Richard M. Gregson

Falls and health status in elderly women following first eye cataract surgery: a randomised controlled trial

Background/aim: A third of elderly people fall each year. Poor vision is associated with increased risk of falls. The authors aimed to determine if first eye cataract surgery reduces the risk of falling, and to measure associated health gain. Methods: 306 women aged over 70, with cataract, were randomised to expedited (approximately 4 weeks) or routine (12 months wait) surgery. Falls were ascertained by diary, with follow up every 3 months. Health status was measured after 6 months. Results: Visual function improved in the operated group (corrected binocular acuity improved by 0.25 logMAR units; 8% had acuity worse than 6/12 compared with 37% of controls). Over 12 months of follow up, 76 (49%) operated participants fell at least once, and 28 (18%) fell more than once. 69 (45%) unoperated participants fell at least once, 38 (25%) fell more than once. Rate of falling was reduced by 34% in the operated group (rate ratio 0.66, 95% confidence interval 0.45 to 0.96, p = 0.03). Activity, anxiety, depression, confidence, visual disability, and handicap all improved in the operated group compared with the control group. Four participants in the operated group had fractures (3%), compared with 12 (8%) in the control group (p = 0.04). Conclusion: First eye cataract surgery reduces the rate of falling, and risk of fractures and improves visual function and general health status.

The Importance of Acuity, Stereopsis, and Contrast Sensitivity for Health-Related Quality of Life in Elderly Women with Cataracts

PURPOSE To investigate the relative contribution of visual and other factors to quality of life among elderly women with bilateral cataract. METHODS Data were analyzed from a trial of first-eye cataract surgery. Visual parameters, general health, and social variables, and disease-specific (VF-14 Index of Visual Function), generic (Euroqol: EQ-5D, London Handicap Scale, Barthel), and intermediate (anxiety, depression, and activity) outcomes were measured at baseline and 6 months later, when approximately half the group had had surgery. RESULTS Three hundred six participants provided data at baseline, and 289 at 6 months. At baseline, acuity, stereopsis, and contrast sensitivity were all associated with quality of life. Acuity and stereopsis were most strongly and consistently associated. Change in VF-14 was associated with changes in stereopsis and contrast sensitivity, while change in handicap was associated with change in stereopsis. CONCLUSIONS Acuity, stereopsis, and contrast sensitivity each contributed to quality of life, across a range of measures, in elderly women with cataract. Acuity was marginally the most consistently and generally the most strongly associated, but in some analyses stereopsis was more important. Change in quality of life was associated with change in stereopsis and contrast sensitivity.

Ophthalmological Aspects of Pierson Syndrome

PURPOSE To study the ocular phenotype of Pierson syndrome and to increase awareness among ophthalmologists of the diagnostic features of this condition. DESIGN Retrospective, observational case series. METHODS A multicenter study of 17 patients with molecularly confirmed Pierson syndrome. The eye findings were reviewed and compared to pertinent findings from the literature. RESULTS The most characteristic ocular anomaly was microcoria. A wide range of additional abnormalities were found, including posterior embryotoxon, megalocornea, iris hypoplasia, cataract, abnormal lens shape, posterior lenticonus, persistent fetal vasculature, retinal detachment, variable axial lengths, and glaucoma. There was high interocular and intrafamilial variability. CONCLUSIONS Loss-of-function mutations in laminin beta2 (LAMB2) cause a broad range of ocular pathology, emphasizing the importance of laminin beta2 in eye development. Patients with Pierson syndrome can initially present with ocular signs alone. In newborns with marked bilateral microcoria, Pierson syndrome should be considered and renal function investigated.

Falls and health status in elderly women following first eye cataract surgery: an economic evaluation conducted alongside a randomised controlled trial

Aim: To evaluate the cost-effectiveness of first eye cataract surgery compared with no surgery from a health service and personal social services perspective. Methods: An economic evaluation undertaken alongside a randomised controlled trial of first eye cataract surgery in secondary care ophthalmology clinics. A sample of 306 women over 70 years old with bilateral cataracts was randomised to cataract surgery (expedited, approximately four weeks) or control (routine, 12 months wait); 75% of participants had baseline acuity of 6/12 or better. Outcomes included falls and the EuroQol EQ-5D. Results: The operated group cost a mean £2004 (bootstrapped) more than the control group over one year (95% confidence interval (CI), £1363 to £2833) (p<0.001), but experienced on average 0.456 fewer falls, an incremental cost per fall prevented of £4390. The bootstrapped mean gain in quality adjusted life years (QALYs) per patient was 0.056 (95% CI, 0.006 to 0.108) (p<0.001). The incremental cost–utility ratio was £35 704, above the currently accepted UK threshold level of willingness to pay per QALY of £30 000. However, in an analysis modelling costs and benefits over patients’ expected lifetime, the incremental cost per QALY was £13 172, under conservative assumptions. Conclusions: First eye cataract surgery, while cost-ineffective over the trial period, was probably cost-effective over the participants’ remaining lifetime.

