Ten-year trends of immediate sequential bilateral cataract surgery (ISBCS) as reflected in the Swedish National Cataract Register.

PURPOSE: To analyse trends of ISBCS reported to the Swedish National Cataract Register (NCR) over a 10-year period. METHODS: Since 2010 the NCR contains social security number of all individuals in the list of parameters reported to NCR after each cataract procedure. Bilateral surgeries were mapped out using social security numbers. When dates of both-eye surgeries are identical for an individual it is classified as an immediate sequential bilateral cataract surgery (ISBCS). This study includes all data reported during the period 1st of January 2010 to 31st of December 2019. During the study period 113 cataract surgery clinics affiliated to the NCR reported their data on consecutive cataract cases. RESULTS: For the whole period 54 194 ISBCS were reported. The total number of bilateral cataract extractions was 422 300. There was a significant trend of increasing ISBCS over time with linear regression (Beta = 1.75, p < 0.001). In ISBCS the occurrence of an ocular comorbidity decreased over time. The use of a capsular tension ring was significantly more common in ISBCS than in delayed sequential bilateral cataract surgery (DSBCS). All other measures taken during surgery were more common in DSBCS. The use of multifocal IOL was significantly more frequent in ISBCS compared to DSBCS (p < 0.001). CONCLUSIONS: The use of ISBCS has increased over the study period. The operated eyes have less risk factors than eyes going through a DSBCS, but both ocular comorbidities and surgical complications occur in ISBCS eyes.

Cost Utility and Value of Information Analysis of Femtosecond Laser-Assisted Cataract Surgery.

Importance: The efficacy and safety of femtosecond laser-assisted cataract surgery is well documented. An important requirement for decision makers is the evaluation of the cost-effectiveness of femtosecond laser-assisted cataract surgery (FLACS) over a sufficiently long horizon. Evaluating the cost-effectiveness of this treatment was a preplanned secondary objective of the Economic Evaluation of Femtosecond Laser Assisted Cataract Surgery (FEMCAT) trial. Objective: To estimate the cost utility of FLACS compared with phacoemulsification cataract surgery (PCS) on a 12-month time horizon. Design, Setting, and Participants: This multicenter randomized clinical trial compared FLACS with PCS in parallel groups. All FLACS procedures were performed using the CATALYS precision system. Participants were recruited and treated in ambulatory surgery settings in 5 university-hospital centers in France. All consecutive patients eligible for a unilateral or bilateral cataract surgery 22 years or older with written informed consent were included. Data were collected from October 2013 to October 2018, and data were analyzed from January 2020 to June 2022. Interventions: FLACS or PCS. Main Outcomes and Measures: Utility was measured through the Health Utility Index questionnaire. Costs of cataract surgery were estimated by microcosting. All inpatient and outpatient costs were collected from the French National Health Data System. Results: Of 870 randomized patients, 543 (62.4%) were female, and the mean (SD) age at surgery was 72.3 (8.6) years. A total of 440 patients were randomized to receive FLACS and 430 to receive PCS; the rate of bilateral surgery was 63.3% (551 of 870). The mean (SD) costs of cataract surgery were €1124.0 (€162.2; US $1235) for FLACS and €565.5 (€61.4; US $621) for PCS. The total mean (SD) cost of care at 12 months was €7085 (€6700; US $7787) in participants treated with FLACS and €6502 (€7323; US $7146) in participants treated with PCS. FLACS yielded a mean (SD) of 0.788 (0.009) quality-adjusted life-years (QALYs), and PCS yielded 0.792 (0.009) QALYs. The difference in mean costs was €545.9 (95% CI, -434.1 to 1525.8; US $600), and the difference in QALYs was -0.004 (95% CI, -0.028 to 0.021). The incremental cost-effectiveness ratio (ICER) was -€136 476 (US $150 000) per QALY. The cost-effectiveness probability of FLACS compared with PCS was 15.7% for a cost-effectiveness threshold of €30 000 (US $32 973) per QALY. At this threshold, the expected value of perfect information was €246 139 079 (US $270 530 231). Conclusions and Relevance: The ICER of FLACS compared with PCS was not within the $50 000 to $100 000 per QALY range frequently cited as cost-effective. Additional research and development on FLACS is needed to improve its effectiveness and lower its price. Trial Registration: ClinicalTrials.gov Identifier: NCT01982006.

Perioperative time and economic impact of an intracameral combination of mydriatics and anaesthetics in routine cataract surgery.

