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Ophthalmic surgical operating lists include intraocular and extraocular procedures, as well as clean non-infectious and dirty infectious cases. Patient age, diabetic status, local or general anaesthesia must be considered during ophthalmic theatre scheduling. Traditionally children and ‘clean cases’ are prioritised. However, factors such as the need for an interpreter, patient transport and latex allergy affect the sequencing of ophthalmic lists. An electronic survey was sent to all UK ophthalmology consultants through the Royal College of Ophthalmologists registry, enquiring about their preference in sequencing mixed theatre lists, what operations they considered clean and dirty, and the presence of departmental protocol for list sequencing. There was a 16.9% response rate ( n = 222/1311). A majority of 75.2% ( n = 167/222) had mixed operating lists of intraocular and extraocular cases. Of those performing mixed operating lists, 44.3% ( n = 74/167) stated they would operate on intraocular cases before extraocular cases, and 92.8% ( n = 155/167) would perform ‘clean’ before ‘dirty’ cases. Fifty-nine per cent ( n = 98/167) have a departmental protocol to help determine list order. This survey has demonstrated that there is a trend to perform ‘clean’ before ‘dirty’ and intraocular before extraocular cases. Given the results of the survey, we outline our recommendation on how to sequence mixed ophthalmic theatre lists.

Purpose: To evaluate the photorefractive keratectomy (PRK) results in patients with moderate to high astigmatism.Methods: 112 eyes of 71 patients with a cylindrical component of greater than 3 diopters (D) who have undergone PRK were reviewed retrospectively. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and subjective refraction before and after surgery (1, 3, 6, 12 months) were extracted.Results: The mean age of patients was 28±6 (33 females and 79 men). The preoperative mean spherical equivalent (SE) was -3.39 ± 1.82 D (range 2.50 to −9.00 D), and the mean cylinder was -3.76 ± 0.78 D (range −3.00 to −6.00 D). The mean postoperative cylinder values were -0.73 ± 0.49 D, -0.72 ± 0.46 D, -0.58 ± 0.48 D, and -0.4 ± 0.63 D at 1- month, 3-month, 6-month, and 12-month visits, respectively. The 12-month efficacy and safety indices were 0.92 ± 0.14 and 0.99 ± 0.10, respectively. The postoperative residual astigmatism was 0.5 D or less in 50% of the eyes. A higher amount of residual astigmatism was observed in the high astigmatism group (Cylinder ≥ 4.00D). Furthermore, postoperative residual astigmatism was correlated with lower preoperative CDVA and mitomycin C time, as well as, higher preoperative cylinder (P Conclusions: PRK is an effective, and predictable method for the correction of moderate to high astigmatism; however, higher residual astigmatism remains in patients with high astigmatism despite the higher levels of correction.

The COVID-19 pandemic necessitates implementation of exposure control measures in all facets of the healthcare sector. Healthcare professionals who work in busy ophthalmology clinics and theaters are amidst the highest at-risk of contracting COVID- 19. The authors review the up-to-date scientific evidence of SARS-CoV-2 transmission to demystify and explain the exposure control options available for ophthalmic workplace and offer insights from an industrial hygiene standpoint. As the we enter the post-COVID world, these measures will be critical to enhance workplace safety, and thus protect patients and staff alike.

Purpose: To describe a novel technique of amniotic membrane (AM) patch graft in the management of double chamber treatment after big-bubble deep anterior lamellar keratoplasty (DALK). Case Report: A 35-year-old male patient with advanced keratoconus underwent big-bubble DALK. Manual lamellar dissection was done due to failed big-bubble. First-day postoperative double chamber was detected. Air bubbling and SF6 injection were tried without any success. Double chamber resolved by fixation of AM transplantation patch graft (1 × 1 mm) over the Descemet's membrane perforation with fibrin glue. Conclusion: Amniotic membrane patch graft can be used in the management of double chamber after DALK not responsive to intracameral gas injection.

