Dear Editor

We read with keen interest the recent article by Churchill et al. that reports a multicentre questionnaire studying out-of-hours clinics.[1] The authors are to be commended for their initiative in performing the first appraisal of patient’s attitudes to government proposals to introduce out- of-hours clinics and operating sessions.[1]

However, it is still left unclear to us as to the accuracy of a key concluding remark of the authors, which we believe is contentious, potentially misleading, and should benefit from clarification by the authors to prevent any confusion. Specifically, we are concerned with the statement that the study found that only 4% of patients will ‘opt for’ out -of-hours clinics. This is a statement of considerable import, which we find extremely surprising given our personal experience of patients attending Saturday morning clinics and based upon a series of interviews we have conducted. When earlier reporting their results the authors also use the figure of 4% to quantify the number of patients reported to have stated that an appointment between 8am and 5pm, Monday to Friday, was inconvenient. Since we are so surprised by the sense of the statement that only 4% of patients will ‘opt for’ out-of-hours clinics, we question whether the authors might not have interpreted this figure of 4% by transposing it from the 4% that found a routine weekday appointment inconvenient, in which case their statement becomes very misleading. Clarification is needed both for the regular readership and beyond, for this is the first study of its kind in a key area of clinical debate, and is thus influential. Even if substantiated, this figure of 4% that are stated to ‘opt for’ out-of-hours clinics might mislead, as the study’s own breakdown of results shows that 52% of patients found Saturday morning clinics ‘convenient’. This breakdown also states that 58% found Saturday morning clinics ‘inconvenient’. But a study we conducted disputes these findings, and suggests instead a spectrum of opinions which by and large resonate with the government’s proposals in this regard.

In a series of interviews conducted by us, 102 consecutive patients who actually attended out-of-hours Saturday morning eye clinics at the Hillingdon Hospital were specifically asked by the examining ophthalmologist whether they preferred a Saturday morning clinic appointment, a routine 9-to-5 weekday clinic, or if they did not mind one way or the other. The results are strikingly different to that suggested by Churchill et al. A slight majority, or 51 patients (50%) simply did not mind whether they were seen on a Saturday morning or in a routine weekday 9-to-5 clinic. The second largest group of 42 patients (41%) said that they actually preferred a Saturday morning clinic, while the smallest group were 9 patients (9%) who said that they preferred a weekday 9-to-5 clinic appointment. Total number of female patients was 65, and male patients 37. Of those preferring Saturday morning clinics 41 % were female and 59% were male. Mean age of patients who preferred Saturday morning clinics was 62, while of those who preferred a weekday appointment it was 70. Reasons for preferring Saturday morning clinics included the following: it was easier for working people and students, which accounts for the younger mean age of patients preferring Saturday morning clinics; reduced traffic; car parking was easy; the hospital was relatively quiet on a Saturday morning making access easy, which was especially important for older people; finally, recent introduction of the weekday ‘congestion charge’ in central London meant that a Saturday morning clinic best suited older patients as friends or relatives saved on the cost of the journey by avoiding travel through central London to pick up the patient and transport them to the hospital – however, this is a factor at present unique to London. Amongst those who were not concerned whether they had a 9-to-5 weekday appointment or one on a Saturday morning, the overwhelming majority, or 86%, were retired. Reasons given for preferring a 9-to-5 weekday clinic appointment were, with six young mothers, children under the age of 12 at home, as the children were at school or nursery during weekdays but not weekends; hospital transport was felt to be easier to obtain on a weekday; surprising reasons were found in two patients who said that they preferred a 9-to-5 weekday appointment so as to have an extra day off work by going to the doctors, while one patient felt a Saturday morning hospital appointment was an infringement into ‘leisure’ time.

While this interview study has fewer patients, there is no missing data for all patients responded at interview - unlike the multicentre study in which only 54% of the despatched questionnaires were used for the analysis. Importantly, these interviews might also be more realistic in that they take into account the experiences of people who have actually attended an out-of-hours clinic. Alternately, it is possible that the markedly different results have arisen as we interviewed patients attending only Saturday morning clinics, while the concluding statement of the authors concerned out-of-hours clinics in general. However, even if this is the case, interviews suggest that the attitude amongst the public to Saturday morning clinics is positive.

Reference

(1) Churchill AJ, Gibbon C, Anand S, McKibbin M. Public opinion on weekend and evening outpatient clinics. Br J Ophthalmol 2003;87:257-8.

Dear Editor

We read with interest the paper by Alwitry showing that the use of surgical facemasks significantly reduced the contamination of agar plates placed in the sterile field during cataract surgery.[1] Previous work has shown that, compared to remaining silent, talking significantly increases the dispersal of bacteria to agar plates placed 30 cm in front of and below the face, particularly if required to speak loudly.[2,3] The use of a surgical facemask prevents contamination of agar plates placed in front of the talking operator.[4] Similar reductions in contamination may be found when agar plates are placed below the operator’s mouth, although this may be partially offset in bearded male operators compared to female operators and clean shaven males as dermabrasion by the mask may increase shedding of skin and bacteria.[5,6]

During cataract extraction using topical anaesthesia it is not uncommon for the operator to continue talking with the patient giving reassurance and directing eye movements. It might be expected that in these circumstances there would be an increase in bacterial dispersal compared to akinetic anaesthetic techniques where such communication is seldom required. Consequently, it would be interesting to know from Alwitry’s study whether there was any difference in anaesthetic techniques between the masked and unmasked groups as this may significantly alter bacterial colony counts.

