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Complications of phacoemulsification on the first postoperative day: can follow-up be safely changed?
Complications of phacoemulsification on the first postoperative day: Can follow-up be safely changed? Edward N. Herbert, FRCOphth, Helen Gibbons, Jean Bell, David S. Hughes, FRCOphth, Declan W. Flanagan, FRCOphth ABSTRACT Purpose: To establish the rate of complications detected on the first postoperative day and therefore the need for evaluation on that day. Setting: Hinchingbrooke Hospital, Huntingdon, England. Methods: Complications detected on the first day after phacoemulsification cataract surgery were retrospectively reviewed over 8 months. Ophthalmic nurse practitioners performed the 1 day postoperative examination and kept a log of patients seen, recording complications detected and whether referral to a physician was required. All patients had had routine phacoemulsification with intraocular lens implantation without anterior vitrectomy or trabeculectomy, as identified from the log book and cross-checked with operating theater records. Notes were reviewed if a complication or referral was recorded. Most cases were performed under local anesthesia as day cases using a temporal corneal approach. Sections were routinely left unsutured unless enlarged or closure was not satisfactory at the conclusion of surgery. Results: The review yielded 392 patients. Six (1.53%) had intraocular pressure (ⱖ30 mm Hg) requiring treatment, 1 (0.26%) had painless iris prolapse, 11 (2.81%) had corneal abrasions, and 7 (1.78%) were given a more intensive steroid regime. No cases of fibrinous uveitis were recorded. Conclusions: Potentially sight-threatening complications present on the first postoperative day, albeit infrequently. With our current practice and case mix, the need for this review persists. It is possible to reduce the demand on physician time by using appropriately trained nonmedical practitioners. J Cataract Refract Surg 1999; 25:985–988 © 1999 ASCRS and ESCRS
S
mall incision phacoemulsification is becoming the technique of choice for cataract surgery, providing rapid visual rehabilitation and reduced problems with astigmatism and suture management. The popularization of this technique—associated with changes in patient expectation, expansion of day surgery, and pressure on clinic time— has made streamlining of follow-up
Reprint requests to Edward N. Herbert, FRCOphth, Highbury House, Wood End, Ardeley, SG2 7BD, England. © 1999 ASCRS and ESCRS Published by Elsevier Science Inc.
protocol desirable. Recent studies suggest that true daycase surgery with the first review performed 4 to 6 hours postoperatively1 or without early review2,3 may be safe alternatives to traditional practice4 if adequate access to advice or the clinic is available. At our unit, first day follow-up (16 to 24 hours after surgery) is performed by ophthalmic nurse practitioners (ONPs) in accordance with shared care principals.5 This review comprises assessment of symptoms, recording of visual acuity and intraocular pressure (IOP) (Goldmann 0886-3350/99/$–see front matter PII S0886-3350(99)00079-6
PHACOEMULSIFICATION COMPLICATIONS ON DAY 1
applanation tonometry or Tono-Pen), and slitlamp examination of the anterior segment. Problems are referred to a physician for review. Patients are instructed on safe drop instillation and given advice on symptoms that merit early attention. All patients reviewed by the ONPs are recorded in a log book along with a note of complications or referral. We attempted to determine the necessity of this first day review by looking at the rate of intervention and incidence of sight-threatening complications based on the log book’s data. Conventionally, retrospective studies such as this involve case note review of the entire study cohort. Limited resources in medical records departments can make it difficult to obtain a complete data set within a reasonable time. We hoped the log book would provide a more accessible source of information and limit the burden on medical records clerks while yielding useful results.