PURPOSE: The aim of this study was to compare the perioperative time and economic impact of a licensed intracameral anaesthetic/mydriatic combination (Mydrane) during routine cataract surgery. METHODS: A real-life, prospective, comparative study was performed in 3 clinical centres in France. Preoperative, surgical, and post-operative times were determined for two mydriasis strategies using conventional preoperative mydriatics/anaesthetics eye drops (control regimen) or Mydrane administered at time of surgery. Staff, surgery schedules and drugs utilisation were collected over 12 surgery half-days. The total cost of each strategy was estimated based on treatment cost and nursing costs. RESULTS: The analysis included 112 routine cataract surgeries (57 surgeries using Mydrane and 55 using the topical regimen) without protocol deviations or complicated surgery. Overall, the mean time between administration of the first mydriatic eye drops or Mydrane and the end of the surgery was 27.4 ± 21.1 min in the Mydrane group vs. 90.3 ± 30.4 min in the control group (P < 0.0001). The total time of the procedure (from admission to discharge) was not significantly different between groups (P = 0.1611). On average, the extra cost of drugs per patient in the Mydrane group (€5.81) was almost balanced by the reduced nursing time (€5.57) with some variations between centres, due to different organisation including staff resource and consumable. CONCLUSIONS: The Mydrane strategy produced perioperative nursing time saving and cost reduction provided that adaptation and reorganisation of routine cataract surgery are implemented.

Health economics and manual small-incision cataract surgery: An illustrative mini review.

Cataract extraction is one of the most common surgical procedures performed worldwide. Manual small-incision cataract surgery (MSICS) is a popular technique of cataract extraction. Full economic evaluation of different techniques is of value to policy makers. This was a systematic review of published literature to present a brief overview of evidence available in respect of economic evaluation measures like cost effectiveness, cost utility, and cost parameters in cataract patients regarding MSICS. The data on these was sparse and heterogeneous. Direct costs of MSICS were lower than phacoemulsification (PE): $25.55 (PE) to $17.03 (MSICS) in India, $15 (MSICS) to $70 (PE) in Nepal, and $62.25 (MSICS) to $104.15 (PE) in Thailand. The cost utility analysis for MSICS demonstrated savings of $79.57 (INR6175) per gain in LogMAR BCVA, $8.91 (INR691) per QALY gained and $1.42 (INR110) per VF 14 score increment in India. Incremental cost-effectiveness ratio (ICER) $368.20 (13,215.50 Baht) for MSICS was better than $489.30 (17,561.70 Baht) for PE in Thailand. ICER for femto laser-assisted cataract surgery (FLACS) compared to was €10,703 in femtosecond laser-assisted versus phacoemulsification cataract surgery (FEMCAT) study. The corrected ICER for PE against MSICS is €146.50. The limited data available demonstrates that MSICS is the most cost-effective technique among FLACS, PE, and MSICS. MSICS scores over other existing alternatives of cataract extraction from cost-effectiveness and cost-minimization approaches. Further research is required in this area.

Femtosecond Laser-Assisted Cataract Surgery: A Report by the American Academy of Ophthalmology.

PURPOSE: To evaluate refractive outcomes, safety, and cost-effectiveness of femtosecond laser-assisted cataract surgery (FLACS) compared with phacoemulsification cataract surgery (PCS). METHODS: A PubMed search of FLACS was conducted in August 2020. A total of 727 abstracts were reviewed and 33 were selected for full-text review. Twelve articles met inclusion criteria and were included in this assessment. The panel methodologist assigned a level of evidence rating of I to all 12 studies. RESULTS: No significant differences were found in mean uncorrected distance visual acuity, best-corrected distance visual acuity, or the percentage of eyes within ± 0.5 and ± 1 diopter of intended refractive target between FLACS and PCS. Intraoperative and postoperative complication rates were similar between the 2 groups, and most studies showed no difference in endothelial cell loss between FLACS and PCS at various time points between 1 and 6 months. In large randomized controlled studies in the United Kingdom and France, FLACS was less cost-effective than PCS. CONCLUSIONS: Both FLACS and PCS have similar excellent safety and refractive outcomes. At this time, one technique is not superior to the other, but economic analyses performed in some populations have shown that FLACS is less cost-effective.

Assessment for Macular Thickness after Uncomplicated Phacoemulsification Using Optical Coherence Tomography.

PURPOSE: Macular edema including cystoid macular edema is one of the main causes of unfavorable visual outcomes after cataract surgery. The macular thickness and the occurrence of macular edema after uncomplicated cataract surgery was evaluated using optical coherence tomography (OCT) in this study. METHODS: Macular map images were taken by OCT before surgery and at 1 week, 1 month, and 2 months postsurgery. The subjects were classified into two groups (group 1, patients with no macular edema; group 2, patients with macular edema). Group 2 was defined as increase in central macular thickness (CMT) by 30% compared with that before surgery. The risk factors for macular edema were evaluated. Group 2 was divided into two subgroups: subclinical macular edema (group 2A) and cystoid macular edema (group 2B) and they were assessed in terms of the clinical course of best-corrected visual acuity and CMT. RESULTS: A total of 376 patients were enrolled in this study, of which 36 (9.57%, group 2) showed macular edema measured by OCT after the surgery. Univariate analysis for group 1 and 2 revealed that intracameral injection of epinephrine during phacoemulsification was associated with the development of macular edema. In group 2, five patients (1.33%) developed cystoid macular edema. Statistically significant differences in the clinical course of CMT were observed at 2 months (201.2 ± 23.1, 250.0 ± 29.8, and 371.0 ± 160.3 in group 1, group 2A, and group 2B, respectively; p < 0.001) and 1 month postoperatively (198.5 ± 23.6, 237.8 ± 40.9, and 314.0 ± 104.5 in group 1, group 2A, and group 2B, respectively; p < 0.001). Group 2B required additional treatment and eventually achieved best-corrected visual acuity of >0.2 with CMT in the normal range. CONCLUSIONS: The intracameral injection of epinephrine may cause macular edema after uncomplicated cataract surgery. Examination of CMT using OCT is recommended for the early detection of macular edema.

