Posterior capsular rent: Prevention and management

The VaMa (Vatavuk and Marić) Artificial Intraocular Lens Capsule: A Novel Device and Method for Reversible Secondary Intraocular Lens Implantation in Patients with Aphakia Without Efficient Capsular Support

We describe a novel experimental device, the VaMa (Vatavuk and Marić) artificial intraocular lens (IOL) capsule, and a method that enables all IOL types to be implanted in the bag. We present the application of the device and the procedure in patients with aphakia and native capsule damage and without efficient capsular support. The VaMa device and the method facilitate IOL exchange due to refractive errors and, in the case of their invention, the implementation of superior IOLs in the future. The postoperative results after the implantation of the VaMa capsule along with IOLs in three patients are promising, with significant visual improvement and without adverse events 7 to 10 months postoperatively.

Intracameral Anaesthetic Mydriatic Versus Topical Mydriasis in Pediatric Cataract Surgery: A Randomized Control Study

PURPOSE

To compare pupil dynamics after using premixed intracameral anesthetic mydriatic combination (ICAM) of phenylephrine (0.31%), tropicamide (0.02%), and lidocaine (1%) versus topical mydriatic (TM) drops consisting of tropicamide 0.8%, phenylephrine 5%, and cyclopentolate 0.5% in pediatric cataract surgery.

DESIGN

Randomized, masked, fellow eye-controlled trial.

SETTING

Tertiary eye care facility.

STUDY POPULATION

Children ≤12 years of age with bilateral cataracts planned for surgery. One eye was randomized to receive ICAM and the other eye (control) TM drops.

INTERVENTION

Commercially available ICAM that was injected at the beginning of surgery or TM 3 times at an interval of 30 minutes, 1 hour before the scheduled time of surgery. The other treatment was administered for the second eye cataract surgery.

MAIN OUTCOME MEASURE

Pupil dynamics at various points of surgery were studied by a masked observer.

RESULTS

Sixty-three patients (126 eyes) were randomized to receive ICAM in 1 eye (group 1) or TM drops (group 2). The mean age of the children in the study was 15.7 ± 24.3 months (range 3 months to 5 years). Adequate mydriasis with a single injection was achieved in 93.5% of patients in group 1 and 88.8% of patients in group 2 without additional pharmacotherapy or intervention. The mean pupillary diameter increased from 1.78 mm to 5.1 mm after injection of 1 unit of ICAM and from 1.75 mm to 6.06 mm with TM drops (P < .0001). The maximum pupillary dilation achieved was 6.06 ± 1.17 mm in group 1 and 6.75 ± 1.07 mm in group 2 (P = .004). The average change in pupillary size from injection of drug until the end of surgery was positive in group 1 (0.75 ± 0.98 mm) and negative in group 2 (-0.3348 ± 2.57 mm), ie, there was a relative miosis in group 2 toward the end of surgery (P = .001).

CONCLUSIONS

Topical drugs achieved a larger maximum pupil size compared with ICAM. However, ICAM provided adequate and stable mydriasis without the need for augmentation compared with topical drops in children undergoing cataract surgery.

Intraocular lens exchange or explantation post cataract surgery

AIM

To report incidence, indications, and visual outcomes of intraocular lens (IOL) exchange/explantation surgery.

METHODS

Retrospective analysis of 60 eyes requiring IOL exchange/explantation surgery between 1st January 2017 and 31st December 2022. The overall outcomes as well as comparison between the trainee versus experienced surgeons were analyzed.

RESULTS

Out of 39 778 cataract surgeries (with no preexisting ocular co-morbidities) during a six-year period (2017-2022), 60 (0.15%) needed IOL exchange/explantation. Surgeons-under-training performed 36/60 cases (60%) while 24/60 (40%) were by experienced surgeons. The commonest indication was subluxated IOL in 26 (43.3%), followed by dislocated IOL in 20 (33.3%), postoperative refractive surprise in 7 (11.6%), IOL induced uveitis in five and broken haptic in two eyes. Twenty-four (40%) eyes had intraoperative complications during primary surgery. Posterior chamber IOL (PCIOL) was the commonest secondary IOL in 21 (35%) eyes, scleral fixated in 20 (31.6%), anterior chamber IOL (ACIOL) in 13 (21.6%), iris fixated IOL in three (5%) and three eyes (5%) were left aphakic. The mean time between primary and secondary surgery was 168d (168±338.8). Best corrected visual acuity (BCVA) of >20/60 was obtained in 43 eyes (71.66%), 20/80-20/200 in 14 (23.33%), 20/250 in two and hand movements in one. No statistically significant difference in visual outcome was noted at post-op one month between trainees versus experienced surgeons (UCVA 0.45±0.29 vs 0.53±0.32, P=0.20, BCVA 0.34±0.25 vs 0.37±0.26, P=0.69).

CONCLUSION

IOL subluxation as the commonest indication and posterior capsular rupture is the commonest intraoperative risk factor. This complication can be effectively addressed with selection of the appropriate secondary IOL achieving good visual outcomes in over 70% of patients.

Abandoned Cataract Surgeries: An Analysis of Surgical Referrals to a Tertiary Eye Center

PURPOSE

This study aims to analyze the outcomes of cases of abandoned cataract surgeries referred to a tertiary eye center.

METHODS

This retrospective observational case series includes eleven cases referred to a tertiary eye center following abandoned cataract surgeries. The preoperative factors, intraoperative management, and postoperative outcomes were recorded and analyzed.

