Corneal astigmatic outcomes after femtosecond laser-assisted cataract surgery combined with surface penetrating arcuate keratotomies.

AIM: To evaluate corneal astigmatic outcomes of femtosecond laser-assisted arcuate keratotomies (FAKs) combined with femtosecond-laser assisted cataract surgery (FLACS) over 12mo follow-up. METHODS: Totally 145 patients with bilateral cataracts and no ocular co-morbidities were recruited to a single-centre, single-masked, prospective randomized controlled trial (RCT) comparing two monofocal hydrophobic acrylic intraocular lenses. Eyes with corneal astigmatism (CA) of >0.8 dioptres (D) received unpaired, unopened, surface penetrating FAKs at the time of FLACS. Visual acuity, subjective refraction and Scheimpflug tomography were recorded at 1, 6, and 12mo. Alpins vectoral analyses were performed. RESULTS: Fifty-one patients (61 eyes), mean age 68.2±9.6y [standard deviation (SD)], received FAKs. Sixty eyes were available for analysis, except at 12mo when 59 attended. There were no complications due to FAKs. Mean pre-operative CA was 1.13±0.20 D. There was a reduction of astigmatism at all post-operative visits (residual CA 1mo: 0.85±0.42 D, P=0.0001; 6mo: 0.86±0.35 D, P=0001; and 12mo: 0.90±0.39, P=0.0001). Alpins indices remained stable over 12mo. Overall, the cohort was under-corrected at all time points. At 12mo, 61% of eyes were within ±15 degrees of pre-operative astigmatic meridian. CONCLUSION: Unpaired unopened penetrating FAKs combined with on-axis phacoemulsification are safe but minimally effective. CA is largely under-corrected in this cohort using an existing unmodified nomogram. The effect of arcuate keratotomies on CA remained stable over 12mo.

Use of a Single Radial Incision to Improve Curvature Matching and Graft Adhesion in Descemet Membrane Endothelial Keratoplasty in a Patient With Keratoconus.

PURPOSE: The purpose of this study was to report a novel surgical technique for altering donor Descemet membrane endothelial keratoplasty (DMEK) curvature to match host posterior stroma in a patient with advanced keratoconus (KC) and endothelial decompensation. METHODS: We report a 56-year-old man with Fuch endothelial dystrophy and KC, who underwent DMEK due to endothelial decompensation. A triangular area of graft detachment centered on the apex of cones persisted after repeat gas tamponade. A radial incision from the graft edge to the apex was used to allow overlapping of the graft, thereby increasing the grafts curvature. RESULTS: The use of a radial incision in the Descemet membrane (DM) graft was made to allow the graft overlap and adapt to the new shape. By matching the donor curvature to that of the hosts posterior curvature, full adhesion of the graft was achieved with the use of a short-acting air bubble by 1 week after the procedure. CONCLUSIONS: The mismatch in the curvature of the DM graft and the host posterior corneal surface, in cases with KC or very steep corneas, should be taken into consideration because it can lead to redundancy folds. These can result in atypical, conical detachments, distinct from the typical peripheral detachments seem commonly in DMEK. A single radial incision in the DM graft combined with air tamponade is a feasible treatment option in cases where DMEK fails to attach because of apparent curvature mismatch between the donor and host.

Intelligent cataract surgery supervision and evaluation via deep learning.

PURPOSE: To assess the performance of a deep learning (DL) algorithm for evaluating and supervising cataract extraction using phacoemulsification with intraocular lens (IOL) implantation based on cataract surgery (CS) videos. MATERIALS AND METHODS: DeepSurgery was trained using 186 standard CS videos to recognize 12 CS steps and was validated in two datasets that contained 50 and 21 CS videos, respectively. A supervision test including 50 CS videos was used to assess the DeepSurgery guidance and alert function. In addition, a real-time test containing 54 CSs was used to compare the DeepSurgery grading performance to an expert panel and residents. RESULTS: DeepSurgery achieved stable performance for all 12 recognition steps, including the duration between two pairs of adjacent steps in internal validation with an ACC of 95.06% and external validations with ACCs of 88.77% and 88.34%. DeepSurgery also recognized the chronology of surgical steps and alerted surgeons to order of incorrect steps. Six main steps are automatically and simultaneously quantified during the evaluation process (centesimal system). In a real-time comparative test, the DeepSurgery step recognition performance was robust (ACC of 90.30%). In addition, DeepSurgery and an expert panel achieved comparable performance when assessing the surgical steps (kappa ranged from 0.58 to 0.77). CONCLUSIONS: DeepSurgery represents a potential approach to provide a real-time supervision and an objective surgical evaluation system for routine CS and to improve surgical outcomes.

