Intraocular Lens Power, Myopia, and the Risk of Nd:YAG Capsulotomy after 15,375 Cataract Surgeries.

The present study estimated the 5-year cumulative probability of Nd:YAG laser posterior capsulotomy according to the diopter power of implanted hydrophobic acrylic intraocular lenses (IOLs). Data were retrospectively collected of 15,375 eyes having cataract surgery and in-the-bag implantation of hydrophobic acrylic monofocal IOLs at the Ophthalmology Unit of Kymenlaakso Central Hospital, Kotka, Finland between the years 2007 and 2016. The cumulative probability of Nd:YAG capsulotomy was calculated by Kaplan-Meier estimates, and potential risk factors were analyzed using the Cox proportional hazards model. The 5-year cumulative probability of Nd:YAG capsulotomy after cataract surgery was 27.4% (95% confidence interval (CI) 22.9-32.6%) for low-diopter (5-16.5 D) IOLs, 14.6% (13.8-15.5%) for mid-diopter (17-24.5 D) IOLs, and 13.6% (11.7-15.6%) for high-diopter (25-30 D) IOLs. A multivariate Cox regression analysis showed that low-diopter IOLs (HR 1.76; 95% CI 1.38-2.25; p < 0.001) were associated with an increased risk of Nd:YAG capsulotomy compared to mid-diopter IOLs over the follow-up period after accounting for other predictors. Real-world evidence shows that low-diopter IOLs are associated with significantly higher risk of Nd:YAG capsulotomy within five years following implantation. Estimation should help in evaluating the risks of cataract surgery in myopic eyes.

Comparison of Two Different Treat-and-Extend Protocols with Aflibercept in Wet Age-Related Macular Degeneration: Two-Year Results.

INTRODUCTION: To optimize the aflibercept treat-and-extend protocol in wet age-related macular degeneration (wAMD) beyond the 1-year interim report. METHODS: This 2-year prospective randomized clinical trial included 52 eyes from 52 patients with treatment-naïve wAMD. After the induction phase of three monthly aflibercept injections, patients were randomized 1:1 to two different treat-and-extend protocols. In the treat-and-extend protocol with moderate extensions (T&Em), the treatment interval was extended 1 week at a time up to 12 weeks, and then by 2 weeks up to 16 weeks. In the treat-and-extend protocol with rapid extensions (T&Er), the treatment interval was initially extended to 8 weeks, and then by 2 weeks up to 16 weeks. Main outcome measure was the number of given aflibercept injections. RESULTS: At the study end point at 2 years, the mean visual gain from the baseline was 7.9 ± 14.5 letters in T&Em, compared to 10.8 ± 16.5 letters in T&Er protocol (P = 0.726). The mean decrease in central subfield macular thickness was 203.0 ± 167.4 µm in T&Em and 192.3 ± 160.2 µm in T&Er protocol (P = 0.822). Treatment interval was 10.3 ± 3.3 weeks in T&Em and 11.7 ± 3.5 in T&Er protocol (P = 0.164) at the end of year 2. The total number of injections in 2 years was 14.1 ± 3.1 in T&Em and 11.6 ± 2.0 in T&Er (P = 0.002), and the number of injections during the second year was 5.4 ± 1.8 and 4.4 ± 1.4, respectively (P = 0.043). A total of 71% of the eyes in both treatment groups had a dry macula at the study end point. CONCLUSIONS: At 2 years, the anatomical and functional responses between the two treatment groups were similar. However, the number of given aflibercept injections was smaller in the rapid extensions protocol. TRIAL REGISTRATION: EU Clinical Trials Register Number, 2015-001394-41/FI.

Comparison of two different treat-and-extend protocols with aflibercept in wet age-related macular degeneration.

