Cataracts.

94 million people are blind or visually impaired globally, and cataract is the most common cause of blindness worldwide. However, most cases of blindness are avoidable. Cataract is associated with decreased quality of life and reduced life expectancy. Most cases of cataract occur after birth and share ageing and oxidative stress as primary causes, although several non-modifiable and modifiable risk factors can accelerate cataract formation. In most patients, phacoemulsification with intraocular lens implantation is the preferred treatment and is highly cost-effective. There has been an increase in the use of comprehensive cataract surgical services, including diagnoses, treatment referrals, and rehabilitation. However, global inequity in surgical service quality is still a limitation. Implementation of preoperative risk assessment, risk reduction strategies, and new surgical technologies have made cataract surgery possible at an earlier stage of cataract severity with the expectation of good refractive outcomes. The main challenge is making the service that is currently available to some patients accessible to all by use of universal health coverage.

Application of sutureless corneal incision for patients with congenital ectopia lentis - Is it feasible, effective and safe?

Purpose: To compare the clinical outcomes, feasibility, and safety between groups with sutured and sutureless wound closure in congenital ectopia lentis (CEL) patients. Methods: Patients with CEL who received phacoemulsification combined with intrascleral fixation of capsular hook (CH) and implantation of capsular tension ring (CTR) and in-the-bag intraocular lens (IOL) were included in this study. Results: A total of 68 eyes of 34 patients aged 18 years or younger were enrolled in this study. Incisions of 21 patients (34 eyes) did not require sutures while sutures were applied in 21 patients (34 eyes). Postoperative uncorrected distance visual acuity, best corrected distance visual acuity and intraocular pressure measurements were comparable on follow-up visits (P > 0.05). The magnitude of surgically induced astigmatism was significantly greater (P = 0.001) in the suture group (Median: 0.47; IQ: 1.63, 2.97) than in the sutureless group (Median: 0.88; IQ: 0.63, 1.35). No cases of endophthalmitis and retinal detachment were found postoperatively in either group, while suture-related complications were observed in the sutured group, including loose suture with discomfort in 5 (14.71%) eyes, loose suture with mucus infiltration in 3 (8.82%) eyes. In total, 22 sutures (64.71%) of 34 eyes required removal. Conclusions: Sutureless clear corneal incision in CEL patients can achieve satisfactory clinical results comparable to sutured wound closure in terms of the efficacy and safety. Advantages of this approach are the reduced risk of suture-related complications, no need for additional surgery under general anesthesia for suture removal, and less cost.

Prospective analysis of anatomic features predisposing patients to intraoperative floppy iris syndrome.

PURPOSE: To aid preoperative risk assessment by identifying anatomic parameters corresponding with a higher risk of intraoperative floppy iris syndrome (IFIS) during cataract surgery. METHODS: Prospective cohort study of 55 patients with α1-adrenergic receptor antagonist (α1-ARA) treatment and 55 controls undergoing cataract surgery. Anterior segment optical coherence tomography (AS-OCT), video pupilometer, and biometry measurements were performed preoperatively and analyzed regarding anatomic parameters that corresponded with a higher rate of IFIS. Those statistically significant parameters were evaluated with logistic regression analysis and receiver operating characteristic (ROC) curve. RESULTS: Pupil diameter was significantly smaller in patients who developed IFIS compared to those who did not develop IFIS (AS-OCT 3.29 ± 0.85 vs. 3.63 ± 0.68, p = 0.03; Pupilometer 3.56 ± 0,87 vs. 3.95 ± 0.67, p = 0.02). Biometric evaluation revealed shallower anterior chambers in the IFIS group (ACD 3.12 ± 0.40 vs. 3.32 ± 0.42, p = 0.02). Cutoff values for 50% IFIS probability (p = 0.5) were PD = 3.18 mm for pupil diameter and ACD = 2.93 mm for anterior chamber depth. ROC curves of combined parameters were calculated for α1-ARA medication with pupil diameter and anterior chamber depth, which yielded an AUC of 0.75 for all IFIS grades. CONCLUSION: The combination of biometric parameters with history of α1-ARA medication can improve assessment of risk stratification for IFIS incidence during cataract surgery.

A potential role for inflammatory cytokines in a rare late-onset capsular block syndrome: a case report.

BACKGROUND: Late-onset capsule block syndrome (CBS) is a rare complication of cataract phacoemulsification and the implantation of a posterior chamber intraocular lens (PCIOL), which manifests six months to years after surgery. The hallmark of CBS is the formation of an opaque liquid substance between the implanted intraocular lens (IOL) and the posterior capsule. However, its pathogenesis remains unclear. CASE PRESENTATION: A 64-year-old female patient with chronic angle-closure glaucoma (axis length < 21 mm) underwent trabeculectomy surgery combined with phacoemulsification and PCIOL. After a 4-year follow-up, a decline in visual acuity occurred in her right eye due to the location of opaque fluid in the visual axis and distension of the capsular bag. The initial course of action was to release the trapped fluid. Neodymium: yttrium-aluminum-garnet (Nd: YAG) laser capsulotomy could not be employed due to her non-dilating pupil and high extension of the posterior capsule. Subsequently, anterior capsule peeling and anterior segment vitrectomy surgery were performed. The depth of the anterior chamber (ACD), the distance between the face of the retro-IOL and the posterior capsule, the best-corrected visual acuity (BCVA), and the visual quality (VQ) were measured both before and after surgery. Inflammatory cytokine levels in the opaque substances (OS) trapped between the PCIOL and the posterior capsule were assessed using a flow cytometer and compared to normal statistical data in aqueous humor. After surgery, the patient experienced a significant improvement in BCVA and VQ. The distance between the face of the retro-IOL and the posterior capsule was on the verge of disappearing. However, ACD did not differ between pre- and post-operatively. Interleukin-8 (IL-8) and basic fibroblast growth factor (BFGF) concentrations were higher in the OS than in aqueous humor, especially in the former. However, the concentration of vascular cell adhesion molecule (VCAM) in the OS was lower than in aqueous humor. CONCLUSIONS: Anterior segment vitrectomy surgery proved to be a successful treatment for late-onset CBS, presenting a challenging case. In the human lens, inflammatory cytokines originating from the opaque substances may contribute to abnormal metabolism in the sealed area, a consequence of late-onset CBS.

