Complication rate of posterior capsule rupture with vitreous loss during phacoemulsification at a Hawaiian cataract surgical center: a clinical audit

Prevalence and outcome of lens capsule disruption in routine canine cataract surgery: A retrospective study of 520 eyes (2012-2019)

OBJECTIVE

To investigate the prevalence and surgical outcome of lens capsule disruption (LCD) in dogs undergoing cataract removal.

ANIMALS STUDIED

Medical records of 924 eyes undergoing phacoemulsification were analyzed retrospectively.

PROCEDURES

Routine cataract surgeries with or without LCD were included. Any LCD other than routine anterior capsulorhexis was defined as LCD and classified according to location and etiology. Odds ratios (OR) were calculated for maintaining vision, implantation of an artificial intraocular lens (IOL), and enucleation.

RESULTS

In total, 520 eyes were included. A LCD occurred in 145 eyes (27.8%; 145/520) and affected the posterior (85.5%; 124/145), anterior (6.2%; 9/145), and equatorial lens capsule (4.8%; 7/145) and at multiple locations (3.4%; 5/145). The etiology of the LCD was spontaneous preoperative in 41 eyes (28.3%; 41/145), accidental intraoperative in 57 eyes (39.3%; 57/145), and planned in 47 eyes (32.4%; 47/145). Disruption did not increase the odds of enucleation (OR = 1.48, 95% confidence interval [CI] 0.56-3.67; p = .36). The presence of LCD significantly increased the risk of losing vision 1 year post-operatively (OR = 8.17, 95% CI 1.41-84.93; p = .007) associated with retinal detachment. However, this was not present at 2 years follow-up or in PCCC cases at any time point. An IOL was implanted in 108 eyes (108/145; 75.2%) with LCD and in 45/47 (95.7%) eyes with a PCCC.

CONCLUSION

Increased surgeon awareness of possible intraoperative, accidental LCDs is important, as LCDs were relatively common and associated with increased odds for vision loss after 1 year in the present study. A prospective study investigating the causes of intraoperative, accidental LCD is warranted.

The Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: Report 17, a risk factor model for posterior capsule rupture

BACKGROUND/OBJECTIVES

To create a risk factor model for posterior capsule rupture (PCR) during cataract surgery.

SUBJECTS/METHODS

Eligible operations between 01/04/2016 and 31/03/2022 from centres supplying data to the UK national cataract audit with complete data including patients' gender and age at surgery, anterior chamber depth (ACD) measurement and preoperative visual acuity (VA) were included. A logistic regression model was fitted to identify risk factors and calculate their odds ratios (OR) and 95% confidence intervals (CI) for PCR.

RESULTS

This analysis included 961,208 cataract operations performed on 682,381 patients from 136 participating centres by 3198 surgeons. 9730 (1.01%) of surgeries were complicated by PCR. The median age was 75.7 and 76.7 years for first and second eye surgery respectively, and 5154 (53.0%) were female. The highest risk factors for PCR were less experienced trainee surgeon (OR 3.75, 95% CI 3.33-4.24, p < 0.001), pseudoexfoliation/phacodonesis (OR 3.47, 95% CI 3.05-3.94, p < 0.001), younger males (OR 3.05, 95% CI 2.23-4.16, p < 0.001) and brunescent/white/mature cataract (OR 2.41, 95% CI 2.24-2.60, p < 0.001). Other risk factors identified were glaucoma, worse preoperative VA, previous intravitreal therapy, high myopia, previous vitrectomy, systemic diabetes, diabetic retinopathy, amblyopia, older age, shallower ACD and inability to lie flat and cooperate.

CONCLUSION

Various surgical, patient and ocular factors increase the risk of PCR during cataract surgery. This risk factor model permits estimation of individualised risks for patients and allows risk-adjustment for surgeons to evaluate their PCR rates based on case complexity.

Risk factors for complications in resident-performed cataract surgery: A systematic review

We assessed risk factors for complications associated with resident-performed cataract surgery. Using the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we searched 4databases in September, 2023. We included peer-reviewed, full-text, English-language articles assessing risk factors for complications in resident performed cataract surgery. We excluded studies describing cataract surgeries performed by fellows, combined surgeries, and studies with insufficient information. Our initial search yielded 6244 articles; 15 articles were included after title/abstract and full-text review. Patient-related risk factors included older age, hypertension, prior vitrectomy, zonular pathology, pseudoexfoliation, poor preoperative visual acuity, small pupils, and selected types of cataracts. Surgeon-related risk factors included resident postgraduate year and surgeon right-handedness. Other risk factors included absence of supervision, long phacoemulsification time, and phacoemulsification with high power and torsion. The quality of the studies was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation; most studies graded as moderate, primarily due to risk of bias. When assigning cases to residents, graduate medical educators should consider general and resident-specific risk factors to facilitate teaching and preserve patient safety.

Clinical and anatomic correlates of objectively measured zonular dehiscence in 427 postmortem pseudophakic eyes

OBJECTIVE

This study aims to objectively measure the degree of zonular dehiscence in postmortem eyes and to assess for clinical and anatomic correlates.

DESIGN

Cross-sectional study.

MATERIALS

Four hundred and twenty-seven postmortem pseudophakic human eyes.

METHODS

Eyes were obtained from the Lions Gift of Sight Eye Bank. Microscope photographs were taken of the eyes in Miyake-Apple view, and region-of-interest analysis was performed using ImageJ to measure the area, circumference, and diameter of the capsular bag, the ciliary ring, and the capsulorhexis. Clinical and anatomic parameters were assessed using simple linear regression analysis and one-way analysis of variance with post hoc Bonferroni testing. Zonular dehiscence was measured via 2 surrogates: capsule area over ciliary ring area ratio (CCR) and capsule-ciliary ring decentration (CCD). Low CCR and high CCD indicate more zonular dehiscence.

RESULTS

CCR was significantly inversely correlated with smaller capsulorhexi (p = 0.012), lower intraocular lens power (p < 0.00001), younger age at death (p = 0.00002), and a longer cataract-to-death time (p = 0.00786). CCR also was significantly lower in glaucomatous cases (p = 0.0291). CCD was significantly correlated with longer cataract-to-death time (p = 0.000864), larger ciliary ring area (p = 0.001), more posterior capsule opacification (p = 0.0234), and higher Soemmering's ring opacity (p = 0.0003). There was also significantly more decentration in male eyes than in female eyes (p = 0.00852).

CONCLUSIONS

CCR and CCD are novel measures of zonular dehiscence in postmortem eyes, with many interesting correlates. An enlarged ciliary ring area is possibly associated with zonular dehiscence in pseudophakic eyes and may be a quantifiable surrogate in vivo.

