United Kingdom National Ophthalmology Database Study of Cataract Surgery: Report 3: Pseudophakic Retinal Detachment

Comparing the efficacy and safety between femtosecond laser-assisted cataract surgery and conventional phacoemulsification cataract surgery: systematic review and meta-analysis

OBJECTIVE

To investigate the efficacy and safety of femtosecond laser-assisted cataract surgery (FLACS) compared with conventional phacoemulsification cataract surgery (CPCS).

METHODS

Randomized controlled trials (RCTs) were systematically searched in PubMed, Embase, Cochrane Library, ClinicalTrials.gov, CNKI, and Wanfang. Main outcomes were visual acuity, capsulotomy parameters, effective lens position, and complications. Secondary outcomes included refractive outcomes, intraoperative parameters, and corneal parameters.

RESULTS

In total, 41 RCTs involving 9310 eyes were included. There was a statistically significant difference in favour of FLACS over CPCS for uncorrected distance visual acuity at 12 months (mean difference [MD] -0.03; 95% CI -0.05 to -0.01); corrected distance visual acuity at 1 week (MD -0.05; 95% CI -0.07 to -0.02) and 12 months (MD -0.02; 95% CI -0.04 to -0.00); area of capsulotomy at 1 month (MD 4.04 mm2; 95% CI 3.45-4.64) and 6 months (MD 5.02 mm2; 95% CI 3.28-6.77); and intraocular lens centroid-pupil centroid distance at 1 week (MD -0.06 mm; 95% CI -0.08 to -0.05), 1 month (MD -0.07 mm; 95% CI -0.09 to -0.06), and 6 months (MD -0.06 mm; 95% CI -0.07 to -0.04). With regard to surgical complications, FLACS was less than CPCS for the incidence of decentred IOL (odds ratio 0.06; 95% CI 0.01-0.24). However, FLACS did not increase the incidence of other intraoperative or postoperative complications except subconjunctival hemorrhage.

CONCLUSIONS

Both FLACS and CPCS are effective and safe. FLACS achieves better visual outcomes in the early postoperative period and long-term follow-up, accompanied by more accurate capsulotomy and more optimized effective lens position than CPCS. However, no difference of visual outcomes was found after middle-term follow-up.

The Royal College of Ophthalmologists' National ophthalmology database study of cataract surgery: Report 14, cohort analysis - the impact of CapsuleGuard® utilisation on cataract surgery posterior capsule rupture rates

BACKGROUND/OBJECTIVES

The aim of this study was to investigate whether the use of the silicone tipped irrigation/aspiration (I/A) handpiece CapsuleGuard® (Bausch + Lomb, Laval, Canada) reduced rates of posterior capsule rupture (PCR) during cataract surgery.

METHODS

Royal College of Ophthalmologists' National Ophthalmology Database (NOD) Cataract Audit data from 01/04/2010 and 31/03/2021 and Bausch + Lomb sales figures were combined to identify centres participating in national cataract audit who have routinely adopted the silicone tipped I/A handpiece, CapsuleGuard®. Data were included only from centres with eligible cataract operations recorded on the NOD both before and after adopting CapsuleGuard®. Review of the literature was undertaken to estimate the proportion of PCR that occurs during I/A, to evaluate the impact of adoption of CapsuleGuard® on PCR occurring in this phase of surgery.

RESULTS

Within the study period, 267 371 eligible cataract operations were performed in 14 centres with >50 eligible operations both before and after adopting CapsuleGuard®. Within centres adopting CapsuleGuard®, the rate of PCR occurrence reduction was 16.4%. Before and after the adoption of CapsuleGuard® the median change of PCR was 21.7% reduction (IQR: 4.8% to 37.7% reduction).

CONCLUSIONS

A reduction in the rate of PCR was seen after regular adoption of CapsuleGuard® during cataract operations. Review of published studies attributing PCR to various components of the cataract operation suggest around 25% of PCR may occur during I/A; adoption of CapsuleGuard may, therefore, be associated with avoidance of a substantial proportion of the PCR during that phase of surgery.