Trends, Factors, and Outcomes Associated with Immediate Sequential Bilateral Cataract Surgery among Medicare Beneficiaries.

PURPOSE: To report the incidence of immediate sequential bilateral cataract surgery (ISBCS) and delayed sequential bilateral cataract surgery (DSBCS) and to identify factors associated with undergoing ISBCS. DESIGN: Retrospective cohort study. PARTICIPANTS: Medicare beneficiaries aged ≥ 65 who underwent ISBCS and DSBCS from 2011 through 2019. METHODS: Population-based analysis of the 100% Medicare fee-for-service carrier claims data. Logistic regression models were performed to evaluate factors associated with ISBCS. MAIN OUTCOME MEASURES: Incidence of ISBCS and DSBCS; demographic, ocular, and medical characteristics associated with receipt of ISBCS; and rates of endophthalmitis and cystoid macular edema (CME) after ISBCS or DSBCS. RESULTS: A total of 4014 (0.2%) ISBCS and 1 940 965 (99.8%) DSBCS patients were identified. Black (odds ratio [OR], 2.31; 95% confidence interval [CI], 2.06-2.59), Asian (OR, 1.82; 95% CI, 1.51-2.19), and Native American (OR, 2.42; 95% CI, 1.81-3.23) patients were more likely to receive ISBCS than White patients. Patients residing in rural areas showed a higher likelihood of ISBCS (OR, 1.26; 95% CI, 1.17-1.35) than patients in metropolitan areas. Patients undergoing surgery at a hospital, compared with an ambulatory setting (OR, 2.71; 95% CI, 2.53-2.89), were more likely to receive ISBCS. Patients with bilateral complex versus noncomplex cataract (OR, 3.23; 95% CI, 2.95-3.53) were more likely to receive ISBCS. Patients with a Charlson comorbidity index (CCI) of 1 to 2 (OR, 1.45; 95% CI, 1.29-1.62), 3 to 4 (OR, 1.70; 95% CI, 1.47-1.97), 5 to 6 (OR, 1.97; 95% CI, 1.62-2.39), and CCI ≥ 7 (OR, 1.97; 95% CI, 1.55-2.50) were more likely to receive ISBCS than those with a CCI of 0. In contrast, patients with glaucoma (OR, 0.82; 95% CI, 0.76-0.89), macular degeneration (OR, 0.75; 95% CI, 0.68-0.82), and macular hole or epiretinal membrane (OR, 0.55; 95% CI, 0.48-0.65) were less likely to undergo ISBCS than those without. Cumulatively, no significant difference was found in endophthalmitis rates within 42 days between ISBCS (1.74 per 1000 ISBCS procedures) and DSBCS (1.01 per 1000 DSBCS procedures; P = 0.15). Similarly, there was no significant cumulative difference between CME rates (P = 0.45) in ISBCS (1.79 per 100 ISBCS procedures) and DSBCS (1.96 per 100 DSBCS procedures). CONCLUSIONS: Overall use of ISBCS among Medicare beneficiaries remained low over the past decade, although rates of endophthalmitis and CME were comparable to DSBCS. Race, geography, and systemic and ocular comorbidities were associated with receiving ISBCS. ISBCS represents a potential opportunity to improve access to cataract surgery.

Immediate versus delayed sequential bilateral cataract surgery in children: a cost-effectiveness analysis.

BACKGROUND/AIMS: Children with bilateral cataracts may undergo immediate sequential bilateral cataract surgery (ISBCS), which involves surgery on both eyes during the same general anaesthesia, or delayed sequential bilateral cataract surgery (DSBCS), which involves operating on each eye on separate days and requires a second anaesthesia. ISBCS is viewed with caution because of the risk of bilateral endophthalmitis. Proponents of ISBCS emphasise that the incidence of serious complications is low and is outweighed by benefits such as avoidance of multiple anaesthesia, faster visual rehabilitation and potential for decreased costs. However, there is a paucity of literature regarding the cost-effectiveness of ISBCS in children. We conducted a cost-effectiveness analysis to determine whether ISBCS is more cost-effective than DSBCS from the societal and health system perspectives in Ontario, Canada, which has a universal, single-payer system. METHODS: A retrospective analysis of children who underwent ISBCS or DSBCS at a tertiary referral paediatric hospital was conducted. A decision tree was constructed using TreeAge Pro 2018 software. Clear visual axis was the measure of effectiveness. A time horizon of 8 weeks postoperatively was adopted. Both direct and indirect costs were included. RESULTS: Fifty-three children were included, 37 in the ISBCS group and 16 in the DSBCS group. ISBCS and DSBCS were equally effective. ISBCS resulted in cost-savings of $3,776 (95% CI:-$4,641 to $12,578) CAD, per patient, from the societal perspective and $2,200 (95% CI:-$5,615 to $10,373) CAD per patient from the health system perspective. CONCLUSION: ISBCS was less costly than DSBCS from both societal and health system perspectives while being equally effective.