RESULTS

The mean age of presentation was 56.8 ± 13.7 years, and the median time from the primary surgery to presentation at the tertiary eye center was four days (range: two hours to four weeks). There was an association with hypermature cataracts in 36.3% (4/11) of cases, diabetes in 36.3% (4/11) of cases, and pseudo-exfoliation syndrome in 18.2% (2/11) of cases. The primary cataract surgery was aborted after making an incision and without initiating capsulorhexis in 45.5% (5/11) of cases. Descemet's membrane detachment and corneal edema were present in nearly half (45.5%) of the cases.

CONCLUSION

A thorough preoperative assessment, early identification of intraoperative complications, timely referral by the primary surgeon, and appropriate and prompt intervention by the second surgeon are essential for improving visual outcomes.

Learning curves of novice residents on cataract surgery simulator: the E3CAPS pedagogic study

INTRODUCTION

Training novice ophthalmology residents on the EyeSi® simulator increases cataract surgery safety. However, there is no consensus regarding how much training residents should perform before their first time on patients. We evaluated the French national training program through the analysis of the learning curves of novice residents.

METHODS

This prospective multicentric pedagogic study was conducted with French novice residents. Each resident completed the recommended four two-hour training sessions and performed a standardized assessment simulating standard cataract surgery before the first session (A0), at the end of the first (A1), second (A2), third (A3) and fourth (A4) sessions. For each surgical step of each attempt, the following data were collected: score, odometer, completion time, posterior capsular rupture and cumulative energy delivered (ultrasounds) during phacoemulsification. A performance threshold was set at a score of 80/100 for each surgical step, 400/500 for the overall procedure. Only descriptive statistics were employed.

RESULTS

Sixteen newly nominated ophthalmology residents were included. Median score progressively increased from 95 [IQR 53; 147]) at A0 to 425 [IQR 411; 451] at A4. Despite a significant progression, the "emulsification" step had the lowest A4 scores 86 [IQR 60; 94] without reduction in completion time, odometer or ultrasounds delivered. The rate of posterior capsular rupture decreased linearly from 75% at A0 to 13% at A4 during "emulsification" and from 69 to 0% during "irrigation and aspiration". At A4, only 25% [8; 53] of residents had > 80 at each step and only 75% [47; 92] had > 400/500 overall.

CONCLUSION

A training program consisting of four two-hour sessions on the EyeSi simulator over four consecutive days effectively enhances the surgical skills of novice ophthalmology residents. Undergoing more training sessions may improve scores and decrease the incidence of surgical complications, particularly at the emulsification step of cataract surgery. The learning curves presented here can reassure residents who are progressing normally and help identify those who need a further personalized training program.  TRIAL REGISTRATION: ClinicalTrials registration number: NCT05722080 (first submitted 22/12/2022, first posted 10/02/2023).

Observations of the efficacy of the artificial lens cushion plate technique in hard-core cataract surgery

Objective

To evaluate the efficacy of intraocular lens (IOL) cushion plate technology in reducing corneal endothelial cell loss during hard-core cataract surgery compared with conventional ultrasonic emulsification.

Methods

Seventy-six patients with hard-core cataracts who underwent surgery at our institution from April 2019 to June 2022 were included. The patients were divided into an observation group (IOL cushion plate technology, 38 patients) and a control group (conventional ultrasonic emulsification, 38 patients). Surgical outcomes, including the corneal endothelial cell loss rate, best corrected visual acuity (BCVA), and central corneal thickness (CCTc), were compared between the two groups.

Results

Preoperative patient characteristics were similar between the groups. Postoperatively, both groups demonstrated similar BCVA and CCTc values on days 7 and 30. However, compared with the observation group, the control group presented a significantly greater rate of corneal endothelial cell loss on postoperative days 7 and 30 (p < 0.05). Intraoperative complications and postoperative complications were notably greater in the control group (p < 0.05). The observation group had reduced ultramilk time and total energy consumption (p < 0.05).

Conclusion

IOL cushion plate technology offers advantages in preserving corneal endothelial cells during hard-core cataract surgery, potentially improving surgical safety and efficacy.

Objective analysis of capsulorrhexis factors and posterior capsular opacification in 420 postmortem eyes

OBJECTIVE

To evaluate the capsulorrhexis structure in postmortem eyes and determine factors associated with posterior capsular opacification (PCO).

DESIGN

Experimental study.

PARTICIPANTS

Postmortem pseudophakic human eyes (n = 420).

METHODS

Postmortem eyes were obtained and examined. Photographs were taken of the eyes in Miyake-Apple view and of the extracted lens-capsule complexes. PCO and Soemmering's ring (SR) were quantified using automated detector opacification software as factors of intensity and area. Miyake-Apple views and ImageJ were used to assess capsulorrhexis diameter, area of anterior capsule-optic overlap, length of the shortest anterior capsular leaflet, and area and angle of capsulorrhexis-optic nonoverlap. Linear regression analysis and Welch's t test were used to determine the relationship of these factors with PCO and SR. All analyses were repeated in sample groups specific to the 5 most common intraocular lens models.

RESULTS

Capsule-optic overlap was positively correlated with PCO (P < 0.0001) and SR (P = 0.0016). Capsulorrhexis diameter was negatively correlated with PCO (P < 0.0001) and SR (P = 0.014). Leaflet length was positively correlated with PCO (P = 0.009). Area and angle of capsulorrhexis-optic nonoverlap were not correlated with PCO or SR. Slopes and coefficients of determination were relatively low for all significant results.