Ethnic Differences in the Rates of Posterior Capsule Rupture and Long-Term Sequelae in Phacoemulsification Cataract Surgery

Purpose The purpose of this study is to investigate the rates of posterior capsular rupture (PCR) and its sequelae during phacoemulsification across different ethnicities. Methods This is a retrospective cohort study of all consecutive phacoemulsification cases complicated by PCR that met the inclusion criteria over a four-year period at a single tertiary eye centre in the United Kingdom (UK). Results PCR occurred in 0.85% of cases overall (157/18,481). PCR rates were 1.8% (26/1485), 1.2% (51/4350), and 0.7% (75/10,927) in African-Caribbean, Indian subcontinent, and Caucasian patients, respectively (p < 0.001). Mean final corrected distance visual acuity improved (p < 0.05) in all ethnic groups (0.40 ± 0.57 logMAR) compared to pre-op (0.78 ± 0.61 logMAR). Post-operative cystoid macular oedema and unstable intraocular pressure rates following PCR did not statistically differ amongst ethnicities (p = 0.37 and p = 0.75, respectively). However, post-operative uveitis rates significantly differed at 11.5%, 15.7%, and 1.3% amongst the three ethnic groups, respectively (p = 0.01). Conclusion This is the first study to highlight a possible link between patient ethnicity and the risk of PCR during phacoemulsification cataract surgery. We observed significantly greater numbers of PCR cases amongst certain ethnic groups (highest in African-Caribbean eyes, then Indian subcontinental eyes, and lowest in Caucasian eyes) within the same multi-cultural urban population. Ethnicity may therefore be a contributing factor for PCR and should potentially be taken into consideration during preoperative risk stratification.

PROPHYLACTIC TREATMENT OF LATTICE DEGENERATION IN FELLOW EYES AFTER REPAIR OF UNCOMPLICATED PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT

PURPOSE

To evaluate prophylactic treatment (PTx) of lattice degeneration (LD) on retinal tear (RT) and rhegmatogenous retinal detachment (RRD) risk in fellow eyes of patients after primary RRD repair in the first eye.

METHODS

This was a consecutive case series with cohort control involving patients with RRD repair from January 1, 2013, through December 31, 2017. Patients received PTx (PTx cohort) or no PTx (No-PTx cohort) in fellow eye with 5-year follow-up. Primary outcome measure was proportion with new fellow eye RT/RRD. Secondary outcomes included logarithm of minimum angle of resolution (logMAR) best-corrected visual acuity (BCVA) and status of myopia, posterior vitreous detachment, and pseudophakia.

RESULTS

Four hundred ninety-eight patients were divided into 146 and 352 in PTx and No-PTx cohorts, respectively. PTx cohort developed significantly ( P < 0.05) fewer RT/RRD (17%) than No-PTx cohort (41%). PTx significantly ( P < 0.05) lowered RT/RRD irrespective of posterior vitreous detachment and myopia status. PTx patients undergoing phacoemulsification demonstrated significantly ( P < 0.05) less RT/RRD (22%) than No-PTx cohort (31%). There was no significant ( P = 0.96) final BCVA difference between PTx (median = 0 logMAR) and No-PTx (median = 0 logMAR) cohorts.

CONCLUSION

PTx of asymptomatic fellow eye LD reduced RT/RRD risk.

Retinal detachment after refractive lens exchange: A narrative review

Refractive lens exchange (RLE) allows to correct ametropias and presbyopia by replacing the crystalline lens with an extended depth of focus or multifocal intraocular lens (IOL). Retinal detachment (RD) is one of the most serious adverse events after RLE. This study aimed to review the evidence related to the risk of RD after RLE and clinical outcomes. A search using PubMed and a snowball search approach was conducted to identify articles and case reports. According to the literature, the risks of RD should be considered in patients <60 years old with axial lengths >23 mm. Only nine articles reported visual acuity (VA) after RD in RLE, and only 25% of eyes had a VA > 20/40. Considering that the decrease in VA might be uniform for all types of IOLs after RD, surgeons should focus on selecting the patient to prevent RD rather than on a particular IOL optical design based on the potential risk of DR.

Safety of office-based lens surgery: U.S. multicenter study

PURPOSE

To evaluate the rate of adverse events after office-based lens surgery performed across multiple private practices in the United States.

SETTING

36 private practices across the U.S.

DESIGN

Retrospective multicenter study.

METHODS

This analysis included case records of all consecutive patients who underwent office-based lens surgery for visually significant cataract, refractive lens exchange, or phakic intraocular lens implantation between August 2020 and May 2022 at 36 participating sites across the U.S. The study outcome measures included the assessment of intraoperative and postoperative complications such as the incidence of unplanned vitrectomy, iritis, corneal edema, and endophthalmitis after lens surgery. The frequency of patients requiring a return to the operating room (OR) or referral to a retina surgeon and the frequency of patients requiring hospitalization or calling emergency services (911) for any reason were also evaluated.