PURPOSE: To optimize the aflibercept treat-and-extend protocol in wet age-related macular degeneration (wAMD). METHODS: A prospective randomized clinical trial consisting of 52 eyes from 52 patients with treatment-naïve wAMD. Patients received three monthly aflibercept injections and were then randomized 1:1 to two different dosing protocols. In treat-and-extend protocol with moderate extensions (T&Em), after the loading phase the treatment interval was extended 1 week at a time up to 12 weeks and then by 2 weeks up to 16 weeks. In treat-and-extend protocol with rapid extensions (T&Er), the interval was first extended to 8 weeks and then by 2 weeks at a time up to 16 weeks. Main outcome measure was the number of given aflibercept injections. RESULTS: Fifty (96%) patients completed the 1-year follow-up. Patient and ophthalmic baseline variables were comparable between the study groups. At 1 year, central subfield macular thickness reduced by 194.3 ± 153.6 µm in T&Em protocol, compared with 194.2 ± 176.6 µm in T&Er (p = 0.997). Eyes with T&Em gained 10.3 ± 11.5 letters from baseline and eyes with T&Er 11.4 ± 10.6 letters (p = 0.434), and dry macula was observed in 72% of eyes with T&Em compared to 68% with T&Er (p = 0.758). At 1 year, the treatment interval was 8.5 ± 2.2 weeks in T&Em and 10.3 ± 2.8 weeks in T&Er (p = 0.017), and the total number of injections 8.64 ± 1.58 and 6.96 ± 0.79, respectively (p < 0.001). In the rapid extensions protocol, 48% of eyes reached a 12-week treatment interval or beyond at 1 year. CONCLUSIONS: At one year, the anatomical and functional responses were comparable between the moderate and rapid extensions protocols, with fewer aflibercept injections in the rapid extension protocol.

Perioperative subconjunctival triamcinolone acetonide injection for prevention of inflammation and macular oedema after cataract surgery.

PURPOSE: To compare the efficacy, safety and tolerability of a single perioperative subconjunctival injection of triamcinolone acetonide (TA) with steroid drops for the prevention of macular oedema and ocular inflammation after cataract surgery. METHODS: This prospective non-randomized controlled clinical trial analysed 101 eyes of 101 patients having an elective cataract surgery at Kymenlaakso Central Hospital, Kotka, Finland. Fifty eyes received conventional postoperative care with dexamethasone 1 mg/ml eye drops (DEX), and 51 eyes received a perioperative 20 mg subconjunctival injection of TA. None of the eyes received postoperative topical antibiotic prophylaxis. The main outcome measures were aqueous flare, central retinal thickness (CRT), corrected distance visual acuity (CDVA) and intraocular pressure (IOP) measured at 7, 28 and 90 days after surgery. RESULTS: Central retinal thickness (CRT) increased in DEX but not in TA-treated eyes at 7 days (+1.2 ± 20.1 µm and -9.2 ± 24.8 µm, p = 0.031), at 28 days (+23.8 ± 62.6 µm and -3.3 ± 27.7 µm, p = 0.008) and at 90 days (+8.5 ± 24.4 µm and -5.5 ± 33.4 µm, p = 0.026). Aqueous flare increased from baseline in both groups but remained higher in DEX eyes at 90 days (+3.3 ± 9.9 photons/ms and -0.2 ± 6.6 photons/ms, p = 0.021). Corrected distance visual acuity (CDVA) and IOP changes were similar, and ocular tolerance was good in both groups. No serious adverse events were observed. CONCLUSIONS: Perioperative subconjunctival TA was effective in preventing ocular inflammation and macular oedema after cataract surgery. Subconjunctival TA combined with intracameral cefuroxime provides a noteworthy option for dropless postoperative care in modern cataract surgery.

Five-Year Cumulative Incidence and Risk Factors of Nd:YAG Capsulotomy in 10 044 Hydrophobic Acrylic 1-Piece and 3-Piece Intraocular Lenses.