CONCLUSIONS

The pathogenesis of PCO development after cataract surgery is multifactorial. This study shows that with modern operating technology, capsulorrhexis factors have at best a modest influence on PCO formation. Factors such as time from surgery to death and intraoperative techniques such as laser capsule polishing, posterior capsule vacuuming, and cortical cleanup are likely to play a more significant role.

Profile of Cataract Surgical Patients at the National Eye Centre, Kaduna, Nigeria

Background

Cataract surgery has evolved over the years. This study aims to highlight the profile of the patients that underwent cataract surgery at a tertiary hospital with emphasis on patient demographics, surgical techniques performed, intraocular lens powers implanted, and the complications managed.

Methodology

A retrospective cross-sectional descriptive study of all patients who had undergone cataract surgery within two years at the National Eye Centre, Kaduna, Nigeria. Data extracted from the electronic version of the manual cataract surgical records included the patient's age, sex, comorbidities, technique of cataract surgery performed, the intraocular lens powers implanted, and complications encountered. Intraoperative and postoperative complications up to the twelfth week were considered. All patients had biometry-guided intraocular lens implantation.

Results

One thousand four hundred and seventy- two (1,472) patient records of all ages met the inclusion criteria with a male-female ratio of 1.4:1. The mean age was 51.4 ± 22.6 years. The difference in the mean age of the sexes was statistically significant (p=0.01) and 95% CI was 7.37- 10.40 years. Glaucoma was the commonest ocular comorbidity 142(9.65%) and only 5% (74) had systemic comorbidities. The mean intraocular lens (IOL) power was 19.25 ± 1.8Diopters (Range 10.5D to 26D). The commonest surgery performed was small incision cataract extraction with posterior chamber intraocular lens implant (SICS + PCIOL) 91.2% followed by Trabeculectomy with SICS + PCIOL (3.87%). Phacoemulsification accounted for 2.72% of surgeries. Intra-operative complications were posterior capsular rent in 7.1% (104) and vitreous loss in 4% (58). The commonest post-operative complications were corneal edema6.9% (103) and striae keratopathy 4.6% (68).

Conclusion

Most cataract patients were male, above 50years of age and likely to be older than the females at surgery. The most performed surgical technique was small incision cataract surgery with posterior chamber intraocular lens implantation (SICS + PCIOL) while the mean intra-ocular lens power was 19.25 ± 1.8Dioptres. Globally accepted cataract surgical techniques utilizing recent technological advancements were employed with biometry-guided intraocular lens power calculation and implantation. Complications fell within the accepted global rates.

Ten-year trends of immediate sequential bilateral cataract surgery (ISBCS) as reflected in the Swedish National Cataract Register

PURPOSE

To analyse trends of ISBCS reported to the Swedish National Cataract Register (NCR) over a 10-year period.

METHODS

Since 2010 the NCR contains social security number of all individuals in the list of parameters reported to NCR after each cataract procedure. Bilateral surgeries were mapped out using social security numbers. When dates of both-eye surgeries are identical for an individual it is classified as an immediate sequential bilateral cataract surgery (ISBCS). This study includes all data reported during the period 1st of January 2010 to 31st of December 2019. During the study period 113 cataract surgery clinics affiliated to the NCR reported their data on consecutive cataract cases.

RESULTS

For the whole period 54 194 ISBCS were reported. The total number of bilateral cataract extractions was 422 300. There was a significant trend of increasing ISBCS over time with linear regression (Beta = 1.75, p < 0.001). In ISBCS the occurrence of an ocular comorbidity decreased over time. The use of a capsular tension ring was significantly more common in ISBCS than in delayed sequential bilateral cataract surgery (DSBCS). All other measures taken during surgery were more common in DSBCS. The use of multifocal IOL was significantly more frequent in ISBCS compared to DSBCS (p < 0.001).

CONCLUSIONS

The use of ISBCS has increased over the study period. The operated eyes have less risk factors than eyes going through a DSBCS, but both ocular comorbidities and surgical complications occur in ISBCS eyes.

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.

Educational Concerns About the Safety of Cataract Surgery During Residency: The E3CAPS Pedagogic Study

INTRODUCTION

Cataract surgery is the most common surgical procedure performed in France. While the incidence of intraoperative complications affecting visual prognosis is extremely low, given the large number of patients operated on, the absolute number of patients affected by complications is quite high. Complication rates are significantly higher when ophthalmology residents (ORs) perform the surgery. Although lack of experience remains the main risk factor, sleep deprivation may adversely affect ORs' successful surgery rate. The value of the EyeSi® surgical simulator in initial training has been demonstrated to increase cataract surgery safety through the transfer of surgical skills from the simulator to the operating room. However, there is no consensus regarding how much training is needed before the first-time ORs are allowed to operate. There is also no scientific evidence that sleep deprivation is associated with a decrease in surgical performance. Establishing a validated protocol for cataract surgery training using the EyeSi surgical simulator (referred to further as the EyeSi) and identifying risk factors for intraoperative complications related to sleep deprivation will improve cataract surgery safety and lead to the reorganization of our healthcare systems.

METHODS AND PLANNED OUTCOMES

This multi-centre educational cohort study will include two distinct axes which will both aim to reduce the risks of cataract surgery. Enrollment will include 16 first-year ORs for Axis 1 and 25 experienced residents for Axis 2, all from the University Hospitals of Nantes, Tours, Angers and Rennes. Axis 1 will focus on investigating the learning curve of first-year ORs using the EyeSi, following the training program recommended by the "College des Ophtalmologistes Universitaires de France" in order to set up a future "licence to operate." Axis 2 will evaluate the impact of sleep deprivation on the surgical performance of experienced ORs using the EyeSi.