RESULTS

The study reviewed 18 005 cases of office-based cataract or refractive lens surgery performed at 36 clinical sites. The rates of postoperative endophthalmitis, toxic anterior segment syndrome, and corneal edema were 0.028%, 0.022%, and 0.027%, respectively. Unplanned anterior vitrectomy was performed in 0.177% of patients. Although 0.067% of patients needed to return to the OR, 0.011% of patients were referred to the hospital.

CONCLUSIONS

The rate of adverse events for office-based cataract or refractive lens surgery is similar to or less than the reported adverse event rate for modern cataract surgery in the ambulatory surgery center setting.

Associated factors with pseudophakic retinal detachment: Long-term follow-up in a Colombian population

OBJECTIVE

To identify associated factors with the appearance of pseudophakic retinal detachment in patients with history of cataract surgery.

METHODS

Retrospective case-control study of 802 eyes of 783 patients with history of cataract surgery. Cases were patients with pseudophakic retinal detachment (n = 258 eyes), while controls were patients with cataract surgery who did not developed retinal detachment during a 10-year follow-up period (n = 544 eyes).

RESULTS

Age at cataract surgery among cases was lower than in the control group (57 ± 13 vs. 67 ± 14 years old, respectively; p < 0.0001). Age at retinal detachment was 59 ± 13 years old (range 6-88) and the time between the cataract surgery and the retinal detachment had a median of 2 years (interquartile range 1-4) with a range of 1 month to 14 years. Associated factors for pseudophakic retinal detachment were younger age (<50 years: adjusted odds ratio [aOR] = 18.03, 95% confidence interval [95%CI] = 5.92-54.87; 50-59 years: aOR = 10.09, 95%CI = 3.37-30.23; and 60-69 years: aOR = 5.48, 95%CI = 1.88-15.93), male sex (aOR = 3.71, 95%CI = 2.54-5.44), anterior vitrectomy (aOR = 3.26, 95%CI = 1.16-9.16), history of retinal detachment in the fellow eye (aOR = 6.95, 95%CI = 3.15-15.31), and intraoperative complications during cataract extraction (aOR = 7.45, 95%CI = 3.54-15.69).

CONCLUSIONS

This is the first report of associated factors with pseudophakic retinal detachment in a Colombian population. Surgical complications, sex, and age were found to be associated with retinal detachment. Patients should be aware of these potential risks to make informed decisions about their eye health.

Incidence of Rhegmatogenous Retinal Detachment (RRD) in a Tertiary Care Center of Pakistan

Background

Regardless of the advancements in ophthalmology, rhegmatogenous retinal detachment (RRD) remains a substantial issue for physicians. The present study assessed the incidence of RRD among our population.

Methodology

A cross-sectional study was performed at the Layton Rehmatullah Benevolent Trust (LRBT) between June 2020 and May 2021. All the patients of RRD, irrespective of gender, within the age bracket of 20 years or more and diagnosed by a consultant ophthalmologist were included in the research study. Patients with serous retinal or tractional detachment and RRD with vitreous leakage were excluded from the study. A slit lamp and dilated fundus examination was performed preoperatively to assess the type of retinal detachment and associated factors as mentioned above. All data were collected on predesigned pro forma.

Results

About 25,000 individuals were presented to the outpatient department during the study period. Out of these, 100 patients were diagnosed with RRD. The incidence rate of the RRD in our center was 0.4%. There were a majority of the males. The mean age of patients did not vary significantly with respect to gender (p < 0.797). The most common type of RD was the total RD with a frequency of 53 cases followed by inferior RD with 19 cases. The majority of those with total RRD were males, i.e., 37%; however, the difference was statistically insignificant (p = 0.476). The study revealed that most of the RRD was diagnosed in patients < 45 years of age; however, the difference was not statistically significant (p < 0.227).

Conclusion

The present study highlighted the incidence of RRD and explored the sociodemographic and other clinical features in the Pakistani population. However, it is possible that the RRD condition is still under-diagnosed in our hospital settings. Further exploration is warranted to study comprehensively the risk factors associated with RRD. 

In-depth analysis of risk factors for pseudophakic retinal detachments and retinal breaks

Purpose

To provide a detailed analysis of risk factors for pseudophakic retinal detachments (PRD) and pseudophakic retinal breaks (PRB).

