Postcataract surgical inflammation

Early Postoperative Changes in Macular Choroidal Thickness After Uncomplicated Phacoemulsification in Patients With and Without Glaucoma: A Swept-Source Optical Coherence Tomography Study

Purpose The objective of this study was to examine the impact of uncomplicated phacoemulsification on macular choroidal thickness (CT) within the first three postoperative months and to investigate its relationship with postoperative cystoid macular edema (CME) in both glaucomatous and healthy subjects, utilizing swept-source optical coherence tomography (SS-OCT). Methods The non-randomized prospective study involved 82 patients, selected via convenience sampling from the First Department of Ophthalmology, Medical School of Athens, "G. Gennimatas" Hospital, Athens, Greece, between May 2018 and May 2022, undergoing phacoemulsification and intraocular lens (IOL) implantation. The inclusion criteria encompassed patients aged 50 years or above, with or without glaucoma. Patients with ocular pathologies that could influence macula or CT measurements were excluded. Data collection focused on retinal and CT variables of the macular area, measured using SS-OCT. Baseline measurements were established preoperatively, with follow-up assessments at one week, one month, and three months postoperatively to monitor CT and macular edema onset. Results A total of 82 eyes from 82 patients with a mean age of 79.1±8.3 years were included. The study population was divided into a glaucoma group (n=28 eyes) and a control group (n=54 eyes). Our findings indicate a consistently significant increase in macular CT measurements one month after cataract surgery, observed in both glaucomatous and non-glaucomatous eyes. In the first postoperative week, statistically significant changes in CT were observed only in patients with CME. Subsequently, at one-month interval, both patient groups, those with and without CME, exhibited statistically significant changes in CT across all macular sectors. CME was detected in 10 out of 28 eyes in the glaucoma group and in 16 out of 54 eyes in the control group. When evaluating the impact of postoperative CME on groups of glaucomatous and non-glaucomatous eyes, it was observed that glaucomatous eyes exhibited a significantly larger magnitude of change in subfoveal CT (SFCT) (p=0.03) at one month (relative to baseline) compared to non-glaucomatous eyes. There was also a 31% increase in the odds of developing CME for glaucoma patients; this result was not statistically significant (odds ratio {OR}, 1.31; 95% confidence interval {CI}, 0.50-3.47; p=0.57). Conclusions During the early postoperative period, the study revealed a significant increase in CT at one month after phacoemulsification in both glaucomatous and non-glaucomatous eyes. When CME was present, a significantly more pronounced magnitude of change in SFCT was observed at one month in glaucomatous eyes, as opposed to non-glaucomatous eyes. This observation suggests a possible selective susceptibility of glaucomatous eyes in the early postoperative period that requires further research.

Cataract surgery in patients with uveitis: Data from the Swedish National Cataract Register

PURPOSE

To investigate the surgical and pharmacological management and outcomes of patients with cataract and concurrent uveitis.

METHODS

Data from the Swedish National Cataract Register, 2018-2019, were collected and analysed. Uveitic eyes were identified and eyes without uveitis were used as controls. Generalized estimating equations were used to adjust for intra-individual correlation.

RESULTS

The study included 719 eyes with and 256 360 without uveitis. The mean age was 66.0 ± 13.5 (standard deviation [SD]) years in the uveitis group and 74.3 ± 8.7 years in the control group (p < 0.001). Surgery was associated with more intraoperative difficulties in eyes with uveitis (27.0%) than in control eyes (7.1%; p < 0.001). Posterior capsule rupture/zonular complications were registered in nine eyes with uveitis (1.3%) and in 1464 eyes without uveitis (0.6%; p = 0.02). Hydrophilic acrylic intraocular lenses (uveitis 3.6%, controls 1.2%) and subconjunctival steroids (uveitis 17.4%, controls 6.1%) were more frequently used in eyes with uveitis (p < 0.001). post-operative best-corrected visual acuity (BCVA) was 0.16 ± 0.38 logarithm of the minimum angle of resolution (logMAR, mean ± SD) in eyes with uveitis (n = 52) and 0.08 ± 0.20 in control eyes (n = 14 489; p = 0.008).

CONCLUSION

In this large registry-based Swedish cohort study, the findings demonstrate that cataract surgery in patients with uveitis poses more challenges and requires special surgical precautions. Eyes with concurrent uveitis had worse BCVA prior to and following surgery. Despite the intraoperative challenges, the visual improvement was greater in the uveitic group.

Management of inflammation after the cataract surgery

PURPOSE OF REVIEW

To review most recent studies and clinical trials regarding pathogenesis, treatment, and prevention of inflammation after the cataract surgery.

