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Cataract surgery is usually of short duration and is associated with minimal pain when employing topical or regional anaesthesia. Patient education regarding the peri-operative process may help alleviate anxiety and avoid the need for sedation. However, sedation may be required, and we discuss the various options. Many consider that pre-operative fasting is necessary due to the risk of aspiration but fasting may not be required if minimal sedation is administered. If the use of sedatives, hypnotics or analgesics is required, then their associated adverse events should be considered.

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PURPOSE: The objective of this study is to estimate the incidence of steroid-induced severe intraocular pressure (IOP) rise following intravitreal triamcinolone acetonide (IVTA) injection and to describe case profiles of the patients affected within the United Kingdom. PATIENTS AND METHODS: A national survey was carried out to identify cases that had developed severe IOP rise requiring laser or surgery following IVTA through the British Ophthalmic Surveillance Unit. Respondents were mailed a questionnaire and with a follow-up questionnaire 1 year later, to ascertain characteristics of the patients identified. We also carried out a midpoint survey to ascertain national practice of IVTA at the time. RESULTS: There were 29 confirmed reports of severe IOP rise after IVTA in the 13-month period of surveillance. All the cases were unilateral and the mean time between the IVTA and the maximum recorded IOP was 16 weeks. Six of these patients had pre-existing glaucoma or ocular hypertension, and a further two were known to be 'steroid responders'. Using the adjusted denominators, obtained from our national survey, the estimated annual incidence would be between 3.6 and 9.5 per 1000 injections. CONCLUSIONS: These results confirm that severe IOP rise after IVTA is an uncommon but serious complication. Data obtained from this national study should aid clinicians in choosing the treatment best suited to their patients.

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AIMS: In recent years, intravitreal triamcinolone acetonide (IVTA) injections have become widely used in the treatment of macular oedema. IVTA can cause elevation of intraocular pressure (IOP), which can be sight threatening. We carried out a nationwide study, which aimed to (i) assess the current usage of IVTA, (ii) estimate the incidence of 'severe' IOP rise following IVTA, in routine practice. METHODS: A postal survey was carried out in January 2007. A questionnaire was mailed to senior ophthalmologists (all consultants and associate specialists) in the United Kingdom. We asked about the use of IVTA over the past year and whether there had been any cases of severe IOP rise (defined as elevation in IOP, commencing after IVTA therapy, requiring laser or surgery to treat the raised pressure). RESULTS: Response rate was 56% (611/1089). Among respondents, 33% (206) had used IVTA during the 12 months of 2006 giving a total of 3899 IVTA injections. There were 45 reported cases of severe IOP rise, following IVTA injections, which were given under their care of the respondent. A further 28 cases were reported to have been referred from colleagues; it is unclear whether any or all of these cases were included in the initial 45. The reported rate of severe IOP rise following IVTA was therefore at least 45/3899 or at least 1.1%. CONCLUSIONS: Usage of IVTA in the United Kingdom is widespread. Severe IOP rise, requiring laser or surgery to control IOP, was reported in at least 1.1% of cases.

