Relationship between retinal microstructures and visual acuity after cataract surgery in patients with retinitis pigmentosa

Retinitis Pigmentosa: Current Clinical Management and Emerging Therapies

Retinitis pigmentosa (RP) comprises a group of inherited retinal dystrophies characterized by the degeneration of rod photoreceptors, followed by the degeneration of cone photoreceptors. As a result of photoreceptor degeneration, affected individuals experience gradual loss of visual function, with primary symptoms of progressive nyctalopia, constricted visual fields and, ultimately, central vision loss. The onset, severity and clinical course of RP shows great variability and unpredictability, with most patients already experiencing some degree of visual disability in childhood. While RP is currently untreatable for the majority of patients, significant efforts have been made in the development of genetic therapies, which offer new hope for treatment for patients affected by inherited retinal dystrophies. In this exciting era of emerging gene therapies, it remains imperative to continue supporting patients with RP using all available options to manage their condition. Patients with RP experience a wide variety of physical, mental and social-emotional difficulties during their lifetime, of which some require timely intervention. This review aims to familiarize readers with clinical management options that are currently available for patients with RP.

Cataract surgery in patients with retinitis pigmentosa: systematic review

Retinitis pigmentosa (RP) is an inherited bilateral retinal degenerative disease with an incidence of 1 in 4000 people. RP affects more than 1 million individuals worldwide. Although night blindness and restricted visual field are the most typical symptoms of these individuals, generalized vision loss due to cataracts can be expected in the latter stages of the disease. It has been demonstrated that posterior subcapsular cataract is the most prevalent cataract in younger individuals with RP, as opposed to age-related cataracts. Although most ophthalmologists may have a negative view of cataract surgery in patients with RP, it appears that it can play an important role in the visual restoration of patients with RP. However, there are concerns about performing cataract surgery for patients with RP. Herein, a systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses on databases of MEDLINE and Scopus.

Use of ellipsoid zone width for predicting visual prognosis after cataract surgery in patients with retinitis pigmentosa

OBJECTIVE

To predict the visual prognosis of cataract surgery in patients with retinitis pigmentosa by measuring ellipsoid zone (EZ) width using spectral-domain optical coherence tomography.

METHODS

This retrospective study included patients with retinitis pigmentosa who underwent uncomplicated cataract surgery between December 2017 and June 2020. Preoperative best-corrected visual acuity (BCVA) and the best postoperative BCVA during follow-up were collected. EZ width was measured on preoperative cross-sectional optical coherence tomography images along the horizontal/vertical meridian through the fovea.

RESULTS

Thirty-eight eyes of 38 patients (22 female; mean [±standard deviation] age, 62.1 ± 11.8 years) were included. The median preoperative logarithm of the minimum angle of resolution BCVA of 0.52 (range, 0.00-3.00) significantly improved to 0.07 (range, -0.18-3.00) after surgery (P < 0.001). On preoperative spectral-domain optical coherence tomography images, the median horizontal, vertical, and average EZ widths were 783 (range, 0-9837), 761 (range, 0-10 250), and 769 (range, 0-10 043) μm, respectively. Postoperative BCVA significantly correlated with the horizontal (r = -0.784, P < 0.001), vertical (r = -0.777, P < 0.001), and average EZ widths (r = -0.777, P < 0.001). The area under the receiver operating characteristic curve for the ability of the horizontal, vertical, and average EZ widths to discriminate eyes with and without postoperative BCVA ≤ 0.3 was 0.971, 0.960, and 0.963, respectively, with best cut-off values of 513, 608, and 515 μm, respectively.

CONCLUSIONS

EZ width measurement can help predict the visual prognosis of cataract surgery in patients with retinitis pigmentosa. A preferable visual acuity prognosis can be expected in patients with an EZ width of approximately 600 μm.

Effects and Prognosis of Cataract Surgery in Patients with Retinitis Pigmentosa

INTRODUCTION

Cataract extraction could improve visual acuity (VA) for patients with retinitis pigmentosa (RP), while the surgery may increase photoreceptor degeneration through light damage. In this study, we conducted a systematic review and meta-analysis to investigate the effectiveness and prediction of VA after cataract surgery in patients with RP.

