Visual outcome of cataract surgery; Study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery

Long-Term Outcomes of Phacoemulsification Surgeries at ECWA Eye Hospital: A Prospective Clinical Cohort Study

Background

Phacoemulsification has proven to be a breakthrough technique in cataract surgery. Its popularity has grown dramatically as procedures and equipment have advanced, improving both safety and efficiency. This study presents long-term outcomes from phacoemulsification surgeries performed at the Evangelical Church Winning All (ECWA) Eye Hospital, a tertiary eye care center.

Method

This prospective clinical cohort study followed standard practices for operations performed under local anesthesia. Ophthalmologists evaluated long-term outcomes and predictors of improved visual acuity after phacoemulsification cataract surgery. The visual recovery of the patients over time was evaluated, and the factors that influence the gains in vision were identified.

Results

A total of 177 patients were subjected to treatment at our facilities during the study period. There were 116 male and 61 female patients, which resulted to a male-to-female ratio of 1 : 0.53. The average age of the patients was 59.18 years with a standard deviation of 11.38 years. Of the 259 eyes treated, 249 eyes (96.1%) achieved a high success rate with visual acuity of 6/6 - 6/18. Ten (10) eyes (3.9%) had moderate acuity between <6/18 and 6/60. Follow-up examinations over five years after phacoemulsification showed poor vision outcomes among old patients. The primary factor that affected improvement in visual acuity among patients was amblyopia, present in 30% of cases. Posterior capsular opacification and macular edema collectively accounted for 20% of poor vision cases, while optic atrophy, glaucoma, and retinal hemorrhage each represented approximately 10% of poor vision cases.

Conclusions

The phacoemulsification approach demonstrated a highly effective restoration of vision for the vast majority, while long-term data analysis indicated the potential for age-related variability in postoperative visual gains.

Incidence of Postsurgical Intraocular Inflammation 6 Months After Implantation with a Multifocal Intraocular Lens

Purpose

This study assessed the incidence of postsurgical intraocular inflammation after cataract extraction by phacoemulsification and implantation with AcrySof IQ ReSTOR intraocular lenses (IOLs) produced using an updated manufacturing process. Incidence rates were compared with historical rates of postsurgical intraocular inflammation.

Methods

This was a prospective, multicenter, post-approval study at 34 sites. Patients aged ≥22 years received a study lens in at least 1 eye. Postsurgical intraocular inflammation (aqueous cell grade ≥3+ within 14 days after surgery, aqueous cell ≥2+ at 14 to ≤60 days after surgery, or aqueous cell ≥1+ at >60 days) was assessed within a 180-day period after implantation. Rates of toxic anterior segment syndrome (TASS), acute postoperative endophthalmitis, chronic postoperative endophthalmitis, and uncategorized cases of postsurgical intraocular inflammation were assessed. Ocular adverse events (AEs) and ocular adverse device effects (ADEs) were evaluated. Historical rates of postsurgical intraocular inflammation were determined from the 2011-2013 Medicare Limited Data Set files (a 5% sample of the Medicare data set representative of patients aged ≥65 years).

Results

Final safety analysis set included 3357 eyes (1792 patients; mean age, 68.6 ± 7.9 years). Postsurgical intraocular inflammation (any type) rate was 5.1 per 1000 attempted IOL implants (95% CI, 2.95, 8.10). TASS, acute postoperative endophthalmitis, and uncategorized inflammation rates were 0.6 (95% CI, 0.07, 2.15), 0.3 (95% CI, 0.01, 1.66), and 4.2 (95% CI, 2.28, 6.99) per 1000 attempted IOL implants, respectively. There were no events of chronic postoperative endophthalmitis. Ocular AEs and ADEs were reported in 17% and 1.5% of eyes, respectively. Most common ADEs were halo (0.63%) and glare (0.51%). The historical postsurgical inflammation rate from 221,519 cataract procedures was 10.3/1000 cataract surgeries, and the endophthalmitis rate was 1.2/1000 surgeries.

Conclusion

The updated IOL manufacturing process resulted in postoperative intraocular inflammation rates that were substantially lower than the historic rate.

Biometric description of 34 589 eyes undergoing cataract surgery: sex differences

PURPOSE

To describe gender differences in the biometric parameters of a large sample of patients with cataract. Cataract surgery has evolved from a vision restoration to a refractive procedure, and population-based studies are vital to optimize normative databases and postsurgical outcomes.

SETTING

Miguel Servet University Hospital, Zaragoza, Spain.

DESIGN

Retrospective single-center observational study.

METHODS

The study included 34 589 eyes (20 004 patients with cataract). Biometric data were obtained from IOL Master 700 and Pentacam HR. Linear mixed models were used to account for intereye correlation. HofferQST formula was used to calculate the hypothetical distribution of intraocular lens (IOL) power (arbitrary lens; A = 119.2).

RESULTS

Most biometric variables showed significant differences between sexes ( P < .0001), such as 0.53 mm shorter eyes found in females, of which 0.16 mm are explained by shorter aqueous depth. Steeper anterior keratometries (∼0.75 diopter [D]) were found in women, to end up in no difference on anterior astigmatism magnitude, but different orientation ( P < .0001). The distribution of IOL power differed between sexes ( P < .001), with the interquartile range shifting 1 D toward more powerful lenses in women and odds ratio (power >26 D) = 2.26, P < .0001 (Fisher).

CONCLUSIONS

Large sample size studies provide smaller margin of error, higher power, and controlled risk of reporting false (negative or positive) findings. Highly significant differences between sexes in ocular biometry were found; this supports the idea that including sex as a parameter in IOL calculation should be explored and may improve results. In addition, the distribution of IOL powers was provided, which may be useful for manufacturers and hospital stock planning.

Prophylaxis against intraocular pressure spikes following uncomplicated phacoemulsification: a systematic-review and meta-analysis

BACKGROUND

To investigate the effect of perioperative intraocular pressure (IOP) lowering medications on controlling postoperative IOP following uncomplicated phacoemulsification.

METHODS

Ovid MEDLINE, EMBASE, and Cochrane CENTRAL databases were searched up until November 2022. Randomised controlled trials (RCTs) that assessed IOP change via applanation tonometry in medicated and control arms following uncomplicated cataract surgery in healthy eyes were included. The primary outcome was the weighted mean difference (WMD) of IOP at 2-8 h, 12-24 h, and 1-7 days postoperatively within each medication class or common fixed-combination formulations. Risk of bias was assessed using the revised risk of bias in randomised trials (RoB-2). Level of evidence was rated using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) RESULTS: From 702 screened articles, 30 RCTs involving 2986 eyes were included. There was a statistically significant reduction in IOP favouring treatment arms at 2-8 h (WMD = -3.87 mmHg; 95% CI [-4.75, -3.00]; p < 0.001) and 12-24 h (WMD = -2.69 mmHg; 95% CI [-3.36, -2.02]; p < 0.001), with the effect wearing off beyond 1 day (p = 0.18). Between medication classes, the largest effect at both 2-8 h and 12-24 h was observed with intracameral cholinergics or fixed-combination carbonic anhydrase inhibitor-beta-blocker (FCCB) formulations. Conversely, the smallest effect was observed with prostaglandin analogues, alpha-agonists, and topical carbonic anhydrase inhibitors (CAIs).

CONCLUSION

Prophylaxis against acute IOP elevations following uncomplicated cataract surgery is effective. FCCB and intracameral cholinergics are the most effective ocular antihypertensive agents, while alpha-agonists, prostaglandin analogues, and topical CAIs were found to be the least effective. These findings may inform future surgical guidelines.

Long-term visual acuity outcomes following cataract surgery in eyes with ocular inflammatory disease

PURPOSE

To evaluate the long-term visual acuity (VA) outcome of cataract surgery in inflammatory eye disease.

SETTING

Tertiary care academic centres.

DESIGN

Multicentre retrospective cohort study.

METHODS

A total of 1741 patients with non-infectious inflammatory eye disease (2382 eyes) who underwent cataract surgery while under tertiary uveitis management were included. Standardised chart review was used to gather clinical data. Multivariable logistic regression models with adjustment for intereye correlations were performed to evaluate the prognostic factors for VA outcomes. Main outcome measure was VA after cataract surgery.

RESULTS

Uveitic eyes independent of anatomical location showed improved VA from baseline (mean 20/200) to within 3 months (mean 20/63) of cataract surgery and maintained through at least 5 years of follow-up (mean 20/63). Eyes that achieved 20/40 or better VA at 1 year were more likely to have scleritis (OR=1.34, p<0.0001) or anterior uveitis (OR=2.2, p<0.0001), VA 20/50 to 20/80 (OR 4.76 as compared with worse than 20/200, p<0.0001) preoperatively, inactive uveitis (OR=1.49, p=0.03), have undergone phacoemulsification (OR=1.45 as compared with extracapsular cataract extraction, p=0.04) or have had intraocular lens placement (OR=2.13, p=0.01). Adults had better VA immediately after surgery, with only 39% (57/146) paediatric eyes at 20/40 or better at 1 year.