Patients and Methods The ONPs’ log books were retrospectively reviewed over 8 months. Entries were cross-checked with operating theater records, and case notes were retrieved if a complication or referral was noted or if the entry was not clear. All patients who had had phacoemulsification during the study and who were seen by an ONP were included unless they had an anterior vitrectomy or a trabeculectomy at the same time as cataract surgery. These cases were excluded so that as far as possible from the available data, surgery could be deemed uneventful. The study population was otherwise unselected. Most surgeries were performed with local anesthesia comprising a peribulbar block with prilocaine 3% to 4% or a 1:1 mix of lignocaine 2% with bupivacaine 0.5% to 0.75% in addition to topical oxybuprocaine 0.4% (Benoxinate威). A self-sealing temporal corneal section was used in most cases. Continuous curvilinear capsulorhexis was performed under hydroxypropyl methylcellulose or sodium hyaluronate (Healon威). A 2-handed divide and conquer technique was performed routinely using Surgical Design’s Ocusystem equipment. Several types of intraocular lenses (IOLs) were used during the study (Table 1) depending on surgeon choice and intraoperative factors. Table 2 shows the grade of surgeon performing the procedures. 986
At the conclusion of surgery, the anterior chamber was reinflated with a balanced salt solution to approximate physiological pressure, and the integrity of the section was checked. Sutures were used if the seal was not adequate or the section was larger than 5.0 mm. Subconjunctival cefuroxime (125 mg) was administered and a Cartella shield applied without a pad. No prophylactic ocular hypotensives were used. First day follow-up was performed by the ONPs at which dexamethasone 0.1%, neomycin 0.35%, and polymyxin B 6000 units/mL drops (Maxitrol威) were initiated 4 times a day. The next review was scheduled 1 week later at the main clinic.
Results Mean age of the 392 patients was 74.8 years (range 26 to 96 years); there were 143 men and 249 women. Seven cases were performed using general anesthesia and 9 with topical anesthesia (benoxinate with subconjunctival lignocaine 2%). Six patients had an IOP of 30 mm Hg or more that required treatment on the first day. One case had painless iris prolapse, 11 had corneal abrasions, and 7 were given a more intensive steroid regime. Case notes were reviewed for these patients. Table 1. Types of IOLs used.
Material
Size (mm)
Silicone
6.0
Pharmacia 920
PMMA
5.0
Pharmacia 809P
31
Silicone
6.0
Staar AA4203*
49
PMMA
7.0
Pharmacia 728A
13
Hydrogel
6.0
Storz H60M
2
Acrylic
6.0
Ioltech Haptibag
2
Acrylic
5.5
Ioltech Stabibag
1
Model
Number Implanted 294
PMMA ⫽ poly(methyl methacrylate) *Plate-haptic lens
Table 2. Grades of surgeons performing procedures. Surgeon Grade
Number of Surgeons
Cases Performed
Consultant
3
351
Senior registrar
1
2
Senior house officer
2
39
J CATARACT REFRACT SURG—VOL 25, JULY 1999
PHACOEMULSIFICATION COMPLICATIONS ON DAY 1
Of the 6 patients with an IOP rise, 2 patients had open-angle glaucoma, 2 patients had type 2 diabetes mellitus (1 with an area of zonular dehiscence noted intraoperatively but not affecting completion of surgery and some residual soft lens matter the next day), and 1 patient had a capsulorhexis tear requiring placement of a 7.0 mm poly(methyl methacrylate) lens in the sulcus with 3 10-0 nylon sutures to close. Recorded indications for an increased steroid regimen are shown in Table 3; 2 of these patients were diabetic, and 5 had increased anterior chamber activity. Ten patients with corneal abrasions had surgery performed with a peribulbar block; 9 of these had large central abrasions. Two patients had small abrasions, 1 of whom had surgery using topical anesthesia. No patient with an abrasion was diabetic. Surgery was documented as routine in the case of iris prolapse, with a 6.0 mm foldable lens inserted through an unsutured corneal tunnel. (A 3.8 mm section is recommended for this lens.)
