Surgical interventions for age-related cataract

Cataract Surgery and Mental Health: A Comprehensive Review on Outcomes in the Elderly

Cataract surgery is a widely performed and highly effective procedure that significantly improves vision in elderly patients. This narrative review examines the impact of cataract surgery on mental health outcomes in the elderly, focusing on conditions such as depression, anxiety, and cognitive decline. The review highlights the prevalence of cataracts in older adults and the importance of mental health in this demographic, emphasizing the interconnectedness of visual and mental health. Improved vision following cataract surgery has been associated with enhanced quality of life, increased independence, and better psychological well-being. Mechanisms linking visual improvement to mental health benefits include biological pathways, psychosocial factors, and overall health improvements. However, socioeconomic factors, access to healthcare, and patient education play crucial roles in achieving positive outcomes. This review also compares cataract surgery with other interventions, providing a cost-benefit analysis and discussing the long-term sustainability of mental health benefits. Practice recommendations include pre-surgical mental health screening, integrative care approaches, and guidelines for postoperative care focusing on mental health. The review concludes with suggestions for future research to further explore the relationship between cataract surgery and mental health in the elderly, aiming to enhance clinical practice and public health strategies.

Laser-assisted cataract surgery versus standard ultrasound phacoemulsification cataract surgery

BACKGROUND

Cataract is the leading cause of blindness in the world and, as such, cataract surgery is one of the most commonly performed operations globally. Surgical techniques have changed dramatically over the past half century with associated improvements in outcomes and safety. Femtosecond lasers can be used to perform the key steps in cataract surgery, such as corneal incisions, lens capsulotomy and fragmentation. The potential advantage of femtosecond laser-assisted cataract surgery (FLACS) is greater precision and reproducibility of these steps compared to manual techniques. The disadvantages are the costs associated with FLACS technology.

OBJECTIVES

To compare the effectiveness and safety of FLACS with standard ultrasound phacoemulsification cataract surgery (PCS) by gathering evidence from randomised controlled trials (RCTs).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; which contains the Cochrane Eyes and Vision Trials Register; 2022, Issue 5); Ovid MEDLINE; Ovid Embase; LILACS; the ISRCTN registry; ClinicalTrials.gov; the WHO ICTRP and the US Food and Drug Administration (FDA) website. We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 10 May 2022.

SELECTION CRITERIA

We included RCTs where FLACS was compared to PCS.

DATA COLLECTION AND ANALYSIS

Three review authors independently screened the search results, assessed risk of bias and extracted data using the standard methodological procedures expected by Cochrane. The primary outcome for this review was intraoperative complications in the operated eye, namely anterior capsule, and posterior capsule tears. The secondary outcomes included corrected distance visual acuity (CDVA), quality of vision (as measured by any validated patient-reported outcome measure (PROM)), postoperative cystoid macular oedema complications, endothelial cell loss and cost-effectiveness. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 42 RCTs conducted in Europe, North America, South America and Asia, which enrolled a total of 7298 eyes of 5831 adult participants. Overall, the studies were at unclear or high risk of bias. In 16 studies the authors reported financial links with the manufacturer of the laser platform evaluated in their studies. Thirteen of the studies were within-person (paired-eye) studies with one eye allocated to one procedure and the other eye allocated to the other procedure. These studies were reported ignoring the paired nature of the data. There was low-certainty evidence of little or no difference in the odds of developing anterior capsular tears when comparing FLACS and PCS (Peto odds ratio (OR) 0.83, 95% confidence interval (CI) 0.40 to 1.72; 5835 eyes, 27 studies) There was one fewer anterior capsule tear per 1000 operations in the FLACS group compared with the PCS group (95% CI 4 fewer to 3 more).  There was low-certainty evidence of lower odds of developing posterior capsular tears with FLACS compared to PCS (Peto OR 0.50, 95% CI 0.25 to 1.00; 5767 eyes, 26 studies). There were four fewer posterior capsule tears per 1000 operations in the FLACS group compared with the PCS group (95% CI 6 fewer to same).  There was moderate-certainty evidence of a very small advantage for the FLACS arm with regard to CDVA at six months or more follow-up, (mean difference (MD) -0.01 logMAR, 95% CI -0.02 to 0.00; 1323 eyes, 7 studies). This difference is equivalent to 1 logMAR letter between groups and is not thought to be clinically important. From the three studies (1205 participants) reporting a variety of PROMs (Cat-PROMS, EQ-5D, EQ-SD-3L, Catquest9-SF and patient survey) up to three months following surgery, there was moderate-certainty evidence of little or no difference in the various parameters between the two treatment arms. There was low-certainty evidence of little or no difference in the odds of developing cystoid macular oedema when comparing FLACS and PCS (Peto OR 0.84, 95% CI 0.56 to 1.28; 4441 eyes, 18 studies). There were three fewer cystoid macular oedema cases per 1000 operations in the FLACS group compared with the PCS group (95% CI 10 fewer to 6 more).  In one study the incremental cost-effectiveness ratio (ICER) (cost difference divided by quality-adjusted life year (QALY) difference) was GBP £167,620 when comparing FLACS to PCS. In another study, the ICER was EUR €10,703 saved per additional patient who had treatment success with PCS compared to FLACS. Duration ranged from three minutes in favour of FLACS to eight minutes in favour of PCS (I2 = 100%, 11 studies) (low-certainty evidence).  There was low-certainty evidence of little or no important difference in endothelial cell loss when comparing FLACS with PCS (MD 12 cells per mm2 in favour of FLACS, 95% CI -40 to 64; 1512 eyes, 10 studies).  AUTHORS' CONCLUSIONS: This review of 42 studies provides evidence that there is probably little or no difference between FLACS and PCS in terms of intraoperative and postoperative complications, postoperative visual acuity and quality of life. Evidence from two studies suggests that FLACS may be the less cost-effective option. Many of the included studies only investigated very specific outcome measures such as effective phacoemulsification time, endothelial cell count change or aqueous flare, rather than those directly related to patient outcomes. Standardised reporting of complications and visual and refractive outcomes for cataract surgery would facilitate future synthesis, and guidance on this has been recently published.

A Systematic Review of Clinical Practice Guidelines for Cataract: Evidence to Support the Development of the WHO Package of Eye Care Interventions

The World Health Organization (WHO) is developing a Package of Eye Care Interventions (PECI) to facilitate the integration of eye care into Universal Health Coverage. This paper presents the results of a systematic review of clinical practice guidelines for cataract in adults, to help inform PECI development. We searched academic and guideline databases, and websites of professional associations, for guidelines published between January 2010 and April 2020. Guidelines were excluded if there was commercial funding or unmanaged conflicts of interest. Quality appraisal was conducted using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. We identified 3778 reports, 35 related to cataract guidelines, four of which met the inclusion criteria (United Kingdom: 2, United States: 1, Iran: 1). The recommendations across the four guidelines covered pre-operative (43%), intra-operative (37%), and post-operative interventions (20%). Most ‘strong’ recommendations were supported by good quality evidence. Differences in recommendations across guidelines may be attributable to time of publication or regional differences in surgical practice. Few guidelines met the quality criteria, and only three countries were represented. The results of this step of the PECI development process will inform subsequent phases for development of the WHO’s package of evidence-based eye care interventions for cataract.

Progression to severe visual impairment and blindness in POAG patients: pace and risk factors—a cohort study using German health claims data

Objective

Glaucoma is a leading cause of severe visual impairment and blindness (SVI/B) worldwide. Hence, it is of utmost importance to explore relevant risk factors and study the pace of progression to SVI/B.

Methods and analysis

We used a random sample of 250 000 persons from administrative individual-level health records of the Allgemeine Ortskrankenkassen between 2004 and 2015. We identified 3535 primary open-angle glaucoma (POAG) patients aged 55 and older and followed them for up to 10 years. Monocular and binocular SVI/B were defined by the ICD-10 classifications H54.0 and H54.4. Ophthalmological and chronic disease risk factors were analysed by applying a multivariable Cox proportional hazard model.

Results

The risk of SVI/B in POAG patients was significantly increased by the presence of specific additional eye diseases such as secondary glaucoma (HR: 3.08, p<0.001), retinal vascular occlusion (HR: 3.00, p<0.001) or age-related macular degeneration (AMD) (HR: 2.26, p<0.001). The risk was highest in the first 2 years after the POAG diagnosis and significantly decreased after the fifth year (HR: 0.36, p=0.002). Ocular injuries, other ocular diseases, non-ophthalmological comorbidities, and age and sex had no significant influence (p>0.05).

Conclusion

Although progression to SVI/B is relatively rare in POAG patients in Germany, one must be aware of additional risk factors, such as secondary glaucoma, retinal vascular occlusion and AMD. Regular ophthalmological examinations help prevent the progression of SVI/B, especially in the first years after the POAG diagnosis. Specific, targeted, and timely treatments for the other eye diseases could help prevent or delay SVI/B.

Intraocular lens optic edge design for the prevention of posterior capsule opacification after cataract surgery

BACKGROUND

Posterior capsule opacification (PCO) is a clouding of the posterior part of the lens capsule, a skin-like transparent structure, which surrounds the crystalline lens in the human eye. PCO is the most common postoperative complication following modern cataract surgery with implantation of a posterior chamber intraocular lens (IOL). The main symptoms of PCO are a decrease in visual acuity, 'cloudy', blurred vision and reduced contrast sensitivity. PCO is treated with a neodymium:YAG (Nd:YAG) laser to create a small opening in the opaque capsule and regain a clear central visual axis. This capsulotomy might cause further ocular complications, such as raised intraocular pressure or swelling of the central retina (macular oedema). This procedure is also a significant financial burden for health care systems worldwide. In recent decades, there have been advances in the selection of IOL materials and optimisation of IOL designs to help prevent PCO formation after cataract surgery. These include changes to the side structures holding the lens in the centre of the lens capsule bag, called IOL haptics, and IOL optic edge designs.

OBJECTIVES

To compare the effects of different IOL optic edge designs on PCO after cataract surgery.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, Ovid Embase, Latin American and Caribbean Health Sciences Literature Database (LILACS), the ISRCTN registry, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) up to 17 November 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared different types of IOL optic edge design. Our prespecified primary outcome was the proportion of eyes with Nd:YAG capsulotomy one year after surgery. Secondary outcomes included PCO score, best-corrected distance visual acuity (BCDVA) and quality of life score at one year. Due to availability of important long-term data, we also presented data at longer-term follow-up which is a post hoc change to our protocol.

DATA COLLECTION AND ANALYSIS

We used standard methods expected by Cochrane and the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 10 studies (1065 people, 1834 eyes) that compared sharp- and round-edged IOLs. Eight of these studies were within-person studies whereby one eye received a sharp-edged IOL and the fellow eye a round-edged IOL. The IOL materials were acrylic (2 studies), silicone (4 studies), polymethyl methacrylate (PMMA, 3 studies) and different materials (1 study). The studies were conducted in Austria, Germany, India, Japan, Sweden and the UK. Five studies were at high risk of bias in at least one domain. We judged two studies to be at low risk of bias in all domains. There were few cases of Nd:YAG capsulotomy at one year (primary outcome): 1/371 in sharp-edged and 4/371 in round-edged groups. The effect estimate was in favour of sharp-edged IOLs but the confidence intervals were very wide and compatible with higher or lower chance of Nd:YAG capsulotomy in sharp-edged compared with round-edged lenses (Peto odds ratio (OR) 0.30, 95% CI 0.05 to 1.74; I² = 0%; 6 studies, 742 eyes). This corresponds to seven fewer cases of Nd:YAG capsulotomy per 1000 sharp-edged IOLs inserted compared with round-edged IOLs (95% CI 9 fewer to 7 more). We judged this as low-certainty evidence, downgrading for imprecision and risk of bias. A similar reduced risk of Nd:YAG capsulotomy in sharp-edge compared with round-edge IOLs was seen at two, three and five years but as the number of Nd:YAG capsulotomy events increased with longer follow-up this effect was more precisely measured at longer follow-up: two years, risk ratio (RR) 0.35 (0.16 to 0.80); 703 eyes (6 studies); 89 fewer cases per 1000; three years, RR 0.21 (0.11 to 0.41); 538 eyes (6 studies); 170 fewer cases per 1000; five years, RR 0.21 (0.10 to 0.45); 306 eyes (4 studies); 331 fewer cases per 1000. Data at 9 years and 12 years were only available from one study. All studies reported a PCO score. Four studies reported the AQUA (Automated Quantification of After-Cataract) score, four studies reported the EPCO (Evaluation of PCO) score and two studies reported another method of quantifying PCO. It was not possible to pool these data due to the way they were reported, but all studies consistently reported a statistically significant lower average PCO score (of the order of 0.5 to 3 units) with sharp-edged IOLs compared with round-edged IOLs. We judged this to be moderate-certainty evidence downgrading for risk of bias. The logMAR visual acuity score was lower (better) in eyes that received a sharp-edged IOL but the difference was small and likely to be clinically unimportant at one year (mean difference (MD) -0.06 logMAR, 95% CI -0.12 to 0; 2 studies, 153 eyes; low-certainty evidence). Similar effects were seen at longer follow-up periods but non-statistically significant data were less fully reported: two years MD -0.01 logMAR (-0.05 to 0.02); 2 studies, 311 eyes; three years MD -0.09 logMAR (-0.22 to 0.03); 2 studies, 117 eyes; data at five years only available from one study. None of the studies reported quality of life. Very low-certainty evidence on adverse events did not suggest any important differences between the groups.

