Systematic review for the development of a core outcome set for monofocal intraocular lenses for cataract surgery.

Introduction: The aim of the study was to define a core outcome set (COS) to be measured following cataract surgery for the postoperative evaluation of monofocal intraocular lenses (IOLs). Compared to current COSs, the present work provides updates considering the advances in the technology due to the development of new generation monofocal IOLs, which are characterized by a safety profile comparable to standard monofocal IOLs but with an extended range of intermediate vision. Methods: Healthcare professionals (ophthalmologist surgeons) and patients were involved in the selection of outcomes to be included in the COS, starting from a list of indicators retrieved from a systematic literature search. The search considered observational studies with both a retrospective or prospective design, case studies and classic randomized controlled trials (RCTs). A mixed methodology integrating a Delphi-driven and an expert panel approach was adopted to reach an agreement among clinicians, while patients were involved in the completion of a questionnaire. Results: The final COS included 15 outcomes. Eleven outcomes, all clinical, were considered for inclusion after a joint discussion among ophthalmologists; seven outcomes were linked to visual acuity, while the remaining to contrast sensitivity, refractive errors, aberrations and adverse events. Measurement metrics, method of aggregation and measurement time point of these outcomes were specified. The most important aspects for the patients were (1) quality of life after cataract surgery, (2) the capacity to perform activities requiring good near vision (e.g., reading), (3) spectacle independence, and (4) safety of movements without fear of getting hurt or falling (intermediate vision). Discussion: In a context with limited healthcare resources, it is important to optimize their use considering also the preferences of end-users, namely patients. The proposed COS, developed involving both ophthalmologists and patients, provides an instrument for the postoperative evaluation of different technologies in the context of monofocal IOLs, which can be used not only in clinical trials but also in clinical practice to increase the body of real-world evidence.

Artificial intelligence for detecting keratoconus.

