Phacoemulsification versus manual small-incision cataract surgery for white cataract

Feasibility of shear wave elastography for evaluating lens stiffness in patients with age-related cataracts: A quantitative analysis

Background

Shear wave elastography (SWE) is a novel imaging technique that provides quantitative assessments of tissue stiffness. This non-invasive method offers real-time, quantitative measurements and has been widely applied to various tissues, providing valuable diagnostic insights.

Purpose

This study aimed to investigate the feasibility of using SWE to evaluate the stiffness of the lens in patients with age-related cataracts.

Materials and methods

A comparative analysis involving 92 patients diagnosed with age-related cataracts and 39 healthy controls was conducted. Lens stiffness was quantified using SWE measurements. The lens nucleus of all participants was graded based on the Lens Opacities Classification System II (LOCS II). Correlations between the stiffness of the lens and age were also analyzed.

Results

The study indicates that both the stiffness of the lens and the lens nucleus were significantly higher in patients with age-related cataracts compared to healthy controls (P < 0.001). In patients with age-related cataracts, although lens nucleus stiffness variations across different grades of cataract severity were not statistically significant, all grades displayed increased stiffness relative to healthy controls. Additionally, a significant positive correlation between lens stiffness and age was observed in all participants (P < 0.001).

Conclusion

SWE appears to be a promising imaging technique for quantitatively assessing the mechanical characteristics of the lens in patients with age-related cataracts.

Study of safety and efficacy of sub-Tenon and subconjunctival anesthesia in manual small-incision cataract surgery for hard-grade cataracts

PURPOSE

The purpose was to study the safety and efficacy of sub-Tenon and subconjunctival anesthesia in manual small-incision cataract surgery (MSICS) in patients with hard-grade cataracts.

STUDY DESIGN

The design of the study was a prospective, observational, and randomized control study.

MATERIALS AND METHODS

A total of 196 eyes, including 98 eyes in the subconjunctival anesthesia group (group A) and 98 eyes in the sub-Tenon anesthesia group (Group B), undergoing MSICS were enrolled in the study. A single surgeon performed all the surgeries. Intraoperative and postoperative pain scores, patient comfort, surgeon's satisfaction, and intraoperative complications were examined.

RESULTS

The mean age of patients in Group A was 66.64 ± 9.95 years and that of patients in Group B was 64.52 ± 9.46. No statistically significant difference was noted in the intraoperative (P = 0.54) and postoperative pain (P = 0.66) scores between the two groups. There was no pain (0 score) in 30% of patients in Group A and 35% of patients in Group B intraoperatively. The average surgical time (P = 0.66) and surgeon's comfort (P = 0.34) were not statistically significant. The mean corneal haze was 0.054 ± 0.12 in group A and 0.065 ± 0.22 in group B (P = 0.45). Two patients in group A required supplemental anesthesia. There were no surgical complications that could compromise visual outcomes. No patients in either group showed alterations in vital parameters or required intravenous sedation.

CONCLUSION

Both techniques of anesthesia are safe and effective for performing MSICS in hard-grade cataracts. However, it is prudent to choose a technique according to the surgeon's requirements.

Cataract Surgery Visual Outcome and Associated Factors Among Adults Attended Jimma University Medical Center, Jimma, Southwest Ethiopia

Background

Cataract is the leading cause of blindness and the second leading cause of visual impairment worldwide, accounting for 51% and 33% of all cases, respectively, in low- and medium-income countries bearing a disproportionately high burden. Hence, this study aimed to assess the visual outcome of age-related cataract surgery and identify factors associated with patients' postoperative visual outcomes in Jimma University Medical Center, Southwest Ethiopia.

Methods

An institution-based cross-sectional study design was conducted among 386 cataract surgery patients from January 1, 2016, to December 30, 2017. The study participants were selected using a systematic random sampling technique. Data were collected by reviewing the selected patients' medical records using a pre-tested checklist, entered into EpiData version 3.1, and exported to SPSS 20 for analysis. Proportions, summary statistics, and tables were used for presentations of the findings. Binary logistic regression was carried out to identify independent predictors of visual outcome. Findings were presented with adjusted odds ratios and their 95% confidence interval. A p-value <0.05 was used to declare a statistically significant association.

Results

About 231 individuals (59.8%) had poor visual results following cataract surgery. Furthermore, age >70 (AOR = 3.64; 95% CI [1.35-9.82]), preoperative ocular co-morbidities (AOR = 2.34; [1.32-4.15]), incision-based cataract surgery (AOR = 7.11; [3.16-16.02]), compared phacoemulsification operated by resident surgeons (AOR = 2.19; [1.23-3.89]), presence of intraoperative complication (AOR = 3.41; [1.47-7.92]), lens remnant (AOR = 2.91; [1.11-4.92]), ocular inflammation (OR = 2.56; [1.34-4.92]), and striate keratopathy/corneal edema (AOR = 1.91; [1.07-3.44]) were significantly associated with poor visual outcome.

Conclusion

The visual outcome following cataract surgery fall below WHO recommendation. In this study, age, ocular co-morbidities, surgical method, surgeon status, intraoperative complication, SK, and ocular inflammation associated with post-operative Uveitis and anterior chamber reaction were associated with a poor visual outcome.

Corneal Edema after Cataract Surgery

This systematic review investigates the prevalence and underlying causes of corneal edema following cataract surgery employing manual phacoemulsification. A comprehensive search encompassing databases such as PubMed, Embase, ProQuest, Cochrane Library, and Scopus was conducted, focusing on variables encompassing cataract surgery and corneal edema. Two independent reviewers systematically extracted pertinent data from 103 articles, consisting of 62 theoretical studies and 41 clinical trials. These studies delved into various aspects related to corneal edema after cataract surgery, including endothelial cell loss, pachymetry measurements, visual performance, surgical techniques, supplies, medications, and assessments of endothelial and epithelial barriers. This review, encompassing an extensive analysis of 3060 records, revealed significant correlations between corneal edema and endothelial cell loss during phacoemulsification surgery. Factors such as patient age, cataract grade, and mechanical stress were identified as contributors to endothelial cell loss. Furthermore, pachymetry and optical coherence tomography emerged as valuable diagnostic tools for assessing corneal edema. In conclusion, this systematic review underscores the link between corneal edema and endothelial cell loss in manual phacoemulsification cataract surgery. It highlights the relevance of factors like patient demographics and diagnostic modalities. However, further research is essential to unravel the complexities of refractive changes and the underlying mechanisms.

4-Flanged intrascleral fixation of an intraocular lens through the dialing hole

The high prevalence of mature, hypermature, and traumatic cataracts in developing countries, combined with the limited availability of surgical resources and skill by anterior segment surgeons to manage the resultant aphakia, leaves the patient needlessly blind. Relying on posterior segment surgeons, expensive surgical setup, and appropriate lenses for aphakia management limits the number of patients receiving a secondary intraocular lens (IOL). Utilizing the well-acknowledged flanging technique and the readily available polymethyl methacrylate (PMMA) lenses with dialing holes in their optic, a hammock can be created through the dialing holes using a 7-0 polypropylene suture on a straight needle. This 4-flanged scleral fixation through the dialing hole of an IOL makes scleral fixation of PMMA lens possible by even anterior segment surgeons without requiring any specialized equipment or scleral fixated lens with eyelet. This technique was successfully performed in a series of 103 cases with no incidence of IOL decentration.

