Nontraditional approaches to sedation for anterior segment surgery: a narrative review.

PURPOSE OF REVIEW: Surgical and anesthetic technological advancement have made both cataract and noncataract anterior segment surgery significantly less invasive and time-intensive, facilitating the transition of some of these procedures from the operating room under monitored anesthesia care (MAC) to the office-based setting without MAC. This transition has been aided by the popularization of nonintravenous approaches to achieving patient sedation for these procedures. In this review, we discuss the literature surrounding traditional and nontraditional methods of achieving patient sedation for anterior segment surgery. RECENT FINDINGS: Our survey of the literature suggests that nonintravenous (IV) approaches to sedation for these procedures may be just as safe, effective, and satisfactory to patients as traditional IV approaches. SUMMARY: As anterior segment surgery becomes less invasive and less time-intensive, providers considering transitioning their cataract and anterior segment surgery out of the operating room and into the office-based setting without MAC anesthesia should consider the non-IV sedation options outlined in this review to achieve adequate patient sedation and comfort.

Comparison of Machine and Human Expert Evaluation of Capsulorrhexis Creation Performance Through Analysis of Surgical Video Recordings.

Purpose: Achieving competency in cataract surgery is an essential component of ophthalmology residency training. Video-based analysis of surgery can change training through its objective, reliable, and timely assessment of resident performance. Methods: Using the Image Labeler application in MATLAB, the capsulorrhexis step of 208 surgical videos, recorded at the University of Michigan, was annotated for subjective and objective analysis. Two expert surgeons graded the creation of the capsulorrhexis based on the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric:Phacoemulsification (ICO-OSCAR:phaco) rating scale and a custom rubric (eccentricity, roundness, size, centration) that focuses on the objective aspects of this step. The annotated rhexis frames were run through an automated analysis to obtain objective scores for these components. The subjective scores were compared using both intra and inter-rater analyses to assess the consistency of a human-graded scale. The subjective and objective scores were compared using intraclass correlation methods to determine relative agreement. Results: All rhexes were graded as 4/5 or 5/5 by both raters for both items 4 and 5 of the ICO-OSCAR:phaco rating scale. Only roundness scores were statistically different between the subjective graders (mean difference = -0.149, p-value = 0.0023). Subjective scores were highly correlated for all components (>0.6). Correlations between objective and subjective scores were low (0.09 to 0.39). Conclusion: Video-based analysis of cataract surgery presents significant opportunities, including the ability to asynchronously evaluate performance and provide longitudinal assessment. Subjective scoring between two raters was moderately correlated for each component.

Evaluation of Methods for Detection and Semantic Segmentation of the Anterior Capsulotomy in Cataract Surgery Video.

Background: The capsulorhexis is one of the most important and challenging maneuvers in cataract surgery. Automated analysis of the anterior capsulotomy could aid surgical training through the provision of objective feedback and guidance to trainees. Purpose: To develop and evaluate a deep learning-based system for the automated identification and semantic segmentation of the anterior capsulotomy in cataract surgery video. Methods: In this study, we established a BigCat-Capsulotomy dataset comprising 1556 video frames extracted from 190 recorded cataract surgery videos for developing and validating the capsulotomy recognition system. The proposed system involves three primary stages: video preprocessing, capsulotomy video frame classification, and capsulotomy segmentation. To thoroughly evaluate its efficacy, we examined the performance of a total of eight deep learning-based classification models and eleven segmentation models, assessing both accuracy and time consumption. Furthermore, we delved into the factors influencing system performance by deploying it across various surgical phases. Results: The ResNet-152 model employed in the classification step of the proposed capsulotomy recognition system attained strong performance with an overall Dice coefficient of 92.21%. Similarly, the UNet model with the DenseNet-169 backbone emerged as the most effective segmentation model among those investigated, achieving an overall Dice coefficient of 92.12%. Moreover, the time consumption of the system was low at 103.37 milliseconds per frame, facilitating its application in real-time scenarios. Phase-wise analysis indicated that the Phacoemulsification phase (nuclear disassembly) was the most challenging to segment (Dice coefficient of 86.02%). Conclusion: The experimental results showed that the proposed system is highly effective in intraoperative capsulotomy recognition during cataract surgery and demonstrates both high accuracy and real-time capabilities. This system holds significant potential for applications in surgical performance analysis, education, and intraoperative guidance systems.

