Phacoemulsification in eyes with pseudoexfoliation

High-risk factors for zonular complications during cataract surgery in eyes with pseudoexfoliation syndrome

AIMS

To predict high-risk factors for zonular complications during cataract surgery due to pre-existing severe zonular dehiscence in eyes with pseudoexfoliation (PXF) syndrome.

METHODS

315 eyes of 315 consecutive patients with PXF scheduled for phacoemulsification surgery underwent preoperative examination of various ocular parameters using an anterior segment-optical coherence tomography and other devices. When zonular complications occurred during surgery due to zonular dehiscence, scleral fixation of the intraocular lens (IOL) or implantation of a capsular tension ring (CTR) was performed. High-risk factors for these intraoperative zonular complications were examined using classification-tree and logistic regression analyses.

RESULTS

Of the 315 eyes, 31 (9.84%) underwent scleral IOL fixation or CTR implantation. High-risk factors identified by classification-tree analysis were a small pupillary diameter after mydriasis <6.30 mm, a shallow anterior chamber depth <2.074 mm and lens decentration >0.260 mm. Based on exact logistic regression analysis, the OR was 4.81-fold higher for eyes with poor mydriasis than for eyes without poor mydriasis (p=0.006, 95% CI 1.49 to 18.23), 23.99-fold higher for eyes with poor mydriasis and a shallow anterior chamber (p<0.001, 5.92 to 109.02) and 287.39-fold higher for eyes with poor mydriasis, a shallow chamber and great lens decentration (p<0.001, 50.46 to infinity).

CONCLUSION

In eyes with PXF, high-risk factors for zonular complications during cataract surgery due to pre-existing severe zonular dehiscence were poor mydriasis, shallow anterior chamber and large lens decentration, suggesting the importance of evaluating these conditions preoperatively.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Neutrophil lymphocyte ratio as a predictor of perioperative complications in patients with PEX Syndrome during cataract surgery

INTRODUCTION

Pseudoexfoliation syndrome (PES) is an age-related process associated with glaucoma and cataracts. It increases the risk of complications during cataract surgery. Blood neutrophil-to-lymphocyte ratio (NLR) is shown to be an effective biomarker of inflammation in PES. We aimed to investigate association of NLR and pseudoexfoliation (PEX) related cataract surgery complications.

METHODS

A total of 210 eyes who underwent cataract surgery between January 2016 and January 2020 in our department were analyzed retrospectively. Patients were grouped with respect to developing complications and the two groups were compared. Medical records were reached to obtain neutrophil and lymphocyte values to calculate NLR. Data obtained were analyzed using chi-square test. Receiver operating characteristics curve analysis was performed to determine cutoff, sensitivity and specificity values. p value of ≤ 0.05 was considered statistically significant.

RESULTS

The mean age was 68.1 ± 7.2 years and mean NLR was 2.11 ± 0.81. Complications were observed in 32 (15.2%) of the patients (group 1). Neutrophil counts (5.19 ± 0.64 vs. 4.43 ± 0.86, p < 0.001) and the NLR (2.68 ± 0.73 vs. 2.01 ± 0.81, p < 0.001) of group 1 were significantly higher than group 2. The ROC analysis revealed a cutoff value of 2.33 for NLR to predict cataract surgery complications with sensitivity of 87.5% and specificity of 78.1%.

CONCLUSION

There is an association between NLR and increased risk of complications during cataract surgery in PES patients. NLR can be used as an easy method to help ophthalmologists in predicting the risks associated with cataract surgery in PEX eyes.

Determinants of the risk of intraoperative complications in phacoemulsification among patients with pseudoexfoliation

PURPOSE

The purpose of the study was to study the relationship between pseudoexfoliation (PES) and other predictors in the development of complications in cataract surgery by phacoemulsification in patients with PES.

METHODS

A retrospective cohort study of patients undergoing cataract surgery by phacoemulsification in the health area of Cee in northwestern Spain during the 2-year period from 2009 to 2010. Capsule rupture, choroidal hemorrhage, and vitreous loss were included as complications and intraoperative nucleus or lens dislocation as the independent variable. PES, age, hardness, type of cataract, myopia, preoperative visual acuity, antiplatelet use, anticoagulant uses, alpha agonist use, mydriasis prior to surgery, anterior chamber depth, and axial length were included as predictor variables. All predictive hierarchical models were tested using as a selection criterion the one minimizing the Akaike index.

RESULTS

A total of 551 patients were initially identified from hospital register, of which 48 were excluded due to the presence of an exclusion factor. After the initial selection, the final sample was 681 eyes of 503 patients. Of the 8192 possible models, a model with the following seven variables was selected: PES, steroid use, alpha agonist use, nuclear hardness, mydriasis, anterior chamber depth, and axial length. The selected model had an Akaike index of 435.4 and an area under the curve of 0.7895 corresponding to a sensitivity of 6.2% and a specificity of 98.5%.

CONCLUSION

PES, nuclear hardness, and alpha agonist use are risk factors strongly predictive of complications.

Intraocular lens power calculations in eyes with pseudoexfoliation syndrome

To compare refractive outcomes after cataract surgery in pseudoexfoliation syndrome (PEX) and control eyes and to investigate the accuracy of 3 intraocular lens (IOL) calculation formulas in these eyes. In this prospective comparative study 42 eyes (PEX group) and 38 eyes (control group) of 80 patients were included. The follow-up was 3 months. The refractive prediction error (RPE), mean absolute error (MAE), median absolute error (MedAE) and the percentages of eyes within ± 0.25 D, ± 0.5 D, ± 1.0 D and ± 2.0 D of prediction error were calculated. Three IOL calculation formulas (SRK/T, Barrett Universal II and Hill-RBF) were evaluated. PEX produced statistically significantly higher mean absolute errors and lower percentages of eyes within ± 0.5 D than control eyes in all investigated IOL calculation formulas. There were no statistically significant differences in the median absolute errors between the 3 formulas in either PEX or control eyes. Refractive outcomes after cataract surgery are statistically significantly worse in PEX than in control eyes. All three IOL calculation formulas produced similar results in both PEX and control eyes.Trial registration: ClinicalTrials.gov registration number NCT04783909.

