Anders Behndig

One million cataract surgeries: Swedish National Cataract Register 1992-2009.

This review summarizes data collected by the Swedish National Cataract Register, which now contains data pertaining to more than a million cataract surgery procedures, representing 95.6% of the surgeries performed in Sweden during 1992-2009. During this period, the rate of cataract surgery rose from 4.47 to 9.00 per 1000 inhabitants. The mean patient age increased until 1999 but has slowly decreased since then. Preoperative visual acuity has risen steadily. The distribution between the sexes was stable until 2000, after which the proportion of women slowly decreased. Registration of subjective benefit has brought new knowledge regarding indications and expectations. An improved questionnaire, Catquest-9SF has been used since 2008. The outcome register generally shows good results from the surgery. Endophthalmitis has decreased from 0.10% to below 0.040%.

Intracameral mydriatics in phacoemulsification cataract surgery.

Purpose: To evaluate intracameral injection of mydriatics in phacoemulsification cataract surgery and compare the results with those of conventional topical mydriatics. Setting: Department of Clinical Science/Ophthalmology, Umeå University Hospital, Umeå, Sweden. Methods: This prospective randomized double‐blind study included 60 patients who were given topical (topical group) or intracameral (intracameral group) mydriatics. The topical mydriatics comprised 3 drops of cyclopentolate 1% and phenylephrine 10% given 15 minutes apart and 150 &mgr;L intracameral lidocaine hydrochloride 1% (Xylocaine®) and the intracameral mydriatics, placebo eyedrops and 150 &mgr;L intracameral cyclopentolate 0.1%, phenylephrine 1.5%, and Xylocaine 1%. The pupil size was recorded preoperatively, throughout surgery, and 1 day and 1 month postoperatively. Preoperative and postoperative corneal endothelial morphology, corneal thickness, intraocular pressure, visual acuity, aqueous cells and flare, phacoemulsification energy, duration of surgery, pulse, blood pressure, and intraoperative sensation of pain and glare were also recorded. Results: With intracameral mydriatics, mydriasis reached 95% ± 3% (SD) of its final value within 20 seconds. In the intracameral group, the pupils were smaller than in the topical group (mean 6.7 ± 1.0 mm versus 7.7 ± 1.0 mm, P<.001) but did not contract intraoperatively. The pupils in the topical group tended to contract, and the difference between groups was significant (P = .0020). The intracameral group reported less glare during the procedure (P<.001). There was no difference in endothelial cell loss, inflammatory reaction, postoperative corneal swelling, or surgical performance between the groups. Conclusions: Intracameral mydriatics were a rapid, effective, and safe alternative to topical mydriatics in phacoemulsification. Their use can simplify preoperative routines and in certain high‐risk groups, may reduce the risk for cardiovascular side effects.

Aiming for emmetropia after cataract surgery: Swedish National Cataract Register study

PURPOSE: To assess and analyze refractive outcome after cataract surgery in Sweden from 2008 though 2010. SETTING: Swedish cataract surgery units participating in outcome registration of National Cataract Register. DESIGN: Cohort study. METHODS: Planned and actual postoperative refractions were analyzed for cataract procedures and preoperative and postoperative corneal astigmatism for procedures performed in 2008 though 2010. Induced astigmatism was calculated with Naeser and Behrens polar coordinates. RESULTS: Postoperative refraction was analyzed for 17 056 procedures and corneal astigmatism for 7448 procedures. Emmetropia was targeted in 78.1% of eyes and achieved in 52.7%; 43.0% had less than 1.00 diopter (D) of astigmatism. “Reading myopia” of −3.5 to −1.6 D was targeted in 7.0% of eyes and achieved in 7.8%. Planned hyperopia greater than 1.0 D or myopia greater than −3.5 D was rare. The mean absolute biometry prediction error was 0.402 D ± 0.338 (SD) in all eyes; however, astigmatic eyes and eyes planned for myopia or hyperopia had higher biometry prediction errors. Younger patients were more often astigmatic and planned for a more myopic outcome. Preoperatively, one third of eyes had more than 1.0 D of corneal astigmatism; postoperatively this figure was largely unaltered. The mean induced astigmatism was 0.525 ± 0.804 D in all eyes. CONCLUSIONS: Emmetropia (spherical equivalent −0.5 to +0.5 D and <1.0 D astigmatism) is the goal in most cataract cases but was reached in only 55% of eyes planned for emmetropia. Factors precluding emmetropia included remaining corneal astigmatism and biometry prediction errors in astigmatic and ametropic eyes. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Visual and optical performance of the akreos adapt advanced optics and tecnis Z9000 intraocular lenses - Swedish multicenter study

