Dispersive-cohesive viscoelastic soft shell technique

A Prospective, Randomized, Controlled Clinical Investigation Comparing the Efficacy and Safety of Sodium Hyaluronate-Based Ophthalmical Viscosurgical Devices FIDIAL PLUS and IAL®-F in Cataract Surgery

Purpose: To protect the corneal endothelium, various ophthalmical viscoelastic devices (OVDs) are used during cataract surgery. In this study, we compared two sodium hyaluronate-based OVD, the bacteria-derived FIDIAL PLUS OVD (test) with the animal-derived IAL®-F OVD (reference) during the surgical procedure. Methods: Fifty patients with bilateral cataract participated in the study: 50 eyes randomly received FIDIAL PLUS and 50 eyes received IAL®-F (ratio 1:1). Noninferior efficacy of FIDIAL PLUS compared with reference OVD (first objective) was evaluated using a paired t-test comparing the mean percent loss of corneal endothelial cells (CECs) with FIDIAL PLUS against the mean percent loss with IAL®-F. Corneal endothelial protection during cataract surgery with FIDIAL PLUS without significant (≥30 mmHg) postoperative intraocular pressure (IOP) increase (main secondary objective) was assessed using a repeated measures logistic model comparing the incidence of significant postoperative IOP elevation between the two groups. Safety, tolerability, and efficacy were also evaluated by assessing secondary endpoints before and after surgery. Results: FIDIAL PLUS showed a statistically noninferior efficacy compared with IAL®-F; there was no significant increase in IOP in either group or different trends of the secondary endpoints were observed between the OVD groups. The safety profile was similar in both OVD groups and no adverse device effects were reported. Conclusions: This study demonstrates the equivalent efficacy, tolerability, and safety of the bacteria-derived FIDIAL PLUS compared with the animal-derived IAL®-F, confirming the clinical value of this product.

Scheimpflug Tomography as a Predictor of Corneal Edema After Phacoemulsification in Fuchs Endothelial Corneal Dystrophy

Purpose

To determine if Scheimpflug tomography pachymetry map and posterior elevation map patterns can predict the occurrence of corneal edema following uneventful phacoemulsification surgery in Fuchs endothelial corneal dystrophy (FECD).

Design

Observational prospective case-control study.

Participants

Fifty FECD eyes (50 patients) with visually significant cataract: 25 with subclinical corneal edema (SCE) versus 25 without SCE.

Methods

Preoperatively, FECD was clinically assessed, and only patients devoid of clinical corneal edema were enrolled. Utilizing the Mayo Clinic classification for subclinical corneal edema (SCE), eligible FECD eyes were stratified based on Scheimpflug imaging pachymetry map and posterior elevation map characteristics, including loss of regular isopachs, displacement of the cornea's thinnest point, and the presence of posterior surface depression, into two groups: Group A representing FECD with SCE, and Group B: FECD without SCE. One week postoperatively, clinical and tomographic evaluation was performed. Regression analysis was conducted to evaluate predictors of corneal edema after uneventful phacoemulsification surgery in both groups.

Results

All patients were successfully imaged before and 1 week after surgery. Visual acuity was significantly improved in both groups (P < 0.001). No postoperative clinical edema was observed in Group B, while 23 (92%) had mild edema and 2 (8%) had moderate edema in Group A. Both groups showed a significant increase in postoperative central corneal thickness (CCT) and thinnest corneal thickness (TCT) (both P < 0.001). Compared to Group B, Group A showed a significant central flattening of the anterior corneal surface (P = 0.007 and P = 0.04 for K1 and K2 respectively), and a significant increase in the postoperative posterior surface depression. Multivariate analysis showed that 94% of postoperative corneal edema could be predicted by the presence of preoperative posterior surface depression (P = 0.04, ARR = 5.8 (1.89-35.7)).

Conclusion

Scheimpflug tomography pachymetry map and posterior elevation map patterns can predict corneal edema after uneventful phacoemulsification surgery in FECD with subclinical corneal edema.

Retention time of different ophthalmic viscosurgical devices during phacoemulsification in rabbit ocular model: A comparative analysis

BACKGROUND

To compare retention times of various ophthalmic viscosurgical devices (OVDs) and soft-shell combinations.

METHODS

Experimental study. Eighteen rabbit eyes were divided into six groups of three eyes, based on OVDs tested. A: Endocoat, B: HealonPro, C: Viscoat, D: Provisc, E: Endocoat and HealonPro and F: Viscoat and Provisc. OVDs were stained with 10% fluorescein dye before being injected into the anterior chamber. Phacoemulsification, using fixed parameters, was performed. If OVD persisted after 60 s, a standardised irrigation and aspiration technique replaced phacoemulsification. The time until central and complete clearance of the OVD were video-recorded and measured.

RESULTS

Mean central retention times (CRT) were found to be: HealonPro-5.33 ± 2.56 s, Provisc-3.33 ± 1.11 s, Endocoat-75.0 ± 3.26 s, Viscoat-62.33 ± 5.19 s, combining HealonPro with Endocoat-22.67 ± 4.75 s and Provisc with Viscoat-11.0 ± 0.82 s. The mean total retention time (TRT) was: Endocoat-80.0 ± 8.17 s, Viscoat-81.67 ± 2.09 s, HealonPro with Endocoat-81.33 ± 3.35 s, and Provisc with Viscoat-71.0 ± 2.94 s. For HealonPro and Provisc, CRT and TRT remained identical across all trials.

CONCLUSIONS

Retention times varied, with cohesive OVDs exhibiting shorter durations than dispersive OVDs. Among dispersive OVDs, TRTs were comparable; however, Endocoat displayed an extended CRT. In soft shell trials, the combination of HealonPro and Endocoat exhibited prolonged CRT and TRT, suggesting enhanced corneal protection.

In Vitro Physicochemical and Pharmacokinetic Properties of Bevacizumab Dissolved in Silicone Oils Compared to Hydrogel-Substitutes and Porcine Vitreous Bodies

Anti-VEGF agents, e.g., bevacizumab, are used in retinal surgery, while their interaction with silicone oils and novel hydrogels remains unclear. This study examines the in vitro pharmacokinetics of bevacizumab in silicone oil-filled eyes compared to various hydrogel replacements and the porcine vitreous body as well as its impact on the interface tension of silicone oils. An in vitro model filled with light or heavy silicone oil, porcine vitreous bodies, or hydrogels (alginate and polyethylene glycol (PEG)-based) was equilibrated with a balanced salt solution. Monitoring of bevacizumab in the aqueous phase was conducted for up to 24 h, and its effect on interfacial tension was studied. Significant differences in bevacizumab partitioning were observed across endotamponades after 24 h. In silicone oils, bevacizumab was found exclusively in the aqueous phase, while in the other endotamponades, it accumulated in the gel phase (96.1% in porcine vitreous body, 83.5% in alginate, and 27.6% in PEG-based hydrogel). Bevacizumab significantly reduced interfacial tension (40 to 8 mN/m), possibly enhancing silicone oil emulsification. The type of endotamponade heavily influenced the bevacizumab concentration in the aqueous. The vitreous body and replacement hydrogels likely serve as a drug reservoir, highlighting the need for in vivo studies to explore these interactions prior to clinical application.

Viscoelastic, Optical, and Surgical Properties of Vitreous Body Replacement Hydrogels After Aging Compared to Porcine Vitreous Bodies And Silicone Oils

Purpose

First- (monomers), second- (pre-gelated), and third- (in situ gelating after injection) generation hydrogels were previously introduced to replace the vitreous body after vitrectomy surgery. In this study, we evaluated the surgical, optical, and viscoelastic properties of vitreous body replacement hydrogels before and after an accelerated aging protocol previously applied to intraocular implants.

Methods

Measurements of injection force, removal speed using a clinically established vitrectomy setup, as well as evaluation of forward light scattering and viscoelastic properties before and after an accelerated aging protocol were conducted. Results were compared to porcine and human vitreous bodies, as well as currently clinically applied lighter- and heavier-than-water silicone oils.

Results

Removal speed of all tested hydrogels is substantially lower than the removal speed of porcine vitreous body (0.2 g/min vs. 2.7 g/min for the best performing hydrogel and porcine vitreous body, respectively). Forward light scattering in second-generation vitreous body replacement hydrogels was higher after the aging process than the straylight of the average 70-year-old vitreous body (9.4 vs. 5.5 deg2/sr, respectively). The viscoelastic properties of all hydrogels did not change in a clinically meaningful manner; however, trends toward greater stiffness and greater elasticity after aging were apparent.

Conclusions

This study demonstrates surgical weaknesses of the hydrogels that need to be addressed before clinical use, especially low removal speed. Pre-linked hydrogels (second-generation) showed inferior performance regarding surgical properties compared to in situ gelating hydrogels (third-generation).

Translational Relevance

This study highlights possible pitfalls regarding surgical and optical properties when applying vitreous replacement hydrogels clinically.