Desarrollo de la anestesia en Oftalmología / Development of anesthesia in Ophthalmology

RESUMEN Para el ser humano la información suministrada por sus ojos resulta esencial en su interacción con el entorno. Por esta razón todos consideramos la vista como nuestro sentido más valioso. Es fácil comprender, por tanto, que cualquier individuo sometido a una operación oftalmológica desarrollará un alto grado de ansiedad; de ahí la importancia de su cooperación para evitar las complicaciones quirúrgicas, donde en muchas ocasiones la cirugía se realiza con anestesia local. Es por eso que evitar el dolor y abolir los movimientos oculares va a ser un paso previo fundamental en la cirugía. Con el advenimiento del desarrollo tecnológico aplicado a la Oftalmología, nuevos procedimientos quirúrgicos persiguen una recuperación visual y social temprana de los pacientes. Dentro de ellos la cirugía de catarata por facoemulsificación exige métodos anestésicos que permitan lograr este propósito, y en la actualidad ya podemos mencionar la anestesia tópica y la crioanalgesia como avances en este sentido, las cuales se aplican en el Instituto Cubano de Oftalmología "Ramón Pando Ferrer". Se realizó una búsqueda de diversos artículos publicados en la plataforma de PubMed, con el objetivo de conocer el desarrollo y las características de los anestésicos aplicados en la cirugía de catarata(AU)

ABSTRACT The information obtained by human beings through their eyes is essential for their interaction with the environment. This is the reason why we all consider our sight as our most valuable sense. It is thus easy to understand that any individual undergoing eye surgery will develop a high degree of anxiety. Hence the importance of their cooperation to prevent surgical complications, since on many occasions surgery is performed with local anesthesia. Preventing pain and stopping eye movement are therefore a crucial previous step in surgery. With the application of technological development to ophthalmology, new surgical procedures have emerged aimed at the patients' visual recovery and early social reincorporation. One of those procedures is phacoemulsification cataract surgery, which requires anesthetic methods that make it possible to achieve such an end. Examples of advances in this field are topical anesthesia and cryoanalgesia, both of which are applied at Ramón Pando Ferrer Cuban Institute of Ophthalmology. A search was conducted for papers published on the PubMed platform with the purpose of becoming acquainted with the development and characteristics of the anesthetics used in cataract surgery(AU)

Análise da qualidade de vida antes e após cirurgia de catarata com implante de lente intraocular / Life quality assessment before and after cataract surgery with intraocular lens implantation

Resumo Objetivo: Analisar a qualidade de vida dos pacientes antes e após cirurgia de remoção da catarata associada ao implante de lente intraocular (LIO). Metodos: Este é um estudo observacional, prospectivo, de série de casos. Os dados foram coletados em um serviço privado de oftalmologia em Aracaju - SE, de agosto de 2018 a julho de 2019. A avaliação da qualidade de vida de pacientes antes e após 4 meses da cirurgia de catarata, pela técnica de facoemulsificação associada ao implante de LIO, foi realizada aplicando a versão brasileira validada do Questionário de Função Visual de 25 itens do National Eye Institute (NEI-VFQ-25) e realização do teste de acuidade visual com a tabela de Snellen. Resultados: O grupo final foi constituído por 41 pacientes, com média de idade de 72 anos (DP: 9,01), sendo 14 do sexo masculino e 27 do feminino. Além disso, dos 41 pacientes, 37 foram submetidos à facectomia em ambos os olhos, 03 apenas no olho direito e 01 apenas no olho esquerdo. Diante da coleta e da análise dos dados, notou-se melhora na qualidade de vida dos pacientes submetidos ao procedimento cirúrgico proposto. Houve um aumento estatisticamente significativo (p<0,001) na acuidade visual binocular, na acuidade visual monocular e nas pontuações de 11 dos 12 subdomínios do NEI-VFQ-25. Não foi observada significância estatística no subdomínio "Dor ocular" (p=0,934). Conclusão: Houve melhora significativa na qualidade de vida dos pacientes submetidos à cirurgia de catarata com implante de LIO.