AUTHORS' CONCLUSIONS

This review provides evidence that sharp-edged IOLs are likely to be associated with less PCO formation than round-edged IOLs, with less Nd:YAG capsulotomy. The effects on visual acuity were less certain. The impact of these lenses on quality of life has not been assessed and there are only very low-certainty comparative data on adverse events.

Efficacy of Nepafenac versus Flurbiprofen in Maintaining Intraoperative Mydriasis During Phacoemulsification: A Comparative Study

Purpose

To compare the efficacy of topical nepafenac (0.1%) with flurbiprofen (0.03%) in maintaining intra-operative mydriasis during phacoemulsification surgery.

Patients and Methods

This study comprised of 160 patients, who were divided into two arms of 80 each (arms A and B) after randomisation. Pre-operatively, all patients received one drop of tropicamide 0.8% and phenylephrine 5% (combination), 4 times, at an interval of 15 minutes on the day of surgery. Thereafter, Nepafenac drop in arm A/Flurbiprofen drop in arm B was administered 4 times, at an interval of 15 minutes keeping a gap of 10 minutes between tropicamide-phenylephrine and any of the experimental drugs. Phacoemulsification was performed one hour after the administration of last drop. Both vertical and horizontal pupillary diameter were measured at three steps; immediately before the surgical incision (baseline), at the end of emulsification of nucleus (before irrigation and aspiration) and at the end of surgery (after stromal hydration).

Results

The difference in pupillary diameter between two groups, was statistically insignificant for vertical diameter (P = 0.08) and horizontal diameter (P = 0.28) at the start of surgery. On the other hand, pupillary diameter difference was statistically significant after emulsification of nucleus and at the end of surgery as well when both vertical (P < 0.05) and horizontal diameter (P < 0.05) were considered. The total reduction in pupillary diameter (both vertically and horizontally) was significantly less in the Nepafenac as compared to Flurbiprofen group (P < 0.05). Analysis of mean cumulative dissipated energy did not document any appreciable difference between the two groups. Phacoemulsification time analysis yielded statistically significant results (P = 0.004) between the Nepafenac and Flurbiprofen group.

Conclusion

In the present study, topical Nepafenac (0.1%) proved to be more efficacious in maintaining intra-operative mydriasis during phacoemulsification surgery as compared to topical Flurbiprofen (0.03%).

Measurement of Force Required for Anterior Displacement of Intraocular Lenses and Its Defining Parameters

Intraocular stability during or after cataract and glaucoma filtration surgeries and vitreous surgery with a gas/silicone oil tamponade might differ among intraocular lenses (IOLs). We used six different one-piece IOL models and measured the force that displaced the IOLs from the vitreous cavity to anterior chamber as a measure of stability against the pressure gradient between the anterior and posterior IOL surfaces. We measured IOL hardness, haptics junction area, and posterior IOL bulge to identify what determines the IOL displacement force. The KOWA YP2.2 IOL (1.231 mN) required significantly greater force than the HOYA XY1 (0.416 mN, p = 0.0004), HOYA 255 (0.409 mN, p = 0.0003), Alcon SN60WF (0.507 mN, p = 0.0010), and Nidek NS60YG (0.778 mN, p = 0.0186) IOLs; J&J ZCB00V IOL (1.029 mN) required greater force than the HOYA XY1 (p = 0.0032) and HOYA 255 (p = 0.0029) IOLs; the Nidek NS60YG IOL required greater force than the HOYA 255 (p = 0.0468) IOL. The haptics junction area was correlated positively with the IOL displacement force (r = 0.8536, p = 0.0306); the correlations of the other parameters were non-significant. After adjusting for any confounding effects, the haptics junction area was correlated significantly with the IOL displacement force (p = 0.0394); the IOL hardness (p = 0.0573) and posterior IOL bulge (p = 0.0938) were not. The forces that displace IOLs anteriorly differed among one-piece soft-acrylic IOLs, and the optics/haptics junction area was the major force determinant.

Interventions to improve the quality of cataract services: protocol for a global scoping review

INTRODUCTION

Cataract is the leading cause of blindness globally and a major cause of vision impairment. Cataract surgery is an efficacious intervention that usually restores vision. Although it is one of the most commonly conducted surgical interventions worldwide, good quality services (from being detected with operable cataract to undergoing surgery and receiving postoperative care) are not universally accessible. Poor quality understandably reduces the willingness of people with operable cataract to undergo surgery. Therefore, it is critical to improve the quality of care to subsequently reduce vision loss from cataract. This scoping review aims to summarise the nature and extent of the published literature on interventions to improve the quality of services for primary age-related cataract globally.

METHODS AND ANALYSIS

We will search MEDLINE, Embase and Global Health for peer-reviewed manuscripts published since 1990, with no language, geographic or study design restrictions. To define quality, we have used the elements adopted by the WHO-effectiveness, safety, people-centredness, timeliness, equity, integration and efficiency-to which we have added the element of planetary health. We will exclude studies focused on the technical aspects of the surgical procedure and studies that only involve children (<18 years). Two reviewers will screen all titles/abstracts independently, followed by a full-text review of potentially relevant articles. For included articles, data regarding publication characteristics, study details and quality-related outcomes will be extracted by two reviewers independently. Results will be synthesised narratively and presented visually using a spider chart.

ETHICS AND DISSEMINATION

Ethical approval was not sought, as our review will only include published and publicly accessible information. We will publish our findings in an open-access peer-reviewed journal and develop an accessible summary of the results for website posting. A summary of the results will be included in the ongoing Lancet Global Health Commission on Global Eye Health.

REGISTRATION DETAILS

Open Science Framework (https://osf.io/8gktz).

Identification and Description of Reliable Evidence for 2016 American Academy of Ophthalmology Preferred Practice Pattern Guidelines for Cataract in the Adult Eye

Importance

Trustworthy clinical practice guidelines require reliable systematic reviews of the evidence to support recommendations. Since 2016, the American Academy of Ophthalmology (AAO) has partnered with Cochrane Eyes and Vision US Satellite to update their guidelines, the Preferred Practice Patterns (PPP).

Objective

To describe experiences and findings related to identifying reliable systematic reviews that support topics likely to be addressed in the 2016 update of the 2011 AAO PPP guidelines on cataract in the adult eye.

Design, Setting, and Participants

Cross-sectional study. Systematic reviews on the management of cataract were searched for in an established database. Each relevant systematic review was mapped to 1 or more of the 24 management categories listed under the Management section of the table of contents of the 2011 AAO PPP guidelines. Data were extracted to determine the reliability of each systematic review using prespecified criteria, and the reliable systematic reviews were examined to find whether they were referenced in the 2016 AAO PPP guidelines. For comparison, we assessed whether the reliable systematic reviews published before February 2010 the last search date of the 2011 AAO PPP guidelines were referenced in the 2011 AAO PPP guidelines. Cochrane Eyes and Vision US Satellite did not provide systematic reviews to the AAO during the development of the 2011 AAO PPP guidelines.

Main Outcomes and Measures

Systematic review reliability was defined by reporting eligibility criteria, performing a comprehensive literature search, assessing methodologic quality of included studies, using appropriate methods for meta-analysis, and basing conclusions on review findings.

Results

From 99 systematic reviews on management of cataract, 46 (46%) were classified as reliable. No evidence that a comprehensive search had been conducted was the most common reason a review was classified as unreliable. All 46 reliable systematic reviews were cited in the 2016 AAO PPP guidelines, and 8 of 15 available reliable reviews (53%) were cited in the 2011 PPP guidelines.

Conclusions and Relevance

The partnership between Cochrane Eyes and Vision US Satellite and the AAO provides the AAO access to an evidence base of relevant and reliable systematic reviews, thereby supporting robust and efficient clinical practice guidelines development to improve the quality of eye care.

Discharge teaching, readiness for discharge, and post-discharge outcomes in cataract patients treated with day surgery: A cross-sectional study

Purpose:

To investigate the quality of discharge teaching, readiness for hospital discharge (RHD), and post-discharge outcomes (PDO) of cataract patients in a day ward and to explore the relationships among these three variables.

Methods:

This cross-sectional study used an opportunistic sample from the ophthalmic day ward in a general hospital in Sichuan province, China. Data were collected using four questionnaires.

Results:

The total average score on the Quality of Discharge Teaching Scale was 192.95, and the dimension with the lowest score was “guidance obtained practically.” The total average score on the Readiness for Hospital Discharge Scale was 175.51, and the dimension with the lowest score was “knowledge of disease.” The total average score on the Post-Discharge Outcome Questionnaire was 77.08, and the four dimensions with the lowest scores were “compliance behaviors,” “avoiding excessive use of eye,” “avoiding strenuous exercise,” and “regular check-up.” Pearson correlation coefficients indicated low to moderate correlations between discharge teaching quality and PDO (0.245, P < 0.01), RHD and PDO (0.271, P < 0.01), and discharge teaching quality and PDO (0.559, P < 0.01).

Conclusion:

The quality of discharge teaching among cataract patients who underwent day surgery was relatively high, and patient preparation for discharge and PDO were good. However, medical staff should focus more attention on patients’ individualized needs for discharge teaching while emphasizing the importance of compliance behavior.

Phacoemulsification Cataract Surgery Affects the Discriminative Capacity of Iris Pattern Recognition

Cataract is a common ophthalmic disorder and the leading cause of blindness worldwide. While cataract is cured via surgical procedures, its impact on iris based biometric recognition has not been effectively studied. The key objective of this research is to assess the effect of cataract surgery on the iris texture pattern as a means of personal authentication. We prepare and release the IIITD Cataract Surgery Database (CaSD) captured from 132 cataract patients using three commercial iris sensors. A non-comparative non-randomized cohort study is performed on the iris texture patterns in CaSD and authentication performance is studied using three biometric recognition systems. Performance is lower when matching pre-operative images to post-operative images (74.69 ± 9.77%) as compared to matching pre-operative images to pre-operative images (93.42 ± 1.76%). 100% recognition performance is observed on a control-group of healthy irises from 68 subjects. Authentication performance improves if cataract affected subjects are re-enrolled in the system, though re-enrollment does not ensure performance at par with pre-operative scenarios (86.67 ± 5.64%). The results indicate that cataract surgery affects the discriminative nature of the iris texture pattern. This finding raises concerns about the reliability of iris-based biometric recognition systems in the context of subjects undergoing cataract surgery.

Anterior chamber depth - a predictor of refractive outcomes after age-related cataract surgery

Background

Anterior chamber depth (ACD) is becoming a hot topic and plays an important role in correcting the refractive errors (REs) after cataract surgery. The aim of this study was to assess the ACD changes and their relationship with the REs after phacoemulsification and intraocular lens (IOL) implantation in patients with age-related cataracts.

Methods

One hundred forty-five eyes of 125 age-related cataract patients from the Department of Ophthalmology, Tangdu Hospital, China, were recruited. IOL Master was used for axial length (AL) and the IOL power calculation measurements, and the Pentacam HR device was used for the ACD and lens thickness (LT) measurements. Every patient underwent uncomplicated phacoemulsification by a single surgeon using a single technique. Postoperative refraction results were obtained at 1 month. The appropriate formula used for the IOL power calculation was chosen depending on the AL, specifically the Hoffer Q (AL < 22.0 mm), SRK/T (22.0 mm ≤ AL ≤ 30.0 mm), and Haigis (AL > 30.0 mm) formulas.

