David F. Chang

Intraoperative Refractive Biometry for Predicting Intraocular Lens Power Calculation after Prior Myopic Refractive Surgery

PURPOSEnTo evaluate a new method of intraoperative refractive biometry (IRB) for intraocular lens (IOL) power calculation in eyes undergoing cataract surgery after prior myopic LASIK or photorefractive keratectomy.nnnDESIGNnRetrospective consecutive cases series.nnnPARTICIPANTSnWe included 215 patients undergoing cataract surgery with a history of myopic LASIK or photorefractive keratectomy.nnnMETHODSnPatients underwent IRB for IOL power estimation. The Optiwave Refractive Analysis (ORA) System wavefront aberrometer was used to obtain aphakic refractive measurements intraoperatively and then calculate the IOL power with a modified vergence formula obtained before refractive surgery. Comparative effectiveness analysis was done for IRB predictive accuracy of IOL power determination against 3 conventional clinical practice methods: surgeon best preoperative choice (determined by the surgeon using all available clinical data), the Haigis L, and the Shammas IOL formulas.nnnMAIN OUTCOME MEASURESnMedian absolute error of prediction and percentage of eyes within ±0.50 diopters (D) and ±1.00 D of refractive prediction error.nnnRESULTSnIn 246 eyes (215 first eyes and 31 second eyes) IRB using ORA achieved the greatest predictive accuracy (Pu2009<u20090.0001), with a median absolute error of 0.35 D and mean absolute error of 0.42 D. Sixty-seven percent of eyes were within ±0.5 D and 94% were within ±1.0 D of the IRBs predicted outcome. This was significantly more accurate than the other preoperative methods: Median absolute error was 0.6, 0.53, and 0.51 D for surgeon best choice, Haigis L method, and Shammas method, respectively.nnnCONCLUSIONSnThe IOL power estimation in challenging eyes with prior LASIK/photorefractive keratectomy was most accurately predicted by IRB/ORA.

Intracameral antibiotics: Safety, efficacy, and preparation

UNLABELLEDnEndophthalmitis is a rare but potentially devastating complication of cataract surgery. This article presents an overview of endophthalmitis prophylaxis and the use of intracameral antibiotics. It highlights available intracameral antibiotics with respect to pharmacology, spectrum of activity, dosage and preparation, safety, and efficacy profiles, as well as toxic anterior segment syndrome risks to better define the potential use of these medications in the prevention of endophthalmitis.nnnFINANCIAL DISCLOSUREnProprietary or commercial disclosures are listed after the references.

Initial Clinical Experience With the CyPass Micro-Stent: Safety and Surgical Outcomes of a Novel Supraciliary Microstent.

Purpose:To evaluate safety and clinical outcomes of a novel supraciliary device, the CyPass Micro-Stent, for surgical treatment of open-angle glaucoma when implanted in conjunction with cataract surgery. Patients and Methods:Subjects (n=142) with open-angle glaucoma and cataract underwent combined phacoemulsification, with intraocular lens insertion, and microstent implantation into the supraciliary space of study eyes (n=167). Two analysis cohorts were prespecified based upon medicated baseline intraocular pressure (IOP): ≥21 mm Hg (cohort 1, n=65) or <21 mm Hg (cohort 2, n=102). Glaucoma medications were discontinued or tapered at surgery, and restarted at investigator discretion. The main postoperative outcome measures were adverse events, IOP changes, and number of IOP-lowering medications. Results:Mean±SD follow-up was 294±121 days. No major intraoperative or postoperative complications occurred. Preoperative baseline mean IOP was 20.2±6.0 mm Hg and mean number of IOP-lowering medications was 2.0±1.1. Cohort 1 showed a 35% decrease in mean IOP and a 49% reduction in mean glaucoma medication usage; cohort 2 demonstrated a 75% reduction in mean medication usage while maintaining mean IOP<21 mm Hg. For all eyes, mean IOP at 12 months was 15.9±3.1 mm Hg (14% reduction from baseline). Early and late postoperative IOP elevation occurred in 1.2% and 1.8% of eyes, respectively. Two subjects developed mild transient hyphema, and none exhibited prolonged inflammation, persistent hypotony, or hypotony maculopathy. Conclusions:CyPass Micro-Stent implantation, combined with cataract surgery, resulted in minimal complications and reduced IOP and IOP-lowering medication use at 12 months postoperatively.

