Estimation of the Economic and Environmental Impact of Single-Use Instruments in Routine Cataract Surgery.

Purpose: To estimate the economic and environmental impact of single-use instruments (SUIs) to perform standard cataract surgery in six ophthalmology centers located in Europe and in the United States. Setting: Online survey and interview. Design: Comparative cost analysis based on an online survey with follow-up questionnaire and interview. The carbon footprint calculation was made by ClimatePartner. Methods: Annual costs of reusable instruments (RUIs) were calculated based on data provided by the centers. Annual costs of SUIs were estimated based on the average-selling price of a single-use cataract set of 5 instruments and the reported annual volume of cataract surgery. The calculation carbon footprint of a cataract instrument covered the whole life cycle from production to end-of-life. Results: Annual costs for SUIs were found inferior or similar to the annual costs for RUIs for 4 out of the 6 centers included in this study. The centers where SUIs were demonstrated to be the most cost-effective were also associated with the highest costs of sterilization per instrument. The carbon footprint of 5-years usage of a cataract instrument was found to be 5478.2 kg CO2 eq for SUIs without recycling, 4639.9 kg CO2 eq for SUIs with recycling and 20.6 kg CO2 eq for RUIs. Conclusion: The study demonstrated that SUIs can be an alternative solution to using RUIs in multispecialty hospitals associated with high sterilization costs.

Intradevice Repeatability and Interdevice Comparison of Two Specular Microscopy Devices in a Real-Life Setting: Tomey EM-4000 and Nidek CEM-530.

Background and Objectives: The purpose of this study was to compare two commercially available specular microscopes (Tomey EM-4000 and Nidek CEM-530) in a real-life clinical setting in terms of intra- and interdevice variability. The study was conducted on all patients seen in a clinical practice specializing in anterior segment pathologies, regardless of the purpose of their visit. Materials and Methods: In total, 112 eyes of 56 patients (age 23-85 years old) were included in the study. Each eye was measured three times with each device (for a total of six measurements), and results for central corneal thickness (CCT) and corneal endothelial cell density (ECD) were recorded. The results were then evaluated with the D'Agostino-Pearson normality test and compared with a Wilcoxon signed-rank test, t-test, ANOVA or Mann-Whitney test for intra- and interdevice variability. Results: Both specular microscopes produced very reliable reproducible intradevice results: The Tomey EM-4000 measured an ECD of 2390 ± 49.57 cells/mm2 (mean ± standard error of mean); the range was 799-3010 cells/mm2. The determined CCT was 546 ± 5.104 µm (mean ± standard error of mean [SEM]); the range was 425-615 µm. The measurements with the Nidek CEM-530 revealed an ECD of 2417 ± 0.09 cells/mm2 (mean ± SEM); the range was 505-3461 cells/mm2 (mean ± SEM). The mean CCT detected was 546.3 ± 4.937 µm (mean ± SEM); the range was 431-621 µm. The interdevice differences were statistically significant for both parameters, ECD (p = 0.0175) and CCT (p = 0.0125) (p < 0.05). Conclusions: The Nidek CEM-530 and the Tomey EM-4000 both produced reliable and reproducible results in terms of ECD and CCT. The absolute measurements were statistically significantly different for CCT and ECD for both devices; the Nidek produces slightly higher values.

Interleukin 12 in the Acute Phase of the Immune Response after Excimer Laser Treatment.

BACKGROUND AND OBJECTIVES: The aim of the research was to investigate the differences in the concentrations of IL-12, IL-4, IL-10, and IFN-γ in tears after LASIK and PRK procedures. MATERIALS AND METHODS: The study included 68 myopic eyes up to -3.0 D refractive spherical equivalent, divided into two groups: Group 1 LASIK (n = 31) and Group 2 PRK (n = 37). Three tear samples were taken from each eye: immediately before the procedure (t0), 1 h after the procedure (t1), and 24 h after the procedure (t2). The concentrations of IL-12p70, IL-4, IL-10, and IFN-γ in the tear samples were determined by flow cytometry. Participants were not taking anti-inflammatory therapy 24 h after the procedure. RESULTS: IL-4 levels 1 h after treatment did not differ between LASIK and PRK (p = 0.990), while 24 h after PRK there was a significant decrease in IL-4 levels (p < 0.05), but not after LASIK (p = 0.476). In both the LASIK (p < 0.05) and PRK (p < 0.05) groups, there is an increase in IL-10 concentrations 1 h after treatment, which persists 24 h after LASIK (p < 0.05) but not after PRK (p = 0.081). There is an increase in IL-12p70 concentration 1 h after treatment in both the LASIK (p < 0.001) and PRK groups (p < 0.001). There is also an increase in IL-12p70 concentration 24 h after PRK (p < 0.005), but not after LASIK (p = 0.775). CONCLUSIONS: IL-4 concentration shows a significantly higher value in the LASIK group than in the PRK group after 24 h. IL-10 and IL-12p70 levels increase one hour after surgery in both groups. After 24 h, the IL-10 levels remain elevated in the LASIK group, and the IL-12p70 levels remain elevated in the PRK group. Thus, LASIK and PRK procedures show different inflammatory dynamics.