Adaptive Tensor-Based Feature Extraction for Pupil Segmentation in Cataract Surgery.

Cataract surgery remains the only definitive treatment for visually significant cataracts, which are a major cause of preventable blindness worldwide. Successful performance of cataract surgery relies on stable dilation of the pupil. Automated pupil segmentation from surgical videos can assist surgeons in detecting risk factors for pupillary instability prior to the development of surgical complications. However, surgical illumination variations, surgical instrument obstruction, and lens material hydration during cataract surgery can limit pupil segmentation accuracy. To address these problems, we propose a novel method named adaptive wavelet tensor feature extraction (AWTFE). AWTFE is designed to enhance the accuracy of deep learning-powered pupil recognition systems. First, we represent the correlations among spatial information, color channels, and wavelet subbands by constructing a third-order tensor. We then utilize higher-order singular value decomposition to eliminate redundant information adaptively and estimate pupil feature information. We evaluated the proposed method by conducting experiments with state-of-the-art deep learning segmentation models on our BigCat dataset consisting of 5,700 annotated intraoperative images from 190 cataract surgeries and a public CaDIS dataset. The experimental results reveal that the AWTFE method effectively identifies features relevant to the pupil region and improved the overall performance of segmentation models by up to 2.26% (BigCat) and 3.31% (CaDIS). Incorporation of the AWTFE method led to statistically significant improvements in segmentation performance (P < 1.29 × 10-10 for each model) and yielded the highest-performing model overall (Dice coefficients of 94.74% and 96.71% for the BigCat and CaDIS datasets, respectively). In performance comparisons, the AWTFE consistently outperformed other feature extraction methods in enhancing model performance. In addition, the proposed AWTFE method significantly improved pupil recognition performance by up to 2.87% in particularly challenging phases of cataract surgery.

CatStep: Automated Cataract Surgical Phase Classification and Boundary Segmentation Leveraging Inflated 3D-Convolutional Neural Network Architectures and BigCat.

Objective: Accurate identification of surgical phases during cataract surgery is essential for improving surgical feedback and performance analysis. Time spent in each surgical phase is an indicator of performance, and segmenting out specific phases for further analysis can simplify providing both qualitative and quantitative feedback on surgical maneuvers. Study Design: Retrospective surgical video analysis. Subjects: One hundred ninety cataract surgical videos from the BigCat dataset (comprising nearly 4 million frames, each labeled with 1 of 11 nonoverlapping surgical phases). Methods: Four machine learning architectures were developed for segmentation of surgical phases. Models were trained using cataract surgical videos from the BigCat dataset. Main Outcome Measures: Models were evaluated using metrics applied to frame-by-frame output and, uniquely in this work, metrics applied to phase output. Results: The final model, CatStep, a combination of a temporally sensitive model (Inflated 3D Densenet) and a spatially sensitive model (Densenet169), achieved an F1-score of 0.91 and area under the receiver operating characteristic curve of 0.95. Phase-level metrics showed considerable boundary segmentation performance with a median absolute error of phase start and end time of just 0.3 seconds and 0.1 seconds, respectively, a segmental F1-score @70 of 0.94, an oversegmentation score of 0.89, and a segmental edit score of 0.92. Conclusion: This study demonstrates the feasibility of high-performance automated surgical phase identification for cataract surgery and highlights the potential for improved surgical feedback and performance analysis. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

The Cost of Standard and Complex Pars Plana Vitrectomy for Retinal Detachment Repair Exceeds Its Reimbursement.

