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Background: Older age is commonly associated with an increased risk of surgical complications and comparatively poor outcomes., Purpose: To report cataract surgery outcomes and risk indicators for patients aged 90 years and older., Methods: Data collected as part of routine cataract care in 34 centres contributing to the United Kingdom Royal College of Ophthalmologists' National Ophthalmology Database (NOD) were analysed. Very elderly people undergoing cataract surgery were profiled in terms of demographics, pre- and postoperative best-measured visual acuity (VA), ocular co-morbidities, intraoperative posterior capsule rupture (PCR) or vitreous loss or both, and risk indicators for operative PCR and adverse VA outcome., Results: 25,856 cataract operations in 19,166 people of 90 years or older between 2000 and 2014 are reported. Preoperative VA was available for 82.4% eyes, being 0.30 LogMAR or better in 21.5%. Postoperative VA was available for 61.8% eyes, being 0.30 LogMAR or better in 74.4%. For those without ocular co-morbidity, postoperative VA was 0.30 LogMAR or better in 84.7%. Various co-morbidities were present in 49% and contributed to an adverse VA outcome. PCR data were available for all operations and occurred in 2.7%. Significant risk indicators for PCR included pseudoexfoliation/phakodonesis, mature cataract, smaller pupil and worse preoperative VA., Conclusions: Slightly poorer cataract surgery outcome results were noted in patients of 90 years or older, more so in patients with ocular co-morbidity which was highly prevalent. However, surgeons should not be deterred from offering cataract surgery to the very elderly as successful visual rehabilitation remains achievable.

Objectives: To report outcome data on the first 5000 consecutive cataract cases at a new paperless eye unit and benchmark against the Royal College of Ophthalmologists' National Ophthalmology Database (RCOphth NOD)., Methods: Using the in-built audit tool of the electronic medical records system, data from all cataract operations performed between 1 April 2014 and 13 January 2017 were compiled., Results: Five thousand and eight cases were recorded of which the overall intra-operative complication rate was 2.4%, the most common being posterior capsular rupture-1.14%. Follow-up data on post-operative complications were recorded in 98.6% of cases. Pre- and post-operative visual acuities was measured in 98.0% of cases. In all, 40.8% of eyes achieved a visual acuity of 6/6 or better and 90.7% achieved 6/12 or better., Conclusions: A data set of >5000 consecutive cataract operations was obtained in this eye department. The recording of pre- and post-operative visual acuity in 98% of cases compare very favourably to the RCOphth NOD Audit Report 2017 where pre- and post-operative visual acuities were recorded in only 57.1% of operations. Despite this difference, the outcome measures from this unit and RCOphth NOD were very similar, validating the results of the RCOphth NOD audit reports. Significantly, when applying the RCOphth NOD audit criteria for measuring post-operative visual acuity, approximately 15% of cases were excluded from the data set, reducing the completeness of the data set. Paperless ophthalmology units are feasible in today's NHS and can produce near complete cataract data sets; this can ultimately lead to more comprehensive and reliable aggregate cataract outcome data.

Purpose: To describe the relationships of axial length with ocular copathology, preoperative visual acuity, and posterior capsule rupture rates in patients undergoing cataract surgery.DesignThe Royal College of Ophthalmologists' National Ophthalmology Database (NOD) study., Methods: Anonymised data on 180 114 eyes from 127 685 patients undergoing cataract surgery between August 2006 and November 2010 were collected prospectively from 28 sites. Data parameters included: demographics, biometry, ocular copathology, visual acuity measurements, and surgical complications including posterior capsule rupture, or vitreous loss or both (PCR)., Results: Consultant surgeons performed a higher proportion of operations on eyes whose axial length were at the extremes. Glaucoma and age related macular degeneration were more common in eyes with shorter axial lengths, whilst previous vitrectomy was associated with longer axial lengths. Eyes with brunescent or white cataracts or amblyopia were more common at both axial length extremes. Preoperative visual acuities were similar for eyes with axial length measurements up to approximately 28 mm and worse for eyes with longer axial length measurements. PCR rates showed little change with axial length (overall mean 1.95%, 95% CI: 1.89 to 2.01%), except for a borderline increase in eyes with axial length <20.0 mm where rates were 3.6% (95% CI: 2.0 to 6.3%). The likelihood of PCR in eyes with axial length <20.0 mm was 1.88 times higher than those of ≥20.0 mm (P=0.0373)., Conclusion: Rates of ocular comorbidities vary by axial length. PCR rates in eyes with very short or long axial lengths were lower than expected.

