Advances in cataract surgery

Cataract surgery is a technique described since recorded history, yet it has greatly evolved only in the latter half of the past century. The development of the intraocular lens and phacoemulsification as a technique for cataract removal could be considered as the two most significant strides that have been made in this surgical field. This review takes a comprehensive look at all aspects of cataract surgery, starting from patient selection through the process of consent, anaesthesia, biometry, lens power calculation, refractive targeting, phacoemulsification, choice of intraocular lens and management of complications, such as posterior capsular opacification, as well as future developments. As the most common ophthalmic surgery and with the expanding range of intraocular lens options, optometrists have an important and growing role in managing patients with cataract.

Childhood ethnic differences in ametropia and ocular biometry:the Aston Eye Study

Purpose: To describe the methodology, sampling strategy and preliminary results for the Aston Eye Study (AES), a cross-sectional study to determine the prevalence of refractive error and its associated ocular biometry in a large multi-racial sample of school children from the metropolitan area of Birmingham, England. Methods: A target sample of 1700 children aged 6–7 years and 1200 aged 12–13 years is being selected from Birmingham schools selected randomly with stratification by area deprivation index (a measure of socio-economic status). Schools with pupils predominantly (>70%) from a single race are excluded. Sample size calculations account for the likely participation rate and the clustering of individuals within schools. Procedures involve standardised protocols to allow for comparison with international population-based data. Visual acuity, non-contact ocular biometry (axial length, corneal radius of curvature and anterior chamber depth) and cycloplegic autorefraction are measured in both eyes. Distance and near oculomotor balance, height and weight are also assessed. Questionnaires for parents and older children will allow the influence of environmental factors on refractive error to be examined. Results: Recruitment and data collection are ongoing (currently N = 655). Preliminary cross-sectional data on 213 South Asian, 44 black African Caribbean and 70 white European children aged 6–7 years and 114 South Asian, 40 black African Caribbean and 115 white European children aged 12–13 years found myopia prevalence of 9.4% and 29.4% for the two age groups respectively. A more negative mean spherical equivalent refraction (SER) was observed in older children (-0.21 D vs +0.87 D). Ethnic differences in myopia prevalence are emerging with South Asian children having higher levels than white European children 36.8% vs 18.6% (for the older children). Axial length, corneal radius of curvature and anterior chamber depth were normally distributed, while SER was leptokurtic (p < 0.001) with a slight negative skew. Conclusions: The AES will allow ethnic differences in the ocular characteristics of children from a large metropolitan area of the UK to be examined. The findings to date indicate the emergence of higher levels of myopia by early adolescence in second and third generation British South Asians, compared to white European children. The continuation of the AES will allow the early determinants of these ethnic differences to be studied.

A review of non-pharmacological and pharmacological management of seasonal and perennial allergic conjunctivitis

Allergic eye disease encompasses a group of hypersensitivity disorders which primarily affect the conjunctiva and its prevalence is increasing. It is estimated to affect 8% of patients attending optometric practice but is poorly managed and rarely involves ophthalmic assessment. Seasonal allergic conjunctivitis (SAC) is the most common form of allergic eye disease (90%), followed by perennial allergic conjunctivitis (PAC; 5%). Both are type 1 IgE mediated hypersensitivity reactions where mast cells play an important role in pathophysiology. The signs and symptoms are similar but SAC occurs periodically whereas PAC occurs year round. Despite being a relatively mild condition, the effects on the quality of life can be profound and therefore they demand attention. Primary management of SAC and PAC involves avoidance strategies depending on the responsible allergen(s) to prevent the hypersensitivity reaction. Cooled tear supplements and cold compresses may help bring relief. Pharmacological agents may become necessary as it is not possible to completely avoid the allergen(s). There are a wide range of anti-allergic medications available, such as mast cell stabilisers, antihistamines and dual-action agents. Severe cases refractory to conventional treatment require anti-inflammatories, immunomodulators or immunotherapy. Additional qualifications are required to gain access to these medications, but entry-level optometrists must offer advice and supportive therapy. Based on current evidence, the efficacy of anti-allergic medications appears equivocal so prescribing should relate to patient preference, dosing and cost. More studies with standardised methodologies are necessary elicit the most effective anti-allergic medications but those with dual-actions are likely to be first line agents.

