|
The closing session of the annual UKISCRS congress saw a series of tricky cases presented to some of the top ophthalmologists from the UK and Ireland, who did not disappoint with their useful, illustrative solutions. The concept of a court of surgical law was borrowed from ISRS 2001 by Sheraz Daya FRCS. Now in its second year, it was a light-hearted affair. Consultant ophthalmologist David Boase took on the mantle and wig of an English judge and was dubbed the Right Honourable Lord Boase of Portsmouth, with Sheraz Daya chairing the session. The audience of gathered ophthalmologists were sworn in as the enthusiastic jury. Case A: A 61-year-old executive who wants to undergo PRELEX. Charles Claoué MD, the always-dapper consultant ophthalmologist from London, presented his arguments for using the AMO Array with aplomb, while the no less able Milind PandŽ, consultant ophthalmologist from Hull recommended the Human Optics ICU. Mr ClaouŽ in his detailed and colourful presentation marshalled his arguments around the comparative performance of functional vision with the two IOLs. The research he cited showed that 83% of patients with the SA40 AMO Array had 6/6 UCVA for distance compared with 78% for those with the 1CU lens, while 78% of the Array patients had UCVA for near of N5 or better, compared to only 44% of the 1CU patients. Even more impressively, 94% of those implanted with the Array lens achieved spectacle independence,compared to just 20% of those with the 1CU lens, he said.
Dr Claoué attacked the belief that contrast sensitivity in the Array is poor, citing research that maintained distance and near monofocal contrast sensitivity improves in bilateral Array patients and is not statistically different to monofocals at 6/12. Dr. Pandé was no less convincing, however. He compared the two lenses, emphasising the glare and halo problems associated with the AMO Array, as well as the low contrast visual acuity loss in Array patients compared to monofocals, thought to be clinically insignificant, but which affects night-driving. Dr. PandŽ even reported that a small number of patients in the US had demanded explantation.
In contrast, he said, patients quickly learned how to use the Humanoptics 1CU accommodative lens, 80% were spectacle independent, using glasses only to read very fine print, and there were none of the halo, glare or contrast sensitivity issues associated with the Array, "making for happy patients and a happy surgeon." Dr. Sheraz Daya summarised, "There are different numbers that have been presented, a lot based on subjective data, some on objective data, you the jury, must decide." A substantial majority of ophthalmic peers came out in favour of the Humanoptics 1CU. "It looks like Mr. Claoué will be doing time," said Judge Boase, to great applause. Case B: 57-year-old man six months following cataract surgery seeks correction of +4.75 D hyperopia in his pseudophakic eye. Keratometry: 41.00 D, pachymetry 555 microns. In favour of Hyperopic LASIK, Jim O'Reilly, a consultant ophthalmologist from Ireland told his assembled peers. "This man has been failed by intraocular surgery. ...Can we seriously tell this poor man that the solution is more intraocular surgery?" As he paused, at some length, to gather his thoughts Judge Boase enquired solicitously whether the good doctor needed an adjournment. Before long, however, Dr. O'Reilly was in full swing emphasising that it was key to avoid complications in this patient, and that LASIK had minimal longterm complications, whereas with a piggy-back IOL there were risks of PCO, and he showed one case where a fibrous membrane grew between the two IOLs, reducing vision and resisting YAG treatment. There is only one option in this, Dr. O'Reilly concluded. LASIK is safer, more effective, it is predictable, and it is repeatable. Paul Chell FRCS from Worcester countered that a piggyback IOL was the only solution."Lord Boase of Portsmouth, you need to have the right tools for the right job." LASIK, he said, is a fine procedure, but was not appropriate for hyperopia of +4.75 D. Normally, the lens exchange should happen quickly, but when it is not possible, a piggyback IOL was the solution. Halos and glare are a problem with LASIK, he added. "If you are going to dig a duck pond you use an excavator, if you are over 2.5 D of hyperopia, then you don't do LASIK." Dr. Chell said he employed a private investigator, a certain Mr Snellen, who found that six clinics, when asked, refused to perform LASIK on hyperopia of that magnitude. "4.75 D is quite big, so a piggy-back IOL is the right choice," he said. Judge Boase asked if, given Dr. Chell's excellent attire, whether it should be called the piggy-bank IOL. The jury found for Dr. Chell. Case C: prevention of endophthalmitis during cataract surgery. The jury could choose between topical povidone and subconjunctival antibiotics or topical povidone and vancomycin intracameral (into the capsular bag) at the end of surgery. David Smerdon FRCS from Middlesborough began strongly: "Do we use povidone drops and subconjunctival antibiotics like any sensible person? Or do we use povidone drops and Vancomycin, like a twit?" He warned that there are increasing reports of Vancomycin resistant enterococci. He cited an in-vitro study of various organisms known to cause endophthalmitis in humans that used bactericidal concentrations of Vancomycin. The study concluded that exposure to the antibiotic, in the little time cataract surgery takes place, and had no effect on organisms commonly responsible for endophthalmitis. While subconjunctival antibiotics did suffer from some conflicting reports regarding its efficacy, there was more evidence that it may play a role in the prevention of endophthalmitis, whereas there was no evidence in favour of Vancomycin, and it could create antibiotic-resistant bacteria, Dr. Smerdon said. Judge Boase asked Mr. Smerdon if he ever had a case of endophthalmitis. "Never," he said, to which the judge replied: "Would you recognise it if you saw it?" After the laughter died down, Clive Peckar, consultant ophthalmologist at Warrington suggested instead that povidone drops with intracameral Vancomycin in the capsular bag at the end of surgery was the best prophylactic and he had convincing evidence. Intracameral Vancomycin 2mm has been injected into the intracapsular bag after surgery since 2001 at Warrington. "Why do we do this?" His presentation recounted how in three years running to 2000 his hospital at Warrington had seen endophthalmitis cases on the rise, from one in 1997-98, to five in 1999 - 2000. The team stopped operating and, checked everything and, on advice, began using Vancomycin because, while there was no objective evidence, he told the jury, there was some anecdotal support. "And we needed to protect our patients," said Dr. Peckar. In the two years since Warrington introduced Vancomycin the team completed 2,480 cataract surgeries with no endophthalmitis. "There are potential problems. Resistance, complications and toxicity, dilution and contamination risk. But resistance is not a significant risk at this dose, as for complications we've seen no changes in VA, IOP, or cystoid macula oedema following the introduction of Vancomycin," noted Dr Peckar. The team takes precautions with dilution and contamination risks, he said. The weight of the evidence swung the jury in Dr. Peckar's favour. The session concluded with champagne awarded to the losers for their efforts. A third session is planned for next year and any readers wishing to contribute other ideas for debate or participate can contact Sheraz Daya at sdaya@centreforsight.com. Sheraz M. Daya MD FACP FACS FRCS(Ed) Queen Victoria Hospital East Grinstead, West Sussex, UK sdaya@centreforsight.com David Boase FRCS Charles Claoué, MA (Cantab), MD, FRCS, FRCOphth, Milind Pande FRCS
Paul B Chell
Jim O'Reilly FRCS North Riding Infirmary, Middlesborough, UK David.Smerdon@stees.nhs.uk Clive Peckar FRCS FRCOphth
|