Aims: To report estimates of the prevalence of diabetic retinopathy (DR) and maculopathy grades for a large cohort of patients managed by the UK hospital eye service (HES)., Methods: Anonymised data were extracted from 30 UK NHS hospital trusts using a single ophthalmic electronic medical record (EMR) for the period from April 2000 to November 2010 to create the National Ophthalmology Database (NOD). From 2007, the EMR facilitated capture of a nationally agreed-upon standardised data set (DR Structured Assessment) relating to the presence or absence of clinical signs of DR and maculopathy. An algorithm in the software automatically calculated the Early Treatment of Diabetic Retinopathy Study grades of retinopathy and maculopathy., Results: Between 2007 and 2010, 307,538 patients had data on the NOD, with 76,127 (24.8%) patients having been recorded as having diabetes. The proportion of patients with diabetes who had a structured assessment increased from 50.7% (2007) to 86.8% (2010). In each NHS year, 12.6-20.6% of eyes with structured assessments had no DR; 59.6-67.3% had non-proliferative DR; and 18.3-20.9% had active or regressed proliferative DR. Clinically significant macular oedema was present in 15.8-18.1% of eyes, and in 8.7-10.0% of eyes, this involved the central macula., Conclusion: This study provides contemporary estimates of the prevalence of retinopathy and maculopathy grades in a large cohort of patients with diabetes managed by the UK HES. Centre-involving diabetic macular oedema, potentially amenable to anti-VEGF therapy, is present in the eyes of almost 10% of these patients. This information is useful for clinicians, health-care economists, and commissioners involved in planning and delivering diabetic eye services.

Aims: To report risk factors for visual acuity (VA) improvement and harm following cataract surgery using electronically collected multi-centre data conforming to the Cataract National Dataset (CND)., Methods: Routinely collected anonymised data were remotely extracted from the electronic patient record systems of 12 participating NHS Trusts undertaking cataract surgery. Following data checks and cleaning, analyses were performed to identify risk indicators for: (1) a good acuity outcome (VA 6/12 or better), (2) the pre- to postoperative change in VA, and (3) VA loss (doubling or worse of the visual angle)., Results: In all, 406 surgeons from 12 NHS Trusts submitted data on 55,567 cataract operations. Preoperative VA was known for 55,528 (99.9%) and postoperative VA outcome for 40,758 (73.3%) operations. Important adverse preoperative risk indicators found in at least 2 of the 3 analyses included older age (3), short axial length (3), any ocular comorbidity (3), age-related macular degeneration (2), diabetic retinopathy (3), amblyopia (2), corneal pathology (2), previous vitrectomy (2), and posterior capsule rupture (PCR) during surgery (3). PCR was the only potentially modifiable adverse risk indicator and was powerfully associated with VA loss (OR=5.74)., Conclusion: Routinely collected electronic data conforming to the CND provide sufficient detail for identification and quantification of preoperative risk indicators for VA outcomes of cataract surgery. The majority of risk indicators are intrinsic to the patient or their eye, with a notable exception being PCR during surgery.

Aims: To develop a methodology for case-mix adjustment of surgical outcomes for individual cataract surgeons using electronically collected multi-centre data conforming to the cataract national data set (CND)., Methods: Routinely collected anonymised data were remotely extracted from electronic patient record (EPR) systems in 12 participating NHS Trusts undertaking cataract surgery. Following data checks and cleaning, analyses were carried out to risk adjust outcomes for posterior capsule rupture rates for individual surgeons, with stratification by surgical grade., Results: A total of 406 surgeons from 12 NHS Trusts submitted data on 55,567 cataract operations between November 2001 and July 2006 (86% from January 2004). In all, 283 surgeons contributed data on >25 cases, providing 54,319 operations suitable for detailed analysis. Case-mix adjusted results of individual surgeons are presented as funnel plots for all surgeons together, and separately for three different grades of surgeon. Plots include 95 and 99.8% confidence limits around the case-mix adjusted outcomes for detection of surgical outliers., Conclusions: Routinely collected electronic data conforming to the CND provides sufficient detail for case-mix adjustment of cataract surgical outcomes. The validation of these risk indicators should be carried out using fresh data to confirm the validity of the risk model. Once validated this model should provide an equitable approach for peer-to-peer comparisons in the context of revalidation.