Use of Cryopreserved Amniotic Membrane During Pterygium Excision: Health Economic Analysis

Purpose

To determine the health economic opportunity cost or gain associated with performing pterygium excision surgery using the TissueTuck technique with cryopreserved amniotic membrane (AM) instead of conjunctival autograft (CAU).

Methods

We performed a literature review to determine the average surgical duration of pterygium surgery using CAU with fibrin glue or sutures to calculate the average time saved with the TissueTuck technique. Such time savings was then used to determine the opportunity revenue gain per national average Medicare reimbursement if adjusted to the average surgical duration of cataract surgery.

Results

The time savings achieved using the TissueTuck technique over CAU with fibrin glue is 8.9 min per procedure, which can be applied to additional MSICS or phacoemulsification procedures to generate an opportunity revenue gain of $1167 or $762 per 2022 National Average Medicare reimbursement, respectively. After subtracting the current list cost of AmnioGraft (ie, $645), the opportunity gain is $522 or $117 if the time saving is applied to the above procedures, respectively. Alternatively, the time savings achieved by using the TissueTuck technique over CAU with sutures is 23.4 min per procedure, which can be applied to additional MSICS or phacoemulsification procedures to generate an opportunity revenue gain of $3068 and $2004 per TissueTuck procedure or $2423 or $1359 when accounting for the list cost of AmnioGraft, respectively.

Conclusion

The TissueTuck surgical technique using cryopreserved AM for pterygium takes less time, has lower recurrence rates, and provides an opportunity gain compared to pterygium excision with CAU.

Intraocular lens scaffolding technique in hypermature/Morgagnian cataract in manual small-incision cataract surgery

PURPOSE

To describe the surgical technique of intraocular lens (IOL) scaffolding in hypermature/Morgagnian cataract in manual small-incision cataract surgery (MSICS).

SETTING

Charitable section of the hospital through direct availed services at free/subsidized cost.

DESIGN

Interventional study.

METHODS

38 eyes of 38 patients operated at the charitable section of the hospital through direct availed services at free/subsidized cost were included in this study.

RESULTS

IOL scaffolding in MSICS was executed in 38 patients, of whom 25 patients were diagnosed as hypermature cataract, pseudoexfoliation syndrome with mature cataract in 5 patients, 5 patients had phacolytic glaucoma, and 3 patients had lens-induced uveitis. This technique was successful in 35 of 38 patients and was not successful in 3 patients in whom traditional SICS was performed in 2 patients and retrohaptic iris fixation in 1 patient.

CONCLUSIONS

A technique that uses the IOL as a scaffold in hypermature cataract in MSICS that provides a stable barrier by stretching the capsular bag to prevent the crumpling of the bag or whole bag removal after nucleus delivery is described.

Novel nucleus management technique in hypermature morgagnian cataracts with liquified cortex during phacoemulsification

PURPOSE

To describe a novel nucleus management technique of variable size mobile nucleus in Hypermature Morgagnian cataracts.

METHODS

In this technique, under topical anesthesia, temporal tunnel incision and capsulorhexis were performed, and the capsular bag was inflated with 2% w/v hydroxypropylmethylcellulose. A chopper and phacoemulsification probe were used to consciously nudge the nucleus towards the capsular periphery (fornix) to immobilize the floating nucleus against the capsular bag recess. Firm nuclear impaling was achieved using longitudinal power in linear mode (range 0-70%), 650 mmHg vacuum, and aspiration flow rate of 42 ml/min. The nucleus was chopped by direct chop technique, total separation achieved, and fragments emulsified. Primary outcome measures included ease of nuclear holding, iatrogenic zonular stress/damage, posterior capsule tear, and endothelial cell loss.

RESULTS

This technique was performed in 29 consecutive cases from June 2019 - December 2021, and no intraoperative or postoperative complications were noted. The average phacoemulsification time and cumulative dissipated energy (CDE) were nearly similar in all cases.

CONCLUSION

This technique would make phacoemulsification much safer in eyes with hypermature cataract and liquified cortex with lower complication rates and maintenance of better endothelial integrity.

Efficacy of femtosecond laser for anterior capsulotomy in complex white cataracts

OBJECTIVE

To determine the advantages and complication rate of capsulotomy performed with femtosecond laser in white complex cataract cases.

STUDY DESIGN

Retrospective case series.

PARTICIPANTS

Sixteen eyes of 16 patients.

METHODS

This was a single-center retrospective review of white cataract surgery cases in which the femtosecond laser (LenSx, Alcon Laboratories, Fortworth, Texas, USA) was used between May 2019 and February 2021. Outcome measures included an assessment of the capsulotomy, identification of tags, surgical time, cumulative dispersed energy (CDE) and postoperative management.

RESULTS

Sixteen eyes of 16 patients were included in this study; capsule tags occurred in six patients (37.5%). In 2 patients, the capsule presented small adhesions that were identified and removed. One patient presented a very significant contraction of the anterior capsule with an incomplete cut zone of 2 to 4hours. In a patient with nystagmus, the capsulotomy was performed without complications under peribulbar anesthesia.

CONCLUSIONS

The femtosecond laser permitted capsulotomies of better shape, size and regularity in complex cases of white cataract and in combination with conditions such as nystagmus and prior corneal transplantation. The microadhesions and untreated areas were identified with trypan blue, which is essential to use in these cases to avoid associated complications.

Outcomes of manual small incision cataract surgery in hypermature/morgagnian cataract

PURPOSE

To evaluate the visual outcome and complication rate of manual small incision cataract surgery (MSICS) in hypermature morgagnian cataract (HMC).

SETTING

Aravind Eye Hospital, Pondicherry, India.

DESIGN

Retrospective, single center study.

METHODS

Case records of patients diagnosed with HMC and who underwent MSICS from January to December 2019 were retrospectively collected. Data were analyzed for demographic details, preoperative risk factors, intraoperative/postoperative complications, and visual outcome at 1-month follow-up.

RESULTS

105 patients were included in the study. Preoperative risk factors like dense pseudoexfoliation were seen in 6 patients (5.7%), phacolytic glaucoma in 7 patients (6.7%), lens induced uveitis in 5 (4.7%), and phacodonesis in 30 patients (28.5%). Overall intraoperative complication rate was 14.3%, which included posterior capsular rent (n = 4), zonular dialysis (n = 7), and whole bag removal (n = 4). Due to poor posterior capsular bag support, 7 patients (6.6%) did not receive intraocular lens implantation in primary surgery. Both the intraoperative and postoperative complication rate were high in those with risk factors, and this difference was statistically significant ( P < .001 and .0005, respectively). On the first postoperative day, 70 patients (66.7%) had a corrected distance visual acuity (CDVA) better than 20/40, and at 1 month, 98 patients (93.3%) had a CDVA of 20/60 or better of which 89.5% had CDVA of ≥20/40.

CONCLUSIONS

MSICS for hypermature cataract is relatively safe and yields adequate visual outcome. Preoperative risk factors, in addition to hypermaturity, increase the complication rate.

Survey of Ophthalmology Training Experiences Among Young Ophthalmologists in the Asia-Pacific

PURPOSE

To describe ophthalmology training experiences across the Asia-Pacific (APAC).

DESIGN

Survey study.

