Are there sex-based disparities in cataract surgery?

AIM: To investigate sex-based differences in the occurrence of intra-operative and post-operative complications and associated visual outcomes following cataract surgery. METHODS: This was a retrospective study of patients who had phacoemulsification cataract surgery at the University of Colorado School of Medicine. Data collected included the patient's health history, ocular comorbidities, operative and post-operative complications, and the post-operative best corrected visual acuity (BCVA). The data were analyzed using univariate and multivariable logistic regression with generalized estimating equations to account for the correlation of some patients having two eyes included in the study. RESULTS: A total of 11 977 eyes from 7253 patients were included in the study. Ocular comorbidities differed by sex, with males having significantly higher percentages of traumatic cataracts (males 0.7% vs females 0.1%), prior ocular surgery (6.7% vs 5.5%), and mature cataracts (2.8% vs 1.9%). Conversely, females had significantly higher rates of pseudoexfoliation (2.0% vs 3.2%). In unadjusted analysis, males had higher rates of posterior capsular rupture (0.8% vs 0.4%) and vitreous loss (1.0% vs 0.6%), but this difference was not significant after adjustment for confounders. Males had a significantly increased risk of post-operative retinal detachment, but in multivariable analysis this was no longer significant. Males were significantly less likely to undergo post-operative neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy for posterior capsule opacification (OR=0.8, 95%CI=0.7-0.9, P=0.0005). The BCVA was slightly worse for males pre-operatively; but post-operatively, both sexes exhibited similar visual acuity of Snellen equivalent 20/25. CONCLUSION: The study finds that in a cohort of patients presenting for cataract surgery, sex differences exist in pre-operative comorbidities and surgical characteristics that contribute to higher rates of some complications for males. However, observed surgical complication rates exhibit almost no difference by sex after adjusting for pre-operative differences and post-operative BCVA is similar between sexes.

Comparison of the Modified Jones Tube Technique and the DMEK EndoGlide Technique With and Without Viscoelastic Material for DMEK Tissue Preparation.

PURPOSE: The aim of this study was to compare endothelial cell loss for DMEK (Descemet membrane endothelial keratoplasty) tissue preparation techniques using the modified Jones tube and the DMEK EndoGlide with and without viscoelastic material to protect the endothelium. METHODS: This ex vivo study included 10 DMEK grafts prepared using each of the 3 abovementioned techniques. After tissue preparation, transport conditions were simulated for a minimum of 45 hours before deployment of the DMEK tissue and quantification of endothelial cell loss. Comparisons between preparation technique groups were made using the Wilcoxon rank-sum test. RESULTS: The Jones tube group had a mean endothelial cell loss of 11.0 ± 4.8% compared with the EndoGlide group with 12.9 ± 6.7% and the EndoGlide with viscoelastic group with 25.7 ± 15.0%. The differences between the EndoGlide with viscoelastic group and the other 2 were statistically significant both before (P < 0.01 and P = 0.01) and after (P = 0.01 and P = 0.02) adjusting for baseline characteristics. The difference between the EndoGlide and Jones tube groups was not significant (P = 0.73 and P = 0.53 after adjustment). Microscopy revealed endothelial cell loss in the area of viscoelastic use for the EndoGlide with viscoelastic group. CONCLUSIONS: Both the Jones tube and DMEK EndoGlide resulted in similar low rates of endothelial cell loss after tissue preparation, transport, and deployment. However, use of viscoelastic material to protect the endothelium using the DMEK technique actually resulted in increased cell loss in the area of its application resulting in overall higher rates of cell loss across the DMEK tissue.

Time Utilization and Refractive Prediction Enhancement Associated with Intraoperative Aberrometry Use During Cataract Surgery.