OBJECTIVE: To measure the total costs and reimbursements associated with standard and complex pars plana vitrectomy using time-driven activity-based costing (TDABC). DESIGN: Economic analysis at a single academic institution. SUBJECTS: Patients who underwent standard or complex pars plana vitrectomy (PPV; Current Procedural Terminology codes 67108 and 67113) at the University of Michigan in the calendar year 2021. METHODS: Process flow mapping for standard and complex PPVs was used to determine the operative components. The internal anesthesia record system was used to calculate time estimates, and financial calculations were constructed from published literature and internal sources. A TDABC analysis was used to determine the costs of standard and complex PPVs. Average reimbursement was based on Medicare rates. MAIN OUTCOME MEASURES: The primary outcomes were the total costs for standard and complex PPVs and the resulting net margin at current Medicare reimbursement levels. The secondary outcomes were the differential in surgical times, costs, and margin for standard and complex PPV. RESULTS: Over the 2021 calendar year, a total of 270 standard and 142 complex PPVs were included in the analysis. Complex PPVs were associated with significantly increased anesthesia time (52.28 minutes; P < 0.001), operating room time (51.28 minutes; P < 0.0001), surgery time (43.64 minutes; P < 0.0001), and postoperative time (25.95 minutes; P < 0.0001). The total day-of-surgery costs were $5154.59 and $7852.38 for standard and complex PPVs, respectively. Postoperative visits incurred an additional cost of $327.84 and $353.86 for standard and complex PPV, respectively. The institution-specific facility payments were $4505.50 and $4935.14 for standard and complex PPV, respectively. Standard PPV yielded a net negative margin of -$976.93, whereas complex PPV yielded a net negative margin of -$3271.10. CONCLUSIONS: This analysis demonstrated that Medicare reimbursement is inadequate in covering the costs of PPV for retinal detachment, with a particularly large negative margin for more complex cases. These findings demonstrate that additional steps may be necessary to mitigate adverse economic incentives so that patients continue to have timely access to care to achieve optimal visual outcomes after retinal detachment. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Cost Drivers of Endothelial Keratoplasty: A Time-Driven Activity-Based Costing Analysis.

PURPOSE: To determine cost drivers of endothelial keratoplasty (EK) through evaluation of surgical costs and procedure length based on type of EK, use of preloaded grafts, and performance of simultaneous cataract surgery. DESIGN: This study was an economic analysis of EKs at a single academic institution using time-driven activity-based costing (TDABC) methodology. PARTICIPANTS: Endothelial keratoplasty surgical cases, including Descemet membrane endothelial keratoplasty (DMEK) and Descemet stripping automated endothelial keratoplasty (DSAEK), at the University of Michigan Kellogg Eye Center from 2016 to 2018 were included in the analysis. METHODS: Data and inputs were obtained via the electronic health record (EHR) and from prior literature. Simultaneous cataract surgeries were included and separately categorized for analysis. Endothelial keratoplasty expenses were determined with TDABC, a method for cost calculation that incorporates the time that key resources are used and each resource's associated cost rate. MAIN OUTCOME MEASURES: Main outcome measures included surgery length (in minutes) and day-of-surgery costs. RESULTS: There were 559 EKs included: 355 DMEKs and 204 DSAEKs. Fewer DSAEKs had simultaneous cataract extraction (47; 23%) than DMEK (169; 48%). Of the DMEKs, 196 (55%) used preloaded corneal grafts. Descemet membrane endothelial keratoplasty cost $392.31 less (95% confidence interval, $251.05-$533.57; P < 0.0001) than DSAEK and required 16.94 fewer minutes (14.16-19.73; P < 0.0001). Descemet membrane endothelial keratoplasty cases that used preloaded corneal grafts cost $460.19 less ($316.23-$604.14; P < 0.0001) and were 14.16 minutes shorter (11.39-16.93; P < 0.0001). In multivariate regression, preloaded graft use saved $457.19, DMEK (compared with DSAEK) saved $349.97, and simultaneous cataract surgery added $855.17 in day-of-surgery costs. CONCLUSIONS: Cost analysis of TDABC identified a day-of-surgery cost and surgical time reduction associated with the use of preloaded grafts for DMEK, DMEK compared with DSAEK, and isolated EK compared with EK combined with cataract surgery. This study provides an improved understanding of surgical cost drivers and margin incentivization, which may explain trends and indirectly influence patient care decisions in cornea surgery practices. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Clinical outcomes of prestripped, prestained, and preloaded Descemet's membrane endothelial keratoplasty ("P3 DMEK").