Abstract Objective: To analyze patients' quality of life before and after cataract removal surgery associated with intraocular lens (IOL) implantation. Methods: This is an observational, prospective, case series study. Data were collected at a private ophthalmology service in Aracaju - SE, from August 2018 to July 2019. The quality of life assessment of patients before and after 4 months of cataract surgery, using the phacoemulsification technique associated with IOL implantation, was performed by applying the validated Brazilian version of the 25-item Visual Function Questionnaire from the National Eye Institute (NEI-VFQ-25) and performing the visual acuity test with the Snellen chart. Results: The final group consisted of 41 patients, with a mean age of 72 years (SD: 9.01), of which 14 were male and 27 female. In addition, out of 41 patients, 37 underwent facectomy in both eyes, 03 only in the right eye and 01 only in the left eye. Given the collection and thorough analysis of the data, the improvement in the quality of life of patients submitted to cataract surgery with intraocular lens implantation was noticed. There was a statistically significant increase (p<0.001) in binocular visual acuity, monocular visual acuity and scores in 11 of the 12 subdomains of the NEI-VFQ-25. No statistical significance was observed in the subdomain "Eye Pain" (p=0.934). Conclusion: There was a significant improvement in the quality of life of patients who underwent cataract surgery with intraocular lens implantation.

A survey exploring ophthalmologists' attitudes and beliefs in performing Immediately Sequential Bilateral Cataract Surgery in the United Kingdom.

BACKGROUND: The standard approach to treat cataracts is Delayed Sequential Bilateral Cataract Surgery (DSBCS), during which patients have a separate operation date for each eye. An alternative method of delivery is Immediately Sequential Bilateral Cataract Surgery (ISBCS). The aim of this project was to examine the attitudes and beliefs of UK ophthalmologists towards ISBCS, explore their reasons to either practise or not practise ISBCS and identify barriers hindering its implementation in the UK. METHODS: A questionnaire was distributed to consultant members of The Royal College of Ophthalmologists (RCOphth, UK) and collected electronically. An initial screening question in regards to prior experience with ISBCS directed the rest of the survey; participants were asked to rate the importance of several factors with regards to performing ISBCS. Free text options were also available. Descriptive analysis was subsequently performed. RESULTS: Of the 1357 recipients, 130 (9.6%) ophthalmologists completed the survey. Of those, 13.9% were currently performing ISBCS, 83.1% had never performed, and 3.1% had previously done so but since stopped. The main factors that acted as barriers were lack of: (1) College approval (20.5%); (2) medico-legal approval (20.2%); (3) evidence to support the use of ISBCS (16.0%); and (4) hospital approval (13.3%). Additionally, the perceived risk of complications for patients played an important role when considering ISBCS, with the risk of endophthalmitis being most feared. CONCLUSIONS: This survey demonstrates some of the barriers that prevent ophthalmologist's performing ISBCS in the UK. There is a need for further exploration in this field to evaluate the effect of addressing any of these concerns on the implementation of ISBCS.

Femtosecond Laser-Assisted Cataract Surgery Versus Phacoemulsification Cataract Surgery (FACT): A Randomized Noninferiority Trial.

PURPOSE: To report the 3-month results of a randomized trial (Femtosecond Laser-Assisted Cataract Trial [FACT]) comparing femtosecond laser-assisted cataract surgery (FLACS) with standard phacoemulsification cataract surgery (PCS). DESIGN: Multicenter, randomized controlled trial funded by the UK National Institute of Health Research (HTA 13/04/46/). PARTICIPANTS: Seven hundred eighty-five patients with age-related cataract. METHODS: This trial took place in 3 hospitals in the UK National Health Service (NHS). Randomization (1:1) was stratified by site, surgeon, and 1 or both eyes eligible using a secure web-based system. Postoperative assessments were masked to the allocated intervention. The primary outcome was unaided distance visual acuity (UDVA) in the study eye at 3 months. Secondary outcomes included corrected distance visual acuity, complications, and patient-reported outcomes measures. The noninferiority margin was 0.1 logarithm of the minimum angle of resolution (logMAR). ISRCTN.com registry, number ISRCTN77602616. MAIN OUTCOME MEASURES: We enrolled 785 participants between May 2015 and September 2017 and randomly assigned 392 to FLACS and 393 to PCS. At 3 months postoperatively, mean UDVA difference between treatment arms was -0.01 logMAR (-0.05 to 0.03), and mean corrected distance visual acuity difference was -0.01 logMAR (95% confidence interval [CI], -0.05 to 0.02). Seventy-one percent of both FLACS and PCS cases were within ±0.5 diopters (D) of the refractive target, and 93% of FLACS and 92% of PCS cases were within ±1.0 D. There were 2 posterior capsule tears in the PCS arm and none in the FLACS arm. There were no significant differences between arms for any secondary outcome. CONCLUSIONS: Femtosecond laser-assisted cataract surgery is not inferior to conventional PCS surgery 3 months after surgery. Both methods are as good in terms of vision, patient-reported health, and safety outcomes at 3 months. Longer-term outcomes of the clinical effectiveness and cost-effectiveness are awaited.

Femtosecond laser-assisted versus phacoemulsification cataract surgery (FEMCAT): a multicentre participant-masked randomised superiority and cost-effectiveness trial.

