Rapid assessment of avoidable blindness-based healthcare costs of diabetic retinopathy in Hungary and its projection for the year 2045.

BACKGROUND/AIMS: The purpose of this study was to estimate the total healthcare cost associated with diabetic retinopathy (DR) in the population aged 18 years and older in Hungary, and its projection for the year 2045. METHODS: A cost model was developed based on the standardised rapid assessment of avoidable blindness with the diabetic retinopathy module (RAAB+DRM) methodology and recently reported prevalent-based cost of illness model. Projection for 2045 was made based on the estimation for increasing diabetes mellitus (DM) prevalence of the International Diabetes Federation. Costs were analysed from the perspective of the healthcare system and the patients. Our DR cost model was constructed according to the Scottish DR grading scale and based on the DR severity stadium. RESULTS: The total DR-associated healthcare cost was US$145.8 million in 2016 and will increase to US$169.0 million by 2045. The two major cost drivers were intravitreal antivascular endothelial growth factor injections and vitrectomies in this study (US$126.4 million in 2016 and US$146.5 million in 2045); they amounted to 86.7% of the total treatment cost of DR. The DR-related cost per patient was US$180.5 in Hungary. CONCLUSIONS: The cost per patient for treating DR was lower in Hungary than in other countries. Due to the increasing socioeconomic burden of proliferative DR and diabetes-related blindness, it would be important to invest in DR screening, prevention and early treatment. Our new RAAB-based cost of DR model may facilitate comparisons of DR treatment costs across countries.

Cataract blindness in Hungary.

AIM: To estimate the prevalence of blindness and visual impairment resulting from cataract in the population aged ≥50y in Hungary, and to assess the cataract surgical services. METHODS: A rapid assessment of avoidable blindness (RAAB) was conducted. A total of 3523 eligible people were randomly selected and examined. Each participant underwent surgery for cataract was interviewed with regard to the year, place, and costs of the surgery. Participants with obvious cataract were asked why they had not yet undergone surgery (barriers to surgery). RESULTS: An estimated 12 514 people were bilaterally blind; the visual acuity (VA) in 19 293 people was <6/60, and the VA in 73 962 people was <6/18 in the better eye due to cataract. An estimated 77 933 eyes are blind; 98 067 eyes had a VA of <6/60, and an estimated 277 493 eyes had a VA of <6/18 due to cataract. Almost all cataract surgeries were conducted in government hospitals. The age- and sex-adjusted cataract surgical coverage with VA<3/60 in eyes was 90.0%. The rate of good visual outcome after surgery was 79.5%. Ocular comorbidity was the main cause of poor outcome (78.1%), followed by late complications (such as posterior capsule opacification) (17.2%), inadequate optical correction (3.1%), and surgical complications (1.6%). The main barrier to surgery in people with bilateral cataract and VA of <6/60 was 'need not felt'. CONCLUSION: The prevalence of visual impairment resulting from cataract is slightly higher than expected. The quality of the cataract surgical service seems adequate in Hungary. However, the number of cataract operations per year should continue to increase due to the increasing patient demands and the aging population.

Evaluation of mechanical resistance to tearing of the anterior lens capsule after staining with different concentrations of trypan blue.

PURPOSE: To evaluate and compare the mechanical resistance to tearing of the anterior lens capsule opening after staining with different concentrations of trypan blue in ex vivo porcine eyes. SETTING: Semmelweis University, and Budapest University of Technology and Economics, Budapest, Hungary. DESIGN: Experimental study. METHODS: The study comprised 75 porcine eyes. The capsule was unstained in the Control Group (n = 25 eyes), 0.06% trypan blue was used to stain the capsule in Stained 1 Group (n = 25 eyes), and 0.1% trypan blue was used to stain the capsule in Stained 2 Group (n = 25 eyes). After capsulorhexis, the capsule openings were stretched with custom-designed testing equipment until they ruptured. The rupture force (RF), circumference stretching ratio (CSR), and secant modulus at 10 mN (SM10mN) and 50 mN (SM50mN) were evaluated. RESULTS: In total, 75 eyes were enrolled. There were no statistically significant differences in the RF (P = .8924) or CSR (P = .3876) among the groups. There were no statistically significant differences in the SM10mN (P = .8215) or SM50mN (P = .4184) among the groups. CONCLUSIONS: In this porcine eye model, the trypan blue concentrations that are routinely used in cataract surgery had no effect on capsular rim stability.