Refractive precision in uncomplicated eyes with pseudoexfoliation: three-piece versus one-piece intraocular lens implantation

PURPOSE

To evaluate the refractive precision of three-piece versus one-piece intraocular lenses (IOLs) in eyes with pseudoexfoliation (PXF) and changes in anterior chamber depth (ACD) following cataract surgery.

METHODS

This prospective, nonrandomized, interventional, comparative case series included PXF eyes, which were implanted with one-piece acrylic IOL or three-piece acrylic IOLs (Group A; n = 31, Group B; n = 30). Non-PXF control eyes were implanted with one-piece acrylic IOL (Group C; n = 30). Postoperative refractive error (RE) and absolute RE, as well as pre- to postoperative ACD changes, were statistically analysed. A p value < 0.05 was considered statistically significant.

RESULTS

Changes in ACD (mean ± standard deviation) in Groups A, B and C were 0.9 ± 0.4, 1.0 ± 0.3 and 0.7 ± 0.4 mm, respectively. Significant differences were found between Groups A and C (p = 0.043) and between Groups B and C (p = 0.008). In Groups A, B and C, the median and interquartile (Q1 to Q3) values were 0.3 (-0.8 to 1.0), -0.5 (-0.8 to -0.3) and 0.1 (-0.4 to 0.3) for RE and 1.0 (0.4 to 1.3), 0.5 (0.3 to 0.8) and 0.3 (0.3 to 0.5) for absolute RE, respectively. The RE differences between Group A and B (p = 0.009) and Group B and C (p < 0.001) were statistically significant. For absolute RE, the differences were significant for all comparisons (p < 0.05).

CONCLUSION

Refractive precision in PXF eyes may be better with three-piece than with one-piece IOL implantation, but worse than with one-piece IOL implantation in non-PXF eyes. Significant changes in ACD in PXF eyes may be related to RE.

Complications and visual outcomes of cataract surgery in patients with pseudoexfoliation

PURPOSE

To compare outcomes of cataract surgery performed by ophthalmic trainees and consultants in patients associated with pseudoexfoliation (PXF) METHODS: Retrospective review of medical records of all patients with PXF who had undergone cataract surgery from January 2016 to December 2018 at L V Prasad Eye Institute, Hyderabad, India, were analysed RESULTS: A total of 914 eyes were included in the study; surgeries on 501 (54.8%) eyes with PXF were performed by trainees, while 413 (45.2%) were performed by consultants. Posterior capsule rupture (PCR) with vitreous loss (VL) occurred in significantly fewer eyes operated on by consultants (n = 8, 1.9%) than those operated on by trainees (n = 23, 4.5%) (p = 0.002). Eyes that underwent small incision cataract surgery (n = 100, 21.2%) had a significantly greater number of complications than those that underwent phacoemulsification (n = 31, 7.1%) (p = 0.00001). Multivariate logistic regression analysis shows that chances of a complication are higher when operated on by a trainee (OR = 1.59, 95% CI: 1.09-2.34, p = 0.02).The mean logMAR corrected distance visual acuity of patients one month post-surgery was significantly higher for patients in the consultant group (0.15 ± 0.3) than for those in the trainee group (0.2 ± 0.4) (p = 0.003).

CONCLUSION

Patients with PXF operated on by trainees for cataract had a relatively higher risk of developing PCR with VL and had poorer visual outcomes than those operated on by consultants.

Comparison of phaco time parameters in eyes with and without glaucoma filtration surgery due to pseudoexfoliation glaucoma

PURPOSE

To compare the phaco time parameters including ultrasound time (UST), effective phaco time (EPT), and average phaco power (APP) in eyes with pseudoexfoliation glaucoma (PEG) and had or had not glaucoma filtration surgery.

METHODS

In this retrospective comparative study, Group 1 was constructed with 84 PEG patients who had not operated previously, and Group 2 was constructed with 49 PEG patients who had glaucoma filtration surgery. The mean values of UST, EPT, and APP were compared. The preoperative clinical characteristics and surgical manipulations were also compared.

RESULTS

The mean ages and male-to-female ratios of the groups were similar (p > 0.05, for both). There was no difference in the preoperative clinical characteristics, including biometric values between the groups (p > 0.05, for all). Some surgical manipulations, including pupillary stretching (p = 0.004), pupillary membrane peeling (p = 0.021), iris hook using (p = 0.041), and capsular tension ring implantation (p = 0.041), were significantly performed more commonly in Group 2. Although the mean UST and EPT values were similar (p > 0.05, for both), the mean APP value was significantly lower in Group 2 (p = 0.011).

CONCLUSION

The lower APP parameter was observed in PEG patients having had glaucoma filtration surgery. Needing more surgical manipulation to overcome poor pupillary dilation and weak zonular instability can be a reason for this result.

