Cataract surgery in patients with Fuchs' endothelial corneal dystrophy: when to consider a triple procedure.

PURPOSE: To ascertain preoperative and intraoperative factors that predict the need for endothelial keratoplasty (EK) in patients with Fuchs' endothelial corneal dystrophy (FECD) undergoing cataract surgery. DESIGN: Prospective, observational cohort study. PARTICIPANTS: Eighty-nine patients (89 eyes) with FECD who require cataract surgery. METHODS: One month before cataract surgery, we assessed best-corrected visual acuity, contrast sensitivity, straylight, keratometry, ultrasonic pachymetry, intraocular pressure, 7 corneal features of FECD and cataract density at slit-lamp examination, and corneal backscatter using in vivo confocal microscopy (IVCM; Confoscan 4, NIDEK Technologies, Padova, Italy). After surgery, measurements were repeated at 1, 2, and 12 months. We used stepwise binary logistic regression analysis to evaluate 30 preoperative and 5 intraoperative parameters for their ability to predict the postoperative need for EK. Receiver operating characteristic (ROC) curves of the predictive factors were used to identify their optimal cutoff points. MAIN OUTCOME MEASURES: Central corneal thickness (CCT) and backscatter at the basal epithelial cell layer (EV). RESULTS: After cataract surgery, 35 (39%) of 89 eyes underwent EK to restore vision. Of all preoperative and intraoperative parameters, only CCT and EV were identified as significant factors, predictive of the need for EK. The area under the ROC curve of EV was significantly higher than that of CCT (P = 0.003), whereas a combination of both factors in a linear discriminant function did not improve the predictive value (P = 0.66). As optimal cutoff points, we chose 1894 scatter units for EV and 630 µm for CCT. Both cutoff points correspond with a specificity of 94% and represent sensitivity of 63% for EV and 40% for CCT. CONCLUSIONS: Backscatter at the basal epithelial cell layer measured by IVCM predicts the need for EK after cataract surgery in patients with FECD. As an indicator for the corneal hydration state, the EV improves patient selection for combined cataract surgery and EK. In deciding whether to perform a triple procedure, CCT remains a less effective, but adequate, alternative. Regardless of the predictive factor used, a tailor-made approach is recommended accounting for individuals' expectations.

Economic evaluation of endothelial keratoplasty techniques and penetrating keratoplasty in the Netherlands.

PURPOSE: To evaluate cost-effectiveness of penetrating keratoplasty (PK), femtosecond laser-assisted Descemet stripping endothelial keratoplasty (FS-DSEK), and Descemet stripping automated endothelial keratoplasty (DSAEK). DESIGN: Cost-effectiveness analysis based on data from a randomized multicenter clinical trial and a noncomparative prospective study. METHODS: Data of 118 patients with corneal endothelial dysfunction were analyzed in the economic evaluation. Forty patients were included in the PK group, 36 in the FS-DSEK group, and 42 in the DSAEK group. The primary incremental cost-effectiveness ratio (ICER) was the incremental costs per clinically improved patient, defined as a patient with a combined effectiveness of both a clinically improved BSCVA (defined as an improvement of at least 2 lines) and a clinically acceptable refractive astigmatism (defined as less than or equal to 3.0 diopters). Analysis was based on a 1-year follow-up period after transplantation. RESULTS: The percentage of treated patients who met the combined effectiveness measures was 52% for DSAEK, 44% for PK, and 43% for FS-DSEK. Mean total costs per patient were €6674 (US$7942), €12 443 (US$14 807), and €7072 (US$8416) in the PK group, FS-DSEK group, and DSAEK group, respectively. FS-DSEK was less effective and more costly compared to both DSAEK and PK. DSAEK was more costly but also more effective compared to PK, resulting in incremental costs of €4975 (US$5920) per additional clinically improved patient. CONCLUSIONS: The results of this study show that FS-DSEK was not cost-effective compared to PK and DSAEK. DSAEK, on the other hand, was more costly but also more effective compared to PK. Including societal costs, a longer follow-up period and preparation of the lamellar transplant buttons in a national cornea bank could improve the cost-effectiveness of DSAEK.