The "Ballerina" Sign: Posterior Capsular Rupture during Cataract Surgery

Introduction

In this case study, we present the "Ballerina" sign as a potentially valuable clinical indicator for detecting posterior capsular rupture (PCR) during cataract surgery. The purpose of this study is to highlight the significance of PCR in the context of cataract surgery and introduce this novel sign.

Case Presentation

During the cataract operation on a 70-year-old patient, we observed a spiraling fragment of the nucleus attached to a vitreous string. Subsequently, an anterior vitrectomy was successfully performed without further intraoperative complications, followed by the insertion of a 3-piece lens into the sulcus. Positive visual outcomes were observed during postoperative follow-up appointments at 1 day, 2 weeks, and 3 months.

Conclusion

The documentation of the "Ballerina" sign in the medical literature is innovative, offering ophthalmic surgeons a valuable tool for early PCR detection during cataract surgeries.

Association between anterior chamber biometry and posterior capsular defects

PURPOSE

To analyze the association between anterior chamber biometric factors and posterior capsular defects (PCDs) that occur during extracapsular cataract extraction.

SETTING

University Eye Hospital, Goethe University Frankfurt, Germany.

DESIGN

Population-based study.

PATIENTS AND METHODS

Extracapsular cataract extractions for inpatient cases within 4 years were retrospectively analyzed. The data on the occurrence of PCDs, age, sex, surgeon, and biometry were obtained. For cases with PCDs, the secondary ocular diseases, number of procedures, lens implant, visual acuity, and course were also recorded. Swept-source optical coherence tomography measurements allowed the measurement of lens thickness (LT) in addition to the usual biometry values.

RESULTS

A total of 1967 cataract surgeries (patients age: 70.56 ± 8.42, 1005 women; 962 men) were included, and PCDs were documented for 59 (2.54%; 31 women, 28 men) cases (patient age: 70.95 ± 8.52 years). There were no differences ( P = .76) related to the surgeons (n = 9) with minimal effect sizes. The mean LT, axial length, corneal curvature, and anterior chamber depth were 4950.36 ± 466.63 μm, 23.73 ± 1.77 mm, 43.89 ± 1.36 diopters, and 3.02 ± 0.71 mm, respectively. The Wilcoxon-Mann-Whitney test showed significant associations between LT ( P = .01) and PCDs with moderate relevance for the Rosenthal effect size (LT R = 0.34; ACD R = 0.29).

CONCLUSIONS

In addition to ACD, a tendency for the occurrence of PCD could be proven, especially for LT. Therefore, special attention should be paid to LT preoperatively for comprehensive risk stratification.

Experimental study comparing 2 different phacoemulsification systems with intraocular pressure control during steady-state flow and occlusion break surge events

PURPOSE

To compare peak surge and surge duration time after occlusion break, incision leakage compensation, and passive vacuum for 2 phacoemulsification systems.

SETTING

Carl Zeiss Meditec AG, Oberkochen, Germany.

DESIGN

Laboratory study.

METHODS

A spring-eye model was used to test Alcon Centurion Vision and Zeiss Quatera 700 systems. Peak surge and duration was measured after an occlusion break. Quatera tested in flow and vacuum priority modes. Vacuum limits ranged from 300 to 700 mm Hg with intraocular pressure (IOP) set at 30 mm Hg, 55 mm Hg, and 80 mm Hg. IOP vs incision leakage rates of 0 to 15 cc/min and passive vacuum were measured.

RESULTS

At 30 mm Hg IOP set point and vacuum limits ranging 300 to 700 mm Hg, the surge duration time after occlusion break ranged 419 to 1740 milliseconds (ms) for Centurion, 284 to 408 ms for Quatera in the flow mode, and 282 to 354 ms for Quatera in the vacuum mode. At 55 mm Hg, values ranged 268 to 1590 ms for Centurion, 258 to 471 ms for Quatera in the flow mode, and 239 to 284 ms for Quatera in the vacuum mode. At 80 mm Hg, values were 243 to 1520 ms for Centurion, 238 to 314 ms for Quatera in the flow mode, and 221 to 279 ms in the vacuum mode. Centurion exhibited slightly less peak surge than the Quatera. At 55 mm Hg: incision leakage rates 0 to 15 cc/min, Quatera held the IOP within ±2 mm Hg of target; Centurion was unable to hold IOP target allowing a 11.7 mm Hg decrease with 32% higher passive vacuum.

CONCLUSIONS

Quatera demonstrated slightly higher surge peak values and notably shorter surge duration times after occlusion break than Centurion. Quatera demonstrated better incision leakage compensation and lower passive vacuum than Centurion.

Trans-Scleral Plugs Fixated FIL SSF IOL: A Review of the Literature and Comparison with Other Secondary IOL Implants

Purpose. To revise the current literature on FIL SSF (Carlevale) intraocular lens, previously known as Carlevale lens, and to compare their outcomes with those from other secondary IOL implants. Methods. We performed a peer review of the literature regarding FIL SSF IOLs until April 2021 and analyzed the results only of articles with a minimum of 25 cases and a follow-up of at least 6 months. The searches yielded 36 citations, 11 of which were abstracts of meeting presentations that were not included in the analysis because of their limited data. The authors reviewed 25 abstracts and selected six articles of possible clinical relevance to review in full text. Of these, four were considered to be sufficiently clinically relevant. Particularly, we extrapolated data regarding the pre- and postoperative best corrected visual acuities (BCVA) and the complications related to the procedure. The complication rates were then compared with those from a recently published Ophthalmic Technology Assessment by the American Academy of Ophthalmology (AAO) on secondary IOL implants. Results. Four studies with a total of 333 cases were included for results analysis. The BCVA improved in all cases after surgery, as expected. Cystoid macular edema (CME) and increased intraocular pressure were the most common complications, with an incidence of up to 7.4% and 16.5%, respectively. Other IOL types from the AAO report included anterior chamber IOLs, iris fixation IOLs, sutured iris fixation IOLs, sutured scleral fixation IOLs, and sutureless scleral fixation IOLs. There was no statistically significant difference in the rates of postoperative CME (p = 0.20), and vitreous hemorrhage (p = 0.89) between other secondary implants and the FIL SSF IOL, whereas the rate of retinal detachment was significantly less with FIL SSF IOLs (p = 0.04). Conclusion. The results of our study suggest the implantation of FIL SSF IOLs is an effective and safe surgical strategy in cases where there is a lack of capsular support. In fact, their outcomes seem to be comparable to those obtained with the other available secondary IOL implants. According to published literature, the FIL SSF (Carlevale) IOL provides favorable functional results with a low rate of postoperative complications.

Visual outcome of cataract surgery in a tertiary care teaching hospital

Objectives

To review the visual outcomes after cataract surgery in a tertiary care teaching hospital, Isra University Hyderabad.

