ESCRS Clinical Trends Survey 2016-2021: 6-year assessment of practice patterns among society delegates.

PURPOSE: To evaluate clinical opinions and practice patterns of delegates to the ESCRS. SETTING: Clinical Trends Surveys were administered during annual ESCRS congresses held between 2016 and 2021, and data collected online and in-person. DESIGN: Survey questions addressed several specialty areas, including cataract surgery, presbyopia-correcting and toric intraocular lenses (IOLs), ocular surface disease, and glaucoma. METHODS: Survey results were compared and analyzed across 6 years. 4 main profile questions were used for cross-tabulation analyses of questions pertaining to refractive surgery-practice location, years in practice, primary surgery setting, and average annual volume of cataract surgery. RESULTS: The highest number of responses (3019) was collected in 2019, with the lowest (569) received in 2020. The use of presbyopia-correcting and toric IOLs has increased significantly from 2016 to 2021, with certain respondent segments using them more frequently than others. Although optical biometry remains the preferred method for obtaining preoperative measurements, the use of tomography (Scheimpflug) has significantly increased. In 2021, 61.1% and 44.9% of respondents always performed preoperative checks of the ocular surface before refractive and cataract surgery, respectively. The number of respondents who perform glaucoma surgery has significantly decreased over the years, with an increasing number of delegates reporting having only a medical glaucoma practice. On average, 5.4% of patients with cataract and glaucoma underwent combined minimally invasive glaucoma surgery and cataract procedures in 2021. CONCLUSIONS: Evaluation of the Clinical Trends Survey data provides valuable insights into the shifting practice patterns and clinical opinions of ESCRS delegates.

Automated qualitative and quantitative assessment of posterior capsule opacification by Automated Quantification of After-Cataract II (AQUA II) system.

BACKGROUND: The present study aims to investigate an automated qualitative and quantitative assessment system (Automated Quantification of After-Cataract [AQUA II]) of posterior capsule opacification (PCO) in high-resolution digital retroillumination images and consequently reduce observer bias and increase accuracy of PCO grading. METHODS: A data set of 100 eyes with no to severe PCO was analysed. Ten eyes were consecutively photographed twice and ten images were rotated to give a total of 120 images for PCO assessment. Validity was determined by including subjective grading and repeatability was determined by evaluating the 20 additional images. Evaluation of posterior capsular opacification (EPCO), posterior capsule opacity (POCO) and AQUA I methods were included for comparative analysis of the data. RESULTS: The system developed proved to classify six types of PCO. Validity was confirmed by a Pearson correlation coefficient of r = 0.95 (EPCO r = 0.93; POCO r = 0.72 and AQUA I r = 0.94). Repeatability was better in AQUA II (95% confidence interval [CI] for mean difference: 0.5 ± 1.2) than in subjective grading (95% CI for mean difference: 0.6 ± 1.7), in EPCO grading (95% CI for mean difference: - 0.2 ± 1.5), in POCO grading (95% CI for mean difference: 1.6 ± 2.7) and in AQUA I (95% CI for mean difference: - 1.1 ± 1.9). CONCLUSIONS: AQUA II is a system that for the first time not only objectively quantifies PCO, but also qualitatively assesses PCO in an automated manner with texture classification. AQUA II showed an excellent validity and repeatability.

Efficacy of ophthalmic viscosurgical devices in maintaining corneal epithelial hydration and clarity: in vitro assessment.