Vitrectorhexis in penetrating eye injuries in adults.

INTRODUCTION: Vitrectorhexis is an alternative for manual continuous curvilinear capsulorhexis originally developed for paediatric cataract surgery. The aim of our study was the evaluation of the technique in adult patients with penetrating ocular injury and traumatic cataracts. METHODS: Eight eyes of 8 patients (23-41 years, all males) had penetrating mechanical corneal trauma. Anterior lens capsule was penetrated in all cases and additional posterior capsule defect in five cases. Intraocular foreign body was detected in one case in the crystalline lens and in two cases in the posterior segment. Standard 23G infusion cannula and vitreous cutter were applied to perform anterior capsule opening, removal of lens material, anterior vitrectomy and pars plana vitrectomy if needed. No phacoemulsification or irrigation/aspiration probe was used. RESULTS: Vitrectorhexis could be performed in 7 out of 8 cases with the preservation of peripheral anterior capsule; primary implantation of posterior chamber intraocular lens was possible in all cases (in the bag in three eyes and into the sulcus in five eyes). Anterior chamber was stable in all cases intraoperatively, and no dropped nucleus or lens fragment loss was observed. Surgery was combined with pars plana vitrectomy in three cases, with foreign body removal (when necessary). No postoperative complication occurred. CONCLUSION: Vitrectorhexis was found to be an effective and safe alternative method in the management of complex anterior segment trauma cases. With its use, traditional cataract surgical devices can be substituted and additional benefits of vitreous cutter can be utilized in selected cases, especially in young adults.

Diabetes and diabetic retinopathy in people aged 50†years and older in Hungary.

BACKGROUND/AIMS: The purpose of this study was to estimate the prevalence of diabetes mellitus (DM) and diabetic retinopathy (DR) in the population aged 50 years and older in Hungary, and to assess the coverage of diabetic eye care services. METHODS: In total, 105 clusters of 35 people aged 50 years or older were randomly selected. The standardised rapid assessment of avoidable blindness (RAAB) with the diabetic retinopathy module (DRM) was used. Participants were classified as having DM if they were known to have DM or if their random blood glucose level was ≥200 mg/dL. Dilated fundus examination and Scottish DR grading were performed. RESULTS: In total, 3523 (95.9%) out of 3675 eligible subjects were examined. And 705 (20.0%) out of 3523 had known (661) or newly diagnosed DM (44). Twenty per cent of participants with known DM had a blood glucose level ≥200 mg/dL, and 27.4% had never had an ophthalmological examination for DR. Prevalence of DR and/or maculopathy was 20.7% and prevalence of sight-threatening DR (STDR) was 4.3% in one or both eyes among participants with DM. CONCLUSIONS: Prevalence of DM was in line with findings of other RAAB+DRM surveys and slightly lower than the unpublished earlier age-matched Hungarian estimate. Prevalence of DR was slightly lower than expected. The prevalence of STDR was low in people aged 50 years and older in Hungary compared with the results of other RAAB with DRM surveys. DR screening coverage was low. To prevent severe complications of DM and possible concomitant visual loss, the coverage of ophthalmic examinations in patients with DM should be increased.

One-Day Use of Preoperative Topical Nonsteroidal Anti-Inflammatory Drug Prevents Intraoperative Prostaglandin Level Elevation During Femtosecond Laser-Assisted Cataract Surgery.

