Visual outcomes and risk factors of uveitis cataract eyes after phacoemulsification and manual small-incision cataract surgery.

PURPOSE: To examine the visual outcomes and risk factors of uveitis cataract eyes after phacoemulsification and manual small-incision cataract surgery (MSICS). SETTING: Tertiary-care eye hospital in southern India. DESIGN: Retrospective interventional case series. METHODS: Of the uveitis eyes operated for cataract surgery between 2017 and 2020, eyes with a minimum of 6 months postoperative follow-up were included. Eyes with ocular trauma, lens subluxation, lens-induced uveitis, or retinal detachment-induced uveitis were excluded. Demography, visual acuity, intraoperative and postoperative records, and surgical outcomes were analyzed. RESULTS: 191 eyes of 191 patients with a mean age of 51.7 ± 14.4 years were included. Phacoemulsification was performed in 134 eyes, and 57 eyes underwent MSICS. Synechiolysis and pupil-expanding maneuvers were required in 74 eyes (38.7%). No differences were noted in the rates of complications between phacoemulsification and MSICS eyes, except at 1 year, where higher rates of posterior capsular opacification and vitritis were noted in MSICS eyes ( P = .018). The visual outcomes of eyes that underwent MSICS and phacoemulsification were comparable ( P = .463). In 12 eyes (13.5%), improvement in vision was not significant. CONCLUSIONS: This study shows phacoemulsification may be a preferred technique in uveitis cataracts, given the lesser incidence of postoperative complications. Patients should be counseled for realistic expectations.

Towards the Identification and Characterization of Putative Adult Human Lens Epithelial Stem Cells.

The anterior lens epithelium has the ability to differentiate into lens fibres throughout its life. The present study aims to identify and functionally characterize the adult stem cells in the human lens epithelium. Whole mounts of lens epithelium from donor eyes (normal/cataract) were immunostained for SOX2, gap junction protein alpha 1 (GJA1), PAX6, α, ß and γ-crystallins, followed by a confocal analysis. The functional property of adult stem cells was analysed by their sphere forming ability using cultured lens epithelial cells from different zones. Based on marker expression, the lens epithelium was divided into four zones: the central zone, characterized by a small population of PAX6+, GJA1-, ß-crystallin- and γ-crystallin- cells; the germinative zone, characterized by PAX6+, GJA1+, ß-crystallin- and γ-crystallin-; the transitional zone, characterized by PAX6+, GJA1+, ß-crystallin+ and γ-crystallin-; and the equatorial zone, characterized by PAX6+/-, GJA1+, ß-crystallin+, and γ-crystallin+ cells. The putative lens epithelial stem cells identified as SOX2+ and GJA1 membrane expression negative cells were located only in the central zone (1.89 ± 0.84%). Compared to the other zones, a significant percentage of spheres were identified in the central zone (1.68 ± 1.04%), consistent with the location of the putative adult lens epithelial stem cells. In the cataractous lens, an absence of SOX2 expression and a significant reduction in sphere forming ability (0.33 ± 0.11%) were observed in the central zone. The above findings confirmed the presence of putative stem cells in the central zone of the adult human lens epithelium and indicated their probable association with cataract development.

Understanding the Role of Yes-Associated Protein (YAP) Signaling in the Transformation of Lens Epithelial Cells (EMT) and Fibrosis.

Fibrotic cataracts, posterior capsular opacification (PCO), and anterior subcapsular cataracts (ASC) are mainly attributed to the transforming growth factor-ß (TGFß)-induced epithelial-to-mesenchymal transition (EMT) of lens epithelial cells (LECs). Previous investigations from our laboratory have shown the novel role of non-canonical TGFß signaling in the progression of EMT in LECs. In this study, we have identified YAP as a critical signaling molecule involved in lens fibrosis. The observed increase in nuclear YAP in capsules of human ASC patients points toward the involvement of YAP in lens fibrosis. In addition, the immunohistochemical (IHC) analyses on ocular sections from mice that overexpress TGFß in the lens (TGFßtg) showed a co-expression of YAP and α-SMA in the fibrotic plaques when compared to wild-type littermate lenses, which do not. The incubation of rat lens explants with verteporfin, a YAP inhibitor, prevented a TGFß-induced fiber-like phenotype, α-SMA, and fibronectin expression, as well as delocalization of E-cadherin and ß-catenin. Finally, LECs co-incubated with TGFß and YAP inhibitor did not exhibit an induction in matrix metalloproteinase 2 compared to those LECs treated with TGFß alone. In conclusion, these data demonstrate that YAP is required for TGFß-mediated lens EMT and fibrosis.