Results

The postoperative ACD was deepened and tended to stabilize gradually after 2 weeks. A concurrent hyperopic shift (0.57 ± 0.47 D) was observed when the change in the ACD was less than 1.65 mm, whereas a myopic shift (− 0.18 ± 0.62 D) occurred contrarily, and the difference between the two groups was statistically significant (P < 0.0001). The change in ACD was significantly larger in the shallow anterior chamber (1.92 ± 0.40 mm) than in the deep chamber (1.33 ± 0.42 mm) (P < 0.0001). Similarly, the change in ACD was larger in the short AL (2.12 ± 0.37 mm) than in the long AL (1.32 ± 0.49 mm). The postoperative ACD and refractive changes were correlated with the preoperative ACD and AL (P < 0.0001), respectively. Two regression formulas were proposed: postoperative ACD = 3.524 + 0.294 × preoperative ACD and postoperative ACD = 3.361 + 0.228× (preoperative ACD + 1/2 LT).

Conclusions

The results of this study showed that the ACD deepened and was associated with a concurrent RE after cataract surgery. Postoperative changes in the ACD were related to the preoperative ACD and AL, which determined the refraction status and visual quality. The regression formula of the postoperative ACD could provide a theoretical basis for predicting refractive errors in the clinic.

Routine preoperative medical testing for cataract surgery

BACKGROUND

Cataract surgery is practiced widely, and substantial resources are committed to an increasing cataract surgical rate in low- and middle-income countries. With the current volume of cataract surgery and future increases, it is critical to optimize the safety and cost-effectiveness of this procedure. Most cataracts are performed on older individuals with correspondingly high systemic and ocular comorbidities. It is likely that routine preoperative medical testing will detect medical conditions, but it is questionable whether these conditions should preclude individuals from cataract surgery or change their perioperative management.

OBJECTIVES

1. To investigate the evidence for reductions in adverse events through preoperative medical testing2. To estimate the average cost of performing routine medical testing SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); Ovid MEDLINE; Embase.com; PubMed; LILACS BIREME, the metaRegister of Controlled Trials (mRCT) (last searched 5 January 2012); ClinicalTrials.gov and the WHO ICTRP. The date of the search was 29 June 2018, with the exception of mRCT which is no longer in service. We searched the references of reports from included studies for additional relevant studies without restrictions regarding language or date of publication.

SELECTION CRITERIA

We included randomized clinical trials in which routine preoperative medical testing was compared to no preoperative or selective preoperative testing prior to age-related cataract surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed abstracts to identify possible trials for inclusion. For each included study, two review authors independently documented study characteristics, extracted data, and assessed risk of bias.

MAIN RESULTS

We identified three randomized clinical trials that compared routine preoperative medical testing versus selective or no preoperative testing for 21,531 cataract surgeries. The largest trial, in which 19,557 surgeries were randomized, was conducted in Canada and the USA. Another study was conducted in Brazil and the third in Italy. Although the studies had some issues with respect to performance and detection bias due to lack of masking (high risk for one study, unclear for two studies), we assessed the studies as at overall low risk of bias.The three randomized clinical trials included in this review reported results for 21,531 total cataract surgeries with 707 total surgery-associated medical adverse events, including 61 hospitalizations and three deaths. Of the 707 medical adverse events reported, 353 occurred in the pre-testing group and 354 occurred in the no-testing group (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.86 to 1.16; high-certainty evidence). Most events were cardiovascular and occurred during the intraoperative period. Routine preoperative medical testing did not reduce the risk of intraoperative (OR 0.99, 95% CI 0.71 to 1.38) or postoperative ocular adverse events (OR 1.11, 95% CI 0.74 to 1.67) when compared to selective or no testing (2 studies; 2281 cataract surgeries; moderate-certainty evidence). One study evaluated cost savings, estimating the costs to be 2.55 times higher in those with preoperative medical testing compared to those without preoperative medical testing (1 study; 1005 cataract surgeries; moderate-certainty evidence). There was no difference in cancellation of surgery between those with preoperative medical testing and those with selective or no preoperative testing, reported by two studies with 20,582 cataract surgeries (OR 0.97, 95% CI 0.78 to 1.21; high-certainty evidence). No study reported outcomes related to clinical management changes (other than cancellation) or quality of life scores.

AUTHORS' CONCLUSIONS

This review has shown that routine preoperative testing does not increase the safety of cataract surgery. Alternatives to routine preoperative medical testing have been proposed, including self administered health questionnaires, which could substitute for health provider histories and physical examinations. Such avenues may lead to cost-effective means of identifying those at increased risk of medical adverse events due to cataract surgery. However, despite the rare occurrence, adverse medical events precipitated by cataract surgery remain a concern because of the large number of elderly patients with multiple medical comorbidities who have cataract surgery in various settings. The studies summarized in this review should assist recommendations for the standard of care of cataract surgery, at least in low- and middle-income settings. Unfortunately, in these settings, medical history questionnaires may be useless to screen for risk because few people have ever been to a physician, let alone been diagnosed with any chronic disease.

Prospective study of Centurion® versus Infiniti® phacoemulsification systems: surgical and visual outcomes

AIM

To evaluate surgical outcomes (SOs) and visual outcomes (VOs) in cataract surgery comparing the Centurion^® phacoemulsification system (CPS) with the Infiniti^® phacoemulsification system (IPS).

METHODS

Prospective, consecutive study in a single-site private practice. Totally 412 patients undergoing cataract surgery with either the CPS using the 30-degree balanced^® tip (n=207) or the IPS using the 30-degree Kelman^® tip (n=205). Intraoperative and postoperative outcomes were documented prospectively up to one month follow-up. Nuclear sclerosis (NS) grade, cumulated dissipated energy (CDE), preoperative corrected distance visual acuity (CDVA), and CDVA at one month were recorded.

RESULTS

CDE was 13.50% less in the whole CPS compared with the whole IPS subcohort. In eyes with NS grade III or greater, CDE was 28.87% less with CPS (n=70) compared with IPS (n=44) (P=0.010). Surgical complications were not statistically different between the two subcohorts (P=0.083), but in the one case of vitreous loss using the CPS, CDVA of 6/4 was achieved at one month. The mean CDVAs (VOs) at one month for NS grade III and above cataracts were -0.17 logMAR (6/4.5) in the CPS and -0.15 logMAR (6/4.5) in the IPS subcohort respectively (P=0.033).

CONCLUSION

CDE is 28.87% less, and VOs are significantly improved, in denser cataracts in the CPS compared with the IPS. The authors recommend the CPS for cases with denser nuclei.

Different-sized incisions for phacoemulsification in age-related cataract

BACKGROUND

Age-related cataract is the principal cause of blindness and visual impairment in the world. Phacoemulsification is the main surgical procedure used to treat cataract. The comparative effectiveness and safety of different-sized incisions for phacoemulsification has not been determined.

OBJECTIVES

The aim of this systematic review was to assess the effectiveness and safety of smaller versus larger incisions for phacoemulsification in age-related cataract. The primary outcome of this review was surgically induced astigmatism at three months after surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 10), MEDLINE Ovid (1946 to 28 October 2016), Embase Ovid (1947 to 28 October 2016), PubMed (1948 to 28 October 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 28 October 2016), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com; last searched 13 May 2013), ClinicalTrials.gov (www.clinicaltrials.gov; searched 28 October 2016), and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp; searched 28 October 2016). We did not use any date or language restrictions in the electronic searches for trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing different-sized incisions in people with age-related cataract undergoing phacoemulsification.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 26 RCTs with a total of 2737 participants (3120 eyes). These trials were conducted in Bosnia and Herzegovina, China, France, India, Italy, Korea, Spain, Switzerland, and Turkey. Half of the 26 trials were conducted in China. We judged all trials as mostly at unclear to low risk of bias. The included RCTs compared four different-sized incisions:<= 1.5 mm, 1.8 mm, 2.2 mm, and approximately 3.0 mm. These incisions were performed using three different techniques: coaxial and biaxial microincision phacoemulsification (C-MICS and B-MICS) and standard phacoemulsification. Not all studies provided data in a form that could be included in this review. Five studies had three arms.Fifteen trials compared C-MICS (2.2 mm) with standard phacoemulsification (about 3.0 mm). Very low-certainty evidence suggested less surgically induced astigmatism in the C-MICS group at three months compared with standard phacoemulsification (mean difference (MD) -0.19 diopters (D), 95% confidence interval (CI) -0.30 to -0.09; 996 eyes; 8 RCTs). There was low-certainty evidence that both groups achieved similar best-corrected visual acuity (MD 0.00 logMAR, 95% CI -0.02 to 0.02; 242 eyes; 3 RCTs). There was low-certainty evidence of little or no difference in endothelial cell loss and central corneal thickness comparing C-MICS with standard phacoemulsification (MD -7.23 cells/mm², 95% CI -78.66 to 64.20; 596 eyes; 4 RCTs) and (MD -0.68 μm, 95% CI -3.26 to 1.90; 487 eyes; 5 RCTs).Nine trials compared C-MICS (1.8 mm) with standard phacoemulsification (about 3.0 mm). Very low-certainty evidence suggested less astigmatism at three months in the C-MICS group compared with standard phacoemulsification group (MD -0.23 D, 95% CI -0.34 to -0.13; 561 eyes; 5 RCTs). Low-certainty evidence suggested little or no difference in best-corrected visual acuity, endothelial cell loss, and central corneal thickness in the two groups at three months (MD -0.02 logMAR, 95% CI -0.03 to -0.00; 192 eyes; 3 RCTs), (MD 7.56 cells/mm², 95% CI -67.65 to 82.77; 380 eyes; 5 RCTs), and (MD -1.52 μm, 95% CI -6.29 to 3.25; 245 eyes; 3 RCTs).Six studies compared C-MICS (1.8 mm) with C-MICS (2.2 mm). There was low-certainty evidence that astigmatism, visual acuity, and central corneal thickness were similar in the two groups at three months (MD 0.04 D, 95% CI -0.09 to 0.16; 259 eyes; 3 RCTs), (MD 0.01 logMAR, 95% CI -0.01 to 0.04; 200 eyes; 3 RCTs), and (MD 0.45 μm, 95% CI -2.70 to 3.60; 100 eyes; 1 RCT). Very low-certainty evidence suggested higher endothelial cell loss in the 1.8 mm group (MD 213.00 cells/mm², 95% CI 11.15 to 414.85; 70 eyes; 1 RCT).Four studies compared B-MICS (<= 1.5 mm) with standard phacoemulsification (about 3.0 mm). Astigmatism was similar in the two groups at three months (MD -0.01 D, 95% CI -0.03 to 0.01; 368 eyes; 2 RCTs; moderate-certainty evidence). There was low-certainty evidence on visual acuity, suggesting little or no difference between the two groups (MD -0.02 logMAR, 95% CI -0.04 to -0.00; 464 eyes; 3 RCTs). Low-certainty evidence on endothelial cell loss and central corneal thickness also suggested little or no difference between the two groups (MD 55.83 cells/mm², 95% CI -34.93 to 146.59; 280 eyes; 1 RCT) and (MD 0.10 μm, 95% CI -14.04 to 14.24; 90 eyes; 1 RCT).None of the trials reported on quality of life. One trial reported that no participants experienced endophthalmitis or posterior capsule rupture; they also reported little or no difference between incision groups regarding corneal edema (risk ratio 1.02, 95% CI 0.40 to 2.63; 362 eyes).

AUTHORS' CONCLUSIONS

Phacoemulsification with smaller incisions was not consistently associated with less surgically induced astigmatism compared with phacoemulsification with larger incisions. Coaxial microincision phacoemulsification may be associated with less astigmatism than standard phacoemulsification, but the difference was small, in the order of 0.2 D, and the evidence was uncertain. Safety outcomes and quality of life were not adequately reported; these should be addressed in future studies.