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

PURPOSE:

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

METHODS:

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

RESULTS:

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

CONCLUSION:

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

The human Descemet's membrane and lens capsule: Protein composition and biomechanical properties

The Descemet's membrane (DM) and the lens capsule (LC) are two ocular basement membranes (BMs) that are essential in maintaining stability and structure of the cornea and lens. In this study, we investigated the proteomes and biomechanical properties of these two materials to uncover common and unique properties. We also screened for possible protein changes during diabetes. LC-MS/MS was used to determine the proteomes of both BMs. Biomechanical measurements were conducted by atomic force microscopy (AFM) in force spectroscopy mode, and complemented with immunofluorescence microscopy. Proteome analysis showed that all six existing collagen IV chains represent 70% of all LC-protein, and are thus the dominant components of the LC. The DM on the other hand is predominantly composed of a single protein, TGF-induced protein, which accounted for around 50% of all DM-protein. Four collagen IV-family members in DM accounted for only 10% of the DM protein. Unlike the retinal vascular BMs, the LC and DM do not undergo significant changes in their protein compositions during diabetes. Nanomechanical measurements showed that the endothelial/epithelial sides of both BMs are stiffer than their respective stromal/anterior-chamber sides, and both endothelial and stromal sides of the DM were stiffer than the epithelial and anterior-chamber sides of the LC. Long-term diabetes did not change the stiffness of the DM and LC. In summary, our analyses show that the protein composition and biomechanical properties of the DM and LC are different, i.e., the LC is softer than DM despite a significantly higher concentration of collagen IV family members. This finding is unexpected, as collagen IV members are presumed to be responsible for BM stiffness. Diabetes had no significant effect on the protein composition and the biomechanical properties of both the DM and LC.

Comparison of phacoemulsification parameters in eyes with and without exfoliation syndrome

OBJECTIVE

To evaluate and to compare the phacoemulsification machine parameters in eyes with and without XFS, requiring cataract surgery.

METHODS

Patients who underwent phacoemulsification and in-the-bag IOL implantation for cataract were included in this retrospective study. All surgeries were performed by the same experienced surgeon using the stop & chop technique with the same phacoemulsification device (Infiniti Vision System, Alcon Laboratories, Inc., USA). Patients were divided into two groups according to the presence of exfoliation material (XFM). Each group consisted of consecutive patients. Their characteristics and intraoperative phacoemulsification parameters were compared.

RESULTS

Sixty-eight eyes of 68 patients [29 in the exfoliation syndrome (XFS) (-) group, 39 in XFS (+)] were enrolled. There were no statistical differences regarding preoperative patient characteristics. There was a statistically significant difference in total U/S time, phaco time, aspiration time and estimated fluid used between the XFS (+) and XFS (-) groups (P=0.021, P=0.017, P=0.009 and P=0.002, respectively). Considering that the use of a CTR (capsule tension ring) might be an important factor potentially affecting surgical parameters, the data were analyzed accordingly. Aspiration time and estimated fluid used remained statistically significant (P=0.046 and P=0.017, respectively); however, although the U/S total and phaco time were found to be longer in XFS (+) group compared to XFS (-) group, the difference did not show statistical significance (P=0.061 and P=0.059, respectively). There were no differences between groups regarding endothelial cell loss or any other postoperative complications.

CONCLUSIONS

The presence of XFS results in longer total U/S time, phaco and aspiration time and more estimated fluid used in phacoemulsification, but this prolongation does not result in additional complications.

Intraoperative and postoperative complications of cataract surgery in eyes with pseudoexfoliation - An 8-year analysis

INTRODUCTION:

Pseudoexfoliation (PXM) is a fibrillar material deposited in the anterior chamber of the eye and can cause disintegration of zonules and make pupillary dilatation difficult. This can make surgery difficult and result in intraoperative and postoperative complications. The aim of this study was to learn about whether the presence of pseudoexfoliation caused significant complications during cataract surgery.

MATERIALS AND METHODS:

We did a secondary data analysis of 12,992 eyes from 2007 to 2014 using the National Eye Database of Melaka Hospital Malaysia on intraoperative and postoperative cataract surgery complications of patients with PXM.

RESULTS:

Patients with PXM were 2.68 times more likely to get intraoperative complications (P < 0.001). They had a higher incidence of lens subluxation, zonular dehiscence, and vitreous loss (P < 0.001). Although posterior capsule rupture (PCR) was the most common intraoperative complication during cataract surgery (4.8%), the presence of pseudoexfoliation was not associated with PCR (P > 0.05). We did not observe any association between patients with pseudoexfoliation and any of the postoperative complications such as corneal decompensation, raised intraocular pressure, and intraocular lens decentration (P > 0.05). Pseudoexfoliation did not cause corneal decompensation (P > 0.05) although corneal decompensation was the highest postoperative complication of cataract surgeries (0.18%).

CONCLUSIONS:

Patients with PXM had a higher rate of intraoperative complications which were mainly vitreous loss and zonular dehiscence and also lens subluxation/dislocation. We observed poorer visual outcomes in those with PXM following cataract surgery. Patients with pseudoexfoliation should be identified and precautions taken to minimize these complications to get better visual outcomes.

Are Elderly Patients Optimally Corrected with Spectacles in the Longer Term after Cataract Surgery?

SIGNIFICANCE

Our study suggests that patients would benefit from adjusting their distance spectacles several years after cataract surgery. This may lead to a better quality of life for these patients.

PURPOSE

The purpose of this study was to determine whether patients' distance vision is optimally corrected with spectacles 6 to 7 years after cataract surgery and whether patients with glaucoma who regularly visit an ophthalmologist have more correct power in their spectacles.

METHODS

A total of 153 patients (153 eyes) who underwent cataract surgery with phacoemulsification at Oslo University Hospital were examined 6 to 7 years after surgery. Patients with better or equal best-corrected distance visual acuity in the study eye compared with the other eye were included (n = 90; 59%). Vision-related outcomes were measured and analyzed, including a modified version of the visual function questionnaire, Visual Function-14 (VF-14).

RESULTS

A significant difference was found in the logMAR score between the patients' habitual correction (if any) and those with best-corrected distance visual acuity measured at the postoperative study examination (0.20 ± 0.40 and 0.10 ± 0.39, respectively; P < .0001). Patients with glaucoma (n = 17) did not have more correct power of their spectacles than did patients without glaucoma (n = 73; P = .38). The overall mean VF-14 score was 89%, with a statistically significant correlation between a high VF-14 score and a good habitual distance correction (r = -0.82; P < .0001).