Monitoring the inflammatory process in herpetic stromal keratitis: the role of in vivo confocal microscopy.

PURPOSE: To investigate the role of in vivo confocal microscopy (IVCM) in the detection of inflammatory activity and follow-up of herpetic stromal keratitis (HSK). DESIGN: Prospective observational cohort study. PARTICIPANTS: Thirty-eight patients with active HSK. METHODS: Within 7 days after diagnosis of active HSK, both eyes of each patient were examined by slit-lamp biomicroscopy and white-light IVCM (Confoscan 4; Nidek Technologies, Padova, Italy). The HSK-affected eyes were followed up at 1, 3, 6, and 12 months, whereas the unaffected fellow eyes were reexamined after 12 months. Three patients did not complete follow-up and were excluded for data analyses. All IVCM examinations were assessed for morphologic alterations characteristic of inflammatory activity and for corneal backscatter. As secondary outcome parameters, best-corrected visual activity (BCVA), central corneal thickness (CCT), intraocular pressure (IOP), and endothelial cell density (ECD) were determined at each study visit. We used repeated-measures analysis of variance to assess changes during the 12-month follow-up period and paired t tests to compare HSK-affected eyes with fellow eyes. MAIN OUTCOME MEASURES: Presence of dendriform cells, pseudoguttae, and keratic precipitates, and follow-up of mean corneal backscatter. RESULTS: An increase of dendriform cells and pseudoguttae often accompanied stromal infiltration. Because these IVCM parameters were indiscernible or overlooked at slit-lamp examination, they proved to be excellent indicators of inflammatory activity. At 12 months' follow-up, mean corneal backscatter had decreased significantly by 36%, but still fell outside the normal range in 24 (69%) of the HSK-affected eyes. By using slit-lamp in conjunction with IVCM, we detected 17 recurrences in 14 of 35 patients (40%). Three of these recurrences were missed by slit-lamp, and 6 of these were missed by IVCM. At 12 months' follow-up, BCVA (-9 letters), CCT (-36 µm), and ECD (-313 cells/mm(2)) were significantly lower, whereas IOP (1.8 mmHg) was significantly higher, in HSK-affected eyes compared with fellow eyes. CONCLUSIONS: The data presented demonstrate that IVCM is complementary to slit-lamp examination in the follow-up of HSK, particularly because of its power to detect early signs of intracorneal inflammatory activity. Therapy guidance based on morphologic assessment and corneal backscatter measurement by combined IVCM and slit-lamp examination may improve the outcome of HSK. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

How normal is the transparent cornea? Effects of aging on corneal morphology.

