Charlotta Zetterström

Prophylactic intracameral cefuroxime: Evaluation of safety and kinetics in cataract surgery

Purpose: To evaluate the safety and kinetics of prophylactic intracameral cefuroxime in cataract surgery. Setting: Department of Ophthalmology, St. Eriks Hospital, Stockholm, Sweden. Methods: In a nonrandomized observer‐masked best‐case trial, the visual rehabilitation and the evolution of laser flare intensity and corneal endothelial cell density after cataract surgery were assessed in 45 patients receiving intracameral cefuroxime and in 45 control patients. Immunoglobulin E‐mediated sensitivity was evaluated using a skin prick test to cefuroxime in a screening program comprising all cataract patients operated on in 1997. Intracameral concentrations of cefuroxime in samples retrieved 30 seconds (n = 10) and 1 hour (n = 9) postoperatively were evaluated in an observer‐masked fashion with a microbiological assay. Results: Intracameral cefuroxime did not have a statistically significant effect on postoperative visual acuity, induced laser flare intensity, or endothelial cell loss compared with nonadministration of intracameral antibiotic prophylaxis. Three positive skin prick tests to cefuroxime were found in the 5813 screened cataract patients. The median aqueous humor concentration of cefuroxime at 30 seconds was 2742 mg/L, declining to 756 mg/L 1 hour after drug instillation. Conclusions: Intracameral cefuroxime 1 mg appears safe in terms of local toxicity. Immunoglobulin E‐mediated allergy to cefuroxime is rare in the cataract population. The treatment achieved high aqueous concentrations even 1 hour after surgery.

Cataracts in children.

&NA; Bilateral congenital cataract is the most common cause of treatable childhood blindness. Nuclear cataract is usually present at birth and is nonprogressive, whereas lamellar cataract usually develops later and is progressive. Surgery must be performed promptly in cases with dense congenital cataract; if nystagmus has developed, the amblyopia is irreversible. A treatment regimen based on surgery within 2 months of birth combined with prompt optical correction of the aphakia and aggressive occlusion therapy with frequent follow‐up has been successful in unilateral and bilateral cases. Both anterior and posterior capsulorhexes are performed in most children. Intraocular lens implantation can be performed safely in children older than 1 year. Anterior dry vitrectomy is recommended in preschool children to avoid after‐cataract. Opacification of the visual axis is the most common complication of cataract surgery in children. Secondary glaucoma is the most sight‐threatening complication and is common if surgery is performed early. Life‐long follow‐up is essential in these cases.

Comparison of endothelial cell loss and phacoemulsification energy during endocapsular phacoemulsification surgery

Abstract We counted central corneal endothelial cells and measured corneal thickness in 64 human eyes before and three months after cataract extraction and posterior chamber lens implantation. Cataract surgery was the same in all patients and included capsulorhexis and posterior chamber phacoemulsification of the nucleus. Total phacoemulsification energy and time were recorded. A heparin‐surface‐modified intraocular lens or a regular poly(methyl methacrylate) lens, both having the same design and a 5.0 mm optic, was implanted in the capsular bag with the aid of sodium hyaluronate (Healon®). Mean endothelial cell loss was 4%. However, the change in cell density did not correlate with the total phacoemulsification energy used during surgery. Three months after surgery, the central corneal thickness was the same as it had been preoperatively. The results suggest that phacoemulsification in the posterior chamber is a safe procedure even in cases with a hard nucleus.