PURPOSE: To determine the efficacy of hydroxypropyl methylcellulose (HPMC) and hyaluronic acid (HA) in maintaining corneal hydration and optical clarity. SETTING: Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. DESIGN: Experimental study. METHODS: In porcine autopsy eyes, the effect of 13 ophthalmic viscosurgical devices (OVDs) (5 formulations of HPMC; 8 formulations of HA) in maintaining corneal hydration and optical clarity was tested. The main outcome variables were the time to reach optical clarity of the cornea during dissipation of the OVD and duration of corneal hydration. These variables were assessed after the first application of the OVD, after balanced salt solution application to rehydrate the gel matrix, and after the second application of OVD on top of the first layer. RESULTS: The study used 57 porcine eyes. High-molecular-weight HA 1.5% (zero shear viscosity [ZSV] 55,122 millipascal seconds [mPa.s]) took a significantly shorter time to reach optical clarity than HA 1.4% (ZSV 36,882 mPa.s) (P=.04). Hyaluronic acid 1.4% and HA 1.5% maintained corneal hydration significantly longer than HPMC 2.0% (P<.001). CONCLUSIONS: For corneal hydration during short-lasting surgical procedures such as cataract surgery, the results suggest using HPMC because it distributes quickly and provides an adequate duration of sufficient corneal hydration. For corneal hydration during prolonged surgical procedures, such as vitreoretinal surgery, results suggest using HA 1.5% in the formulation because it provides long-lasting corneal hydration. FINANCIAL DISCLOSURE: Dr. Prinz has a proprietary interest in Croma Pharma GmbH, Leobendorf, Austria. Dr. Findl is a scientific advisor to Croma Pharma GmbH. No other author has a financial or proprietary interest in any material or method mentioned.

Assessment of a new averaging algorithm to increase the sensitivity of axial eye length measurement with optical biometry in eyes with dense cataract.

PURPOSE: To assess the capability of new software to decrease the proportion of eyes that have insufficient signal-to-noise ratio (SNR) in optical biometry. SETTING: Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom. DESIGN: Evaluation of diagnostic test or technology. METHODS: In a prospective study, consecutive cataract patients coming for biometry who were unsuccessfully measured with the former software (version 4) of the IOLMaster partial coherence interferometry (PCI) device were reevaluated with the new composite software (version 5). Subsequently, in a retrospective study, consecutive cataract patients were measured with software version 5. For unsuccessful scans, the type and intensity of cataract were assessed at the slitlamp. RESULTS: Altogether, 2713 eyes (1956 patients) were included in the study. The prospective study comprised 458 eyes (244 patients), 10.6% of which could not be measured successfully with software version 4. With the composite software, 30% of cases were measured successfully, with a higher proportion (42%) in the posterior subcapsular cataract subgroup. In the retrospective study, of 2255 eyes (1712 patients), 4.7% were not measured successfully using the new algorithm because of white cataract (70 eyes), posterior subcapsular cataract (14 eyes), or dense nuclear cataract combined with posterior subcapsular cataract (13 eyes) or for other reasons (8 eyes). CONCLUSION: The composite software (version 5) enhanced the SNR, allowing valid measurements in eyes in which optical biometry had previously failed, especially in cases of posterior subcapsular cataract. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes.

Optical coherence tomography assessment of capsule closure after cataract surgery.

PURPOSE: To develop a technique for documenting and quantifying capsule bend formation in pseudophakic eyes, evaluate when the anterior and posterior lens capsules become completely apposed to the optic, and determine how soon a capsule bend is created at the optic edge of an intraocular lens (IOL) after cataract surgery. SETTING: Medical University of Vienna, Department of Ophthalmology, Vienna, Austria. METHODS: This prospective study comprised 33 eyes of 33 patients with age-related cataract who were scheduled to have cataract surgery. All eyes had phacoemulsification with implantation of 1 of 3 types of open-loop IOLs: 1-piece acrylic (SA60AT, Alcon), 3-piece acrylic (AcrySof MA60BM, Alcon), or 3-piece silicone (911A, AMO). Each group included 11 eyes. One and 3 days and 1, 2, 3, and 4 weeks after surgery, contact between the lens capsule and IOL optic as well as capsule bend formation were evaluated using optical coherence tomography (OCT). The postoperative times at which the capsule came into contact with the IOL optic and when the capsule bend formed were determined. RESULTS: One day postoperatively, the mean distance between the anterior capsule and the IOL was 197 microm in the 1-piece acrylic IOL group, 161 microm in the 3-piece acrylic IOL group, and 220 microm in the 3-piece silicone IOL group. The posterior capsule was in contact with the IOL on the same day or earlier than the anterior capsule in 28 patients (85%). Postoperatively, the capsule bend formed at a mean of 10 days in the 1-piece acrylic group, 13 days in the 3-piece acrylic group, and 15 days in the 3-piece silicone group. The short-term reproducibility of the OCT technique was excellent (r = 0.99). CONCLUSIONS: Optical coherence tomography produced cross-sectional tomograms of capsule-IOL contact in the early postoperative period. There was no significant difference in the time to capsule bend formation between the 3 IOLs. However, capsule bend formation at the optic edge occurred earlier with the 1-piece acrylic IOL than with the 3-piece silicone IOL.

