CRSToday Europe News – September 2008

Unmet Cataract Surgery Needs Creating Patient Backlog
Cataract surgery rates continue to increase throughout Europe. Combined with an aging population and broader indication criteria, the rate of unmet needs in cataract surgery is growing.

Researchers in Spain recently estimated that the rate of cataract surgery procedures must increase by more than 50% to prevent the current backlog from growing, according to a study in the British Journal of Ophthalmology.

Xavier Castells, MD, and Mercé Comas, MD, lead investigators of the study, and colleagues, built a discrete-event simulation model to assess future trends for cataract surgery in Spain.

The researchers found that the predicted volume of need in 2008 for 20/40 and 20/50 visual acuity thresholds was 69,214 and 51,315 surgeries per 1 million citizens, respectively. However, unmet needs decreased for the 20/70 threshold. To prevent the cataract backlog from increasing in Spain, cataract surgery rates need to increase 60% for a 20/40 threshold and 50% for a 20/50 threshold, the study's authors concluded.

Sheraz M. Daya, MD, Director and Consultant Ophthalmic Surgeon at the Corneoplastic Unit, Queen Victoria Hospital and in private practice at the Center for Sight clinics, said he was not surprised by the investigators' findings. Unmet cataract surgery needs were recently addressed in the United Kingdom.

"I am sure if similar studies are performed in other European countries, the findings would be similar," Dr. Daya said in an e-mail to CRST Europe. Dr. Daya is the Chief Medical Editor of CRST Europe.

In the United Kingdom, cataract surgeries increased from approximately 175,000 in 2003 to approximately 300,000 in 2008, said Larry Benjamin, DO, FRCS, FRCOphth, in an e-mail to CRST Europe. Dr. Benjamin is from the Royal College of Ophthalmologists, a member of the Department of Ophthalmology at Stoke Mandeville Hospital, in Aylesbury, UK, and a member of the CRST Europe Editorial Board.

As a result of targeted funding from the UK Department of Health, local ophthalmic services have expanded considerably. Increased resources equipped the United Kingdom with the capability to keep up with the cataract surgery needs of its patients, Dr. Benjamin said.

Assessing cataract surgery needs via visual acuity may not be the most accurate way to determine the true workload and backlog, Dr. Benjamin stated. "Targeting efficiency in the operating theater and streamlining the outpatient assessments are efficient ways to raise surgical numbers and meet the increasing demands of patients," he stated.

Although the United Kingdom may presently be at an advantage compared with Spain and other European countries, Dr. Daya does not discount the possibility of a cataract surgery backlog recurrence.

"In time, I expect the need will increase and the limiting factors will once again be funding and capacity," Dr. Daya said.

Felt-Tipped Marker Pens May Transmit Bacteria Between Patients
Using a new felt-tipped marker pen for each case may be the best way to prevent transmitting bacteria from one cataract surgery patient to another, a recent study suggested.

Researchers at Moorfields Eye Hospital in London found that the survival of bacteria inoculated onto felt-tipped pens decreased with time, but they identified "a theoretical risk of transmission" between patient through reused pens. The length of time between marking the foreheads of patients with the same felt-tipped marker pen before cataract surgery may affect the likelihood of bacterial transmission, according to the study published in Eye.

To evaluate the potential risk of bacterial transmission between patients from the felt-tipped marker pens, researchers tested 64 pens taken from clinical stock and cultured 48 new pens in the laboratory. After drying the pens for 0, 4, or 16 hours, researchers dipped them into solutions of coagulase negative staphylococci, methicillin-resistant Staphylococcus aureus (MRSA), and coliform bacteria. These inoculated pens were then transferred onto culture medium after 5, 10, 30, and 120 minutes of air exposure. The researchers also collected and cultured 16 pens after routine clinical use for 5 days.

Cultures were positive in 100% of pens immediately after exposure to the bacteria. After 5 minutes of air exposure, the percentage of positive culture decreased to 44.4%. Escherichia coli showed the least transmissibility, with no growth in all plates after 5 minutes of exposure. Only MRSA showed heavy growth after 10 minutes of exposure.

No pattern emerged with reference to the length of time each pen was left to dry. No growth was observed in the cultures of any of the 16 marking pens that had been in clinical use, the researchers reported.

"I hope this study will generate a discussion as to whether this practice is still reasonable, said Dawn Sim, MD, the study's principal investigator, in an e-mail to CRST Europe. "Marker pens are part of the folklore of ophthalmology but are not essential to clinical practice. They were first used when surgery was mostly done with general anesthesia. Today, patients can be asked which eye they are having operated on. Drawing on skin with a nonsterilized instrument might be considered bad practice if it was not a historical practice," Dr. Sim said.

CEO Appointed at Carl Zeiss Meditec AG
Michael Kaschke, PhD, was named Chief Executive Officer of Carl Zeiss Meditec AG (Jena, Germany). Prior to this appointment, Dr. Kaschke was chairman of the supervisory board. He is accredited with making Carl Zeiss Medical Technologies a publicly traded company, which led to the establishment of Carl Zeiss Meditec AG. Additional changes were made to the structure of the management board to accelerate growth, the company reported in a news release.

