The European registry of quality outcomes for cataract and refractive surgery (EUREQUO): a database study of trends in volumes, surgical techniques and outcomes of refractive surgery

Lens Factor Choice in IOL Power Calculation after Laser Refractive Surgery: The Right Constant for Advanced Lens Measurement Approach (ALMA)

Background/Objectives: To evaluate the advanced lens measurement approach (ALMA) formula accuracy using different lens constants available on the user group for laser interference biometry (ULIB) and IOL Con platforms. Methods: In this retrospective, comparative, case-series study, 150 eyes of 160 patients with previous myopic Photorefractive Keratectomy (PRK) or laser-assisted in situ keratomileusis (LASIK), who underwent uneventful cataract surgery and IOL implantation, were examined. The ALMA formula was evaluated to calculate the refractive prediction error (PE), analysing four different categories of lens constants: both nominal and optimized A-Constant for SRKT, which are available on the ULIB and IOL Con platforms. An additional analysis was carried out in this study, evaluating if a decreased ULIB optimized constant (DUOC) with different fixed factors (-1.2 -1.3 -1.4 -1.5) could improve refractive outcomes. Median absolute error (MedAE) and percentage of eyes within ±0.50 and ±1.00 diopters (D) of prediction error were measured as the main outcomes. Results: Comparing the lens factors available on ULIB and IOL Con platforms, the ALMA formula reported a lower MedAE and higher percentages of eyes with a refractive PE within 1.0 D using ULIB nominal constants (all p < 0.05). Using DUOC (-1.3), and there was a statistically significant improvement of both MedAE and of the percentages of eyes with PE within ±0.50 D with the ALMA method compared to nominal ULIB constants (all p < 0.05). Conclusions: The impact of different lens factors in the IOL power calculation after myopic LRS should be carefully evaluated. The ALMA formula, in the absence of optimized constants by zeroing the mean error, should be used by subtracting 1.3 from the optimized ULIB constants available on the IOL Con website. This finding suggests further studies to test which of these constants could work better with the other post-refractive surgery formulas.

[oregis-The German ophthalmological registry]

BACKGROUND

Medical registries have shown their potential for medical research in different areas of healthcare in the past. The United States of America uses the well-known national ophthalmology registry Intelligent Research in Sight (IRIS®), on the basis of which insights into the ophthalmological care situation in the USA can be gained. Comparable projects do not currently exist in Germany. The oregis is the first disease-independent registry to collect comprehensive data in the field of ophthalmology in Germany for the purpose of healthcare research.

METHODS

The oregis collects anonymized clinical patient information from all subfields of ophthalmology and makes it available for research purposes. Participating centers read their data into the registry free of charge and preferably in an automated fashion. Currently, the oregis parameter list contains about 600 parameters, of which about 100 are used in the current pilot phase.

RESULTS

Since its initiation, the German ophthalmological registry oregis has compiled data on more than 1.75 million physician visits for more than 400,000 patients from German ophthalmologic centers. As of late 2022, more than 2.8 million visual acuity measurements and an equal number of intraocular pressure measurements have been recorded.

DISCUSSION

The aim of the oregis project is to establish a nationwide ophthalmology databank that forms the basis for a learning healthcare system in the field of ophthalmology. With the help of continuous updating, oregis can also illustrate short-term innovations in ophthalmological care.

Long-term results of a new posterior chamber phakic intraocular lens in patients with high myopia: 5-year results

PURPOSE

To evaluate the long-term refractive outcomes of Eyecryl posterior chamber spherical phakic intraocular lens (pIOL) implantation in high myopia and endothelial cell density (ECD) change.

SETTING

Beyoglu Eye Training and Research Hospital, Istanbul, Turkey.

DESIGN

Retrospective.

METHODS

Eyes that were not suitable for corneal refractive surgery, had high myopia between -6.00 diopters (D) and -20.00 D, had Eyecryl posterior chamber spherical pIOL implantation, and had at least 5 years of follow-up were included. Preoperative ECD was ≥2300 cells/mm 2 and cylindrical value was ≤2.0 D in all cases. Preoperative and postoperative first, third, and fifth years of refraction, uncorrected and corrected distance visual acuity (UDVA/CDVA), and ECD were recorded.

RESULTS

36 eyes of 18 patients were examined. The mean UDVA and CDVA in postoperative fifth years were 0.24 ± 0.19 logMAR and 0.12 ± 0.18 logMAR, respectively. The safety and efficacy indices were 1.52 ± 0.54 and 1.14 ± 0.38, respectively. At 5 years, the spherical equivalent was ±0.50 D in 75% of eyes and ±1.00 D in 92% of eyes. After 5 years, the mean cumulative ECD loss was 6.91% ( P = .07). The annual ECD loss was 1.57% in the first year, 0.26% between 1 year and 3 years, and 2.38% between 3 years and 5 years. Asymptomatic anterior capsule opacity developed in 1 eye 4 years after surgery. Rhegmatogenous retinal detachment developed in 1, and myopic choroidal neovascular membrane occurred in 1 eye.

CONCLUSIONS

Eyecryl posterior chamber spherical pIOL implantation is one of the effective and safe refractive surgical methods in correcting high myopia with predictable and stable refractive results over a 5-year period. Longer-term studies are needed for complications such as decreased ECD, retinal complications, and lens opacity.

Posterior-Chamber Phakic Implantable Collamer Lenses with and without a Central Hole: A Comparative Study

Purpose

 This study aimed to compare the short-term outcome of implanting the Visian implantable collamer lens V4 ICL versus the Visian V4c ICL in patients with moderate and high myopia.

Patients and Methods

 This is a retrospective that was conducted on patients with moderate or high myopia who were scheduled for ICL implantation at our institution, Patients who underwent V4 ICL implantation with peripheral iridectomy were assigned to group A, and those who underwent V4c ICL implantation without peripheral iridectomy were assigned to group B. In group A, a preoperative peripheral iridectomy was performed. In group B, the patients received cycloplegic and dilating agents. The patients underwent a complete ocular examination preoperatively and during the follow-up visits that were conducted at 3, 6, and 12 months postoperatively.

