Changes in Intraocular Pressure and Angle Structure after Dilation in Primary Angle-Closure Suspects with Visually Significant Cataract.

PURPOSE: To evaluate the safety of pupillary dilation in primary angle-closure suspects (PACS) with concurrent visually significant cataract (VSC), to identify risk factors associated with elevated intraocular pressure (IOP), and to describe changes in anterior segment anatomy after pupillary dilation. DESIGN: Prospective study. PARTICIPANTS: Patients with PACS and VSC and no prior laser or intraocular surgery were recruited. Visually significant cataract was defined as best-corrected visual acuity ≤ 20/40 due to cataract. METHODS: Subjects' eyes were dilated with 0.5% tropicamide and 0.5% phenylephrine hydrochloride. A standardized eye examination, biometry, and swept-source OCT (SS-OCT) were performed before dilation. Intraocular pressure and SS-OCT were repeated 1, 4, and 6 hours postdilation (PDH1, PDH4, and PDH6, respectively). All parameters were compared between time points before and after dilation using paired t test. Linear regression models were used to determine the risk factors associated with postdilation IOP changes. MAIN OUTCOME MEASURES: Change in IOP and SS-OCT parameters from baseline. RESULTS: Seventy-eight eyes from 78 patients were included, with 78, 66, and 12 patients completing the study at PDH1, PDH4, and PDH6, respectively. Mean IOP increased from 14.8 ± 2.6 mmHg at baseline to 15.5 ± 3.5 mmHg at PDH1 (P = 0.03) and decreased to 14.9 ± 3.1 mmHg at PDH4 (P = 0.09). Four patients (5.13%) and 3 patients (3.85%) had an increase in IOP ≥ 5 mmHg at PDH1 and PDH4, respectively. Two patients (2.56%) and 1 patient (1.28%) had an increase in IOP ≥ 8 mmHg at PDH1 and PDH4, respectively. None developed acute primary angle-closure during the observation period. Almost all anterior chamber parameters showed a significant increase after dilation at PDH1 and PDH4, except lens vault and iris volume, which decreased at PDH1 and PDH4 from baseline. Increase in anterior chamber depth was negatively associated with the level of IOP elevation after dilation (P < 0.01). CONCLUSIONS: Dilation of patients' eyes with PACS and VSC in this cohort appears to have a low risk for IOP spike. This may be associated with relaxation of the ciliary muscle leading to posterior displacement of the lens-iris diaphragm and deepening of the anterior chamber.

Long-term impact of dry eye symptoms on vision-related quality of life after phacoemulsification surgery.

PURPOSE: To observe the long-term changes in dry eye symptoms and vision-related quality of life in age-related cataract patients after phacoemulsification. METHODS: A total of 101 cataract patients after phacoemulsification combined with IOL implantation (Ph-IOL) in one eye were enrolled. Visual acuity, tear film breakup time (BUT), and Schirmer test 1 (ST1) were measured before and 1, 3, and 6 months after surgery. Ocular Surface Disease Index (OSDI) scores were used to evaluate the severity of dry eye symptoms. Utility values were assessed by the time trade-off (TTO), standard gamble for death (SGD), standard gamble for blindness (SGB) and rating scale (RS). RESULTS: The average LogMAR visual acuity in the operated eye was 1.35 ± 0.50 and increased rapidly after Ph-IOL, approaching a peak at 3 months (0.26 ± 0.15). The BUT and ST1 results decreased abruptly 1 month after surgery and gradually recovered until 6 months. OSDI scores increased significantly after surgery and gradually decreased until 6 months. Utility values evaluated by TTO, SGD, SGB and RS before surgery were 0.67 ± 0.19, 0.75 ± 0.15, 0.67 ± 0.20 and 0.2 ± 0.18, respectively, and increased to 0.91 ± 0.06, 0.98 ± 0.04, 0.92 ± 0.52 and 0.91 ± 0.06, 6 months after. Utility values measured with TTO, SGB or RS correlated significantly (P < 0.05) with visual acuity and OSDI scores pre- and postoperatively. CONCLUSIONS: Dry eye symptoms persist more than 3 months after Ph-IOL. Utility values were negatively influenced by dry eye symptoms.

LY2109761, Transforming Growth Factor ß Receptor Type I and Type II Dual Inhibitor, is a Novel Approach to Suppress Endothelial Mesenchymal Transformation in Human Corneal Endothelial Cells.

