Triamcinolone Acetonide Subconjunctival Injection as Stand-alone Inflammation Prophylaxis after Phacoemulsification Cataract Surgery.

PURPOSE: To compare the effectiveness and safety of a single injection of subconjunctival triamcinolone acetonide (TA) with that of postoperative topical prednisolone acetate (PA) with and without nonsteroidal anti-inflammatory drugs (NSAIDs) for cataract surgery prophylaxis. DESIGN: Retrospective, comparative effectiveness cohort study. PARTICIPANTS: Patients at Kaiser Permanente Northern California from 2018 through 2021. INTERVENTION: Exposure groups included topical PA with or without NSAID and subconjunctival injection of TA (Kenalog; Bristol-Myers-Squibb) 10 mg/ml or 40 mg/ml in a low dose (1.0-3.0 mg) or high dose (3.1-5.0 mg). MAIN OUTCOME MEASURES: The adjusted odds ratio (OR) and 95% confidence interval (CI) for the association of postoperative macular edema (ME) and iritis diagnoses 15 to 120 days after surgery (effectiveness measures) and a glaucoma-related event (safety measure) between 15 days and 1 year after surgery. RESULTS: Of 69 832 eligible patient-eyes, postoperative ME, iritis, and a glaucoma-related event occurred on average in 1.3%, 0.8%, and 3.4% of eyes in the topical groups and 0.8%, 0.5%, and 2.8% of eyes in the injection groups, respectively. In multivariable analysis, compared with the PA reference group, the PA plus NSAID group had a lower OR of ME (OR, 0.88; 95% CI, 0.74-1.04; P = 0.135). and all injection groups had even lower odds, with the high-dose TA 10-mg/ml group reaching statistical significance (OR, 0.64; 95% CI, 0.43-0.97; P = 0.033). A trend of lower odds of a postoperative iritis diagnosis was noted in the high-strength (40 mg/ml) groups. For postoperative glaucoma-related events, compared with PA, the TA 10-mg/ml low-dose group showed lower odds (OR, 0.69; 95% CI, 0.55-0.86; P = 0.001), the TA 10-mg/ml high-dose group showed similar odds (OR, 0.90; 95% CI, 0.70-1.15; P = 0.40), and the TA 40-mg/ml low-dose and high-dose groups showed higher odds of an event occurring (OR, 1.46 [95% CI, 0.98-2.18; P = 0.062] and OR, 2.14 [95% CI, 1.36-3.37; P = 0.001], respectively). CONCLUSIONS: The TA 10-mg/ml high-dose (4 mg) group was associated with a lower risk of postoperative ME and a similar risk of glaucoma-related events compared with the topical groups. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Drop-free approaches for cataract surgery.

PURPOSE OF REVIEW: Routine prophylaxis for adverse events following cataract surgery is evolving. Prior reliance on topical eyedrop instillation by patients is giving way to surgeon directed injections at the time of cataract surgery. The benefit of this new approach is assured delivery of drugs in standardized doses which should optimize the healing process and reduce the incidence of untoward events with higher confidence. RECENT FINDINGS: Adoption rates of intracameral antibiotic injection amongst European and American cataract surgeons is increasing. Techniques to inject periocular corticosteroid for routine inflammation prophylaxis are also in development. In combination with intraoperative pharmacologic dilation, a drop-free modality can be achieved. SUMMARY: Intraoperative injections offer the patient and surgeon assured drug delivery and hold promise to avoid the pitfalls of patient adherence, incorrect topical instillation, and topical drop-associated corneal issues.

Immediate Sequential vs. Delayed Sequential Bilateral Cataract Surgery: Retrospective Comparison of Postoperative Visual Outcomes.