RECENT FINDINGS

FLACS gave opportunity to evaluate inflammatory cytokines in the aqueous humour right after the laser procedure, which led to acknowledging the inflammation pathogenesis during the phacoemulsification. Although there is still a lack of evidence, which would prove the long-term benefit of NSAIDs, they are indicated and effective when risk factors for PCME are present. PREMED studies showed that combination of NSAID and steroids after the surgery for healthy subjects is cost-effective. The triamcinolone injection together with topical steroids and NSAIDs for diabetic patients after the cataract surgery was the most cost-effective in preventing PCME according to the PREMED. Dropless cataract surgery is another emerging topic: dexamethasone implants and suspensions look promising as we await more clinical trials with drug-loaded IOLs.

SUMMARY

Inflammation after the cataract surgery can be prevented, and these methods are one of the most essential topics with growing phacoemulsification rate. Topical NSAIDs are cost-effective not only for patients with risk factors for PCME but also for healthy subjects. New dropless techniques are being successfully introduced in the clinical practice.

Advances in ophthalmic drug delivery technology for postoperative management after cataract surgery

INTRODUCTION

Cataract surgery is becoming more common due to an aging world population. Intraocular lenses and surgical technique have developed remarkably recently, but the development of postoperative medication to prevent postsurgery complications has been relatively delayed. We still largely depend on eye drops for the management of post-cataract-surgery patients. Mental and physical problems that often occur in elderly cataract patients make it difficult for patients to apply eye drops by themselves. It is necessary to develop new effective drug delivery methods.

AREAS COVERED

This updated review article provides a brief review of why drug management is needed following cataract surgery and an overview of current developments in new drug delivery methods for ophthalmic treatment. In particular, various novel drug delivery methods that can be used for post-cataract-surgery management and their current development stages are extensively reviewed.

EXPERT OPINION

Rapidly developing technologies, such as intraocular and external ophthalmic implants, polymers, and nanotechnology, are being actively applied to develop novel drug delivery systems for safe and effective management after cataract surgery. Their goal is to achieve sufficient drug release for the desired duration with a single application. These will largely replace the inconvenience of eye drops for elderly patients in the future.

Long-Term Variations in Retinal Parameters after Uncomplicated Cataract Surgery

Background: Cataract phacoemulsification surgery provides excellent refractive results; however, it also elicits changes in the posterior segment of the eye. This study aimed to determine changes in retinal parameters measured by spectral-domain optical coherence tomography (SD-OCT) and OCT angiography (OCTA) after an uncomplicated cataract surgery, including the impact of effective phacoemulsification time (EPT). Methods: The study included 44 patients without retinal abnormalities, followed up after unilateral uncomplicated cataract phacoemulsification in a single ophthalmological unit. Patients were evaluated for the following parameters at baseline and at 2 weeks, 3 months, and 12 months after the surgery: best corrected visual acuity, central retinal thickness (CRT), average central retinal thickness (CRTA), central retinal volume (cube volume (CV)), vessel density central (VDC), vessel density full (VDF), vessel perfusion central (VPC), and vessel perfusion full (VPF). The EPT recorded at each procedure was used as a covariant for the evaluation of changes in retinal parameters after the surgery. Analysis included 44 eyes for SD-OCT and 17 for OCTA evaluation, according to adopted scan quality thresholds. Results: A significant increase in CRT, CRTA, and CV was noted at each follow-up point compared with baseline. The rising tendency was observed in the first 3 months after the surgery, with a decline over the subsequent months. The VPF parameter showed a stable improvement after the surgery. The analysis of covariance did not confirm any significant effect of the EPT on variations in CRT, CV, CRTA, VDC, and VPF and there was a weak effect on the VDF parameter. Conclusions: Uncomplicated cataract surgery results in an increase in retinal thickness and volume in the first few months after the surgery, followed by a spontaneous decline in these parameters in the subsequent months. A long-standing improvement is noted in the VPF parameter.

