Mortality of emergency abdominal surgery in high-, middle- and low-income countries

Background: Surgical mortality data are collected routinely in high-income countries, yet virtually no low- or middle-income countries have outcome surveillance in place. The aim was prospectively to collect worldwide mortality data following emergency abdominal surgery, comparing findings across countries with a low, middle or high Human Development Index (HDI). Methods: This was a prospective, multicentre, cohort study. Self-selected hospitals performing emergency surgery submitted prespecified data for consecutive patients from at least one 2-week interval during July to December 2014. Postoperative mortality was analysed by hierarchical multivariable logistic regression. Results: Data were obtained for 10 745 patients from 357 centres in 58 countries; 6538 were from high-, 2889 from middle- and 1318 from low-HDI settings. The overall mortality rate was 1⋅6 per cent at 24 h (high 1⋅1 per cent, middle 1⋅9 per cent, low 3⋅4 per cent; P < 0⋅001), increasing to 5⋅4 per cent by 30 days (high 4⋅5 per cent, middle 6⋅0 per cent, low 8⋅6 per cent; P < 0⋅001). Of the 578 patients who died, 404 (69⋅9 per cent) did so between 24 h and 30 days following surgery (high 74⋅2 per cent, middle 68⋅8 per cent, low 60⋅5 per cent). After adjustment, 30-day mortality remained higher in middle-income (odds ratio (OR) 2⋅78, 95 per cent c.i. 1⋅84 to 4⋅20) and low-income (OR 2⋅97, 1⋅84 to 4⋅81) countries. Surgical safety checklist use was less frequent in low- and middle-income countries, but when used was associated with reduced mortality at 30 days. Conclusion: Mortality is three times higher in low- compared with high-HDI countries even when adjusted for prognostic factors. Patient safety factors may have an important role. Registration number: NCT02179112 (http://www.clinicaltrials.gov)

Fulminant Panuveitis following Iris Suture Fixation of Posterior Chamber Intraocular Lens

We present a case of fulminant panuveitis following iris suture fixation of a posterior chamber intraocular lens. We hypothesize that the zonular dehiscence allowed the inflammatory cells in the anterior compartment to gain access to the posterior segment mimicking endophthalmitis or toxic anterior segment syndrome. Also certain bulky lens designs, like the current Rayner hydrophilic acrylic lens, are difficult to manipulate and hold in the optic capture position, and hence the iris fixation of these lenses can be traumatic and lengthy. It is advised to exchange such lenses with 3-piece intraocular lenses that are easy to fixate

Phakic intraocular lenses and refractory lensectomy for myopia

Phakic intraocular lens implantation (IOLs) and clear lens extraction for high to extreme myopia have grown in popularity recently as a consequence of potentially unsatisfactory results with corneal refractive surgery in higher ranges of refractive errors. The refractive outcome of these alternative modalities has been encouraging to date, yet the potential for significant complications exists. Current evidence shows that the risk of retinal detachment after clear lens extraction for myopes is high. Trials with angle-supported phakic IOLs revealed unacceptable rates of pupillary ovalization, IOL rotation, and endothelial cell loss. Iris-fixated and posterior chamber phakic IOLs have proven sufficient safety, but long-term follow-ups of current cohorts are still to be awaited. The implantation of either of the latter two phakic IOLs followed by laser in situ keratomileusis or photorefractive keratectomy (bioptics) provides another option in refractive surgery for high ametropia

Refractory interface haze developing after epithelial ingrowth following laser in situ keratomileusis and small aperture corneal inlay implantation

Purpose: To report the occurrence and the management of refractory interface haze that developed after epithelial ingrowth following small aperture inlay implantation. Observations: A 52 year-old man with sub-clinical anterior basement membrane dystrophy (ABMD) underwent combined hyperopic laser in situ keratomileusis and KAMRA corneal inlay implantation to correct presbyopia. Post-operatively, epithelial ingrowth developed requiring debridement and KAMRA removal. Significant diffuse interface haze, ground-glass in texture, involving the central 6 mm of the cornea developed the next day, and was refractory to topical and systemic steroids, necessitating flap irrigation, gentle scraping, and MMC application to the residual stromal bed after 12 days. The interface haze gradually improved to near complete resolution over 12-months. Conclusions and importance: Epithelial ingrowth can lead to flap interface haze refractory to medical therapy. Early surgical intervention is key to haze resolution. Keywords: Refractory interface haze, KAMRA, Inlay implantation, Anterior basement membrane dystrophy, Epithelial ingrowth, Laser in situ keratomileusi