BACKGROUND/AIMS: Preventing undesirable endothelial-mesenchymal transformation (EnMT) with repetitious in vitro expansion of human corneal endothelial cells (CECs) is a pivotal issue in cornea regeneration. Previous studies have shown that inhibition of the TGF-ß pathway reduces epithelial-mesenchymal transformation. However, its potential role in EnMT remains poorly understood. As such, the effect of LY2109761, a novel TGF-ß receptor type I and type II dual inhibitor, was investigated on EnMT. METHODS: CECs cultured with various concentrations of LY2109761 were evaluated for their growth rate and phenotype. Additionally, the expression of functional markers (sodium-potassium pump Na+/K+-ATPase and the tight junction protein ZO-1) and mesenchymal markers (CD73, fibronectin, and vimentin) was detected using immunostaining and western blot. The mRNA expressions were also assayed by real-time polymerase chain reaction analysis. RESULTS: At a 1 µM concentration, LY2109761 did not influence the proliferation of CECs and subsequent experiments were therefore performed using this concentration. Furthermore, CECs cultured in the presence of 1 µM LY2109761 maintained their ability to grow as a monolayer of hexagonal-shaped cells. The expression of functional markers increased in LY2109761-treated CECs, while the expression of mesenchymal markers decreased (both in protein and mRNA levels). CONCLUSION: Inhibition of TGF-ß receptor type I and type II by LY2109761 maintained the phenotype of CECs and inhibited the EnMT process. These results indicate the possible continuous in vitro expansion of CECs with normal function.

Cost-Utility Analyses of Cataract Surgery in Advanced Age-Related Macular Degeneration.

PURPOSE: To explore the cost-utility of cataract surgery in patients with advanced age-related macular degeneration (AMD). METHODS: Patients who were diagnosed as having and treated for age-related cataract and with a history of advanced AMD at the Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University, were included in the study. All of the participants underwent successful phacoemulsification with foldable posterior chamber intraocular lens implantation under retrobulbar anesthesia. Best-corrected visual acuity (BCVA) and utility value elicited by time trade-off method from patients at 3-month postoperative time were compared with those before surgery. Quality-adjusted life years (QALYs) gained in a lifetime were calculated at a 3% annual discounted rate. Costs per QALY gained were calculated using the bootstrap method, and probabilities of being cost-effective were presented using a cost-effectiveness acceptability curve. Sensitivity analyses were performed to test the robustness of the results. RESULTS: Mean logarithm of the minimum angle of resolution BCVA in the operated eye increased from 1.37 ± 0.5 (Snellen, 20/469) to 0.98 ± 0.25 (Snellen, 20/191) (p < 0.001); BCVA in the weighted average from both eyes (=75% better eye + 25% worse eye) was changed from 1.13 ± 0.22 (Snellen, 20/270) to 0.96 ± 0.17 (Snellen, 20/182) (p < 0.001). Utility values from both patients and doctors increased significantly after surgery (p < 0.001 and p = 0.007). Patients gained 1.17 QALYs by cataract surgery in their lifetime. The cost per QALY was 8835 Chinese yuan (CNY) (1400 U.S. dollars [USD]). It is cost-effective at the threshold of 115,062 CNY (18,235 USD) per QALY in China recommended by the World Health Organization. The cost per QALY varied from 7045 CNY (1116 USD) to 94,178 CNY (14,925 USD) in sensitivity analyses. CONCLUSIONS: Visual acuity and quality of life assessed by utility value improved significantly after surgery. Cataract surgery was a cost-effective intervention for patients with coexistent AMD.

Combination of iris vessel area density and surgery interval as the predictor of perceived pain during consecutive second-eye cataract surgery.