METHODS

We comprehensively extracted data from literature of available studies with quality control processing. Improvement of VA before and after cataract surgery of different durations of follow-up and different structural integrity of the preoperative macular ellipsoid zone (EZ) in patients with RP were compared. VA was measured by the logarithm of the minimum angle of resolution (logMAR).

RESULTS

Sixteen studies were subjected to analysis. Postoperative VA was significantly improved versus preoperative, with a mean difference (MD) of 0.57 [95% confidence interval (CI) 0.45, 0.69], and a fixed-effect model was applied during follow-up durations of 1 day to 1 month (I² = 0%). Similarly, for follow-up durations of 1-3 months, 3-6 months, and 6-12 months, postoperative VAs were all better than preoperative values, with MDs of 0.36 (95% CI 0.31, 0.41), 0.35 (95% CI 0.23, 0.46), and 0.22 (95% CI 0.14, 0.30) (I² < 50%). For follow-up duration of 1-5 years, the random-effect model was applied for higher heterogeneity (I² = 81%), with an MD of 0.26 (95% CI 0.09, 0.43). There was no significant difference in the improvement of the EZ-invisible group, with an MD of 0.27 (95% CI - 0.17, 0.70) (I² = 82%). There were significant differences between EZ-abnormal and EZ-normal groups in preoperative and postoperative VA, with MDs of 0.56 (95% CI 0.27, 0.85) and 0.46 (95% CI 0.27, 0.65) (I² > 50%).

CONCLUSIONS

Cataract surgery could improve VA for patients with RP during long-term follow-up, and the surgery is not recommended for patients with invisible preoperative macular EZ. However, further studies are required to address the problem of excessive light exposure to the degenerated retina in patients with RP with the cataract removed. The study protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42022340165).

Long-term Outcomes of Cataract Surgery in Patients with Retinitis Pigmentosa

PURPOSE

To investigate the long-term outcomes of cataract surgery in patients with retinitis pigmentosa (RP).

DESIGN

Retrospective, observational study.

PARTICIPANTS

Sixty-four patients with typical RP (22 males, 42 females, average age 62.8 ± 10.1 years) who underwent cataract surgery at Kyushu University Hospital between May 2007 and October 2015 and who were followed up for ≥3 years post-surgery.

METHODS

Differences between pre- and post-surgery visual function, including best-corrected visual acuity (BCVA) and parameters in the Humphrey Field Analyzer (HFA) examinations using the central 10-2 program were investigated. The pre-surgery conditions of the foveal ellipsoid zone (EZ) were classified into three grades (grade 1: invisible; grade 2: abnormal; grade 3: normal) based on optical coherence tomography findings.

MAIN OUTCOME MEASURES

BCVA, the retinal sensitivity in HFA 10-2 tests.

RESULTS

Cataract surgery was performed in 96 eyes, with an average follow-up period of 5.8 ± 2.4 years. The mean pre-surgery BCVA was 0.64 ± 0.52 logarithm of the minimum angle of resolution (logMAR), and the final post-surgery BCVA was 0.61 ± 0.67 logMAR (p=0.57). Significant improvement of post-surgery BCVA was observed only in the eyes with preserved foveal EZ (grade 3) (p<0.01). In 62 eyes of the 45 patients who received HFA 10-2 tests, the mean values of deviation, macular sensitivity and foveal sensitivity at the final visit were significantly decreased compared with preoperative values (p<0.01), while those in the grade 3 eyes did not change significantly post-surgery (p=0.13).

CONCLUSIONS

In the long-term course after cataract surgery in RP patients, many cases experienced vision loss with progression of the disease. A preoperative finding of preserved foveal EZ was associated with a better visual prognosis, suggesting that EZ evaluation is useful to predict the long-term visual outcome after cataract surgery in RP patients.