PURPOSE: To ascertain the effects of aging on corneal morphology and to illustrate the morphologic diversity of the different layers in the normal cornea as seen by in vivo confocal microscopy (IVCM). DESIGN: Observational cross-sectional study. PARTICIPANTS: A total of 150 healthy subjects, evenly distributed over 5 age categories, comprising 75 men and 75 women. METHODS: Both transparent corneas (n = 300) of all subjects were examined in duplicate by white light IVCM (Confoscan 4, NIDEK Technologies, Albignasego, Padova, Italy). After reviewing the IVCM examinations for morphologic variations of the corneal layers, we selected the 8 most common features to illustrate the morphologic diversity. Subsequently, all 600 IVCM examinations were assessed for the presence of these features. We used binary logistic regression analyses to assess the age-relatedness of each feature. MAIN OUTCOME MEASURES: Age distribution of bright superficial epithelial cells, dendriform cells, alterations characteristic of epithelial basement membrane dystrophy (EBMD), tortuous stromal nerves, stromal microdots in the anterior stroma, folds in the posterior stroma, opacification of Descemet's membrane, and corneal guttae. RESULTS: Four features were found characteristic of the aging cornea: stromal microdots in the anterior stroma (P<0.0001), folds in the posterior stroma (P<0.0001), opacification of Descemet's membrane (P<0.0001), and corneal guttae (P<0.0001). Alterations characteristic of EBMD were found in 3% of all eyes and only detected in subjects aged ≥40 years, suggesting age-relatedness (P = 0.09). Other features, such as bright superficial epithelial cells (n = 38, 13%), dendriform cells (n = 42, 14%), and tortuous stromal nerves (n = 115, 38%), were age-independent. We also found a novel phenotype of corneal endothelium in 4 normal eyes of 2 subjects, which we coined "salt and pepper endothelium." We could not establish whether this novel phenotype represented a morphologic variant of normal endothelium, an early stage of a known corneal endothelial disorder, or a completely new disease entity. CONCLUSIONS: Knowledge of the common morphologic variations of the corneal layers and the effects of aging on corneal morphology as seen by IVCM increases our understanding of corneal degenerative disorders and is essential to detect corneal pathology. Our finding of a novel phenotype of corneal endothelium emphasizes the morphologic diversity of this optically transparent tissue.

Descemet stripping automated endothelial keratoplasty: effect of intraoperative lenticule thickness on visual outcome and endothelial cell density.

PURPOSE: To determine the correlation between the intraoperative donor lenticule thickness in Descemet stripping automated endothelial keratoplasty (DSAEK) and both the best-corrected visual acuity (BCVA) and endothelial cell density (ECD) at 6 months. To describe relevant surgical considerations with regard to the choice of microkeratome head. DESIGN: Prospective case series. METHODS: Thirty-five patients (37 eyes) undergoing DSAEK were included in this prospective case series. Intraoperative donor lenticule thickness, assessed by ultrasound pachymetry, was compared with BCVA and ECD 6 months postoperatively. RESULTS: Mean BCVA logarithm of the minimal angle of resolution (logMAR) was 0.58 preoperatively and 0.29 6 months postoperatively. Three eyes were excluded from BCVA analysis. The average donor lamellae thickness was 175 µm. Mean ECD loss was 39% 6 months postoperatively compared with that preoperatively. There was no correlation between donor lamella pachymetry and BCVA logMAR and ECD at 6 months in this series (P = 0.13 and P = 0.09, respectively). Analogous to our findings, a review of published reports on donor pachymetry in DSAEK did not provide data to suggest a correlation between donor corneal thickness and postoperative BCVA or ECD. CONCLUSIONS: Donor lenticule thickness does not have a direct effect on 6-month postoperative visual acuity or endothelial cells. Efforts should be made to reduce surgical trauma to the lenticule rather than adhering to a strict depth when cutting the graft. We propose using the Moria 350 µm microkeratome head for corneal thickness more than 600 µm and the 300 footplate for corneal thickness less than 600 µm.

Normative database for corneal backscatter analysis by in vivo confocal microscopy.

PURPOSE: To ascertain the sex and age relatedness, diurnal variation, and repeatability of backscatter measurement in the normal human cornea. METHODS: Seven corneal backscatter variants were measured by in vivo confocal microscopy (IVCM) in both normal eyes (n = 314) of 157 healthy subjects. These subjects were assigned to one or more of three groups. The sex and age relatedness of corneal backscatter were assessed in group 1 (n = 300), which comprised 75 men and 75 women evenly distributed over five age categories. To assess diurnal variation, eyes in group 2 (n = 40) were measured four times a day, at 3-hour intervals. The eyes in group 3 (n = 50) were examined four times a year to determine intersession repeatability. Intrasession repeatability was determined by performing all IVCM examinations in duplicate. Linear mixed models were used to assess the effects of sex, age, and time of measurement on corneal backscatter. RESULTS: Mean corneal backscatter was 3.5% higher in men (P = 0.003). From the age of 50 years, backscatter increased significantly in the anterior stroma (P = 0.0003). A small but statistically significant diurnal variation was found in all seven backscatter variants (P < 0.01). The test-retest coefficient of variation of mean corneal backscatter was 5.3%, comprising intra- and intersession repeatability. CONCLUSIONS: Sex and time of measurement significantly affect corneal backscatter measured by IVCM, whereas age affects only backscatter in the anterior stroma. All three factors should be taken into account when conducting scientific research. For ophthalmic practice, the authors suggest ignoring these factors and propose a generalized normal range and minimum detectable change for each backscatter variant.

