Femtosecond Laser-Assisted Cataract Surgery Versus Phacoemulsification Cataract Surgery (FACT): A Randomized Noninferiority Trial.

PURPOSE: To report the 3-month results of a randomized trial (Femtosecond Laser-Assisted Cataract Trial [FACT]) comparing femtosecond laser-assisted cataract surgery (FLACS) with standard phacoemulsification cataract surgery (PCS). DESIGN: Multicenter, randomized controlled trial funded by the UK National Institute of Health Research (HTA 13/04/46/). PARTICIPANTS: Seven hundred eighty-five patients with age-related cataract. METHODS: This trial took place in 3 hospitals in the UK National Health Service (NHS). Randomization (1:1) was stratified by site, surgeon, and 1 or both eyes eligible using a secure web-based system. Postoperative assessments were masked to the allocated intervention. The primary outcome was unaided distance visual acuity (UDVA) in the study eye at 3 months. Secondary outcomes included corrected distance visual acuity, complications, and patient-reported outcomes measures. The noninferiority margin was 0.1 logarithm of the minimum angle of resolution (logMAR). ISRCTN.com registry, number ISRCTN77602616. MAIN OUTCOME MEASURES: We enrolled 785 participants between May 2015 and September 2017 and randomly assigned 392 to FLACS and 393 to PCS. At 3 months postoperatively, mean UDVA difference between treatment arms was -0.01 logMAR (-0.05 to 0.03), and mean corrected distance visual acuity difference was -0.01 logMAR (95% confidence interval [CI], -0.05 to 0.02). Seventy-one percent of both FLACS and PCS cases were within ±0.5 diopters (D) of the refractive target, and 93% of FLACS and 92% of PCS cases were within ±1.0 D. There were 2 posterior capsule tears in the PCS arm and none in the FLACS arm. There were no significant differences between arms for any secondary outcome. CONCLUSIONS: Femtosecond laser-assisted cataract surgery is not inferior to conventional PCS surgery 3 months after surgery. Both methods are as good in terms of vision, patient-reported health, and safety outcomes at 3 months. Longer-term outcomes of the clinical effectiveness and cost-effectiveness are awaited.

Femtosecond laser-assisted cataract surgery in a public teaching hospital setting.

BACKGROUND: To evaluate the efficiency and practicality of femtosecond laser assisted cataract surgery (FLACS) in a public teaching hospital setting using a mobile FLACS system compared to conventional phacoemulsification cataract surgery (CPCS). METHODS: Ninety eyes from 90 patients underwent either FLACS or CPCS (45 in each group). Cataracts were graded using the Lens Opacities Classification System III system. Outcome measures included total surgery duration, femtosecond laser treatment time, vacuum time (VT), total phacoemulsification time (TPT) and total phacoemulsification power (TPP). RESULTS: No differences were observed in the preoperative mean cataract grades and co-morbidities. FLACS took longer than CPCS with a mean difference of 5.2 ± 4.5 min (range: 0-18.8 min). The average femtosecond laser treatment time was 4.3 ± 3.4 min (range: 1-15.5 min). The VT was 2.51 ± 0.45 min (range: 1.59-4.10 min). Although not significant, TPT in FLACS showed a trend towards improvement (mean 1.0 ± 0.6 s; range: 0.1-2.4 s) compared to CPCS (mean 1.2 ± 0.6 min; range: 0.5-2.5 min). Whereas, TPP was significantly less in FLACS (mean 17.9 ± 5.0%; range: 5-27%) compared to CPCS (mean 20.3 ± 4.1%; range: 12.0-28.7%)(p = 0.031). CONCLUSIONS: The mobile FLACS system housed in the same operating room increased the surgical duration by 5.2 min. The average VT was 2.51 min, which was lower in comparison to published experience using non-mobile FLACS systems.

Modified Descemet's stripping automated endothelial keratoplasty for eyes with glaucoma drainage devices and shallow anterior chambers.