Results

This study included 214 eyes from 107 patients; group A included 110 eyes, and group B included 104 eyes. Postoperatively, the UCVA and BCVA showed statistically significant improvement across the follow-up time points (p<0.001), with no significant difference between the two groups. No statistically significant difference was found between the two groups in the mean achieved correction or the residual refraction. Both groups showed a strong correlation between the target and the achieved correction, with R2 = 0.99 in the two groups. No significant difference was found between the two groups in the IOP across all time measures. However, the intraocular pressure showed a statistically significant postoperative increase in group A (p=0.004), and no significant change in group B (p=0.817). There was a downward slope in the vaults of both groups across time, with significant variation in the last follow-up measure compared to the 3-month measure in the two groups (p<0.001). No significant difference was found between the two groups across all time measures.

Conclusion

The current study adds new evidence concerning the feasibility, safety, and efficacy of ICL V4c implantation for the treatment of moderate and high myopia, with safer postoperative IOP.

Catquest-9SF questionnaire: Validation in a Greek-speaking population using Rasch analysis

PURPOSE

The Catquest-9SF questionnaire is a tool measuring visual disability and vision-related limitation in patients' daily activities. The primary objective of this study was the validation of Catquest-9SF in a Greek-speaking cataract population.

METHODS

The questionnaire was translated into Greek and translated back into English. A pre-final Greek version was formed and tested by 10 Greek-English bilingual participants and by the translation team, and the final version was produced. Patients scheduled for cataract surgery completed the questionnaire preoperatively and postoperatively. Rasch analysis was performed for the assessment of the Catquest-9SF psychometric properties, including response category ordering, item fit statistics, principal components analysis, precision, differential item functioning and targeting for preoperative and postoperative data collectively.

RESULTS

A total of 100 (55 men, 45 women, mean age = 71.94±6.63) cataract patients completed the Greek version of Catquest-9SF questionnaire preoperatively and postoperatively. Rasch analysis showed a significant improvement in the median person Rasch score from -1.49 preoperatively to -4.71 logits postoperatively, while the effect size was 1.3. Unidimensionality was confirmed since infit and outfit mean square values varied between 0.66 and 1.37. Rasch analysis showed good precision and separation ability (Person Separation Index of 3.28, and Person Reliability of 0.92). Four response categories were found for all items. The item-person means difference was -1.83 logits. The difference between preoperative and postoperative Catquest-9SF logit score was positively correlated with preoperative Catquest-9SF logit score (coeff. = 0.798, p<0.0001) and negatively correlated with postoperative spherical equivalent (coeff. = -0.825, p = 0.011).

CONCLUSION

The Greek version of Catquest-9SF proved to be reliable, valid, unidimensional and responsive to changes after cataract surgery presenting good psychometric properties for cataract patients. Some postoperative mistargeting was found indicating that the tasks were easily performed by respondents after cataract surgery.

TRIAL REGISTRATION

NCT05323526 -retrospectively registered.

Ectasia After Corneal Refractive Surgery: A Systematic Review

INTRODUCTION

The incidence of ectasia following refractive surgery is unclear. This review sought to determine the worldwide rates of ectasia after photorefractive keratectomy (PRK), laser-assisted in situ keratomileusis (LASIK), and small incision lenticule extraction (SMILE) based on reports in the literature.

METHODS

A systematic review was conducted according to modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Publications were identified by a search of eight electronic databases for relevant terms between 1984 and 2021. Patient characteristics and preoperative values including manifest refractive spherical refractive equivalent (MRSE), central corneal thickness (CCT), anterior keratometry, postoperative residual stromal bed (RSB), and percent tissue altered (PTA) were summarized. In addition, annual rates of each refractive surgery were determined, and incidence of post-refractive ectasia for each type was calculated using the number of ectatic eyes identified in the literature.

RESULTS

In total, 57 eyes (70 eyes including those with preoperative risk factors for ectasia) were identified to have post-PRK ectasia, while 1453 eyes (1681 eyes including risk factors) had post-LASIK ectasia, and 11 eyes (19 eyes including risk factors) had post-SMILE ectasia. Cases of refractive surgery performed annually were estimated as 283,920 for PRK, 1,608,880 for LASIK, and 96,750 for SMILE. Reported post-refractive ectasia in eyes without preoperative identifiable risk factors occurred with the following incidences: 20 per 100,000 eyes in PRK, 90 per 100,000 eyes in LASIK, and 11 per 100,000 eyes in SMILE. The rate of ectasia in LASIK was found to be 4.5 times higher than that of PRK.

CONCLUSION

Post-refractive ectasia occurs at lower rates in eyes undergoing PRK than LASIK. Although SMILE appears to have the lowest rate of ectasia, the number of cases already reported since its recent approval suggests that post-SMILE ectasia may become a concern. Considering that keratoconus is a spectrum of disease, pre-existing keratoconus may play a larger role in postoperative ectasia than previously accounted for in the literature.

The application of clinical registries in ophthalmic trauma-the International Globe and Adnexal Trauma Epidemiology Study (IGATES)

Ophthalmic trauma is a leading cause of preventable monocular blindness worldwide. The prevalence of ophthalmic trauma varies considerably based on geographic location, socio-economic status, age groups, occupation, and cultural practices such as firework celebrations. Clinical registries are known to be valuable in guiding the diagnosis, management, and prognostication of complex diseases. However, there is currently a lack of a centralized international data repository for ophthalmic trauma. We draw lessons from past and existing clinical registries related to ophthalmology and propose a new suitable international multicenter clinical registry for ophthalmic trauma: the International Globe and Adnexal Trauma Epidemiology Study (IGATES). IGATES is hosted on a secure web-based platform which exhibits user-friendly smart features, an integrated Ocular Trauma Score (OTS) prognosis calculator, efficient data collection points, and schematic graphical software. IGATES currently has 37 participating centers globally. The data collected through IGATES will be primarily used to develop a more robust and improved ophthalmic trauma prognostic classification system, the Ocular Trauma Score-2 (OTS-2), which builds on previous systems such as the Birmingham Eye Trauma Terminology System (BETTS) and Ocular Trauma Score (OTS). Furthermore, IGATES will act as a springboard for further research into the epidemiology, diagnosis, and management of ophthalmic trauma. Ultimately, IGATES serves to advance the field of ophthalmic trauma and improve the care that patients with ophthalmic trauma receive.

Transepithelial photorefractive keratectomy on the same day of the initial consultation for the correction of myopia

PURPOSE

To examine the clinical outcomes, efficacy, safety, and predictability of transepithelial photorefractive keratectomy (Trans-PRK) operations performed on the day of the first screening visit in comparison with operations scheduled at a following appointment.