Visual Acuity Apps for Rapid Integration in Teleconsultation Services in all Resource Settings: A Review.

PURPOSE: There is a need for a simple and accurate way to assess visual acuity in telemedicine consultations in ophthalmology and other related specialties. DESIGN: We surveyed visual acuity testing apps available that allow patients to measure their own acuity, focusing on freely accessible resources suitable for all resource settings. METHODS: A systematic search was performed for visual acuity testing apps on 2 major platforms: Google Play Store (Google, CA, USA) and Apple App Store (Apple, CA, USA). RESULTS: Sixteen apps (67%) tested near vision, 5 apps (21%) tested distance vision, and 3 apps (13%) offered options for both near and distance vision testing. Of the 24 apps, 5 (21%) offered a method of calibration of optotype size. Three apps (13%) demonstrated evidence of clinical validation. Only 3 apps fulfilled our criteria for suitability for clinical practice. CONCLUSIONS: We have recommended 3 apps that may be quickly integrated into clinical practice in both ophthalmic and non-ophthalmic all resource settings.

A randomised controlled trial comparing femtosecond laser-assisted cataract surgery versus conventional phacoemulsification surgery: 12-month results.

AIMS: To report 12-month outcomes of randomised controlled trial comparing conventional phacoemulsification surgery (CPS) with femtosecond laser-assisted cataract surgery (FLACS). METHODS: This was a single-centre, prospective single-masked randomised case-controlled trial. Four hundred patients were randomised to CPS or FLACS with the LenSx platform (Alcon Laboratories Inc.). Visual acuity, refraction, central corneal thickness, endothelial cell loss (ECL), adverse events and quality of life outcomes, using EuroQOL 5-dimensions (EQ-5D-3 L) and cataract surgery patient-reported outcome measures (PROMs) questionnaires (Cat-PROM5), were recorded. RESULTS: Two hundred and thirty four patients (58.5%) attended 12-month follow-up (116 FLACS, 118 CPS). Mean LogMAR unaided distance visual acuity) (±SD) was 0.12 (0.18) with FLACS and 0.13 (0.19) with CPS (p=0.68; 95% Confidence Interval [CI]-0.06,0.04). Mean spherical equivalent (SE) refraction was -0.1±0.6 diopters (D) with FLACS and -0.2±0.6 D with CPS (p=0.44; 95% CI -0.09, 0.21). Mean corrected distance visual acuity (±SD) was -0.01 (0.1) with FLACS and 0(0.1) with CPS (p=0.45; 95% CI -0.04,0.02). Two patients per group underwent YAG laser capsulotomy for posterior capsular opacification (p=1). Mean ECL (per mm2±SD) was 301±320 with FLACS and 228±303 with CPS (p=0.07; 95% CI -7.26, 153.26). Mean Cat-PROM scores (±SD) were -5.5 (2.6) with FLACS and -5.8 (2.5) with CPS (p=0.3; 95% CI 0.31,1.01). EQ5-3DL mean index score (±SD) was 0.92 (0.13) with FLACS and 0.89 (0.14) with CPS (p=0.1; 95% CI -0.1, 0.01). Vector analysis comparing manual limbal relaxing incisions (LRIs) and intrastromal femtosecond laser-assisted astigmatic keratotomies (iFAKs) showed a greater correction index (p=0.02; 95% CI 0.06 to 0.60) and smaller difference vector (p=0.046; 95% CI -0.54, -0.01) with iFAK. CONCLUSIONS: There were no differences in vision, refraction, adverse postoperative events or PROMs between FLACS and CPS groups at 12 months. iFAKs may provide more effective astigmatic correction compared to LRIs, 12 months postoperatively.

A randomised, prospective study of 'off-the-shelf' use of toric intraocular lenses for cataract patients with pre-existing corneal astigmatism in the NHS.

