Preoperative optimization of ocular surface disease before cataract surgery

Post-refractive Surgery Dry Eye: A Systematic Review Exploring Pathophysiology, Risk Factors, and Novel Management Strategies

Dry eye disease frequently manifests following corneal refractive procedures, significantly impacting patients' quality of life. This review systematically synthesizes current evidence on the pathophysiological mechanisms, risk factors, and therapeutic interventions for post-refractive surgery dry eye. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of literature published until August 2023 was conducted, focusing on post-refractive surgery dry eye. Eighteen relevant studies were identified through screening and eligibility assessment. A qualitative synthesis of outcomes was performed using narrative and thematic analysis methods. Surgically induced neurotrophic deficiency, stemming from nerve transection, triggers a cascade of events including apoptosis, inflammation, and lacrimal dysfunction, ultimately leading to tear film instability. Risk factors such as female gender, thyroid eye disease, meibomian gland dysfunction, higher ablation depths, and the use of LASIK over surface ablation exacerbate the condition. While conventional treatments like artificial tears provide temporary relief, emerging interventions such as nerve growth factors, matrix metalloproteinase inhibitors, serum eye drops, and specialized contact lenses show promise in promoting nerve regeneration and epithelial healing. Strategies such as customized ablation profiles, smaller optical zones, and nerve-sparing techniques like small incision lenticule extraction demonstrate potential advantages. A multifaceted therapeutic approach targeting neuroprotection, anti-inflammatory mechanisms, and tear film stabilization is imperative for effectively managing post-refractive surgery dry eye. Future research should focus on evaluating prognostic biomarkers, exploring precision medicine approaches, and investigating neuroprotective adjuvants to further enhance treatment outcomes.

Validity and reliability of the Thai version of the ASCRS SPEED II preoperative OSD questionnaire in Thai cataract surgery candidates

OBJECTIVES

To develop a Thai version of the American Society of Cataract and Refractive Surgery (ASCRS)-modified Standard Patient Evaluation of Eye Dryness (SPEED) II© preoperative ocular surface disease (OSD) questionnaire (ASCRS SPEED II-Thai) and evaluate its validity and reliability in Thai cataract surgery candidates.

METHODS

The original English version of the questionnaire was translated and adapted cross-culturally to Thai language. The ASCRS SPEED II-Thai was evaluated for content validity, internal consistency, and test-retest reliability. Five experts in the ocular surface field critically reviewed the ASCRS SPEED II-Thai to measure the content validity indexes (CVI). A total of 105 cataract surgery candidates were recruited from an ophthalmology clinic to complete the questionnaire. Cronbach's alpha and intraclass correlation coefficient (ICC) were calculated to assess internal consistency and test-retest reliability, respectively.

RESULTS

During the translation and cross-cultural adaptation processes, only two minor modifications were made to the original version for clarification without changing their meaning. All items in the ASCRS SPEED II-Thai had an item-level CVI of 1.00, representing complete agreement among content experts. The scale-level CVI was 1.00, indicating excellent content validity of the questionnaire. The participants found no difficulty in understanding each question in the pilot test. Cronbach's alpha for the ASCRS SPEED II-Thai was 0.82, indicating good internal consistency. The test-retest reliability was good to excellent, with ICC values ranging from 0.83 to 1.00 (P < 0.001).

CONCLUSIONS

The ASCRS SPEED II-Thai is a valid clinical tool with adequate reliability for preoperative OSD screening among Thai cataract surgery candidates.

Intraocular lens power calculation: angle κ and ocular biomechanics

PURPOSE

To study the effect of ocular biomechanics on the prediction error of intraocular lens (IOL) power calculation.

SETTING

Centro Hospitalar Universitário do Porto, Porto, Portugal.

DESIGN

Prospective longitudinal study.

METHODS

This study included 67 subjects. Before cataract surgery subjects underwent biometry with IOLMaster 700 and biomechanical analysis with Corvis Scheimpflug technology. The targeted spherical equivalent was calculated with SRK-T and Barrett Universal II. Associations between prediction error (PE), absolute prediction error (AE), and biometric and biomechanical parameters were performed with stepwise multivariate linear correlation analysis.

RESULTS

Using the SRKT formula, there was association between PE and Corvis Biomechanical Index (CBI, B = -0.531, P = .011) and between AE and the horizontal offset between the center of the pupil and the visual axis (angle κ, B = -0.274, P = .007). Considering the Barret Universal II formula, PE was independently associated with anterior chamber depth ( B = -0.279, P = .021) and CBI ( B = -0.520, P = .013) and AE was associated with angle κ ( B = -0.370, P = .007).

CONCLUSIONS

A large angle κ may reduce the predictability of IOL power calculation. Ocular biomechanics likely influence the refractive outcomes after IOL implantation. This study showed that eyes with softer corneal biomechanics had more myopic PE. This may relate to anteriorization of the effective lens position. Dynamic measurements may be the way to progress into future formulas.

Novel Management of Ocular Surface Inflammation in Patients With Ocular Graft-Versus-Host Disease in the Setting of Cataract Surgery

PURPOSE

To report the outcomes of cataract surgery in patients with ocular graft-versus-host disease (oGVHD) using a novel preoperative immunomodulatory regimen in a collaborative subspecialty care setting.

