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Paul Rosen - articles & editorials





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.

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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