BACKGROUND/OBJECTIVES: To compare visual and refractive outcomes of monofocal intraocular lenses (IOLs) with limbal relaxing incisions (LRI) with 'off-the-shelf' use of toric IOLs (TIOLs), with a fixed 2-dioptre cylinder (DC) correction, for cataract patients with pre-existing corneal astigmatism in a public-sector setting. SUBJECTS/METHODS: Seventy-seven patients (77 eyes, first treated eye) with visually significant cataract and pre-operative corneal astigmatism ≥2.00 DC were randomised to receive either 'off-the-shelf' TIOLs, with a fixed 2.00 DC cylinder correction (39 eyes), or monofocal IOLs (38 eyes) with LRIs. The concept of fixing the cylindrical correction was to minimise costs, allow a full TIOL bank to be available and eliminate the need for individual TIOL ordering. Outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA) and refraction. Astigmatic changes were evaluated using the Alpins vector method. RESULTS: Mean UDVA improved from logMAR 0.88 (SD 0.56)[~20/150] pre-operatively to 0.18 (SD 0.19)[~20/30] post-operatively in TIOL group, versus 0.82 (SD 0.55)[~20/130] to 0.27 (SD 0.15)[~20/40] in monofocal/LRI group (P = 0.02; 95% CI: -0.17, -0.01). Mean CDVA improved from logMAR 0.40 (SD 0.26)[~20/50] to 0.01 (SD 0.12)[~20/20] in TIOL group, and 0.41 (SD 0.38)[~20/40] to 0.06 (SD 0.12)[~20/25] in LRI group (P = 0.07; 95% CI: -0.11, 0.01). Average post-operative refractive cylinder in TIOL group was 1.35 DC (SD 0.84 DC) and in LRI group 1.91 DC (SD 1.07 DC) (P = 0.01; 95% CI: -1, -0.12). Mean difference vector magnitude was 1.92 DC (SD 1.08 DC) in LRI group and 1.37 DC (SD 0.84 DC) in TIOL group (P = 0.02; 95% CI: 0.11, 0.99). CONCLUSIONS: TIOLs with a fixed 2.00 DC correction during cataract surgery may improve UDVA, reduce post-operative cylinder and result in a more reliable astigmatic correction compared with monofocal IOLs with LRIs.

Visual and refractive outcomes and glistenings occurrence after implantation of 2 hydrophobic acrylic aspheric monofocal IOLs.

PURPOSE: To compare the Clareon IOL with the Tecnis PCB00 IOL in terms of visual performance, refractive outcomes, glistenings occurrence, and quality-of-life outcomes. SETTING: Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom. DESIGN: Single-center, single-masked, prospective, randomized controlled trial. METHODS: One hundred thirty-nine patients with bilateral cataracts were randomized to receive the Clareon (C IOL) or Tecnis (T IOL) IOL. Visual acuity, refraction, central corneal thickness (CCT), endothelial cell loss, contrast sensitivity, mesopic gap acuity, evaluation of glistenings, and rates of perioperative and postoperative complications were recorded. Quality-of-life outcomes were measured with the EuroQOL-5 dimensions questionnaire and the patient-reported outcome measures (PROMs) questionnaire. Optimized A-constants were available for the T IOL but not for the C IOL. RESULTS: Seventy-one patients (140 eyes) received the C IOLs and 68 patients (134 eyes) received the T IOLs. Data were analyzed for the first implanted eye. At 12 months, mean uncorrected distance visual acuity (logarithm of the minimum angle of resolution) was 0.02 ± 0.10 and 0.01 ± 0.08 (mean ± SD; P = .49; 95% CI, -0.02 to 0.04) in the C IOL and T IOL groups, respectively. Corrected distance visual acuity was -0.02 ± 0.09 and -0.03 ± 0.06, respectively (P = .45; 95% CI, -0.02 to 0.04). The increase in CCT was 14 ± 19 and 16 ± 28 µm, respectively (P = .63; 95% CI, -10.16 to 6.16). Mean absolute refraction spherical equivalent error from target refraction was 0.41 ± 0.28 for the C IOL and 0.25 ± 0.2 for the T IOL groups (P = .002; 95% CI, 0.08 to 0.24). Glistenings were minimal (median grade 0), with no difference in grades between groups (P = .2). PROMs improved postoperatively and were similar in both groups. CONCLUSIONS: There were no differences in visual outcomes between the Clareon IOL and Tecnis PCB00 IOL. Glistenings were rarely observed in either IOL with no difference in grades. There was no difference in perioperative or postoperative complications. Surgeon optimization of the A-constant for the Clareon IOL is recommended.

Clinical and material degradations of intraocular lenses: A review.