Discussion First day review serves a number of roles: (1) screens for treatable early complications; (2) educates patients in postoperative care and drop installation; (3) reassures patients; (4) provides feedback to the surgeon. Streamlining follow-up may release limited resources but is only desirable if standards of care are maintained. We therefore aimed to examine the necessity of this review in relation to the first of these roles. The heterogeneity of our study population reflects a “typical” cataract workload for an eye department in the British National Health Service, with a number of surTable 3. Indications recorded for increasing steroid treatment. Patient
Comorbidity
Indication Recorded
1
None
2
Diabetes
3
None
Cells 2⫹; flare; residual soft lens matter; corneal edema
4
None
Cells ⫹; pain
5
Diabetes
6
None
Corneal edema, conjunctival injection 2⫹
7
None
Cells 2⫹; conjunctival injection 2⫹
Chemosis 3⫹; fibrin⫹ Hyphema; corneal edema
Cells ⫹
geons, including trainees, performing operations. A variety of anesthesia methods and IOLs are used, and the population includes patients with comorbidity. In our unit, we reinflate the anterior chamber at the conclusion of surgery to approximate physiological IOP, which is not measured. No prophylactic ocular hypotensive agents are used, which reflects standard practice at many units. Clearly, our results are most relevant to units with similar practices but may also be of value to others in planning appropriate and efficient postoperative management. Intraocular pressure spikes after cataract surgery are thought to be self-limiting, peaking at approximately 6 hours,6 and may be more common in glaucoma patients.7 The risk of anterior ischemic optic neuropathy,8 other vascular events, and field progression in glaucomatous patients is of concern during this period, although the actual incidence appears low. Treating elevated IOPs persisting at first follow-up may only marginally alter this risk as the pressure is likely to have developed soon after surgery and been high for several hours. Elevated IOP is not consistently associated with pain or blurring9 so that self-referral in the absence of routine review may miss cases. Ideally, the pressure spike can be diminished,10,11 although prophylaxis does not appear to be uniformly successful.12 Iris prolapse is rare after small incision surgery and is thought to be associated with poor wound construction or postoperative manipulation.13,14 Delayed presentation can increase the risk of a poor outcome. The other complications seen in our series are likely self-limiting, without deviation from standard treatment, or produce symptoms provoking self-referral. Shorter acting local anesthetic agents or topical anesthesia may reduce the rate of corneal abrasion through earlier recovery of corneal sensation. Endophthalmitis is not usually apparent before 48 hours postoperatively,15 even when caused by virulent organisms. Therefore, its detection is unlikely to be affected if follow-up procedures are changed. A small number of potentially sight-threatening complications were recognized in this unselected population at a rate comparable to those of other reports.1–3,16 Patient selection may reduce the complication rate on day 1. There are many alternatives to first day review. Review on the day of surgery, 4 to 6 hours postoperatively, would be expected to reveal most significant IOP rises7 and allow early treatment.
J CATARACT REFRACT SURG—VOL 25, JULY 1999
987
PHACOEMULSIFICATION COMPLICATIONS ON DAY 1
The need for patient selection in this group would be no greater than for conventional day cases. Such a protocol reduces travel for the patients and avoids the risks of side effects from medical prophylaxis, which may only benefit a small number. This check could be performed by nonmedical practitioners; however, this would be less practical after afternoon surgeries. To do without the first review requires reduction of complications to an absolute minimum, which may be achieved through careful patient selection, with or without ocular hypotensive prophylaxis. Careful consideration is required if follow-up protocols are to be changed while maintaining quality of care. The ONPs log book provided an accessible method for data extraction and greatly reduced the number of case notes required from medical records. However, considerable time was required for cross-checking with operating theater records and the quantity of available data was limited without access to all case notes. Significant complications are recognized on day 1, albeit infrequently. To do away with this review in the absence of other safeguards may compromise levels of care. Use of appropriately trained nonmedical practitioners provides an alternative means of review, reducing demand on physician time.