METHODS

Retrospective case series of patients with oGVHD who underwent cataract surgery using a novel preoperative immunomodulatory regimen in a collaborative care setting. A preoperative regimen consisting of pooled human immune globulin 1%, autologous serum 50%, and methylprednisolone 1% eye drops was prescribed. Outcome measures included visual acuity (VA), ocular surface disease index (OSDI) score, lissamine green staining, and complications with a minimum of 2 years of follow-up.

RESULTS

Thirty-five eyes from 20 patients with oGVHD were studied. The mean age was 59 years (range 30-70 years). A healthy comparison group included 35 eyes from 24 patients with a mean age of 63 years (range 44-74 years). At the 2-year follow-up, the mean corneal staining score was 2.3/15, the mean OSDI score was 37.5, and the mean VA was 20/30 (logarithm of the minimal angle of resolution 0.17). The global complication rate was 2.8% at the last follow-up with no difference versus a healthy comparison group.

CONCLUSIONS

A collaborative care model improving ocular surface health before cataract surgery with dry eye and cataract subspecialists can optimize outcomes in patients with oGVHD.

Cataract surgery in setting of ocular surface disease

PURPOSE OF REVIEW

The purpose of this article is to review the available strategies to successfully identify and manage ocular surface disease (OSD) pre, intra and post-cataract surgery.

RECENT FINDINGS

Cataract surgery and OSD have an intricate relationship: the surgical procedure can induce or exaggerate OSD symptoms, while OSD can negatively impact surgical refractive outcomes and increase the rate of postoperative complications.

SUMMARY

Improving the health and stability ocular surface is the key to enhance post cataract surgery refractive outcomes and avoid complications. This is pivotal for patients affected by severe OSD, but is also important for patients with minimal signs or symptoms. A correct diagnosis and a stepwise approach are the keys to improve the quality of life of such patients.

Paper waste from instructions for use brochures in cataract surgery implant packaging in Europe and the United States

PURPOSE

To assess the extent of paper waste generated per year by instructions for use (IFUs) brochures included in intraocular lens (IOL) packaging in Europe and the U.S.

SETTING

Rothschild Foundation Hospital, Paris, France; Royal Free London NHS Foundation Trust; Center for Sight, London, United Kingdom.

DESIGN

Experimental study.

METHODS

A sample of IOLs were collected and each IFU was weighed. In addition, the cumulative weight of these brochures used in cataract surgeries performed annually in Europe and the U.S. was estimated, and the potential annual paper conservation that could be achieved if all manufacturers adopted electronic IFUs (e-IFUs) in Europe and the U.S. was determined.

RESULTS

The mean and standard deviation of the weight for overall IFUs, classic IFUs, and e-IFUs were 17.6 ± 13.8 g, 23.5 ± 13.2 g, and 2.9 ± 1.9 g, respectively. The estimated cumulative weight of paper generated from the IFUs accompanying implants used in European and U.S. cataract surgeries is 153 tons. If all manufacturers transition to e-IFUs, the cumulative weight saved would be 128 tons (-84%), equivalent to 120 tons of carbon dioxide equivalent and the preservation of more than 2000 trees annually.

CONCLUSIONS

The classic IFUs in IOL packaging result in a significant amount of paper waste annually. Therefore, there is an urgent need for a rapid transition to e-IFU technology. The adoption of e-IFUs has already been authorized in Europe and the U.S., and it is crucial to expedite this process.

Refractive cataract surgery

PURPOSE OF REVIEW

The aim of this study to provide an overview of recent publications and opinions in refractive cataract surgery.

RECENT FINDINGS

With the advent of intraocular lenses (IOLs) on different platforms, the surgeon has a wide arena of types of IOL to choose, depending on the patient's visual requirement. Optimization of the tear film, integrating tomography and topography devices for appropriate keratometry values, biometry, use of advanced formulas for IOL power calculation and application of newer IOLs can help achieve target refraction in cases scheduled for cataract surgery. Intraoperative aberrometry can be a useful aid for cataract surgery in postrefractive cases and can help minimize residual postoperative astigmatism.

SUMMARY

Evolvement and rapid advancement of technology allows to impart desired refractive outcomes in most of the cases postcataract surgery. Appropriate preoperative and intraoperative factors should be considered to achieve the desired postoperative outcome.

Factors Predictive of Refractive Error After Toric Lens Implantation

Purpose

To identify factors related to suboptimal refractive outcomes after toric intraocular lens implantation.

Patients and Methods

A retrospective case-control chart review of 446 eyes with toric lens insertion by the same surgeon at a university hospital from 2016 to 2020 was conducted. Pre-operative exam findings, biometry, and one month and three month post-operative vision and refraction were noted. Reviewed charts were considered cases if uncorrected distance visual acuity (UDVA) was worse than 20/40, spherical equivalent (SE) >1 diopter (D) off target, or cylinder >1 D off target.