Implantable Telescope for End-Stage Age-related Macular Degeneration: Long-term Visual Acuity and Safety Outcomes

PURPOSEnTo evaluate long-term safety and best-corrected visual acuity (BCVA) results of a telescope prosthesis in patients with end-stage age-related macular degeneration (AMD).nnnDESIGNnProspective, open-label clinical trial with fellow-eye controls.nnnMETHODSnPatients with end-stage AMD (bilateral geographic atrophy or disciform scars; BCVA, 20/80 to 20/800) received the telescope prosthesis at 28 centers. Methods were similar to those described in the one-year results, with follow-up visits continuing at 18 and 24 months. Main outcome measures included BCVA change from baseline, endothelial cell density (ECD) and morphometry, and incidence of complications.nnnRESULTSnAt two years, data from 174 (92.6%) of 188 available patients were analyzed. Overall, 103 (59.5%) of 173 telescope-implanted eyes gained three lines or more (doubling of visual angle) of BCVA compared with 18 (10.3%) of 174 fellow control eyes (P < .0001). Mean BCVA improved 3.6 lines (standard deviation [SD], 1.9 lines) and 2.8 lines (SD, 2.3 lines) from baseline in eyes with the 3X and 2.2X device models, respectively. Mean ECD stabilized through two years, with 2.4% mean cell loss occurring from one to two years. There was no significant change in coefficient of variation or percentage of hexagonal endothelial cells from within six months to two years after surgery. The most common complication was inflammatory deposits.nnnCONCLUSIONSnLong-term results of this telescope prosthesis show the substantial BCVA improvement at one year is maintained at two years. Key indicators of corneal health demonstrate ECD change that reflects remodeling of the endothelium associated with the implantation procedure. ECD stabilizes over time, and there is no evidence of any ongoing endothelial trauma.

Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: Clinical Characteristics of 36 Eyes

PURPOSEnTo expand understanding of presentation, diagnosis, and outcomes of hemorrhagic occlusive retinal vasculitis (HORV).nnnDESIGNnRetrospective case series.nnnPARTICIPANTSnThirty-six eyes of 23 patients.nnnMETHODSnThe American Society of Cataract and Refractive Surgery (ASCRS) and the American Society of Retina Specialists (ASRS) formed a joint task force to define clinical characteristics of HORV and to study its prevalence, cause, treatment, and outcomes. An online registry was established on both societies web sites. Surveys were e-mailed to members of both societies soliciting cases of suspected HORV. A literature search was performed to uncover additional cases.nnnMAIN OUTCOME MEASURESnHistorical data including intraoperative characteristics, images, treatment regimens, and visual and anatomic outcomes.nnnRESULTSnCharacteristic findings of HORV included unremarkable postoperative day 1 undilated examination, delayed-onset painless vision loss, mild anterior chamber and vitreous inflammation, sectoral retinal hemorrhages in areas of ischemia, and predilection for venules and peripheral involvement. Based on predetermined diagnostic criteria, 36 eyes of 23 patients were diagnosed with HORV. All eyes received intraocular vancomycin via intracameral bolus (33/36), via intravitreal injection (1/36), or through the irrigation bottle (2/36). Patients sought treatment with HORV 1 to 21 days after surgery or intravitreal injection. Visual results usually were poor: 22 of 36 eyes (61%) had 20/200 or worse visual acuity and 8 of 36 eyes (22%) had no light perception (NLP). Neovascular glaucoma developed in 20 of 36 eyes (56%). Seven eyes received additional intravitreal vancomycin after surgery; 5 of these 7 eyes had NLP visual acuity at the most recent examination. Three eyes received intravitreal corticosteroids and had final visual acuities of 20/40, 20/70, and hand movements.nnnCONCLUSIONSnHemorrhagic occlusive retinal vasculitis is a rare, potentially devastating condition that can develop after cataract surgery or intraocular injection. All cases in this series were associated with intraocular vancomycin. Disease course and findings suggest that HORV is caused by a delayed hypersensitivity reaction to vancomycin. Early treatment with corticosteroids likely is beneficial. Subsequently, anti-vascular endothelial growth factor injections and panretinal photocoagulation are important to prevent neovascular glaucoma, a common complication. Avoidance of additional intravitreal vancomycin is recommended if HORV is suspected.