PURPOSE: To evaluate the 5-year cumulative incidence and risk factors of Nd:YAG capsulotomy between hydrophobic acrylic intraocular lenses (IOLs). DESIGN: A retrospective cohort study. METHODS: A review of the registry of operations between the years 2007 and 2016 was carried out at the Ophthalmology Unit of Kymenlaakso Central Hospital, Kotka, Finland. A total of 10 044 eyes having cataract surgery and in-the-bag implantation of ZCB00 (Abbott Medical Optics Johnson & Johnson Vision, Inc, Abbott Park, Illinois, USA), SN60WF (Alcon Laboratories, Inc, Fort Worth, Texas, USA), or ZA9003 (Abbott Medical Optics Johnson & Johnson Vision, Inc) IOLs were included in the study. The cumulative incidence of Nd:YAG capsulotomy was estimated with competing risks methodology. Competing risks regression modeling was used to evaluate potential risk factors, including the patient's age, sex, type of IOL, dioptric power of IOL, and operating surgeon's seniority. RESULTS: The 5-year cumulative incidence of Nd:YAG capsulotomy after cataract surgery was 13.2% (95% confidence interval [CI] 12.5%-14.0%) for all eyes and 18.1% (16.5%-20.0%), 11.5% (10.5%-12.6%), and 9.6% (8.2%-11.4%) for ZCB00, SN60WF, and ZA9003 IOLs, respectively. Implantation of SN60WF and ZA9003 IOLs was associated with a 38% and 47% subhazard reduction (SHR), respectively, compared to ZCB00, after accounting for other predictors (SHR = 0.62; 95% CI 0.54-0.71; P < .001 and SHR = 0.53; 95% CI 0.43-0.64; P < .001). Increased risk of Nd:YAG capsulotomy was associated with eyes of patients aged younger than 60 years, female sex, and eyes implanted with an IOL of <22.5 diopters power. CONCLUSION: Real-world evidence suggests that the cumulative incidence of Nd:YAG capsulotomy is significantly lower in eyes receiving SN60WF or ZA9003 IOLs compared to ZCB00.

Postoperative management in cataract surgery: nepafenac and preservative-free diclofenac compared.

PURPOSE: Current cataract surgery guidelines recommend routine use of topical nonsteroidal anti-inflammatory drugs (NSAIDs) in preventing pseudophakic cystoid macular oedema (PCME). Here, we compare the clinical efficacy and tolerability of two potent NSAIDs, nepafenac and preservative-free diclofenac following cataract surgery. METHODS: Randomized, double-blind, prospective single-centre study. Ninety-six eyes of 95 patients undergoing routine cataract surgery were randomized 1:1 either to nepafenac (Nevanac, 1 mg/ml) or diclofenac (Dicloabak, 1 mg/ml) for 3 weeks. Seventy-three patients accounting for 73 eyes completed the entire follow-up. Aqueous flare and central retinal thickness (CRT) analysis were conducted preoperatively and at control visits 28 days and 3 months after surgery. A structured home questionnaire and interview were used to record any adverse effects of the topical medications, subjective visual recovery and the dispenser's ease of use. RESULTS: No differences were observed between the groups for aqueous flare, CRT, speed of recovery or visual acuity gain. Seven patients (16%) on nepafenac and 20 patients (48%) on preservative-free diclofenac reported symptoms related to topical use of NSAID medications (p = 0.001). CONCLUSION: No differences in clinical efficacy were found between potent NSAIDs, while tolerability might be an issue.

Improving eye care services with a lean approach.