BACKGROUND: Keratoconus remains difficult to diagnose, especially in the early stages. It is a progressive disorder of the cornea that starts at a young age. Diagnosis is based on clinical examination and corneal imaging; though in the early stages, when there are no clinical signs, diagnosis depends on the interpretation of corneal imaging (e.g. topography and tomography) by trained cornea specialists. Using artificial intelligence (AI) to analyse the corneal images and detect cases of keratoconus could help prevent visual acuity loss and even corneal transplantation. However, a missed diagnosis in people seeking refractive surgery could lead to weakening of the cornea and keratoconus-like ectasia. There is a need for a reliable overview of the accuracy of AI for detecting keratoconus and the applicability of this automated method to the clinical setting. OBJECTIVES: To assess the diagnostic accuracy of artificial intelligence (AI) algorithms for detecting keratoconus in people presenting with refractive errors, especially those whose vision can no longer be fully corrected with glasses, those seeking corneal refractive surgery, and those suspected of having keratoconus. AI could help ophthalmologists, optometrists, and other eye care professionals to make decisions on referral to cornea specialists. Secondary objectives To assess the following potential causes of heterogeneity in diagnostic performance across studies. • Different AI algorithms (e.g. neural networks, decision trees, support vector machines) • Index test methodology (preprocessing techniques, core AI method, and postprocessing techniques) • Sources of input to train algorithms (topography and tomography images from Placido disc system, Scheimpflug system, slit-scanning system, or optical coherence tomography (OCT); number of training and testing cases/images; label/endpoint variable used for training) • Study setting • Study design • Ethnicity, or geographic area as its proxy • Different index test positivity criteria provided by the topography or tomography device • Reference standard, topography or tomography, one or two cornea specialists • Definition of keratoconus • Mean age of participants • Recruitment of participants • Severity of keratoconus (clinically manifest or subclinical) SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register), Ovid MEDLINE, Ovid Embase, OpenGrey, the ISRCTN registry, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). There were no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 29 November 2022. SELECTION CRITERIA: We included cross-sectional and diagnostic case-control studies that investigated AI for the diagnosis of keratoconus using topography, tomography, or both. We included studies that diagnosed manifest keratoconus, subclinical keratoconus, or both. The reference standard was the interpretation of topography or tomography images by at least two cornea specialists. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted the study data and assessed the quality of studies using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. When an article contained multiple AI algorithms, we selected the algorithm with the highest Youden's index. We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS: We included 63 studies, published between 1994 and 2022, that developed and investigated the accuracy of AI for the diagnosis of keratoconus. There were three different units of analysis in the studies: eyes, participants, and images. Forty-four studies analysed 23,771 eyes, four studies analysed 3843 participants, and 15 studies analysed 38,832 images. Fifty-four articles evaluated the detection of manifest keratoconus, defined as a cornea that showed any clinical sign of keratoconus. The accuracy of AI seems almost perfect, with a summary sensitivity of 98.6% (95% confidence interval (CI) 97.6% to 99.1%) and a summary specificity of 98.3% (95% CI 97.4% to 98.9%). However, accuracy varied across studies and the certainty of the evidence was low. Twenty-eight articles evaluated the detection of subclinical keratoconus, although the definition of subclinical varied. We grouped subclinical keratoconus, forme fruste, and very asymmetrical eyes together. The tests showed good accuracy, with a summary sensitivity of 90.0% (95% CI 84.5% to 93.8%) and a summary specificity of 95.5% (95% CI 91.9% to 97.5%). However, the certainty of the evidence was very low for sensitivity and low for specificity. In both groups, we graded most studies at high risk of bias, with high applicability concerns, in the domain of patient selection, since most were case-control studies. Moreover, we graded the certainty of evidence as low to very low due to selection bias, inconsistency, and imprecision. We could not explain the heterogeneity between the studies. The sensitivity analyses based on study design, AI algorithm, imaging technique (topography versus tomography), and data source (parameters versus images) showed no differences in the results. AUTHORS' CONCLUSIONS: AI appears to be a promising triage tool in ophthalmologic practice for diagnosing keratoconus. Test accuracy was very high for manifest keratoconus and slightly lower for subclinical keratoconus, indicating a higher chance of missing a diagnosis in people without clinical signs. This could lead to progression of keratoconus or an erroneous indication for refractive surgery, which would worsen the disease. We are unable to draw clear and reliable conclusions due to the high risk of bias, the unexplained heterogeneity of the results, and high applicability concerns, all of which reduced our confidence in the evidence. Greater standardization in future research would increase the quality of studies and improve comparability between studies.

Enhanced Monofocal Intraocular Lenses: A Retrospective, Comparative Study between Three Different Models.

The purpose of this study was to compare the visual performance and optical quality between three new enhanced monofocal intraocular lenses (IOLs). This retrospective study included patients affected by cataracts with corneal astigmatism less than 0.75 D and no ocular comorbidities who underwent cataract surgery with bilateral implantation of Tecnis Eyhance ICB00 (Johnson & Johnson Vision Care, Inc., Jacksonville, FL, USA), Vivinex Impress XY1-EM (Hoya Surgical Optics, Singapore) or IsoPure 123 (PhysIOL, Liege, Belgium) IOLs. Three months postoperatively, monocular and binocular uncorrected and corrected distant, and intermediate and near visual acuities were measured. Binocular defocus curve, photopic contrast sensitivity, Point Spread Function (PSF), low order aberrations (LOAs), high order aberrations (HOAs), objective scatter index (OSI), halo and glare perception were also evaluated. This study included a total of 72 eyes from 36 patients. Visual acuity outcomes, PSF, LOAs, HOAs and OSI were similar between groups. There were no statistically significant differences in terms of photopic contrast sensitivity, halo or glare perception. In patients without ocular comorbidities, the Eyhance ICB00 IOL, the Vivinex Impress IOL and the Isopure IOL-even though based on different optical properties-provided similar results in terms of visual acuity, contrast sensitivity and intraocular aberrations, with no influence on photic phenomena.

Beyond vision:Cataract and health status in old age, a narrative review.