Cataracts

An estimated 95 million people worldwide are affected by cataract. Cataract still remains the leading cause of blindness in middle-income and low-income countries. With the advancement of surgical technology and techniques, cataract surgery has evolved to small-incisional surgery with rapid visual recovery, good visual outcomes, and minimal complications in most patients. With the development of advanced technology in intraocular lenses, the combined treatment of cataract and astigmatism or presbyopia, or both, is possible. Paediatric cataracts have a different pathogenesis, surgical concerns, and postoperative clinical course from those of age-related cataracts, and the visual outcome is multifactorial and dependent on postoperative visual rehabilitation. New developments in cataract surgery will continue to improve the visual, anatomical, and patient-reported outcomes. Future work should focus on promoting the accessibility and quality of cataract surgery in developing countries.

The treatment methods for post-stroke visual impairment: A systematic review

AIM

To provide a systematic overview of interventions for stroke related visual impairments.

METHOD

A systematic review of the literature was conducted including randomized controlled trials, controlled trials, cohort studies, observational studies, systematic reviews, and retrospective medical note reviews. All languages were included and translation obtained. This review covers adult participants (aged 18 years or over) diagnosed with a visual impairment as a direct cause of a stroke. Studies which included mixed populations were included if over 50% of the participants had a diagnosis of stroke and were discussed separately. We searched scholarly online resources and hand searched articles and registers of published, unpublished, and ongoing trials. Search terms included a variety of MESH terms and alternatives in relation to stroke and visual conditions. Article selection was performed by two authors independently. Data were extracted by one author and verified by a second. The quality of the evidence and risk of bias was assessed using appropriate tools dependant on the type of article.

RESULTS

Forty-nine articles (4142 subjects) were included in the review, including an overview of four Cochrane systematic reviews. Interventions appraised included those for visual field loss, ocular motility deficits, reduced central vision, and visual perceptual deficits.

CONCLUSION

Further high quality randomized controlled trials are required to determine the effectiveness of interventions for treating post-stroke visual impairments. For interventions which are used in practice but do not yet have an evidence base in the literature, it is imperative that these treatments be addressed and evaluated in future studies.

Comparison of the Posterior Capsule Rupture Rates Associated with Conventional (Start to Finish) Versus Reverse Methods of Teaching Phacoemulsification

Purpose:

Comparison of the rates of posterior capsule rupture (PCR) associated with conventional versus a reverse method of teaching phacoemulsification.

Methods:

Trainees were taught conventional (start-to-finish) phacoemulsification beginning with an incision (tunnel construction) to capsulorhexis, sculpting, nucleus cracking, segment removal, cortex aspiration, intraocular lens implantation, and viscoelastic removal. In the reverse method, after incision and capsulorhexis, the trainees were progressively taught viscoelastic wash, cortex aspiration, segment removal, nucleus cracking, sculpting, and intraocular lens implantation. Trainees from a Tertiary Eye Care Centre were classified as beginners, for their first 30 cases and then trainees for their next 70 surgeries. Data were collected on posterior capsular rent and vitreous loss during each step of training.

Results:

Thirty-two ophthalmic surgeons learning phacoemulsification surgery on 609 cataracts cases were supervised by 3 trainers. Fifteen beginners performed 287 surgeries using the conventional method, and 17 beginners performed 322 surgeries with the reverse method. The incidence of PCR was 18/287 (6.2%) with the conventional method and 15/322 (4.6%) with the reverse method (P = 0.38). PCR occurred during cortex aspiration (8/287, 2.8%) and segment removal (5/287, 1.7%) in the conventional method. PCR occurred during nucleus cracking, segment removal, and cortex aspiration (4/322 surgeries for each step, 1.2%). In the follow, 70 cases (trainees) there was no difference in PCR with either method (4.7% vs. 4.3%, P = 0.705).

Conclusion:

Conventional and reverse method for training phacoemulsification were both safe in a supervised setting.

Effective cataract surgical coverage: An indicator for measuring quality-of-care in the context of Universal Health Coverage

OBJECTIVE

To define and demonstrate effective cataract surgical coverage (eCSC), a candidate UHC indicator that combines a coverage measure (cataract surgical coverage, CSC) with quality (post-operative visual outcome).

METHODS

All Rapid Assessment of Avoidable Blindness (RAAB) surveys with datasets on the online RAAB Repository on April 1 2016 were downloaded. The most recent study from each country was included. By country, cataract surgical outcome (CSOGood, 6/18 or better; CSOPoor, worse than 6/60), CSC (operated cataract as a proportion of operable plus operated cataract) and eCSC (operated cataract and a good outcome as a proportion of operable plus operated cataract) were calculated. The association between CSC and CSO was assessed by linear regression. Gender inequality in CSC and eCSC was calculated.

FINDINGS

Datasets from 20 countries were included (2005-2013; 67,337 participants; 5,474 cataract surgeries). Median CSC was 53.7% (inter-quartile range[IQR] 46.1-66.6%), CSOGood was 58.9% (IQR 53.7-67.6%) and CSOPoor was 17.7% (IQR 11.3-21.1%). Coverage and quality of cataract surgery were moderately associated-every 1% CSC increase was associated with a 0.46% CSOGood increase and 0.28% CSOPoor decrease. Median eCSC was 36.7% (IQR 30.2-50.6%), approximately one-third lower than the median CSC. Women tended to fare worse than men, and gender inequality was slightly higher for eCSC (4.6% IQR 0.5-7.1%) than for CSC (median 2.3% IQR -1.5-11.6%).

CONCLUSION

eCSC allows monitoring of quality in conjunction with coverage of cataract surgery. In the surveys analysed, on average 36.7% of people who could benefit from cataract surgery had undergone surgery and obtained a good visual outcome.

Surgery for cataracts in people with age-related macular degeneration

BACKGROUND

Cataract and age-related macular degeneration (AMD) are common causes of decreased vision that often occur simultaneously in people over age 50. Although cataract surgery is an effective treatment for cataract-induced visual loss, some clinicians suspect that such an intervention may increase the risk of worsening of underlying AMD and thus have deleterious effects on vision.

OBJECTIVES

The objective of this review was to evaluate the effectiveness and safety of cataract surgery compared with no surgery in eyes with AMD.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 11), Ovid MEDLINE, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to December 2016), Embase (January 1980 to December 2016), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to December 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 2 December 2016.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized trials that enrolled participants whose eyes were affected by both cataract and AMD in which cataract surgery was compared with no surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated the search results against the inclusion and exclusion criteria. Two review authors independently extracted data, assessed risk of bias for included studies, and graded the certainty of evidence. We followed methods as recommended by Cochrane.

MAIN RESULTS

We included two RCTs with a total of 114 participants (114 study eyes) with visually significant cataract and AMD. We identified no ongoing trials. Participants in each RCT were randomized to immediate cataract surgery (within two weeks of enrollment) or delayed cataract surgery (six months after enrollment). The risk of bias was unclear for most domains in each study; one study was registered prospectively.In one study conducted in Australia outcomes were reported only at six months (before participants in the delayed-surgery group had cataract surgery). At six months, the immediate-surgery group showed mean improvement in best-corrected visual acuity (BCVA) compared with the delayed-surgery group (mean difference (MD) -0.15 LogMAR, 95% confidence interval (CI) -0.28 to -0.02; 56 participants; moderate-certainty evidence). In the other study, conducted in Austria, outcomes were reported only at 12 months (12 months after participants in the immediate-surgery group and six months after participants in the delayed-surgery group had cataract surgery). There was uncertainty as to which treatment group had better improvement in distance visual acuity at 12 months (unit of measure not reported; very low-certainty evidence).At 12 months, the mean change from baseline between groups in cumulated drusen or geographic atrophy area size was small and there was uncertainty which, if either, of the groups was favored (MD 0.76, 95% CI -8.49 to 10.00; 49 participants; low-certainty evidence). No participant in one study had exudative AMD develop in the study eye during 12 months of follow-up; in the other study, choroidal neovascularization developed in the study eye of 1 of 27 participants in the immediate-surgery group versus 0 of 29 participants in the delayed-surgery group at six months (risk ratio 3.21, 95% CI 0.14 to 75.68; 56 participants; very low-certainty evidence). Quality of life was measured using two different questionnaires. Scores on the Impact of Vision Impairment (IVI) questionnaire suggested that the immediate-surgery group fared better regarding vision-related quality of life than the delayed-surgery group at six months (MD in IVI logit scores 1.60, 95% CI 0.61 to 2.59; low-certainty evidence). However, we could not analyze scores from the Visual Function-14 (VF-14) questionnaire from the other study due to insufficient data. No postoperative complication was reported from either study.

AUTHORS' CONCLUSIONS

At this time, it is not possible to draw reliable conclusions from the available data as to whether cataract surgery is beneficial or harmful in people with AMD after 12 months. Although cataract surgery provides short-term (six months) improvement in BCVA in eyes with AMD compared with no surgery, it is unclear whether the timing of surgery has an effect on long-term outcomes. Physicians must make recommendations to their AMD patients regarding cataract surgery based on experience and clinical judgment until large controlled trials are conducted and their findings published.There is a need for prospective RCTs in which cataract surgery is compared with no surgery in people with AMD to better evaluate whether cataract surgery is beneficial or harmful in all or a subset of AMD patients. However, ethical considerations preclude withholding surgery, or delaying it for several years, if it may be a potentially beneficial treatment. Designers of future trials are encouraged to utilize existing standardized systems for grading cataract and AMD and for measuring key outcomes: visual acuity, change in visual acuity, worsening of AMD, quality of life measures, and adverse events.

Laser-assisted cataract surgery versus standard ultrasound phacoemulsification cataract surgery

BACKGROUND

Cataract is the leading cause of blindness in the world, and cataract surgery is one of the most commonly performed operations in the Western world. Preferred surgical techniques have changed dramatically over the past half century with associated improvements in outcomes and safety. Femtosecond laser platforms that can accurately and reproducibly perform key steps in cataract surgery, including corneal incisions, capsulotomy and lens fragmentation, are now available. The potential advantages of laser-assisted surgery are broad, and include greater safety and better visual outcomes through greater precision and reproducibility.

OBJECTIVES

To compare the effectiveness of laser-assisted cataract surgery with standard ultrasound phacoemulsification cataract surgery by gathering evidence on safety from randomised controlled trials (RCTs).

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 4), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to May 2016), EMBASE (January 1980 to May 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to May 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en) and the U.S. Food and Drugs Administration (FDA) website (www.fda.gov). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 10 May 2016.

SELECTION CRITERIA

We included randomised controlled trials where laser-assisted cataract surgery was compared to standard ultrasound phacoemulsification cataract surgery. We graded the certainty of the evidence using GRADE.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results, assessed risk of bias and extracted data using the standard methodological procedures expected by Cochrane. The primary outcome for this review was intraoperative complications in the operated eye, namely anterior capsule and posterior capsule tears. The secondary outcomes were visual acuity (corrected distance visual acuity (CDVA) and uncorrected distance visual acuity (UDVA)), refractive outcomes, quality of vision (as measured by any validated visual function score), postoperative complications and cost-effectiveness.

MAIN RESULTS

We included 16 RCTs conducted in Germary, Hungary, Italy, India, China and Brazil that enrolled a total of 1638 eyes of 1245 adult participants. Overall, the studies were at unclear or high risk of bias. In 11 of the studies the authors reported financial links with the manufacturer of the laser platform evaluated in their studies. Five of the studies were within-person (paired-eye) studies with one eye allocated to one procedure and the other eye allocated to the other procedure. These studies were reported ignoring the paired nature of the data.The number of anterior capsule and posterior capsule tears reported in the included studies for both laser cataract surgery and manual phacoemulsification cataract surgery were low. There were four anterior capsule tears and one posterior capsule tear in 1076 eyes reported in 10 studies (2 anterior capsule tears in laser arms, 2 anterior capsule tears and 1 posterior capsule tear in standard phacoemulsification arms). We are very uncertain as to the effect of laser-assisted surgery compared to standard phacoemulsification surgery with respect to these two outcomes. For postoperative cystoid macular oedema and elevated postoperative intraocular pressures, again the evidence was inconclusive (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.20 to 1.68; 957 eyes, 9 studies, low certainty evidence; and OR 0.57, 95% CI 0.11 to 2.86; 903 eyes, 8 studies, low certainty evidence).We found little evidence of any important difference in postoperative visual acuity between laser-assisted and standard phacoemulsification arms. There was a small advantage for laser-assisted cataract surgery at six months in CDVA. However, the mean difference (MD) was -0.03 logMAR (95% CI -0.05 to -0.00; 224 eyes, 3 studies, low certainty evidence) which is equivalent to 1.5 logMAR letters and is therefore, clinically insignificant. No studies reported patient-reported outcome measures such as visual function.There were no data reported on costs or resource use but three studies reported the time taken to do the surgery. There was little evidence of any major difference between the two procedures in this respect (MD 0.1 minutes, 95% CI -0.02 to 0.21; 274 eyes, low certainty evidence).