CONCLUSIONS

This study indicates that, although the patients are quite satisfied with their visual function 6 to 7 years after cataract surgery, many patients are not making the most of their visual potential. Thus, there seems to be a need for better monitoring of patients' distance refraction and spectacle use for an extended period after cataract surgery.

Intraoperative complications of phacoemulsification in pseudoexfoliation: Metaanalysis

This review analyzed the effect of pseudoexfoliation (PXF) syndrome on the risk for surgical complications during phacoemulsification. Peer-reviewed literature in Medline, Embase, Lilacs, Web of Science, and Cochrane databases was systematically searched, along with gray literature in the Teseo and National Institutes of Health clinical trials database. Clinical trial, cohort, case-control, and cross-sectional studies comparing phacoemulsification complications in patients with and without PXF were identified, and 22 of 30 studies were selected for analysis. Odds ratios (ORs) for posterior capsule rupture or zonular dialysis were calculated and pooled using random-effects models. A random-effects meta-regression model was also generated. Using the random-effects model, the pooled OR was 2.1363 (95% confidence interval, 1.5394-2.9648), which corresponds to a risk of more than 10%. No significant changes to this risk were observed in the cumulative or stratified analyses. Although advances in surgical technique have been made, PXF syndrome continues to be a risk factor in phacoemulsification.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Posterior capsular rent: Prevention and management

This review article deals with a potentially sight threatening complication – rupture of the posterior capsule – during cataract surgery. Cataract surgery is the most commonly performed surgical procedure in ophthalmology and despite tremendous technical and technological advancements, posterior capsular rent (PCR) still occurs. PCR occurs both in the hands of experienced senior surgeons and the neophyte surgeons, although with a higher frequency in the latter group. Additionally, certain types of cataracts are prone to this development. If managed properly in a timely manner the eventual outcome may be no different from that of an uncomplicated case. However, improper management may lead to serious complications with a higher incidence of permanent visual disability. The article covers the management of posterior capsular rent from two perspectives: 1. Identifying patients at higher risk and measures to manage such patients by surgical discipline, and 2. Intraoperative management of posterior capsular rent and various case scenarios to minimize long-term complications. This review is written for experienced and not-so-experienced eye surgeons alike to understand and manage PCR.

Late In-the-Bag Intraocular Lens Dislocation: A Randomized Clinical Trial Comparing Lens Repositioning and Lens Exchange

PURPOSE

To compare the efficacy and safety of 2 operation methods for late in-the-bag intraocular lens (IOL) dislocation.

DESIGN

Prospective, randomized, parallel-group surgical trial.

PARTICIPANTS

Patients referred to Oslo University Hospital (tertiary referral center).

METHODS

We randomly assigned 104 patients (104 eyes) either to IOL repositioning by scleral suturing (n = 54) or to IOL exchange with retropupillary fixation of an iris-claw IOL (n = 50). One surgeon performed all operations. Patients were evaluated comprehensively before surgery, and most patients (82%) attended an examination 6 months after surgery.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA) 6 months after surgery.

RESULTS

The mean postoperative BCVA was 0.24±0.29 logarithm of the minimum angle of resolution (logMAR) units (range, -0.18 to 1.16 logMAR) in the repositioning group and 0.35±0.54 logMAR (range, -0.20 to 3.0 logMAR) in the exchange group (P = 0.23). A BCVA of 20/40 or better (Snellen) was reached by 61% and 62% of the patients, respectively (P = 0.99). The mean postoperative corneal cylinder was 1.2±1.0 and 1.2±0.8 diopters, respectively (P = 0.84), and the postoperative endothelial cell density changes were -3±10% (P = 0.07) and -10±14% (P = 0.001), respectively (group difference, P = 0.04). Repositioning had a longer mean surgical time than exchange (P < 0.001). There were 2 (4%) and 0 cases of perioperative fluid misdirection syndrome, respectively. Postoperative complications were intraocular pressure (IOP) increase (n = 12), cystoid macular edema (CME; n = 3), and nonarteritic anterior ischemic optic neuropathy (n = 1) in the repositioning group, and IOP increase (n = 9), pupillary block (n = 1), choroidal effusion (n = 2), CME (n = 4), and redislocation (n = 1) in the exchange group.

CONCLUSIONS

We found satisfactory and not significantly different outcomes for BCVA 6 months after surgery in the 2 groups. Both operation methods seemed safe, with low frequencies of serious perioperative and postoperative complications. However, some of the observed differences in complications should be taken into consideration when selecting the most suitable method in clinical practice.

Risk factors for corneal endothelial cell loss by cataract surgery in eyes with pseudoexfoliation syndrome

PURPOSE

The aim of this study was to investigate the factors associated with decreases in corneal endothelial cell density (ECD) resulting from cataract surgery in eyes with pseudoexfoliation syndrome (PEX).

METHODS

The clinical records of 78 eyes of 78 patients with PEX who had undergone cataract surgery were reviewed. ECD was measured preoperatively and at 3 months postoperatively with specular microscopy. Multiple regression analysis was used to assess the factors that were significantly related to the rate of ECD loss. Explanatory variables included age, preoperative ECD, pupil diameter, cataract grade, concomitance of glaucoma or diabetes mellitus, preoperative anterior chamber depth, surgery time, total time and power of ultrasound, performance of intraoperative pupillary enlargement manipulation, and postoperative aqueous flare intensity at 1 week and 1 month.

RESULTS

ECD before and after surgery was 2,464±337 cells/mm(2) and 2,400±347 cells/mm(2), respectively, with an ECD loss rate of 2.6%±5.1% (mean ± SD). Multiple regression analysis revealed that ECD loss was significantly associated with the cataract grade (P=0.019) and preoperative anterior chamber depth (P=0.023).

CONCLUSION

With modern small incision cataract surgery, the ECD loss varied with surgical invasions due to severe cataract and shallow anterior chamber, and the presence of PEX was least affected.