Oxidative stress induces inflammation of lens cells and triggers immune surveillance of ocular tissues

Recent reports have challenged the notion that the lens is immune-privileged. However, these studies have not fully identified the molecular mechanism(s) that promote immune surveillance of the lens. Using a mouse model of targeted glutathione (GSH) deficiency in ocular surface tissues, we have investigated the role of oxidative stress in upregulating cytokine expression and promoting immune surveillance of the eye. RNA-sequencing of lenses from postnatal day (P) 1-aged Gclc^f/f;Le-Cre^Tg/- (KO) and Gclc^f/f;Le-Cre^-/- control (CON) mice revealed upregulation of many cytokines (e.g., CCL4, GDF15, CSF1) and immune response genes in the lenses of KO mice. The eyes of KO mice had a greater number of cells in the aqueous and vitreous humors at P1, P20 and P50 than age-matched CON and Gclc^w/w;Le-Cre^Tg/- (CRE) mice. Histological analyses revealed the presence of innate immune cells (i.e., macrophages, leukocytes) in ocular structures of the KO mice. At P20, the expression of cytokines and ROS content was higher in the lenses of KO mice than in those from age-matched CRE and CON mice, suggesting that oxidative stress may induce cytokine expression. In vitro administration of the oxidant, hydrogen peroxide, and the depletion of GSH (using buthionine sulfoximine (BSO)) in 21EM15 lens epithelial cells induced cytokine expression, an effect that was prevented by co-treatment of the cells with N-acetyl-l-cysteine (NAC), a antioxidant. The in vivo and ex vivo induction of cytokine expression by oxidative stress was associated with the expression of markers of epithelial-to-mesenchymal transition (EMT), α-SMA, in lens cells. Given that EMT of lens epithelial cells causes posterior capsule opacification (PCO), we propose that oxidative stress induces cytokine expression, EMT and the development of PCO in a positive feedback loop. Collectively these data indicate that oxidative stress induces inflammation of lens cells which promotes immune surveillance of ocular structures.

Clinical Results of Cataract Surgery Using the ARTIS ® PL E Intraocular Lens

Purpose: To compare the clinical outcomes of cataract surgery using the ARTIS ® PL E (Cristalens Industrie, Lannion, France) intraocular lens (IOL) and conventional Tecnis ® ZCB00 (Johnson & Johnson Vision, Santa Ana, CA, USA) IOL.Methods: This retrospective study examined patients who underwent in-the-bag implantation of either an ARTIS ® PL E (33 eyes, group A) or Tecnis ® ZCB00 (45 eyes, group B) IOL after phacoemulsification performed by a single surgeon. Best-corrected visual acuity (BCVA), spherical equivalent, and higher-order aberrations (HOA) were measured 1 and 3 months after cataract surgery.Results: Preoperative BCVA did not differ significantly in groups A and B. Postoperative BCVA at 1 and 3 months improved significantly (p < 0.001) in both groups compared to preoperative baseline BCVA. At 1 and 3 months postoperatively, total HOA, spherical aberration, and coma were significantly lower compared to the preoperative baseline HOA (p < 0.05) in both groups. However, there were no significant differences in the trefoil values 1 and 3 months postoperatively compared to the preoperative baseline in both groups. The absolute refractive error 3 months postoperatively was 0.27 ± 0.20 (group A) and 0.28 ± 0.20 (group B), both within ± 0.50 diopters of the targeted goal diopter; there were no significant differences in the accuracy or predictability of the IOL power calculation in both groups (p = 0.390, p = 0.959). The absolute refractive error 1 and 3 months postoperatively did not differ significantly; there were no significant differences in the stability of both IOLs (p = 0.482, p = 0.372).Conclusions: Conventional cataract surgery using the ARTIS ® PL E IOL significantly increased the BCVA, while obtaining comparable clinical results to the verified Tecnis ® ZCB00 IOL in postoperative visual acuity and HOA.

Diagnosis and Management of Idiopathic Persistent Iritis after Cataract Surgery (IPICS)

PURPOSE

To investigate the diagnosis and management of patients with idiopathic persistent iritis after cataract surgery (IPICS).

DESIGN

Retrospective interventional case series.

METHODS

Patients diagnosed with IPICS were evaluated for demographic and clinical characteristics and immune blood markers. Those with more than 6 months of follow-up were evaluated for treatment efficacy to achieve remission (ie, absence of inflammation for 3 months), with either exclusive slow tapering of topical steroids or the need for systemic immunosuppression.

RESULTS

Forty-five patients presented with IPICS. Most were African American (39, 86.7%) or female (33, 77.3%). Antinuclear antibodies were present in 23 (69.9%) of patients. Main complications were steroid dependency (38,84.4%), glaucoma (24,53.5%), and macular edema (11,37.5%). Thirty two patients presented treatment follow up. On these,the proposed treatment strategy achieved remission in 30 (93.8%) of cases in a mean of 6.1 months via tapering of topical steroids in 15 (46.9%) of patients. However, in 17 (53.1%) of cases, adjuvant anti-inflammatory systemic medication was indicated. Meloxicam use was associated with remission in 11 (64.7%) of these patients and, in a minority with persistent iritis, treatment was escalated to methotrexate, which was successful in 4 (100%) of the cases.