PURPOSE: To explore clinical indicators to predict perceived pain during second-eye phacoemulsification surgery in patients with bilateral cataracts. SETTING: Shanghai General Hospital, China. DESIGN: A case‒control study and a prospective cohort study. METHODS: Patients with age-related cataract who underwent first-eye or second-eye uneventful phacoemulsification surgery were enrolled. Before surgery, ocular examination results, including vessel area density (VAD) and vessel skeleton density (VSD), obtained by optical coherence tomography angiography examination of the iris were performed. Patients completed a visual analog scale pain survey 3 times postoperatively: 1 hour, 3 hours, and 24 hours postoperatively. RESULTS: 70 patients were enrolled in the case‒control study, and the pain scores of the second-eye surgery group under local anesthesia were significantly greater than those of the first-eye surgery group ( P = .0005). Preoperative iris VAD in the second-eye group affected perioperative pain scores ( P = .0047). The optimal cutoff value of VAD was 0.2167 with a specificity of 76% and a sensitivity of 62%. In the prospective cohort study, 124 patients were included in the second-eye group. Preoperative iris VAD ( P = .0361) and the time interval ( P = .0221) were independent factors for second-eye surgery pain. Combined with preoperative iris VAD and surgical interval, the negative predictive value and positive predictive value were 0.95 and 0.29 for predicting moderate pain or above, the sensitivity and specificity were 0.97 and 0.23, respectively. CONCLUSIONS: The combination of iris VAD and the time interval between both eye surgeries can be an effective method to predict the timing of the second-eye cataract surgery and to avoid intraoperative pain.

Matricellular Protein Levels in Aqueous Humor and Surgical Outcomes of Trabeculectomy.

Purpose: The purpose of this study was to quantify levels of three matricellular proteins in the aqueous humor in patients with previous acute primary angle closure (APAC) and investigate their correlation with bleb morphology and surgical outcomes of trabeculectomy. Methods: In this prospective study, aqueous humor samples were collected from 40 previous APAC eyes. Concentrations of three matricellular proteins-secreted protein acidic and rich in cysteine (SPARC), thrombospondin-2, and osteopontin-were measured using multiplexed immunoassays kits. Intraocular pressure was measured using Goldmann application tonometry. Bleb morphology was assessed using anterior segment optical coherence tomography, and bleb score was calculated according to bleb size and reflectivity. Results: When previous APAC eyes were divided according to surgical outcome 18 months after trabeculectomy, SPARC protein was significantly higher in aqueous humor in the failure group (P = 0.009). When previous APAC eyes were divided according to SPARC level, eyes with low SPARC levels had significantly higher overall success rate compared with eyes with high SPARC levels (P = 0.005 for complete success and P = 0.018 for qualified success). Multiple logistic regression analyses showed that eyes with higher levels of SPARC were more likely to have a failed filtration surgery than were eyes with lower levels of SPARC. For complete success, P = 0.006 and odds ratio (OR) = 6.458; for qualified success, P = 0.033 and OR = 2.608. The level of SPARC was found to have a positive correlation with bleb score (P < 0.001, R2 = 0.471). Conclusions: In previous APAC patients, the SPARC level in aqueous humor is a prognostic factor for surgical results of trabeculectomy. Modulation of SPARC expression may have potential clinical applications after filtration surgery.

Accuracy of the Haigis and SRK/T Formulas in Eyes Longer than 29.0 mm and the Influence of Central Corneal Keratometry Reading.

PURPOSE: To examine the potential relationship of central corneal keratometry reading (K value) to intraocular lens (IOL) power calculation in extremely long eyes. MATERIALS AND METHODS: Sixty-three consecutive eyes with an axial length (AL) longer than 29.0 mm were prospectively enrolled at Shanghai General Hospital. All eyes underwent uneventful cataract surgery. Central corneal keratometry, anterior chamber depth, and AL were measured, and IOL power was calculated using the Haigis and SRK/T formulas. The refractive error associated with both formulas was calculated, and its relationship with associated factors was also analyzed. RESULTS: Linear regression showed a statistically significant relationship between prediction error and K value with both Haigis and SRK/T (P < 0.001, R2 = 0.343 and P < 0.001, R2 = 0.225, respectively). In general, a higher K value was associated with a hyperopic outcome, whereas a lower K value was associated with a myopic outcome. There was no difference in the median absolute error (MedAE) when comparing Haigis and SRK/T (P = 0.081). The 63 eyes were subsequently divided into an L group (K value < 44.02) and an H group (K value > 44.02) according to the K value. The MedAE produced by SRK/T was lower than that produced by Haigis in group L, while the MedAE produced by SRK/T was similar to that produced by Haigis in group H (P = 0.020 and P = 0.799, respectively). CONCLUSIONS: The average keratometry reading significantly correlated with the prediction error using Haigis and SRK/T. An adjustment of formulas according to the K value could achieve better outcomes in long eyes.

Cataract surgery in patients with bilateral advanced age-related macular degeneration: Measurement of visual acuity and quality of life.

