Researchers from St. Elizabeth’s Hospital in the Netherlands utilized a retrospective, observational cohort study to determine that cataract surgery can be safely performed in an outpatient clinic in the absence of the anesthesia service and with limited workup and monitoring. Basic first aid and life support skills seem to be sufficient in the case of an adverse event, and a medical emergency team provides a generous failsafe for what is a low-risk procedure.
All patients who underwent elective phacoemulsification/intraocular lens surgery under topical anesthesia in the ophthalmology outpatient unit between January 1, 2011 and December 31, 2012 were included as study participants. Within the cataract pathway, 6,961 eyes of 4,347 patients were eligible for analysis. The primary outcome measure was the incidence of adverse events requiring medical emergency team interventions through the pathway. Secondary outcome measures were surgical ocular complication rates, use of oral sedatives and reported reasons to perform the surgery in the classical operation room complex.
Cataract surgery was performed by phacoemulsification under topical anesthesia. The intake process mainly embraced ophthalmic evaluation, obtaining a medical history and proposing the procedure. A staff ophthalmologist performed the procedure assisted by two registered nurses in an independent outpatient clinic operating room within the hospital. The clinical pathway was without dedicated presence of or access to anesthesia service. Perioperative monitoring was limited to blood pressure and plethysmography preoperatively and intraoperatively. Patients were offered supportive care and instructed to avoid fasting and continue all their chronic medication.
Three medical emergency team interventions related to the phacoemulsification/intraocular lens pathway occurred in the study period, resulting in an intervention rate of 0.04 percent. None of the interventions was intraoperative. All three patients were diagnosed as vasovagal collapse and recuperated uneventfully. No hospital admittance was required. Eight other incidents occurred within the general ophthalmology outpatient unit population during the study period.
Koolwijk J, Fick M, Selles C, Turgut G, Noordergraaf J, et al.
Central Corneal Thickness Impact on Risk of Glaucoma
New research supports the recent assertion that thin central corneal thickness is a predictor of glaucoma progression and explains a substantial portion of the increased risk of glaucoma seen among blacks and Hispanics.
Patients who were aged 40 years and older in the Kaiser Permanente Northern California health plan from January 1, 2007 through December 31, 2011 with a documented CCT (n=81,082) were included in this cross-sectional study. Patients with any cornea-related diagnoses or a history of corneal refractive surgery were excluded. Demographic characteristics, including age, sex and race/ethnicity, as well as clinical information including glaucoma-related diagnosis, diabetic status, CCT and intraocular pressure were gathered from the electronic medical records.
Multivariate linear regression analysis indicated that female sex, increased age and black race were significantly associated with thinner corneas. A subgroup analysis among Asians revealed that Chinese, Japanese and Koreans had corneas 6 to 13 μm thicker than South and Southeast Asians, Filipinos and Pacific Islanders for each diagnosis (p<0.001). Within the patient population, 24.5 percent (n=19,878) had some form of open-angle glaucoma; 21.9 percent (n=17,779) did not have any glaucoma-related diagnosis. Variation in CCT accounted for only 6.68 percent (95 percent confidence interval, 6.14 percent to 7.24 percent) of the increased risk of open-angle glaucoma seen with increasing age, but explained as much as 29.4 percent (95 percent CI, 27 to 32.6 percent) of the increased risk of glaucoma seen among blacks and 29.5 percent (95 percent CI, 23.5 to 37 percent) of the increased risk of glaucoma seen among Hispanics.
J Glaucoma 2014;23:606-612.
Wang S, Mellex R, Lin S.
DME, Ranibizumab and Prompt vs. Deferred Laser Treatment
Five-year randomized trial results suggest focal/grid laser treatment at the initiation of intravitreal ranibizumab is no better than deferring laser treatment for ≥24 weeks in eyes with diabetic macular edema involving the central macula with vision impairment. Although more than half of eyes in which laser treatment is deferred may avoid laser for at least five years, such eyes may require more injections to achieve these results when following this protocol. Most eyes treated with ranibizumab and either prompt or deferred laser maintain vision gains obtained by the first year through five years with little additional treatment after three years.
Participants were from a previously reported three-year trial evaluating 0.5 mg intravitreal ranibizumab every four weeks until no longer improving (with resumption if worsening) with prompt vs. deferred (for ≥24 weeks) focal/grid laser treatment; of those who consented to and completed the two-year extension, 124 patients (97 percent) were from the prompt group and 111 (92 percent) were from the deferred group. The main outcome measure at the five-year visit was best-corrected visual acuity.
The mean change in visual acuity letter score from baseline to the five-year visit was +7.2 letters in the prompt laser group compared with +9.8 letters in the deferred laser group (mean difference, -2.6 letters; 95 percent CI, -5.5 to +0.4 letters; p=0.09). At the five-year visit, there was a vision loss of ≥10 letters in 9 percent vs. 8 percent of the prompt vs. deferred laser groups; an improvement of ≥10 letters in 46 percent of the prompt laser group vs. 58 percent of the deferred laser group; and an improvement of ≥15 letters in 27 percent vs. 38 percent of the prompt vs. deferred laser groups. From baseline to five years, 56 percent of the participants in the deferred group did not receive laser treatment. The median number of injections was 13 vs. 17 in the prompt and deferred groups, including 54 percent and 45 percent receiving no injections during year four and 62 percent and 52 percent receiving no injections during year five, respectively.