Outcome of cataract surgery in children with presumed trematode-induced granulomatous anterior uveitis.

PURPOSE: To examine the 6-month visual outcomes and complications following cataract surgery in patients with persumed trematode induced granulomatous anterior uveitis. SETTING: Assiut university hospital, Assiut, Egypt. DESIGN: This is a retrospective non comparative case series study. METHODS: Patients presenting with significant cataract secondary to uveitis caused by trematode induced anterior chamber granuloma were included in this study. Cases with active anterior uveitis, within the last 3 months preceding surgery, and those with a history of trauma, were excluded from this study. Data collected included demographic characteristics, history of the condition including when uveitis started, treatment received and history of other health conditions that may be relevant to uveitis.Complete opthalmologic examination including assessment of best corrected visual acuity (BCVA) and OCT macula, if possible, were done. These was repeated 1 week, 1 month, 3 months and 6 months after surgery. Specular microscopy was performed preoperatively and 3 months after surgery. Patients underwent cataract surgery with posterior chamber intra ocular lens and statistical analysis was performed to compare preoperative and postoperative BCVA and corneal endothelial cell counts. Postoperative complications were recorded. RESULTS: Five eyes of 5 patients were included in the study. All study eyes showed improvement in the post-operative visual acuity. A statistically significant improvement was observed in VA in the sixth postoperative month compared to the baseline measurements (p = 0.004). No statistically significant difference was observed between the preoperative and postoperative endothelial cell counts (p = 0.696). Cystoid macular edema did not occur as a postoperative complication. CONCLUSION: Visual outcomes of cataract surgery in eyes with persumed trematode induced granulametous anterior uveitis are favorable. No sight threatening complication was observed in our series.

Hyperproliferation of Elschnig pearl-type posterior capsule opacification and spontaneous regression in two pseudophakic canine eyes.

OBJECTIVE: To describe the hyperproliferation of Elschnig pearl-type posterior capsule opacification and concurrent uveitis in two canine eyes after phacoemulsification, followed by spontaneous resolution of the Elschnig pearls. ANIMAL STUDIED: A 10-year-old castrated male Spitz (Case 1) and a 4-year-old spayed female Bichon Frise (Case 2). PROCEDURE: Elschnig pearls proliferating beyond the anterior capsulotomy site were observed in the right eye 10 months after bilateral diabetic cataract surgery (Case 1) and 7 months after unilateral cataract surgery (Case 2). In both cases, hyperproliferation occurred where the anterior capsule did not overlap with the intraocular lens (IOL), and was accompanied by aqueous flare. In Case 1, the pearls extended from the anterior capsule and adhered to the iris, causing focal posterior synechia. No other possible causes of uveitis were apparent. RESULTS: Initially, uveitis severity improved after the administration of topical and systemic anti-inflammatory drugs. However, uveitis recurred when the dosage of anti-inflammatory treatment was reduced. The Elschnig pearls underwent morphological changes throughout the follow-up period. In both cases, the pearls beyond the anterior capsulotomy resolved spontaneously after 5 months. Only a few pearls remained between the IOL and posterior capsule, and no recurrence of pearl proliferation was observed at the last follow-up. CONCLUSIONS: To the best of our knowledge, this is the first report of spontaneous Elschnig pearl regression in dogs. Lens-induced uveitis (LIU) may have been caused by anterior chamber hyperproliferative pearls. LIU associated with hyperproliferative pearls may be managed with appropriate anti-inflammatory treatment and monitoring.

Corneal endothelial changes seven years after phacoemulsification cataract surgery.

PURPOSE: To evaluate long-term postoperative corneal changes after phacoemulsification cataract surgery. METHODS: Twenty patients who participated in a previous study regarding corneal endothelial changes after phacoemulsification cataract surgery were examined after 7 years. The patients were divided in three groups based on their initial increase in central corneal thickness day one after the surgery: < 5% increase, 6-20% increase and ≥ 20% increase. The primary outcome measures were corneal endothelial cell loss (ECL), endothelial cell count (ECC) and endothelial morphology. RESULTS: After 7 years, a difference in cell loss between the groups was observed, except for groups 1 and 2. Endothelial cell count (ECC) differed significantly between groups 1 and 3 at 3 months. At 7 years, there was no difference in ECC between the three groups. Cell loss was found exclusively in group 1 between 3 months and 7 years. Endothelial cell morphology showed a converging pattern between 3 months and 7 years. CONCLUSION: After phacoemulsification cataract surgery, long-term ECC and morphology appear to converge towards a comparable steady state regardless of initial corneal swelling and endothelial cell loss.

Anterior chamber flare and choroidal vascular index as inflammatory markers after uncomplicated phacoemulsification surgery.

