Sarah B. Wang

Rethinking cataract surgery benchmarking, key performance indicators and maintaining professional standards in Australia

We were pleasantly surprised and indeed encouraged to read the Editorial by Dr Sukhpal Sandhu of the Royal Victorian Eye and Ear Hospital, Centre for Eye Research Australia. This is related to our article from 1993 documenting the surgical and postoperative experience of one surgeon’s first 100 cataract procedures. Dr Sandhu felt that it was perhaps the first of its kind. It was certainly a ‘belt and braces’ report, as phacoemulsification was relatively new to Australia at that time, and most experienced cataract surgeons were attending courses and observing their colleagues, both locally and overseas, in order to hone their skills in this technique. In the study quoted, the complication rate was, by today’s standards, unacceptable. However, the way forward was clear, and the surgeon in question has todateperformed5324endocapsularphacoemulsification procedures. The number of cases in this cohort may be seen by some ophthalmic surgeons as somewhat unremarkable in terms of volume. According to documentation of our last 1382 cases, studied prospectively and consecutively, with no exclusions, and one month follow up in 100% of cases, the corrected distance visual acuity (CDVA) was 6/4 in 92.3% of cases. While the authors acknowledge that some of these may have been relatively straightforward surgical cases, many surgeons find that the more difficult cases are actually easier to operate on. This is because the cataract nuclei are more easily managed with standard sculpting followed by phaco stop-and-chop. This particularly applies to nuclear sclerosis grades 2+ to 3+ or more. It has been said that it is essential to document surgical outcomes for any practising surgeon. While patients want to see well, preferably without glasses, and patient satisfaction is important, the definitive outcome should be quantifiable and focus on visual outcomes (VOs). To that end, documenting the VO (as CDVA) at each relevant time point is central, and we applaud Dr Sandhu for his Editorial. Furthermore, the notion of transparency is also critical, because the ‘feel good’ response by the patient may simply reflect the fact that a 6/60 eye now sees 6/12. This particularly applies to a recent article in the German literature, in which patient satisfaction was measured as a score out of 10, apparently minimally related to final CDVA. While patient satisfaction should be regarded as important, our group feels that surgeons need to have an objective measure of success. This also permits investigators and insurance providers to compare the visual outcomes between cataract surgeons reliably and readily. Our group considers that the mandatory logbooks issued by RANZCO for trainees in ophthalmology are an excellent tool in promoting satisfactory VOs. Indeed, our group believes that a case could be made for all cataract surgeons to document fully the preoperative, operative and postoperative findings for every patient.

Materials in the vitreous during cataract surgery: nature and incidence, with two cases of histological confirmation.

To identify and classify materials in the vitreous observed during phacoemulsification cataract surgery (phaco).

Hydropolish: a controlled trial on a technique to eradicate residual cortical lens fibers in phacoemulsification cataract surgery

Purpose To assess the efficacy and safety of a noncontact, fluid-based capsular polishing technique (hydropolish) to remove residual cortical fibers (RCFs) and epithelial cells from the posterior and equatorial capsule in phacoemulsification cataract surgery. Methods Hydropolish involved manual irrigation of the posterior and equatorial capsule after irrigation/aspiration, using a 27-G hydrodissection cannula. This prospective, consecutive, single surgeon controlled trial was conducted at a dedicated ophthalmic surgery center in Sydney, Australia, between December 20, 2006, and July 14, 2010. Single eyes of consecutive patients underwent cataract surgery without use of hydropolish (control group), while those on or after July 21, 2010, underwent hydropolish (intervention group). Corrected distance visual acuity (CDVA) up to 1 month postoperatively, surgical complications, and hydropolish time were documented. Results A total of 1531 eyes were included in this study (hydropolish n = 682; control n = 849). After adjusting for age, sex, and nuclear sclerosis grade, no significant difference was found between hydropolish and control groups when preoperative CDVA was compared against postoperative CDVA at 1 day, 1 week, and 1 month (p>0.05). Conclusions Hydropolish is a rapid and safe technique that can remove RCFs from the posterior and equatorial capsule in phacoemulsification cataract surgery. It does not compromise postoperative CDVA.