Materials and methods

We reviewed the medical records of cataract surgeries between 1996 and 2017 at a tertiary care hospital in Austria. A Cox proportional‐hazard regression model was used to analyse risk factors for PRD and PRB.

Results

Sixty‐five thousand six hundred and sixty‐two eyes (45 043 patients) underwent phacoemulsification, and 393 eyes (cumulative incidence 0.6%) were diagnosed with PRD (327 eyes) or PRB (66 eyes) during the follow‐up (median 7.1 years, range 0–21). Calculation of adjusted hazard ratios (HR) revealed a hierarchy of risk factors for either event including (from the highest to the lowest risk) posterior capsular rupture (PCR), patient age <65 years (compared with the age group >75 years), male gender and high myopia. Diabetes mellitus was associated with a lower risk. PCR was the strongest risk factor for PRD both in patients with and without perioperative vitrectomy (i.e. vitreous loss), but time to PRD was significantly reduced only following PCR with vitrectomy.

Conclusions

Posterior capsular rupture, young patient age, male gender and high myopia were risk factors for PRD, but diabetes mellitus was associated with a lower risk. PCR had the strongest association with PRD, regardless of the need for perioperative vitrectomy due to vitreous loss. Time to PRD was reduced in patients with PCR and vitrectomy compared with PCR without the need for vitrectomy or uneventful surgery.

CHARACTERISTICS AND SURGICAL OUTCOMES OF RHEGMATOGENOUS RETINAL DETACHMENT IN OLDER ADULTS: A Multicenter Comparative Cohort Study

PURPOSE

To describe characteristics and outcomes of primary rhegmatogenous retinal detachment in older adults (age ≥ 80).

METHODS

Consecutive patients with rhegmatogenous retinal detachment undergoing pars plana vitrectomy (PPV), scleral buckling (SB), or PPV/SB in the Primary Retinal Detachment Outcomes Study were evaluated. Outcome measures included single surgery anatomic success and visual acuity.

RESULTS

Of 2,144 patients included, 125 (6%) were 80 years or older. Compared with younger patients (age 40-79), older adults were more likely to be pseudophakic (P < 0.001), have macula-off detachments (P < 0.001), and have preoperative proliferative vitreoretinopathy (P = 0.02). In older adults, initial surgery was PPV in 73%, PPV/SB in 27%, and primary SB in 0%. Single surgery anatomic success was 78% in older adults compared with 84% in younger patients (P = 0.03). In older adults, single surgery anatomic success was 74% for PPV and 91% for PPV/SB (P = 0.03). The final mean logMAR was lower for older adults (0.79 [20/125] vs. 0.40 [20/40], [P < 0.001]). In older adults, the final mean logMAR for eyes that underwent PPV was 0.88 (20/160) compared with 0.50 (20/63) for PPV/SB (P = 0.03).

CONCLUSION

Octogenarians and nonagenarians presented with relatively complex pseudophakic rhegmatogenous retinal detachments. Single surgery anatomic success and visual outcomes were worse compared with younger patients, and PPV/SB had better outcomes compared with PPV alone.

Cost-Benefit Analysis of Single versus Repeated Use of Single-Use Devices in Cataract Surgery

PURPOSE

To estimate the net cost effect associated with the real-world practice of repeated use of designated single-use medical devices (SUDs) versus their proper single use in cataract surgery in Greece.

DESIGN

A cost-benefit analysis model was constructed in the form of a decision tree.

METHODS

A digital expert panel was assembled in order to estimate the probabilities of intraoperative and postoperative complications associated with single and repeated use of SUDs. Unit costs for the management of each complication were obtained from the official Greek bulletins. A Monte Carlo-type sensitivity analysis was performed to assess the robustness of the results.

RESULTS

Based on the probabilities of complications attained from the expert panel, repeated use of SUDs is associated with a higher chance of complications compared to single use, which results in higher cost of complication management. Under the healthcare sector perspective, the total expected cost per cataract surgery is 1,403.98€ (1,244.20€ the initial cost of cataract surgery plus 159.78€ the cost of adverse events) in the case of single use, while for repeated use the total cost is 1,486.29€ (1,146.86€ + 339.43€, respectively) and, thus, repeated use of SUDs in cataract surgery results in 82.31€ higher expected cost per patient compared to their single use. Moreover, the societal perspective analysis indicated even higher additional costs in the case of SUD reuse (108.24€).

