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Paul Rosen -
articles & editorials
Editorial
This issue of EuroTimes has special focus on digital
highlighting the impact of electronic and information technology on ophthalmic
practice today.
From the Editor - Paul Rosen FRCS FRCOphth
Despite the rejection by the people of France and The Netherlands of the
European Constitution, pan – European collaboration at a professional level is
stronger than ever. Many of the studies reported in this issue of Eurotimes
involve international collaboration. As the only European organisation to
represent Surgeons doing cataract, refractive and corneal surgery, Mary D’Ardis,
CEO, organised an ESCRS visit to EU headquarters in Brussels. The delegation
included myself, Mary, Paul McGinn, Ulf Stenevi and Marie-Jose Tassignon.
It is clear that there is huge scope for collaboration and cooperation within
the EU. Their general priorities are very similar to ours in many areas: they
wish to involve the accession and candidate states, would like to see patient
centred information systems and the introduction of guidelines e.g. for
refractive surgery. The latter is very relevant at the moment. In the UK
the Parliament will begin the process of regulating laser refractive surgery.
This has caused much distress amongst those who undertake refractive surgery
because of perceived inequalities.
One solution would be stricter, tightly controlled self regulation and the
Society is developing a Web based real-time database which will significantly
contribute to this. A comprehensive database or information system will
work at two levels. Firstly providing confidential audit data and benchmarking
to the individual surgeon and his clinic. In turn this will improve standards,
patient safety and ultimately patient confidence: this has been shown with the
cataract database used in Sweden. At a second level the information system will
be used to collect additional information for research and health technology
assessment. A wider remit of such a project will be the development of quality
of care indicators, methods of assessment of patient safety and dealing with
issues such as where there are poor clinical results. The Society is already the
premier provider of scientific educational programmes in cataract and refractive
surgery, an essential component of this project.
Patient and surgeon confidentiality will be of paramount importance and the
involvement of the National Societies essential as regulation varies in this
regard for each country. The Society is in a prime position to promote patient
safety for example by assisting surgeons in managing risk in refractive surgery
to reduce complications. ET is sponsoring a symposium on “Regulating Refractive
Surgery, Improving Patient Confidence” at the satellite meeting of UKISCRS in
Chester, England on 21st September to provide a forum to discuss these issues.
There is now a tremendous opportunity for the ESCRS to work with the EU which we
must seize with great enthusiasm and determination.
August
2005
Ophthalmology. 2004 Apr;111(4):679-85.
Effect of
cataract surgery on the corneal endothelium: modern phacoemulsification compared
with extracapsular cataract surgery.
Bourne RR, Minassian DC, Dart JK, Rosen P, Kaushal S, Wingate N.
Moorfields Eye Hospital, London, United Kingdom.
PURPOSE: To investigate whether modern phacoemulsification surgery results in
more damage to the corneal endothelium than extracapsular cataract extraction
(ECCE), and to examine which preoperative, operative, and postoperative factors
influence the effect of cataract surgery on the endothelium. DESIGN: Randomized
controlled trial. PARTICIPANTS: Five hundred patients 40 years or older were
randomized into 2 groups (ECCE, 249; phacoemulsification, 251). METHODS: Central
corneal endothelial cell counts, coefficient of variation of cell size, and
hexagonality were assessed before surgery and up to 1 year postoperatively. MAIN
OUTCOME MEASURE: Endothelial cell count. RESULTS: Four hundred thirty-three
patients completed the trial. The initial preoperative mean cell count for the
entire sample was 2481 (standard error [SE]: 18.6), reduced at 1 year
postoperatively to 2239 (SE: 23.5). An average 10% reduction in cell count was
recorded by 1 year postoperatively. There was no such change in hexagonality or
in the coefficient of variation. There was no significant difference in overall
percentage cell loss between the 2 treatment groups. Factors associated with
excessive cell loss (> or =15% by 1 year) were a hard cataract (odds ratio [OR]:
2.1, 95% confidence limits: 1.1-4.1; P = 0.036), age (OR: 1.04, P = 0.005), and
capsule or vitreous loss at surgery (OR: 2.38, P = 0.106). Phacoemulsification
carried a significantly higher risk (OR: 3.7, P = 0.045) of severe cell loss in
the 45 patients with hard cataracts relative to ECCE (52.6% vs. 23.1%;
chi-square test, P = 0.041), with both procedures achieving similar
postoperative visual acuity outcomes. CONCLUSIONS: No significant difference in
overall corneal endothelial cell loss was found between these 2 operative
techniques. The increased risk of severe cell loss with phacoemulsification in
patients with hard cataracts suggests that phacoemulsification may not be the
optimal procedure in these cases, and that ECCE should be preferred.
