Randomized Controlled Trial Comparing Femtosecond Laser-Assisted with Conventional Phacoemulsification on Dense Cataracts.

PURPOSE: To compare the benefit of femtosecond laser-assisted cataract surgery (FLACS) versus phacoemulsification (PE) and 2 fragmentation patterns in managing dense cataracts. DESIGN: Randomized controlled trial. METHODS: Patients with nuclear opacity (NO) grade >5 (Lens Opacities Classification System III) were enrolled at the Singapore National Eye Centre. Patients who were unsuitable for FLACS, whose corneal endothelial cell count (ECC) was <1,500 cells/mm2, or had cataracts with additional complexities were excluded from the study. Eyes were randomized to PE, 600 µm grid (FLACSg), or 16-segment fragmentation (FLACS16) in 2:1:1 ratio. The Victus (Bausch & Lomb) laser platform and in situ phacoemulsification chop technique was used. Data for patient demographics, preoperative, and 1 month postoperative best-corrected visual acuity (BCVA), ECC, effective phacoemulsification time (EPT), and perioperative complications were collected. Outcome measurements were the loss of ECC at 1 month and EPT. RESULTS: Ninety-three patients were randomized to PE (48), FLACSg (22), and FLACS16 (23). Majority were Chinese (87; 93.5%). Mean age was 74.3 ± 8.8 years of age. Cataracts were mostly graded as NO 5-6 (49; 61.3%). EPT among treatment arms was not different (P = .097, one-way ANOVA) but was significantly higher for NO >6 than NO <6 (P < .001, general linear model). ECC loss was significantly less in FLACSg than in PE (P = .018, Bonferroni correction). Mean 1-month postoperative LogMAR BCVA (0.23 ± 0.20) was significantly better than preoperative BCVA (1.02 ± 0.85; P < .001, paired t test) but not different between PE and FLACS. CONCLUSIONS: FLACSg but not FLACS16 significantly lowered the mean ECC loss during phacoemulsification in dense cataracts.

Femtosecond laser-assisted cataract surgery for the white cataract.

AIM: To report the capsulotomy and lens fragmentation outcomes of white cataracts managed with the femtosecond laser (FL). METHODS: Outcomes of a prospective, observational consecutive case series of white cataracts (June 2012-November 2016) that underwent FL-assisted cataract surgery (FLACS) (Victus, Bausch+Lomb, Munich, Germany) at the Singapore National Eye Centre were audited. Data collected: patient demographics, type of white cataract, levelness of docking, anterior capsule position following laser, completeness of capsulotomy and fragmentation, best-corrected visual acuity (BCVA) at 1 month, intraoperative complications. Outcome measures: capsulotomy integrity, fragmentation capability and BCVA at 1 month. RESULTS: 58 eyes of 54 patients underwent FLACS. White cataract types included dry white (24 eyes), intumescent (28 eyes) and Morgagnian (6 eyes). Docking was level in 22 eyes (38.6%). Following FL, the anterior capsule level dropped in 20 eyes (34.5%). Incomplete capsulotomies occurred in 10 eyes (17.2%). Lens fragmentation attempted in 38 eyes was effective or partially effective in 31 eyes (81.6%). No anterior or posterior capsule tears occurred. LogMAR BCVA at 1 month was 0.073 (SD 0.09). Risk factors for incomplete capsulotomy were Morgagnian cataract and lens thickness (multiple logistic regression, p<0.01 and p=0.03, respectively). CONCLUSION: The main complication of FLACS in white cataracts was incomplete capsulotomy (17.2%), significantly associated with Morgagnian cataracts and increased lens thickness. Lens fragmentation was effected in four-fifths of white cataracts but should be avoided in Morgagnian cataracts due to possible overlap of the lens fragmentation plan and the anterior capsule.

Analysis of competency in phacoemulsification trainees using the cumulative sum analysis.

PURPOSE: To determine the number of cases required to achieve competency in phacoemulsification in terms of the posterior capsule rupture rate. SETTING: Singapore National Eye Centre, Singapore. DESIGN: Retrospective cohort study. METHODS: The posterior capsule rupture rate of the first 300 phacoemulsification cases performed by each trainee in the Singapore National Eye Centre (2004 to 2012) was charted using cumulative sum graphs. Competency was primarily defined as a posterior capsule rupture rate of 2% or lower and secondarily as 5% or lower. RESULTS: Twenty trainees fulfilled the inclusion criteria. Four trainees (20%) and 19 trainees (95%) achieved a posterior capsule rupture rate of 2% and 5%, respectively. At least 41 cases were required to achieve a 5% posterior capsule rupture rate (mean 106, median 83). CONCLUSIONS: There was considerable variation in the trainees' abilities. Only 20% of the trainees achieved a posterior capsule rupture rate of 2% or lower and required at least 212 cases.

Clinical outcomes in the first two years of femtosecond laser-assisted cataract surgery.