TRIAL REGISTRATION

ClinicalTrial.gov identifier: NCT05722080.

Visual Outcome and Complications in White Mature Cataracts after Phacoemulsification

PURPOSE

To identify risk factors and perioperative complications and assess postoperative visual outcome in patients of white mature cataracts undergoing phacoemulsification surgery.

METHODS

This cross-sectional study was conducted on 46 patients of white mature cataract undergoing phacoemulsification. Preoperatively, a detailed ocular examination was done, and anterior chamber depth (ACD) and lens thickness (LT) were measured on ultrasound biomicroscopy. Intraoperative and postoperative complications (on days 1, 7, and 30) and best-corrected visual acuity on postoperative day 30 were noted.

RESULTS

The mean age of patients was 60.78 ± 9.001 years. The study group consisted of 41.3% of males and 58.7% of females. 8 (19.56%) cases encountered complications during phacoemulsification surgery. The intraoperative complications were capsulorhexis-related in 5 (10.86%) patients, posterior capsular rent in 2 (4.3%) patients, and 1 (2.17%) case had zonular dialysis. There was no difference in mean ACD and LT in cases who developed complications and those who underwent uneventful surgery (P > 0.05). The commonly observed postoperative complications on day 1 were corneal edema (41.3%), anterior chamber flare (45.65%), and cells (39.13%) which resolved with routine topical medications. All patients showed a significant reduction in postoperative intraocular pressure (P < 0.001). A total of 37 (80.43%) eyes regained vision between 6/6 and 6/9 postoperatively (P < 0.001).

CONCLUSION

Phacoemulsification surgery is safe in white mature cataract that results in significant visual improvement. Common intraoperative complications are capsule related, while frequently encountered postoperative complications are corneal edema and anterior chamber reaction. Preoperative ACD and LT have no role in predicting intraoperative complications.

Retrospective analysis of the role of anterior segment optical coherence tomography and outcomes of cataract surgery in posterior polar cataract

Purpose

To evaluate the visual and surgical outcomes of cataract surgery in patients with posterior polar cataract (PPC) and to evaluate the benefits of preoperative anterior segment optical coherence tomography (AS-OCT).

Methods

This was a retrospective, single-center study. Case records of patients diagnosed with PPC who underwent cataract surgery either by phacoemulsification or manual small-incision cataract surgery (MSICS) from January to December 2019 were analyzed. Data collected include demographic details, preoperative best corrected visual acuity (BCVA), AS-OCT, type of cataract surgery, intraoperative and postoperative complications, and visual outcome at 1-month follow-up.

Results

One hundred patients were included in the study. Preoperative posterior capsular defect was noted on AS-OCT in 14 patients (14%). Seventy-eight underwent phacoemulsification and 22 underwent MSICS. Intraoperatively, posterior capsular rupture (PCR) was seen in 13 patients (13%) and cortex drop was noted in one among them (1%). Out of 13 PCRs, 12 were found to have posterior capsular dehiscence preoperatively in AS-OCT. The sensitivity of AS-OCT for detecting posterior capsule dehiscence was 92.3% and specificity was 97.7%. The positive predictive value and negative predictive value were 85.7% and 98.8%, respectively. There was no significant difference in the incidence of PCR between phacoemulsification and MSICS (P = 0.475). The mean BCVA at 1 month was found to be better with phacoemulsification than MSICS (P = 0.004).

Conclusion

Preoperative AS-OCT has excellent specificity and negative predictive value in identifying posterior capsular dehiscence. It thus helps to plan the surgery and counsel patients appropriately. Both phacoemulsification and MSICS provide good visual outcome with similar complication rates.

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.

Pupil diameter during cataract surgery after intracameral injection of the first ready-to-use combination of mydriatics and anaesthetic at the beginning of surgery in patients with a preoperative pupil diameter <6 mm

PURPOSE

We evaluated, in a real-life setting, the effect of Mydrane® (ready-to-use combination of tropicamide, phenylephrine hydrochloride and lidocaine, injected into the anterior chamber at the beginning of cataract surgery to induce mydriasis and intraocular anaesthesia) on the pupil diameter during cataract surgery in patients with a preoperative pupil diameter <6 mm after the use of topical mydriatics.

METHODS

We collected and analysed the data of 59 consecutive patients whose pupils dilated to a diameter <6 mm after the administration of mydriatic eye drops during the preoperative visit and who received Mydrane® during cataract surgery.

RESULTS

In the group of 59 patients with a preoperative pupil diameter <6 mm after topical mydriatics, cataract surgery was performed in 36 patients (61.0%) using only Mydrane® to obtain mydriasis, with no additional drug or medical device. The mean pupil diameters in this group (36 of 59) during the preoperative assessment after topical mydriatics and just before capsulorhexis when Mydrane® was injected during surgery were 5.1 ± 0.74 and 6.15 ± 1.14 mm. Additional drugs were used in 23 patients (39%). In this group, the mean pupil diameters after topical mydriatics and just before capsulorhexis using Mydrane® were 4.58 ± 1.06 and 5.6 ± 1.26 mm, respectively.

