Incidence and factors associated with complications of sutured and sutureless cataract surgery following pars plana vitrectomy at a tertiary referral centre in Turkey

Suprachoroidal Hemorrhage

Suprachoroidal hemorrhage (SCH) refers to the accumulation of blood in the suprachoroidal space, a relatively uncommon but significant complication that can occur spontaneously, during ophthalmic surgery, or as a consequence of ocular trauma. If left undiagnosed and untreated, SCH can lead to severe vision loss or even blindness. Therefore, it is crucial for ophthalmologists to have a thorough understanding of this complication, taking proactive measures to prevent it during surgery and being knowledgeable about effective management strategies for patients with SCH. This review article aimed to provide a comprehensive overview of SCH, covering its risk factors, diagnostic approaches, and the best practices for its management. By enhancing awareness and knowledge in this area, we can improve patient outcomes and minimize the impact of SCH in ophthalmic practice.

A Modified Technique for Preventing Lens-Iris Diaphragm Retropulsion Syndrome in Vitrectomized Eyes during Phacoemulsification

BACKGROUND

Lens-iris diaphragm retropulsion syndrome (LIDRS) is common in vitrectomized or high myopic eyes during phacoemulsification. We evaluated the results of a modified technique for cataract treatment using phacoemulsification in vitrectomized eyes.

METHODS

In this retrospective study, we enrolled thirty-four vitrectomized eyes treated with modified phacoemulsification (Modified Group) and nineteen vitrectomized eyes treated with routine phacoemulsification (Control Group). The modified technique comprised irrigation with a balanced salt solution underneath the pupil before phacoemulsification instrument entry, lens implantation and stromal hydration to stabilize the anterior chamber and equilibrate the pressure between the anterior chamber and posterior cavity.

RESULTS

We compared the incidences of intra and postoperative complications and visual outcomes between modified and routine phacoemulsification. Pain, LIDRS and difficulty in stromal hydration were significantly more common in the Control Group than in the Modified Group (p < 0.05). There were no significant differences in the rates of posterior capsular rupture, iris trauma, lens dislocation, or posterior capsular opacification between the Modified and Control Groups (p > 0.05). However, there was no significant difference in visual acuity between the groups (p > 0.05). Complications such as loss of nuclear fragments into the vitreous cavity, cystoid macular edema, retina redetachment, suprachoroidal hemorrhage and vitreous hemorrhage did not occur either intra or postoperatively in any of our patients.

CONCLUSIONS

Our modified technique prevents LIDRS and complications arising during cataract surgery in vitrectomized eyes. Aside from this, the results of modified and routine phacoemulsification are similar in vitrectomized eyes.

The Postvitrectomy Cataract

To review the recent literature regarding risk factors for cataract formation after vitrectomy, the challenges and management strategies for anterior segment surgeons when facing post-vitrectomy cataract surgery, and the visual outcomes of patients undergoing post-vitrectomy cataract surgery. Cataract surgery after vitrectomy can be safely performed to significantly improve the visual outcome in most post-vitrectomy patients, although final visual acuity is primarily limited by the patient’s underlying vitreoretinal pathology.

Early-Onset Posterior Capsule Opacification: Incidence, Severity, and Risk Factors

INTRODUCTION

To evaluate the incidence, severity, and risk factors of early-onset posterior capsule opacification (PCO) following uneventful phacoemulsification and intraocular lens (IOL) implantation.

METHODS

Patients with cataracts who underwent phacoemulsification and IOL implantation surgery for 3 months from September 2019 to April 2020 were enrolled. All the subjects completed a comprehensive ocular examination. Retroillumination images of the posterior capsule were obtained using a slit lamp with imaging system, and PCO was graded by two ophthalmologists. Univariate and multivariate logistic regression analyses were performed to assess the risk factors for PCO.

RESULTS

A total of 1039 subjects were enrolled, with mean age 66.68 ± 11.43 years and 42.06% were male. The incidence of early-onset PCO in the 3 months after cataract surgery was 29.93%, and PCO of grade 3 and grade 4 was present in 31 patients (2.98%). Patients with complicated cataract had a higher incidence of PCO than age-related cataract, especially for patients with previous pars plana vitrectomy (PPV) surgery (P < 0.001). Moreover, the incidence of PCO increased with the deficiency of capsulorhexis-IOL overlap (P < 0.001). Multivariate logistic regression also showed that previous PPV surgery (OR 2.664, P = 0.003) and incomplete capsulorhexis-IOL overlap were risk factors for PCO (180-360° overlap: OR 2.058, P < 0.001; < 180° overlap: OR 5.403, P < 0.001).