CONCLUSIONS

IPICS is a distinct clinical anterior uveitis most common in African American and female patients, characterized by an unexpected onset of iritis after cataract surgery and high rates of steroid dependency, glaucoma, and macular edema. It is best treated with an initial slow taper of topical steroids; although adjuvant systemic anti-inflammatory therapy may be necessary to obtain remission and avoid complications.

Topical bromfenac reduces multiple inflammatory cytokines in the aqueous humour of pseudophakic patients

Intraocular surgery is associated with increased ocular inflammation. If maintained for a prolonged period after surgery, this inflammation can cause various complications, including subconjunctival fibrosis and bleb scarring. This clinical trial was a prospective, randomised, single-blind, interventional study comparing the efficacy and safety of 0.1% bromfenac sodium ophthalmic solution and 0.02% fluorometholone ophthalmic suspension in the inhibition of multiple inflammatory cytokines in the aqueous humour of 26 patients with pseudophakic eyes who had undergone phacoemulsification and intraocular lens implantation. The patients were randomly assigned to one of the trial drugs, and aqueous humour samples were collected before and after drug administration. Platelet-derived growth factor-AA levels significantly decreased in both drug groups, but they were significantly higher in the fluorometholone group than in the bromfenac group (P = 0.034). Bromfenac also significantly decreased vascular endothelial growth factor level (P = 0.0077), as well as monocyte chemoattractant protein-1 level (P = 0.013), which was elevated for a prolonged period after phacoemulsification. These data suggest that bromfenac is useful to alleviate prolonged microenvironmental alterations in the aqueous humour of pseudophakic eyes.

Cytokines, chemokines, and flare in the anterior chamber after femtosecond laser-assisted cataract surgery

PURPOSE

To analyze anterior chamber inflammation after pretreatment with a femtosecond laser platform during cataract surgery and compare the results with those of the manual procedure.

SETTING

Eye Clinic, Department of Surgery and Translational Medicine, University of Florence, Italy.

DESIGN

Prospective case series.

METHODS

Aqueous humor was collected after femtosecond laser pretreatment (femtosecond group) and at the beginning of routine cataract surgery before the primary incision was created (control group). The levels of 14 cytokines and chemokines were measured using a multiplex array system. Surgical parameters (suction time, laser time, effective phacoemulsification time [EPT]) were recorded. Anterior chamber flare was measured by laser photometry preoperatively and 1 day and 7 days postoperatively.

RESULTS

Each group comprised 20 eyes. The EPT was significantly lower in the femtosecond group than in the control group. In the femtosecond group, the concentrations of IL (interleukin)-6, IL-8, IL-10, IL-12, vascular endothelial growth factor, and interferon-γ were significantly higher than in the control group. Flare in the anterior chamber measured with flare-cell meter was not significantly different between groups at any timepoint. No correlation was found between cytokine concentrations and age in either group and between cytokine levels and suction or laser time and postoperative flare in the femtosecond group. Also, no correlation was found between postoperative aqueous flare and EPT in either group.

CONCLUSIONS

Despite the rise of proinflammatory cytokines in the aqueous humor after femtosecond laser pretreatment, the anterior chamber flare after cataract surgery was similar to that in controls. This might be a result of the lower EPT required after pretreatment.

Evaluation of the etiology of persistent iritis after cataract surgery

Background

The purpose of this study was to evaluate patients with persistent iritis after cataract surgery to determine its incidence and risk factors. Adjusting the management of patients at risk could allow for a more predictable post-operative course and outcome. A retrospective chart review was performed of patients who had post-operative iritis longer than 1 month after cataract surgery during a 2-year period at Storm Eye Institute at the Medical University of South Carolina (MUSC) in Charleston, South Carolina. Patient demographics and various pre-operative, intra-operative, and post-operative factors were analyzed for trends.

Results

Thirty-nine patients (49 eyes) met the inclusion criteria, and this group was compared to a control cohort of 40 patients (66 eyes) who did not have persistent iritis after cataract surgery. The overall incidence of post-operative iritis was 1.75%. In all patients with post-operative iritis lasting greater than 1 month, African American race and pupil expansion device use were statistically significant factors. After excluding patients with a history of ocular inflammation or known inflammatory or autoimmune diagnosis (1.20% incidence), there were still a significantly higher proportion of African Americans compared to the control group. When patients with post-operative iritis of less than 6 months in duration were additionally excluded, the incidence was 0.32%, and history of diabetes was statistically significant in addition to race.