BACKGROUND: Cataract extraction is the most frequently performed surgical intervention in the world and demand is rising due to an ageing demography. One option to address this challenge is to offer selected patients immediate sequential bilateral cataract surgery (ISBCS). This study aims to investigate patient and operative characteristics for ISBCS and delayed bilateral cataract surgery (DSCS) in the UK. METHODS: Data were analysed from the Royal College of Ophthalmologists' National Ophthalmology Database Audit (NOD) of cataract surgery. Eligible patients were those undergoing bilateral cataract extraction from centres with a record of at least one ISBCS operation between 01/04/2010 and 31/08/2018. Variable frequency comparison was undertaken with chi-square tests. RESULTS: During the study period, 1073 patients had ISBCS and 248,341 DSCS from 73 centres. A higher proportion of ISBCS patients were unable to lie flat (11.3% vs. 1.8%; p

Purpose To assess the attitudes and beliefs held toward immediate sequential bilateral cataract surgery (ISBCS), including estimating the incidence of European Society of Cataract and Refractive Surgeons (ESCRS) members currently performing ISBCS, exploring the barriers of ISBCS implementation, and assessing the relevance of these findings to practice in the United Kingdom. Setting European consultant members of the ESCRS. Design Survey-based questionnaire. Methods The survey was sent and collected electronically. An initial screening question directed the rest of the survey; participants were asked to rate the importance of several factors with regard to performing ISBCS. Free text options were also available. Descriptive analysis was performed. Results Of the 2200 recipients, 303 (13.7%) responded, of which 247 were eligible for analysis. Of the 247 eligible respondents, 166 (67.2%) reported performing ISBCS, 71 (28.7%) said they did not perform ISBCS, and 10 (4.0%) said they had previously done so but have since stopped. Of those who were currently practicing ISBCS, the three most important factors to consider were all directly related to infection risk. Of those who did not perform ISBCS, the most important reasons for not performing the surgery were a risk for endophthalmitis (69.0%) and the medicolegal issues should ISBCS go wrong (57.8%). The most common reason for stopping ISBCS was that the respondent no longer believed in the benefit of ISBCS (n = 4). Conclusions The survey reflects ophthalmologists' concerns regarding infection and medicolegal risks; however, reports of bilateral endophthalmitis are extremely rare when the correct recommendations are followed. The findings from this survey could be used to inform service provision of ISBCS in the U.K., taking into consideration the voices of colleagues overseas.

A significant increase in prevalence of cataract is anticipated over the next two decades due to increasing life expectancy. This demands an increase in capacity of eye care services which is limited by insufficient human resources including ophthalmologists and inadequate financial investment in this field. Developing new systems for cataract surgery delivery can be part of the solution to fulfill this demand. One promising approach is immediately sequential bilateral cataract surgery (ISBCS). It has attracted attention of ophthalmologists in different countries. Although there are some studies to compare outcomes of this style to traditional one, many aspects of this approach remain controversial. Improvement in efficacy of referral for cataract surgery and patient flow in eye care units is another crucial step.

To evaluate corneal subbasal nerve plexus by in vivo confocal microscopy (IVCM) following punctal occlusion in patients with moderate to severe dry eye disease (DED).Patients with grade 3 or 4 severity of DED based on Delphi Panel dry eye severity grading scheme were enrolled in the study. Permanent inferior punctal occlusion was performed. A comprehensive ophthalmic evaluation, including Ocular Surface Disease Index (OSDI) questionnaire, tear break-up time (TBUT), corneal fluorescein staining, conjunctival Rose bengal staining, Schirmer's test, and corneal sensation by Cochet-Bonnet esthesiometry, were performed at baseline, and 1 and 3 months after punctal occlusion. Furthermore, density and number of corneal subbasal nerves were evaluated by IVCM.Forty-one eyes of 23 patients with a mean age of 46.3 ± 9.0 years were enrolled. Corneal fluorescein staining, Rose bengal staining, and TBUT significantly improved at 3 months following punctal occlusion (Corneal subbasal nerve density and total number increased following punctal occlusion in patients with moderate to severe DED. These findings were associated with improvements in corneal sensation, and signs and symptoms of DED. This emphasizes the effect of punctal occlusion in regeneration of corneal subbasal nerve plexus.