CONCLUSIONS

Our results suggest that adult and paediatric eyes with uveitis typically have improved VA following cataract surgery and remain stable thereafter for at least 5 years.

Prospective Randomized Single-Masked Study of Bilateral Isofocal Optic-Design or Monofocal Intraocular Lenses

PURPOSE

To assess refractive and visual outcomes of bilateral implantation of an isofocal optic-design intraocular lens (IOL) or a monofocal IOL following cataract surgery.

METHODS

A total of 127 patients were recruited into a prospective, single-masked, randomized trial. Sixty-five patients bilaterally implanted with the Isopure Isofocal IOL and 62 patients with the Micropure Monofocal IOL were followed for 4-6 months. Refraction, monocular and binocular uncorrected-distance-visual acuity, corrected-distance-visual acuity (CDVA), uncorrected-intermediate-visual acuity and distance-corrected-intermediate-visual acuity (DCIVA, 66/80 cm), uncorrected-near-visual acuity, and distance-corrected-near-visual acuity (DCNVA, 40 cm) were evaluated. Binocular defocus curve, binocular contrast sensitivity (photopic, mesopic with/without glare), and glare and halo phenomena were also measured.

RESULTS

99.23% of eyes were within ±1.00D and 84.62% of eyes within ±0.50D for the Isopure patients and 98.39% and 82.26% for the Micropure patients, respectively. The mean spherical-equivalent was -0.06 ± 0.36D and 0.10 ± 0.32D for the Isopure and Micropure patients, respectively. 98.5% and 100% of patients implanted with the Isopure and Micropure IOLs showed a cumulative binocular CDVA value ≥20/20, respectively. 80% and 67.70% of patients implanted with the Isopure presented a binocular DCIVA ≥20/25 at 80 and 66 cm, respectively. These percentages were 46.8% and 40.3% with the Micropure IOL, respectively. For Isopure, 7.7%, 30.8%, and 58.5% of patients presented a DCNVA ≥20/25, ≥20/32 and ≥20/40, respectively. These values were lower for the Micropure: 1.6%, 19.4% and 46.8%, respectively. Defocus curves showed similar good visual acuity at distance for both lenses with better intermediate vision for the Isopure. Both groups presented good contrast sensitivity, and the size and intensity of halo and glare phenomena were similar between the two. No adverse-events were reported.

CONCLUSION

Our trial shows that both IOLs provide excellent visual acuity and contrast sensitivity for far vision with similar photic phenomena, and the Isopure IOL improved unaided intermediate vision performance.

Postoperative Complications of True Dropless Cataract Surgery versus Standard Topical Drops

Purpose  Compare postoperative outcomes in cataract surgery between eyes with standard drop regimen versus dropless protocol by residents. Design  Retrospective cohort study between April 1, 2018 and March 31, 2020. Methods  The study was performed at Lyndon B. Johnson General Hospital in Houston, Harris County, Texas. A total of 547 eyes (234 dropless vs. 313 standard) with phacoemulsification cataract surgery and minimum of 1-month follow-up with best-corrected visual acuity (BCVA) were included. Dropless received 40 mg sub-Tenon's triamcinolone and intracameral moxifloxacin. Patients were followed at postoperative day 1 (POD1), week 1 (POW1), and month 1 (POM1). Postoperative rate of BCVA better than 20/40 (Good vision) and rate of complications were compared between groups. Results  Good vision on POM1 in dropless (77.8%) was noninferior to standard (75.1%, p  = 0.80). Complication rate in dropless (28.6%) was noninferior to standard (24.0%, p  = 0.13). Intraocular pressure (IOP) elevation on POD1 ( p  = 0.041) and anterior chamber (AC) cells on POW1 and POM1 ( p  < 0.001) were more frequent in dropless. Mean spherical equivalent at POM1 was better in dropless (-0.37 D [±0.81 D]) compared with standard (-0.61D [±0.77 D], p  = 0.001). Early posterior capsular opacification (early PCO) was more frequent in dropless ( p  = 0.042). Conclusions  Postoperative rate of BCVA better than 20/40 and rate of postoperative complications were noninferior, although dropless had higher rates of AC inflammation, IOP elevation, and early PCO.

Comparison of cataract surgery outcomes in patients with type 1 vs type 2 diabetes mellitus and patients without diabetes mellitus

PURPOSE

To report outcomes of cataract surgery in type 1 diabetes mellitus (T1DM) compared with type 2 diabetes mellitus (T2DM) and patients without diabetes mellitus (DM).

SETTING

Academic tertiary referral university hospital eye center, Aurora, Colorado.

DESIGN

Retrospective chart review using the University of Colorado Cataract Outcomes Database for all cataract surgeries between 2014 and 2020.

METHODS

Demographics, ocular history, and postoperative outcomes were compared across groups using general linear and logistic regression modeling with estimating equations to account for some patients having 2 eyes included.

RESULTS

8117 patients and 13 383 eyes were included. Compared with T2DM eyes undergoing cataract surgery (n = 3115), T1DM eyes (n = 233) were more likely to have a history of diabetic retinopathy (DR) (60.5% vs 23.6%, P < .0001), of which proliferative DR was the most common (63.1% vs 42.4%, P < .0001). T1DM eyes were also more likely to have a history of retinal detachment (RD) (9.0% vs 2.9%, P < .0001) and prior vitrectomy surgery (12.9% vs 4.0%, P < .0001). Despite having similar preoperative corrected distance visual acuity (CDVA) as T2DM eyes (logMAR 0.52 vs 0.44, P = .092), T1DM eyes had worse CDVA after cataract surgery (logMAR 0.27 vs 0.15, P = .0003). In a multivariate analysis, a history of proliferative DR and prior RD were significant predictors of worse postoperative CDVA ( P < .0001) but type of DM was not ( P = .894).

CONCLUSIONS

T1DM eyes have worse visual outcomes after cataract surgery compared with T2DM eyes. Worse postoperative visual acuity was associated with worse preoperative DR and history of RD rather than type of DM.

Retinitis Pigmentosa: Current Clinical Management and Emerging Therapies

Retinitis pigmentosa (RP) comprises a group of inherited retinal dystrophies characterized by the degeneration of rod photoreceptors, followed by the degeneration of cone photoreceptors. As a result of photoreceptor degeneration, affected individuals experience gradual loss of visual function, with primary symptoms of progressive nyctalopia, constricted visual fields and, ultimately, central vision loss. The onset, severity and clinical course of RP shows great variability and unpredictability, with most patients already experiencing some degree of visual disability in childhood. While RP is currently untreatable for the majority of patients, significant efforts have been made in the development of genetic therapies, which offer new hope for treatment for patients affected by inherited retinal dystrophies. In this exciting era of emerging gene therapies, it remains imperative to continue supporting patients with RP using all available options to manage their condition. Patients with RP experience a wide variety of physical, mental and social-emotional difficulties during their lifetime, of which some require timely intervention. This review aims to familiarize readers with clinical management options that are currently available for patients with RP.

Pseudoexfoliation Glaucoma as a Predictor of Refractive Surprise After Uneventful Cataract Surgery

PRCIS

The pseudoexfoliation glaucoma group produced higher mean absolute error (MAE) and higher percentages of large-magnitude prediction error, in all investigated intraocular lens formulas. Postoperative anterior chamber angle and change in intraocular pressure (IOP) were associated with absolute error.

PURPOSE

The purpose of this study is to evaluate refractive outcomes of cataract surgery in patients with pseudoexfoliation glaucoma (PXG) and to determine the predictive factors for refractive errors.

MATERIALS AND METHODS

Fifty-four eyes with PXG, 33 eyes with primary open angle glaucoma (POAG) and 58 normal eyes undergoing phacoemulsification, in Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey, were included in this prospective study. The follow-up was 3 months. Preoperative and postoperative anterior segment parameters measured by Scheimpflug camera were compared after adjusting for age, sex, and axial length. The mean prediction error, MAE, and percentages of large-magnitude prediction error (>±1.0 D) in SRK/T, Barrett Universal II, and Hill-RBF formulas were compared.

RESULTS

There was a significantly greater anterior chamber angle (ACA) enlargement in PXG eyes compared with POAG ( P =0.006) and normals ( P =0.04). The PXG group showed significantly higher MAE in SRK/T, Barrett Universal II, and Hill-RBF (0.72, 0.79, and 0.79 D, respectively) than POAG (0.43, 0.25, and 0.31 D, respectively) and normals (0.34, 0.36, 0.31 D, respectively) ( P <0.0001). The large-magnitude error was significantly more frequent in the PXG group among the 3 groups with SRK/T (37%, 18%, and 12%, respectively) ( P =0.005), Barrett Universal II (32%, 9%, and 10%, respectively) ( P =0.005), and Hill-RBF (32%, 9%, and 9%, respectively) ( P =0.002). The MAE was correlated with postoperative ACA and IOP decrease in Barrett Universal II ( P =0.02 and 0.007, respectively) and Hill-RBF ( P =0.03 and 0.02, respectively).

