The impact of COVID-19 lockdown on cataract surgery: a surgeons' perspective.

CLINICAL RELEVANCE: In the last months, the whole world is dealing with an unprecedented public health crisis due to COVID-19 outbreak. Consequently, many governments have implemented lockdowns on a national level, affecting, among others, ophthalmic surgical practice in a globe scale. BACKGROUND: The aim of this study is to evaluate the impact of surgical theatre lockdown due to COVID-19 pandemic on the surgical performance of cataract surgeons. METHODS: Intraoperative complications and surgical time of the first 160 cataract surgeries performed by eight consultants (20 cases each) after a two-month lockdown were recorded and analysed in a cross-sectional study. The results were plotted against the last 30 cases of each surgeon before the implementation of the lockdown (240 cases). Cataract surgeons were asked to rate their subjective perspective and difficulties faced after re-opening through a questionnaire. RESULTS: The average duration of all surgeries after the lockdown was 19.1 ± 6.2 minutes showing a 14% increase compared to the one before the lockdown (16.8 ± 5.1 minutes, p = 0.0001). The complications rate was 2.09% (5/240 cases) before the abstention and 3.12% (5/160 cases) after the abstention not yielding any statistically significant difference (p = 0.74). When complicated surgeries were excluded from the analysis, surgical time was still higher after the lockdown (18.9 ± 5.9 minutes) than before (16.6 ± 5.0 minutes, p < 0.0001). 37.5% of consultants (3/8) stated that the two-month abstention from cataract surgeries has affected their surgical skills somewhat or a lot, while 62.5% (5/8) reported being more careful in their first cases after the lockdown. Most complications occurred in the hands of one surgeon who stated to be very anxious upon restart. CONCLUSION: The operating theatres' lockdown due to COVID-19 pandemic did not seem to affect the intraoperative complications rate in cataract surgery. A slight increase of surgical duration was noted, while most surgeons reported being more careful upon restart.

Peri-Operative Intracameral Antibiotics: The Perfect Storm?

In our University journal club we discussed a large, retrospective study of cataract surgery endophthalmitis rates before and after instituting the use of an intracameral fluoroquinolone antibiotic. We identified several factors involved in the use of off-label, compounded moxifloxacin in intraocular surgery. The introduction of phacoemulsification for cataract surgery led to the potential for smaller incisions. Intraocular lens technology improved to allow for foldable lenses, obviating the requirement to enlarge the incision. This allowed for clear corneal incisions, which unfortunately allow bidirectional passage of liquid. Preservatives were introduced into multi-dose ophthalmic products in the mid 20th century to retard microbial growth. However, more recently, chronic use of benzalkonium chloride has led to concerns about concerns about conjunctival toxicity, especially in patients with ocular surface disease. In the formulation of ocular moxifloxacin, developers were able to develop a "self-preserved", multi-dose product. Other concerns with eyedrops include varying levels of adherence and performance, and the expansion of compounding pharmacies from a named-patient basis to widespread national delivery, with concerns for lower quality. Integrating these factors, use of intracameral moxifloxacin as a prophylactic during cataract and other anterior segment surgery has become a standard of care in much of the U.S. We are concerned that the current position is on a narrow ledge-the standard of care for millions of surgeries each year based upon off-label, compounting use of a single product. We discuss possible ramifications and solutions to this public health issue.

Lack of recall after sedation for cataract surgery and its effect on the validity of measuring patient satisfaction.

BACKGROUND: We evaluated the validity of assessing patient satisfaction with the sedation regimen among patients being discharged 45 min after receiving midazolam. If most patients do not have recall, then the sedation cannot be considered complete at the time of evaluation. METHODS: In this prospective cohort study, 20 patients underwent cataract surgery with nurse-administered midazolam and fentanyl. The 11-item Iowa Satisfaction with Anesthesia Scale was administered  30 min after sedation in the recovery room. Recalled items were evaluated the next morning. RESULTS: Eleven patients recalled 0 themes, 4 recalled 1, 4 recalled 2, and 1 recalled 3 themes. Thus, 15/20 patients (75%) recalled 0 or 1 of the 11 themes (P = 0.021 versus half the patients). The 95% one-sided lower confidence limit for 0, 1, or 2 themes was 80% of patients (P < 0.001 versus half). Patients who received less midazolam recalled more themes (Kendall's τb = 0.43, P = 0.039). CONCLUSIONS: Evaluating patient satisfaction with sedation shortly after admission to the post-anesthesia care unit is invalid because of a lack of recall; the sedation/amnesia is ongoing. Patient comfort may be assessed, but comfort is not synonymous with satisfaction; 'satisfaction' implies presence of recall. Because we studied sedation with low doses of midazolam and fentanyl, the same conclusion reliably would apply to larger doses of anxiolytics administered intraoperatively. The results match previous findings that when patients receive preoperative midazolam prior to meeting the anesthesiologist, even if the patient fully answers questions, they may have negligible recall of having met the anesthesiologist.