PURPOSE: To evaluate the time cost of intraoperative aberrometry (IA), to compare IA prediction error to the prediction error associated with conventional formulas using preoperative calculations (PC) and evaluate when IA provides clinically relevant benefit. METHODS: This is a retrospective study of eyes that underwent cataract phacoemulsification surgery with IA at an academic eye center. IA versus PC prediction error were compared amongst various preoperative and intraoperative characteristics. Additionally, a dichotomous variable indicating clinically relevant benefit of IA, where IA absolute prediction error was less than 0.5D and PC absolute prediction error greater than 0.5D, was associated with clinical factors. RESULTS: Five hundred eyes of 341 patients were included in the analysis. The quantitative difference between mean absolute prediction errors for IA versus PC was between 0.0D and 0.03D in most subgroups. For the 11.0% of eyes that had clinically relevant benefit to IA, the multivariable model identified the following strongest predictors: prior myopic corneal refractive surgery (Odds ratio (OR) 3.9, p<0.01 for myopic LASIK/PRK, OR 5.5, p=0.01 for radial keratotomy), toric or multifocal/EDOF lens implantation (OR 2.7, p=0.03 for toric monofocal lenses, OR 3.1, p=0.01 for EDOF/multifocal lenses), and short and long axial lengths (p<0.01). On average, IA implementation added 3.0 minutes to surgery (p<0.01). CONCLUSION: For greatest likelihood of a clinically meaningful improvement in outcomes despite increased surgical time, surgeons and patients should consider using IA for eyes with extremes in axial length, eyes with prior myopic corneal refractive surgery, or when implanting lenses with toric or extended-depth-of-focus/multifocal properties.

Accuracy of Intraoperative Aberrometry, Barrett True-K With and Without Posterior Cornea Measurements, Shammas-PL, and Haigis-L Formulas After Myopic Refractive Surgery.

PURPOSE: To assess the accuracy of intraoperative aberrometry, the Barrett True-K No History (Barrett TKNH), Barrett TKNH with posterior corneal measurements (Barrett TKNH with PC), Shammas-PL, and Haigis-L formulas in patients with cataract who had prior myopic refractive surgery. METHODS: This was a retrospective consecutive case series of patients with prior myopic refractive surgery undergoing cataract extraction. Mean absolute error (MAE) and median absolute error (MedAE) of refraction prediction were compared for each formula. Interactions of each biometry measurement were modeled for each formula to evaluate those with the most significant impact on refraction prediction. RESULTS: One hundred sixteen eyes of 79 patients were analyzed. MAE was 0.40 ± 0.33 diopters (D) for intraoperative aberrometry and 0.42 ± 0.31 D for the Barrett TKNH, 0.38 ± 0.30 D for the Barrett TKNH with PC, 0.47 ± 0.38 D for the Shammas-PL, and 0.56 ± 0.39 D for the Haigis-L formulas. Comparisons between formulas were significant for Barrett TKNH versus Barrett TKNH with PC formulas (P = .046), Barrett TKNH with PC versus Shammas-PL formulas (P = .023), and for all comparisons with the Haigis-L formula (P < .001), and not significant for all other comparisons (P > .05). Eyes were within ±0.50 D of prediction 73%, 72%, 69%, 62%, and 52% of the time for intraoperative aberrometry, the Barrett TKNH with PC, Barrett TKNH, Shammas-PL, and Haigis-L formulas, respectively. Corneal asphericity (Q value) was significantly associated with prediction error for all five methods. Changes in anterior chamber depth had a significant impact on Shammas-PL prediction errors. CONCLUSIONS: Newer technology using information from the posterior cornea modestly improved outcomes when compared to established methods for intraocular lens selection in eyes that had previous laser refractive surgery for myopia. [J Refract Surg. 2021;37(1):60-68.].

Posterior Capsule Rupture during Cataract Surgery in Eyes Receiving Intravitreal anti-VEGF Injections.