OBJECTIVE: We conducted a retrospective comparative-effectiveness study of best-corrected visual acuity (BCVA) and refractive error (RE) after immediate sequential (ISBCS) and delayed sequential (DSBCS) bilateral cataract surgery. We tested 2 hypotheses: (1) among DSBCS patients, second-eye outcomes were no different than first-eye outcomes; (2) averaged between each patient's 2 eyes, outcomes did not differ between ISBCS and DSBCS patients. DESIGN: Retrospective comparative-effectiveness study. PARTICIPANTS: Kaiser Permanente Northern California members who underwent noncomplex bilateral cataract surgery from January 1, 2013, through June 30, 2015. METHODS: We performed an intention-to-treat analysis comparing ISBCS to DSBCS using conditional logistic regression analysis, accounting for surgeon and patient-level factors. MAIN OUTCOME MEASURES: BCVA, RE. RESULTS: The analysis of visual outcomes included both eyes of 13 711 DSBCS and 3561 ISBCS patients. Because of the large sample size, some statistical differences lacked clinical significance. Ocular comorbidities were slightly more prevalent in DSBCS patients. Postoperative BCVA was 20/20 or better in 48% of DSBCS first eyes, 49% of DSBCS second eyes, 53% of ISBCS right eyes, and 51% of ISBCS left eyes. The within-person difference in postoperative BCVA averaged zero (0.00) between the first and second DSBCS eyes, and between the ISBCS right and left eyes. After adjustment, average postoperative BCVA was better in ISBCS patients, although the difference was not statistically significant (compared with 20/20 or better: odds ratio for worse than 20/20 was 0.91, 95% confidence interval 0.83-1.01). Emmetropia (spherical equivalent -0.5 to 0 diopter) was achieved in 61% of first DSBCS eyes, 61% of second DSBCS eyes, 63% of ISBCS right eyes, and 63% of ISBCS left eyes. After adjustment, average postoperative RE was no different in ISBCS compared with DSBCS patients (compared with emmetropia: odds ratio for ametropia was 1.02, confidence interval 0.92-1.12). We confirmed 1 case of postoperative endophthalmitis in 10 494 ISBCS eyes (1.0 per 10 000 eyes) and 2 cases in 38 736 DSBCS eyes (0.5 per 10 000 eyes) (P = 0.6), and no patient had bilateral endophthalmitis. CONCLUSIONS: Compared with DSBCS, we found no evidence that ISBCS was associated with worse postoperative BCVA or RE, or with an increased complication risk.

Natural language processing to ascertain two key variables from operative reports in ophthalmology.

PURPOSE: Antibiotic prophylaxis is critical to ophthalmology and other surgical specialties. We performed natural language processing (NLP) of 743 838 operative notes recorded for 315 246 surgeries to ascertain two variables needed to study the comparative effectiveness of antibiotic prophylaxis in cataract surgery. The first key variable was an exposure variable, intracameral antibiotic injection. The second was an intraoperative complication, posterior capsular rupture (PCR), which functioned as a potential confounder. To help other researchers use NLP in their settings, we describe our NLP protocol and lessons learned. METHODS: For each of the two variables, we used SAS Text Miner and other SAS text-processing modules with a training set of 10 000 (1.3%) operative notes to develop a lexicon. The lexica identified misspellings, abbreviations, and negations, and linked words into concepts (e.g. "antibiotic" linked with "injection"). We confirmed the NLP tools by iteratively obtaining random samples of 2000 (0.3%) notes, with replacement. RESULTS: The NLP tools identified approximately 60 000 intracameral antibiotic injections and 3500 cases of PCR. The positive and negative predictive values for intracameral antibiotic injection exceeded 99%. For the intraoperative complication, they exceeded 94%. CONCLUSION: NLP was a valid and feasible method for obtaining critical variables needed for a research study of surgical safety. These NLP tools were intended for use in the study sample. Use with external datasets or future datasets in our own setting would require further testing. Copyright © 2017 John Wiley & Sons, Ltd.

Pathogens and antibiotic sensitivities in endophthalmitis.

