Comparison of Ectasia Detection in Early Keratoconus Using Scheimpflug-Based Corneal Tomography and Biomechanical Assessments.

PURPOSE: The aim of this study was to determine the detection of keratoconus using corneal biomechanical parameters only, a corneal tomographic parameter only, and a parameter that combines corneal biomechanical and tomographic indices. METHODS: The discriminatory power of the Pentacam Random Forest Index (PRFI), Belin/Ambrósio Enhanced Ectasia Display (BAD-D) index, Corvis Biomechanical Index (CBI), and Tomographic and Biomechanical Index (TBI) to differentiate between normal eyes (n = 84), eyes with very asymmetric corneal ectasia (VAE-E, n = 21), and the fellow eyes without apparent ectasia based on normal tomography (VAE-NT, n = 21) was assessed. Statistical analyses were completed with R software using t -tests, Wilcoxon rank sum tests, and receiver operating characteristic (ROC) curves. The DeLong test was used to compare the area under the ROC curve (AUROC). RESULTS: The TBI and PRFI had the highest AUROC when distinguishing between normal and VAE-E corneas (AUROC = 1.00, 95% CI = 1.00-1.00); however, they were not statistically superior to the CBI (AUROC = 0.97, P = 0.27) or BAD-D (AUROC = 1.00, P = 0.34). The TBI (AUROC = 0.92, 95% CI = 0.86-0.98) was superior to CBI (AUROC = 0.78, P = 0.02) and BAD-D (AUROC = 0.81, P = 0.02) when distinguishing between healthy and VAE-NT corneas. At a threshold of 0.72, the TBI had 99% sensitivity, 67% specificity, and 92% accuracy in distinguishing normal and VAE-NT corneas. CONCLUSIONS: The TBI is a useful parameter for the screening of subclinical and frank keratoconus in tomographically normal eyes.

Progression of keratoconus in children and adolescents.

AIMS: To evaluate the rates of keratoconus progression and associated factors in eyes of children and adolescents. METHODS: Retrospective, cohort study of individuals ≤18 years old at the time of keratoconus diagnosis and with at least 6 months of follow-up. Corneal tomography was performed using an Orbscan tomographer (Bausch & Lomb, Rochester, New York, USA) to determine whether progression occurred. Tomographic progression of keratoconus was defined as a change in any of the investigated parameters (keratometry values, KMAX, maximum anterior or posterior elevation, central pachymetry, thinnest pachymetry) beyond the limits of repeatability. RESULTS: 148 eyes of 106 patients with a mean age of 15.2±2.5 years were studied over a mean follow-up period of 2.9±2.2 years. The overall rate of tomographic progression was 77.0% (114/148 eyes). Eyes that progressed had more advanced disease at presentation with higher anterior curvature (KMAX55.4±6.3 vs 52.2±5.4 dioptres; p<0.01), posterior elevation (108.2±40.9 vs 86.3±35.6 µm; p<0.01) and lower central pachymetry measurements (442.1±56.7 vs 454.4±47.5 µm; p=0.01). Age at presentation, gender, atopy, documented eye rubbing, ethnicity and duration of follow-up were not significantly associated with progression in the multivariate analyses. There was a higher rate of bilateral progression if at least one eye had severe keratoconus (73.9%) compared with no severe keratoconus in either eye (36.8%; p=0.03). CONCLUSIONS: A high rate of progression was identified in keratoconic eyes of children and adolescents. More advanced disease at initial presentation may increase the risk of further keratoconus progression.

Prospective one year study of corneal biomechanical changes following high intensity, accelerated cornea cross-linking in patients with keratoconus using a non-contact tonometer.

PURPOSE: To characterize corneal biomechanical properties utilizing a dynamic ultra-high-speed Scheimpflug camera equipped with a non-contact tonometer (CorVis ST, CST) in keratoconic corneas following continuous high intensity, high irradiance corneal cross-linking. DESIGN: Prospective longitudinal single-centre study at a tertiary referral center. METHODS: Corneal biomechanical properties were measured in patients with progressive keratoconus undergoing high intensity (30 mW/cm2), high irradiance (5.4 J/cm2), accelerated corneal cross-linking with continuous exposure to ultraviolet-A for 4 min. CST was used to assess corneal biomechanical properties pre-operatively and at 1, 3, 6 and 12 months post-operatively. CST output videos were further analyzed using several previously reported algorithms. RESULTS: A total of 25 eyes of 25 participants were examined. The mean age of participants was 20.9 ± 5.3 years; 56% were male and 80% were of Maori or Pacific Island origin. Energy absorbed area (mN mm), was the only significantly changed parameter compared to baseline at all time points measuring 3.61 ± 1.19 preoperatively, 2.81 ± 1.15 at 1 month (p = 0.037), 2.79 ± 0.81 (p = 0.033) at 3 months, 2.76 ± 0.95 (p = 0.028) at 6 months and 2.71 ± 1.18 (p = 0.016) at 12 months. CONCLUSIONS: The significant difference between the pre and post-operative energy absorbed area appears to reflect changes in corneal viscous properties that occur following corneal cross-linking.