CONCLUSION

Repeated use of SUDs in cataract surgery is not appropriate, it jeopardizes patient safety and carries a legal liability for the reuser. The present study, which is the first to attach a monetary value to the common yet questionable practice of SUD reuse, shows that it is not cost beneficial. Therefore, it is expected that the results will have implications in policy formulations to improve the delivery of cataract healthcare.

Retinal detachment after phacoemulsification in refractive surgery clinics: a large series analysis with variable follow-up during 16 years

PURPOSE

To determine the long-term incidence of pseudophakic retinal detachment (PRD) after phacoemulsification and the weight of the main risk factors in the appearance of such complication in a large sample. To implement a customized formula and a software calculation program able to quantify the risk of suffering PRD applicable to all lens extraction patients.

METHODS

Retrospective cumulative risk analysis conducted on 178,515 eyes operated under similar conditions in a group of refractive surgery clinics (Clínica Baviera SL) located in a relatively limited geographical area (Spain). A survival analysis was performed and the data were modelled using the Weibull regression to determine the risk over a period of 16 years and to estimate the association of different risk factors: sex, age, axial length (AXL) of the eye, intraoperative posterior capsule rents (PCR), and YAG laser capsulotomies. The resulting estimates were translated into a predictive equation for hazard rates and survival probabilities. Later, an application was developed to make prediction available for the clinical community in order to estimate the potential risk of any hypothetical case before lens surgery.

RESULTS

Globally, 1521 (0.85%) cases of PRD were diagnosed during the period. The risk for PRD was significantly greater in males (5.48 [2.94-10.2]; p < 0.001), in long eyes (1.24 [1.21-1.26]; p < 0.001), and also after posterior capsule rents (13.97 [11.61-16.82]; p < 0.001). Posterior capsule rupture increased the risk of PRD up to fourteen times.

CONCLUSIONS

From weaker to stronger impact, age, axial length, sex, and intraoperative posterior capsule rent were significant risk factors for the appearance of PRD after lens extraction.

Changing clinical patterns of Rhegmatogeneous Retinal Detachments during the COVID19 pandemic lockdown in the North West of the UK

INTRODUCTION

The UK Government imposed a COVID19 lockdown (LD) restricting all but essential activities from 24th March 2020. Subsequently, there has been a significant reduction in casualty attendances nationwide including for ophthalmic emergencies. We aim to study the presentation of rhegmatogenous retinal detachments (RRD) and significant vitreous haemorrhage caused by posterior vitreous detachment (PVD-VH) in three tertiary centres covering most of the North West of England in the 6 weeks before and during the lockdown.

METHODS

A retrospective multicenter non-randomised consecutive case series study was designed to collect information on all cases of RRD and PVD-VH requiring surgery presenting to the vitreoretinal departments of Manchester Royal Eye Hospital, East Lancashire NHS Foundation Trust and the Lancashire NHS Foundation Trust from 11th February to 4th May 2020.

RESULTS

A total of 137 eyes of 137 patients were identified between the three centres of which 132 eyes were operated for RRD. Of these, 86 (64.7%) were operated pre-LD compared with 46 eyes (34.8%) during LD. Forty-five out of 86 eyes (52.3%) were macula-off pre-LD compared with 31 out of 46 eyes (67.3%) during LD (p = 0.06). There was lower proportion of non-PVD related RRD during LD (11 pre-LD to 1 during LD, p = 0.05). PVR was present in four cases during LD compared to 2 before (p = 0.19).

CONCLUSION

There was a clinically significant reduction in the overall incidence of RRD in our centres with an increase in the proportion of macula-off and proliferative vitreoretinopathy during the LD period compared to a similar period before.

Combined pars plana vitrectomy (PPV) and phacoemulsification (phaco) versus PPV and deferred phaco for phakic patients with full-thickness macular hole (FTMH) and no significant cataract at baseline: 1-year outcomes of a randomized trial combined PPV/phaco vs PPV/deferred phaco for MH

PURPOSE

To compare functional and anatomic outcomes of combined pars plana vitrectomy (PPV) and phacoemulsification (phaco) versus PPV and deferred phaco in patients with full-thickness macular hole (FTMH) and no significant cataract.

METHODS

Thirty-four patients were randomized to group 1 (combined PPV/phaco) and 34 to group 2 (PPV/deferred phaco). Group 2 patients could undergo phaco any time after FTMH surgery if significant cataract developed.