Aim: To examine the outcome of care for patients with glaucoma followed up by the hospital eye service compared with those followed up by community optometrists., Methods: A randomised study with patients allocated to follow up by the hospital eye service or community optometrists was carried out in the former county of Avon in south west England. 403 patients with established or suspected primary open angle glaucoma attending Bristol Eye Hospital and meeting defined inclusion and exclusion criteria were studied. The mean number of missed points on visual field testing in the better eye (using a "better/worse" eye analysis) in each group were measured. The visual field was measured using the Henson semiautomated central field analyser (CFA 3000). Measurements were made by the research team on all patients at baseline before randomisation and again 2 years after randomisation. The mean number of missed points on visual field testing in the worse eye, mean intraocular pressure (mm Hg), and cup disc ratio using a "better/worse" eye analysis in each group at 2 years were also measured. Measurements were made by the research team on all patients at baseline before randomisation and again 2 years after randomisation. An analysis of covariance comparing method of follow up taking into account baseline measurements of outcome variables was carried out. Additional control was considered for age, sex, diagnostic group (glaucoma suspect/established primary open angle glaucoma), and treatment (any/none)., Results: From examination of patient notes, 2780 patients with established or suspected glaucoma were identified. Of these, 752 (27.1%) fulfilled the entry criteria. For hospital and community follow up group respectively, mean number of missed points on visual field testing at 2 year follow up for better eye was 7.9 points and 6.8 points; for the worse eye 20.2 points and 18.4 points. Similarly, intraocular pressure was 19.3 mm Hg and 19.3 mm Hg (better eye), and 19.1 mm Hg and 19.0 mm Hg (worse eye); cup disc ratio at 2 year follow up was 0.72 and 0.72 (better eye), and 0.74 and 0.74 for hospital and community follow up group respectively. No significant differences in any of the key visual variables were found between the two groups before or after adjusting for baseline values and age, sex, treatment, and type of glaucoma., Conclusions: It is feasible to set and run shared care schemes for a proportion of patients with suspected and established glaucoma using community optometrists. After 2 years (a relatively short time in the life of a patient with glaucoma), there were no marked or statistically significant differences in outcome between patients followed up in the hospital eye service or by community optometrists. Decisions to implement such schemes need to be based on careful consideration of the costs of such schemes and local circumstances, including geographical access and the current organisation of glaucoma care within the hospital eye service.

Background/aims: Primary open angle glaucoma patients and glaucoma suspects make up a considerable proportion of outpatient ophthalmological attendances and require lifelong review. Community optometrists can be suitably trained for assessment of glaucoma. This randomised controlled trial aims to assess the ability of community optometrists in the monitoring of this group of patients., Methods: Measures of cup to disc ratio, visual field score, and intraocular pressure were taken by community optometrists, the hospital eye service and a research clinic reference "gold" standard in 405 stable glaucoma patients and ocular hypertensives. Agreement between and within the three centres was assessed using mean differences and intraclass correlation coefficients. Tolerance limits for a change in status at the level of individual pairs of measurements were also calculated., Results: Compared with a research clinic reference standard, measurements made by community optometrists and those made in the routine hospital eye service were similar. Mean measurement differences and variability were similar across all three groups compared for each of the test variables (IOP, cup to disc ratio, and visual field). Overall, the visual field was found to be the most reliable measurement and the cup to disc ratio the least., Conclusions: Trained community optometrists are able to make reliable measurements of the factors important in the assessment of glaucoma patients and glaucoma suspects. This clinical ability should allow those optometrists with appropriate training to play a role in the monitoring of suitable patients.