References

(1) Alwitry A, Jackson E, Chen H, Holden R. The use of surgical facemasks during cataract surgery: is it necessary? Br J Ophthalmol 2002;86:975-977.

(2) O'Kelly S, Marsh D. Face masks and spinal anaesthesia. British Journal of Anaesthesia 1993;53:239

(3) Schiff FS. The shouting surgeon as a possible source of endophthalmitis. Ophthalmic Surg 1990;21:438-40

(4) Phillips B, Fergusson S, Armstrong P et al. Surgical face masks are effective in reducing bacterial contamination caused by dispersal from the upper airway. Br J Anaesth 1992;53:407-8.

(5) McLure HA, Talboys CA, Yentis SM et al. Surgical face masks and downward dispersal of bacteria. Anaesthesia 1998;53:624-626.

(6) McLure HA, Mannam M, Talboys CA et al. The effect of facial hair and sex on the dispersal of bacteria below a masked subject. Anaesthesia 2000;55:173-6.

Dear Editor

We read with interest the article by Dr Li and colleagues about trypan blue staining of the vitreomacular interface during vitrectomy [1]

We congratulate the authors on their work. In particular, we appreciate their critical approach of testing trypan blue for staining of the internal limiting membrane (ILM) and epiretinal membrane (ERM) as well as their comments on potential untowards effects of indocyanine green (ICG) in macular surgery. We would like to comment on two remarks concerning the ultrastructural findings on the retinal side of the ILM following ILM- removal with and without the use of ICG.

We agree with Dr Li and collegues that fragments of glial cells are commonly found in ILM-specimens. Ultrastructurally, they appear as tiny fragments of Müller cell membranes adherent to and enclosed within the undulations of the retinal side of the ILM. These glial structures had been described in detail by Eckhardt and collegues, and are in accordance with previous work of our group, in an investigation of the ultrastructure of the vitreomacular interface of 93 specimens in 91 consecutive patients with macular holes, epiretinal membranes, diffuse diabetic macular edema, and vitreomacular traction syndrome without the use of indocyanine green or other dyes (unpublished data).[2] We also agree with the authors, that the surgical technique and the underlying disease may influence the amount of glial structures adherent to the retinal side of the ILM, as these structures are predominantly found within undulations and folds of the ILM.[3,4] However, we would like to emphasize the effect of ICG in this context. Firstly, there are obvious differences between ILM specimens removed with and without the use of ICG not only in terms of quantity of glial structures but in terms of quality. A continuous layer of cell membranes, undetermined cellular debris, and entire footplates of Müller cells were commonly observed following ICG-assisted peeling of the ILM, whereas such structures had never been found in the series of 93 unstained specimens described above.[5] Secondly, all stained and unstained specimens having been investigated by electron microscopy were removed by one experienced surgeon (A.K.). Beside the use of ICG, there was no change of the surgical technique. Moreover, retinal elements as described above were not found before the introduction of the dye at our institution in September 2000, nor after having stopped ICG-staining in April 2001. Thirdly, in an experimental setting in human donor eyes published recently, retinal structures adherent to the undulating side of the ILM as described above could be found following the application of ICG to the macula only.5 No attempt of peeling or any other mechanical approach to the vitreomacular interface was made in these eyes. However, the ILM was detached from the macula. Retinal elements were adherent to the retinal side of the ILM showing an identical morphology like those obtained during vitrectomy with ICG-assisted ILM-removal.[6] Therefore, in our experience, there is increasing evidence that at least some commonly used preparations of ICG may affect the ultrastructure of the inner retina, and are primarily responsible for obvious differences in the ultrastructure of the surgically removed ILM. ILM-removal by itself results in removal of tiny fragments of Müller cell membranes. Their morphological and functional implications to the macula remain unknown. Finally, we would like to encourage the authors to follow-on their promising approach of staining the ILM and ERM with trypan blue. In our institution, single specimens which had been stained and peeled using trypan blue revealed no evidence of retinal damage (submitted data).

References

(1) K Li, D Wong, P Hiscott, P Stanga, C Groenewald, and J McGalliard. Trypan blue staining of internal limiting membrane and epiretinal membrane during vitrectomy: visual results and histopathological findings. Br J Ophthalmol 2003;87:216-219.

(2) Eckardt C, Eckardt U, Groos S, Luciano L, Reale E. [Removal of the internal limiting membrane in macular holes. Clinical and morphological findings]. Ophthalmologe 1997;94:545-51.