CONCLUSIONS

Larger capsulorhexis and PPV surgery history contribute to the occurrence of early-onset PCO, indicating that primary posterior continuous curvilinear capsulorhexis can be considered during cataract surgery for patients with PPV history.

Phacoemulsification outcomes and complications in vitrectomised versus non-vitrectomised eyes

Clinical relevance: Pars plana vitrectomy techniques have evolved in the recent years and the number of patients undergoing phacoemulsification for post-vitrectomy cataract has increased. Eye-care practitioners need to be aware of intraoperative complications and post-operative outcomes in previously vitrectomised eyes.Background: The aim of the present study is to compare the outcomes and related complications of phacoemulsification in previously vitrectomised versus non-vitrectomised eyes.Methods: This is a retrospective case-control study. Visual acuity, refractive outcomes, intra- and post-operative complications were analysed in consecutive phacoemulsification patients between January 2015 and August 2017. Patients with no post-operative data were excluded.Results: One hundred and forty-nine previously vitrectomised eyes and 608 non-vitrectomised eyes were included in the analysis. Previous pars plana vitrectomy was associated with worse logMAR visual acuity pre-operatively (0.75 ± 0.54 vs. 0.40 ± 0.33, p < 0.0001) and post-operatively (0.15 ± 0.29 vs. 0.09 ± 0.22, p = 0.014). There were no statistically significant differences between the two groups regarding refractive outcomes (p = 0.393) or posterior capsule rupture rate (p = 0.223). Previous pars plana vitrectomy was associated with a higher risk of post-operative macular oedema (p = 0.046) and posterior capsule opacification (p < 0.0001).Conclusions: Previous pars plana vitrectomy was not associated with a higher risk of intraoperative complications. However, a higher incidence of cystoid macular oedema and posterior capsule opacification were identified in the present study. Further research can provide insight into the mechanisms involved and any appropriate prevention strategies for these conditions.

Effect of capsular tension ring implantation on capsular stability after phacoemulsification in patients with weak zonules: a randomized controlled trial. CTR implantation in cataract patients with weak zonules

BACKGROUND

The use of capsular tension ring (CTR) implantation to treat cataract patients with weak zonules is still controversial. The aim of this study was to examine the effects of CTR implantation on capsular stability after phacoemulsification in patients with weak zonules, especially patients who have undergone pars plana vitrectomy (PPV) or those who suffer from severe myopia.

METHODS

A total of 42 patients who underwent phacoemulsification and received an intraocular lens (IOL) were randomized to undergo CTR implantation or not. The control and CTR groups were compared in terms of uncorrected distant visual acuity (UDVA), best corrected distant visual acuity (BCDVA), refractive prediction error, the area of anterior capsulorhexis, and IOL inclination angle. Follow-up visits were conducted postoperatively at 1 day, 1 week, 1 month and 3 months. Subgroup analyses were performed based on PPV and severe myopia.

RESULTS

Surgery significantly improved UDVA and BCDVA to similar extents in CTR and control patients, and refraction prediction error was similar between the two groups at all follow-up times. At 3 months after surgery, the area of anterior capsulorhexis was significantly larger in CTR patients than in controls (p = 0.0199). These differences were also significant between the subgroups of patients with severe myopia. Vertical IOL inclination was less within CTR groups at 3 months after surgery, especially in patients with severe myopia (p = 0.0286). At 1 week postoperatively, the proportion of individuals whose posterior lens capsule that had completely adhered to the posterior IOL surface was significantly higher among CTR patients (p = 0.023). No serious surgical complications were observed.

CONCLUSION

CTR implantation can benefit cataract patients with weak zonules by maintaining the shape of the capsular bag, reducing capsule shrinkage and stabilizing IOL inclination.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-INR-17011217 , date of registration April 22, 2017, prospectively registered.

Cataract surgery of eyes with previous vitrectomy: risks and benefits as reflected in the European Registry of Quality Outcomes for Cataract and Refractive Surgery

PURPOSE

To explore the frequency and outcomes of cataract surgery in eyes with previous vitrectomy.

SETTING

Fifteen European countries.

DESIGN

Retrospective cross-sectional register-based study.

METHODS

The European Registry of Quality Outcomes of Cataract and Refractive Surgery (EUREQUO) contains data on baseline characteristics, surgery, and follow-up for cataract surgeries. Previous vitrectomy is included as a mandatory parameter in baseline characteristics. According to the protocol for EUREQUO, consecutive cases should be reported by participating units.