METHODS

Data of consecutive patients with myopia of various degrees, who underwent Trans-PRK, were retrospectively analyzed. Findings were compared between patients who underwent Trans-PRK on the same day of first consultation to patients that underwent surgery at subsequent visits, following initial consultation on a different day.

RESULTS

The study included 599 eyes treated on the initial visit day and 1936 eyes treated on a subsequent visit. Mean final spherical equivalent was close to emmetropia in both groups (p = 0.183). Efficacy indices were 0.928 ± 0.192 in the initial-visit group and 0.945 ± 0.163 in the second-visit group (p = 0.152). Safety indices were 0.954 ± 0.156 and 0.955 ± 0.151 (p = 0.707), respectively. No differences between the groups were seen in uncorrected visual acuity (UDVA) of ⩾20/20, ⩾20/25, and ⩾20/32. Only the sub-analysis of patients reaching UDVA of 20/40 or better was slightly lower in the first-visit (95.5%) compared with the second-visit group (97.9%, p = 0.001). Results of attempted correction within ±0.50 D were: 63.3% and 69.0%, respectively (p = 0.009). Complications profiles in the two groups were comparable.

CONCLUSIONS

Trans-PRK completed on the day of the first screening appointment demonstrated a similar safety outcome compared with subsequent-visits procedures, and slightly lower, yet comparable, results regarding efficacy and predictability.

Advances in refractive corneal lenticule extraction

Refractive errors are the leading cause of reversible visual impairment worldwide. In addition to the desired spectacle independence, refractive procedures can improve quality of life, working ability, and daily working performance. Refractive corneal lenticule extraction (RCLE) is a relatively new technique, dependent only on a femtosecond laser (FS). This leads to potential benefits over laser-assisted in situ keratomileusis (LASIK) including a quicker recovery of dry eye disease, a larger functional optical zone, and no flap-related complications. SMILE, available with the VisuMax FS (Carl Zeiss Meditec AG, Jena, Germany), is the most established RCLE application, offering visual and refractive outcomes comparable to LASIK. SmartSight (SCHWIND eye-tech-solutions GmbH, Kleinostheim, Germany) and CLEAR (Ziemer Ophthalmic Systems AG, Port, Switzerland) are two new RCLE applications that received Conformité Européenne (CE) approval in 2020. In this article, we review refractive and visual outcomes, advantages, and disadvantages of RCLE and also report on the latest advances in RCLE systems.

Efficacy and safety of iris-supported phakic lenses (Verisyse) for the treatment of high myopia: 5-year results

PURPOSE

Evaluating efficacy and safety of iris-supported phakic lenses (Verisyse) for high myopia treatment.

METHODS

Patients treated with Verisyse (Abbott Medical Optics, Santa Ana, CA, USA) intraocular lens (IOL) implants were evaluated retrospectively. Patients with follow-up periods of more than 5 years were included in the study. Pre- and postoperative fifth-year spheric equivalent (SE) of manifest refraction values, uncorrected and corrected distance visual acuities (UDVA and CDVA, respectively), and endothelial cell density (ECD) values were recorded. Complications were evaluated.

RESULTS

Forty-seven eyes of 31 patients were included in the study. Pre- and postoperative fifth year mean SE was - 12.50 ± 3.51D and - 0.72 ± 0.40D, respectively. Pre- and postoperative fifth-year UDVA was 1.56 ± 0.22 and 0.33 ± 0.18 logMAR (p < 0.001), respectively. The safety index (pre- and postoperative CDVA) was 1.39 ± 0.63 at the 5-year follow-up (p > 0,05). The efficacy index (ratio of mean postoperative UDVA to mean preoperative CDVA) of the patients was 1.14 ± 0.60. The mean postoperative endothelial cell loss at 5 years was -7.42%. None of the patients had lost 25% of their preoperative endothelial cells at 5-year follow-up. The mean postoperative endothelial cell loss was -3.05% at 1 year, -1.23% between years one and three, -1.02% between the third and fifth years.

CONCLUSION

Verisyse IOL implantation is an effective and safe for high myopia surgical treatment. However, the 5-year follow-up period is not sufficient to evaluate the safety profiles in terms of endothelial cells.

Haze prevention following photorefractive keratectomy in brown eyes

OBJECTIVES

To study corneal haze following myopic photorefractive keratectomy (PRK) in a high-risk population and to assess methods for minimizing the risk.

METHODS

The medical records of 150 patients who underwent PRK were reviewed. A total of 300 eyes were included. All patients underwent myopic PRK using the Allegretto Wave Concerto 500Hz (Wavelight AG, Erlangen, Germany)excimer laser platform with intraoperative mitomycin-C (MMC) application. Demographic data including age, gender and ethnicity in addition to preoperative and postoperative subjective manifest refraction, spherical equivalent, best-corrected distance visual acuity, uncorrected distance visual acuity (UDVA), postoperative corneal haze grade and other possible postoperative complications were retrieved. Hanna grading (0-4+) was used to evaluate corneal haze.

RESULTS

The patients were comprised of 74 men (49.3%) and 76 women (50.7%). The mean age at the time of surgery was 26.5±6.0 (range, 17-46) years. All patients were Saudis with brown irides. UDVA improved to 20/25 in 93.8% at 3 months. The mean and standard deviation of preoperative spherical equivalent was -3.02±1.63 (range, -7.63 - -0.13). At 3 months, postoperative spherical equivalent improved to 0.05±0.50 (-1.00 - +1.00). At 6 months, 13.6% exhibited corneal haze of grade 1, and none exhibited grades 2 or 3.

CONCLUSIONS

The results of this study confirmed that patients with brown irides can achieve favorable outcomes after PRK. MMC, postoperative topical steroids and ultraviolet protection evidently play a major role in preventing corneal haze in high-risk populations.

Prevention of infection after corneal refractive surgery: a French survey

PURPOSE

To report the French refractive surgeons' real-life practices for preventing infection after corneal refractive surgery (photorefractive keratotomy [PRK], laser in situ keratomileusis [LASIK], and small-incision lenticule extraction).

SETTING

France.

DESIGN

Anonymous practice survey.