PURPOSE: To present a modified Descemet's stripping automated endothelial keratoplasty (DSAEK) technique to avoid risks of endothelial cell loss related to the presence of a glaucoma tube in cases with shallow anterior chamber. METHOD: A 72-year-old patient with an only eye and corneal decompensation secondary to a Baerveldt tube was referred for keratoplasty. He was pseudophakic and had shallow anterior chamber. His best-corrected visual acuity was counting fingers close to face. He underwent a combined procedure with withdrawal and shortening of tube followed by a modified DSAEK employing a 7.5-mm donor graft in which a peripheral notch was performed to overlay the silicon tube. RESULTS: No intraoperative or postoperative complications were noted. The endothelial cell count was 2000/mm2 after 15 months of the surgery. His best-corrected visual acuity remains 6/18 with a stable glaucoma. CONCLUSION: This modified technique of DSAEK offers the benefits of endothelial transplant, and it could represent an option to reduce risks of corneal decompensation due to the presence of tubes in cases with shallow anterior chambers.

Peripheral corneal relaxing incisions based on anterior keratometry from Scheimpflug tomography versus Placido topography during standard cataract surgery.

AIM: To compare the outcomes of peripheral corneal relaxing incisions (PCRIs) based on standardized nomogram using keratometry from Scheimpflug and Placido machines during standard cataract surgery and to assess the astigmatism neutralization potential of PCRIs. METHODS: In this prospective, comparative case series of eyes with keratometric astigmatism between 0.75D to 2.5D, undergoing routine cataract surgery, PCRIs were performed using standardized nomogram and keratometric data from either Scheimpflug or Placido machines. A single eye of 42 consecutive patients was recruited in each group. Data on pre- and postoperative uncorrected distance visual acuity (UDVA), corrected DVA (CDVA), keratometry and refraction were assessed at 10 weeks postoperatively. Refractive and keratometric J0 J45 vectors were also analyzed. RESULTS: Data on 41 and 39 eyes were available in each group, respectively. There was a significant reduction in keratometric astigmatism in both groups. However, between Scheimpflug and Placido groups, there was no difference in postoperative logMAR UDVA [0.15 ± 0.18 vs 0.14 ± 0.16, p = 0.82] and CDVA [0.11 ± 0.11 vs 0.09 ± 0.10, p = 0.58], postoperative spherical equivalent [-0.34D ± 0.40D vs -0.50D ± 0.43D, p = 0.11], keratometric J0 [-0.03 ± 0.39 vs 0.01 ± 0.85, p = 0.67] and J45 [-0.03 ± 0.41 vs 0.01 ± 0.86, p = 0.65] and refractive J0 [0.05 ± 0.46 vs -0.03 ± 0.92, p = 0.47)] and J45 [-0.06 ± 0.49 vs -0.03 ± 0.99, p = 0.82] vectors, reduction of keratometric astigmatism [-0.40D ± 0.55D vs -0.35D ± 1.24D, p = 0.75] and the keratometric astigmatism neutralization potential [38.56 % ± 29.71 % vs 52.66 % ± 44.06 %, p = 0.12]. - CONCLUSIONS: Although PCRIs performed using Scheimpflug or Placido keratometry reduced the keratometric astigmatism significantly during standard cataract surgery. The astigmatic neutralization potentials of PCRIs comparing these two groups were not significantly different and remain low during the early postoperative period.

Management of corneal decompensation 4 decades after Sputnik intraocular lens implantation.

OBJECTIVES: We report an unusual case of corneal decompensation occurring four decades after complicated cataract extraction with implantation of a Sputnik intraocular lens (IOL) and highlight the clinical and practical issues faced in managing corneal decompensation with a Sputnik IOL. METHODS: A 72-year-old woman presented with deterioration of the vision in her left eye, four decades after intracapsular cataract extraction with Sputnik IOL implantation. Ocular examination revealed diffuse corneal edema and thickened vitreous strands in the anterior chamber. Her best-corrected visual acuity (BCVA) worsened to 6/60 within 3 months. Anterior vitrectomy and inferior iridectomy combined with Desçemet-stripping automated endothelial keratoplasty was performed. RESULTS: The procedure was successful, with the patient achieving best-corrected visual acuity of 6/6 at 8 months postoperatively. CONCLUSION: Corneal decompensation after Sputnik IOL implantation can occur four decades later. When the historical preoperative visual acuity is good in such cases, careful anterior vitrectomy with Desçemet-stripping automated endothelial keratoplasty provides good visual rehabilitation.