Results

Overall, 93.7% (n = 343) of eyes achieved UDVA of 20/40 or better, 92.7% (n = 306) were within 1 D of target SE, and 90.9% (n = 300) were within 1 D of target cylinder. UDVA cases had more eyes with prior LASIK (21.7% vs 7.0%, p = 0.01) and keratoconus (8.7% vs 0.6%, p < 0.001) than controls. More SE cases had prior radial keratotomy (RK) (8.3% vs 0%, p < 0.001) and keratoconus (12.5% vs 0%, p < 0.001) than controls. More cylinder cases had prior LASIK (30.0% vs 8.7%, p < 0.001) and higher mean astigmatism (2.3 vs 1.5 D, p = 0.02) than controls. More cases in all three analyses had higher toric cylinder power (T5-T9) than controls. Age, sex, eye laterality, axial length, anterior chamber depth, lens power, dry eye, anterior basement membrane dystrophy, and Fuchs' endothelial dystrophy differences were not significant.

Conclusion

Prior LASIK or RK, keratoconus, and higher astigmatism may increase the chance of a suboptimal outcome.

Dry Eye Disease as a Cause of Refractive Errors After Cataract Surgery - A Systematic Review

Dry eye disease (DED) is a multifactorial ocular surface disorder characterized by loss of tear film homeostasis with associated ocular symptoms, like dryness, foreign body sensation, and inflammation. Numerous reports confirm an increase in dry eye symptoms after cataract surgery. DED also significantly disturbs preoperative biometric measurements, mainly by changes in keratometry measurements. The purpose of this study is to evaluate the effect of DED on biometric measurements before cataract surgery and postoperative refractive errors. PubMed database was searched for keywords: cataract surgery, dry eye disease, refractive error, refractive outcomes, keratometry, and biometry. Four clinical studies evaluating the effect of DED on refractive errors were included. In all studies, biometry was performed before and after dry eye treatment, and the mean absolute error was compared. Various substances have been used to treat dry eye, such as cyclosporin A, liftitegrast, and loteprednol. The refractive error was significantly lower after treatment in all studies. The results unanimously indicate that refractive errors can be reduced by proper treatment of DED before cataract surgery.

Prevalence of Dry Eye Disease Among Individuals Scheduled for Cataract Surgery in a Norwegian Cataract Clinic

Purpose

To determine the prevalence of dry eye disease (DED) in patients scheduled for cataract surgery in a Norwegian eye clinic.

Patients and Methods

218 patients scheduled for cataract surgery were examined for DED in one randomly selected eye and questioned regarding symptoms and risk factors. Patients were diagnosed with DED if they fulfilled the DEWS II criteria with symptom score >12/100 with Ocular Surface Disease Index (OSDI) questionnaire, and the presence of any of the three signs: tear osmolarity >307 mOsm/L in either eye or a difference in osmolarity between the two eyes of >8 mOsm/L, corneal fluorescein staining (CSF) ≥ grade 2 and non-invasive tear film breakup time (NIKBUT) of <10 seconds. Additional tests were the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire, tear meniscus height (TMH), Schirmer 1, tear film thickness (TFT), corneal sensitivity and meibography (meiboscore). Dry eye test outcomes were correlated with risk factors for DED.

Results

The prevalence of DED was 55.5% according to the DEWS II criteria. The abnormal osmolarity percentage was 66.5, while 29.8% had shortened NIKBUT and 19.7% exhibited CFS ≥2. 57% had Schirmer 1 ≤ 10 mm/5 min, and 81.1% had a meiboscore of ≥1. 71.2% of subjects scored positive for DED symptoms using the OSDI questionnaire and 69.3% using SPEED. Logistic regression analysis showed that higher age correlated with a lower OSDI symptom score, reduced corneal sensitivity and increased meibomian gland atrophy. Female sex was associated with higher odds of having DED, abnormal NIKBUT and abnormal CFS. Ocular tests for DED did not correlate with OSDI symptom scores when assessed with Spearman`s rank analysis.

Conclusion

The prevalence of DED in an elderly Norwegian population scheduled for cataract surgery is high and associated with female sex. There was a lack of correlation between signs and symptoms of DED.

Management of inflammation in dry eye disease: Recommendations from a European panel of experts

Introduction

Early initiation of anti-inflammatory therapies is recommended for dry eye disease (DED) to break the vicious cycle of pathophysiology. However, there is limited guidance on how to implement topical ciclosporin (CsA) and corticosteroid treatment into clinical practice. This expert-led consensus provides practical guidance on the management of DED, including when and how to use topical CsA.

Methods

A steering committee (SC) of seven European DED experts developed a questionnaire to gain information on the unmet needs and management of DED in clinical practice. Consensus statements on four key areas (disease severity and progression; patient management; efficacy, safety and tolerability of CsA; and patient education) were generated based on the responses. The SC and an expanded expert panel of 22 members used a nine-point scale (1  =  strongly disagree; 9  =  strongly agree) to rate statements; a consensus was reached if ≥75% of experts scored a statement ≥7.