Outcomes of toric intraocular lens realignment surgery done using slit-lamp method and wavefront aberrometry method.

Purpose: To compare the slit-lamp method and wavefront aberrometry method based on outcomes of toric realignment surgeries. Settings: Tertiary care ophthalmic hospital. Design: Retrospective study. Methods: This study included all eyes undergoing toric intraocular lens (TIOL) realignment surgery between January 2019 and December 2021 for which TIOL axis assessment by slit-lamp method and wavefront aberrometry method was available. Data were retrieved from electronic medical records, and we documented demographics, uncorrected visual acuity (UCVA), subjective refraction, and TIOL axis by slit-lamp and wavefront aberrometry methods on postoperative day 1 and day 14. In patients with misalignment, TIOL was realigned to the original position in group 1 (27 patients) and to an axis based on calculations provided by wavefront aberrometer in group 2 (25 patients). Post-realignment surgery, UCVA, subjective refraction, and TIOL axis by slit-lamp and wavefront aberrometry methods were assessed and analyzed. Results: We analyzed 52 eyes and found that the mean preoperative misalignment with the slit-lamp method (44.9° ±20.0°) and wavefront aberrometry (47.1° ±19.5°) was similar. The corresponding degrees of misalignment post-TIOL repositioning surgeries were 5.2° ±5.2° (slit-lamp method) and 4.7° ±5.1° (wavefront aberrometry) (P = 0.615). Both groups showed significant improvement in median log of minimum angle of resolution (logMAR) UCVA and reduction in median refractive cylinder. Conclusions: Slit-lamp method is as good as wavefront aberrometer method to assess TIOL axis. Toric realignment surgery is found to be safe, and realigning TIOL based on either slit-lamp method or wavefront aberrometer method equally improved UCVA and decreased residual refractive cylinder.

Accuracy of an artificial intelligence-based mobile application for detecting cataracts: Results from a field study.

Purpose: To assess the accuracy of e-Paarvai, an artificial intelligence-based smartphone application (app) that detects and grades cataracts using images taken with a smartphone by comparing with slit lamp-based diagnoses by trained ophthalmologists. Methods: In this prospective diagnostic study conducted between January and April 2022 at a large tertiary-care eye hospital in South India, two screeners were trained to use the app. Patients aged >40 years and with a best-corrected visual acuity <20/40 were recruited for the study. The app is intended to determine whether the eye has immature cataract, mature cataract, posterior chamber intra-ocular lens, or no cataract. The diagnosis of the app was compared with that of trained ophthalmologists based on slit-lamp examinations, the gold standard, and a receiver operating characteristic (ROC) curve was estimated. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were computed. Results: The two screeners used the app to screen 2,619 eyes of 1,407 patients. In detecting cataracts, the app showed high sensitivity (96%) but low specificity (25%), an overall accuracy of 88%, a PPV of 92.3%, and an NPV of 57.8%. In terms of cataract grading, the accuracy of the app was high in detecting immature cataracts (1,875 eyes, 94.2%), but its accuracy was poor in detecting mature cataracts (73 eyes, 22%), posterior chamber intra-ocular lenses (55 eyes, 29.3%), and clear lenses (2 eyes, 2%). We found that the area under the curve in predicting ophthalmologists' cataract diagnosis could potentially be improved beyond the app's diagnosis based on using images only by incorporating information about patient sex and age (P < 0.0001) and best-corrected visual acuity (P < 0.0001). Conclusions: Although there is room for improvement, e-Paarvai app is a promising approach for diagnosing cataracts in difficult-to-reach populations. Integrating this with existing outreach programs can enhance the case detection rate.

