Intracameral illuminator-assisted advanced cataract surgery combined with 23-gauge vitrectomy in eyes with poor red reflex

Surgical time and efficacy of illuminated chopper-assisted cataract surgery involving miosis after femtosecond laser pretreatment

PURPOSE

To evaluate the efficacy of the illuminated chopper-assisted cataract surgery in terms of shortening the surgical time in eyes with miosis after femtosecond laser pretreatment.

METHODS

As retrospective study, three hundred thirty-six eyes of 336 consecutive patients who underwent the femtosecond laser and illuminated chopper-assisted cataract surgery were included. Cases with pupil less than 6 mm after femtosecond laser pretreatment were included in the miosis group. Pupil diameter, surgical time, and improved efficacy (100/surgical time×pupil size) were compared between eyes with and without miosis.

RESULTS

Of 336 eyes, 20 were included in the miosis group (6.0%). Pupil diameter was smaller in eyes with miosis than in those without miosis (5.23 ± 0.38 mm vs 7.35 ± 0.64 mm, p < 0.001); however, surgical time was not different (6.86 ± 0.73 min vs 6.60 ± 1.27 min, p = 0.071) between the two groups. Mechanical pupil dilations were not needed in any cases. As a result, improved efficacy was calculated to be higher in patients with miosis (2.83 vs 2.14, p < 0.001).

CONCLUSION

In terms of surgical time and improved efficacy, using the illuminated chopper simplified cataract surgery involving miosis after femtosecond laser pretreatment. The use of an illuminated chopper is expected to be a good solution for femtosecond laser-assisted cataract surgeries.

Evaluation of new approach to enhance visualization performance in cataract surgery: 3D visualization system with coaxial illumination

PURPOSE

To evaluate the visualization performance of different approaches, including the 3D visualization system with coaxial illumination and the 3D system or microscope with standard illumination.

SETTING

Fuzhou Eye Hospital, Fuzhou City, China.

DESIGN

Cross-sectional study.

METHODS

This 2-part performance assessment for visualization composed of an objective analysis using surgical video images and a subjective survey collecting feedback from surgeons. Data of each eye were obtained with 3 approaches: standard operating microscope with standard illumination (SOM-S), 3D visualization system with standard illumination (3D-S), and 3D visualization system with coaxial illumination (3D-C).

RESULTS

112 eyes (107 cases) and 6 cataract surgeons were involved. The red reflex value was markedly greater in the 3D-C approach compared with other 2 approaches ( P < .001). Compared with the SOM-S approach, the red reflex increased by 55%, 57%, and 53% in the 3D-C approach, corresponding to nuclear grades of II, III, and IV, respectively. In the questionnaire survey, red reflex scores were consistently significantly higher in the 3D-C approach than those in the others ( P < .001). Depth of field was enhanced in both 3D approaches compared with the SOM-S approach ( P < .05). The only minor advantage of the SOM system over the 3D-C approach was in the surrounding field clarity score, and the difference was not statistically significant ( P = 1.000).

CONCLUSIONS

The 3D-C approach significantly increased the red reflex in both objective and subjective assessments. Surgeon responses also showed a superior performance for the 3D-C approach.

Intraoperative challenges and complications of cataract surgery between cataract surgery alone and phacovitrectomy in eyes with diabetic retinopathy: efficacy of illuminated chopper-assisted cataract surgery

BACKGROUND

To compare the intraoperative challenges, complications, and operation time of illuminated chopper-assisted cataract surgery between cataract surgery only and phacovitrectomy in eyes with diabetic retinopathy.

METHODS

One university hospital, retrospective case series. Two hundred ninety-five eyes of 295 consecutive patients with diabetic retinopathy who underwent cataract surgery only or phacovitrectomy were retrospectively reviewed. Intraoperative challenges and complications of cataract surgery were thoroughly analyzed by 3D viewing of digitally recorded videos. The pupil diameter, operation time, and improved efficacy (100/operation time × pupil diameter) were compared between the cataract surgery only and phacovitrectomy groups.