Purpose To analyze and review the clinical features and main outcomes of laminar resorption from the UK osteo-odonto-keratoprosthesis (OOKP) cohort. Methods A retrospective review of case records was undertaken for patients who underwent keratoprostheses between 1996 and 2014 at the Sussex Eye Hospital, Brighton, UK. The main clinical outcomes of resorption, including its clinical signs, complications, treatments, and laminar survival, were evaluated. Results Sixty-four patients (25-females, 39-males) were included, and in total, 74 laminae (3-tibial, 11-allografts, 60-autografts) were implanted. The age of the patients ranged from 20 to 91 years. Focal laminar thinning was the first sign of detectable resorption in 50% of autografts and 27% of allografts. All the tibial grafts and 55% of allografts presented with complications of resorption like endophthalmitis and aqueous leakage as the first signs of resorption. The survival of first implanted autografts was 82.4%(±6.3%) at 18 years, which was enhanced to 91.5%(±5.0%) by prophylactic exchanges of critically resorbed laminae with new laminae. Visual acuity survival analysis did not reveal a statistically significant difference between grafts with and without resorption for all graft types (p = 0.825). Patients treated with Alendronic acid and acetazolamide demonstrated trends toward the slower progression of resorption, but this was not statistically significant. Conclusions Focal laminar thinning was the common presenting feature of resorption in autografts. Timely replacement of the resorbed laminae with new laminae should be considered to avoid complications. Alendronic acid supplementation may be considered in high-risk cases of resorption to reduce further progression.

Purpose: To compare the effectiveness of onion extract, topical steroid, and petrolatum emollient in the prevention of scars in cases who underwent bilateral upper eyelid blepharoplasty. Methods: A prospective, interventional, comparative, double-blinded case series was designed on cases who underwent upper lid blepharoplasty. After suture removal (1 week following the surgery), the eyelids of participants were randomly allocated into the three groups: The first group used onion extract on the right eyelids (n = 18), and the second group used topical steroid on the right eyelids (n = 19). In the third group, the control group, petrolatum emollient was used on the left eyelids (n = 37) of the first and second group's cases. They used drugs for 2 months and were evaluated by the Manchester Scar Scale (MSS) objectively by two graders who were blinded to the type of medication. MSS evaluates five different characteristics of the scar in addition to the Visual Analog Scale (VAS). These characteristics include color, distortion, contour, texture, and transparency. VAS scores the overall scar appearance which ranged among 0–10. The sum of the scores for the five different parameters, and VAS was calculated, analyzed, and compared among the groups. Results: A total of 37 cases (74 eyelids) who underwent bilateral upper blepharoplasty were included. The mean ± standard deviation (SD) of age was 51.94 ± 9.26 years, 49.40 ± 9.37 years, and 47.00 ± 9.06 years in the onion extract, topical steroid, and petrolatum emollient groups, respectively (P = 0.275). There were no statistically significant differences in the mean ± SD of the sum of the MSS scores among the three groups (P = 0.924) or between the onion extract and topical steroid groups (P = 0.951). Furthermore, the color, distortion, contour, texture, transparency, and VAS scores were not statistically significantly different among the three groups or between the onion extract and topical steroid groups (P > 0.05). Conclusion: There were no significant differences among these three groups of drugs regarding the appearance of the upper blepharoplasty scar.

COVID-19 pandemic of 2020 has impacted all aspects of clinical practice in the UK. Cataract services suffered severe disruption due to necessary measures taken to reduce elective surgery in order to release capacity to support intensive care requirements. Faced with a potential 50% increase in cataract surgery workload per week in the post-COVID-19 world, eye units should use this event to innovate, not just survive but to also evolve for a sustainable future. In this article, we discuss the inadequacies of existing service rationing options to tackle the COVID-19 cataract backlog. This includes limiting rationing based on visual acuity, limiting surgery to first or only seeing eyes, and postponing clinic and surgical dates according to referral dates. We propose units use the lockdown time to reset and develop a comprehensive patient-centred care pathway using principles of value-based healthcare: the cataract integrated practice units. Developing an agile surgical database that incorporates all aspects of patient need from education to follow-up in their individual cataract journey will allow units to react and plan quickly in the early phase of recovery and beyond. We also discuss the considerations units should bear in mind on telemedicine, modifications for face-to-face clinics, theatre organisation and options of expanding cataract throughput capacity. The pause in elective surgery due to the pandemic may have provided cataract services a rare opportunity to reset and transform cataract service pathways for the digital era.