RESULTS

This study included data from units in 15 European countries from 2008 to 2018; 1 715 348 cataract extractions with follow-up data were reported to EUREQUO. Previous vitrectomy was reported in 19 416 eyes comprising 1.1% of all cases. This proportion was about the same for each study year. Most patients were men, and their mean age was 64.1 years compared with 73.7 years for the rest of the database. The preoperative visual acuity was modestly worse in postvitrectomy eyes compared with the opposite (corrected distance visual acuity [CDVA] 0.45 vs 0.25, respectively). A postoperative CDVA of 0.5 or better was achieved by 82.8% of the postvitrectomy eyes compared with 95.6% for the non-postvitrectomy eyes. The absolute mean biometry prediction error for the same groups was 0.52 diopters (D) vs 0.43 D, respectively.

CONCLUSIONS

Patients undergoing cataract extraction after previous vitrectomy were younger and mostly men. Their visual and refractive outcomes were slightly inferior compared with the patients without vitrectomy.

Auckland Cataract Study IV: Practical application of NZCRS cataract risk stratification to reduce phacoemulsification complications

IMPORTANCE

Reduction of intraoperative complications in phacoemulsification cataract surgery.

BACKGROUND

To assess practicability of a risk stratification system, the New Zealand Cataract Risk Stratification (NZCRS) system, in a major teaching hospital service, without investigator oversight, to ascertain whether benefits identified in research studies are maintained in busy clinical practice.

DESIGN

Prospective cohort study in a major public teaching hospital.

PARTICIPANTS

Five hundred cases of phacoemulsification cataract surgery.

METHODS

NZCRS system inserted into 621 consecutive preoperative cataract patient files. Recommendation to allocate higher-risk cases to experienced surgeons.

MAIN OUTCOME MEASURES

NZCRS system uptake and adherence, appropriate identification of high risk cases and intraoperative complication rates.

RESULTS

NZCRS scores calculated in 500 of 621 (80.5%) cases and 98 (19.6%) scored as "high risk." Cataract surgery (N = 500) performed by: 12 Registrars (20%), 4 Fellows (7.2%), 26 Consultants (72.8%). Risk scores adhered to in 99%. Overall intraoperative complications (3.0%) included iris prolapse 1.6% and posterior capsule tear 0.8%. No statistical difference in complication rates identified between surgeon grades. Mean best-corrected visual acuity was 6/10 (20/32). Postoperatively, cystoid macular oedema occurred in 3.2%. Rescoring by an experienced investigator noted a greater number of "high risk scores" (31.6% vs 19.6%) related to differences in subjective scoring of anterior chamber depth and cataract density.

CONCLUSIONS AND RELEVANCE

Practical uptake of cataract risk stratification was promising in this study with NZCRS calculated in 80.5% with 99% adherence to scoring recommendations. Compared to baseline studies, in the day-to-day clinical setting, a continued, decreasing trend in frequency and severity of intraoperative complications was noted. Subjective variability of risk scoring may be further improved by better, objective, standardization.

Trocar opening: silicone oil removal with phacoemulsification and intraocular lens implantation

AIM

To evaluate the efficacy and safety of a modified technique [trocar opening (TO)] for silicone oil removal (SOR) in combination with phacoemulsification and intraocular lens (IOL) implantation.

METHODS

A total of 60 eyes of 60 patients with cataract and silicone oil-filled eyes were enrolled in this study. The patients were divided into two groups: the patients in the control group underwent 23-gauge pars plana active SOR surgery with phacoemulsification and IOL implantation, while the patients in the TO group underwent TO methods during surgery. Best corrected visual acuity (BCVA), surgery time, intraocular pressure, and operative complications were observed 6mo after surgery.

RESULTS

There was no significant difference between the two groups in terms of age, gender, preoperative, intraocular pressure, or time of silicone oil stay. Prior to surgery, the mean BCVA for the control and TO groups was 1.34±0.44 and 1.36±0.42. At 6mo following surgery, the mean BCVA improved to 0.74±0.36 and 0.77±0.32, respectively (P<0.001). There was no significant difference between the two groups. The mean SOR time was 6.9±2.3min and 4.8±1.2min in the control and TO groups (P=0.008). The total operation time was 28.2±8.5min and 24.6±6.4min, respectively (P=0.035). Posterior capsule rupture occurred in four eyes of control and none of TO group (P<0.01). Late recurrent retinal detachment occurred in one eye in the control group (2mo after surgery) and in one eye in the TO group (4mo after surgery).