Laserinterferometric assessment of pilocarpine-induced movement of an accommodating intraocular lens: a randomized trial.

PURPOSE: To measure the axial movement of an accommodating intraocular lens (IOL) induced by ciliary muscle contraction after application of pilocarpine. DESIGN: Randomized, controlled, patient- and examiner-masked trial with intrapatient comparison. PARTICIPANTS AND CONTROLS: One hundred ten eyes of 55 patients with age-related bilateral cataract. METHODS: This study was divided into 3 parts. In the first, the accommodating IOL (1CU) was compared with a 3-piece open-loop acrylic IOL that served as the control. In the second, to assess the effect of capsule fibrosis on the potential accommodating performance of the accommodating IOL, extensive polishing of the anterior capsule with a slit cannula was compared with standard surgery. In the third, the effect of a posterior capsulorhexis was compared with that of standard surgery. Anterior chamber depth (ACD) was assessed with partial coherence interferometry, measured before and after topical application of pilocarpine 2%, and near visual acuity (VA) was evaluated 3 months after surgery. MAIN OUTCOME MEASURE: Pilocarpine-induced change in ACD. RESULTS: The accommodating IOL showed a forward movement under pilocarpine with a median amplitude of movement of -314 microm (95% confidence interval [CI]: -148 to -592), compared with the backward movement of 63 microm (95% CI: 161 to -41) for the open-loop control IOL (P = 0.001). Capsule polishing and a posterior capsulorhexis had no effect on IOL movement with the accommodating IOL. The median near VA with distance correction was 20/60. CONCLUSION: Pilocarpine induced a small but significant forward movement of the accommodating IOL. However, the amount of movement was calculated to result in a refractive change of <0.5 diopters (D) in most patients, reaching 1 D or slightly more in only single cases, with a large variability of movement. Neither polishing of the capsule bag nor a posterior capsulorhexis could enhance the accommodative ability.

Early objective assessment of intraocular inflammation after phacoemulsification cataract surgery.

PURPOSE: To evaluate the time course of blood-aqueous barrier (BAB) disturbance in the early period after small-incision cataract surgery. SETTING: Department of Ophthalmology, Vienna University, Vienna, Austria. METHODS: In a prospective study, 15 eyes of 15 patients with age-related cataract had small-incision cataract surgery by phacoemulsification with intraocular lens implantation. Care was taken to minimize trauma to the uvea during surgery. Postoperative inflammation was assessed by measuring aqueous flare and cell count with a laser flare-cell meter. Postoperative measurements were performed hourly for the first 6 hours, every 2 hours until 12 hours, every 4 hours until 40 hours, and every 8 hours until 56 hours. RESULTS: The time course of aqueous flare and cell count differed significantly among patients. The peak inflammatory response in most cases was 1 hour after surgery, with the response decreasing thereafter. The pattern of the time course was classified into subgroups defined by the presence and size of an initial spike immediately after surgery and the intensity of the subsequent inflammatory reaction. A slight increase in flare and cells was seen in the morning hours of the first postoperative day. CONCLUSIONS: Acute BAB disturbance within the first 48 hours after small-incision cataract surgery showed high interpatient variability. However, many differences were not detectable 1 day after surgery.

Corneal endothelial cell protection with a dispersive viscoelastic material and an irrigating solution during phacoemulsification: low-cost versus expensive combination.