Endothelial keratoplasty versus penetrating keratoplasty for Fuchs endothelial dystrophy.

BACKGROUND: Fuchs endothelial dystrophy (FED) is a condition in which there is premature degeneration of corneal endothelial cells. When the number of endothelial cells is reduced to a significant degree, fluid begins to accumulate within the cornea. As a result, the cornea loses its transparency and the individual suffers a reduction in vision. The only successful surgical treatment for this condition is replacement of part or all of the cornea with healthy tissue from a donor. The established procedure, penetrating keratoplasty (PKP), has been used for many years and its safety and efficacy are well known. Endothelial keratoplasty (EK) techniques are relatively new surgical procedures and their safety and efficacy relative to PKP are uncertain. OBJECTIVES: The objective of this review was to compare the benefits and complications related to two surgical methods (EK and PKP) of replacing the diseased endothelial layer of the cornea with a healthy layer in people with FED. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2014, Issue 1), MEDLINE (January 1950 to January 2014), EMBASE (January 1980 to January 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to January 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrials.gov). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 27 January 2014. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) comparing EK versus PKP for people (of any age and gender) who had been clinically diagnosed with FED. DATA COLLECTION AND ANALYSIS: Two authors independently screened the search results, assessed trial quality and extracted data using the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: We included three RCTs that enrolled a total of 139 eyes of 136 participants and analysed 123 (88%) eyes. Two RCTs randomised eyes into either the endothelial keratoplasty (EK) group or penetrating keratoplasty (PKP) group and one RCT randomised eyes into either the femtosecond laser-assisted endothelial keratoplasty (FLEK) group or PKP group. The RCTs comparing EK with PKP did not show any significant differences between procedures with respect to best corrected visual acuity (BCVA) at two years (mean difference (MD) 0.14 logMAR; 95% confidence interval (CI) -0.08 to 0.36; P = 0.23) or at one year (MD 0.09 logMAR; 95% CI -0.05 to 0.23; P = 0.22), whereas the trial comparing FLEK with PKP showed significantly better BCVA after PKP (MD 0.20 logMAR; 95% CI 0.10 to 0.30; P = 0.0001). Only one RCT reported on irregular astigmatism (higher-order aberration), which was less with EK than PKP (MD -1.20 µm; 95% CI -1.53 to -0.87; P < 0.001). Only one RCT reported on endothelial cell counts (lower after FLEK than PKP: MD -969 cells/mm²; 95% CI -1161 to -777; P < 0.001), primary graft failure (higher after FLEK than PKP: RR 7.76; 95% CI 0.41 to 145.22; P = 0.10), and graft rejection (more after FLEK than PKP: RR 1.11; 95% CI 0.07 to 17.12; P = 0.94). Only one RCT reported that 27.8% of participants had graft dislocation, 2.8% had epithelial ingrowth and postoperative pupillary block, and 13.9% had intraocular pressure (IOP)-related problems in the FLEK group compared with the PKP group, in whom 10% had suture-related problems, 5% had wound dehiscence and 10% had suture revision to correct astigmatism. Overall, the adverse events in the FLEK group appeared to be more frequent than in the PKP group. No trials reported information about quality of life or economic data. The overall methodological quality of the three trials was not satisfactory as most did not perform allocation concealment or masking of participants and outcome assessors, and all trials had a small sample size. AUTHORS' CONCLUSIONS: The rapid growth of endothelial keratoplasty as the treatment of choice for FED is based upon the belief that visual recovery is more rapid, surgically induced astigmatism (regular and irregular) is less and rates of transplant rejection are lower with EK. This change in practice also assumes that the rates of long term transplant survival are equal for the two procedures. The practical differences between the surgical procedures mean that visual recovery is inherently more rapid following EK, but this review found no strong evidence from RCTs of any difference in the final visual outcome between EK and PKP for people with FED. This review also found that higher order aberrations are fewer following EK but endothelial cell loss is greater following EK. The RCTs that we included employed different EK techniques, which may have a bearing on these findings. EK procedures have evolved over the years and can be performed using different techniques, for example deep lamellar endothelial keratoplasty, Descemets stripping endothelial keratoplasty (DSEK), Descemets stripping automated endothelial keratoplasty (DSAEK), femtosecond laser-assisted endothelial keratoplasty and Descemet membrane endothelial keratoplasty (DMEK). More RCTs are needed to compare PKP with commonly performed EK procedures such as DSEK, DSAEK and DMEK in order to determine the answers to two key questions, whether there is any difference in the final visual outcome between these techniques and whether there are differences in the rates of graft survival in the long term?