Outcomes of manual small incision cataract surgery (MSICS) in eyes with corneal opacity.

PURPOSE: To report the outcomes of manual small incision cataract surgery (MSICS) in eyes with corneal opacity. SETTING: Tertiary care ophthalmic hospital. DESIGN: Retrospective study. METHODS: This retrospective study included 286 eyes of 286 patients having cataract with a pre-existing corneal opacity who underwent manual small incision cataract surgery (MSICS) at a tertiary eye institute between January 2020 and January 2022. Data were retrieved from electronic medical records, and we documented demographics, history, detailed anterior and posterior segment examination, cataract grading, pre- and post-operative vision, intra-operative complications and its management, and post-operative course. All these parameters were recorded at the baseline visit, day 1 and at 1 month post-operatively. RESULTS: Two hundred eighty-six eyes having cataract with a pre-existing corneal opacity which underwent MSICS were evaluated. Corneal opacity was graded as nebular, nebulo-macular, macular and leucomatous types; nebular opacity being the most common. Trauma was the most common cause of opacity followed by infective keratitis. Intra-operative complication rate was 4.89%; which included-7 posterior capsular rent with vitreous disturbance, 2 zonular dialysis, 2 iridodialysis, 2 eyes with aphakia and 1 with Descemet membrane detachment. On follow-up, 6 patients had decentered intraocular lens and 10 had residual cortex. Median logMAR vision improved significantly (p < 0.001) from 1.08 (5/60) pre-operatively to 0.3 (6/12) post-operatively. CONCLUSION: MSCIS is efficient in providing favorable visual outcomes in patients where corneal opacity makes it difficult for the surgeon to perform a phacoemulsification surgery.

Microbiological Profile of Post-cataract Surgery Endophthalmitis with Usage of Prophylactic Intracameral Moxifloxacin.

PURPOSE: To study the effect of prophylactic intracameral moxifloxacin (ICM) on microbiological profile and antimicrobial sensitivity of culture-proven postoperative endophthalmitis (POE). METHODS: This study evaluated culture-proven POE diagnosed within 6 weeks of cataract surgery over two periods, period-1 (January 2010-March 2015) and period-2 (April 2015-December 2019), before and after introduction of prophylactic ICM, respectively. RESULTS: In period-1, 100 cases of culture-positive POE were reported (1 in 4879, 0.02%), while 20 cases (1 in 24635, 0.004%) were reported in period-2 (5-fold reduction, p < .001). The cumulative culture positivity rate decreased from 27.6% to 17.1% (1.6-fold) . Coagulase-negative Staphylococci (CoNS) were significantly reduced (p = .005). CONCLUSIONS: ICM reduced the incidence of culture-proven POE, CoNS in particular. In future, POE caused by rarer pathogens may become more prevalent due to reduction in the rate of commoner and more virulent pathogens with use of intracameral antibiotics. The moxifloxacin sensitivity of CONS did not show change with the use of ICM. Studies with larger population of POE will be more helpful to understand the trend better.

Intraocular lens scaffolding technique in hypermature/Morgagnian cataract in manual small-incision cataract surgery.

PURPOSE: To describe the surgical technique of intraocular lens (IOL) scaffolding in hypermature/Morgagnian cataract in manual small-incision cataract surgery (MSICS). SETTING: Charitable section of the hospital through direct availed services at free/subsidized cost. DESIGN: Interventional study. METHODS: 38 eyes of 38 patients operated at the charitable section of the hospital through direct availed services at free/subsidized cost were included in this study. RESULTS: IOL scaffolding in MSICS was executed in 38 patients, of whom 25 patients were diagnosed as hypermature cataract, pseudoexfoliation syndrome with mature cataract in 5 patients, 5 patients had phacolytic glaucoma, and 3 patients had lens-induced uveitis. This technique was successful in 35 of 38 patients and was not successful in 3 patients in whom traditional SICS was performed in 2 patients and retrohaptic iris fixation in 1 patient. CONCLUSIONS: A technique that uses the IOL as a scaffold in hypermature cataract in MSICS that provides a stable barrier by stretching the capsular bag to prevent the crumpling of the bag or whole bag removal after nucleus delivery is described.