PURPOSE: Despite faster healing and reduced risk of rejection, some surgeons are hesitant to adopt Descemet membrane endothelial keratoplasty (DMEK) due to difficult intraoperative tissue preparation. Use of eye bank prestripped, prestained, and preloaded (p3) DMEK tissue can reduce the learning curve and risk of complications. MATERIALS AND METHODS: We conducted a prospective study including 167 eyes undergoing p3 DMEK and compared outcomes to a retrospective chart review of 201 eyes that underwent standard DMEK surgery. The primary outcomes were graft failure, detachment, and re-bubbling frequency. The secondary outcomes included baseline and postoperative visual acuity at months 1, 3, 6, and 12. Baseline and postoperative central corneal thickness (CCT) and endothelial cell counts (ECC) were collected. RESULTS: ECC decrease for p3 DMEK at 3, 6, and 12 months were 15.0%, 18.0%, and 21.0%, respectively. Forty (24%) of p3 DMEK and 72 (35.8%) of standard DMEK eyes had at least a partial graft detachment. There was no difference in CCT, graft failures, or re-bubble frequency. At 6 months, mean visual acuity was 20/26 and 20/24 for standard and p3 DMEK, respectively. Mean case time for p3 DMEK with phaco or p3 DMEK alone was 33 and 24 min, respectively. Mean case time for eyes undergoing DMEK with phaco or DMEK alone was 59 and 45 min, respectively. CONCLUSION: P3 DMEK tissue is safe and can provide excellent clinical outcomes that are comparable to standard DMEK tissue. Eyes undergoing p3 DMEK may have lower graft detachment and ECC loss.

A Novel 13q12 Microdeletion Associated with Familial Syndromic Corneal Opacification.

Progressive corneal opacification can result from multiple etiologies, including corneal dystrophies or systemic and genetic diseases. We describe a novel syndrome featuring progressive epithelial and anterior stromal opacification in a brother and sister and their mildly affected father, with all three family members having sensorineural hearing loss and two also with tracheomalacia/laryngomalacia. All carried a 1.2 Mb deletion at chromosome 13q12.11, with no other noteworthy co-segregating variants identified on clinical exome or chromosomal microarray. RNAseq analysis from an affected corneal epithelial sample from the proband's brother revealed downregulation of XPO4, IFT88, ZDHHC20, LATS2, SAP18, and EEF1AKMT1 within the microdeletion interval, with no notable effect on the expression of nearby genes. Pathway analysis showed upregulation of collagen metabolism and extracellular matrix (ECM) formation/maintenance, with no significantly down-regulated pathways. Analysis of overlapping deletions/variants demonstrated that deleterious variants in XPO4 were found in patients with laryngomalacia and sensorineural hearing loss, with the latter phenotype also being a feature of variants in the partially overlapping DFNB1 locus, yet none of these had reported corneal phenotypes. Together, these data define a novel microdeletion-associated syndromic progressive corneal opacification and suggest that a combination of genes within the microdeletion may contribute to ECM dysregulation leading to pathogenesis.

Comparison of Incremental Costs and Medicare Reimbursement for Simple vs Complex Cataract Surgery Using Time-Driven Activity-Based Costing.

Importance: Cataract surgery is one of the most commonly performed surgeries across medicine and an integral part of ophthalmologic care. Complex cataract surgery requires more time and resources than simple cataract surgery, yet it remains unclear whether the incremental reimbursement for complex cataract surgery, compared with simple cataract surgery, offsets the increased costs. Objective: To measure the difference in day-of-surgery costs and net earnings between simple and complex cataract surgery. Design, Setting, and Participants: This study is an economic analysis at a single academic institution using time-driven activity-based costing methodology to determine the operative-day costs of simple and complex cataract surgery. Process flow mapping was used to define the operative episode limited to the day of surgery. Simple and complex cataract surgery cases (Current Procedural Terminology codes 66984 and 66982, respectively) at the University of Michigan Kellogg Eye Center from 2017 to 2021 were included in the analysis. Time estimates were obtained using an internal anesthesia record system. Financial estimates were obtained using a mix of internal sources and prior literature. Supply costs were obtained from the electronic health record. Main Outcomes and Measures: Difference in day-of-surgery costs and net earnings. Results: A total of 16 092 cataract surgeries were included, 13 904 simple and 2188 complex. Time-based day-of-surgery costs for simple and complex cataract surgery were $1486.24 and $2205.83, respectively, with a mean difference of $719.59 (95% CI, $684.09-$755.09; P < .001). Complex cataract surgery required $158.26 more for costs of supplies and materials (95% CI, $117.00-$199.60; P < .001). The total difference in day-of-surgery costs between complex and simple cataract surgery was $877.85. Incremental reimbursement for complex cataract surgery was $231.01; therefore, complex cataract surgery had a negative earnings difference of $646.84 compared with simple cataract surgery. Conclusions and Relevance: This economic analysis suggests that the incremental reimbursement for complex cataract surgery undervalues the resource costs required for the procedure, failing to cover increased costs and accounting for less than 2 minutes of increased operating time. These findings may affect ophthalmologist practice patterns and access to care for certain patients, which may ultimately justify increasing cataract surgery reimbursement.