References 1. Tufail A, Foss AJE, Hamilton AMP. Is the first day postoperative review necessary after cataract extraction? Br J Ophthalmol 1995; 79:646 – 648 2. Whitefield L, Crowston J, Little BC. First day follow up for routine phacoemulsification? Br J Ophthalmol 1996; 80:148 –150 3. Allan BDS, Baer RM, Heyworth P, et al. Conventional routine clinical review may not be necessary after uncomplicated phacoemulsification. Br J Ophthalmol 1997; 81: 548 –550 4. Royal College of Ophthalmologists. Guidelines for Cataract Surgery. London, RCO, 1995 5. Royal College of Ophthalmologists. Guidelines for Shared Care. London, RCO, 1996
988
6. Rich WJ, Radtke ND, Cohan BE. Early ocular hypertension after cataract extraction. Br J Ophthalmol 1974; 58:725–731 7. Barak A, Desatnik H, Ma-Naim T, et al. Early postoperative intraocular pressure pattern in glaucomatous and nonglaucomatous patients. J Cataract Refract Surg 1996; 22:607– 611 8. Hayreh SS. Anterior ischemic optic neuropathy. IV. Occurrence after cataract extraction. Arch Ophthalmol 1980; 98:1410 –1416 9. Chong NHV, Aggarwal RK, Shah P, Murray PI. Is measuring intraocular pressure necessary on the first postoperative day following uncomplicated cataract surgery? Eye 1994; 8:115–116 10. Wiles SB, MacKenzie D, Ide CH. Control of intraocular pressure with apraclonidine hydrochloride after cataract extraction. Am J Ophthalmol 1991; 111:184 –188 11. Araie M, Ishi K. Effects of apraclonidine on intraocular pressure and blood–aqueous barrier permeability after phacoemulsification and intraocular lens implantation. Am J Ophthalmol 1993; 116:67–71 12. Bo¨mer TG, Lagre`ze W-DA, Funk J. Intraocular pressure rise after phacoemulsification with posterior chamber lens implantation: effect of prophylactic medication, wound closure, and surgeon’s experience. Br J Ophthalmol 1995; 79:809 – 813 13. Menapace R. Delayed iris prolapse with unsutured 5.1 mm clear corneal incisions. J Cataract Refract Surg 1995; 21:353–357 14. Francis PJ, Morris RJ. Post-operative iris prolapse following phacoemulsification and extracapsular cataract surgery. Eye 1997; 11:87–90 15. Hughes DS, Hill RJ. Infectious endophthalmitis after cataract surgery. Br J Ophthalmol 1994; 78:227–232 16. Desai P. The National Cataract Surgery Survey: II. Clinical outcomes. Eye 1993; 7:489 – 494
Accepted for publication January 27, 1999. From Hinchingbrooke Hospital, Huntingdon, England. Presented as a poster at the Oxford Ophthalmological Congress, Oxford, England, July 1998.
J CATARACT REFRACT SURG—VOL 25, JULY 1999
S
mall incision phacoemulsification is becoming the technique of choice for cataract surgery, providing rapid visual rehabilitation and reduced problems with astigmatism and suture management. The popularization of this technique—associated with changes in patient expectation, expansion of day surgery, and pressure on clinic time— has made streamlining of follow-up
Reprint requests to Edward N. Herbert, FRCOphth, Highbury House, Wood End, Ardeley, SG2 7BD, England. © 1999 ASCRS and ESCRS Published by Elsevier Science Inc.