PURPOSE: To examine the risk of posterior capsule rupture (PCR) during phacoemulsification cataract surgery in patients who received intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections prior to surgery. METHODS: A retrospective study was conducted of cataract surgeries at the Sue Anschutz-Rodgers UCHealth Eye Center from January 1, 2014, through December 31, 2018. The primary outcome was the occurrence of PCR during surgery. Other variables of interest included age, race, sex, ocular comorbidities, diabetes, mature cataract, primary surgeon, injection frequency and type, and date of most recent injection. Predictors of PCR were assessed using logistic regression with generalized estimating equations to account for correlation between patient eyes. Additional sub-analysis was performed on eyes with PCR with and without anti-VEGF injection history to compare intraoperative characteristics, post-operative complications, and visual outcomes. RESULTS: In total 10,327 cataract surgeries were included in the analysis, and 308 of these eyes received anti-VEGF injections prior to surgery. Of the 308 eyes that received anti-VEGF injections, eight (2.6%) had a PCR during surgery compared to 45 of 10,019 eyes (0.5%) that did not receive injections (unadjusted OR = 5.9, 95% CI: 2.8-12.7, p < .0001). Males and diabetics were more likely to have received injections and had higher rates of PCR, so these variables were adjusted for in the multivariate analysis of the association between injections and PCR (adjusted OR = 4.7, 95% CI: 2.1-10.4, p-value = 0.0001). Eyes with mature cataracts and those that underwent surgery with a resident as the primary surgeon were also at higher risk of PCR, but these variables were not associated with the anti-VEGF injection. Injection frequency, time between most recent injection and surgery, and type of anti-VEGF agent were not significantly associated with PCR. CONCLUSIONS: History of intravitreal anti-VEGF injections was associated with higher odds of PCR during cataract surgery.

Association of Federal Regulations in the United States and Canada With Potential Corneal Donation by Men Who Have Sex With Men.

Importance: Federal policy in the United States prohibits corneal donation by men who have had sex with another man (MSM) in the preceding 5 years, whereas Canada enforces a 12-month ban. The potential consequences of these policies on corneal donations should be evaluated. Objective: To estimate the number of potential corneal donations associated with MSM deferral policies in the United States and Canada. Design, Setting, and Participants: A nonvalidated telephone survey study was conducted of all 65 eye banks in the United States and Canada to investigate how many potential corneal donors were disqualified in 2018 because of federal MSM restrictions. Published demographic data were also used to arrive at a separate estimate. Survey data were gathered from May 2019 to February 2020. Main Outcomes and Measures: Eye banks were asked if they keep records of referrals disqualified specifically because of the federal MSM restrictions and, if so, how many referrals they disqualified in 2018 owing to MSM status. Results: Fifty-four of 65 eye banks (83%) responded to the survey, with 30 eye banks reporting they do not keep specific records of MSM deferrals. The remaining 24 eye banks reported disqualifying 360 referrals in 2018 because of MSM status, equating to 720 corneas. The 24 eye banks accounted for 46.2% of corneal donations in the United States and Canada in 2018, yielding an estimate of approximately 1558 corneas rejected that year because of MSM status. A separate estimate using published MSM demographic data indicates that up to 3217 potential corneal donations may have been disqualified in 2018 because of these federal policies. Conclusions and Relevance: Findings suggest that between 1558 and 3217 corneal donations were disqualified in 2018 because of federal regulations prohibiting corneal donation by men who have had sex with another man in the preceding 5 years in the United States or 1 year in Canada. With modern virologic testing that is reliable within days of HIV exposure and given the global shortage of corneal tissue, these policies should be reevaluated using current scientific evidence to increase the availability of vision-restoring surgery worldwide.

What Is the Cost of a Posterior Capsule Rupture Complication?