PURPOSE: To determine if pretreatment with topical nonsteroidal anti-inflammatory drug (NSAID) prior to femtosecond laser-assisted cataract surgery (FLACS) prevents intraoperative prostaglandin level elevation as a potential risk factor of postoperative complications. PATIENTS AND METHODS: Thirty-six patients with clinically significant cataract and without any concomitant general or ophthalmic disease were enrolled into the three age-matched groups of the study. The mean age of the patients was 62.3 ± 13.1 years. The first group of patients underwent traditional phacoemulsification (Control group), on the second group of patients FLACS was performed, and the third group of patients received topical 0.1% nepafenac pretreatment for 1one day prior to FLACS. Before the phacoemulsification part of the cataract surgery, approximately 110 µL of aqueous humor was collected in all groups. Total prostaglandin concentrations of the collected aqueous humor samples were evaluated by enzyme immunoassay (EIA). RESULTS: The mean of the total prostaglandin concentrations of the aqueous humor samples was 208.8 ± 140.5 pg/mL in patients in the control group, 1449.1 ± 1019.7 pg/mL in the FLACS group (p > 0.001), and 92.2 ± 51.7 pg/mL in the group pretreated with topical NSAID before the FLACS (p > 0.001 compared to FLACS; p > 0.01 compared to control), respectively. CONCLUSIONS: FLACS surgery increases intracameral prostaglandin concentration. However, using preoperative 1-day-long nonsteroid anti-inflammatory drops prior to FLACS, this intraoperative increase diminishes. Our study raises the possibility that NSAID pretreatment may be routinely administered before FLACS cataract surgeries to achieve a further decrease in the potential complications of increased total prostaglandin concentration during FLACS surgeries.

Evaluation of the mechanical properties of the anterior lens capsule following femtosecond laser capsulotomy at different pulse energy settings.

PURPOSE: To evaluate and compare the mechanical properties of anterior capsule opening performed with femtosecond laser capsulotomy at different energy settings in ex vivo porcine anterior lens capsule specimens. METHODS: Twenty-five fresh porcine eyes per group were included in the study. Femtosecond laser capsulotomy was performed with three different pulse energy levels: 2 µJ (low energy group), 5 µJ (intermediate energy group), and 10 µJ (high energy group). The capsule openings were stretched with universal testing equipment until they ruptured. The morphologic profile of the cut capsule edges was evaluated using scanning electron microscopy. RESULTS: The high energy group had significantly lower rupture force (108 ± 14 mN) compared to the intermediate energy group (118 ± 10 mN) (P < .05) and low energy group (119 ± 11 mN) (P < .05), but the difference between the intermediate energy and low energy groups was not significant (P = .9479). The high energy group had significantly lower circumference stretching ratio (144% ± 3%) compared to the intermediate energy group (148% ± 3%) (P < .05) and low energy group (148% ± 3%) (P < .05), but the difference between the intermediate energy group and low energy group was not significant (P = .9985). Scanning electron microscopy images showed that the edge was only serrated with low and intermediate energy, but additional signs of collagen melting and denaturation were observed at high energy. CONCLUSIONS: Anterior capsule openings created at a high energy level were slightly weaker and less extensible than those created at low or intermediate levels, possibly due to the increased thermal effect of photo-disruption.

[Results of femtosecond laser-assisted cataract surgery using the new 2.16 software and the SoftFit® Patient Interface]. / A femtoszekundumlézer-asszisztált szürkehályog-mutét eredményei az új 2.16-os szoftverrel és a módosított SoftFit® páciensi felszínnel.

INTRODUCTION: Femtosecond laser-assisted cataract surgery improved the results of cataract surgeries. AIM: Outcome analysis of femtosecond laser-assisted cataract surgery using the novel 2.16 software and the SoftFit(®) Patient Interface. METHOD: The novel software and the newly developed Patient Interface were used in 100 eyes of 100 patients. RESULTS: Length of femtosecond laser pretreatment decreased to 45-60 seconds. The smaller size of the new patient interface resulted in easier docking even on pediatric eyes. Suction force used for docking decreased from 40-50 mmHg to 16-20 mmHg. Incidence rate of subconjunctival suffusion decreased from 40% to 15-20% and its clinical severity was reduced, too. No corneal microfolds evolved, thus the incidence rate of the free-floating capsulotomies increased from 30% to 97%. The total energy of femtosecond laser pretreatment was decreased by almost 50%. Corneal wounds had the desired structure, and they were easy to open and closed precisely. CONCLUSIONS: The SoftFit(®) patient interface and the novel software widened the possible uses of the femtosecond laser-assisted cataract surgery, e.g. in pediatric ophthalmology. Innovations improved the safety and the predictability of the method.