Outcomes of cataract surgery in patients with Human Immunodeficiency Virus infection in a developing country.

PURPOSE: To report the outcomes of cataract surgery in patients with Human Immunodeficiency Virus (HIV) infection. Setting Tertiary care ophthalmic hospital DESIGN: Retrospective study METHODS: This study included all eyes of patients with known HIV infection undergoing cataract surgery with a minimum follow-up of 6 months between January 2017 and December 2020. Patients who underwent combined surgeries and pediatric patients were excluded from analysis. Data were retrieved from electronic medical records and we documented demographics, history, detailed anterior and posterior segment examination, pre-operative grade and type of cataract, type of surgery done, its complication and post-operative course. All these parameters were recorded at the baseline visit and at 1 month and 6 months postoperatively. RESULTS: One hundred and twenty nine eyes of 107 HIV infected patients that underwent cataract surgery were evaluated. Mature cataract was seen in 31% of the eyes. Features of HIV related uveitis/retinitis were seen in 21 (16.2%) eyes. Phacoemulsification was performed in 44 (34.1%) eyes while manual small incision cataract surgery (MSICS) was done in 85 (65.9%) eyes. Intra-operative complications were encountered in 4 (3.1%) eyes. At the final follow-up, there was a significant improvement in median corrected distance visual acuity (CDVA) from LogMAR 1.08 (5/60) at baseline to LogMAR 0 (6/6) at 6 months follow-up. CONCLUSION: Patients with HIV infection usually present early and with advanced cataracts. Visual outcomes after cataract surgery are generally good but affected by presence of prior HIV related uveitis or retinitis.

Clinical outcomes of femtosecond laser-assisted cataract surgery versus conventional phacoemulsification: A retrospective study in a tertiary eye care center in South India.

Purpose: To compare the clinical outcomes of femtosecond laser-assisted cataract surgery (FLACS) versus conventional phacoemulsification (CP) in terms of refractive outcomes, cumulative dissipated energy, and intraoperative complications. Methods: In this retrospective study performed in a tertiary care ophthalmic hospital, we reviewed 2124 eyes that underwent FLACS or CP. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), cumulative dissipated energy (CDE), and intraoperative complications were analyzed in the study. Results: Out of 2124 eyes, 873 underwent FLACS and 1251 underwent CP. The postoperative mean UCVA after one month was 0.05 ± 0.11 logMAR and 0.14 ± 0.23 logMAR for FLACS and CP, respectively (P < 0.00001). Mean CDVA one month post operation was 0.02 ± 0.07 logMAR and 0.06 ± 0.19 logMAR for FLACS and CP, respectively (P < 0.0001). The CDE for the FLACS group was 6.17 ± 3.86 (P < 0.00001) and it was 9.74 ± 6.02 for the CP group. The intraoperative complication for the FLACS group was 1.60% and the CP group was 2.39% (P < 0.00001). Conclusion: The visual outcomes were better in FLACS compared to CP. The CDE was lower for the FLACS group and FLACS had significantly less intraoperative complications.

An objective evaluation of simulated surgical outcomes among surgical trainees using manual small-incision cataract surgery virtual reality simulator.

Purpose: The purpose of this study was to evaluate trainee performance across six modules of a virtual reality (VR) simulator. Methods: A retrospective observational study was conducted on 10 manual small-incision cataract surgery (MSICS) trainees who practiced cataract surgery on an MSICS VR simulator for one month. They were assessed in six major steps which included scleral groove, tunnel dissection, keratome entry, capsulorhexis, nucleus delivery, and intraocular lens (IOL) insertion under a trainer's supervision. The information included in their score metrics was collected, and their overall performance was evaluated. Results: Thirty attempts were evaluated for scleral groove, tunnel dissection, and capsulorhexis and 15 attempts for keratome entry. Candidates had varied results in the dimensional aspects and their rates of complications with a mean satisfactory score of 3.1 ± 4.17, 6.8 ± 5.75, 5.8 ± 7.74, and 1.8 ± 2.57, respectively. Nucleus delivery (n = 5) had more of iris pull and IOL insertion (n = 5) had more of lost IOL as complications but both had a higher satisfactory outcome. Conclusion: A VR simulator is a useful tool for training surgeons before their entry into live surgery. It is an effective method for evaluating objectively the structural characteristics of each phase in MSICS and their associated complications, helping them anticipate it earlier during live surgery by giving them a near real world experience.