Measurement of refractive, wavefront, topographic, and keratometric changes attributable to epithelial removal in keratoconus.

OBJECTIVE: The corneal epithelium is able to mask topographic and keratometric abnormalities of the underlying Bowman layer in keratoconus, but its contribution to refractive and wavefront parameters has not yet been studied. This study compared the refractive and aberrometric features of the corneal epithelium and Bowman layer in eyes with keratoconus before and after epithelial debridement. METHODS: Corneal refractive and wavefront variables were measured in patients with keratoconus undergoing corneal crosslinking-immediately before and after epithelial debridement using a third-generation combined corneal topographer, autorefractor, and aberrometer. RESULTS: After epithelial debridement, there were significant changes in spherical equivalent (-1.37 D; p < 0.01) and asphericity (-0.64; p = 0.03). The mean difference in the magnitude of epithelium-induced astigmatism in the 3rd and 5th central millimeter rings was 0.44 ± 3.20 D × 8 and 0.43 ± 2.75 D × 21 (positive cylinder), respectively. Corneal astigmatism axis shifted in the against-the-rule orientation after epithelial debridement. There were no significant changes in any corneal higher-order aberration parameter after epithelial debridement (p > 0.05). CONCLUSIONS: In eyes with keratoconus, epithelial debridement increased the magnitude of anterior corneal prolateness and tended to increase astigmatism and shift its axis toward the against-the-rule orientation. This study supports the notion that the corneal epithelium smooths underlying Bowman layer irregularity in keratoconus.

Peripheral Cornea Crosslinking Before Deep Anterior Lamellar Keratoplasty.

Since Cornea crosslinking (CXL) has been proven to halt progression and biomechanically stabilize keratoconus, we hypothesized that CXL of the corneal periphery 3 months prior to corneal transplantation can reduce the incidence of recurrent ectasia by strengthening the peripheral corneal tissue and causing apoptosis of diseased peripheral host keratocytes. Thus, the aim of this case-report was to propose a novel peripheral CXL technique prior to keratoplasty and evaluate its safety. A 22-year-old woman was admitted with advanced right keratoconus and corrected distance visual acuities of 20/30 in the right eye and 20/200 in the left eye with a manifest refraction of -3.00D/ -8.00D × 36° and -17.00D/ -11.50D × 90°, respectively. The proposed treatment involved crosslinking of peripheral corneal tissue (6.5-9.5mm), sparing the central cornea and limbus, three months prior to corneal transplantation as a means of biomechanically strengthening the peripheral cornea tissue. This procedure was feasible and safe with repopulation of the peripheral cornea with keratocytes, no significant endothelial cell loss and a routine postoperative course following CXL and DALK. This method might reduce or eliminate the need for repeat corneal transplantation in patients with recurrent ectasia. Further studies are needed to confirm the results.

Prospective Clinical Study of Keratoconus Progression in Patients Awaiting Corneal Cross-linking.

PURPOSE: Keratoconus progression should be treated with corneal cross-linking (CXL) in a timely manner. This study aimed to investigate patient factors associated with keratoconus progression between time of listing and at time of CXL. METHODS: Prospective observational study at a tertiary center. Ninety-six eyes of 96 patients with keratoconus. Demographic, clinical, and tomographic parameters were analyzed to determine the risk factors for keratoconus progression. Analyzed tomographic indices included steepest keratometry, average keratometry, cornea thinnest point, index of surface variance, index of vertical asymmetry, keratoconus index, center keratoconus index, index of height asymmetry, and index of height decentration. RESULTS: A total of 38 eyes (39.6%) were found to have keratoconus progression during an average waiting time of 153 ± 101 days. There were significant differences in preoperative tomographic parameters such as index of surface variance (111.3 ± 36.6 vs. 88.3 ± 31.8; P = 0.002), index of vertical asymmetry (1.1 ± 0.4 vs. 0.9 ± 0.4; P = 0.005), keratoconus index (1.31 ± 0.12 vs. 1.22 ± 0.11; P < 0.001), and index of height decentration (0.16 ± 0.07 vs. 0.11 ± 0.06; P = 0.015) between eyes that progressed and those that remained stable. There were no significant differences in steepest keratometry, average keratometry, cornea thinnest point, and center keratoconus index. Multivariate analysis did not reveal age, presence of atopy/atopic keratoconjunctivitis, eye rubbing, or waiting time to be a significant risk factor for progression; however, Maori ethnicity was a risk factor (odds ratio = 3.89; P = 0.02). CONCLUSIONS: A significant proportion of eyes were found to be progressing while waiting for CXL. A risk stratification score for patients awaiting CXL may reduce the risk of progression.