CONCLUSIONS

PXG may be a predictor for refractive surprise after cataract surgery. Prediction errors may be due to IOP-lowering effect of surgery and larger postoperative ACA than expected, in the presence of zonular weakness.

Visual Performance at Different Distances After Implantation of an Isofocal Optic Design Intraocular Lens

PURPOSE

To evaluate refractive and visual outcomes at different distances after implantation of an isofocal optic design intraocular lens (IOL) following cataract surgery.

METHODS

This multicentric, retrospective/prospective, open-label, observational study considered 183 eyes of 109 patients who were implanted with the ISOPURE 123 (PhysIOL) IOL. The main outcome measures were refractive error and monocular and binocular uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), uncorrected intermediate visual acuity (UIVA), and distance-corrected intermediate visual acuity (DCIVA) at 66 and 80 cm, uncorrected near visual acuity (UNVA), and distance-corrected near visual acuity (DCNVA) at 40 cm. Binocular visual acuity at different vergences (defocus curve) was also measured. Patients were evaluated at least 120 days postoperatively.

RESULTS

A total of 95.7% of the eyes were within ±1.00 diopter (D) and 73.2% of the eyes were within ±0.50 D; the mean postoperative spherical equivalent was -0.12 ± 0.42 D. There were 90.54% and 98.57% of patients presenting a cumulative binocular UDVA and CDVA value of 20/25 or better, respectively; 80.65% and 50.0% of patients presented a binocular DCIVA value of 20/25 or better at 80 and 66 cm, respectively; and 41.94% of patients presented a binocular DCNVA value of 20/40 or better. The through-focus curve showed good visual acuity at far and intermediate distances with a depth of focus value of 1.50 D. No adverse events were reported.

CONCLUSIONS

The current study shows that this isofocal optic design IOL provides excellent visual performance for far vision and functional intermediate vision with an extended range of vision. This lens is an effective option for providing functional intermediate vision and correcting aphakia. [J Refract Surg. 2023;39(3):150-157.].

Micro-Computed Tomography (µCT) as a Tool for High-Resolution 3D Imaging and Analysis of Intraocular Lenses: Feasibility and Proof of the Methodology to Evaluate YAG Pits

INTRODUCTION

Posterior capsule opacification (PCO) is the most frequent late sequelae after successful cataract surgery. Neodymium:yttrium aluminum garnet (Nd:YAG) laser capsulotomy is considered the gold standard and a well-accepted, safe, and effective measure in treating PCO. However, iatrogenic damage of the intraocular lens (IOL) due to inappropriate focusing is a quite common side effect. These permanent defects (YAG pits) can critically affect overall optical quality.

METHODS

In this laboratory study, we used the micro-computed tomography (µCT) technique to obtain high-resolution 3D images of the lens and the YAG pits.

RESULTS

To the best of our knowledge, this is the first description of a detailed analysis of IOLs with µCT technology. This non-destructive technique seems to be ideal for comparative studies, measuring dimensions of the damage, and visualizing shooting channels within the material.

CONCLUSION

µCT is excellently suited to examine an IOL in detail, analyze optics and haptics in three dimensions, and to describe all kinds of changes within the IOL without damaging it.

Outcome of Cataract Surgery in Patients With Retinitis Pigmentosa

PURPOSE

To assess the visual outcome of cataract surgery in patients with retinitis pigmentosa (RP).

DESIGN

Retrospective, noncomparative clinical study.

METHODS

Preoperative, intraoperative, and postoperative data of patients with RP who were undergoing cataract surgery were collected from several expertise centers across Europe.

RESULTS

In total, 295 eyes of 226 patients were included in the study. The mean age at surgery of the first eye was 56.1 ± 17.9 years. Following surgery, best-corrected visual acuity (BCVA) improved significantly from 1.03 to 0.81 logMAR (ie, 20/214 to 20/129 Snellen) in the first treated eye (-0.22 logMAR; 95% CI = -0.31 to -0.13; P < .001) and from 0.80 to 0.56 logMAR (ie, 20/126 to 20/73 Snellen) in the second treated eye (-0.24 logMAR; 95% CI = -0.32 to -0.15; P < .001). Marked BCVA improvements (postoperative change in BCVA of ≥0.3 logMAR) were observed in 87 of 226 patients (39%). Greater odds for marked visual improvements were observed in patients with moderate visual impairment or worse. The most common complications were zonular dialysis (n = 15; 5%) and (exacerbation of) cystoid macular edema (n = 14; 5%), respectively. Postoperative posterior capsular opacifications were present in 111 of 295 eyes (38%).

CONCLUSION

Significant improvements in BCVA are observed in most patients with RP following cataract surgery. Baseline BCVA is a predictor of visual outcome. Preoperative evaluation should include the assessment of potential zonular insufficiency and the presence of CME, as they are relatively common and may increase the risk of complications.

Combined phacoemulsification surgery and intravitreal triamcinolone injection versus stand-alone surgery in patients with type 2 diabetes: a prospective randomized trial

Background

We would assess the efficacy of intravitreal injection of triamcinolone acetonide IVTA combined with standard phacoemulsification on the central subfield macular thickness (CSMT), the progression of diabetic retinopathy (DR), and the corrected distant visual acuity (CDVA) in type 2 diabetic patients.

Methods

In this prospective single-blinded randomized clinical trial we recruited patients with type 2 diabetes who were eligible for cataract surgery. The patients were randomly assigned to two groups. The case group received an intravitreal IVTA at the end of phacoemulsification, and the control group had routine surgery. CSMT, progression of DR, CDVA, IOP, and adverse events including endophthalmitis were compared between the groups preoperatively and at 1, 3, and 6 months postoperatively.

Results

Among a total of 66 patients that were treated within the study period, 50 patients were included in the final analysis. The case group comprised 21 eyes, and the control group included 29 eyes. Regression models and corrected ANOVA test for repeated measures showed a significant reduction in CSMT at 3 and 6 months postoperatively, which was most significant when the preoperative CSMT was ≥300 μm, with a cut-off value of 347.3 μm in the case group (p < 0.000). DR progression was halted in the case group at 6 months with 52.38% of patients having their DR classified as moderate (P = 0.012). CDVA was significantly improved from baseline 6/60 (logMAR 1.0) pre-op to 6/6 (logMAR 0.00) at 6 months post-op in the case group, and from baseline 6/120 (logMAR 1.3) pre-op to 6/12 (logMAR 0.3) at 6 months post-op in the control group. The gain in visual acuity was significantly higher in the case group at all study points (p < 0.001). No significant rise in IOP was observed at any study point in both groups (p = 0.23 > 0.05). No endophthalmitis was recorded.

Conclusions

Diabetic patients benefit significantly from cataract surgery. This study supports IVTA injection at the end of phacoemulsification in diabetic patients. Triamcinolone is an affordable (which is of particular importance in low-income countries as per our setting), and relatively safe “phaco-enhancer”.

Trial registration

NCT05413330. Initial release 10/06/2022. Unique Protocol ID: UDMS-Opthal-01-2022.

Risk factors affecting cataract surgery outcome: The Malaysian cataract surgery registry

This is a 5 years multicentre database study that recruited subjects from the Malaysian Ministry of Health Cataract Surgery Registry (MOH CSR), aimed to determine risk factors that affect cataract surgery visual outcome and evaluates post-cataract surgery vision. All age-related cataract surgeries with primary intraocular lens (IOL) implantation were included. Cases with secondary cataract, previous ocular surgeries and incomplete data were excluded. A total of 131425 cases were included in the study. Amongst all types of cataract surgery, 92.9% attained post-operative best-corrected visual acuity better than 6/18 and the outcome improved to 97.1% when ocular comorbidities were excluded. Factors with Odds Ratio (OR) >1.5 associated with an impaired visual outcome included: elderly patients of 80 years old and above; systemic disease such as renal failure; ocular co-morbidities; pre-operative vision worse than 6/60; general anaesthesia, retrobulbar anaesthesia or subconjunctival anaesthesia; extracapsular cataract extraction (ECCE), intracapsular cataract extraction (ICCE), anterior chamber intraocular lens (ACIOL) implantation or combined cataract surgery; the presence of intra- and post-operative complications. In conclusion, a good visual outcome was achieved after cataract surgery in most cases. This large multicentre study provides information about risk factors for poor visual outcome post-cataract surgery and may serve as a basis for evidence-based guidelines.

Predictors of visual acuity improvement after phacoemulsification cataract surgery

Purpose

This study aimed to assess preoperative predictors of visual outcome after phacoemulsification cataract surgery in Jordan, a Middle Eastern country.

Methods

This was a retrospective longitudinal study of adult patients who underwent phacoemulsification cataract surgery from January 2019 to July 2021. For each patient, we included only the first operated eye. We obtained pre-operative ocular history, cataract surgery complication risk based on a predesigned score, visual acuity, best correction, and best corrected visual acuity. We recorded intraoperative complications. We also obtained postoperative best corrected visual acuity and refractive error for correction after 1–3 months.