BACKGROUND AND OBJECTIVE: To examine the cost of a posterior capsule rupture (PCR) in patients who underwent planned phacoemulsification. PATIENTS AND METHODS: Retrospective review of 8,113 cataract surgeries performed between January 2014 and December 2017 at one academic institution. The rate of PCR was 0.55%, and 34 patients with PCR who met inclusion criteria were identified. Investigators evaluated the added operating room time required to manage PCR, subsequent surgeon visits beyond the typical average, referrals to other specialties, further imaging, and additional required surgeries. RESULTS: Patients with PCR had an additional 2.76 (standard deviation [SD] ± 3.27) postoperative encounters and 3.06 (SD ± 3.78) visits to another subspecialty. Operating room time was found to average 61.43 minutes (range: 21 to 191 minutes) at an additional cost of $455.48 (SD ± $407.37). Additional visits, imaging, and procedures added $655.59 (SD ± $767.21). The total additional average cost was $1,111.07 (SD ± $1,021.20) per PCR. CONCLUSION: Posterior capsular ruptures impose a substantial cost burden on the health care system. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:444-447.].

Keratoconus and corneal morphology in patients with Down syndrome at a pediatric hospital.

PURPOSE: To evaluate patients with Down syndrome for keratoconus and corneal abnormalities using Scheimpflug imaging (Pentacam HR) in a pediatric setting. METHODS: The Pentacam scans of patients with Down syndrome seen at Children's Hospital Colorado Ophthalmology Department were reviewed retrospectively, and the following data were collected: keratometry values, pachymetry values, components of the Belin ABCD Grading System, the Belin/Ambrosio enhanced ectasia display D value, and topometric indices, including ISV, IVA, and KI. Subjective interpretation was used to classify scans as normal, abnormal, keratoconus suspect, and definite keratoconus. RESULTS: A total of 56 eyes of 31 patients aged 4-24 years (mean, 12.4) were included. The average value for K1 was 44.95 ± 1.73 D (range, 40.90-49.3 D); for K2, 46.87 ± 2.16 D (range, 42.50-51.80 D); for Kmax, 48.20 ± 3.11 D (range, 43-61.7 D); and for Kmean, 45.81 ± 1.85 D (range, 41.7-50.35 D). Mean pachymetry at the thinnest point was 509 ± 44.24 µm (range, 410-612 µm) and at the apex was 519 ± 44.24 µm (range, 412-646 µm). The mean D value was 2.08 ± 1.57 (range, 0.08-9.71). There were 10 patients (32%) with either keratoconus suspect or definite keratoconus in at least one eye. CONCLUSIONS: We found a high frequency of keratoconus and keratoconus suspect in pediatric and young adult patients with Down syndrome. The corneas in this population had steeper K values and thinner pachymetry values compared to previously reported controls.

Comparison of Visual Outcomes of Extended Depth of Focus Lenses in Patients With and Without Previous Laser Refractive Surgery.

PURPOSE: To compare visual outcomes of eyes with and without previous laser refractive surgery that received an extended depth of focus intraocular lens during cataract surgery. METHODS: This was a retrospective review of all eyes implanted with an extended depth of focus intraocular lens by two surgeons. Preoperative demographic and eye examination information were collected, as well as postoperative refraction, uncorrected distance visual acuity, and Visual Function Index (VF-14) questionnaire responses. Medical records were reviewed postoperatively to collect the number of patients who required a refractive touch-up or lens exchange. RESULTS: Most patient eyes (187 of 215, 87%) had no prior refractive surgery, and there was no significant difference in preoperative characteristics between this group and the 28 eyes that did have previous laser refractive surgery. Postoperatively, most patients had a refractive error within ±0.50 diopters (D) (79% without vs 77% with previous laser refractive surgery, P = .40). Although more patients in the group without previous laser refractive surgery achieved 20/20 uncorrected distance visual acuity (UDVA) (56.8% versus 28.6%, P = .01), the majority in both groups achieved 20/25 or better UDVA (79.5% versus 85.7% for without versus with previous laser refractive surgery, P = .42). Postoperative subjective visual function score was also similar between the two groups as measured by the VF-14 questionnaire (86.9 vs 79.4, P = .15). Few patients required refractive surgery enhancement in either group (9 of 187 (4.8%) versus 1 of 28 (3.6%) for without versus with previous laser refractive surgery, P = .77). CONCLUSIONS: The data suggest that extended depth of focus lens implantation can have successful results for patients with prior laser refractive surgery. [J Refract Surg. 2020;36(1):28-33.].