Results

A stepwise approach to DED management is required in patients presenting with moderate corneal staining. Early topical CsA initiation, alone or with corticosteroids, should be considered in patients with clinical risk factors for severe DED. Patient education is required before and during treatment to manage expectations regarding efficacy and tolerability in order to optimise adherence. Follow-up visits are required, ideally at Month 1 and every 3 months thereafter. Topical CsA may be continued indefinitely, especially when surgery is required.

Conclusion

This consensus fills some of the knowledge gaps in previous recommendations regarding the use of topical corticosteroids and CsA in patients with DED.

Differential response to topical lubrication in patient with dry eye disease, based on age

BACKGROUND

To compare the Ocular surface disease index (OSDI) score, Schirmer I test (SIT), fluorescein break up time (FBUT) and fluorescence staining (FLCS) score of dry eye patients at different ages.

METHODS

90 eyes of 90 patients with mild to moderate dry eye from September 2020 to September 2021 were retrospectively included and were divided into young group (20-39 years, n = 29), middle-age group (40-59 years, n = 30), and elder group (> 60 years, n = 31). Patients were given a 28-day topical lubricating ocular surface and repair-promoting drugs combined with local physical therapy. Patients were followed up at 7, 14 and 28 days. The OSDI score, SIT, FBUT and FLCS score were examined.

RESULTS

There were differences between the OSDI score in three groups at each time point (all P < 0.001). SIT were different among the three groups (F = 350.61, P < 0.001), and a time effect was found (F = 80.87, P < 0.001). SIT at 14 and 28 days after treatment in middle-age and elder groups were lower than young group (all P < 0.001). SIT at 7, 14 and 28 days in elder group were lower than middle-age group (all P < 0.001). FLCS score was lower at 28 days than other time points (all P < 0.001).

CONCLUSION

Dry eye patients are given a 28-day topical lubricating ocular surface and repair-promoting drugs combined with local physical therapy, which can promote tear secretion, film stability, and the recovery of corneal integrity. Age affects the treatment effect of mild to moderate dry eye, among which tear secretion is the most significant.

Outcomes and complications of cataract surgery in patients with chronic ocular graft-versus-host-disease-a multicenter, retrospective analysis

PURPOSE

To evaluate the outcome of phacoemulsification in patients with chronic ocular Graft-versus-host disease (oGVHD) after allogeneic hematopoietic stem cell transplantation (aHSCT).

METHODS

Retrospective, observational multicenter study from 1507 oGVHD patients. From the patient files, data were collected including best-corrected visual acuity (BCVA), intraocular pressure (IOP), Schirmer's test I, tear film break-up time (TFBUT), corneal fluorescein staining score, postoperative complications, and pre- and post-operative topical therapy.

RESULTS

Seventy-three patients underwent cataract surgery in 104 eyes. In n = 84 eyes, the oGVHD NIH grade was documented; 12% (n = 12) of analyzed eyes were staged oGVHD NIH grade 1, 31% (n = 32) NIH 2 and 39% (n = 41) NIH 3. The mean BCVA improved in 82% of the eyes (n = 86 eyes). BCVA significantly increased from 0.7 ± 0.5 to 0.4 ± 0.4 LogMAR after surgery independent from oGVHD severity. The mean IOP decreased from 14 ± 4 to 13 ± 4 mmHg after surgery. Visual acuity was moderately correlated to the pre-operative degree of corneal staining (Pearson p = 0.26, p = 0.002, Cohen's effect size f = 0.29). The visual acuity decreased by 0.078 LogMar units (95% CI = 0.027-0.141) with each increase of corneal staining by one grade (p = 0.05). After surgery, corneal epitheliopathy increased significantly in 42% (n = 44) of the eyes. Postoperative complications included corneal perforation (n = 6, 6%), cystoid macular edema (n = 4, 4%), and endophthalmitis (n = 1, 1%).

CONCLUSION

Phacoemulsification in patients with chronic oGVHD significantly improves visual acuity, but is associated with an increased risk of complications in particular corneal epitheliopathy and corneal perforations.

Risk of Refractive Prediction Error After Cataract Surgery in Patients with Thyroid Eye Disease

Purpose

To investigate the risk of unexpected refractive prediction error after cataract surgery in patients with thyroid eye disease (TED) at the University of Colorado.

Patients and Methods

A retrospective observational study was performed using records of patients who underwent cataract surgery (2014 to 2018) who were included in a Cataract Surgery Outcomes database. Any patient with documentation of thyroid eye disease (TED) in the medical record was classified as TED. Post-operative refraction error greater than or equal to ±1.0 diopter from the target refraction was the main outcome of this study. Eyes with history of refractive surgery, ocular trauma, retinal detachment, non-Graves’ disease thyroid conditions or Graves’ disease without TED, and eyes without refractive error at follow-up were excluded.

Results

A total of 5716 eyes from 3692 patients who underwent cataract surgery were analyzed. Sixty-five eyes of thirty-nine patients (1.1%) had TED. Former and/or current cigarette use was associated with having TED (p = 0.0504). Patients with TED had a statistically significant shorter axial length as compared to eyes without TED (p = 0.0257). Three hundred and forty-nine eyes (6.1%), including 9 eyes (13.8%) in patients with TED, had refractive prediction error greater than ±1.0 diopter following surgery (univariate OR = 2.5, 95% CI: 1.1–5.7, p = 0.0274). After multivariate analysis controlling for race, tobacco use, combined surgery, and axial length, TED was associated with an increased risk of our primary outcome, refractive prediction error greater than ±1.0 diopter (OR = 2.4, 95% CI: 1.0–5.7, p = 0.0506).