METHODS

We utilized an anonymous online survey, which was previously validated and conducted in Europe, through Young Ophthalmologist leaders from the national member societies of the Asia-Pacific Academy of Ophthalmology (APAO) from September 2019 to July 2021. Responses were based on a 5-point Likert scale (where applicable) and data were analyzed using Microsoft Excel. Our main outcome measures were differences between regions, that is, Southeast Asia (SEA) and Western Pacific (WP); and seniority, that is, trainees/junior ophthalmologists and senior ophthalmologists.

RESULTS

We collated 130 responses representing 20 regions in the APAC region. The year of completion of ophthalmic training ranged from 1999 to 2024. The mean duration of training was 3.7±1.0 years. Most (98/130, 75%) indicated an interest for a common training standard across the APAC. Comparing SEA and WP trainees, both regions had similar working environments, but those in SEA reported significantly lower remuneration than their counterparts in WP ($600 vs $3000, P <0.05). WP trainees performed more phacoemulsification surgeries (76 WP vs 19 SEA), while SEA trainees conducted more manual small incision cataract surgeries (157 WP vs 1.5 SEA per duration of training). Senior ophthalmologists performed more cataract surgeries (210.9 senior ophthalmologists vs 40.1 junior ophthalmologists). Trainees had less confidence in medical competency areas such as interpreting an electroretinogram/visual evoked potential/electrooculogram (SEA=1.8, WP=2.1) and conducting an angiography (SEA=2.8, WP=3.4).

CONCLUSIONS

Our study highlighted heterogeneity among ophthalmology training experiences in the APAC region, with the majority indicating an interest in a common training standard.

Manual small incision cataract surgery: a viable option for cataract with pseudoexfoliation

PURPOSE

The aim of the study was to assess the spectrum of clinical presentation, intraoperative challenges and immediate surgical outcome of cataract patients with pseudoexfoliation syndrome (PXF) following manual small incision cataract surgery (MSICS).

METHODS

This prospective observational study which was conducted in a rural tertiary care hospital included adult patients with cataract and associated PXF. MSICS was performed for all after a complete ophthalmic and systemic examination. Clinical profile, intraoperative and post-operative complications were noted. Uncorrected visual acuity on first day post-surgery was used to assess the surgical outcome following MSICS.

RESULTS

MSICS was performed in 80 eyes with varying grades of cataract and PXF. The mean age of the patients was 62.5 ± 8.9 years. PXF material on pupillary margin in 77(96%) patients was the most common finding noted. Majority of the patients had advanced cataract (72, 90%) and inadequate mydriasis (62, 77.5%). Posterior capsular rent (8, 10%) and zonular dehiscence (8, 10%) were the intraoperative difficulties faced. Uncorrected visual outcome on first post-operative day was moderate to good in 71 (88.8%) patients, limited by post-operative corneal oedema (21, 26.3%), iritis (31, 38.8%) and aphakia (9, 11.3%).

CONCLUSION

Patients with pseudoexfoliation had poor pupillary dilatation, advanced cataracts and higher rate of posterior capsular rent. Our study showed good outcome of MSICS in PXF patients, even with advanced cataract suggesting that MSICS is a safe, effective and viable option for patients with PXF and cataract.

Effect of intravenous sedation on patients' visual experience and vital signs during cataract surgery under topical anesthesia: A randomized controlled trial

Purpose

Effect of intravenous sedation on patients' visual experience and vital signs during cataract surgery under topical anesthesia: a randomized controlled trial.

Design

Prospective, double masked, randomized controlled trial.

Methods

150 eyes of 150 patients undergoing phacoemulsification and IOL implantation under topical anesthesia were randomized to receive either intravenous midazolam (0.015 ​mg/kg) or normal saline. The patients' experience was evaluated using a questionnaire. Vital signs including blood pressure and heart rate were measured before, during and after surgery. Mean arterial pressure (MAP) was calculated.

Results

Both groups were comparable except that fewer patients in the control group were pseudophakic in the fellow eye (25.3% vs. 41.3%). More patients in the control group perceived hand movements (p ​< ​0.01), surgeon/medical staff (p ​= ​0.04) and sudden increase in vision during surgery (p ​< ​0.01) compared to midazolam group. More control group patients experienced fear (p ​< ​0.001), pain (p ​= ​0.06) and unpleasant surgical experience (20.3% vs. 1.3%, p ​< ​0.001). They also experienced greater fluctuation in MAP (16.9 ​± ​7.9 vs.7.2 ​± ​5.3, p ​< ​0.001) and this was accentuated in hypertensives. After adjusting for age, gender, hypertension status and other eye lens status, multivariable logistic regression analysis revealed that subjects in the control arm (OR ​= ​11.7, 95% [CI] ​= ​1.3-108, p ​= ​0.03), had a longer duration of surgery, experienced pain and more likely to report unpleasant experience. Adjusting for similar covariates, multivariable linear regression analysis showed that control group patients (β ​= ​8.5 ​mmHg, 95% CI ​= ​6.2-10.8, p ​= ​0.03) had hypertension, experienced fear during surgery and greater fluctuations in the MAP.

Conclusions

A sedative dose of intravenous midazolam during phacoemulsification under topical anesthesia significantly reduces patients' visual experience, fear and fluctuations in MAP and improves overall surgical experience.

Incidence and causes of negative dysphotopsia after uncomplicated cataract surgery - A randomized clinical trial

Purpose:

The purpose of this study is to find incidence of negative dysphotopsia (ND) in eyes undergoing clear corneal phacoemulsification and identify its causes including corneal wound hydration and type of intraocular lens (IOL).

Methods:

In this randomized clinical trial, consenting adult patients undergoing phacoemulsification were randomized to receive a hydrophobic (Alcon Acrysof^® SN60WF) or a hydrophilic acrylic IOL (CT Asphina^® 603P, Carl Zeiss Meditec) in a 1:1 ratio. At time of surgery, eyes were again randomized in 1:1 fashion to receive stromal wound hydration or not (n = 80 each in four groups). Primary outcome measure was the incidence of ND between eyes receiving stromal hydration versus no hydration. Those with ND were observed for 5 years after surgery.

Results:

Of the 320 eyes, 29 (9.06%) reported ND of which 24 (83%) were transient. Eyes with wound hydration had significantly higher proportion of ND (n = 21/160, 13%) compared to no hydration (n = 8/160, 5%) (P = 0.01). Additionally, eyes with wound hydration were three times more likely to experience ND (odds ratio = 3.29, 95% CI = 1.3–8.2, P = 0.01). Majority of eyes (20/21, 95%) with ND after hydration had it transiently while half (4/8, 50%) of those with ND without wound hydration had it persistently at 6 weeks (P < 0.001) and continued to experience ND for 5 years but did not request intervention.

Conclusion:

ND occurred in 9% cases with majority being transient. Corneal wound hydration led to significant higher likelihood of experiencing transient ND. Those with persistent ND for more than 6 weeks (1.5%) continue to experience ND for at least 5 years.

Single-snip paralimbal incision: A quick approach to rectus muscles

INTRODUCTION:

Less invasive and quicker surgeries have become common. We compared two conjunctival incisional approaches in strabismus, namely Follow standard paralimbal approach for (SPLA) and single-snip paralimbal (SSPLA).