METHODS

The questionnaire was sent in a single email invitation to 400 declared refractive surgeons. The following information was recorded between December 2019 and April 2020, before the coronavirus pandemic: demographics data, preoperative evaluation and preparation of the patient, surgical management, immediate and postoperative protocol, and infections reported after corneal refractive surgery.

RESULTS

Eighty-three of 400 surgeons (20.75%) responded to the questionnaire; 55 (66.0%) performed more than 50 corneal refractive surgeries a year, and 25 (30.1%) performed more than 200 procedures a year. Thirty-six (43.4%) surgeons wore 3 protective items, 37 (44.6%) 2, 5 (6.0%) 1, and 5 (6.0%) zero. Seventy-seven (92.8%) surgeons used povidone-iodine for skin area disinfection and 54 (65%) for conjunctival fornix disinfection. The contact time of povidone-iodine was less than 3 minutes for 71 (85.0%) surgeons. Twenty surgeons (24.1%) reported at least 1 postrefractive surgery infection. Twenty percent of surgeons who wore sterile gloves for PRK reported postoperative infections compared with 62.5% for those who did not (P = .008). These figures were, respectively, 8.7% and 66.7% for the use of sterile gloves during LASIK (P = .002); 8.9% of surgeons who wore surgical masks for LASIK reported postoperative infections compared with 50.0% for those who did not (P = .01).

CONCLUSIONS

Practices are variable among French refractive surgeons. Wearing a surgical mask and sterile gloves during corneal refractive surgery appears to be advisable.

Clear lens extraction for patients who are unfit for laser-assisted in situ keratomileusis and implantable contact lenses in central Indian population

Purpose:

The purpose of this study is to establish the safety of clear lens extraction (CLE) for the correction of high myopia in patients unfit for implantable contact lenses (ICLs) and laser in situ keratomileusis in the central Indian population.

Methods:

In this retrospective observational study performed at a tertiary care centre, medical records of the patients who had undergone CLE with implantation of intraocular lens (IOL) to treat high myopia were retrieved. Details of the demographic profile, surgical procedure, complications, power, and type of IOLs implanted were recorded.

Results:

The average postoperative follow-up period was 64.1 ± 4.2 months. The average postoperative spherical power was −1.4 ± 0.6 D, which was much lower than the preoperative spectacle power - 15 ± 4.4 D. There was improvement in the postoperative visual acuity (0.4 ± 0.2 logMAR) from the preoperative distant uncorrected visual acuity (0.8 ± 0.2 logMAR). No significant change in intraocular pressure (IOP) was observed. The postoperative average anterior chamber depth (ACD) (2.66 ± 0.1 mm) was significantly deeper than the preoperative ACD (2.61 ± 0.1 mm) P = 0.00. Barrage laser was required for lattice degeneration in one patient before CLE and in two patients during follow-up. Two patients (8.7%) required Nd:YAG capsulotomy for posterior capsular opacification. None of the patients had corneal decompensation, retinal detachment, or endophthalmitis.

Conclusion:

CLE with implantation of IOL is the safe procedure for correcting high myopia in patients who are unfit for ICL. None of the patient had eye loss in the follow-up period of 5 years. The low incidence of complications can be attributable to the closed chamber lens removal and implantation of IOL and prophylactic retinal treatment.

Design, development and deployment of a web-based interoperable registry for inherited retinal dystrophies in Portugal: the IRD-PT

Background

The development of multicenter patient registries promotes the generation of scientific knowledge by using real-world data. A country-wide, web-based registry for inherited retinal dystrophies (IRDs) empowers patients and community organizations, while supporting formal partnerships research. We aim to describe the design, development and deployment of a country-wide, with investigators and stakeholders in the global aim to develop high-value, high-utility web-based, user-friendly and interoperable registry for IRDs—the IRD-PT.

Results

The IRD-PT is a clinical/genetic research registry included in the retina.pt platform (https://www.retina.com.pt), which was developed by the Portuguese Retina Study Group. The retina.pt platform collects data on individuals diagnosed with retinal diseases, from several sites across Portugal, with over 1800 participants and over 30,000 consultations to date. The IRD-PT module interacts with the retina.pt core system which provides a range of basic functions for patient data management, while the IRD-PT module allows data capture for the specific purpose of IRDs. All IRDs are coded accordingly to the International Statistical Classification of Diseases and Related Health Problems (ICD) 9, ICD 10, ICD 11, and Orphanet Rare Disease Ontology (ORPHA codes) to make the IRD-PT interoperable with other IRD registries across the world. Furthermore, the genes are coded according to the Ontology of Genes and Genomes and Online Mendelian Inheritance in Man, whereas signs and symptoms are coded according to the Human Phenotype Ontology. The IRD-PT module pre-launched at Centro Hospitalar e Universitário de Coimbra, the largest reference center for IRDs in Portugal. As of April 1st 2020, finalized data from 537 participants were available for this preliminary analysis.

Conclusions

In the specific field of rare diseases, the use of registries increases research accessibility for individuals, while providing clinicians/investigators with a coherent data ecosystem necessary to boost research. Appropriate design and implementation of patient registries enables rapid decision making and ongoing data mining, ultimately leading to improved patient outcomes. We have described here the principles behind the design, development and deployment of a web-based, user-friendly and interoperable software tool aimed to generate important knowledge and collecting high-quality data on the epidemiology, genomic landscape and natural history of IRDs in Portugal.

Refractive, visual, and subjective quality of vision outcomes for very high myopia LASIK from - 10.00 to - 13.50 diopters

Background

To evaluate laser-assisted in situ keratomileusis (LASIK) outcomes, subjective quality of vision (QoV) and patient satisfaction in eyes with very high myopia (VHM) above − 10.00 diopters (D).

Methods

Consecutive myopic and myopic-astigmatism eyes with spherical equivalent (SEQ) ranging between − 10.00 to − 13.50 D underwent LASIK with the WaveLight® Allegretto Wave® Eye-Q 400 Hz excimer laser. Treatment accuracy, efficacy, safety, stability, cylinder vectors, and higher-order aberrations were evaluated, together with subjective QoV and night vision disturbances (NVDs).