Cataract is a leading cause of visual impairment in old age. Lens opacification is notoriously associated with several geriatric conditions, including frailty, fall risk, depression and cognitive impairment. The association is largely attributable to visual impairment, while other mechanisms, associated with extraocular comorbidity and lifestyle, might partly explain this correlation. Available literature suggests that cataract surgery may be effective in decreasing fall risk, improving depressive symptoms and limiting the risk of cognitive impairment and dementia incidence, although intervention studies on these outcomes are still limited. In this review we also emphasize the need to move from the concept of visual acuity to functional vision, especially in the context of the geriatric patient. Research is needed regarding the effect on the cited outcomes of different cataract treatment strategies, such as systematic bilateral versus monolateral surgery and use of different intraocular lenses.

Efficacy of vector thermal pulsation treatment in reducing postcataract surgery dry eye disease in patients affected by meibomian gland dysfunction.

PURPOSE: To evaluate the effect of a single LipiFlow vector thermal pulsation treatment performed before cataract surgery in reducing signs and symptoms of postoperative dry eye disease (DED) in patients with mild-moderate meibomian gland dysfunction (MGD). SETTING: Eye Clinic, Careggi Hospital, University of Florence, Florence, Italy. DESIGN: Prospective unmasked randomized controlled clinical trial. METHODS: This study included patients affected by age-related cataract and mild-moderate MGD, who were randomized into 2 groups: (1) a single LipiFlow treatment performed at 5 preoperative weeks and (2) warm compresses and eyelid massages twice a day for 1 preoperative month (control group). Noninvasive break-up time (NI-BUT), Schirmer test, Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, and MG functionality parameters were evaluated at visit 0 (5 preoperative weeks), visit 1 (1 preoperative week), and visit 2 (1 postoperative month). Confocal microscopy of the MG of lower eyelids was performed at visit 0 and visit 2. RESULTS: A total of 46 patients (46 eyes) were enrolled. In the LipiFlow group (n = 23), NI-BUT, SPEED questionnaire, and MG functionality parameters significantly improved at visit 1 ( P < .05) and visit 2 ( P < .05) compared with baseline and remained stable postoperatively. In the control group (n = 23), they did not significantly improve after treatment, while worsened postoperatively. Moreover, the changes in all parameters from baseline were significantly different between the 2 groups. Confocal microscopy imaging highlighted lower postoperative MG alterations in the LipiFlow group. CONCLUSIONS: A single preoperative LipiFlow treatment was effective in preventing postcataract surgery DED in patients with mild-moderate MGD. Postoperatively, treated patients displayed a better ocular surface status compared with warm compresses.

3D Visualization System in Descemet Membrane Endothelial Keratoplasty (DMEK): A Six-Month Comparison with Conventional Microscope.

Background: To compare the efficacy and safety of Descemet membrane endothelial keratoplasty (DMEK) surgery using the three-dimensional (3D) display system NGENUITY to DMEK surgery performed with the traditional microscope (TM) in patients affected by Fuchs Endothelial Corneal Disease (FECD). Methods: Retrospective comparative study of 40 pseudophakic eyes of 40 patients affected by FECD who underwent DMEK surgery. Twenty patients (3D group) were operated on using the 3D display system and 20 patients (TM group) were operated on using the traditional microscope. Best spectacle corrected visual acuity (BSCVA), central corneal thickness (CCT), endothelial cell density (ECD) and corneal densitometry (CD) values were documented before and at 1, 3 and 6 months after DMEK. Intra- and postoperative complications were recorded. Results: The baseline assessments did not differ between the two groups (p > 0.05). Global surgical time and time to perform descemetorhexis were significantly lower in the TM group (p = 0.04 and p = 0.02, respectively). BSCVA, CCT, ECD and CD values did not differ significantly in the two groups at all follow-ups (p > 0.05). Complication rate was similar between the two groups. Conclusion: Three-dimensional display systems can be securely employed in DMEK surgery considering the satisfactory clinical outcomes, including Scheimpflug CD. Nevertheless, the slightly longer surgical time of the 3D DMEKs may lead to surgeons' hesitancy. The main advantages of the heads-up approach may be the improved ergonomic comfort during surgery and the utility of assistants in surgical training.

Manual DALK in Keratoconus: An Ex Vivo Light and Transmission Electron Microscopy Analysis 2 Years After Surgery.