Quality of vision after femtosecond laser-assisted descemet stripping endothelial keratoplasty and penetrating keratoplasty: a randomized, multicenter clinical trial.

PURPOSE: To compare the quality of vision (straylight and contrast sensitivity) after femtosecond laser-assisted Descemet stripping endothelial keratoplasty (FS DSEK) and penetrating keratoplasty (PK). DESIGN: Prospective, randomized clinical trial. METHODS: setting: Multicenter (5 ophthalmic centers in The Netherlands). study population: Eighty eyes of 80 patients with corneal endothelial dysfunction were included and were randomized to FS DSEK or PK. observation procedures: FS DSEK and PK. main outcome measures: Straylight, contrast sensitivity, astigmatism, uncorrected visual acuity, best spectacle-corrected visual acuity (BSCVA), and visual symptom score. RESULTS: Straylight at 12 months was 1.37 ± 0.2 logarithm of straylight for FS DSEK and 1.46 ± 0.2 logarithm of straylight for PK (P = .151). During 12 months of follow-up, there was a significant improvement of straylight and contrast sensitivity after FS DSEK (P < .001) and PK (P < .001). The change of straylight and contrast sensitivity correlated significantly with the change of BSCVA after FS DSEK (r = -0.645; r = 0.580) and PK (r = -0.370; r = 0.659). The visual symptom score was comparable between the 2 groups during the 12 months of follow-up. CONCLUSIONS: Improvement of straylight and contrast sensitivity was significantly correlated with an improvement of BSCVA. Straylight and contrast sensitivity were improved significantly after FS DSEK and were comparable with those after PK, although BSCVA was slightly better in the PK group.

Economic evaluation of deep anterior lamellar keratoplasty versus penetrating keratoplasty in The Netherlands.

PURPOSE: To evaluate the cost effectiveness of deep anterior lamellar keratoplasty (DALK) versus penetrating keratoplasty (PK) in The Netherlands. DESIGN: Cost-effectiveness analysis alongside a randomized, multicenter clinical trial. METHODS: Fifty-three patients with corneal stromal pathologic features not affecting the endothelium were included with 28 patients in the DALK group and 25 in the PK group. Quality of life was measured before surgery and 3, 6, and 12 months after surgery. The main outcome measures were incremental cost-effectiveness ratios per clinically improved patient on the 25-item National Eye Institute Visual Functioning Questionnaire and per patient with endothelial cell loss of maximally 20% within the first year. RESULTS: Mean total bootstrapped costs per patient were €7607 (US$10,498) in the DALK group and €6552 (US$9042) in the PK group. The incremental cost-effectiveness ratios were €9977 (US$13,768) per clinically improved patient on the 25-item National Eye Institute Visual Functioning Questionnaire and €6900 (US$9522) per patient with cell loss of maximally 20%. In patients without perforation of the Descemet membrane, the incremental cost-effectiveness ratio was €5250 (US$7245) per patient. CONCLUSIONS: This study shows that DALK is more costly and more effective as compared with PK. Results on the 25-item National Eye Institute Visual Functioning Questionnaire were in favor of DALK, and endothelial cell loss in DALK patients remained stable after 6 months, whereas cell loss in PK patients continued. Furthermore, DALK procedures performed without perforation of the Descemet membrane were more effective. However, because it is unknown what society is willing to pay for an additional improved patient, cost effectiveness of DALK within a limited follow-up period of 12 months is unclear. Cost effectiveness of DALK may improve over time because of lower graft failure.

