Effect of IOP based infusion system with and without balanced phaco tip on cumulative dissipated energy and estimated fluid usage in comparison to gravity fed infusion in torsional phacoemulsification

Phacoemulsification using an active fluidics system at physiologic vs high intraocular pressure: impact on anterior and posterior segment physiology

PURPOSE

Evaluate the impact of high vs low intraoperative intraocular pressure (IOP) during phacoemulsification on anterior and posterior physiology.

SETTING

Private practice in Des Moines, Iowa.

DESIGN

Prospective, randomized, paired-eye clinical trial of patients anticipating bilateral cataract surgery.

METHODS

27 participants randomized at the time of their first cataract surgery to either low IOP or high IOP group. The subsequent cataract surgery was performed under the alternate condition. During phacoemulsification and cortex removal, IOP was maintained either at low (≤28 mm Hg) or at high (≥55 to 60 mm Hg) levels. The primary outcome was fluid usage, with secondary outcomes of central corneal thickness, foveal avascular zone area, foveal and macular thickness, endothelial cell density (ECD), and postoperative inflammation.

RESULTS

Surgery with low IOP settings used less fluid (40.0 mL vs 55.6 mL, P < .0001). Corneal thickness changes were smaller in low IOP eyes at 1 day and 1 week (3.0% vs 8.1%, P = .01; 3.1% vs 4.4%, P = .01) but were similar by 1 and 3 months. ECD dropped less in low IOP eyes at 1 and 3 months (-1.7% vs -12.3%, P = .001, 2.1% vs -8.9%, P = .0003.) IOP remained a significant predictor of ECD change when relationship was controlled for fluid use and phacoemulsification energy. Retinal parameters did not vary among all eyes or when compared by IOP setting. Visual acuity was similar at all timepoints.

CONCLUSIONS

Low IOP settings resulted in less inflammation and less corneal trauma, as evidenced by a smaller drop in ECD and less postoperative corneal edema, when compared with high IOP settings. Retinal parameters did not change significantly. The different outcomes did not result in a difference in visual acuity.

Narrative review after post-hoc trial analysis of factors that predict corneal endothelial cell loss after phacoemulsification: Tips for improving cataract surgery research

PURPOSE

Identifying pre/perioperative factors that predict corneal endothelial-cell loss (ECL) after phacoemulsification may reveal ways to reduce ECL. Our literature analysis showed that 37 studies have investigated one or several such factors but all have significant limitations. Therefore, the data of a large randomized controlled trial (PERCEPOLIS) were subjected to post-hoc multivariate analysis determining the ability of nine pre/perioperative variables to predict ECL.

METHODS

PERCEPOLIS was conducted in 2015-2016 to compare two phacoemulsification techniques (subluxation and divide-and-conquer) in terms of 3-month ECL. Non-inferiority between the techniques was found. In the present study, post-hoc univariate and multivariate analyses were conducted to determine associations between ECL and age, sex, cataract density, preoperative endothelial-cell density, phacoemulsification technique, effective phaco time (EPT), and 2-hour central-corneal thickness. The data are presented in the context of a narrative review of the literature.

RESULTS

Three-month data were available for 275 patients (94% of the randomized cohort; mean age, 74 years; 58% women). Mean LOCSIII cataract grade was 3.2. Mean EPT was 6 seconds. Mean ECL was 13%. Only an older age (beta = 0.2%, p = 0.049) and higher EPT (beta = 1.2%, p = 0.0002) predicted 3-month ECL. Cataract density was significant on univariate (p = 0.04) but not multivariate analysis. The other variables did not associate with ECL.

CONCLUSIONS

Older age may amplify ECL due to increased endothelial cell fragility. EPT may promote ECL via cataract density-dependent and -independent mechanisms that should be considered in future phacoemulsification research aiming to reduce ECL. Our literature analysis showed that the average ECL for relatively unselected consecutively-sampled cohorts is 12%.