Morphological variations influencing the outcomes in posterior polar cataract.

Purpose: To study the intraoperative complications and postoperative clinical outcomes in different types of posterior polar cataract (PPC) following phacoemulsification, based on morphological classification. Methods: All consecutive patients with PPC who underwent phacoemulsification during the study period from 2016 to 2019 were included and sub-grouped based on the morphological characteristics according to Daljit Singh's classification. Intraoperative complications such as posterior capsular rupture (PCR), vitreous loss, nucleus drop, and Postoperative best-corrected visual acuity (BCVA) at day 1 and day 30 were documented. Results: A total of 388 eyes of 380 patients were included. Eighty nine (22.9%) eyes belonged to type 1, 135 (34.8%) belonged to type 2, 8 (2.1%) belonged to type 3, and 156 (40.2%) belonged to type 4. Thirty-five (9.3%) eyes had intraoperative PCR, with vitreous loss in 21 (60%) eyes, and nucleus/cortex drop in 5 (1.3%) eyes. Six (75%) eyes of type 3, 14 (10.04%) eyes of type 2, 12 (17.7%) eyes of type 4, and 3 (3.4%) eyes of type 1 PPC had PCR. PCR occurred more during the emulsification of the nucleus (18 cases, 51.4%). A significant correlation was seen between intraoperative PCR and type of PPC with a higher incidence in type 3 (P < 0.001). BCVA was found to be significantly worse on day 1 among patients with PCR compared to those who did not and improved well by day 30. Conclusion: PPC morphology is significantly co-related with the occurrence of PCR, emphasizing the need for careful grading of posterior polar cataracts in predicting the risk of intraoperative complications.

"Stay Back Technique" of scleral fixation of decentred intraocular lensbag complex.

Background: Even though rare, posterior chamber intraocular lens (IOL)-bag complex dislocation is a serious complication following cataract surgery. Preoperative trauma or zonular weakness, capsule contraction syndrome, and surgical or postoperative trauma to the zonules have been proposed as the causative mechanism. Various risk factors have been described such as pseudoexfoliation (PXF), aging, high myopia, uveitis, trauma, previous vitreoretinal surgery, retinitis pigmentosa, diabetes mellitus, and connective tissue disorders, among which PXF is the most common risk factor. The management of late IOL-bag complex dislocation poses a challenge even for an experienced surgeon. Purpose: To demonstrate the "stay back technique" of scleral fixation of decentered IOL-bag complex. Synopsis: We demonstrate three cases of scleral fixation of anteriorly dislocated IOL-bag complex. The first two cases are traumatic subluxation of IOL-bag complex and the third case is late decentration of both the haptics in a case of PXF. A scleral flap/groove is made along the area of haptic dislocation. Dislocated haptic is allowed to stay in the same position and one arm of 9-0 prolene suture is passed between the optic-haptic junction and docked in a 26-gauge needle passed beneath the scleral flap, 2 mm from the limbus. Haptic is then repositioned beneath the iris and the second arm of prolene suture is passed above the haptic. Sutures are pulled underneath the scleral flap and secured with 5 to 6 knots. Highlights: This is a simplified approach of scleral fixation of anteriorly dislocated IOL-bag complex. This novel technique gives better visualization of the optic-haptic junction during the passage of prolene suture. Online Video Link: https://youtu.be/vKQCR0fow68.

Reasons for delay in cataract surgery in patients with advanced cataracts during the COVID-19 pandemic.