Intraoperative Performance and Early Postoperative Outcomes Following Phacoemulsification With Three Fluidic Systems: A Randomized Trial

PURPOSE

To compare intraoperative performance and early postoperative outcomes following phacoemulsification with two systems using active fluidics and one using gravity-based fluidics.

METHODS

In this prospective randomized trial, 200 eyes were randomized to the traditional and Active Sentry groups (n = 80 eyes each) where the Centurion Vision System was used with traditional or Active Sentry (Alcon Laboratories, Inc) hand-pieces, respectively, or the Infinit group (n = 40 eyes) where the Infiniti Vision System (Alcon Laboratories, Inc) was used. Within the traditional and Active Sentry groups, there were two subgroups with low (30 mm Hg) or high (55 mm Hg) intraocular pressure (IOP) used. Outcome measures compared were: cumulative dissipated energy (CDE), percentage change in central corneal thickness (CCT) at 1 day, 1 week, and 1 month, anterior chamber cells at 1 day and 1 week, rate of rise and fall of IOP following occlusion break, corneal endothelial cell density (ECD), and macular thickness 6 months postoperatively.

RESULTS

CDE was significantly lower in group II compared to the traditional group (2.96 ± 1.4 vs 4.14 ± 2.2, P = .001). With 30 mm Hg IOP, the Active Sentry group had significantly less percentage change in CCT at 1 week postoperatively compared to the traditional handpiece group (0.01% vs 0.02%, P = .008). Incidence of anterior chamber cells less than grade 2 on day 1 was significantly higher in the Active Sentry group (82.9% vs 52%, P = .03). Percentage change in ECD was significantly lower in the Active Sentry group (-0.957 vs -0.98%, P = .005). Significantly faster rise of IOP to baseline following occlusion break was seen in the Active Sentry group.

CONCLUSIONS

The use of Active Sentry handpiece was associated with lower CDE, less postoperative increase in CCT, fewer anterior chamber cells, and faster rise of IOP following occlusion break. [J Refract Surg. 2024;40(5):e304-e312.].

Preventing the Argentinian flag sign and managing anterior capsular tears: A review

The Argentinian flag sign (AFS) is a feared complication during cataract extraction. Intralenticular pressures, especially excessive posterior pressure, have been identified as potential mechanisms for capsular stress and tearing associated with AFS. Capsular tension is created by positive intralenticular pressures, which cause the irido-lens diaphragm to move anteriorly once the manual capsulorhexis has been initiated. This tension can cause inadvertent tears that self-propagate to the lens equator, causing an AFS, among other intraoperative complications. Thus, this review highlights the importance of identifying intumescent cataracts as well as a combination of techniques to relieve intracapsular pressures needed to prevent AFS. However, some instances of anterior capsular tears are unavoidable. Therefore, focus will also be placed on techniques during cataract extraction used to manage anterior capsular tears, mitigating extension to the posterior capsule.

The outcomes of postoperative eye patching after cataract surgery in patients with Fuchs' endothelial corneal dystrophy

PURPOSE

To investigate the influence of post-operative eye patching on corneal thickness, endothelial cells' loss and visual acuity in patients diagnosed Fuchs' endothelial corneal dystrophy (FECD).

SETTING

Public healthcare centre, Shamir Medical Centre, Israel.

METHODS

This randomized controlled trial included patients with FECD undergoing routine cataract surgery in a public medical centre. Patients were randomly assigned to 2 groups: the eye undergoing surgery was covered with a patch for 24 h in the first group (patched group), and a plastic shield was used in the second (non-patched group). Both groups received a unique dose of a local steroid and antibiotic post-operatively. The eyes were examined pre-operatively, and on days 1, 7 and 30 post-surgery . Examination included: best corrected visual acuity (BCVA), comeplete slit lamp examination, intra ocular pressure (IOP), anterior chamber depth (ACD), central corneal thickness (CCT) using the IOL Master 700 (Zeiss, Germany) and endothelial cell density (ECD) using Specular microscopy. Cumulative dissipated energy (CDE) and operation time were recorded for all cases.

RESULTS

The study included 46 eyes of 46 patients diagnosed with FECD. Twenty-three eyes in the patched group, and 23 eyes in the non-patched group . Thirty days post-operatively the CCT in the patched group decreased by 60 ± 38 mµ (9%) compared to 92 ± 80 mµ (13.5%) in the non- patched group (p = 0.04). Seven days post-operatively the CCT in the patched group decreased by 31 ± 35 mµ (5%) compared to 58 ± 76 (8%) in the non-patched group, but this difference did not reach statistical significance (p = 0.081). There was no statistically significant difference in endothelial cells loss as well as BCVA at 1, 7 and 30 days post-operatively between the study groups.

CONCLUSIONS

Avoiding eye patch post-operatively after cataract surgery in patients with FECD results in better corneal clarity recovery and reduced corneal edema one month post-operatively. Visual acuity and endothelial cell's loss were not influenced by patching.

Effect of low and passive flow on OVD thermal properties during phacoemulsification

OBJECTIVE

To study the thermal properties and response magnitude of a forced-infusion phacoemulsification machine on 4 ophthalmic viscosurgical devices (OVDs).

DESIGN

Experimental study.

METHODS

A phacoemulsification tip, thermocouple, and gauge were placed into an artificial anterior chamber with balanced saline solution (BSS) or approximately 0.1 mL of OVD. Once the thermocouple measured a consistent temperature, the pedal was engaged for 60 seconds; then the tip was removed. The machine was cooled for 5 minutes and flushed with BSS to return to baseline. This was repeated 10 times for each OVD. The research consisted of 2 scenarios: vacuum-blocked flow rate and low aspiration flow rate.

RESULTS

All OVDs showed greater temperature changes than BSS. In the vacuum-blocked scenario, these increases were statistically significant. The medium viscosity dispersive OVD (DiscoVisc) reached temperatures exceeding 60°C. In the low-flow scenario, HEALON5 and DisCoVisc were significantly different at 5 seconds and only HEALON5 at 10 seconds. No temperature increases over BSS were greater than 1.0°C.

CONCLUSIONS

The dispersive, cohesive, and viscoadaptive OVDs demonstrated higher temperature changes than BSS but did not reach the threshold for corneal incision contracture. The study team verified the need for at least a minimal flow rate before ultrasound, which is especially evident in the first 10 seconds, because a flow rate of only 20 mL/minute mitigated OVD-related thermal effects. Understanding thermal responses enables corneal incision contracture risk reduction.

Descemet membrane endothelial keratoplasty combined with presbyopia-correcting and toric intraocular lenses - a narrative review

Fuchs endothelial corneal dystrophy (FECD) is the leading indication for EK and may coexist with cataract and presbyopia. Notably, the outcomes of phacoemulsification in FECD patients are not as favorable as those in eyes without this condition. Historically, only monofocal intraocular lenses (IOLs) were recommended for these patients. However, recent reports have described the implantation of Premium-IOLs (such as Multifocal IOLs, Enhanced Depth of Focus IOLs, and Toric IOLs) in FECD eyes undergoing cataract surgery and Descemet membrane endothelial keratoplasty (DMEK). While the results are encouraging, they are not as optimal as those from unoperated eyes, especially when comparing simultaneous procedures to sequential ones. It's advised to perform the DMEK first to improve the accuracy of IOL calculations. Still, even successfully operated eyes may experience secondary graft failure or graft rejection after DMEK. The success rate of a secondary DMEK is typically lower than that of the initial procedure. Furthermore, if the postoperative thickness after DMEK is less than anticipated, laser enhancements might not be an option. There's a pressing need for more controlled and randomized clinical trials to ascertain the safety and effectiveness of Premium-IOLs for FECD eyes. This narrative review aims to collate evidence on the use of Premium IOL technologies in eyes receiving EK and to underscore key points for surgeons performing EK combined with cataract surgery.

Forward Light Scattering of First to Third Generation Vitreous Body Replacement Hydrogels after Surgical Application Compared to Conventional Silicone Oils and Vitreous Body

To treat certain vitreoretinal diseases, the vitreous body, a hydrogel composed of mostly collagen and hyaluronic acid, must be removed. After vitrectomy surgery, the vitreous cavity is filled with an endotamponade. Previously, pre-clinical hydrogel-based vitreous body substitutes either made from uncrosslinked monomers (1st generation), preformed crosslinked polymers (2nd generation), or in situ gelating polymers (3rd generation) have been developed. Forward light scattering is a measure of Stray light induced by optical media, when increased, causing visual disturbance and glare. During pinhole surgery, the hydrogels are injected into the vitreous cavity through a small 23G-cannula. The aim of this study was to assess if and to what extent forward light scattering is induced by vitreous body replacement hydrogels and if Stray light differs between different generations of vitreous body hydrogel replacements due to the different gelation mechanisms and fragmentation during injection. A modified C-Quant setup was used to objectively determine forward light scattering. In this study, we found that the 1st and 3rd generation vitreous body replacements show very low stray light levels even after injection (2.8 +/- 0.4 deg2/sr and 0.2 +/- 0.2 deg2/sr, respectively) as gel fragmentation and generation of interfaces is circumvented. The 2nd generation preformed hydrogels showed a permanent increase in stray light after injection that will most likely lead to symptoms such as glare when used in patients (11.9 +/- 0.9 deg2/sr). Stray light of the 2nd generation hydrogels was 3- and 2-fold increased compared to juvenile and aged vitreous bodies, respectively. In conclusion, this significant downside in the forward light scattering of the 2nd generation hydrogels should be kept in mind when developing vitreous body replacement strategies, as any source of stray light should be minimized in patients with retinal comorbidities.