Background The standard approach to treat cataracts is Delayed Sequential Bilateral Cataract Surgery (DSBCS), during which patients have a separate operation date for each eye. An alternative method of delivery is Immediately Sequential Bilateral Cataract Surgery (ISBCS). The aim of this project was to examine the attitudes and beliefs of UK ophthalmologists towards ISBCS, explore their reasons to either practise or not practise ISBCS and identify barriers hindering its implementation in the UK. Methods A questionnaire was distributed to consultant members of The Royal College of Ophthalmologists (RCOphth, UK) and collected electronically. An initial screening question in regards to prior experience with ISBCS directed the rest of the survey; participants were asked to rate the importance of several factors with regards to performing ISBCS. Free text options were also available. Descriptive analysis was subsequently performed. Results Of the 1357 recipients, 130 (9.6%) ophthalmologists completed the survey. Of those, 13.9% were currently performing ISBCS, 83.1% had never performed, and 3.1% had previously done so but since stopped. The main factors that acted as barriers were lack of: (1) College approval (20.5%); (2) medico-legal approval (20.2%); (3) evidence to support the use of ISBCS (16.0%); and (4) hospital approval (13.3%). Additionally, the perceived risk of complications for patients played an important role when considering ISBCS, with the risk of endophthalmitis being most feared. Conclusions This survey demonstrates some of the barriers that prevent ophthalmologist’s performing ISBCS in the UK. There is a need for further exploration in this field to evaluate the effect of addressing any of these concerns on the implementation of ISBCS.

To analyse the factors affecting laminar resorption in the UK osteo-odonto-keratoprosthesis (OOKP) cohort and present a detailed review.A retrospective review of the case records of the patients who underwent OOKP between 1996 and 2014 was performed at the Sussex Eye Hospital in Brighton, UK.Sixty-four patients (25 females and 39 males) were included, and 74 laminae were implanted consisting of 3 tibial grafts, 11 tooth allografts and 60 tooth autografts. In total, 69% (n = 51) showed resorption. Non-smokers had better oral health compared to smokers (71% vs 50%, respectively). Poor oral health was strongly associated with poor quality dentition and edentulism (p 0.001). The laminar thickness and waiting for the time between stages 1 and 2 surgeries did not show significant influence on the onset and progression of resorption. From the Cox multivariate analysis for autografts, smoking, age and gender were not associated with a statistically significant difference in the rates of resorption. The maximum number of laminae with resorption belonged to Stevens-Johnson syndrome patients (n = 32 or 43%).Two-thirds of the cases of resorption were detected in the first three years of OOKP, and the maximum were noted in the first year of follow up (40%). The laminar thickness did not influence the post-operative onset and progression of resorption. The presence of resorption after stage 1 did not show a measurable effect on the onset and progression of post-stage 2 resorption.

In this study, unary CuO and CuO/CeO2 composites with various contents of CeO2 were synthesized by the Pechini process. Transmission electron microscopy, scanning electron microscopy, energy dispersive X-ray spectroscopy, and X-ray diffraction were used for structural characterizations. Impedance spectroscopy was also used to determine the resistance of grains and grain boundaries. The results showed that the CuO/CeO2 composites with the average crystallite size of 32 nm are successfully synthesized by the Pechini method, where cerium oxide particles are accumulated in grain boundaries. It was also found that the presence of CeO2 in the CuO/CeO2 composites increases the dielectric constant and decreases the dielectric loss, in comparison to pure copper oxide. Also, the optimum content of cerium oxide to attain the maximum dielectric constant was determined to be 2 wt%.