Color vision in sight recovery individuals.

BACKGROUND: Color vision has been consistently shown to be unaffected in animals that are raised in dark or in color-deprived environments. However, there are only a few studies that directly addressed the effect of congenital visual deprivation in color perception in humans. OBJECTIVE: The goal of the current study was to assess the effect of congenital visual deprivation on color vision using a panel based color arrangement test. METHODS: We investigated the recovery of color vision using the Farnsworth D15 test in a group of individuals who had experienced visual deprivation since birth due to bilateral dense congenital cataracts before undergoing cataract-reversal surgery (Congenital cataract, CC, n = 12). In addition, we tested two groups of control participants: (1) individuals who had had non-dense congenital cataract or developed cataract later in their childhood (Developmental cataract, DC, n = 10), and (2) sighted controls with normal or corrected to normal vision (n = 14). Based on the methods proposed by Vingrys and King-Smith (1988), we derived the following metrics of color vision performance: (1) total error score, (2) confusion index, (3) confusion angle, and (4) selectivity index. RESULTS: All of the measured indices of color vision performance were unaltered by a period of congenital visual deprivation. CONCLUSIONS: Our results support the view that, development of visual functions such as color discrimination and color arrangement does not depend on typical visual experience during a sensitive phase in early childhood.

Trends in glaucoma procedures and surgeries at the eye foundation hospital group, Nigeria.

AIMS: To review the trends in glaucoma procedural treatments from January 2009 to December 2017. METHODOLOGY: A retrospective search was carried out from the operating theater and laser room records of the Eye Foundation Hospitals in Lagos, Abuja, and Ijebu-Imushin. Consecutive glaucoma procedures for each year from January 2009 to December 2017 were recorded in the data sheet prepared for the study. Data were analyzed using SPSS version 25. RESULTS: From 2009 to 2017, trabeculectomy had been decreasing in frequency from 117 to 65 (44%), except for 2015. The frequency of use of glaucoma drainage device (GDD) has been steadily increasing from 1 in 2013 to 26 in 2017, but this is not statistically significant. The frequency of cataract extraction with trabeculectomy reduced drastically from 20 in 2009 to 3 (566%) in 2014. Bleb review (BR) increased from 2 in 2009 to 18 (800%) in 2015, however, it dropped to 6 in 2017 (66%). Among the laser procedures, transscleral cyclophotocoagulation (g-probe) is commonly done. It increased from 40 procedures in 2009 to 98 in 2014 (145%). There has been an increase in laser trabeculoplasty from 15 in 2009 to 44 in 2013 (193%). Laser iridotomy increased from 12 in 2009 to 26 in 2015 (116%). From 2009 to 2015, there was an increase in glaucoma procedures and surgeries - 206 to 325 (58%) but this declined by 27% from 2015 to 2017. CONCLUSION: Trabeculectomy is the most performed procedure at our centers. This is followed by g-probe and laser trabeculoplasty. The rate of trabeculectomy is on the decrease, while the rate of GDD is increasing. The laser procedures are also on the increase.

Differences in Cataract Surgery Rates Based on Dementia Status.

