The prevalence of glaucoma in a 70-year-old Swedish population in the city area of Gothenburg

PURPOSE

To determine the prevalence of and risk factors for open-angle glaucoma in a population of 70-year-olds in Gothenburg, Sweden and to compare the visual function between the glaucoma population and the non-glaucoma population.

METHODS

Of the entire cohort (n = 1203), 1182 participants responded a questionnaire on self-reported glaucoma and were tested for blood pressure (BP) and diabetes. In all, 560 participants underwent ophthalmic examination including best-corrected visual acuity (BCVA), intraocular pressure (IOP), central corneal thickness (CCT), contrast sensitivity (CS), perimetry and photos of the retina and lens.

RESULTS

Glaucoma prevalence was 4.8% (95% confidence interval, 3.0%-6.6%), of which 56% was previously undiagnosed. The proportion of participants with diastolic BP >90 mmHg was higher in the non-glaucomatous group (8.3%) than the glaucoma group (0%), p < 0.001. A family history of glaucoma was present in a larger proportion of the glaucoma group (39%) than of the non-glaucomatous group (1.1%), p = 0.001. Mean IOP in individuals without glaucoma was 16 mmHg, versus 21 mmHg in participants with glaucoma detected at the examination. IOP was ≤21 mmHg in 67% among participants with previously unknown glaucoma. BCVA was lower in eyes with previously unknown glaucoma than in eyes without glaucoma (p = 0.017) but BCVA in the best eye did not differ. CCT and CS were similar in all cases.

CONCLUSIONS

The prevalence of glaucoma was comparable to that reported previously. A family history of glaucoma and higher IOP were risk factors associated with glaucoma. BCVA in the best eye did not differ significantly between subjects with and without glaucoma.

Vision-related quality of life among 70-year-olds diagnosed with glaucoma

PURPOSE

To evaluate the effect of glaucoma on vision-related quality of life (VRQoL), lifestyle, physical factors and socioeconomic status in a 70-year-old population in Gothenburg, Sweden.

METHODS

Responses to questionnaires (N = 1182) between groups with and without self-reported glaucoma were analysed. Questionnaires included National Eye Institute Visual Functioning Questionnaire (NEI VFQ-25), Short-Form Health Survey (SF-36), physical activity, socioeconomics, alcohol and tobacco consumption. Balance test and body mass index were also included. About half of the participants were randomized to ophthalmic examination (N = 560), variables were analysed separately according to known and confirmed glaucoma, ocular hypertension and/or cases of previously unknown glaucoma.

RESULTS

Both conventional and Rasch analysis of the NEI VFQ-25 showed that VRQoL was lower for individuals self-reporting glaucoma (p = 0.003/p = 0.024). Regarding general QoL, the participants did not differ apart from people self-reporting glaucoma reported worse general health (p = 0.01). Using logistic regression with lower VRQoL as the dependent variable glaucoma was not a significant predictor of poor VRQoL, odds ratio (OR) 1.83 (95% confidence interval (CI) 0.76-4.39, p = 0.18). Low household income was associated with lower VRQoL (OR 1.63, 95% CI 1.14-2.33, p = 0.01). Socioeconomics, physical activity and lifestyle factors were comparable between the groups (N = 915). Among participants who underwent ophthalmic examination no significant differences were found between glaucoma cases and non-glaucoma cases in relation to VRQoL (N = 560).

CONCLUSIONS

Patients with self-reported glaucoma assessed a lower VRQoL but not lower general quality of life. Poorer household income was associated with worse VRQoL. General health was reported low in the glaucoma population but lifestyle or physical factors did not diverge.

Optimal Performance of Selective Laser Trabeculoplasty: Results from the Swedish Optimal SLT Multicenter Randomized Controlled Trial

PURPOSE

Selective laser trabeculoplasty (SLT) is a first-line treatment for glaucoma and ocular hypertension. However, due to insufficient comparative evidence in efficacy and safety, several SLT treatment protocols are currently used in practice. The objective of this trial was to compare the clinical outcomes of the 4 most significant SLT variants.

DESIGN

Prospective, multicenter, masked, randomized controlled trial (RCT).

PARTICIPANTS

Four hundred patients with glaucoma or ocular hypertension. The cohort consisted of both treatment-naive patients and patients undergoing glaucoma treatment, at different stages of disease.

METHODS

Selective laser trabeculoplasty was performed with 50 ± 5 laser spots in 180 degrees or with 100 ± 10 spots in 360 degrees. The laser power was titrated to either just below the cavitation bubble level ("standard energy") or to a level producing cavitation bubbles at 50% to 75% of laser applications ("high energy"). Thus, 4 different treatment protocols were included - 180/standard, 180/high, 360/standard, and 360/high. The study adhered as close as possible to regular clinical management, but within a scientific framework.

MAIN OUTCOME MEASURES

Reduction of intraocular pressure (IOP) 1 to 6 months after SLT. The proportion of patients achieving a 20% IOP reduction without any further intervention. Time to glaucoma treatment escalation in a Kaplan-Meier survival analysis.

RESULTS

SLT performed with the 360/high protocol was shown to be superior regarding all primary endpoints. The IOP reduction 1 to 6 months after SLT was 5.4 mmHg in the 360/high group, compared to 3.4, 3.2, and 4.2 mmHg with the 180/standard, 180/high, and 360/standard protocols, respectively (P < 0.001). Furthermore, the success rate after 6 months was significantly higher -58.3%, compared with 30.2%, 29.3%, and 41.7% (P < 0.001). The median time to glaucoma treatment escalation was more than twice as long with 360/high SLT -1323 days, compared to 437 days, 549 days, and 620 days (P < 0.001). Although postoperative discomfort was more frequent with the 360/high protocol, symptoms were generally mild and transient. Adverse events were rare in all groups.

CONCLUSIONS

The magnitude and longevity of SLT results increases substantially if SLT is performed according to the 360/high protocol, without compromising safety. Therefore, we recommend that 360/high SLT be considered as standard treatment.

FINANCIAL DISCLOSURES

The authors have no proprietary or commercial interest in any materials discussed in this article.

[2.6 million cataract surgeries: 31 years with the Swedish National Cataract Register 1992-2022]

This review summarizes data collected by the Swedish National Cataract Register (NCR), which by the end of 2022 contained data on more than 2.6 million cataract surgeries between 1992-2022. During these 31 years, the cataract surgery rate (CSR) rose from 3 700 to 14 407. The coverage of NCR is very high, including 93% of all cataract procedures in Sweden during the last decade. A clear trend is that the procedure is performed in eyes with increasingly high visual acuity. The proportion of patients with Snellen 0.5 or worse in the first eye at surgery has decreased from 88% in 2007 to 69% in 2022. Patient Reported Outcome Measures (PROM) have been registered with the Catquest-9SF questionnaire since 2008, demonstrating stable favorable outcomes. Surgical complications have decreased; endophthalmitis has decreased from 0.10% to below 0.02%, and posterior capsule rupture from 2.8% to 0.6%.

Visual Improvement and Lowered Intraocular Pressure After Surgical Management of In-The-Bag Intraocular Lens Dislocation and Aphakia Correction; Retrospective Analysis of Scleral Suturing versus Retropupillary Fixated Iris-Claw Intraocular Lens During a 5-Year Period

Purpose

We compare and evaluate the visual outcome and complication rate of two different techniques of surgical management of in-the-bag intraocular lens (IOL) dislocation or aphakia correction. In addition, we evaluate possible risk factors for IOL dislocation or aphakia.

Patients and Methods

This retrospective case series reviewed medical records for all patients who had undergone surgery for IOL dislocation or aphakia during a 5-year period at a single ophthalmic center in Sweden. The two most common procedures, scleral suturing of dislocated in-the-bag IOL and retropupillary fixation of iris-claw IOL, were further analyzed. Main outcome measures were best-corrected visual acuity (BCVA), reoperations, and complications.

Results

The study comprised 110 eyes, including scleral suturing procedures (n=35) and retropupillary iris-claw IOL (n=75). There was a significantly higher rate of dense cataract (p=0.030) and posterior capsular rupture (PCR), (p=0.016) among iris-claw cases at the primary cataract extraction with pseudoexfoliations in about two-thirds of patients in both groups. All eyes in the scleral suturing group had an IOL dislocation. In the iris-claw group, 23 eyes (30.7%) were aphakic following complicated cataract surgery with PCR. No intraoperative complications occurred in any eyes during the secondary IOL procedure. Both groups showed significant improvement in BCVA, yet there was no significant difference between groups in postoperative BCVA (p=0.263). However, the scleral suturing group experienced a significantly larger improvement in BCVA due to worse BCVA preoperatively (p=0.005). Intraocular pressure decreased significantly after both repositioning and exchange surgery (p=0.002 and 0.010 respectively), but improvement between groups was not significantly different (p=0.264).

Conclusion

Both surgical methods resulted in significantly improved BCVA and lowering of IOP and can be considered safe with limited complications. The outcome was similar between groups. Pseudoexfoliation prevalence was high in both groups indicating that it may be a risk factor for either aphakia or late IOL dislocation.

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.

Genetic variants in the FOXO1 and ZNF469 genes are associated with keratoconus in Sweden: a case-control study

BACKGROUND

Keratoconus (KC) is characterized by pathological thinning and bulging of the cornea that may lead to visual impairment. The etiology of sporadic KC remains enigmatic despite intensive research in recent decades. The purpose of this study was to examine the relationship between previously highlighted genetic variants associated with KC and sporadic KC in a Swedish cohort.

