatomy of the plica as well as the nasal edge of the plica semilunaris (i.e. the border between the plica semilunaris and the caruncle) display considerable variations, which could potentially affect the accuracy of measurements. Accordingly, findings will have to be confirmed by prospective studies that would include patients with pterygium at an early stage of growth and would allow sufficient follow-up time to evaluate a potential association between pterygium growth rate and the size of the plica semilunaris.