PURPOSE: Effective provision of eye care services in government-financed hospitals is essential to balance the discrepancy between growing demand and limited resources. We aimed to improve efficiency of the treatment protocol for Nd:YAG laser posterior capsulotomy. Predetermined quality targets were a patient-oriented and patient-safe approach and the development of a clinical care process with purposeful use of competences. METHODS: We utilized a lean process improvement methodology to develop a streamlined Nd:YAG laser posterior capsulotomy treatment protocol. A total of 206 patient visits were evaluated, where the lean-oriented treatment protocol was utilized in 158 of the visits and the conventional (CONV) protocol was followed in 48 of the visits. RESULTS: All baseline variables were comparable between the study groups. Compared to the CONV protocol, implementation of new operational principles shortened the total reception time per patient from 55:36 ± 30:23; 12-136 min to 44:40 ± 4:49; 37-54 min (mean ± SD; range, p = 0.040). The per hour number of patients and eyes treated in the operation room improved from 4.7 ± 1.6; 2.6-8.4 patients and 5.5 ± 2.0; 3.5-11.3 eyes to 16.3 ± 2.3; 14.3-19.4 patients (p < 0.001) and 18.0 ± 1.6; 16.8-20.4 eyes (p < 0.001). The time spent by the operating physician reduced from 8:19 ± 3:06; 3:57-14:30 min to 3:01 ± 1:00; 1:34-6:38 min in unilateral procedure (p < 0.001) and from 8:45 ± 3:55; 5:52-14:10 min to 4:40 ± 2:03; 2:38-10:14 min in bilateral procedure (p < 0.006). Furthermore, the overall patient satisfaction grade improved from 17.3 ± 1.04; 15-18 points to 17.8 ± 0.61; 15-18 points (p = 0.001). CONCLUSIONS: The lean approach improved the treatment protocol for Nd:YAG laser posterior capsulotomy with substantial reductions in lead times without compromising patient satisfaction.

Anti-inflammatory medication following cataract surgery: a randomized trial between preservative-free dexamethasone, diclofenac and their combination.

PURPOSE: To examine the anti-inflammatory efficacy and tolerance between preservative-free dexamethasone (DEX) and diclofenac (DICL) eye drops, and their combination following cataract surgery. METHODS: A randomized, double-blind, prospective single-centre study with 189 eyes of 180 patients undergoing routine cataract surgery. Laser flare meter measurement and spectral-domain optical coherence tomography imaging were conducted before surgery and at the 28-day postoperative visit. Clinical characteristics, surgical parameters and assessment of postoperative symptoms were recorded. RESULTS: Preoperative flare was 9.0 ± 0.6 pu/ms and central retinal thickness (CRT) 269.6 ± 1.9 µm (mean ± SEM). On day 28, flare was 22.1 ± 2.9 pu/ms for DEX, 17.4 ± 2.5 pu/ms for DICL and 13.0 ± 1.6 pu/ms (p < 0.05) for their combination. Central retinal thickness (CRT) increase was 31.5 ± 8.8 µm for DEX, 6.0 ± 0.8 µm (p = 0.001) for DICL, and 3.5 ± 0.5 µm (p < 0.001) for their combination. The incidence of ocular symptoms related to the eye drops was 11% for DEX, 37% for DICL and 34% for their combination (p < 0.001). Clinically significant pseudophakic cystoid macular oedema (PCME) was observed in seven eyes which were all treated with DEX (p < 0.001). CONCLUSION: Diclofenac (DICL), as well as the combination of DEX and DICL, were superior to DEX monotherapy in minimizing CRT change and the incidence of PCME. Combination medication showed no added value compared to DICL monotherapy in uneventful cataract surgery.

Poor glycemic control as a risk factor for pseudophakic cystoid macular edema in patients with diabetes.

PURPOSE: To specify the risk factors for pseudophakic cystoid macular edema (CME) in patients with diabetes. SETTING: Kymenlaakso Central Hospital, Unit of Ophthalmology, Kotka, Finland. DESIGN: Prospective case series. METHODS: Patients with type 1 or type 2 diabetes having routine cataract surgery were evaluated. Spectral-domain optical coherence tomography imaging was performed before surgery and 1 month postoperatively. RESULTS: The study comprised 93 patients (95 eyes). The central retinal thickness increase was 9.7 µm ± 1.7 (SEM) in diabetic patients with no retinopathy, 22.7 ± 8.6 µm in those who had nonproliferative retinopathy, and 73.8 ± 37.4 µm in those who had proliferative retinopathy (P < .001). The central retinal thickness increase was greater in the eyes of diabetic patients with insulin dependence than in eyes of patients using noninsulin medication (21.9 ± 5.9 µm versus 8.3 ± 1.8 µm, P = .017). Serum hemoglobin A1c concentration and inversely, patient age, were associated with central retinal thickness increase, even after adjustment for confounding factors (r = 0.607, P < .001 and r = 0.417, P = .001, respectively). The central retinal thickness change was smaller in the eyes of patients who had a nonsteroidal antiinflammatory drug (NSAID) as their postoperative antiinflammatory medication than in eyes of patients who were not prescribed NSAID medication when retinopathy was analyzed as a covariant (8.2 ± 3.6 µm versus 13.6 ± 2.9 µm, P = .016). CONCLUSIONS: Young patient age and poor glycemic control were risk factors for postoperative central retinal thickness increase. This study showed it is necessary to identify, effectively treat, and follow-up with patients with diabetes who are at a greater risk for pseudophakic CME.

