A comparison of anterior and posterior chamber lenses after cataract extraction in rural Africa: a within patient randomised trial

The Minimally Important Difference (MID) in Visual Acuity That Represents Changes in Patients' Quality of Life

To assess the minimal change in visual acuity perceived by patients as important in different eye-related interventions. PubMed was utilized to search articles on each of the four major interventions: cataract surgery, keratoplasty, different glaucoma treatments, and refractive eye surgery, each combined with quality of life (QoL) and visual acuity keywords. The search was narrowed to articles between 2000 and 2023. Seventy-four major articles were thus reviewed. Of these, 27 studies reviewed the results of cataract surgery, 20 studies discussed the effect of keratoplasty interventions on the vision-related QoL (VRQoL), most showing that VRQoL improved significantly after keratoplasty, 11 studies investigated the effect of different glaucoma interventions on patients' visual acuity and the QoL, 16 studies reviewed refractive surgery, where they showed an improved QoL in most of the cases, although some of the studies showed a slight superiority of one intervention over the other in the short term. The minimally important difference (MID) perceived in visual acuity depends mainly on the type of surgical intervention (keratoplasty, glaucoma, or refractive surgery), and the impact on QoL on improved visual acuity differs depending on the intervention.

Refractive Outcomes of Four-Point Scleral Fixation of Akreos AO60 Intraocular Lens Using Gore-Tex Suture

Background/Objective

To determine the refractive outcomes after 4-point scleral fixation of the Akreos AO60 intraocular lens with Gore-Tex suture.

Methods

This was a single referral center, multi-surgeon, retrospective consecutive case series. A total of 63 eyes met the inclusion criteria for having received surgical implantation of the Akreos AO60 intraocular lens with Gore-Tex suture from August 2014 to December 2018. Exclusion criteria included all ocular pathology that precluded an accurate refraction, concurrent ocular surgery, poor corrected pre-operative visual potential, among other factors. Main outcome measures included post-operative uncorrected visual acuity (VA), best-corrected VA, and spherical equivalent deviation from target.

Results

Mean pre-operative BCVA was 0.67 ± 0.64 LogMAR (20/93 Snellen). Mean final post-operative BCVA was 0.17 ± 0.18 (20/28 Snellen) and mean final post-operative UCVA was 0.31 ± 0.22 (20/41 Snellen). Mean post-operative spherical equivalent was −0.57 D. Mean post-operative astigmatism was 0.85 D.

Conclusion

Refractive outcomes after secondary implantation with Akreos AO60 are favorable in eyes with good visual potential.

Histopathological changes in the anterior segment with anterior and posterior chamber intraocular lens

OBJECTIVE

Patients have shown a lowering of intraocular pressure (IOP) after cataract surgery. Histopathology studies have reported trabecular meshwork (TM) changes in pseudophakic eyes with posterior chamber intraocular lens (PCIOL) and have eluded to the mechanisms for IOP decrease. Unlike PCIOLs, TM histopathology changes after implantation of an anterior chamber intraocular lens (ACIOL) have not been studied, to our knowledge. Therefore, this study aims to examine the histopathological changes in both the TM and corneal endothelium among donor eyes with ACIOL, PCIOL, and phakic eyes.

METHODS

Forty fixed postmortem donor eyes were obtained, sectioned, and embedded. Slides were stained with Masson's trichrome and CD31 vascular endothelial antibody, and further digitalized. Customized Medical Parachute TMAN software quantified the cellular components, the trabecular extracellular matrix (ECM), ECM fibrosis, and trabecular area. Schlemm's canal and corneal endothelium were quantified across the ACIOL, PCIOL, and phakic groups.

RESULTS

Cellular area component of the TM was lower in the ACIOLs and PCIOLs than in phakic eyes, but statistically significant only between PCIOL and phakic eyes (p = 0.0023). ECM area component, TM fibrosis score and TM lamellae area, ciliary process fibrosis, and CD31 expression in Schlemm's canal showed no differences (p = 0.40, 0.99, 0.10, 0.83, 0.45). Significantly lower corneal endothelial cells were seen in ACIOLs compared with both PCIOLs and phakic eyes (p = 0.0002).

CONCLUSIONS

ACIOLs and PCIOLs in our sample group showed that there is loss of cellular components in the TM compared with the phakic eyes, with PCIOLs displaying the least amount of TM cells statistically, in this cohort. The ACIOLs led to a greater loss of corneal endothelial cells than both PCIOLs and phakic eyes after cataract surgery. The endothelial cells in Schlemm's canal did not seem to be affected by the IOL placements. Therefore, this study illustrates that there are histopathological differences seen with the placements of ACIOLs in both TM and cornea.

CONSORT 2010 statement: extension checklist for reporting within person randomised trials

Evidence shows that the quality of reporting of randomised controlled trials (RCTs) is not optimal. The lack of transparent reporting impedes readers from judging the reliability and validity of trial findings and researchers from extracting information for systematic reviews and results in research waste. The Consolidated Standards of Reporting Trials (CONSORT) statement was developed to improve the reporting of RCTs. Within person trials are used for conditions that can affect two or more body sites, and are a useful and efficient tool because the comparisons between interventions are within people. Such trials are most commonly conducted in ophthalmology, dentistry, and dermatology. The reporting of within person trials has, however, been variable and incomplete, hindering their use in clinical decision making and by future researchers. This document presents the CONSORT extension to within person trials. It aims to facilitate the reporting of these trials. It extends 16 items of the CONSORT 2010 checklist and introduces a modified flowchart and baseline table to enhance transparency. Examples of good reporting and evidence based rationale for CONSORT within person checklist items are provided.