PURPOSE: To compare the subjective visual and objective optical performance of 2 aspherical intraocular lenses (IOLs), the Akreos Adapt Advanced Optics (AO) (Bausch & Lomb, Inc.) and the Tecnis Z9000 (Advanced Medical Optics, Inc.). SETTING: Four university hospitals in Sweden. METHODS: This study comprised 80 patients, 20 each from 4 university hospital centers in Sweden. All patients had bilateral clear corneal phacoemulsification with implantation of an Akreos Adapt AO IOL in 1 eye and Tecnis Z9000 IOL in the other eye according to a randomization protocol. Preoperatively, 90% contrast Early Treatment Diabetic Retinopathy Study (ETDRS) visual acuity was measured and the mesopic pupil sizes were determined. Ten to 12 weeks postoperatively, 12.5% and 90% contrast ETDRS visual acuities and photopic and mesopic Functional Acuity Contrast Test chart contrast sensitivities were determined. Wavefront analysis was performed with the Zywave II aberrometer (Bausch & Lomb, Inc.), and a questionnaire on the subjective quality of vision was completed by each patient. RESULTS: The Akreos AO IOL and Tecnis Z9000 IOL produced similar high‐ and low‐contrast visual acuities as well as photopic and mesopic contrast sensitivities. The Tecnis Z9000 IOL resulted in lower spherical aberrations of the eye (mean 0.05 ± 0.13 μm versus 0.35 ± 0.13 μm root mean square, 6.0 mm pupil) (P<.001); however, the Akreos AO IOL provided a larger depth of field (mean 1.22 diopter [D] ± 0.48 [SD] versus 0.86 ± 0.50 D, 6.0 mm pupil) (P<.001). Patient satisfaction was generally high, although 68.8% of the patients reported some type of visual disturbance postoperatively. Twenty‐eight percent of patients reported better subjective visual quality in the Akreos AO eye and 14%, in the Tecnis Z9000 eye (P<.0001). Accordingly, 33% perceived more visual disturbances in the Tecnis Z9000 eye and 11%, in the Akreos AO eye (P<.0001). CONCLUSIONS: Maximum reduction of spherical aberration did not maximize subjective visual quality. The higher perceived quality of vision with the Akreos AO IOL could be because of differences in depth of field, IOL material, or IOL design.

Capsule complication during cataract surgery: Case-control study of preoperative and intraoperative risk factors : Swedish Capsule Rupture Study Group report 2

PURPOSE: To identify preoperative and intraoperative factors associated with a capsule complication; that is, a capsule tear or a zonular dehiscence during cataract surgery. SETTING: Ten ophthalmic surgery departments in Sweden. METHODS: A retrospective review of files of patients with a capsule complication and control patients with no complication operated on in 2003 was performed. RESULTS: The review comprised 324 patients with a capsule complication and 331 control patients. In the logistic regression analyses, preoperative conditions associated with a capsule complication were previous trauma, white and brunescent/hard cataract, and phacodonesis. The intraoperative factors of loose zonules, the use of trypan blue, and miosis were all statistically significantly overrepresented in the capsule complication group. The same was true for eyes operated on by surgeons with the least experience. CONCLUSIONS: By preoperatively identifying cataract cases with the identified risk factors and allocating them to surgeons with the longest experience, the number of capsule complications could be kept low. Operating early in the course of the disease to prevent the cataract from becoming a poor surgical risk and improving training of junior surgeons should further reduce the frequency of capsule complications.

Endophthalmitis prophylaxis in cataract surgery: overview of current practice patterns in 9 European countries.

Data on practice patterns for prophylaxis against infectious postoperative endophthalmitis (IPOE) during cataract surgery in 9 European countries were searched in national registers and reviews of published surveys. Summary reports assessed each nations IPOE rates, nonantibiotic prophylactic routines, topical and intracameral antibiotic use, and coherence to the European Society of Cataract & Refractive Surgeons (ESCRS) 2007 guidelines. Although the reliability and completeness of available data vary between countries, the results show that IPOE rates differ significantly. Asepsis routines with povidone-iodine and postoperative topical antibiotics are generally adopted. Use of preoperative and perioperative topical antibiotics as well as intracameral cefuroxime varies widely between and within countries. Five years after publication of the ESCRS guidelines, there is no consensus on intracameral cefuroxime use. Major obstacles include legal barriers or persisting controversy about the scientific rationale for systematic intracameral cefuroxime use in some countries and, until recently, lack of a commercially available preparation.