Application of the Active-Fluidics System in Phacoemulsification: A Review

The fluidics system is an indispensable and primary component of phacoemulsification. Both the gravity-fluidics system and active-fluidics system are commonly used in practice. The irrigation pressure of the gravity-fluidics system is determined by the bottle height, which is relatively constant, while the active-fluidics system is paired with a cassette that contains pressure sensors to monitor intraocular pressure changes. The active-fluidics system allows surgeons to preset a target intraocular pressure value, and it replenishes the fluids proactively; thus, the intraocular pressure is consistently maintained near the target value. Under such circumstances, stable intraocular pressure and anterior chamber volume values could be acquired. Research on surgical safety, efficiency and results have reported several strengths of the active-fluidics system. It is also advantageous in some complicated cataract surgeries. However, the system is not widely used at present, mainly due to its low penetration rate and high equipment cost. Some of its updates such as the new Active Sentry handpiece showed potential superiority in laboratory studies recently, but there is still further research to be conducted. This article gives an overview of the mechanism and performance of the active-fluidics system, and it is expected to provide clues for future research.

A prospective randomized clinical trial of active-fluidics versus gravity-fluidics system in phacoemulsification for age-related cataract (AGSPC)

BACKGROUND

To figure out the efficacy, effects, safety and patient's subjective perceptions of phacoemulsification with the active-fluidics system (AFS).

PATIENTS AND METHODS

This was a prospective, randomized, double-masked, controlled clinical study. Age-related cataract patients were recruited and randomly assigned to the AFS group and gravity-fluidics system (GFS) group in a ratio of 1:1 to have phacoemulsification. Participants were followed up at one day, one week, one month and three months postoperatively (Chinese Clinical Trial Registry, ChiCTR2100044409).

RESULTS

The overall included participants were 107 finally. The total aspiration time of the AFS group was significantly less than that of the GFS group (p = .020), while no significant difference existed in cumulative dissipated energy and estimated fluid usage between the two groups. The best corrected visual acuity was significantly better in the AFS group at one day and one week postoperatively (p = .002, p = .038 respectively). The recovery of central corneal thickening and macular superficial vasculature increase was earlier in the AFS group. The central retinal thickness was significantly higher in the GFS group at one month and three months postoperatively (p = .029, p = .016 respectively). The incidence of corneal adverse events was higher in GFS group (p = .035). No serious adverse events occurred in either group. Pain scores and the scores of Cat-PROM5 questionnaire of the AFS group were significantly lower than that of the GFS group (p = .011, p = .002 respectively).

CONCLUSION

AFS improves the efficiency, effects, safety and patients' subjective perceptions of phacoemulsification compared with GFS. It is worthwhile to promote its application in cataract surgery.KEY MESSAGESThe active-fluidics system automatically detects and maintains stable intraocular pressure at the set value.The active-fluidics system improves the efficiency, effects, safety and patients' subjective perceptions in phacoemulsification.

Comparisons of the energy efficiency and intraocular safety of two torsional phacoemulsification tips

Background

During cataract phacoemulsification surgery, an Intrepid® balanced (IB) tip can achieve a larger amplitude, which may lead to higher energy efficiency than a Kelman (K) tip when paired with a torsional phaco platform. In this retrospective cohort study, we compared their energy efficiency and damage to the cornea under a new energy setting.

Methods

The medical records of 104 eyes of 79 patients were reviewed, with 47 eyes belonging to the IB group and 57 eyes belonging to the K group. All surgeries were performed on an Alcon Centurion® platform with gravity infiltration. Surgical parameters, visual outcome, central corneal thickness (CCT) changes, and endothelial cell density (ECD) loss rate were recorded and calculated.

Results

No significant differences in postoperative best corrected visual acuity (BCVA), intraocular pressure (IOP), total ultrasound time, estimated fluid aspirated, CCT changes, or ECD loss rate were observed between the two groups. We divided the included eyes into soft nucleus and hard nucleus subgroups and found lower cumulative dissipated energy (CDE, 8.15 ± 8.02 vs 14.82 ± 14.16, P = 0.023), cumulative torsional energy (CTE, 8.06 ± 7.87 vs 14.13 ± 13.02, P = 0.027), and cumulative longitudinal energy (CLE, 0.09 ± 0.17 vs 0.69 ± 1.37, P = 0.017) in the IB group than in the K group, implying less energy used and higher energy efficiency of the IB tip.

Conclusion

Lower CLE in the IB group indicates fewer phaco tip obstructions and a significantly higher capability to conquer hard nuclei with IB tips with statistical significance. With an ultra-perfusion cannula, the balanced tip does not cause more corneal damage.