Transepithelial Photorefractive Keratectomy-Review.

The type and nature of refractive surgery procedures has greatly increased over the past few decades, allowing for almost all patient populations to be treated to extremely high satisfaction. Conventional photorefractive keratectomy involves the removal of the corneal epithelium through mechanical debridement or dilute alcohol instillation. An improvement to this method utilises laser epithelial removal in a single-step process termed transepithelial photorefractive keratectomy (transPRK). We explore the history of transPRK from its early adoption as a two-step process, identify different transPRK platforms from major manufacturers, and describe the role of transPRK in the refractive surgery armamentarium. This is a narrative review of the literature. This review finds that TransPRK is a safe and effective procedure that works across a variety of patient populations. Though often not seen as a primary treatment option when compared to other corneal-based procedures that offer a faster and more comfortable recovery, there are many scenarios in which these procedures are not possible. These include, but are not limited to, cases of corneal instability, previous refractive surgery, or transplant where higher-order aberrations can impair vision in a manner not amenable to spectacle or contact lens correction. We discuss refinements to the procedure that would help improve outcomes, including optimising patient discomfort after surgery as well as reducing corneal haze and refractive regression.

Development of a Web-Based Algorithm for Understanding the Intraocular Lens-Based Surgery in Stable and Progressing Keratoconus for Non-Specialist Ophthalmologists.

PURPOSE: To propose an algorithm to facilitate lens-based surgery in keratoconus. METHODS: A literature review was performed to prepare a software algorithm based on cone location, stability, best spectacle-corrected distance visual acuity (BSCVA) level and whether there is a clear or cataractous lens. The software usability was assessed through a 10-question questionnaire and two hypothetical keratoconus case histories (moderately simple and moderately complex) given to 15 trainees. The usability questionnaires were graded on a Likert scale (1 = strongly disagree to 5 = strongly agree) and two case histories (1 = very difficult to 7 = very easy). RESULTS: The algorithm can be found at https://www.sussexeyelaserclinic.co.uk/keratoconus/. Thirteen trainees completed the questionnaire. 91.9% would frequently use it; for 100%, it was easy to use independently without technical support; for 63.7%, it was strongly integrated; for 100%, it was consistent; 100% thought that most people would learn to use it quickly, 91.9% found the system not cumbersome to use, felt very confident to use it and need not learn a lot to use it. The first case was found easy by 63.7% and the second by 45%. CONCLUSION: We present an algorithm as a guide for lens-based surgery in stable and progressing keratoconus, which is classified based on cone location. This algorithm will help trainee and "non-specialist" ophthalmic surgeons understand the pre-operative planning for the surgery and referral to the "specialist" corneal surgeon, considering factors such as progression, BSCVA, keratometry, topography and apex location of the cone in keratoconus patients.

Toric Intraocular Lens versus Peripheral Corneal Relaxing Incisions for Astigmatism between 0.75 and 2.5 Diopters: 5-Years Outcomes.

PURPOSE: To compare 5-year outcomes of toric intraocular lens (tIOL) or peripheral corneal relaxing incision (PCRI) for correction of keratometric astigmatism (KA) between 0.75 and 2.5 diopters (D). METHODS: Setting: University Hospital. Design: Randomized clinical trial. Eighty eyes (80 participants) received either tIOL or PCRI. Patients were assessed preoperatively, 1-month, 1, and 5 years. Primary outcomes were uncorrected (UDVA) and best-corrected distance logMAR visual acuity (CDVA). Secondary outcomes were a manifest refractive sphere, refractive astigmatism (Ra), spherical equivalent (SEQ), KA & mean keratometry (KM), and Quality-of-Life Impact of Refractive Correction (QIRC) scores. RESULTS: There was no difference between the two groups in UDVA, CDVA, refractive sphere, KM, RA, and SEQ. KA reduced after 1 month in the PCRI group and remained stable until 5 years. From 1 to 5 years, the number of eyes with distance emmetropia (within ±0.13D) changed from 59% (20/34 eyes) to 32% (6/19 eyes) for tIOLs and from 43% (15/36 eyes) to 20% (4/21 eyes) for PCRIs with 32% (6/19 eyes) and 20% (4/21 eyes) showing >0.5D change in SEQ at 5-years respectively. Compared to 1-year, Ra significantly increased at 5 years in both groups with no difference between the groups. Mean overall QIRC scores were not different between the groups (tIOL: 49.88 ± 7.47; PCRI: 52.09 ± 7.02; p = .18). CONCLUSIONS: Although there was no difference between the overall visual and vision-related quality of life outcomes between tIOLs and PCRIs, an increase in refractive astigmatism and reduction in distance emmetropia with time was noted in both groups.

