Robert L. Johnston

Topical versus peribulbar anesthesia, without sedation, for clear corneal phacoemulsification.

Purpose: Purpose: To investigate patient and surgeon acceptance of topical anesthesia as an alternative to peribulbar anesthesia for clear corneal phacoemulsification. Setting: Department of Ophthalmology, Whipps Cross Hospital, London, England. Methods: All cataract surgery was performed using a temporal clear corneal approach, bimanual phacoemulsification, and in‐the‐bag intraocular lens implantation. The results of 51 patients having surgery under topical anesthesia (amethocaine) were compared with those of 30 patients having peribulbar anesthesia (50:50 mixture of lignocaine 2% and bupivacaine 0.5% with hyaluronidase). No sedation was used in either group. Pain perception on administration of the anesthetic, perioperatively (period immediately surrounding and during surgery), and postoperatively was assessed using a visual analog scale from 0 to 10 (0 = no pain; 10 = worst pain imaginable). A questionnaire was used to assess the degree of patient and surgeon satisfaction. Results: Administration of topical amethocaine was significantly less painful than peribulbar bupivacaine (P = .03). Perioperative pain showed a trend toward being worse in the topical anesthesia group but did not reach statistical significance. There was no difference in the postoperative pain scores of the two groups. The surgical experience was rated very satisfactory by 67% in the topical group and 73% in the peribulbar group. The surgeons reported no difficulties or complications. Conclusion: Topical anesthesia was safe and effective for clear corneal phacoemulsification and was well tolerated by patients. The slightly greater awareness of ocular discomfort in the topical group perioperatively did not alter patient satisfaction with the surgical experience when compared with the peribulbar group.

The neovascular age-related macular degeneration database: report 2: incidence, management, and visual outcomes of second treated eyes.

PURPOSEnTo study the characteristics of second treated eyes in patients with neovascular age-related macular degeneration (nAMD) treated with ranibizumab in the United Kingdom National Health Service.nnnDESIGNnMulticenter national nAMD database study.nnnPARTICIPANTSnTwelve thousand nine hundred fifty-one treatment-naïve eyes of 11,135 patients receiving 92,976 ranibizumab injections.nnnMETHODSnUp to 5 years of routinely collected, anonymized data within electronic medical record systems were extracted remotely from 14 centers. Participating centers exclusively used ranibizumab to treat nAMD (loading phase of 3 monthly injections followed by monthly visits and pro re nata re-treatment). The minimum data set included: age, logarithm of the minimum angle of resolution (logMAR) visual acuity (VA) at baseline and at all subsequent visits, and injection episodes.nnnMAIN OUTCOME MEASURESnBaseline, change and actual VA over 3 years, and number of treatments and clinic visits.nnnRESULTSnDuring the study, 1816 (16.3%) of the 11 135 patients received treatment to the fellow eye. Mean baseline and final VA were 0.66 (standard deviation, 0.32) and 0.65 (0.40) for first treated eyes and 0.41 (0.34) and 0.56 (0.40) for second treated eyes. The rate of VA loss after the loading phase was similar in first and second treated eyes (0.03 and 0.05 logMAR units/year). When fellow eyes with baseline VA worse than 20/200 were excluded to restrict analyses to eyes at risk of nAMD, the rate of second-eye involvement was 14.0% per year (42%/3 years). Mean number of injections/visits in years 1, 2, and 3 were similar for first and second treated eyes (5.6/8.2, 3.9/8.0, 3.8/8.2 and 5.5/8.7, 3.6/9.4, and 3.8/9.1, respectively).nnnCONCLUSIONSnSecond treated eyes with nAMD commence treatment with better baseline VA, do not show significant vision gain but maintain better VA than first treated eyes at all time points for at least 3 years, making them the more important eye functionally. These data highlight the high burden of second eye involvement, with almost half of all eyes at risk requiring bilateral treatment by 3 years, and the need for regular monitoring of fellow eyes for best visual outcomes which theoretically may reduce the benefits of extended monitoring regimens.