Results

114 eyes had a preoperative SEQ of − 11.02 ± 0.81 D, with a median follow-up of 24 months. A total of 72, 84, and 94% of eyes were within ± 0.50, ± 0.75 and ± 1.00 D of intended SEQ (R² = 0.71). The efficacy index was 0.93 ± 0.20, with 51 and 81% of eyes achieving 20/20 and 20/25. The astigmatism correction index was 0.95 ± 0.33. The safety index was 1.05 ± 0.12. The average myopic regression was − 0.51 ± 0.38 D. Preoperative QoV scores improved significantly postoperatively (7.5 ± 0.8 vs. 9.1 ± 0.7; P <  0.001), with less NVDs (P <  0.001). Total, spherical and coma root mean square (RMS) postoperative ocular higher-order aberrations were 1.07 ± 0.34, 0.67 ± 0.25, and 0.70 ± 0.40 μm.

Conclusions

Very high myopia LASIK between − 10.00 to − 13.50 D is safe and results in good visual outcomes, with high patient satisfaction and a significant improvement in patient-reported QoV after surgery. Appropriately selected patients within this very high myopia group can be included as LASIK candidates.

Incidence of Intraoperative and Early Postoperative Adverse Events in a Large Cohort of Consecutive Refractive Lens Exchange Procedures

PURPOSE

To evaluate the incidence of adverse events (AEs) in patients who underwent refractive lens exchange.

DESIGN

Retrospective case series.

METHODS

Setting: Private refractive surgery clinics. Patients/Study Population: Patients who underwent refractive lens exchange between July 1, 2014, and June 30, 2016. Intervention/Observation Procedures: All AEs recorded in the electronic medical record were extracted and retrospectively reviewed. The total incidence of AEs and serious AEs was calculated. Loss of 2 or more lines of corrected distance visual acuity (CDVA) was calculated for the entire cohort of patients that attended a minimum of 3 months follow-up.

MAIN OUTCOME MEASURES

AEs.

RESULTS

The total number of patients included was 10,206 (18,689 eyes). A multifocal intraocular lens (IOL) was implanted in 84.3% of eyes; 15.7% of eyes received a monofocal IOL. A total of 1164 AEs were recorded (1112 eyes of 1039 patients, incidence 6.0% of eyes, 1:17 eyes). The most common AE was posterior capsular opacification (PCO; 748 eyes, incidence 4.0%). Of all AEs, 171 events (occurring in 165 eyes of 151 patients, incidence 0.9%, 1:113 eyes) were classified as serious, potentially sight threatening. Loss of 2 or more lines of CDVA was 0.56% when excluding eyes where the loss of CDVA was due to PCO; the majority of these were due to macular causes.

CONCLUSION

The incidence of sight-threatening AEs and significant loss of CDVA in elective refractive lens exchange surgery was low. Other than PCO, postoperative macular issues were the most common cause of vision loss in this cohort.

[Clinical and functional outcomes of correcting low to moderate myopia with FemtoLASIK performed with Russian and Swiss femtolaser platforms]

PURPOSE

To compare the effectiveness, safety, predictability and stability of FemtoLASIK procedure in low to moderate myopia using Femto Visum and Femto LDV Z6 femtosecond laser platforms and to evaluate the effect of these procedures on corneal higher-order aberrations.

MATERIAL AND METHODS

Russian femtolaser platform (1 MHz) was used to form the corneal flap in the main group consisting of 98 patients (98 eyes) with mean spherical equivalent (SE) of -3.73±1.42 D. Swiss femtolaser platform (5 MHz) was used in the control group (94 patients, 94 eyes; mean SE -3.81±1.44 D). Excimer laser ablation was performed using the Russian platform (500 Hz) in both groups. All patients underwent complete ophthalmological examination. The follow-up period was 12 months.

RESULTS

Twelve month postoperatively, in the '1 MHz' group uncorrected visual acuity (UCVA) of 1.0 or better was achieved in 91.8% of patients, and in the '5 MHz' group - in 90.4% (p>0.05). There were no registered losses of 2 or more lines of best-corrected visual acuity (BCVA) in either group. In the '1 MHz' group, predictability of targeted refraction within ±0.5 D was achieved in 91.8% of patients, within ±1.0 D - in 99.0%; in the '5 MHz' group - in 91.5% and 98.9% of patients, respectively (p>0.05). Root-mean-square (RMS) deviation of corneal higher-order aberrations in the 6-mm optical zone was increased by 0.072 μm (by 1.21 times) and by 0.077 μm (by 1.22 times) in the '1 MHz' and '5 MHz' groups (p>0.05), respectively.

CONCLUSION

The FemtoLASIK procedures performed using Russian (1 MHz) and Swiss (5 MHz) femtosecond laser platforms are effective, safe, predictable, have stable postoperative visual and refractive outcomes, and lead to increase in RMS of corneal higher-order aberrations using both platforms in patients with low to moderate myopia. There were no statistically significant differences between the two femtolaser platforms (p>0.05) for all examined parameters.

Unwanted Astigmatism and High-order Aberrations One Year after Excimer and Femtosecond Corneal Surgery

SIGNIFICANCE

Small incision lenticule extraction (SMILE) is advanced as the most minimally invasive and least traumatic corneal procedure for correcting refractive errors using a single laser. Although SMILE obtains similar results to femtosecond laser in situ keratomileusis (LASIK) with spherical myopia, it has deficiencies in astigmatism correction.

PURPOSE

The purpose of this study was to compare refractive outcomes and high-order aberrations (HOAs) between SMILE and femtosecond LASIK corneal procedures at 1 year post-operative.

METHODS

Ninety-two patients (181 eyes) with myopia/myopic astigmatism underwent either SMILE (group 1) or femtosecond LASIK (group 2). The refractive target was to achieve emmetropia in all cases. Data were analyzed to determine significance of change in refraction and HOAs. Furthermore, astigmatism was subjected to vector analysis using the Thibos (calculation of change, Δ, in J0 and J45 values) and Alpins (calculation of difference, ΔC, between target-induced astigmatism [TIA] and surgically induced astigmatism) methods.