Prospective, Randomized, Multicenter, Double-Masked, Clinical Trial of Corneal Cross-Linking for Boston Keratoprosthesis Carrier Tissue.

PURPOSE: To assess whether cross-linking the carrier donor cornea of the Boston Keratoprosthesis (BKPro) improves retention of the device in participants at high risk for keratolysis. DESIGN: Prospective, double-masked, randomized clinical trial. METHODS: In this multicenter study, 68 adult participants who were scheduled for BKPro implantation were enrolled. Masked participants were randomized to receive either a cross-linked (CXL) or non-cross-linked (non-CXL) donor corneal carrier. The Kaplan-Meier event-free survival was determined by the product-limit method and compared by the log-rank test to examine whether survival curves were different between the CXL and non-CXL groups. The primary outcome of the study was time from surgery to BKPro removal. The secondary endpoint was 12-month retention rate. RESULTS: A total of 68 participants were enrolled and randomized 1:1 to each group. The average age at the time of surgery was 62 (range = 24-89) years, and 42 participants (62%) were male. The overall BKPro retention rate was 70% during a mean follow-up time of 93 (range = 6-201) weeks. Twenty BKPros were removed, 10 in the CXL group and 10 in the non-CXL group, with 18 requiring removal because of sterile keratolysis. There was no difference in the time to removal between the groups during the study (P = .910). At 12 months, there was no significant difference in the retention rate in the CXL group (94%) vs the non-CXL group (82%, P = .150). CONCLUSIONS: In this prospective study, cross-linking of the carrier cornea prior to BKPro implantation did not reduce the incidence of sterile keratolysis or increase device retention among participants at high risk for retention failure.

Clinical outcomes and visual prognostic factors in congenital aniridia.

BACKGROUND: Evaluate outcomes and identify prognostic factors in congenital aniridia. METHODS: Retrospective interventional case series of patients with congenital aniridia treated between 2012-2020. Ocular examination and surgical details were collected. Surgical failure was defined as disease progression or need for additional surgery for same/related indication. Kaplan-Meier survival curves, Wilcoxon test, and univariate and multivariate linear regression analyses were performed. RESULTS: Ninety-four patients with congenital aniridia presented at median 19.0 years. Two-thirds of patients underwent ≥ 1intraocular surgery, with average of 1.7 ± 2.3 surgeries/eye. At final follow-up (median 4.0 years), 45% of eyes had undergone lensectomy. Aphakic eyes showed worse visual acuity (VA) than phakic or pseudophakic eyes. Glaucoma affected 52% of eyes, of which half required IOP-lowering surgery. Glaucoma drainage devices showed the highest success rate (71%) at 14.2 ± 15.4 years of follow-up. Keratopathy affected 65% of eyes and one-third underwent corneal surgery. Keratoprosthesis had the longest survival rates at 10-years (64% with 95% CI [32,84]). LogMAR VA at presentation and final follow-up were not statistically different. Half of patients were legally blind at final follow-up. Final VA was associated with presenting VA, glaucoma diagnosis, and cataract or keratopathy at presentation. Penetrating keratoplasty and keratoprosthesis implantation correlated with worse BCVA. CONCLUSIONS: Most aniridic patients in this large US-based cohort underwent at least 1 intraocular surgery. Cataract, glaucoma, and keratopathy were associated with worse VA and are important prognostic factors to consider when managing congenital aniridia.

Analysis of Cataract Surgery Instrument Identification Performance of Convolutional and Recurrent Neural Network Ensembles Leveraging BigCat.

Purpose: To develop a method for accurate automated real-time identification of instruments in cataract surgery videos. Methods: Cataract surgery videos were collected at University of Michigan's Kellogg Eye Center between 2020 and 2021. Videos were annotated for the presence of instruments to aid in the development, validation, and testing of machine learning (ML) models for multiclass, multilabel instrument identification. Results: A new cataract surgery database, BigCat, was assembled, containing 190 videos with over 3.9 million annotated frames, the largest reported cataract surgery annotation database to date. Using a dense convolutional neural network (CNN) and a recursive averaging method, we were able to achieve a test F1 score of 0.9528 and test area under the receiver operator characteristic curve of 0.9985 for surgical instrument identification. These prove to be state-of-the-art results compared to previous works, while also only using a fraction of the model parameters of the previous architectures. Conclusions: Accurate automated surgical instrument identification is possible with lightweight CNNs and large datasets. Increasingly complex model architecture is not necessary to retain a well-performing model. Recurrent neural network architectures add additional complexity to a model and are unnecessary to attain state-of-the-art performance. Translational Relevance: Instrument identification in the operative field can be used for further applications such as evaluating surgical trainee skill level and developing early warning detection systems for use during surgery.