Risk factors, complications, and outcomes of phacoemulsification cataract surgery complicated by retained lens fragments in Asian eyes: A 10-year retrospective study

PURPOSE

To study the risk factors, visual outcomes, and sequelae of phacoemulsification surgery complicated by retained lens fragments (RLFs).

METHODS

This single-center case-control study enrolled consecutive eyes complicated by RLF and compared them to age- and gender-matched uneventful cataract surgery cases at a tertiary care teaching hospital. Biometric, intraoperative, and postoperative data were collected. The primary outcome measures were risk factors, visual outcomes, and rate of postoperative complications.

RESULTS

The study and control groups included 282 and 289 eyes, respectively. The estimated incidence of RLF was 1.47% during the study. We found a statistically higher risk of RLF among diabetics (P < 0.001), those with a history of intravitreal injections (P = 0.001), eyes with dense nuclear sclerosis, anterior capsular cataract (P < 0.001), and posterior polar cataract (P = 0.01). There was a statistically higher risk of RLF in eyes with a higher mean preoperative visual acuity (logarithm of the minimum angle of resolution) (P < 0.001) and in cases performed by trainees (P < 0.001). Most eyes in the RLF group (n = 207, 73.4%) retained their preoperative vision or experienced a one-line improvement in visual acuity and 14 eyes (5.3%) experienced more than one-line improvement in vision.

CONCLUSION

Although RLFs are rare, they can affect the quality of postoperative vision and outcomes of complicated phacoemulsification surgery.

Corneal Endothelial Cell Loss After Endocapsular and Supracapsular Phacoemulsification: The PERCEPOLIS Randomized Clinical Trial

PURPOSE

Subluxation techniques are superior to divide-and-conquer in procedure duration, pain, and ultrasound quantity, but their safety in endothelial cell loss (ECL) is unclear. This randomized single-blind noninferiority clinical trial aimed to determine whether subluxation supracapsular phacoemulsification techniques are inferior to a reference endocapsular technique (divide-and-conquer) regarding postoperative corneal ECL.

METHODS

Patients (aged18 years or older) with greater than +0.2 logarithm of the minimum angle of resolution best spectacle-corrected visual acuity and normal to severe density cataract were randomized to subluxation or divide-and-conquer phacoemulsification in 2015 to 2016. Follow-up with ophthalmic tests was conducted on day 4 and months 1, 3, and 12. The primary study outcome was ECL at all time points. Secondary study end points were operative variables, including effective phaco time and procedure duration. A clinically relevant noninferiority ECL limit was established on the basis of the literature.

RESULTS

In total, 292 patients (mean age, 73 yrs; 59% female) were randomized and underwent subluxation (n = 148) or divide-and-conquer (n = 144). Day 4 and month 1, 3, and 12 data were available for 243, 270, 275, and 198 patients, respectively. The unexpectedly high dropout at 12 months meant that the 12-month ECL data could only be assessed qualitatively. Surgery was successful in all patients. Subluxation was noninferior to divide-and-conquer in ECL. Effective phaco times were similar, but subluxation associated with shorter procedure duration.

CONCLUSIONS

The subluxation technique was noninferior to divide-and-conquer regarding postoperative ECL, at least in the first 3 months, and associated with reduced intervention time. Subluxation techniques may be suitable alternatives to endocapsular techniques.Clinical Trial Registration-URL: ClinicalTrials.gov. Unique identifier: NCT02535819.

Comparison of effective phacoemulsification time and corneal endothelial cell loss using three different ultrasound frequencies: A randomized controlled trial

Purpose

Comparison of three ultrasound (US) frequencies for phacoemulsification of hard cataracts to determine a frequency that makes phacoemulsification more efficacious and safer.

Methods

A randomized controlled trial was undertaken at a medical college and hospital. In total, 207 patients with grade 5.6-6.9 (LOCS III) senile cataract were randomized into three groups. Group I underwent phacoemulsification with 28-kHz frequency, group II with 42-kHz frequency, and group III with 53-kHz frequency. The effective phacoemulsification time (EPT) and estimated fluid usage (EFU) were compared intraoperatively. The endothelial cell parameters were analyzed for 6 months.