Comparison of Conventional and Femtosecond Laser-Assisted Cataract Surgery Regarding Macula Behavior and Thickness.

Background: The aim of the study was to compare macular thickness behavior and clinical outcomes after femtosecond laser-assisted cataract surgery (FLACS) versus phacoemulsification conventional surgery (PCS). Methods: Macular Optical Coherence Tomography OCT was analyzed in 42 patients preoperatively, 1 day, 12 days, 4 weeks and 6 weeks postoperatively according to the 9-field Early Treatment Diabetic Retinopathy Study (ETDRS) grid. Clinical findings were collected in both the FLACS group and the PCS group. Results: There was no significant difference in macular thickness between the FLACS and PCS groups (p > 0.05). However, from postoperative day 12 onwards, there was a significant increase in macular thickness observed in both groups (p < 0.001). In the FLACS group, a significant increase in visual acuity was observed on the first postoperative day, as compared to the PCS group (p = 0.006). Conclusions: The use of a low-energy high-frequency femtosecond laser has potentially no effect on postoperative macular thickness. In the FLACS group, visual rehabilitation was significantly faster as compared to the PCS group. No complications occurred intraoperatively in either group.

Bowman Layer Transplantation for Treating Keratoconus-Preliminary Findings.

(1) Background: Mid-stromal isolated Bowman layer transplantation aims to reduce and stabilize corneal ectasia in patients with advanced, progressive keratoconus. The purpose of this review is to evaluate the effectiveness and safety of this new surgical technique. (2) Methods: Following the PRISMA statement and checklist, we searched Medline, the Cochrane Controlled Trials Register, and Embase and used a broad systematic search strategy according to the Cochrane Collaboration. (3) Results: Eight studies with a total number of 120 eyes of 106 patients met our inclusion criteria. One month after Bowman layer transplantation, patients with keratoconus showed a significant decrease in the measured simulated keratometry (-4.74 D [95% CI -6.79 to -2.69]) and the maximum keratometry (-7.41 D [95% CI -9.64 to -5.19]), which remained significant one year postoperatively (-2.91 D [95% CI -5.29 to -0.53] and -5.80 D [-8.49 to -3.12]). Intra- and postoperative complications were observed in 3% and 9% of the patients, respectively. An estimated success rate of 75% to 85% was achieved by experienced surgeons at 5 to 8 years postoperatively. (4) Conclusions: Bowman layer transplantation may be an effective and safe treatment option in patients with advanced, progressive keratoconus. Additional multicenter prospective interventional studies are needed to confirm these preliminary findings.

Posterior Corneal Asphericity Effect on Postoperative Astigmatism after EDOF Intraocular Lens Implantation in Cataract Patients.

AIM: To assess the impact of posterior corneal asphericity on postoperative astigmatism. METHODS: We included retrospectively 70 eyes of 70 patients that underwent cataract surgery. We included data of the Q value, K max, K1, K2, astigmatism AL, and ACD. We performed a vectorial analysis to calculate the astigmatic vectors. RESULTS: Seventy eyes were evaluated. 40 eyes were of females (58%) and 30 of males (42%). The average cohort age was 73 ± 8.9 years. Axial length (AL) was 23.5 ± 0.9, anterior chamber depth (ACD) was 3.13 ± 0.3, and the average posterior Q value was -0.35 ± 0.2. The only significant predictive variable for the correction index (CI) was the posterior Q value (r = 0.24, p < 0.05) and for the surgically induced astigmatism (SIA) (ß = 0.34, r = 0.58, p < 0.05). CONCLUSION: Posterior corneal surface asphericity significantly influences the surgically induced astigmatism and the overcorrection for cataract patients after Lucidis EDOF IOL implantation.