Purpose: To analyze the reasons for delay in cataract surgery in patients with advanced cataracts during the COVID-19 pandemic. Methods: This was a prospective, cross-sectional, multicenter questionnaire study which included patients with mature cataract, nuclear sclerotic cataract grade IV, and cataracts with best corrected visual acuity (BCVA) <5/60, during the COVID-19 pandemic from December 2020 to April 2021. Reasons for delay in presentation to the hospital were analyzed. Results: One thousand four hundred seventy two patients were recruited with advanced cataracts. Absence of ophthalmic care nearby (44.2%), lack of awareness regarding elective surgeries (42.6%), lack of public transportation (37%), fear of contracting COVID-19 (23.4%), and waiting for outreach camps (20.4%) were found to be the reasons behind the delay in cataract surgery. 53.7% of the patients had worsening of defective vision and 55.3% of them had difficulty in carrying out activities of family living. 30.8% of the patients faced difficulty in commuting and 8.4% of the patients suffered a fall during this pandemic due to worsening of the visual acuity. Conclusion: The lockdown imposed during the pandemic has created a significant backlog of patients who are progressing to advanced cataracts due to lack of ophthalmic care nearby, lack of awareness regarding elective surgeries, lack of public transportation, and no outreach camps. Proactive measures to deal with this backlog are of utmost need to prevent blindness due to cataract.

Clinical features, management, and outcomes of expulsive choroidal hemorrhage during cataract surgery: 13-year experience of a tertiary eye center.

PURPOSE: To study the risk factors, clinical features, management, and outcomes of intraoperative expulsive choroidal hemorrhage (ECH) during cataract surgery. SETTING: Aravind Eye Hospital, Madurai, Tamil Nadu, India. DESIGN: Retrospective hospital-based study. METHODS: Of the 1 167 250 patients who underwent cataract surgery between 2008 and 2020, patients diagnosed with intraoperative ECH were included. Demography, ocular and systemic risk factors, visual acuity, type of ocular anesthesia, intraoperative and postoperative records, management, and surgical outcomes were analyzed. RESULTS: 52 eyes (0.004%) of 1 167 250 patients had ECH. Of the 52 cases, 43 cases (incidence rate 0.006%) were reported in the years 2008 to 2015 and 9 cases (incidence rate 0.002%) in the years 2016 to 2020. The change in the ocular anesthesia from peribulbar and retrobulbar anesthesia (2008 to 2015) to sub-Tenon anesthesia (2016 to 2020) was associated with a reduced rate of ECH ( P = .002). 28 eyes (53.8%) experienced limited ECH and 24 eyes (46.2%) full-blown ECH. The visual outcome was better in eyes with limited ECH compared with full-blown suprachoroidal hemorrhage in all follow-up visits. The median vision (interquartile range) before the cataract surgery and at postoperative day 1 were 1.30 (0.78 to 2.60) and 2.45 (1 to 2.75), respectively. The median final vision (interquartile range) after the secondary surgical intervention was 2.2 (0.60 to 2.60). CONCLUSIONS: This series included 52 eyes with ECH, recognized associations of ECH with different types of anesthesia and with different cataract surgical procedures, and described management of ECH. Postoperative visual outcome was poor.

Iridodialysis repair - A simplified approach.

BACKGROUND: Iris root is the thinnest and weakest portion of the iris stroma. It can detach easily due to blunt trauma or accidental engagement of the iris during intraocular surgery resulting in glare, photophobia and monocular diplopia. Multiple techniques described for iridodialysis repair such as hang back technique, stroke and dock technique and sewing machine technique are technically challenging. PURPOSE: To describe an simplified approach of iridodialysis repair using 9-0 prolene suture. SYNOPSIS: We demonstrate the technique of iridodialysis repair using animation for better understanding. Scleral flap is made adjacent to the iridodialysis area and a paracentesis is made oppsite to the iridodialysis. One arm of the double armed straight needle with 9-0 prolene suture is passed through the paracentesis into the iris root and docked in the 26G needle which is passed underneath the scleral flap 1.5mm posterior to the limbus. Then the needle is pulled out underneath the scleral flap and the manoeuvre is repeated for the second arm as well. The sutures are secured with 5-6 knots under the scleral flap. Intra-operative surgical videos of two patients with traumatic cataract and iridodialysis following blunt trauma are shown. After stabilizing the detached iris using iris hooks, phacoemlsification is done with implantation of foldable acrylic IOL, followed by iridodialysis repair as described above. Both the patients were relieved of their pre-operative symtoms and had good visual recovery. HIGHLIGHTS: We describe a simplified approach of iridodialysis repair that can significantly reduce the patient's troublesome symptoms such as glare and monocular double vision. ONLINE VIDEO LINK: https://youtu.be/-axYnSfWSb0.