METHODS

A total of 176 patients (age 16-70 years) with sporadic KC diagnosed by Scheimpflug-topography (Pentacam) were included. The control group (n = 418; age 70 years) was a subsample originating from the Gothenburg H70 Birth Cohort Studies of ageing. Extraction of DNA from blood samples was performed according to standard procedures, and genotyping was performed using competitive allele specific PCR (KASP) technology. A total of 11 single nucleotide polymorphisms (SNPs) were selected for analysis.

RESULTS

Statistically significant associations (p = 0.005) were found between the SNPs rs2721051 and rs9938149 and sporadic KC. These results replicate earlier research that found associations between genetic variants in the FOXO1 and BANP-ZNF469 genes and sporadic KC in other populations.

CONCLUSION

Genetic variations in the FOXO1 and BANP-ZNF469 genes may be involved in the pathogenesis of sporadic KC.

A Novel Primary Porcine Retinal Pigment Epithelium Cell Model with Preserved Properties

PURPOSE

To establish an ethical, reliable, and expandable retinal pigment epithelial (RPE) cell model with maintained RPE properties compatible with multifarious assays.

METHODS

RPE cells from abattoir-obtained porcine eyes were cultured under various conditions. Morphology, RPE cell-specific protein markers (RPE-65, CRALBP), and the tight junction marker ZO-1 were analyzed by phase-contrast microscopy, immunocytochemistry, and western blot, and transepithelial electrical resistance (TEER) was determined to assess barrier function.

RESULTS

The porcine RPE cells (pRPE) were best established using TrypLE Express, 10% fetal bovine serum (FBS) supplemented high-glucose media, and subculturing at semi-confluency. The pRPE cells maintained epithelioid morphology with ZO-1 positive tight junctions at the cell-to-cell borders, the ability to establish proper barrier function (TEERmax: 346/375 Ω⋅cm2 at passage I/passage VI), and expressed CRALBP and RPE-65 for several passages. The RPE characteristics decreased and disappeared with transdifferentiation.

CONCLUSIONS

This work describes, for the first time, a pRPE cell model that exhibits preserved RPE properties for several passages on cell culture plastic plates. Though RPE characteristics were maintained for at least 6 passages, the reduced CRALBP and RPE-65 with passaging emphasize that lower passage cells are advantageous to utilize, and that morphology, barrier function, and ZO-1 localization cannot be solely employed as a quality measure of RPE identity. Pigs are phylogenetically similar to humans, including similar physiology, anatomy and immune system. Therefore, porcine RPE cells constitute a relevant model system for studying human eye diseases, such as AMD.

A new diagnostic method for retinal breaks in patients with posterior vitreous detachment: Ultra-wide-field imaging with the Zeiss Clarus 700

PURPOSE

This study was performed with the aim of finding a more convenient and less time-consuming method to diagnose retinal breaks in posterior vitreous detachment (PVD) patients.

METHODS

A prospective double-blind observational case study was performed with patients who were admitted to the Eye Emergency Department Sahlgrenska University Hospital with PVD symptoms and approved to participate in the study (n = 128). Standard slit lamp examination was compared with images from a Zeiss Clarus 700 ultra-wide-field camera (UWFC). Patients were examined and photographed by an independent operator. Data and image review was performed by three independent reviewers with varying experience. Retinal break detection with the two different methods (detailed eye examination by well-trained ophthalmologist and UWFC evaluations) was analysed statistically.

RESULTS

After excluding diagnoses other than PVD as well as unclear images due to cataracts, vitreous bleeding, etc., a total of 103 eyes with PVD were evaluated. A total of 38 ruptures in 25 patients were detected by routine examination and were subjected to laser treatment. UWFC images were reviewed by three ophthalmology consultants and compared with routine examinations. Sensitivity values in detecting retinal ruptures in UWFC images of the three reviewers were 0.89, 0.87 and 0.79, and specificity values were 0.88, 0.86 and 0.93 (kappa values: 0.742, 0.689 and 0.728) respectively.

CONCLUSION

Although there have been rapid developments in imaging with UWFC in recent years and it is a very promising method for the future, routine clinical examination is still the only valid method for the detection of retinal tears today.

Visual Acuity Prior to Cataract Surgery and Risk of Retinal Detachment - A Population-Based Study

Purpose

To analyze preoperative visual acuity before cataract surgery regarding the risk of rhegmatogenous retinal detachment (RRD) after cataract surgery.

Methods

The preoperative visual acuity in an observational cohort study of patients undergoing cataract surgery in Skåne, southern Sweden, during 2015-2017 was analyzed with data retrieved from the Swedish National Cataract Register. This was then cross-referenced with patients undergoing surgery for retinal detachment at the Skåne University Hospital in Lund from 2015 to 2020. The main outcome was the risk-benefit ratio of measuring preoperative visual acuity before cataract surgery and the risk of RRD.

Results

The mean visual acuity in the whole study group (N=58,624), expressed as LogMAR, was 0.40 ± 0.32 (SD). In the group with RRD (n=298), the mean visual acuity was 0.44 ± 0.36 (p=0.07). In the subgroups of RRD, those aged <60 years 0.49 ± 0.44 (p=0.07), aged <60 years and axial length (AL) >25 mm 0.42 ± 0.38 (p=0.68), and in those aged <60 years, AL >25 mm and male sex 0.44 ± 0.39 (p=0.53). However, there is considerable variations in visual acuity of the various groups and in the high-risk group with RRD aged <60 years with AL>25 mm, 15% had a visual acuity of 0.8 or better in the operated eye.

Conclusion

There must be strong indications for performing cataract surgery in those with a high risk of retinal detachment, and the patient must be given adequate information on the risk of retinal detachment.

Four-Year Outcome of XEN 45 Gel Stent Implantation in a Swedish Population

Purpose

To report the long-time success rate of XEN 45 gel stent implantation in a Scandinavian population.

Patients and Methods

This was a retrospective single-center analysis of all patients undergoing XEN 45 stent surgery between December 2015 and May 2017. The main outcome was success rate according to several definitions of success. Subgroup analysis was performed. Secondary outcomes were change in intraocular pressure (IOP) and number of IOP-lowering agents. Need for secondary glaucoma surgery, needling rate and complications were recorded.

Results

A total of 103 eyes could be evaluated after four years. Mean age was 70.6 years. Primary open-angle glaucoma (POAG) accounted for 46.6% and exfoliative glaucoma (PEXG) for 39.8%. Mean IOP dropped from 24.0 to 15.9 mmHg (p<0.001) and IOP-lowering agents from 3.5 to 1.5 (p<0.001). The success rate with individual target pressures after four years was 43.7%. Secondary glaucoma surgery was performed in 45 (43.7%) of cases. Combined cases (n=12) were not statistically different to stand-alone procedures (p=0.28). No difference between PEXG and POAG could be detected (p=0.44). During the learning curve, stent misplacement was common and resulted in worse outcome for less experienced surgeons.

Conclusion

The overall success rate of XEN 45 gel stent surgery in the present cohort is relatively low in a long-time follow-up under the given circumstances if all initial patients are included to follow-up. The influence of the surgeon's learning curve is obvious, and improvement in success can be expected when used by experienced and high-volume surgeons. No significant differences were found in PEXG compared to POAG or in XEN surgery combined with cataract surgery compared to stand-alone.

Cataract surgery in patients with uveitis: Data from the Swedish National Cataract Register

PURPOSE

To investigate the surgical and pharmacological management and outcomes of patients with cataract and concurrent uveitis.

METHODS

Data from the Swedish National Cataract Register, 2018-2019, were collected and analysed. Uveitic eyes were identified and eyes without uveitis were used as controls. Generalized estimating equations were used to adjust for intra-individual correlation.

RESULTS

The study included 719 eyes with and 256 360 without uveitis. The mean age was 66.0 ± 13.5 (standard deviation [SD]) years in the uveitis group and 74.3 ± 8.7 years in the control group (p < 0.001). Surgery was associated with more intraoperative difficulties in eyes with uveitis (27.0%) than in control eyes (7.1%; p < 0.001). Posterior capsule rupture/zonular complications were registered in nine eyes with uveitis (1.3%) and in 1464 eyes without uveitis (0.6%; p = 0.02). Hydrophilic acrylic intraocular lenses (uveitis 3.6%, controls 1.2%) and subconjunctival steroids (uveitis 17.4%, controls 6.1%) were more frequently used in eyes with uveitis (p < 0.001). post-operative best-corrected visual acuity (BCVA) was 0.16 ± 0.38 logarithm of the minimum angle of resolution (logMAR, mean ± SD) in eyes with uveitis (n = 52) and 0.08 ± 0.20 in control eyes (n = 14 489; p = 0.008).

CONCLUSION

In this large registry-based Swedish cohort study, the findings demonstrate that cataract surgery in patients with uveitis poses more challenges and requires special surgical precautions. Eyes with concurrent uveitis had worse BCVA prior to and following surgery. Despite the intraoperative challenges, the visual improvement was greater in the uveitic group.