CONCLUSION

TO is a simple, effective, time-saving, and safe method for SOR combined with phacoemulsification and IOL implantation.

Auckland Cataract Study III: Refining Preoperative Assessment With Cataract Risk Stratification to Reduce Intraoperative Complications

PURPOSE

To assess intraoperative complications of phacoemulsification surgery in public teaching hospital settings using modified preoperative risk stratification systems.

DESIGN

Prospective cohort study.

METHODS

Preoperative risk stratification of 500 consecutive cataract cases using the New Zealand Cataract Risk Stratification (NZCRS) scoring system. Recommended allocation of higher-risk phacoemulsification procedures to experienced surgeons in public teaching hospital setting.

MAIN OUTCOME MEASURE

Intraoperative complications relative to adherence to stratification recommendations.

RESULTS

NZCRS classified 192 cases (38%) as high-risk, recommended for fellows or consultants (attendings). Primary surgeons were residents (n = 142, 28%), fellows (n = 88, 18%), and consultants (n = 270, 54%). Overall rate (N = 500) of any intraoperative complication was 5.0%. Where NZCRS scoring recommendations were observed (n = 448) the intraoperative complication rate was 4.5% but in "nonadherence" cases (n = 52 residents operating on higher-risk cases) this nearly doubled (9.6%). Postoperative complications occurred in 5.2%, primarily cystoid macular edema (3.7%). Postoperatively, mean unaided visual acuity was 6/12 (20/40) and best-corrected visual acuity improved from 6/20 (20/63) preoperatively to 6/10 (20/32) postoperatively (P < .05).

CONCLUSIONS

The NZCRS system aids identification of higher-risk cataract cases and appropriate case-to-surgeon allocation and may increase surgeon awareness of risk factors. Compared to 2 previous studies under similar conditions in the same institution, the NZCRS system was associated with a 40% reduction in intraoperative complications (8.4% to 5%). The rate of posterior capsular tear was 0.6% (P = .035) compared to 2.6% in baseline phase and 1.4% in a prior risk stratification phase. Risk stratification seems to reduce intraoperative phacoemulsification complications in public teaching hospital settings.

Favorable outcome after choroidal drainage for postoperative kissing suprachoroidal hemorrhage following trabeculectomy in a high myopic vitrectomised eye

A 39-year-old lady with past history of vitreoretinal surgery for retinal detachment and cataract surgery with Intraocular lens implantation was diagnosed as uncontrolled glaucoma. She had high myopia. She underwent Trabeculectomy and following which she presented with massive suprachoroidal hemorrhage in the first postoperative day with severe loss of vision. This case depicts the risk of suprachoroidal hemorrhage in a high myopic vitrectomised eye following glaucoma filtration surgery. It also demonstrates a favorable outcome following intervention for postoperative Suprachoroidal hemorrhage. At present, there is no evidence in literature of such event in a high myopic Vitrectomised eye following Trabeculectomy.

Microperimetric Assessment after Epiretinal Membrane Surgery: 4-Year Follow-Up

Purpose. To investigate retinal function using microperimetry in patients affected by idiopathic epiretinal membrane (iERM) and cataract who underwent combined surgery: 4-year follow-up. Design. Prospective, interventional case series. Methods. 30 eyes of 30 consecutive patients with iERM and age-related cataract underwent 25-gauge vitrectomy and cataract surgery. At baseline, 90 and 180 days, and 1 and 4 years, we examined retinal mean sensitivity (MS), retinal mean defect (MD), fixation stability, and frequency of microscotomas using MP1 microperimetry. Best-corrected visual acuity (BCVA) and central retinal thickness (CRT) using a spectral domain optical coherence tomography (SD-OCT) were also performed. Results. All patients completed 1-year follow-up, while 23 patients reached last follow-up. Baseline MS and MD (10.48 ± 4.17 and −9.18 ± 4.40 dB) significantly changed at one year (12.33 ± 3.66 and −7.49 ± 3.31 dB, p < 0.01), at four years (14.18 ± 3.46 and −4.66 ± 2.85, p < 0.01), and between one and four years (p < 0.01) after surgery. Compared to baseline, CRT and BCVA significantly changed at one year and remained stable at four years. No variations were observed in fixation stability and frequency of microscotomas compared to baseline. Conclusions. Long-term follow-up using microperimetry seems useful to evaluate patients after iERM surgery: retinal sensitivity changes even when BCVA and CRT remain stable.