Measurement of In Vivo Biomechanical Changes Attributable to Epithelial Removal in Keratoconus Using a Noncontact Tonometer.

PURPOSE: To compare the biomechanical properties of the cornea after epithelial removal in eyes with keratoconus undergoing corneal cross-linking. METHODS: Prospective interventional case series at a university hospital tertiary referral center. Corneal biomechanical properties were measured in patients with keratoconus undergoing corneal cross-linking, immediately before and after epithelial debridement by using a dynamic ultrahigh-speed Scheimpflug camera equipped with a noncontact tonometer. RESULTS: The study comprised 45 eyes of 45 patients with a mean age of 19.6 ± 4.9 years (range 14-34). The cornea was found to be 23.7 ± 15.7 µm thinner after epithelial removal (P < 0.01). Corneal stiffness was reduced after epithelial removal as demonstrated by a significant decrease of parameters such as stiffness parameter A1 (12.31, P < 0.01), stiffness parameter-highest concavity (2.25, P < 0.01), A1 length (0.13 mm, P = 0.04), highest concavity radius of curvature (0.26 mm, P = 0.01), highest concavity time (0.22 ms, P = 0.04) and an increase in A1 velocity (-0.01 m/s, P = 0.01), A1 deformation amplitude (-0.03 mm, P ≤ 0.01), A1 deflection length (-0.32 mm, P < 0.01), A2 deformation amplitude (-0.03 mm, P = 0.01), and A2 deflection length (-1.00 mm, P < 0.01). There were no significant differences in biomechanical intraocular pressure (0.15 mm Hg, P = 0.78), deformation amplitude (0.03, P = 0.54), maximum inverse radius (-0.01 mm, P = 0.57), and whole eye movement length (-0.02 mm, P = 0.12). CONCLUSIONS: Dynamic ultrahigh-speed Scheimpflug camera equipped with a noncontact tonometer offers an alternative method for in vivo measurements of the epithelial layer's contribution to corneal biomechanical properties. Our results suggest that corneal epithelium may play a more significant role in corneal biomechanical properties in patients with keratoconus than previously described.

Prospective two year study of changes in corneal density following transepithelial pulsed, epithelium-off continuous and epithelium-off pulsed, corneal crosslinking for keratoconus.

PURPOSE: To compare the corneal densitometry changes after transepithelial pulsed (t-ACXL), epithelium-off continuous (c-ACXL) and epithelium-off pulsed (p-ACXL), accelerated corneal crosslinking for patients with progressive keratoconus. METHODS: Prospective, interventional case series at a university hospital tertiary referral center. Forty eyes received t-ACXL, 40 eyes received c-ACXL, and 40 eyes received p-ACXL. Corneal tomography, densitometry and visual acuity were evaluated preoperatively and at 1, 3, 6, 12 and 24 months postoperatively. RESULTS: Total densitometry values of the total layer over the annular diameters 0-12 mm expressed in grayscale units (GSU) showed no significant change after t-ACXL and p-ACXL but increased significantly after c-ACXL at 1 month (16.76 ± 2.38, P value < 0.01) and 3 months (16.12 ± 2.22, P value 0.04), returning to baseline levels at month 6 (14.97 ± 2.13, P value 0.99) and remained stable until final follow-up. At 1 month, the mean change in total densitometry value of the t-ACXL group (-0.53 ± 2.08) was significantly lower than the p-ACXL (0.70 ± 1.96 P value 0.04) and c-ACXL (1.97 ± 2.65 P value < 0.01). There was no statistical difference in the mean change in total densitometry between the three groups from 6 to 24 months. In the c-ACXL group, a higher degree of CXL-induced corneal haze at 1 month was observed in patients with steeper preoperative keratometry readings and in individuals where a greater flattening effect was achieved at 24 months. CONCLUSIONS: Continuous epithelium-off accelerated cornea crosslinking appears to induce more corneal haze than pulsed epithelium-off and transepithelial pulsed cornea crosslinking in the early postoperative period. Differences resolve by six-months.