Two point four million cataract surgeries: 30-years with the Swedish National Cataract Register 1992-2021

ABSTRACT

The present review summarizes data collected by the Swedish National Cataract Register (NCR), which by the end of 2021 contained data for more than 2.4 million cataract surgeries between 1992-2021. During these 30 years, the cataract surgery rate (CSR) rose from 3700 to 12800. The coverage of NCR is very high including 93% of all cataract procedures in Sweden between 2010-2021. Independently of demographic changes, the proportion of operations of patients age 60-79 has increased while the proportion of 80-90+ has decreased. The median visual acuity of the first eye planned for surgery was 0.1 decimal in 1992 and has increased to 0.5 decimal in 2021. Patient Reported Outcome Measures (PROM:s) have been registered with the Catquest-9SF questionnaire since 2008, demonstrating intervention at an earlier stage, but consistently favorable outcomes. Surgical complications have decreased; endophthalmitis has decreased from 0.10% to below 0.02%, and posterior capsule rupture from 2.8% to 0.6%.

Late-onset glaucoma following congenital cataract surgery: Occurrence, visual acuity and risk factors: A 37-year longitudinal follow-up

PURPOSE

The aim of this study was to determine the prevalence of late-onset glaucoma after surgery for congenital cataract in a cohort with long-term follow-up and to evaluate visual development following the diagnosis of postoperative glaucoma in comparison with no glaucoma development.

METHODS

All children born between 1980 and 1997 in the western counties of Sweden who had undergone congenital cataract surgery were included (patients n = 77, eyes n = 122). Cataract was considered congenital if there was no proof of clear lens at birth. Medical records were reviewed with regard to onset of glaucoma, age at surgery, surgical technique, coexisting eye anomalies and changes in visual acuity. Glaucoma was considered late onset if occurring after 1 year following surgery.

RESULTS

Total glaucoma prevalence was 14.8%, including late (10.7%) and early onset (4.1%), with a mean follow-up of 23.2 ± 6.6 years. Microphthalmos was a significant risk factor for developing glaucoma (RR 7.75, p < 0.001). Bilaterally treated eyes had a mean visual acuity of 0.43 ± 0.33 (decimal value) at the last follow-up. With glaucoma, mean visual acuity was 0.19 ± 0.17 (decimal value). Treated eyes of patients with unilateral cataract surgery had a lower visual acuity.

CONCLUSIONS

Life-long follow-up of all patients who have undergone surgery for congenital cataract in childhood is recommended. Annual check-ups of adults, including measurements of IOP and visual acuity, are recommended for patients with microphthalmos and/or who had surgery <3 months of age.

Risk Factors for Cytomegalovirus Retinitis in a National Survey in Sweden

PURPOSE

To investigate predisposing immunosuppressive conditions causing cytomegalovirus retinitis (CMVr) and risk factors for delayed diagnosis in patients diagnosed between 2008 and 2018 in the Swedish population of 10 million.

RESULTS

Sixty-three consecutive patients (100 eyes) were diagnosed with CMVr. The most common immunosuppressive state predisposing for CMVr was hematopoietic stem cell transplant recipients (27%) and hematological malignancy (24%). Two patients (3.2%) had no other predisposing factor than diabetes mellitus (DM). Patients with delayed diagnosis (≤30 days) were older than those with earlier diagnosis, mean age 68.7 (±9.8) and 48.8 (±17.6), respectively, p = .001. Signs of intraocular inflammation (IOI) were seen in 42 (70%) of cases and more common in delayed than early diagnosis, 16 (89%) and 21 (60%) respectively (p = .03).

CONCLUSION

Delayed diagnosis was more common in older individuals with signs of IOI. DM may be a risk factor for CMVr, and clinical signs can be mistaken for diabetic retinopathy.

Single nucleotide polymorphisms in LOXL1 as biomarkers for progression of exfoliation glaucoma in Sweden

PURPOSE

Exfoliation glaucoma is a common and aggressive type of glaucoma with high prevalence in Scandinavia. The aim of this study was to elucidate whether the allele frequencies of two single nucleotide polymorphisms (SNPs) located in LOXL1 were associated with the progression of exfoliation glaucoma in Swedish patients.

METHODS

In this non-randomised cohort study, we enrolled patients with exfoliation glaucoma, and they performed at least five reliable visual field tests. Blood samples were collected, and genotyping was performed using competitive allele-specific PCR genotyping. Glaucoma progression was evaluated using the guided glaucoma progression analysis (GPA), mean deviation (MD) difference and rate of progression (ROP). In addition, associations between allele frequencies and glaucoma progression were tested using logistic regression for GPA and linear regression for MD and ROP.

RESULTS

We enrolled a total of 130 patients in the study. The general genetic model showed statistical significance for LOXL1_rs2165241 (p = 8 × 10^-7 , Fisher's exact test) and LOXL1_rs1048661 (p = 2 × 10^-6 , Fisher's exact test). Regression analyses using an additive genetic model showed significant values for LOXL1_rs2165241SNP in relation to GPA, MD and ROP as outcomes (p = 1.8 × 10^-4 , 4 × 10^-2 , 6 × 10^-4 ) and for LOXL1_rs1048661 SNP in relation to GPA, MD and ROP (p = 7 × 10^-5 , 8 × 10^-3 , 2 × 10^-4 ).

CONCLUSIONS

This was the first study to show an association of the SNPs LOXL1_rs2165241 and LOXL1_rs1048661 with the progression of exfoliation glaucoma. Further large-scale studies are required to verify these findings.

Retinal detachment after cataract surgery: a population-based study

PURPOSE

To analyse the risk of rhegmatogenous retinal detachment (RRD) after cataract surgery, and to identify possible risk factors.

METHOD

Observational cohort study of patients undergoing cataract surgery in Region Skåne, southern Sweden, during 2015-2017 were retrieved from the Swedish National Cataract Register. These were then cross-referenced with cases of retinal detachment surgery performed at the Skåne University Hospital in Lund from 2015 to 2020. The main outcome was RRD after cataract surgery. The influence of sex, age, axial length of the eye, rupture of the posterior capsule, patient comorbidity and other cataract complications were analysed.

RESULTS

Among the 58 624 cases of cataract surgery, a total of 298 RRDs (0.51%) were identified up to the end of 2020. The mean time from cataract surgery to RRD was 667 days. The mean age was 65.3 years, compared to 74 years in the control group. A strong correlation was found between RDD and age: <60 years, incidence = 0.50%; 60-75 years, incidence = 0.14%; and >75 years, incidence = 0.04%. The correlation with axial length was also very strong: mean value 23.73 mm in those without RRD, and 25.13 mm in those with RRD (p < 0.001). Sex was also strongly correlated to RDD; 68.8% of cases of RRD being men. Among men younger than 60 years of age, with an axial length ≥25 mm, 9.46% exhibited RRD within the follow-up period (mean 4.7 years). Rupture of the posterior capsule was found in 2.01% of RRD patients compared to 0.74% in the control group. Diabetes, glaucoma or pseudoexfoliation had no impact on the prevalence of RRD.

CONCLUSIONS

The three main risk factors for RRD following cataract surgery were found to be sex, age and axial length. The highest incidence of RRD (9.46%) were identified among men younger than 60 years of age and an axial length ≥25 mm.

The impact of topical NSAID treatment on selective laser trabeculoplasty efficacy

PURPOSE

Selective laser trabeculoplasty (SLT) is a first-line intervention for glaucoma, with the aim to reduce the intraocular pressure (IOP). Topical non-steroidal anti-inflammatory drugs (NSAIDs) are sometimes prescribed after SLT. However, it has been proposed that such treatment may either increase or reduce SLT efficacy. The purpose of this study was to investigate this further.

METHODS

The study was a retrospective chart review, including 192 eyes of 192 patients, half of which received a course of NSAID eyedrops after SLT. Absolute and relative IOP reduction 3-12 weeks after SLT was compared. Furthermore, subgroup analyses, a multiple linear regression analysis, and a Kaplan-Meier survival analysis regarding time to treatment escalation were performed.

RESULTS

The mean absolute IOP reduction was 4.3 ± 3.4 mmHg in the NSAID group and 5.4 ± 4.1 mmHg in the control group (p = 0.049). Relative IOP reduction was 17.5% ± 13.0% and 21.8% ± 14.8% in the NSAID and control groups, respectively (p = 0.033). The same tendency of superior results in control eyes compared with NSAID eyes was seen in an extensive subgroup analysis. A multiple linear regression analysis confirmed NSAID treatment as a negative predictor of IOP reduction after adjustment for covariates (p = 0.023). Survival analysis showed a longer median time to treatment escalation in the control group, though not statistically significant.

CONCLUSION

Topical NSAID treatment was not associated with an increased SLT efficacy. On the contrary, the present study is the first to demonstrate that SLT effectiveness may even be reduced by NSAIDs.

Pseudophakia and Lens Opacities in 70-Year-Olds in Gothenburg, Sweden; Gender Differences, Impact on Self-Reported Visual Function and Validation of Self-Reported Cataract and Pseudophakia

Purpose

The study aimed at determining the prevalence and sex differences in cataract, pseudophakia, lens opacities and self-reported cataract in 70-year-old people in Gothenburg, Sweden. The purpose was also to identify correlations between lens opacities, visual acuity and subjective visual function, and to validate self-reported cataract and cataract surgery.