RESULTS

Of the 295 eyes, 211 underwent cataract surgery only, and 84 underwent phacovitrectomy. Intraoperative challenges such as small pupil, miosis, or poor red reflex occurred more frequently (46 [21.8%] vs. 28 [33.3%], p = 0.029); pupil diameter was smaller (7.34 ± 0.94 vs. 6.89 ± 0.88 mm, p < 0.001) in the phacovitrectomy group than in the cataract surgery only group; however, rates of posterior capsule rupture and operation time were not different between the two groups (0 [0%] vs. 1 [1.2%], p = 0.285; 16.54 ± 2.65 vs. 16.31 ± 4.30 min, p = 0.434). Improved efficacy was higher in the phacovitrectomy group (0.85 ± 0.18 vs. 0.97 ± 0.28, p = 0.002).

CONCLUSIONS

The use of an illuminated chopper is a potential solution for diabetic cataract surgery, particularly in phacovitrectomy, by decreasing the use of supplemental devices, operation time, and posterior capsule rupture.

TRIAL REGISTRATION

Retrospectively registered.

Learning Curve in Phaco Chop Cataract Surgery Using an Illuminated Chopper

Purpose: To confirm that the phaco chop method using an illuminated chopper (iChopper; Oculight, Seongnam, Korea) can reduce cataract surgery complications, and that even beginners can safely and effectively perform phaco chop.Methods: We retrospectively analyzed the medical records of the first 30 phaco chop cases using illuminated chopper of four cataract surgeons. Four ophthalmologists had a variety of empirical backgrounds, from those who have experienced more than 10,000 cataract surgery, to beginners who have experienced 20 cataract surgery.Results: Of the total 120 eyes, two eyes (1.67%) had posterior capsule rupture. The chopping method was changed from phaco chop to stop and chop in three eyes (2.5%) including one eye with brown cataract with pseudoexofoliation syndrome and two eyes with nuclear opacity grade ≥5.Conclusions: The rates of posterior capsule rupture of phaco chop using an illuminated chopper were very low in four surgeons with various experiences and who became proficient shortly in phaco chop.

Illuminated Chop Using an Illuminated Chopper in Cataract Surgery: on the Way to Minimal-energy Phacoemulsification

Purpose: To minimize ultrasound power use and surgical phaco time in illuminated chop cataract surgery.Methods: The charts of patients who underwent senile cataract surgery by a single surgeon were reviewed retrospectively. A conventional intracameral endoilluminator was used in a Stop & Chop group (n = 45), while an illuminated chopper was used in an illuminated chop (I-Chop) group (n = 71). EFX, a unitless value that roughly correlates with ultrasound energy during phacoemulsification, surgical phaco time, and changes in endothelial cell count were compared between the two groups and the ratio of zero phacoemulsification in the I-Chop group was evaluated.Results: EFX of the Stop & Chop and I-Chop groups was 18.08 ± 16.15 and 0.82 ± 3.53, respectively (p = 0.001), while the surgical phaco time was 185.08 ± 41.42 and 162.04 ± 49.65 seconds (p = 0.01). However, the endothelial loss did not differ in the two groups (7.03 ± 7.89 vs. 7.13 ± 9.47%, p = 0.76). In the I-Chop group, 56 (86%) eyes had zero phaco energy and patients with EFX >1 (n = 6) had more severe nuclear sclerosis grading (2.90 ± 0.71 vs. 4.5 ± 1.0; p = 0.001).Conclusions: The I-Chop group had lower EFX and shorter surgical phaco time than the Stop & Chop group. Illuminated chop using an illuminated chopper is one way to attain minimal phacoemulsification.

Contrast, visibility, and color balance between the microscope versus intracameral illumination in cataract surgery using a 3D visualization system

Purpose:

To compare image resolution and depth between the microscope versus intracameral illumination images during 3D heads-up cataract surgery.

Methods:

We collected 25 consecutive patients who had cataract surgery using the 3D viewing system. Based on bright, contrast, visibility, and color balance, the digital images (RGB color and three monochromes) extracted at the same point of the procedures were compared between the two illuminations.