Endothelial cell loss and visual outcome of deep anterior lamellar keratoplasty versus penetrating keratoplasty: a randomized multicenter clinical trial.

OBJECTIVE: To compare endothelial cell (EC) loss, visual and refractive outcomes, and complications after deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK). DESIGN: Randomized, multicenter clinical trial. PARTICIPANTS: Fifty-six eyes of 56 patients with a corneal stromal pathology not affecting the endothelium were randomized to DALK or PK. METHODS: The DALK procedure was performed according to Anwar's big-bubble technique. Patients underwent an ophthalmic examination preoperatively and 3, 6, and 12 months postoperatively. MAIN OUTCOME MEASURES: Endothelial cell loss, refractive and topographic astigmatism, spherical equivalent, uncorrected visual acuity, and best spectacle-corrected visual acuity (BSCVA) were measured, and complications were recorded. RESULTS: Endothelial cell loss was significantly higher after PK compared with DALK procedures performed without perforation of Descemet's membrane (12 months: 27.7% ± 11.1% vs. 12.9% ± 17.6%). The BSCVA was significantly better in the PK group at 3 and 6 months after surgery but was not significantly different 12 months after surgery (0.39 ± 0.3 logarithm of the minimum angle of resolution [logMAR] in DALK and 0.31 ± 0.3 logMAR in PK). At 12 months postoperatively, refractive and topographic astigmatism in the DALK and PK groups were -3.37 ± 2.3 diopters (D) and -3.76 ± 2.1 D (P = 0.53), and 3.57 ± 2.3 D and 4.16 ± 2.0 D (P = 0.34), respectively. (Micro)perforation of the Descemet's membrane occurred in 32% (9/28) of the DALK eyes, and 18% (5/28) of the patients required conversion to PK. Endothelial cell loss was not significantly different between DALK and PK when cases with perforation of Descemet's membrane were included in the (intention-to-treat) analysis (12 months: 19.1 ± 21.6 vs. 27.7 ± 11.1 P = 0.112). Rejection episodes were reported in 1 patient in the DALK group (epithelial rejection) and 3 patients in the PK group (all endothelial rejections). No graft failure occurred. CONCLUSIONS: One year after DALK performed without perforation of Descemet's membrane, EC loss is significantly lower, whereas the BSCVA is comparable to that in the PK group. In addition, no endothelial rejection occurred in the DALK group. However, Descemet's membrane perforation remains a major complication in DALK and warrants improvements to standardize the big-bubble technique.

Corneal graft dehiscence during swinging eyelid orbital decompression.

A 68-year-old man with Graves orbitopathy underwent a bilateral swinging eyelid orbital decompression for disfiguring proptosis. A penetrating keratoplasty for keratoconus of the left eye had been performed 13 years earlier. Prior to orbital decompression, biomicroscopy of the left eye showed a partially decompensated sutureless corneal graft with good wound apposition. The corneal stroma appeared edematous, and some epithelial bullae were seen. During orbital wall removal, the corneal wound dehisced for 270 degrees. Swinging eyelid orbital decompression is the technique of choice in the Netherlands for proptosis reduction in Graves orbitopathy. However, spatula pressure on the eye during surgery may cause rupture of the graft-host interface in eyes with previous corneal surgery such as penetrating keratoplasty.

Efficacy and safety of femtosecond laser-assisted corneal endothelial keratoplasty: a randomized multicenter clinical trial.