Methods

This retrospective clinical study was carried out for six months at Isra University Hyderabad from December 2020-May 2021. Total patients included were 982. The data comprised of patients who underwent cataract surgery from Sept 2018 - Aug 2020. Individuals over 40 years were included and who returned for out-patient appointments. Visual acuity before and six weeks after cataract surgery were noted and categorized according to World Health Organization criteria (i-e Good, Moderate and Poor).. Data analysis was done with the help of SPSS version 22.0.

Results

Out of 982 patients who underwent Phacoemulsification at Isra University Hospital, the operated eyes were 483 right and 499 left respectively. Meanwhile, 966 had good visual acuity six weeks after the surgery, while 16 had moderate visual acuity noted after six weeks.

Conclusion

Clinical audit of cataract surgeries by measuring visual acuity postoperatively is an excellent approach in improving the outcomes and maintaining the good care facilities at a tertiary care hospital.

Intraoperative floppy iris syndrome: an updated review of literature

Intraoperative Floppy iris syndrome(IFIS) remains a challenge for surgeons during phacoemulsification. Initially, it was related to the use of tamsulosin, an alpha adrenergic receptor blocker used in benign prostatic hyperplasia. Subsequently, other alpha adrenergic receptor such as alfuzosin, terazosin and doxazosin alongwith different other class of medications and systemic risk factors were identified. Other class of medications includes 5-alpha reductase inhibitor, angiotensin receptor antagonist, benzodiazepines, antipsychotics and antidepressants. Other risk factors include increasing age, male gender, diabetes, hypertension and decreased preoperative pupil diameter. It is very important for surgeons to identify these risk factors preoperatively and take appropriate preoperative and intraoperative measures to tackle the dreaded complications of IFIS. Sometimes, it is important for an ophthalmologist to work in cooperation with physician and urologist to minimize the complications. In conclusion, awareness of the risk factors associated with IFIS, their detailed preoperative assessment and intraoperative measures and surgical intervention is crucial in addressing IFIS. Lack of awareness can turn a routine, uneventful surgery into one with significant visual morbidity.

Pharmacologic interventions for mydriasis in cataract surgery

BACKGROUND

Cataract surgery is one of the most common surgical procedures performed worldwide. Achieving appropriate intraoperative mydriasis is one of the critical factors associated with the safety and performance of the surgery. Inadequate pupillary dilation or constriction of the pupil during cataract surgery can impair the surgeon's field of view and make it difficult to maneuver instruments.

OBJECTIVES

To evaluate the relative effectiveness of achieving pupillary dilation during phacoemulsification for cataract extraction using three methods of pupillary dilation: topical mydriatics, intracameral mydriatics, or depot delivery systems. We also planned to document and compare the risk of intraoperative and postoperative complications following phacoemulsification for cataract extraction, as well as the cost-effectiveness of these methods for pupillary dilation.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which contains the Cochrane Eyes and Vision Trials Register) (2021, Issue 1); Ovid MEDLINE; Embase.com; PubMed; Latin American and Caribbean Health Sciences Literature Database (LILACS); ClinicalTrials.gov; and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We did not use any date or language restrictions in the electronic search for trials. We last searched the electronic databases on 22 January 2021.

SELECTION CRITERIA

We included only randomized controlled trial (RCTs) in which participants underwent phacoemulsification for cataract extraction.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology.

MAIN RESULTS

We included a total of 14 RCTs (1670 eyes of 1652 participants) in this review. Of the 14 trials, 7 compared topical versus intracameral mydriatics, 6 compared topical mydriatics versus depot delivery systems, and 1 compared all three methods. We were unable to calculate overall estimates of comparative effectiveness for most outcomes due to statistical heterogeneity among the estimates from individual studies or because outcome data were available from only a single study. Furthermore, the certainty of evidence for most outcomes was low or very low, due primarily to imprecision and risk of bias. Comparison 1: topical mydriatics versus intracameral mydriatics Four RCTs (739 participants, 757 eyes) of the 8 RCTs that had compared these two methods reported mean pupillary diameters at the time surgeons had performed capsulorhexis; all favored topical mydriatics, but heterogeneity was high (I2 = 95%). After omitting 1 RCT that used a paired-eyes design, evidence from three RCTs (721 participants and eyes) suggests that mean pupil diameter at the time of capsulorhexis may be greater with topical mydriatics than with intracameral mydriatics, but the evidence is of low certainty (mean difference 1.06 mm, 95% confidence interval (CI) 0.81 mm to 1.31 mm; I2 = 49%). Four RCTs (224 participants, 242 eyes) reported mean pupillary diameter at the beginning of cataract surgery; the effect estimates from all trials favored topical mydriatics, with very low-certainty evidence. Five RCTs (799 participants, 817 eyes) reported mean pupillary diameter at the end of cataract surgery. Data for this outcome from the largest RCT (549 participants and eyes) provided evidence of a small difference in favor of intracameral mydriasis. On the other hand, 2 small RCTs (78 participants, 96 eyes) favored topical mydriatics, and the remaining 2 RCTs (172 participants) found no meaningful difference between the two methods, with very low-certainty evidence. Five RCTs (799 participants, 817 eyes) reported total intraoperative surgical time. The largest RCT (549 participants and eyes) reported decreased total intraoperative time with intracameral mydriatics, whereas 1 RCT (18 participants, 36 eyes) favored topical mydriatics, and the remaining 3 RCTs (232 participants) found no difference between the two methods, with very low-certainty evidence. Comparison 2: topical mydriatics versus depot delivery systems Of the 7 RCTs that compared these two methods, none reported mean pupillary diameter at the time surgeons performed capsulorhexis. Six RCTs (434 participants) reported mean pupillary diameter at the beginning of cataract surgery. After omitting 1 RCT suspected to be responsible for high heterogeneity (I2 = 80%), meta-analysis of the other 5 RCTs (324 participants and eyes) found no evidence of a meaningful difference between the two methods, with very low-certainty evidence. Three RCTs (210 participants) reported mean pupillary diameter at the end of cataract surgery, with high heterogeneity among effect estimates for this outcome. Estimates of mean differences and confidence intervals from these three RCTs were consistent with no difference between the two methods. A fourth RCT reported only means for this outcome, with low-certainty evidence. Two small RCTs (118 participants) reported total intraoperative time. Surgical times were lower when depot delivery was used, but the confidence interval estimated from one trial was consistent with no difference, and only mean times were reported from the other trial, with very low-certainty evidence. Comparison 3: Intracameral mydriatics versus depot delivery systems Only one RCT (60 participants) compared intracameral mydriatics versus depot delivery system. Mean pupillary diameter at the time the surgeon performed capsulorhexis, phacoemulsification time, and cost outcomes were not reported. Mean pupil diameter at the beginning and end of cataract surgery favored the depot delivery system, with very low-certainty evidence. Adverse events Evidence from one RCT (555 participants and eyes) comparing topical mydriatics versus intracameral mydriatics suggests that ocular discomfort may be greater with topical mydriatics than with intracameral mydriatics at one week (risk ratio (RR) 10.57, 95% CI 1.37 to 81.34) and one month (RR 2.51, 95% CI 1.36 to 4.65) after cataract surgery, with moderate-certainty evidence at both time points. Another RCT (30 participants) reported iris-related complications in 11 participants in the intracameral mydriatics group versus no complications in the depot delivery system group, with very low-certainty evidence. Cardiovascular related adverse events were rarely mentioned.