Prospective masked comparison of intraoperative floppy iris syndrome severity with tamsulosin versus alfuzosin.

OBJECTIVEnTo determine whether severe intraoperative floppy iris syndrome (IFIS) is more or equally likely with tamsulosin or alfuzosin.nnnDESIGNnProspective, masked, multicenter, cross-sectional study.nnnPARTICIPANTS AND CONTROLSnConsecutive patients taking systemic tamsulosin or alfuzosin and scheduled for routine cataract surgery (case group) and patients with no history of systemic α1-antagonists scheduled for routine cataract surgery (control group).nnnMETHODSnPhacoemulsification with intraocular lens implantation was performed and recorded on video. Intracameral phenylephrine or epinephrine, either by direct injection or placement in the irrigation bottle, was not permitted. Every surgical video subsequently was reviewed remotely by 2 masked investigators who diagnosed the presence or absence of IFIS and graded the severity of IFIS as follows: none, mild (billowing only), moderate (billowing and either iris prolapse or ≥2 mm of pupil constriction), or severe (billowing accompanied by iris prolapse and ≥2 mm of pupil constriction).nnnMAIN OUTCOME MEASURESnRate and severity of IFIS and surgical complication rate.nnnRESULTSnA total of 226 eyes (70 in the tamsulosin group, 43 in the alfuzosin group, and 113 in the control group) were enrolled. Severe IFIS was noted in 34.3% (24/70) of the tamsulosin eyes and in 16.3% (7/43) of the alfuzosin eyes compared with 4.4% (5/113) of the control eyes. The differences between each of the 3 groups were statistically significant. In the absence of epinephrine in the irrigation bottle, 12.4% of control eyes had moderate to severe IFIS. There were no instances of posterior capsular rupture or significant surgical complications in either the case or control groups.nnnCONCLUSIONSnModerate to severe IFIS can occur in low-risk eyes when epinephrine is omitted from the irrigation bottle. Although both tamsulosin and alfuzosin significantly increase the risk of IFIS compared with patients without prior α1-antagonist intake, severe IFIS statistically was more likely with tamsulosin than with alfuzosin (Pxa0= 0.036). Patients with symptomatic benign prostatic hyperplasia and cataracts requiring a uroselective α1-antagonist may consider trying alfuzosin first.

Factoring cost, is phacoemulsification still the procedure of choice?

As with any ophthalmic condition, the choice of which cataract procedure to employ must primarily be based upon clinical outcomes. However, given the status of cataract surgery as the most frequent, and therefore largest, overall procedural expenditure, the cost to the healthcare system should be considered as well. In their article in this issue of the BJO (p 822), Minassian and co-authors give us a definitive answer. This is a well designed prospective study in which eight experienced surgeons each performed equal numbers of phacoemulsification (Phako) and standard large incision extracapsular (ECCE) procedures; 500 patients were enrolled. Measured outcomes included uncorrected and best corrected visual acuity, astigmatism, intraoperative and postoperative complications, and cost.nnA very important feature of this prospective study makes it unique in the cataract literature. The patients operated on by each surgeon were randomised between the two different procedures. This was necessary in order to avoid two potential and significant biases that would otherwise affect retrospective or non-randomised comparisons. Firstly, those surgeons primarily performing standard ECCE in recent years have tended to do a lower volume of surgery.1 Secondly, when surgeons regularly perform both procedures they tend to utilise standard …

Prevalence of blindness and outcomes of cataract surgery in Hainan Province in South China.