RESULTS

Forty-five patients (89 eyes) from group 1 and 47 patients (92 eyes) from group 2 completed the study. The main significant (P ≤ .001) findings were as follows: (a) residual astigmatism was greater in group 1; (b) group 1, ΔJ0 = 1.015J0 + 0.040 (R = 0.861), ΔJ45 = 1.082J45 + 0.019 (R = 0.792), ΔC = 0.401TIA + 0.323 (R = 0.489), and mean spherical aberration increased from -0.003 (SD, ±0.059; 95% confidence interval [CI], -0.015 to 0.009) to 0.028 μm (SD, ±0.041; 95% CI, -0.037 to -0.020); and (c) group 2, ΔJ0 = 0.952J0 - 0.005 (R = 0.921), ΔJ45 = 0.962J45 - 0.002 (R = 0.923), ΔC = 0.187TIA + 0.101 (R = 0.272), mean coma reduced from 0.114 (SD, ±0.087; 95% CI, 0.096 to 0.132) to 0.077 μm (SD, ±0.059; 95% CI, 0.065 to 0.089), and trefoil from 0.089 (SD, ±0.049; 95% CI, 0.079 to 0.0990) to 0.056 μm (SD, ±0.047; 95% CI, 0.046 to 0.066).

CONCLUSIONS

In comparison with SMILE, femtosecond LASIK offered better precision in the overall control of astigmatism and HOAs.

Dental Implant Quality Register-A possible tool to further improve implant treatment and outcome

The Board of EAO (European Association for Osseointegration) has discussed an initiative to explore the conditions to establish a Dental Implant Register. It was suggested to bring this issue to the EAO Consensus Conference 2018 for a discussion and to possibly propose relevant and manageable parameters. This article presents some select examples from quality registers in the medical field. Based on the experience of established registers, essentially in the medical field, factors considered to be of importance, if and when establishing a Dental Implant Register are introduced and discussed.

Binocular vision alterations after refractive and cataract surgery: a review

To review binocular and accommodative disorders documented after corneal or intraocular refractive surgery, in normal healthy prepresbyopic patients. A bibliographic revision was performed; it included works published before 1st July 2017 where accommodation and/or binocularity was assessed following any type of refractive surgical procedure. The search in Pubmed yielded 1273 papers, 95 of which fulfilled the inclusion criteria. Few publications reporting binocular vision and/or accommodative changes after refractive surgery in normal subjects were found. The reduction in fusional vergence is the most frequently reported alteration. Anisometropia is an important risk factor for postoperative binocular vision-related complaints. Most diplopia-related visual complaints, irrespective of the surgical procedure, were in fact misdiagnosed preoperative disorders. The preoperative evaluation of patients seeking spectacle/contact lens independence should include a complete binocular and accommodation assessment where parameters such as the phoric posture, accommodative amplitude and facility, near point of convergence, fusional reserves and accommodative convergence/accommodation coefficient are measured. This would allow the identification of risk factors that could compromise the success of the refractive surgery and cause clinical symptoms.

Clinical Registries in Ophthalmology

TOPIC

Clinical registries in ophthalmology.

CLINICAL RELEVANCE

In recent years, advancements in digital technology and increasing use of electronic medical records in health systems have led to the dramatic growth in large clinical data sets. Clinical data registries are organized systems that collect data on patients diagnosed with a disease or condition or who undergo a certain procedure.

METHODS

A search of the PUBMED database was conducted in January 2018 for clinical registries in ophthalmology.

RESULTS

Ninety-seven clinical eye registries were found, with significant growth in numbers in the last 4 decades. The most common conditions captured were blindness or low vision, corneal transplantation, glaucoma, and cataract surgery. Most registries originate in the European region, North America, and Australia. Nine registries had multinational coverage, whereas 48 were national registries. As the numbers and scope of clinical registries have expanded, valuable observational data have been used to study real-world clinical outcomes in healthcare quality measurement and improvement and to develop new guidelines and standards. Pertinent areas of its use include studying treatments and outcomes in cataract surgery, corneal transplantation, and macular degeneration.

CONCLUSIONS

The use of clinical registries for quality improvement and research has grown significantly in the last few decades, and this trend will continue as information technology infrastructures develop.

Verisyse versus Veriflex Phakic Intraocular Lenses: Refractive Outcomes and Endothelial Cell Density 5 Years after Surgery

Purpose

To compare refractive stability, central endothelial cell density (ECD), and complications between Verisyse (Abbott Medical Optics, Netherlands) and Veriflex (Abbott Medical Optics, Netherlands) phakic intraocular lenses (pIOL) over five years.

Methods

We retrospectively reviewed the medical records of patients who underwent Verisyse or Veriflex pIOL implantation for surgical correction of myopia. Patients with a 5-year follow-up period were included in the study. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent of manifest refraction (SE), and ECD were compared between the groups preoperatively and 1, 3, and 5 years postoperatively.

Results

The study included 47 eyes in the Verisyse group and 50 eyes in the Veriflex group. There was no significant difference in mean SE, UDVA, CDVA, and ECD preoperatively or postoperatively. In both groups, there was a statistically significant myopic shift between 1-year and 5-year visits (−0.25 ± 0.30 D and −0.23 ± 0.48 D in the Verisyse and Veriflex groups, respectively). There was no significant difference between the groups in terms of efficacy and safety indexes at 5 years. ECD loss was highest during the first year (3.9% loss in the Verisyse group and 3.9% loss in the Veriflex group, p=0.670). At 5 years, the mean cumulative ECD losses in the Verisyse and Veriflex groups were 7.42% and 7.64%, respectively (p=0.709). Cataracts developed in 2.1% of the eyes in the Verisyse group and in 2.0% of those in the Veriflex group. No sight-threatening complications were observed.

Conclusion

Verisyse and Veriflex pIOLs are highly effective for treating high myopia up to 5 years after surgery. Longitudinal studies with longer follow-up periods are necessary to determine the endothelial safety profile.

Intraoperative optical coherence tomography measurements of aphakic eyes to predict postoperative position of 2 intraocular lens designs

PURPOSE

To evaluate intraoperative anterior chamber depth (ACD) measurements of the aphakic eye to predict the postoperative ACD and compare 2 intraocular lens (IOL) designs.

SETTING

Hanusch Hospital, Vienna, Austria.

DESIGN

Prospective study.

METHODS

In this prospective study, patients scheduled for cataract surgery received a plate-haptic IOL (Asphina, Carl Zeiss Meditec AG) or an open-loop haptic IOL (ZCB00, Johnson & Johnson). Preoperatively, optical biometry (IOLMaster 700, CZM, or Lenstar, Haag-Streit) was performed. Intraoperatively, a prototype setup was used to perform time-domain OCT scans of the anterior eye segment (Visante connected to OPMI Lumera 200, both CZM). The intraoperative ACD was measured and used to predict the postoperative IOL position. Optical biometry and subjective refraction and autorefraction (RM 8800, Topcon) were performed 2 months postoperatively.