The Impact of Cataract Surgery on Contrast Visual Acuity and Retinal Sensitivity in Patients with Retinitis Pigmentosa

Purpose

To determine the effects of cataract surgery on contrast visual acuity and retinal sensitivity in patients with retinitis pigmentosa.

Methods

Retinal sensitivity and contrast visual acuity were determined by microperimetry (MAIA) and contrast sensitivity acuity tester (CAT-CP), respectively, before and after cataract surgery. The significance of the correlations between visual acuity, retinal sensitivity, contrast visual acuity, improvements after surgery, and macular structure before and after cataract surgery was determined.

Results

Retinal sensitivity and contrast visual acuity were significantly improved after cataract surgery. The correlations among postoperative visual acuity, postoperative retinal sensitivities, and preoperative ellipsoid zone length were significant. The postoperative retinal sensitivity of the central 10° and the ellipsoid zone length was particularly significantly correlated. Preoperative contrast visual acuity and the amount of improvement and preoperative retinal sensitivity and the amount of improvement were significantly negatively correlated. The contrast visual acuity under both the 100% and 10% photopic and mesopic conditions improved significantly after cataract surgery.

Conclusions

Cataract surgery in retinitis pigmentosa patients with preserved ellipsoid zones significantly improved retinal sensitivity and contrast visual acuity. Cataract surgery can be expected to improve retinal sensitivity and contrast visual acuity under various conditions, even if preoperative visual parameters are low, as long as the ellipsoid zone is preserved.

Effect of lens capsular tension ring on preventing capsular contraction syndrome in the surgery of retinitis pigmentosa combined with cataract: Retrospective case series

PURPOSE

To observe the effect of phacoemulsification and intraocular lens (IOL) implantation with or without lens capsular tension ring (CTR) on retinitis pigmentosa (RP) combined with cataract patients.

DESIGN

Retrospective cases series study.

METHODS

Sixty-three cases (84 eyes) of RP with cataract were collected, including 30 males and 33 females. Phacoemulsification with 3.0 mm clear corneal incision was performed in all the patients. IOL and CTR implantation were performed in 44 eyes, and IOL implantation alone was performed in 40 eyes. All cases were followed up at 1 day, 1 week and 1, 3, 6,12 months after the surgery to compare the best-corrected visual acuity (BCVA), intraocular pressure (IOP), corneal endothelial cell count (ECC) and complications before and after the surgery.

RESULTS

All surgery were successfully completed by the same physician, and IOL and CTR were all implanted in capsule without complications. The BCVA at 6 months after surgery was 0.91 ± 0.88 LogMAR, showing an improvement compared with the BCVA(1.3 ± 0.7LogMAR) before surgery and there was a statistically significant difference (P = .003). Four cases of capsule contraction syndrome (CCS) occurred in no CTR implantation group and there was no CCS in CTR group. There was a statistically significant difference in the incidence of CCS between two groups (P = .047).

CONCLUSIONS

Phacoemulsification for RP combined with cataract is safe and reliable, and CTR implantation is conducive to reducing the complications caused by capsule contraction.

Long-term Clinical Outcomes of Cataract Surgery in Patients with Retinitis Pigmentosa

Purpose: The long-term clinical outcomes of cataract surgery in patients with retinitis pigmentosa (RP) were evaluated. Methods: A retrospective analysis of medical records was performed for patients who were diagnosed with RP and underwent cataract surgery. Preoperative best-corrected visual acuity (BCVA) was compared with BCVA at 1 month postoperatively and at the final visit. The proportion of patients with cystoid macular edema development or aggravation after surgery was evaluated, as was the proportion of patients with intraocular lens subluxation/dislocation. For patients who underwent optical coherence tomography, factors associated with a BCVA of 0.5 or better at 1 month were analyzed. Results: In total, 133 eyes were included and the mean follow-up period was 58.7 months. The mean logarithm of minimal angle of resolution BCVA was 0.69 ± 0.65 at diagnosis. The BCVA was significantly improved to 0.51 ± 0.47 at 1 month postoperatively (p < 0.001). However, the BCVA at the final visit (0.70 ± 0.81) was similar to the baseline value (p = 1.000). Cystoid macular edema development or aggravation was noted in 8 eyes (6.0%) and intraocular lens subluxation/dislocation was noted in 4 eyes (3.0%). A subgroup analysis involving 108 eyes revealed that preoperative BCVA (p < 0.001) and ellipsoid zone status (p = 0.001) were associated with postoperative visual acuity. Conclusions: Short-term outcomes of cataract surgery in patients with RP were comparatively good. However, long-term visual deterioration was noted with disease progression. Preoperative BCVA and ellipsoid zone status are useful markers for predicting short-term visual outcomes.