Results

The groups were matched for age (P = 0.467), gender (P = 0.497), nuclear grade (P = 0.321), and anterior chamber depth (P = 0.635). The EPT and EFU were significantly lower in group III, compared to group II and group I, with P < 0.0001 and P < 0.0001, respectively. Postoperatively, the endothelial cell density (ECD) was significantly higher in group III at 1 month (P < 0.0001), 3 months (P < 0.0001), and 6 months (P < 0.0001). The percentages of ECD loss were also significantly lower in group III; the difference was statistically significant (P < 0.0001) up to 6 months postoperatively.

Conclusion

Higher frequency ultrasound was associated with a lower EPT and EFU as well as better endothelial preservation than lower frequencies in hard cataracts.

The efficacy and safety profile of cataract procedures performed with a sensor-embedded handpiece and a new hybrid phaco tip

OBJECTIVE

To evaluate the efficacy and safety of the new Intrepid Hybrid tip and Active Sentry handpiece in comparison to the Intrepid Balanced tip and Centurion Ozil handpiece.

METHODS

One hundred sixty-eight eyes were included in the study and randomized into Group 1 (Active Sentry handpiece + Intrepid Hybrid tip, n = 86) and Group 2 (Centurion Ozil handpiece + Intrepid Balanced tip, n = 82). Data were collected from the phaco device, including total U/S time, cumulative dissipated energy (CDE), the total number of active surge mitigation actuations (ASM actuations), torsional amplitude, torsional amplitude on time, estimated fluid of aspirated, and aspiration time. Endothelial cell count (ECC) and central corneal thickness (CCT) were assessed. A correlation analysis was performed between ASM actuations, phaco metrics, and patient characteristics in Group 1.

RESULTS

The CDE, torsional amplitude measured in Group 1 (8.8 ± 3.9, 51.2 ± 13.3, respectively) were significantly lower than those of Group 2 (10.4 ± 4.2, 65.2 ± 9.3, respectively). While no complications were observed in group 1, there were posterior capsule rupture in 2 eyes and iris damage in 1 eye in group 2. The mean ECC and CCT were similar at 1 month. The ASM actuations were more engaged in the eyes with pseudoexfoliation and small pupils.

CONCLUSION

The combination of the new Intrepid Hybrid tip and Active Sentry handpiece enables safer cataract procedures without compromising efficacy due to its surge prevention mechanisms and special tip design. It could be a good option for residents in training.

Active-fluidics versus gravity-fluidics system in phacoemulsification for age-related cataract (AGSPC): study protocol for a prospective, randomised, double-blind, controlled clinical trial

INTRODUCTION

The active-fluidics system is a new irrigation system of phacoemulsification that automatically detects and maintains stable intraocular pressure at the set value. This trial is designed to compare the efficacy, visual outcomes, safety and patients' subjective perceptions of cataract surgery with the active-fluidics system and gravity-fluidics system.

METHODS AND ANALYSIS

This trial will recruit 110 patients with age-related cataract at the Chinese People's Liberation Army (PLA) General Hospital (Beijing, China) and they will be randomly assigned to the active-fluidics group and gravity-fluidics group in a ratio of 1:1 to have phacoemulsification. Patients will be followed up at 1 day, 1 week, 1 month and 3 months postoperatively. The primary outcomes are the cumulative dissipated energy and best corrected visual acuity. Secondary outcomes include: estimated fluid usage, U/S time, total aspiration time, intraocular pressure, corneal endothelium parameters, retinal thickness, macular superficial vessel density, pain scores, scores of the Cataract surgery Patient-Reported Outcome Measures Questionnaire and the complication rates. The data will be independently analysed by the statistical team, who will be masked for the allocation information as participants are.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of Chinese PLA General Hospital (approval no. S2021-068-01). Informed consent will be obtained from each participant. All the results will be published in peer-reviewed journals and used for scholarly communication or technical guidance. Protocol version 1.0.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR2100044409).

Efficacy of Balanced Torsional Phacoemulsification Tip for Cataract Surgery

Purpose:

To compare the efficacy of the Intrepid® Balanced torsional phacoemulsification tip to that of the 30° Ozil® and 45° Kelman® tips using Centurion Vision System.

Methods:

This study included 150 eyes that underwent torsional phacoemulsification surgery using 30° Ozil^® tip (Group 1, 48 eyes), Intrepid^® Balanced tip (Group 2, 52 eyes), or 45° Kelman^® tip (Group 3, 50 eyes). Ultrasound time (UST), cumulative dissipated energy (CDE), average phaco power, average torsional amplitude, balanced salt solution volume, aspiration and operation time, and preoperative, postoperative corrected distance visual acuity, central corneal thickness were recorded.