Pars plana vitrectomy and sutured posterior chamber lens implantation.

Transcleral suturing of posterior chamber intraocular lenses (IOLs) was developed to extend the benefits of IOL visual rehabilitation to eyes lacking capsular support and to avoid the complications of closed loop interior chamber IOLs. Although most frequently implanted after complicated cataract surgery or penetrating keratoplasty, they are indicated in several situations following pars plana vitrectomy. The surgical techniques have evolved to minimize the risk of complications, but the surgery remains technically more demanding and time-consuming than insertion of a modern open loop anterior chamber IOL. No randomized trials have compared the relative risks of each lens type, which leaves surgeon preference as the major determinant of what lens is implanted. It is likely, however, that in eyes with extensive anterior chamber angle damage or large iris defects, sutured posterior chamber IOLs will remain the first choice for surgical rehabilitation.

Real-world experience with 0.2 μ g/day fluocinolone acetonide intravitreal implant (ILUVIEN) in the United Kingdom

AimsTo compare safety outcomes and visual function data acquired in the real-world setting with FAME study results in eyes treated with 0.2u2009μg/day fluocinolone acetonide (FAc).MethodsFourteen UK clinical sites contributed to pseudoanonymised data collected using the same electronic medical record system. Data pertaining to eyes treated with FAc implant for diabetic macular oedema (DMO) was extracted. Intraocular pressure (IOP)-related adverse events were defined as use of IOP-lowering medication, any rise in IOP>30u2009mmu2009Hg, or glaucoma surgery. Other measured outcomes included visual acuity, central subfield thickness (CSFT) changes and use of concomitant medications.ResultsIn total, 345 eyes had a mean follow-up of 428 days. Overall, 13.9% of patients required IOP-lowering drops (included initiation, addition and switching of current drops), 7.2% had IOP elevation >30u2009mmu2009Hg and 0.3% required glaucoma surgery. In patients with prior steroid exposure and no prior IOP-related event, there were no new IOP-related events. In patients without prior steroid use and without prior IOP-related events, 10.3% of eyes required IOP-lowering medication and 4.3% exhibited IOP >30u2009mmu2009Hg at some point during follow-up. At 24 months, mean best-recorded visual acuity increased from 51.9 to 57.2 letters and 20.8% achieved ≥15-letter improvement. Mean CSFT reduced from 451.2 to 355.5u2009μm.ConclusionsWhile overall IOP-related emergent events were observed in similar frequency to FAME, no adverse events were seen in the subgroup with prior steroid exposure and no prior IOP events. Efficacy findings confirm that the FAc implant is a useful treatment option for chronic DMO.

UK Age-Related Macular Degeneration Electronic Medical Record System (AMD EMR) Users Group Report IV: Incidence of Blindness and Sight Impairment in Ranibizumab-Treated Patients

PURPOSEnTo study the incidence of blindness and sight impairment in treatment-naive patients receiving ranibizumab (Lucentis) for neovascular age-related macular degeneration (nAMD) in the United Kingdom (UK) National Health Service.nnnDESIGNnMulticenter nAMD database study.nnnPARTICIPANTSnA total of 11u2009135 patients who collectively received 92u2009976 treatment episodes to 12u2009951 eyes.nnnMETHODSnData were extracted from 14 UK centers using the same electronic medical record system (EMR). The EMR-mandated collection of a data set (defined before first data entry) including: age, Early Treatment Diabetic Retinopathy Study visual acuity letter score (VA) for both eyes at all visits, and injection episodes. Participating centers used overwhelmingly a pro re nata re-treatment posology at intended monthly follow-up visits following a loading phase of 3 monthly injections.nnnMAIN OUTCOME MEASURESnIncidence of blindness and sight impairment (VA in the better-seeing eye <38 letters [≤20/200 Snellen, approximately], and <68 letters [≤20/50 Snellen, approximately] at 2 consecutive visits, or 1 visit if no further follow-up data) in each year after initiating treatment.nnnRESULTSnInformation from >300u2009000 clinic visits (2.8 million data points) collected over 5 years was collated from 14 centers. Mean age at first treatment was 79.7 years (standard deviationxa0= 9.19 years), with a female preponderance (63%). The mean (median) VA at baseline in the better-seeing eye was 67.2 (72.0) letters, 20/40- (20/40+) approximate Snellen conversion. The cumulative incidence of new blindness and sight impairment in patients with treated nAMD in at least 1 eye at years 1 to 4 after first injection were 5.1%, 8.6%, 12% and 15.6% for new blindness and 29.6%, 41.0%, 48.7%, and 53.7% for new sight impairment, but with significant reductions in the rates between year cohorts initiating treatment (blindness [Pxa0= 4.72xa0× 10-08], sight impaired [Pxa0= 3.27xa0× 10-06]).nnnCONCLUSIONSnTo the best of our knowledge, this is the first multicenter real-world study on the incidence of blindness and sight impairment based on VA data in patients treated with ranibizumab for nAMD, and its results show low incidences of both blindness and sight impairment, which both declined during the study period.