Results:

Contrast values of green and blue channels except for red channel and visibility values of all three channels were higher in the intracameral illumination images than in the microscope images (P < 0.001, t-test). Color balance values of both green/red and blue/red were higher in the intracameral illumination images than in the microscope images (P < 0.001, t-test).

Conclusion:

The digital images in the digitally assisted cataract surgery were enhanced by using the intracameral illumination. Considering the contrast and color balance in the 3D cataract surgery, the intracameral illumination may be better than the microscope illumination.

Light exposure from microscope versus intracameral illumination during cataract surgery

Purpose:

To evaluate light exposure from microscope versus intracameral illuminations to patient's and surgeon's retina during cataract surgery.

Methods:

Thirty consecutive patients who had cataract surgery using microscope and intracameral illuminations. At the point of the ocular of an operating microscope, optical illuminance and irradiance from the microscope illumination (60, 40, 20% intensity) and the intracameral illumination (60% intensity) were measured using a light meter and a spectrometer at a pause after lens capsule polishing in cataract surgery.

Results:

Average illuminance (lux) was 1.46, 0.66, 0.27, and 0.1 from 60%, 40%, 20% intensity microscope illuminations and 60% intracameral illumination. Average total spectral irradiance (μW/cm2) was 1.25, 0.65, 0.26, and 0.03 from 60%, 40%, 20% intensity microscope illuminations and 60% intracameral illumination.

Conclusion:

Microscope ocular illuminance and irradiance during cataract surgery were higher in the microscope illumination than in the intracameral illumination. It suggests that light exposure reaching patient's and surgeon's retina during cataract surgery is lower in the intracameral illumination than in the microscope illumination.

Macular photostress and visual experience between microscope and intracameral illumination during cataract surgery

PURPOSE

To evaluate macular photostress and visual experience between coaxial microscope illumination versus oblique intracameral illumination during cataract surgery.

SETTING

Gachon University Gil Hospital, Incheon, South Korea.

DESIGN

Prospective case series.

METHODS

Consecutive patients who had cataract surgery using microscope illumination and intracameral illumination were included. The patients were asked to complete a questionnaire (seeing strong lights, feeling photophobia, feeling startled (fright) when seeing lights, seeing any colors, seeing any instruments or surgical procedures, and estimating intraoperative visual function) designed to describe their cataract surgery experience. The images projected on the retina of the model eye (rear view) with artificial opaque fragments in the anterior chamber during simulating cataract surgery were compared between the 2 illumination types.

RESULTS

Sixty patients completed the questionnaire. Scores for strong lights, photophobia, fright, and color perception were significantly higher with microscope illumination than with intracameral illumination (all P < .001). More patients preferred the intracameral illumination (45 [75.0%]) to the microscope illumination (13 [21.7%]). In the rear-view images created in a model eye, only the bright microscope light in the center was seen without any lens image in the microscope illumination. However, in the intracameral illumination, the less bright light from the light pipe in the periphery and the lens fragments were seen more clearly.

CONCLUSIONS

In a view of the patients' visual experience, oblique intracameral illumination caused less subjective photostress and was preferred over coaxial microscope illumination. Objective findings from the model-eye experiment correlated to the result of visual experience.

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.

Phacoemulsification Outcomes with Different Illumination Techniques

PURPOSE

To compare surgeon experience and the outcomes of phacoemulsification using 2 different illumination techniques for cataract extraction.

METHODS

A prospective interventional case series was performed on 20 consecutive patients (20 eyes) with senile cataract who underwent phacoemulsification enhanced with a 23-G endoillumination probe. The main outcome measures were the surgeon's perception of depth of field and quality of visibility of intraocular structures, ease of performance of the surgical procedure, effectiveness, and complications related to the procedure. A surgeon-specific questionnaire was administered at the end of the procedure.

RESULTS

Surgery was successfully performed in all patients without any complications. The surgeon indicated that lateral endoillumination markedly enhanced the details of the lens structures, mainly the posterior capsule visualization, better than the coaxial lighting with the surgical microscope. Lateral endoillumination created an enhanced 3D effect and improved the depth perception of lens intraoperatively.