One-day postoperative intraocular pressure spikes after phacoemulsification cataract surgery in patients taking tamsulosin.

PURPOSE: To evaluate the relationship between 1-day postoperative intraocular pressure (IOP) after phacoemulsification cataract surgery and tamsulosin use. SETTING: University of Colorado Health Eye Center, Aurora, Colorado, USA. DESIGN: Retrospective cohort study. METHODS: Registry data from men who had cataract surgery were used. Patients taking tamsulosin at the time of surgery were included as cases, while patients with no history of tamsulosin use were used as controls. The primary outcome was a 1-day postoperative IOP spike defined as an IOP increase greater than 10 mm Hg compared with baseline or a 1-day postoperative IOP of 30 mm Hg or higher. General estimating equations were used for analysis. RESULTS: The study comprised 584 men (864 eyes). An IOP increase greater than 10 mm Hg or IOP 30 mm Hg or higher after cataract surgery occurred in 12.4% and 9.3%, respectively, of eyes in the tamsulosin group versus 4.4% and 2.1%, respectively, in the control group (all P = .001). After adjusting for significant covariates, patients on tamsulosin were 2.6 times (95% confidence interval [CI], 1.2-5.7; P = .01] and 3.8 (95% CI, 1.3-10.9; P = .01) more likely to have a 1-day postoperative IOP increase greater than 10 mm Hg or a 1-day postoperative IOP of 30 mm Hg or higher. CONCLUSION: Patients on tamsulosin had an increased risk of a 1-day postoperative IOP spike after cataract surgery, showing the importance of identifying patients on tamsulosin preoperatively to better manage and potentially mitigate IOP spikes. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Continuous Curvilinear Capsulorhexis Performed With the VERUS Ophthalmic Caliper.

PURPOSE: To compare size, circularity, and centration outcomes of continuous curvilinear capsulorhexis (CCC) performed with or without assistance from the VERUS ophthalmic caliper (Mile High Ophthalmics, Denver, CO). METHODS: This was a multicenter retrospective consecutive case controlled series review. RESULTS: Data from 40 consecutive cases using the VERUS device for CCC were compared to 40 consecutive cases with standard manual CCC. VERUS-assisted CCC size, circularity, and centration were closer to target compared to that of manual only procedures (P < .05). The average time from initiation to completion of the capsulotomy was shorter with manual (40 ± 11 seconds) compared to VERUS-assisted (71 ± 13 seconds) cases (P < .0001). CONCLUSIONS: The VERUS ophthalmic caliper is effective at improving size, circularity, and centration of the CCC in a time-efficient manner when compared to manual procedures performed without VERUS guidance. [J Refract Surg. 2016;32(10):654-658.].

Femtosecond laser-assisted cataract surgery in complex cases.

PURPOSE: To describe the use of the femtosecond laser in complex cataract cases. SETTING: Department of Ophthalmology, University of Colorado, Aurora, Colorado, USA. DESIGN: Retrospective case series. METHODS: This was a single-center retrospective review of consecutive complex cataract surgery cases in which the Lensx femtosecond laser was used between October 2012 and February 2015. Complex cases were defined as white cataracts, dense brunescent cataracts, or cataracts in which zonulopathy was identified preoperatively. Outcome measures included an assessment of the capsulotomy, surgical complications, and postoperative corrected distance visual acuity (CDVA). RESULTS: Thirty-four eyes of 34 patients were included in this study; 27 had white cataract, 3 had dense brunescent cataract, and 6 had zonulopathy (2 of these also had white cataract). Three patients had an incomplete capsulotomy, and 3 had small radial tears in the anterior capsule. Four patients (11.7%) developed posterior capsule tears during phacoemulsification; 1 of these subsequently had pars plana vitrectomy for a retained lens fragment. Twenty-eight (97%) of 29 patients had a postoperative CDVA of 20/40 or better. Three patients were identified with comorbidities that limited postoperative CDVA. One patient developed postoperative cystoid macular edema. CONCLUSION: The femtosecond laser was useful in the surgical approach to patients with complex cataracts, especially for the creation of the capsulotomy. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Time and cost of teaching cataract surgery.