Modified Technique of Setting Capsulotomy Thickness in Reducing Capsulotomy-Related Complications During Femtosecond Laser-Assisted Cataract Surgery: A Prospective, Comparative Cohort Study

INTRODUCTION

Although uncommon, incomplete capsulotomy, anterior capsule tags and anterior capsule tears are still encountered during femtosecond laser-assisted cataract surgery (FLACS), resulting in surgical complications. This highlights the need to improve femtosecond laser-assisted capsulotomy technique to reduce capsulotomy-related complications. Therefore, the purpose of this study was to investigate the efficacy of a newly developed, modified technique of setting capsulotomy irradiation thickness in lowering the incidence of capsulotomy-related complications in FLACS.

METHODS

This open-label prospective, comparative cohort study included 440 eyes (220 patients) treated with FLACS using the LenSx laser system (Alcon Laboratories, Inc. Fort Worth, TX, USA). Varying capsulotomy irradiation thicknesses were applied in each eye of the same patient. In Group 1, capsulotomy irradiation thickness was set between the upper edge of the highest point of the anterior capsule and the lower edge of the lowest point of the anterior capsule (modified technique). In Group 2, this was set between the center of the highest point of the anterior capsule and the center of the lowest part of the anterior capsule (conventional technique). Incidence rates of incomplete capsulotomy, anterior capsule tags and tears, and posterior capsule tears were compared.

RESULTS

Preoperative baseline characteristics showed no significant differences. Mean total of the irradiation thicknesses was 877.1 ± 81.9 µm in Group 1 and 808.9 ± 80.0 in Group 2, with a statistically significant difference (P < 0.001). Incidences of incomplete capsulotomy were 1.8% and 7.7%, anterior capsule tags were 2.3% and 8.6%, and anterior capsule tears were 0% and 3.2% in Groups 1 and 2, respectively. These differences were statistically significant (P = 0.006, 0.005, and 0.015, respectively). No posterior capsule tears were reported in either group.

CONCLUSION

The modified technique for capsulotomy in FLACS may significantly reduce the occurrence of capsulotomy-related complications, maximizing the benefits of FLACS.

Safety and effectiveness comparison of a new cohesive ophthalmic viscosurgical device

PURPOSE

To evaluate the safety and effectiveness of a new cohesive ophthalmic viscosurgical device (OVD) (StableVisc) compared with a marketed cohesive OVD (ProVisc) in patients undergoing cataract surgery.

SETTING

22 sites in the United States.

DESIGN

Prospective multicenter controlled double-masked and randomized 1:1 (StableVisc:ProVisc; stratified by site, age group, and cataract severity).

METHODS

Adults (≥45 years) with age-related noncomplicated cataract considered amenable to treatment with standard phacoemulsification cataract extraction and intraocular lens implantation were included. Patients were randomized to receive either StableVisc or ProVisc during standard cataract surgery. Postoperative visits occurred at 6 hours, 24 hours, 7 days, 1 month, and 3 months. The primary effectiveness outcome was the change in endothelial cell density (ECD) from baseline to 3 months. The primary safety endpoint was the proportion of patients who experienced at least 1 intraocular pressure (IOP) measurement ≥30 mm Hg at any follow-up visit. Noninferiority between the devices was tested. Inflammation and adverse events were evaluated.

RESULTS

390 patients were randomized; 187 patients with StableVisc and 193 patients with ProVisc completed the study. StableVisc was noninferior to ProVisc in mean ECD loss from baseline to 3 months (17.5% and 16.9%, respectively). StableVisc was noninferior to ProVisc in the proportion of patients with postoperative IOP ≥30 mm Hg at any follow-up visit (5.2% and 8.2%, respectively).

CONCLUSIONS

The StableVisc cohesive OVD, which provides both mechanical and chemical protection, was safe and effective when used in cataract surgery and provides surgeons with a new cohesive OVD.

Corneal Outcomes Following Cataract Surgery Using Ophthalmic Viscosurgical Devices Composed of Chondroitin Sulfate-Hyaluronic Acid: A Systematic Review and Meta-Analysis

Background

Ophthalmic viscosurgical devices (OVDs) are commonly used during cataract surgery to protect the corneal endothelium. A systematic literature review and meta-analysis were conducted to assess the clinical evidence of OVDs composed of chondroitin sulfate-hyaluronic acid (CS-HA) versus other OVDs in maintaining endothelial cell density (ECD) and corneal thickness (CT).

Methods

MEDLINE and EMBASE databases were searched from 2000 to 2020. Randomized controlled trials (RCTs, N ≥ 20 per group) comparing an OVD containing CS-HA (ie, VISCOAT^®, DuoVisc^® or DisCoVisc^®) to any other OVD were included. The identified comparators were limited to the OVDs found in the literature, which included those composed of HA-only or hydroxypropyl methylcellulose (HPMC). Outcomes of focus included changes in ECD (baseline to 3 months) and CT (baseline to 24 hours). Meta-analyses were performed using R software, to assess mean differences (MD) in ECD and CT change between CS-HA OVDs and HA-only or HPMC OVDs.

Results

A total of 966 abstracts were screened, and data were extracted from 12 RCTs. Meta-analyses using a random-effects model revealed significantly lower percent (%) decrease in ECD for CS-HA OVDs compared to both HA-only (MD: -4.10%; 95% CI: -5.81 to -2.40; p < 0.0001; 9 studies) and HPMC (MD: -6.47%; 95% CI: -10.41 to -2.52; p = 0.001; 2 studies) products. Similarly, % CT increase was significantly lower with CS-HA than with HA-only OVDs (MD: -3.22%; 95% CI: -6.24% to -0.20%; p = 0.04; 4 studies). However, there were no significant differences when comparing % CT change between CS-HA and HPMC OVDs (MD: 2.65%; 95% CI: -0.43% to 0.95%; p = 0.4; 2 studies).

Conclusion

CS-HA OVDs lead to less postoperative loss of endothelial cells and may better protect corneal endothelium during cataract surgery, relative to other OVDs. Future randomized studies may be needed to solidify these findings.

Mechanical protective effect of lens anterior capsule disc on corneal endothelial cells during femtosecond laser-assisted cataract surgery in a rabbit model

PURPOSE

To evaluate the effects of a novel technique using an isolated lens anterior capsule disc (LACD) to protect corneal endothelial cells in rabbit eyes during femtosecond laser-assisted cataract surgery.

METHODS

Experimental study. 40 rabbits were divided into endothelium-protected (experimental) and control groups, with 20 rabbits in each group. In the experimental group, after femtosecond laser capsulotomy, the isolated capsule disc was lifted to the corneal endothelium by an ophthalmic viscosurgical device. The endothelium was damaged for 1 min with an ultrasonic probe. The control group underwent the same surgery, except that the disc was removed immediately after capsulorhexis. Corneal endothelioscopy was performed preoperatively and on postoperative days (PODs) 3 and 7 to observe endothelial cell counts (ECC) and endothelial cell loss rate. Central corneal thickness (CCT) was measured before and at PODs 1, 3 and 7.

RESULTS

There were 3.59%±1.88% (p < 0.001) and 2.92%±2.14% (p < 0.001) loss of ECC in experimental group at POD3 and POD7, respectively, while those in the control group were 11.62%±7.43% and 10.34%±5.77%, respectively. On POD 1, the difference in central corneal thickness was significant(P = 0.019) between the two groups. At POD 3 and POD 7, CCT was not significantly different (P = 0.597;0.913) between the two groups.

CONCLUSIONS

The isolated LACD technique significantly reduced damage to the endothelium caused by ultrasonic energy and protects corneal endothelial cells during phacoemulsification.

Floppy iris syndrome associated with specific medication intake: A narrative review

Intraoperative floppy iris syndrome (IFIS) is a cataract surgery complication that remains a challenge for eye surgeons. It is caused by the antagonism of alfa-1-adrenergic receptors within the dilator muscle of the iris, thus preventing the iris from dilation during a cataract surgery. The long-term blocking alfa-1 adrenergic receptors by the chronic use of a number of systemic medications may lead to permanent anatomical atrophy of the dilator muscle of the iris. The most common drugs associated with the development of IFIS are tamsulosin and other alpha-1 adrenergic receptor antagonists prescribed to patients with low urinary tract symptoms (LUTS). There are other systemic medications that have been reported to have increased risk for IFIS. It is crucial for the ophthalmologist to identify the high-risk patients prone to develop IFIS. Its presence may complicate the course of cataract surgery, ultimately negatively affecting visual outcome. Cataract surgery should be performed by an experienced eye surgeon using alternative pharmacological and surgical techniques. Interdisciplinary cooperation is essential to mitigate potential complications. Patients should be informed by their physicians about the need to report a medication history to their eye specialists, especially before cataract surgery.