BACKGROUND: Antibiotic prophylaxis in cataract surgery is intended to minimize endophthalmitis. We describe pathogenic organisms, antibiotic sensitivities and antibiotic prophylaxis in culture-proven endophthalmitis cases. DESIGN: Retrospective consecutive case series and community-based setting were used. PARTICIPANTS: Two hundred fifteen cases of endophthalmitis after cataract surgery performed during 2007-2012 in Kaiser Permanente, California. METHODS AND MAIN OUTCOME MEASURES: Descriptive analysis of isolated organisms and antibiotic sensitivities in relation to antibiotic prophylaxis in culture-proven endophthalmitis cases. RESULTS: The majority of culture-confirmed organisms (n = 83) were Gram positive (96%), most notably coagulase-negative Staphylococci (n = 34, 52%), of which all that underwent testing were sensitive to vancomycin (n = 32). Among 19 cases that had received only topical antibiotic prophylaxis, seven (37%) were resistant to the antibiotic given: 50% of cases (5 of 10 isolates) that had received ofloxacin were resistant to this antibiotic, 40% (2 of 5 isolates) that had received gatifloxacin were resistant. In contrast, 100% of cases (n = 4) that had received aminoglycosides were susceptible. Few culture-confirmed cases occurred in patients who received intracameral antibiotic (n = 4). CONCLUSIONS: In cases where fluoroquinolones were administered as antibiotic prophylaxis, isolates demonstrated a degree of bacterial resistance. The majority of endophthalmitis cases isolated occured following topical antibiotic prophylaxis only and were attributed to Gram-positive organisms, while few occurred in association with intracameral antibiotic.

Comparative Effectiveness of Antibiotic Prophylaxis in Cataract Surgery.

PURPOSE: Intracameral injection is an effective method for preventing infection, but no controlled study has been published in the United States. DESIGN: We conducted an observational, longitudinal cohort study to examine the effect of topical and injected antibiotics on risk of endophthalmitis. PARTICIPANTS: We identified 315 246 eligible cataract procedures in 204 515 members of Kaiser Permanente, California, 2005-2012. METHODS: The study used information from the membership, medical, pharmacy, and surgical records from the electronic health record. MAIN OUTCOME MEASURES: The adjusted odds ratio (OR) and 95% confidence interval (CI) for the association of antibiotic prophylaxis (route and agent) with risk of endophthalmitis was estimated using logistic regression analysis. RESULTS: We confirmed 215 cases of endophthalmitis (0.07% or 0.7/1000). Posterior capsular rupture was associated with a 3.68-fold increased risk of endophthalmitis (CI, 1.89-7.20). Intracameral antibiotic was more effective than topical agent alone (OR, 0.58; CI, 0.38-0.91). Combining topical gatifloxacin or ofloxacin with intracameral agent was not more effective than using an intracameral agent alone (compared with intracameral only: intracameral plus topical, OR, 1.63; CI, 0.48-5.47). Compared with topical gatifloxacin, prophylaxis using topical aminoglycoside was ineffective (OR, 1.97; CI, 1.17-3.31). CONCLUSIONS: Surgical complication remains a key risk factor for endophthalmitis. Intracameral antibiotic was more effective for preventing post-cataract extraction endophthalmitis than topical antibiotic alone. Topical antibiotic was not shown to add to the effectiveness of an intracameral regimen.

Comparative Effectiveness of Three Prophylactic Strategies to Prevent Clinical Macular Edema after Phacoemulsification Surgery.

PURPOSE: To study the relationship of chemoprophylaxis and other factors with the occurrence of acute, clinical, postoperative macular edema. DESIGN: Retrospective cohort study. The drug regimens consisted of postoperative topical prednisolone acetate (PA) alone or with a nonsteroidal anti-inflammatory drug (NSAID) or intraoperative subconjunctival injection of 2 mg triamcinolone acetonide (TA) alone. PARTICIPANTS: Patients undergoing phacoemulsification at Kaiser Permanente, Diablo Service Area, Northern California, from 2007 through 2013. METHODS: We identified incident macular edema diagnoses that had been recorded 5 to 120 days after phacoemulsification with visual acuity 20/40 or worse and evidence of macular thickening by optical coherence tomography. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained from logistic regression analysis, conditioned on the surgeon and adjusted for year, patient age and race, diabetic retinopathy status, other ocular comorbidities, systemic comorbidities, and posterior capsular rupture status. MAIN OUTCOME MEASURES: Incident rates of acute, clinical, postoperative macular edema. RESULTS: We confirmed 118 cases among 16 070 cataract surgeries (incidence, 0.73%). Compared with PA alone, the OR for the relationship of macular edema with PA+NSAID was 0.45 (95% CI, 0.21-0.95) and that for TA injection was 1.21 (95% CI, 0.48-3.06). The frequency of intraocular pressure spikes of 30 mmHg or more between postoperative days 16 and 45 was 0.6% in the topical PA group, 0.3% in the topical PA+NSAID group (P = 0.13), and 0.8% for the TA group (P = 0.52). Black race was associated with a risk of macular edema (OR, 2.86; 95% CI, 1.41-5.79). CONCLUSIONS: Adding a prophylactic NSAID to PA treatment was associated with a reduced risk of macular edema with visual acuity of 20/40 or worse. The risk and safety of TA injection were similar to those of PA alone. Further research is needed on the prognostic significance of postoperative macular edema, the role of prophylaxis, the risk among black people, and the effectiveness of depot medications.