PURPOSE: To determine the effect of phacoemulsification surgery, which is one of the types of cataract surgery by using ultrasonic power to break up the crystalline lens and clean it with vacuum, on anterior chamber flare (ACF) and choroidal vascular index (CVI). METHODS: For this cross-sectional study, patients were included if they had cataract with nucleus hardness grade 2 or 3, no systemic inflammatory disease, and not use of anti-inflammatory drugs/prostaglandins preoperatively. ACF using a laser flare meter and CVI in patients underwent uncomplicated phacoemulsification was recorded preoperatively, on the postoperative 1st day, 1st week, and 1st month. RESULTS: Fifty-six eyes were included. ACF was 9.00 ± 2.90 ph/ms preoperatively. Although ACF increased significantly on postoperative day-1 (39.38 ± 23.31ph/ms) and decreased gradually until the 1st month (14.03 ± 6.03ph/ms) after the operation, it was still significantly higher at the 1st month (p < 0.001). Macular and peripapillary CVI increased significantly on postoperative day-1 (0.64 ± 0.03/0.63 ± 0.05) and week-1 (0.64 ± 0.04/0.62 ± 0.04) (p = 0.01, p < 0.001); the postoperative 1st month was similar to the preoperative one (0.59 ± 0.06/0.58 ± 0.06). The relationship between the change in ACF and the change in CVI was not significant. CONCLUSION: Phacoemulsification causes raises in ACF and CVI due to increased intraocular inflammation. The fact that ACF was significantly higher in postoperative month-1 and CVI returned to its preoperative value suggests that the effect of uncomplicated phacoemulsification surgery on the increase in inflammation in the anterior segment lasts longer than in the posterior segment. These results suggest that ACF and CVI follow-up may be clinically important in the follow-up of postoperative inflammation.

Posterior vitreous detachment rates post-uncomplicated phacoemulsification surgery: a systematic review.

PURPOSE: It is commonly accepted that phacoemulsification surgery is a risk factor for the development of posterior vitreous detachment (PVD) and may accelerate the process. This is an important consideration particularly in cases involving young patients who pre-operatively have no PVD, given the increased risk of retinal tears and detachments. METHODS: A comprehensive literature search was conducted to identify studies reporting incidence of PVD post-uncomplicated phacoemulsification surgery. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used for search strategy. Of 3071 titles, 7 studies met the inclusion criteria; The outcomes measured were PVD occurrence by (1) time, (2) type, (3) age, (4) gender and (5) axial length, with all statistical analysis performed using Review Manager. RESULTS: A total of 2034 eyes were included for analysis with a mean follow-up time of 28.3 months. 33.3% of patients developed a PVD, either partial or complete, with rates increasing in a time dependent manner. No significant difference was noted in sub-group analysis by age, gender or axial length. CONCLUSIONS: The results from our systematic review show that uncomplicated phacoemulsification accelerates the physiological process of PVD development. Pre-operative evaluation of the vitreoretinal interface should be performed with careful post-operative follow-up advised in those without a pre-existing PVD.

Ocular characteristics and outcomes of phacoemulsification in patients with cataract after renal transplantation.

PURPOSE: To explore ocular characteristics of patients with cataracts after renal transplantation and analyze the results of phacoemulsification combined with intraocular lens (IOL) implantation. METHODS: Patients with cataracts after renal transplantation and control patients who underwent phacoemulsification combined with IOL implantation were enrolled. All patients underwent phacoemulsification combined with IOL implantation. Visual acuity, intraocular pressure, type of lens opacity, corneal endothelial cell density, and ocular biological parameters were evaluated before surgery. Visual prognosis, dry eye, and postoperative complications were monitored for 6 months after phacoemulsification. RESULTS: We analyzed 25 eyes of 16 patients after renal transplantation and 30 eyes of 21 control patients. The most common type of cataract of renal transplantation group was posterior subcapsular, while the most common type of cataract of control group was cortical. Significant differences in corneal astigmatism, white-to-white ratio, and keratometry values were observed between the groups. The postoperative visual acuity of both groups significantly improved following surgery. Postoperative complications, such as the degree of anterior and posterior capsule opacification and the incidence of a requirement of neodymium-doped yttrium aluminum garnet laser capsulotomy, were significantly lower in the renal transplantation group. Moreover, secondary glaucoma occurred in two eyes in the renal transplantation group. CONCLUSION: This study showed that cataracts after renal transplantation were mostly posterior subcapsular. Postoperative visual acuity recovered well in most patients, with reduced incidence of postoperative complications. This study suggested that phacoemulsification combined with IOL implantation was safe and effective, providing a reference for multi-focal IOL implantation in kidney transplant recipients.

Nucleus drop following phacoemulsification surgery: Incidence, risk factors and clinical outcomes.

PURPOSE: To determine the incidence, risk factors and clinical outcomes in patients with nucleus drop (ND) following phacoemulsification surgery at a tertiary care ophthalmic institute. METHODS: Medical records of patients with ND during phacoemulsification between January'2019 and December'2022 were reviewed retrospectively. Incidence of ND was calculated overall, and according to surgical expertise levels and surgical steps. Associated pre- and intra-operative risk factors were assessed. Clinical outcome parameters [best-corrected visual acuity (BCVA) and intraocular pressure (IOP)] were compared with respect to timing of PPV (immediate vs early vs delayed), location (sulcus vs scleral fixated-IOL) and timing of IOL placement (primary vs secondary). RESULTS: Among 93,760 phacoemulsifications, ND was noted in 130 patients (0.1%). Significant direct and associated pre-operative risk factors were advanced cataract, glaucoma, posterior polar cataract, and diabetes mellitus. Junior medical consultants had 40 ND (mostly in non-complex cases), whereas senior medical consultants had 90 ND (mostly in complex cases). ND most frequently occurred during emulsification of nuclear fragments. Sulcus placement of IOL during primary surgery yielded significantly better visual outcome compared to secondary procedures, although timing of PPV had insignificant effect. 77.1% had BCVA of 6/12 or better at final follow-up. Timing of IOL implantation, PPV, and type of IOL did not have any significant effect on IOP. CONCLUSIONS: Though the incidence of ND is low, it is a dreaded complication. Accurate pre-operative evaluation, risk stratification, distribution of cases among surgeons based on their surgical expertise, and immediate or early management of ND yields better anatomical and functional outcomes.

An analysis of the factors involved in IOL decentration after phacoemulsification using CASIA 2 anterior segment optical coherence tomography.