Materials in the vitreous demonstrated under the operating microscope during cataract surgery and confirmed histologically

1. Kam AW, Chen TS, Wang SB, et al. Materials in the vitreous during cataract surgery: nature and incidence, with two cases of histological confirmation. Clin Experiment Ophthalmol 2016; 44: 797–802. 2. Grzybowski A, Prasad S. Acute aqueous misdirection syndrome: pathophysiology and management. J Cataract Refract Surg 2014; 40: 2167. 3. Mackool RJ, Sirota M. Infusion misdirection syndrome. J Cataract Refract Surg 1993; 19: 671–2; erratum, 819. 4. Olson RJ, Younger KM, Crandall AS, Mamalis N. Subcapsular fluid entrapment in extracapsular cataract surgery. Ophthalmic Surg 1994; 25: 688–9. 5. Little BC, Hitchings RA. Pseudophakic malignant glaucoma: Nd:YAG capsulotomy as a primary treatment. Eye 1993; 7: 102–4.

Teaching hospital cataract surgical outcomes in Adelaide, Australia.

We read with pleasure the report in Clinical and Experimental Ophthalmology Issue 43, pages 514–522) on the Cataract surgery audit at the Queen Elizabeth Hospital in Adelaide. We congratulate the authors on their assessment of success by the measurement of Corrected Distance Visual Acuity (CDVA), and the finding that 87.59% of patients at one month were close to the desired refractive outcome of +/ 1D of target spherical equivalent. Indeed, this sort of refractive outcome is not unusual, reflecting the effectiveness of modern laser interferometric measurement techniques. An important addition to the paper might have been inclusion of the CDVA at one week and one month in the cohort. In our study of the senior author’s last 1382 cases, the CDVA at one month was 6/4 in 92.2%, the CDVA being little different between grade 3 Nuclear Sclerosis (NS: LOCS3) and grade 2 NS (data submitted for publication). The published study reports a post-cataract Endophthalmitis rate of 0.11%.Endophthalmitis is arguably the most devastating complication encountered by cataract surgeons. Our group agrees with the Authors’ observation about the relationship between corneal wound hydration and the incidence of postcataract Endophthalmitis. It is probable that definitive wound closure with either a suture, the new hydrogel closure or the traditional subconjunctival short scleral/corneoscleral incision, will be the way to go to avoid post-cataract Endophthalmitis. Not only has corneal wound hydration been shown to last as little as 15min, resulting in all the sequelae of the sucking corneal wound, cannular wound hydration has now become the commonest cause of a high-speed projectile injury into the eye. Furthermore, our article quoting the Endophthalmitis rate in New South Wales Australia of 0.834%, the highest documented rate in the world, was based on hospital admissions for Endophthalmitis between 1994 and 2003. The likely reason for this high incidence in Endophthalmitis in the six years before and three years after 2000, when clear corneal incisions became popular, is acute emergency hospital bedswere being filled with patients with post-cataract Endophthalmitis, and this became untenable. Outpatient management (Tap and Inject) became prevalent, and the resultingdatadeficiency thus came to the fore.Although our group does not believe that this suggests that eyes undergoing cataract surgery in New South Wales are anymore likely to developpost-cataract Endophthalmitis, the implication is that the data on Endophthalmitis, based on Outpatient records, are not reliable. The Swedish experience documents that intracameral second generation cephalosporins at the conclusion of surgery improve the Endophthalmitis rate, but anyEndophthalmitis is unacceptable to the patient and the surgeon. Furthermore, none of the Swedish studies documented admission to hospitals, thus possibly underestimating the number of cases of Endophthalmitis.

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.

Endophthalmitis in Europe: data collection conundrum.