BACKGROUND: Cataract surgery is one of the most common operations in health care. Femtosecond laser-assisted cataract surgery (FLACS) enables more precise ocular incisions and lens fragmentation than does phacoemulsification cataract surgery (PCS). We hypothesised that FLACS might improve outcomes in cataract surgery compared with PCS despite having higher costs. METHODS: We did a participant-masked randomised superiority clinical trial comparing FLACS and PCS in two parallel groups (permuted block randomisation stratified on centres via a centralised web-based application, allocation ratio 1:1, block size of 2 or 4 for unilateral cases and 2 or 6 for bilateral cases). Five French University Hospitals enrolled consecutive patients aged 22 years or older who were eligible for unilateral or bilateral cataract surgery. Participants, outcome assessors, and technicians carrying out examinations were masked to the surgical treatment allocation until the last follow-up visit and a sham laser procedure was set up for participants randomly assigned to the PCS arm. The primary clinical endpoint was the success rate of surgery, defined as a composite of four outcomes at a 3-month postoperative visit: absence of severe perioperative complication, a best-corrected visual acuity (BCVA) of 0·0 LogMAR (logarithm of the minimum angle of resolution) or better, an absolute refractive error of 0·75 dioptres or less, and unchanged postoperative corneal astigmatism power (≤0·5 dioptres) and axis (≤20°). The primary economic endpoint was the incremental cost per additional patient who had treatment success at 3 months. Primary outcomes were assessed in all randomly assigned patients who met all eligibility criteria (missing data considered as failure). We used mixed logistic regression models or mixed linear regression models for statistical comparisons, adjusted on centres and whether cataract surgery was bilateral or unilateral. The study is registered with ClinicalTrials.gov, NCT01982006. FINDINGS: Of the 907 patients (1476 eyes) randomly assigned between Oct 9, 2013, and Oct 30, 2015, 870 (704 eyes in FLACS group and 685 eyes in the PCS group) were analysed. We identified no significant difference in the success rate of surgery between the FLACS and PCS groups (FLACS: 41·1% [289 eyes]; PCS: 43·6% [299 eyes]); adjusted odds ratio 0·85, 95% CI 0·64-1·12, p=0·250). The incremental cost-effectiveness ratio was €10 703 saved per additional patient who had treatment success with PCS compared with FLACS. We observed no severe adverse events during the femtosecond laser procedure, and most of the complications in the FLACS group related to the primary outcome measures occurred during the phacoemulsification phase or postoperatively. INTERPRETATION: Despite its advanced technology, femtosecond laser was not superior to phacoemulsification in cataract surgery and, with higher costs, did not provide an additional benefit over phacoemulsification for patients or health-care systems. FUNDING: French Ministry of Social Affairs and Health.

Femtosecond laser-assisted cataract surgery: A review.

PURPOSE: Review scientific literature concerning femtosecond laser-assisted cataract surgery. METHODS: Following databases were searched: CENTRAL (Cochrane Eyes and Vision Trials Register; Cochrane Library: Issue 2 of 12, June 2019), Ovid MEDLINE® without Revisions (1996 to June 2019), Ovid MEDLINE® (1946 to June 2019), Ovid MEDLINE® Daily Update June 2019, MEDLINE and MEDLINE Non-Indexed Items, Embase (1980-2019), Embase (1974 to June 2019), Ovid MEDLINE® and Epub Ahead of Print, in-Process & Other Non-Indexed Citations and Daily (1946 to June 2019), Web of Science (all years), the metaRegister of Controlled Trials ( www.controlled-trials.com ), ClinicalTrials.gov ( www.clinicaltrial.gov ) and World Health Organization International Clinical Trials Registry Platform ( www.who.int/ictrp/search/en ). Search terms/keywords included 'Femtosecond laser' combined with 'cataract', 'cataract surgery'. RESULTS: Based on quality of their methodology and their originality, 121 articles were reviewed, including randomised controlled trials, cohort studies, case-controlled studies, case series, case reports and laboratory studies. Each step of the femtosecond laser-assisted cataract surgery procedure (corneal incisions, arcuate keratotomies, capsulotomy and lens fragmentation) has been discussed with relevance to published outcomes, as well as complication rates of femtosecond laser-assisted cataract surgery, and what we can learn from the larger studies/meta-analyses and the economics of femtosecond laser-assisted cataract surgery within different healthcare settings. CONCLUSION: Studies suggest that the current clinical outcomes of femtosecond laser-assisted cataract surgery are not different to conventional phacoemulsification surgery and it is not cost effective when compared with conventional phacoemulsification surgery. In its current technological form, it is a useful surgical tool in specific complex cataract scenarios, but its usage has not been shown to translate into better clinical outcomes.

Health policy regulations pertaining to advanced surgical devices-their socio-economic effects on ophthalmology practice.