PURPOSE: To evaluate the magnitude of IOL transversal shift (ITS) after phacoemulsification and to analyse the factors contributing to IOL decentration and ITS. METHODS: 94 consecutive patients who underwent cataract surgery and IOL implantation was enrolled. Each patient underwent anterior segment optical coherence tomography with CASIA 2 (Tomey, Nagoya, Japan) to assess crystalline lens decentration, thickness and diameter seven days preoperatively and at one and sixty days postoperatively. Univariate and multivariate linear regression analysis were performed to evaluate the determinants of ITS and final decentration. RESULTS: The preoperative crystalline lens diameter was associated with the ITS and with the IOL final decentration. A positive association between the final IOL decentration and the first post-surgical day decentration was found (p < 0.0001). CONCLUSION: Greater crystalline lens diameter was associated with greater decentration and with greater ITS. Day-one IOL decentration seems to be the main determinant of final IOL decentration.

Immediate Sequential Bilateral Surgery in Refractive Lens Exchange Patients: Clinical Outcomes and Adverse Events.

PURPOSE: To evaluate outcomes and the incidence of adverse events (AEs) in patients who underwent bilateral same-day refractive lens exchange (RLE). DESIGN: Retrospective case series. PARTICIPANTS: Patients of a private intraocular surgery provider in the United Kingdom who underwent RLE in both eyes on the same day with treatment dates between March 2018 and December 2021. METHODS: Clinical outcomes and AEs were collected for a continuous cohort of patients undergoing bilateral same-day RLE (in the absence of visually significant cataracts) or had mild cataracts (corrected visual acuity ≥ 20/40). One-month clinical outcomes were analyzed. MAIN OUTCOME MEASURES: Refractive outcomes and visual acuity, intraoperative and postoperative AEs, and secondary surgical interventions recorded within the first month after surgery. RESULTS: A total of 17 330 patients (34 660 eyes) were included in the analysis. Of these, 28 827 eyes received a multifocal intraocular lens (IOL), and 5833 eyes had a monofocal IOL. The percentage of eyes within ±0.50 diopters (D) of intended refraction was 85.5% and 86.2% for monofocal and multifocal IOL eyes, respectively. There was a total of 55 intraoperative AEs recorded in 55 eyes of 54 patients (per-eye incidence: 0.159%). Posterior capsule tear was the most common intraoperative event occurring in 37 eyes (0.107%). The number of AEs recorded within the first postoperative month was 267, occurring in 263 eyes of 177 patients (per-eye incidence: 0.759%). These included cystoid macular edema (CME) (172 eyes; 0.496%), significant corneal edema (28 eyes; 0.081%), persistent inflammation (27 eyes; 0.078%), significantly raised intraocular pressure (27 eyes; 0.078%), toxic anterior segment syndrome (8 eyes; 0.023%), wound leak (3 eyes; 0.009%), retinal detachment (1 eye; 0.003%), and retinal tear (1 eye; 0.003%). There were 56 secondary surgical interventions recorded within the first month of surgery, occurring in 54 eyes of 47 patients (per-eye incidence: 0.156%). The most common secondary intervention was the rotation of a misaligned toric IOL (24 eyes; 0.069%). CONCLUSIONS: Elective same-day bilateral RLE had a low incidence of serious AEs, and high refractive predictability. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Cystoid Macular Edema after Cataract Surgery in the United States: IRIS® Registry (Intelligent Research in Sight) Analysis.

PURPOSE: To determine the incidence, risk factors, and visual outcomes of cystoid macular edema (CME) after cataract surgery in the United States. DESIGN: Retrospective, longitudinal, case-control study. PARTICIPANTS: Patients aged ≥ 18 years who underwent phacoemulsification cataract surgery. METHODS: The American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight) was used to analyze patients who underwent cataract surgery between 2016 and 2019. Patients who received a diagnosis of CME within 90 days after cataract surgery were classified as cases, and the rest were classified as controls. Multivariable logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for risk factors associated with the development of CME as well as poor visual outcome (defined as a best-recorded visual acuity worse than 20/40 Snellen equivalent at postoperative month 12). MAIN OUTCOME MEASURES: Incidence, demographics, baseline characteristics, and visual outcomes. RESULTS: Of 3.1 million cataract surgeries performed during the study period, CME was diagnosed in 25 595 eyes (0.8%), with an average onset of 6 weeks. Patients with CME were more likely to be male, to be aged < 65 years, to be Black, and to have preexisting diabetic retinopathy. Patients with CME were more likely to have a poor visual outcome (OR, 1.75; 95% CI, 1.66-1.84; P < 0.001), with a mean best-recorded visual acuity of 20/30 at postoperative month 12 (compared with 20/25 for those without CME; P < 0.001). Other factors associated with a poor visual outcome included smoking, Medicaid insurance, non-White race, and baseline ocular comorbidities such as macular degeneration and retinal vein occlusion. CONCLUSIONS: Although the incidence of CME after cataract surgery is low and most eyes achieve a visual acuity of 20/40 or better, there are significant outcome disparities that warrant further exploration. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Analysis of influencing factors of corneal edema after phacoemulsification for diabetic cataract.