protocol desirable. Recent studies suggest that true daycase surgery with the first review performed 4 to 6 hours postoperatively1 or without early review2,3 may be safe alternatives to traditional practice4 if adequate access to advice or the clinic is available. At our unit, first day follow-up (16 to 24 hours after surgery) is performed by ophthalmic nurse practitioners (ONPs) in accordance with shared care principals.5 This review comprises assessment of symptoms, recording of visual acuity and intraocular pressure (IOP) (Goldmann 0886-3350/99/$–see front matter PII S0886-3350(99)00079-6
PHACOEMULSIFICATION COMPLICATIONS ON DAY 1
applanation tonometry or Tono-Pen), and slitlamp examination of the anterior segment. Problems are referred to a physician for review. Patients are instructed on safe drop instillation and given advice on symptoms that merit early attention. All patients reviewed by the ONPs are recorded in a log book along with a note of complications or referral. We attempted to determine the necessity of this first day review by looking at the rate of intervention and incidence of sight-threatening complications based on the log book’s data. Conventionally, retrospective studies such as this involve case note review of the entire study cohort. Limited resources in medical records departments can make it difficult to obtain a complete data set within a reasonable time. We hoped the log book would provide a more accessible source of information and limit the burden on medical records clerks while yielding useful results.
Patients and Methods The ONPs’ log books were retrospectively reviewed over 8 months. Entries were cross-checked with operating theater records, and case notes were retrieved if a complication or referral was noted or if the entry was not clear. All patients who had had phacoemulsification during the study and who were seen by an ONP were included unless they had an anterior vitrectomy or a trabeculectomy at the same time as cataract surgery. These cases were excluded so that as far as possible from the available data, surgery could be deemed uneventful. The study population was otherwise unselected. Most surgeries were performed with local anesthesia comprising a peribulbar block with prilocaine 3% to 4% or a 1:1 mix of lignocaine 2% with bupivacaine 0.5% to 0.75% in addition to topical oxybuprocaine 0.4% (Benoxinate威). A self-sealing temporal corneal section was used in most cases. Continuous curvilinear capsulorhexis was performed under hydroxypropyl methylcellulose or sodium hyaluronate (Healon威). A 2-handed divide and conquer technique was performed routinely using Surgical Design’s Ocusystem equipment. Several types of intraocular lenses (IOLs) were used during the study (Table 1) depending on surgeon choice and intraoperative factors. Table 2 shows the grade of surgeon performing the procedures. 986
At the conclusion of surgery, the anterior chamber was reinflated with a balanced salt solution to approximate physiological pressure, and the integrity of the section was checked. Sutures were used if the seal was not adequate or the section was larger than 5.0 mm. Subconjunctival cefuroxime (125 mg) was administered and a Cartella shield applied without a pad. No prophylactic ocular hypotensives were used. First day follow-up was performed by the ONPs at which dexamethasone 0.1%, neomycin 0.35%, and polymyxin B 6000 units/mL drops (Maxitrol威) were initiated 4 times a day. The next review was scheduled 1 week later at the main clinic.
Results Mean age of the 392 patients was 74.8 years (range 26 to 96 years); there were 143 men and 249 women. Seven cases were performed using general anesthesia and 9 with topical anesthesia (benoxinate with subconjunctival lignocaine 2%). Six patients had an IOP of 30 mm Hg or more that required treatment on the first day. One case had painless iris prolapse, 11 had corneal abrasions, and 7 were given a more intensive steroid regime. Case notes were reviewed for these patients. Table 1. Types of IOLs used.
Material
Size (mm)
Silicone
6.0
Pharmacia 920
PMMA
5.0
Pharmacia 809P
31
Silicone
6.0
Staar AA4203*
49
PMMA
7.0
Pharmacia 728A
13
Hydrogel
6.0
Storz H60M
2
Acrylic
6.0
Ioltech Haptibag
2
Acrylic
5.5
Ioltech Stabibag
1
Model
Number Implanted 294
PMMA ⫽ poly(methyl methacrylate) *Plate-haptic lens
Table 2. Grades of surgeons performing procedures. Surgeon Grade
Number of Surgeons
Cases Performed
Consultant
3
351
Senior registrar
1
2
Senior house officer
2
39
J CATARACT REFRACT SURG—VOL 25, JULY 1999
PHACOEMULSIFICATION COMPLICATIONS ON DAY 1
Of the 6 patients with an IOP rise, 2 patients had open-angle glaucoma, 2 patients had type 2 diabetes mellitus (1 with an area of zonular dehiscence noted intraoperatively but not affecting completion of surgery and some residual soft lens matter the next day), and 1 patient had a capsulorhexis tear requiring placement of a 7.0 mm poly(methyl methacrylate) lens in the sulcus with 3 10-0 nylon sutures to close. Recorded indications for an increased steroid regimen are shown in Table 3; 2 of these patients were diabetic, and 5 had increased anterior chamber activity. Ten patients with corneal abrasions had surgery performed with a peribulbar block; 9 of these had large central abrasions. Two patients had small abrasions, 1 of whom had surgery using topical anesthesia. No patient with an abrasion was diabetic. Surgery was documented as routine in the case of iris prolapse, with a 6.0 mm foldable lens inserted through an unsutured corneal tunnel. (A 3.8 mm section is recommended for this lens.)
