Endogenous bacterial endophthalmitis: a 17-year prospective series and review of 267 reported cases.

• With the use of data published during the period from 1966 through 1988, a pooled analysis (meta-analysis) of 5-year mortality rates among patients who had an eye enucleated for choroidal melanoma was performed to provide a more robust estimate of this rate than could be obtained from any single study. The literature concerning mortality following a diagnosis of choroidal melanoma has been reviewed systematically and described in a separate article. Of 76 reports published from 1966 through 1988, 29 were excluded from the meta-analysis because there were no cases treated by enucleation alone, mortality was not reported by time from enucleation, fewer than 10 cases were reported, or 5-year mortality rates were not reported or derivable from the data presented. Ten additional reports were excluded because they were based on data for the same set of patients as another article in the series. Of the remaining 37 reports, 29 contained data for patients with tumors of varying sizes that could not be separated into subgroups based on the size of the tumor at the time of treatment. The remaining eight articles reported 5-year mortality rates by tumor size, specifically for small, medium, or large tumors. The combined weighted estimates of 5-year mortality rates following enucleation were 16% for small tumors (95% confidence interval [CI]: [14%, 18%]), 32% for medium tumors (95% CI: [29%, 34%]), and 53% for large tumors (95% CI: [50%, 56%]). Different methods of pooling the data yielded consistent estimates for all three tumor size categories. These results supported the finding by other investigators that tumor size at time of enucleation is a major prognostic factor for patients who have choroidal melanoma.

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=OPHTH&articleId=639529&pdfFileName=archopht_110_2_036.pdf

A review of mortality from choroidal melanoma. II. A meta-analysis of 5-year mortality rates following enucleation, 1966 through 1988.

Background
Good unaided distance visual acuity (VA) is now a realistic expectation following cataract surgery and intraocular lens (IOL) implantation Near vision, however, still requires additional refractive power, usually in the form of reading glasses Multiple optic (multifocal) IOLs are available which claim to allow good vision at a range of distances It is unclear whether this benefit outweighs the optical compromises inherent in multifocal IOLs

Objectives
To assess the visual effects of multifocal IOLs in comparison with the current standard treatment of monofocal lens implantation

Search methods
We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to June 2016), Embase (January 1980 to June 2016), the ISRCTN registry (wwwisrctncom/editAdvancedSearch), ClinicalTrialsgov (wwwclinicaltrialsgov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (wwwwhoint/ictrp/search/en) We did not use any date or language restrictions in the electronic searches for trials We last searched the electronic databases on 13 June 2016

Selection criteria
All randomised controlled trials comparing a multifocal IOL of any type with a monofocal IOL as control were included Both unilateral and bilateral implantation trials were included We also considered trials comparing multifocal IOLs with "monovision" whereby one eye is corrected for distance vision and one eye corrected for near vision

Data collection and analysis
We used standard methodological procedures expected by Cochrane We assessed the 'certainty' of the evidence using GRADE

Main results
We found 20 eligible trials that enrolled 2230 people with data available on 2061 people (3194 eyes) These trials were conducted in Europe (13), China (three), USA (one), Middle East (one), India (one) and one multicentre study in Europe and the USA Most of these trials compared multifocal with monofocal lenses; two trials compared multifocal lenses with monovision There was considerable variety in the make and model of lenses implanted Overall we considered the trials at risk of performance and detection bias because it was difficult to mask participants and outcome assessors It was also difficult to assess the role of reporting bias

There was moderate-certainty evidence that the distance acuity achieved with multifocal lenses was not different to that achieved with monofocal lenses (unaided VA worse than 6/6: pooled RR 096, 95% confidence interval (CI) 089 to 103; eyes = 682; studies = 8) People receiving multifocal lenses may achieve better near vision (RR for unaided near VA worse than J3/J4 was 020, 95% CI 007 to 058; eyes = 782; studies = 8) We judged this to be low-certainty evidence because of risk of bias in the included studies and high heterogeneity (I2 = 93%) although all included studies favoured multifocal lenses with respect to this outcome