Simulation-based training for intraoperative posterior capsule rupture management: an analysis of nontechnical skills development and the relationship between technical and nontechnical skills.

OBJECTIVES: To analyse development of individual nontechnical skills (NTS) domains after undertaking a previously developed simulation-based training model and analyse the relationship between technical skills (TS) and NTS in ophthalmic surgery. METHODS: The simulation-based training model involved a cataract surgery case complicated by intraoperative posterior capsule rupture. Cataract surgeons underwent the simulation twice, separated by a training intervention. Two blinded independent experts assessed participants' NTS using HUFOES, NOn-Technical Skills for Surgeons (NOTSS), and the OSATS global rating scale for TS. Paired t-tests assessed differences in individual NTS domains, with p < 0.05 indicating significance. The Pearson Product Moment Correlation Coefficient was used to assess the correlation between scores from each scoring system. RESULTS: All NTS domains within HUFOES and NOTSS demonstrated statistically significant improvements secondary to the training intervention. Positive correlations were demonstrated between HUFOES and OSATS scores in the pre- and post-training simulations, r = 0.870 (p < 0.001) and r = 0.861 (p < 0.001), respectively. Positive correlations were also demonstrated between NOTSS and OSATS scores in pre- and post-training simulations, r = 0.849 (p < 0.001) and r = 0.757 (p = 0.001), respectively. Positive correlations were demonstrated between HUFOES and NOTSS scores; r = 0.979 (p < 0.001) (n = 17) and r = 0.959 (p < 0.001) for pre- and post-training simulations, respectively. CONCLUSION: All NTS domains contained within HUFOES and NOTSS demonstrated significant increases following the completion of the simulation-based training model. Positive correlations exist between an ophthalmic surgeon's TS and NTS. This is the first study to report these findings within ophthalmic surgery.

Unusual case of dislocation of cyanoacrylate glue into the anterior chamber.

A patient with history of previous right eye penetrating keratoplasty for viral keratitis presented with an inferonasal graft melt, loose sutures and a flat anterior chamber (AC) in the same eye. B-scan ultrasound revealed 360° choroidal detachment. Cyanoacrylate adhesive and bandage contact lens were placed to restore ocular integrity. About 5 weeks after the procedure, the glue was found inside the AC with healed corneal melt. An emergency procedure was planned to remove the intraocular glue to prevent long-term toxicity. During the procedure, glue was found adherent to the intraocular lens (IOL), which necessitated an IOL exchange. Following the procedure, the eye settled well with residual scarring and an uncorrected visual acuity of 6/60, which improved to 6/18 with a pinhole. We discuss this case of late dislocation of the glue into the AC, which was managed with an IOL exchange highlighting a rare complication of corneal glueing.

Full-Thickness Compressive Corneal Sutures with Removal of Anterior Chamber Air Bubble in the Management of Acute Corneal Hydrops.

Acute hydrops is a rare complication of corneal ectatic disease, which occurs secondary to Descemet membrane break. Spontaneous resolution of this condition is associated with longstanding ocular discomfort and corneal scar. Intracameral gas/air injection with or without corneal suturing, anterior segment ocular coherence tomography (ASOCT)-guided drainage of intrastromal fluid, and penetrating keratoplasty are some of the described surgical interventions to manage this condition. The purpose of our study was to assess the effect of full-thickness corneal suturing as a solo treatment in the management of acute hydrops. A total of five patients with acute hydrops received full-thickness corneal sutures perpendicular to their Descemet break. A complete resolution of symptoms and corneal oedema was observed between 8 to 14 days post-operation with no complications. This technique is simple, safe, and effective in the management of acute hydrops and saves patients from a corneal transplant in an inflamed eye.