The microbiology of the eye

Infection of the external structures of the eye is one of the commonest types of eye disease worldwide. In addition, although relatively impermeable to microorganisms, infection within the eye can result from trauma, surgery or systemic disease. This article reviews the general biology of viruses, bacteria, fungi and protozoa and the major ocular infections that they cause. In addition, the effectiveness of the various antimicrobial agents in controlling ocular disease is discussed. Because of changes in the normal ocular flora, continuous monitoring of the microbiology of the eye will continue to be important in predicting future types of eye infection. Basic research is also needed into the interactions of microbes at the ocular surface. There is increasing microbial resistance to the antimicrobial agents used to treat ocular infections and hence, new antimicrobial agents will continue to be needed together with new methods of drug delivery to increase the effectiveness of existing antimicrobial agents.

An introduction to analysis of variance (ANOVA) with special reference to data from clinical experiments in optometry

This article is aimed primarily at eye care practitioners who are undertaking advanced clinical research, and who wish to apply analysis of variance (ANOVA) to their data. ANOVA is a data analysis method of great utility and flexibility. This article describes why and how ANOVA was developed, the basic logic which underlies the method and the assumptions that the method makes for it to be validly applied to data from clinical experiments in optometry. The application of the method to the analysis of a simple data set is then described. In addition, the methods available for making planned comparisons between treatment means and for making post hoc tests are evaluated. The problem of determining the number of replicates or patients required in a given experimental situation is also discussed. Copyright (C) 2000 The College of Optometrists.

Vitamin and mineral deficiencies in the developed world and their effect on the eye and vision

Vitamin and mineral deficiencies are common in developing countries, but also occur in developed countries. We review micronutrient deficiencies for the major vitamins A, cobalamin (B-12), biotin (vitamin H), vitamins C and E, as well as the minerals iron, and zinc, in the developed world, in terms of their relationship to systemic health and any resulting ocular disease and/or visual dysfunction. A knowledge of these effects is important as individuals with consequent poor ocular health and reduced visual function may present for ophthalmic care.

Reliability, normative data, and the effect of age-related macular disease on the Eger Macular Stressometer photostress recovery time

Purpose: To assess repeatability and reproducibility, to determine normative data, and to investigate the effect of age-related macular disease, compared with normals, on photostress recovery time measured using the Eger Macular Stressometer (EMS). Method: The study population comprised 49 healthy eyes of 49 participants. Four EMS measurements were taken in two sessions separated by 1 h by two practitioners, with reversal of order in the second session. EMS readings were also taken from 17 age-related maculopathy (ARM), and 12 age-related macular degeneration (AMD), affected eyes. Results: EMS readings are repeatable to within ± 7 s. There is a statistically significant difference between controls and ARM affected eyes (t = 2.169, p = 0.045), and AMD affected eyes (t = 2.817, p = 0.016). The EMS is highly specific, and demonstrates sensitivity of 29% for ARM, and 50% for AMD. Conclusions: The EMS may be a useful screening test for ARM, however, direct illumination of the macula of greater intensity and longer duration may yield less variable results. © 2004 The College of Optometrists.

Accommodative amplitude required for sustained near work

Purpose: Many practitioners base the prescription of near vision additions on the assertion that only one half or two-thirds of an individual’s amplitude of accommodation is sustainable for a prolonged period. To better understand how much eye focus needs to be restored for presbyopic corrections to be adequate, this study investigated the robustness of the pre-presbyopic human accommodative system during a sustained and intensive near vision task. Methods: Twenty-one pre-presbyopic volunteers (aged 26.1 ± 4.7 years) participated in the study. Binocular subjective amplitude of accommodation was measured before and after a prolonged reading exercise, using the RAF rule. During the 30 min reading task, the subject’s closest comfortable eye-to-text distance and pupil size was monitored. Accommodative accuracy to 0.2, 1.0, 2.0, 3.0 and 4.0 D stimuli was determined objectively using a validated binocular open-view autorefractor immediately before, and after the reading task. Results: Amplitude of accommodation (p = 0.09) and accommodative accuracy (p > 0.05) were statistically unchanged following the intensive near task. The mean proportion of accommodation exerted throughout the near exercise was 80.6% (range 45.3 ± 3.7 to 96.6 ± 4.3%), which increased as the task progressed (F = 2.24, p = 0.02). The mean percentage of accommodation utilised increased with subject age (r = 0.517, p = 0.016). Conclusion: The pre-presbyopic human accommodative system is robust to fatigue during intense and prolonged near work. A greater proportion of one’s amplitude of accommodation may be continuously exerted than previously suggested.