Comparison of corneal biomechanical properties following penetrating keratoplasty and deep anterior lamellar keratoplasty for keratoconus.

IMPORTANCE: Keratoplasty is a surgical procedure to create a more regular optical surface following biomechanical weakening of the cornea in keratoconus. The ideal keratoplasty procedure should also restore corneal biomechanics to that of the healthy cornea. BACKGROUND: This study aimed to evaluate and compare the biomechanical properties of corneas following penetrating keratoplasty (PKP) and predescematic deep anterior lamellar keratoplasty (DALK) to those of healthy eyes. DESIGN: Prospective cross-sectional study. PARTICIPANTS: Two cohorts of post-keratoplasty eyes (42 eyes with PKP and 27 eyes with DALK) with each other, and with a cohort of 152 healthy eyes. METHODS: All eyes were examined by slit-lamp biomicroscopy, tomography, anterior segment-OCT and non-contact tonometry CorVis ST (CST). MAIN OUTCOME MEASURES: CST biomechanical parameters, maximum corneal deformation (MCD) and corneal energy dissipation were compared between keratoplasty techniques, and with healthy eyes. RESULTS: The mean age of participants with PKP and DALK were 35 ± 13.7 and 36.1 ± 12.6 years, respectively. None of the CST parameters were significantly different between PKP and DALK eyes. However, when compared to healthy corneas, numerous parameters were significantly different for both keratoplasty techniques. Of note, MCD was significantly higher in PKP compared to DALK and healthy corneas, after controlling for co-factors. CONCLUSIONS AND RELEVANCE: Neither type of keratoplasty technique utilized in keratoconus completely restored corneal biomechanical properties to that of healthy corneas. However, PKP resulted in a greater number of parameters significantly different to healthy corneas, compared to DALK.

Prospective 2-year study of accelerated pulsed transepithelial corneal crosslinking outcomes for Keratoconus.

AIMS: To report 2-year outcomes of transepithelial, accelerated, pulsed, corneal crosslinking (t-ACXL) for patients with progressive keratoconus. METHODS: Prospective, interventional case series at a university hospital tertiary referral centre. Forty eyes with progressive keratoconus undergoing t-ACXL were included. Treatment was performed with pulsed illumination (1 s on/1 s off) using 45 mW/cm2 for 5 min and 20 s, for a surface dose of 7.2 J cm2. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction spherical equivalent (MRSE), corneal tomography, anterior segment optical coherence tomography (OCT) and confocal microscopy were evaluated preoperatively and at 12 and 24 months postoperatively. RESULTS: The mean patient age was 23.32 ± 5.18 years (SD) (range 14-42 years). The mean CDVA significantly improved from 0.38 ± 0.32 logMAR at baseline to 0.30 ± 0.21 logMAR at 24 months (P < 0.01). There was no significant difference in UDVA, MRSE, asymmetry indices, tomographic parameters and endothelial density. The improvement in visual acuity was inversely correlated with preoperative CDVA and preoperative KMax. No complications were encountered. CONCLUSIONS: In this prospective study, t-ACXL appeared safe and effective in halting progression of keratoconus within a follow-up period of 24 months.

Prospective two-year study of clinical outcomes following epithelium-off pulsed versus continuous accelerated corneal crosslinking for keratoconus.