FLACS vs conventional phacoemulsification by junior cataract surgeons: randomized trial

PURPOSE

To report intraoperative performance and postoperative outcomes of femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification (PE) in the hands of junior surgeons.

SETTING

Iladevi Cataract & IOL Research Centre, Ahmedabad, Gujarat, India.

DESIGN

Prospective single-masked randomized controlled trial.

METHODS

320 eyes (320 patients) undergoing cataract surgery for uneventful cataracts in the hands of junior surgeons were randomized to Group 1-FLACS or Group 2-PE. Intraoperatively, cumulative dissipated energy (CDE) and fluid used were compared. Postoperatively, the following were compared: central corneal thickness (CCT) on day 1, 1 week, and 1 month; corneal clarity (day 1 and 1 week); anterior chamber inflammation (day 1 and 1 week); change in endothelial cell density (ECD) at 6 months postoperatively; and corrected distance visual acuity (CDVA) at 1 week and 1 month postoperatively.

RESULTS

157 and 158 patients in groups 1 and 2 analysed. Intraoperatively, CDE (5.41 ± 2.73 vs 8.83 ± 4.28 in Groups 1 and 2, P = .0001) and fluid used (79.33 ± 33.46 vs 101.82 ± 32.23 mL in Groups 1 and 2, P < .0001) were significantly lesser in Group 1. CCT was significantly higher in Group 2 on day 1 (550.96 ± 33.64 vs 587.70 ± 55.76 μm in Groups 1 and 2, P < .0001) and at 1 week postoperatively (527.94 ± 30.78 vs 545.11 ± 35.17 μm in Groups 1 and 2, P = .001). 72% of eyes had clear corneas on day 1 in Group 1 compared with 39% in Group 2 ( P = .01). Anterior chamber inflammation and CDVA were comparable. Change in ECD was significantly lower (9.3%) in Group 1 vs 12.7% in Group 2, P < .0001.

CONCLUSIONS

FLACS showed lower intraoperative CDE, fluid usage, lesser increase in CCT, better early postoperative corneal clarity, and lesser change in ECD at 6 months postoperatively in the hands of junior surgeons during standard cataract surgery.

Cataract surgery in adult eyes with short axial length

PURPOSE OF REVIEW

Cataract surgery in eyes of patients with short axial length (AL) can be technically challenging and is associated with a high risk of intra- and postoperative complications. Several technical and surgical strategies have been proposed to optimize the visual outcome and decrease the rate of surgical complications and it is important to understand their applications in these cases.

RECENT FINDINGS

Traditional intraocular lens (IOL) measurement formulas in eyes with short AL have reduced reliability. Novel formulas such as the Kane formula provide a better refractive prediction. Surgery can be difficult in short eyes due to the crowdedness of the anterior chamber (AC) and the associated scleral abnormalities increasing the risk of uveal effusion. Surgical techniques such as prophylactic scleral incisions, limited pars plana anterior vitrectomy, and modified hydrodissection, have been shown to facilitate surgery in extremely short eyes and decrease the rate of operative complications. Although cataract surgery improves vision in these cases, short AL and shallow AC have been associated with worse visual outcomes.

SUMMARY

Newer 4 th generation IOL formulas have improved the refractive outcomes of cataract surgery in eyes with short AL. There are multiple evolving surgical strategies for optimizing surgery in these eyes. However, studies on the surgical and visual outcomes of cataract surgery in eyes with short AL are limited by their design and sample size. With further research and continued clinical experiences, we hope to develop evidence-based algorithms for the management of these complex cases.

Corneal endothelium protection provided by ophthalmic viscosurgical devices during phacoemulsification: experimental study in rabbit eyes

PURPOSE

To compare the protection of the corneal endothelium provided by a cohesive and a dispersive ophthalmic viscosurgical device (OVD) against damage from torsional ultrasound and simulated lenticular debris during phacoemulsification.

SETTING

University setting, Salt Lake City, Utah.

DESIGN

Experimental study.

METHODS

15 New Zealand rabbits were included. After incision, each eye received cohesive or dispersive OVD (ProVisc or Viscoat). 10 1.0 mm beads were injected to simulate lenticular debris. The Intrepid Balanced tip (Centurion Ozil handpiece) was inserted into the anterior chamber, and 60% torsional ultrasound with 50 mL/min flow, 70 mm Hg intraocular pressure, and 600 mm Hg vacuum was applied (20 seconds). Cumulative dissipated energy (CDE) was noted. After euthanasia and enucleation, corneas were removed, stained with trypan blue/alizarin red, and photographed (5 ×400 magnification photos and 1 overview photograph from each cornea). ImageJ was used to evaluate cell damage and loss.

RESULTS

CDE was 4.70 ± 0.26 and 4.64 ± 0.10 in the cohesive and dispersive OVD groups, respectively ( P = .8647). The analysis of the ×400 photographs showed that the percentage of intact cells was statistically higher in the dispersive OVD group ( P = .0002), whereas the percentages of damaged and lost cells were statistically higher in the cohesive OVD group ( P = .0002 and .0059, respectively). Overview photographs revealed the presence of residual OVD on the endothelium, especially in the dispersive group.

CONCLUSIONS

In this experimental study using a rabbit model, the corneal endothelium protection provided by the dispersive OVD was superior to that provided by the cohesive OVD.

Comparative evaluation of the results of phacoemulsification using domestic and foreign viscoelastics

BACKGROUND: Phacoemulsification, being the safest technique, is the golden standard of cataract surgery worldwide. However, as any surgery, it is accompanied by inevitable damage to intraocular structures. The most prevalent among them is the loss of corneal endothelial cells. In order to prevent these complications, various viscoelastics with particular features and characteristics are widely used. AIM: To compare the anatomical and functional state of ocular structures after standard phacoemulsification with monofocal posterior chamber intraocular lens (IOL) implantation using domestic (Kogevisc and Adgevisc) and foreign (Viscoat and Amvisc Plus) viscoelastics. MATERIALS AND METHODS: 60 cataract patients (60 eyes) were included in the clinical study, which were divided into two equal groups. In the first group (30 patients, 30 eyes), Adgevisc and Kogevisc (Solofarm, Russia) were used during the procedure. The mean age of the patients was 66 11 years. In the second group (30 patients, 30 eyes), Viscoat (Alcon) and Amvisc Plus (BauschLomb) were used. The mean age of the patients was 69.03 10.44 years. All patients underwent phacoemulsification with the implantation of the AcrySof IOL (model SA60AT, Alcon) according to the standard technique. Visual acuity, IOP level, CCT, corneal endothelial cell density were assessed. All studies were performed before surgery, the next day, 7 days and 1 month after surgery. RESULTS: In patients of the second group, on the 1st (p 0.05) and 7th day (p 0.01) after surgery, a statistically significant increase in IOP was revealed compared to the first group. The central cornea thickness in the early postoperative period was higher in patients of the second group, however, it was not statistically significant. The loss of corneal endothelial cells 1 month after surgery was 8.5 7.0% (p 0.01) in the first group and 6.6 6.4% in the second group (p 0.01). The mean value of endothelial cell loss in patients of the first group was higher, however, it was not statistically significant. The best corrected visual acuity in both groups at all stages of follow-up after surgery (days 1, 7 and 30) was comparable, there was no significant difference between the groups. CONCLUSIONS: The clinical efficacy of domestic adhesive and cohesive viscoelastics Adgevisc and Kogevisc (Solofarm, Russia) in phacoemulsification using the soft-shell technique is comparable to the foreign analogues Viscoat (Alcon) and Amvisc Plus (Bausch Lomb), which is confirmed by the absence of statistically significant differences in the studied parameters of the postoperative state of ocular structures and explained by their similar composition, molecular weight and viscosity.

Thickness of the Protective Layers of Different Ophthalmic Viscosurgical Devices During Lens Surgery in a Porcine Model

Purpose

To evaluate the thickness of the intraoperative layers of 10 different ophthalmic viscosurgical devices (OVD) covering the corneal endothelium during simulated lens surgery in a porcine model.

Methods

This experimental study took place at the Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Austria. Ten OVDs with different viscoelastic properties (ProVisc, Z-Hyalin plus, Amvisc plus, DisCoVisc, Healon EndoCoat, Viscoat, Z-Hyalcoat, Combivisc, Duo-Visc, and Twinvisc) were assessed in 10 porcine eyes each, yielding a total of 100 eyes. Simulated cataract surgery was performed with volumetric intraoperative OCT imaging during phacoemulsification and during irrigation/aspiration to determine the remaining amount of OVD coating the endothelium over a scan field of 6 × 6 mm. Indirect visualization of the OVD was enabled by replacing the irrigating solution by a higher scattering diluted milk solution. A deep convolutional neural network (CNN) was used to evaluate OVD layer thickness based on the B-scans.