Patients and Methods

Population-based cross-sectional study where participants (n=1182) answered questions about self-reported diagnosis of cataract and cataract surgery. A total of 1139 subjects completed the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25), 560 subjects underwent ophthalmic examination including visual acuity and lens photography. t-test, Pearson chi-square and Mann-Whitney U-test were used for obtaining p-values. ANOVA (analysis of variances, Kruskal-Wallis, one-way) was used to compare VFQ-25 between 3 groups; no cataract, cataract and pseudophakia. To clarify the differences between specific pairs of groups post-hoc test (Bonferroni) was used after ANOVA.

Results

Self-reported cataract was more common in women than in men (27.2% vs 19.1%, p=0.001, chi-square). Cataract surgery was reported by 16.3% of women and 12.6% of men (p=0.072). Upon eye examination, the prevalence of pseudophakia was 16.9% in women compared to 10.2% in men (p=0.020). The prevalence of cataract, including pseudophakia, was 31.9% in women versus 23.8% in men (p=0.033). Significant correlations (Spearman's rho) were found between lens opacities and visual acuity. Self-reported cataract surgery showed a very high specificity and high sensitivity. The composite score from NEI VFQ-25 was lower in people with pseudophakia than in people with/without cataract (p=0.012, Kruskal-Wallis).

Conclusion

The prevalence of cataract including pseudophakia in 70-year-olds in Gothenburg is higher compared to previous studies in similar geographical areas. Also, it is more common in women than in men. The lack of significant sex differences in lens opacities may be due to cataract surgery at an earlier stage. Validation showed very good agreement between pseudophakia and self-reported cataract surgery.

Absence of Herpesvirus DNA in Aqueous Humor from Asymptomatic Subjects

Purpose

To assess herpesvirus DNA detection in aqueous humor from a cohort of asymptomatic Scandinavian patients undergoing elective cataract surgery.

Patients and Methods

Prospective case series. Aqueous samples were obtained from 30 patients undergoing elective cataract surgery. Polymerase chain reaction (PCR) analysis for herpes simplex virus 1 (HSV1), herpes simplex virus 2 (HSV2), cytomegalovirus (CMV), Epstein Barr virus (EBV) was performed. Toxoplasma was added to the analysis due to its role as pathogen with ocular latency.

Results

Mean age of participants was 75.3 years. Sixteen subjects (53%) had ocular comorbidities. Five subjects (17%) had endothelial dysfunction without known hereditary pattern. None of the samples were positive for herpesviruses or toxoplasma.

Conclusion

None of the aqueous samples were positive, suggesting shedding does not frequently occur in the aqueous humor of asymptomatic patients.

Outcome of cataract surgery in eyes with diabetic retinopathy: a Swedish national cataract register report

PURPOSE

To analyse if patients with diabetic retinopathy (DR) subjected to cataract surgery differ in outcome compared to patients without DR with regard to best-corrected visual acuity (BCVA), deviation from target refraction, intraoperative difficulties and risk of complications.

METHODS

A register-based study from the Swedish National Cataract Register (NCR) during the years 2015-2017 including 358 040 cataract procedures. Patients with other ocular pathology than cataract and DR were omitted from outcome analyses.

RESULTS

Diabetic retinopathy was reported in 13 724 of all eyes (3.8%). Preoperative BCVA was significantly worse in DR patients than in patients without DR, 0.54 ± 0.33 compared to 0.40 ± 0.27 (logMAR, mean ± SD, p < 0.001). The same was evident for postoperative BCVA, 0.15 ± 0.25 for DR patients versus 0.06 ± 0.13 (p < 0.001). The improvement in BCVA was slightly better in DR than in non-DR, -0.40 ± 0.32 (logMAR; mean ± SD) versus -0.35 ± 0.27, p < 0.001. The absolute mean biometry prediction error was 0.42 ± 0.50 diopters (D) in DR and 0.43 ± 0.71 D in non-DR patients, p = 0.768. One or more intraoperative difficulties, including mechanical pupil dilation, capsular stain, hooks at capsulorhexis margin or capsular tension ring, had an adjusted odds ratio (OR) of 1.75 (95% confidence interval [CI] 1.61-1.90, p < 0.001) in DR versus non-DR cases and the rate of posterior capsular tears (PCR) had an adjusted OR of 1.76 (95% CI 1.40-2.20, p < 0.001).

CONCLUSION

Eyes with DR have inferior pre- and postoperative BCVA compared to non-DR eyes. There is little difference in improvement of BCVA and no difference in absolute mean biometry prediction error. Importantly, intraoperative difficulties and PCRs are almost twice as common in DR patients, strongly indicating that these patients should be managed by experienced surgeons.

Survival-Span Method: How to Qualitatively Estimate Lifespan to Improve the Study of Aging, and not Disease, in Aging Studies

Lifespan analyses are important for advancing our understanding of the aging process. There are two major issues in performing lifespan studies: 1) late-stage animal lifespan analysis may include animals with non-terminal, yet advanced illnesses, which can pronounce indirect processes of aging rather than the aging process per se and 2) they often involves challenging welfare considerations. Herein, we present an option to the traditional way of performing lifespan studies by using a novel method that generates high-quality data and allows for the inclusion of excluded animals, even animals removed at early signs of disease. This Survival-span method is designed to be feasibly done with simple means by any researcher and strives to improve the quality of aging studies and increase animal welfare.

[Xerophthalmia in a 7-year-old autistic child]

Vitamin A deficiency and xerophthalmia is a rare finding in developed countries. We report a severe case of xerophthalmia in a 7-year-old autistic child with restricted diet. Both eyes had Bitot's spots and ulceration. The right cornea had a perforation at admission. After treatment with high doses of vitamin A the right cornea epithelialized with formation of the anterior chamber and the left eye healed completely. This case adds to the increasing number of reports on cases of xerophthalmia particularly in autistic children and highlights the importance of considering vitamin A deficiency in patients with risk of malnutrition also in developed countries.

Association of Single Nucleotide Polymorphisms Located in LOXL1 with Exfoliation Glaucoma in Southwestern Sweden

Introduction: Glaucoma is an optic neuropathy that leads to visual field defects. Genetic mechanisms seem to be involved in glaucoma development. Lysyl Oxidase Like 1 (LOXL1) has been described in previous studies as a predictor factor for exfoliation glaucoma. The present article studied the association between three single nucleotide polymorphisms (SNPs) in the LOXL1 gene and the presence of exfoliation glaucoma in Southwestern Sweden. Methods: Case-control study for genetic association. In total, 136 patients and 1011 controls were included in the study. Patients with exfoliation glaucoma were recruited at the Eye Department of Sahlgrenska University Hospital and Skaraborgs Hospital, Sweden. Controls were recruited from the Gothenburg H70 Birth Cohort Study. Three different SNPs were genotyped: LOXL1_rs3825942, LOXL1_rs2165241 and LOXL1_rs1048661. Results: The distribution of allele frequencies was significantly different between controls and glaucoma patients; for rs3825942 (p = 2 × 10⁻¹²), for rs2165241 (p = 3 × 10⁻¹⁶) and for rs1048661 (p = 2 × 10⁻⁶). Logistic regression analyses using an additive genetic model, adjusted for sex and age, also showed associations between the studied SNPs and glaucoma (p = 9 × 10⁻⁶; p = 2 × 10⁻¹⁴; p = 1 × 10⁻⁴). Conclusion: A strong association was found between allele frequencies of three different SNPs (LOXL1_rs3825942, LOXL1_rs2165241, and LOXL1_rs1048661) and the presence of exfoliation glaucoma in a Southwestern Swedish population.

Anatomical outcome of retinal detachment surgery comparing different surgical approach

PURPOSE

To describe the outcome of retinal detachment surgery in a population affected by rhegmatogenous retinal detachment (RRD) in southern Sweden 2011-2013.

METHOD

All primary retinal detachments that underwent surgery at the Skåne University Hospital were registered during the period of 2011-2013. Age, sex, lens status and the different surgical methods including type of tamponade were recorded. For outcome assessment, no reoperation within 6 months was considered as primary success with one surgery except silicone oil removal.

RESULTS

In total, 918 primary retinal detachments were recorded during the 3-year period. Pars plana vitrectomy (PPV) alone was used in 618 eyes (67.3%), whereas an external approach with scleral buckling (SB) was used in 184 cases (20.0%) and a combination of PPV + SB in 116 eyes (12.6%). Pars plana vitrectomy (PPV) in combination with phacoemulsification and IOL implantation was performed in 169 eyes (18.4%), which was 43.6% of the phakic eyes having a PPV procedure. A total of 346 eyes (37.7%) were pseudophakic preoperatively. The success rate of one surgery was 86.9% for the entire cohort. In 120 eyes (13.1%), there was a re-detachment during the 6-month follow-up time. Higher age at the primary surgery turned out to be correlated to an increased risk of primary failure (p = 0.018) but gender was not (p = 0.84). Preoperative lens status did not affect the risk of re-detachment (p = 0.36), and there were no differences in outcome between surgeons (p = 0.27). No surgical procedure - alone or in combination - showed superior outcome as primary surgical approach.

CONCLUSIONS

There were no significant differences in anatomical outcome between the various surgical procedures in this large cohort of 918 RRD cases.