To evaluate in vivo confocal microscopy (IVCM) findings of ocular surface squamous neoplasia (OSSN) during treatment with topical interferon alfa-2b (IFN alfa-2b).In this prospective interventional case series, 20 eyes from 20 patients with OSSN were treated with topical IFN alfa-2b 3 million IU/mL four times a day. Treatment was continued for 2 or 3 months after clinical resolution. IVCM was done at baseline, on a monthly basis, and at the end of treatment. Confocal images were evaluated in conjunction with clinical findings during treatment. Limbal dendritic cell (DC) density within the involved areas was calculated manually in confocal images.Topical therapy resulted in clinical resolution of neoplasia in 80% of eyes. Main features of OSSN on IVCM were hyper-reflectivity of epithelium, demarcation line between neoplastic and normal epithelium, and pleomorphic cells. These findings became less prominent in response to IFN alfa-2b therapy. However, some degree of residual epithelial hyper-reflectivity could be detected in 9 (56.2%) subjects who responded to therapy at time of treatment cessation. Limbal DCs density within involved areas was significantly increased at month 1 follow-up compared to baseline only in responders (P .0001). There was a trend toward higher limbal DCs density in responders to topical IFN alfa-2b than non-responders (208.6 ± 53.5 vs. 153.1 ± 48.2 cell/mmIVCM is proposed as an adjunctive tool for monitoring OSSN during topical treatment. IVCM documents epithelial cell response as well as limbal DC density increase during topical IFN therapy.

Keratoprosthesis (KPro) is the last resort for corneal blindness. Boston KPro I and osteo-odonto-keratoprosthesis (OOKP) have the most favorable outcomes for their respective indications. Recently, better outcomes have been achieved for these 2 devices mainly because of improvements in postoperative care and modifications in complication management through years of experience and research. Unfortunately, some patients cannot benefit from these KPros due to lack of access to devices, trained surgeons, or both. Boston KPro I is heading toward a more affordable variation particularly for patients in developing countries. In addition, more patients with severely compromised ocular surface will be candidates for Boston KPro II variants. Biosynthetic or synthetic OOKP analogues will make the operation less complex and suitable for patients without canine tooth.

To review and compare the published reports of Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping endothelial keratoplasty/Descemet stripping automated endothelial keratoplasty (DSEK/DSAEK) procedures with regard to endothelial cell density/loss, best spectacle-corrected visual acuity, central corneal thickness, subjective outcomes (patient's reported satisfaction/preference), and postoperative complications.A thorough search was conducted in the databases including AMED, EMBASE, Cochrane Database of Systematic Reviews, and MEDLINE without date restrictions. Systematic reviews, meta-analysis, randomized controlled trials, case series, and audits comparing DMEK and DSAEK were included.DMEK is superior to DSAEK for the following outcomes: visual acuity, central corneal thickness, and patient satisfaction. There was a statistically significant difference in the mean spectacle-corrected visual acuity at 6 months for DMEK (mean = 0.161, SD = 0.129) and DSAEK eye (mean = 0.293, SD = 0.153) conditions; t (297) = 8.042, P0.0001. The pooled mean difference was -0.13 (95% confidence interval, -0.16 to -0.09) and I = 44%, indicating better visual acuity for DMEK. Mean postoperative endothelial cell density showed statistically no significant difference in the mean values for DMEK (mean = 1855, SD = 442) and DSAEK eye (mean = 1872, SD = 429) conditions; t (336) = 0.375, P = 0.708. A higher proportion of patients prefer DMEK to DSAEK. However, DSAEK is superior to DMEK with respect to the need for rebubbling as the rebubbling rate was higher in the DMEK group.Although DMEK is associated with a higher rate of rebubbling, better visual outcomes were seen in DMEK.