MATERIALS AND METHODS:

Forty-four patients with horizontal strabismus qualifying for uniocular recession–resection surgeries were randomized to SPLA and SSPLA. SSPLA involved a single v-shaped incision, with the apex of the V near the limbus, and the limbs facing away: by pinching up the conjunctiva with a forceps and delivering the single snip with a spring scissors. We compared the postoperative grades of redness, congestion, chemosis, foreign body sensation, and drop intolerance at day 1, 2 weeks, and 6–8 weeks; scar visibility, as yes or no, at 6–8 weeks; success rates, considered to be within 10 prism diopters of orthophoria, at 6–8 weeks; and operation duration in minutes.

STATISTICAL ANALYSIS:

Statistical analysis was done using Mann–Whitney U-test, for inflammatory grades, Chi-square for proportions, and t-test for parametric measures. Statistical significance was set at P < 0.05.

RESULTS:

On postoperative day 1, congestion (P = 0.02), foreign-body sensation (P = 0.04), and total inflammatory score (P = 0.003) were statistically significantly favoring the SSPLA group. While at 2 weeks, only congestion (P = 0.02) was found to be significantly less in the SSPLA group. There were no significant differences in the proportions of scar visibility (5/22 in the SPLA vs. 3/22 in the SSPLA) and success rate: 20/22 vs. 18/22. The SSPLA was quicker on an average by 6 min (P < 0.001, 95% confidence interval: 3.2–8.7).

CONCLUSION:

Compared to the SPLA, the SSPLA is quicker and results in lesser inflammation in the immediate postoperative period.

Extent of multifocality with corneal manipulation in manual small incision cataract surgery with monofocal posterior chamber intraocular lens implantation

Purpose:

To compare the visual outcome in terms of multifocality in Manual Small Incision Cataract Surgery (MSICS) with and without intraoperative manipulation of corneal curvature.

Methods:

This was a prospective study on 80 subjects (80 eyes) who underwent MSICS with monofocal posterior chamber intraocular lens (PCIOL) implantation between January 2018 and October 2019. Intraoperative manipulation of corneal curvature using viscoelastics was performed during MSICS in 40 subjects (cases) while this intraoperative manipulation was not performed in the remaining 40 subjects (controls). Uncorrected distance visual acuity (UDVA) and uncorrected near visual acuity (UNVA) were compared at day 1, 7, 30 and 180postoperatively.

Results:

At 1 month and 6 months of follow up, UDVA was comparable in the 2 groups. UNVA was better in cases than controls at 1 month and6 months (P < 0.001). At 6 months of follow up,76% of cases with UDVA of 6/9 or better had UNVA of N8 while only 15% of controls with UDVA of 6/9 or better had UNVA of N8 (P <0.001). Mean near add requirement to achieve a best corrected near vision (BCNV)of N6 at 6 months was significantly lesser (P =0.002) in cases (+2.05 D) compared to controls (+2.43D).

Conclusion:

MSICS with intra operative manipulation of corneal curvature resulted in better unaided near visual acuity compared to that without intra operative manipulation of corneal curvature, without compromising unaided distant visual acuity.

Can the postoperative follow-up visit be deferred up to four weeks after an uneventful cataract surgery? - A randomized controlled trial

Purpose:

The aim of this study was to compare the postoperative visual outcome after a Day 0 examination in patients with two follow-ups, one between Day 3 to Day 7 and other between Day 25 to Day 30 to those with a single ophthalmic follow-up directly after 25–30 Days and to assess the safety of deferral of the first follow-up visit at 1 week.

Methods:

Randomized Controlled Trial was conducted at a tertiary eye care hospital, with 848 patients enrolled for the study. Patients meeting the inclusion criteria were selected. Their pre-operative and post-operative data was collected and the patients were divided into groups based on the type of cataract surgery and the postoperative follow-up protocol through randomization.

Results:

No significant difference was observed in the postoperative visual outcome in patients that underwent postoperative review at Day 3–7 and Day 25–30 as opposed to those that followed up directly at Day 25–30 after a mandatory Day 0 examination for all patients.

Conclusion:

In patients with no preexisting ocular or systemic comorbidity undergoing an uneventful cataract surgery, the postoperative follow-up visit can be safely deferred until 4 weeks, without any impact on the postoperative visual outcome, thereby conserving the available resources which can be deviated towards better eye care services.

The visual outcomes and complications of manual small incision cataract surgery and phacoemulsification: long term results

Objective: To compare visual outcomes and complications between manual small incision cataract surgery (MSICS) and phacoemulsification.

Methods: A retrospective study was conducted in the tertiary care center. A total of 1281 cases underwent manual small incision cataract surgery and phacoemulsification from January 2014 to December 2016. The postoperative best corrected visual acuity (BCVA) along with the rates of complications were compared between both groups.

Results: Five hundred and twenty-one patients (40.67%) and 760 patients (59.33%) were subjected by staff members and residents, respectively. Altogether, 689 cases (53.79%) were subjected to MSICS technique and 592 cases (46.21%) to phacoemulsification. The MSICS group had significantly harder cataract (cataract grading ≥ 4+ :31.64% vs. 7.77%; p<0.001). One month postoperatively, good visual outcome (BCVA ≥ 6 /18) in the phacoemulsification group was higher than that in the MSICS group (86.33% vs. 72.12%, p<0.001). The risk factor for poor outcome (post-operative BCVA < 6 /60 in both groups) was the presence of associated ocular pathologies. The intraoperative and perioperative complications rates were higher in the MSICS group (16.55% vs. 6.6%, p<0.001). The most common complications were hyphema (4.35%), posterior capsule ruptures (4.21%), and prolapsed iris (3.05%). Long-term postoperative complication rates were higher in the phacoemulsification group (9.29% vs. 21.28%, p<0.001). The most common complication was posterior capsule opacity (8.71% vs. 20.44%, p<0.001). Pseudophakic bullous keratopathy (PBK) was similar in both groups (0.29% vs. 0.17%, p=1.00).

Conclusion: The number of patients who had experienced good visual outcomes was higher in the phacoemulsification group. However, for both groups, no significant differences were found on the long-term complication rate.

Efficacy of intracameral antibiotics following manual small incision cataract surgery in reducing the rates of endophthalmitis: A meta-analysis

BACKGROUND

Manual small incision cataract surgery (MSICS) is a widely used technique for cataract surgery in the developing world. Higher rates of postoperative endophthalmitis have been reported with this technique compared with phaco-emulsification. The purpose of this study was to evaluate the efficacy of prophylactic intracameral (IC) antibiotics in reducing the rates of postoperative endophthalmitis following MSICS.

METHODS

Systematic review and meta-analysis of patients undergoing MSICS. A literature search in PubMed and EMBASE databases was performed to identify studies published from October 1992 to April 2020 evaluating MSICS with a minimum of 500 eyes reported. Two authors independently assessed eligibility, extracted data and assessed the risk of bias. Heterogeneity was assessed using the I² test.

RESULTS

Twelve studies enrolling 1 494 307 eyes were included. IC antibiotics were used in 725 324 (48.5%) eyes. The risk ratio of developing endophthalmitis was 2.94 (95% CI, 1.07-8.12; P = .037) in eyes that did not receive IC antibiotics.

CONCLUSIONS

Routine use of IC antibiotics may help to reduce the rates of endophthalmitis following MSICS and significantly improve the safety of this effective form of cataract surgery.