Cataract Surgery and Possible Complications in Patients with Pseudoexfoliation Syndrome

OBJECTIVE

The aim of this study was to evaluate the demographic characteristics and intraoperative complications of cataract surgery in patients with pseudoexfoliation syndrome (PEX).

MATERIALS AND METHODS

Cases of 225 eyes (80 eyes with pseudoexfoliation and 145 eyes without pseudoexfoliation as the control group) that underwent phacoemulsification cataract surgery and IOL implantation at the Silifke State Hospital Ophthalmology Clinic between April 2011 and April 2013 were analysed retrospectively. Patients with a history of previous ocular surgeries, ocular trauma, uveitis, glaucoma or corneal pathology were not included in the study. All cataract procedures were performed by the same surgeon. Patients' age, gender, anterior segment and fundus findings in both eyes, presence of pseudoexfoliative material, pre- and postoperative day 1 intraocular pressure (IOP) and surgery notes were evaluated.

RESULTS

There were 51 (34.7%) males and 29 (38.6%) females among the PEX cataract patients, and 98 (65.3%) male and 47 (61.8%) female controls. The incidence of pseudoexfoliation was similar in women (38.2%) and men (34.7%) (p=0.660). The mean age was 74.64±6.8 in the PEX group and 68.95±7.5 in the control group. Mean age was significantly higher in the PEX group compared to controls (p<0.001). Poor pupil dilation occurred intra-operatively in 60 (75%) of the patients with pseudoexfoliation and in 17 (11.7%) of the control patients. Frequency of poor intraoperative pupil dilation was significantly higher in the PEX group (p<0.001). Intraoperative vitreous loss occurred in 7 (8.8%) PEX patients and 5 (3.4%) controls, but this difference was statistically insignificant (p=0.090).

CONCLUSION

Surgeons should be aware of the potential complications of cataract procedures in patients with PEX. Caution should be taken at every stage of the surgery to prevent these complications, and surgeons should be knowledgeable and skilful in complication management should they arise.

Predictive modeling of risk factors and complications of cataract surgery

PURPOSE

Cataract surgery is generally safe; however, severe complications exist. Preexisting conditions are known to predispose patients to intraoperative and postoperative complications. This study quantifies the relationship between aggregated preoperative risk factors and cataract surgery complications, and builds a model predicting outcomes on an individual level, given a constellation of patient characteristics.

METHODS

This study utilized a retrospective cohort of patients age 40 years or older who received cataract surgery. Risk factors, complications, and demographic information were extracted from the Electronic Health Record based on International Classification of Diseases, 9th edition codes, Current Procedural Terminology codes, drug prescription information, and text data mining. We used a bootstrapped least absolute shrinkage and selection operator model to identify highly associated variables. We built random forest classifiers for each complication to create predictive models.

RESULTS

Our data corroborated existing literature, including the association of intraoperative complications, complex cataract surgery, black race, and/or prior eye surgery with increased risk of any postoperative complications. We also found other, less well-described risk factors, including diabetes mellitus, young age (&lt;60 years), and hyperopia, as risk factors for complex cataract surgery and intraoperative and postoperative complications. Our predictive models outperformed existing published models.

CONCLUSIONS

The aggregated risk factors and complications described here can guide new avenues of research and provide specific, personalized risk assessment for a patient considering cataract surgery. Furthermore, the predictive capacity of our models can enable risk stratification of patients, which has utility as a teaching tool as well as informing quality/value-based reimbursements.

Cataract surgery in pseudoexfoliation syndrome

Pseudoexfoliation (PXF) syndrome is characterized by the deposition of distinctive fibrillar material in the anterior segment of the eye. It is an age-related process that is associated with open and narrow angle glaucomas and the formation of cataracts. Not only is PXF associated with the formation of dense nuclear cataracts, it is also well known that those presenting with PXF are at a higher risk of developing complications during, and even after, cataract surgery. Complications associated with cataract surgery in PXF can occur from poor pupillary dilation, zonular weakness leading to intraoperative or postoperative lens dislocation and vitreous loss, postoperative intraocular pressure (IOP) spikes potentiating glaucomatous damage, capsular phimosis, prolonged inflammation, and postoperative corneal decompensation. The surgeon should be prepared to encounter the various potential intraoperative and postoperative complications in eyes with pseudoexfoliation syndrome during cataract surgery. In this way, the surgeon can plan his/her surgical technique to help avoid surprises during cataract surgery and be prepared to manage the potential postoperative complications that can occur in pseudoexfoliation eyes.

Intraoperative and Immediate Postoperative Outcomes of Cataract Surgery using Phacoemulsification in Eyes with and without Pseudoexfoliation Syndrome

BACKGROUND

To compare the intraoperative and immediate postoperative behavior and complications in eyes with pseudoexfoliation (PEX) syndrome with eyes having senile cataract without PEX during cataract surgery using phacoemulsification (PKE).

MATERIALS AND METHODS

In this prospective study, 68 eyes of 68 patients were divided into two groups: Group 1 (test) comprised 34 eyes with immature senile cataract with PEX and Group 2 (control) included 34 eyes with immature senile cataract without PEX and any coexisting ocular pathology. Phacoemulsification (modern cataract surgery) was performed on both groups through stop and chop technique and comparative analysis of the incidence of intraoperative and immediate postoperative complications was made.

RESULTS

There was no significant difference in rates of intraoperative complications between PEX (2.9%) and Control (0%) group. The mean pupil diameter was significantly smaller in Group 1 (p<0.001). No eye in either group had phacodonesis. 58.8% of eyes in Group 1 and 29.4% in Group 2 had a harder cataract (nuclear sclerosis) ≥ grade 3 (p=0.017). PKE was performed in all eyes with cataract in both groups. Intraoperative complication (zonular dialysis (dehiscence) was encountered in only 2.9% (1 case) of eyes with PEX. PC (posterior capsule) tear (rent) with vitreous loss was seen in 2.9% eyes of Group 1 and none in Group 2. Postoperatively, IOP (intraocular pressure) and aqueous flare response were comparable between the groups. Significantly higher inflammatory cell response was observed in Group 1 (p=0.014). BCVA (best corrected visual acuity) using Snellen chart with pinhole on postoperative day1 was significantly better in the control group compared to the group with PEX (p=0.027).