CONCLUSION

In a real-life setting, the mean pupil diameter achieved during cataract surgery after the intracameral injection of Mydrane® in patients with a preoperative pupil diameter <6 mm was over 1 mm larger than the mean pupil diameter after topical mydriatics, despite the trauma caused by the operation.

Dilation devices in cataract surgery

PURPOSE OF REVIEW

Cataract surgery in the setting of small pupil represent a major challenge and it is associated with a higher risk of complications. When pharmacologic pupil dilation fails, mechanical pupil expansion devices are needed to obtain and maintain sufficient intraoperative mydriasis. The purpose of this review is to assess the pupil expansion devices currently available.

RECENT FINDINGS

A variety of pupil expansion devices are offered on the market. They differ for design, material, shape, size, cost, and easiness of insertion/removal, nonetheless they all seem to be effective in improving the pupil size and easing the cataract surgery.

SUMMARY

Mechanical pupil expansion can be effectively achieved with a variety of devices, which are well tolerated and can facilitate cataract surgery in the setting of poor mydriasis.

Comparative Study of Safety Outcomes Following Nucleus Disassembly with and without the miLOOP Lens Fragmentation Device During Cataract Surgery

Purpose

To determine the effect of a microinterventional lens prefragmentation wire loop device (miLOOP®; Carl Zeiss Meditec AG, Oberkochen, Germany), on adverse events (AEs), cumulative dispersed energy (CDE), and vision outcomes when used before phacoemulsification of high-grade mature cataracts.

Setting

Three ambulatory surgical centers in the Peoria, IL region.

Design

Retrospective comparative consecutive case series; single-surgeon.

Methods

Patient outcomes were compared before and after introduction of miLOOP-assisted lens fragmentation prior to phacoemulsification during cataract surgeries performed 2016‒2020. The primary outcome was intraoperative AE rate/type. Secondary outcomes included ultrasound cumulative dispersed energy (CDE) administered during phacoemulsification, postoperative AEs, and best-corrected visual acuity (BCVA).

Results

Data from 765 subjects (mean age 72.9 years; 1025 eyes) comprised 524 conventional lens disassembly (Control) eyes and 501 Device eyes. One hundred percent of the cataracts in both groups were advanced WHO Grade 3+ nuclei. Significantly fewer intraoperative AEs occurred in the Device group versus Controls (2.2% and 6.3% of eyes, respectively; p=0.0011). Postoperative AE rates were comparable between groups (Controls=2.9%, Device=3.5%). Mean CDE from ultrasound was significantly reduced by 21% when the microfilament loop device was used for nuclear disassembly (9.6±5.2 CDE units) versus Controls (11.6±6.4 CDE units; p<0.0001). Median postoperative BCVA was 20/25 Snellen (0.091 logMAR) in both groups. More than 70% of both Control and Device eyes had postoperative BCVA better than 20/30 Snellen.

Conclusion

Microinterventional lens fragmentation was associated with lower ultrasound energy use and improved intraoperative safety than traditional unassisted surgery of advanced high-grade cataracts, while maintaining similarly acceptable postoperative complication rates and BCVA functional outcomes.

Outcomes of cataract surgery complicated by posterior capsule rupture in the European Registry of Quality Outcomes for Cataract and Refractive Surgery

PURPOSE

To analyze the outcomes of cataract surgery complicated by posterior capsule rupture (PCR).

SETTING

European clinics affiliated to the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO).

DESIGN

Retrospective cross-sectional register-based study.

METHODS

Data were retrieved from the EUREQUO between January 1, 2008, and December 31, 2018. The database consists of data on demographics, intraoperative complications such as PCR, type of intraocular lens (IOL) material, postoperative refraction, corrected distance visual acuity (CDVA), and postoperative complications.

RESULTS

1 371 743 cataract extractions with complete postoperative data were reported in the EUREQUO. In 12 196 cases (0.9%), PCR was reported. After PCR, patients were more likely to receive a poly(methyl methacrylate) IOL (5.2% vs 0.4%, respectively) or no IOL (1.1% vs 0.02%, respectively) compared with patients without PCR. The refractive and visual outcomes in patients with PCR were significantly worse than in those without PCR (mean CDVA 0.13 ± 0.21 vs 0.05 ± 0.16 logMAR, P < .001; mean absolute biometry prediction error 1.15 ± 1.60 diopters [D] vs 0.41 ± 0.45 D, P < .001). A multivariate linear regression analysis, adjusting for potential explanatory variables, confirmed a statistically significant difference (0.04 logMAR, P < .001, and .70 D, P < .001, respectively). Patients with PCR had significantly more postoperative complications (corneal edema 0.88% vs 0.17%, adjusted odds ratio [aOR], 2.80 95% CI, 2.27-3.45, endophthalmitis 0.11% vs 0.02%, aOR, 4.40 95% CI, 2.48-7.81, uncontrolled intraocular pressure 0.55% vs 0.03%, aOR, 14.58 95% CI, 11.16-19.06, P < .001).

CONCLUSIONS

Patients with PCR had significantly worse visual and refractive outcomes and more postoperative complications than patients without PCR. However, most of these patients achieved better postoperative visual acuity than that preoperatively.

Previous intravitreal injection as a risk factor of posterior capsule rupture in cataract surgery: a systematic review and meta-analysis

PURPOSE

Intravitreal injections and cataract surgery are two common procedures in the elderly. Posterior capsular rupture (PCR) is a rare but important complication of cataract surgery. We systematically reviewed the literature on previous intravitreal injections as a risk factor of PCR and performed meta-analyses to provide pooled summary risk estimates.