(3) Haritoglou C, Gandorfer A, Gass CA, Kampik A. Ultrastructure of epiretinal tissue removed during indocyanine green assisted peeling in macular pucker surgery [ARVO Abstract No 3516]. Invest Ophthalmol Vis Sci 2002.

(4) Haritoglou C, Gandorfer A, Gass CA, Schaumberger M, Ulbig M, Kampik A. Indocyanine green-assisted peeling of the internal limiting membrane in macular hole surgery affects visual outcome: a clinicopathologic correlation. Am J Ophthalmol 2002;134:836-41.

(5) Gandorfer A, Haritoglou C, Gass CA, Ulbig MW, Kampik A. Indocyanine green-assisted peeling of the internal limiting membrane may cause retinal damage. Am J Ophthalmol 2001;132:431-3.

(6) Gandorfer A, Haritoglou C, Gandorfer A, Kampik A. Retinal damage from indocyanine green in experimental macular surgery. Invest Ophthalmol Vis Sci 2003;44:316-23.

Dear Editor

Dr Johansson's thorough and well-written article concerning 'same day' bilateral cataract surgery brought home keen memories and stirred up thoughts of my own experience with this approach to certain patients legally blind due to cataracts.

Periodically from 1951 through 1968, I was the Eye Surgeon-in-Charge of the then modern one hundred bed Kurji (Patna, Bihar, India) Holy Family Hospital Eye Clinic and Eye Hospital on the banks of the Ganges - 350 miles northwest of Calcutta. During the 1951 through 1952 operating season (the winter months), my schedule averaged twenty cataract operations daily. At that time my cataract surgery involved using either the erisiphake or Smith Indian technique . During that period I performed several dozen 'same day' - I prefer 'simultaneous' - bilateral cataract operations. The cataracts were primarily Morgagnian or cataracta nigra in type. The patients were legally blind with light perception only. They were primarily rural patients who in many cases had traveled - many times walked - with attending family members from distant villages, 'Same day' bilateral cataract surgery was frequently offered them - a golden opportunity for patients who might never again have access to surgery in a hospital under the aegis of the dedicated and skilled Medical Mission Sisters of Philadelphia. Most patients - and the burdened relatives - readily accepted the offer of 'same day' bilateral cataract surgery. For the patient, it was a matter of convenience; for the relatives, it was matter of expediency. I also realized that with vision restoration in one eye, the patient - or perhaps more so, the relatives - might not be interested in returning for surgery on the second eye. A prevalent philosophy was: "Two eyes are a luxury , one eye is a necessity". As a result, the patient frequently would develop the complications of a leaking hypermature (Morgagnian) cataract - phacolytic glaucoma. Such a painful glaucoma - a medical emergency - in a patient distant from acceptable medical care is a horrendous problem for the patient - and the family .

In spite of my own successful results with 'same day' bilateral cataract surgery in rural India , even there I was very selective - just as Dr Johansson has been - in offering this procedure to patients. In fact, during the eye clinic sessions subsequent to that of 1951-1952, I did not perform 'same day' bilateral cataract surgery but separated the two operations by at least a few days. I felt that the risk to the patient and to the reputation of the hospital was unacceptable. There is a basic rule in cataract surgery: "The second eye frequently behaves like the first eye." A complication in the first eye - often a delayed one - may presage a similar complication in the second when that eye is subjected to the same surgical procedure. This is particularly devastating in cases of endophthalmitis - more so in purulent panophthalmitis. Dr Johansson was fortunate in that it was the second, not the first eye, of his patient that developed the endophthalmitis. One can imagine the potentiality for infection of the second eye in cases where the first eye developed endophthalmitis in a 'same day' bilateral cataract operation.

In America (USA), 'same day' bilateral cataract surgery with rare exception cannot be advisable. With a sufficient number of qualified cataract surgeons with access to readily available ambulatory facilities and with scheduling of cataract surgery - on the first eye and subsequently on the second - at the convenience of the patient, Dr Johansson's standards for 'same day' bilateral cataract surgery would rarely if ever be met.

In addition, that ever-threatening incubus - the legal profession - hovers constantly above the American surgeon. 'Same day' bilateral cataract surgery is simply a bete noir for the American surgeon to avoid.

After completing the 1951-1952 cataract operating season in India, I returned to my private eye practice in Rochester , New York. There I was asked by a leading eye surgeon in the area if I would testify in court in his behalf. He had performed 'same day' bilateral cataract surgery on an older patient in an attempt to save her the expense of a second hospital stay. Unfortunately, postoperatively the patient developed diffuse retinal hemorrhaging bilaterally and was permanently blind with vaguest light perception. I informed the surgeon - a good friend - that I could not testify favorably for him, because I felt that he had demonstrated poor judgment in performing 'same day' bilateral cataract surgery in America (USA). In court, the eye surgeon was found guilty of malpractice. From that day he never again performed surgery of any type.

Dr Johansson's criteria in his country and my criteria in India cannot normally be met in contemporary America (USA).

Cataract surgeon, beware!