PURPOSE: To analyze outcomes of femtosecond laser cataract surgery cases in the first 2 years in an ophthalmic institution. DESIGN: Nonrandomized treatment comparison with matched, historical controls. METHODS: Outcomes and intraoperative events of all laser cataract surgeries (5.0- to 5.5-mm-diameter laser capsulotomies and nuclear fragmentation) at the Singapore National Eye Centre (May 2012-December 2013) were prospectively audited. The 6-weeks-postoperative unaided visual acuities (UAVA), mean absolute error (MAE), mean square error (MSE), and manifest refraction spherical equivalent (MRSE) results of surgeons with >50 laser cases were compared with controls, a random sample of manual cases with similar age, axial length, and preoperative cylinders. Statistical analysis was performed with SPSS (P < .05). RESULTS: A total of 1105 eyes (803 patients) underwent laser cataract surgery by 18 surgeons. The majority were female (56.9%) and Chinese (90.9%) with mean age 66.1 ± 11.0 years. Intraoperative complications were subconjunctival hemorrhage (290, 26.2%), anterior capsule tear (9 eyes, 0.81%), posterior capsule rupture (3 eyes, 0.27%), suction loss (5 eyes, 0.45%), iris hemorrhage (1 eye, 0.09%), and endothelial incision (1 eye, 0.09%). There was no dropped nucleus. Visual outcomes of 794 laser surgeries were compared to 420 controls. The %UAVA 20/25 or better was higher in laser cases (68.6% vs 56.3%; P < .0001) but MAE (0.30 ± 0.25 diopter [D] vs 0.33 ± 0.25; P = .062) and MSE (0.16 ± 0.27 D vs 0.17 ± 0.28 D; P = .065) were not significant. MRSE comparison was significant (target plano, preoperative cylinder <1.5 D -0.08 ± 0.36 D vs -0.13 ± 0.40 D; P = .034). CONCLUSIONS: Femtosecond laser cataract surgery has a low complication rate. Cases compared to controls had statistically better %UAVA ≤20/25 and MRSE, although MAE was not significant.

A 5-year audit of cataract surgery outcomes after posterior capsule rupture and risk factors affecting visual acuity.

PURPOSE: To describe the posterior capsule rupture rates and visual outcomes after phacoemulsification, analyze risk factors for poor vision, and compare results of faculty (F) and residents (R). DESIGN: Retrospective audit study. METHODS: Visual success of all capsule ruptures (2006-2010) was analyzed and compared to uneventful cases. Rupture rates of faculty and residents were compared (χ², P < .05). Success was defined as % best-corrected visual acuity (BCVA) ≥20/40 at 3 months (excluding poor-prognosis eyes) and studied in relation to age, sex, surgeon type, stage of surgery, vitreous loss, dropped nucleus, and other complications (eg, retinal detachment, corneal decompensation, dislocated intraocular lens [IOL]). Final risk factors were identified using multivariate logistic regression analysis. RESULTS: From 2006 to 2010, there were 887 capsule ruptures in 48 377 phacoemulsification cases (rate 1.8%). Uneventful cases had significantly better visual outcomes than capsule ruptures (98.5% vs 93.9%; P < .01). Faculty rupture rates were lower (F = 1.4%) than residents' (R = 3.4%; P < .01), but visual outcomes were similar (F = 93.8%, R = 93.7%; P > .05). Ruptures most frequently occurred during phacoemulsification (59.6%) and irrigation and aspiration (24.8%) stages. Risk factors for poor outcomes included age >65 years, dropped nuclei, and other complications. CONCLUSION: The overall capsule rupture rate was 1.8%. Although residents had higher rates, visual success matched faculty's, possibly attributable to case mix and close supervision. Associated risk factors for poor vision included age >65 years, dropped nuclei, and postoperative retinal, corneal, and IOL complications.

Descemet membrane detachment after phacoemulsification surgery: risk factors and success of air bubble tamponade.

PURPOSE: To evaluate the efficacy of air bubble (AB) tamponade for Descemet membrane detachment (DMD) after clear corneal incision phacoemulsification surgery and to evaluate the risk factors for DMD. METHODS: This is a retrospective analysis of patients with DMD managed with AB tamponade, within 42 postoperative days (PODs), over a 4-year period. Data collected were as follows: demographics, cataract density (Lens Opacities Classification System III), visual acuity, AB technique, clinical outcome, and total surgeries over the time period. Successful end points were DM reattachment and corneal clarity. Risk factors were assessed using a case-control study, with univariate and multivariate logistic regression analyses (significance at P < 0.05). RESULTS: Incidence rate of DMD was 0.044% per year. Sixteen patients (mean age of 76 years) had AB tamponade for DMD, with corneal clarity restored in 14 cases (87.5%; n = 11 with 1 AB procedure, n = 3 with 2 AB procedures). The main clear corneal incision was the major site of DMD (n = 14, 87.5%). Pre-AB visual acuity was 20/100 and at 1 month, 20/40. Corneal clarity occurred by 30 days (range: 4-82 days) and remained clear throughout the median follow-up of 12.9 months. Significant univariate factors were as follows: age >65 years, nuclear sclerosis grade ≥4 (Lens Opacities Classification System III), preexisting endothelial disease, and first POD corneal edema. Multivariate logistic regression analyses revealed endothelial disease (odds ratio = 18.66) and first POD edema (odds ratio = 7.88) as significant independent risk factors for DMD occurrence (P < 0.05). CONCLUSIONS: AB tamponade for DMD effectively restored corneal clarity in 87.5% of cases (14 of 16 eyes). Significant risk factors included endothelial disease and first POD corneal edema.