Clinical Outcomes of Descemet's Membrane Endothelial Keratoplasty without Routine Prophylactic Peripheral Iridotomy.

Objectives: To analyze the outcomes and complications of Descemet's membrane endothelial keratoplasty (DMEK) performed without prophylactic peripheral iridotomy (PI). Methods: Design: Retrospective study. SETTING: Institutional, tertiary care eye hospital. STUDY POPULATION: All patients who underwent DMEK or DMEK combined with phacoemulsification (DMEK triple) for Fuchs endothelial dystrophy, using a standardized protocol between August 2016 and July 2021, were included. Previous glaucoma surgery, laser PI, aphakia, or complicated pseudophakia were excluded. MAIN OUTCOME MEASURES: Primary outcomes: Incidence of pupillary block (PB). SECONDARY OUTCOMES: Graft detachment (GD), rebubbling rates, uncorrected (UCDVA) and best corrected logMAR distance visual acuity (BCDVA), and endothelial cell loss (ECL) at six months. Data were analyzed using the chi-square test and stepwise backward regression analysis. Results: 104 eyes of 72 patients were included. Four eyes (3.8%) developed PB; in two of these cases, standard protocol was not followed. Overall minor GD occurred in 43.2% (n = 45); significant GD was present only in 7 eyes (6.6%). Overall slit lamp rebubbling rate was 30% (n = 35), though only four patients were rebubbled in theatre (3.8%). PB, GD, and rebubbling rates did not vary with the surgeon, surgery, or tamponade (air or SF6 gas). UCDVA, BCDVA, and ECL at 6 months were 0.29 ± 0.31, 0.20 ± 0.28, and 40.46 ± 20.36%, respectively. Conclusions: Compared to previously reported outcomes of DMEK with PI, our results of PI less DMEK using a standardized protocol have a similar incidence of pupillary block, graft detachment, and rebubbling, with comparable visual acuity and endothelial cell loss.

Preoperative fundoscopy versus optical coherence tomography to detect occult maculopathy during cataract surgery preassessment.

PURPOSE: To assess the proportion of maculopathy detectable only on optical coherence tomography (OCT) versus slit lamp indirect ophthalmoscopy (SLIO) during cataract assessment. METHODS: Population: Consecutive patients attending cataract assessments. DATA COLLECTION: All patients underwent OCT and SLIO. SLIO findings were recorded before reviewing OCT. Scans were examined to compare with recorded SLIO findings. PRIMARY OUTCOME: analyse the proportion of eyes with maculopathy missed by SLIO. SECONDARY OUTCOME: to assess the proportion of patients with maculopathy on OCT, the incidence of maculopathy in the fellow eye on OCT and proportion with cataracts too dense to allow SLIO or OCT. RESULTS: Six hundred twenty-six patients were enroled. Eighty (12.8%) had maculopathy detectable only on OCT which included: 26 (4.2%) epiretinal membrane (ERM), 25 (4%) dry age-related macular degeneration (AMD), 19 (3%) vitreomacular traction (VMT), 5 (0.8%) lamellar macular hole (LMH), 2 (0.3%) cystoid macular oedema (CMO) and 1 (0.2%) wet AMD. 166 (26.5%) had maculopathy on OCT, of which only 48 (7.7%) had known history of maculopathy. In fellow eyes, 29 (4.6%) had significant findings and 29 (4.6%) were unable to have SLIO or OCT due to dense cataract. CONCLUSIONS: A quarter of the patients had occult maculopathy. One-tenth of the occult maculopathy were missed without OCT, with ERM, dry AMD, VMT, LMH, CMO and wet AMD being the primary missed diagnosis. Less than 5% had occult maculopathy in fellow eye, and <5% had dense cataracts where neither SLIO nor OCT was not possible.

Outcomes of Descemet's membrane endothelial keratoplasty performed in combination with, before, or after cataract surgery in Fuchs' endothelial dystrophy: A review of the literature and meta-analysis.