Indications and outcomes for intravitreal injection of C3F8 gas for symptomatic vitreomacular traction.

To evaluate the indications and outcomes of perfluoropropane (C3F8) gas injection for symptomatic vitreomacular traction (VMT). A retrospective analysis of eyes with VMT treated with 0.3 mL of C3F8 gas was performed. Patients were not asked to posture after gas injection. In phakic patients, cataract surgery was performed simultaneously. Patients were examined after one week and one month postoperatively. Twenty-nine consecutive eyes of 26 patients with symptomatic VMT who underwent pneumatic vitreolysis were included. A complete posterior vitreous detachment was achieved in 18 eyes (62.1%) after a single gas injection at the final visit. The rate of posterior vitreous detachment was reduced significantly with the presence of epiretinal membrane (ERM) (p = 0.003). Three eyes formed a macular hole (MH) postoperatively and another eye developed a retinal detachment. Mean visual acuity increased significantly after one month (p < 0.008). Pneumatic vitreolysis is a viable option for treating VMT with few adverse events. Patient with concomitant ERM had a significantly lower success rate.

Long-term outcome of macular shift after retinal detachment repair.

BACKGROUND: This study aimed to evaluate the long-term change of postoperative retinal shift after pars plana vitrectomy for macular off retinal detachment. METHODS: In this retrospective study, patients with retinal shift after pars plana vitrectomy for macula-off rhegmatogenous retinal detachment (RRD) were examined at 3 weeks and 12 months postoperatively. Fundus autofluorescence images were obtained to visualize retinal rotation. Best-corrected visual acuity was measured and metamorphopsia assessed using the Amsler grid. RESULTS: Nine patients with postoperative retinal shift were included in the study. Retinal shift decreased significantly in these patients, on average by 1.07° (range 0.52-1.62, p = 0.002) after 12 months. However, more patients complained of distorted vision after 12 months (odds ratio for change = 3.0, 95% CI: 0.24 to 157.49). The main reason was the new formation of an epiretinal membrane (odds ratio for change = infinity, 95% CI: 0.41 to infinity). There was no change in visual acuity observed (p = 0.16). CONCLUSION: Postoperative retinal shift after RRD repair decreases over a 1-year span. While retinal shift is the main cause for metamorphopsia in the early postoperative period, formation of an ERM is the main reason for distorted vision long term.

Predictive Risk Factors for Retinal Redetachment Following Uncomplicated Pars Plana Vitrectomy for Primary Rhegmatogenous Retinal Detachment.

PURPOSE: To investigate clinical and surgical factors influencing the outcome after primary rhegmatogenous retinal detachment surgery. METHODS: A retrospective, single-centre, case-control study of 1017 eyes of 1017 consecutive patients with primary rhegmatogenous retinal detachment (RRD) who underwent pars plana vitrectomy (PPV), were included in the study. Analysed surgical factors were: combined procedure with phacoemulsification, type of retinopexy (cryocoagulation, endolaser, combined), type of tamponade (gas, silicone oil), and anatomical factors: primary proliferative vitreoretinopathy (PVR) and macular detachment at the time of surgery. RESULTS: Overall retinal re-detachment rate was 10.1%. The main reason for re-detachment was an insufficient retinopexy in 53.6%, followed by PVR (37.3%), and retinal detachment occurred at a different location caused by another break in 9.1%. No significant difference in the rate of re-detachment was found if a phacoemulsification with simultaneous IOL implantation was performed (p = 0.641). No significant difference between the various retinopexy techniques was found (p = 0.309). Risk factors re-detachment were primary PVR (p = 0.0003), silicone oil as initial tamponade (p = 0.0001) as well as macula off detachments (p = 0.034). CONCLUSIONS: The present study showed no significant difference between the types of retinopexy and if additional phacoemulsification was performed or not. Factors associated with a higher risk for re-detachment were detached macula at surgery, primary PVR and primary oil-filling.

Correction to: Influence of Postoperative Posture on Macular Slippage after Macula-Off Retinal Detachment: A Randomized Controlled Trial.