Factors Associated with Complications and Postoperative Visual Outcomes of Cataract Surgery; a Study of 1,632 Cases

Purpose:

Cataract surgery is the most common intraocular surgery performed all over the world and has advanced technically in recent years. As in all surgeries, complications are unavoidable. Herein we report factors associated with complications and visual outcomes of cataract surgery.

Methods:

This retrospective cohort study included data of 1,632 cataract surgeries performed from 2007 to 2010 which was obtained from the cataract registry of the Malaysian National Eye Database. Demographic features, ocular and systemic comorbidites, grade of surgeon expertise and duration of surgery, type of anesthesia, intraoperative and postoperative complications, and the type of intraocular lens were recorded. Best corrected visual acuities were compared before and after the operation.

Results:

Mean patient age was 66.9 years with equal gender distribution. The majority of subjects had age related cataracts. Phacoemulsification was done faster than other surgeries, especially by specialist surgeons. History of prior ocular surgery and operations performed under general anesthesia were associated with greater complications. Phacoemulsification was associated with less complications and better visual outcomes. The age and etiology of cataract did not affect complications. Malays, absence of ocular comorbidities, left eyes and eyes operated under local anesthesia were more likely to experience more visual improvement. Gender, age, cause of cataract, systemic comorbidities and surgeon expertise as well as intra-and postoperative complications did not affect the visual outcomes.

Conclusion:

Phacoemulsification had good visual outcomes in cataract surgery. Duration of surgery, expertise of the surgeon and complications did not affect the visual outcomes.

The surgical management of cataract: barriers, best practices and outcomes

Cataract is the leading cause of blindness in the world. Cataract surgery has been shown by multiple studies to be one of the most cost-effective health interventions, and leads to a dramatic increase in quality of life and productivity for many patients. Though there has been marked improvement in the last several decades, surgical delivery services in developing nations are still suboptimal, and a large backlog in cataract cases continues to grow. To decrease this backlog, barriers to surgery, such as direct and indirect patient costs, geographic access to surgical facilities and surgeons, cultural factors, and patient education, must be addressed. In particular, access to services by women and rural patients needs to be improved. It is clear that extracapsular techniques are cost-effective and lead to better post-operative outcomes than intracapsular cataract extraction with aphakic correction. In addition, monitoring surgical outcomes is essential for improving the quality of surgical services. However, other issues regarding the delivery of cataract surgical services, including the role of average power intraocular lenses and the role of non-physician surgeons, are yet unresolved. Information about the true cost of surgery, including costs of surgeon training, equipment, and patient outreach programs, is needed so that the goal of self-sustaining programs may be obtained.

Surgical interventions for age-related cataract

BACKGROUND

Cataract accounts for 50% of blindness globally and remains the leading cause of visual impairment in all regions of the world, despite improvements in surgical outcomes (WHO 2005). This number is expected to rise due to an aging population and increase in life expectancy. Although cataracts are not preventable, their surgical treatment is one of the most cost-effective interventions in healthcare.

OBJECTIVES

To compare the effects of different surgical interventions for age-related cataract.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE up to July 2006, NRR Issue 3 2005, the reference lists of identified trials and we contacted investigators and experts in the field for details of published and unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTS).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and discrepancies were resolved by discussion. Where appropriate, risk ratios, odds ratios and weighted mean differences were summarised after assessing heterogeneity between the studies.

MAIN RESULTS

We identified 17 trials that randomised a total of 9627 people. Phacoemulsification gave a better visual outcome than extracapsular surgery but similar average cost per procedure in Europe but not in poorer countries. Extracapsular surgery with posterior chamber lens implant and ICCE with or without an anterior chamber intraocular lens (IOL) implant gave acceptable visual outcomes but extracapsular surgery had less complications. Manual small incision surgery provides better visual outcome than ECCE but slightly inferior unaided visual acuity compared to phacoemulsification.

AUTHORS' CONCLUSIONS

This review provides evidence from seven RCTs that phacoemulsification gives a better outcome than ECCE with sutures. We also found evidence that ECCE with a posterior chamber lens implant provides better visual outcome than ICCE with aphakic glasses. The long term effect of posterior capsular opacification (PCO) needs to be assessed in larger populations. The data also suggests that ICCE with an anterior chamber lens implant is an effective alternative to ICCE with aphakic glasses, with similar safety. Phacoemulsification provides the best visual outcomes but will only be accessible to the poorer countries if the cost of phacoemulsification and foldable IOLs decrease. Manual small incision cataract surgery provides early visual rehabilitation and comparable visual outcome to PHACO. It has better visual outcomes than ECCE and can be used in any clinic that is currently carrying out ECCE with IOL. Further research from developing regions are needed to compare the cost and longer term outcomes of these procedures e.g. PCO and corneal endothelial cell damage.