IMPORTANCE: Keratoconus is a debilitating condition with a disproportionately high impact on health resources and vision-specific quality of life. BACKGROUND: This study aimed to compare 2-year outcomes of epithelium-off pulsed (p-ACXL) and epithelium-off continuous (c-ACXL) accelerated corneal crosslinking in progressive keratoconus. DESIGN: Prospective, interventional case series. PARTICIPANTS: Eighty eyes of 80 patients were included. METHODS: The visual, refractive and tomographic results of the two crosslinking protocols were compared. MAIN OUTCOME MEASURES: Uncorrected distance visual acuity, corrected distance visual acuity (CDVA), manifest refraction spherical equivalent (MRSE) and maximum keratometry (KMAX ) on corneal tomography assessment. RESULTS: The mean patient age was 22.51 ± 6.12 years (SD) and 22.08 ± 5.72 years in the p-ACXL and c-ACXL groups, respectively. The mean CDVA significantly improved from 0.30 ± 0.16 logMAR at baseline to 0.23 ± 0.17 logMAR at 24 months (P = .04) in the p-ACXL group and from 0.36 ± 0.22 logMAR to 0.26 ± 0.27 logMAR (P = .02) in the c-ACXL group. The mean induced change in MRSE (+1.79 ± 2.30 D vs +0.27 ± 3.19 D, P = .04) and KMAX (-1.75 ± 1.80 D vs -0.39 ± 1.95 D, P = .04) were superior in the c-ACXL group compared to the p-ACXL group at 24 months. No complications were encountered. CONCLUSIONS AND RELEVANCE: In this prospective study, both p-ACXL and c-ACXL treatments were safe methods to halt the progression of keratoconus within a follow-up period of 24 months. c-ACXL appeared to offer superior refractive and tomographic outcomes when compared to p-ACXL but this did not translate into better visual outcomes.

Improved Refractive Outcomes of Small-Incision Extracapsular Cataract Surgery after Implementation of a Biometry Training Course.

PURPOSE: To determine whether a biometry training course could improve refractive outcomes of patients undergoing manual small-incision extracapsular cataract surgery (SICS). MATERIALS AND METHODS: This was a prospective, interventional, cohort study at the Pacific Eye Institute, Fiji. SICS refractive outcomes were evaluated before and after a structured biometry teaching course. Eyes that underwent evaluation and subsequent SICS with placement of a posterior chamber intraocular lens (IOL) were included. Axial length measurements were obtained using A-scan applanation ultrasound and keratometry with a handheld keratometer. Main outcome measures included mean absolute prediction error of IOL calculations, percentage of eyes within ±0.5 D and ±1.0 D of intended spherical equivalent, and proportion of eyes with ≥6/18 uncorrected visual acuity. RESULTS: A total of 240 eyes were analyzed: 120 eyes before and 120 eyes after the structured biometry training. The mean absolute prediction error was 50% lower following the training (1.13 ± 0.84 D pre vs. 0.56 ± 0.44 D post; P < 0.001). A higher percentage of the eyes had a postoperative spherical equivalent within ±0.5 D (26.7% pre vs. 52.5% post; P < 0.001) and ±1.0 D (55.0% pre vs. 90.0% post; P < 0.001) of the intended target. A higher proportion of the eyes achieved ≥6/18 uncorrected visual acuity (77.5% pre vs. 91.7% post, P = 0.004), while the proportion with ≥6/18 corrected visual acuity was similar (94.4% pre vs. 98.3% post; P = 0.28). CONCLUSIONS: A structured biometry training course may improve the accuracy of preoperative IOL calculations to achieve the postoperative refractive target. Ophthalmology training programs should include structured biometry teaching in their curricula.

Ex vivo evaluation of the stability, safety and antibacterial efficacy of an extemporaneous povidone-iodine preparation for ophthalmic applications.

BACKGROUND: Povidone-iodine is used as a cost-effective broad-spectrum antiseptic in the prophylaxis and treatment of certain ocular infections. In this study, the stability, ophthalmic irritation potential and antibacterial efficacy of an extemporaneous povidone-iodine preparation was determined using established ex vivo and in vitro assays. METHODS: Extemporaneous iodine was prepared by simple dilution in normal saline. Preparation stability was evaluated by monitoring concentration and pH. Ocular safety was determined using the bovine cornea opacity and permeability assay. Efficacy was assessed by determining the minimum inhibitory and minimum bactericidal concentration of the preparation on Staphylococcus aureus and Pseudomonas aeruginosa. RESULTS: Diluted povidone-iodine maintained its stability over the 28-day evaluation. The formulation caused mild ocular irritation at the lowest prepared concentration (0.5 per cent w/v), with irritation noticeably increased at higher concentrations. The preparation showed minimum bactericidal and inhibitory concentrations of 0.078 and 0.3 per cent w/v on S. aureus and P. aeruginosa, respectively. CONCLUSIONS: This study confirms the stability and broad-spectrum antibacterial efficacy of povidone-iodine, while addressing the ocular irritation potential of this chemical.

Direct measurement of anterior corneal curvature changes attributable to epithelial removal in keratoconus.