A Review of Complicated Cataract in Retinitis Pigmentosa: Pathogenesis and Cataract Surgery

Retinitis pigmentosa (RP) is a set of inherited retinal degenerative diseases that affect photoreceptor and retinal pigment epithelial cells (RPEs), possibly associated with some ocular complications, including cataract. The complicated cataract formation is most likely the result of RP-related inflammation response, and the most common morphology category is posterior subcapsular cataract (PSC). Despite the absence of curative pharmacologic treatment, phacoemulsification with intraocular lens implantation to deal with opacification in the lens is preferred due to the considerable visual outcomes. However, the incidence of intraocular and postoperative complications is higher in RP patients than those without, including intraoperative phototoxic retinal damage, posterior capsular opacification (PCO), capsular contraction syndrome (CCS), pseudophakic cystoid macular edema (PCME), increased postoperative intraocular pressure (IOP), and intraocular lens (IOL) dislocation. Hence, it needs much attention to surgery progress and close follow-up. In this review, we discuss the current understanding of RP patients with complicated cataracts from morphology to potential pathogenesis to cataract surgical procedure and provide a concise description and the recommended management of related surgery complications to broaden the knowledge and lower the latent risks to yield better clinical outcomes.

Cataract surgery in patients with late-onset retinal degeneration

PURPOSE

To review the outcomes in a series of patients with long anterior lens zonular fibers associated with late-onset retinal degeneration who had phacoemulsification cataract surgery.

SETTING

Newcastle Eye Centre, Newcastle upon Tyne, United Kingdom.

DESIGN

Retrospective case series.

METHODS

Inclusion criteria were patients with genetically confirmed late-onset retinal degeneration requiring cataract surgery. Perioperative data relating to surgery were collected. In addition, the corrected distance visual acuity (CDVA) and retinal imaging data were recorded. Selected lens capsules were examined using immunohistochemistry or scanning electron microscopy (SEM).

RESULTS

Eleven eyes of 7 patients were included. The long anterior lens zonular fibers made capsulorhexis challenging; however, it was completed safely in all cases. There were no intraoperative or postoperative issues with lens stability. The CDVA improved postoperatively in those cases with intact foveal photoreceptors and retinal pigment epithelium. Over the longer term, the CDVA slowly declined because of progressive atrophy of the macula. Most patients noticed a subjective improvement in vision, even those with advanced disease at baseline. Immunohistochemistry showed that the C1QTNF5 protein was expressed within the lens capsule epithelial cells, although SEM of the long anterior lens zonular fibers showed them to be smaller in diameter than normal anterior lens zonular fibers and to be composed of a helix of fibers.

CONCLUSIONS

In this small series of patients with late-onset retinal degeneration, cataract surgery was successfully performed without long-term complications involving intraocular lens stability. The objective improvement in CDVA seemed to be limited to patients with good foveal photoreceptor architecture.