METHODS

We searched 13 literature databases on 1 June 2021 for studies evaluating the risk of PCR in eyes undergoing cataract surgery with data on previous intravitreal injections. Data extraction was made independently by two authors and discussed afterwards until reaching consensus. Random effects meta-analyses on the pooled odds ratio (OR) of PCR in eyes with previous intravitreal injections were made using MetaXL 5.3.

RESULTS

Six studies on 1 051 097 eyes undergoing cataract surgery were eligible for the qualitative and quantitative review. Previous history of intravitreal injections was present in 7034 eyes (majority was anti-VEGF). Our meta-analyses revealed that any previous intravitreal injection was a risk factor for PCR with an OR of 2.30 (95% CI 1.39-3.81). For each previous intravitreal injection, the risk of PCR was OR 1.04 (95% CI 1.01-1.08) (equivalent of relative risk ~1.04). In other words, risk of PCR increases by 4% for each previous intravitreal injection.

CONCLUSIONS

Previous intravitreal injection is a risk factor for PCR and should be taken into account when planning cataract surgery. However, to be regarded as a clinically significant risk of PCR, a substantial number of previous intravitreal injection (e.g. ≥10) should have been administered, considering that the a priori risk of PCR is very low (~1%).

Risk factors for posterior capsule rupture in cataract surgery as reflected in the European Registry of Quality Outcomes for Cataract and Refractive Surgery

PURPOSE

To analyze the incidence and risk factors for posterior capsule rupture (PCR) in cataract surgery.

SETTING

European clinics affiliated with the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO).

DESIGN

Retrospective cross-sectional register-based study.

METHODS

Data were obtained from the EUREQUO. The database contains data on demographics, comorbidities, and intraoperative complications, including PCR for the study period from January 1, 2008, to December 31, 2018. Univariate and multivariate logistic regression analyses were performed to estimate the (adjusted) odds ratio (OR) and 95% confidence intervals (CIs).

RESULTS

We analyzed EUREQUO registry data of 2,853,376 patients, and 31,749 (1.1%) cataract surgeries were complicated by a PCR. Data were available of 2 853 376 patients, and 31 749 (1.1%) cataract surgeries were complicated by a PCR. The PCR rate ranged from 0.60% to 1.65% throughout the years, with a decreasing trend (P < .001). The mean age of the PCR cohort was 74.8 ± 10.5 years, and 17 29 (55.5%) patients were female. Risk factors most significantly associated with PCR were corneal opacities (OR 3.21, 95% CI, 3.02-3.41, P < .001), diabetic retinopathy (OR 2.74, 95% CI, 2.59-2.90, P < .001), poor preoperative visual acuity (OR 1.98, 95% CI, 1.88-2.07, P < .001), and white cataract (OR 1.87, 95% CI, 1.72-2.03, P < .001).

CONCLUSIONS

Risk factors for PCR were identified based on the EUREQUO, and the incidence of this complication is decreasing over time.

Risk of Posterior Capsular Rupture during Phacoemulsification in Patients with the History of Anti-VEGF Intravitreal Injections: Results from the Pan-American Collaborative Retina Study (PACORES) Group

Purpose

To assess the risk for capsular rupture during routine phacoemulsification in patients with a history of anti-VEGF injections and other possible risk modifiers such as treatment patterns, type of anti-VEGF agent, and experience of the surgeon, among others.

Methods

This study reviewed the medical records of 11,129 patients from 7 different hospitals in 5 countries. The study included 939 patients that underwent routine phacoemulsification and had a history of anti-VEGF therapy. We excluded patients with known risk factors for capsular rupture, as well as patients with a history of other retinal procedures. The study extracted data regarding general demographics, the number of previous injections, type of anti-VEGF agent, details of cataract surgery, and anti-VEGF treatment patterns.

Results

Overall prevalence of posterior capsular rupture: 7.45% (95% CI: 5.9–9.32%). The mean number of injections per patient was 3.37 ± 2.8. More than 50% of the patients received their last anti-VEGF injection within three months before cataract surgery. The complication rate during intravitreal injections was 1.07%. In the univariate analysis, the experience of the cataract surgeon (inexperience surgeons; OR: 2.93) and the history of prior anti-VEGF therapy (OR: 1.77) were significant risk indicators for PCR (p < 0.05). However, after controlling for age in the multivariate analysis, the trend did not reach a statistical significance.

Conclusion

The risk for capsular rupture is higher in patients with a history of intravitreal anti-VEGF injections.

Incidence of corneal transplantation after challenging cataract surgery in patients with and without corneal guttata

PURPOSE

To study the risk for corneal transplantation after phacoemulsification with dense cataract or posterior capsule rupture (PCR) and the impact of corneal guttata.

SETTING

Forty-nine Swedish cataract surgical units and 8 Swedish cornea transplantation units.

DESIGN

Registry-based cohort study.

METHODS

Patient data from the Swedish National Cataract Registry (2010 to 2012) were linked with data from the Swedish Cornea Transplant Registry (2010 to 2017). The outcome measures were risk for future corneal transplantation, visual acuity, and self-assessed visual function after phacoemulsification. Logistic and Poisson regression analyses with adjustment for confounder effects were used to investigate the association of the outcome measures with dense cataract, indicated by trypan blue capsular staining (TB) and PCR, separately and together.