Comparison of the mechanical properties of the anterior lens capsule following manual capsulorhexis and femtosecond laser capsulotomy.

PURPOSE: To evaluate and compare the mechanical properties of anterior capsule openings performed with the continuous curvilinear capsulorhexis (CCC) technique and femtosecond laser capsulotomy (FLC) in ex vivo porcine lens capsule specimens. METHODS: Fresh porcine eyes were included in the study (CCC group, n = 50; FLC group, n = 30). The capsule openings were stretched with universal testing equipment until they ruptured. The rupture force and circumference stretching ratio were evaluated. The morphologic profile of the cut capsule edges was evaluated using scanning electron microscopy (SEM). RESULTS: The average rupture force was higher in the CCC group (median: 155 mN; interquartile range [IQR]: 129 to 201 mN; range: 71 to 294 mN) than in the FLC group (median: 119 mN; IQR: 108 to 128 mN; range: 91 to 142 mN) (P < .01, Mann-Whitney U test). The average circumference stretching ratio in the CCC group was greater (median: 150%; IQR: 146% to 156%; range: 136% to 161%) than in the FLC group (median: 148%; IQR: 145% to 150%; range: 141% to 154%) (P = .0468, Mann-Whitney U test). When less than 71 mN, no capsular tear occurred in either group. When less than 91 mN, no capsular tear occurred in the FLC group, whereas at 91 mN, the probability of capsular tears was 9% for the CCC group. SEM examination found that the CCC group had smooth edges, whereas those of the FLC group were gently serrated. CONCLUSIONS: According to the current results in a porcine eye model, FLC had less average resistance to capsule tear than CCC, but the weakest openings were seen in the CCC group.

The effect of femtosecond laser capsulotomy on the development of posterior capsule opacification.

PURPOSE: To evaluate and compare the effects of femtosecond laser-assisted anterior capsulotomy and manual anterior capsulorhexis on posterior capsule opacification (PCO) development. METHODS: Femtosecond laser-assisted anterior capsulotomy was performed in 40 eyes of 40 patients (FS group) and manual anterior capsulorhexis was performed in 39 eyes of 39 patients (CCC group). An AcrySof one-piece hydrophobic acrylic intraocular lens (Alcon Laboratories, Inc., Fort Worth, TX) was implanted in all eyes. The PCO level was measured using Open-Access Systematic Capsule Assessment (OSCA) software 18 to 26 months after surgery. Postoperative intraocular lens position (ie, tilt and decentration) was measured using Scheimpflug images (Pentacam; Oculus Optikgeräte GmbH, Wetzlar, Germany). RESULTS: There was no statistically significant difference in age, axial length, and follow-up time between the two groups (P > .05). Vertical tilt, horizontal and total decentration of intraocular lenses, and PCO proved to be significantly higher in the CCC group (P = .03, .04, .03, and .01, respectively). After adjusting for axial length and follow-up time, manual anterior capsulorhexis was found to be a significant predictor of higher PCO scores in the multivariable regression model (ß: 0.33; 95% CI: 0.01 to 0.65; P = .04). Vertical tilt affected PCO scores after adjusting for axial length and follow-up time (ß: 0.07; 95% CI: 0.01 to 0.12; P = .02). No capsulotomies were performed during follow-up in either group. CONCLUSIONS: Femtosecond laser-assisted anterior capsulotomy proved to be a safe procedure for postoperative PCO rates. Due to better intraocular lens position, femtosecond laser-assisted anterior capsulotomy resulted in slightly decreased PCO scores; however, evaluating its clinical significance requires further studies.

Complications of femtosecond laser-assisted cataract surgery.

PURPOSE: To analyze complications of femtosecond lasers used for cataract surgery. SETTING: Department of Ophthalmology Semmelweis University, Budapest, Hungary. DESIGN: Retrospective analysis. METHODS: Intraoperative complications of the first 100 femtosecond laser-assisted (Alcon-Lensx, Inc.) cataract surgeries were collected. Possible complications of femtosecond capsulotomies and their management were also assessed. RESULTS: The complications were as follows: suction break (2%), conjunctival redness or hemorrhage (34%), capsule tags and bridges (20%), anterior tear (4%), miosis (32%), and endothelial damage due to cut within the endothelial layer (3%). There were no cases of capsule blockage or posterior capsule tear. During the learning curve, there was no complication that would require vitrectomy. All complications occurred during the first 100 cases. CONCLUSIONS: Femtosecond laser cataract surgery had a learning curve during the first 100 cases. With cautious surgical technique, the complications can be avoided. The femtosecond laser-assisted method was efficient and safe for cataract surgery.