RESULTS

The study comprised 203 eyes of 203 patients. A partial least-square regression model for ACD generated 2 months postoperatively showed that the predictive power of the intraoperative ACD (0.48) was highest followed by the axial eye length (0.45) and then the preoperatively measured ACD (0.30). These findings were confirmed in a bootstrapping model. Regression models combining the preoperative ACD and intraoperative ACD resulted in further significant improvement.

CONCLUSIONS

Intraoperative ACD measurements predicted the postoperative position of open-loop IOLs and plate-haptic IOLs better than preoperative ACD measurements. Combining preoperative and intraoperative ACD measurements further improved the prediction.

Early Results with a New Posterior Chamber Phakic Intraocular Lens in Patients with High Myopia

Purpose

To report clinical results of a foldable, hydrophilic acrylic, single-piece, injectable, posterior chamber phakic intraocular lens (pIOL).

Material and Methods

Medical records of patients who underwent posterior chamber phakic IOL (Eyecryl Phakic IOL, Biotech Vision Care, Ahmedabad, India) implantation for surgical correction of myopia were retrospectively reviewed. Only patients with at least a one-year follow-up were included. Manifest refraction, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), endothelial cell density (ECD), and pIOL vault were analyzed at 1, 3, 6, and 12 months after surgery. Complications observed during and after surgery were also recorded.

Results

The study included 58 eyes of 29 patients. Mean patient age was 32 ± 7 years. Spherical equivalent of manifest refraction was −13.41 ± 3.23 D preoperatively and −0.44 ± 0.55 D postoperatively. Preoperative CDVA was 0.29 ± 0.71 logMAR. Postoperative UDVA and CDVA were 0.21 ± 0.66 and 0.15 ± 0.69 logMAR, respectively, at the 12-month visit. At the 12-month visit, the efficacy index was 1.20 and the safety index was 1.39. Mean ECD was 2713 ± 339 cells/mm² at the preoperative visit and 2608 ± 362 cells/mm² at the 12-month visit (3.9% loss, p < 0.001). ECD loss from 3 months to 12 months was not statistically significant. No significant cataract formation, significant endothelial cell loss, glaucoma, uveitis, or any other vision-threatening complication was observed.

Conclusion

Based on postoperative experience, we have found that Eyecryl Phakic IOL is safe and effective for treating high myopia.

Efficacy and safety of a 3-month loteprednol etabonate 0.5% gel taper for routine prophylaxis after photorefractive keratectomy compared to a 3-month prednisolone acetate 1% and fluorometholone 0.1% taper

Purpose

To compare the outcome of photorefractive keratectomy (PRK) and complications in patients treated with either loteprednol etabonate 0.5% gel or prednisolone acetate 1% suspension and fluorometholone (fml) 0.1% suspension.

Setting

John A Moran Eye Center, University of Utah, Salt Lake City, UT, USA.

Design

Prospective, randomized, partially masked trial.

Methods

PRK was performed on 261 eyes of 132 participants. Patients were randomized to a postoperative corticosteroid regimen of either loteprednol etabonate 0.5% gel (loteprednol) or prednisolone 1% acetate suspension followed by fluorometholone 0.1% suspension (prednisolone/fml). Primary outcome measures included incidence and grade of postoperative corneal haze and incidence of increased intraocular pressure of 10 mmHg above baseline, or any intraocular pressure over 21 mmHg. Secondary outcome measures included uncorrected distance visual acuity, best corrected distance visual acuity, and manifest refraction spherical equivalent.

Results

The incidence of haze in the first 3 months was 2.6% (3/114 eyes) in the loteprednol group and 4.8% (7/147 eyes) in the prednisolone/fml group and was not statistically significant between groups (P=0.37). The incidence of elevated intraocular pressure was 1.8% (2/114 eyes) in the loteprednol group and 4.1% (6/147 eyes) in the prednisolone/fml group, and was not statistically significant between the groups (P=0.12). The mean 3-month postoperative logMAR uncorrected visual acuity was −0.078±0.10 and −0.075±0.09 in the loteprednol and prednisolone/fml groups, respectively (P=0.83).

Conclusion

Postoperative corneal haze and elevated intraocular pressure were uncommon in both treatment arms. There was no statistically significant difference between each postoperative regimen. Refractive results were similar and excellent in both treatment arms. A tapered prophylactic regimen of loteprednol 0.5% gel is equally effective to prednisolone 1%/fml 0.1% after PRK.

Modern Phacoemulsification and Intraocular Lens Implantation (Refractive Lens Exchange) Is Safe and Effective in Treating High Myopia

Improved efficacy, predictability, and safety of modern phacoemulsification have resulted in cataract surgery being considered as a refractive procedure. Refractive lens exchange by definition is a surgery aimed at replacing the cataractous or clear crystalline lens with an intraocular lens (IOL) in cases of high ametropia. The excellent intraocular optics of this procedure provide a better visual outcome as compared with laser refractive surgery in high myopia. With advances in technology and IOL formulas, the predictability of refractive outcome after cataract surgery in high myopes has improved. The option of addressing presbyopia using multifocal/accommodating IOLs or monovision results in patients achieving reasonable spectacle independence. The most important concern with respect to phacoemulsification in high myopia is the risk of pseudophakic retinal detachment. High myopia is an independent risk factor for retinal detachment, and recent publications have reported a much lesser risk of retinal detachment specifically attributable to phacoemulsification in high myopes, especially if a thorough posterior segment evaluation is done and patients are followed up until development of complete posterior vitreous detachment. Refractive lens exchange is an effective and safe option to correct high myopia and can significantly improve quality of life in select patients.

Axial Length Measurement Failure Rates With Biometers Using Swept-Source Optical Coherence Tomography Compared to Partial-Coherence Interferometry and Optical Low-Coherence Interferometry

PURPOSE

To compare a new swept-source optical coherence tomography (SSOCT)-based biometer (OA-2000) with the IOLMaster v5.4 (partial-coherence interferometry) and Aladdin (optical low-coherence interferometry) biometers in terms of axial length measurement and failure rate in eyes with cataract.

DESIGN

Reliability study.