Results

Median thickness values after phacoemulsification were lowest for the cohesive OVDs Z-Hyalin plus (38 µm) and ProVisc (39 µm), followed by the combination systems Twinvisc (342 µm) and Duo-Visc (537 µm). Highest values were observed for the dispersive OVDs and the combination system Combivisc (Viscoat: 957 µm; Z-Hyalcoat: 988 µm, Combivisc: 1042 µm; Amvisc plus: 1259 µm; Healon EndoCoat: 1303 µm; DisCoVisc: 1356 µm). The difference between the OVDs was statistically significant (P < 0.01).

Conclusions

The results of this study confirm that at completion of phacoemulsification, thickest residual layers of OVD remain when using dispersive substances, followed by combination systems and lowest thickness values were observed with cohesive OVDs. The use of an intraoperative OCT and a deep convolutional neural network allowed measurements over a large scan field of 6 × 6 mm and a precise evaluation of the OVD layer coating the corneal endothelium. The OVD layer seemed to be more like a ragged terrain instead of a flat layer, indicating that the film-forming effect of dispersive OVDs is the result of their volume rheology rather than a surface interaction.

Translational Relevance

Evaluating the protective properties provides valuable insights into how different OVDs with different viscoelastic properties form layers beneath the corneal endothelium and helps to understand their persistence during the various steps of cataract surgeries.

A Risk Prediction Model for Endothelial Keratoplasty After Uncomplicated Cataract Surgery in Fuchs Endothelial Corneal Dystrophy

PURPOSE

To develop a risk prediction model for endothelial keratoplasty (EK) after uncomplicated cataract surgery in Fuchs endothelial corneal dystrophy (FECD) using Scheimpflug imaging.

DESIGN

Prospective, observational cohort study.

METHODS

The study was conducted at the Ramón y Cajal University Hospital (Madrid, Spain) on 127 eyes from 93 consecutive patients with vision loss, FECD, and cataracts.

OBSERVATION

We assessed the corneas using Scheimpflug imaging pachymetry and elevation maps for loss of regular isopachs, displacement of the thinnest point, and posterior surface depression according to the Mayo Clinic subclinical corneal edema classification. We also recorded other preoperative data. Primary Endpoints: The primary endpoint was the need for EK after uncomplicated phacoemulsification within 2 years (median duration, 18 months). We calculated the risk using hazard ratios and the Kaplan-Meier cumulative incidence risk.

RESULTS

Forty-four participants required EK, and those eyes with 1, 2, or all 3 tomographic features had a hazard risk of 21.8, 57.2, and 76.5, respectively (P < .005), compared with those eyes with normal tomographic patterns. The best predictive model was based on the number of tomographic features simultaneously present in an eye and the central corneal thickness (CCT) at the pupillary center. We aimed to develop a risk score from 0 to 8. The cumulative risk for EK ranged from virtually 0 for risk scores <4 to almost 100% for those with a score of 8.

CONCLUSIONS

The combination of CCT values and tomographic features can be employed to make valid predictions of the risk of requiring EK after phacoemulsification.

Ophthalmic Viscosurgical Devices (OVDs) in Challenging Cases: a Review

Ophthalmic viscoelastic devices (OVDs) are currently used in cataract surgery and have significantly improved the safety and effectiveness of this surgical procedure. OVDs are classified according to the zero-shear viscosity and the cohesion-dispersion index in cohesive, dispersive, and viscoadaptives. OVDs create and maintain anterior chamber depth and visibility, protecting the corneal endothelium and other intraocular tissues during surgery. The selection of the most adequate OVD is especially relevant when performing cataract surgery in challenging cases, such as in hard, mature cataracts, flat anterior chamber, pseudoexfoliation syndrome, intraoperative floppy iris syndrome, or glaucoma surgery. In such cases, OVD is crucial for facilitating the surgical procedure and the associated minimal complication rate. The use of a combination of OVDs (soft-shell technique and modifications), the use of blue-colored OVDs, and the combination of sodium hyaluronate with lidocaine have also been described as useful tools in some of these challenging cases.

[Cataract surgery and the small eye: relative anterior microphthalmos, high hyperopia and nanophthalmos]

Relativer anteriorer Mikrophthalmus, hochgradige Hyperopie und Nanophthalmus bezeichnen klein gebaute Augen mit unterschiedlichem morphologischem Verhältnis zwischen Vorderabschnitt und Achsenlänge. Im Rahmen dieses Beitrags werden intraoperative Herausforderungen und chirurgische Lösungsansätze für die Kataraktoperation bei Patienten mit einer der 3 genannten morphologischen Veränderungen diskutiert. Zusätzlich wird auf mögliche, vorliegende Komorbiditäten, wie z. B. das Glaukom, und die präoperative Planung eingegangen.

Phacoemulsification After Descemet Membrane Endothelial Keratoplasty: Incidence and Influence on Endothelial Cell Density

PURPOSE

To analyze the incidence of cataract extraction after Descemet membrane endothelial keratoplasty (DMEK) in phakic eyes and to evaluate the effect of phacoemulsification after DMEK on the donor endothelial cell density (ECD).

METHODS

The clinical data of phakic patients with DMEK were examined. From this cohort, all patients who subsequently underwent phacoemulsification after DMEK were reviewed. Data from a prospectively collected dataset were analyzed, including demographic profile, ECD, corrected distance visual acuity (CDVA), central corneal thickness (CCT), and complications.

RESULTS

From a series of 261 phakic patients with DMEK, 35 eyes (13.4%) required cataract surgery within the mean follow-up period of 54.2 ± 28 months. The mean time from DMEK to phacoemulsification was 18 ± 13 months (range: 3 to 69 months). The probability of cataract extraction after DMEK was 0.06 (95% CI: 0.03 to 0.09) at 1 year and 0.17 (95% CI: 0.12 to 0.22) at 10 years, respectively. ECD decreased from 1,314 ± 524 cells/mm² before phacoemulsification to 1,167 ± 443 cells/mm² (-11%) at 1 to 6 months postoperatively (P = .333). CDVA improved from 0.27 ± 0.13 logMAR preoperatively to 0.07 ± 0.12 logMAR at 1 to 6 months postoperatively. CCT before phacoemulsification was 532 ± 46 µm and remained stable at 539 ± 56 µm at 1 to 6 months after phacoemulsification. Phacoemulsification did not elicit DMEK graft detachment in any of the eyes studied.

CONCLUSIONS

The incidence and 10-year projection of cataract extraction in phakic eyes with DMEK was relatively low. Phacoemulsification after DMEK provided excellent CDVA outcomes, did not induce graft detachment, and was associated with an acceptable decrease in ECD. [J Refract Surg. 2021;37(2):119-125.].

The cold eye irrigation BSS solution used during phacoemulsification reduces post-surgery patients discomfort preventing the inflammation

PURPOSE

The aim of this study was to assess whether the intraoperative use of the cold eye irrigation balanced salt solution (BSS) could have a protective effect in preventing the anterior chamber flare and conjunctival hyperemia and, thus, in reducing patients discomfort after phacoemulsification.

MATERIALS AND METHODS

About 214 patients were enrolled and randomly divided into: patients whose eye were irrigated with BSS at ~ 20°C (Group 1) and patients whose eye were irrigated with BSS at 2.7°C (Group 2). Anterior chamber flare, visual analogue score and conjunctival hyperemia were evaluated at 1, 3, 5, and 30 days after surgery.

RESULTS

In patients of Group 2 the anterior chamber flare, the visual analogue score and the conjunctival hyperemia, used as parameters to evaluated clinical inflammation, at 1 day after surgery were significantly lower than those in Group 1 who received BSS solution at operating room temperature (p < 0.001), while at day 3, 5, and 30 there were not any significant differences.

CONCLUSION

Our study provided evidence supporting the efficacy of the treatment with cold irrigation solution on reduction of anterior chamber flare, pain and conjunctival hyperemia already at 1 day after phacoemulsification, suggesting that cooling procedure was fully effective at controlling early post-operative inflammation.

Descemet Membrane Endothelial Keratoplasty and light adjustable lens triple procedure

Purpose

The objective of this series is to report the early post-operative visual outcomes of a novel triple procedure utilizing Descemet membrane endothelial keratoplasty (DMEK) plus light adjustable lens (LAL) in two patients (four eyes).

Methods

Two patients with bilateral, visually significant cataracts and Fuchs' dystrophy were selected for DMEK plus LAL triple procedure. Patient B also exhibited a high amount of preoperative astigmatism. Both patients desired spectacle independence and were initially targeted for monovision with the dominant eye corrected for distance and the nondominant eye corrected for near. Best corrected visual acuity (BCVA), uncorrected visual acuity (UCVA), and manifest refraction were recorded at each postoperative appointment and light treatment.