PURPOSE: To measure the change in visual acuity and vision-related quality of life in patients with both age-related cataract and bilateral age-related macular degeneration (AMD) after cataract surgery. SETTING: Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China. DESIGN: Prospective case series. METHODS: Patients with age-related cataract and bilateral advanced AMD who were diagnosed and treated between January 2006 and January 2012 were enrolled. The patients had successful phacoemulsification with foldable posterior chamber intraocular lens implantation. The corrected distance visual acuity (CDVA) and vision-related quality of life measured by the Chinese-version Low Vision Quality of Life (CLVQOL) questionnaire were collected. The Wilcoxon signed-rank test was used to compare the differences. Binary logistic regression analysis was performed to explore potential factors associated with the change in CLVQOL scores. RESULTS: Sixty eyes of 51 patients were included. The CDVA improved significantly (median difference 0.30 logMAR; range 0 to 1.38 logMAR; P < .001). The CLVQOL composite scores and the 4 subscale scores improved significantly (all P < .001). A greater increase in the CLVQOL scores was associated with inferior preoperative logMAR CDVA in the more severely affected eye (regression coefficient 3.36; P < .001). CONCLUSIONS: Cataract surgery improved visual acuity and the vision-related quality of life in patients with both age-related cataract and bilateral advanced AMD. Thus, it is beneficial for patients with coexistent advanced AMD to have cataract surgery. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Accuracy of Intraocular Lens Power Formulas Involving 148 Eyes with Long Axial Lengths: A Retrospective Chart-Review Study.

Purpose. This study aims to compare the accuracy of intraocular lens power calculation formulas in eyes with long axial lengths from Chinese patients subjected to cataract surgery. Methods. A total of 148 eyes with an axial length of >26 mm from 148 patients who underwent phacoemulsification with intraocular lens implantation were included. The Haigis, Hoffer Q, Holladay 1, and SRK/T formulas were used to calculate the refractive power of the intraocular lenses and the postoperative estimated power. Results. Overall, the Haigis formula achieved the lowest level of median absolute error 1.025 D (P < 0.01 for Haigis versus each of the other formulas), followed by SRK/T formula (1.040 D). All formulas were least accurate when eyes were with axial length of >33 mm, and median absolute errors were significantly higher for those eyes than eyes with axial length = 26.01-30.00 mm. Absolute error was correlated with axial length for the SRK/T (r = 0.212, P = 0.010) and Hoffer Q (r = 0.223, P = 0.007) formulas. For axial lengths > 33 mm, eyes exhibited a postoperative hyperopic refractive error. Conclusions. The Haigis and SRK/T formulas may be more suitable for calculating intraocular lens power for eyes with axial lengths ranging from 26 to 33 mm. And for axial length over 33 mm, the Haigis formula could be more accurate.

Changes of vision-related quality of life in retinal detachment patients after cataract surgery.

Rhegmatenous retinal detachment (RRD) is one of the most serious complications after phacoemulsification combined with intraocular lens implantation surgery. It has been reported that vision-related quality of life (VRQoL), as well as visual acuity rapidly decreased when RRD developed. However, little is known of the VRQoL in those RRD patients after anatomical retinal re-attachment, especially whether or not the VRQoL is higher than that before cataract surgery. In this prospective case series study, we use the Chinese-version low vision quality of life questionnaire (CLVQOL) to assess the changes of VRQoL in age-related cataract patients who suffered from RRD after phacoemulsification with intraocular lens (phaco-IOL) implantation. All participants were asked to complete questionnaires in face- to-face interviews one day before and two weeks after cataract surgery, as well as one day before and three months after RRD surgery. A total of 10,127 consecutive age-related cataract patients were followed up to one year after phaco-IOL implantation; among these patients, 17 were diagnosed as RRD. The total CLVQOL scores and subscale scores except "Mobility" decreased significantly when RRD developed. After retinal surgery, only the score of "General vision and lighting" in the CLVQOL questionnaires improved when compared to the scores two weeks after cataract surgery, although the best corrected visual acuity of all patients significantly raised up. However, the mean CLVQOL scores and subscale scores were still considerably higher than the level prior to cataract surgery. Our study suggests that cataract patients at high risk of postoperative RRD should not deny the opportunity to undergo phaco-IOL implantation, even though potential VRQoL impairment induced by RRD exists.