The Israel Ministry of Health enacted regulations that aim to reduce private expenditure on healthcare services and mitigate social inequality. According to the modified rules, which went into effect in the second half of 2016, patients who undergo surgery in a private hospital and are covered by their healthcare provider's supplemental insurance (SI) make only a basic co-payment.The modified regulations limited the option of self-payment for advanced devices not covered by national health basket, meaning that patients for whom such devices are indicated had to pay privately for the entire procedure. These regulations applied to all medical and surgical devices not covered by national health insurance (NHI).Toric intraocular lenses (IOLs) are a case in point. These advanced lenses are implanted during cataract surgery to correct corneal astigmatism and, in indicated cases, obviate the need for complex eyeglasses postoperatively. Toric IOL implantation has been shown to be highly cost-effective in both economic and quality-of-life terms. Limitations of the use of these advanced IOLs threatened to increase social inequality.In 2017, further adjustments of the regulations were made which enabled supplemental charges for these advanced IOLs, performed through the SI programs of the healthcare medical organizations (HMOs). Allowing additional payment for these lenses at a fixed pre-set price made it possible to apply a supplemental part of the insurance package to the surgery itself. In mid 2018 these IOLs were included without budget in the national health basket, allowing for self-payment for the additional cost in addition to the basic coverage for all patients with NHI.This case study suggests that, in their efforts to enhance health care equity, policymakers may benefit if exercising due caution when limiting the extent to which SI programs can charge co-payments. This is because, when a service or product is not available via the basic NHI benefits package, limiting SI co-payments can sometimes result in a boomerang effect - leading to an increase in inequality rather than the sought-after decrease in inequality.

Everything is ok on YouTube! Quality assessment of YouTube videos on the topic of phacoemulsification in eyes with small pupil.

OBJECTIVE: Usage of YouTube as an educational tool is gaining attention in academic research. To date, there has been no study on the content and quality of eye surgery videos on YouTube. The aim of this study was to analyze YouTube videos on phacoemulsification in eyes with small pupil. METHODS: We searched for the phrases "small pupil cataract surgery," "small pupil phacoemulsification," "small pupil cataract surgery complications," and "small pupil phacoemulsification complications" in January 2015. Each resulting video was evaluated by all authors, and Krippendorff's alpha was calculated to measure agreement. Videos were classified according to pupil size (small/very small) in the beginning of the surgery, and whether pupillary diameter was large enough to continue surgery safely after pupillary dilation by the surgeon in the video (safe/not safe). Methods of dilatation were also analyzed. Any stated ocular comorbidity or surgical complications were noted. RESULTS: A total of 96 videos were reviewed. No mechanical intervention for pupillary dilatation was performed in 46 videos. Fifty-eight operated eyes had no stated ocular comorbidity. Ninety-five operations ended successfully without major complication. There was fair agreement between the evaluators regarding pupil sizes (Kα = 0.670) but poor agreement regarding safety (Kα = 0.337). CONCLUSIONS: YouTube videos on small pupil phacoemulsification have low complication rates when compared to the literature, although no reliable mechanical dilatation methods are used in almost half of these videos. Until YouTube's place in e-learning becomes clearer, we suggest that viewers be cautious regarding small pupil phacoemulsification videos on YouTube.

Auckland Cataract Study III: Refining Preoperative Assessment With Cataract Risk Stratification to Reduce Intraoperative Complications.

PURPOSE: To assess intraoperative complications of phacoemulsification surgery in public teaching hospital settings using modified preoperative risk stratification systems. DESIGN: Prospective cohort study. METHODS: Preoperative risk stratification of 500 consecutive cataract cases using the New Zealand Cataract Risk Stratification (NZCRS) scoring system. Recommended allocation of higher-risk phacoemulsification procedures to experienced surgeons in public teaching hospital setting. MAIN OUTCOME MEASURE: Intraoperative complications relative to adherence to stratification recommendations. RESULTS: NZCRS classified 192 cases (38%) as high-risk, recommended for fellows or consultants (attendings). Primary surgeons were residents (n = 142, 28%), fellows (n = 88, 18%), and consultants (n = 270, 54%). Overall rate (N = 500) of any intraoperative complication was 5.0%. Where NZCRS scoring recommendations were observed (n = 448) the intraoperative complication rate was 4.5% but in "nonadherence" cases (n = 52 residents operating on higher-risk cases) this nearly doubled (9.6%). Postoperative complications occurred in 5.2%, primarily cystoid macular edema (3.7%). Postoperatively, mean unaided visual acuity was 6/12 (20/40) and best-corrected visual acuity improved from 6/20 (20/63) preoperatively to 6/10 (20/32) postoperatively (P < .05). CONCLUSIONS: The NZCRS system aids identification of higher-risk cataract cases and appropriate case-to-surgeon allocation and may increase surgeon awareness of risk factors. Compared to 2 previous studies under similar conditions in the same institution, the NZCRS system was associated with a 40% reduction in intraoperative complications (8.4% to 5%). The rate of posterior capsular tear was 0.6% (P = .035) compared to 2.6% in baseline phase and 1.4% in a prior risk stratification phase. Risk stratification seems to reduce intraoperative phacoemulsification complications in public teaching hospital settings.

Incidence of Management Changes at the Postoperative Week 1 Visit after Cataract Surgery: Results from the Perioperative Care for IntraOcular Lens Study.