AUTHORS' CONCLUSIONS

The evidence from the 16 randomised controlled trials RCTs included in this review could not determine the equivalence or superiority of laser-assisted cataract surgery compared to standard manual phacoemulsification for our chosen outcomes due to the low to very low certainty of the evidence available from these studies. As complications occur rarely, large, adequately powered, well designed, independent RCTs comparing the safety and efficacy of laser-assisted cataract surgery with standard phacoemulsification cataract surgery are needed. Standardised reporting of complications and visual and refractive outcomes for cataract surgery would facilitate future synthesis. Data on patient-reported outcomes and cost-effectiveness are needed. Paired-eye studies should be analysed and reported appropriately.

Customized Clinical Practice Guidelines for Management of Adult Cataract in Iran

Purpose:

To customize clinical practice guidelines (CPGs) for cataract management in the Iranian population.

Methods:

First, four CPGs (American Academy of Ophthalmology 2006 and 2011, Royal College of Ophthalmologists 2010, and Canadian Ophthalmological Society 2008) were selected from a number of available CPGs in the literature for cataract management. All recommendations of these guidelines, together with their references, were studied. Each recommendation was summarized in 4 tables. The first table showed the recommendation itself in clinical question components format along with its level of evidence. The second table contained structured abstracts of supporting articles related to the clinical question with their levels of evidence. The third table included the customized recommendation of the internal group respecting its clinical advantage, cost, and complications. In the fourth table, the internal group their recommendations from 1 to 9 based on the customizing capability of the recommendation (applicability, acceptability, external validity). Finally, customized recommendations were sent one month prior to a consensus session to faculty members of all universities across the country asking for their comments on recommendations.

Results:

The agreed recommendations were accepted as conclusive while those with no agreement were discussed at the consensus session. Finally, all customized recommendations were codified as 80 recommendations along with their sources and levels of evidence for the Iranian population.

Conclusion:

Customization of CPGs for management of adult cataract for the Iranian population seems to be useful for standardization of referral, diagnosis and treatment of patients.

Recovery after cataract surgery

Cataract surgery is the most common ophthalmological surgical procedure, and it is predicted that the number of surgeries will increase significantly in the future. However, little is known about the recovery after surgery. The first aim of this study was to evaluate the prevalence, severity and duration of pain and other ocular discomfort symptoms experienced after cataract surgery. The other objectives were to identify the factors associated with lower postoperative patient satisfaction and to measure the effect of cataract surgery on patients' health-related quality of life (HRQoL) and visual function in everyday life. The study design was a prospective follow-up study. The course of the recovery and the presence of ocular symptoms were evaluated by interviewing the patients via a questionnaire at 1 day, 1 week, 6 weeks and one year after surgery The visual functioning in everyday life was measured with Visual Functioning Index VF-7 and Catquest-9SF-questionnaires and furthermore the HRQoL was measured with the 15D-instrument before surgery and at 12 months after surgery. The patients returned the questionnaires by mail and were interviewed in the hospital on the day of the surgery. The same patients filled-in all the questionnaires. The patient reports were used to collect the data on medical history. A total of 303 patients were approached at Kuopio University Hospital in 2010-2011 and of these 196 patients were eligible and willing to participate, with postoperative data being available from 186 (95%) patients. A systematic review article was included in the study procedure and it revealed the wide range in the reported incidence of postoperative ocular pain. Some of the identified randomized controlled studies reported no or only minor pain whereas in some studies significant pain or pain lasting for several weeks has been described in more than 50% of the study patients. In the present study setting, pain was reported by 34% during the first postoperative hours and by approximately 10% of patients during the first six weeks after surgery. During the early recovery in the hospital, only a minority of the patients reporting pain were provided with pain medication. The ocular discomfort symptoms such as itchiness, burning, foreign-body sensation and tearing were common both before (54%) and after surgery (38-52%). These symptoms can also be described as painful symptoms and are often difficult to distinguish from ocular pain. The symptoms are also typical of ocular surface disease, and some patients may benefit from the postoperative administration of tear substitutes. The patients reporting postoperative ocular symptoms were less satisfied with the treatment outcome at 12 months after surgery (p = 0.001) compared to the patients who experienced no symptoms. Those patients reporting less disability in visual functioning before surgery were more satisfied than patients with more reported disability. The HRQoL improved significantly after cataract surgery (p = 0.002). However, when compared to an age-and gender-standardized control population, in cataract subjects the HRQoL remained slightly worse both before and at 12 months after surgery.

Usefulness of surgical complexity classification index in cataract surgery process

OBJECTIVE

To evaluate the usefulness of surgical complexity classification index (SCCI) to predict the degree of surgical difficulty in cataract surgery.

MATERIAL AND METHODS

This retrospective study includes data collected between January 2013 and December 2014 from patients who underwent cataract extraction by phacoemulsification at our hospital. A sample size of 159 patients was obtained by simple random sampling (P=.5, 10% accuracy, 95% confidence). The main variables were: recording and value of SCCI in electronic medical record (EMR), presence of exfoliation syndrome (XFS), criteria for inclusion in surgical waiting list (SWL), and functional results. SCCI was classified into 7 categories (range: 1-4) according to predictors of technical difficulty, which was indirectly estimated in terms of surgical time (ST). All statistical analyses were performed using SPSS v15.0 statistical software.

RESULTS

Prevalence of XFS was 18.2% (95%CI: 11.9-24.5). In terms of quality indicators in the cataract surgery process, 96.8% of patients met at least one of the criteria to be included in SWL, and 98.1% gained ≥2 Snellen lines. The SCCI was recorded in EMR of 98.1% patients, and it was grouped for study into 2 categories: High and low surgical complexity. Statistically significant differences in the distribution of ST were found depending on the assigned SCCI (P<.005) and the presence of XFS (P<.005).

CONCLUSIONS

The SCCI enables to estimate the degree of surgical complexity in terms of ST in cataract surgery, which is especially useful in those areas with high prevalence of XFS, because of the higher theoretical risk of surgical complications.

Aquaporin-1 down regulation associated with inhibiting cell viability and inducing apoptosis of human lens epithelial cells

AIM

To investigate the role of Aquaporin-1 (AQP-1) in lens epithelial cells (LECs) and its potential target genes. AQP-1 is specifically expressed in LECs of eyes and is significant for lens homeostasis and transparency maintenance. Herein, AQP-1 expression in LECs was investigated to evaluate its influence on cell survival in association with its potential role in cataract formation.

METHODS

LECs were transfected with lentivirus carrying AQP-1 small interfering RNA (siRNA). Real-time polymerase chain reaction (PCR) and Western blotting were conducted to detect AQP-1 expression in LECs from different groups. Meanwhile, cell counting kit-8 (CCK-8) assay and flow cytometry were performed to measure LEC proliferation and apoptosis, respectively.

RESULTS

AQP-1 expression was significantly reduced in LECs, both at mRNA and protein levels (P<0.05), after siRNA treatment. Decreased cell viability was detected by CCK-8 assay in LECs with siRNA interference, compared to control cells (P<0.05). The apoptosis rate significantly increased in cells after siRNA interference (P<0.05).

CONCLUSION

The decreased cell viability following AQP-1 down regulation is largely due to its induction of apoptosis of LECs. AQP-1 reduction might lead to changes of physiological functions in LECs, which might be associated with the occurrence and development of cataracts.

Day care versus in-patient surgery for age-related cataract

BACKGROUND

Age-related cataract accounts for more than 40% of cases of blindness in the world with the majority of people who are blind from cataract living in lower income countries. With the increased number of people with cataract, it is important to review the evidence on the effectiveness of day care cataract surgery.

OBJECTIVES

To provide authoritative, reliable evidence regarding the safety, feasibility, effectiveness and cost-effectiveness of day case cataract extraction by comparing clinical outcomes, cost-effectiveness, patient satisfaction or a combination of these in cataract operations performed in day care versus in-patient units.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 7), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2015), EMBASE (January 1980 to August 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to August 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 17 August 2015.

SELECTION CRITERIA

We included randomised controlled trials comparing day care and in-patient surgery for age-related cataract. The primary outcome was the achievement of a satisfactory visual acuity six weeks after the operation.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials.

MAIN RESULTS

We included two trials. One study was conducted in the USA in 1981 (250 people randomised and completed trial) and one study conducted in Spain in 2001 (1034 randomised, 935 completed trial). Both trials used extracapsular cataract extraction techniques that are not commonly used in higher income countries now. Most of the data in this review came from the larger trial, which we judged to be at low risk of bias.The mean change in visual acuity (in Snellen lines) of the operated eye four months postoperatively was similar in people given day care surgery (mean 4.1 lines standard deviation (SD) 2.3, 464 participants) compared to people treated as in-patients (mean 4.1 lines, SD 2.2, 471 participants) (P value = 0.74). No data were available from either study on intra-operative complications.Wound leakage, intraocular pressure (IOP) and corneal oedema were reported in the first day postoperatively and at four months after surgery. There was an increased risk of high IOP in the day care group in the first day after surgery (risk ratio (RR) 3.33, 95% confidence intervals (CI) 1.21 to 9.16, 935 participants) but not at four months (RR 0.61, 95% CI 0.14 to 2.55, 935 participants). The findings for the other outcomes were inconclusive with wide CIs. There were two cases of endophthalmitis observed at four months in the day care group and none in the in-patient group. The smaller study stated that there were no infections or severe hyphaemas.In a subset of participants evaluated for quality of life (VF14 questionnaire) similar change in quality of life before and four months after surgery was observed (mean change in VF14 score: day care group 25.2, SD 21.2, 150 participants; in-patient group: 23.5, SD 25.7, 155 participants; P value = 0.30). Subjective assessment of patient satisfaction in the smaller study suggested that participants preferred to recuperate at home, were more comfortable in their familiar surroundings and enjoyed the family support that they received at home. Costs were 20% more for the in-patient group and this was attributed to higher costs for overnight stay.

AUTHORS' CONCLUSIONS

This review provides evidence that there is cost saving with day care cataract surgery compared to in-patient cataract surgery. Although effects on visual acuity and quality of life appeared similar, the evidence with respect to postoperative complications was inconclusive because the effect estimates were imprecise. Given the wide-spread adoption of day care cataract surgery, future research in cataract clinical pathways should focus on evidence provided by high quality clinical databases (registers), which would enable clinicians and healthcare planners to agree clinical and social indications for in-patient care and so make better use of resources.

Manual small incision cataract surgery (MSICS) with posterior chamber intraocular lens versus extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens for age-related cataract

BACKGROUND

Age-related cataract is the opacification of the lens, which occurs as a result of denaturation of lens proteins. Age-related cataract remains the leading cause of blindness globally, except in the most developed countries. A key question is what is the best way of removing the lens, especially in lower income settings.

OBJECTIVES

To compare two different techniques of lens removal in cataract surgery: manual small incision surgery (MSICS) and extracapsular cataract extraction (ECCE).

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2014, Issue 8), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to September 2014), EMBASE (January 1980 to September 2014), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to September 2014), Web of Science Conference Proceedings Citation Index- Science (CPCI-S), (January 1990 to September 2014), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 23 September 2014.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) only. Participants in the trials were people with age-related cataract. We included trials where MSICS with a posterior chamber intraocular lens (IOL) implant was compared to ECCE with a posterior chamber IOL implant.

DATA COLLECTION AND ANALYSIS

Data were collected independently by two authors. We aimed to collect data on presenting visual acuity 6/12 or better and best-corrected visual acuity of less than 6/60 at three months and one year after surgery. Other outcomes included intraoperative complications, long-term complications (one year or more after surgery), quality of life, and cost-effectiveness. There were not enough data available from the included trials to perform a meta-analysis.