The original article can be found online.

Successful Treatment of Peripheral Proliferative Vitreoretinopathy with Cryocoagulation During Retinal Detachment Repair - A New Surgical Technique.

PURPOSE: To evaluate the effect of extrascleral cryocoagulation for the treatment of proliferative vitreoretinopathy (PVR) during retinal detachment repair. METHODS: Patients with a rhegmatogenous retinal detachment associated with peripheral PVR Grade C star-folds were included in this study and analysed retrospectively. In all patients, PVR star-folds were treated by extrascleral cryocoagulation. RESULTS: A total of six patients with a rhegmatogenous retinal detachment associated with at least one peripheral PVR star-fold were included in this study. Reattachment of the retina was successfully achieved in all patients. CONCLUSION: This novel and simple technique for the treatment of localized PVR using extrascleral cryocoagulation appears to be a safe and effective approach with favourable surgical success rates.

Influence of Postoperative Posture on Macular Slippage after Macula-Off Retinal Detachment: A Randomized Controlled Trial.

INTRODUCTION: To evaluate the effect of postoperative posture on the retinal shift after retinal detachment repair. METHODS: Patients who underwent pars plana vitrectomy (PPV) for macula-off rhegmatogenous retinal detachment (RRD) were included prospectively in the current study. Patients were randomized into two groups: group A included patients who did a log roll postoperatively, and group B included patients who had to lie flat on their backs for 6 h postoperatively before moving into the end position. Patients in group A and patients in group B were reviewed after 3 weeks and after 6 weeks, respectively, and fundus autofluorescence images (FAF) were obtained to visualize the retinal rotation. RESULTS: The sample included 50 eyes from 49 patients. Retinal shift occurred after RRD repair in 17 patients (34%). There was no statistically significant difference between the two groups (p = 0.94). Postoperative macular shift occurred significantly less often (p = 0.049) in participants in whom heavy fluid was used in the procedure. Metamorphopsia was reported postoperatively by 10 of 17 patients with retinal shift (p < 0.001). CONCLUSION: In our study, postoperative posture did not significantly influence postoperative macular slippage after RRD repair. The use of intraoperative heavy liquid appears to be associated with a lower occurrence of retinal shift.

Outcomes after Epiretinal Membrane Surgery with or Without Internal Limiting Membrane Peeling.

INTRODUCTION: The aim of this study was to assess the incidence of persistent postoperative cystoid macular edema (pCME) in patients undergoing pars plana vitrectomy with epiretinal membrane peel (ERM) only versus those with ERM peel combined with internal limiting membrane peel (ILM). Secondary endpoints of the study were to review both the central macular thickness (CMT) and visual acuity. METHODS: The patients were divided in two groups, one group in which only the ERM was peeled (n = 36 patients) and another group in which both the ERM and the ILM were removed (n = 62 patients). The results were analyzed retrospectively. Each patient received a complete ophthalmological examination, including best-corrected visual acuity (BCVA) using an ETDRS chart and spectral domain optical coherence tomography, at three time points: prior to surgery and 3 weeks and 3 months after surgery. RESULTS: A total 98 eyes of 98 patients were included in this study. The mean follow-up time was 7.7 months. CMT decreased significantly after surgery in all patients, and none of these changes differed significantly between the two groups. The BCVA increased significantly after surgery across all patients, and there were no significant changes between the two treatment groups. Postoperative pCME occurred in eight patients in each group, representing 22.2% of the 36 patients in the ERM only group and 12.9% of the 62 patients in the ERM/ILM peel group. However, this difference was not statistically significant. CONCLUSIONS: No difference was found between the two groups in terms of incidence of pCME. Both groups experienced had similar decrease in the CMT and improvement in the BCVA postoperatively.

First experience with Oasis Collagen SOFT SHIELD® for epithelial defect after corneal cross-linking.