Vergence control across saccades in dyslexic adults

Many aspects of vision have been investigated in developmental dyslexia. Some research suggests deficits in vergence control (e.g. Buzzelli, 1991, Optom. Vision Sci. 68, 842±846), although ability to control vergence across saccades has not yet been investigated. We have explored this question indirectly using Enright's (1996 Vision Res. 36, 307±312.) sequential stereopsis task. The task requires observers to set two adjacent targets (whose textures cannot be resolved simultaneously if either is fixated) to appear equi-distant. Enright has argued that sequential stereopsis stereoacuity thresholds offer an indication of vergence control across saccades. We report two experiments using a total of 17 dyslexic and 18 control adults. Performance was measured on a sequential stereopsis task and an ordinary `simultaneous' stereopsis task. No significant differences between groups were found. However, whereas practice of the sequential task lowered control group thresholds on the simultaneous task, for the dyslexic group it significantly raised thresholds, suggesting that visual fatigue is especially important in investigations of visual functions in dyslexia. Although the small samples used limit conclusions at this stage, the main sequential stereopsis results suggest that, if Enright is correct, dyslexic adults can show normal vergence control across saccades.

Transient cardiac ischaemia and abnormal variations in systemic blood pressure in unselected primary open angle glaucoma patients

To investigate the relationship between the occurrence of transient cardiac ischaemic episodes and variations in the ambulatory 24-h blood pressure and heart rate measurements in a group of unselected glaucoma patients.

Influence of corneal asymmetry on the phakometric measurement of ocular surface alignment

Phakometric measurements of corneal and crystalline lens surface alignment are influenced by corneal asymmetry in which the corneal apex does not coincide with the limbal centre. The purpose of this study was to determine the horizontal separation (e) between these corneal landmarks. Measurements were made in 60 normal eyes (30 subjects) using the Orbscan Ilz corneal analysis workstation. Our results show that both corneal landmarks typically coincide, so that e = 0, but that inter-subject variations of about ±1 mm can be expected (so that the corneal apex may fall nasal or temporal to the visual axis). This suggests that no correction for corneal asymmetry is required when estimating average amounts of ocular alignment from samples of eyes but that the measurement of e is strongly recommended for measurements in individual eyes. © 2004 The College of Optometrists.

Phakometric measurement of ocular surface radii of curvature, axial separations and alignment in relaxed and accommodated human eyes

Measurements (autokeratometry, A-scan ultrasonography and video ophthalmophakometry) of ocular surface radii, axial separations and alignment were made in the horizontal meridian of nine emmetropes (aged 20-38 years) with relaxed (cycloplegia) and active accommodation (mean ± 95% confidence interval: 3.7 ± 1.1 D). The anterior chamber depth (-1.5 ± 0.3 D) and both crystalline lens surfaces (front 3.1 ± 0.8 D; rear 2.1 ± 0.6 D) contributed to dioptric vergence changes that accompany accommodation. Accommodation did not alter ocular surface alignment. Ocular misalignment in relaxed eyes is mainly because of eye rotation (5.7 ± 1.6° temporally) with small amounts of lens tilt (0.2 ± 0.8° temporally) and decentration (0.1 ± 0.1 mm nasally) but these results must be viewed with caution as we did not account for corneal asymmetry. Comparison of calculated and empirically derived coefficients (upon which ocular surface alignment calculations depend) revealed that negligible inherent errors arose from neglect of ocular surface asphericity, lens gradient refractive index properties, surface astigmatism, effects of pupil size and centration, assumed eye rotation axis position and use of linear equations for analysing Purkinje image shifts. © 2004 The College of Optometrists.