PURPOSE: To ascertain the incidence of unexpected management changes at the postoperative week 1 visit in asymptomatic patients who have had an uncomplicated cataract surgery and a routine postoperative day 1 examination. DESIGN: Retrospective observational study. METHODS: A retrospective chart review was conducted of all cases of cataract extraction by phacoemulsification with intraocular lens insertion performed by the Comprehensive Ophthalmology Service at Massachusetts Eye and Ear between January 1, 2014 and December 31, 2014. The preoperative consultation, operative report, and postoperative day 1 and week 1 (postoperative days 5-14) visits were reviewed. Cases with intraoperative complications, as well as clinical findings at postoperative day 1 requiring close follow-up, were excluded. The main outcome measure was incidence of unexpected management changes at the postoperative week 1 visit after cataract surgery, defined as an unanticipated change in postoperative drops, additional procedures, or urgent referral to a specialty service. RESULTS: Overall, 1938 surgical cases of 1471 patients were reviewed, and 1510 cases (77.9%) underwent uncomplicated phacoemulsification with intraocular lens implantation with a routine postoperative day 1 examination. Of these 1510 cases, 238 (15.8%) reported symptoms at the postoperative week 1 visit, including flashes, floaters, redness, pain, or decreased vision, which warranted an examination. In total, 1272 cases were asymptomatic, and only 11 of these cases (0.9%) had an unexpected management change at postoperative week 1. Eight of 11 patients were asymptomatic steroid responders requiring alteration of their postoperative drops. Two of these patients had an intraocular pressure >30 mm Hg. CONCLUSIONS: Unexpected management changes at the postoperative week 1 timepoint after cataract surgery are rare in asymptomatic patients who have had uncomplicated cataract surgery and a routine postoperative day 1 examination. Limited data are available to outline an optimal postoperative regimen after cataract surgery. The results of this study suggest that postoperative week 1 examinations could potentially be performed on an as-needed basis in the appropriate subgroup of patients after cataract surgery.

Functional assessment of a new extended depth-of-focus intraocular lens.

BACKGROUND/OBJECTIVE: This study aimed to investigate the visual performance of a new extended depth-of-focus intraocular lens (EDOF-IOL). SUBJECTS/METHODS: In this multicenter, prospective, observational study, we enrolled 97 patients who underwent cataract surgery or refractive lens exchange with implantation of the Mini Well EDOF-IOL (SIFI, Italy). Patients underwent postoperatively the following examinations between 4 and 8 weeks after surgery: corrected distance visual acuity (CDVA), reading speed with Radner's chart, distance-corrected near visual acuity (DCNVA), defocus curve, contrast sensitivity, and haloes quantitative assessment. RESULTS: In the whole sample, the mean monocular CDVA and DCNVA were, respectively, 0.02 ± 0.07 logMAR and 0.38 ± 0.15 logRAD (logarithm of the reading acuity determination). In the 67 bilaterally implanted patients, binocular CDVA and DCNVA were better (0.00 ± 0.05 logMAR and 0.26 ± 0.13 logRAD) than the corresponding monocular values (p = 0.02 and p = 0.0002, respectively). Ninety-two percent of patients bilaterally implanted reached a binocular reading speed >80 words per minute at a 0.5 logRAD print size (corresponding to the common book print size). The defocus curves showed that the EDOF-IOL provided increased depth of focus through 2.0 D of defocus, with the best performance at 1.0 and 1.5 D. Contrast sensitivity was within normal limits at all spatial frequencies. The mean visual disturbance index was 0.08 ± 0.12, suggesting low night visual disturbances. CONCLUSIONS: The new EDOF-IOL provided good visual acuity for distance, intermediate, and near vision, with no loss of contrast sensitivity and low risk of night visual disturbances.

Trial-based cost-effectiveness analysis of toric versus monofocal intraocular lenses in cataract patients with bilateral corneal astigmatism in the Netherlands.

PURPOSE: To evaluate the cost-effectiveness of toric versus monofocal intraocular lens (IOL) implantation in cataract patients with bilateral corneal astigmatism. SETTING: Two ophthalmology clinics in the Netherlands. DESIGN: Prospective cost-effectiveness analysis. METHODS: Resource-use data were collected over a 6-month postoperative period. Consecutive patients with bilateral age-related cataract and 1.25 diopters or more of corneal astigmatism were included in the economic evaluation. Patients were randomized to phacoemulsification with bilateral toric or monofocal IOL implantation. All relevant resources were included in the cost analysis. The base-case analysis was performed from a societal perspective based on quality-adjusted life years (QALYs). The main outcome was the incremental cost-effectiveness ratio. RESULTS: The analysis comprised 77 consecutive patients (33 toric IOL; 44 monofocal IOL). Societal costs were higher in the toric IOL group (€3203 [$3864]) than in the monofocal IOL group (€2796 [US$3373]). QALYs were slightly lower in the toric IOL group (0.30 versus 0.31; P = .75). Toric IOLs were therefore inferior to monofocal IOLs from a cost-effectiveness perspective. The cost-effectiveness probability ranged from 1% to 15%, assuming a ceiling ratio for the incremental cost-effectiveness ratio of €2500 to €20 000 per QALY. CONCLUSIONS: From a societal perspective, bilateral toric IOL implantation in cataract patients with corneal astigmatism was not cost-effective compared with monofocal IOL implantation. Copayment by patients should therefore be considered.