AUTHORS' CONCLUSIONS

Data from 14 completed RCTs were inadequate to establish the superiority of any of three methods to achieve mydriasis for cataract surgery, based on pupillary dilation at different times during the surgery or on time required for surgery. Only one trial had a sample size adequate to yield a robust effect estimate. Larger, well-designed trials are needed to provide robust estimates for the comparison of mydriasis approaches for beneficial and adverse effects.

Risk model for intraoperative complication during cataract surgery based on data from 900 000 eyes: previous intravitreal injection is a risk factor

BACKGROUND/AIMS

The aim of this study was to develop a risk model for intraoperative complication (IC) during cataract surgery, defined as posterior capsule rupture and/or zonular dehiscence, and to include previous intravitreal therapy (pIVT) in the model.

METHODS

This retrospective register-based study covered patients reported to the Swedish National Cataract Register (SNCR) between 1 January 2010 and 30 June 2018. Odds ratios (ORs) were used to quantify association strength of each variable with IC. Data from the SNCR were cross referenced with the Swedish Macula Register to include data on pIVT. Variables statistically significant in the univariate analyses (p<0.05) were included in a multivariate logistic regression model.

RESULTS

The inclusion criteria were met by 907 499 eyes. The overall rate of IC was 0.86%. Variables significantly associated with IC were best corrected visual acuity ≥1.0 LogMAR (OR (adjusted): 1.75, p<0.001), age ≥90 years (OR: 1.25, p<0.001), male sex (OR: 1.09, p<0.01), pseudoexfoliation (OR: 1.33, p<0.001), glaucoma (OR: 1.11, p<0.05), diabetic retinopathy (OR: 1.35, p<0.001), pIVT (OR: 1.45, p<0.05), surgeon's experience <600 surgeries (OR: 2.77, p<0.001), use of rhexis hooks (OR: 6.14, p<0.001), blue staining (OR: 1.87, p<0.001) and mechanical pupil dilation (OR: 1.52, p<0.001).

CONCLUSION

The risk model can be used in the preoperative setting to predict the probability of IC, to facilitate planning of surgery and improving patient communication. Patients who have undergone intravitreal therapy prior to cataract surgery have an increased risk of IC during cataract surgery.

Minimum volume standards in day surgery: a systematic review

BACKGROUND

The aim was to find out if and for what indications are minimum volume standards (MVS) applied in the day surgery setting and whether the application of MVS improves patient relevant outcomes.

METHODS

We conducted a comprehensive systematic literature search in seven databases on July 12th, 2019. Concerning effectiveness and safety, the data retrieved from the selected studies were systematically extracted into data-extraction tables. Two independent researchers (MS, CS) systematically assessed the quality of evidence using the quality assessment tool for individual studies of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) called Task Force Checklist for Quality Assessment of Retrospective Database Studies. No instances of disagreement occurred. No further data processing was applied.

RESULTS

The systematic literature search, together with hand search, yielded 595 hits. No prospective or controlled studies were found. Data from eight retrospective studies were used in the analysis of clinical effectiveness and safety on seven indications: anterior cruciate ligament reconstruction, cataract surgery, meniscectomy, thyroidectomy, primary hip arthroscopy, open carpal tunnel release, and rotator cuff repair. All interventions (except for carpal tunnel release and thyroidectomy) confirmed a volume-outcome relationship (VOR) with relation to surgeon/hospital volume, however, none established MVS for the respective interventions. Safety related data were reported without its relationship to surgeon/hospital volume.

CONCLUSIONS

This present paper provides some evidence in favor of the VOR, however, it based on low quality retrospective data-analyses. The present results cannot offer any clear-cut MVS thresholds for the day surgery setting and so the simple transition from inpatient results (that support MVS) to the day surgery setting is questionable. Further quality assuring policy approaches should be considered.

What Is the Cost of a Posterior Capsule Rupture Complication?

BACKGROUND AND OBJECTIVE

To examine the cost of a posterior capsule rupture (PCR) in patients who underwent planned phacoemulsification.

PATIENTS AND METHODS

Retrospective review of 8,113 cataract surgeries performed between January 2014 and December 2017 at one academic institution. The rate of PCR was 0.55%, and 34 patients with PCR who met inclusion criteria were identified. Investigators evaluated the added operating room time required to manage PCR, subsequent surgeon visits beyond the typical average, referrals to other specialties, further imaging, and additional required surgeries.

RESULTS

Patients with PCR had an additional 2.76 (standard deviation [SD] ± 3.27) postoperative encounters and 3.06 (SD ± 3.78) visits to another subspecialty. Operating room time was found to average 61.43 minutes (range: 21 to 191 minutes) at an additional cost of $455.48 (SD ± $407.37). Additional visits, imaging, and procedures added $655.59 (SD ± $767.21). The total additional average cost was $1,111.07 (SD ± $1,021.20) per PCR.

CONCLUSION

Posterior capsular ruptures impose a substantial cost burden on the health care system. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:444-447.].

Nuclear scaffold: Three-dimensional indigenous capsular bag support combined with IOL scaffold and capsular tension ring to prevent posterior capsule rupture in zonulopathy

We describe a technique for performing phacoemulsification in eyes with zonular fiber dehiscence of less than 90 degrees using hard nuclear fragments as a scaffold. In conjunction with a capsular tension ring (CTR), hard nuclear fragments and the intraocular lens (IOL) are used as scaffolds during different steps of nuclear emulsification to prevent posterior capsule rupture and aggravation of zonulopathy. Devices such as capsular hooks, CTRs, and IOLs are used to support the capsular bag associated with zonulopathy. The mass of hard nuclear fragments provides support toward the anteroposterior and the horizontal planes, thereby providing 3-dimensional capsular bag support.

A Simple, Novel Approach to Capsulorhexis Formation in the Setting of A Mature Cataract and Miotic Pupil

Purpose

To report a simple, effective technique for surgeons creating a capsulorhexis in patients with pupillary miosis and a dense, mature cataract.

Methods

A single center, two-year retrospective chart review examined 1408 phacoemulsification cataract surgeries. The criteria for inclusion involved a dense, mature cataract and a pupil that was unresponsive to pharmacologic dilation preoperatively. A standardized technique was used for all cases consisting of a 1mm corneal paracentesis and 2.4mm temporal clear corneal incision. Synecholysis was performed if present, followed by the insertion of a 6.25mm malyugin ring under cohesive viscoelastic. The cohesive viscoelastic was removed via the irrigation aspiration tip. The paracentesis was sealed with a small amount of viscoelastic and an air bubble was placed in the anterior chamber. The anterior capsule was then painted with trypan blue. The air bubble and trypan blue were then replaced by a dispersive viscoelastic. Curvolinear capsulorrhexis was performed followed by standard phacoemulsion.