PA28α overexpressing female mice maintain exploratory behavior and capacity to prevent protein aggregation in hippocampus as they age

With age, protein damage accumulates and increases the risk of age-related diseases. The proteasome activator PA28αβ is involved in protein damage clearance during early embryogenesis and has demonstrated protective effects against proteinopathy. We have recently discovered that adult female mice overexpressing PA28α (PA28αOE) have enhanced learning and memory, and protein extracts from their hippocampi prevent aggregation more efficiently than wild type. In this study, we investigated the effect of overexpressing PA28α on aging using C57BL/6N×BALB/c F2 hybrid mice. We found that the hippocampal anti-aggregation effect was maintained in young adult (7 months) to middle-aged (15 months) and old (22 months) PA28αOE females. While the PA28αOE influence on learning and memory gradually decreased with aging, old PA28αOE females did not display the typical drop in explorative behavior-a behavioral hallmark of aging-but were as explorative as young mice. PA28αOE lowered PA28-dependent proteasome capacity in both heart and hippocampus, and there was no indication of lower protein damage load in PA28αOE. The life span of PA28αOE was also similar to wild type. In both wild type and PA28αOE, PA28-dependent proteasome capacity increased with aging in the heart, while 26S and 20S proteasome capacities were unchanged in the timepoints analyzed. Thus, PA28αOE females exhibit improved hippocampal ability to prevent aggregation throughout life and enhanced cognitive capabilities with different behavioral outcomes dependent on age; improved memory at early age and a youth-like exploration at old age. The cognitive effects of PA28αβ combined with its anti-aggregation molecular effect highlight the therapeutical potential of PA28αβ in combating proteinopathies.

Anti-inflammatory treatment after cataract surgery in Sweden: changes in prescribing patterns from 2010 to 2017

Aims

To investigate changes in the prescribing patterns of postoperative eye drops following cataract surgery in Sweden from 2010 to 2017.

Methods

Data from cataract procedures registered in the National Cataract Register during the month of March from 2010 to 2017 were record linked and sent to the Swedish Prescribed Drug Register, which allowed us to determine which eye drops the patients had obtained from 3 months presurgery to 2 weeks post surgery.

Results

During the 8-year study period, 54 889 surgeries were registered. Combination treatment with steroid and non-steroidal anti-inflammatory drug (NSAID) eye drops increased from 12% in 2010 to 60% in 2017 (p<0.001) while monotherapy with steroids decreased from 71% in 2010 to 26% in 2017 (p<0.001). Monotherapy with NSAIDs after surgery was fairly stable, at 17% in 2010 and 13% in 2017 (p<0.001). Combination treatment was more frequent in patients with diabetic retinopathy (p<0.001) or age-related macular degeneration (p<0.001), while monotherapy with steroids was more frequent in patients with glaucoma (p<0.001). The proportion of monotherapy or combination therapy varied widely between ophthalmic clinics. The prescription of antibiotic eye drops after surgery also varied greatly between clinics, from 0% to 63%, with a national average of 4.9%.

Conclusion

There is a change in the prescription pattern of anti-inflammatory eye drops after cataract surgery in Sweden, with less monotherapy and an increasing proportion of patients receiving a combination of steroid and NSAID eye drops.

Descemet Membrane Endothelial Keratoplasty versus Descemet Stripping Automated Keratoplasty - Outcome of One Single Surgeon's More Than 200 Initial Consecutive Cases

Purpose

To compare clinical outcome and complications of Descemet stripping automated keratoplasty (DSAEK) and Descemet membrane endothelial keratoplasty (DMEK).

Methods

This is a retrospective study of the first consecutive cases of DSAEK and DMEK performed by a single surgeon at a tertiary referral centre. Best-corrected visual acuity (BCVA), postoperative complications, rate of rebubbling and regraft were the main outcome measures.

Results

The study included 241 eyes, 116 subjected to DSAEK and 125 to DMEK. Fuchs endothelial dystrophy (FED) was the predominant diagnosis in both groups. Mean BCVA at all follow-ups up to 2 years was in favour of DMEK. Median BCVA (decimal) at 1 year was 0.4 (0.13–0.60; interquartile range) for the DSAEK and 0.8 (0.6–1.0) for the DMEK group, p<0.001. Preoperative BCVA in the DSAEK group was lower than in DMEK. There was no significant difference in visual improvement between groups at 1 year postoperatively. The most common postoperative complication in both groups was a pupillary block with high intraocular pressure, 27% and 34% respectively. This was not affected by the presence of an iridectomy/iridotomy. In the DMEK group, gas provided significantly better adherence than air (p=0.020). Rebubbling for partial/total detachment was performed in 7% (DSAEK) and 11% (DMEK) of cases, p=0.361. Regraft within 2 years was performed in 13% of eyes in the DSAEK and 17% in the DMEK group, p=0.450. No case of graft rejection occurred.

Conclusion

Both DSAEK and DMEK provide overall satisfying outcome and the two techniques do not differ significantly in postoperative pupillary block, detachment rate, early graft failure or graft rejection. However, differences at baseline may have influenced or obscured potential differences. In DMEK procedures, gas seems to facilitate early graft adherence.

H2O2-induced cataract as a model of age-related cataract: Lessons learned from overexpressing the proteasome activator PA28αβ in mouse eye lens

Cataract, the world-leading cause of blindness, is formed when crystallin aggregates cloud the eye lens. We overexpressed PA28αβ, a proteasome activator with properties protective against aggregation and oxidative stress, and examined whether they are less prone to develop cataract arisen from aging and/or hydrogen peroxide (H₂O₂) treatment. Another objective of this work was to compare the H₂O₂-induced cataracts of mouse lenses ex vivo to cataracts formed upon aging in mice. As part of an aging study of F2 hybrid C57BL/6NxBALB/c mice, ocular lenses of mature adult (7 months), middle-aged (15 months), and old (22 months of age) PA28αOE mice and their wildtype littermates (n = 22-44 lenses per group) were dissected and evaluated with regard to their cataractous state. In parallel, ocular lenses from 3 to 4 months old PA28αOE and wildtype C57BL/6 N littermates were treated with 100 μM H₂O₂ every 24 h for 7 days, with progression of cataract and physical appearance monitored daily. Lenses from both studies were also subjected to analysis of oxidative protein damage (carbonylation) and protein solubility. We found that overexpression of PA28αβ had no effect on neither age-related nor H₂O₂-induced cataract and conclude that overexpression of PA28αβ does not protect mice from developing cataract. The inefficiency of PA28αβ against cataract could be due to its anti-aggregation activity being already excessively present in the eye lens, exerted by crystallins. Crystallins are likely also constituting the 20-25 kDa proteins that were the dominant carbonyl targets in the eye lens irrespective of cataractous state. Assessment of H₂O₂-induced cataract in relation to age-related cataract demonstrated that high molecular weight protein carbonylation correlates to cataract both in vivo and ex vivo, while reduced protein solubility is more pronounced in age-related cataract. Furthermore, this work highlights vast dissimilarities in the physical manifestations of cataract upon aging and H₂O₂ ex vivo treatment. Age-related cataract initiation can take various forms, as a vague general blurriness or as a barely visible demarcated opacity, while H₂O₂-induced cataractogenesis seems to follow a specific scheme. In mice, this scheme begins with relatively opaque peripheral areas emerging that clear up later on as the lenses start to display a hat-like appearance. This transformation takes place synchronous to swelling of the eye lens, and is likely a result of osmotic disturbances causing a phase separation between the viscous lens cortex and the more solid fibers of the lens nucleus.

Catquest-9SF functioning over a decade - a study from the Swedish National Cataract Register

Background

The Swedish National Cataract Register (NCR) collects data on cataract surgery outcomes during March, including patient-reported outcomes using the Catquest-9SF questionnaire for over 11 years. Previous studies from NCR have shown that the preoperative visual acuity has improved over time. The main purpose of this study was to evaluate the Catquest-9SF Rasch scoring performance in this changing environment. A second purpose was to describe clinical data over the same period for those who completed the questionnaire.

Methods

The performance of the Catquest-9SF was analysed by a separate Rasch analysis for each year, resulting in a preoperative and postoperative score for each participating patient in the annual cohorts. The clinical data and questionnaire scoring were analysed for each year in the period 2008–2018 inclusive.

Results

Data were available for 42,023 eyes for 11 annual cohorts (2008–2018). The psychometric properties of the questionnaire were stable during the study period. Person separation (precision) for the whole period was 2.58 and varied between 2.45 and 2.72. The person reliability was 0.87 and varied between 0.86 and 0.88. The targeting of question difficulty to person ability became less accurate over time meaning that the item activities became easier to carry out without difficulty. The average targeting for the whole period was −2.06 and changed from −1.92 in 2008 to −2.31 in 2018. The person score improved both before surgery and after surgery, indicating that patients are undergoing surgery at a more able level and getting better outcomes. The average improvement by surgery decreased from 3.41 logits in 2008 to 3.21 logits in 2018 (p = 0.003).

Over time, patient age decreased from 75 to 74 years (p < 0.001) and the proportion of women decreased from 63.9 to 57.9% (p < 0.001). The mean preoperative visual acuity in both the operated eye and the better eye improved over time (0.47 to 0.40 logMAR, p < 0.001 and 0.22 to 0.19 logMAR, p < 0.001, respectively), as did the mean postoperative visual acuity in the operated eye (0.14 to 0.09 logMAR, p < 0.001).

Conclusions

The Catquest-9SF retained stable psychometric properties over this 11-year period although more recent cohorts included slightly younger patients with somewhat better vision.