CONCLUSION

Phacoemulsification can be safely performed by experienced hands in cataractous eyes with PEX. The incidence of intraoperative and immediate post-operative complications in eyes with PEX was not significantly different compared to eyes without PEX in our study. Further studies among a larger population are required.

Washout of pseudoexfoliation material combined with cataract surgery: a new surgical approach to lower intraocular pressure in pseudoexfoliation syndrome

Glaucoma or ocular hypertension can be caused by the presence of pseudoexfoliation (PEX) material and/or pigmented cells in the trabecular meshwork (TM) and/or in the irido-corneal angle (ICA). Accumulation of this material can be highlighted by slit-lamp (SL), gonioscopy, and ultrasound biomicroscopy (UBM). Such material prevents aqueous humor from flowing out and thus induces intraocular pressure (IOP) elevation. A new technique using a special cannula for washing the TM and ICA, combined with cataract surgery, can lower IOP and reduce the number of hypotensive drugs needed. This study analyzed 11 patients (13 eyes) presenting a pseudoexfoliation glaucoma with cataract. They all had cataract surgery combined with the special washing technique. Visual acuity and IOP were noted before surgery, just after surgery and during follow-up. The number of hypotensive drugs needed was also recorded. Mean follow-up time was 34.4 months (range 21.8–59.2). The first case underwent surgery in 2007 and has a 5-year follow-up time. Local status was controlled by SL, gonioscopy, and UBM. Mean age was 79 years (range 71.6–86.0). Mean visual acuity was 0.37 pre-op (range 0.05–0.6) and 0.89 post-op (range 0.05–1.0). Mean IOP before and after surgery was 32.8 ± 8.7 mmHg (range 20–53) and 15.1 ± 3.5 mmHg (range 10–20), respectively. The amount of hypotensive drugs needed was 87 % lower after surgery. No PEX material recurrence was seen with SL, gonioscopy, and UBM during the mean follow-up of 3 years. No complication was recorded in this study. Cataract surgery combined with the new washout technique of the TM and ICA to remove PEX material or pigmented cells significantly lowers IOP and the amount of drugs needed. Long-term follow-up gives good results with no complication or recurrence. Eye status after surgery remains physiological and further glaucoma surgery can be performed if necessary. More research with a higher number of patients should be initiated to confirm this technique.

Late in-the-bag intraocular lens dislocation in eyes with pseudoexfoliation syndrome

PURPOSE

To assess preoperative features, frequency, surgical approaches and outcomes of late in-the-bag dislocation of posterior chamber intraocular lenses (IOLs) in eyes with pseudoexfoliation syndrome.

METHODS

Seventy-seven patients (81 eyes) were enrolled. Inclusion criteria were patients with pre-existing pseudoexfoliation syndrome who underwent surgery for late in-the-bag IOL dislocation between March 2004 and April 2010. Medical records were reviewed. Data from before and after secondary surgery were analysed.

RESULTS

Mean time between cataract extraction and secondary surgery for late in-the-bag dislocation of posterior chamber IOLs was 8.5 years. The increase in frequency within the reviewed period was statistically significant, ranging from six patients in the first year to 25 patients in the final year (p = 0.004). When surgical correction was performed within 1 month of referral, deterioration of the dislocation occurred in only one of 23 patients (4.3%). Complications, especially vitreous loss, occurred significantly more frequently during exchange surgery (n = 23) when compared with scleral suturing (n = 50) (p < 0.0001). After surgery, however, no differences in complications (p = 0.98) or best-corrected visual acuity (p = 0.74) was found. In general, following secondary surgery, there was a statistically significant improvement in best-corrected visual acuity (p < 0.0001).

CONCLUSION

The frequency of late in-the-bag dislocation of posterior chamber IOLs in eyes with pseudoexfoliation syndrome increased during the observation period. Our study suggests that surgical repair should not be delayed beyond 1 month and that scleral suturing is preferable to exchange surgery, because of less intraoperative complications.

Posterior capsular opacification in patients with pseudoexfoliation syndrome: a long-term perspective

PURPOSE

To compare posterior capsular opacification in patients with and without pseudoexfoliation syndrome 6-7 years following surgery.

METHODS

Forty-four eyes of 44 patients with pseudoexfoliation syndrome who underwent cataract surgery with phacoemulsification in 2001 and 2002 were available for follow-up in 2008. These patients were compared to 86 age- and gender-matched patients (86 eyes) without pseudoexfoliation syndrome who had surgery during the same time period. Posterior capsule opacification was assessed using digital retroillumination photography. The images were analysed with a software program (POCOman) to determine the extent and severity of the capsular opacification.

RESULTS

Percentage and severity of posterior capsular opacification within the central 4.0 and 1.3 mm of the optical zone were compared in eyes with and without pseudoexfoliation syndrome. Neither of these results were statistically significant. Before the re-examination in 2008, neodymium:yttrium-aluminium-garnet laser posterior capsulotomy had been conducted in 16% (n = 7) of eyes with pseudoexfoliation syndrome, as well as in 16% (n = 14) of eyes without pseudoexfoliation syndrome.

CONCLUSION

Our study indicates that, with phacoemulsification, development of long-term posterior capsular opacification is not increased in patients with pseudoexfoliation syndrome after uncomplicated cataract surgery.