Conclusions

Risk factors for persistent iritis after cataract surgery include being diabetic, of African American racial background, and pupil expansion device use. These patients can be better informed of the higher risk of prolonged inflammation in their post-operative course, and peri-operative management can be tailored accordingly.

Injectable drug depot engineered to release multiple ophthalmic therapeutic agents with precise time profiles for postoperative treatment following ocular surgery

A multi-drug delivery platform is developed to address current shortcomings of post-operative ocular drug delivery. The sustained biodegradable drug release system is composed of biodegradable polymeric microparticles (MPs) incorporated into a bulk biodegradable hydrogel made from triblock copolymers with poly(ethylene glycol) (PEG) center blocks and hydrophobic biodegradable polyester blocks such as poly(lactide-co-glycolide) (PLGA), Poly(lactic acid) (PLA), or Poly(lactide-co-caprolactone) (PLCL) blocks. This system is engineered to flow as a liquid solution at room temperature for facile injection into the eye and then quickly gel as it warms to physiological body temperatures (approximately 37 °C). The hydrogel acts as an ocular depot that can release three different drug molecules at programmed rates and times to provide optimal release of each species. In this manuscript, the hydrogel is configured to release a broad-spectrum antibiotic, a potent corticosteroid, and an ocular hypotensive, three ophthalmic therapeutic agents that are essential for post-operative management after ocular surgery, each drug released at its own timescale. The delivery platform is designed to mimic current topical application of postoperative ocular formulations, releasing the antibiotic for up to a week, and the corticosteroid and the ocular hypotensive agents for at least a month. Hydrophobic blocks, such as PLCL, were utilized to prolong the release duration of the biomolecules. This system also enables customization by being able to vary the initial drug loading to linearly tune the drug dose released, while maintaining a constant drug release profile over time. This minimally invasive biodegradable multi-drug delivery system is capable of replacing a complex ocular treatment regimen with a simple injection. Such a depot system has the potential to increase patient medication compliance and reduce both the immediate and late term complications following ophthalmic surgery.

STATEMENT OF SIGNIFICANCE

After ocular surgery, patients routinely receive multiple medications including antibiotics, steroids and ocular hypotensives to ensure optimal surgical outcomes. The current standard of care for postoperative treatment after ocular surgery involves using eye drops daily, which has limited effectiveness mainly due to poor patient adherence. To improve patient experience and outcomes, this article presents the first thermoresponsive hydrogel able to release multiple drug molecules for the application of post-operative treatment following ocular surgery. By varying the parameters such as hydrogel type and polymer hydrophobicity, the drug release profile, duration and dosage can finely be tuned. The approach presented in this article can readily be applied to other applications by simply changing the drug loaded in the drug delivery system.

Opacification of the C-flex 570C intraocular lens after sulcus fixation

PURPOSE

To report a case of diffuse intraocular lens (IOL) opacification in a patient who started complaining of blurred vision in his left eye over the course of three years after having phacoemulsification surgery combined with capsular bag fixation of a C-flex 570C IOL. The IOL had been repositioned in the ciliary sulcus following its subluxation.

METHOD

An IOL exchange was performed, and the explanted IOL was sent for histopathological analysis.

RESULTS

Scanning electron microscopy identified multiple crystalline-like deposits on both sides of the IOL. The optic was more extensively involved than the haptics. Energy-dispersive X-ray spectroscopy confirmed the predominance of calcium within the deposits.

CONCLUSIONS

The breakdown of the blood-aqueous barrier seems to be a key component of this calcification process. Ciliary sulcus fixation is not a suitable option for C-flex 570C IOLs.

Biocompatibility of Intraocular Lenses

The performance of an intraocular lens is determined by several factors such as the surgical technique, surgical complications, intraocular lens biomaterial and design, and host reaction to the lens. The factor indicating the biocompatibility of an intraocular lens is the behavior of inflammatory and lens epithelial cells. Hence, the biocompatibility of intraocular lens materials is assessed in terms of uveal biocompatibility, based on the inflammatory foreign-body reaction of the eye against the implant, and in terms of capsular biocompatibility, determined by the relationship of the intraocular lens with residual lens epithelial cells within the capsular bag. Insufficient biocompatibility of intraocular lens materials may result in different clinical entities such as anterior capsule opacification, posterior capsule opacification, and lens epithelial cell ongrowth. Intraocular lenses are increasingly implanted much earlier in life in cases such as refractive lens exchange or pediatric intraocular lens implantation after congenital cataract surgery, and these lenses are expected to exhibit maximum performance for many decades. The materials used in intraocular lens manufacture should, therefore, ensure long-term uveal and capsular biocompatibility. In this article, we review the currently available materials used in the manufacture of intraocular lenses, especially with regard to their uveal and capsular biocompatibility, and discuss efforts to improve the biocompatibility of intraocular lenses.