Results

In the early post-operative course, Patient A chose to pursue binocular distance correction instead of monovision. This was adjusted for accordingly using the LAL. Following final lock-in, Patient A had a distance UCVA of 20/15 in the right eye (OD) and a distance UCVA of 20/20 in the left eye (OS). Patient B was targeted for monovision. After final lock-in, Patient B had a distance UCVA of 20/15 in the dominant eye (OD) and a near UCVA of Jaeger No. 1+ in the nondominant eye (OS).

Conclusions and Importance

The first reported cases of DMEK plus LAL triple procedures achieved exceptional UCVA at the desired target. The post-operative customizability of the LAL allows for the achievement of excellent refractive outcomes after DMEK, even in patients with significant astigmatism and in patients who change their mind regarding refractive target.

Eye patching after cataract surgery is associated with an increased risk of short-term corneal oedema

PURPOSE

To evaluate the effect of postoperative eye patching after routine cataract surgery on corneal oedema and visual acuity on the first postoperative day.

SETTING

One public healthcare centre.

DESIGN AND METHODS

This randomized controlled trial included patients undergoing uneventful cataract surgery in one medical centre. Patients were randomized into two groups: the surgical eye was patched with a single dose of a local steroid and antibiotic for 24 hr in the first group, and a plastic shield was used in the second with local steroid and antibiotic drops. The eyes were examined preoperatively and on the first postoperative day. Examination included the following: best-corrected visual acuity (BCVA), full slit lamp examination, intraocular pressure (IOP), anterior chamber depth (ACD) and central corneal thickness (CCT) using the IOL Master 700 (Zeiss, Germany). Cumulative dissipated energy (CDE) and operation time were recorded for all cases.

RESULTS

One hundred eyes of 100 patients were included in the study. The postoperative increase in CCT 24 hr after surgery was 138 and 70 µm in the patched group as compared to the non-patched group, respectively (p = 0.001). Best-corrected visual acuity (BCVA) on the first postoperative day was 0.5 ± 0.45 LogMAR and 0.3 ± 0.3 LogMAR in the patched and non-patched group, respectively (p = 0.01). There was no difference in CDE (11.33 ± 9.2 and 10.22 ± 7.3; p = 0.94) between the two groups.

CONCLUSIONS

Eye patching after routine cataract surgery is associated with an increase in corneal oedema and slower visual recovery on the first postoperative day.

Evaluation of femtosecond laser-assisted anterior capsulotomy in the presence of ophthalmic viscoelastic devices (OVDs)

The introduction of femtosecond laser-assisted cataract surgery is an alternative approach to conventional cataract surgery. Our study aimed to determine the effectiveness of femtosecond laser-assisted capsulotomy in the presence of different ophthalmic viscoelastic devices (OVDs) in the anterior chamber. Fresh porcine eyes (n = 96) underwent LDV Z8-assisted anterior capsulotomy, either in the presence of an OVD (Viscoat, Provisc, Healon, Healon GV or HPMC) or without, using 90% and 150% energies respectively. Following that, the capsule circularity, tag’s arc-length, tag-length, tag-area and rupture strength (mN) of the residual capsular bag were evaluated. We found that increasing energy from 90 to 150% across the OVD sub-groups improved the studied capsulotomy parameters. Amongst the 90% energy sub-groups, the circularity and tag-parameters were worse with Viscoat and Healon GV, which have higher refractive index and viscosity compared to the aqueous humour. Using 150% energy, Healon GV showed a significantly worse total arc-length (p = 0.01), total tag-length (p = 0.03) and total tag-area (p = 0.05) compared to the control group. We concluded that; an OVD with a refractive index similar to aqueous humour and lower viscosity, such as Healon or Provisc, as well as a higher energy setting, are recommended, to enhance the efficacy of laser capsulotomy.

The role of lens extraction in glaucoma management

Cataract extraction has become a much safer procedure with the development of phacoemulsification, extending its application in ocular conditions such as glaucoma for better disease control. This review aims at summarizing the effect of lens extraction with or without combined glaucoma surgeries in different types of glaucoma and describing the intraoperative techniques and changes of glaucoma care postoperatively. A comprehensive literature search was performed through Medline and PubMed, and 67 studies were selected for this review. In primary angle closure (PAC) diseases, studies have revealed significant intraocular pressure (IOP) and medication requirement reduction after lens extraction. Fewer studies described its application in primary open angle glaucoma (POAG) and ocular hypertension (OHT), but literature available suggests that it can also lead to better disease control. Likewise, lower postoperative IOP and pressure fluctuations have been shown in normal tension glaucoma (NTG). Advanced glaucoma, shallow anterior chamber and pseudoexfoliation glaucoma (PXG) are three difficult scenarios that are commonly encountered in cataract operations. Special techniques in preventing complications such as wipe out phenomenon are depicted. Goniosynechialysis, endoscopic cyclophotocoagulation and trabecular microbypass stents are a few of the popular choices of glaucoma procedures that can be performed concomitantly with phacoemulsification but evidence of their efficacy needs to be further verified. Cataract operation can improve visual field and retinal nerve fiber layer examination parameters and it is advised to set new baselines after the surgery for subsequent progression monitoring. Clearance of an optically significant cataract results in better quality of life, and with detailed and thorough explanation of the indications, expectations and risks of the surgery, cataract extraction could be considered even in cases of advanced glaucoma.

Comparative evaluation of femtosecond laser-assisted cataract surgery and conventional phacoemulsification in eyes with a shallow anterior chamber

PURPOSE

To compare intraoperative performance and postoperative outcomes between femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification in eyes with a shallow anterior chamber (AC).

SETTING

Iladevi Cataract & IOL Research Centre, India.

DESIGN

Prospective randomized masked clinical study.

METHODS

Patients undergoing cataract surgery with a shallow AC (<2.5 mm) were randomized to have FLACS (Group 1, n = 91) or conventional phacoemulsification (Group 2, n = 91). Patients were followed up at 1 day, 1 week, and at 1, 3, and 6 months. The primary outcome measure was central corneal thickness (CCT). The secondary outcome measures were corneal clarity, AC cells and flare, endothelial cell density (ECD), coefficient of variance, hexagonality, and uncorrected distance visual acuity (UDVA) at 1 week.

RESULTS

The study comprised 182 eyes (91 in each group) The cumulative dissipative energy was lower in the FLACS group (P < .05). The mean CCT was significantly lower with FLACS (540.40 μm + 49.40 [SD] vs 556 + 12.5 μm, P = .03) at 1 day and 1 week (535.5 + 44.3 μm vs 551 + 40.8 μm, P = .04), with fewer eyes having higher than grade 2 AC cells and flare with FLACS (85% vs 72%, P = .056) at 1 day and 1 week (15% vs 28%, P = .03). At 1 week, the UDVA was better with FLACS (0.089 ± 0.31 logarithm of the minimum angle of resolution [logMAR] vs 0.178 ± 0.65 logMAR, P = .042). At 6 months, the reduction in ECD was lower in the FLACS group; however, the difference was not statistically significant.

CONCLUSION

In eyes with shallow ACs, compared with conventional phacoemulsification, FLACS maintained clearer corneas, showed less increase in CCT, lower AC inflammation, and better UDVA in the early postoperative period.

Effects of Combinations of Ophthalmic Viscosurgical Devices and Suction Flow Rates on the Corneal Endothelial Cell Damage Incurred during Phacoemulsification

We examined the effects of different ophthalmic viscosurgical devices (OVDs) and suction flow rates during phacoemulsification on the amount of ultrasound power used and damage to the corneal endothelium. In total, 48 eyes of 24 patients who underwent phacoemulsification and intraocular lens insertion with different OVD settings in the left and right eye between February and August 2018 were examined retrospectively from medical records. Each of the following types of OVDs was used in either the right or left eye of each patient: a viscoadaptive OVD (V group) or a combination of dispersive and cohesive OVDs (soft-shell technique; S group). There was no significant difference in the lens nucleus hardness between the two groups. A 2.4 mm transconjunctival scleral incision was made, and phacoemulsification was performed by the same surgeon. The cumulative dissipated energy (CDE) and ultrasound time intraoperatively were compared between the two groups. The CDE was significantly larger in the V group (9.9 ± 4.6) than the S group (6.4 ± 3.0; p=0.006). The reduction rate of the endothelial cell density at the center of the cornea was significantly higher in the V group (4.1% ± 6.7%) than the S group (0.3% ± 4.5%; p=0.03) at 1 week postoperatively. Both groups had a good postoperative course. There was less corneal endothelial damage with the soft-shell technique combined with a normal flow setting than the viscoadaptive OVD combined with a low flow setting.

Preoperative Risk Assessment for Progression to Descemet Membrane Endothelial Keratoplasty Following Cataract Surgery in Fuchs Endothelial Corneal Dystrophy

PURPOSE

To identify preoperative corneal tomographic features that predict progression to endothelial keratoplasty (EK) following cataract surgery in Fuchs endothelial corneal dystrophy (FECD) and establish a regression model to identify high-risk patients.

DESIGN

Prospective, observational cohort study.

METHODS

Setting: Hospital Universitario Ramón y Cajal, Madrid, Spain.