Results:

The mean UST, CDE, average phaco power, average torsional amplitude were 49.9 ± 15.7 s, 10.8 ± 4.5%-s, 23.9 ± 4.6%, and 51.4 ± 5.7% in the Ozil^® group and 47.5 ± 10.6 s, 5.3 ± 2.2%-s, 12.5 ± 5.3%, and 28.9 ± 7.2% in the Intrepid® Balanced group, and 48.1 ± 12.7 s, 6.9 ± 3.3%-s, 18.9 ± 5.9%, and 39.2 ± 7.9% in the Kelman^® group, respectively. The CDE, average phaco power, and average torsional amplitude of the Intrepid® Balanced group were significantly lower than other groups (P < 0.05). There was no statistically significant difference between the three groups in terms of UST and operation time (P > 0.05).

Conclusion:

Intrepid^® Balanced tip, by means of its distinctive “double bent” design and balanced energy distribution, offers more effective phacoemulsification compared to conventional 30° Ozil^® and 45° Kelman^® tips.

Efficient use of ultrasound in cataract surgery

PURPOSE OF REVIEW

Modern phacoemulsification machines apply ultrasound through a variety of settings and parameters to remove a cataract. Using these new technologies efficiently is critical for both reducing surgical times and improving postoperative outcomes. The present article reviews recent findings in phacodynamics to explore the optimum use of ultrasound in cataract surgery.

RECENT FINDINGS

In studies seeking to determine the optimum parameters in both fluidics and power, increased power and aspiration does not necessarily equate to more efficiency. New developments, such as torsional ultrasound, micropulse, and burst mode have shown increased efficiency in randomized control trials and in-vitro compared with conventional ultrasound. Regarding vacuums, the venturi pump has demonstrated greater efficiency compared with the peristaltic pump. We also explore other parameters, such as chamber pressure and tip selection. Meta-analyses on femtosecond-laser assisted cataract surgery (FLACS) have shown similar long-term visual outcomes compared to conventional cataract surgery.

SUMMARY

Though conventional cataract surgery remains highly effective, surgeons have increasing options for customizing their ultrasound settings and phacoemulsification techniques.

Active sentry versus ozil hand piece - A prospective randomized comparative study

PURPOSE

To compare the safety and efficacy of active sentry hand piece with ozil hand piece for centurion phacoemulsification system.

SETTING

Tertiary eye centre, South India.

DESIGN

Prospective observational study.

METHODS

A total of 204 eyes of 204 patients with uncomplicated cataract who underwent phacoemulsification cataract surgery with centurion vision system were randomized into two groups: Ozil hand piece (n=101) and active sentry hand piece (n =103). Intra-operative factors like patient's pain perception, surgeon's comfort level, amount of phacoemulsification energy and aspiration fluid used, frequency of activation of active surge mitigation (ASM) were analyzed and post-operatively corrected distance visual acuity (CDVA) and corneal edema on day one were compared.

RESULTS

Patient's pain perception was comparable between the groups with no significant differences in proportion of patients who had pain free surgery (66% vs 61.3%) or those experienced moderate pain (24.3% vs 28.7%). Surgeons were more comfortable using ozil hand piece during entry into anterior chamber and emulsification of hard nuclei (48.5% vs 28.6%). The mean CDE for soft cataracts was 5.6 and 4.8 and for hard cataracts it was 9.3 and 9.4 for ozil and active sentry group respectively. ASM was activated for 53 (51.5%) eyes, of which 42 (79.2%) eyes had soft cataract and 11 (20.7%) had hard cataract. Post-operative CDVA and incidence of corneal edema was comparable between the groups.

CONCLUSION

For centurion vision system, active sentry hand piece is safe and efficacious as the ozil hand piece with added benefit of operating at lower IOP levels.