PURPOSE: The aim of this study was to evaluate the microscopic structure of a human cornea 2 years after manual deep anterior lamellar keratoplasty (DALK) for keratoconus with a recipient residual stromal bed thickness of 100 µm, using light and transmission electron microscopy. METHODS: A human cornea treated with manual DALK for keratoconus 2 years before was removed during penetrating keratoplasty because of stromal opacity of unknown origin, involving about half of the sample. The transparent half of the specimen was processed for light and transmission electron microscopy. RESULTS: Light microscopy examination performed with different staining techniques (hematoxylin and eosin, Picrosirius red, and Masson trichrome) revealed a homogeneous stroma. No interface was detected. Electron microscopy confirmed these findings. CONCLUSIONS: This study confirmed the available clinical and confocal studies that show progressive stromal remodeling after manual DALK. Two years after surgery, no posterior stromal interface was detected.

Hyaluronic Acid/Trehalose Ophthalmic Solution in Reducing Post-Cataract Surgery Dry Eye Signs and Symptoms: A Prospective, Interventional, Randomized, Open-Label Study.

The purpose of this prospective study was to evaluate the efficacy of the perioperative use of a hyaluronic acid (HA) and trehalose ophthalmic solution (Thealoz® Duo) in reducing post-cataract surgery dry eye signs and symptoms in patients with mild/moderate dry eye disease (DED). One hundred and twenty patients, scheduled for unilateral cataract surgery, were randomized into three groups: (1) group A: HA/trehalose three times/day in the preoperative week and for 5 postoperative weeks; (2) group B: HA/trehalose for only 5 postoperative weeks; (3) group C: no artificial tears. In groups A and B, OSDI (Ocular Surface Disease Index) questionnaire scores were significantly lower than group C at all the postoperative visits; in group A they were significantly lower than group B on the day of surgery, with similar results in the first and fifth weeks after surgery. In groups A and B, break-up time (BUT) was significantly higher than group C during the postoperative period (p ≤ 0.001). In comparison to the preoperative values, BUT in group A remained stable 7 days after surgery; however, in groups B and C, it significantly decreased. In conclusion, the HA/trehalose ophthalmic solution effectively reduced post-cataract surgery DED signs and symptoms in patients with mild/moderate DED, particularly if also administered in the preoperative period.

Co-expression of the SARS-CoV-2 entry receptors ACE2 and TMPRSS2 in healthy human conjunctiva.

The purpose of this study was to evaluate the expression of the SARS-CoV-2 receptors ACE2 and TMPRSS2 in an immortalized human conjunctival epithelial cell line and in healthy human conjunctiva excised during ocular surgery, using Western blot, confocal microscopy and immunohistochemistry. The Western blot showed that ACE2 and TMPRSS2 proteins were expressed in human immortalized conjunctival cells, and this was confirmed by confocal microscopy images, that demonstrated a marked cellular expression of the viral receptors and their co-localization on the cell membranes. Healthy conjunctival samples from 11 adult patients were excised during retinal detachment surgery. We found the expression of ACE2 and TMPRSS2 in all the conjunctival surgical specimens analyzed and their co-localization in the superficial conjunctival epithelium. The ACE2 Western blot levels and immunofluorescence staining for ACE2 were variable among specimens. These results suggest the susceptibility of the conjunctival epithelium to SARS-CoV-2 infection, even though with a possible interindividual variability.

Iatrogenic Dry Eye Disease: Dealing with the Conundrum of Post-Cataract Discomfort. A P.I.C.A.S.S.O. Board Narrative Review.

The incidence and prevalence of dry eye disease (DED) after cataract surgery is greatly underestimated. The severity of dry eye symptoms has been reported to peak 7 days after cataract surgery and may persist for months, significantly affecting patients' quality of life (QoL). The importance of considering surgical outcomes not only in terms of visual acuity, but also in terms of the patients' QoL, necessitates the assessment and evaluation of the ocular surface by the cataract surgeon prior to the procedure. This narrative review, drafted by the P.I.C.A.S.S.O. (Italian Partners for the Correction of Ocular Surface Alterations) board, analyses the physiopathology of post-cataract surgery DED and highlights the pre-, intra- and postoperative risk factors that may alter ocular surface homeostasis; it proposes a practical comprehensive algorithm for the prevention, treatment and management of DED associated with cataract surgery. Particular attention needs to be paid to the pre- and intraoperative risk factors to reduce the incidence of postoperative dry eye and to improve cataract surgery outcome.