BACKGROUND: Cataract surgery substantially improves patient quality of life. Despite the rising prevalence of dementia in the US, little is known about use of cataract surgery among this group. OBJECTIVE: To evaluate the relationship between dementia status and cataract surgery. METHODS: Using administrative insurance claims for a representative sample of 1,125,387 US Medicare beneficiaries who received eye care between 2006 and 2015, we compared cataract surgery rates between patients with and without dementia via multivariable regression models to adjust for patient characteristics. Main outcome measures were annual rates of cataract surgery and hazard ratio and 95% confidence interval (CI) for receiving cataract surgery. RESULTS: Cataract surgery was performed in 457,128 patients, 23,331 with a prior diagnosis of dementia. 16.7% of dementia patients underwent cataract surgery, compared to 43.8% of patients without dementia. 59 cataract surgeries were performed per 1000 dementia patients annually, versus 105 surgeries per 1000 nondementia patients. After adjusting for patient characteristics, dementia patients were approximately half as likely to receive cataract surgery compared to nondementia patients (adjusted HR = 0.53, 95% CI 0.53-0.54). Among the subset of patients who received a first cataract surgery, those with dementia were also less likely to receive second-eye cataract surgery (adjusted HR = 0.87, 95% CI 0.86-0.88). CONCLUSION: US Medicare patients with dementia are less likely to undergo cataract surgery than those without dementia. This finding has implications for quality of care and dementia progression. More information is necessary to understand why rates of cataract surgery are lower for these patients, and to identify conditions where benefits of surgery may outweigh risks.

Analysis of Positional Relationships of Various Centers in Cataract Surgery.

PURPOSE: To analyze the positional relationships of various centers in patients undergoing femtosecond laser-assisted cataract surgery (FLACS). METHODS: The locations of the pupil center (PC), limbal center (LC) and lens center were analyzed in each patient using optical coherence tomography during FLACS in 35 eyes of 35 patients. Using the preoperative corneal aberrometry device, angle kappa and the location of the visual axis (VA) were calculated. After acquiring the relative horizontal and vertical coordinates of each center, the distance and location among each center were compared. The relative location and distance of each center were statistically evaluated. RESULTS: The distance from the PC to the lens center was 0.147 ± 0.103 mm, that from the LC to the lens center was 0.205 ± 0.104 mm, and that from the VA to the lens center was 0.296 ± 0.198 mm. The distance from the PC to the VA was 0.283 ± 0.161 mm, that from the LC to the VA was 0.362 ± 0.153 mm, and that from the lens center to the VA was 0.296 ± 0.198 mm. Among the various centers, the PC was the closest to the lens center, whereas the LC and VA were the farthest. Based on the location of the lens center, the PC, LC, and VA exhibited differences in the X and Y coordinate positions (vertical p = 0.004, horizontal p < 0.001). Among them, the LC was significantly inferior and temporal compared to the PC (vertical p = 0.026, horizontal p = 0.023). Based on the location of the VA, the respective locations of the PC, LC and lens center in two dimensions did not significantly differ (vertical p = 0.310, horizontal p = 0.926). CONCLUSIONS: This study demonstrated the positional and locational relationships between the centers regarding FLACS. The locations of the PC, LC, and VA were different from the lens center with the PC being the closest. Surgeons should be aware of these positional relationships, especially in FLACS.

Trends in cataract surgical rate and resource utilisation in Egypt.

PURPOSE: To describe cataract services in Egypt and explore resources and practices in public and private sectors. METHODS: The study was conducted between June and August 2015. All facilities in the country providing cataract services were contacted to obtain information on surgeries performed in 2014. Hospitals performing eye surgery in Quena, Sharkia, and Fayoum regions were visited and a questionnaire on resources for cataract surgery was completed. RESULTS: Cataract surgery was offered in the public sector by 64 government and 16 university teaching hospitals and in the private sector by 101 hospitals. Over 90% of all facilities in the country contacted participated in the study. In 2014, the national cataract surgical rate (CSR) was 3674 varying in governorates from 7579 in Ismailia to 402 in Suez. The private sector performed 70% of cataract surgeries. Analysis of three regions showed an 11.7% increase in cataract output between 2010 and 2014. The average number of cataract surgeries per unit in 2014 was 2272 in private, 1633 in university, and 824 in government hospitals. Private hospitals had 60% of human resources for eye care. Phacoemulsification was the surgical technique in 85.6% of private, 72.1% of university, and 41% of government hospitals. Reasons explaining the differences in output between public and private sectors were the lack of trainers, supervisors, and incentives. CONCLUSION: The private sector provides most of the cataract services in Egypt, resulting in inadequate services for the poor. There is a 15-fold variation in CSR between the best and least served regions. The public sector could increase cataract output by improving training, supervision, and incentives.