MAIN RESULTS

Three trials randomly allocating people with age-related cataract to MSICS or ECCE were included in this review (n = 953 participants). Two trials were conducted in India and one in Nepal. Trial methods, such as random allocation and allocation concealment, were not clearly described; in only one trial was an effort made to mask outcome assessors. The three studies reported follow-up six to eight weeks after surgery. In two studies, more participants in the MSICS groups achieved unaided visual acuity of 6/12 or 6/18 or better compared to the ECCE group, but overall not more than 50% of people achieved good functional vision in the two studies. 10/806 (1.2%) of people enrolled in two trials had a poor outcome after surgery (best-corrected vision less than 6/60) with no evidence of difference in risk between the two techniques (risk ratio (RR) 1.58, 95% confidence interval (CI) 0.45 to 5.55). Surgically induced astigmatism was more common with the ECCE procedure than MSICS in the two trials that reported this outcome. In one study there were more intra- and postoperative complications in the MSICS group. One study reported that the costs of the two procedures were similar.

AUTHORS' CONCLUSIONS

There are no other studies from other countries other than India and Nepal and there are insufficient data on cost-effectiveness of each procedure. Better evidence is needed before any change may be implemented. Future studies need to have longer-term follow-up and be conducted to minimize biases revealed in this review with a larger sample size to allow examination of adverse events.

The Zeb proteins δEF1 and Sip1 may have distinct functions in lens cells following cataract surgery

PURPOSE

Posterior capsular opacification (PCO), the most prevalent side effect of cataract surgery, occurs when residual lens epithelial cells (LECs) undergo fiber cell differentiation or epithelial-to-mesenchymal transition (EMT). Here, we used a murine cataract surgery model to investigate the role of the Zeb proteins, Smad interacting protein 1 (Sip1) and δ-crystallin enhancer-binding factor 1 (δEF1), during PCO.

METHODS

Extracapsular extraction of lens fiber cells was performed on wild-type and Sip1 knockout mice. Protein expression patterns were assessed at multiple time points after surgery using confocal immunofluorescence. βB1-Crystallin mRNA levels were measured using quantitative RT-PCR. We used Transfac searches to identify δEF1 binding sites in the βB1-crystallin promoter and transfection analysis to test the ability of δEF1 to regulate βB1-crystallin expression.

RESULTS

δEF1, which, in other systems, can activate fibrotic genes (e.g., α-smooth muscle actin) and repress epithelial genes, upregulates by 48 hours after fiber cell removal. In culture, δEF1 repressed βB1-crystallin promoter activity, suggesting that it may also turn off lens gene expression following surgery, contributing to "fibrotic PCO" development. Sip1 also upregulates in LECs by 48 hours, but analysis of Sip1 knockout lenses demonstrated that Sip1 does not play a major role in EMT or fiber cell differentiation after surgery. However, Sip1 knockout LECs do express the ectodermal marker keratin 8, suggesting that Sip1 may limit the reprogramming of residual LECs to an embryonic state.

CONCLUSIONS

Zeb transcription factors likely play important, but distinct roles in PCO development after cataract surgery.

Foldable vs rigid lenses after phacoemulsification for cataract surgery: a randomised controlled trial

PURPOSE

To compare the outcomes of phacoemulsification with either a 2.5-mm clear corneal incision and a foldable intraocular lens (IOL) or a 5-mm sclerocorneal tunnel incision and a rigid polymethyl methacrylate (PMMA) IOL.

METHODS

In a prospective, randomised clinical trial of phacoemulsification cataract surgery, 1200 patients received either a foldable hydrophilic acrylic IOL through a 2.5-mm corneal incision or an inexpensive rigid PMMA IOL via a 5-mm sclerocorneal tunnel. Intra- and post-operative data and visual acuity at discharge, 6 weeks, and 1 year follow-up were analysed.

RESULTS

At 1 year after surgery, 996 (83.0%) patients were followed up with an uncorrected visual acuity of 6/18 or better in 90.3% of the foldable and 94.3% in the rigid IOL group (risk ratio (RR) 0.96, 95% confidence intervals (CI) 0.92-0.99). Poor outcome (best-corrected acuity 6/60 or worse) occurred in 1.0% and 0.4%, respectively (RR 4.28, 95% CI 0.48-38.18). The surgical cost of consumables and overall surgical time were similar in both groups; however, the cost of the foldable IOL was eight times higher than the PMMA IOL. Posterior capsule opacification was more common in the rigid IOL group at 12 months (36.1% vs 23.3%); however, this did not affect post-operative vision.

CONCLUSION

In the hands of experienced cataract surgeons, phacoemulsification with implantation of a foldable or a rigid IOL gives excellent results. Using an inexpensive rigid PMMA IOL will make phacoemulsification more affordable for poor patients in low- and middle-income countries.

Phacoemulsification with posterior chamber intraocular lens versus extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens for age-related cataract

BACKGROUND

Age-related cataract is one of the leading causes of blindness worldwide. Therefore, it is important to establish the most effective surgical technique for cataract surgery.

OBJECTIVES

The aim of this review is to examine the effects of two types of cataract surgery for age-related cataract: phacoemulsification and extracapsular cataract extraction (ECCE).

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 4), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to May 2013), EMBASE (January 1980 to May 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to May 2013), Web of Science Conference Proceedings Citation Index - Science (CPCI-S) (January 1970 to May 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 13 May 2013.

SELECTION CRITERIA

We included randomised controlled trials of phacoemulsification compared to ECCE for age-related cataract.

DATA COLLECTION AND ANALYSIS

Two authors independently selected and assessed all studies. We defined two primary outcomes: 'good functional vision' (presenting visual acuity of 6/12 or better) and 'poor visual outcome' (best corrected visual acuity of less than 6/60) at three and 12 months after surgery. We also collected data on intra and postoperative complications, and the cost of the procedures.

MAIN RESULTS

We included 11 trials in this review with a total of 1228 participants, ranging from age 45 to 94. The studies were generally at unclear risk of bias due to poorly reported trial methods. No study reported presenting visual acuity, so we report both uncorrected (UCVA) and best corrected visual acuity (BCVA). Studies varied in visual acuity assessment methods and time frames at which outcomes were reported. Participants in the phacoemulsification group were more likely to achieve UCVA of 6/12 or more at three months (risk ratio (RR) 1.81, 95% confidence interval (CI) 1.36 to 2.41, two studies, 492 participants) and one year (RR 1.99, 95% CI 1.45 to 2.73, one study, 439 participants). People in the phacoemulsification group were also more likely to achieve BCVA of 6/12 or more at three months (RR 1.12, 95% CI 1.03 to 1.22, four studies, 645 participants) and one year (RR 1.06, 95% CI 0.99 to 1.14, one study, 439 participants), but the difference between the two groups was smaller. No trials reported BCVA less than 6/60 but three trials reported BCVA worse than 6/9 and 6/18: there were fewer events of this outcome in the phacoemulsification group than the ECCE group at both the three-month (RR 0.33, 95% CI 0.20 to 0.55, three studies, 604 participants) and 12-month time points (RR 0.62, 95% CI 0.36 to 1.05, one study, 439 participants). Three trials reported posterior capsule rupture: this occurred more commonly in the ECCE group than the phacoemulsification group but small numbers of events mean the true effect is uncertain (Peto odds ratio (OR) 0.56, 95% CI 0.26 to 1.22, three studies, 688 participants). Iris prolapse, cystoid macular oedema and posterior capsular opacification were also higher in the ECCE group than the phacoemulsification group. Phacoemulsification surgical costs were higher than ECCE in two studies. A third study reported similar costs for phacoemulsification and ECCE up to six weeks postoperatively, but following this time point ECCE incurred additional costs due to additional visits, spectacles and laser treatment to achieve a similar outcome.

AUTHORS' CONCLUSIONS

Removing cataract by phacoemulsification may result in a better visual acuity compared to ECCE, with a lower complication rate. The review is currently underpowered to detect differences for rarer outcomes, including poor visual outcome. The lower cost of ECCE may justify its use in a patient population where high-volume surgery is a priority, however, there are a lack of data comparing phacoemulsification and ECCE in lower-income settings.

Manual small incision cataract surgery (MSICS) with posterior chamber intraocular lens versus phacoemulsification with posterior chamber intraocular lens for age-related cataract

BACKGROUND

Age-related cataract is a major cause of blindness and visual morbidity worldwide. It is therefore important to establish the optimal technique of lens removal in cataract surgery.

OBJECTIVES

To compare manual small incision cataract surgery (MSICS) and phacoemulsification techniques.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 6), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to July 2013), EMBASE (January 1980 to July 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to July 2013), Web of Science Conference Proceedings Citation Index - Science (CPCI-S) (January 1970 to July 2013), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 23 July 2013.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) for age-related cataract that compared MSICS and phacoemulsification.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed all studies. We defined two primary outcomes: 'good functional vision' (presenting visual acuity of 6/12 or better) and 'poor visual outcome' (best corrected visual acuity of less than 6/60). We collected data on these outcomes at three and 12 months after surgery. Complications such as posterior capsule rupture rates and other intra- and postoperative complications were also assessed. In addition, we examined cost effectiveness of the two techniques. Where appropriate, we pooled data using a random-effects model.

MAIN RESULTS

We included eight trials in this review with a total of 1708 participants. Trials were conducted in India, Nepal and South Africa. Follow-up ranged from one day to six months, but most trials reported at six to eight weeks after surgery. Overall the trials were judged to be at risk of bias due to unclear reporting of masking and follow-up. No studies reported presenting visual acuity so data were collected on both best-corrected (BCVA) and uncorrected (UCVA) visual acuity. Most studies reported visual acuity of 6/18 or better (rather than 6/12 or better) so this was used as an indicator of good functional vision. Seven studies (1223 participants) reported BCVA of 6/18 or better at six to eight weeks (pooled risk ratio (RR) 0.99 95% confidence interval (CI) 0.98 to 1.01) indicating no difference between the MSICS and phacoemulsification groups. Three studies (767 participants) reported UCVA of 6/18 or better at six to eight weeks, with a pooled RR indicating a more favourable outcome with phacoemulsification (0.90, 95% CI 0.84 to 0.96). One trial (96 participants) reported UCVA at six months with a RR of 1.07 (95% CI 0.91 to 1.26).Regarding BCVA of less than 6/60: there were only 11/1223 events reported. The pooled Peto odds ratio was 2.48 indicating a more favourable outcome using phacoemulsification but with wide confidence intervals (0.74 to 8.28) which means that we are uncertain as to the true effect.The number of complications reported were also low for both techniques. Again this means the review is underpowered to detect a difference between the two techniques with respect to these complications. One study reported on cost which was more than four times higher using phacoemulsification than MSICS.

AUTHORS' CONCLUSIONS

On the basis of this review, removing cataract by phacoemulsification may result in better UCVA in the short term (up to three months after surgery) compared to MSICS, but similar BCVA. There is a lack of data on long-term visual outcome. The review is currently underpowered to detect differences for rarer outcomes, including poor visual outcome. In view of the lower cost of MSICS, this may be a favourable technique in the patient populations examined in these studies, where high volume surgery is a priority. Further studies are required with longer-term follow-up to better assess visual outcomes and complications which may develop over time such as posterior capsule opacification.

Training of an ophthalmologist in concepts and practice of community eye health

Training in community eye health (CEH; public health applied to ophthalmology) complements clinical ophthalmology knowledge and enhances the physician's ability to meet the needs at the individual and community level in the context of VISION 2020. The upcoming version of the ophthalmological residency curriculum that was developed by the International Council of Ophthalmology (ICO) includes a new, specific section on CEH. It has basic, standard, advanced and very advanced levels of goals (the last one is exclusively for fellows/master students), and provides a public health approach to the main causes of blindness and low vision. The number of individuals aged ≥60 years is increasing twice as fast as the number of ophthalmologists, and as this age group is more likely to become blind/visually impaired, accessibility to eye care in the near future might be suboptimal even in wealthier countries. In order to achieve VISION 2020 goals, it is necessary to train more ophthalmologists and other eye care workers. However, the adoption of CEH component of the ICO curriculum for ophthalmology residents will enable them to meet local needs for eye care.

Systematic reviews need to consider applicability to disadvantaged populations: inter-rater agreement for a health equity plausibility algorithm

Background

Systematic reviews have been challenged to consider effects on disadvantaged groups. A priori specification of subgroup analyses is recommended to increase the credibility of these analyses. This study aimed to develop and assess inter-rater agreement for an algorithm for systematic review authors to predict whether differences in effect measures are likely for disadvantaged populations relative to advantaged populations (only relative effect measures were addressed).