Background: As new methods for corneal curvature measurement have evolved, users of videokeratscopes need to know the practical limitations of these instruments. We assessed agreement between keratometry and videokeratography in measuring highly astigmatic corneas., Methods: Two independent examiners made three keratometric and videokeratographic measurements on each of 33 corneas after penetrating keratoplasty. The non-orthogonal keratometric readings obtained with a Zeiss 10 SL/O keratometer (Carl Zeiss Ltd.) were compared to the non-orthogonal simK readings (maxK, minK) calculated by the algorithms of a TMS-1 videokeratoscope (Tomey). Measurement agreement was evaluated for steep and flat meridian power and location, and astigmatism magnitude (D)., Results: A systematic bias of the TMS-1 in measuring steeper than keratometry for the steep meridian was demonstrated (95% confidence interval: -0.34 to -1.20 D). The limits of agreement (d - 2SD to d + 2SD) between the two instruments were found to be unacceptable for clinical purposes in measuring steep meridian power (-3.17 to +1.63 D), flat meridian power (-4.92 to +4.48 D) and astigmatism magnitude (-5.84 to +4.87 D). Clinically acceptable differences were observed in identification of steep and flat meridian location., Conclusions: The Zeiss 10 SL/O keratometer and the TMS-1 videokeratoscope showed poor measurement agreement for irregular corneal surfaces, despite the good correlation previously shown between keratometry and videokeratography in calibrated spheres and regular corneas. The TMS-1 showed a systematic bias, measuring a greater power in the steeper meridian than the Zeiss 10 SL/O keratometer. It is suggested that the two instruments cannot be used interchangeably in comparing the curvature of corneas after penetrating keratoplasty.

Aims: To evaluate intra- and interobserver variability in measurements on normal and astigmatic corneas with keratometry and computerized videokeratography., Methods: Keratometric readings with the 10 SL/O Zeiss keratometer and topographic maps with the TMS-1 were obtained by two independent examiners on 32 normal and 33 postkeratoplasty corneas. Inter- and intraobserver coefficients of variability (COR) for measurements of steep and flat meridian power and location, in addition to the magnitude of astigmatism, were assessed., Results: Compared with TMS-1, the 10 SL/O keratometer showed a superior repeatability in measuring normal corneas (intraobserver COR for keratometry and TMS-1 respectively: 0.22 and 0.30 D for steep meridian power; 0.18 and 0.44 D for flat meridian power; 0.26 and 0.40 D for astigmatism; 5 degrees and 26 degrees for steep meridian location; 5 degrees and 13 degrees for flat meridian location). Astigmatism intraobserver COR (0.20 D and 0.26 D for the two observers) and interobserver COR (0.28 D) of the keratometer for normal corneas was very good and not affected by observers' experience. Repeatability of the TMS-1 on normal corneas was found to be: (a) observer related, and (b) astigmatism related. A novice observer showed a much greater COR (1.62 D for astigmatism, 30 degrees for flat meridian location) compared with the experienced examiner (0.40 D for astigmatism, 13 degrees for flat meridian location). Higher deviation scores were observed for corneas with higher astigmatism. For the postkeratoplasty corneas, again the keratometer achieved superior reproducibility (astigmatism interobserver COR 1.12 D for keratometry, 4.06 D for TMS-1; steep meridian location interobserver COR 10 degrees for keratometry, 34 degrees for TMS-1)., Conclusion: Keratometric readings are more reproducible than topographic data both for normal and postkeratoplasty corneas. The two instruments should not be used interchangeably especially on highly astigmatic corneas. For the TMS-1, users with the same level of experience should be employed in clinical or experimental studies.

Intra-observer (within observers) and inter-observer (between observers) variability of the Oxford Clinical Cataract Classification and Grading System were studied. Twenty cataracts were examined and scored independently by four observers. On a separate occasion two of the observers repeated the assessments of the same cataracts in the absence of information from the initial observations. The chance corrected and weighted kappa statistics for observer agreement, both for inter-observer and intra-observer variability demonstrated satisfactory repeatability of the cataract grading system. The overall intra-observer mean weighted kappa was kappa w = +0.68 (range SE kappa = 0.012-0.052) and the overall inter-observer mean weighted kappa was kappa w = +0.55 (range SE kappa = 0.011-0.043).