Learning Curve and One-Year Outcome of XEN 45 Gel Stent Implantation in a Swedish Population

Purpose

Evaluation of 1-year-outcome of XEN 45 gel stent surgery in a Swedish cohort with regard to clinical success, complications, and learning curve.

Patients and Methods

This was a retrospective study of glaucoma patients undergoing glaucoma XEN-stent surgery alone or combined with phacoemulsification between December 2015 and May 2017. Intraocular pressure (IOP), number of medical agents, and adverse events were assessed. Clinical success rate was defined as achieving individual target pressure with/without medication.

Results

A total of 113 eyes were included in the final statistics. Mean age was 70.8±11.8 years. Primary open angle glaucoma (POAG) accounted for 46.9% and exfoliative glaucoma (PEXG) for 40.7%. Mean preoperative IOP was 23.8±6.2 mmHg and mean number of agents 3.4. After 1 year, mean IOP was reduced to 16.1±4.7 mmHg and medication to 1.34 substances on average. Failure rate at 1-year follow-up was 34% with no significant difference between POAG and PEXG. There was a trend of higher success rate for combined cases (P=0.116). Stents with malpositioned or curved appearance had significantly worse outcome. The failure rate of the most productive surgeon dropped from 33% to 10% from the first implantations. Temporary hypotony (19.5%) and choroidal detachment (9.7%) were the most common complications. Blockage of the inner stent lumen was common (8.8%), with a high proportion of failure.

Conclusion

XEN-stent surgery is a surgical option in uncontrolled glaucoma in both POAG and PEXG. A XEN-stent can reduce both IOP and the number of antiglaucoma medications needed. The learning curve is significant and stent positioning is crucial for optimal results. Combined XEN-cataract surgery is not inferior to stand-alone procedures. The long-time effectiveness is still to be proven.

Neurofilament light chain in the vitreous humor of the eye

BACKGROUND

Neurofilament light chain (NfL) is a promising biomarker of neurodegeneration in the cerebrospinal fluid and blood. This study investigated the presence of NfL in the vitreous humor and its associations with amyloid beta, tau, inflammatory cytokines and vascular proteins, apolipoprotein E (APOE) genotypes, Mini-Mental State Examination (MMSE) scores, systemic disease, and ophthalmic diseases.

METHODS

This is a single-site, prospective, cross-sectional cohort study. Undiluted vitreous fluid (0.5-1.0 mL) was aspirated during vitrectomy, and whole blood was drawn for APOE genotyping. NfL, amyloid beta (Aβ), total Tau (t-Tau), phosphorylated Tau (p-Tau181), inflammatory cytokines, chemokines, and vascular proteins in the vitreous were quantitatively measured by immunoassay. The main outcome measures were the detection of NfL levels in the vitreous humor and its associations with the aforementioned proteins. Linear regression was used to test the associations of NfL with other proteins, APOE genotypes, MMSE scores, and ophthalmic and systemic diseases after adjustment for age, sex, education level, and other eye diseases.

RESULTS

NfL was detected in all 77 vitreous samples. NfL was not found to be associated with ophthalmic conditions, APOE genotypes, MMSE scores, or systemic disease (p > 0.05). NfL levels were positively associated with increased vitreous levels of Aβ40 (p = 7.7 × 10-5), Aβ42 (p = 2.8 × 10-4), and t-tau (p = 5.5 × 10-7), but not with p-tau181 (p = 0.53). NfL also had significant associations with inflammatory cytokines such as interleukin-15 (IL-15, p = 5.3 × 10-4), IL-16 (p = 2.2 × 10-4), monocyte chemoattractant protein-1 (MCP1, p = 4.1 × 10-4), and vascular proteins such as vascular endothelial growth factor receptor-1 (VEGFR1, p = 2.9 × 10-6), Vegf-C (p = 8.6 × 10-6), vascular cell adhesion molecule-1 (VCAM-1, p = 5.0 × 10-4), Tie-2 (p = 6.3 × 10-4), and intracellular adhesion molecular-1 (ICAM-1, p = 1.6 × 10-4).

CONCLUSION

NfL is detectable in the vitreous humor of the eye and significantly associated with amyloid beta, t-tau, and select inflammatory and vascular proteins in the vitreous. Additionally, NfL was not associated with patients' clinical eye condition. Our results serve as a foundation for further investigation of NfL in the ocular fluids to inform us about the potential utility of its presence in the eye.

Vision-related quality of life and visual function in a 70-year-old Swedish population

PURPOSE

To investigate vision-related quality of life (VRQoL), visual function and predictors of poor vision in a population of 70-year-olds.

METHODS

Self-reported ocular morbidity and responses to the National Eye Institute Visual Functioning Questionnaire-25 (NEI VFQ-25) in a cross-sectional population study (N = 1203) in Gothenburg, Sweden, were compared with results from ophthalmic examination (N = 560).

RESULTS

The most common self-reported ophthalmic morbidities were cataract (23.4%), age-related macular degeneration (AMD; 4.7%), glaucoma (4.3%) and diabetic retinopathy (1.4%). Cataract was more prevalent in women (p = 0.001). The composite score from NEI VFQ-25 for the entire cohort was 91.4 (standard deviation: 27.5). When comparing composite score for different eye diseases, persons with cataract or AMD exhibited lower scores (p = 0.029 and 0.018, respectively). Best-corrected visual acuity (BCVA) was normal (≥0.5 decimal) in 98.9%; two individuals had low vision (<0.3). Men exhibited better BCVA (median: -0.08 logMAR) than women (-0.06; p = 0.005). Visual field defects were observed in 16.3% and uncorrected refractive errors in 61.5%. Poor vision was reported by 7.4% of participants with presenting visual acuity (PVA) ≥0.5 (decimal), while 66.7% with PVA <0.5 reported good vision. Of 27 individuals with PVA <0.5, 55.6% obtained a BCVA of ≥1.0 with the right correction. Low contrast sensitivity was a significant predictor of experiencing poor vision (p = 0.008), while PVA and visual field defects were not.

CONCLUSIONS

Low contrast sensitivity is a predictor of experiencing poor vision. There is a discrepancy between subjective/objective visual function and a high prevalence of uncorrected refractive errors. Women have more cataract, and men demonstrate slightly better visual acuity.

A Composite Risk Score for Capsule Complications Based on Data from the Swedish National Cataract Register: Relation to Surgery Volumes

PURPOSE

To investigate case mix in relation to capsule complication, possible associations between case mix and operation volume, and change in case mix over time.

DESIGN

Register-based study.

PARTICIPANTS

Swedish patients who underwent cataract surgery between 2007 and 2016.

METHODS

Demographics and data on ocular comorbidity, intraoperative difficulties, and capsule complications were registered from 2007 to 2016 and analyzed retrospectively in relation to coded data on individual surgeons' operation volume. Single factor analysis and logistic regression were performed, and a composite risk score was created.

MAIN OUTCOME MEASURES

Risk of capsule complication, given as adjusted and composite odds ratio in relation to cataract surgery volume.

RESULTS

Preoperative and intraoperative variables significantly associated with capsule complications were best-corrected visual acuity (BCVA) ≤0.1 (decimal, adjusted odds ratio [aOR], 1.82; P < 0.001); pseudoexfoliation (PEX) (aOR, 1.53; P < 0.001); sight-threatening ocular comorbidity other than age-related macular degeneration (AMD), diabetic retinopathy, glaucoma, or cornea guttata (aOR, 1.35; P = 0.006); use of Trypan blue (aOR, 1.76; P < 0.001); mechanical pupil dilation (aOR, 1.36; P = 0.024); and iris hooks at the rhexis margin (aOR, 6.99; P < 0.001). The composite risk score was 3.09 ± 6.40 (mean ± standard deviation) for patients with capsule complication and 1.28 ± 1.66 for uncomplicated procedures (P < 0.001). High-volume cataract surgeons (≥500 procedures yearly) had a significantly lower composite risk score (mean risk score ≤1.28; range, 1.01-2.02) compared with low- and medium-volume cataract surgeons (1.34 ± 0.56; range, 1.00-4.55 and 1.49 ± 0.58; range, 1.01-5.19), respectively. During the period 2007-2016, the proportion of patients aged >88 years, patients with BCVA ≤0.1, and patients with intraoperative difficulties decreased.

CONCLUSIONS

Case mix, as calculated from a composite risk score based on preoperative and intraoperative parameters registered in the National Cataract Register (NCR), may contribute to the decrease in capsule complications from 2007 to 2016 and the lower complication rate observed in cases managed by high-volume cataract surgeons.

Deep Sequencing of Varicella-Zoster Virus in Aqueous Humor From a Patient With Acute Retinal Necrosis Presenting With Acute Glaucoma

We report a case of acute retinal necrosis presenting with acute glaucoma preceding inflammatory signs by several days. High-throughput sequencing on aqueous humor revealed a low-level diversity in the viral genome comparable to diversity seen in cutaneous vesicles in contrast to high diversity in encephalitis.

Secondary glaucoma and visual outcome after paediatric cataract surgery with primary bag-in-the-lens intraocular lens

PURPOSE

To determine predictors of secondary glaucoma and poor visual outcome in children undergoing cataract surgery with bag-in-the-lens (BIL)-IOL implantation.