The paper aimed to explore the influence factors of corneal edema after phacoemulsification for diabetic cataracts. For this aim, 80 patients (80 eyes) with senile cataracts who underwent phacoemulsification implantation in our hospital from August 2021 to January 2022 were included in this study, including 39 males (48.75%) and 41 females (51.25%), with an average age of 70.35±5.22 years. The OCT system during ophthalmology was used to capture corneal OCT images in the center of the cornea in real time before the phacoemulsification (the phacoemulsification probe just entered the anterior chamber after the balanced saline left the separated nucleus), at the end of phacoemulsification (when the phacoemulsification ultrasound probe was still in the anterior chamber and the perfusion pressure did not change compared with that in the previous step), at the end of perfusion aspiration (after the perfusion aspiration probe left the anterior chamber), and after surgery (after the watertight incision is closed). The corneal thickness was measured at each time point using Photoshop software. AL, curvature and ACD were measured using IOL-Master bio-measurement technology, and ACD referred to the distance between the front surface of the cornea and the front surface of the lens. Endothelial cell density was measured using CIM-530 non-contact mirror microscope. A handheld rebound tonometer was used to measure intraocular pressure and optical coherence tomography was used to assess the macular area of the fundus. Fundus photography was performed with a non-diffuse fundus camera. The results indicated that the preoperative corneal thickness was 514.35±29.62 µm, and the average corneal thickness at the end of the operation was 535.26±30.29µm, which was increased by 20.91±1.67 µm compared with that before operation (P<0.05), and the increase rate of corneal thickness was 4.07%. The corneal thickness of patients tended to increase with the increase in operation time and intraocular operation time (P<0.05). The distribution of corneal edema-related features showed that 42.50% of patients had persistent edema at the time of cataract surgery. The median onset time of corneal edema in the remaining patients was 5.44 years (1.96-21.35 years for 90% CR). The higher the nuclear hardness, the more severe the cataract, and the higher APT, EPT, APE, and TST (P<0.05). The older the patient, the higher the grade of cataract nucleus, and the higher EPT, APE, and TST, the greater the intraoperative corneal thickening (P<0.05). The higher the maximum area of endothelial cells, the greater the intraoperative corneal thickness increase, the lower the corneal endothelial cell density and the greater the intraoperative corneal thickness increase (P<0.05). It was concluded that postoperative corneal edema in phacoemulsification surgery for diabetic cataracts is closely related to intraocular perfusion pressure, nuclear hardness of lens, the density of corneal endothelial cells, the energy of phacoemulsification and duration.

Lens extraction versus laser peripheral iridotomy for acute primary angle closure.

BACKGROUND: Acute primary angle closure (APAC) is a potentially blinding condition. It is one of the few ophthalmic emergencies and carries high rates of visual morbidity in the absence of timely intervention. Laser peripheral iridotomy (LPI) has been the standard of care thus far. However, LPI does not eliminate the long-term risk of chronic angle closure glaucoma and other associated sequelae. There has been increasing interest in lens extraction as the primary treatment for the spectrum of primary angle closure disease, and it is as yet unclear whether these results can be extrapolated to APAC, and whether lens extraction provides better long-term outcomes. We therefore sought to evaluate the effectiveness of lens extraction in APAC to help inform the decision-making process.  OBJECTIVES: To assess the effect of lens extraction compared to LPI in the treatment of APAC. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2022, Issue 1), Ovid MEDLINE, Ovid MEDLINE E-pub Ahead of Print, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to 10 January 2022), Embase (January 1947 to 10 January 2022), PubMed (1946 to 10 January 2022), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 10 January 2022), ClinicalTrials.gov, and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search. We last searched the electronic databases on 10 January 2022. SELECTION CRITERIA: We included randomized controlled clinical trials comparing lens extraction against LPI in adult participants ( ≥ 35 years) with APAC in one or both eyes. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodology and assessed the certainty of the body of evidence for prespecified outcomes using the GRADE approach. MAIN RESULTS: We included two studies conducted in Hong Kong and Singapore, comprising 99 eyes (99 participants) of predominantly Chinese origin. The two studies compared LPI with phacoemulsification performed by experienced surgeons. We assessed that both studies were at high risk of bias. There were no studies evaluating other types of lens extraction procedures.  Phacoemulsification may result in an increased proportion of participants with intraocular pressure (IOP) control compared with LPI at 18 to 24 months (risk ratio (RR) 1.66, 95% confidence interval (CI) 1.28 to 2.15; 2 studies, n = 97; low certainty evidence) and may reduce the need for further IOP-lowering surgery within 24 months (RR 0.07, 96% CI 0.01 to 0.51; 2 studies, n = 99; very low certainty evidence). Phacoemulsification may result in a lower mean IOP at 12 months compared to LPI (mean difference (MD) -3.20, 95% CI -4.79 to -1.61; 1 study, n = 62; low certainty evidence) and a slightly lower mean number of IOP-lowering medications at 18 months (MD -0.87, 95% CI -1.28 to -0.46; 1 study, n = 60; low certainty evidence), but this may not be clinically significant. Phacoemulsification may have little to no effect on the proportion of participants with one or more recurrent APAC episodes in the same eye (RR 0.32, 95% CI 0.01 to 7.30; 1 study, n = 37; very low certainty evidence). Phacoemulsification may result in a wider iridocorneal angle assessed by Shaffer grading at six months (MD 1.15, 95% CI 0.83 to 1.47; 1 study, n = 62; very low certainty evidence). Phacoemulsification may have little to no effect on logMAR best-corrected visual acuity (BCVA) at six months (MD -0.09, 95% CI -0.20 to 0.02; 2 studies, n = 94; very low certainty evidence). There was no evidence of a difference in the extent of peripheral anterior synechiae (PAS) (clock hours) between intervention arms at 6 months (MD -1.86, 95% CI -7.03 to 3.32; 2 studies, n = 94; very low certainty evidence), although the phacoemulsification group may have less PAS (degrees) at 12 months (MD -94.20, 95% CI -140.37 to -48.03; 1 study, n = 62) and 18 months (MD -127.30, 95% CI -168.91 to -85.69; 1 study, n = 60).  In one study, there were 26 adverse events in the phacoemulsification group: intraoperative corneal edema (n = 12), posterior capsular rupture (n = 1), intraoperative bleeding from iris root (n = 1), postoperative fibrinous anterior chamber reaction (n = 7), and visually significant posterior capsular opacification (n = 5), and no cases of suprachoroidal hemorrhage or endophthalmitis. There were four adverse events in the LPI group: closed iridotomy (n = 1) and small iridotomies that required supplementary laser (n = 3). In the other study, there was one adverse event in the phacoemulsification group (IOP > 30 mmHg on day 1 postoperatively (n = 1)), and no intraoperative complications. There were five adverse events in the LPI group: transient hemorrhage (n = 1), corneal burn (n = 1), and repeated LPI because of non-patency (n = 3).  Neither study reported health- or vision-related quality of life measures. AUTHORS' CONCLUSIONS: Low certainty evidence suggests that early lens extraction may produce more favorable outcomes compared to initial LPI in terms of IOP control. Evidence for other outcomes is less clear. Future high-quality and longer-term studies evaluating the effects of either intervention on the development of glaucomatous damage and visual field changes as well as health-related quality of life measures would be helpful.