Adjustment of intraocular lens power for sulcus implantation

The SRK/T formula was developed with reference to data from 1677 eyes; T2 was developed using data from 5588 eyes. The original analysis of the performance of the SRK/T formula evaluated 1050 eyes, and the 3 largest independent series analyzed between 786 and 858 eyes. Our analysis of the relative performance of the SRK/T and T2 formulas examined 5601 eyes. This is the largest such series published to date and by somemargin. The discovery of the SRK/T cusp was attributed to Ken Hoffer and Alan Ritter and first reported in 1992. In 1993, the authors of the SRK/T formula acknowledged that the cusp was “an unexpected side effect” and stated that they were “gathering data.to determine the best method of adjusting the SRK/T formula to eliminate the cusp and, if possible, to improve IOL power prediction.” In the intervening 17 years, nothing further has been published. We have simply applied the scientific method and have succeeded on both counts. The SRK/T formula authors believed that the cusp phenomenon affected only a small percentage of eyes with high corneal powers. We demonstrated that this is not the case; the SRK/T formula contains a systematic error that affects eyes with high and low corneal powers to the greatest degree, but the error in corneal height prediction has some effect for any eye that is not close to average axial length and corneal power.

Visual Acuity Improvement When Switching From Ranibizumab To Aflibercept Is Not Sustained

Purpose: To assess whether visual benefits exist in switching to aflibercept in patients who have been chronically treated with ranibizumab for neovascular age-related macular degeneration. Methods: A multicenter, national, electronic medical record database study was performed. Patients undergoing six continuous monthly ranibizumab injections and then switched to continuous aflibercept were matched to those on continuous ranibizumab therapy. Matching was performed in a 2:1 ratio and based on visual acuity 6 months before and at the time of the switch, and the number of previous ranibizumab injections. Results: Patients who were switched to aflibercept demonstrated transiently significant improvement in visual acuity that peaked at an increase of 0.9 Early Treatment Diabetic Retinopathy Study letters 3 months after the switch, whereas control patients continued on ranibizumab treatment showed a steady decline in visual acuity. Visual acuity differences between the groups were significant (P < 0.05) at 2, 3, and 5 months after the switch. Beginning at 4 months after the switch, the switch group showed a visual acuity decline similar to the control group. Conclusion: Transient, nonsustained improvement in visual acuity occurs when switching between anti–vascular endothelial growth factor agents, which may have implications in treating patients on chronic maintenance therapy on one anti–vascular endothelial growth factor medication.