BACKGROUND: To evaluate the efficacy and safety of femtosecond laser-assisted endothelial keratoplasty (FLEK) versus penetrating keratoplasty (PK) in patients with corneal endothelial disease. METHODS: A randomized multicenter clinical trial of 80 eyes of 80 patients with corneal endothelial disease were randomized to FLEK or PK. Clinical outcomes (astigmatism and visual acuity) and incidence of postoperative complications were compared between the two groups. RESULTS: At 12 months, the percentage of eyes with a refractive astigmatism less than or equal to 3 diopters was higher in the FLEK group in comparison with the PK group (86.2% vs. 51.3%, P=0.004). The mean postoperative best corrected visual acuity was 20/70+/-2 lines in the FLEK group and 20/44+/-2 lines in the PK group (P<0.001), but the gain in the best corrected visual acuity between the two groups was not significantly different. The endothelial cell loss in the FLEK and PK group was 65+/-12% and 23+/-15% (P<0.001). The most common postoperative complication in the FLEK group was graft dislocation (27.8%). Wound healing related problems occurred in six eyes (15%) in the PK group and in none of the FLEK eyes. CONCLUSIONS: FLEK effectively reduces postoperative astigmatism and results in an absence of wound healing related problems in patients with endothelial disease. However, visual acuity is lower as compared with conventional PK, and the high level of endothelial cell loss warrants a modification of the insertion technique of the endothelial graft.

Preliminary results of femtosecond laser-assisted descemet stripping endothelial keratoplasty.

OBJECTIVE: To evaluate the preliminary visual results of femtosecond laser-assisted Descemet stripping endothelial keratoplasty (FS-DSEK). METHODS: We prospectively analyzed results of 20 consecutive patients with Fuchs endothelial dystrophy or aphakic/pseudophakic bullous keratopathy who underwent FS-DSEK. Best spectacle-corrected visual acuity (BSCVA), refraction, corneal topography, and endothelial cell density were measured preoperatively and 3 and 6 months after FS-DSEK. Corneal thickness was measured using an optical coherence tomography technique. RESULTS: The average BSCVA of 11 eyes with normal visual potential significantly improved from 20/110 +/- 4 lines to 20/57 +/- 1 line at 6 months (P < .007). At 6 months, the mean (SD) hyperopic shift was 2.24 (2.3) diopters (D). Preoperative and 6 months postoperative refractive astigmatism were -0.75 (0.9) D and -1.58 (1.1) D (P = .01), but the topographic astigmatism did not change postoperatively (P = .95). Mean (SD) endothelial cell density at 6 months was 1368 (425) cells/mm(2). There was a persistent deswelling of the graft up to 3 months postoperatively. Complications included graft dislocations requiring repositioning (20%), pupillary block glaucoma (5%), epithelial ingrowth (5%), and primary graft failure (5%). CONCLUSIONS: Femtosecond laser-assisted Descemet stripping endothelial keratoplasty was effective in treating endothelial failure with minimal induced refractive astigmatism, limited improvement of BSCVA, and induction of a hyperopic shift. Endothelial cell count and dislocation rate were significant, which may be related to the surgical technique.

Femtosecond laser-assisted inverted mushroom keratoplasty.