METHODS

Medical records were retrospectively analysed for children with primary implantation with BIL-IOL during 2009-2013.

RESULTS

The study included 109 eyes. Median age at surgery was 2.5 years (range 2 weeks-14.1 years), 26.6% being ≤12 weeks of age (= early group). Median follow-up time was 2.8 years (7 months-5.8 years). 15 eyes (13.8%) developed glaucoma, 14 (48.3%) in the early group and 1 (1.3%) in the late group (p < 0.001). Within the early group, mean time for surgery differed significantly. Patients developing glaucoma had cataract surgery at 3.5 ± 1.1 weeks (mean ± SD) and the non-glaucoma patients at 5.7 ± 3.3 weeks (p = 0.024). In the entire cohort, 21 eyes (19.3%) had conditions associated with glaucoma; 57.1% of these developed glaucoma compared to 3.4% without these conditions (p < 0.001). Corrected distance visual acuity (CDVA) (decimal) of ≥0.5 was seen in 50 eyes (48.5%), median 0.63 in the late group and 0.15 in the early group. Glaucoma eyes in the early group (surgery at 3.5 weeks) achieved 0.56 median (range, 0.4-1.0) logMAR, (0.28 decimal) CDVA, whereas non-glaucoma eyes (surgery at 5.7 weeks) achieved 0.89 median (range 0.7-1.6) logMAR (0.13 decimal) CDVA; p = 0.016. Glaucoma development in infants between 5 weeks and 2 years of age was 6.7% (n = 2/30).

CONCLUSIONS

Comorbidity strongly increases the risk of secondary glaucoma. Surgery during the first month is correlated with better CDVA outcome and glaucoma. After 5 weeks of age, glaucoma rate is low with the BIL-IOL.

Visual Function And Quality Of Life In A Cohort Of Swedish Children With Juvenile Idiopathic Arthritis

Purpose

To evaluate quality of life (QoL) in children with juvenile idiopathic arthritis (JIA).

Methods

Forty children with a mean age of 7.9 years were included. The children underwent an ophthalmological examination and completed questionnaires on physical function (CHAQ) and vision-related (VR) QoL (EYE-Q).

Results

No differences regarding visual acuity (VA), refraction, intraocular pressure or physical or VRQoL were found between those with JIA without (n=33) and those with JIA-associated uveitis (n=7). When comparing physical function measured by CHAQ disability index and JIA subtype, a difference was found; children with polyarthritis scored the worst (p=0.0098). Children with subnormal VA scored worse on EYE-Q compared with those with normal VA (p=0.013). We found correlations between duration of JIA and CHAQ disability index (r=-0.42, p=0.0007) and CHAQ well-being (r=-0.34, p=0.022).

Conclusion

This study indicates the importance of measuring not only physical function but also VRQoL in children with JIA and JIA-associated uveitis.

Evaluation of selective laser trabeculoplasty as an intraocular pressure lowering option

PURPOSE

Selective laser trabeculoplasty (SLT) is one of the many treatment options for lowering intraocular pressure (IOP) in patients with glaucoma. This study aimed to evaluate the effect of SLT.

METHODS

Data were collected from medical records of 289 patients who underwent SLT treatment (180° of trabecular meshwork) during 2014 and 2015 at the Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal, Sweden. Baseline characteristics and information from a follow-up within 100 days were also recorded. The study analysed different subtypes of glaucoma with regard to SLT, with a particular focus on exfoliative glaucoma, a common subtype in Sweden. Successful treatment was defined as an IOP lowering effect of >20% with no further changes in treatment. The impact of surgeon's experience on treatment outcome was also analysed.

RESULTS

Both patients with exfoliative glaucoma and those with primary open-angle glaucoma showed a reduction in mean IOP; no significant difference was found between these two subtypes before treatment or at the first follow-up. The success rate at follow-up (within 100 days) was 52%. There was a significant difference in outcome between surgeons with different levels of experience, but this difference could likely be explained by differences in treatment strategies and total energy used.

CONCLUSION

For many patients with glaucoma, SLT was an effective treatment option for lowering IOP. It was also effective for several glaucoma subtypes. However, not all patients had a significant reduction in IOP after treatment with SLT, and some may require additional treatment.

Conclusions from a behavioral aging study on male and female F2 hybrid mice on age-related behavior, buoyancy in water-based tests, and an ethical method to assess lifespan

Due to strain-specific behavioral idiosyncrasies, inbred mouse strains are suboptimal research models for behavioral aging studies. The aim of this study is to determine age-related behavioral changes of F2 hybrid C57BL/6NxBALB/c male and female mice. Lifespan was followed (n_males=48, n_females=51) and cohorts of mature adult (7 months), middle-aged (15 months), and old mice (22 months of age; n=7-12 per group) were assessed regarding open-field activity, exploration, passive avoidance learning/memory, and depressive-like behavior. We found that both males and females demonstrated decreased exploratory behavior with age, while memory and depressive-like behavior were maintained. Females exhibited enhanced depressive-like behavior compared to males; however, a correlation between fat mass and swimming activity in the test directly accounted for 30-46% of this behavioral sex difference. In addition, we suggest a method to qualitatively estimate natural lifespan from survival analyses in which animals with signs of pain or severe disease are euthanized. This is, to our knowledge, the first behavioral study to consider both sex and aging in hybrid mice. We here define decreased exploratory behavior as a conserved hallmark of aging independent of sex, highlight the effect of buoyancy in water tests, and provide a method to assay lifespan with reduced animal suffering.

Myopic shift and lens turbidity following hyperbaric oxygen therapy - a prospective, longitudinal, observational cohort study

PURPOSE

To examine visual acuity, refraction and ocular status before, during and after hyperbaric oxygen therapy (HBOT).

METHODS

Twenty-nine patients underwent 40 standard protocol HBOT treatments. In all subjects, refraction and best corrected visual acuity were measured at baseline and after ten, 20, 30 and 40 treatments, and at a 12-week follow-up. A subgroup (n = 19) were given additional examinations at baseline, after 40 treatments and at follow-up including measuring central corneal thickness (CCT), corneal curvature, anterior chamber depth, lens thickness, axial length, fundus morphology, blood pressure and intraocular pressure (IOP). Lens colour and opalescence were graded using the Lens Opacities Classification System III (LOCS III).

RESULTS

Myopic shifts [≥0.5 dioptre (D) spherical equivalent (SE)] occurred in 45 (77.6%) eyes. Median refractive changes of -0.75 D SE (right eye; p < 0.001) and -0.66 D SE (left eye; p < 0.001) were observed between pretreatment and treatment end (Wilcoxon signed rank test). Refraction returned to baseline at follow-up, except for a small persisting change towards myopia, median -0.25 D SE (left eye; p = 0.01). Using the LOCS III, median increases in lens nuclear colour, of 0.6 (right eye; p < 0.001) and 0.7 (left eye; p < 0.001), and opalescence of 0.7 (both eyes; p = 0.01) were found at the last examination. Small reductions were noted in CCT of -6.00 μm (right eye; p = 0.03) and -4.00 μm (left eye; p = 0.03), and IOP of -1.50 mmHg (left eye; p = 0.01).

CONCLUSIONS

The transient myopic shift may have been due to lenticular refractive index changes. Reduced lens transparency is a potential consequence of HBOT.

Alpha herpes virus type and viral load in intraocular fluids in patients with acute retinal necrosis

Objectives

To identify all patients tested positive for herpes viruses in intraocular samples between 2007 and 2016 in South-Western Sweden and evaluate which of these met the criteria of acute retinal necrosis (ARN). To compare viral load in intraocular samples and virus type with clinical outcome.

Method and analysis

Retrospective case series. Intraocular samples and serum were analysed with quantitative real-time PCR (qPCR) and presence of antibodies (IgG and IgM) were detected by ELISA in serum.

Results

Between 2007 and 2016, 13 patients met the clinical criteria of ARN and were PCR-positive in aqueous or vitreous for herpes simplex virus 1 (HSV1; n=4), herpes simplex virus 2 (HSV2; n=3) and varicella zoster virus (VZV; n=6). None of the patients tested positive for cytomegalovirus (n=13) or Epstein Barr virus (n=2) met the criteria of ARN. All ARN patients had specific serum IgG and three patients exhibited virus DNA in serum. There was no correlation between high viral load and worse visual outcome. However, higher viral loads were seen in samples taken earlier in the disease process. Median age was higher (p=0.049) in VZV-ARN than for HSV-ARN patients (60.5 and 45.4 years, respectively) with a tendency of worse best corrected visual acuity at presentation (1.62 and 0.79 log MAR, respectively; p=0.079).

Conclusion

ARN is a reactivation of alpha herpes virus and presence of herpes DNA in serum may occur. VZV-ARN are older than HSV-ARN patients. High viral load does not appear to be a predictor of worse visual outcome, but rather indicates earlier sampling.

Does retinopathy predict stroke recurrence in type 2 diabetes patients: A retrospective study?

AIMS

To study if retinopathy increases the risk of stroke recurrence in stroke patients with type 2 diabetes. Also, to study if stroke patients with type 2 diabetes have an increased risk of stroke recurrence compared to non-diabetics and if stroke patients with type 2 diabetes, regardless of retinopathy, have a higher incidence of carotid stenosis. Also, to study if stroke patients with type 2 diabetes retinopathy have increased incidence of carotid stenosis.