Wavefront properties of the anterior and posterior corneal surface after photorefractive keratectomy.

PURPOSE: The aim of this study was to evaluate the balance and changes of corneal higher order aberrations (HOAs) after photorefractive keratectomy (PRK). METHODS: Myopic and myopic-astigmatic patients (89 eyes of 48 patients) were enrolled in this study. A PRK was performed using an Asclepion Meditec MEL 80 G flying-spot excimer laser. The mean ablation depth and diameter were 76.78 µm (±19.40 µm) and 6.0 mm (±0.06 mm), respectively. Before and 1 year after the surgery, uncorrected and best spectacle-corrected visual acuities were determined. Wavefront aberrations of the anterior [root mean square (RMS)-HOA anterior], posterior (RMS-HOA posterior), and total cornea (RMS-HOA total) were measured using a Scheimpflug Camera. Linear piecewise regression analysis was used for correlations between the ablation depth and aberration of the anterior corneal surface. The follow-up time was 1 year. RESULTS: At baseline, RMS-HOA anterior proved to be significantly higher compared with RMS-HOA total (P < 0.001). After the PRK was performed, the RMS-HOA anterior (P < 0.001) and RMS-HOA total values (P < 0.001) increased significantly; however, RMS-HOA posterior values (P = 0.12) remained stable. Above an ablation depth of 76.78 µm, the RMS-HOA anterior increased 2.4-fold. Uncorrected and best spectacle-corrected visual acuities were 1.0 (20/20) in 95.5% and 98.8% of the patients 1 year postoperatively. CONCLUSIONS: Aberrations of the posterior corneal surface seem to compensate for wavefront alterations of the anterior cornea, decreasing the amount of wavefront error regarding the total cornea in myopic patients. PRK induced increased HOAs with respect to the anterior corneal surface; however, the posterior surface remained stable. The increase in the HOAs was measured to be significantly larger above 76.78 µm photoablation depth.

Intraocular lens tilt and decentration measured by Scheimpflug camera following manual or femtosecond laser-created continuous circular capsulotomy.

PURPOSE: To compare intraocular lens (IOL) decentration and tilt following a circular capsulotomy created with a femtosecond laser (laser CCC) to a manually performed continuous curvilinear capsulorrhexis (manual CCC). METHODS: In a prospective, randomized study, a laser CCC (Alcon LenSx Inc) was performed in 20 eyes from 20 patients and a manual CCC was performed in 25 eyes from 25 patients. Intraocular lens decentration and tilt were measured using a Scheimpflug camera (Pentacam, Oculus Optikgeräte GmbH) 1 year after surgery. Uncorrected (UDVA) and corrected distance visual acuity (CDVA) and manifest refraction were also determined postoperatively. Between-group differences of IOL decentration and tilt as well as the correlation between IOL decentration and postoperative refractive changes and between IOL tilt and visual acuity were analyzed. RESULTS: Horizontal and vertical tilt were significantly higher in the manual CCC group (P=.007 and P<.001, respectively). Lenses implanted after manual CCC showed greater horizontal and total decentration (P=.034 and P=.022, respectively). Significant differences were found in the homogeneity of dichotomized IOL vertical tilt and both horizontal and total decentration distribution (P=.008, P=.036, and P=.017, respectively). Total IOL decentration showed a significant correlation with changes in manifest refraction values between 1 month and 1 year after surgery (R=0.33, P=.032). A significant correlation was noted between IOL vertical tilt and CDVA (R(2)=0.17, ß=-0.41, 95% confidence limit: -0.69 to -0.13, P=.005). CONCLUSIONS: Continuous curvilinear capsulorrhexis created with a femtosecond laser resulted in a more stable refractive result and less IOL tilt and decentration than manual CCC.