Cost Analysis of Dropless Cataract Surgery Prophylaxis with Intracameral Antibiotics and Subconjunctival Steroids.

PURPOSE: To determine whether dropless, injection-based cataract surgery prophylaxis with intracameral antibiotic and subconjunctival steroid may reduce healthcare system costs and patient out-of-pocket costs compared to topical medication regimens. SETTING: United States national medical expenditures database. DESIGN: Retrospective cost analysis. METHODS: Costs were analyzed for topical ophthalmics from the 2020 Medical Expenditure Panel Survey (MEPS) and for dropless medications from pharmaceutical invoices/catalogs. Main outcomes included system costs, from insurance and patient payments, and out-of-pocket costs for cataract surgery topical and dropless, injection-based prophylactic medication regimens, per eye and nationally. System costs for individual topical medications and same-class dropless, injection-based medications were compared using two-sided, one-sample t-tests. RESULTS: There were 583 prophylactic topical ophthalmic purchases in MEPS. Mean system costs per eye were $76.20 ± SD 39.07 for the lowest cost topical steroid (prednisolone) compared to $4.01 for the lowest cost subconjunctival steroid (triamcinolone acetonide) (p < 0.001). Per eye, the lowest cost dropless, injection-based regimen, at $15.91, results in an $87.99 (84.7%) reduction in overall healthcare costs and a $43.64 (100%) reduction in patient out-of-pocket costs relative to the lowest cost topical regimen ($103.90 ± 43.14 mean system cost and $43.64 ± 37.32 mean out-of-pocket cost per eye). Use of intracameral moxifloxacin and subconjunctival triamcinolone acetonide can reduce annual national healthcare system and out-of-pocket costs up to $450,000,000 and $225,000,000, respectively. CONCLUSIONS: An evidence-based cataract surgery prophylactic medication regimen of intracameral moxifloxacin and subconjunctival triamcinolone acetonide can reduce healthcare system and patient out-of-pocket costs in comparison to various topical regimens.

ASCRS clinical advisory on intracameral moxifloxacin injection for infection prophylaxis.

Moxifloxacin solution is frequently injected at the conclusion of cataract surgery for endophthalmitis prophylaxis. 2 different concentrations are most commonly available in the United States for intracameral (IC) use: 0.5% (5 mg/mL) and 0.1% (1 mg/mL). The recommended volume to be injected is different for the 2 concentrations, and incorrect dosing can increase the risk of toxic anterior segment syndrome or endophthalmitis. In addition, the U.S. Food and Drug Administration recently published an alert regarding potential adverse events associated with intraocular compounded moxifloxacin. This clinical advisory reviews the optimal dosing of IC moxifloxacin based on current evidence.

Patient Experience and Satisfaction With Immediate Sequential and Delayed Sequential Bilateral Cataract Surgery.

PURPOSE: In bilaterally pseudophakic patients who received immediate or delayed sequential bilateral cataract surgery (ISBCS or DSBCS), we sought to determine patient experience, particularly related to the loss of opportunity to modify the surgical plan for the second eye. DESIGN: Cross-sectional. METHODS: Patients who received ISBCS (n = 1818) and DSBCS (n = 1818) in the Kaiser Permanente Northern California system between 2017 and 2019 who actively used the electronic patient portal were randomly selected and sent a survey link. The survey inquired about reasons for choosing ISBCS or DSBCS, concerns about surgery, and whether the loss of opportunity to modify the surgical plan for the second eye affected the patient's decision to undergo ISBCS. RESULTS: Participation was 18% among patients who received ISBCS and 17% among patients who received DSBCS. Of the patients who received ISBCS, 96% would choose ISBCS again while 80% of patients who received DSBCS would choose DSBCS again (P < .0001). Convenience was the leading reason patients chose ISBCS (65%), whereas surgeon recommendation was the primary reason patients chose DSBCS (68%). Sixteen percent of patients who received ISBCS and 38% of patients who received DSCBS reported that the possibility of modifying the surgical plan to reduce the need for corrective lenses in the second eye was an important consideration (P < .0001). CONCLUSIONS: Compared with patient who chose DSBCS, patients who chose ISBCS were more likely to choose ISBCS again and to recommend ISBCS to a family member or friend. The option to modify the surgical plan for the second eye to reduce need for glasses or contact lenses was not an important consideration for most of either group.