METHODS

A total of 377 eyes of 210 patients were scanned with the 3 biometers in a random order. For each biometer, the number of unobtainable axial length measurements was recorded and grouped as per the type and severity of cataract based on the Lens Opacities Classification System III by the same experienced ophthalmologist. The Bland-Altman limits-of-agreement (LoA) method was used to assess the agreement in axial length measurements between the 3 biometers.

RESULTS

The failure rate was 0 eyes (0%) with the OA-2000, 136 eyes (36.07%) with the IOLMaster, and 51 eyes (13.53%) with the Aladdin. χ² analyses indicated a significant difference in failure rate between all 3 devices (P < .001). Logistic regression analysis highlighted a statistically significant trend of higher failure rates with increasing severity of nuclear, cortical, and posterior subcapsular cataracts. Bland-Altman statistics indicated small mean differences and narrow LoA (OA-2000 vs IOLMaster -0.09 to 0.08 mm; OA-2000 vs Aladdin -0.10 to 0.07 mm; IOLMaster vs Aladdin -0.05 to 0.04 mm).

CONCLUSIONS

The OA-2000, a new SSOCT-based biometer, outperformed both the IOLMaster and Aladdin biometers in very advanced cataracts of various morphologies. The use of SSOCT technology may be the reason for the improved performance of the OA-2000 and may lead to this technology becoming the gold standard for the measurement of axial length.

Effects of phacoemulsification and intraocular lens implantation combined with ciliarotomy in the treatment of angle-closure glaucoma with cataract

The aim of the present study was to examine the effects of phacoemulsification and intraocular lens implantation combined with ciliarotomy in the treatment of angle-closure glaucoma with cataract in the elderly. A total of 68 patients were consecutively selected and divided into the control group with 33 cases (48 eyes) and the observation group with 35 cases (53 eyes). Cataract surgery combined with trabeculectomy was performed on the patients in the control group and phacoemulsification cataract extraction combined with ciliarotomy was performed on the subjects in the observation group, to compare postoperative effects and complications. Following surgery, the visual acuity of patients in the two groups significantly improved, intraocular pressure decreased, and improvement of the observation group was more evident (P<0.05). Following surgery, the depth of central anterior chamber and width of chamber angle of patients in two groups was increased, and improvement of the observation group was significantly more evident (P<0.05). Additionally, the incidence of complications, including corneal swelling, shallow of anterior chamber, fibrinous exudate in iris, and filtering bleb leaking and following cataract removal, of patients in the observation group was significantly reduced compared to the control group (P<0.05). In summary, the results of the present study show that, phacoemulsification and intraocular lens implantation combined with ciliarotomy in the treatment of angle-closure glaucoma with cataract in the elderly is a safe and effective method and should be applied in the clinic.

The Italian Catquest-9SF cataract questionnaire: translation, validation and application

BACKGROUND

To validate the Catquest-9SF questionnaire in Italian, assess the change in visual disability with cataract surgery and determine the correlation between pre-operative Catquest-9SF scores and Lens Opacities Classification System (LOCS) III cataract grading.

METHODS

Prospective, questionnaire validation study. The Catquest-9SF questionnaire was forward and back translated and completed by 209 Italian patients before and three months following cataract surgery. Rasch analysis was used to assess its psychometric properties.

RESULTS

The Italian Catquest-9SF demonstrated ordered response categories, unidimensionality (item fit statistics range: 0.73-1.34), adequate person separation (2.04), and no differential item functioning. Mistargeting was evident with a mean difference in item difficulty and person ability of 2.04 logits but improved with inclusion of pre-operative data only. There was a statistically significant (Friedman tests, p < 0.001) median improvement in visual disability of 1.92, 3.57, 1.44 and 2.94 logits in patients undergoing first eye surgery with and without ocular comorbidity, and second eye surgery with and without ocular comorbidity respectively. There was no statistically significant difference in the improvements among the four groups (Kruskal-Wallis H test, X (2) (3) = 5.445, p = 0.142). There was no correlation between Catquest-9SF scores and nuclear opalescence (r s = 0.049, p = 0.478), nuclear colour (r s = 0.008, p = 0.909), cortical (r s = 0.066, p = 0.341), and posterior subcapsular components (r s = 0.048, p = 0.494).

CONCLUSIONS

The Italian Catquest-9SF demonstrated good psychometric properties and is suitable for use in Italian speaking patients. There were similar improvements in visual disability in patients undergoing first or second eye surgery, with or without ocular comorbidity. There was no correlation between pre-operative Catquest-9SF scores and LOCS III cataract grading.

Patient considerations in cataract surgery - the role of combined therapy using phenylephrine and ketorolac

Cataract, a degradation of the optical quality of the crystalline lens, progressive and age-related, is the leading cause of treatable blindness worldwide. Cataract surgery is the most common surgical procedure performed by ophthalmologists and is the only effective treatment for cataracts. Advances in the surgical techniques and better postoperative visual outcomes have progressively changed the primary concern of cataract surgery to become a procedure refined to yield the best possible refractive results. Sufficient mydriasis during cataract removal is critical to a successful surgical outcome. Poor pupil dilation can lead to serious sight-threatening complications that significantly increase the cost of surgery and decrease patients comfort. Mydriasis is obtained using anticholinergic and sympathomimetic drugs. Phenylephrine, an α1-adrenergic receptor agonist, can efficiently dilate the pupil when administered by intracameral injection. Additionally, nonsteroidal anti-inflammatory drugs (NSAIDs) like ketorolac, which inhibit the synthesis of prostaglandins, are used to decrease intraoperative miosis, control pain and inflammation associated with cataract surgery, and to prevent the development of cystoid macular edema following surgery. Recently, a new combination of phenylephrine and ketorolac (Omidria^®) has been approved by United States Food and Drug Administration for use during cataract surgery to maintain intraoperative mydriasis, prevent miosis, and reduce postoperative pain and inflammation. Clinical trials have shown that this new combination is effective, combining the positive effects of both drugs with a good safety profile and patient tolerability. Moreover, recent reports suggest that this combination is also effective in patients with high risk of poor pupil dilation. In conclusion, cataract is a global problem that significantly affects patients' quality of life. However, they can be managed with a safe and minimally invasive surgery. Advances in surgical techniques and newer pharmacological agents such as the combination of phenylephrine and ketorolac, together with better intraocular lenses, have greatly improved visual outcomes and thus patients' expectations regarding visual recovery are also increasing.