Uncited biometry study

Uncited biometry study In Hoffman and H€ utz’s recent paper describing the ocular biometric characteristics of 15 448 patients attending their clinic in Germany and the related editorial, the authors state that they believe this analysis to be the largest ocular biometric study to date and the first in the era of partial coherence interferometric axial length (AL) measurement. In fact, more than a year ago, our group, also using the IOLMaster with software version 3.0 (Carl Zeiss Meditec AG), reported the ocular biometric characteristics of 32 556 eyes, 14 016 of which were paired. The mean AL was 23.40 mm G 1.32 (SD) and the mean Kmean, 43.90 G 1.55 diopters (equivalent to a mean radius of anterior corneal curvature of 7.69 mm if a keratometric index of 1.3375 is assumed), values almost identical to those described by Hoffman and H€ utz. Surprisingly, we did not find a change in Jaeger (J)45 or J0 power vectors with age. Unlike in the Hoffman and H€ utz’s study, the corneal diameter, phakic anterior chamber depth, and emmetropic intraocular power were not determined. Although the similarity of results obtained in these 2 studies validates the methodology used in each, it is uncertain whether these findings can be extrapolated to non-European populations.

Cat-PROM5: a brief psychometrically robust self-report questionnaire instrument for cataract surgery.

PurposeTo develop a short, psychometrically robust and responsive cataract patient reported outcome measure suitable for use in high-volume surgical environments.MethodsA prospective study in which participants completed development versions of questionnaires exploring the quality of their eyesight using items harvested from two existing United Kingdom developed parent questionnaires. Participants were 822 patients awaiting cataract surgery recruited from 4 cataract surgical centres based in the UK. Exclusion criteria were other visually significant comorbidities and age <50 years. An iterative multi-stage process of evaluation using Rasch and factor analyses with sequential item reduction was undertaken.ResultsA definitive item set of just five items delivered performance in accordance with the requirements of the Rasch model: no threshold disordering, no misfitting items, Rasch-based reliability 0.90, person separation 2.98, Cronbach’s α 0.89, good targeting of questions to patients with cataract with pre-operative item mean −0.41 logits and absence of significant floor or ceiling effects, minor deviations of item invariance, and confirmed unidimensionality. The test–re-test repeatability intra-class correlation coefficient was 0.89 with excellent responsiveness to surgery, Cohen’s d −1.45 SD. Rasch calibration values are provided for Cat-PROM5 users.ConclusionsA psychometrically robust and highly responsive five-item cataract surgery patient reported outcome measure has been developed, which is suitable for use in high-volume cataract surgical services.

Cataract surgery patient reported outcome measures: a head-to-head comparison of the psychometric performance and patient acceptability of the Cat-PROM5 and Catquest-9SF self-report questionnaires

Background Cataract surgery is the most frequently undertaken NHS surgical procedure. Visual acuity (VA) provides a poor indication of visual difficulty in a complex visual world. In the absence of a suitable outcome metric, recent efforts have been directed towards the development of a cataract patient-reported outcome measure (PROM) of sufficient brevity, precision, and responsiveness to be implementable in routine high volume clinical services.Aim To compare and contrast the two most promising candidate PROMs for routine cataract surgery.Method The psychometric performance and patient acceptability of the recently UK developed five-item Cat-PROM5 questionnaire was compared with the English translation of the Swedish nine-item Catquest-9SF using Rasch-based performance metrics and qualitative semistructured interviews.Results Rasch-based performance was assessed in 822 typical NHS cataract surgery patients across four centres in England. Both questionnaires demonstrated good to excellent performance for all metrics assessed, including Person Reliability Indices of 0.90 (Cat-PROM5) and 0.88 (Catquest-9SF), responsiveness to surgery (Cohen’s standardized effect size) of 1.45u2009SD (Cat-PROM5) and 1.47u2009SD (Catquest-9SF) and they were highly correlated with each other (R=0.85). Qualitative assessments confirmed that both questionnaires were acceptable to patients, including in the presence of ocular comorbidities. Preferences were expressed for the shorter Cat-PROM5, which allowed patients to map their own issues to the questions as opposed to the more restrictive specific scenarios of Catquest-9SF.Conclusion The recently UK developed Cat-PROM5 cataract surgery questionnaire is shorter, with performance and patient acceptability at least as good or better than the previous ‘best of class’ Catquest-9SF instrument.