RESULTS

Altogether, data from 276 362 cataract patients were linked with data from 2091 patients with endothelial failure who underwent corneal transplantation.The risk for future corneal transplantation increased more than 3-fold with the presence of dense cataract or PCR, and a trend toward an ever-higher risk with the combination of TB and PCR together, but without any significant synergy of corneal guttata. Dense cataract, but not PCR, was significantly associated with an increased probability of inferior visual acuity after phacoemulsification. The impact on satisfaction was not statistically significant for any of the factors.

CONCLUSIONS

Challenging cataract surgery increases the risk for future corneal transplantation equally in patients both with and without corneal guttata, despite a more vulnerable endothelium in the guttata group. This supports a strategy where PCR is limited and handled optimally and that cataract surgery is performed before the cataract turns critically dense.

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.

Prognostic Factors for Low Visual Acuity after Cataract Surgery with Vitreous Loss

Purpose

The purpose of this study is to find prognostic factors associated with low visual acuity in patients experiencing vitreous loss during cataract surgery.

Methods

A retrospective, noncomparative, interventional, case study of patients experiencing vitreous loss during cataract surgery. Data collected included demographics, best corrected visual acuity (BCVA), axial length (AL), presence of ocular comorbidity affecting central vision, timing of intraocular lens (IOL) implantation, position of the implanted lens, and the presence of corneal sutures. Low visual outcome was defined as BCVA < 20/40.

Results

Overall, 179 patients (60.3% males) with a mean age of 73 ± 12 years and axial length of 23.5 ± 1.3 mm with a mean follow-up of 12 ± 13 months were included. In multivariable logistic regression analysis, low visual outcome was independently associated with persisting postoperative complications (OR 6.25, 95% CI 1.378–30.9), preexisting ocular comorbidities (OR 4.45, 95% CI 1.1–18.00), and secondary intraocular lens (IOL) implant (OR 10.36, 95% CI 1.8–60.00). Conversely, pars plana vitrectomy (PPV) for dislocated fragments of lens material, age > 70 years, gender, axial length, degree of surgeon, corneal suturing, and anterior chamber lens implantation were not found to have significant associations with low visual outcomes (P > 0.05).

Conclusions

Low visual outcome after vitreous loss during cataract surgery was associated with ocular comorbidities, secondary IOL implantation, development of cystoid macular edema, and additional surgical complications.

Jagat and Bala intraocular lens supporting system: An artificial platform for intraocular lens implantation in an aphakic patient with inadequate capsular support

We describe a novel device, Jagat and Bala Intraocular lens Supporting System (JBISS), an artificial Intraocular lens (IOL) platform that facilitates IOL fixation in an aphakic patient with poor capsular support and also facilitates IOL exchange in case of myopic shift or refractive surprise. Implantation of JBISS along with IOL was carried out in four patients and results are promising without any adverse events.

Resident Performed Sutureless Manual Small Incision Cataract Surgery (MSICS): Outcomes

Purpose

To show the surgical and visual outcomes of a resident-performed manual small incision cataract surgery.

Study Type

Retrospective observational case series.

Study Setting

Ruby Eye Hospital.

Materials and Methods

Manual small incision cataract surgery was performed on 339 uncomplicated cataract cases by three in-house residents. Preoperative visual acuity and vision with a pinhole were meticulously noted in the record sheets. All patients underwent thorough preoperative evaluation with the help of a slit lamp. Eyes with corneal guttae, un-dilated pupils, pseudo-exfoliation, raised intraocular pressure and posterior segment abnormalities were excluded from the study. The mean patient age was 59 years (min: 47 years and max: 85 years). Forty-seven percent were males, and the rest were females. The mean uncorrected preoperative visual acuity recorded was 1.3 logMAR units (max: 1 and min: 1.6, Std dev: 0.4). Forty-two percent of the eyes had dense nuclear cataracts (≥ Nuclear Sclerosis grade III from LOCS II).

Results

The mean postoperative visual acuity recorded was 0.4 logMAR units [standard deviation 0.3 logMAR units (max: 1 and min: 0.1 p-value <0.001)]. Forty-three cases (12.6%) had tunnel-related complications (premature entry/button hole). Thirty-six cases (10.6%) had iatrogenic prolapse of the iris tissue. Eight cases (2.3%) had a runaway capsulorhexis, while 18 cases (5.3%) had iatrogenic posterior capsular rupture. Two cases (0.58%) had a large zonular dialysis. Ten cases (2.9%) were retaken to the operating room again for repeat intervention.

Conclusion

The ophthalmic resident learning curve for manual small incision cataract surgery is steep, unlike what is reported in the literature. A good training program with a special emphasis on wound construction is of paramount importance for future residents.

CaDIS: Cataract dataset for surgical RGB-image segmentation

Video feedback provides a wealth of information about surgical procedures and is the main sensory cue for surgeons. Scene understanding is crucial to computer assisted interventions (CAI) and to post-operative analysis of the surgical procedure. A fundamental building block of such capabilities is the identification and localization of surgical instruments and anatomical structures through semantic segmentation. Deep learning has advanced semantic segmentation techniques in the recent years but is inherently reliant on the availability of labelled datasets for model training. This paper introduces a dataset for semantic segmentation of cataract surgery videos complementing the publicly available CATARACTS challenge dataset. In addition, we benchmark the performance of several state-of-the-art deep learning models for semantic segmentation on the presented dataset. The dataset is publicly available at https://cataracts-semantic-segmentation2020.grand-challenge.org/.

Phacoemulsification in eyes with long anterior zonules

PURPOSE

To study the safety of phacoemulsification in eyes with long anterior zonules (LAZs).