Conclusion

Patients with TED are at increased risk for refractive prediction error following cataract surgery. Discussion with patients regarding their risk and possible need for glasses following surgery is important for setting realistic patient expectations.

Cataract: Advances in surgery and whether surgery remains the only treatment in future

Background

Cataract is the world's leading eye disease that causes blindness. The prevalence of cataract aged 40 years and older is approximately 11.8%-18.8%. Currently, surgery is the only way to treat cataracts.

Main Text

From early intracapsular cataract extraction to extracapsular cataract extraction, to current phacoemulsification cataract surgery, the incision ranges from 12 to 3 ​mm, and sometimes to even 1.8 ​mm or less, and the revolution in cataract surgery is ongoing. Cataract surgery has transformed from vision recovery to refractive surgery, leading to the era of refractive cataract surgery, and premium intraocular lenses (IOLs) such as toric IOLs, multifocal IOLs, and extended depth-of-focus IOLs are being increasingly used to meet the individual needs of patients. With its advantages of providing better visual acuity and causing fewer complications, phacoemulsification is currently the mainstream cataract surgery technique worldwide. However, patient expectations for the safety and accuracy of the operation are continually increasing. Femtosecond laser-assisted cataract surgery (FLACS) has entered the public's field of vision. FLACS is a combination of new laser technology and artificial intelligence to replace fine manual clear corneal incision, capsulorhexis, and nuclear pre-fragmentation, providing new alternative technologies for patients and ophthalmologists. As FLACS matures, it is being increasingly applied in complex cases; however, some think it is not cost-effective. Although more than 26 million cataract surgeries are performed each year, there is still a gap in the prevalence of cataracts, especially in developing countries. Although cataract surgery is a nearly ideal procedure and complications are manageable, both patients and doctors dream of using drugs to cure cataracts. Is surgery really the only way to treat cataracts in the future? It has been verified by animal experiments that lanosterol therapy in rabbits and dogs could make cataract severity alleviated and lens transparency partially recovered. Although there is still much to learn about cataract reversal, this groundbreaking work provided a new strategy for the prevention and treatment of cataracts.

Conclusions

Although cataract surgery is nearly ideal, it is still insufficient, we expect the prospects for cataract drugs to be bright.

Detailed corneal and genetic characteristics of a pediatric patient with macular corneal dystrophy - case report

BACKGROUND

Corneal dystrophies are a group of rare, inherited disorders that are usually bilateral, symmetric, slowly progressive, and not related to environmental or systemic factors. The majority of publications present the advanced form of the disease with a typical clinical demonstration. The initial signs and symptoms of different epithelial and stromal corneal dystrophies are not specific; therefore, it is very important to establish the early characteristic corneal features of these disorders that could guide the diagnostic process.

CASE PRESENTATION

The main purpose of this study was to report the differential diagnosis of a pediatric patient with bilateral anterior corneal involvement suspected of corneal dystrophy. An 8-year-old male patient presented with asymptomatic, persistent, superficial, bilateral, diffuse, anterior corneal opacities. Slit lamp examination results were not specific. Despite the lack of visible stromal involvement on the slit lamp examination, corneal analysis based on confocal microscopy and optical coherence tomography revealed characteristic features of macular corneal dystrophy (MCD). The diagnosis of MCD was confirmed by CHST6 gene sequencing. The early corneal characteristic features of MCD, established based on the findings of this case report, include corneal astigmatism (not specific), diffuse corneal thinning without a pattern of corneal ectasia (specific), and characteristic features on confocal microscopy (specific), including multiple, dark, oriented striae at different corneal depths.

CONCLUSIONS

The clinical examination should be complemented with corneal imaging techniques, such as confocal microscopy and optical coherence tomography. In patients suspected of corneal dystrophy, genetic testing plays an important role in establishing the final diagnosis.

Ocular Surface Failure in Urban Syndrome

BACKGROUND

Nowadays, the continuous increase in air pollution has significantly changed air quality, leading to the onset of the so-called urban syndrome (US), an allergic-like conjunctivitis triggered by pollutants. These patients are characterized by persistent dysregulation of ocular surface para-inflammation, causing chronic low-grade inflammation and ocular discomfort, with significant consequences for occupational health and job productivity prospects. This study aims to investigate the effects of topical glycerophosphoinositol (GPI) eye drops on the signs and symptoms of US.

METHODS

A multicenter prospective open interventional study was performed. Patients affected by US, enrolled from occupational medicine clinics, were treated with eye drops containing 0.001% GPI in 0.2% HA vehicle three times a day. Ocular surface disease index (OSDI), tear break-up time (T-BUT), Schirmer test, Oxford score, hyperemia and ocular surface symptoms were recorded at patient enrolment (T0), after 1 week (T1) and after 1 month (T2) of treatment.