METHODS

We included 445 patients with type 2 diabetes mellitus and a matched control group of 445 patients without diabetes, who had all suffered their first stroke or TIA. Information on retinopathy, risk factors and stroke recurrence were obtained from registers and medical records.

RESULTS

Retinopathy did not increase the risk of stroke recurrence in diabetes patients, HR 0.89 (0.51-1.53), p = 0.67. The risk of stroke recurrence was not increased in diabetics compared to non-diabetes. Diabetes patients had an increased prevalence of carotid stenosis compared to non-diabetics, 1.69 (1.15-2.48), p = 0.008. The prevalence of carotid stenosis in diabetics with retinopathy was not increased compared to diabetics without retinopathy.

CONCLUSION

Retinopathy is not a predictor of stroke recurrence or carotid stenosis in type 2 diabetes patients.

The Gothenburg H70 Birth cohort study 2014-16: design, methods and study population

To improve health care for older persons, we need to learn more about ageing, e.g. identify protective factors and early markers for diseases. The Gothenburg H70 Birth Cohort Studies (the H70 studies) are multidisciplinary epidemiological studies examining representative birth cohorts of older populations in Gothenburg, Sweden. So far, six birth cohorts of 70-year-olds have been examined over time, and examinations have been virtually identical between studies. This paper describes the study procedures for the baseline examination of the Birth cohort 1944, conducted in 2014–16. In this study, all men and women born 1944 on specific dates, and registered as residents in Gothenburg, were eligible for participation (n = 1839). A total of 1203 (response rate 72.2%; 559 men and 644 women; mean age 70.5 years) agreed to participate in the study. The study comprised sampling of blood and cerebrospinal fluid, psychiatric, cognitive, and physical health examinations, examinations of genetics and family history, use of medications, social factors, functional ability and disability, physical fitness and activity, body composition, lung function, audiological and ophthalmological examinations, diet, brain imaging, as well as a close informant interview, and qualitative studies. As in previous examinations, data collection serves as a basis for future longitudinal follow-up examinations. The research gained from the H70 studies has clinical relevance in relation to prevention, early diagnosis, clinical course, experience of illness, understanding pathogenesis and prognosis. Results will increase our understanding of ageing and inform service development, which may lead to enhanced quality of care for older persons.

PA28αβ overexpression enhances learning and memory of female mice without inducing 20S proteasome activity

Background

The proteasome system plays an important role in synaptic plasticity. Induction and maintenance of long term potentiation is directly dependent on selective targeting of proteins for proteasomal degradation. The 20S proteasome activator PA28αβ activates hydrolysis of small nonubiquitinated peptides and possesses protective functions upon oxidative stress and proteinopathy. The effect of PA28αβ activity on behavior and memory function is, however, not known. We generated a mouse model that overexpresses PA28α (PA28αOE) to understand PA28αβ function during healthy adult homeostasis via assessment of physiological and behavioral profiles, focusing on female mice.

Results

PA28α and PA28β protein levels were markedly increased in all PA28αOE tissues analyzed. PA28αOE displayed reduced depressive-like behavior in the forced swim test and improved memory/learning function assessed by intersession habituation in activity box and shuttle box passive avoidance test, with no significant differences in anxiety or general locomotor activity. Nor were there any differences found when compared to WT for body composition or immuno-profile. The cognitive effects of PA28αOE were female specific, but could not be explained by alterations in estrogen serum levels or hippocampal regulation of estrogen receptor β. Further, there were no differences in hippocampal protein expression of neuronal or synaptic markers between PA28αOE and WT. Biochemical analysis of hippocampal extracts demonstrated that PA28α overexpression did not increase PA28–20S peptidase activity or decrease K48-polyubiquitin levels. Instead, PA28αOE exhibited elevated efficiency in preventing aggregation in the hippocampus.

Conclusions

This study reveals, for the first time, a connection between PA28αβ and neuronal function. We found that PA28α overexpressing female mice displayed reduced depressive-like behavior and enhanced learning and memory. Since the positive effects of PA28α overexpression arose without an activation of 20S proteasome capacity, they are likely independent of PA28αβ’s role as a 20S proteasome activator and instead depend on a recognized chaperone-like function. These findings suggest that proteostasis in synaptic plasticity is more diverse than previously reported, and demonstrates a novel function of PA28αβ in the brain.

Electronic supplementary material

The online version of this article (10.1186/s12868-018-0468-2) contains supplementary material, which is available to authorized users.

Toric IOL implantation in a patient with keratoconus and previous penetrating keratoplasty: a case report and review of literature

BACKGROUND

Cataract surgery in patients with keratoconus with or without previous penetrating keratoplasty (PKP) can be demanding due to difficulties in selecting the intraocular lens (IOL) and predicting the refractive outcome. We report a case of cataract surgery in a patient with keratoconus and previous PKP in one eye.

CASE PRESENTATION

A 71-year-old man with bilateral cataract and advanced bilateral keratoconus and previous PKP in the left eye. Preoperatively, best corrected visual acuity (BCVA) was 20/150, with - 5.75 sph - 9.75 cyl 72°, in the right eye and 20/40, with - 0.25 sph - 5.0 cyl 50°, in the left eye. The patient was subjected to phacoemulsification with implantation of a spherical IOL in the right eye and a toric IOL in the left eye. BCVA postoperatively was 20/80 with + 1.25 sph - 3 cyl 65° in the right eye and 20/25 with - 0.5 sph - 3.25 cyl 80° in the left eye.

CONCLUSIONS

Correction of post-PKP astigmatism and cataract with phacoemulsification and implantation of a toric IOL can be an effective and safe choice. Predicting the refractive outcome in cataract surgery is difficult in patients with advanced keratoconus even when using non-toric IOLs, and the surgeon should be aware of different sources of biometric errors and the possible consequences.

Implantation of toric intraocular lenses in patients with cataract and keratoconus: a case series

Purpose

To describe the results of phacoemulsification and implantation of toric intraocular lenses (IOLs) in patients with cataract and keratoconus.

Patients and methods

Prospective study of 4 patients (4 eyes) with cataract and keratoconus who underwent phacoemulsification with implantation of a toric IOL. Two different toric IOLs were used: AcrySof IQ SN6AT9 and AT Torbi 709M(P). Corneal tomography was performed preoperatively using Scheimpflug technique with Pentacam. Astigmatism was regular or slightly irregular in all patients. Postoperatively, best-corrected visual acuity (BCVA), astigmatism, spherical equivalent, and complications were recorded for all patients. Follow-up time was between 4 weeks and 7 months.

Results

BCVA increased and astigmatism decreased in all patients. BCVA increased from 20/50 to 20/40 in patient 1, from 20/63 to 20/20 in patient 2, from 20/40 to 20/32 in patient 3, and from hand motion to 20/40 in patient 4. Astigmatism decreased from −6.12 to −3.75 D in patient 1, from −4.62 to −1.75 D in patient 2, from −9.0 to −3.0 D in patient 3, and from −8.0 to −2.75 D in patient 4. One patient developed pseudophakic cystoid macular edema, but at last follow-up after 6 months the edema had resolved. Another patient developed posterior capsular opacification after 2 months. No misalignment of the axis of the IOL was observed.

Conclusion

Correction of both astigmatism and cataract with phacoemulsification and implantation of a toric IOL can be an effective and safe choice for patients with cataract and keratoconus. However, predicting the refractive outcome in cataract surgery is difficult in patients with keratoconus, and the surgeon should be aware of different sources of biometric errors and the possible consequences.

Phacoemulsification and primary implantation with bag-in-the-lens intraocular lens in children with unilateral and bilateral cataract

PURPOSE

To report outcome in a paediatric cohort with cataract extraction and implantation of bag-in-the-lens intraocular lens (BIL-IOL).

METHODS

Children younger than 16 years of age subjected to phacoemulsification with primary implantation of BIL-IOL during 2009 through 2013 were analysed retrospectively. Exclusion criteria were uveitis or ≤6 months of follow-up.

RESULTS

In total, 109 eyes of 84 children were included; 40 unilateral and 44 bilateral cataracts. For all eyes, median age at surgery was 2.5 years (range 2 weeks to 14.1 years) and 16 children (24 eyes) were ≤6 weeks. Coexisting systemic disease was more common in children with bilateral cataract (24 patients, 54.5%) compared to unilateral cataract (6 patients, 15.0%, p < 0.0001). Ocular comorbidity was more common in unilateral cataracts; n = 14 eyes (35.0%) compared to bilateral cataracts; n = 10 eyes (14.5%; p = 0.017). Median follow-up was 2.8 years (range 7 months to 5.8 years). During the follow-up period, 15 (13.8%) eyes developed glaucoma and five (4.6%) eyes required treatment for visual axis opacification (VAO). Corrected distance visual acuity (CDVA) for bilateral cataracts at last follow-up was 0.42 ± 0.45 (logMAR; mean±SD) with 35 (55.6%) eyes attaining a CDVA of ≥0.5 (dec). For unilateral cataracts mean CDVA was significantly poorer; 0.67 ± 0.51 (p = 0.010) with 15 (37.5%) eyes attaining a CDVA of ≥0.5.

CONCLUSION

For children having cataract surgery with primary implantation of BIL-IOL, VAO is rare and visual outcome overall good. Unilateral cataracts are associated with a higher proportion of ocular comorbidity and poorer visual outcome.