Surface Modification of Intraocular Lenses

Objective:

This paper aimed to review the current literature on the surface modification of intraocular lenses (IOLs).

Data Sources:

All articles about surface modification of IOLs published up to 2015 were identified through a literature search on both PubMed and ScienceDirect.

Study Selection:

The articles on the surface modification of IOLs were included, but those on design modification and surface coating were excluded.

Results:

Technology of surface modification included plasma, ion beam, layer-by-layer self-assembly, ultraviolet radiation, and ozone. The main molecules introduced into IOLs surface were poly (ethylene glycol), polyhedral oligomeric silsesquioxane, 2-methacryloyloxyethyl phosphorylcholine, TiO₂, heparin, F-heparin, titanium, titanium nitride, vinyl pyrrolidone, and inhibitors of cytokines. The surface modification either resulted in a more hydrophobic lens, a more hydrophilic lens, or a lens with a hydrophilic anterior and hydrophobic posterior surface. Advances in research regarding surface modification of IOLs had led to a better biocompatibility in both in vitro and animal experiments.

Conclusion:

The surface modification is an efficient, convenient, economic and promising method to improve the biocompatibility of IOLs.

Perioperative prophylaxis to prevent recurrence following cataract surgery in uveitic patients: a two-centre, prospective, randomized trial

PURPOSE

To compare the postoperative risk of inflammatory relapse in two groups of uveitic patients who underwent cataract surgery: one group had perioperative topical steroids alone and the other used topical and oral steroids.

METHODS

Prospective, randomized, unmasked, duocentric clinical trial conducted at the University of Parma (Italy), and the Jules Gonin Eye Hospital of Lausanne (Switzerland). Patients with a history of non-infectious uveitis requiring cataract surgery in 2009-2013 were assigned to two groups of perioperative prophylaxis: (A) intensive topical steroids alone; (B) the same topical regimen combined with oral steroids. Uveitis relapse over a period of 6 months was assessed.

RESULTS

In total, 52 eyes in 50 patients were randomized: 28 eyes were assigned to group A (topical) and 24 eyes to group B (topical + oral). Mean relapse-free survival time was 131 ± 11 days in group A and 150 ± 13 days in group B. This difference was not statistically significant (p = 0.42). At the end of follow-up, the groups were also comparable in terms of significant improvement in visual acuity (p < 0.01), mean central macular thickness (CMT) and IOP variation.

CONCLUSIONS

Absolute and long-lasting control of ocular, and possibly systemic, inflammation predisposes uveitis patients to satisfactory results after cataract extraction and intraocular lens implantation. Despite a lower rate of recurrences following oral steroid supplementation, the efficacy of an intensive perioperative topical steroid regimen alone in preventing postoperative uveitis relapse was statistically comparable. Secondary outcomes were also comparable between the two groups. Transient IOP elevation should be expected until treatment discontinuation.

Recovery after cataract surgery

Cataract surgery is the most common ophthalmological surgical procedure, and it is predicted that the number of surgeries will increase significantly in the future. However, little is known about the recovery after surgery. The first aim of this study was to evaluate the prevalence, severity and duration of pain and other ocular discomfort symptoms experienced after cataract surgery. The other objectives were to identify the factors associated with lower postoperative patient satisfaction and to measure the effect of cataract surgery on patients' health-related quality of life (HRQoL) and visual function in everyday life. The study design was a prospective follow-up study. The course of the recovery and the presence of ocular symptoms were evaluated by interviewing the patients via a questionnaire at 1 day, 1 week, 6 weeks and one year after surgery The visual functioning in everyday life was measured with Visual Functioning Index VF-7 and Catquest-9SF-questionnaires and furthermore the HRQoL was measured with the 15D-instrument before surgery and at 12 months after surgery. The patients returned the questionnaires by mail and were interviewed in the hospital on the day of the surgery. The same patients filled-in all the questionnaires. The patient reports were used to collect the data on medical history. A total of 303 patients were approached at Kuopio University Hospital in 2010-2011 and of these 196 patients were eligible and willing to participate, with postoperative data being available from 186 (95%) patients. A systematic review article was included in the study procedure and it revealed the wide range in the reported incidence of postoperative ocular pain. Some of the identified randomized controlled studies reported no or only minor pain whereas in some studies significant pain or pain lasting for several weeks has been described in more than 50% of the study patients. In the present study setting, pain was reported by 34% during the first postoperative hours and by approximately 10% of patients during the first six weeks after surgery. During the early recovery in the hospital, only a minority of the patients reporting pain were provided with pain medication. The ocular discomfort symptoms such as itchiness, burning, foreign-body sensation and tearing were common both before (54%) and after surgery (38-52%). These symptoms can also be described as painful symptoms and are often difficult to distinguish from ocular pain. The symptoms are also typical of ocular surface disease, and some patients may benefit from the postoperative administration of tear substitutes. The patients reporting postoperative ocular symptoms were less satisfied with the treatment outcome at 12 months after surgery (p = 0.001) compared to the patients who experienced no symptoms. Those patients reporting less disability in visual functioning before surgery were more satisfied than patients with more reported disability. The HRQoL improved significantly after cataract surgery (p = 0.002). However, when compared to an age-and gender-standardized control population, in cataract subjects the HRQoL remained slightly worse both before and at 12 months after surgery.