People receiving multifocal lenses may be less spectacle dependent (RR 063, 95% CI 055 to 073; eyes = 1000; studies = 10) We judged this to be low-certainty evidence because of risk of bias and evidence of publication bias (skewed funnel plot) There was also high heterogeneity (I2 = 67%) but all studies favoured multifocal lenses We did not additionally downgrade for this

Adverse subjective visual phenomena were more prevalent and more troublesome in participants with a multifocal IOL compared with monofocals (RR for glare 141, 95% CI 103 to 193; eyes = 544; studies = 7, low-certainty evidence and RR for haloes 358, 95% CI 199 to 646; eyes = 662; studies = 7; moderate-certainty evidence)

Two studies compared multifocal lenses with monovision There was no evidence for any important differences in distance VA between the groups (mean difference (MD) 002 logMAR, 95% CI -002 to 006; eyes = 186; studies = 1), unaided intermediate VA (MD 007 logMAR, 95% CI 004 to 010; eyes = 181; studies = 1) and unaided near VA (MD -004, 95% CI -008 to 000; eyes = 186; studies = 1) compared with people receiving monovision People receiving multifocal lenses were less likely to be spectacle dependent (RR 040, 95% CI 030 to 053; eyes = 262; studies = 2) but more likely to report problems with glare (RR 141, 95% CI 114 to 173; eyes = 187; studies = 1) compared with people receiving monovision In one study, the investigators noted that more people in the multifocal group underwent IOL exchange in the first year after surgery (6 participants with multifocal vs 0 participants with monovision)

Authors' conclusions
Multifocal IOLs are effective at improving near vision relative to monofocal IOLs although there is uncertainty as to the size of the effect Whether that improvement outweighs the adverse effects of multifocal IOLs, such as glare and haloes, will vary between people Motivation to achieve spectacle independence is likely to be the deciding factor

/pdf/multifocal-versus-monofocal-intraocular-lenses-after-2ypb97izw2.pdf

Multifocal versus monofocal intraocular lenses after cataract extraction

The ReSTOR intraocular lens presents a unique apodized diffractive design within a refractive foldable acrylic optic, which makes an unprecedented level of mulifocal optical performance available. We describe the history and principles of diffractive optics used in the development of this refractive-diffractive IOL.

History and development of the apodized diffractive intraocular lens.

Multifocal versus monofocal intraocular lenses in cataract surgery: A systematic review

Purpose To assess the per-operative complications occurring during the first 3000 phacoemulsification cases performed by an experienced consultant surgeon. Methods A prospective analysis of 3000 consecutive cases performed without supervision between November 1992 and November 1998 was carried out. Data recorded for each case included details of per-operative complications, pre-operative best corrected visual acuity, nuclear density, history of previous pars plana vitrectomy, and whether phacoemulsification was performed as part of a phacotrabeculectomy procedure. Results The overall rate of vitreous loss was 1.3%. Nuclear fragments were lost to the vitreous in 6 cases (0.2%). The initial rate of vitreous loss was 4.0% in the first 300 cases falling to 0.7% in the last 300 cases. Capsulorhexis failure was the commonest per-operative complication observed, but the risk of subsequent posterior capsule rupture fell significantly from 9 of 45 (20.0%) in the first 100 cases to 1 of 49 (2.0%) in the next 2000 cases (p = 0.0061, Fisher's exact test). There was a significant increase in risk with denser cataracts, especially for capsulorhexis failure, rising to over 35% in the densest cases. The increases in posterior capsule rupture and vitreous loss were less dramatic but nonetheless very significant. There was no significant increase in the risk of per-operative complications with phacotrabeculectomy, and no increased risk in patients who had previously undergone pars plana vitrectomy. Posterior capsule rupture occurred in 22 of 612 (3.6%) local anaesthesia cases compared with 31 of 2269 (1.4%) topical anaesthesia cases. Per- operative best corrected visual acuity of 6/9 or better was recorded in 2.0% of the first 1000 cases compared with 13.9% of the last 1000 cases. Conclusions (1) Per-operative surgical risks could be reduced to low levels during the learning curve, but complications continued to occur at a low frequency. (2) The risk of per- operative complications was not significantly elevated in previously vitrectomised eyes. (3) Nuclear density correlated significantly with per-operative complication risk. (4) The visual threshold for cataract surgery fell dramatically with increasing experience of phacoemulsification. (5) Topical anaesthesia was not associated with an increased risk of per-operative complications.