BACKGROUND: To investigate response of dissolving collagen contact lenses as an alternative for bandage contact lenses, for the post-interventional care of epithelial defects after corneal cross-linking (CXL) treatment for keratoconus. PATIENTS AND METHODS: Follow-up visits were performed at day 1, 4 and 1 month after the intervention. We reviewed notes for re-epithelialization, comfort/pain and any untoward effects of Collagen SOFT SHIELD®. Assessment included visual acuity (VA), refraction (SE); corneal haze, epithelial erosion and pain status were assessed subjectively on a 4-point scale, from 0 (none) to 3 (severe). RESULTS: Thirty consecutive CXL patients with collagen shield application after CXL were included. Mean age was 28 years (range from 16 to 51 years old). Pre-CXL VA was 0.7 logMAR IQR 0.4-1.0; post-CXL VA at day 4 and month 1 was 0.6 logMAR IQR 0.4-0.9. Post-operative mean SE was 5.5D ± 4.1D. In all patients, the Collagen SOFT SHIELD® was completely dissolved at the 4-day follow-up visit. In most cases, epithelial defect was closed at day 4, on average 0.8 ± 0.5 days post-intervention; all epithelial defects were closed by month 1. Haze was minimal (mean haze score 1.4 ± 0.7 at day 4 and 1.0 ± 0.6 at 1 month). No adverse effects such as infection were observed. CONCLUSIONS: This study indicates that Oasis Collagen SOFT SHIELD® is valuable and safe alternative to standard bandage contact lens for the treatment of epithelial defects. This outcome may be of particular interest in patients where the contact lens removal is likely to be problematic.

[Clinical Outcomes after Keraring Implantation for Keratoconus Management in Thin Corneas]. / Klinische Ergebnisse nach Keraring-Implantation zur Behandlung von Keratokonuspatienten mit sehr dünnen Hornhäuten.

BACKGROUND: The aim of our study was to evaluate the clinical outcomes after Keraring implantation for keratoconus in patients with thin corneas. PATIENTS AND METHODS: Ten eyes from 10 patients with keratoconus, who underwent femtosecond laser-assisted Keraring implantation for keratoconus, were included in this retrospective study. Uncorrected visual acuity (UCVA), corrected visual acuity (CDVA), keratometric readings, central corneal thickness and thinnest corneal pachymetry have been evaluated preoperatively and 6 months after the Keraring implantation. RESULTS: UCVA, BCVA and keratometric readings improved at 6 months postoperatively. CONCLUSIONS: Our data showed significant keratometric amelioration and visual improvement after Keraring implantation for keratoconus in patients with thin corneas at 6 months postoperatively.

12-Year Outcomes of Microkeratome-Assisted Anterior Lamellar Therapeutic Keratoplasty (ALTK) for Disorders of the Anterior Part of the Corneal Stroma - A Comparative Review of Adult and Children.

PURPOSE: To report the visual outcomes and complications of automated anterior lamellar therapeutic keratoplasty (ALTK) in adults and children, and to examine these outcomes as a function of age and etiology. METHODS: A consecutive series of cases undergoing automated ALTK procedures performed at the Jules-Gonin Eye Hospital Lausanne, Switzerland, between June 2003 and January 2015. Only patients with at least 3 months of follow-up were included. RESULTS: There were 53 eyes (24 right) of 51 patients (17 female, 16 juvenile), with a mean age of 34.8 years (range from 3 months to 88 years), analyzed. The mean follow-up was 35 (± 26) months. Diagnosis in the adult (n = 37) vs. juvenile (n = 16) eyes was different: opacity following surgical complication 8 vs. 0, congenital 1 vs. 1, dystrophy 5 vs. 2, infection 12 vs. 5, keratectasia 3 vs. 0, trauma 7 vs. 0, tumor 1 vs. 3, and allergy 0 vs. 5. Visual impairment as a consequence of corneal scarring was the principle indication for surgery in both adult (70%; 26) and juvenile eyes (63%; 10); other indications were choristoma, dermoid, other tumors, astigmatism, and congenital opacity. In adult vs. juvenile eyes, the mean visual acuity (spectacle and contact lenses) was, at last visit, 0.55 vs. 0.45 LogMAR (p = 0.78), with a range of 100% to hand movements. Failure occurred in 6 (16%) vs. 2 (13%) cases and complications were observed in 14 (38%) vs. 9 (56%) cases, however, more surgical revision was required in juvenile eyes, 4 (11%) vs. 7 (43%) (p = 0.01, Fisher test). CONCLUSIONS: This study shows that anterior lamellar keratoplasty in children retains good visual function when combined with adequate amblyopic therapy. However, the rate of complications is higher in juveniles and requires more intensive interdisciplinary follow-up.