Second-eye cataract surgery in elderly women: a cost-utility analysis conducted alongside a randomized controlled trial

AimThe aim of this study was to evaluate the cost-effectiveness of second-eye cataract surgery for older women with minimal visual dysfunction in the eye to be operated on from a Health and Personal Social Services perspective, compared to waiting list controls who had already undergone first-eye cataract surgery.MethodsA cost-utility analysis was undertaken alongside a randomized controlled trial of second-eye cataract surgery in secondary care ophthalmology clinics. A total of 239 women over 70 years old with one unoperated cataract were randomized to cataract surgery (expedited, approximately 4 weeks) or control (routine surgery, 12 months wait). Outcomes were measured in terms of quality-adjusted life years (QALYs), with health-related quality of life estimated using the EuroQol EQ-5D.ResultsThe operated group had costs which were, on average, £646 more than the control group (95% confidence interval, £16–1276, P<0.04) and had a mean QALY gain of 0.015 (95% confidence interval, −0.039 to 0.068, P=0.59) per patient over 1 year. Therefore, the incremental cost-utility ratio was £44 263 over the 1-year trial period. In an analysis modelling costs and benefits over patients’ expected lifetime, the incremental cost per QALY was £17 299, under conservative assumptions.ConclusionsSecond-eye cataract surgery is not likely to be cost-effective in the short term for those with mild visual dysfunction pre-operation. In the long term, second-eye cataract surgery appears to be cost-effective unless carer costs are included.

Ochroconis gallopava endophthalmitis in fludarabine treated chronic lymphocytic leukaemia

Editor,—Disseminated fungal infection is an important cause of morbidity and mortality in immunocompromised patients, often due to candida and aspergillus species. Endogenous endophthalmitis is a recognised complication.1 We present, to our knowledge, the first reported case of endogenous intraocular infection with the emerging pathogen Ochroconis gallopava , acquired following treatment for chronic lymphocytic leukaemia (CLL). ### CASE REPORT A 69 year old man presented with a 4 day history of painless loss of vision in the left eye after receiving four courses of fludarabine (25 mg/m2 over 5 days) for CLL. Standard infection prophylaxis following myelosuppression included oral fluconazole 50 mg once daily. His neutropenia improved (7.96×109/l) but profound lymphopenia persisted (0.11×109/l). Visual acuity was right eye 6/6+4 and left eye hand movements. The right eye was normal throughout. Anterior uveitis, hypopyon, lens opacity, and vitritis compromised left funduscopy. A lymphoproliferative or infective aetiology was suspected. Anterior chamber paracentesis …

Surgical revolution vs surgical evolution

There can be revolutions in treatment, and there can be evolutions. When a piece of research establishes that a disease is treatable, a revolution occurs because suddenly diagnosis of the disease becomes vital. This happened over 10 years ago when the CRYO-ROP study reported that treating ROP was worthwhile. In this study, the treatment ‘threshold’ was set at a level where the risk of blindness untreated was 50%. In 2003, revised indications for treatment were published, following the Early Treatment of ROP study. Now, the treatment ‘threshold’ was set at a 15% risk of blindness. One of the reasons why earlier treatment has become popular is that cryotherapy has gradually been replaced by diode laser of the retina. Although there was a large multi-centre study on outcome (where either diode laser or cryotherapy could be used), the comparative studies between cryotherapy and diode laser treatment have been rather small. The replacement of one by the other has been an evolution rather than a revolution, and is almost complete, as the paper on page Insert the page number and title of the paper here shows. This is rather similar to the way that extracapsular cataract surgery replaced intracapsular cataract surgery, and then was itself replaced by phakoemulsification surgery. Hardly any prospective randomized trials, and only small ones at that. Staunch advocates of evidence-based medicine may roll their eyes up in horror at the behaviour of ophthalmic surgeons, but I find it difficult to regard this gradual replacement as wrong. The precise moment as to when the premature infant’s retina should be treated was never set with any great rigour, from the point of view of the risks vs benefits, or blindness vs risk of mortality. One of the reasons the initial (rather high) threshold for treatment was chosen as a 50% risk of blindness was the necessity of getting a statistically viable result in the trial. For several reasons, refinements of treatment cannot be subject to similar randomized trials. One of these is the fact that the more mild treatment is often given at an earlier stage because the risks of the procedure are lower. Another is that many ophthalmologists have strongly held views and would not contemplate allowing their patients to be randomized in a trial. Differences in the incidence of ROP from country to country are large, reflecting differences in neonatal care, provision of medical services, and screening. These differences must also exist, to a lesser degree, within nations, making multi-centre trials impossible if small effects are being sought. Personally, I believe that the way ophthalmologists moved from one operation to the other, with so few prospective studies, is actually also the right way. Early on, phakoemulsification was incompletely developed, the surgeons not fluent in the technique, and the hardware not as sophisticated as it now is. A prospective study at the outset would have certainly shown phakoemulsification in a poor light. It would have been unlikely to be introduced, and patients would have been deprived of the undoubted benefits. Later on, the procedure techniques honed, any randomized trial would be unethical. There is also a definite Darwinism about these processes: not all ophthalmologists may agree about whether the newer treatment is better than the established one, but newer ophthalmologists embraced diode laser for ROP (or phakoemulsification for that matter) and the older ophthalmologists, who did not, gradually retire and are removed from the gene pool.