Phacoemulsification vs manual small incision cataract surgery in eyes affected by pseudo exfoliation syndrome with grade II and III cataracts

PURPOSE:

To compare the postoperative alteration of central corneal thickness (CCT) and visual outcomes between phacoemulsification (group A) and manual small incision cataract surgery (MSICS) (group B) in grade II and III nuclear cataracts (NS II and III) with pseudoexfoliation syndrome (PXF).

METHODS:

It is a double masked prospective randomised interventional study. A total of 60 eyes of 60 patients were assigned randomly to either the phacoemulsification (group A) or MSICS (group B) groups. All eyes had nuclear sclerosis grade II and III (LOCS II grading system) with pseudoexfoliation material either over the pupillary margin, anterior lens capsule, or both. All surgeries were done by a single surgeon. Postoperative evaluation was scheduled on the 1st, 30th, 90th, and 180th-day. Statistical analyses were done using appropriate methods. Outcome of the study were measured with changes in central corneal thickness (CCT), Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA) and the spherical equivalent in the operated eye up to 6 months post surgery.

RESULTS:

The mean preoperative CCT showed no difference between the groups (0.9659). The mean rise in CCT on the 1st postoperative day (POD) showed a significant difference between the groups {24.65 (SD 9.32) [group A (Phacoemulsification)] and 33.34 (SD11.68) [group B (MSICS)] (P < 0.0023)}. At the 1st, 3rd, and 6th month postoperative visits, there was no significant difference. The mean uncorrected distance visual acuity (UDVA) on the 1st POD was 0.189 (SD 0.118) in Group A and 0.302 (SD 0.121) in group B (P < 0.0005) which was significantly better with the phacoemulsification procedure. At the 1st month it was 0.039 (SD 0.084) in group A and 0.148 (SD 0.089) in group B (P < 0.004), which remained almost stable after that. The mean corrected distance visual acuity (CDVA) at the 1st, 3rd, and 6th-month postoperative visits showed no significant difference (P 0.8). The mean spherical equivalent was 0.29 in group A and 0.8 in group B.

CONCLUSION:

In moderately hard nuclear cataracts with PXF, phacoemulsification provides better unaided visual outcomes with less endothelial dysfunction than MSICS in the immediate and subsequent postoperative period.

Intraoperative Complications of Cataract Surgery Using Intracameral Illumination in the Elderly over 75 Years

Purpose

To evaluate intraoperative complications and utilization of adjunctive devices between microscope and intracameral illuminations during cataract surgery in the elderly over 75 years.

Design

A retrospective, consecutive, interventional case series Participants. Two hundred eighty-six eyes of 184 patients older than 75 years who underwent cataract surgery using microscope and intracameral illuminations.

Methods

A chart review was performed on an advanced cataract surgery group of 141 consecutive cases in which the intracameral illumination was used and on a standard cataract surgery group of 145 consecutive cases in which the intracameral illumination was not used.

Main Outcome Measures

Intraoperative complications (posterior capsule rupture, radial tear of the anterior capsule, dropped nucleus, or sulcus-implanted/sclera-fixated IOL) and utilization of adjunctive devices (pupil expansion device or anterior capsule staining).

Results

The frequency of use of the pupil expansion device was lower in the advanced cataract surgery group than that in the standard cataract surgery group (0.7% vs 6.9%; p=0.007). Furthermore, the rates of a posterior capsule rupture and at least one intraoperative complication were lower in the advanced cataract surgery group than those in the standard cataract surgery group (0.7% vs 4.8%; p=0.067) (0.7% vs 7.6%; p=0.004).

Conclusions

In the current cohort of patients over 75 years, the rate of intraoperative complications was lower when using the intracameral illumination than that when using the conventional method. Cataract surgery using intracameral illumination would be good option for elderly people.

Safety and efficacy of fibrin glue versus infinity suture in SICS with extended scleral flap

Purpose:

To study the safety and efficacy of biologic fibrin glue (FG) in comparison with infinity suture in SICS with compromised scleral flap.

Methods:

A retrospective comparative study of patients who were treated with FG (Group A) with 10–0 nylon (Group B) as sealing agent for intraoperative compromised tunnels in SICS. Parameters noted were postoperative inflammation, wound integrity, anterior chamber (AC) depth, intraocular pressure (IOP), and surgically induced astigmatism (SIA) at postoperative day 1, 4 weeks, 6 weeks, and 6 months, respectively. Epi Info 7 software and SIA calculator, Version 2.1 were used to analyze the result.

Results:

We reviewed the two groups of 18 patients each and noted that there was no statistically significant difference in postoperative inflammation (P > 0.05), AC depth (P > 0.05), and IOP (P > 0.05) between both groups at each postoperative visit. One patient in Group A showed postoperative shallow AC and subconjunctival bleb. Exposed sutures causing foreign body sensation had to be removed in five patients in Group B. At the end of 6-month postoperative period, no statistically significant difference was found in SIA (P = 0.92) between the two groups.

Conclusion:

Biologic FG can be safely used in securing the compromised scleral incisions in SICS. It also avoids suture-related complications.

Residents' Learning Curve for Manual Small-Incision Cataract Surgery at Aravind Eye Hospital, India

PURPOSE

The goal of this study was to document the resident learning curve for manual small-incision cataract surgery (MSICS) and to identify implications for the design of ophthalmology residency programs aimed to train surgeons for developing countries.

DESIGN

Hospital-based retrospective cohort study.

PARTICIPANTS

All 38 residents entering 2 postgraduate residency programs at Aravind Eye Hospital, Madurai, in 2012 and 2013.

METHODS

Surgical complications and reoperations for all MSICSs performed by residents during the residency training period were evaluated using a computerized patient database. Multivariate logistic regression models were used to estimate the effect of the cumulative number of surgeries performed on incidence of intraoperative complications, postoperative complications, and reoperations, controlling for covariates.

MAIN OUTCOME MEASURES

Incidence of intraoperative and first-day postoperative complications of Oxford Cataract Treatment and Evaluation Team (OCTET) grades II and III and the incidence of reoperations. Analyses controlled for patient-, resident-, and residency program-level covariates.

RESULTS

The study evaluated 13 159 surgeries performed by the 38 residents between October 15, 2012, and August 24, 2016. The mean number of surgeries performed by a resident was 346.3 (standard deviation, 269.4). Three hundred forty-two eyes (2.60%) with at least 1 intraoperative complication, 234 eyes (1.78%) with at least 1 first-day postoperative complication, and 154 reoperations (1.17%) were observed. After controlling for baseline covariates, increasing surgical experience was associated with reduced risk of intraoperative and postoperative complications, as well as reoperations. The odds decreased by 17% (intraoperative complications), 12% (postoperative complications measured 1 day after surgery), and 7% (reoperations) per 100 additional surgeries performed. Patient-level factors such as older age, left eye surgery, and lower preoperative uncorrected visual acuity were found to be associated with higher risk of intraoperative complications (P < 0.01 for all).

CONCLUSIONS

The risk of surgical complications and reoperations in MSICS decreased steadily with surgical experience gained by resident surgeons. We recommend that ophthalmology residency programs in developing nations teaching MSICS provide opportunities to perform 300 surgeries or more by residents so as to achieve rates of intraoperative and postoperative complications of less than 2%.