STUDY POPULATION

Sixty-eight patients (84 eyes) with FECD who underwent phacoemulsification.

INTERVENTION

We assessed preoperative best-corrected visual acuity; ultrasound central corneal thickness; pachymetric, anterior chamber depth, and corneal backscatter variables using Scheimpflug imaging; and endothelial cell density.

MAIN OUTCOME MEASURES

Progression to EK.

RESULTS

A total of 33 eyes (39.3%) needed EK after phacoemulsification to rehabilitate vision. On multivariate analysis, anterior layer (AL) corneal backscatter between 0 and 2 mm from the apex and relative increase in central corneal thickness from the "relative pachymetry display" by the Pentacam were significant predictors of the risk of progression to EK. Using these 2 variables, a risk score (RISC score) was derived from the regression model (area under the curve = 0.973; best cutoff point with a specificity of 95% representing a sensitivity of 96%). Excluding corneal backscatter data from the multivariate regression model, corneal thickness at the pupil center by the Pentacam and relative increase in central corneal thickness were significant predictors and provided a modified risk score (RIPT score) with similar performance.

CONCLUSION

Both scores demonstrated accuracy in predicting progression to EK using easily accessible preoperative data. This approach, which can be readily implemented by surgeons, allows for individualized risk assessment.

Effects of Hydrogen in Prevention of Corneal Endothelial Damage During Phacoemulsification: A Prospective Randomized Clinical Trial

PURPOSE

Hydrogen (H₂) has been reported to scavenge free radicals, particularly the hydroxyl radical (·OH). Ultrasound oscillation in an aqueous solution produces ·OH. Our recent study demonstrated that H₂ dissolved in an irrigation solution prevented corneal endothelial damage during phacoemulsification in an animal model. We examined the effects of H₂ during clinical phacoemulsification.

DESIGN

A single-center, prospective, randomized, double-masked clinical trial.

METHODS

Thirty-two patients who had cataracts of similar nucleus hardness in both eyes (age: 75.4±7.68 years; 17 males, 15 females) were recruited. Phacoemulsification was performed using a solution of dissolved H₂ in one eye, and a conventional solution in the contralateral eye. Endothelial cell density (ECD) at the center of the cornea was measured using noncontact specular microscopy preoperatively and at 1 day, 1 week, and 3 weeks postoperatively.

RESULTS

Reduction rates of ECD (mean ± standard deviation) were 16.0%±15.7% at 1 day, 15.4%±16.1% at 1 week, and 18.4%±14.9% at 3 weeks in the control group, compared to 6.5%±8.7% at 1 day (P = .003), 9.3%±11.0% at 1 week (P = .039), and 8.5%±10.5% at 3 weeks (P = .004) in the H₂ groups. These rates were significantly smaller in the H₂ group at all time points.

CONCLUSIONS

H₂ dissolved in irrigation solution reduced corneal endothelial damage during phacoemulsification. This suggests that a considerable part of the corneal endothelial damage during phacoemulsification is caused by oxidative stress, and that H₂ is useful in clinical phacoemulsification.

Addition Of D-Sorbitol Improves The Usability Of Ophthalmic Viscosurgical Devices

Purpose

To evaluate the effects of D-sorbitol addition on changes in the extrusion force of ophthalmic viscosurgical devices (OVDs).

Methods

OVD formulations; the mixtures of 3% hyaluronic acid (HA) and 4% chondroitin sulfate (CS) containing 0%, 0.5%, or 1.0% D-sorbitol were prepared. Each prefilled syringe of OVD was stored at room temperature for 0, 15, 30, 60, or 120 mins after a small amount of viscoelastic agent was discharged from the needle. The extrusion force values (kgf) of these OVDs when reused after storage were measured with a texture analyzer. Moreover, 10 healthy adults (5 men and 5 women) used a pinch sensor to measure the extrusion force values for the HA/CS combination without D-sorbitol which was stored in the above manner, and used a 4-step scale to score the usability of OVD.

Results

For the HA/CS combination without D-sorbitol, the extrusion force value was increased from its initial value (storage duration, 0 min) as storage duration increased. However, for the HA/CS combination containing 0.5% or 1.0% D-sorbitol, this value remained almost unchanged over time. Likewise, the pinch sensor-determined extrusion force values of HA/CS combination without D-sorbitol increased, depending on storage duration.

Conclusion

The addition of D-sorbitol to viscoelastic agent may suppress the needle clogging that occurs with OVD storage, and may improve the usability of OVDs during surgery.

Refractive Laser-Assisted Cataract Surgery versus Conventional Manual Surgery: Comparing Efficacy and Safety in 3144 Eyes

PURPOSE

To report on outcomes of the efficacy and safety in 1 of the largest series of eyes undergoing either conventional manual cataract surgery (MCS) or refractive femtosecond laser-assisted cataract surgery (ReLACS).

DESIGN

Retrospective, consecutive, interventional comparative case series.

METHODS

This study included 3144 consecutive eyes, of which 1580 were treated via MCS, and 1564 were treated via ReLACS at Uptown Surgical Centre in Vaughan, Ontario, Canada. Preoperative characteristics, best corrected visual acuity (BCVA), mean absolute spherical error (MAE), rates of intraoperative posterior capsular rupture, and postoperative complications were evaluated.

RESULTS

Across all eyes, ReLACS was superior to MCS for reducing surgical time (MCS: 7.7 ± 0.1 min vs ReLACS: 6.8 ± 0.1 min, P < 0.001); was less commonly associated with postoperative cystoid macular edema (OR = 0.36, 95% CI: 0.14-0.91, P = 0.031) and more commonly reduced MAE (MCS: 0.60 ± 0.02 diopters (D) vs ReLACS: 0.54 ± 0.02 D, P = 0.02). There were no differences in rates of posterior capsular rupture (P = 0.918), overall postoperative complications (P = 0.088) or final BCVA (P = 0.881). When analyzing a subgroup of more difficult cases (n = 833), ReLACS was superior to MCS for: 1) being more likely to yield an improvement of more than 0.1 logarithm of the minimum angle of resolution BCVA (OR = 1.80, 95% CI: 1.15-2.74, P = 0.01); 2) reducing MAE (MCS: 0.73 ± 0.3 D vs ReLACS: 0.60 ± 0.27 D, P = 0.04); and 3) being more likely to yield an MAE within 0.5 D (OR = 1.61, 95% CI: 1.11-2.33, P = 0.012).

CONCLUSIONS

Across all eyes, our results support that ReLACS and MCS yield similar outcomes. However, our results show trends toward a more pronounced benefit of ReLACS compared to MCS when treating more difficult eyes.

New ophthalmic dual-viscoelastic device in cataract surgery: a comparative study

Objective

To compare the performance and safety in cataract surgery of two ophthalmic viscoelastic devices (OVDs), each having separate dispersive and cohesive characteristics and different concentrations.

Methods and analysis

In this prospective, randomised, controlled clinical study, one eye of each patient was injected with OVD1 (Viscopack14) or OVD2 (DuoVisc) during phacoemulsification and intraocular lens implantation. Endothelial cell count, intraocular pressure (IOP), central corneal thickness (CCT), intraocular inflammation and corrected distance visual acuity (CDVA) were compared 3 months postoperatively.

Results

The study enrolled 127 patients. Randomisation assigned 50 eyes of as many patients to each arm of the study. The postoperative mean endothelial cell loss was 14.4% and 7.1% from baseline in the OVD1 and OVD2 groups, respectively (p=0.08). The incidence of IOP spikes at 2 hours was 0% and 8%, respectively (p=0.02). There were intergroup differences in postoperative IOP values, the OVD2 group showed significantly higher values at all of the follow-up visits starting from the 24 hours examination (p<0.05). There was no statistically significant difference in the CCT, intraocular inflammation and CDVA at the end of follow-up.

Conclusion

Both OVDs showed similar clinical performances and were equally effective during cataract surgery. Viscopack14 showed more corneal endothelial cell reduction, while DuoVisc had more occurrences of IOP values and spikes. Future studies are mandatory to support these preliminary results.

[Evaluation of Rheological Properties of Cohesive Ophthalmic Viscosurgical Devices Composed of Sodium Hyaluronate with High Molecular Weight-2019]

Ophthalmic viscosurgical devices (OVDs), mainly containing sodium hyaluronate (HA), are used in cataract surgeries to protect the cornea endothelium. In this study, the rheological properties of 9 launched products (containing 1% HA) were evaluated. The molecular weights (MWs) of HA estimated based on intrinsic viscosity varied widely, between 1100-2500 kDa, and showed a particular value for each product. Of the 9 products, 6 are classified as cohesive OVDs and their product specifications show the same value for intrinsic viscosity (25-45 dL/g), with high MW HA (>2000 kDa); however, the MW of each HA showed a particular value (2200-2500 kDa) within the range of the product specification. As with the MW of HA, apparent viscosity and dynamic rheological parameters showed particular values for each OVD. The product Opegan-Hi exhibited the highest value of apparent viscosity at low shear rate, and a solid-like behavior among the OVDs. In a questionnaire survey among 198 cataract surgeons, 42% of surgeons had experienced a difference in ability to maintain the depth of anterior chamber during surgery among the different cohesive OVDs used. This suggested that surgeons select OVD properties based on surgical procedure and patient cases. In conclusion, we demonstrated that each OVD has particular rheological properties within the range of the product specification defined by the intrinsic viscosity. The results might provide useful information for surgeons in their selection of OVDs based on their experience.