RESULTS

Sixty-five patients (33 group 1 and 32 group 2) completed the 12-month visit. Mean ± SEM logMAR best-corrected visual acuity (BCVA) was 0.92 ± 0.04 and 0.90 ± 0.04 at baseline and improved significantly to 0.60 ± 0.05 and 0.58 ± 0.05 at month 12 (p < 0.0001) in groups 1 and 2, respectively. There was no significant difference between the groups in mean BCVA at baseline or at month 12. Mean macular sensitivity (dB) was 18.22 ± 0.93 and 16.72 ± 0.93 at baseline and increased to 21.13 ± 0.86 and 21.07 ± 0.85 in groups 1 and 2, respectively (p < 0.05) with no significant difference between the groups (p = 0.449) at month 12. FTMH closure rate was 73% and 75% in groups 1 and 2, respectively (p = 0.834).

CONCLUSION

Among patients with FTMH and no significant cataract at baseline, combined PPV/phaco was associated with similar BCVA, microperimetry, and FTMH closure outcomes at 1-year compared with PPV/deferred phaco.

TRIAL REGISTRATION

( clinicaltrials.gov.br ): Ensaios clínicos brasileiros: RBR-3wmd9s; UTN number: U1111-1190-5013; Plataforma Brasil CAAE number: 50455415.3.0000.5440; IRB number: 1.433.000.

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.

Retinal detachment following cataract phacoemulsification-a review of the literature

A link between cataract surgery and rhegmatogenous retinal detachment (RRD) has long been considered. Indeed, pseudophakic retinal detachment (PPRD) forms a substantial and increasing proportion of RRD. We reviewed the literature to answer the following questions: what is the incidence of PPRD in eyes following phacoemulsification cataract surgery and how does its risk change over time following surgery? We also sought to assess how the risk is modified by intraoperative factors (operative complications, surgeon grade, subsequent laser capsulotomy), intrinsic eye-related factors (laterality, myopia, previous RRD, previous trauma, previous PVD) and patient factors (sex, age, ethnicity, affluence, systemic comorbidities). Secondarily we asked how the incidence of PPRD after phacoemulsification compares with the RRD incidence in the general population and how identified risk factors contribute to the pathophysiology of PPRD. A search of the Medline and Ovid databases was conducted for relevant publications from 1990 onwards using defined search terms with pre planned inclusion and exclusion criteria. The 10-year PPRD incidence after phacoemulsification was identified as being between 0.36 and 2.9%. This decreases over time to 0.1-0.2% annually but remains above the general population. The PPRD risk is further elevated by (in order of decreasing effect) intraoperative vitreous loss, increasing axial length, younger age, male sex and trainee operating surgeons. The PPRD risk after phacoemulsification is approximately ten times the general population's RRD risk. This risk is modified by the interplay of a hierarchy of risk factors, of which intraoperative vitreous loss, myopia, age and sex have the biggest effect.

Femtosecond laser-assisted versus phacoemulsification cataract surgery (FEMCAT): a multicentre participant-masked randomised superiority and cost-effectiveness trial

BACKGROUND

Cataract surgery is one of the most common operations in health care. Femtosecond laser-assisted cataract surgery (FLACS) enables more precise ocular incisions and lens fragmentation than does phacoemulsification cataract surgery (PCS). We hypothesised that FLACS might improve outcomes in cataract surgery compared with PCS despite having higher costs.

METHODS

We did a participant-masked randomised superiority clinical trial comparing FLACS and PCS in two parallel groups (permuted block randomisation stratified on centres via a centralised web-based application, allocation ratio 1:1, block size of 2 or 4 for unilateral cases and 2 or 6 for bilateral cases). Five French University Hospitals enrolled consecutive patients aged 22 years or older who were eligible for unilateral or bilateral cataract surgery. Participants, outcome assessors, and technicians carrying out examinations were masked to the surgical treatment allocation until the last follow-up visit and a sham laser procedure was set up for participants randomly assigned to the PCS arm. The primary clinical endpoint was the success rate of surgery, defined as a composite of four outcomes at a 3-month postoperative visit: absence of severe perioperative complication, a best-corrected visual acuity (BCVA) of 0·0 LogMAR (logarithm of the minimum angle of resolution) or better, an absolute refractive error of 0·75 dioptres or less, and unchanged postoperative corneal astigmatism power (≤0·5 dioptres) and axis (≤20°). The primary economic endpoint was the incremental cost per additional patient who had treatment success at 3 months. Primary outcomes were assessed in all randomly assigned patients who met all eligibility criteria (missing data considered as failure). We used mixed logistic regression models or mixed linear regression models for statistical comparisons, adjusted on centres and whether cataract surgery was bilateral or unilateral. The study is registered with ClinicalTrials.gov, NCT01982006.