Results

A total of 1,370 patients were included in this study, with a mean age of 66.39 (± 9.48). 48.4% of patients achieved visual acuity ≥ 0.8, and 72.7% achieved visual acuity ≥ 0.5. The mean visual acuity improvement after phacoemulsification cataract surgery was 0.33 (95% CI 0.31–0.35). In the regression model, significant predictors that affected visual acuity improvement included the presence of diabetic retinopathy, glaucoma, and complication risk factors (i.e., high-risk surgery).

Conclusion

Predictors of visual acuity improvement vary between studies. This study was conducted in a developing country; we defined predictors of visual acuity improvement. We also provided a new preoperative phacoemulsification cataract surgery complication risk score.

Factors Influencing Visual Improvement after Phacoemulsification Surgery among Malaysian Cataract Patients

Blindness and visual impairment are part of the global burden of eye disease, with cataract being one of the leading causes of blindness. This study aimed to determine the factors affecting visual acuity (VA) improvement among cataract patients after phacoemulsification surgery in Malaysia. Cataract patients aged over 18 who underwent phacoemulsification surgery between January 2014 and December 2018 were included in this retrospective cohort study. Patients' sociodemographic, comorbidities, surgical, and related complication factors were extracted from the National Eye Database. The outcome was measured by the difference in visual acuity before and after the operation and was categorized as "improved", "no change", and "worse". A total of 180,776 patients were included in the final analysis. Multinomial logistic regression analysis showed "no changes in VA" was significantly higher in patients aged less than 40 years old (OR: 1.66; 95% CI: 1.22, 2.26), patients with ocular comorbidities (OR: 1.65; 95% CI: 1.53, 1.77), patients who had undergone surgery lasting more than 60 min (OR: 1.39; 95% CI: 1.14, 1.69), patients who had surgery without an intraocular lens (IOL) (OR: 1.64; 95% CI: 1.20, 2.26), and patients with postoperative complications (OR: 8.76; 95% CI: 8.13, 9.45). Worsening VA was significantly higher among male patients (OR: 1.11; 95% CI: 1.01, 1.22), patients who had ocular comorbidities (OR: 1.76; 95% CI: 1.59, 1.96), patients who had undergone surgery lasting more than 60 min (OR: 1.94; 95% CI: 1.57, 2.41), patients who had surgery without an IOL (OR: 2.03; 95% CI: 1.48, 2.80), and patients with postoperative complications (OR: 21.46; 95% CI: 19.35, 23.80). The factors impacting "no changes" in and "worsening" of VA after cataract surgery were the following: older age, male gender, ethnicity, ocular comorbidities, surgeon grade, absence of IOL, intraoperative complication, and postoperative problems.

Comparing Efficacy and Safety of Intracameral Injection of Marcaine and Lidocaine on Postoperative Pain and Recovery After Cataract Surgery

Background: Various topical (intracameral) analgesics are used to relieve postoperative pain after cataract surgery. Objectives: We decided to compare the effects of intracameral Marcaine and lidocaine on pain intensity after the cataract operation. Methods: In this double-blind, randomized clinical trial, 64 patients who were candidates for cataract surgery were randomly assigned to either anesthesia with lidocaine or bupivacaine (Marcaine) by intracameral injection. Study endpoints included pain score, hemodynamic status, patient satisfaction, and recovery duration. Results: The Marcaine group experienced a shorter recovery than another group (P = 0.001). The mean pain score at the different time points after the operation was significantly lower in the group receiving Marcaine than those receiving lidocaine (P < 0.001). Our study showed a higher level of patients’ satisfaction with Marcaine as compared to the lidocaine group (P = 0.026). However, postoperative hemodynamic status was similar in both groups. Conclusions: Compared with lidocaine, intracameral injection of Marcaine results in a shorter postoperative recovery period, reduced pain intensity, and higher satisfaction among patients after cataract surgery.

Outcomes of cataract surgery complicated by posterior capsule rupture in the European Registry of Quality Outcomes for Cataract and Refractive Surgery

PURPOSE

To analyze the outcomes of cataract surgery complicated by posterior capsule rupture (PCR).

SETTING

European clinics affiliated to the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO).

DESIGN

Retrospective cross-sectional register-based study.

METHODS

Data were retrieved from the EUREQUO between January 1, 2008, and December 31, 2018. The database consists of data on demographics, intraoperative complications such as PCR, type of intraocular lens (IOL) material, postoperative refraction, corrected distance visual acuity (CDVA), and postoperative complications.

RESULTS

1 371 743 cataract extractions with complete postoperative data were reported in the EUREQUO. In 12 196 cases (0.9%), PCR was reported. After PCR, patients were more likely to receive a poly(methyl methacrylate) IOL (5.2% vs 0.4%, respectively) or no IOL (1.1% vs 0.02%, respectively) compared with patients without PCR. The refractive and visual outcomes in patients with PCR were significantly worse than in those without PCR (mean CDVA 0.13 ± 0.21 vs 0.05 ± 0.16 logMAR, P < .001; mean absolute biometry prediction error 1.15 ± 1.60 diopters [D] vs 0.41 ± 0.45 D, P < .001). A multivariate linear regression analysis, adjusting for potential explanatory variables, confirmed a statistically significant difference (0.04 logMAR, P < .001, and .70 D, P < .001, respectively). Patients with PCR had significantly more postoperative complications (corneal edema 0.88% vs 0.17%, adjusted odds ratio [aOR], 2.80 95% CI, 2.27-3.45, endophthalmitis 0.11% vs 0.02%, aOR, 4.40 95% CI, 2.48-7.81, uncontrolled intraocular pressure 0.55% vs 0.03%, aOR, 14.58 95% CI, 11.16-19.06, P < .001).

CONCLUSIONS

Patients with PCR had significantly worse visual and refractive outcomes and more postoperative complications than patients without PCR. However, most of these patients achieved better postoperative visual acuity than that preoperatively.

Artificial Intelligence for the Estimation of Visual Acuity Using Multi-Source Anterior Segment Optical Coherence Tomographic Images in Senile Cataract

Purpose

To investigate an artificial intelligence (AI) model performance using multi-source anterior segment optical coherence tomographic (OCT) images in estimating the preoperative best-corrected visual acuity (BCVA) in patients with senile cataract.

Design

Retrospective, cross-instrument validation study.

Subjects

A total of 2,332 anterior segment images obtained using swept-source OCT, optical biometry for intraocular lens calculation, and a femtosecond laser platform in patients with senile cataract and postoperative BCVA ≥ 0.0 logMAR were included in the training/validation dataset. A total of 1,002 images obtained using optical biometry and another femtosecond laser platform in patients who underwent cataract surgery in 2021 were used for the test dataset.

Methods

AI modeling was based on an ensemble model of Inception-v4 and ResNet. The BCVA training/validation dataset was used for model training. The model performance was evaluated using the test dataset. Analysis of absolute error (AE) was performed by comparing the difference between true preoperative BCVA and estimated preoperative BCVA, as ≥0.1 logMAR (AE_≥0.1) or <0.1 logMAR (AE _<0.1). AE_≥0.1 was classified into underestimation and overestimation groups based on the logMAR scale.

Outcome Measurements

Mean absolute error (MAE), root mean square error (RMSE), mean percentage error (MPE), and correlation coefficient between true preoperative BCVA and estimated preoperative BCVA.

Results

The test dataset MAE, RMSE, and MPE were 0.050 ± 0.130 logMAR, 0.140 ± 0.134 logMAR, and 1.3 ± 13.9%, respectively. The correlation coefficient was 0.969 (p < 0.001). The percentage of cases with AE_≥0.1 was 8.4%. The incidence of postoperative BCVA > 0.1 was 21.4% in the AE_≥0.1 group, of which 88.9% were in the underestimation group. The incidence of vision-impairing disease in the underestimation group was 95.7%. Preoperative corneal astigmatism and lens thickness were higher, and nucleus cataract was more severe (p < 0.001, 0.007, and 0.024, respectively) in AE_≥0.1 than that in AE _<0.1. The longer the axial length and the more severe the cortical/posterior subcapsular opacity, the better the estimated BCVA than the true BCVA.

Conclusions

The AI model achieved high-level visual acuity estimation in patients with senile cataract. This quantification method encompassed both visual acuity and cataract severity of OCT image, which are the main indications for cataract surgery, showing the potential to objectively evaluate cataract severity.

Visual and refractive outcomes of monofocal toric intraocular lens implantation in amblyopic eyes

PURPOSE

To evaluate the visual and refractive outcomes of monofocal toric intraocular lens (IOL) implantation after cataract surgery in amblyopic eyes.

METHODS

Our center's database was used to identify patients who had undergone bilateral cataract surgery between 2016 and 2020 with the implantation of a toric IOL in their amblyopic eye. Exclusion criteria were the presence of strabismus, ocular pathologies other than cataract or intra-surgical complications. The outcomes analysed were uncorrected distance visual acuity (UDVA), subjective refraction and corrected distance visual acuity (CDVA) one month after surgery.