Methods

A health equity plausibility algorithm was developed using clinimetric methods with three items based on literature review, key informant interviews and methodology studies. The three items dealt with the plausibility of differences in relative effects across sex or socioeconomic status (SES) due to: 1) patient characteristics; 2) intervention delivery (i.e., implementation); and 3) comparators. Thirty-five respondents (consisting of clinicians, methodologists and research users) assessed the likelihood of differences across sex and SES for ten systematic reviews with these questions. We assessed inter-rater reliability using Fleiss multi-rater kappa.

Results

The proportion agreement was 66% for patient characteristics (95% confidence interval: 61%-71%), 67% for intervention delivery (95% confidence interval: 62% to 72%) and 55% for the comparator (95% confidence interval: 50% to 60%). Inter-rater kappa, assessed with Fleiss kappa, ranged from 0 to 0.199, representing very low agreement beyond chance.

Conclusions

Users of systematic reviews rated that important differences in relative effects across sex and socioeconomic status were plausible for a range of individual and population-level interventions. However, there was very low inter-rater agreement for these assessments. There is an unmet need for discussion of plausibility of differential effects in systematic reviews. Increased consideration of external validity and applicability to different populations and settings is warranted in systematic reviews to meet this need.

Preclinical safety and stability study of a next generation telescope prosthesis for end-stage macular degeneration

BACKGROUND

To assess the surgical procedure, safety and stability of a next generation injectable telescope prosthesis in a rabbit model.

METHODS

After removal of the crystalline lenses of eight New Zealand White rabbits, the next generation device was randomly implanted in one eye, and the available telescope prosthesis (Normal device) was implanted in the fellow eye. Operative parameters (incision, capsulorrhexis size and operative time), intraoperative and postoperative complications rates, endothelial cell density changes and the distance between the corneal endothelium and the telescope (central clearance distance) were measured and compared between the groups.

RESULTS

Incision size and capsulorrhexis size were smaller, and operative time was shorter in the next generation group in comparison with the Normal group. No difference was found in the intraoperative and postoperative complication rates between the groups. Endothelial cell density loss observed in the next generation group was less than the loss in the Normal group, but the difference was not significant statistically. The central clearance distance was significantly larger in the next generation group in comparison with the Normal group (P = 0.001).

CONCLUSIONS

The next generation telescope was implanted through a smaller incision, with a shorter surgical time and a larger central clearance distance in the rabbit eyes, in comparison with the Normal group. The next generation device may allow reduced trauma to the corneal endothelium, better control during surgery and induce less astigmatism while preserving the optical advantages of the Food and Drug Administration-approved telescope prosthesis.

Multifocal versus monofocal intraocular lenses after cataract extraction

BACKGROUND

Good unaided distance visual acuity is now a realistic expectation following cataract surgery and intraocular lens (IOL) implantation. Near vision, however, still requires additional refractive power, usually in the form of reading glasses. Multiple optic (multifocal) IOLs are available which claim to allow good vision at a range of distances. It is unclear whether this benefit outweighs the optical compromises inherent in multifocal IOLs.

OBJECTIVES

The objective of this review was to assess the effects of multifocal IOLs, including effects on visual acuity, subjective visual satisfaction, spectacle dependence, glare and contrast sensitivity, compared to standard monofocal lenses in people undergoing cataract surgery.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 2), MEDLINE (January 1946 to March 2012), EMBASE (January 1980 to March 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 6 March 2012. We searched the reference lists of relevant articles and contacted investigators of included studies and manufacturers of multifocal IOLs for information about additional published and unpublished studies.

SELECTION CRITERIA

All randomised controlled trials comparing a multifocal IOL of any type with a monofocal IOL as control were included. Both unilateral and bilateral implantation trials were included.

DATA COLLECTION AND ANALYSIS

Two authors collected data and assessed trial quality. Where possible, we pooled data from the individual studies using a random-effects model, otherwise we tabulated data.

MAIN RESULTS

Sixteen completed trials (1608 participants) and two ongoing trials were identified. All included trials compared multifocal and monofocal lenses but there was considerable variety in the make and model of lenses implanted. Overall we considered the trials at risk of performance and detection bias because it was difficult to mask patients and outcome assessors. It was also difficult to assess the role of reporting bias. There was moderate quality evidence that similar distance acuity is achieved with both types of lenses (pooled risk ratio (RR) for unaided visual acuity worse than 6/6: 0.98, 95% confidence interval (CI) 0.91 to 1.05). There was also evidence that people with multifocal lenses had better near vision but methodological and statistical heterogeneity meant that we did not calculate a pooled estimate for effect on near vision. Total freedom from use of glasses was achieved more frequently with multifocal than monofocal IOLs. Adverse subjective visual phenomena, particularly haloes, or rings around lights, were more prevalent and more troublesome in participants with the multifocal IOL and there was evidence of reduced contrast sensitivity with the multifocal lenses.

AUTHORS' CONCLUSIONS

Multifocal IOLs are effective at improving near vision relative to monofocal IOLs. Whether that improvement outweighs the adverse effects of multifocal IOLs will vary between patients. Motivation to achieve spectacle independence is likely to be the deciding factor.

Focussing both eyes on health outcomes: revisiting cataract surgery

Background

The appropriateness of cataract surgery procedures has been questioned, the suggestion being that the surgery is sometimes undertaken too early in the disease progression. Our three study questions were: What is the level of visual impairment in patients scheduled for cataract surgery? What is the improvement following surgery? Given the thresholds for a minimal detectable change (MDC) and a minimal clinically important difference (MCID), do gains in visual function reach the MDC and MCID thresholds?

Methods

The sample included a prospective cohort of cataract surgery patients from four Fraser Health Authority ophthalmologists. Visual function (VF-14) was assessed pre-operatively and at seven weeks post-operatively. Two groups from this cohort were included in this analysis: ‘all first eyes’ (cataract extraction on first eye) and ‘both eyes’ (cataract removed from both eyes). Descriptive statistics, change scores for VF-14 for each eye group and proportion of patients who reach the MDC and MCID are reported.

Results

One hundred and forty-two patients are included in the ‘all first eyes’ analyses and 55 in the ‘both eyes’ analyses. The mean pre-operative VF-14 score for the ‘all first eyes’ group was 86.7 (on a 0–100 scale where 100 is full visual function). The mean change in VF-14 for the 'both eyes' group was 7.5. Twenty-three percent of patients achieved improvements in visual function beyond the MCID threshold and 35% saw improvement beyond the MDC.

Conclusions

Neither threshold level for MDC or MCID for the VF-14 scale was achieved for a majority of patients. A plausible explanation for this is the very high levels of pre-operative visual functioning.

Analysis of resident-performed manual small incision cataract surgery (MSICS): an efficacious approach to mature cataracts

To examine and improve outcomes of resident-performed manual small incision cataract surgery (MSICS) cases via analysis of visual recovery, intraoperative adverse events, and early postoperative course. Particular focus was directed toward mature cataracts extracted by MSICS. A retrospective review was performed to identify MSICS cases performed by resident surgeons unfamiliar with the technique (initial ten cases) in an academic setting. Preoperative history, intraoperative adverse events, and postoperative course were reviewed. Of 30 cases identified, mean preoperative acuity was 1.8 ± 0.9 logMAR units (Snellen equivalent = 20/1262) improving to 0.20 ± 0.35 logMAR units (20/31) at final follow-up (p < 0.0001). Mean follow-up was 22.1 ± 19.0 days. The most frequent intraoperative adverse events were wound leak requiring intraoperative suturing (33 %), vitreous loss (6.7 %), and capsulorhexis radialization (6.7 %). Transient cornea edema was the most frequent (56.7 %) early postoperative minor complication. Two major complications occurred that required wound revision in one eye and iridoplasty in one eye. Of the 30 eyes undergoing surgery, 19 were noted to have mature cataracts. In this subset, mean acuity was 2.25 ± 0.64 logMAR units (20/3557) improving to 0.28 ± 0.42 logMAR (20/38) at final follow-up (p < 0.0001). Complications were similar in nature and frequency to the entire population in this subgroup. Supervised resident MSICS cataract surgery can result in excellent anatomic and visual outcomes. Appropriate wound construction is a frequently encountered difficulty, so particular attention should be directed to this step by both trainers and trainees.

Surgery for cataracts in people with age-related macular degeneration

BACKGROUND

Cataract and age-related macular degeneration (AMD) are common causes of decreased vision that often occur simultaneously in people over age 50. Although cataract surgery is an effective treatment for cataract-induced visual loss, some clinicians suspect that such an intervention may increase the risk of worsening of underlying AMD and thus have deleterious effects on vision.

OBJECTIVES

The objective of this review was to evaluate the effectiveness and safety of cataract surgery in eyes with AMD.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 4), MEDLINE (January 1950 to April 2012), EMBASE (January 1980 to April 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to April 2012), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 16 April 2012.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized trials of eyes affected by both cataract and AMD in which cataract surgery would be compared to no surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated the search results against the inclusion and exclusion criteria. Two authors independently extracted data and assessed risk of bias for included studies. We resolved discrepancies by discussion.

MAIN RESULTS

One RCT with 60 participants with visually significant cataract and AMD was included in this review. Participants were randomized to immediate cataract surgery (within two weeks of enrollment) (n = 29) or delayed cataract surgery (six months after enrollment) (n = 31). At six months, four participants were lost to follow-up; two participants from each group. The immediate surgery group showed mean improvement in best-corrected visual acuity (BCVA) compared with the delayed surgery group at six months (mean difference (MD) 0.15 LogMAR, 95% confidence interval (CI) 0.28 to 0.02). There was no significant difference in the development of choroidal neovascularization between groups (1/27 eyes in the immediate surgery group versus 0/29 eyes in the delayed surgery group). Results from Impact of Vision Impairment (IVI) questionnaires suggested that the immediate surgery group faired better with quality of life outcomes than the delayed surgery group (MD in IVI logit scores 1.60, 95% CI 0.61 to 2.59). No postoperative complication was reported. We identified a second potentially relevant study of immediate versus delayed cataract surgery in 54 people with AMD. Results for the study are not yet available, but may be eligible for future updates of this review.

AUTHORS' CONCLUSIONS

At this time, it is not possible to draw reliable conclusions from the available data to determine whether cataract surgery is beneficial or harmful in people with AMD. Physicians will have to make practice decisions based on best clinical judgment until controlled trials are conducted and their findings published.It would be valuable for future research to investigate prospective RCTs comparing cataract surgery to no surgery in patients with AMD to better evaluate whether cataract surgery is beneficial or harmful in this group. However ethical considerations need to be addressed when delaying a potentially beneficial treatment and it may not be feasible to conduct a long-term study where surgery is withheld from the control group. Utilization of pre-existing, standardized systems for grading cataract and AMD and measuring outcomes (visual acuity, change in visual acuity, worsening of AMD and quality of life measures) should be encouraged.

Antioxidant vitamin supplementation for preventing and slowing the progression of age-related cataract

BACKGROUND

Age-related cataract is a major cause of visual impairment in the elderly. Oxidative stress has been implicated in its formation and progression. Antioxidant vitamin supplementation has been investigated in this context.

OBJECTIVES

To assess the effectiveness of antioxidant vitamin supplementation in preventing and slowing the progression of age-related cataract.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 2), MEDLINE (January 1950 to March 2012), EMBASE (January 1980 to March 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to March 2012), Open Grey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 2 March 2012. We also checked the reference lists of included studies and ongoing trials and contacted investigators to identify eligible randomized trials.

SELECTION CRITERIA

We included only randomized controlled trials in which supplementation with one or more antioxidant vitamins (beta-carotene, vitamin C and vitamin E) in any form, dosage or combination for at least one year was compared to another antioxidant vitamin or to placebo.

DATA COLLECTION AND ANALYSIS

Two authors extracted data and assessed trial quality independently. We pooled results for the primary outcomes, i.e., incidence of cataract and incidence of cataract extraction. We did not pool results of the secondary outcomes - progression of cataract and loss of visual acuity, because of differences in definitions of outcomes and data presentation. We pooled results by type of cataract when data were available. We did not perform a sensitivity analysis.