The nuclear colour of in vivo human lenses has been investigated by means of a colour matching technique, using 'Munsell' colour samples. Observations covered an extended age range, and included all degrees of nuclear pigmentation. A positive correlation was noted between increasing nuclear pigmentation and age. The colour matching data generated was used as a basis for establishing a system of nuclear brunescence grading. The system of grading consists of a Grade 0 for absence of brunescence, and Grade 1 to Grade 5 for increasing brunescence. The 'Munsell' notation for samples representing these grades are: Grade 0 (5GY 6/1), Grade 1 (5Y 7/4), Grade 2 (2.5Y 7/8), Grade 3 (7.5YR 6/8), Grade 4 (5YR 4/6), and Grade 5 (2.5YR 2.5/2). Assessments of both inter- and intra-observer variability in the use of the derived scale have shown the new colour grading system to be reliable. The measure is simple to use during biomicroscopic slit-lamp examination of the lens, and has the potential for routine clinical application as well as for use in clinical trials where detailed documentation of lens morphology is required. The new colour scale may be used either as an isolated measure, or as part of a battery of lens measures in the Oxford Clinical Cataract Classification and Grading system.

AimTo report the vitreoretinal (VR) surgical case mix in the United Kingdom, the intraoperative complication rate of pars plana vitrectomy (PPV), and the incidence of post-vitrectomy cataract extraction.MethodsParticipating hospitals prospectively collected ophthalmic data using a single electronic medical record system, with automatic extraction of anonymised data to a national database. This study included the subset of 11 618 VR operations undertaken on 9619 eyes, of 8741 patients, over 8 years, from 27 sites. Surgical data included the indication for surgery, all procedure elements, and whether or not an intraoperative complication occurred. Post-vitrectomy cataract data were also analysed. The main outcome measures were a description of the indications for surgery, intraoperative PPV complication rate, and percentage of eyes undergoing post-vitrectomy cataract surgery (PVCS).ResultsThe most common indications for VR intervention were retinal breaks and rhegmatogenous retinal detachment (48.5%), macular hole (9.8%), epiretinal membrane (9.6%), and diabetic eye disease (7.3%). Overall, 7.8% of PPVs had at least one intraoperative complication-the most common were iatrogenic retinal breaks (3.2%), and lens touch (1.2-1.6% of phakic eyes). PVCS occurred in 50.2, 68.7, and 74.0% of eyes at 1, 2, and 3 years, respectively.ConclusionVR surgery is undertaken for a wide range of conditions, but a small number of diagnoses encompass the majority of cases. Intraoperative PPV complications are not uncommon, and post-vitrectomy cataract is to be expected in most phakic eyes. [ABSTRACT FROM AUTHOR]

Waterclefts and retrodots are independently associated with visual impairment, yet a review identified no data on risk factors.PurposeTo investigate risk factors for these two human lens cataract subtypes.MethodTwo nested case–control studies: The host study comprised 1078 subjects (≥55 years) attending the Somerset and Avon Eye Study (SAES). In total, 197 watercleft cases (≥Oxford grade 0.2 in either eye) and 199 retrodot cases (≥Oxford grade 1.0 in either eye) were individually age/gender matched to controls. Detailed ophthalmic and potential risk factor data were collected, including body mass index (BMI), smoking, alcohol, diabetes, hypertension, analgesics, vitamin supplementation, nutrition, sunlight exposure, dehydration, hormonal (women), blood lipids, glucose, urea, creatinine, uric acid, and vitamin levels.ResultsFor waterclefts, univariable analysis identified BMI, alcohol intake, vitamin status, sunlight, urea, creatinine, and uric acid as possible risk factors. Multivariable analysis identified two independent associations. Total number of ‘any’ analgesics in the previous year: adjusted P<0.01 (U-shaped risk profile, unadjusted high vsmedium use (=reference) OR 2.39, 95% CI 1.35–4.26 with medium use vsnone (=reference) OR 0.43, 95% CI 0.26–0.72); total sunlight: adjusted P=0.03 (unadjusted highest exposure vslowest (=reference) OR 3.25, 95% CI 1.11–9.50). For retrodots, univariable analysis identified alcohol, HRT, and lipids. Multivariable analysis identified two independent associations. Mean number of alcohol units consumed per month, adjusted P=0.02 and HDL cholesterol levels, adjusted P=0.02 (unadjusted ORs NS both).ConclusionThis is the first available published information on risk factors for the human cataractous lens features waterclefts and retrodots.Eye (2006) 20, 1254–1267. doi:10.1038/sj.eye.6702087; published online 14 October 2005 [ABSTRACT FROM AUTHOR]