Three Learning Organizations in Cataract Surgery: The Example of Intracameral Antibiotic Injection.

BACKGROUND: The recent systematic adoption of intracameral antibiotic injection during cataract surgery in Sweden, India, and the US serves as a model for the successful transitioning of local quality improvement initiatives to organization-wide implementation. Although the delivery of eye care in the 3 countries is distinctly organized with differing governances and technological infrastructure, each contains elements of a learning organization (ie, an organization that has adopted a culture of creating, acquiring, and transferring knowledge into practice through system-level and clinician-level change). METHODS: We describe a retrospective and organizational implementation study of intracameral antibiotic injection in Sweden, through the efforts of the National Cataract Registry; in the US by Kaiser Permanente; and in India by the Aravind Eye Hospital System. Leadership structure, training in problem solving, benchmarking, sharing of technical knowledge, and data and workforce engagement are compared. RESULTS: Each of the 3 organizations share the key elements of effective leadership, which values the exchange of ideas in the workforce, training and resourcing for change, and information management in the form of benchmarking and data sharing. In the case of intracameral antibiotic injection, a new technique was identified to improve quality and safety with a reduction in infections as evidence of the success of the programs. CONCLUSION: Committing to a culture of collective learning, and leveraging each stakeholder's personal investment, health-care systems may improve care delivery and set new benchmarks in quality and safety.

Endophthalmitis Prophylaxis Failures in Patients Injected With Intracameral Antibiotic During Cataract Surgery.

PURPOSE: To estimate the association of cefuroxime and moxifloxacin in relation to the occurrence of endophthalmitis following phacoemulsification cataract surgery. DESIGN: Retrospective clinical cohort study. METHODS: We studied patients with noncomplex phacoemulsification cataract surgery in Kaiser Permanente Northern California during 2014-2019. Data were obtained for acute, postoperative endophthalmitis within 90 days of phacoemulsification, including culture and antibiogram results, intracameral and topical antibiotic agent, and dose. In a post hoc analysis, we also examined preoperative anterior chamber depth (ACD) and postoperative anterior chamber volume (ACV). RESULTS: Of 216,141 surgeries, endophthalmitis occurred in 0.020% of moxifloxacin-injected eyes and 0.013% of cefuroxime eyes (relative risk 1.62 with 95% CI 0.82-3.20, P = .16). Of the 34 (0.016%) cases of endophthalmitis, cefuroxime 1 mg was injected into 13 eyes and moxifloxacin 0.1% into 21 eyes. Organisms with antibiograms were identified in 12 (35%) cases. Of these, bacteria recovered from cefuroxime-injected eyes were resistant to cefuroxime in all cases (4/4), with Enterococcus comprising half of these. In eyes injected with moxifloxacin 0.1%, 6 out of 7 organisms were sensitive to moxifloxacin injected with 0.1 mL and in 1 eye injected with 1 mL. Streptococcus was the most common organism recovered (6/9) in moxifloxacin-injected eyes. Preoperative ACD and postoperative calculated ACV were higher in eyes injected with moxifloxacin. CONCLUSIONS: Endophthalmitis cases with positive cultures were generally related to organism resistance in cefuroxime eyes but to sensitive organisms in moxifloxacin eyes. Moxifloxacin doses may have been insufficient in eyes with larger ACV.

Visual outcomes after cataract surgery: topical nonsteroidal anti-inflammatory drug prophylaxis compared with prednisolone.