Laser-assisted cataract surgery versus standard ultrasound phacoemulsification cataract surgery.

BACKGROUND: Cataract is the leading cause of blindness in the world and, as such, cataract surgery is one of the most commonly performed operations globally. Surgical techniques have changed dramatically over the past half century with associated improvements in outcomes and safety. Femtosecond lasers can be used to perform the key steps in cataract surgery, such as corneal incisions, lens capsulotomy and fragmentation. The potential advantage of femtosecond laser-assisted cataract surgery (FLACS) is greater precision and reproducibility of these steps compared to manual techniques. The disadvantages are the costs associated with FLACS technology. OBJECTIVES: To compare the effectiveness and safety of FLACS with standard ultrasound phacoemulsification cataract surgery (PCS) by gathering evidence from randomised controlled trials (RCTs). SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 5); Ovid MEDLINE; Ovid Embase; LILACS; the ISRCTN registry; ClinicalTrials.gov; the WHO ICTRP and the US Food and Drug Administration (FDA) website. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 10 May 2022. SELECTION CRITERIA: We included RCTs where FLACS was compared to PCS. DATA COLLECTION AND ANALYSIS: Three review authors independently screened the search results, assessed risk of bias and extracted data using the standard methodological procedures expected by Cochrane. The primary outcome for this review was intraoperative complications in the operated eye, namely anterior capsule, and posterior capsule tears. The secondary outcomes included corrected distance visual acuity (CDVA), quality of vision (as measured by any validated patient-reported outcome measure (PROM)), postoperative cystoid macular oedema complications, endothelial cell loss and cost-effectiveness. We assessed the certainty of the evidence using GRADE. MAIN RESULTS: We included 42 RCTs conducted in Europe, North America, South America and Asia, which enrolled a total of 7298 eyes of 5831 adult participants. Overall, the studies were at unclear or high risk of bias. In 16 studies the authors reported financial links with the manufacturer of the laser platform evaluated in their studies. Thirteen of the studies were within-person (paired-eye) studies with one eye allocated to one procedure and the other eye allocated to the other procedure. These studies were reported ignoring the paired nature of the data. There was low-certainty evidence of little or no difference in the odds of developing anterior capsular tears when comparing FLACS and PCS (Peto odds ratio (OR) 0.83, 95% confidence interval (CI) 0.40 to 1.72; 5835 eyes, 27 studies) There was one fewer anterior capsule tear per 1000 operations in the FLACS group compared with the PCS group (95% CI 4 fewer to 3 more).  There was low-certainty evidence of lower odds of developing posterior capsular tears with FLACS compared to PCS (Peto OR 0.50, 95% CI 0.25 to 1.00; 5767 eyes, 26 studies). There were four fewer posterior capsule tears per 1000 operations in the FLACS group compared with the PCS group (95% CI 6 fewer to same).  There was moderate-certainty evidence of a very small advantage for the FLACS arm with regard to CDVA at six months or more follow-up, (mean difference (MD) -0.01 logMAR, 95% CI -0.02 to 0.00; 1323 eyes, 7 studies). This difference is equivalent to 1 logMAR letter between groups and is not thought to be clinically important. From the three studies (1205 participants) reporting a variety of PROMs (Cat-PROMS, EQ-5D, EQ-SD-3L, Catquest9-SF and patient survey) up to three months following surgery, there was moderate-certainty evidence of little or no difference in the various parameters between the two treatment arms. There was low-certainty evidence of little or no difference in the odds of developing cystoid macular oedema when comparing FLACS and PCS (Peto OR 0.84, 95% CI 0.56 to 1.28; 4441 eyes, 18 studies). There were three fewer cystoid macular oedema cases per 1000 operations in the FLACS group compared with the PCS group (95% CI 10 fewer to 6 more).  In one study the incremental cost-effectiveness ratio (ICER) (cost difference divided by quality-adjusted life year (QALY) difference) was GBP £167,620 when comparing FLACS to PCS. In another study, the ICER was EUR €10,703 saved per additional patient who had treatment success with PCS compared to FLACS. Duration ranged from three minutes in favour of FLACS to eight minutes in favour of PCS (I2 = 100%, 11 studies) (low-certainty evidence).  There was low-certainty evidence of little or no important difference in endothelial cell loss when comparing FLACS with PCS (MD 12 cells per mm2 in favour of FLACS, 95% CI -40 to 64; 1512 eyes, 10 studies).  AUTHORS' CONCLUSIONS: This review of 42 studies provides evidence that there is probably little or no difference between FLACS and PCS in terms of intraoperative and postoperative complications, postoperative visual acuity and quality of life. Evidence from two studies suggests that FLACS may be the less cost-effective option. Many of the included studies only investigated very specific outcome measures such as effective phacoemulsification time, endothelial cell count change or aqueous flare, rather than those directly related to patient outcomes. Standardised reporting of complications and visual and refractive outcomes for cataract surgery would facilitate future synthesis, and guidance on this has been recently published.