Protecting the Ocular Surface at the Time of Cataract Surgery: Intracameral Mydriatic and Anaesthetic Combination Versus A Standard Topical Protocol.

INTRODUCTION: An intracameral mydriatic and anaesthetic combination has been approved for injection into the anterior chamber in order to provide rapid and stable mydriasis and sustained intraocular anaesthesia during cataract surgery. METHODS: In this prospective study, conducted at the Eye Clinic, University of Florence, Italy, we compared phacoemulsification using the standard mydriatic-anaesthetic eye-drop protocol with that using the standard protocol in terms of corneal changes, ocular surface parameters and visual quality. Sixty patients (60 eyes) were included in the study, with 30 eyes receiving Mydrane®, a novel injectable intracameral solution, during phacoemulsification (Mydrane protocol, MP) and 30 eyes receiving the standard mydriatic-anaesthetic eye drops (standard protocol, SP). The following parameters were assessed using in vivo confocal microscopy (IVCM): central corneal thickness (CCT); flare and cells in the aqueous humor (Flare); keratocyte activation (KA), Langerhans' cell density (LCD), nerve fibre density (NFD) and endothelial cell density (ECD). The Ocular Surface Disease Index (OSDI) score, tear breakup time (TBUT) and Schirmer's test I (STI) were also evaluated. The Optical Scattering Index (OSI) and its standard deviation (OSI-SD) were assessed using the Optical Quality Analysing System (Visiometrics SL, Terrassa, Spain). RESULTS: In the MP group, CCT, Flare, KA and LCD values returned to baseline values within 15 postoperative days. The mean ECD and NFD decreased significantly in both groups from baseline at all follow-up assessments, with no statistically significant difference between groups. TBUT returned to the preoperative level at postoperative day 15 in the MP group. OSDI scores and STI were significantly worse in both groups at all follow-up assessments compared to baseline. At postoperative day 15 OSI and OSI-SD values were significantly better in the MP group than in the SP group. CONCLUSIONS: The use of Mydrane during cataract surgery showed a good safety profile and few toxic side effects, ensuring better optical quality and tear film stability.

A new ophthalmic formulation containing antiseptics and dexpanthenol: In vitro antimicrobial activity and effects on corneal and conjunctival epithelial cells.

Antibiotic resistance is increasing even in ocular pathogens, therefore the interest towards antiseptics in Ophthalmology is growing. The aim of this study was to analyze the in vitro antimicrobial efficacy and the in vitro effects of an ophthalmic formulation containing hexamidine diisethionate 0.05%, polyhexamethylene biguanide (PHMB) 0.0001% disodium edetate (EDTA) 0.01%, dexpanthenol 5% and polyvinyl alcohol 1.25% (Keratosept, Bruschettini, Genova, Italy) on cultured human corneal and conjunctival cells. The in vitro antimicrobial activity was tested on Staphylococcus aureus, Methicillin-Resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Streptococcus pneumoniae, Streptococcus pyogenes and Streptococcus mitis. For each microbial strain 10 µL of a 0.5 MacFarland standardized bacterial inoculum were incubated at 25 °C with 100 µL of ophthalmic solution for up to 6 h. After different periods of time, samples were inoculated on blood agar with 5% sheep blood. Moreover, a 0.5 MacFarland bacterial inoculum was seeded in triplicate on Mueller-Hinton Agar or on Mueller-Hinton Fastidious Agar; then a cellulose disc soaked with 50 µL of ophthalmic solution was applied on the surface of agar and plates were incubated for 18 h at 37 °C, in order to evaluate the inhibition of bacterial growth around the disc. Human corneal and conjunctival epithelial cells in vitro were incubated for 5, 10 and 15 min with Keratosept or its components. The cytotoxicity was assessed through the release of cytoplasmic enzyme lactate dehydrogenase (LDH) into the medium immediately after exposure to the drugs; the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay was performed to evaluate the metabolic cell activity. Our results show that Keratosept ophthalmic solution gave an average logarithmic (log) reduction of bacterial load of 2.14 ± 0.35 within 6 h of exposure (p-value < 0.05 versus control saline solution). On agar plates, all microbial strains, excluding P. Aeruginosa, showed an inhibition zone of growth around the Keratosept-soaked discs. Keratosept and its components after 5 and 10 min did not show any cytotoxic effect on cultured corneal and conjunctival cells, and only after 15 min a significant reduction of cell viability and an increase of cytotoxicity compared to control (vehicle) was seen; dexpanthenol 5% and polyvinyl alcohol accelerated the wounding of corneal cells in vitro. In conclusion, Keratosept showed good antimicrobial activity on the tested strains; the ophthalmic solution and its components were safe and non-toxic for the corneal and conjunctival epithelial cells for 5 and 10 min at the concentrations analyzed, and dexpanthenol 5% and polyvinyl alcohol promoted the wounding of corneal cells.