PURPOSE: To evaluate best-corrected visual acuity (BCVA), refractive outcome, corneal topography, optical coherence tomography, and endothelial cell density 12 months after femtosecond laser-assisted inverted mushroom keratoplasty. METHODS: We performed a prospective study of a surgical case series of 5 patients undergoing femtosecond laser-assisted inverted mushroom keratoplasty for pseudophakic bullous keratopathy or pre-Descemet X-linked ichthyosis. The femtosecond laser was used to create a top-hat configuration in the donor cornea and recipient cornea. Laser parameters were as follows: energy, 4.0 (anterior inner vertical side cut and horizontal lamellar cut) and 7.0 microJ (posterior outer vertical side cut); spiral pattern with a firing rate of 15 kHz. The size of the anterior inner diameter was 7.4 mm in the donor cornea and 7.0 mm in the recipient cornea. The posterior outer diameter was 9.0 mm in all eyes. RESULTS: At 6 and 12 months after surgery, all corneal grafts were clear and showed an excellent adaptation of the lamellar donor and recipient wound surfaces. At 12 months postoperatively, BCVA averaged 20/32 (range, 20/60-20/20), refractive cylinder averaged -3.20 +/- 2.0 D, topographical cylinder averaged 3.26 +/- 2.1 D, and the mean endothelial cell density was 1793 +/- 491 cells/mm2 (range, 954-2237 cells/mm2). The mean central corneal thickness and thickness of the posterior shelf was 517 +/- 3 and 175 +/- 8 microm, respectively. CONCLUSIONS: The femtosecond laser-assisted inverted mushroom keratoplasty shows good promise in surgical treatment of corneal diseases. The multiplanar fit between the donor and recipient cornea allows early suture removal and visual rehabilitation.

Graft insertion during Descemet-stripping automated endothelial keratoplasty: pulling the graft inward.

We describe a technique to facilitate insertion of the folded donor graft during Descemet-stripping automated endothelial keratoplasty (DSAEK). Surgery is performed using a standard technique, and the graft is pulled into the anterior chamber using a double-armed 10-0 polypropylene suture with straight 16 mm needles. The technique of pulling the graft inside the anterior chamber is easy and ensures that the graft is inserted and unfolded in the right direction. There is no compression of tissue so mechanical trauma to the endothelium is less than when an inserting forceps is used. The results in 12 cases are presented.

Late postoperative complications of backward implantation of a Vivarte phakic intraocular lens.

A 34-year-old man had bilateral implantation of a Vivarte phakic intraocular lens (pIOL) (Ciba Vision) to correct high myopia. Postoperatively, both pIOLs appeared to have been implanted backward. After a few weeks, the position of the pIOL in the right eye was corrected in a second procedure. For unknown reasons, the pIOL in the left eye was untouched. Three years after the initial implantation, the patient visited our hospital for a second opinion. He presented with a decrease in visual acuity from an intrapupillary membrane in the left eye. Endothelial cell count of the left cornea showed markedly decreased endothelial cell density. The patient was successfully treated by removing the IOL and excising the intrapupillary membrane, leading to recovery of visual acuity. This case presents the rare occurrence and management of late postoperative complications of backward implantation of a Vivarte pIOL.

Predicting cataract surgery results using a macular function test.

PURPOSE: To assess the predictive value of a macular function test in the preoperative evaluation of cataract patients. SETTING: Clinique Generale St-Jean, Brussels, Belgium. METHODS: This prospective study comprised 396 uneventful consecutive cataract procedures performed by 1 surgeon from September 2000 to February 2001. The best corrected visual acuity (BCVA) and the density and location of the lens opacities were recorded preoperatively. Macular function was assessed preoperatively using a Parinaud test at 12 cm with a hyperaddition of +8.0 diopters and extra illumination. The postoperative BCVA was compared with the results of the macular function test. RESULTS: Of the 359 eyes (90.7%) that could read the Parinaud 1 line on the preoperative hyperaddition test, 338 (94.2%) attained a final BCVA of 20/25 or better and 356 (99.2%), of 20/30 or better. Twenty-five eyes that could not read Parinaud 1 and presented with a dense nuclear or posterior subcapsular cataract also achieved a BCVA of 20/25 or better. Three eyes could read Parinaud 1 preoperatively but did not attain a BCVA of 20/30 or better postoperatively; 2 of the eyes had macular edema and 1, an opaque posterior capsule. CONCLUSIONS: The results of this study suggest that this simple macular function test has a positive predictive value of 94.2% in predicting a visual outcome of 20/25 or better after cataract surgery. The sensitivity was 94.2% and the specificity, 32.4%. The negative predictive value was 32.4% and the positive predictive value for a BCVA of 20/30 or better, 99.2%.