This review aimed to compare the outcomes of Descemet's membrane endothelial keratoplasty (DMEK) in combination with (category 1), before (category 2), or after cataract surgery (category 3) in patients with Fuchs' endothelial dystrophy (FED). Primary outcome was gain in best-corrected log of minimum angle of resolution (logMAR) visual acuity (BCVA). Secondary outcomes were graft detachment, rebubbling rates, rejection, failure, and endothelial cell loss (ECL). In category 1, 2, and 3, 12 studies (N = 1932) were included (five in category 1 [n = 696], one in category 2 [n = 286], and two in category 3 [n = 950], and the remaining four compared between two of the three categories). At 6 months, the gain in BCVA was 0.34 ± 0.04, 0.25 ± 0.03, and 0.38 ± 0.03 logMAR in category 1, 2, and 3, respectively. The difference was significant between categories 1 and 2 (Chi2 = 11.47, P < 0.01) and categories 2 and 3 (Chi2 = 35.53, P < 0.01). At 12 months, the gain in BCVA was 0.52 ± 0.05 and 0.38 ± 0.06 logMAR in categories 1 & 3 (Chi2 = 14.04, P < 0.01). The rebubbling rates were 15%, 4%, and 10% (P < 0.01) and the graft detachment rates were 31%, 8%, and 13% (P < 0.01) in categories 1, 2, and 3, respectively. However, graft rejection, survival rates, and ECL at 12 months were not different between categories 1 and 3. There is low certainty evidence that gain in BCVA in category 1 was comparable to category 3 at 6 months; however, it was significantly better with category 3 at 12 months. Although rebubbling and graft detachment rates were highest in category 1, there was no significant difference in graft rejection, survival rates, and ECL. Further high-quality studies are likely to change the effect estimate and have an impact on the confidence of the estimate.

Incidence and factors for pseudoaccommodation after monofocal lens implantation: the Monofocal Extended Range of Vision study.

PURPOSE: To screen patients with a monofocal intraocular lens (IOL) for incidence of unaided 20/40 and 0.3 LogMAR for distance and near (pseudoaccommodation) and to find factors for pseudoaccommodation. SETTINGS: University Hospitals Sussex NHS Foundation Trust, Brighton, United Kingdom. DESIGN: Prospective study. METHODS: This was a single-eye study ( ClinicalTrials.gov : NCT04011696). At 3 to 9 months, refraction, uncorrected and corrected distance and uncorrected near visual acuity (logMAR), spherical equivalent (SEQ), mesopic pupil size (PS), total eye spherical (Z 40 ), vertical coma (Z 3-1 ) aberrations, reading speed and smallest print size were assessed. Refractive astigmatism (RA) was classified as against-the-rule, with-the-rule, oblique and no astigmatism. Data on preoperative axial length (AL) and anterior chamber depth (ACD) were collected. RESULTS: 29 patients (9.6%, 95% CI, 6.5-13.5) had pseudoaccommodation. In cases vs controls, median SEQ, PS, total Z 40 , Z 3-1 , reading speed, smallest print size, preoperative ACD, preoperative AL were: -0.39 vs 0.0 diopters; 3.62 vs 4.10 mm; 0.01 vs 0.02 µm; 0.018 vs 0.022 µm; 106 vs 133 words per minute; 0.30 vs 0.50 logMAR; 2.94 vs 3.13 mm, 23.4 vs 23.7 mm, respectively. RA was not different between the groups. Univariate analysis revealed preoperative ACD (odds ratio [OR], 0.38, 95% CI, 0.16-0.94, P = .04), SEQ (OR, 0.61, 95% CI, 0.42-0.88, P = .01), total Z 40 (OR, 0.0003, 95% CI, 0.00-0.39, P = .03) and PS (OR, 0.39, 95% CI, 0.22-0.69, P < .041) to be significant. Whereas multivariable logistic regression identified: preoperative AL (OR, 0.62, 95% CI, 0.42-0.91, P = .02), SEQ (OR, 0.49, 95% CI, 0.31-0.78, P = .01), Z 40 (OR, 0.00, 95% CI, 0.0-0.01, P = .01) and PS (OR, 0.41, 95% CI, 0.23-0.75, P = .01) to be significant. CONCLUSIONS: A combination of low myopic SEQ, lower Z 40 , shorter preoperative AL, and smaller PS increases the chances of pseudoaccommodation.