Results

Nine patients ranging from 76 ± 12 years (mean ± standard deviation) met the criteria with a 4+ NS (n=5), white mature (n=3), or deep brunescent (n=1) cataract and 3mm pupil preoperatively. Pupillary miosis was caused by posterior synechia in 44.5% of the cases followed by pharmacologic interactions from tamsulosin and donepezil in 22.25% of cases respectively. One case involved idiopathic miosis likely from aging. Capsulorhexis formation was successful in all cases with no capsular tear, vitreous loss, or conversion to extracapsular cataract extraction (ECCE). However, one case had cortex retention requiring a second procedure for removal.

Conclusion

Dense, mature cataracts and small pupils both compromise the view for the surgeon and may be significant risk factors for training ophthalmologists. Thus, good visualization of the anterior capsule and peripheral nucleus with our simple technique facilitates a reliable capsulorhexis, potentially limiting the risk of complications for ophthalmic surgeons.

Intraoperative and postoperative complications of cataract surgery in eyes with pseudoexfoliation - An 8-year analysis

INTRODUCTION:

Pseudoexfoliation (PXM) is a fibrillar material deposited in the anterior chamber of the eye and can cause disintegration of zonules and make pupillary dilatation difficult. This can make surgery difficult and result in intraoperative and postoperative complications. The aim of this study was to learn about whether the presence of pseudoexfoliation caused significant complications during cataract surgery.

MATERIALS AND METHODS:

We did a secondary data analysis of 12,992 eyes from 2007 to 2014 using the National Eye Database of Melaka Hospital Malaysia on intraoperative and postoperative cataract surgery complications of patients with PXM.

RESULTS:

Patients with PXM were 2.68 times more likely to get intraoperative complications (P < 0.001). They had a higher incidence of lens subluxation, zonular dehiscence, and vitreous loss (P < 0.001). Although posterior capsule rupture (PCR) was the most common intraoperative complication during cataract surgery (4.8%), the presence of pseudoexfoliation was not associated with PCR (P > 0.05). We did not observe any association between patients with pseudoexfoliation and any of the postoperative complications such as corneal decompensation, raised intraocular pressure, and intraocular lens decentration (P > 0.05). Pseudoexfoliation did not cause corneal decompensation (P > 0.05) although corneal decompensation was the highest postoperative complication of cataract surgeries (0.18%).

CONCLUSIONS:

Patients with PXM had a higher rate of intraoperative complications which were mainly vitreous loss and zonular dehiscence and also lens subluxation/dislocation. We observed poorer visual outcomes in those with PXM following cataract surgery. Patients with pseudoexfoliation should be identified and precautions taken to minimize these complications to get better visual outcomes.

Evaluation of the capsular safety of a new hybrid phacoemulsification tip in a cadaver eye model

PURPOSE

To evaluate the use of a new hybrid phacoemulsification tip made with a high strength polymer overmold designed to prevent posterior capsule rupture (PCR) compared with a metal tip.

SETTING

John A. Moran Eye Center, University of Utah, USA.

DESIGN

Experimental study.

METHODS

This ex vivo crossover study compared a new phacoemulsification tip to a metal tip. After a preliminary experiment applying the tips to the posterior capsule with the bevel down, 10 phakic cadaver eyes were prepared using the Miyake-Apple technique, after which each tip was tested in a series. After lensectomy, the posterior capsule was subjected to direct contact from the tip with the bevel up. The vacuum limit was set to 150 mm Hg, and the aspiration flow rate to 30 cc/min, after which the torsional power was increased by increments of 5% up to a maximum amplitude of 60%. The primary endpoint was the torsional power required to produce PCR.

RESULTS

Vacuum alone did not cause PCR with either tip. All tests showed that a higher torsional power was required for PCR with the hybrid tip. With the bevel directed upward, the hybrid tip required higher torsional power before PCR than the metal tip (55% ± 10.0% [SD] versus 15% ± 4.1%, respectively) (P value < .001). This indicates that there is a lower likelihood for PCR with the hybrid tip.

CONCLUSION

The hybrid tip used in this study can be an effective means of preventing surgical complications such as PCR. This tip would be useful for experienced surgeons as well as for those who are in training.

Visual and anatomic outcomes of cataract surgery with intraoperative or postoperative complications in a teaching institution

OBJECTIVE

To review visual and anatomic outcomes after cataract surgery with complications in a teaching institution.

METHODS

Consecutive case series. A chart review was conducted of patients who underwent phacoemulsification with intraoperative or postoperative complications, performed by ophthalmology residents under direct supervision of experienced ophthalmology attending physicians. Best corrected visual acuity (BCVA), OCT parameters, and postoperative treatments were reviewed at 1, 3, 6, and 12 months postoperatively.

RESULTS

One hundred thirty-three eyes were analyzed. Mean BCVA was 50 ± 23 approximate Early Treatment Diabetic Retinopathy Study letters at the preoperative visit and improved by a mean of 8 letters (n = 128; p = 0.001), 16 letters (n = 117; p < 0.001), 14 letters (n = 79; p < 0.001), and 4 letters (n = 34; p = 0.37) at 1, 3, 6, and 12 months. The mean OCT central subfoveal thickness increased by less than 50 μm at all time points and this change was not statistically significant at 12 months. BCVA increased by 3 lines in 41%, 56%, 57%, and 44% of eyes at 1, 3, 6, and 12 months. Median BCVA was 20/40 or better at each follow-up period. Fifty-three (40%) eyes required a secondary surgical procedure due to intraoperative or postoperative complication. A significant proportion of eyes received anti-inflammatory drops through 1 year.

CONCLUSIONS

After cataract surgery with intraoperative or postoperative complications, a majority of eyes experienced substantial visual gains and only mild retinal thickening while being managed with long-term anti-inflammatory drops and additional surgical procedures.

National survey and outcomes of resident-performed cataract surgery in monocular patients in the United States

PURPOSE

To identify nationwide policies surrounding cataract surgery in monocular patients and compare outcomes of those surgeries between residents and attending surgeons.

SETTING

Wilmer Eye Institute, Baltimore, Maryland, USA.

DESIGN

Retrospective case series.

METHOD

Cataract surgery educators across the United States were surveyed on their policies concerning residents performing cataract surgery on monocular patients. A second survey assessed resident opinions on performing surgery in such patients. In addition, a retrospective chart review was performed of all monocular patients (n = 72) who had resident-performed and attending-performed cataract surgery at the same academic institution.