RESULTS

A total of 113 consecutive patients (226 eyes) were included. OSDI score displayed a significant improvement after one week (T0: 39.9 ± 19, T1: 20.8 ± 17.9, T2: 18.4 ± 15.6, p < 0.0001); T-BUT (T0: 5.2 ± 2, T1: 7.7 ± 2.2, T2: 9.7 ± 1.8, p < 0.0001) and Schirmer Test (T0: 6.6 ± 2.4, T1: 9.7 ± 2.7, T2: 12.6 ± 2.6, p < 0.0001) progressively improved from T0 to T2.

CONCLUSIONS

trice-daily topic instillation of 0.001% GPI in 0.02% HA vehicle resulted an effective and well tolerated treatment in US patients.

Dry Eye and Phacoemulsification Cataract Surgery: A Systematic Review and Meta-Analysis

Purpose: To evaluate whether dry eye deteriorates after phacoemulsification cataract surgery, and to explore the influential factors.

Methods: Studies published before February 2020 indexed on PubMed and the Cochrane Central Register of Controlled Trials were retrieved. A meta-analysis, including meta-regression, a sensitivity analysis, and a subgroup analysis, were performed.

Results: Twenty studies with 2,247 eyes were included in the meta-analysis, dry eye-related parameters were investigated preoperatively and 1 month postoperatively. Patients with pre-existing meibomian gland dysfunction (MGD) had worsened subjective symptoms of dry eye (1.31, 95% confidence interval (CI) [0.66, 1.95], P < 0.0001), a reduced tear break-up time (BUT) (−2.27, 95% CI [−2.66, −1.88], P < 0.0001), and a worse corneal fluorescein staining (CFS) score (0.75, 95% CI [0.5, 1.0], P < 0.0001) after phacoemulsification cataract surgery, whereas in the general population, the subjective symptoms score and CFS remained unchanged and BUT decreased slightly after surgery. Patients without diabetes showed significantly reduced total tear secretion after phacoemulsification cataract surgery (−1.25, 95% CI [−1.62, −0.88], P < 0.0001).

Conclusion: Dry eye generally remained unchanged 1 month after phacoemulsification cataract surgery. Notably, worsened symptoms and signs of dry eye were observed more frequently in patients with pre-existing MGD. Patients without diabetes were more susceptible to reduced tearing postoperatively.

Clinical Trial Registration: Identifier: PERSPERO (2020: CRD42020203316).

Clinical Outcomes After Femtosecond Laser-Assisted Arcuate Corneal Incisions versus Manual Incisions

Purpose

To compare the relative effectiveness of Verion-LenSx guided femtosecond arcuate incisions and manual incisions in reducing postoperative refractive astigmatism.

Patients and Methods

This was a contralateral eye, prospective study that included subjects with 0.50 D to 1.75 D of corneal astigmatism who wanted less refractive astigmatism post cataract surgery. The surgeon used anterior keratometry and the Woodcock astigmatism nomogram for preoperative planning, while the LenSx femtosecond laser with the Verion Image Guided System was used to create all laser arcuate incisions. Manual incisions were planned using the Donnenfeld nomogram and made with a fixed-depth diamond knife. The primary outcome measure was the residual refractive astigmatism at 3 months postoperative. Secondary outcome measures included the manifest refraction, uncorrected distance visual acuity and the change in corneal astigmatism from 1 to 3 months postoperative.

Results

Forty-one subjects were successfully enrolled in the study, with data from 38 subjects available at 3 months. There were no statistically significant differences in refractive astigmatism, corneal astigmatism, uncorrected distance visual acuity or manifest refraction between the Manual and Femto groups at either 1 month or 3 months. Significant changes in refractive and corneal astigmatism were noted between 1 months and 3 months. Ninety percent of eyes in both groups had ≤0.50 D of refractive astigmatism at 3 months. Two minor non-serious adverse events (full-thickness incisions of the cornea) occurred in two eyes of two different subjects in the Manual group; they were resolved without incident.

Conclusion

Laser arcuate incisions appear to be an effective means of reducing postoperative refractive astigmatism at the time of cataract surgery. No significant clinical differences were observed between incisions made manually and those made with an image-guided femto-second laser system. The lower number of minor adverse events experienced with the femtosecond laser system is an apparent advantage.

Ocular Surface Changes Associated with Ophthalmic Surgery

Dry eye disease causes ocular discomfort and visual disturbances. Older adults are at a higher risk of developing dry eye disease as well as needing for ophthalmic surgery. Anterior segment surgery may induce or worsen existing dry eye symptoms usually for a short-term period. Despite good visual outcomes, ocular surface dysfunction can significantly affect quality of life and, therefore, lower a patient’s satisfaction with ophthalmic surgery. Preoperative dry eye disease, factors during surgery and postoperative treatment may all contribute to ocular surface dysfunction and its severity. We reviewed relevant articles from 2010 through to 2021 using keywords “cataract surgery”, ”phacoemulsification”, ”refractive surgery”, ”trabeculectomy”, ”vitrectomy” in combination with ”ocular surface dysfunction”, “dry eye disease”, and analyzed studies on dry eye disease pathophysiology and the impact of anterior segment surgery on the ocular surface.