Modeling of the increased intraocular pressure effect on changes in the stress state of the eyeball’s internal structures

The aim of the study was creating a model and evaluating the effect of elevated IOP in the anterior chamber during phacoemulsification on the changes in the stress state of various ocular structures. Materials and methods.A simplified axial symmetrical anatomical model of the eyeball was created using the finite element method. Using the Deform software package, the deformation problem was worked out by calculating the redistribution of the excess pressure in the anterior chamber during phacoemulsification, on the changes in the stress state of different ocular structures.Results. At processing of modeling results, data were obtained on redistribution of the excess pressure delivered to the anterior chamber towards its decrease in the posterior pole area. The pressure level amounted to 0.85 % of excess pressure applied. The findings are supported by few animal experiments. Conclusions.Proposed model of the increased IOP level effect on changes in the stressed state of various ocular structures demonstrates that the autoregulation mechanism maintaining ocular blood flow at a constant level includes a compensating mechanism for a steep IOP increase due to elastic properties of the vitreous body. This model allows calculating the redistribution of pressure in different parts of the eyeball, depending on the state of resilient-elastic properties of the vitreous, as well as on avitreal eyes, and in patients with silicone oil tamponade.

Intraoperative intraocular pressure fluctuation during standard phacoemulsification in real human patients

INTRODUCTION

To evaluate the results of the fluctuations of intraocular pressure (IOP) and calculated mean ocular perfusion pressure (MOPP) during the usual steps of standard phacoemulsification.

METHODS

Nine human eyes were evaluated. The IOP was measured indirectly by electronic applanation tonometer. The MOPP was calculated using the systolic blood pressure (SBP), the diastolic blood pressure (DBP) and the IOP: MOPP = 2/3x[DBP + 1/3x(SBP - DBP)] - IOP. The operations were performed with the INFINITI^® Vision System: main incision 2.2 mm, coaxial handpiece, 2 paracenteses 1.1 mm, bimanual irrigation/aspiration, bottle height 100 cm. As ocular viscoelastic device (OVD) Hypromel 2.5% (UNIMED) was used.

RESULTS

The initial and final IOPs were 17-30 Torr (median 18) and 6-16 Torr (median 8), respectively. The IOP values oscillated between 4 and 63 Torr during the procedure. The highest values of the IOP were achieved at the beginning of phacoemulsification (from 42 to 63 Torr). The maximum pressure higher than 50 mmHg and 60 mmHg was found in 89% and 30% of cases, respectively. The mean ocular perfusion pressure (MOPP) at the beginning of the procedure was 46.4-67.0 (median 53.3) and 0.4-42.0 (median 19.3) during the maximum intraocular pressure.

CONCLUSIONS

Measured IOP as well as MOPP varied in all normal steps of real phacoemulsification. High values of intraoperative IOL induced by irrigation may compromise the intraocular perfusion. These fluctuations may induce impairment of the optic nerve perfusion, as well as retina, or choroid.

Comparative studies between longitudinal and torsional modes in phacoemulsification, using active fluidics technology along with the intrepid balanced tip

Purpose:

To compare and report the intra- and postoperative outcomes of phacoemulsification between longitudinal (LPKE) and torsional (TPKE) mode, using active fluidics along with the intrepid balanced tip.

Methods:

This single center prospective randomized comparative study comprised a total 108 consecutive eyes of 108 patients having senile cataract subdivided into nuclear opalescence (NO) grades II–IV according to the lens opacities classification system III (LOCS III). Cataracts of each grade were randomly assigned to two groups LPKE (n = 54) and TPKE (n = 54) mode, who were operated on by the same surgeon using same machine (Centurion^® Alcon Laboratories, Inc., USA) having features of both active fluidics and intrepid balanced tip. Pre-, intra-, and postoperative evaluations were done independently by a different author, who was masked to the surgical procedures. Patients were evaluated on the postoperative days (PODs) 1, 7, 15, and 28. Intraoperative outcome measures were cumulative dissipated energy (CDE) and ultrasound time (UST). Postoperative outcome measures were endothelial cell loss (ECL), central corneal thickness (CCT), and best-corrected visual acuity (BCVA).

Results:

Age, gender, and NO-grade distribution among two modes were comparable (P > 0.05). Difference of CDE and UST between modes were found to be significant (P < 0.001) in favor of TPKE with all NO-grades. TPKE mode performs better than LPKE mode with regard to ECL, CCT-change, and BCVA-change, although the differences were found to be insignificant (P > 0.05).

Conclusion:

When using active fluidics along with the intrepid balanced tip, TPKE mode appeared to be a more efficient mode of PKE with reduced mean UST and CDE across all NO-grades, as compared to LPKE mode. However, ECL, CCT-change, and BCVA-change were seemed to be comparable between the two modes.