PURPOSE: To review the published scientific literature concerning clinical and material degradations of intraocular lenses after implantation in cataract surgery. METHODS: A search was undertaken using the following databases: CENTRAL (including Cochrane Eyes and Vision Trials Register; The Cochrane Library: Issue 2 of 12 February 2019), Ovid MEDLINE (R) without Revisions (1996 to February week 2, 2019), Ovid MEDLINE (R) (1946 to February week 2, 2019), Ovid MEDLINE (R) Daily Update 19 February 2019, MEDLINE and MEDLINE non-indexed items, Embase (1980-2019, week 7), Embase (1974-2019, 19 February), Ovid MEDLINE (R) and Epub Ahead of Print, in-Process & Other Non-Indexed Citations and Daily (1946 to 19 February 2019), Web of Science (all years), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrial.gov) and the WHO International Clinical Trials Registry Platform (www.who.int/ictrp/search/en). Only published articles in English were selected. Search terms/keywords included 'IOL' or 'intraocular lens', combined with 'opacification', degradation, glistenings, nanoglistenings, whitening, transmittance, light scatter, discolouration/discoloration, performance, quality, material, biocompatibility, calcification, explantation and ultraviolet/UV radiation. Relevant in-article references not returned in our searches were also considered. RESULTS: After review of the available articles, the authors included 122 publications in this review, based on the quality of their methodology and their originality. The studies included in this review were randomized controlled trials, cohort studies, case-controlled studies, case series, case reports, laboratory studies and review papers. Differing material degradations of intraocular lenses have been described and their associated pathophysiology studied. Reported anomalies include photochemical alterations, water vacuoles, internal and surface calcific deposits, surface coatings and discolouration. The nature of such changes has been shown to depend on the type of intraocular lenses material used and/or manufacturing processes and storage conditions employed. Changes in the intraocular lens can also be influenced by surgical technique, coexisting ocular pathologies and topical and systemic medications. The clinical significance of these degradations is variable, with some resulting in significant visual disturbance and the need for intraocular lens explantation and others producing only minimal visual impairments. Failure to recognize the precise nature of the problem may lead to unnecessary laser capsulotomy procedures. CONCLUSION: Clinical degradations of intraocular lenses are uncommon but have been reported following the implantation of intraocular lenses made of differing biomaterials. Their correct identification and thorough investigation to determine the underlying cause is necessary for optimal patient management and the prevention of such problems. Choosing a lens made of a particular material may be important in patients with certain ocular conditions.

Effects of intraocular lens glistenings on visual function: a prospective study and presentation of a new glistenings grading methodology.

OBJECTIVE: To investigate the effect of intraocular lens (IOL) glistenings on visual performance and evaluate a new glistenings grading methodology. METHODS AND ANALYSIS: Thirty-four patients (34 eyes) were recruited. Corrected distance visual acuity (CDVA), mesopic gap acuity (MGA), functional contrast sensitivity (FCS) and forward light scatter were measured (Advanced Vision and Optometric Tests, City Occupational, London, UK). The IOL centre was imaged and glistenings density graded by three observers using the Miyata scale and a new system. Inter-rater reliability, association between the two grading scales, and correlations between glistenings grades and visual performance parameters were evaluated. RESULTS: The intraclass correlation coefficient between graders for the new grading system was 0.769 (95% Confidence Interval [CI] 0.636 to 0.868). There was a significant association between the Miyata scale and the new grading system for all graders (rs=0.533-0.895, p≤0.001). There was no association between CDVA or MGA and glistenings grade (rs=- 0.098, p=0.583 and rs=0.171, p=0.359, respectively). There was no association between FCS at mesopic light levels and glistenings grade (rs=-0.032, p=0.864), or the straylight parameter and glistenings grade (rs=0.021, p=0.916). No association was found between the integrated straylight parameter and glistenings grade (rs=0.078, p=0.701). CONCLUSION: The new glistenings grading scale was highly reproducible. In this cohort, glistenings in the same hydrophobic acrylic IOL after cataract surgery were not associated with changes in visual function, as assessed by a series of tests not previously used in glistenings research.

Refractive surprise after routine cataract surgery with multifocal IOLs attributable to corneal epithelial basement membrane dystrophy.

We describe two patients in whom postsurgical refractive error occurred after routine refractive lens exchange cataract surgery with multifocal intraocular lens insertion most likely attributable to the presence of underlying corneal epithelial basement membrane dystrophy (EBMD). In Case 1, there was an unexpected hyperopic postoperative spherical equivalent refractive error of +1.50 diopters and in Case 2, a cylindrical refractive error of 2.75 diopter cylinder. We examine the possible causes of error and discuss potential management strategies to prevent and address these unpredictable postoperative outcomes. The importance of comprehensive and careful ocular surface assessment before cataract or refractive surgery as part of the presurgical workup is reemphasized. EBMD can be subtle and if overlooked, can affect the validity of biometric keratometric measurements preoperatively, resulting in an inaccurate biometry measurement, incorrect IOL selection, and reduced visual performance and patient satisfaction.