Expression of Cytokines, Chmokines and Growth Factors in Patients Undergoing Cataract Surgery with Femtosecond Laser Pretreatment

Purpose

To describe cytokines, chemokines and growth factors profiles in patients undergoing cataract surgery with femtosecond laser pretreatment and investigate their relationships with the postoperative in vivo inflammation index.

Methods

Aqueous humor was collected from 22 eyes after femtosecond laser pretreatment and from 22 eyes at the beginning of routine cataract surgery. The levels of 45 inflammation-related mediators were measured using multiplex fluorescent bead-based immunoassays. Laser flare photometry was measured preoperatively and at 1 day, 7 days and 30 days postoperatively.

Results

Compared with the control group, the femtosecond laser treatment group showed significantly higher aqueous humor levels of fibroblast growth factor (FGF-2), tumor necrosis factor (TNF)-α, leukemia inhibitor factor (LIF), interleukin (IL)-1ra and IL-18, and significantly lower aqueous humor levels of IL-9, platelet-derived growth factor (PDGF)-BB, eotaxin and TNF-β. Postoperative aqueous flare was significantly greater in the manual cataract surgery group at 1 day (p<0.001), 7days (p<0.001) and 30 days (p = 0.002).No correlation was found between the analyzed mediators and the aqueous flare values.

Conclusions

The expression profiles of cytokines, chemokines and growth factors and the correlations of these profiles with the in vivo inflammatory indexes for patients undergoing cataract surgery with femtosecond laser pretreatment were identified. Our data indicate a disturbance of postoperative inflammation response after femtosecond laser treatment.

Role of Concomitant Triamcinolone Acetonide Injection in Small-Gauge Vitrectomy for Idiopathic Epiretinal Membrane Peel

PURPOSE

The concomitant use of triamcinolone acetonide (TA) at the completion of pars plana vitrectomy for the treatment of epiretinal membrane may speed up the anatomical and functional outcomes of surgery. We report the outcome of patients undergoing small-gauge vitrectomy for idiopathic epiretinal membrane peel with or without adjuvant TA therapy.

DESIGN

This is a retrospective, single-center case series.

METHODS

We included 75 eyes of 75 individual patients. Twenty-six patients (group A) had an adjuvant TA injection during surgery, whereas 49 patients (group B) were not injected. We assessed the patients for change in visual acuity (VA) and central macular thickness before and after surgery.

RESULTS

Group A had a mean logarithm of the minimum angle of resolution VA of 0.63 ± 0.33 and 0.51 ± 0.31 preoperatively and 3 months after surgery, respectively. Group B had a mean logarithm of the minimum angle of resolution VA of 0.47 ± 0.17 and 0.36 ± 0.17 preoperatively and 3 months after surgery, respectively. No significant difference was found between the groups in change of VA. The mean central macular thickness for groups A and B patients before surgery was 474.12 ± 120 μm and 445 ± 85 μm, decreasing to 369 ± 70 μm and 386 ± 60 μm at the final visit, respectively. The difference in macular thickness reduction between the groups was statistically significant.

CONCLUSIONS

Anatomical and functional improvement was found in both groups after surgery. Macular thickness was further reduced in the group of patients treated with adjuvant TA.

Peripheral retinal vasculopathy in childhood glaucoma

PURPOSE

To report wide-field fluorescein angiography findings in the peripheral retina of eyes with childhood glaucoma.