Cataract surgery in children with capsulorhexis of anterior and posterior capsules and heparin-surface-modified intraocular lenses

Abstract Cataract surgery was performed in 21 eyes in 14 children (one to 12 years, 5.6 ± 4.0 [mean ± SD]). Cataract surgery was standardized and included capsulorhexis of the anterior capsule, irrigation/aspiration of the nucleus and cortex, puncture of the posterior capsule, injection of sodium hyaluronate (Healon GV®, 14 mg/ml) between the posterior capsule and the vitreous, and capsulorhexis of the posterior capsule. At the end of the procedure, a heparin‐surface‐modified (HSM) poly(methyl methacrylate) intraocular lens (IOL) was implanted in the capsular bag. Follow‐up ranged from four to 16 months. No complications such as the appearance of vitreous in the anterior chamber occurred during surgery. A mild postoperative inflammation was seen in all cases. Opacification of the visual axis was seen in one eye ten months after surgery. Posterior synechial formation was seen in one eye. Our results suggest that capsulorhexis of the anterior and posterior capsules with implantation of an HSM IOL in the capsular bag is a safe procedure in children and produces good postoperative results.

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.

Sulcus fixation without capsular support in children

PURPOSE To evaluate long-term follow-up in eyes of children who had sulcus fixation of an intraocular lens (IOL) without capsular support. SETTING St. Eriks Eye Hospital/Karolinska Institute, Stockholm, Sweden. METHODS This retrospective study included 21 eyes of 13 children. Seven eyes had Marfans syndrome, 7 essential lens dislocation, 2 perforation with lens injury, and 5 spherophakia. The IOL implantation was primary in 16 eyes and secondary in 5 eyes. Lensectomy was performed with a limbal approach. An IOL with holes in the haptics was sutured in the sulcus, with the knots buried in the scleral bed. RESULTS Mean patient age was 5.8 years +/- 2.6 (SD). Follow-up ranged from 9 to 33 months. No complications occurred during surgery. In all cases after IOL implantation, best corrected visual acuity was equal to or better than preoperatively. After surgery, no opacification of the visual axis, secondary glaucoma, or retinal complication was recorded. Posterior synechia formation occurred in 4 eyes, and 4 had cells on the IOL surface in 2 eyes, the IOL optic subluxated into the anterior chamber with the haptics in place. Both cases were successfully treated with pilocarpine 4%. CONCLUSION Our results suggest that sulcus fixation of an IOL without capsular support is an option to correct aphakia in children.

Visual outcome after phacoemulsification and IOL implantation in diabetic patients

AIMS To follow visual acuity (VA) and progression of diabetic retinopathy (DR) after phacoemulsification in diabetic patients with different stages of DR and controls. METHODS This prospective study included 27 diabetic patients with no or mild to moderate non-proliferative DR; 25 patients with moderate to severe non-proliferative, or proliferative DR; and 22 non-diabetic controls. All patients underwent uncomplicated, phacoemulsification surgery, with implantation of a heparin-surface modified (HSM) poly(methylmethacrylate) (PMMA) intraocular lens (IOL) into the capsular bag. Colour fundus photographs and fluorescein angiograms (FA) were taken at 1 week (baseline), 3 months, and 1 year postoperatively to determine stability or progression of DR. RESULTS The VA of 46 diabetic eyes (88%), was improved 1 year after surgery and only six eyes (12%) were unchanged or worse. 41 diabetic eyes (79%) achieved a VA of 0.5 or better and 11 eyes (21%) had a final VA lower than 0.5. Significantly lower final corrected VA was found 1 year after surgery in eyes with advanced DR (median 0.5; range 0.1–1.0) compared with controls (1.0; 0.1–1.0) and eyes with no or mild to moderate DR (1.0; 0.1–1.0). Eyes with mild to moderate DR and clinically significant macular oedema (CSMO) 1 week postoperatively had a lower final VA than those without CSMO. Angiographic cystoid macular oedema (CMO) was detected with FA in 15% of all diabetic eyes 1 week postoperatively. 41 eyes (79%) showed no change or improvement of the retinal status 1 year after cataract surgery. Progression was found in 11 eyes (21%), mainly in eyes with mild to moderate DR and moderate to severe DR. Eyes with an indication for laser photocoagulation at baseline showed a significantly higher rate of progression of DR after surgery than those without indication for laser treatment. CONCLUSION The final visual outcome was improved in the majority of diabetic eyes. Eyes with CSMO at the time of surgery had the worst prognosis regarding postoperative VA.