DDX58(RIG-I)-related disease is associated with tissue-specific interferon pathway activation.

BACKGROUND: Singleton-Merten syndrome (SGMRT) is a rare immunogenetic disorder that variably features juvenile open-angle glaucoma (JOAG), psoriasiform skin rash, aortic calcifications and skeletal and dental dysplasia. Few families have been described and the genotypic and phenotypic spectrum is poorly defined, with variants in DDX58 (DExD/H-box helicase 58) being one of two identified causes, classified as SGMRT2. METHODS: Families underwent deep systemic phenotyping and exome sequencing. Functional characterisation with in vitro luciferase assays and in vivo interferon signature using bulk and single cell RNA sequencing was performed. RESULTS: We have identified a novel DDX58 variant c.1529A>T p.(Glu510Val) that segregates with disease in two families with SGMRT2. Patients in these families have widely variable phenotypic features and different ethnic background, with some being severely affected by systemic features and others solely with glaucoma. JOAG was present in all individuals affected with the syndrome. Furthermore, detailed evaluation of skin rash in one patient revealed sparse inflammatory infiltrates in a unique distribution. Functional analysis showed that the DDX58 variant is a dominant gain-of-function activator of interferon pathways in the absence of exogenous RNA ligands. Single cell RNA sequencing of patient lesional skin revealed a cellular activation of interferon-stimulated gene expression in keratinocytes and fibroblasts but not in neighbouring healthy skin. CONCLUSIONS: These results expand the genotypic spectrum of DDX58-associated disease, provide the first detailed description of ocular and dermatological phenotypes, expand our understanding of the molecular pathogenesis of this condition and provide a platform for testing response to therapy.

Feasibility of a Risk-Based Approach to Cataract Surgery Preoperative Medical Evaluation.

IMPORTANCE: In 2019, the US Centers for Medicare & Medicaid Services implemented the Patients Over Paperwork initiative, allowing hospitals and ambulatory surgery centers to establish their own policies on preoperative history and physical requirements. A risk-based approach to preoperative medical evaluation may allow surgeons to provide high-value patient care. OBJECTIVE: To assess the feasibility of a risk-based approach to cataract surgery preoperative medical evaluation through a lens of safety and throughput. DESIGN, SETTING, AND PARTICIPANTS: A pilot study was performed to evaluate the implementation of a risk-based approach to preoperative medical evaluation for cataract surgery using a virtual medical history questionnaire. The intervention group, seen from June to September 2020, received the risk assessment and those who were low risk proceeded to surgery without further preoperative evaluation prior to the day of surgery. The preintervention control group included patients who received standard care from January to December 2019. MAIN OUTCOMES AND MEASURES: Primary outcomes included rates of intraoperative complications, noneye-related emergency department visits within 7 days, inpatient admissions within 7 days of surgery, case delays, and rates of case cancellation. The secondary outcome included patient perception regarding preoperative care. RESULTS: A total of 1095 patients undergoing cataract surgery were included in the intervention group (1813 [58.2%] female) and 3114 were in the control group (621/1095 [56.7%] female). The mean (SD) age was 68.6 (11.0) in the control group and 68.4 (10.5) in the intervention group. The intervention group included 126 low-risk individuals (11.5%) and 969 individuals who received standard care (88.5%). There were no differences between the control and intervention groups in terms of rates of intraoperative complications (control group vs intervention group: 21 [0.7%] vs 3 [0.3%]; difference, -0.4% [95% CI, -0.82 to 0.02]), 7-day noneye-related ED visits (5 [0.2%] vs 3 [0.3%]; difference, 0.1% [95% CI, -0.23 to 0.45]), 7-day inpatient admissions (6 [0.2%] vs 2 [0.2%]; difference, -0.01% [95% CI, -0.31 to 0.29]), or same-day cancellations (31 [0.8%] vs 10 [0.6%]; difference, -0.15% [95% CI, -0.63 to 0.34]). The control group had more case delays (59 [1.9%] vs 7 [0.6%]; difference, -1.3% [95% CI, -1.93 to -0.58]). CONCLUSIONS AND RELEVANCE: This study suggests that a virtual, risk-based approach to preoperative medical evaluations for cataract surgery is associated with safe and efficient outcomes. These findings may encourage health care systems and ambulatory surgery centers to tailor preoperative requirements for low-risk surgery patients.