Cataract surgery in colobomatous eyes with advanced cataract.

BACKGROUND: Cataract surgeries are challenging in colobomatous eyes as they are associated with features such as microphthalmia, microcornea, zonular deficit, etc. These factors predispose to capsulorhexis extension, posterior capsular rent, zonular dialysis and result in unfavourable visual outcomes. The most critical step of cataract surgery in such cases is the capsulorhexis as the chances of extension are high in the colobomatous area. In presence of pre-existing zonular dehiscence, nucleus management becomes more challenging in advanced cataracts. PURPOSE: To illustrate efficient management of advanced cataract in colobomatous eyes. SYNOPSIS: A 39-year old lady presented with complaints of gradually progressive diminution of vision in both eyes. Examination revealed bilateral nuclear sclerosis grade III-IV with irido-lenticular retinochoroidal coloboma (ILRCC). The patient was scheduled for bilateral cataract surgery after a thorough evaluation. Initially, the left eye was planned for phacoemulsification, in the course of which capsulorhexis extension occurred, leading to nucleus tilt and vitreous disturbance during emulsification. Automated anterior vitrectomy was done and the surgical approach was shifted to manual small incision cataract surgery (MSICS) with 3-piece intraocular lens placement in sulcus. The right eye was hence planned for MSICS and a rhexis extension was noted in this eye as well. Comparing the outcome of both the surgeries it was noted that both had capsulorhexis extension, but the management of nucleus and intraocular lens implantation was efficient in case of MSICS than phacoemulsification. Posterior chamber intraocular lens were placed in both eyes and the patient attained good visual outcome. HIGHLIGHTS: MSICS is a better approach to cases of ILRCC with advanced cataract. The capsulo should be tailored according to the site of coloboma such that it should be smaller in the area involving the coloboma and larger away from it. VIDEO LINK: https://youtu.be/d9FC0eavhRs.

Comparison of two phacoemulsification system handpieces: prospective randomized comparative study.

PURPOSE: To compare the safety and efficacy of Active Sentry handpiece with Ozil handpiece for Centurion phacoemulsification system. SETTING: Tertiary eye center, South India. DESIGN: Prospective observational study. METHODS: 204 eyes of 204 patients with uncomplicated cataract who underwent phacoemulsification cataract surgery with Centurion Vision System were randomized into 2 groups: Ozil handpiece (n = 101) and Active Sentry handpiece (n = 103). Intraoperative factors such as patient pain perception, surgeon comfort level, amount of phacoemulsification energy and aspiration fluid used, and frequency of activation of active surge mitigation (ASM) were analyzed, and postoperatively, corrected distance visual acuity (CDVA) and corneal edema on day 1 were compared. RESULTS: A total of 204 eyes of 204 patients were included among which 101 underwent surgery with ozil hand piece and 103 with Active Sentry handpiece. Patient pain perception was comparable between the groups with no statistically significant differences in patients who had pain-free surgery (66% vs 61.3%) and those who experienced moderate pain (24.3% vs 28.7%). Surgeons were more comfortable using Ozil handpiece during entry into anterior chamber and emulsification of hard nuclei (48.5% vs 28.6%). The mean cumulative dissipated energy for soft and hard cataracts was 5.6 and 4.8 and 9.3 and 9.4 for Ozil and Active Sentry groups, respectively. ASM was activated for 53 eyes (51.5%), of which 42 eyes (79.2%) had soft cataract and 11 eyes (20.7%) hard cataract. Postoperative CDVA and incidence of corneal edema were comparable between the groups. CONCLUSIONS: For Centurion Vision System, Active Sentry handpiece was as safe and efficacious as the Ozil handpiece with added benefit of operating at lower intraocular pressure levels.