/pdf/the-phacoemulsification-learning-curve-per-operative-50omb3e6oo.pdf

The phacoemulsification learning curve: per-operative complications in the first 3000 cases of an experienced surgeon.

Purpose: To compare a Pharmacia diffractive bifocal intraocular lens (IOL) with a monofocal lens of the same design without the diffractive grating. Setting:. Multicenter study. Methods: This randomized, prospective study comprised 70 patients with a monofocal IOL and 79 with a diffractive bifocal IOL. Follow-up was 5 to 6 months. Near and distance visual acuities, contrast sensitivity, patient satisfaction, and spectacle use were evaluated. Results: All patients achieved a best corrected visual acuity of 0.5 or better; 80% in the monofocal and 71 % in the bifocal group had a best corrected visual acuity of 1.0 or better. Without correction, 93% of the bifocal and 9% of the monofocal group could read J3 or better. With distance correction, 99% and 4%, respectively, could read J3 or better. Contrast sensitivity was slightly lower in the bifocal group at distance and near for all spatial frequencies. In the bifocal group, 46% never used spectacles for near tasks. Overall satisfaction was rated good by 86% of the monofocal and 85% of the bifocal group. Conclusions: The diffractive bifocal IOL performed well at distance and near. Patients who no longer require spectacles will benefit significantly from a bifocal IOL, but many with a bifocal IOL in one eye will require spectacles for the fellow eye.

Comparison of a diffractive bifocal and a monofocal intraocular lens

Pour les tumeurs choroidiennes de moins de 15 mm de diametre, notamment si le corps ciliaire n'est pas atteint, un traitement par resection chirurgicale localisee peut etre envisage

/pdf/local-resection-versus-enucleation-in-the-management-of-3n3smdy5sh.pdf

Local resection versus enucleation in the management of choroidal melanoma.

Fifty unselected patients undergoing routine cataract surgery were randomised to receive either topical or sub-Tenon's local anaesthesia with 2% prilocaine administered by a blunt cannula. Visual analogue scales were used to assess pain during administration of sub-Tenon's anaesthetic and pain during surgery, and any complications were noted. Sub-Tenon's anaesthesia proved to be entirely comfortable to administer, and allowed for a statistically significantly more pain-free operation, at the expense of some residual eye movement and an inevitable subconjunctival haemorrhage. Both techniques compared well with other studies assessing periorbital or retro-orbital injections, and both have significant safety advantages which are discussed in the context of the joint Royal Colleges report on ophthalmic anaesthesia. It is suggested that a combination of one or other technique could safely cover all requirements for intraocular surgery under local anaesthesia.

/pdf/randomised-trial-of-topical-versus-sub-tenon-s-local-tlkh627uco.pdf

Randomised trial of topical versus sub-Tenon's local anaesthesia for small-incision cataract surgery.

Purpose To determine the value of routine review on the first post-operative day following phacoemulsification cataract surgery.

/pdf/phacoemulsification-cataract-surgery-is-routine-review-4bmet5f8fs.pdf

Robert L Burton

Papers

The phacoemulsification learning curve: per-operative complications in the first 3000 cases of an experienced surgeon.

Comparison of a diffractive bifocal and a monofocal intraocular lens

Local resection versus enucleation in the management of choroidal melanoma.

Randomised trial of topical versus sub-Tenon's local anaesthesia for small-incision cataract surgery.

Phacoemulsification cataract surgery: is routine review necessary on the first post-operative day?