Discussion First day review serves a number of roles: (1) screens for treatable early complications; (2) educates patients in postoperative care and drop installation; (3) reassures patients; (4) provides feedback to the surgeon. Streamlining follow-up may release limited resources but is only desirable if standards of care are maintained. We therefore aimed to examine the necessity of this review in relation to the first of these roles. The heterogeneity of our study population reflects a “typical” cataract workload for an eye department in the British National Health Service, with a number of surTable 3. Indications recorded for increasing steroid treatment. Patient
Comorbidity
Indication Recorded
1
None
2
Diabetes
3
None
Cells 2⫹; flare; residual soft lens matter; corneal edema
4
None
Cells ⫹; pain
5
Diabetes
6
None
Corneal edema, conjunctival injection 2⫹
7
None
Cells 2⫹; conjunctival injection 2⫹
Chemosis 3⫹; fibrin⫹ Hyphema; corneal edema
Cells ⫹
geons, including trainees, performing operations. A variety of anesthesia methods and IOLs are used, and the population includes patients with comorbidity. In our unit, we reinflate the anterior chamber at the conclusion of surgery to approximate physiological IOP, which is not measured. No prophylactic ocular hypotensive agents are used, which reflects standard practice at many units. Clearly, our results are most relevant to units with similar practices but may also be of value to others in planning appropriate and efficient postoperative management. Intraocular pressure spikes after cataract surgery are thought to be self-limiting, peaking at approximately 6 hours,6 and may be more common in glaucoma patients.7 The risk of anterior ischemic optic neuropathy,8 other vascular events, and field progression in glaucomatous patients is of concern during this period, although the actual incidence appears low. Treating elevated IOPs persisting at first follow-up may only marginally alter this risk as the pressure is likely to have developed soon after surgery and been high for several hours. Elevated IOP is not consistently associated with pain or blurring9 so that self-referral in the absence of routine review may miss cases. Ideally, the pressure spike can be diminished,10,11 although prophylaxis does not appear to be uniformly successful.12 Iris prolapse is rare after small incision surgery and is thought to be associated with poor wound construction or postoperative manipulation.13,14 Delayed presentation can increase the risk of a poor outcome. The other complications seen in our series are likely self-limiting, without deviation from standard treatment, or produce symptoms provoking self-referral. Shorter acting local anesthetic agents or topical anesthesia may reduce the rate of corneal abrasion through earlier recovery of corneal sensation. Endophthalmitis is not usually apparent before 48 hours postoperatively,15 even when caused by virulent organisms. Therefore, its detection is unlikely to be affected if follow-up procedures are changed. A small number of potentially sight-threatening complications were recognized in this unselected population at a rate comparable to those of other reports.1–3,16 Patient selection may reduce the complication rate on day 1. There are many alternatives to first day review. Review on the day of surgery, 4 to 6 hours postoperatively, would be expected to reveal most significant IOP rises7 and allow early treatment.