ANTECEDENTES: La catarata es la principal causa de ceguera en el mundo y, como tal, la cirugía de cataratas es una de las operaciones más realizadas en todo el mundo. Las técnicas quirúrgicas han cambiado radicalmente en el último medio siglo, con las consiguientes mejoras en los desenlaces y la seguridad. Los láseres de femtosegundo se pueden utilizar para realizar los pasos clave de la cirugía de cataratas, como las incisiones corneales, la capsulotomía y la fragmentación del cristalino. La ventaja potencial de la cirugía de cataratas asistida por láser de femtosegundo (FLACS por sus siglas en inglés) es la mayor precisión y reproducibilidad de estos pasos en comparación con las técnicas manuales. Las desventajas son los costes asociados con la tecnología FLACS. OBJETIVOS: Comparar la eficacia y la seguridad de la FLACS con la cirugía de cataratas estándar por facoemulsificación (PCS) con ultrasonido mediante la recopilación de evidencia de ensayos controlados aleatorizados (ECA). MÉTODOS DE BÚSQUEDA: Se realizaron búsquedas en el Registro Cochrane central de ensayos controlados (Cochrane Central Register of Controlled Trials [CENTRAL]; que contiene el Registro de ensayos del Grupo Cochrane de Salud ocular y de la visión [Cochrane Eyes and Vision]; 2022, número 5); en Ovid MEDLINE; Ovid Embase; LILACS; el registro ISRCTN; ClinicalTrials.gov; la ICTRP de la OMS y el sitio web de la Food and Drug Administration (FDA) de los EE. UU. No se aplicaron restricciones de fecha ni de idioma en las búsquedas electrónicas de ensayos. La última búsqueda en las bases de datos electrónicas se realizó el 10 de mayo de 2022. CRITERIOS DE SELECCIÓN: Se incluyeron los ECA en los que la FLACS se comparó con la PCS. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Tres autores de la revisión examinaron de forma independiente los resultados de la búsqueda, evaluaron el riesgo de sesgo y extrajeron los datos mediante los procedimientos metodológicos estándar previstos por Cochrane. El desenlace principal de esta revisión fueron las complicaciones intraoperatorias en el ojo operado, concretamente, desgarros de la cápsula anterior y posterior. Los desenlaces secundarios incluyeron la agudeza visual corregida a distancia (AVCD), la calidad de la visión (medida por cualquier medida de desenlace notificada por el paciente [PROM] validada), las complicaciones posoperatorias del edema macular cistoide, la pérdida de células endoteliales y la coste­efectividad. La certeza de la evidencia se evaluó mediante el método GRADE. RESULTADOS PRINCIPALES: Se incluyeron 42 ECA realizados en Europa, Norteamérica, Sudamérica y Asia, que reclutaron un total de 7298 ojos de 5831 participantes adultos. En general, los estudios tuvieron riesgo de sesgo incierto o alto. En 16 estudios, los autores informaron vínculos financieros con el fabricante de la plataforma láser evaluada en sus estudios. Trece de los estudios fueron estudios intrapersonales (ojo pareado) con un ojo asignado a un procedimiento y el otro ojo asignado al otro procedimiento. El informe de estos estudios no consideró la naturaleza pareada de los datos. Hubo evidencia de certeza baja de poca o ninguna diferencia en las probabilidades de desarrollar desgarros de la cápsula anterior al comparar FLACS y PCS (odds ratio [OR] de Peto 0,83; intervalo de confianza [IC] del 95%: 0,40 a 1,72; 5835 ojos, 27 estudios). Hubo un desgarro de la cápsula anterior menos por cada 1000 cirugías en el grupo de FLACS en comparación con el grupo de PCS (IC del 95%: 4 menos a 3 más).  Hubo evidencia de certeza baja de menores probabilidades de desarrollar desgarros de la cápsula posterior con FLACS en comparación con PCS (OR de Peto 0,50; IC del 95%: 0,25 a 1,00; 5767 ojos, 26 estudios). Hubo cuatro desgarros de la cápsula posterior menos por cada 1000 cirugías en el grupo de FLACS en comparación con el grupo de PCS (IC del 95%: 6 menos a igual).  Hubo evidencia de certeza moderada de una ventaja muy pequeña en el grupo de FLACS con respecto a la AVCD a los seis meses o más de seguimiento, (diferencia de medias [DM] ­0,01 logMAR; IC del 95%: ­0,02 a 0,00; 1323 ojos, siete estudios). Esta diferencia equivale a 1 letra logMAR entre los grupos y no se considera clínicamente importante. De los tres estudios (1205 participantes) que informaron sobre una variedad de PROM (Cat­PROMS, EQ­5D, EQ­SD­3L, Catquest9­SF y encuesta de pacientes) hasta tres meses después de la cirugía, hubo evidencia de certeza moderada de poca o ninguna diferencia en los diversos parámetros entre los dos grupos de tratamiento. Hubo evidencia de certeza baja de poca o ninguna diferencia en las probabilidades de desarrollar edema macular cistoide al comparar FLACS y PCS (OR de Peto 0,84; IC del 95%: 0,56 a 1,28; 4441 ojos, 18 estudios). Hubo tres casos menos de edema macular cistoide por cada 1000 cirugías en el grupo de FLACS en comparación con el grupo de PCS (IC del 95%: 10 menos a 6 más).  En un estudio, el cociente coste­efectividad incremental (ICER) (diferencia de coste dividida por la diferencia de años de vida ajustados por la calidad [AVAC]) fue de 167 620 GBP al comparar FLACS con SCP. En otro estudio, el ICER fue de 10 703 euros ahorrados por paciente adicional que tuvo un tratamiento exitoso con PCS en comparación con FLACS. La duración varió entre tres minutos a favor de FLACS y ocho minutos a favor de PCS (I 2 = 100%, 11 estudios) (evidencia de certeza baja).  Hubo evidencia de certeza baja de poca o ninguna diferencia importante en la pérdida de células endoteliales al comparar la FLACS con la PCS (DM 12 células por mm 2 a favor de la FLACS; IC del 95%: ­40 a 64; 1512 ojos, 10 estudios).  CONCLUSIONES DE LOS AUTORES: Esta revisión de 42 estudios aporta evidencia de que probablemente haya poca o ninguna diferencia entre la FLACS y la PCS en cuanto a las complicaciones intraoperatorias y posoperatorias, la agudeza visual posoperatoria y la calidad de vida. La evidencia de dos estudios indica que la FLACS podría ser la opción menos coste­efectiva. Muchos de los estudios incluidos solo investigaron medidas de desenlace muy específicas, como el tiempo efectivo de facoemulsificación, el cambio en el recuento de células endoteliales o el brote acuoso, en lugar de las directamente relacionadas con los desenlaces de los pacientes. La notificación estandarizada de las complicaciones y los desenlaces visuales y refractarios de la cirugía de cataratas facilitaría la síntesis futura, y recientemente se han publicado guías al respecto.