Purpose To evaluate the safety and efficacy of tacrolimus eye drops as adjunctive therapy in the treatment of severe corneal endothelial rejection after penetrating keratoplasty refractory to corticosteroids. Methods In this prospective interventional case series, 11 eyes of 11 patients assessed for severe corneal endothelial rejection, with an inadequate response to topical, local, and systemic corticosteroids, were treated with either 0.01% or 0.05% tacrolimus eye drops 4 times daily. Improvement in signs of rejection, visual function, and development of complications were monitored. Results The duration of steroid treatment before intervention was 8.1 ± 1.4 days (range = 7-11). Patients were subsequently administered topical tacrolimus 0.01% or 0.05% qid. The time to clinical improvement was 10.3 ± 3.4 days (range = 3-17). The time to rejection reversal was 27.8 ± 16.3 days (range = 7-52). After 3 months, 10 patients (90.8%) demonstrated clinical improvement, and complete restoration of graft clarity was achieved in 5 patients (45.4%). In responsive cases, steroid therapy was successfully tapered off after 60.2 ± 19.7 days (range = 36-93). The best spectacle-corrected visual acuity improved from 1.7 ± 0.9 to 0.8 ± 0.5 logMAR (P = 0.0016). Reported side effects included stinging on drop instillation and punctate epithelial keratopathy. Conclusions Tacrolimus eye drops may be able to play an adjunctive therapeutic role in patients with severe corneal endothelial rejection refractory to conventional steroid treatment. Controlled studies are needed to further investigate the role of tacrolimus in this setting.

Purpose of review To describe the practice of and recent developments in the osteo-odonto-keratoprosthesis. Recent findings Formal psychological assessment and support have been described. A sub-aqua system for fashioning the osteo-odonto-keratoprosthesis lamina; adoption of thicker laminae; use of bisphosphonate drugs; advances in laminar imaging; and use of bone augmentation and bone morphogenetic protein have been described for prevention, detection, and management of laminar resorption. Two systems of optical cylinders available commercially. A stepladder approach to buccal mucous membrane overgrowth onto the optical cylinder has been described, including use of mitomycin-C. Orbital decompression has been used for cosmetic improvement. Detection of glaucoma may be aided by an intraocular pressure sensor, whereas surgical treatment is mainly by way of glaucoma drainage devices, as endolaser ciliary ablation and recti muscle disinsertion and reinsertion not having prolonged and significant long-term beneficial effect. Sublingual timolol has been described. The use of endoscopy has been proposed for preoperative evaluation of the posterior segment, ciliary ablation and for vitreoretinal surgery although wide-angle viewing systems remains standard practice. Summary The osteo-odonto-keratoprosthesis is the procedure of choice for rehabilitation of corneal blindness for end-stage ocular surface disease, serving a completely different patient group to the Boston Type 1 KPro.

The Cornea and Conjunctiva represents the components of the ocular surface; the Cornea is the transparent structure with optical functions and the Conjunctiva constitutes the remaining part of the ocular surface covering the sclera. The ocular surface may be affected by a variety of disorders, caused by a variety of external or internal pathogens. The basics, mechanism and treatment of these diseases will be briefly discussed in this chapter.

To introduce an assessment tool (rubric) for evaluating ophthalmology residents' competency in pterygium surgery.A panel of experienced international surgeons collaborated and developed the rubric. After describing various stages of the procedure, the Dreyfus scale of skill acquisition was used for scoring each stage. After finalizing the rubric, two surgeons independently evaluated 20 masked pterygium surgery videos of 10 residents and scored the videos according to the rubric. The agreement between the scores of them was examined with the intra-class correlation coefficient test.This rubric divides pterygium surgery into 13 different stages and covers the two most common techniques of pterygium surgery; conjunctival autograft and amniotic membrane transplant. The rubric showed face and content validity. Overall, an intraclass correlation coefficient of 0.90 (95% confidence interval 0.76-0.96, P 0.001) was achieved between the two surgeons. The residents scored significantly higher on surgeries performed later in their rotation compared to the earlier surgeries (4.32 ± 0.35 vs 3.96 ± 0.31, P = 0.006). Certain stages of pterygium surgery were more strongly correlated with the residents' past pterygium surgical experience.This study introduces an international rubric for assessing competency in pterygium surgery. In addition to face and content validity, this rubric shows high inter-rater reliability. This may be a useful tool for teaching and measuring competency in pterygium surgery.