RESULTS

Ninety patients were included, with a mean age of 68.96 ± 7.81years. CDVA was lower for the amblyopic eye, both before and after surgery. There was a mean improvement in CDVA of 0.23 ± 0.21 LogMAR for the dominant eye and of 0.39 ± 0.33 for the amblyopic eye, p < 0.001 in both cases. Postoperative subjective refractive cylinder was higher in the amblyopic eye (-0.24 ± 0.39 D versus -0.10 ± 0.25 D, p < 0.01), as well as mean cylinder prediction error (-0.30 ± 0.47 D versus 0.02 ± 0.42 D, p < 0.01), compared to the dominant eye. There was a statistically significant correlation between preoperative and postoperative CDVA in amblyopic eyes (Spearmańs Rho = 260, p = 0.013). Mean postoperative UCVA was 0.15 ± 0.25 for amblyopic and 0.03 ± 0.12 for dominant eyes. Only one patient required distance spectacle correction due to residual astigmatism.

CONCLUSIONS

Cataract surgery with toric IOL implantation in amblyopic eyes leads to an improvement in visual acuity and to spectacle independence in almost all cases, even in the presence of a higher cylinder prediction error.

Risk factors for predicted refractive error after cataract surgery in clinical practice. Retrospective observational study

OBJECTIVES

To describe the preoperative characteristics of patients undergoing cataract surgery in our hospital, to determine the final visual and refractive results and to determine the preoperative characteristics that conditioned the presence of a residual refractive error (RRE) greater than one diopter.

METHODS

Retrospective analysis of cataract surgeries performed at Araba University Hospital between February 2017 and December 2019. Sociodemographic, eye comorbidity, biometric, surgical and post-surgical characteristics were collected.

RESULTS

A total of 1419 patients and 1578 surgeries were included for analysis. Of these, 9.07% had preoperative legal blindness, 31.69% eye comorbidity and 4.18% had previous surgery. Overall, 95.82% of patients achieved a corrected final visual acuity (VA) ≥ 0.5 Snellen decimal and 63.12% ≥ 1, and 96.70% of patients improved VA after surgery. RRE was between ±0.5 diopters in 77.82% of patients and between ±1 diopter in 94.74%. The most prominent risk factors that conditioned the presence of RRE greater than 1 diopter were the use of ultrasonic contact biometer, a history of glaucoma surgery, the presence of white or hard cataract, and prior legal blindness.

CONCLUSIONS

The visual results of cataract surgery were excellent, with 63.12% of patients obtaining corrected VA ≥ 1 and an RRE of ±1 diopter in 94.74%. Different risk factors influenced the achievement of poor refractive outcomes: preoperative conditions (previous surgeries, white/hard cataract, previous VA) and biometrics.

Macular Optical Coherence Tomography before Cataract Surgery

Purpose:

To determine the benefits of performing preoperative spectral domain optical coherence tomography (SD-OCT) and to identify occult macular pathologies in patients scheduled for routine cataract surgery.

Methods:

In this cross-sectional study, macular SD-OCT scans were performed on all patients with clinically undetected macular abnormalities who were scheduled for cataract surgery. Patients with clinically evident macular abnormalities were excluded from the study. A retinal specialist reviewed all the scans. The severity of the cataract was determined using the Oxford Clinical Cataract Classification and Grading System.

Results:

Of the 598 evaluated cases, 33 patients (5.52%) had an occult macular abnormality. The most common pathology found in these patients was idiopathic epiretinal membrane, which was detected in 17 eyes (51.52%), followed by vitreomacular traction in nine eyes (27.27%), and dry age-related macular degeneration in four eyes (12.12%). Full-thickness macular holes and a lamellar macular hole were found in two patients (6.06%) and one patient (3.03%), respectively. The frequency of cortical cataracts was significantly lower in patients without macular lesions (P = 0.012) than in those with macular lesions. Multivariate logistic regression analysis revealed that age >70 years (P = 0.025 and odds ratio [OR] =11.12), smoking history (P = 0.043 and OR = 3.43), and hypertension were independently associated with occult macular lesions. The surgical plan was changed for five patients (0.83%).

Conclusions:

Macular SD-OCT can be used to detect occult macular lesions and provide useful information about a macula before cataract surgery. Although preoperative OCT found macular abnormalities in about 5% of patients with presumed normal fundus examination, it can result in changing the surgical plan in 0.83% of all patients.

Combined Phacoemulsification and Intravitreal Dexamethasone Is an Effective Option for High-Risk Diabetic Macula Oedema Patients

Objective

Cataract surgery in diabetic patients carries an increased risk of post-operative macula oedema, particularly in those with a history of diabetic macula oedema (DMO) treatment or DMO at the time of surgery. We investigated whether simultaneous phacoemulsification with intravitreal Ozurdex^® reduces the risk of developing new, or deteriorating current, DMO.

Methods

We conducted a retrospective review of 79 consecutive ‘high-risk’ diabetic patients who underwent phacoemulsification with intraocular lens insertion and intravitreal Ozurdex^® implantation immediately subsequently. ‘High risk’ was defined as diabetic patients with prior treatment history for DMO or current DMO. Central macula thickness (CMT), best-corrected visual acuity and intraocular pressure were recorded pre-operatively, at two to four weeks and at three months post-operatively. A significant change in CMT was defined as a change of ≥0.1 LogOCT units.

Results

The mean age was 72.6 years; 52% were males. The mean pre-operative CMT was 365um. Thirty-seven per cent (37%) patients had prior DMO history that had resolved; 63% had confirmed DMO in surgery. Two to four weeks post-operatively, 82% of patients had stable CMT and 18% showed improvement. No patients deteriorated. Three months post-operatively, 48% of patients had stable CMT relative to pre-operative measurements, 38% improved, and 14% deteriorated. Analysis of variance (ANOVA) indicated no significant differences in response with demographical or pathological factors, including diabetic retinopathy grade and treatment history.

Conclusion

Phacoemulsification surgery combined with Ozurdex^® insertion at the end of the procedure is a highly effective strategy for protecting against the formation of new, or the deterioration of current DMO, in the highest risk diabetic patients undergoing cataract surgery.

Changing practice patterns in European cataract surgery as reflected in the European Registry of Quality Outcomes for Cataract and Refractive Surgery 2008 to 2017

PURPOSE

To study practice patterns in European cataract surgery over a 10-year period.

SETTING

European clinics affiliated to the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO).

DESIGN

Registry cohort study.

METHODS

The EUREQUO contains preoperative, intraoperative, and postoperative parameters reported by surgeons in many European clinics. All data reported to the registry are anonymized. Preoperative parameters included age, sex, visual acuity, target refraction, ocular comorbidity, and surgical difficulties. Surgical data included anesthesia, surgical technique, intraocular lens optic biomaterial, and complications. Postoperative parameters included visual acuity, refraction, and short-term complications.

RESULTS

During the study period (January 1, 2008, to December 31, 2017), a total of 2 714 108 cataract extractions were reported to the EUREQUO. Preoperative data changed over time, with decreases in mean age (74.5-73.0 years), proportion of women from 60.6% (100 373/165 628) to 57.2% (174 908/305 845), and proportion of coexisting eye diseases from 30.0% (49 638/165 650) to 27.0% (82 704/305 846) and with improvements in preoperative visual acuity (mean logarithm of minimum angle of resolution [logMAR] 0.46 to 0.37). The use of topical anesthesia increased over time from 28.1% (26 238/93 320) to 71.7% (130 525/182 083). Surgical complications showed a significant decrease from 2.5% (4107/165 650) to 1.2% (3573/305 846). The visual outcome improved over time (mean logMAR 0.08 to 0.05), as did the absolute median prediction error (0.38 diopter [D] to 0.28 D).

CONCLUSIONS

Trends in European cataract surgery practice patterns from 2008 to 2017 have moved toward younger patients with better preoperative visual acuity, fewer surgical complications, and better predicted refractions and visual outcomes.

How can we improve the quality of cataract services for all? A global scoping review

BACKGROUND

Cataract is a leading cause of blindness and vision impairment globally. Cataract surgery is one of the most frequently performed operations worldwide, but good quality services are not universally available. This scoping review aims to summarise the nature and extent of published literature on interventions to improve the quality of services for age-related cataract globally.

METHODS

We used the dimensions of quality adopted by WHO-effectiveness, safety, people-centredness, timeliness, equity, integration and efficiency-to which we added planetary health. On 17 November 2019, we searched MEDLINE, Embase and Global Health for manuscripts published since 1990, without language or geographic restrictions. We included studies that reported quality-relevant interventions and excluded studies focused on technical aspects of surgery or that only involved children (younger than 18 years). Screening of titles/abstracts, full-text review and data extraction were performed by two reviewers independently. Studies were grouped thematically and results synthesised narratively.

RESULTS

Most of the 143 included studies were undertaken in high-income countries (n = 93, 65%); 29 intervention groups were identified, most commonly preoperative education (n = 17, 12%) and pain/anxiety management (n = 16, 11%). Efficiency was the quality element most often assessed (n = 58, 41%) followed by people-centredness (n = 40, 28%), while integration (n = 4) and timeliness (n = 3) were infrequently reported, and no study reported outcomes related to planetary health.