Femtosecond laser-assisted cataract surgery in eyes with shallow anterior chamber depth: comparison with conventional phacoemulsification.

PURPOSE: To compare the postoperative outcomes between femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification in eyes with shallow anterior chamber depth (ACD). SETTING: Eye Clinic, NEUROFARBA Department, University of Florence, Italy. DESIGN: Prospective case series. METHODS: Forty eyes of 40 patients with senile cataract and true ACD less than 2.00 mm underwent FLACS (femto group, n = 20) or manual phacoemulsification (phacoemulsification group, n = 20). Preoperatively and 1 week and 1 month and 6 months postoperatively, central corneal thickness (CCT) and endothelial cell density were evaluated; basal epithelial cell (BEC) and Langerhans dendritic cell (LDC) densities and keratocyte activation were assessed using in vivo corneal confocal microscopy. Intraoperative parameters such as cumulative dissipated energy (CDE) and ultrasound (US) power were recorded. RESULTS: Endothelial cell loss (ECL) was significantly lower in the femto group at all timepoints (P ≤ .001). In the phacoemulsification group, the CCT was significantly higher 1 week (P < .001) and 1 month (P < .001) postoperatively than preoperatively; conversely, in the femto group, it was higher only after 1 week (P < .001). BECs and LDCs significantly increased at 1 postoperative week (P < .001), returning to preoperative values after 1 month in both groups. Keratocyte activation remained significantly higher at 1 postoperative month only in the phacoemulsification group (P = .005). CDE and US power were lower in the femto group (P = .017 and P = .001, respectively); they were correlated with ECL (r = 0.662, P = .000; r = 0.389, P = .013). CONCLUSIONS: In eyes with shallow ACD, FLACS was a safe and an effective technique, significantly reducing the postoperative ECL and corneal inflammation compared with conventional phacoemulsification.

Protecting the Ocular Surface in Cataract Surgery: The Efficacy of the Perioperative Use of a Hydroxypropyl Guar and Hyaluronic Acid Ophthalmic Solution.