FINDINGS

Of the 907 patients (1476 eyes) randomly assigned between Oct 9, 2013, and Oct 30, 2015, 870 (704 eyes in FLACS group and 685 eyes in the PCS group) were analysed. We identified no significant difference in the success rate of surgery between the FLACS and PCS groups (FLACS: 41·1% [289 eyes]; PCS: 43·6% [299 eyes]); adjusted odds ratio 0·85, 95% CI 0·64-1·12, p=0·250). The incremental cost-effectiveness ratio was €10 703 saved per additional patient who had treatment success with PCS compared with FLACS. We observed no severe adverse events during the femtosecond laser procedure, and most of the complications in the FLACS group related to the primary outcome measures occurred during the phacoemulsification phase or postoperatively.

INTERPRETATION

Despite its advanced technology, femtosecond laser was not superior to phacoemulsification in cataract surgery and, with higher costs, did not provide an additional benefit over phacoemulsification for patients or health-care systems.

FUNDING

French Ministry of Social Affairs and Health.

Current Trends in Modern Visual Intraocular Lens Enhancement Surgery in Stable Keratoconus: A Synopsis of Do's, Don'ts and Pitfalls

Keratoconus is a relatively common ectatic, non-inflammatory corneal disorder that involves gradual visual deterioration through progressive alteration of the shape of the cornea. The corneal thinning, irregular astigmatism and higher order aberrations that occur as the disease progresses pose major challenges in the visual rehabilitation of such patients. This paper summarizes the current literature regarding the results of visual enhancement procedures in patients with stable keratoconus treated with standalone anterior or posterior chamber phakic intraocular lens implantation and monofocal, toric or multifocal toric intraocular lens implantation following phacoemulsification for age-related cataract extraction or refractive lens exchange.

Peak Occurrence of Retinal Detachment following Cataract Surgery: A Systematic Review and Pooled Analysis with Internal Validation

Introduction

Timing of retinal detachment (RD) following cataract surgery is of importance for both diagnostic and prognostic factors. However, results on RD onset-time following cataract surgery have been conflicting.

Method

A systematic pooled analysis of the literature regarding timing of retinal detachment following cataract surgery. Outcomes were verified against an independent dataset.

Results

Twenty-one studies, reporting on rates of RD in 3,352,094 eyes of 2,458,561 patients, met our inclusion criteria and were included in the analysis. The mean pooled time to RD following surgery was 23.12 months (95% CI: 17.79-28.45 months) with high heterogeneity between studies (I ²=100%, P < 0.00001). Meta-analytic pooling for the risk of retinal detachment revealed a risk of 1.167% (95% CI: 0.900 to 1.468, I ²=99.50%, P < 0.0001). A retrospective chart review identified 54 pseudophakic RD cases (mean age 65.5, 59.3% males). The 95% confidence interval for the mean time to RD was 3.1-6.75 years.

Conclusions

The interval between cataract surgery and RD in a pooled analysis revealed a mean time of approximately 1.5-2.3 years. However, there was high variability between studies. Validation based on our local results showed similar yet slightly longer time frames. Timing of pseudophakic retinal detachment might direct appropriate follow-up, assisting in earlier detection.

Trainee-led versus specialist-led management of neovascular age-related macular degeneration: a registry-based study

OBJECTIVE

To compare the outcomes of trainee-led and specialist-led management of neovascular age-related macular degeneration.

DESIGN

Prospective multicentre registry-based observational study.

SETTING

Ophthalmology training centres in Australia and Europe where both trainee-led and specialist-led models of care coexist.

PARTICIPANTS

Treatment-naïve eyes with neovascular age-related macular degeneration and at least 12 months follow-up. 726 eyes were included in the study from two centres, 534 receiving trainee-led treatment and 192 specialist-led treatment.

INTERVENTIONS

The management and outcomes of patients receiving trainee-led care were compared with those receiving specialist-led care.

MAIN OUTCOMES MEASURES

The primary outcome was the mean change in visual acuity at 12 months from first injection. Outcomes were also presented at 36 months where available.