Decreasing rate of capsule complications in cataract surgery: eight-year study of incidence, risk factors, and data validity by the Swedish National Cataract Register.

PURPOSE: To define the incidence of capsule complication and its risk factors in Sweden over an 8‐year period. SETTING: Fifty‐two ophthalmic surgery units in Sweden. DESIGN: Database study. METHODS: Data were collected prospectively in the Swedish National Cataract Register (NCR) from 2002 through 2009. The NCR contains 97.3% of the total number of cataract extractions in Sweden over the 8‐year study period. One mandatory variable in the register is capsule complications during surgery. As a means to validate the accuracy of register data on capsule complications, a randomly selected sample of 2400 registrations was compared with corresponding medical records. RESULTS: The analyses were based on 602 553 cataract extractions reported to the NCR. A capsule complication was reported in 12 574 cataract extractions, corresponding to a frequency of 2.09%. The incidence of this complication consistently decreased each year from 2002 to 2006, after which it stabilized. Poor corrected distance visual acuity in the surgical eye (≤ 0.1), the occurrence of glaucoma, diabetic retinopathy, and age were among the parameters significantly related to a capsule complication. Some of these parameters also decreased over time. However, even after adjusting for this, there was an obvious decrease in capsule complications over time. The validity test showed a certain underreporting of capsule complications to the registry, but it was not significant and did not change over time. CONCLUSION: The incidence of capsule complications decreased over time. This may be partly the result of fewer risk factors and of better surgical quality. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Impact on visual function from light scattering and glistenings in intraocular lenses, a long‐term study

Purpose:  To investigate the impact on visual function from light scattering and glistenings in intraocular lenses (IOLs) in patients who had cataract surgery 10 years previously.

transient corneal edema after phacoemulsification: comparison of 3 viscoelastic regimens ☆

Purpose: To evaluate the effect of different viscoelastic substances on the grade and time course of postoperative corneal edema. Setting: Department of Clinical Sciences/Ophthalmology, Umeå University Hospital, Umeå, Sweden. Methods: This study comprised 62 patients with otherwise healthy eyes who had routine phacoemulsification and intraocular lens (IOL) implantation. Patients were divided into 3 groups. Group 1 was given Healon GV® (sodium hyaluronate 1.4%) at phacoemulsification and IOL implantation. Group 2 was given Viscoat® (sodium hyaluronate 3.0%–chondroitin sulfate 4.0%) at phacoemulsification and Healon GV at IOL implantation. Group 3 was given Viscoat at phacoemulsification and Provisc® (sodium hyaluronate 1.0%) at lens implantation. The central corneal thickness was measured with ultrasonic pachymetry before surgery and 5 and 24 hours, 1 week, and 1 month after surgery. Results: The mean increase in corneal thickness was significantly greater in Group 1 than in the other 2 groups 5 and 24 hours and 1 week after surgery. Conclusions: The transient postoperative increase in central corneal thickness was greater in patients receiving Healon GV during phacoemulsification than in patients receiving Viscoat. The use of Provisc or Healon GV for IOL implantation did not affect the postoperative corneal thickness when Viscoat was used for phacoemulsification. The time course of the edema may be explained by a difference between the 2 agents in endothelial protection from ultrasonic, mechanical, or irrigation trauma.

In vitro photochemical cataract in mice lacking copper-zinc superoxide dismutase.

We here evaluate cataract formation in mice lacking the cytosolic copper-zinc superoxide dismutase (CuZn-SOD) in an in vitro model using irradiation with visible light and riboflavin as a photosensitizing agent. Isolated, cultured lenses from wild-type and CuZn-SOD-null mice were irradiated for 1.5 h by a daylight fluorescent light after preincubation with 10 microM riboflavin for 24 h. Cataract formation was evaluated daily with digital image analysis and ocular staging, and after 5 d 86Rb uptake and water contents of the lenses were determined. Basal superoxide concentrations in freshly isolated lenses from wild-type and CuZn-SOD-null mice were determined with lucigenin-derived chemiluminescense, and enzymatic activities of all three SOD isoenzymes in the murine lens were determined with a direct spectrophotometric method. The cytosolic CuZn-SOD accounts for 90% of the total SOD activity of the murine lens. CuZn-SOD-null lenses showed a doubled basal superoxide concentration, and were more prone to develop photochemical cataract in the present model with more opacification, more hydration, and less 86Rb uptake than lenses from wild-type mice. We conclude that CuZn-SOD is an important superoxide scavenger in the lens, and that it may have a protective role against cataract formation.