Microinterventional endocapsular nucleus disassembly: novel technique and results of first-in-human randomised controlled study

Aim

To assess the safety and efficacy of microinterventional endocapsular nuclear fragmentation in moderate to severe cataracts.

Methods

This was a prospective single-masked multisurgeon interventional randomised controlled trial (ClinicalTrials.gov NCT02843594) where 101 eyes of 101 subjects with grade 3‒4+ nuclear cataracts were randomised to torsional phacoemulsification alone (controls) or torsional phacoemulsification with adjunctive endocapsular nuclear fragmentation using a manual microinterventional nitinol filament loop device (miLOOP group). Outcome measures were phacoemulsification efficiency as measured by ultrasound energy (cumulative dispersed energy (CDE) units) and fluidics requirements (total irrigation fluid used) as well as incidence of intraoperative and postoperative complications.

Results

Only high-grade advanced cataracts were enrolled with more than 85% of eyes with baseline best corrected visual acuity (BCVA) of 20/200 or worse in either group. Mean CDE was 53% higher in controls (32.8±24.9 vs 21.4±13.1 with miLOOP assistance) (p=0.004). Endothelial cell loss after surgery was low and similar between groups (7‒8%, p=0.561) One-month BCVA averaged 20/27 Snellen in miLOOP eyes and 20/24 in controls. No direct complications were caused by the miLOOP. In two cases, capsular tears occurred during IOL implantation and in all remaining cases during phacoemulsification, with none occurring during the miLOOP nucleus disassembly part of the procedure.

Conclusions

Microinterventional endocapsular fragmentation with the manual, disposable miLOOP device achieved consistent, ultrasound-free, full-thickness nucleus disassembly and significantly improved overall phaco efficiency in advanced cataracts.

Trial registration number

NCT02843594

Review of manual small-incision cataract surgery

Cataract surgery has undergone many changes with the size of incision progressively decreasing over time with an incision of 12.0 mm for intracapsular cataract extraction to 2.2–2.8 mm in phacoemulsification. However, phacoemulsification due to high cost and equipment maintenance cannot be employed widely in developing countries. Manual small-incision cataract surgery (MSICS) offers similar advantages with the merits of wider applicability, less time consuming, a shorter learning curve, and lower cost. MSICS can be performed in high-volume setups due to fast technique. Here, we review the various techniques, safety and efficacy of MSICS, and its progress and utility in developing and underdeveloped countries.

[Phacoemulsification versus manual small incision cataract surgery: Anatomic and functional results]

PURPOSE

Prospective randomised study to compare the impact of phacoemusification (PHACO) and small incision cataract surgery (SICS) on endothelial structure (cell density and morphology) and refractive results (visual acuity, induced astigmatism).

METHODS

Prospective study of 57 patients (63 eyes) over 20 months (May 2012-January 2014) undergoing surgery by 2 experienced surgeons. We included patients with senile or presenile cataracts, LOCS III class 2, 3 and 4. Patients were randomized into 2 groups based on their birth month (group 1: PHACO [33]; group 2: SICS [30]). All pre- intra- and postoperative data were collected prospectively. The minimum follow-up was 6 months. We used the SPSS 18.0 for statistical analysis. Statistical tests used included the test-t Student, the Anova test, the Mann-Witney non-parametric test and the Khi² test. A threshold of significance was set at 0.05.

RESULTS

The mean preoperative endothelial cell density was 2447.5±225 c/mm² with no significant difference between the two groups (P=0.207). The mean percentage of hexagonality was 55.5±8.2% in groups 1 and 2. The most significant cell loss was during the first immediate postoperative period for both groups. At Day 15 postoperative, the decrease in cell loss was significant (P<0.001) with a mean loss of 312.9±208.9 c/mm² (P<10^-2). Postoperatively, the mean best-corrected visual acuity was 0.057 log MAR for all of our patients (P=0.170); no patient had an acuity ≤1/10. The mean astigmatism at the conclusion of follow-up was 1.08±0.42 D in group 1 and 1.51±0.55 D in group 2, with a significant difference (P=0.001).

CONCLUSION

Both SICS and PHACO give excellent results, both anatomical and refractive. However, SICS appears to be more advantageous than PHACO in terms of speed, cost, and independence from technology, and appears to be better suited to dense cataracts and mass surgery.

Postoperative Corneal and Surgically Induced Astigmatism following Superior Approach Manual Small Incision Cataract Surgery in Patients with Preoperative Against-the-Rule Astigmatism

The aim of the study was to report postoperative corneal and surgically induced astigmatism (SIA) in patients with preoperative against-the-rule (ATR) astigmatism who underwent superior approach manual small incision cataract surgery (MSICS). 58 eyes of 58 cataract patients with preoperative ATR astigmatism were involved in this study. All patients had operable cataracts and underwent superior approach MSICS. Keratometric (K) readings were taken prior to surgery and at 12 weeks after surgery. Centroid values of SIA, preoperative astigmatism, and postoperative astigmatism were calculated using Cartesian coordinates based analysis. Wilcoxon signed rank test was used to compute statistical significance between mean preoperative and postoperative corneal astigmatism. Cohen's d was used as effect size measure. Centroid values of 1.42 D × 179, 2.48 D × 0, and 1.07 D × 1 were recorded, respectively, for preoperative astigmatism, postoperative astigmatism, and SIA. Wilcoxon signed rank test indicated that mean ± SD postoperative corneal astigmatism (2.80 ± 1.40 D) was statistically significantly greater than preoperative corneal astigmatism (1.49 ± 1.34 D), Z = −6.263, p < 0.0001. A high Cohen's d of 1.32 was found. Our results suggest statistical and clinically significant greater postoperative corneal astigmatism than preoperative corneal astigmatism for ATR astigmatism cataract patients who underwent superior approach MSICS.

Goat's eye integrated with a human cataractous lens: A training model for phacoemulsification

A relatively simple and inexpensive technique to train surgeons in phacoemulsification using a goat's eye integrated with a human cataractous nucleus is described. The goat's eye is placed on a bed of cotton within the lumen of a cylindrical container. This is then mounted on a rectangular thermocol so that the limbus is presented at the surgical field. After making a clear corneal entry with a keratome, the trainer makes a 5–5.5 mm continuous curvilinear capsulorhexis in the anterior lens capsule, creates a crater of adequate depth in the cortex and inserts the human nucleus within this crater in the goat's capsular bag. The surgical wound is sutured, and the goat's eye is ready for training. Creating the capsulorhexis with precision and making the crater of adequate depth to snugly accommodate the human nucleus are the most important steps to prevent excessive wobbling of the nucleus while training.

Cost-effectiveness analysis should continually assess competing health care options especially in high volume environments like cataract surgery

Context:

Cost-effectiveness analysis should continually assess competing health care options especially in high volume environments like cataract surgery.

Aims:

To compare the cost effectiveness of phacoemulsification (PE) versus manual small-incision cataract surgery (MSICS).

Settings and Design:

Prospective randomized controlled trial. Tertiary care hospital setting.

Subjects and Methods:

A total of 52 consenting patients with age-related cataracts, were prospectively recruited, and block randomized to PE or MSICS group. Preoperative and postoperative LogMAR visual acuity (VA), visual function-14 (VF-14) score and their quality-adjusted life years (QALYs) were obtained, and the change in their values calculated. These were divided by the total cost incurred in the surgery to calculate and compare the cost effectiveness and cost utility. Surgery duration was also compared.