CONCLUSIONS

The lateral illumination technique with a 23-G endoilluminator probe placed in the anterior chamber through a paracentesis creates an enhanced 3D effect and improves depth perception of lens during phacoemulsification. These benefits increase the safety of the procedure.

Comparative analysis of brilliant blue G and an intracameral illuminator in assisting visualization of the anterior capsule in eyes with vitreous hemorrhage

PURPOSE

To compare the safety and efficacy of 0.025 mg/mL brilliant blue G (BBG) and an intracameral illuminator for visualizing the anterior capsule.

SETTING

University-based tertiary referral center, South Korea.

DESIGN

Retrospective cases series.

METHODS

The medical records of patients with vitreous hemorrhage for which they had pars plana vitrectomy and cataract surgery were retrospectively reviewed. The patients were classified into 2 groups. The BBG group comprised patients having capsule staining with BBG. The illuminator group comprised patients who had capsulorhexis assisted with an intracameral illuminator. The status of the endothelial cells was analyzed.

RESULTS

There were 27 eyes in the BBG group and 35 eyes in the illuminator group. In the BBG group, endothelial cell density (ECD) was reduced 3 months after surgery (10.6% loss) (P = .003). The illuminator group had no significant loss (1.5% loss) (P = .264). The ECD loss was greater in the BBG group than the illuminator group 3 months after surgery (P = .01). There was no statistically significant difference in the coefficient of variation of cell area or percentage of hexagonal cells between the 2 groups.

CONCLUSIONS

The ECD loss was higher in eyes with 0.025 mg/mL BBG staining than in eyes using an intracameral illuminator. Further studies are necessary to establish the safety profile of BBG on the endothelium.

FINANCIAL DISCLOSURE

None of the authors has a financial or proprietary interest in any material or method mentioned.

Chandelier-assisted retroillumination for phacoemulsification in phacovitrectomy

Purpose:

To describe chandelier-assisted retroillumination for phacoemulsification in patients with poor fundal glow due to posterior segment pathology during combined phacovitrectomy procedure.

Methods:

This was a prospective observational study. Thirty eyes underwent combined phacoemulsification and 25G sutureless pars plana vitrectomy. Sclerotomy port for chandelier tip was made in the inferotemporal or superonasal quadrant based on the incision site for phacoemulsification. Later, it was replaced with infusion cannula or endoilluminator. Cases included had posterior segment pathologies such as vitreous hemorrhage and vitritis.

Results:

Red reflex was markedly enhanced during phacoemulsification for all cases. In all eyes, a continuous curvilinear capsulorhexis was achieved without the use of dye. The posterior capsule remained intact in all cases. The visual acuity in all patients improved, and the median best-corrected visual acuity was 20/60 (range: 4/60–20/30) at 6 months. There were no intraoperative or postoperative complications.

Conclusion:

Cases with poor red reflex pose a challenge for anterior segment surgeons, and chandelier-assisted retroillumination proves to be a safe and effective tool in combined phacovitrectomy surgeries. Moreover, no additional cannula port is required for this chandelier insertion.

PRIMARY CORE VITRECTOMY TECHNIQUE BEFORE CATARACT SURGERY IN COMBINED PHACOVITRECTOMY FOR EYES WITH DENSE VITREOUS HEMORRHAGES

PURPOSE

To investigate the efficacy and safety of a primary core vitrectomy technique for combined phacovitrectomy in eyes showing a poor red reflex because of dense vitreous hemorrhage before cataract surgery.

METHODS

A total of 156 eyes from 156 patients, who underwent combined phacovitrectomy because of cataract and dense vitreous hemorrhage, and who were followed up for at least 6 months were included. The patients were divided into a primary phacoemulsification group (Group A, 80 eyes) who underwent phacoemulsification first followed by total vitrectomy and a primary vitrectomy group (Group B, 76 eyes) who underwent core vitrectomy first followed by cataract surgery and followed by total vitrectomy. A conventional 23-gauge combined phacovitrectomy was performed in all patients. The operation time, including the total continuous curvilinear capsulorhexis time and total cataract surgery time, and the incidence of surgery-related complications were evaluated in the two groups.