METHODS

Fluorescein angiograms were examined retrospectively in 12 patients with childhood glaucoma who underwent wide-field fluorescein angiography after surgical or medical treatment of glaucoma. This series included 12 eyes of 6 patients with primary congenital glaucoma, 5 eyes of 3 patients with glaucoma associated with congenital cataract surgery, 4 eyes of 2 patients with glaucoma associated with a systemic condition, and 1 eye of 1 patient with phakomatosis pigmentovascularis Type II. RetCam fundus photography images and digital fluorescein angiography were performed under general anesthesia.

RESULTS

The most common finding observed in our series was peripheral retinal nonperfusion, which affected 20 eyes (91%). Other notable features seen were circumferential branching of the retinal vessels parallel to the ora serrata (77%), venous shunts (50%), and abnormal capillary branching patterns, including capillary dilatation (41%) and tortuous capillary tangles (18%). Leakage at the junction of vascular and avascular retina was not commonly seen (13.6%). None of the eyes had evidence of retinal neovascularization or fibrovascular proliferation.

CONCLUSION

Retinal vascular abnormalities and peripheral nonperfusion are novel findings in childhood glaucoma. Further studies are needed to understand the significance and possible long-term consequences of these findings.

Anterior eye segment drug delivery systems: current treatments and future challenges

New technologies for delivery of drugs, such as small molecules and biologics, are of growing interest among clinical and pharmaceutical researchers for use in treating anterior segment eye disease. The challenge is to deliver effective drugs at therapeutic concentrations to the targeted ocular tissue with minimal side effects. To achieve this, a better understanding of the unmet needs, what is required of the various methods of delivery to achieve successful delivery, and the potential challenges of anterior segment drug delivery is necessary and the primarily aim of this review. This review covers the various physiological and anatomical barriers that exist for effective delivery to the targeted tissue of the eye, the pathological conditions of the anterior segment, and the unmet needs for treatment of these ocular diseases. Second, it reviews the novel delivery technologies that have the potential to maintain and/or improve the drug's therapeutic index and improving both patient adherence for chronic therapy and potential patient outcomes. This review bridges the pharmaceutical and clinical research/challenges and provides a detailed overview of anterior segment drug delivery accomplishments thus far, for researchers and clinicians.

Short-term outcomes of coaxial microincision cataract surgery for uveitis-associated cataract without postoperative systemic steroid therapy

PURPOSE

To study the necessity of prophylactic systemic steroid therapy after coaxial microincision cataract surgery (MICS) conducted in aged patients during remission of uveitis.

PROCEDURES

A total of 17 consecutive patients who underwent MICS were enrolled in this retrospective study. The median age was 73 years. MICS via a 2.2-mm incision was performed. None of the patients received systemic steroid administration after surgery. The visual acuity, intraocular pressure (IOP) and inflammation scores were recorded.

RESULTS

The mean logMAR visual acuity was significantly improved from 0.56 ± 0.58 to 0.10 ± 0.30, and the mean inflammation score was reduced from 0.20 to 0.14. Postoperative complications were recurrence of ocular inflammation in 1 eye and elevation of IOP more than 21 mm Hg in 1 eye, which were resolved by topical steroids and topical antiglaucoma medication.

CONCLUSIONS

Prophylactic systemic steroid therapy after MICS may not be necessary in aged uveitis patients without posterior complications before cataract surgery.

Anterior chamber flare after femtosecond laser-assisted cataract surgery

PURPOSE

To determine whether postoperative ocular inflammation is less after femtosecond laser-assisted cataract surgery than after conventional phacoemulsification (manual) cataract surgery.

SETTING

Private clinic, Launceston, Tasmania, Australia.

DESIGN

Prospective consecutive investigator-masked nonrandomized parallel cohort study.

METHODS

Consecutive cataract patients who had femtosecond laser-assisted cataract surgery or manual cataract surgery by the same surgeon at a single center were assessed. The primary endpoint was postoperative aqueous flare measured by laser flare photometry at 1 day and 4 weeks. Secondary endpoints included retinal thickness measured by optical coherence tomography and slitlamp examination findings at 4 weeks.

RESULTS

The per-protocol population comprised 176 patients (100 in laser group; 76 in manual group). Postoperative aqueous flare was significantly greater in the manual cataract surgery group at 1 day (P=.0089) and at 4 weeks (P=.003). There was a significant correlation between effective phacoemulsification time and 1-day postoperative aqueous flare (r = 0.35, P<.0001). The increase in outer zone thickness measured by optical coherence tomography was less in the laser group (P=.007).

CONCLUSION

Anterior segment inflammation was less after femtosecond laser-assisted cataract surgery than after manual cataract surgery, and this appeared to be due to a reduction in phacoemulsification energy.