Eye. 2004 Jan 30
Outcome of ICG-assisted ILM peel in macular hole surgery.
Lochhead J, Jones E, Chui D, Lake S, Karia N, Patel CK, Rosen P.
1Oxford Eye Hospital, Radcliffe Infirmary, Woodstock Road, UK.
Purpose To investigate whether indocyanine green (ICG) staining of the internal
limiting membrane (ILM) improves surgical outcome.Methods A total of 34 patients
were identified who underwent macular hole surgery with ILM peeling augmented
with ICG. These were matched retrospectively with 34 patients who underwent
macular hole surgery without the use of ICG. Closure rates from primary and
secondary procedures were compared, as were changes in Snellen and Logmar visual
acuity.Results There was no significant difference between the two groups with
reference to demographic features of age, sex, staging of the macular holes, and
the proportion subsequently undergoing cataract surgery. The mean follow-up
period was 7.7 months in the ICG group and 6.3 months in the non-ICG group.
Closure rates from primary surgery were 91.2% in the ICG group and 73.5% in the
non-ICG group (P=0.056), whereas overall closure rates following further surgery
were similar in both groups (94.1 and 91.2%, respectively). Logmar visual
improvement above baseline was achieved in 53% of the non-ICG group compared to
82% of the ICG group (P=0.01). Where primary hole closure occurred, there was no
statistically significant difference in visual outcome between the two
groups.Conclusion ICG-assisted ILM peel in macular hole surgery is associated
with a higher closure rate following a single surgical procedure. This
difference was found to approach statistical significance (P=0.056). Overall
visual improvement was greater in the ICG group (P=0.01); however, this
reflected the higher closure rates. Visual outcomes between the two groups were
comparable where primary hole closure occurred.
Eye advance online publication, 30 January 2004
Eur J Anaesthesiol. 2003 Dec;20(12):973-8.
Sub-Tenon's block reduces both intraoperative and
postoperative analgesia requirement in vitreo-retinal surgery under general
anaesthesia.
Farmery AD, Shlugman D, Rahman R, Rosen P.
Oxford Eye Hospital, Department of Anaesthetics, Oxford, UK.
andrew.farmery@nda.ox.ac.uk
BACKGROUND AND OBJECTIVE: We compared the effects of sub-Tenon's
local anaesthetic block and placebo on peri-operative opioid requirement and
cardiovascular stability and on postoperative pain, nausea and vomiting in
patients undergoing vitreo-retinal surgery under general anaesthesia. METHODS:
We studied 43 patients undergoing vitreo-retinal surgery under general
anaesthesia in a randomized double blind study. Patients received a standard
general anaesthetic followed by a sub-Tenon's injection of 4-5 mL of either
bupivacaine 0.75% or saline. We recorded intraoperative invasive arterial
pressure, then the incidence and severity of pain and of nausea and vomiting,
for 24 h postoperatively. RESULTS: In the sub-Tenon's bupivacaine group, there
was a significant reduction in the perioperative opioid use and a reduction in
the frequency of bradycardia and hypertensive episodes, defined as a rise > 25%
of baseline for a duration of > 3 min. The sub-Tenon's bupivacaine group also
had significantly lower pain scores and nausea scores at 12 h, concomitant with
a lower consumption of analgesia and antiemetics. CONCLUSIONS: This local
anaesthetic technique is effective in vitreo-retinal surgery and can be safely
applied to this population of patients regardless of axial length.
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