RESULTS

The mean age of participants was 79 years and 65% were female. The adjusted change in acuity at 12 months in trainee-led vs specialist-led eyes was +3.2 letters vs +4.1 letters (difference -0.9 letters, 95% CI -3.4 to 1.5, p=0.473). The mean adjusted change in acuity at 36 months was -0.9 letters in trainees vs +0.2 letters for specialists (difference -1.1 letters, 95% CI -5.1 to 2.9, p=0.596). Eyes treated by trainees received fewer injections on average to 36 months (15.0 vs 19.0, p=0.004), although this trend was observed at one centre only.

CONCLUSIONS

No significant differences in outcome between eyes managed by trainees and eyes managed by specialists were observed. Appropriately structured trainee-led management of neovascular age-related macular degeneration is a reasonable approach where regulatory and practical considerations allow it.

Posterior capsular complication rates with femtosecond laser-assisted cataract surgery: a consecutive comparative cohort and literature review

Purpose

The aim of the study was to determine whether femtosecond-assisted laser cataract surgery (FLACS) reduces the posterior capsular complication (PCC) rate compared to manual cataract surgery when performed by an experienced surgeon.

Patients and methods

We reviewed 2,021 consecutive FLACS procedures between 1 June 2012 and 30 August 2017. All cases of posterior capsular rupture (PCR) with or without vitreous prolapse or zonular dialysis (ZD) that prevented an in-the-bag placement of the intraocular lens were included. Risk factors were noted and outcomes documented.

Results

Six eyes of 2,021 (0.3%) who underwent FLACS had either a PCR or ZD. One eye (0.25%) of 403 eyes that had manual cataract surgery had a PCR. There was no significant difference in outcomes. Risk factors included advanced age, dense nuclei, pseudoexfoliation and small pupil. Only a single case in the FLACS series may have been directly attributed to the FLACS procedure.

Conclusion

This study provides evidence that there is no significant difference in the PCC rate between FLACS and manual cataract surgery in the hand of an experienced surgeon who performs >350 cases annually. This low rate of complications may be achieved by less experienced surgeons adopting FLACS.

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".

Fluidics and rheology in phaco surgery: what matters and what is the hype?

Rheology can be defined as the study of materials flow behaviour under applied deformation forces (stresses). Inside the eye during cataract surgery, transient or reversible deformation (elasticity) and permanent or irreversible deformation (flow) can both apply. Although the fluidics of modern phaco machines is an important part of this talk, there are a number of issues relating to flow and fluids in the eye during cataract surgery, which are unrelated to the machine, which can hinder or help the operating surgeon in removing a cataract. In addition, coping with the numerous complications, which can occur in the eye at the time of surgery, relies on an understanding of how fluidics and rheology can help to control the pressurised eye and bring the surgery to a successful conclusion.

Pseudophakic retinal detachment in young-aged patients

Objective

To investigate the incidence and risk factors for retinal detachment (RD) after cataract surgery or refractive lens exchange (RLE) in patients aged below 61 years.

Methods

Retrospective medical chart review of 7,886 patients (13,925 eyes) who underwent cataract surgery or RLE. Patients aged below 61 years were selected. Age, gender, axial length, follow-up times, and the occurrence of RD were recorded. Additional characteristics documented for RD cases were: history of RD, preexisting retinal findings, laser capsulotomy, status of macula at RD, date and details of RD.

Results

From a total of 421 patients (677 eyes) aged below 61 years 24 cases of RD were identified, resulting in an overall cumulative incidence per eyes of 3.55%. The mean follow-up time was 45 ± 32.8 months. Ninety-two % of all RDs occurred within 3.6 years from surgery. Axial length had a significant effect on the risk of RD after cataract/ RLE surgery (HR = 1.42, P = 0.0001, 95% CI 1.19–1.69). The highest incidence of RD occurred in the subgroup of 25 to 28.9 mm axial length (10.2%). With an increase in age of ten years, the hazard of postoperative RD was not significantly increased by a factor of 1.50 (P = 0.286, 95% CI 0.71–3.15). The highest incidence of RD occurred in patients aged 50–54 years (5.39%). Compared to females, males had an almost twofold not significant risk of postoperative RD (HR = 1.96, P = 0.123, 95% CI 0.83–4.63). None of the RD cases had a history of RD.

Conclusions

Axial length is a significant risk factor for pseudophakic RD. The need for cataract surgery or RLE should be carefully considered in patients with axial lengths between 25 and 29 mm, aged 50–54 years, in males, and in case of preexisting retinal findings.