Factors influencing aqueous flare after cataract surgery and its evaluation with laser flare photometry.

Despite the refinement of modern cataract surgery, postoperative inflammation still constitutes a substantial amount of visual morbidity worldwide. A surrogate for intraocular inflammation and blood-aqueous barrier breakdown can be objectively quantified by Laser flare photometry (LFP). This review outlines the utility of LFP in assessing the assessment of post-cataract surgery inflammation. It highlights the impact of preoperative pathological states such as uveitis and diabetes, intraoperative techniques, including efficient phacoemulsification and direct comparisons between postoperative anti-inflammatory regimes. There is a large interobserver variation in the subjective flare measurement after cataract surgery and the continued use of LFP amongst other objective, noninvasive measurements of intraocular inflammation, particularly in the further development of cataract surgery, is recommended.

Non-technical skills simulation-based training model for managing intraoperative posterior capsule rupture during cataract surgery.

OBJECTIVES: To develop and implement a simulation-based training model for the management of posterior capsule rupture (PCR) from a non-technical skills (NTS) perspective, and analyse changes in participant's NTS and technical skills (TS). METHODS: The simulation-based training model consisted of two identical PCR simulations with NTS stressors applied, separated by a predominantly NTS focussed training intervention. Participants' TS and NTS were evaluated by two blinded assessors using the Objective Structured Assessment of Technical Skill (OSATS) global rating scale and the HUman Factors in intraoperative Ophthalmic Emergencies Scoring System (HUFOES) respectively. Paired t-tests were used to establish the difference in mean HUFOES and OSATS scores between initial and repeat simulations; p < 0.05 indicated statistical significance. McGaghie's model of translational outcomes for simulation-based learning was used to establish the simulation model's educational status. RESULTS: Seventeen cataract surgeons of varying training grades participated in the simulation-based training model. NTS improved with statistical significance; mean HUFOES scores increased from 48.7 ± 16.6 to 59.2 ± 14.8 (p < 0.001). Mean OSATS scores increased without statistical significance from 16.0 ± 7.3 to 17.9 ± 8.3 (p = 0.07). This simulation model achieved Level 1 (internal acceptability) and Level 2 (contained effects) according to McGaghie's model. CONCLUSIONS: This novel simulation-based training model was designed to improve the NTS required for managing intraoperative PCR, through the provision of an interactive training session. Statistically significant improvements in participants' NTS in combination with statistically insignificant improvements in TS demonstrate that the simulation-based training model has specificity within the NTS domain.

Three-year multinational clinical study on an aspheric hydrophobic acrylic intraocular lens.

PURPOSE: To present the results of a study investigating the 3-year effectiveness and safety of the Clareon single-piece intraocular lens (IOL). SETTING: 19 multinational sites. DESIGN: Prospective multicenter single-arm study. METHODS: Patients were bilaterally implanted with Clareon IOLs. Assessments included uncorrected distance visual acuity, corrected distance visual acuity (CDVA), manifest refraction, tilt, decentration, applanation tonometry, and fundus examination, including glistenings and posterior capsule opacification (PCO) evaluation. The primary outcomes for effectiveness and safety were evaluated at 1 year and compared with ISO historical safety and performance endpoint (SPE) rates. Patients were followed for up to 3 years after implantation. RESULTS: 424 eyes of 215 patients were implanted (n = 215 first eye, n = 209 second eye), and 183 patients completed the trial at 3 years (with 364 binocular and 1 monocular patient). At 1 year, the cumulative and persistent adverse event rates were below SPE targets, and 99.5% of eyes achieved a monocular CDVA of ≤0.3 logMAR (vs the SPE target of 92.5%). At 3 years, the mean monocular CDVA was -0.032, with 93.4% (341/365) of eyes achieving a CDVA of 0.1 logMAR or better, 100% of eyes presented with grade 0 glistenings ≤25 MV/mm 2 , and 92.9% of eyes (394/424) had either no PCO or clinically nonsignificant PCO. CONCLUSIONS: This study supports the long-term safety and effectiveness of the Clareon IOL. The visual outcomes were excellent and stable over the 3-year study period, PCO rates were very low, and 100% of IOLs had grade 0 glistenings.