Povidone-Iodine Attenuates Viral Replication in Ocular Cells: Implications for Ocular Transmission of RNA Viruses.

Several RNA viruses, including SARS-CoV-2, can infect or use the eye as an entry portal to cause ocular or systemic diseases. Povidone-Iodine (PVP-I) is routinely used during ocular surgeries and eye banking as a cost-effective disinfectant due to its broad-spectrum antimicrobial activity, including against viruses. However, whether PVP-I can exert antiviral activities in virus-infected cells remains elusive. In this study, using Zika (ZIKV) and Chikungunya (CHIKV) virus infection of human corneal and retinal pigment epithelial cells, we report antiviral mechanisms of PVP-I. Our data showed that PVP-I, even at the lowest concentration (0.01%), drastically reduced viral replication in corneal and retinal cells without causing cellular toxicity. Antiviral effects of PVP-I against ZIKV and CHIKV were mediated by direct viral inactivation, thus attenuating the ability of the virus to infect host cells. Moreover, one-minute PVP-I exposure of infected ocular cells drastically reduced viral replication and the production of infectious progeny virions. Furthermore, viral-induced (CHIKV) expression of inflammatory genes (TNF-α, IL-6, IL-8, and IL1ß) were markedly reduced in PVP-I treated corneal epithelial cells. Together, our results demonstrate potent antiviral effects of PVP-I against ZIKV and CHIKV infection of ocular cells. Thus, a low dose of PVP-I can be used during tissue harvesting for corneal transplants to prevent potential transmission of RNA viruses via infected cells.

A Modified Flanged Intrascleral Intraocular Lens Fixation Technique Using an Externalized Needle for Haptic Docking.

The Yamane intrascleral flanged haptic fixation technique has obviated the need for resources such as suture or glue. However, intraocular maneuvers to properly dock haptics into the needles for externalization can be difficult for even adept eye surgeons and is especially difficult when visualization through the cornea is poor. Additionally, one traditional resource, intraocular forceps, has been critical in both the original technique and proposed modifications since its inception. We describe a modified flanged intrascleral intraocular lens fixation technique by docking the second haptic externally at the main corneal incision. This technique does not require the use of microforceps, which is advantageous to surgeons who lack access to specialized instrumentation. Additionally, this technique may provide added safety, visibility, and ease for surgeons by docking the haptic externally at the corneal incision rather than within the eye.

Patient-Reported Outcomes After Corneal Transplantation.

PURPOSE: To characterize vision-related quality of life after penetrating keratoplasty (PKP), deep anterior lamellar keratoplasty (DALK), Descemet stripping automated endothelial keratoplasty (DSAEK), and Descemet membrane endothelial keratoplasty (DMEK) using the National Eye Institute Visual Function Questionnaire (NEI-VFQ 9). METHODS: Using the Sight Outcomes Research Collaborative ophthalmology electronic health record repository, questionnaire responses were obtained from 103 PKP patients, 24 DALK patients, 42 DSAEK patients, and 50 DMEK patients undergoing postoperative examination. No exclusions were made based on preoperative diagnosis, age, complications, or comorbidities. Associations between clinical characteristics and vision-related quality of life were analyzed using nonparametric and linear regression methods. RESULTS: Patients were surveyed an average of 1.5 years postoperatively (range 24 d to 4.4 yrs). Participants who had undergone DALK, DMEK, DSAEK, and PKP had median composite VFQ scores of 77.8, 84.2, 76.1, and 70.6, respectively (P= 0.002). There were no significant differences in VFQ scores between patients treated with DMEK versus DSAEK (P = 0.440) or between patients treated with PKP versus DALK (P = 1.000). Higher postoperative acuities in the operative and fellow eyes were associated with higher VFQ scores (P < 0.001 and P < 0.001). When controlling for postoperative acuity by regression modeling, surgery type was not associated with patient-reported composite VFQ scores. CONCLUSIONS: In this study, patient-reported vision-related quality of life was similar among DMEK and DSAEK participants and also among DALK and PKP participants. When controlling for postoperative acuity, vision-related quality of life was similar among all study participants, irrespective of the keratoplasty technique.