CONCLUSION

Evidence on interventions to improve quality of cataract services shows unequal regional distribution. There is an urgent need for more evidence relevant to low- and middle-income countries as well as across all quality elements, including planetary health.

Diabetic retinopathy and diabetic macular oedema pathways and management: UK Consensus Working Group

The management of diabetic retinopathy (DR) has evolved considerably over the past decade, with the availability of new technologies (diagnostic and therapeutic). As such, the existing Royal College of Ophthalmologists DR Guidelines (2013) are outdated, and to the best of our knowledge are not under revision at present. Furthermore, there are no other UK guidelines covering all available treatments, and there seems to be significant variation around the UK in the management of diabetic macular oedema (DMO). This manuscript provides a summary of reviews the pathogenesis of DR and DMO, including role of vascular endothelial growth factor (VEGF) and non-VEGF cytokines, clinical grading/classification of DMO vis a vis current terminology (of centre-involving [CI-DMO], or non-centre involving [nCI-DMO], systemic risks and their management). The excellent UK DR Screening (DRS) service has continued to evolve and remains world-leading. However, challenges remain, as there are significant variations in equipment used, and reproducible standards of DMO screening nationally. The interphase between DRS and the hospital eye service can only be strengthened with further improvements. The role of modern technology including optical coherence tomography (OCT) and wide-field imaging, and working practices including virtual clinics and their potential in increasing clinic capacity and improving patient experiences and outcomes are discussed. Similarly, potential roles of home monitoring in diabetic eyes in the future are explored. The role of pharmacological (intravitreal injections [IVT] of anti-VEGFs and steroids) and laser therapies are summarised. Generally, IVT anti-VEGF are offered as first line pharmacologic therapy. As requirements of diabetic patients in particular patient groups may vary, including pregnant women, children, and persons with learning difficulties, it is important that DR management is personalised in such particular patient groups. First choice therapy needs to be individualised in these cases and may be intravitreal steroids rather than the standard choice of anti-VEGF agents. Some of these, but not all, are discussed in this document.

A decision aid to facilitate informed choices among cataract patients: A randomized controlled trial

OBJECTIVE

To assess the effect of a patient decision aid on the quality of decision-making for patients with age-related cataracts.

METHODS

773 patients with cataracts aged 50-80 years were randomly assigned to receive either the intervention decision aid (including standard information, quantitative information on the possible outcomes of cataract surgery and a value clarification exercise) or the control booklet (including standard information). The primary outcome was informed choice (defined as adequate knowledge and congruency between attitudes and surgical intentions), which was assessed at 2 weeks after intervention via a telephone interview.

RESULTS

The decision aid increased the proportion of participants making an informed choice, from 5.68 % in the control group to 27.7 % in the intervention group (P < 0.001). Compared with controls, more participants in the intervention group had adequate overall knowledge about cataract surgery (36.8 % vs. 8.79 % in controls; P < 0.001), and fewer participants intended to undergo surgery (22.5 % vs. 34.1 % in controls; P < 0.001).

CONCLUSION

Use of the patient decision aid may increase the proportion of patients making informed choices. Importantly, it might also reduce the acceptance of operations.

PRACTICE IMPLICATIONS

Patient decision aids represent a simple and low-cost tool to facilitate informed choice among patients with cataracts.

Cataract standard set for outcome measures: An Italian tertiary referral centre experience

PURPOSE

Implementation of the International Consortium for Health Outcomes Measurements (ICHOM) standard for cataract surgery into clinical practice at an Italian tertiary referral centre.

METHODS

Prospective, observational, descriptive study consisting of the registry and analysis of cataract surgeries performed during a 6-month enrolment period at the University Eye Clinic of Trieste, Trieste, Italy. Outcomes were recorded and analysed according to the ICHOM Cataract Standard Set version 2.0.1. Records included clinician-reported outcome measures (CROMs) - visual outcome and complications - and patient-reported outcome measures (PROMs) - self-assessed vision with the Catquest-9SF questionnaire. Correlations between PROMs and CROMs were evaluated. A multiple linear regression was used for predicting the change in PROMs with surgery.

RESULTS

A total of 218 eyes (of 218 patients) were analysed. Postoperative corrected distance visual acuity (CDVA) was ⩾0.3 in 89.0% (194/218) of eyes. There was a statistically significant improvement of the post-operative Catquest-9SF global average score. (p < 0.001). The change in the Catquest-9SF score significantly correlated with the change in Item 2 score (related to intermediate vision) (r = 0.634, p < 0.001). A predictive model of the change in the Catquest-9SF score was found (p < 0.001, R2: 0.527) based on preoperative Catquest-9SF total score, presence or not of macular degeneration, presence or not of intraoperative complications, age >75 years old, and preoperative CDVA.

CONCLUSIONS

Cataract surgery improves the functional vision, with some factors limiting the outcomes such as comorbidities. Self-perceived improvement in intermediate vision significantly influenced the improvement in self-assessed vision.

Global multi-site, prospective analysis of cataract surgery outcomes following ICHOM standards: the European CAT-Community

PURPOSE

To evaluate in a large sample of patients from 10 different European centers the results of cataract surgery, characterizing the relationship between patient-reported outcomes (PROMs) and clinician-reported outcome measures (CROMs).

METHODS

Prospective non-interventional multicenter observational descriptive study analyzing the clinical outcomes of a total of 3799 cases undergoing cataract surgery (mean age: 72.7 years). In all cases, the cataract surgery standard developed by the International Consortium for Health Outcomes Measurements (ICHOM) was used to register the clinical data. Three-month postoperative visual acuity and refraction data were considered CROMs, whereas Rasch-calibrated item 2 (RCCQ2) and total Catquest-9SF score (CQ) were considered PROMs.

RESULTS

Postoperative corrected distance visual acuity (CDVA) was 0.3 logMAR or better in 88.7% (2505/2823) of eyes. Mean differences between preoperative and postoperative RCCQ2 and CQ scores were -3.09 and -2.39, respectively. Visual function improvement with surgery was reported by 91.5% (2163/2364) of patients. Statistically significant, although weak, correlations of postoperative CDVA with postoperative refraction, PROMs, and complications were found (0.133 ≤ r ≤0.289, p < 0.001). A predictive model (R²: 0.254) of postoperative CDVA considering 10 variables was obtained, including preoperative CDVA, different ocular comorbidities, age, gender and intraoperative complications. Likewise, another predictive model (R²: 0.148) of postoperative CQ considering a total of 14 variables was obtained, including additionally preoperative CQ, target refraction and previous surgeries.

CONCLUSIONS

Cataract surgery provides an improved functional vision in most of patients although this improvement can be limited by ocular comorbidities and complications. The relationship between PROMs and CROMs is multifactorial and complex.

The impact of cataract progression on accuracy of intraocular lens power measurement

Purpose

The aim of this study was to assess the impact of cataract progression using the Haigis formula-calculated intraocular lens (IOL) power and investigate the accuracy of IOL power measured at different time points.

Methods

This prospective study was performed on 75 eyes of 75 patients who underwent uneventful cataract surgery. Preoperative ocular parameters including axial length (AL), keratometry (K), anterior chamber depth (ACD), corneal astigmatism, corrected distance visual acuity (CDVA) and uncorrected distance visual acuity (UDVA) examined at the two time points, more than 3 months preoperatively and preoperative 1 day were compared. The ocular parameters measured in the two time points were used to calculate the predicted implanted IOL power and the actual IOL power was chosen on the basis of parameters measured earlier before surgery using the Haigis formula. The mean numerical error (MNE) and mean absolute error (MAE) predicted by the two time points were also compared.

Results

There were significant differences in the ACD, IOL power, UDVA and CDVA (P<0.01), but no statistical differences in AL, mean K and corneal astigmatism (P>0.05) during the average of 5.6 months before surgery. No statistically significant difference was detected in MNE (P>0.05), while the MAE had a significant difference in the two time points (P<0.05).

Conclusion

The IOL power measured earlier before surgery might result in a higher accuracy and the postoperative refractive outcome tended towards emmetropia.

Effect of cataract surgery on quality of life for patients with severe vision impairment due to age-related macular degeneration

Background

To determine whether patients with severe vision impairment due to advanced age-related macular degeneration (AMD) benefit from bilateral cataract surgery in terms of vision-related quality of life (QoL).

Methods

A prospective interventional single-center study. Ten patients with severe vision impairment due to advanced bilateral AMD were included. The preoperative corrected distance visual acuity (CDVA) was ≥1.0/≥1.0 LogMAR units on Snellen chart and <20/<20 points on Early Treatment Diabetic Retinopathy Study (ETDRS) chart. Patients were not on active treatment for wet AMD as the treatment was expected to have no effect or benefit. The patients were scheduled for immediate sequential bilateral cataract surgery, with target refraction emmetropia (SN60WF, Alcon). Vision-related QoL was measured with National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) preoperatively, at 3 months and 1 year.

Results

The mean age of the patients was 82.5±6.2 years. The mean NEI VFQ-25 overall composite score changed from 44.0±7.1 preoperatively to 54.9±13.7 at 3 months and to 56.9±15.6 at 1 year (P=0.045, Friedman test). During the 1-year follow-up, there was an improvement in the subscale scores indicating difficulty with peripheral vision, mental health symptoms, and role difficulties due to vision (P<0.05 for all, Wilcoxon sign-rank test).