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AIMS: This study aims to establish the prevalence of aspirin, dipyridamole, clopidogrel, and warfarin use in patients undergoing cataract surgery, and to compare local anaesthetic and intraoperative complication rates between users and non-users. METHODS: The Cataract National Dataset was remotely extracted and anonymised on 55,567 operations at 12 NHS Trusts using electronic patient records (EPRs) between 2001 and 2006. RESULTS: This report analyses 48,862 of the 55,567 operations from the eight centres, which routinely recorded a drug history. In all, 28.1% of the 48,862 patients were taking aspirin, 5.1% warfarin, 1.9% clopidogrel, and 1.0% dipyridamole. The recording of any complication of a sharp needle or subtenon's cannula local anaesthetic block was increased in patients taking clopidogrel, 8.0% (P<0.0001) or warfarin, 6.2% (P=0.0026) vs non-users, 4.3%, but no increase in potentially sight-threatening complications was identified. The incidence of subconjunctival haemorrhage was increased in patients taking clopidogrel, 4.4% (P<0.0001) or warfarin, 3.7% (P<0.0001) vs non-users, 1.7%. The recording of any operative complication was increased in those taking clopidogrel, 7.3% (P=0.0002) vs non-users, 4.4%, but the haemorrhagic operative complications of choroidal/suprachoroidal haemorrhage and hyphaema were not significantly increased. The non-haemorrhagic complication of posterior capsular rupture (PCR) was increased in those taking clopidogrel, 3.23% (P=0.0057) vs non-users, 1.77%. CONCLUSIONS: Clopidogrel or warfarin use was associated with a significant increase in minor complications of sharp needle and subtenon's cannula local anaesthesia but was not associated with a significant increase in potentially sight-threatening local anaesthetic or operative haemorrhagic complications.

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PURPOSE: The primary aim of this study was to detail anaesthetic techniques and complications for cataract surgery in the UK. METHODS: The Cataract National Dataset was extracted from 12 National Health Service Trusts that used the same electronic patient record system between November 2001 and July 2006 on a total of 55,567 cataract operations. RESULTS: Anaesthesia was administered by an ophthalmologist in 56.7% of the cases, a career anaesthetist in 42.1% of the cases, a clinical assistant anaesthetist in 0.3% of the cases, and staff were not recorded in 0.9% of the cases. Local anaesthesia (LA) was used in 95.5%, with topical anaesthesia alone in 22.3% (range by site, 0-99.8%), topical and intracameral in 4.7% (range, 0-24.1%), subtenons in 46.9% (range, 0-81.8%), peribulbar in 19.5% (range, 0-63.4%), and retrobulbar in 0.5% (range, 0-5.3%). One or more minor complications occurred in 4.3% of 38,058 local blocks administered by either sharp needle or subtenons (blunt) cannula. Minor complications were 2.3 times more common with subtenons blocks (P<0.001). Serious complications, defined as sight or life threatening occurred in 25 eyes, 0.066%, undergoing sharp needle or subtenons cannula blocks. Sharp needle techniques had a 2.5-fold increased risk of serious complications compared with subtenons cannula techniques (P=0.026). CONCLUSION: Subtenons anaesthesia was the most widely used anaesthetic technique for cataract surgery but wide variation existed by site. There was a low rate of reported LA complications. There was a statistically significant increased risk of serious complications with sharp needle anaesthesia compared with subtenons technique.

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AIM: To investigate final visual outcome in primary open angle glaucoma (POAG) including low-tension glaucoma (LTG). METHODS: Retrospective review of case notes for patients who died between 1999 and 2002. All were booked for a follow-up appointment in glaucoma clinic at time of death. RESULTS: A total of 121 case notes were reviewed. In all, 113 patients had POAG and eight had LTG. All were White Caucasians. Mean ages at presentation and death were 74.6 (SD 9.6, range 49-94) and 81.9 (SD 8.3, range 51-98) years, respectively. Mean follow-up duration was 7.4 (SD 6.8, range up to 29) years. Average number of clinic visits was 18 (SD 17, range 1-95). At final visit, 50.4% had cataract operations, and 45.5% had glaucoma operations. At final visit, vision was inadequate for driving in the UK in 47.1%. In 18.2%, this was due to glaucoma alone, while in 28.9%, other ocular pathologies contributed to poor vision. In all, 14% were eligible for partial sight certification, with 6.6% due to glaucoma alone. A total of 3.3% were eligible for blind certification, none due to glaucoma alone. CONCLUSION: This study shows that POAG does affect the quality of life, with regards to glaucoma clinic visits, eye drops, and surgical procedures. Most patients with treated POAG in Norfolk will retain useful vision for their whole life. A significant proportion of patients with POAG do lose vision resulting in driving ineligibility and certification as visually impaired, although actual blindness is uncommon.

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