PURPOSE: To compare the differences in the time of completion of cataract surgery for residents and attending surgeons and to assign a dollar cost. SETTING: University of Colorado teaching hospital, Aurora, Colorado, USA. DESIGN: Comparative case series. METHODS: Cataract cases were divided into 3 levels of difficulty for comparison. Main outcome measures were total case time (incision to patch) and degree of difficulty. RESULTS: Nine residents and 6 attending surgeons participated in the study. Case times were collected for 324 resident cases and 319 attending surgeon cases. The mean attending surgeon case time was 25.75 minutes ± 12.32 (SD) and the mean resident case time, 46.35 ± 16.75 minutes. There was no significant difference in the degree of difficulty between resident cases and attending surgeon cases. Approximately 600 total cases were performed by 4 residents during 3 years of residency training. Taking into account the mean time of case completion for attending surgeons versus residents, the total difference in time if attending surgeons had performed 600 cataracts would be 12,360 minutes. Using a dollar cost of approximately $11.24 per minute at the institution, the cost difference was calculated to be $138,926.40. CONCLUSION: There was a significant time and dollar cost incurred in teaching cataract surgery. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Descemet-stripping automated endothelial keratoplasty donor tissue preparation using the double-pass microkeratome technique.

PURPOSE: To compare human donor corneal lenticule thickness, endothelial cell viability, area of cell damage, and cell counts between corneal tissue prepared with a double-pass microkeratome cut versus the standard single-pass microkeratome cut. SETTING: University of Colorado Teaching Hospital, Aurora, Colorado, USA. DESIGN: Experimental study. METHODS: Eleven matched pairs of human donor corneas unfit for transplantation were used for analysis. Tissue was prepared using a Moria CB microkeratome and artificial anterior chamber. One cornea was prepared using the standard single-pass cut; the second cornea was prepared with a double-pass technique. Visante optical coherence tomography images were obtained from each cornea, and central and peripheral thickness measurements were made. The tissue was also stained with trypan blue and alizarin red to assess tissue damage from preparation. RESULTS: The mean central thickness measurement was 92 µm ± 20 (SD) for the double-pass technique and 126 ± 34 µm for the single-pass technique. The area of cell damage after preparation was not significantly different between the 2 methods; however, there was a statistically significant increase in the ratio of nonviable to viable cells for the double-pass technique. CONCLUSION: The double-pass microkeratome technique for donor preparation resulted in a thinner lenticule than a single-pass technique and an increase in endothelial cell damage.

Characterizing the learning curve in phacoemulsification.

PURPOSE: To characterize how residents learn phacoemulsification and determine which steps of the procedure are most difficult to master. SETTING: University of Colorado Hospital, Aurora, Colorado, USA. DESIGN: Comparative case series. METHODS: Cataract cases were divided into 3 levels of difficulty for comparison. Residents were given a grade for each step of the procedure by the attending surgeon. Main outcome measures were total case time and a proficiency grade. Independent variables were level of resident experience and degree of difficulty. Case times of attending cases were collected for comparison. RESULTS: Nine residents were evaluated by 4 attending surgeons while performing 324 cases of phacoemulsification. Case times of 319 attending cases were used for comparison. The easiest-to-learn steps (highest scores versus level of experience) included intraocular lens insertion, ophthalmic viscosurgical device removal, hydrodissection, and nucleus sculpting. Wound integrity, nucleus disassembly and removal, cortex removal, and capsulorhexis had the lowest scores versus level of experience. Resident case times decreased significantly with experience, approaching average case times for attendings. CONCLUSIONS: For this study, competency was defined as the ability of the resident to perform a case in a reasonable time without intervention or complication. Using this definition, competency was achieved when case experience exceeded 75 cataract surgeries. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.