Elman M, Ayala A, Bressler N, Browning D, Flaxel C, et al.
IV Pentamidine Before TKP to Treat Acanthamoeba Keratitis
Research from the University of Iowa Hospitals and Clinics on patients treated with intravenous pentamidine before therapeutic keratoplasty for Acanthamoeba keratitis suggests that the adjunctive use of IVP before surgery may assist with the achievement of microbiological cure, clear graft and good visual outcome in a majority of cases.
A retrospective medical chart review of every patient treated with IVP before therapeutic keratoplasty for Acanthamoeba keratitis at the UIHC between January 1, 2002 and December 31, 2012 found eight eyes of seven patients that met inclusion criteria for the study. Preoperatively, all eight eyes had failed traditional antiamoebic therapy, including five eyes with recurrent infections after previous therapeutic keratoplasty. The patients were treated with IVP (190 to 400 mg/day) for a median of 14 days (r: seven to 26 days). After eight therapeutic keratoplasties, a microbiological cure was achieved and a clear graft maintained in five eyes (62.5 percent) during a mean follow-up interval of 31.2 months (r: one to 95.7 months). Repeat therapeutic keratoplasty in three eyes with recurrent Acanthamoeba keratitis resulted in two additional microbiological cures and one more clear graft. The final best-corrected visual acuity was ≥20/40 in five eyes (62.5 percent) and worse than 20/200 in three eyes. Overall, the final vision was improved in six eyes (75 percent), remained the same in one eye (12.5 percent) and was worse in one eye (12.5 percent).
Sacher B, Wagoner M, Goins K, Sutphin J, Greiner M, et al.
Three-year Outcomes for AMD Treat-and-Extend Regimens
Researchers from the Wills Eye Hospital have determined that a treat-and-extend regimen is effective in achieving and maintaining visual and anatomic improvements with neovascular age-related macular degeneration for up to three years of treatment.
The Wills Eye Retina Service treated 212 eyes from 196 patients diagnosed with treatment-naïve neovascular AMD between January 2009 and March 2013; they were treated with either ranibizumab or bevacizumab for a minimum of one year, using a treat-and-extend regimen. The main outcome measures were change from baseline best-corrected Snellen visual acuity, proportion of eyes losing <3 BCVA lines, proportion of eyes gaining ≥3 BCVA lines, change from baseline central retinal thickness and mean number of injections at one, two and three years of follow-up.
The mean follow-up period was 1.88 years (median, two years). At baseline, BCVA was 20/139; it improved to 20/79 (p<0.0001) after one year of treatment and was maintained at 20/69 and 20/64 at two and three years follow-up (p<0.001). At baseline, mean central retinal thickness was 351 μm and significantly decreased to 285 μm, 275 μm and 276 μm at one, two and three years of follow-up (p<0.001). Patients received, on average, 7.6, 5.7 and 5.8 injections over years one, two and three of treatment. At final follow-up, 94 percent of eyes had lost <3 lines BCVA and 34.4 percent of eyes had gained ≥3 lines of BCVA.
Am J Ophthalmol 2015;159:3-8.
Rayess N, Houston S, Gupta O, Ho A, Regillo C.
Hydrogel Sealant vs. Sutures to Prevent Postop Fluid Loss
Results from a multicenter study indicate that hydrogel sealant is safe and effective, and is better than sutures for the intraoperative management of clear corneal incisions with wound leakage as seen on Seidel testing, and for the prevention of postoperative fluid egress.
Healthy patients having uneventful clear corneal incision cataract surgery were recruited for this study at 24 ophthalmic clinical practices in the United States. Spontaneous and provoked fluid egress from wounds was evaluated at the time of surgery using a calibrated force gauge. Eyes with leakage were randomized to receive a hydrogel sealant (ReSure) or a nylon suture at the main incision site. Incision leakage was reevaluated one, three, seven and 28 days postoperatively.
Of 500 eyes, 488 had leakage at the time of cataract surgery. The leak was spontaneous in 244 cases (48.8 percent) and 488 (97.6 percent) of all incisions leaked with one ounce or less of applied force. After randomization, 12 (4.1 percent) of 295 eyes in the sealant group and 60 (34.1 percent) of 176 eyes in the suture group had wound leakage with provocation (p<0.0001). The overall incidence of adverse ocular events was statistically significantly lower in the sealant group than in the suture group (p<0.05).
Six of this article’s authors are consultants to and shareholders of Ocular Therapeutix.
J Cataract Refract Surg 2014;40: 2057-2066.
Masket S, Hovanesian J, Levenson J, Tyson F, et al.