Time Series Changes in Cataract Surgery in Korea.

PURPOSE: We analyzed time series changes in cataract surgeries in Korea, and provide basic data to enhance the efficiency of medical services for cataract surgery. METHODS: Among cataract surgery statistics registered in the Korean National Health Insurance Cooperation from 2006 to 2012, we used data regarding the number of patients and operations and the number of patients and operations per 100,000 people. We analyzed various time series changes, including differences by sex and age. RESULTS: The total numbers of patients from 2006 to 2012 by year were 207,370; 228,170; 250,289; 268,548; 289,867; 308,111; and 302,182, respectively. The total numbers of operations from 2006 to 2012 by year were 272,920; 305,807; 338,332; 365,874; 398,338; 428,158; and 420,905, respectively. The number of patients and operations per 100,000 people were highest in men 80 to 84 years old and women 75 to 79 years old. Comparing the number of operations in 2006 and after, the patient age group with the highest increase rate changed from over 85 years old to 75-79 years old since 2010 in men and from over 85 years old to 50-54 years old since 2009 in women. For each year investigated, the number of operations performed was higher than the number of patients who received operations. CONCLUSIONS: Over the study period, the number of cataract surgeries increased, while the age of cataract patients decreased. Additionally, the number of cataract-related surgeries increased in relation to the number of patients.

Incidence and Characteristics of Cataract Surgery in Poland, during 2010-2015.

Background: To assess the incidence and characteristic of cataract surgery in Poland from 2010 to 2015 and to interpret these findings. Patients and methods: Data from all patients who underwent cataract surgery alone or in combined procedures in Poland between January 2010 and December 2015 were evaluated. Patient data were from the national database of hospitalizations maintained by National Health Fund. Data on the population of Poland were obtained from Central Statistical Office of Poland. Results: In total, 1,218,777 cataract extractions (alone or combined with other procedures) were performed in 1,081,345 patients during 2010-2015. Overall, the incidence of cataract surgery increased from 5.22/1000 person-years in 2010 to 6.17/1000 person-years in 2015. Phacoemulsification was performed in 97.46% of cataract extractions, and 3.02% of cataract extractions were combined procedures. The rate of one-day procedures increased from 28.3% in 2010 to 43.1% in 2015. The probability of second-eye surgery 12 months after the first-eye surgery increased from 44% in 2010 to 73% in 2015 (log-rank test p < 0.0001). Conclusion: In Poland, from 2010 to 2015, the total incidence of cataract surgery, the number of people who underwent surgery, and the number of one-day cataract surgeries increased significantly.

Risk Factors for Early Intraocular Pressure Elevation After Cataract Surgery in a Cohort of United States Veterans.

INTRODUCTION: Cataract surgery is the most frequently performed surgery in the Veterans Health Administration (VHA). A well-known complication is a transient but potentially harmful elevation in intraocular pressure (IOP) within the 24-h postoperative period. The purpose of this study is to investigate the risk factors for IOP elevation 1 d after cataract surgery in a cohort of United States (US) veterans. MATERIALS AND METHODS: The study included 784 patients who underwent cataract surgery between April 2013 and April 2016 at a single Veterans Affairs medical center in Providence, RI. One thousand one hundred thirty-seven cataract surgeries were considered in total. Institutional Review Board (IRB) approval was obtained through the Providence Veterans Affairs Medical Center (PVAMC). Logistic regression, adjusted for patients with bilateral surgeries, was used to evaluate risk factors for first postoperative day IOP elevation (≥28 mmHg). The main outcome measure was elevated IOP on postoperative day 1 (POD1) after cataract surgery. RESULTS: The average patient age was 74 yr. Ninety-eight percent (1,110/1,137) of cases involved male patients; 75.3% (856/1,137) of the cataract surgeries were performed by resident surgeons. Type II diabetes mellitus (DM) was present in 41% (461/1,137), alpha-1 blocker use in 31% (358/1,137), ocular hypertension (ocular HTN) in 4% (44/1,137), and glaucoma in 11% (126/1,137) of cases. Twenty-two percent (232/1,137) of eyes had elevated IOP. Independent risk factors were a history of ocular HTN (OR: 8.74 [4.03-18.9]), glaucoma (OR: 3.54 [2.17-5.75]), a preoperative IOP ≥22 mmHg (OR: 2.51 [1.12-5.62]), and complicated cataract surgery (OR: 2.45 [1.18-5.08]), defined as vitreous loss, anterior capsular tear (ACT), posterior capsular tear (PCT), or presence of zonular lysis. CONCLUSION: These findings suggest that cataract surgery patients with ocular HTN, glaucoma, a preoperative IOP ≥22 mmHg, or significant intraocular complications may benefit from prophylactic ocular anti-hypertensive medication.