Early intervention for perioperative hypertension in cataract surgery.

PURPOSE: Although perioperative blood-pressure control is important, especially for high-risk patients, no previous report has examined early monitoring of perioperative blood-pressure changes before cataract surgery. In this single-center, retrospective, observational study, we evaluated the early intervention for perioperative hypertension in cataract surgery with topical anesthesia. METHODS: Hospitalized patients who underwent phacoemulsification and intraocular-lens insertion and whose blood pressure was controlled using standardized management to start early monitoring and control (standardized group; 134 eyes of 134 patients) were compared to age- and sex-matched patients who underwent the same cataract surgery and whose blood pressure was controlled using conventional means (control group; 134 eyes of 134 patients). The perioperative blood pressure, pulse pressure, and heart rate were compared preoperatively, upon entering the operation room, and at the beginning, end, and after the operation. RESULTS: Although there was no difference before the operation, the changes in systolic pressure in the standardized group were significantly lower at the point of entering the operation room, at the beginning of the operation, and at the end of the operation (P = 0.003, < 0.001, and < 0.001, respectively). No significant difference was observed between etizolam and nicardipine use. CONCLUSION: Early monitoring and control of blood pressure in cataract surgery could effectively control perioperative hypertension without additional drug use and could be widely applied in the clinical setting.

The impact of case complexity in resident-performed cataract surgery.

PURPOSE: To evaluate the association of capsular dye and/or a pupil expansion device (PED) usage on the rate of major complication in resident-performed cataract extraction. METHODS: Resident cataract surgeries between 2016 and 2019 were included. The primary outcomes were anterior or posterior vitrectomy (AVx and PPVx). Cases were grouped by the use of a PED and/or capsular staining along with additional preoperative risk factors. RESULTS: Of the 1,348 cases, 371 (27.5%) documented capsular staining ("Dye-only"), 91 (6.8%) required pupil expansion ("PED-only"), and 100 (7.4%) used both capsular stain and a PED ("Both"). The remainder of cases (n=786, 58.3%) were classified as "Routine." Compared to the "Routine" group, "PED-only" and "Both" had significantly higher odds of an AVx (OR=2.90, 95% CI 1.27-6.19, P=0.01) and/or a PPVx (OR=2.33, 95% CI 1.07-5.12, P=0.04). Among the PPVx cases, the "PED-only" group has significantly higher odds than "Routine" and "Dye-only" (OR=4.64, 95% CI 1.68-12.79, P=0.01; and OR=6.48, 95% CI 1.7-25.0, P=0.005, respectively). In case-control analysis, vision, intraocular pressure, anterior chamber depth, axial length, cataract type, or severity had no significant overall association with complication. When compared to nuclear sclerotic cataract, posterior subcapsular (OR=7.86, 95% CI 1.46-42.47, P=0.017) and white/mature cataracts (OR=3.05, 95% CI 1.1-8.43, P=0.032) had increased odds of complication. CONCLUSION: Resident-performed cataract surgery frequently required capsular staining and/or a PED, and intuitively, these cases had a higher overall complication rate compared to routine cases. However, the use of a PED independently was associated with significantly higher odds of a major complication requiring an unplanned vitrectomy independent of predisposing factors.

Impact of axial length on visual outcomes and complications in phacoemulsification surgery: a multicenter database study.

PURPOSE: To analyze the impact of axial length (AL) on the visual outcome and rate of perioperative complications in phacoemulsification surgery. DESIGN: Retrospective clinical database study. METHODS: Cataract surgery data of 217,556 eyes was extracted from the electronic medical records of 8 ophthalmic centers in the United Kingdom from July 2003 to March 2015. A total of 88,774 eyes without ocular co-pathologies were grouped eyes according to AL (mm): short AL (< 22), average AL (22-26; reference group), and long AL (> 26). MAIN OUTCOMES AND MEASURES: We analyzed visual acuity (VA) outcomes at 4 weeks, 4-12 weeks, and 12-24 weeks postoperatively, as well as the incidence of posterior capsular rupture (PCR), torn iris (TI), cystoid macular edema (CME), and retinal detachment (RD). RESULTS: Mean pre-operative VA (logMAR) was the worst in eyes with long AL compared to average and short AL eyes (VA 0.59 vs. 0.58 and 0.56; p < 0.001). However, post-operative VA at 4-12 weeks was slightly better in the long AL group (0.14 in short and average AL; 0.12 in long AL, p < 0.001). We observed an increased odds of TI in the short AL group (OR 2.09, 95% CI 1.60-2.75). There was increased risk of RD in long AL eyes (p < 0.001). However, PCR and CME rates were not different. CONCLUSION: In the absence of any coexisting ocular pathology, AL alone did not have an impact on VA improvement or the risk of encountering PCR or CME. The risk of TI was greater in the short AL group, and the risk of RD was higher in the long AL group.