Clinical Outcomes after Keraring Implantation for Keratoconus Management in Patients Older Than 40 Years: A Retrospective, Interventional, Cohort Study.

BACKGROUND: Intracorneal ring segment implantation is an effective and safe method of visual improvement in patients with keratoconus. The aim of our study was to evaluate the long-term clinical outcomes after Keraring implantation for keratoconus in patients older than 40 years. METHODS: Eleven eyes from 11 patients with keratoconus who underwent femtosecond laser-assisted Keraring implantation for keratoconus were included in this retrospective study. The uncorrected visual acuity (UCVA), corrected visual acuity, keratometric readings, central corneal thickness and thinnest corneal pachymetry were evaluated preoperatively and 6 months after the Keraring implantation. RESULTS: UCVA, BCVA and keratometric readings improved at 6 months postoperatively. CONCLUSION: Our data showed significant keratometric amelioration and visual improvement after Keraring implantation for keratoconus in patients older than 40 years at 6 months postoperatively.

Identifying more reliable parameters for the detection of change during the follow-up of mild to moderate keratoconus patients.

BACKGROUND: Reaching a consensus on which parameters are most reliable at detecting progressive keratoconus patients with serial topography imaging is not evident. The aim of the study was to isolate the parameters best positioned to detect keratoconus progression using the Pentacam HR® measures based on the respective limits of repeatability and range of measurement. METHOD: Using the Pentacam HR®, a tolerance index was calculated on anterior segment parameters in healthy and keratoconic eyes. The tolerance index provides a scale from least to most affected parameters in terms of measurement noise relative to that observed in healthy eyes. Then, based on the "number of increments" from no disease to advanced disease, a relative utility (RU) score was also calculated. RU values close to 1 indicate parameters best positioned to detect a change in keratoconic eyes. RESULTS: The tolerance index values indicated that 36% of ocular parameters for keratoconic eyes had repeatability limits which were wider than normative limits (worse), but 28% of the ocular parameters were narrower than normative limits (better). Considering only those parameters with a RU greater than 0.95, a small number of parameters were within this range, such as corneal curvature and asphericity indices. CONCLUSIONS: This study demonstrates that measurement error in keratoconic eyes is significantly greater than healthy eyes. Indices implemented here provide guidance on the levels of expected precision in keratoconic eyes relative to healthy eyes to aid clinicians in distinguishing real change from noise. Importantly maximal keratometry (Kmax), central corneal thickness (CCT) and thinnest corneal thickness (TCT) were highlighted as problematic indices for the follow-up of keratoconus in terms of repeatability.

Refractive outcomes and complications after combined copolymer phakic intraocular lens explantation and phacoemulsification with intraocular lens implantation.

PURPOSE: To assess safety, efficacy, and predictability of combined Implantable Collamer Lens phakic intraocular lens (pIOL) explantation and phacoemulsification and to report the rate of complications. A secondary aim was to examine whether intraocular lens (IOL) power calculation was affected by the pIOL in situ. SETTING: Jules-Gonin Eye Hospital, Lausanne, Switzerland. DESIGN: Retrospective case series. METHODS: The records of patients having pIOL implantation with subsequent phacoemulsification were reviewed. Data analysis was performed between July 1, 2015, and December 31, 2015. The mean corrected distance visual acuity (CDVA), safety, stability of refraction, predictability of IOL power calculation, and postoperative complications were recorded. RESULTS: The study comprised 38 eyes (29 patients). Of the eyes, 32 (82%) were within ±1.00 diopter (D) of the target refraction and 21 (57.9%) were within ±0.50 D. The mean CDVA after IOL implantation was significantly better than before pIOL implantation (P < .001) and similar to after pIOL implantation (P = .87). The safety of this multistepped procedure was good; on average, 1.6 Snellen lines of CDVA were gained over before pIOL implantation. Branch retinal vein occlusion occurred in 1 eye; no other sight-threatening complications were observed. Posterior capsule opacification developed in 15 eyes (39.5%) and was treated successfully with neodymium:YAG capsulotomy. CONCLUSIONS: The highest mean CDVA was recorded at the final visit. Good safety, stability, and predictability were also observed. Postoperative complications were few and in all but 1 case, not sight threatening. Overall, results indicate the combination of procedures does not negatively affect the final visual outcome.