Center for Eye Research Opened in New Zealand
The New Zealand National Eye Center (NZ-NEC) opened at the University of Auckland in July, according to a news release.

New Zealand's eye health and vision science professionals will conduct and participate in the center's curriculum. Programs of study include developing treatments for eye diseases, including cataract, glaucoma, keratoconus and retinal disease; new approaches to eye surgery and wound healing; understanding the mechanisms of human vision; and developing technologies for the treatment of vision defects.

In addition to becoming a national center for clinical trials and the assessment of rare ocular diseases in New Zealand, NZ-NEC will also teach and train undergraduate students, postgraduate researchers, and host professional education programs.

Silicone IOLs Cause Significant Myopic Shift After Phaco
Implanting a silicone IOL following cataract surgery may cause a myopic shift and a shortened anterior chamber depth (ACD), according to a study in the European Journal of Ophthalmology.

Researchers studied 339 eyes randomly assigned to receive a rigid PMMA IOL (811C or 824C; Pharmacia & Upjohn, Tokyo), an acrylic IOL (AcrySof MA60BM; Alcon Laboratories Inc, Fort Worth, Texas), or the AQ110NV (Canon Staar, Inc., Tokyo) silicone IOL. Patients were monitored for 48 weeks.

Researchers observed a statistically significant myopic shift at 8 weeks after surgery in patients with silicone IOLs. Mean myopic shift at 48 weeks was -0.53 D. Shortened ACD was observed at 12 weeks.

Postoperative refraction and IOL position did not change in patients who received a rigid PMMA IOL or an acrylic IOL after surgery, researchers said.

Tamsulosin Associated With IFIS in UK Population
Intraoperative floppy iris syndrome (IFIS) was found in more than half of eyes of patients taking tamsulosin (Flomax; Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut; Astellas Pharma Inc., Tokyo).

Researchers reporting in The Surgeon, investigated the incidence of IFIS associated with tamsulosin in patients undergoing cataract surgery in a UK district general hospital.

The prospective, observational study included 23 eyes (16 male patients between 65 and 95 years of age). Researchers found features of IFIS in 13 eyes. These 11 patients took tamsulosin for 37 months on average (range, 2 months–7 years).

Researchers concluded that the incidence of IFIS in the UK cataract population is about 1%. Among approximately 1,500 cataract patients, 1.3% used tamsulosin. Approximately 69% of tamsulosin users have IFIS, researchers said.

Furthermore, the study's authors forecasted that ophthalmologists who practice in a UK hospital that treats on average 280,000 patients over 65 years of age will encounter a minimum of 46 cataract surgery patients who take tamsulosin each year—approximately one case per week. In two-thirds of these patients, cataract surgery may be technically challenging and increase the risk of complications, the researchers cautioned.

Outdoor Light May Lower Risk of Myopia in Children
Outdoor light may significantly contribute to the incidence of myopia in children, according to a study published in Ophthalmology. Kathryn A. Rose, MD, and colleagues theorized that dopamine, the retinal neurotransmitter released when intense light is encountered, inhibits the eye's growth.

The researchers examined data from the Sydney Myopia Study of more than 4,000 Australian children. The lowest rates of myopia in 12-year-olds were associated with high levels of outdoor activity, independent of their level of near work (eg, intensive reading). Myopia was most strongly associated in 12-year-olds with high levels of near work and low levels of outdoor activity.

"Higher exposure to intense outdoor light may explain the lower prevalence of myopia in children in Australia, compared with ethnically matched peers in other countries," Dr. Rose said in a news release. "This protective effect suggests that a public health measure aimed at preventing development of myopia could be based on increasing … outdoor activity—including family and school activities and sports."

Further research is needed to determine what amount of time spent outdoors may control myopia and to define the mechanisms involved, according to the study's authors.

Blindness Crisis in Nigeria
A national survey of blindness and visual impairment in Nigeria found that nearly 500,000 adults 40 years and older need cataract surgery. The survey, initiated by the Federal Ministry of Health and supported by Sightsavers International, said that more than 1 million adults are blind and 3 million are visually impaired. Additionally, 42 of every 1,000 adults 40 years and older are blind.

Leading causes of blindness include glaucoma, corneal scarring, onchocerciasis, trachoma, cataract, and improperly performed cataract surgery.

"Nigerians now account for one in five Africans, and the survey indicates the growing and urgent need to increase access to eye care as well as the importance of reaching people who are illiterate," said Sightsavers representative Elizabeth Elhassan, MD, in a news release.

As a result of the survey, more than 3,500 cataract operations were performed, 5,800 pairs of reading glasses were dispensed, more than 200 pairs of aphakic glasses were distributed at no cost, and thousands of patients with minor ailments were treated.

– Compiled by Jennifer Kreatsoulas, News and Contributing Editor