Creating Hybrid Monovision with 7.0 mm XL Optic and High-Add AMD Intraocular Lenses (XL-MAGS) in a Patient with Retinitis Pigmentosa

We report a case of a patient with progressed retinitis pigmentosa (RP) who underwent bilateral cataract extraction with implantation of a monofocal enlarged optic in the far dominant eye and a high-add AMD intraocular lens (IOL) in the near dominant eye (hybrid monovision XL-MAGS). A 71-year-old woman presented to our clinic complaining of reduced visual acuity additionally to her diagnosis of RP. The high-add IOL LENTIS® MAX LS-313 MF80 (Oculentis, Germany) was implanted in the right eye and the 7.0 mm optic ASPIRA-aXA IOL (HumanOptics, Germany) in the left eye. Six months postoperatively, the uncorrected distance visual acuity improved from hand motion to 0.5 logMAR in the right eye and to 0.3 logMAR in the left eye. Similarly, best corrected near visual acuity significantly improved to 0.4 and 0.7 logMAR, respectively. The patient's subjective quality of life and autonomy improved significantly. RP is a severe retinal disease which leads to loss of vision and typical “tunnel vision” with visual field defects. As this genetic disorder is incurable, many ophthalmologists are not willing to perform cataract surgery. However, this case report shows that creating hybrid monovision with a high-add lens and a 7.0 mm optic IOL led to improvement of visual function and, more importantly, enhanced quality of life and self-autonomy of the patient.

Non-syndromic retinitis pigmentosa

Retinitis pigmentosa (RP) encompasses a group of inherited retinal dystrophies characterized by the primary degeneration of rod and cone photoreceptors. RP is a leading cause of visual disability, with a worldwide prevalence of 1:4000. Although the majority of RP cases are non-syndromic, 20-30% of patients with RP also have an associated non-ocular condition. RP typically manifests with night blindness in adolescence, followed by concentric visual field loss, reflecting the principal dysfunction of rod photoreceptors; central vision loss occurs later in life due to cone dysfunction. Photoreceptor function measured with an electroretinogram is markedly reduced or even absent. Optical coherence tomography (OCT) and fundus autofluorescence (FAF) imaging show a progressive loss of outer retinal layers and altered lipofuscin distribution in a characteristic pattern. Over the past three decades, a vast number of disease-causing variants in more than 80 genes have been associated with non-syndromic RP. The wide heterogeneity of RP makes it challenging to describe the clinical findings and pathogenesis. In this review, we provide a comprehensive overview of the clinical characteristics of RP specific to genetically defined patient subsets. We supply a unique atlas with color fundus photographs of most RP subtypes, and we discuss the relevant considerations with respect to differential diagnoses. In addition, we discuss the genes involved in the pathogenesis of RP, as well as the retinal processes that are affected by pathogenic mutations in these genes. Finally, we review management strategies for patients with RP, including counseling, visual rehabilitation, and current and emerging therapeutic options.

Evaluating Structural Progression of Retinitis Pigmentosa After Cataract Surgery

PURPOSE

To determine whether cataract surgery accelerates disease progression in retinitis pigmentosa (RP).

DESIGN

Retrospective cohort study.

METHODS

Seventy eyes of 40 patients with RP were categorized as having had phacoemulsification with intraocular lens implantation vs no cataract surgery at a single tertiary-level institution. Spectral-domain optical coherence tomography (SDOCT) was used to measure the ellipsoid zone (EZ) width, which has been demonstrated to be a reliable marker of RP severity, at baseline and throughout follow-up (median 768 days). RP progression was calculated as the loss of EZ width over time for all patients. Additional postoperative data were collected for the cataract surgery group, including preoperative and postoperative best-corrected visual acuity, incidence of macular edema, posterior capsular opacification, epiretinal membrane, and intraocular lens subluxation.

RESULTS

Multivariable analysis including age, baseline EZ width, mode of inheritance, and cataract surgery status showed that there was no significant difference in RP progression between the cataract surgery and control groups (P = .23). Mode of inheritance was associated with RP progression, with autosomal recessive RP progressing at 148 μm/year and autosomal dominant RP progressing at 91 μm/year (P = .003). Visual acuity improved in almost all eyes that underwent surgery (17/19, 89%) and remained stable in remaining eyes (2/19, 11%). There was a high incidence of postsurgical posterior capsular opacification (18/19, 95%). There were no serious complications, such as lens subluxation or endophthalmitis.

CONCLUSIONS

Our findings suggest that cataract surgery is a safe and effective means of improving visual acuity in RP patients and that it does not seem to be associated with faster disease progression as measured using SDOCT.