Intravitreal bevacizumab injections versus dexamethasone implant for treatment-naïve retinal vein occlusion related macular edema.

PURPOSE: To compare the short-term effects of three monthly intravitreal bevacizumab (IVB) injections to single dexamethasone (DEX) implantation in treatment-naïve patients with cystoid macular edema (CME) secondary to branch (BRVO) and central retinal vein occlusion (CRVO). DESIGN: A retrospective single-center study. SUBJECTS: A total of 135 eyes of 135 patients with BRVO (n=83) and CRVO (n=52). METHODS: Changes in clinical parameters were recorded before treatment and at the first and third month after commencement of IVB (n=121) and DEX (n=14). MAIN OUTCOME MEASURES: Central retinal thickness (CRT), intraocular pressure (IOP), and best-corrected visual acuity (BCVA). RESULTS: The baseline parameters were comparable between IVB and DEX groups. After the first month, CRT decreased by 131.3±42.9 µm in IVB and by 266.9±48.3 µm in DEX (mean ± SEM; p=0.047). IOP change was -0.29±0.39 mmHg in IVB and +3.70±2.34 mmHg in DEX (p=0.005). IOP elevation to ≥25 mmHg and ≥5 mmHg from the baseline was observed in two of the DEX- and in none of the IVB-treated eyes (p=0.010). After the third month, no differences regarding CRT and IOP were observed between the treatment modalities. Moreover, BCVA gain was comparable between IVB (0.37±0.05 logarithm of minimum angle of resolution [logMAR] units) and DEX (0.33±0.30 logMAR units) groups. CONCLUSION: DEX was associated with faster resolution of CME, but had greater probability for short-term IOP elevation when compared to IVB. After the third month, treatments were comparably effective. Anatomical outcomes and adverse drug reactions of IVB versus DEX should be considered case specifically in patients having CME secondary to BRVO/CRVO.

Medical treatment of carotid endarterectomy patients requires attention.

OBJECTIVES: The benefits of prophylactic carotid endarterectomy (CEA) together with best medical treatment (BMT) are well-established. Early initiation of proper medical treatment reduces the risk of new strokes as waiting periods for CEA operation can be considerably long. We investigated: (1) preoperative medical treatment of CEA patients at our hospital and (2) how well the present medical treatment coheres with national and international secondary prevention guidelines and other CEA cohorts. METHODS: A retrospective study cohort of 135 consecutive patients planned for CEA in a tertiary center because of symptomatic (n = 100) or asymptomatic (n = 35) carotid artery stenosis during a 14-month period (2007-2008). RESULTS: One hundred and twenty-six of 135 (93.3%) patients received antiplatelet therapy at the time of surgery, 125/135 (92.6%) were on statin, and 121/135 (89.6%) used antihypertensive medications. Ten of the 100 symptomatic patients had recurrence or progression in their ischemic symptoms while waiting for the operation, with a median time of 8.5 days (range 1-30 days). DISCUSSION: Carotid artery stenosis patients are considered high-risk patients regardless of symptomatology. The high proportion of medication use exceeds the use in the past proof-of-concept randomized controlled trials on the benefit of CEA+BMT over BMT. Nevertheless, there is room for improvement.