PURPOSE: To compare visual outcomes in patients without a history of macular edema after phacoemulsification using combination topical nonsteroidal anti-inflammatory drug plus prednisolone with prednisolone alone. SETTING: Kaiser Permanente Northern California, USA. DESIGN: Retrospective cohort study. METHODS: Information was obtained from the electronic health record. The first measure of corrected distance visual acuity (CDVA) recorded during the period 3 weeks to 1 year after phacoemulsification was obtained. Confounding factors and clustering of eyes within patients were adjusted using linear mixed effects regression models for the continuous outcome of CDVA improvement and general estimating equations for the dichotomous outcome of 20/20 or better vs 20/25 or worse. RESULTS: The study included 62 700 health plan members of whom 26,309 (42%) used topical prednisolone alone, whereas 36,391 (58%) used combination treatment. The mean within-person change in CDVA from the preoperative measurement to the postoperative measurement was the same (-0.43 logMAR) for patients in the 2 groups. However, the group that received combination treatment was somewhat more likely to achieve CDVA of 20/20 or better (odds ratio 1.24 with 95% CI, 1.20-1.28). CONCLUSIONS: In this large study of cataract surgery patients, a small statistically significant association of combination treatment compared with prednisolone alone was observed.

Intraocular Pressure Reduction after Phacoemulsification: A Matched Cohort Study.

PURPOSE: Phacoemulsification has been linked to lowered intraocular pressure (IOP) in patients with glaucoma, ocular hypertension, anatomic narrow angles, and in glaucoma suspects, but the magnitude of change has varied. DESIGN: Retrospective cohort study. PARTICIPANTS: Patients with glaucoma treated from June 2010 through May 2015 who underwent phacoemulsification (surgical group) were matched to patients who did not (nonsurgical group) for age, gender, type of glaucoma, baseline IOP, and number and type of glaucoma medications. METHODS: Electronic medical record information was used to compare the matched surgical and nonsurgical groups. MAIN OUTCOME MEASURES: Change in IOP, change in number of glaucoma medications, and likelihood of a glaucoma procedure within 36 months after phacoemulsification. Intraocular pressure measures were obtained from Goldmann applanation tonometry when available (45%), and otherwise with the iCare tonometer (iCare USA, Raleigh, NC), the Tono-Pen (Reichert Technologies, Depew, NY), noncontact tonometry, and pneumotonometry. RESULTS: Among 16 169 matched pairs, average IOP after the index date was lower in the surgical than nonsurgical group throughout follow-up to 36 months. The difference was greatest during months 1 through 18, during which IOP increased by 0.22 mmHg from 16.49 mmHg in the average nonsurgical patient and decreased by 0.99 mmHg from 16.50 mmHg in the average surgical patient (difference in difference, 1.21 mmHg; 95% confidence interval [CI], 1.12-1.30 mmHg). The difference in difference was greatest for patients with ocular hypertension (2.00 mmHg) and for patients with preoperative IOP of 20 mmHg or more (2.46 mmHg). By 30 to 36 months, 5% (95% CI, 4%-6%) fewer surgical patients used an ophthalmic medication. In the surgical group, the odds of selective laser trabeculoplasty were reduced in patients with ocular hypertension (odds ratio [OR], 0.27; 95% CI, 0.10-0.74) or glaucoma suspects (OR, 0.31; 95% CI, 0.20-0.47), whereas the odds of glaucoma surgery were elevated in surgical patients with primary open-angle glaucoma (OR, 1.48; 95% CI, 1.08-2.01). CONCLUSIONS: The association of phacoemulsification for cataract with IOP reduction was lower than in past referral-based studies. Surgeons should expect to reduce IOP approximately 1 to 2 mmHg with phacoemulsification in patients with preoperative IOP of less than 20 mmHg.

Development and Validation of Machine Learning Models: Electronic Health Record Data To Predict Visual Acuity After Cataract Surgery.