PURPOSE: To evaluate the effects of a hydroxypropyl guar (HPG) and hyaluronic acid (HA) ophthalmic solution in terms of post-cataract surgery dry-eye disease (DED) prevention. PATIENTS AND METHODS: In this retrospective study, the data of 419 patients not previously affected by DED, who had undergone unilateral cataract surgery in 17 Italian centers with different perioperative lubricating regimens, were retrospectively reviewed. Patients who had instilled HPG/HA solution 3 times/day in the preoperative week and for two postoperative months were included in group A; group B only instilled HPG/HA for two postoperative months; group C did not instill any perioperative artificial tears. All patients followed the same antibiotic and anti-inflammatory postoperative topical regimen. The scores of SPEED (Standard Patient Evaluation of Eye Dryness) questionnaire, tear break-up time (BUT) and corneal fluorescein staining (CFS, Oxford scale), performed at the preoperative visit and at one, four and eight postoperative weeks, were evaluated. RESULTS: In groups A and B, the SPEED scores were significantly lower than group C in the whole postoperative period. In group A, the SPEED scores were significantly lower than group B 1 and 4 weeks after surgery (p<0.001 and p=0.021). In group C, 25% of patients reported symptom scores corresponding to mild-moderate dry eye 4 and 8 weeks after surgery. The fluorescein tear BUT in groups A and B was significantly higher than group C in the whole postoperative period (p<0.001). In group A, BUT was significantly higher than group B 4 weeks after surgery (p=0.016). More patients showed no corneal fluorescein staining (CFS grade=0) in groups A and B than group C at all the postoperative visits. CONCLUSION: The hydroxypropyl guar and hyaluronic acid ophthalmic solution was effective at reducing post-cataract surgery ocular discomfort and tear instability, particularly if also administered in the preoperative period.

Effect of manual, preloaded, and automated preloaded injectors on corneal incision architecture after IOL implantation.

PURPOSE: To analyze the effects on corneal morphology of manual, preloaded, and automated preloaded intraocular lens (IOL) injectors in eye bank human corneas by environmental scanning electron microscopy (ESEM) and in patients after phacoemulsification using anterior segment optical coherence tomography (AS-OCT). SETTINGS: Eye Clinic, Careggi University Hospital, Florence, Italy. DESIGN: Retrospective and experimental study. METHODS: Seventy-eight corneal incisions were examined after IOL implantation: 30 in human corneas mounted on an artificial chamber using ESEM (ex vivo); 48 in patients undergoing phacoemulsification (in vivo). Three different injectors were used for both analyses: manual (Monarch III, n = 26), manual preloaded (UltraSert, n = 26), and automated preloaded system (AutonoMe, n = 26). Thirty IOLs were implanted in the ex vivo study: 5 intermediate and 5 high dioptric powers for AcrySof IQ (Monarch and UltraSert) and for Clareon (AutonoMe) IOLs. In the in vivo analysis, 16 corneal wounds for each injector were evaluated using AS-OCT; in the ex vivo study, incision width was measured and Descemet membrane detachment, posterior wound retraction, and posterior gape were analyzed. RESULTS: In the eye bank corneas, the incision width was significantly wider in the high dioptric power IOL manual subgroup (P < .05), with more Descemet tearing compared with AutonoMe. In the in vivo study, the incidence of Descemet membrane detachment, posterior gape, and wound retraction was lower in the automated preloaded group at 1 postoperative day 1. CONCLUSIONS: The automated preloaded injector ensured less trauma to the wound and contributed to preserving the endothelial side of the incision even during the implantation of high-power IOLs and in the early postoperative period.

Ultrathin Descemet stripping automated endothelial keratoplasty versus Descemet membrane endothelial keratoplasty: a fellow-eye comparison.

BACKGROUND: To compare the visual outcome and patients' satisfaction after ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) and Descemet membrane endothelial keratoplasty (DMEK) performed on fellow eyes of the same patients. METHODS: In this retrospective study, the records of 18 pseudophakic patients affected by Fuchs endothelial dystrophy who underwent DMEK in one eye and UT-DSAEK in the fellow eye were reviewed. Best corrected visual acuity (BCVA), corneal pachymetry, keratometry, corneal aberrations, photopic and mesopic contrast sensitivity, and endothelial cell counts measured 12 months after surgery in either eye were analyzed and compared. The results of a satisfaction questionnaire were also reviewed. RESULTS: Twelve months after surgery, BCVA was not significantly different in UT-DSAEK and DMEK eyes (0.10 ± 0.04 and 0.07 ± 0.07 logMAR, respectively); at both 4- and 6 mm optical zones total and posterior corneal higher order aberrations (HOAs), posterior astigmatism and total coma were significantly lower after DMEK; BCVA in both groups was significantly correlated mainly with anterior corneal aberrations; contrast sensitivity was higher after DMEK especially in mesopic conditions and at medium spatial frequencies; the endothelial cell density was similar, although slightly higher in the UT-DSAEK group (p = 0.10). The satisfaction questionnaire showed that although patients were highly satisfied from both procedures, more than half of them preferred DMEK and reported a more comfortable and quicker postoperative recovery. CONCLUSIONS: DMEK and UT-DSAEK showed no evidence of difference in terms of postoperative BCVA, although DMEK had a better performance in terms of contrast sensitivity, posterior corneal aberrations and overall patient satisfaction.