RESULTS

Forty-seven residency programs responded to the survey. Although the majority of cataract surgery educators from these programs thought it was ethical for residents to perform cataract surgery on monocular patients, only 18 programs (38.3%) had implemented specific policies. The resident survey response rate was 39.1%. Residents were more anxious and did more preparation for monocular cases than for routine cataract surgery cases. Analysis of the comparative case series found intraoperative complications (9.7% versus 5.6%; P = .37) and postoperative visual outcomes were comparable between resident and attending surgeon monocular cases. The resident status of the surgeon was not predictive of an increased risk for complications (odds ratio, 0.98; 95% confidence interval, 0.13-7.55; P = .99).

CONCLUSIONS

Although most educators and resident trainees deemed resident-performed cataract surgery on monocular patients to be acceptable, the majority of residency programs did not have specific guidelines for residents performing surgery on such patients. Outcomes of resident-performed cataract surgeries on monocular patients at the same institution were comparable to surgeries performed by attending surgeons.

Ciliary sulcus implantation of intraocular lens in manual small incision cataract surgery complicated by large posterior capsule rupture

The present study aimed to evaluate the safety and efficiency of ciliary sulcus implantation of intraocular lens (IOL) in patients that had undergone manual small incision cataract surgery (MSICS) complicated by large posterior capsule rupture (LPCR). A total of 11 eyes taken from 11 patients in Brazzaville, Republic of the Congo, that had experienced LPCR following MSICS were included in the current study. A rigid single-piece IOL (5.5 mm optic, 12.50 mm overall length) was implanted into the ciliary sulcus. Postoperative follow-up assessments evaluated visual acuity, anterior segment biomicroscopy, IOL centration and position, and fundus biomicroscopy. The median follow-up time was 3.7 months (range, 2-6 months). All patients experienced vision improvement: Uncorrected visual acuity 2 months following surgery was 0.3-0.5 in 9 patients and >0.5 in 2 patients. Postoperative complications included pronounced anterior segment inflammation (1 patient), mild corneal endothelium edema (3 patients), residual cortex (1 patient) and intraocular pressure elevation (1 patient). Significant IOL decentration and tilt were not observed in any patients. The results of the present study indicate that ciliary sulcus implantation of a rigid single-piece IOL may be a feasible and effective method of treating patients that have experienced LPCR complications following cataract surgery, as it provides satisfactory visual acuity outcomes. Appropriate intraoperative management may reduce the incidence of postoperative complications.

Posterior capsular complication rates with femtosecond laser-assisted cataract surgery: a consecutive comparative cohort and literature review

Purpose

The aim of the study was to determine whether femtosecond-assisted laser cataract surgery (FLACS) reduces the posterior capsular complication (PCC) rate compared to manual cataract surgery when performed by an experienced surgeon.

Patients and methods

We reviewed 2,021 consecutive FLACS procedures between 1 June 2012 and 30 August 2017. All cases of posterior capsular rupture (PCR) with or without vitreous prolapse or zonular dialysis (ZD) that prevented an in-the-bag placement of the intraocular lens were included. Risk factors were noted and outcomes documented.

Results

Six eyes of 2,021 (0.3%) who underwent FLACS had either a PCR or ZD. One eye (0.25%) of 403 eyes that had manual cataract surgery had a PCR. There was no significant difference in outcomes. Risk factors included advanced age, dense nuclei, pseudoexfoliation and small pupil. Only a single case in the FLACS series may have been directly attributed to the FLACS procedure.

Conclusion

This study provides evidence that there is no significant difference in the PCC rate between FLACS and manual cataract surgery in the hand of an experienced surgeon who performs >350 cases annually. This low rate of complications may be achieved by less experienced surgeons adopting FLACS.

Intraoperative difficulties, complications and self-assessed visual function in cataract surgery

PURPOSE

To study associations between intraoperative difficulties and changes in patient-perceived and postoperative visual function and visual satisfaction after cataract surgery.

METHODS

Swedish multicenter, prospective, cross-sectional, nonrandomized, National Cataract Register study. A total of 10 979 patients (n = 10 979) who underwent cataract surgery from 2008 to 2011 completed the Catquest-9SF questionnaire before and 3 months postoperatively. Using Rasch analysis, we converted the nonparametric grading of the answers to parametric data and performed parametric statistical analyses. Multiple regression models were used to examine possible predictors associated with self-assessed visual function after cataract surgery.

RESULTS

Greater improvement in self-assessed visual function was seen in patients in whom trypan blue dye was used; those without a posterior capsular tear or an ocular comorbidity; and those who were younger, female and had low preoperative corrected distance visual acuity (CDVA) or high postoperative CDVA compared with their counterparts. Significantly higher self-assessed postoperative visual function was seen in patients in whom trypan blue dye was used and those with no posterior capsular tear or ocular comorbidity and no use of capsular hooks; and those who were younger and had low preoperative or high postoperative CDVA compared with their counterparts. The risk of general dissatisfaction after cataract surgery was significantly greater in patients with a posterior capsule tear, ocular comorbidity or low postoperative CDVA, and those in whom mechanical pupillary stretching was performed.

CONCLUSION

Several intraoperative difficulties, posterior capsular tear, ocular comorbidity, age, gender, and preoperative and postoperative CDVAs affect patient improvement and self-assessed visual function after cataract surgery.

[Capsule rupture and vitrectomy during phacoemulsification]

BACKGROUND

Rupture of the posterior capsule can occur as one of the complications during phacoemulsification.

OBJECTIVE

The aim of this study was to determine whether the risk of capsule rupture depends on the surgeon's concentration or experience, time of day and season, the side to be operated on and anatomy of the eye as well as the frequency with which it can be expected.

MATERIAL AND METHODS

The patient collective was derived from patients who underwent cataract surgery by phacoemulsification between 2004 and 2014. All surgeries were performed by the same surgeon and constituted no primarily combined operations. Thereby, it was determined how many capsule ruptures occurred, with and without vitrectomy.

RESULTS

There were so significant differences between the left or right eye, weekday or month. During the various surgical steps of cataract surgery, the occurrence of capsule rupture was only significantly more frequent at the time of capsule polishing.

CONCLUSION

Compared to the results of other studies, the risk of complications was lower in the operation collective investigated in this study.

Posterior capsular rent: Prevention and management

This review article deals with a potentially sight threatening complication – rupture of the posterior capsule – during cataract surgery. Cataract surgery is the most commonly performed surgical procedure in ophthalmology and despite tremendous technical and technological advancements, posterior capsular rent (PCR) still occurs. PCR occurs both in the hands of experienced senior surgeons and the neophyte surgeons, although with a higher frequency in the latter group. Additionally, certain types of cataracts are prone to this development. If managed properly in a timely manner the eventual outcome may be no different from that of an uncomplicated case. However, improper management may lead to serious complications with a higher incidence of permanent visual disability. The article covers the management of posterior capsular rent from two perspectives: 1. Identifying patients at higher risk and measures to manage such patients by surgical discipline, and 2. Intraoperative management of posterior capsular rent and various case scenarios to minimize long-term complications. This review is written for experienced and not-so-experienced eye surgeons alike to understand and manage PCR.