J CATARACT REFRACT SURG—VOL 25, JULY 1999
987
PHACOEMULSIFICATION COMPLICATIONS ON DAY 1
The need for patient selection in this group would be no greater than for conventional day cases. Such a protocol reduces travel for the patients and avoids the risks of side effects from medical prophylaxis, which may only benefit a small number. This check could be performed by nonmedical practitioners; however, this would be less practical after afternoon surgeries. To do without the first review requires reduction of complications to an absolute minimum, which may be achieved through careful patient selection, with or without ocular hypotensive prophylaxis. Careful consideration is required if follow-up protocols are to be changed while maintaining quality of care. The ONPs log book provided an accessible method for data extraction and greatly reduced the number of case notes required from medical records. However, considerable time was required for cross-checking with operating theater records and the quantity of available data was limited without access to all case notes. Significant complications are recognized on day 1, albeit infrequently. To do away with this review in the absence of other safeguards may compromise levels of care. Use of appropriately trained nonmedical practitioners provides an alternative means of review, reducing demand on physician time.
References 1. Tufail A, Foss AJE, Hamilton AMP. Is the first day postoperative review necessary after cataract extraction? Br J Ophthalmol 1995; 79:646 – 648 2. Whitefield L, Crowston J, Little BC. First day follow up for routine phacoemulsification? Br J Ophthalmol 1996; 80:148 –150 3. Allan BDS, Baer RM, Heyworth P, et al. Conventional routine clinical review may not be necessary after uncomplicated phacoemulsification. Br J Ophthalmol 1997; 81: 548 –550 4. Royal College of Ophthalmologists. Guidelines for Cataract Surgery. London, RCO, 1995 5. Royal College of Ophthalmologists. Guidelines for Shared Care. London, RCO, 1996
988
6. Rich WJ, Radtke ND, Cohan BE. Early ocular hypertension after cataract extraction. Br J Ophthalmol 1974; 58:725–731 7. Barak A, Desatnik H, Ma-Naim T, et al. Early postoperative intraocular pressure pattern in glaucomatous and nonglaucomatous patients. J Cataract Refract Surg 1996; 22:607– 611 8. Hayreh SS. Anterior ischemic optic neuropathy. IV. Occurrence after cataract extraction. Arch Ophthalmol 1980; 98:1410 –1416 9. Chong NHV, Aggarwal RK, Shah P, Murray PI. Is measuring intraocular pressure necessary on the first postoperative day following uncomplicated cataract surgery? Eye 1994; 8:115–116 10. Wiles SB, MacKenzie D, Ide CH. Control of intraocular pressure with apraclonidine hydrochloride after cataract extraction. Am J Ophthalmol 1991; 111:184 –188 11. Araie M, Ishi K. Effects of apraclonidine on intraocular pressure and blood–aqueous barrier permeability after phacoemulsification and intraocular lens implantation. Am J Ophthalmol 1993; 116:67–71 12. Bo¨mer TG, Lagre`ze W-DA, Funk J. Intraocular pressure rise after phacoemulsification with posterior chamber lens implantation: effect of prophylactic medication, wound closure, and surgeon’s experience. Br J Ophthalmol 1995; 79:809 – 813 13. Menapace R. Delayed iris prolapse with unsutured 5.1 mm clear corneal incisions. J Cataract Refract Surg 1995; 21:353–357 14. Francis PJ, Morris RJ. Post-operative iris prolapse following phacoemulsification and extracapsular cataract surgery. Eye 1997; 11:87–90 15. Hughes DS, Hill RJ. Infectious endophthalmitis after cataract surgery. Br J Ophthalmol 1994; 78:227–232 16. Desai P. The National Cataract Surgery Survey: II. Clinical outcomes. Eye 1993; 7:489 – 494
Accepted for publication January 27, 1999. From Hinchingbrooke Hospital, Huntingdon, England. Presented as a poster at the Oxford Ophthalmological Congress, Oxford, England, July 1998.
J CATARACT REFRACT SURG—VOL 25, JULY 1999