Objective To assess the visual outcome of eyes undergoing Artisan lens implantation for aphakia, to identify reasons for poor outcomes, and to report incidences of post-operative uveitis, glaucoma, or hyphaema. Methods A retrospective analysis of 32 eyes rendered aphakic through various causes, which subsequently underwent Artisan lens implantation. Results A total of 32 eyes from 31 patients were reviewed. Follow-up ranged from 6 to 42 months, mean 17.3 months. The commonest cause of aphakia was following complicated phacoemulsification in 17 of the 32 eyes (53.1%). At final follow-up, 21 of the 32 eyes (65.6%) achieved best-corrected visual acuity (BCVA) better than that measured pre-operatively and 10 of the 32 eyes (31.3%) matched their pre-operative BCVA. Of 33 eyes, only 1 (0.03%) attained a final BCVA worse than pre-operatively, owing to non-arteritic anterior ischaemic optic neuropathy. A total of 4 of the 33 eyes (12.5%) had pre-existing glaucoma or ocular hypertension; no additional intraocular pressure problems were identified during the follow-up period. Conclusion This study suggests that Artisan iris claw lens insertion is beneficial in acquired aphakia, matching or exceeding pre-operative BCVA in the overwhelming majority of the cases. In addition, this series did not identify any post-operative problems with uveitis, glaucoma, or hyphaema.

<b><i>Purpose:</i></b> During bank holidays and weekends (BHWE), many primary macula-on retinal detachments (RD) across the United Kingdom are performed unsupervised out-of-hours by experienced vitreoretinal (VR) fellows. We aimed to determine whether first-year (F1) and second-year (F2) fellows could safely operate out-of-hours independently with remote supervision on primary macula-on RDs. <b><i>Methods:</i></b> This is a retrospective consecutive series of 435 patients attending the Birmingham and Midlands Eye Centre from January 2017 to July 2020. We evaluated (i) 6-month re-detachment rate and (ii) visual outcomes of F1, F2, and consultants during office hours and BHWE as well as the effects of supervision versus non-supervision. <b><i>Results:</i></b> For the re-detachment rate, no difference was found between surgeon grade (<i>p</i> = 0.821), whether supervised (<i>p</i> = 1.000), whether BHWE (<i>p</i> = 1.000), unsupervised BHWE and supervised mid-week (<i>p</i> = 0.757), and unsupervised F1 and F2 (<i>p</i> = 1.000), with non-significance maintained on multivariate regression. No difference was detected in the level of supervision (15.7%) between fellow grades during BHWE (<i>p</i> = 0.761) or mid-week (<i>p</i> = 0.295) or between surgeon grade and logMAR letters gained pre-postoperatively (<i>p</i> = 0.834). <b><i>Conclusion:</i></b> Safe VR services can be provided by experienced VR fellows during office hours, BHWE, supervised, or unsupervised, with similar primary success and visual outcomes to consultants in this patient subgroup. Initial intensive supervision and feedback and a gradual increase in independence is fundamental for VR fellows to gain confidence and become safe independent surgeons.

A significant proportion of patients required further treatment, and more than half of patients were referred to the vitreoretinal team. Over the years, trainees' indirect ophthalmoscopy and laser retinopexy skills have become progressively inadequate. Further training of junior physicians on indirect laser retinopexy may improve patient care and reduce the inconvenience of repeated visits.

Sir, Reply to MA Elgohary, DYL Leung and DSC LamWe would like to thank Dr Elgohary for the interest in and comments on our paper. 1 The evidence for the relative importance of the immunomodulatory effects of oestrogen and progesterone remains inconclusive. In specifying the exact date of onset of acute uveitis, we were sensitive to the problem that there may be a short delay between immune 'trigger' and onset of symptoms. In view of this, it would be difficult to draw firm conclusions about the hormonal influence on particular days within the late phase of the menstrual cycle, at which time hormonal levels change precipitately. We can confirm that no patient was using concurrent oral steroid or immunosuppression at presentation.We are also grateful for the comments on our paper 1 by Leung and Lam. While we understand and appreciate the points made, we disagree with most. Almost all regularly menstruating women have excellent recall of the date of last menstrual period (LMP). Where there was doubt, the patient was not included in our study; there was therefore no recall bias on this parameter. We commented that it may be interesting to measure oestrogen and progesterone levels in such patients; however, the absence of these data does not affect the validity of our comments. Our proposition is not that uveitis commences at a particular hormone level, but that it may be precipitated by hormone withdrawal in the predisposed. It is not necessary to measure hormone levels to prove that a woman is in the late phase of the menstrual cycle, if the LMP date is known.We strongly disagree that it is 'not unusual' for anterior uveitis to be relatively silent in the early phase of disease; all our patients had acute-onset anterior uveitis with clear memory of the date of onset of symptoms, and rapid attendance at our ophthalmic emergency department, usually within 24 h. No patient had acuteon-chronic disease and no patient had recently discontinued topical steroid. Where there was doubt, the patient was excluded. We disagree that the aetiology of uveitis could affect presentation; while uveitis such as that related to juvenile idiopathic arthritis (JIA) can indeed be asymptomatic, that is not relevant to acuteonset symptomatic uveitis presenting in adulthood. We can confirm that no patient had JIA-related uveitis. We disagree that measurement of objective signs of severity might be a more reliable indicator of onset than reported symptoms; there is a wide variation in the severity of inflammation in those presenting with acute anterior uveitis; there is no evidence that this has a bearing on the duration of inflammation before presentation. On the contrary, it is not unknown for patients with recurrent anterior uveitis to be aware of recurrence (and to present with symptoms) before cells are detected in the anterior chamber. Finally, although the incidence of uveitis in the premenstrual phase did not quite reach statistical significance, the incidence in the whole postovulatory phase did; having carefully stated potential so...

Purpose To measure the visual outcomes, proliferative vitreoretinopathy (PVR) and retinectomy rates following primary rhegmatogenous retinal detachment (RRD) repair, comparing silicone oil (SO) and heavy SO (Densiron). Methods Retrospective, continuous comparative study from January 2017 to May 2021 of all primary RRD. Multivariable linear (logMAR gain) and binary-logistic (PVR-C and retinectomy rate) regression models to compare tamponade were performed. Covariates included age, gender, ocular co-morbidities, high myopia, macula-status, giant-retinal-tear (GRT), pre-op vision, PVR-C, oil type, perfluorocarbon-use, combined scleral buckle/vitrectomy, combined phaco-vitrectomy, 360-degrees-endolaser and oil duration. Cases with trauma or less than six-month follow-up were excluded. Results A total of 259 primary RD were analysed. There were 179 SO patients and 80 Densiron patients that had six-month primary re-detachment in 18 (10.1%) and 8 (10.0%) respectively (p = 1.000). No difference in logMAR gain was detected between tamponade choice on multivariable linear regression. Subsequent glaucoma surgery was 5 (2.8%) and 4 (5.0%) for SO and Densiron patients respectively (p = 0.464). On multivariate binary-logistic regression we found no difference in development of PVR-C between oil tamponades. However, SO had significantly higher subsequent retinectomy rate compared to Densiron (odds ratio 15.3, 95% CI 1.9–125.5, p = 0.011). Duration of oil tamponade was not linked to differences in logMAR gain, PVR-C formation or increased retinectomy rate. Conclusions We report no difference in primary anatomical success, number of further RRD surgeries, subsequent glaucoma surgery, visual outcomes, PVR-C between both tamponades on multivariable models. Densiron oil was found to be more retinectomy sparing relative to SO.