Iatrogenic Dry Eye Disease: Dealing with the Conundrum of Post-Cataract Discomfort. A P.I.C.A.S.S.O. Board Narrative Review

The incidence and prevalence of dry eye disease (DED) after cataract surgery is greatly underestimated. The severity of dry eye symptoms has been reported to peak 7 days after cataract surgery and may persist for months, significantly affecting patients' quality of life (QoL). The importance of considering surgical outcomes not only in terms of visual acuity, but also in terms of the patients' QoL, necessitates the assessment and evaluation of the ocular surface by the cataract surgeon prior to the procedure. This narrative review, drafted by the P.I.C.A.S.S.O. (Italian Partners for the Correction of Ocular Surface Alterations) board, analyses the physiopathology of post-cataract surgery DED and highlights the pre-, intra- and postoperative risk factors that may alter ocular surface homeostasis; it proposes a practical comprehensive algorithm for the prevention, treatment and management of DED associated with cataract surgery. Particular attention needs to be paid to the pre- and intraoperative risk factors to reduce the incidence of postoperative dry eye and to improve cataract surgery outcome.

Refractive enhancements for residual refractive error after cataract surgery

PURPOSE OF REVIEW

Advances in cataract surgery have allowed surgeons to achieve superior refractive outcomes but have also led to higher patient expectations. Despite ever-evolving technology, residual refractive errors still occur. Postcataract refractive enhancements may be required to deliver satisfactory visual outcomes. This review aims to discuss the potential causes of residual refractive errors and the various enhancement modalities to correct them.

RECENT FINDINGS

A thorough preoperative workup to detect and address underlying pathologic causes of impaired vision should be performed prior to enhancement or corrective procedures. Corneal-based procedures are the safest and most accurate methods of correcting mild cases of residual refractive error. Hyperopic, high myopic, and high astigmatic errors are best managed with lens-based enhancements. Piggyback intraocular lenses (IOLs) are safer and more effective compared with IOL exchange. Toric IOL rotation and IOL exchange are ideally performed in the early postoperative period.

SUMMARY

A multitude of options exist for effective correction of residual refractive errors. The choice on how to best manage these patients depends on many factors such as the cause of refractive error, type of IOL used, ocular comorbidities, and patient preference.

Cataract surgery and dry eye disease: A review

AIM

To review published literature concerning cataract surgery and dry eye disease (DED).

METHODS

A search was undertaken using the following: PubMed (all years), Web of Science (all years), Ovid MEDLINE(R) (1946 to 12 December 2019), Ovid MEDLINE(R) Daily Update 10 December 2019, MEDLINE and MEDLINE non-indexed items, Embase (1974-2019, week 49), Ovid MEDLINE (R) and Epub Ahead of Print, In-Process and Other Non-Indexed Citations and Daily (1946 to 12 December 2019), CENTRAL (including Cochrane Eyes and Vision Trials Register; Cochrane Library: Issue 12 of 12 December 2019), metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrial.gov) and WHO International Clinical Trials Registry Platform (www.who.int/ictrp/search/en). Search terms included 'cataract surgery', 'phacoemulsification' and 'cataract extraction', combined with 'dry eyes' and 'ocular surface'. Relevant in-article references not returned in our searches were also considered.

RESULTS

Publications identified included systematic reviews, meta-analysis, randomized controlled trials, cohort studies, case series and laboratory-based studies. Published data highlighting the burden of DED both prior and following cataract surgery were reviewed as well as studies highlighting the effects of cataract surgery on the ocular surface, intra-operative measures to reduce deleterious effects on the ocular surface and current evidence on the management options of post-operative DED.

CONCLUSIONS

DED is common and can be exacerbated by cataract surgery. Ophthalmologists need to assess for pre-existing DED and instigate treatment before surgery; be aware of reduced accuracy of measurements for surgical planning in the presence of DED; limit intra-operative surgical factors damaging to the ocular surface; and consider management to reduce DED post-operatively.

How Can We Improve Toric Intraocular Lens Calculation Methods? Current Insights

In this paper, we review current strategies for calculating toric intraocular lenses (IOLs). We discuss the prevalence and clinical relevance of astigmatism and the assessment of toric IOL candidates. We detail recommendations for evaluating astigmatism and current biometry and IOL power calculation techniques. Finally, error sources and results of current toric IOL calculators are discussed.

Acute corneal perforation 1 week following uncomplicated cataract surgery: the implication of undiagnosed dry eye disease and topical NSAIDs

Dry eye disease is a common ocular surface disease in patients who are undergoing cataract surgery. The significance of dry eye disease is often underestimated or overlooked during preoperative assessment of cataract. We report an 80-year-old patient, with a background of seropositive rheumatoid arthritis and diabetes, who presented with an acute corneal melt and perforation associated with undiagnosed dry eye disease and use of topical ketorolac 1 week following an uncomplicated cataract surgery. The patient underwent repeated corneal gluing for corneal perforation and was subsequently diagnosed and treated for bilateral moderate-severe dry eye disease. This case highlights the importance of meticulous preoperative assessment and management of the ocular surface, especially in patients with systemic diseases such as rheumatoid arthritis and diabetes prior to cataract surgery. The implication of the use of topical nonsteroidal anti-inflammatory drugs following cataract surgery - which might have contributed to the process of corneal melt in our case - is also discussed.