The Melaka Hospital cataract complications study analysis of 12,992 eyes

Introduction:

As in all surgeries, complications during cataract surgery are unavoidable and cause distress to the surgeon and the patient. This study was conducted to know the factors contributing to complications in our settings, to be able to counsel patients about complications and outcomes and to reduce litigations.

Materials and Methods:

The secondary data analysis was conducted using the National Eye Database from 2007 to 2014. Demographic features, ocular comorbidities, technique of surgery, grade of surgeons, types of intraoperative complications, and reasons for not obtaining good visual acuity following intraoperative complications were studied. Statistics was done using Statistical Package for Social Sciences version 20.

Results:

Out of 12,992 eyes, 6.1% had intraoperative complications. The highest rate of complications was when more trainees (medical officers [MOs] and gazetting specialists) operated. Posterior capsule rupture (PCR) was the most common complication followed by vitreous loss and zonular dehiscence. Those aged below 40 years had more complications (P < 0.05), and females had more complications. Ethnicity did not affect complications. Pseudoexfoliation was the only comorbidity causing complications (P < 0.05). Phacolytic lenses had 8.118 times the odds of getting intraoperative complications. MOs and gazetting specialists got more complications. Good outcomes were obtained in cases without complications and those operated by specialists. High astigmatism was the main reason for poorer outcomes.

Conclusion:

Intraoperative complications were caused mostly by less experienced doctors and had poorer outcomes. Age below 40 years, females, the presence of pseudoexfoliation and phacolytic lenses had more complications. PCR was the most common complication.

Influence of an intentionally induced posterior lens capsule rupture on the real-time intraocular pressure during phacoemulsification in canine ex vivo eyes

OBJECTIVE

To evaluate the changes in the intraocular pressure (IOP) following an intentionally induced posterior lens capsule rupture (PLCR) during phacoemulsification in enucleated canine eyes. Furthermore, to compare the IOPs between different stages of phacoemulsification for two different bottle heights (BH).

PROCEDURES

Coaxial phacoemulsification was performed using a venturi-based machine at a 60 or 90 cm BH. A pressure transducer, inserted into the anterior chamber through the peripheral cornea, monitored real-time IOP. For one half of the lens, the sculpt-segment removal (SS) was followed by irrigation/aspiration (IA). The PLCR was intentionally created, and the SS and IA were repeated on the residual lens fragments.

RESULTS

For the 60 cm BH, the mean IOP following the PLCR was significantly higher than before the PLCR during SS (28.30 ± 12.56 and 38.71 ± 9.43 mmHg before and after PLCR, respectively) and IA (42.76 ± 12.46 and 47.88 ± 7.10 mmHg before and after PLCR, respectively) stages (P < 0.001). For the 90 cm BH, the mean IOP following the PLCR was also significantly higher than before the PLCR during SS (33.39 ± 11.09 and 58.17 ± 6.89 mmHg before and after PLCR, respectively) and IA (62.39 ± 12.46 and 72.04 ± 8.59 mmHg before and after PLCR, respectively) stages (P < 0.001).

CONCLUSIONS

The occurrence of a PLCR led to an increase in IOP during both the SS and IA stages. The elevated IOP after the PLCR might be one of the most important factors for ocular tissue damage, as it reduces ocular perfusion. Additionally, the BH should be reduced following PLCR to prevent complications stemming from the raised IOP.

The Malaysian Cataract Surgery Registry: risk Indicators for posterior capsular rupture

AIM

To identify the risk indicators for posterior capsular rupture (PCR) in the Malaysian Cataract Surgery Registry (CSR).

METHODS

Data from the web-based CSR were collected for cataract surgery performed from 2008 to 2013. Data was contributed by 36 Malaysian Ministry of Health public hospitals. Information on patient's age, ethnicity, cause of cataract, ocular and systemic comorbidity, type of cataract surgery performed, local anaesthesia and surgeon's status was noted. Combined procedures and type of hospital admission were recorded. PCR risk indicators were identified using logistic regression analysis to produce adjusted OR for the variables of interest.

RESULTS

A total of 150 213 cataract operations were registered with an overall PCR rate of 3.2%. Risk indicators for PCR from multiple logistic regression were advancing age, male gender (95% CI 1.04 to 1.17; OR 1.11), pseudoexfoliation (95% CI 1.02 to 1.82; OR 1.36), phacomorphic lens (95% CI 1.25 to 3.06; OR 1.96), diabetes mellitus (95% CI 1.13 to 1.29; OR 1.20) and renal failure (95% CI 1.09 to 1.55; OR 1.30). Surgical PCR risk factors were combined vitreoretinal surgery (95% CI 2.29 to 3.63; OR 2.88) and less experienced cataract surgeons. Extracapsular cataract extraction (95% CI 0.76 to 0.91; OR 0.83) and kinetic anaesthesia were associated with lower PCR rates.

CONCLUSIONS

This study was agreed with other studies for the risk factors of PCR with the exception of local anaesthesia given and type of cataract surgery. Better identification of high-risk patients for PCR decreases intraoperative complications and improves cataract surgical outcomes.

Risk factors for corneal endothelial cell loss by cataract surgery in eyes with pseudoexfoliation syndrome

PURPOSE

The aim of this study was to investigate the factors associated with decreases in corneal endothelial cell density (ECD) resulting from cataract surgery in eyes with pseudoexfoliation syndrome (PEX).

METHODS

The clinical records of 78 eyes of 78 patients with PEX who had undergone cataract surgery were reviewed. ECD was measured preoperatively and at 3 months postoperatively with specular microscopy. Multiple regression analysis was used to assess the factors that were significantly related to the rate of ECD loss. Explanatory variables included age, preoperative ECD, pupil diameter, cataract grade, concomitance of glaucoma or diabetes mellitus, preoperative anterior chamber depth, surgery time, total time and power of ultrasound, performance of intraoperative pupillary enlargement manipulation, and postoperative aqueous flare intensity at 1 week and 1 month.

RESULTS

ECD before and after surgery was 2,464±337 cells/mm(2) and 2,400±347 cells/mm(2), respectively, with an ECD loss rate of 2.6%±5.1% (mean ± SD). Multiple regression analysis revealed that ECD loss was significantly associated with the cataract grade (P=0.019) and preoperative anterior chamber depth (P=0.023).

CONCLUSION

With modern small incision cataract surgery, the ECD loss varied with surgical invasions due to severe cataract and shallow anterior chamber, and the presence of PEX was least affected.