RESULTS

Diabetic retinopathy was the most common cause for vitreous hemorrhage in both groups (Group A: 51 eyes; Group B: 39 eyes). The total continuous curvilinear capsulorhexis time (P = 0.001) and total cataract surgery time (P = 0.036) were significantly shorter in Group B than in Group A. Among the complications, radial tears occurred more frequently in Group A than Group B, but these differences were not statistically significant (P = 0.211). Pupil size reduction during cataract surgery was greater in Group B than in Group A (P = 0.034). There were no significant differences in posterior capsular ruptures or posterior capsular opacities between the two groups. Other postoperative complications were not observed in either group until 6 months after surgery.

CONCLUSION

Primary core vitrectomy combined with phacovitrectomy of patients who had dense vitreous hemorrhage helped to obtain a good red reflex and enabled surgeons to perform successful cataract surgery. In addition, primary core vitrectomy was an easy and safe technique, which reduced the surgery time and surgery-related complications. This surgical technique would, therefore, be helpful to vitreoretinal surgeons.

To assess surgical outcomes of combined femtosecond laser-assisted cataract surgery with 25-gauge vitrectomy surgery at a tertiary eye care center

Background:

The aim of this study was to assess the surgical outcomes of combined femtosecond laser-assisted cataract surgery (FLACS) with 25-gauge vitrectomy surgery.

Materials and Methods:

A retrospective analysis of 45 patients who underwent combined FLACS with 25-gauge vitrectomy surgery.

Results:

A total number of 45 eyes of 45 patients were treated with a mean age of 63.27 years (range 45–75). The mean follow-up was 3 months (range 3–12 months). The mean preoperative best-corrected visual acuity was 1.47 ± 0.86. The mean postoperative vision was 0.36 ± 0.36 and 0.275 ± 0.184 at a paired t-test revealed a statistically significant improvement in visual acuity at 1 month (P < 0.001) and 3 months (P < 0.001). The most common indication for surgery was full-thickness macular hole (51.1%), vitreous hemorrhage (24.4%), followed by epiretinal membrane (17.7%) and rhegmatogenous retinal detachment (4.4%).

Conclusion:

Combining FLACS with vitrectomy may be a step toward achieving better outcomes when combined CS and vitrectomy is performed.

Chandelier retroillumination-assisted cataract surgery during vitrectomy

PurposeTo present an alternative cataract surgical technique in patients with cataract and intravitreal hemorrhage.MethodsTwelve cases with poor fundus reflex caused by severe vitreus hemorrhage were included in the study. All patients underwent combined phaco surgery and 23-gauge vitrectomy. Chandelier retroillumination was inserted into the infusion trochar during the cataract operations and was used with low power (50-75%) in necessary steps.ResultsWe did not experience phaco complications or complications due to technique during surgery. Retroillumination assistance was especially useful during final stages of cataract surgery, particularly irrigation-aspiration of cortical material.ConclusionRetroillumination in absence of red fundus reflex may be helpful and can be practiced more often in cataract surgery combined with vitrectomy.

Phacoemulsification using a chisel-shaped illuminator: enhanced depth trench, one-shot crack, and phaco cut

PURPOSE

To evaluate the efficacy and outcomes of intracameral illuminator-assisted nucleofractis technique in cataract surgery.

METHODS

Since June 2012, this novel technique has been performed in all cataract cases by one surgeon (approximately 300 cases of various densities). Trenching continues until the posterior plate white reflex between an endonucleus and an epinucleus is identified (enhanced depth trench). After trenching, cracking is initiated with minimal separation force, and completion of cracking is confirmed by posterior capsule reflex (one-shot crack). With followability enhanced by an elliptical phaco mode, the divided nucleus is efficiently cut into small fragments by a chisel-shaped illuminator (phaco cut).

RESULTS

We have not experienced any capsular bag or zonular complications, and the effective phacoemulsification time seemed to be shorter than that with the conventional technique.

CONCLUSIONS

This technique simplifies the complete division of the nucleus, which is the most challenging step in safe and efficient phacoemulsification.