Statistical Analysis Used:

Two group comparison with Student's t-test. Significance set at P < 0.05; 95% confidence interval (CI) quoted where appropriate.

Results:

Both the MSICS and PE groups achieved comparative outcomes in terms of change (difference in mean [95% CI]) in LogMAR VA (0.03 [−0.05−0.11]), VF-14 score (7.92 [−1.03−16.86]) and QALYs (1.14 [−0.89−3.16]). However, with significantly lower costs (INR 3228 [2700–3756]), MSICS was more cost effective, with superior cost utility value. MSICS was also significantly quicker (10.58 min [6.85–14.30]) than PE.

Conclusions:

MSICS provides comparable visual and QALY improvement, yet takes less time, and is significantly more cost-effective, compared with PE. Greater push and penetration of MSICS, by the government, is justifiably warranted in our country.

Patterns of pseudophakic retinal detachment in a referral tertiary care center and the need for improving cataract surgical training

PURPOSE

To determine the risk factors associated with development of rhegmatogenous retinal detachment (RRD) in patients undergoing different types of cataract surgery.

METHODS

Records of 200 patients presenting with pseudophakic retinal detachment (PRD) between January 2012 and July 2013 at a tertiary care center were reviewed. Duration and type of cataract surgery (phacoemulsification, extracapsular cataract extraction [ECCE], and small-incision cataract surgery [SICS]) and history of YAG capsulotomy with risk factors were recorded. Presence or absence of these risk factors was analyzed and their association with type of cataract surgery was evaluated.

RESULTS

Of these 200 patients, 137 were male and 63 were female. The mean age of the patients was 55.19 ± 12.60 years and mean duration of cataract surgery to diagnosis of RRD was 8.64 ± 5.15 months. Most patients underwent phacoemulsification (45%), followed by ECCE (31.5%) and SICS (23.5%). Most of the patients with PRD had complicated cataract surgery with intraocular lens (IOL) in sulcus in 63%, anterior chamber IOL in 3%, and aphakia in 0.5%. There was no difference among the 3 types of surgery performed in mean presenting visual acuity, duration between cataract surgery and YAG capsulotomy, or number of posterior chamber IOLs. Incidence of posterior capsular rent (p = 0.02) and presence of vitreous in anterior chamber (p = 0.01) were significantly higher for patients with retinal detachment (RD) who underwent SICS.

CONCLUSIONS

Many risk factors are associated with RD development after cataract surgery. More stringent efforts at improving the quality of cataract surgical training are likely to help in reducing the risk of PRD.

Intraocular Pressure Reduction after Phacoemulsification versus Manual Small-Incision Cataract Surgery: A Randomized Controlled Trial

PURPOSE

To compare reduction in intraocular pressure (IOP) and change in anterior chamber angle configuration between eyes undergoing phacoemulsification versus those undergoing manual small-incision cataract surgery (MSICS).

DESIGN

Prospective, randomized, double-masked, parallel assignment clinical trial.

PARTICIPANTS

Five hundred eyes of 500 participants 40 to 70 years of age with normal IOP, gonioscopically open angles, and age-related cataract.

METHODS

Eyes underwent phacoemulsification or MSICS after a 1:1 randomization and allocation code. Best-corrected vision, IOP, comprehensive slit-lamp evaluation, and anterior segment (AS) optical coherence tomography (OCT) were performed at baseline and at 1, 3, and 6 months follow-up.

MAIN OUTCOME MEASURES

Change in IOP (ΔIOP) and AS OCT parameters between baseline and 6 months after surgery.

RESULTS

Six months, similar IOP reduction was observed in eyes undergoing phacoemulsification (ΔIOP = 2.7±2.9 mmHg) and MSICS (ΔIOP = 2.6±2.6 mmHg; P = 0.70). Widening of the angle opening distance (AOD) 500 μm from the scleral spur (median ΔAOD500 = 103 μm; interquartile range = 39-179 μm) was also similar in both groups (P = 0.28). Multivariate linear regression analysis showed that eyes with higher baseline IOP experienced significantly greater reduction in IOP at 6 months (ΔIOP = 0.46-mmHg reduction for every 1-mmHg increment in baseline IOP; 95% confidence interval [CI], 0.4-0.5 mmHg; P < 0.001). After adjusting for covariates, the magnitude of widening of AOD500 was not associated significantly with reduction in IOP (1.33-mmHg reduction for every 1-mm increment in AOD500; P = 0.07). Baseline AOD500 (β = -0.60-mm change/1-mm increment of baseline AOD; 95% CI, -0.67 to -0.53 mm) and anterior chamber depth (β = 0.07-mm change/1-mm increment of baseline anterior chamber depth; 95% CI, 0.04-0.1 mm) were significant predictors of AOD500 widening at 6 months.

CONCLUSIONS

Both phacoemulsification and MSICS led to significant and similar IOP reductions 6 months after surgery, and both surgeries produced similar changes in anterior chamber and angle parameters. Higher baseline IOP was associated with greater IOP reduction; IOP reduction also can be attributed partly to changes in angle and anterior chamber configuration, although these parameters were unable to predict significantly predict IOP drop at 6 months.

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.

Willingness to Pay for Cataract Surgery Provided by a Senior Surgeon in Urban Southern China

Purpose

To study willingness to pay for cataract surgery and surgical service provided by a senior cataract surgeon in urban Southern China.

Methods

This study was a cross-sectional willingness-to-pay (WTP) interview using bidding formats. Two-hundred eleven persons with presenting visual impairment in either eye due to cataract were enrolled at a tertiary eye hospital. Participants underwent a comprehensive eye examination and a WTP interview for both surgery and service provided by a senior surgeon. Demographic information, socioeconomic status and clinical data were recorded.

Results

Among 211 (98% response rate) persons completing the interview, 53.6% were women and 80.6% were retired. About 72.2% had a monthly income lower than 1000 renminbi (US $161). A total of 189 (89.6%) were willing to pay for cataract and the median amount of WTP was 6000 renminbi (US$968). And 102 (50.7%) were willing to pay additional fees for surgery performed by a senior surgeon, and the median amount of WTP was 500 renminbi (US$81). In regression models adjusting for age and gender, persons with preexisting eye diseases other than cataract, were more likely to pay for cataract surgery and service provided by a senior surgeon (P = 0.04 for both).

Conclusions

In urban China, cataract patients, especially those with preexisting eye conditions, are willing to pay additional fees for a senior surgeon. Moving to a system where the price of cataract surgery is proportional to the consultant’ skill and expertise is possible and may have a potential impact on waiting list and quality of eye care. Further studies are needed to examine the impact of such pricing system on attitudes and choices of cataract patients.

Phacoemulsification versus small incision cataract surgery in patients with uveitis

AIM

To compare the safety and efficacy of phacoemulsification and small incision cataract surgery (SICS) in patients with uveitic cataract.