PURPOSE: To evaluate the protective effect on corneal endothelial cells of a low-cost and an expensive combination of a dispersive viscoelastic material and an irrigating solution during phacoemulsification. SETTING: Department of Ophthalmology, University of Vienna, Vienna, Austria. METHODS: This prospective randomized examiner- and patient-masked study comprised 90 eyes of 45 consecutive patients with age-related cataract in both eyes. For each patient, the first eye was randomly assigned to receive hydroxypropyl methylcellulose 2% (Ocucoat) and Ringer's solution (low-cost combination) or sodium chondroitin sulfate 4%-sodium hyaluronate 3% (Viscoat) and an enriched balanced salt solution (BSS Plus) (expensive combination) during phacoemulsification. The contralateral eye received the other treatment. Endothelial cell function was evaluated by measuring corneal thickness (CT) using partial coherence interferometry, morphology assessment, and endothelial cell counts. RESULTS: The acute postoperative increase in CT was +9.8 microm in the low-cost group and +10.9 microm in the expensive group; the difference between groups was not significant. After 1 month, the CT still differed significantly from baseline in the low-cost group. Three months after surgery, the CT had returned to baseline values in both groups. There was no significant between-group difference in endothelial cell counts or morphology. CONCLUSIONS: During phacoemulsification in a nonselected patient population, there was no difference in acute postoperative corneal edema and endothelial cell morphology after 3 months between a Viscoat and BSS Plus combination and an Ocucoat and Ringer's solution combination. Eyes receiving the expensive combination had marginally faster recovery of corneal swelling by 3 months. However, the cost of Viscoat and 500 mL BSS Plus is 5 times that of Ocucoat and Ringer's solution.

Removal of reflections in the photographic assessment of PCO by fusion of digital retroillumination images.

PURPOSE: Automated image-analysis systems for objective assessment of posterior capsule opacification (PCO) depend on good image quality. One major drawback is the existence of light-reflection artifacts (Purkinje spots) in retroillumination images of the posterior capsule. Therefore, a software algorithm was developed that removes these artifacts by fusion of two or more digital images from the same eye, photographed in slightly different directions of gaze. METHODS: The image-fusion process comprises five steps: definition of a primary and a secondary image, automated segmentation of the region of interest and the Purkinje spots, manual selection of three pairs of corresponding points in both images, geometric registration and radiometric calibration of the regions to be inserted from the secondary image into the primary image. The program was tested with an image set of 30 eyes that had various degrees of PCO. A digital image acquisition system with a coaxial optical path was used to take retroillumination images from each eye in at least three different directions of gaze. RESULTS: In 28 cases all light-reflection artifacts within the capsulorrhexis rim could be removed entirely. In two cases, small parts of single Purkinje spots remained visible, because the reflections were located too closely in the primary and the secondary images. CONCLUSIONS: Fusion of digital retroillumination images provides high-quality, reflection-free PCO images. This allows objective PCO assessment systems to analyze 100% of the posterior capsule, leading to more accurate results.

Assessment of anterior capsule opacification: photographic technique and quantification.

PURPOSE: To develop and evaluate a standardized slitlamp photographic technique to document and quantify anterior capsule opacification (ACO) in the pseudophakic eye. SETTING: University of Vienna, Medical School, Department of Ophthalmology, Vienna, Austria. METHODS: In this prospective study, slitlamp photographs were taken in 29 eyes of 19 patients with ACO of varying degrees and intraocular lenses of different materials. Digital slitlamp photographs were taken by 2 examiners using a standardized protocol. The intensity of anterior fibrosis was evaluated using subjective grading by 2 masked examiners and by image analysis. RESULTS: A standardized protocol was developed for documentation of ACO. The intraexaminer (or short-term) reproducibility (r = 0.96, P < .01) and interexaminer reproducibility (r = 0.93, P < .01) were excellent. The results of image analysis used to objectively quantify ACO correlated with the subjective grading (r = 0.95, P < .01). CONCLUSION: This standardized technique of slitlamp photography and image analysis provided reproducible documentation and can therefore serve as a basis for the quantification of ACO.