SETTING

Institute.

DESIGN

Retrospective interventional case series.

METHODS

All patients with clinically proven LAZs who had undergone phacoemulsification by a single surgeon from January 2014 to December 2018 were included. All cases of LAZs with cataract extraction by procedures other than phacoemulsification or combined with any other ocular surgery were excluded. Sixty-five eyes of 52 patients were analyzed. Phacoemulsification with capsulorhexis that involves sacrificing the LAZs was performed. The primary outcome measures were the incidence of capsulorhexis extension or the need to rescue intraoperatively and the rate of intraoperative complications. Secondary outcomes assessed were the percentage of eyes within ±0.5 diopters (D) and ±1 D of the target refraction.

RESULTS

Sixty-five eyes (52 patients) were analyzed; the mean age of patients was 67.3 ± 7.4 years. The successful completion of an adequately sized capsulorhexis without extension or rescue was seen in 100% of cases. The incidence of intraoperative complications was 1.5% (posterior capsular rupture in 1 eye). The mean postoperative corrected distance visual acuity was 0.05 ± 0.1 (logarithm of the minimum angle of resolution) at a mean of 26.8 ± 7.6 days. The mean spherical equivalent was -0.15 ± 0.7 D. Eyes within ±0.5 D and ±1.00 D of the target refraction were 77% and 94%, respectively.

CONCLUSIONS

Phacoemulsification in eyes with LAZs can be safely performed through an adequately sized capsulorhexis by sacrificing, ie, cutting or breaking, the anteriorly inserted zonules 360 degrees without significant intraoperative complications.

Propensity and quantification of aerosol and droplet creation during phacoemulsification with high-speed shadowgraphy amid COVID-19 pandemic

PURPOSE

To study propensity of aerosol and droplet generation during phacoemulsification using high-speed shadowgraphy and quantify its spread amid COVID-19 pandemic.

SETTING

Aerosol and droplet quantification laboratory.

DESIGN

Laboratory study.

METHODS

In an experimental set-up, phacoemulsification was performed on enucleated goat eyes and cadaveric human corneoscleral rims mounted on an artificial anterior chamber. Standard settings for sculpt and quadrant removal mode were used on Visalis 100 (Carl Zeiss Meditec AG). Microincision and standard phacoemulsification were performed using titanium straight tips (2.2 mm and 2.8 mm in diameter). The main wound incisions were titrated equal to and larger than the sleeve size. High-speed shadowgraphy technique was used to detect the possible generation of any droplets and aerosols. The visualization and quantification of size of the aerosols and droplets along with calculation of their spread were the main outcome measures.

RESULTS

In longitudinal phacoemulsification using a peristaltic pump device with a straight tip, no aerosol generation was seen in a closed chamber. In larger wounds, there was a slow leak at the main wound. The atomization of balanced salt solution was observed only when the phacoemulsification tip was completely exposed next to the ocular surface. Under this condition, the nominal size of the droplet was approximately 50 µm, and the maximum calculated spread was 1.3 m.

CONCLUSIONS

There was no visible aerosol generation during microincision or standard phacoemulsification. Phacoemulsification is safe to perform in the COVID-19 era by taking adequate precautions against other modes of transmission.

Comparison of flanged intrascleral intraocular lens fixation versus iris claw intraocular lens fixation: A retrospective study

Purpose

To compare the visual outcome and complications of retropupillary fixated iris claw intraocular lens (IOL) and sutureless intrascleral IOL fixation using the flanged fixation technique at 1 year.

Methods

In this retrospective study, eyes that underwent either iris claw or flanged SFIOL from January 2016 to July 2017 with a minimum of 1-year follow-up were enrolled. Improvement in visual acuity, intraocular pressure measurements, endothelial cell count, central macular thickness, and complications were compared between and within groups at 6 weeks, 3 months, and 1 year postoperatively.

Results

Data from 150 eyes were analyzed (n = 90 in the iris claw group and n = 60 in the flanged SFIOL group). Posterior capsular rent was the most common indication for IOL implantation (n = 51, 34%). The iris claw and SFIOL groups were comparable in terms of demographics and baseline characteristics. There was significant improvement in uncorrected distance visual acuity (UCDVA) at 6 weeks in both groups (P = 0.77), and at 1 year, the UCDVA was comparable between groups (0.36 ± 0.32 in the iris claw group and 0.30 ± 0.28 in the SFIOL, P= 0.75). Transient elevation of intraocular pressure was seen slightly more in eyes with SFIOL (17%), while ovalization of the pupil was the main sequelae seen in the iris claw group (20%).

Conclusion

Both iris claw IOL fixation and SFIOL using flange are viable options for surgical correction of aphakia. Visual outcomes are excellent at 6 weeks and are maintained till 1-year follow-up, and complication rates are acceptably low, although ovalization of pupil is common with iris claw IOLs.

Flap motility sign: not diagnostic of posterior extension of anterior capsular tears

Flap motility sign has been recently described as an aid to guide the surgeons regarding the feasibility of continuing safe phacoemulsification in the presence of peripheral extension of anterior capsular tears. While this sign may seem to provide a safety assurance to the operating surgeon who at such times may be under considerable stress, we believe, this sign may not always hold true and this hypothesis needs further investigation. We present a case in which an everted and fluttering flap was noted in the presence of a complete posterior extension of the anterior capsular tear, thus refuting the accuracy of flap motility sign.

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.