METHODS

In a prospective, randomized multi-centric study, consecutive patients with uveitic cataract were randomized to receive phacoemulsification or manual SICS by either of two surgeons well versed with both the techniques. A minimum inflammation free period of 3mo (defined as less than 5 cells per high power field in anterior chamber) was a pre-requisite for eligibility for surgery. Superior scleral tunnel incisions were used for both techniques. Improvement in visual acuity post-operatively was the primary outcome measure and the rate of post-operative complications and surgical time were secondary outcome measures, respectively. Means of groups were compared using t-tests. One way analysis of variance (ANOVA) was used when there were more than two groups. Chi-square tests were used for proportions. Kaplan Meyer survival analysis was done and means for survival time was estimated at 95% confidence interval (CI). A P value of <0.05 was considered statistically significant.

RESULTS

One hundred and twenty-six of 139 patients (90.6%) completed the 6-month follow-up. Seven patients were lost in follow up and another six excluded due to either follow-up less than six months (n=1) or inability implant an intraocular lens (IOL) because of insufficient capsular support following posterior capsule rupture (n=5). There was significant improvement in vision after both the procedures (paired t-test; P<0.001). On first postoperative day, uncorrected distance visual acuity (UDVA) was 20/63 or better in 31 (47%) patients in Phaco group and 26 (43.3%) patients in SICS group (P=0.384). The mean surgically induced astigmatism (SIA) was 0.86±0.34 dioptres (D) in the phacoemulsification group and 1.16±0.28 D in SICS group. The difference between the groups was significant (t-test, P=0.002). At 6mo, corrected distance visual acuity (CDVA) was 20/60 or better in 60 (90.9%) patients in Phaco group and 53 (88.3%) in the manual SICS group (P=0.478). The mean surgical time was significantly shorter in the manual SICS group (10.8±2.9 versus 13.2±2.6min) (P<0.001). Oral prednisolone, 1 mg/kg body weight was given 7d prior to surgery, continued post-operatively and tapered according to the inflammatory response over 4-6wk in patients with previously documented macular edema, recurrent uveitis, chronic anterior uveitis and intermediate uveitis. Rate of complications like macular edema (Chi-square, P=0.459), persistent uveitis (Chi-square, P=0.289) and posterior capsule opacification (Chi-square, P=0.474) were comparable between both the groups.

CONCLUSION

Manual SICS and phacoemulsification do not differ significantly in complication rates and final CDVA outcomes. However, manual SICS is significantly faster. It may be the preferred technique in settings where surgical volume is high and access to phacoemulsification is limited, such as in eye camps. It may also be the appropriate technique for uveitic cataract under such circumstances.

Meta-analysis to Compare the Safety and Efficacy of Manual Small Incision Cataract Surgery and Phacoemulsification

PURPOSE

A systematic review and meta-analysis comparing the safety, efficacy, and expenses related to phacoemulsification versus manual small incision cataract surgery (SICS).

METHODS

PubMed, Cochrane, and Scopus databases were searched with key words manual SICS 6/18 and 6/60; astigmatism and endothelial cell loss postoperatively, intra- and post-operative complications, phacoemulsification, and comparison of SICS and phacoemulsification. Non-English language manuscripts and manuscripts not indexed in the three databases were also search for comparison of SICS with phacoemulsification. Data were compared between techniques for postoperative uncorrected and corrected distance visual acuity (UCVA and best corrected visual acuity [BCVA], respectively) better than 6/9, surgical cost and duration of surgery. The Oxford cataract treatment and evaluation team scores were used for grading intraoperative and postoperative complications, uncorrected near vision.

RESULT

This review analyzed, 11 comparative studies documenting 76,838 eyes that had undergone cataract surgery considered for analysis. UCVA of 6/18 UCVA and 6/18 BCVA were comparable between techniques (P = 0.373 and P = 0.567, respectively). BCVA of 6/9 was comparable between techniques (P = 0.685). UCVA of 6/60 and 6/60 BCVA aided and unaided vision were comparable (P = 0.126 and P = 0.317, respectively). There was no statistical difference in: Endothelial cell loss during surgery (P = 0.298), intraoperative (P = 0.964) complications, and postoperative complications (P = 0.362). The phacoemulsification group had statistically significantly less astigmatism (P = 0.005) and more eyes with UCVA of 6/9 (P = 0.040). UCVA at near was statistically significantly better with SICS due to astigmatism and safer during the learning phase (P = 0.003). The average time for SICS was lower than phacoemulsification and cost <½ of phacoemulsification.

CONCLUSION

The outcome of this meta-analysis indicated there is no difference between phacoemulsification and SICS for BCVA and UCVA of 6/18 and 6/60. Endothelial cell loss and intraoperative and postoperative complications were similar between procedures. SICS resulted in statistically greater astigmatism and UCVA of 6/9 or worse, however, near UCVA was better.

Advances in cataract surgery: preserving the corneal endothelium

PURPOSE OF REVIEW

Cataract surgery is known to lead to some degree of corneal endothelial cell loss (ECL). The purpose of this review is to describe how recent technological advancements such as femtosecond laser-assisted cataract surgery (FLACS) affect corneal endothelium during cataract surgery.

RECENT FINDINGS

It has been suggested that FLACS may reduce the amount of required ultrasound energy used in cataract surgery, a factor known to be directly related to ECL. Several recent studies demonstrate either no difference or less ECL with FLACS than with standard phacoemulsification 1-3 months after surgery. However, results at 6 months show comparable ECL between the two techniques. Other recent advancements in surgical technique, such as biaxial microincision surgery, result in similar ECL rates to that of standard phacoemulsification. The use of ultraviolet light in the newly developing light-adjustable intraocular lenses does not increase ECL. Studies show either similar results or less ECL with the use of the newer viscous-dispersives when compared with other viscoelastic devices. Other aspects such as the use of intracameral injections have no adverse effects on corneal endothelium.

SUMMARY

Newly emerging cataract surgical techniques cause comparable ECL to that of conventional phacoemulsification. Femtosecond laser-assistance may reduce ECL, but likely only in the early postoperative period. Further studies are needed to better elucidate short and long-term effects of FLACS on the corneal endothelium. Viscous dispersives may offer equal or increased protection of the corneal endothelium during surgery compared with viscoelastic devices currently in wide use, but further studies are required to support these results.

Technology and Intraocular Lenses to Enhance Cataract Surgery Outcomes-Annual Review (January 2013 to January 2014)

PURPOSE

This article is aimed to provide a clinical update on recent developments in cataract surgical techniques, with specific focus on femtosecond laser technology. The article also focuses on recent improvements in the technology used in implanting intraocular lenses (IOLs).

DESIGN

Literature review.

METHODS

The authors conducted a review of literature available in the last 12 months in the English language using PubMed. The period used to conduct the literature search was from January 1, 2013, to December 31, 2013. The following search terms were used during the PubMed search: phacoemulsification, femtosecond laser, toric IOLs, multifocal IOLs, multifocal toric IOLs, manual small-incision cataract surgery, outcomes, surgically induced astigmatism, rotational stability, trifocal IOLs, laser cataract surgery, safety, and efficacy.

RESULTS

This review incorporates selected original articles that provide fresh insights and updates on the fields of toric and multifocal IOLs, femtosecond laser cataract surgery, and manual small-incision cataract surgery. Particular attention has been paid to observational, randomized controlled clinical trials, experimental trials, and analyses of larger cohorts with prospective and retrospective study designs. Letters to the editor, unpublished works, and abstracts do not fall under the purview of this review.

CONCLUSIONS

This review is not designed to be all-inclusive. It highlights and provides insights on literature that is most useful and applicable to practicing ophthalmologists.