First and second eye cataract surgery and driver self-regulation among older drivers with bilateral cataract: a prospective cohort study.

BACKGROUND: Driving a car is the most common form of transport among the older population. Common medical conditions such as cataract, increase with age and impact on the ability to drive. To compensate for visual decline, some cataract patients may self-regulate their driving while waiting for cataract surgery. However, little is known about the self-regulation practices of older drivers throughout the cataract surgery process. The aim of this study is to assess the impact of first and second eye cataract surgery on driver self-regulation practices, and to determine which objective measures of vision are associated with driver self-regulation. METHODS: Fifty-five older drivers with bilateral cataract aged 55+ years were assessed using the self-reported Driving Habits Questionnaire, the Mini-Mental State Examination and three objective visual measures in the month before cataract surgery, at least one to three months after first eye cataract surgery and at least one month after second eye cataract surgery. Participants' natural driving behaviour in four driving situations was also examined for one week using an in-vehicle monitoring device. Two separate Generalised Estimating Equation logistic models were undertaken to assess the impact of first and second eye cataract surgery on driver-self-regulation status and which changes in visual measures were associated with driver self-regulation status. RESULTS: The odds of being a self-regulator in at least one driving situation significantly decreased by 70% after first eye cataract surgery (OR: 0.3, 95% CI: 0.1-0.7) and by 90% after second eye surgery (OR: 0.1, 95% CI: 0.1-0.4), compared to before first eye surgery. Improvement in contrast sensitivity after cataract surgery was significantly associated with decreased odds of self-regulation (OR: 0.02, 95% CI: 0.01-0.4). CONCLUSIONS: The findings provide a strong rationale for providing timely first and second eye cataract surgery for older drivers with bilateral cataract, in order to improve their mobility and independence.

What are the priorities for improving cataract surgical outcomes in Africa? Results of a Delphi exercise.

PURPOSE: The quality of cataract surgery delivered in sub-Saharan Africa (SSA) is a significant constraint to achieving the elimination of avoidable blindness. No published reports from routine SSA cataract services attain the WHO benchmarks for visual outcomes; poor outcomes (<6/60) often comprise 20% in published case series. This Delphi exercise aimed to identify and prioritise potential interventions for improving the quality of cataract surgery in SSA to guide research and eye health programme development. METHODS: An initial email open-question survey created a ranked list of priorities for improving quality of surgical services. A second-round face-to-face discussion facilitated at a Vision 2020 Research Mentorship Workshop in Tanzania created a refined list for repeated ranking. RESULTS: Seventeen factors were agreed that might form target interventions to promote quality of cataract services. Improved training of surgeons was the top-ranked item, followed by utilisation of biometry, surgical equipment availability, effective monitoring of outcomes of cataract surgery by the surgeon, and well-trained support staff for the cataract pathway (including nurses seeing post-operative cases). CONCLUSION: Improving the quality of cataract surgery in SSA is a clinical, programmatic and public health priority. In the absence of other evidence, the collective expert opinion of those involved in ophthalmic services regarding the ranking of factors to promote quality improvement, refined through this Delphi exercise, provides us with candidate intervention areas to be evaluated.

Reviewing the visual benefits of femtosecond laser-assisted cataract surgery: Can we improve our outcomes?

Femtosecond laser-assisted cataract surgery (FLACS) was introduced in 2009 and has increasingly been incorporated into surgical practice. The automation of three key aspects of cataract surgery was expected to deliver a significant improvement in both refractive and safety outcomes. The published literature has not yet shown consistent refractive improvement above conventional techniques. The purpose of this paper is to review current FLACS refractive outcomes and explore factors that may have contributed to the current findings and whether future improvements are possible.