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SHOULD CATARACT SURGERY BE PERFORMED ON PATIENTS WITH MACULAR DEGENERATION?
A substantial number of patients undergoing cataract extraction have coexisting macular degeneration. The question might be asked whether these operations are justified. A study from Sweden from six surgical departments documents that patients with dry age related macular degeneration who underwent cataract surgery showed significant improvements in daily life activities that had been difficult before surgery. Moreover, satisfaction with vision also improved. Activity level and independence were unchanged. The most important predictor of a good self assessed functional outcome was postoperative visual acuity. This paper does not address the question of whether a cataract extraction may worsen macular degeneration. See p 1330
SYSTEMIC ANTI-INFLAMMATORY THERAPY RESCUES FAILING TRABECULECTOMY BLEBS
Despite a number of advances in surgical technique and local anti-inflammatory fibrosis suppression, trabeculectomy bleb failure still happens far too often. Molteno and colleagues describe a prospective, non-comparative case series of 77 eyes of 63 patients in which early bleb failure was recognised. These patients were treated with oral prednisone and colchicine. In addition to the standard postoperative topical medication in this study, intraocular pressure was controlled with a probability of 0.91 at 8 years. No serious side effects were associated with the use of systemic anti-inflammatory therapy. The authors recommend its use when, during the postoperative course of filtering surgery, there are signs of bleb failure. See p 1352
SAME DAY BILATERAL CATARACT SURGERY: IS IT JUSTIFIED?
The debate continues as to whether or not bilateral intraocular surgery should be performed on the same day. The main reservation about this procedure is the potential for bilateral catastrophic endophthalmitis. Wertheim describes 218 eyes of 109 patients over 21 months that underwent sequential phacoemulsification using topical anaesthesia as a day care procedure. A single senior surgeon was involved in all cases. Best corrected visual acuity was 6/9 or better in 86% of the cases. Postoperative complications occurred in 13.8% of eyes and bilateral complications occurred in 5.5% of patients. There were no cases of endophthalmitis. These authors suggest that sequential phacoemulsification with topical anaesthesia performed as a day case is not associated with an increased number of complications. They undoubtedly recognise that since the incidence of endophthalmitis is relatively low, the number of patients operated in this study may not be adequate to document that the endophthalmitis rate using this procedure is not increased. See p 1356
ORAL ANTIOXIDANT SUPPLEMENTATION IN DIABETIC PATIENTS PREVENTS OCULAR SURFACE DISEASE
Diabetes mellitus is regrettably associated with a number of ocular complications. Ocular surface manifestations in diabetics have been a subject of increased interest over the past few years. Sitaras and colleagues present the findings of 50 patients with non-insulin dependent diabetes who were given vitamin C (100 mg/day) and vitamin E (400 IU/day) for 10 days. Nitrite levels were found to be significantly reduced after 10 days of vitamin C and E supplementation. Moreover, improved values for the Schirmer test and increased goblet cell density were also demonstrated. The authors suggest that oxidative stress and free radical production that is known to be associated with diabetes can be inhibited by vitamin C and E supplementation. This in turn reduces the oxidative damage produced by nitric oxide and other free radicals and thus improves the ocular surface disorders associated with diabetes. See p 1369
ANTI-INFLAMMATORY USE FOLLOWING CATARACT SURGERY
Although cataract surgery is less traumatic than formerly, routine use of topical anti-inflammatories postoperatively continues. Although postoperative steroid therapy has been the norm, recently some authorities have suggested the use of non-steroidal anti-inflammatory drugs instead in order to avoid the complications associated with steroid therapy. Laurell reports the findings of a prospective, randomised, controlled, doubled masked study of 180 patients undergoing cataract surgery. Patients were randomised to topical treatment with dexamethasone phosphate 0.1%, diclofenac sodium 0.1%, or placebo (saline 0.9%). The patients were studied at 3 and 8 days and 1 month after surgery. In this study dexamethasone and diclofenac were equally effective in reducing postoperative inflammation after phacoemulsification and intraocular lens implantation. Both substances were more effective than placebo. The authors conclude that topical anti-inflammatory treatment is generally warranted after cataract surgery in order to alleviate inflammatory response and possible risks of complications such as corneal damage and cystoid macular oedema. See p 1380