Comparison of the performance and safety of 2 ophthalmic viscosurgical devices in cataract surgery

PURPOSE

To compare the clinical performance and safety of 2 ophthalmic viscosurgical devices (OVDs)-Twinvisc (OVD 1) and Duovisc (OVD 2)-in cataract surgery.

SETTING

European multicenter study.

DESIGN

Prospective randomized controlled study.

METHODS

Patients with cataract had phacoemulsification and intraocular lens implantation in 1 eye. They were randomly assigned to receive OVD 1 or OVD 2. Preoperative and postoperative examinations over 3 months included mean intraocular pressure (IOP), incidence of IOP peaks (≥30 mm Hg and ≥24 mm Hg), endothelial cell count (ECC), corneal thickness, and intraocular inflammation. A subjective evaluation of the OVDs was performed.

RESULTS

The study comprised 220 patients. The incidence of IOP peaks and the mean IOP were not statistically significantly different between the 2 groups at any of the follow-up visits. At 6 hours, the incidence of IOP spikes 30 mm Hg or higher was 6.5% and 7.2% in the OVD 1 and the OVD 2 groups, respectively (P = .846). For the IOP spikes 24 mm Hg or higher, the incidence was 16.8% and 25.2%, respectively (P = .128). Three months postoperatively there was no statistically significant difference in ECC and pachymetry between the 2 groups. Mild inflammation was noticed up to 7 days postoperatively after which it resolved in both groups. Subjectively, the OVD 2 was easier to use, whereas the OVD 1 had better cohesive and dispersive properties.

CONCLUSIONS

Both OVDs have similar performance and safety profiles in phacoemulsification cataract surgery. No clinically relevant differences were found between the 2 devices regarding transient IOP spikes, mean IOP, corneal endothelium injury, or inflammation.

Precision pulse capsulotomy: an automated alternative to manual capsulorhexis in paediatric cataract

Objective

To report our operative experience with precision pulse capsulotomy (PPC) for anterior capsulotomy in a paediatric cataract series.

Methods and analysis

This study is a retrospective interventional, descriptive series of consecutive paediatric eyes (≤16 years) undergoing cataract surgery using PPC. Surgical time and the time required to perform PPC was recorded. Any intraoperative and postoperative adverse events were noted. Postoperatively, visual acuity, anterior segment examination and intraocular pressure (IOP) were recorded for all children at day 1, 1 week and 1 month.

Results

21 eyes of 14 patients were included in the study, with the median age at surgery of 6.0 years (IQR; 5-7.75, range=1–16 years). Male to female ratio was 11:3. 13 eyes had lamellar cataract, 3 eyes had total cataract, 2 had posterior subcapsular cataract, 2 had traumatic cataract, while 1 eye had sutural cataract. Median surgical time was 26 min (IQR 21-32) and median PPC time was 75.0 secs (IQR 56-86.5). The anterior capsulotomy was round and complete in most cases, except in one case due to faulty suction. All patients underwent a successful in the bag implantation of intraocular lens with capsulotomy margins overlapping the optic edges in 19 eyes (90%). Median PPC size was 5.54 mm (n=9, IQR 5.39 -5.75) which was slightly larger than expected. None of the cases had any intraoperative or postoperative adverse events with no radial tears of capsulotomy. Postoperatively, the mean final follow-up was 5.71+3.20 weeks.

Conclusion

To conclude PPC can be used as an alternative to manual continuous curvilinear capsulorhexis in paediatric cataract surgery producing round well- centred and strong capsulotomy with an easier learning curve.

Rheological and Adhesive Properties to Identify Cohesive and Dispersive Ophthalmic Viscosurgical Devices

The purpose of this study is to evaluate the usefulness of the rheological properties and adhesive force of ophthalmic viscosurgical devices (OVDs) as parameters for understanding and identifying the surgical behavior of cohesive and dispersive OVDs. The apparent viscosity, and the storage and loss moduli (dynamic rheological parameters) of 50% chondroitin sulfate (CS), 3% sodium hyaluronate (HA), Shellgan (the combination of 3% HA and 4% CS), Opegan (1% HA with a low molecular mass) and Opegan-Hi (1% HA with a high molecular mass) were obtained with a rheometer. The adhesive force of each sample was measured by using a texture analyzer. Opegan-Hi showed a solid-like behavior, while 50% CS showed a fluid-like behavior from their apparent viscosity and dynamic rheological parameters. Shellgan, 3% HA, and Opegan exhibited similar rheological properties and intermediate characteristics between Opegan-Hi and 50% CS, although their respective values were slightly different. Among these OVD samples, the adhesive force was higher in the order of 50% CS > Shellgan, 3% HA > Opegan > Opegan-Hi. The adhesive force of dispersive OVDs tended to be higher than that of cohesive OVDs, which correlated well with the removal times of OVDs from the eye that have previously been reported. In conclusion, we demonstrated that cohesive OVDs and dispersive OVDs have particular rheological and adhesive properties that can be applied to identify both types. These parameters obtained in this study provide useful information for a greater understanding and prediction of the behavior of OVDs in the eye during surgery.

Monitoring and management of the patient with pseudoexfoliation syndrome: current perspectives

Pseudoexfoliation syndrome (PES) is a complex and age-related systemic disorder characterized by the progressive accumulation and granular deposition of pseudoexfoliative material in various intraocular and extraocular tissues. The diagnosis of PES is so important because it is a major risk factor for complications during cataract surgery and the most frequent cause of secondary glaucoma. In addition to ocular complications, PES is related with numerous systemic abnormalities, for which the list is growing steadily. Therefore, management and monitoring of patients with PES are crucial. The aim of this paper was to review current perspectives on monitoring patients with PES and addressing management of ocular and systemic associations of this clinically important and biologically fascinating disease.

Dispersive viscosurgical devices demonstrate greater efficacy in protecting corneal endothelium in vitro

Objective

During phacoemulsification, the corneal endothelium is protected by an ophthalmic viscosurgical device (OVD). In this in vitro study, we assessed six different OVDs for their effectiveness in protecting the corneal endothelium.

Methods and analysis

Phacoemulsification was performed in cadaver eyes of young pigs. Five syringe units of six different OVDs were tested (Healon EndoCoat, Viscoat, Methylvisc, Healon, Healon GV, ProVisc). After surgery, the area of endothelium coated with OVD was determined in relation to the total endothelial surface. Additionally, an endothelial cell count was obtained. As a control, an endothelial cell count was obtained from freshly trephined corneas. Statistical analysis was performed using the Mann-Whitney U test and the Spearman correlation.

Results

The least postoperative endothelial coating and cell count were observed in the cohesive OVDs while the dispersive OVDs showed statistically significant higher values. Healon EndoCoat and Viscoat yielded a coating area of 86 (85-92)% and 85 (85-90)%, respectively. Endothelial cell count was highest in the two dispersive groups with 4065 (3928-4088) cells/mm² (Methylvisc) and 4032 (4015-4115) cells/mm² (Viscoat). Endothelial coating area and endothelial cell count correlated statistically significantly.

Conclusion

Dispersive OVDs from this study showed greater adherence to the endothelial surface than the cohesive ones. Furthermore, postoperative endothelial cell counts of corneas treated with dispersive OVDs were higher than of corneas treated with cohesive OVDs. Our in vitro results suggest that dispersive OVDs protect the corneal endothelium better during phacoemulsification than cohesive OVDs.

Cataract surgery with implantation of a high-add intraocular lens LENTIS® MAX LS-313 MF80 in end-stage, age-related macular degeneration: A case report of magnifying surgery

A new treatment option for cataracts and advanced ARMD: the simultaneous intravitreal injection of anti-vascular endothelial growth factor and implantation of a high-add IOL. We believe major opportunities arise from a new subcategory in cataract surgery-called magnifying surgery (MAGS). Our case proves the potential of this brand-new technology.

Combined use of an iris hook and pupil expansion ring for femtosecond laser-assisted cataract surgery in patients with cataracts complicated by insufficient mydriasis and an ectopic pupil

We developed a surgical technique that combines use of an iris hook and a pupil expansion ring in femtosecond laser-assisted cataract surgery complicated by insufficient mydriasis and an ectopic pupil. With this technique, the surgery, including femtosecond laser assistance, phacoemulsification, and intraocular lens implantation, can be accomplished successfully prior to iris repair.

FINANCIAL DISCLOSURE

Dr. Malyugin receives travel grants from Alcon Laboratories, Inc. and Novartis Corp.; he receives royalties from Microsurgical Technology, Inc. None of the other authors has a financial or proprietary interest in any material or method mentioned.