Endophthalmitis following cataract surgery: the role of prophylactic postoperative chloramphenicol eye drops

PURPOSE

The main aim of the study was to assess whether omitting prophylactic postoperative topical antibiotics (chloramphenicol) influenced the risk of developing endophthalmitis after cataract surgery.

METHODS

We conducted a retrospective study including all patients who had cataract surgery at our outpatient cataract unit between 2004 and 2011. Postoperative topical antibiotics (chloramphenicol) were omitted from 2007 onwards, as was the first postoperative day review. Patients with a diagnosis of endophthalmitis after cataract surgery were extracted, and the rate of postoperative endophthalmitis (PE) before and after changing these routines was compared. The diagnosis of PE was defined as severe intraocular inflammation requiring prompt vitreous sampling for culture.

RESULTS

Seven thousand one hundred and twenty-three and 8131 cataract surgeries were performed in the following periods: January 2004 through December 2006 (period 1) and January 2007 through December 2010 (period 2), respectively. Five cases of PE were identified in period 1 (0.070%) and four patients in period 2 (0.049%). The median time between cataract surgery and onset of symptoms was 6 days in period 1 and 4.5 days in period 2. Median time for intervention was 7 and 5 days postsurgery, respectively.

CONCLUSION

We found no difference in the frequency of PE following cataract surgery when changing the postoperative topical medication from a mixture of corticosteroids and antibiotics to only corticosteroids.

Corneal endothelial cells 6-7 years following cataract surgery in patients with pseudoexfoliation syndrome

PURPOSE

To assess the condition of the corneal endothelium an extended period after cataract surgery in eyes with and without pseudoexfoliation syndrome (PES).

METHODS

Forty-six patients with PES who underwent cataract surgery in the Eye Department, Oslo University Hospital, in 2001 and 2002 were enrolled and compared to 101 matched controls without PES who had surgery in the same period. They were re-examined 6-7 years following surgery with measurements taken of corneal endothelial cell density (ECD), pleomorphism, polymegathism and corneal thickness.

RESULTS

Mean ECD was 2024 ± 371 cells/mm(2) in eyes with PES and 2144 ± 365 cells/mm(2) in eyes without PES. The difference was not statistically significant. No significant difference in polymegathism and pleomorphism was noted. Mean corneal thickness was 543 and 547 μm in eyes with and without PES, respectively (not statistically significant). The presence of glaucoma in pseudoexfoliative eyes was not associated with endothelial cell changes.

CONCLUSION

Six to 7 years following cataract surgery, no statistically significant differences were established in ECD, pleomorphism, polymegathism and corneal thickness in eyes with and without PES. No clinical signs of corneal decompensation were noted amongst the participants.

Outcome of phacoemulsification in patients with and without Pseudoexfoliation syndrome in Kashmir

Background

The aim of the study is to compare the outcome of phacoemulsification in patients with and without pseudoexfoliation syndrome in Kashmir.

Methods

200 patients were prospectively evaluated and divided into 2 groups. Group 1 comprised 100 cases with pseudoexfoliation and Group 2 (control) 100 cases without pseudoexfoliation. Phacoemulsification with posterior chamber intraocular lens implantation was performed by 3 surgeons. Intraoperative and postoperative observations were made in both the groups at regular intervals upto 6 months. A chi square test was used for statistical analysis.

Results

Patients with pseudoexfoliation were significantly older (P = 0.000), had harder cataract(P = 0.030) and smaller mean pupil diameter(P = 0.000) than the control group. Intraoperative complications were comparable between the 2 groups except the occurrence of zonular dehiscence which was seen in 7% patients of Group 1 compared to 0% in Group 2. Higher postoperative inflammatory response was seen in Group 1(P = 0.000). Decrease in intraocular pressure (IOP) at all postoperative measurements was more in Group 1(P = 0.000). The visual acuity was better in the control group in the early postoperative period (P = 0.029), however the final visual acuity at 6 months was comparable between the 2 groups.

Conclusions

Phacoemulsification in presence of pseudoexfoliation necessitates appropriate surgical technique to avoid intraoperative complications. Pseudoexfoliation is associated with higher inflammatory response, significant postoperative IOP drop and satisfactory visual outcome.

Phacoviscocanalostomy in pseudoexfoliation glaucoma versus primary open-angle glaucoma

OBJECTIVE

To compare the outcome of phacoviscocanalostomy in pseudoexfoliation glaucoma (PEXG) versus that in primary open-angle glaucoma (POAG).

DESIGN

Prospective comparative study.

PARTICIPANTS

Sixty eyes of 60 patients who underwent phacoviscocanalostomy for cataract and medically uncontrolled PEXG (30 eyes) or POAG (30 eyes).

METHODS

Success rate was based on intraocular pressure (IOP) reduction and need for antiglaucoma medication. Visual acuity (VA) and complication rates were secondary outcomes.

RESULTS

The mean follow-up was 19.7 months (range, 12-36 months). The mean IOP values in both groups were significantly less than the preoperative values at all postoperative intervals (p < 0.001). From 1 month onward, the decrease in IOP was more dramatic in PEXG eyes than in POAG eyes (p < 0.05). At last visit, the mean percentage of IOP reduction was 49.7% in the PEXG group and 30.9% in the POAG group. All study eyes required decreased antiglaucoma medications and showed improved VA postoperatively. Transient complications included Descemet's membrane microperforations, macroperforation, zonular dehiscence, and postoperative IOP spike. No eyes developed trabeculectomy-type bleb, hyphema, fibrin exudation, or bleb-related complications.

CONCLUSIONS

Phacoviscocanalostomy achieved excellent IOP control and VA improvement in both PEXG and POAG groups. PEXG demonstrated greater IOP reduction and fewer postoperative medications than POAG. The complication rate was low and did not affect surgical outcome. Phacoviscocanalostomy can be an effective and safe surgical alternative to phacotrabeculectomy in both groups of patients.