Cataract extraction and intraocular lens implantation in children with uveitis

AIM To evaluate the long term results of cataract surgery with intraocular lens implantation (IOL) in children with uveitis. METHODS The study included 10 eyes in seven children (age 3.5–10 years, mean 6.5 years). The cataract surgery included capsulorhexis of the anterior and the posterior capsule, anterior vitrectomy in some eyes, and implantation of a heparin surface modified (HSM) poly(methyl methacrylate) (PMMA) IOL into the capsular bag. RESULTS Follow up periods ranged from 1 to 5 years. Best corrected visual acuity after surgery reached 20/50–20/20 in all but two eyes. Opacities or membranes requiring reoperation developed in seven eyes. Glaucoma developed in three eyes after the cataract operation. CONCLUSION These results suggest that implantation of a HSM PMMA IOL is an alternative to correct aphakia also in children with uveitis.

Posterior capsule opacification after phacoemulsification in patients with diabetes mellitus

PURPOSE To compare posterior capsule opacification (PCO) after phacoemulsification and implantation of heparin-surface-modified (HSM) poly(methyl methacrylate) (PMMA) intraocular lenses (IOLs) in the capsular bag in patients with diabetes mellitus with that in a control group. SETTING St. Eriks Eye Hospital, Stockholm, Sweden. METHODS This prospective study comprised 26 patients with diabetes mellitus and 26 control patients without diabetes. Those with glaucoma, exfoliation syndrome, uveitis, and pupil size smaller than 6.0 mm after dilation were excluded. All patients received the same standardized phacoemulsification procedure with implantation of an HSM PMMA IOL in the capsular bag. Posterior capsule opacification was scored 1 and 2 years after surgery by evaluating retroillumination images taken with a Scheimpflug camera (Nidek Anterior Eye Segment Analysis System) after pupil dilation with phenylephrine 10% and cyclopentolate 1%. The PCO density behind the IOL optic was graded clinically from 0 to 4 (0 = none, 1 = minimal, 2 = mild, 3 = moderate, 4 = severe) and scored using the Evaluation of Posterior Capsule Opacification medical software developing system. RESULTS No differences in PCO were found between the diabetic and control groups 1 year after surgery. The total PCO score was significantly less in diabetic than in control eyes 2 years after surgery (P < .05, Mann-Whitney). In addition, progression of PCO from 1 year to 2 years after surgery was significantly less in diabetic groups with different stages of diabetic retinopathy than in the control group (P < or = .05, Kruskal-Wallis analysis of variance and multiple comparisons). CONCLUSION The rate of PCO after phacoemulsification was statistically significantly lower in patients with diabetes mellitus than in those without diabetes.

Posterior capsule opacification: Comparison of 3 intraocular lenses of different materials and design

Purpose: To compare posterior capsule opacification (PCO) after cataract surgery with implantation of 3 intraocular lenses (IOLs) of different materials and design. Setting: St. Eriks Eye Hospital, Stockholm, Sweden. Methods: In this prospective clinical study, 180 patients had standardized phacoemulsification performed by a single surgeon and were randomized to have implantation of a heparin‐surface‐modified (HSM) poly(methyl methacrylate) (PMMA) IOL (809C, Pharmacia & Upjohn), a silicone IOL (SI‐40NB, Allergan), or an acrylic IOL (AcrySof® MA60BM, Alcon). To morphologically evaluate PCO, retroillumination photographs were obtained and analyzed using Evaluation of Posterior Capsule Opacification computer software. The neodymium:YAG (Nd:YAG) capsulotomy rate was recorded. Results: After 2 years, the HSM PMMA IOL group had significantly more PCO than the silicone and AcrySof IOL groups; the silicone group had significantly more PCO than the AcrySof group (P<.05). The Nd:YAG capsulotomy rate was 20% in the HSM PMMA group, 22% in the silicone group, and 8% in the AcrySof group. Conclusion: Patients with an AcrySof IOL developed significantly less PCO than those with a silicone or HSM PMMA IOL with a round‐edged design.