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

Purpose:

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

Methods:

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

Results:

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

Conclusion:

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

[Long-term results of phacoemulsification in pseudoexfoliation syndrome]

INTRODUCTION

The prevalence of pseudoexfoliation syndrome is estimated at 8 % of all cataracts operated within our institution. The goal of our study was to describe the frequency of intraoperative and postoperative complications and long-term anatomical and functional results of phacoemulsification in pseudoexfoliation syndrome.

PATIENTS AND METHODS

A retrospective observational study of a series including 103 patients (107 eyes) with cataract associated with pseudoexfoliation syndrome admitted between January 2010 and September 2014. All patients underwent phacoemulsification.

RESULTS

The average age of our patients was 72.5±6 years. The average initial corrected visual acuity was 0.52±0.14LogMAR. The cataract was grade C3N3 in 58 % of cases. The pseudoexfoliation syndrome was bilateral in 69 % of cases. Pupillary dilatation was≤6mm in 54 % of cases. Among intraoperative complications, zonular dialysis was found in 1.8 % of cases. Posterior capsular rupture and vitreous loss was noted at 5.4 % of patients. The incidence of secondary cataract was 31.7 % at 12 months. The mean postoperative best corrected visual acuity was 0.13±0.15 LogMAR.

DISCUSSION

The small pupil associated with high grade of the cataracts in our series explains the slightly higher frequency of intraoperative zonular dialysis. Cataract surgery by phacoemulsification allows for a statistically significant improvement in visual acuity (P<0.001). The incidence of secondary cataract, the main postoperative complication, is higher in our series compared to data in the literature.

CONCLUSION

Pseudoexfoliation syndrome is common in our country. Functional results of phacoemulsification are very satisfactory, and secondary cataract is the main complication. A meticulous search for pseudoexfoliation is mandatory during the initial examination in order to reduce intraoperative complications. Careful removal of the cortex and systematic polishing of the lens capsule should limit the incidence of secondary cataracts.

Continuous Curvilinear Capsulorhexis in Cataract Surgery Using a Modified 3-Bend Cystotome

We modified a 2-bend cystotome for continuous curvilinear capsulorhexis (CCC) in manual or phacoemulsification cataract surgery to improve the safety and ease of performance. A 26G needle was converted into a cystotome with 3 bends. In this retrospective study, the performance of modified 3-bend cystotome was compared with conventional 2-bend cystotome. During cataract surgery, in the 3-bend cystotome group, mean completion time of CCC was shorter, mean times of viscoelastic agent supplement were less, and CCC success rate was higher than that in 2-bend group. Complication incidence, such as postoperative transient corneal edema and irreparable V-shaped tear, was also lower in 3-bend group. No posterior capsular rupture or no other complication was observed in either group. A polymethyl methacrylate intraocular lens or a hydrogel intraocular lens was implanted in the capsular bag in all eyes. We conclude that it is safe and efficient to accomplish a CCC using the 3-bend cystotome due to its ability to sustain the anterior chamber depth (ACD) and keep the posterior lip intact. Using the 3-bend cystotome also allowed for an adequate view into the anterior chamber from lack of wound deformation.

Determinants of patient satisfaction and function related to vision following cataract surgery in eyes with no visually consequential ocular co-morbidity

PURPOSE

To investigate subjectively reported outcomes following cataract surgery and the relationships between such outcomes in the context of falling thresholds for cataract surgery.

SETTING

Large, private, non-refractive cataract practice, Institute of Eye Surgery, Whitfield Clinic, Waterford, Ireland

METHODS

Pre-operative, intra-operative and post-operative data of 2552 eyes undergoing phacoemulsification and implantation of the Tecnis(R) ZCB00 1-piece intraocular lens (IOL) by a single surgeon between July 2009 and October 2013 was analysed. Patients without visually consequential ocular co-morbidity completed two validated questionnaires, designed to assess subjectively perceived visual functioning and identify symptoms of dysphotopsia following cataract surgery.

RESULTS

54.8 % of questionnaire respondents were entirely satisfied (satisfaction 10/10) post-operatively, with 83.7 % reporting satisfaction of ≥7/10. Satisfaction was positively associated with patient age and negatively associated with spectacle dependence, dysphotopsia, and function related to vision (NEI VF-11) score. The mean (±standard deviation[SD]) dysphotopsia score was 1.36 (±1.9; scale 0-10), with 40 % of respondents reporting no dysphotopsia symptoms and 9.8 % reporting clinically meaningful dysphotopsia. The mean (±SD) National Eye Institute visual function-11 (NEI VF-11) score was 0.33 (±0.53; scale 0-4) and reduced function related to vision was associated with increasing severity of dysphotopsia symptoms. When linear regression was applied, 17.5 % of the variation in functionality was attributable to symptoms of dysphotopsia.

CONCLUSION

Dysphotopsia is an important determinant of a patient having difficulty with vision-related tasks following cataract surgery, and patient satisfaction is positively associated with patient age and negatively associated with spectacle in dependence, dysphotopsia and function related to the vision (NEI VF-11) score.

Intraoperative management of posterior capsular rupture

PURPOSE OF REVIEW

Posterior capsular rupture (PCR) and vitreous loss are inevitable complications encountered in cataract surgery across all levels of surgical experience and in spite of technological advances to improve safety. Thus, cataract surgeons must always be prepared to practice safe and effective intraoperative management strategies for capsular rupture.

RECENT FINDINGS

Novel approaches for lens fragment removal, vitrectomy, and lens implantation have expanded the available options for cataract surgery in the setting of an open posterior capsule. Intraoperative PCR management strategies should prioritize safety and strive to minimize vitreous traction, stabilize anterior chamber volume, maintain capsular and zonular integrity, and protect the corneal endothelium and other anterior segment structures.

SUMMARY

With appropriate management of PCR and vitreous, surgeons may still deliver safe and satisfactory visual outcomes for modern cataract surgery.

Small pupil and cataract surgery

PURPOSE OF REVIEW

Presence of a small pupil is still considered a major challenge for cataract surgeons. Appropriate mydriasis and maintaining it is of paramount importance to prevent potential serious complications. Recently, more interventions and instruments are available for the cataract surgeons to deal with these challenging cases. The intention of this review is to discuss the preoperative and intraoperative considerations and techniques for cataract surgery in small pupil and related conditions and to discuss new developments in management of small pupil in femtosecond laser-assisted cataract surgery.

RECENT FINDINGS

There are new techniques and pharmaceuticals available to cataract surgeons in the setting of small pupil. Intracameral ketorolac may soon be available to maintain mydriasis and to control pain and inflammation. Malyugin ring has been added to pupil expansion rings and has already been used for small pupil in different settings. In femtosecond laser-assisted cataract surgery, presence of a small pupil can now be managed by applying intracameral mydriatics and intraocular devices successfully.

SUMMARY

Accurate preoperative examinations adjunct with intraoperative use of appropriate pharmacologic and mechanical devices can yield favorable outcomes in cataract surgery with a small pupil.