In situ nuclear disassembly: efficient phacoemulsification without nuclear rotation using lateral sweep sculpting and in situ cracking techniques

We describe an in situ nuclear disassembly technique using a simplified form of sculpting and cracking, enhanced by phacoemulsification technology with a Kelman-style tip. The technique does not require mobilization or rotation of the nucleus within the capsular bag, and hydrodissection is optional. The technique requires a Kelman-style curved tip and Kuglen hook and takes advantage of the versatility of the curved phacoemulsification needle for sculpting and cracking. Since in situ nuclear disassembly requires no rotation of the nucleus for extraction, it is useful in cases in which zonules are compromised or the surgeon suspects posterior lenticonus and the potential for loss of integrity of the posterior capsule.

Grading the surgical difficulty of cataract phacoemulsification

BACKGROUND AND OBJECTIVE

To propose a new grading system to preoperatively evaluate the difficulty of phacoemulsification surgery according to the anatomic condition of a patient's eye.

PATIENTS AND METHODS

In this prospective case series, a grading system covering the entire cataract spectrum was developed and field-tested in 400 consecutive patients undergoing phacoemulsification. For each eye, nine anatomic parameters were evaluated and a level of severity was assigned. The system identifies five levels of surgical difficulty based on the combined degree of severity of each parameter considered.

RESULTS

Preoperative score and intraoperative difficulty closely corresponded in the first 400 test cases. Analysis using the Fleiss-Cohen kappa coefficient showed substantial agreement between preoperative and intraoperative scores (k value = 0.76; 95% confidence interval = 0.71 to 0.81).

CONCLUSION

A grading system of the preoperative difficulties of each phacoemulsification procedure is provided. This system is easy to complete and interpret and can be transmitted to the surgeon, patient, and anyone who may subsequently examine the case.

Serum alpha-1-antitriypsin levels in patients with pseudoexfolative syndrome

PURPOSE

To evaluate the levels of serum alpha 1-antitrypsin in patients with pseudoexfoliation syndrome (PEX) and healthy control subjects without PEX.

MATERIAL AND METHODS

Forty-four patient with PEX and 40 healthy control subjects (84 subjects total) were enrolled into the study. Serum ATT levels were measured using nephelometry.

RESULTS

The mean serum AAT concentration in PEX group was significantly higher than in the controls (p=0.0001).

CONCLUSION

Serum AAT levels were found to be increased in patients with PEX. Increased serum AAT levels in PEX may explain the role of inflammation in this group of patients.

The Cataract National Dataset electronic multicentre audit of 55,567 operations: risk stratification for posterior capsule rupture and vitreous loss

AIMS

To identify and quantify risk factors for posterior capsule rupture or vitreous loss or both (PCR or VL or both) during cataract surgery and provide a method of composite risk assessment for individual operations.

METHODS

The Cataract National Dataset was extracted on 55,567 operations from 12 National Health Service (NHS) Trusts using an electronic patient record (EPR) system between November 2001 and July 2006. Risk indicators for variations in the rate of 'PCR or VL or both' were identified by univariate and multivariate analyses. Adjusted odds ratios (ORs) were used to formulate a composite 'bespoke' risk for individual cases.

RESULTS

Overall 'PCR or VL or both' rate was 1.92% (95% CI=1.81-2.04%). Risk indicators for this complication were increasing age, male gender, presence of glaucoma, diabetic retinopathy, brunescent/white cataract, no fundal view/vitreous opacities, pseudo-exfoliation/phacodonesis, reducing pupil size, axial length > or = 26.0 mm, the use of the alpha-blocker doxazosin, inability to lie flat and trainee surgeons performing operations. Adjusted ORs for these variables are used to estimate overall composite risk across multiple risk indicators in the form of a predicted probability of PCR or VL or both. Predicted probability for this complication ranged from less than 0.75% to more than 75%, depending on risk profile of individual operations.

CONCLUSIONS

Higher-risk cases can be predicted, thus better informing the consent process and allowing surgeons to take appropriate precautions. Case-mix is a major determinant of the probability of an intraoperative complication. A simple composite risk estimation system has been developed.

Results of combined phacoemulsification and viscocanalostomy in patients with cataract and pseudoexfoliative glaucoma

PURPOSE

Coexisting pseudoexfoliation glaucoma (PEXG) and cataract represents a special challenge. Although phacotrabeculectomy is an effective procedure, it combines the risks of phacoemulsification and trabeculectomy. This study evaluates phacoviscocanalostomy to manage eyes with PEXG and cataract.

METHODS

We conducted a prospective noncomparative study that included 30 consecutive eyes of 22 patients with uncontrolled PEXG and cataract. Phacoviscocanalostomy was performed in all. Success rate based on postoperative intraocular pressure (IOP) reduction and requirement for topical antiglaucoma medication was evaluated as the main outcome measure. Visual acuity and complication rates were secondary outcomes.

RESULTS

The mean follow-up was 18.6 months +/-6.2 (SD) (range 12 to 36 months). There was statistically significant decrease in mean IOP from 25.3+/-5.2 mmHg preoperatively to 13.5+/-6.0 mmHg 1 day after surgery (p< .05), 12.3+/-3.1 mmHg at the final follow-up (p< .05), and at all evaluations to the last postoperative visit. Only three eyes (10%) required a single antiglaucoma medication to achieve the target IOP. A complete surgical success (IOP <21 mmHg without medication) was achieved in 90%, while a qualified success (IOP <21 mmHg with or without glaucoma medication) was achieved in 100% of cases. Complications included Descemet membrane microperforations (13.3%), macroperforation (3.3%), zonular dehiscence (6.6%), and transient postoperative IOP spike (3.3%).

CONCLUSIONS

Phacoviscocanalostomy achieved excellent IOP control and visual acuity improvement in pseudoexfoliation patients with coexisting cataract and glaucoma. Complication rate was low and did not affect the surgical outcome.