PURPOSE: To compare the tomography of the corneal epithelium and Bowman layer in eyes with moderate to severe keratoconus before and after epithelial debridement. SETTING: University hospital tertiary referral center. DESIGN: Prospective case series. METHODS: Dual-channel Scheimpflug combined with Placido-disk tomography was used to measure the corneal variables in eyes with keratoconus having corneal crosslinking immediately before and after epithelial debridement. The differences in pachymetry, axial keratometry, astigmatism magnitude, asphericity, total corneal power, and spherical aberrations were computed. RESULTS: The study comprised 30 eyes of 30 patients. After epithelial removal, the central (0.0 to 4.0 mm) and midperipheral (4.0 to 7.0 mm) corneal zones were significantly thinner mean (21 µm ± 14 [SD] and 35 ± 44 µm, respectively). The mean anterior axial flat keratometry (K) (+1.71 diopters [D]), steep K (+2.14 D), maximum K (+2.13 D), corneal astigmatism (+1.11 D), asphericity (-0.31), and total corneal power changes (+2.03 D) were significantly different after epithelial debridement. There were no significant changes in posterior corneal flat K or steep K, posterior corneal astigmatism, or posterior asphericity. There were no significant differences in the mean astigmatic axis (anterior or posterior corneal surface) or spherical aberration after epithelial debridement. CONCLUSIONS: In eyes with moderate to severe keratoconus, the tomography of Bowman layer was significantly steeper than that of the epithelium; thus, epithelial debridement increased the magnitude of anterior corneal keratometry, astigmatism, and prolateness. These data suggest that the corneal epithelium smooths the underlying Bowman layer irregularity in keratoconus.

Advanced anterior segment imaging in keratoconus: a review.

Advances in anterior segment imaging have enhanced our ability to detect keratoconus in its early stages and characterize the pathologic changes that occur. Computerized corneal tomography has elucidated the alterations in shape of the anterior and posterior corneal surfaces and alterations in thickness as the disease progresses. Automated screening indices such as the keratoconus screening index were developed to assist in detecting keratoconus in suspicious cases. In vivo assessment of keratoconic corneas has revealed that compromised corneal biomechanics can now be measured clinically. Optical coherence tomography has demonstrated alterations in corneal epithelial thickness and distribution in keratoconus, has a role in assessing Descemet's membrane detachment in acute corneal hydrops (ACH) and the depth of the demarcation line following corneal collagen cross-linking. In vivo confocal microscopy has exhibited cellular changes that occur in keratoconus and provided insight into cellular events that may be related to the development of neovascularization in ACH.

Short-term outcomes of small incision cataract surgery provided by a regional population in the Pacific.

BACKGROUND: This study aims to describe patient demographics, visual and surgical outcomes of a cohort undergoing small incision cataract surgery at a Pacific regional ophthalmic training facility. DESIGN: This is a prospective, longitudinal study conducted at the Pacific Eye Institute, Fiji. PARTICIPANTS: One hundred fifty-six patients underwent small incision cataract surgery. METHODS: Preoperatively, a complete ophthalmic examination, including pachymetry and macular optical coherence tomography performed by two independent investigators. Temporal small incision cataract surgery with intraocular lens insertion was performed by ophthalmologists, and trainee ophthalmologists. Follow-up occurred at day one, four weeks and 3 months. MAIN OUTCOME MEASURES: Patient characteristics, visual outcomes including surgically induced astigmatism and complications. RESULTS: Ninety-one per cent (142/156) attended 3-month follow-up with median age 63 years (range 19-82), 52% female (81/156) and 58% (90/156) Fijian ethnicity. In 37% (57/156), the contralateral eye was pseudophakic. Mean preoperative best spectacle-corrected visual acuity was logMAR 1.44 (6/165). At 3 months, 74% (105/142) achieved ≥6/18 unaided vision (94% [133/142] best spectacle-corrected visual acuity). Mean postoperative spherical equivalent was -0.78 (SD 0.95) D and mean surgically induced astigmatism 1.04 (0.57) D. Complications included posterior capsular rupture with vitreous loss (4% [6/156]), optical coherence tomography confirmed macular oedema (8% [12/152] at 4 weeks), significant posterior capsular opacity (23% [31/136]) and >5% increase in preoperative pachymetry (1% [1/142]) at 3 months. Reduction in preoperative best spectacle-corrected visual acuity occurred in 2% (3/142). No cases of endophthalmitis. CONCLUSION AND RELEVANCE: Small incision cataract surgery provided to a regional population is effective with 94% achieving the World Health Organisation's definition of 'Good Vision' (≥6/18). Refinements in biometric and surgical techniques may allow a greater proportion of patients to achieve good unaided vision.