Conclusions

Cataract surgery may improve the vision-related QoL in patients with severe vision impairment due to bilateral advanced AMD.

Contemporary Outcomes and Prognostic Factors of 23-Gauge Vitrectomy for Retained Lens Fragments After Phacoemulsification

PURPOSE

To provide data on visual acuity (VA) outcomes and prognostic factors of microincision (23-gauge) vitrectomy surgery (MIVS) for retained lens fragments after complicated cataract surgery.

DESIGN

Retrospective, interventional case series from 2012 to 2017.

METHODS

Precataract surgery and intraoperative (vitrectomy) parameters, postvitrectomy complications, and best-corrected visual acuities (BCVAs) were identified. Vitrectomy was performed as early as corneal clarity permitted. Univariate and multivariate logistic regression were used to characterize factors associated with achieving VA better than 20/40, or worse than 20/200 at 6 months.

RESULTS

This study included 291 consecutive eyes (291 patients). LogMAR BCVA improved from 0.73 ± 0.70 before cataract surgery to 0.46 ± 0.63 (P < .001) after vitrectomy. The previtrectomy VA was 1.43 ± 0.79. At 6 months, 183 (62.9%) and 45 patients (15.5%) achieved BCVAs better than 20/40 and worse than 20/200, respectively. Most frequent complications were de novo ocular hypertension (29 eyes, 10%) and transient cystoid macular edema (25 eyes, 8.6%). Postvitrectomy retinal detachment occurred in 9 eyes (3.1%). Final VA of 20/40 or better was independently associated only with better precataract surgery VA, age <75 years, absence of preexisting diabetic macular edema (DME) or postvitrectomy persistent cystoid macular edema (P < .05). Only poorer precataract surgery VA, delaying vitrectomy to later than 2 weeks, and final aphakic status were independently predictive of 20/200 or worse VA (P < .05).

CONCLUSION

Contemporary VA outcomes of 23-gauge vitrectomy for retained lens fragments are comparable with that of prior predominantly non-MIVS cohorts, but fall short of benchmarks for uncomplicated cataract surgery. IOL type or timing of placement do not impact final VA.

Visual and subjective outcomes following trifocal intraocular lens implantation in Iranian cataractous patients

BACKGROUND

The aim of this study was to evaluate visual and refractive outcomes and quality of vision after implantation of the AT LISA tri 839MP intraocular lens (IOL).

PATIENTS AND METHODS

This interventional clinical trial comprised 46 cataractous eyes of patients who underwent phacoemulsification with IOL implantation (mean age of 58.08 ± 11.01 years; range: 36-76 years old). Spherical equivalent (SE), uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), uncorrected intermediate visual acuity (UIVA), corrected intermediate visual acuity (CIVA), uncorrected near visual acuity (UNVA), and corrected near visual acuity (CNVA) were measured 1, 3, and 6 months after surgery. Contrast sensitivity (CS) was measured at 6 months. Subjective quality of vision and presence of dysphotopsia by a short questionnaire were evaluated postoperatively.

RESULTS

At 6 months, the mean visual acuity was 0.08 ± 0.11, 0.03 ± 0.08, 0.07 ± 0.09, 0.02 ± 0.08, 0.05 ± 0.09, and 0.02 ± 0.08 LogMAR for UDVA, CDVA, UIVA, CIVA, UNVA, and CNVA, respectively. The mean values of SE were - 0.4728 ± 0.32D. These variables improved over time, yet significant changes were detected in UDVA (P = 0.009) and SE (P = 0.0001). The mean CS value was 1.74 ± 0.08. The mean scores (0% = no symptoms; 100% = strong symptoms/unable to perform activities) for glare and halos were 7.07 ± 0.22% and 8.70 ± 0.23%, respectively. These items were reduced over time. Patients' level of satisfaction mean score for performing activities was 96.66%.

CONCLUSIONS

The AT LISA tri 839MP IOL provides excellent uncorrected distance, intermediate and near vision, and CS. This IOL showed a minimal level of photic phenomena and a high level of patient satisfaction.

Clinical safety and efficacy of a hydrophilic acrylic intraocular lens in a real-world population: a 1-year follow-up retro-prospective study

Background

This multicentre, retro-prospective real-world study evaluated the visual, refractive and safety outcomes of a monofocal lens 1 year after implantation in cataract patients with or without pre-existing ocular pathologies.

Methods

Records from 4 centres in Germany and Sweden were reviewed to select eyes with aged-related cataracts, having undergone crystalline lens extraction by phacoemulsification and implantation of a CT ASPHINA 409 IOL. Preoperative, 1-month and 3-month postoperative data was collected retrospectively. In addition, included patients attended a prospective visit 12 months or later after surgery. The examination included: monocular uncorrected (UDVA) and corrected distance visual acuity (CDVA), subjective refraction, slit-lamp examination, optical biometry, intraocular pressure (IOP), endothelial cell count and postoperative complications.

Results

282 eyes, including 94 with pre-existing ocular pathologies, were analysed. Twelve months after the surgery, 95% of eyes achieved monocular CDVA equal or better than 0.3 logMAR, mean postoperative CDVA was 0.06 ± 0.17 logMAR, and mean UDVA 0.31 ± 0.29 logMAR. Visual acuity outcomes were better in eyes with no pre-existing ocular pathologies, but both groups showed a statistically significant improvement after surgery compared with preoperative values (p ≤ 0.002). The mean sphere and spherical equivalent values also improved significantly postoperatively (p = 0.003). Overall, 62.1% of eyes had spherical equivalent within ±0.5 D and 80.9% within ±1.0 D. The IOL was stable in the capsular bag as demonstrated by tilt and decentration measurements. IOP, corneal status, and endothelial cell count values were in the normal range. Nd:YAG treatment was performed on 9.9% of the eyes.

Conclusion

The implantation of the monofocal CT ASPHINA 409 IOL was beneficial to restore vision in eyes with or without concomitant ocular pathology such as macular degeneration, glaucoma, Sicca syndrome, epiretinal membrane, cornea guttata, or amblyopia. Good to excellent long-term visual and refractive outcomes, and a low rate of complications in both healthy and pathological eyes were found 12 months after the surgery.

Trial registration

Trial registered on under the identification NCT03145103 (date of registration 9 May 2017).

Patient-centred and economic effectiveness of a decision aid for patients with age-related cataract in China: study protocol of a randomised controlled trial

INTRODUCTION

The need for cataract surgery is on the rise due to our ageing population and high demands for greater visual functioning. Although the majority of patients want to participate in a shared decision-making process, no decision aid has been available to improve the quality of decision. The present study aims to determine whether a decision aid increases informed decision about cataract surgery.

METHODS AND ANALYSIS

A parallel randomised controlled trial (772 participants) will be conducted. The decision aid will be implemented among patients with any age-related cataract in Yuexiu District, which is socioeconomically representative of a major metropolitan region in Southern China. Participants will be randomly assigned to receive either a patient decision aid or a traditional booklet, and they will complete three surveys: (1) baseline assessment before the intervention (time point (T)1), 2 weeks (T2) and 1 year (T3) after the intervention. The control group receives a traditional booklet with standard general information developed by the National Eye Institute to help patients understand cataract, whereas the intervention group receives a patient decision aid that includes not only the standard general information, but also the quantitative risk information on the possible outcomes of cataract surgery as well as value clarification exercise. The primary study outcome is the informed decision, the percentage of patients who have adequate knowledge and demonstrate consistency between attitudes and intentions. Secondary outcomes include perceived importance of cataract surgery benefits/harms, decision conflict and confidence, anticipated regret and booklet utilisation and acceptability at 2 weeks, and surgical rates and a cost-utility estimate of the decision aid at 1 year.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of Zhongshan Ophthalmic Center (reference number: 2019KYPJ090). Results will be published in peer-reviewed journals and presented at scientific meetings for academic audiences.

TRIAL REGISTRATION NUMBER

NCT03992807.

Visual and Refractive Outcomes of Cataract Surgeries Performed in One Year in a Private Practice Setting: Review of 2714 Procedures

Methods

Our center's database was used to identify all isolated cataract procedures performed during 2017. The electronic records were reviewed to collect the preoperative information, presence of intra- or postsurgical complications, and visual and refractive outcomes one month after surgery.

Results

In 2017, 2714 eyes of 1543 patients underwent cataract surgery in our center. Mean patient age was 70.42 years. 775 eyes (28.55%) had prior ophthalmic pathologies, and 113 eyes (4.16%) had undergone previous surgical procedures. Surgical complications developed in 35 eyes (1.29%), including 9 posterior capsule tears (0.33%) and 3 cases of dropped lens fragments (0.11%). A toric or multifocal intraocular lens was implanted in 45.6% of eyes. As regards postoperative complications, 59 eyes (2.17%) required a return to the operating theater, including 29 eyes (1.07%) requiring reinterventions due to an unexpected refractive result. There were no cases of endophthalmitis. Mean LogMAR-corrected distance visual acuity (CDVA) improved from 0.25 (SD 0.34) preoperatively to 0.04 (SD 0.17) postoperatively; 86.5% of eyes achieved a CDVA ≤0.0, with 97.5% achieving ≤0.3. In 86.4% of eyes, the difference between target and residual spherical equivalent difference was of 0.50 D or lower; 88% of eyes had a spherical equivalent ±0.50 D.