BACKGROUND: To develop predictive models of final corrected distance visual acuity (CDVA) following cataract surgery using machine learning algorithms and electronic health record data. METHODS: In this predictive modeling study we used decision tree, random forest, and gradient boosting. We included the first surgical eye of 64,768 members of Kaiser Permanente Northern California who underwent cataract surgery from June 1, 2010 through May 31, 2015. We measured discrimination and calibration of machine learning models for predicting postoperative CDVA 20/50 or worse vs 20/40 or better. RESULTS: The training set included 51,712 patients, and the validation set included 13,056 patients. We compared 3 machine learning models and found that the gradient boosting model provided the best discrimination ability for CDVA. The most important variables for predicting final CDVA 20/50 or worse were preoperative CDVA, age, and age-related macular degeneration, which together accounted for 41% of the gain in optimization of the gradient boosting model. Other important variables in the model included dispensed glaucoma medication, epiretinal membrane, cornea disorder, cataract surgery operating time, surgeon experience, and census block neighborhood characteristics (household income, family income, family poverty, college education, and home residence by owner). CONCLUSION: For predicting CDVA after cataract surgery, gradient boosting had the best ability to discriminate patients with postoperative CDVA 20/50 or worse from patients with postoperative CDVA 20/40 or better. Machine learning has the potential to improve prognosis and can improve patient information when making decisions to undergo cataract surgery.

Injection volume and intracameral moxifloxacin dose.

PURPOSE: To test the effect of injection volume and concentration on dosing and residence time of moxifloxacin in the anterior chamber (AC). SETTING: Kaiser Permanente, Walnut Creek, California, USA. DESIGN: Experimental study. METHODS: Moxifloxacin 0.5%/0.05 mL, moxifloxacin 0.5%/0.10 mL, and moxifloxacin 0.15%/0.50 mL were drawn into 5 1.0 mL syringes each, injected into tared vials, and weighed. The doses delivered were calculated. The AC concentrations and elimination rates of the drug for two AC volumes were modeled for each dosing method. RESULTS: The 0.05 mL injection volume resulted in the greatest range (35 µg) of delivered dose compared with larger injection volumes (≤25 µg). The mathematical model predicted that variation in dosing in each group would result in differences of 12 minutes or less for the presence of the drug in the AC. Injection of 0.5%/0.1 mL produced AC concentrations above 500 µg/mL for 1.9 to 3.0 hours and above 64 µg/mL for 5.5 to 6.5 hours, depending on the AC volume; however, flushing with a 0.15% concentration sustained AC levels for 1.9 hours and 5.5 hours, respectively, for the two AC volumes. CONCLUSIONS: Smaller injection volumes of a higher concentration moxifloxacin resulted in less accuracy and less precision in the delivered dose (0.05 mL, P = .005; 0.10 mL, P = .03); however, the clinical significance of this might vary. Injection of 0.5%/0.1 mL and flushing with 0.15%/0.5 mL of moxifloxacin would provide similar drug AC residence times according to the model. Flushing provided more consistent AC concentrations with differing AC volumes.

Visual outcomes after cataract surgery in patients with type 2 diabetes.

PURPOSE: To assess the relation between diabetic retinopathy (DR) severity, duration of diabetes, insulin dependence, and preoperative hemoglobin A1c (HbA1c) with visual outcome after phacoemulsification for cataract in patients with type 2 diabetes. SETTING: Kaiser Permanente Northern California, USA. DESIGN: Retrospective case series. METHODS: Information was obtained from the electronic medical record for patients, June 1, 2010, through May 31, 2015. Confounding factors and clustering of eyes within patients were controlled for using linear mixed-effects regression models for continuous outcomes and general estimating equations for dichotomous outcomes. RESULTS: The study included 65 370 patients; 28% had type 2 diabetes without DR, 5% nonproliferative DR, and 1.2% proliferative DR. Patients with diabetes and no DR were as likely as those without diabetes to achieve a corrected distance visual acuity (CDVA) of 20/20 (odds ratio, 1.01; 95% confidence interval, 0.94-1.10). The odds of a postoperative CDVA of 20/25 or worse increased with the severity of retinopathy duration of diabetes and insulin dependence, but not with the preoperative HbA1c. Although the odds of a postoperative CDVA of 20/20 was lower in patients with DR, every DR group averaged 4 lines of CDVA improvement, the same as patients without diabetes. A longer duration of diabetes, insulin dependence, and elevated HbA1c were not associated with worse postoperative outcomes. CONCLUSION: Patients with DR and cataracts were less likely to achieve a CDVA of 20/20 vision but gained as many lines of CDVA from phacoemulsification as patients without diabetes, showing no evidence that cataract surgery should be delayed in diabetic patients with elevated HbA1c.