Changes in ocular surface status and dry eye symptoms following femtosecond laser-assisted cataract surgery

AIM

To observe the changes in ocular surface and the dry eye symptoms following femtosecond laser-assisted cataract surgery (FLACS).

METHODS

Patients with no eye signs or symptoms in Guangzhou Aier Eye Hospital between October 2017 and September 2018, who underwent FLACS and intraocular lens (IOL) implantation for age-related cataract were enrolled. Tear film stability assessed with OCULUS Keratograph 5M, Schirmer's I test (SIT), and corneal fluorescein staining (CFS) were evaluated before and after surgery at 1d, 1wk, 1, and 3mo in order. Ocular Surface Disease Index scores (OSDI) and Subjective Symptom Questionnaires (SSQs) were recorded at the same time point.

RESULTS

Thirty-eight eyes of 38 patients were enrolled. The noninvasive tear film break-up time (first break-up time and average break-up time) decreased in a peak at the 1wk visit, and then increased to basic levels at 1mo. The tear meniscus height (TMH) increased transiently at 1d, and declined in the following 3mo visits. The SIT had a transient increase at 1d (P=0.357) and a decrease at 1wk and 1mo (both P<0.05) but returned to the preoperative levels at 3mo after surgery (P=0.062). CFS scores were significantly improved compared with those before surgery, and had a statistical difference (P<0.05). OSDI scores and SSQs after surgery were obviously higher, and had a statistical difference (P<0.001) but didn't return to the basic level by 3mo.

CONCLUSION

Dry eye signs and symptoms can occur immediately following FLACS and have a peak severity on day 7 postoperatively. Most signs of dry eye can return to preoperative basic levels within 3mo postoperatively. However, all cases can not recover from CFS and dry eye symptoms at 3mo postoperatively.

Topical Cyclosporine (0.05%) for Management of Dry Eyes in Patients Undergoing Cataract Surgery-A Comparative Study

Purpose:

To assess the efficacy of topical cyclosporine 0.05% in the management of cataract surgery induced dry eye.

Methods:

This prospective, comparative, randomized, interventional study included 67 patients undergoing cataract surgery. The patients were randomized into three categories Group A: patients on topical lubricants and cyclosporine 0.05%, Group B: patients on topical lubricants only and Group C: patients not on any dry eye medication. Patients were given the respective treatment 2 weeks prior and 3 months after cataract surgery, along with an identical perioperative regimen of topical steroids, antibiotics and NSAIDs. Dry eye evaluation done 2 weeks pre-op, 1 week post-op and 3 months post-op consisted of a subjective questionnaire, tear osmolarity, Tear Break Up Time (TBUT) and Schirmer’s 1 without and with anaesthesia.

Results:

Pre-operatively, all the 3 groups were matched in terms of mean age, tear osmolarity, TBUT and Schirmer’s 1 without and with anaesthesia scores. At 3 months, patients treated with both topical lubricants and cyclosporine (0.05%)(Group A) showed improvement subjective questionnaire, tear osmolarity, TBUT and Schirmer’s 1 tests. Patients treated with lubricants only (Group B) showed a significant worsening in TBUT and tear osmolarity at 1 week, however, the values returned to baseline at 3 months.The control group (Group C) had the worst TBUT scores at the end of 3 months and showed the persistence of raised tear osmolarity, suggestive of a prolonged ocular inflammation resulting in patient dissatisfaction.

Conclusion:

Topical cyclosporine (0.05%) may be a useful adjuvant to prevent and treat cataract surgery associated with dry eye symptoms, especially in patients with pre-existing dry eye disease.

Preoperative evaluation for cataract surgery

PURPOSE OF REVIEW

To provide a consolidated update regarding preoperative evaluation for cataract surgery.

RECENT FINDINGS

Visual acuity alone is a poor gauge of cataract disability. Modalities such as wave front aberrometry, lens densitometry, and light-scatter assessments can quantify optical aspects of cataract and may prove clinically useful in surgical evaluation. Advances in biometry are driving improvements in refractive outcomes, which in turn have increased patient expectations. Future advances in biometry technology may include three-dimensional imaging of the cornea and lens. Screening for ocular comorbidities has become increasingly important, particularly to guide lens selection. Risk stratification systems can help guide surgical decisions and may decrease intraoperative complication rate. A comprehensive medical history and physical is currently mandated for all Medicare patients undergoing cataract surgery but may be of limited utility for low-risk patients.

SUMMARY

Rising patient expectations and a growing number of surgical choices have expanded the cataract preoperative evaluation. A systematic and comprehensive examination which includes identifying any ocular comorbidity is essential for surgical planning and counseling on visual prognosis. New technologies will continue to inform, but not replace, sound clinical judgment.