Conclusions

The visual and refractive outcomes of cataract surgery in a private practice setting were excellent, well over the benchmarks set by the ESCRS. The safety profile was also within expected standards. This study provides information for ophthalmologists in private practice on expected outcomes.

Development and preliminary evaluation of a decision aid to support informed choice among patients with age-related cataract

OBJECTIVE

Shared decision making and meaningful patient involvement are key in improving cataract treatment outcomes, but no decision aid has been formally developed and validated for this purpose. Our aims were to develop a patient decision aid to guide patients' decision about when to undergo cataract surgery, and to determine patient's comprehension and booklet's acceptability.

METHODS

The patient decision aid was developed and included evidence-based information about general cataract, its benefits, risks of treatment options, and value clarification exercise. A total of 30 patients with age-related cataract aged between 50 and 80 years were interviewed after using either the patient decision aid (n = 15) or the traditional education booklet (n = 15).

RESULTS

The patients who received the decision aid agreed that the information was new (n = 15, 100%), the length of the aid was "just about right" (n = 13, 87%), the information was clear and easy to understand (n = 13, 87%), the decision aid was helpful in making decision (n = 13, 87%) and would like to recommend this decision aid to others (n = 14, 93%).

CONCLUSIONS

The decision aid was assessed positively by patients with age-related cataract. There is a need for its further verification in the context of primary eye care setting.

Protective Effect of β-Glucogallin on Damaged Cataract Against Methylglyoxal Induced Oxidative Stress in Cultured Lens Epithelial Cells

BACKGROUND ß-glucogallin (GG) is one of the major plant polyphenolic antioxidants that have been associated with positive effects on human health and are crucial in the developing defense mechanism against the risk of diseases. However, reports on the protective mechanism of GG in lens epithelial cells are limited. MATERIAL AND METHODS ARPE-19 cells (a human retinal epithelial cell line) were exposed to methylglyoxal (MG) with or without GG to illuminate the protective role of GG in counteracting the cataract signaling. RESULTS Cells predisposed to MG demonstrated an increase in oxidative stress with augmented (P<0.01) inflammatory cytokines such as cyclooxygenase (COX)-2, chemokine receptor CXCR4, interleukin (IL)-6, IL-8, monocyte chemoattractant protein-1 (MCP-1), and intercellular adhesion molecule 1 (ICAM-1) genes. In addition, the expression of aldose reductase (AR) was increased to 2-fold with accumulated sorbitol in MG exposed cells compared to control. On the other hand, cells exposed to MG evidenced a 3-fold increase in RAGE (receptor for advanced glycation end products) and a 2-fold increase in NF-kappaB (nuclear factor kappa-light-chain-enhancer of activated B cells) expression compared to control cells. Intriguingly, lens epithelial cells pre-treated with GG attenuated the reactive oxygen species levels with improved antioxidant enzymes. Simultaneously, the levels of AR and other inflammatory cytokines were observed in the levels closer to control cells in GG pre-treated cells. CONCLUSIONS Thus, the results of the present investigation show that GG may be a potential drug for the prevention of cataract development and progression.

Results of cataract surgery in a third-level teaching hospital. More than just a simple number

OBJECTIVE

To analyse a series of cataract surgeries performed in a third-fourth level teaching hospital, providing complementary data to the number of surgeries that can be used as a further reference, and to compare them with those published by other Public Health Systems, mainly the British one.

METHODS

Retrospective study of 1052 cataract procedures at the University Hospital of Valladolid from January 2016 to July 2016. Collected variables: age, gender, pre- and postsurgical visual acuity, degree of complexity of the cataract, duration of the surgery, and surgical complications.

RESULTS

The mean age of the patients was 74.1 ± 9.5 years, and 81.61% started from a VA <0.5. The duration of the surgery was collected only in 12% of the procedures. The complications rate was 1.8%, with one case of endophthalmitis. A final postoperative refraction was performed in only 44.7% of the cases. A total of 87.2% of the eyes achieved a VA ≥ 0.5 after surgery.

CONCLUSIONS

The results of the series show significant differences from those from the audit of the English National Healthcare System, with our patients being more complex and having less complications. There are missing-data in the collection of important variables such as post-surgical refraction or the duration of the surgery, which despite this, this work can be a good reference.

Clinical Registries in Ophthalmology

TOPIC

Clinical registries in ophthalmology.

CLINICAL RELEVANCE

In recent years, advancements in digital technology and increasing use of electronic medical records in health systems have led to the dramatic growth in large clinical data sets. Clinical data registries are organized systems that collect data on patients diagnosed with a disease or condition or who undergo a certain procedure.

METHODS

A search of the PUBMED database was conducted in January 2018 for clinical registries in ophthalmology.

RESULTS

Ninety-seven clinical eye registries were found, with significant growth in numbers in the last 4 decades. The most common conditions captured were blindness or low vision, corneal transplantation, glaucoma, and cataract surgery. Most registries originate in the European region, North America, and Australia. Nine registries had multinational coverage, whereas 48 were national registries. As the numbers and scope of clinical registries have expanded, valuable observational data have been used to study real-world clinical outcomes in healthcare quality measurement and improvement and to develop new guidelines and standards. Pertinent areas of its use include studying treatments and outcomes in cataract surgery, corneal transplantation, and macular degeneration.

CONCLUSIONS

The use of clinical registries for quality improvement and research has grown significantly in the last few decades, and this trend will continue as information technology infrastructures develop.

Quantifying the real-world cost saving from using surgical adjuncts to prevent complications during cataract surgery

INTRODUCTION

Surgical adjuncts in cataract surgery are often perceived as sometimes necessary, always expensive, particularly in the "lean" cost-saving era. However, prevention of a surgical complication, rather than subsequent management, should always be the preferred strategy. We wished to model real-world costs associated with surgical adjuncts use and test the maxim for cataract surgery-"if you think of it, use it".

METHODS

We compared UK list prices for equipment and related costs of preventing vitreous loss (VL) via use of surgical adjuncts vs its subsequent management in a hypothetical cataract surgery scenario of a white swollen cataract with a moderately dilated pupil.

RESULTS

The original surgery costs for the "cautious with adjuncts, no complications" approach was £943.54, including adjuncts costing £137.47. In the "minimalist, no adjunct" scenario, management of VL using the Anterior Vitrectomy Kit cost £142.45, and additional management and follow-up costs resulted in total cost of £1178.20 (£234.66 (25%) more expensive). If left aphakic, an additional operation for secondary iris clip IOL insertion and further follow-up to address the impact of the complication ultimately cost £2124.67 overall. An additional initial spend on surgical adjuncts of £137.47 could potentially prevent £1293.60 (9× increase) in direct costs in this scenario.

CONCLUSIONS

Through simple scenario modelling, we have demonstrated the cost benefits provided by the use of precautionary surgical adjuncts during cataract surgery. VL costs significantly more in terms of complication management and follow-up. This supports the cataract surgeon's maxim-"if you think of it, use it".

Premium intraocular lenses: The past, present and future

Purpose

To present potential benefits as well as limitations of premium intraocular lens (IOL) use, and provide insight in future of premium cataract surgery.

Methods

Bibliographic research was performed in PubMed/Medline database, and the most recently updated papers were evaluated. Keywords used were: premium intraocular lens, multifocal intraocular lens, toric intraocular lens, toric multifocal intraocular lens, accommodative intraocular lens, and the respective brand names.

Results

Multifocal IOLs provide uncorrected distance visual acuity (UDVA) of 0.03 logMAR in 82.3%–95.7% of patients and overall spectacle independence in 81%–85% of patients. Toric IOLs provide UDVA of 0.3 logMAR in 70%–95% of patients, residual astigmatism of 1 D or less is noted in 67%–88% of patients, and spectacle independence is reported in 60%–85% of patients. Toric multifocal IOLs provide UDVA of 0.3 logMAR in 92%–97% of patients, and spectacle independence is reported in 79%–90% of patients. Accommodative IOLs represent intensively developing field in ophthalmology, and the results are still variable depending on the IOL model.

Conclusions

Premium IOL technology and advanced surgical techniques have significantly improved postoperative visual outcomes. Future developments will potentiate development of new premium IOL designs that will provide spectacle independence and excellent visual outcomes after cataract surgery.

[Mechanical dilation of the pupil and its possible applications in femtosecond laser-assisted cataract surgery]

In certain cases intraoperative pupil dilation during cataract surgery may be necessary to improve the visualization of intraocular structures and assure the atraumatic nature of surgical manipulations. The article reviews a wide range of pupil expanders, their historical aspects and possibilities of their application in modern cataract surgery.