Endophthalmitis in Europe: Data collection conundrum Behndig et al. have summarized available data pertaining to the use of intracameral cefuroxime in Europe for prophylaxis against endophthalmitis following cataract surgery. The readership was alerted to the significant differences in data collectionmethods between its component countries. Data from mandatory National Registries were available from only Sweden and the Netherlands. No information on endophthalmitis rates was available from Belgium and Italy. Therefore, figures were extrapolated from the European Registry of Quality Outcomes for Cataract and Refractive Surgery database and the European Society of Cataract and Refractive Surgeons trial, respectively. Data were collected from France, United Kingdom, Germany, Spain, and Poland by way of nonmandatory registries or surveys. The significant differences in data collection allow limited conclusions to be drawn about the true rate of endophthalmitis within each country. This therefore eliminates the ability to compare endophthalmitis rates between European countries. There are widely varying reported rates of endophthalmitis. These variations were apparent in the data reported by Behndig et al., in which rates ranged from less than 0.04% in Sweden to 0.50% in Spain. Considerable disparity in published rates of endophthalmitis also exists within single countries; eg, 0.03% to 0.20% in the United Kingdom. These variations are evident in other studies from around the world regarding purported rates of endophthalmitis. The systematic review by Taban et al. suggests that in 2000 to 2003, the worldwide incidence of endophthalmitis was 0.265%. Correspondence published by our group in 2009 reviewed all public hospital admissions for endophthalmitis in the most populous state in Australia, New South Wales. It revealed the alarmingly high endophthalmitis incidence of 0.834% between July 1994 and June 2003. These large discrepancies in endophthalmitis rates may be accounted for by the differing methods of data collection. Data obtained in a nonmandatory fashion will probably underestimate true rates of endophthalmitis. We concur with the statement by Behndig et al. that “the [given] overview does not pretend to report actual practice patterns and epidemiological facts.” For this reason and others mentioned, we recommend a cautious interpretation of the figures. Furthermore, the role of intracameral cefuroxime in the prophylaxis of endophthalmitis remains uncertain. There are other confounders to consider, including variations in patient factors, perioperative

Five cases of orbital extramedullary plasmacytoma: diagnosis and management of an aggressive malignancy

ABSTRACT Purpose: Multiple myeloma is an insidious haematological malignancy characterised by monoclonal proliferation of plasma cells in the bone marrow. Extramedullary plasmacytoma is a rare manifestation of multiple myeloma and usually occurs in the upper respiratory tract. Orbital involvement is particularly uncommon, but may be associated with devastating visual impairment and poor clinical outcomes. Therefore, this article aims to highlight the need for multidisciplinary management of orbital extramedullary plasmacytoma. Methods: This is a retrospective observational case series of five patients. All presented to the authors for management of orbital extramedullary plasmacytomas from 2004 to 2015 at Prince of Wales and Mater Hospitals in Sydney, Australia. Medical records were reviewed for pertinent information including demographics, disease features, management strategy, and clinical progress. The study met Medical Ethics Board standards and is in accordance with the Helsinki Agreements. Results: This case series of five patients underscores the poor prognosis of orbital extramedullary plasmacytoma. Despite aggressive multidisciplinary management, four of these five patients succumbed to their illness during the study period. However, multidisciplinary management did manage to minimise symptoms and preserve quality of life. Conclusions: On a case-by-case basis, patients may derive palliative benefit from orbital surgery in conjunction with radiotherapy and chemotherapy. Orbital surgeons are encouraged to work within a multidisciplinary framework of medical specialists, including haematologists and radiation oncologists, when determining the optimal management plan in cases of orbital extramedullary plasmacytoma.

Anterior Chamber Culture at the Conclusion of Cataract Surgery and Its Relation to Post-Cataract Surgery Endophthalmitis

Purpose: The purpose of this study is to reassess the pathogenesis of postoperative endophthalmitis (POE), aiming to determine the presence of bacteria in the anterior chamber at the conclusion of phacoemulsification cataract surgery, and the subsequent development of POE. Methods: A single surgeon performed all cataract procedures across the two nominated day surgical centres. Phacoemulsification surgery with intraocular lens implantation (IOL) was performed on 209 eyes. Patient demographics and POE risk factors were obtained, as well as an anterior chamber (AC) aspirate from each patient at the conclusion of the surgical procedure. The aspirate was cultured for 1 – 5 days. Fourteen eyes also underwent bacterial 16S polymerase chain reaction (PCR) analysis of the AC aspirate. Any subsequent development of POE was recorded. No intracameral antibiotics were used. Results: Of the 209 cultures, three cases (1.4%) were positive for growth (95% confidence interval). The three positive cases yielded different microorganisms. One case was positive for bacteria (Corynebacterium species) while the other two cases were positive for fungi (Candida species and a Zygomycete). Cases with positive culture growth had no statistically significant difference in the incidence of preoperative, operative and postoperative risk factors for POE, compared with patients with negative culture. No patient in this study developed POE. Conclusion: The bacterial contamination rate of the AC after phacoemulsification surgery with IOL implantation is extremely low. Strict aseptic technique and definitively closed incisions can potentially be attributed to the zero percentage incidence of POE. It is probable that POE is more likely due to postoperative factors.