MAIN RESULTS

Nine trials involving 117,272 individuals of age 35 years or older are included in this review. The trials were conducted in Australia, Finland, India, Italy, the United Kingdom and the United States, with duration of follow-up ranging from 2.1 to 12 years. The doses of antioxidant vitamins were higher than the recommended daily allowance. There was no evidence of effect of antioxidant vitamin supplementation in reducing the risk of cataract, cataract extraction, progression of cataract or in slowing the loss of visual acuity. In the pooled analyses, there was no evidence of effect of beta-carotene supplementation in reducing the risk of cataract (two trials) (relative risk (RR) 0.99, 95% confidence interval (CI) 0.91 to 1.08; n = 57,703) or in reducing the risk of cataract extraction (three trials) (RR 1.00, 95% CI 0.91 to 1.10; n = 86,836) or of vitamin E supplementation in reducing the risk of cataract (three trials) (RR 0.97, 95% CI 0.91 to 1.04; n = 50,059) or of cataract extraction (five trials) (RR 0.98, 95% CI 0.91 to 1.05; n = 83,956). The proportion of participants developing hypercarotenodermia (yellowing of skin) while on beta-carotene ranged from 7.4% to 15.8%.

AUTHORS' CONCLUSIONS

There is no evidence from RCTs that supplementation with antioxidant vitamins (beta-carotene, vitamin C or vitamin E) prevents or slows the progression of age-related cataract. We do not recommend any further studies to examine the role of antioxidant vitamins beta-carotene, vitamin C and vitamin E in preventing or slowing the progression of age-related cataract. Costs and adverse effects should be weighed carefully with unproven benefits before recommending their intake above recommended daily allowances.

Manual small incision cataract surgery (MSICS) with posterior chamber intraocular lens versus extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens for age-related cataract

BACKGROUND

Age-related cataract is the opacification of the lens, which occurs as a result of denaturation of lens proteins. Age-related cataract remains the leading cause of blindness globally, except in the most developed countries. A key question is what is the best way of removing the lens, especially in lower income settings.

OBJECTIVES

To compare two different techniques of lens removal in cataract surgery: manual small incision surgery (MSICS) and extracapsular cataract extraction (ECCE).

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 1), MEDLINE (January 1950 to February 2012), EMBASE (January 1980 to February 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to February 2012), Web of Science Conference Proceedings Citation Index- Science (CPCI-S), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 14 February 2012.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) only. Participants in the trials were people with age-related cataract. We included trials where MSICS with a posterior chamber intraocular lens (IOL) implant was compared to ECCE with a posterior chamber IOL implant.

DATA COLLECTION AND ANALYSIS

Data were collected independently by two authors. We aimed to collect data on presenting visual acuity 6/12 or better and best-corrected visual acuity of less than 6/60 at three months and one year after surgery. Other outcomes included intraoperative complications, long-term complications (one year or more after surgery), quality of life, and cost-effectiveness. There were not enough data available from the included trials to perform a meta-analysis.

MAIN RESULTS

Three trials randomly allocating people with age-related cataract to MSICS or ECCE were included in this review (n = 953 participants). Two trials were conducted in India and one in Nepal. Trial methods, such as random allocation and allocation concealment, were not clearly described; in only one trial was an effort made to mask outcome assessors. The three studies reported follow-up six to eight weeks after surgery. In two studies, more participants in the MSICS groups achieved unaided visual acuity of 6/12 or 6/18 or better compared to the ECCE group, but overall not more than 50% of people achieved good functional vision in the two studies. 10/806 (1.2%) of people enrolled in two trials had a poor outcome after surgery (best-corrected vision less than 6/60) with no evidence of difference in risk between the two techniques (risk ratio (RR) 1.58, 95% confidence interval (CI) 0.45 to 5.55). Surgically induced astigmatism was more common with the ECCE procedure than MSICS in the two trials that reported this outcome. In one study there were more intra- and postoperative complications in the MSICS group. One study reported that the costs of the two procedures were similar.

AUTHORS' CONCLUSIONS

There are no other studies from other countries other than India and Nepal and there are insufficient data on cost-effectiveness of each procedure. Better evidence is needed before any change may be implemented. Future studies need to have longer-term follow-up and be conducted to minimize biases revealed in this review with a larger sample size to allow examination of adverse events.

Interventions for age-related visual problems in patients with stroke

BACKGROUND

The prevalence of eye problems increases with age and, consequently, so does the level of visual impairment. As the incidence of stroke also increases with age, a significant proportion of stroke patients will have age-related visual problems. It is possible that the effect of interventions for age-related visual problems may differ in the population of stroke patients compared to the wider population of older people. The interaction between the problems arising directly from stroke and those arising directly from age-related visual problems will be complex. Interventions for age-related visual problems may also be affected by the presence of other stroke-related co-morbidities. Consequently, the nature and outcome of interventions for age-related visual problems may be different in patients with stroke.

OBJECTIVES

The aim of this review is to determine if interventions for age-related visual problems improve functional ability following stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (March 2011), the Cochrane Eyes and Vision Group Trials Register (December 2009) and nine electronic bibliographic databases including: the Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), MEDLINE (1950 to February 2011), EMBASE (1980 to February 2011), CINAHL (1982 to February 2011), AMED (1985 to February 2011) and PsycINFO (1967 to February 2011). We also searched reference lists and trials registers, handsearched journals and conference proceedings, and contacted experts.

SELECTION CRITERIA

Randomised trials in adults after stroke, where the intervention is specifically targeted at assessing, treating or correcting age-related visual problems, or improving the ability of the patient to cope with visual impairment. Primary outcome was functional ability in activities of daily living and secondary outcomes included functional ability in extended activities of daily living, visual acuity, visual field, visual function, balance, falls, depression and anxiety, discharge destination/residence after stroke, quality of life and social isolation, adverse events and death.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts and planned to extract data and appraise trials. We planned that assessment of methodological quality would be undertaken for allocation concealment, blinding of outcome assessor, method of dealing with missing data and other potential sources of bias.

MAIN RESULTS

We considered 7357 titles, 460 abstracts and 85 full papers. We identified no studies for inclusion in this review.

AUTHORS' CONCLUSIONS

There are no implications for practice arising from this review. Evidence relating to the management of patients (from the general population) with age-related visual problems is available from other Cochrane reviews and is likely to be the best evidence available for making treatment decisions about individual patients. Subgroup analyses within these reviews to explore the effect of interventions for age-related visual problems in patients with stroke are recommended. We recommend that the objectives and selection criteria for this Cochrane review are amended and clarified prior to any future updates.

Routine preoperative medical testing for cataract surgery

BACKGROUND

Cataract surgery is practiced widely and substantial resources are committed to an increasing cataract surgical rate in developing countries. With the current volume of cataract surgery and the increases in the future, it is critical to optimize the safety and cost-effectiveness of this procedure. Most cataracts are performed on older individuals with correspondingly high systemic and ocular comorbidities. It is likely that routine preoperative medical testing will detect medical conditions, but it is questionable whether these conditions should preclude individuals from cataract surgery or change their perioperative management.

OBJECTIVES

(1) To investigate the evidence for reductions in adverse events through preoperative medical testing, and (2) to estimate the average cost of performing routine medical testing.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 12), MEDLINE (January 1950 to December 2011), EMBASE (January 1980 to December 2011), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to December 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 9 December 2011. We used reference lists and the Science Citation Index to search for additional studies.

SELECTION CRITERIA

We included randomized clinical trials in which routine preoperative medical testing was compared to no preoperative or selective preoperative testing prior to age-related cataract surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed abstracts to identify possible trials for inclusion. For each included study, two review authors independently documented study characteristics, extracted data, and assessed methodological quality.

MAIN RESULTS

The three randomized clinical trials included in this review reported results for 21,531 total cataract surgeries with 707 total surgery-associated medical adverse events, including 61 hospitalizations and three deaths. Of the 707 medical adverse events reported, 353 occurred in the pretesting group and 354 occurred in the no testing group. Most events were cardiovascular and occurred during the intraoperative period. Routine preoperative medical testing did not reduce the risk of intraoperative (OR 1.02, 95% CI 0.85 to 1.22) or postoperative medical adverse events (OR 0.96, 95% CI 0.74 to 1.24) when compared to selective or no testing. Cost savings were evaluated in one study which estimated the costs to be 2.55 times higher in those with preoperative medical testing compared to those without preoperative medical testing. There was no difference in cancellation of surgery between those with preoperative medical testing and those with no or limited preoperative testing, reported by two studies.

AUTHORS' CONCLUSIONS

This review has shown that routine pre-operative testing does not increase the safety of cataract surgery. Alternatives to routine preoperative medical testing have been proposed, including self-administered health questionnaires, which could substitute for health provider histories and physical examinations. Such avenues may lead to cost-effective means of identifying those at increased risk of medical adverse events due to cataract surgery. However, despite the rare occurrence, adverse medical events precipitated by cataract surgery remain a concern because of the large number of elderly patients with multiple medical comorbidities who have cataract surgery in various settings. The studies summarized in this review should assist recommendations for the standard of care of cataract surgery, at least in developed settings. Unfortunately, in developing country settings, medical history questionnaires would be useless to screen for risk since few people have ever been to a physician, let alone been diagnosed with any chronic disease.

Drug-Eluting Intraocular Lenses

Notable advances in materials science and in surgical techniques make the management of cataract by replacement of the opaque crystalline with an intraocular lens (IOL), one of the most cost-effective interventions in current healthcare. The usefulness and safety of IOLs can be enhanced if they are endowed with the ability to load and to sustain drug release in the implantation site. Drug-eluting IOLs can prevent infections and untoward reactions of eye tissues (which lead to opacification) and also can act as drug depots for treatment of several other ocular pathologies. Such a myriad of therapeutic possibilities has prompted the design of drug-IOL combination products. Several approaches are under study, namely combination of the IOL with an insert in a single device, soaking in drug solutions, impregnation using supercritical fluids, coating with drug/polymer layers, and covalent grafting of the drug. The advantages/limitations of each technique are discussed in the present review on selected examples. Although more in vivo data are required, the information already available proves the interest of some approaches in ocular therapeutics.

Day care versus in-patient surgery for age-related cataract

BACKGROUND

Age-related cataract accounts for more than 40% of cases of blindness in the world with the majority of people who are blind from cataract found in the developing world. With the increased number of people with cataract there is an urgent need for cataract surgery to be made available as a day care procedure.

OBJECTIVES

To provide reliable evidence for the safety, feasibility, effectiveness and cost-effectiveness of cataract extraction performed as day care versus in-patient procedure.

SEARCH STRATEGY

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 5), MEDLINE (January 1950 to May 2011), EMBASE (January 1980 to May 2011), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to May 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com) and ClinicalTrials.gov (www.clinicaltrials.gov). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 23 May 2011.

SELECTION CRITERIA

We included randomised controlled trials comparing day care and in-patient surgery for age-related cataract. The primary outcome was the achievement of a satisfactory visual acuity six weeks after the operation.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Adverse effects information was collected from the trials.

MAIN RESULTS

We included two trials (conducted in Spain and USA), involving 1284 people. One trial reported statistically significant differences in early postoperative complication rates in the day care group, with an increased risk of increased intraocular pressure, which had no clinical relevance to visual outcomes four months postoperatively. The mean change in visual acuity (Snellen lines) of the operated eye four months postoperatively was 4.1 (standard deviation (SD) 2.3) for the day care group and 4.1 (SD 2.2) for the in-patient group and not statistically significant. The four-month postoperative mean change in quality of life score measured using the VF14 showed minimal differences between the two groups. Costs were 20% more for the in-patient group and this was attributed to higher costs for overnight stay. One study only reported hotel costs for the non-hospitalised participants making aggregation of data on costs impossible.

AUTHORS' CONCLUSIONS

This review provides some evidence that there is a cost saving but no significant difference in outcome or risk of postoperative complications between day care and in-patient cataract surgery. This is based on one detailed and methodologically sound trial conducted in the developed world. The success, safety and cost-effectiveness of cataract surgery as a day care procedure appear to be acceptable. Future research may well focus on evidence provided by high quality clinical databases and registers which would enable clinicians and healthcare planners to agree clinical and social indications for in-patient care and so make better use of resources, by selecting day case surgery unless these criteria are met.