New Therapeutic Strategy and Innovative Lubricating Ophthalmic Solution in Minimizing Dry Eye Disease Associated with Cataract Surgery: A Randomized, Prospective Study.

INTRODUCTION: To evaluate the effects of a new lubricating, antioxidant solution (VisuEvo®) on dry eye disease (DED) in patients undergoing cataract surgery. METHODS: Patients requiring cataract surgery with either healthy ocular surface or mild DED (tear break-up time, TBUT > 7, Schirmer I test > 15 mm/5 min) were enrolled in this multicenter, open-label, randomized, prospective study. Scheduled visits were 2 weeks before surgery (screening), day of surgery (V0), week 1 (V1), and 2 (V2) after surgery. VisuEvo® was self-administered three times daily for the whole study duration (group A); the control group (group B) had no tear substitute administration. The primary endpoint was the change in TBUT over time; the secondary endpoints were changes in Ocular Surface Disease Index (OSDI), ocular surface staining, the Schirmer I test, and osmometry. RESULTS: A total of 45 patients were included (group A, 23; group B, 22; age 74 ± 8 years). At the screening, TBUT was similar between the groups (group A, 8.5 ± 1.8 s; group B, 7.8 ± 0.7, p = 0.11). At the scheduled visits, TBUT increase vs screening visit was significantly higher in group A: +1.2 s at V0, +1.4 s at V1, and +1.9 s at V2 (p < 0.01). Also, OSDI was significantly lower in group A at V0, V1, and V2 (p < 0.027). After surgery, corneal staining was absent in 65-78% of group A compared with 54-59% in group B. The two groups did not show any significant differences of osmometry and the Schirmer I test. CONCLUSIONS: The ocular surface was more protected and quickly restored from surgery when VisuEvo® was used from 2 weeks preoperatively to 2 weeks postoperatively. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT03833908.

Visual outcome, optical quality, and patient satisfaction with a new monofocal IOL, enhanced for intermediate vision: preliminary results.

PURPOSE: To compare visual outcomes, contrast sensitivity, optical quality, spectacle independence, and visual disturbances in patients implanted with 2 models of monofocal intraocular lenses (IOLs). SETTING: Eye Clinic, Department of NEUROFARBA, University of Florence, Italy. DESIGN: Prospective case series METHODS:: Patients without ocular comorbidities and corneal astigmatism less than 0.75 diopters (D) had cataract surgery with bilateral implantation of either of 2 monofocal IOLs, the Tecnis ZCB00 or the Tecnis Eyhance ICB00 (Johnson & Johnson Vision Care, Inc.). Six months postoperatively, monocular and binocular uncorrected and corrected (at 4 m) distance visual acuities, as well as uncorrected (UIVA), distance corrected, and corrected intermediate (at 66 cm) and near (at 40 cm) visual acuities were measured. Photopic contrast sensitivity, binocular defocus curve, objective scatter index (OSI), Strehl ratio, modulation transfer function (MTF) cutoff, halo and glare perception, and spectacle independence were also evaluated. RESULTS: A total of 80 eyes of 40 patients were evaluated in this study. Although monocular and binocular uncorrected and corrected distance and near visual acuities were similar between groups, monocular and binocular UIVA were significantly higher in the Eyhance group. There were no statistically significant differences between the 2 groups in terms of photopic contrast sensitivity, OSI, MTF cutoff, Strehl ratio, and glare and halo perception. The ICB00 IOL provided better spectacle independence than the ZCB00 IOL for intermediate distance. CONCLUSIONS: In patients without ocular comorbidities, the Eyhance ICB00 IOL provided better UIVA and higher intermediate spectacle independence without impairment of far vision and visual quality, compared with the ZCB00 IOL.