OBJECTIVEnTo define the prevalence of blindness and visual impairment (VI) in people in rural Hainan using the rapid assessment of avoidable blindness (RAAB) and to report the outcomes of cataract surgery among the residents.nnnDESIGNnPopulation-based, cross-sectional survey.nnnPARTICIPANTSnA total of 6482 rural residents of the Hainan province.nnnMETHODSnA total of 136 clusters, each of which consisted of 50 people aged ≥50 years, were selected through probability-proportionate-to-size sampling. Door-to-door visits were performed by 2 outreach teams. Visual acuity (VA) was measured on site, and those with VA <6/18 in either eye were examined by an ophthalmologist. Causes of blindness and VI were determined. The causes of poor visual outcome after cataract surgery were evaluated. Information regarding barriers to receiving surgery was collected by trained interviewers.nnnMAIN OUTCOME MEASURESnPrevalence and causes of blindness (VA <3/60), severe VI (SVI) (VA <6/60 but ≥3/60), and VI (VA <6/18 but ≥6/60) based on presenting VA (PVA) were assessed. Outcomes of cataract surgery performed in public and private hospitals and charitable organizations were compared.nnnRESULTSnA total of 6482 subjects were examined (response rate, 95.3%). The sample prevalence of blindness was 4.4% (95% confidence interval [CI], 2.0-6.8). The prevalence of SVI and VI was 1.9% (95% CI, 0-4.3) and 9.9% (95% CI, 7.6-12.2), respectively. Age and sex were associated with increased prevalence of blindness, SVI, and VI. Overall, cataract accounted for approximately 60% of blindness and SVI. Of the 524 eyes that had received cataract surgery, 87.2% had intraocular lenses implanted, 21% had a poor visual outcome (PVA <6 /60), and 20% had a borderline visual outcome (PVA <6/18 but ≥6/60). Eyes that received surgery in charitable organizations had a higher rate of intraocular lens implantation and good visual outcome (VA ≥6/18) compared with eyes that were operated on elsewhere.nnnCONCLUSIONSnThe prevalence of blindness, SVI, and VI was high among rural residents in Hainan. Cataract remained the leading cause of avoidable blindness. Outcomes of cataract surgery performed in public hospitals were suboptimal. Quality-control initiatives should be introduced to improve cataract surgery outcomes.

Barriers for poor cataract surgery uptake among patients with operable cataract in a program of outreach screening and low-cost surgery in rural china

Abstract Aims: To identify the reasons for poor uptake of cataract surgery in a program of outreach screening and low-cost surgery in Pucheng County, a rural area in northwestern China. Methods: Detailed interviews with a semi-structured questionnaire were conducted by telephone or face-to-face for participants who had been advised to attend a low-cost cataract surgery program but did not schedule the surgery within 3 months after the initial screening. Results: Among 432 eligible subjects, 355 (82.2%) were interviewed (mean age 70.6u2009±u20096.6 years, 73.8% female). A total of 138 subjects (38.9%) were interviewed by phone and 217 (61.1%) were interviewed face-to-face. Lack of family support (nu2009=u2009106, 29.9%) and failure to understand the need for surgery (nu2009=u200996, 27.0%) were the two main reasons for not undergoing cataract surgery. Other factors included fear of surgery (nu2009=u200962, 17.5%), lack of faith in doctors (nu2009=u200936, 10.1%), financial constraints (nu2009=u200925, 7.0%) and lack of transportation (nu2009=u20094, 1.1%). Conclusion: The principal barriers to low-cost cataract surgery uptake in rural China included lack of family support and failure to understand the need for surgery. Education targeting entire families to eliminate these barriers and development of community support systems at the family level are required to achieve greater uptake of low-cost cataract surgery programs in rural China.

Project vision: a new and sustainable model for eliminating cataract blindness in China.

Cataract is by far the most common cause of major vision loss, accounting for approximately half of all global blindness. According to the World Health Organization (WHO), roughly 18 million people worldwide are bilaterally blind from cataract. These sobering statistics have a profound societal economic impact through the combined loss of productivity of both the blind and those who must care for them. This, and the significant reduction of life expectancy for the blind, makes sight restoring cataract surgery one of society’s most cost-effective medical interventions. It is estimated that increased economic productivity during the first postoperative year alone exceeds the cost of the surgery by a factor of 15. The costly societal burden of cataract blindness is not for lack of an effective treatment, as residents of all developed countries enjoy the hi-tech miracle of modern cataract surgery. Instead, cataract blindness results from the sizable gap in health-care delivery between affluent and poor societies. Cataract remains the leading cause of blindness in developing countries where the significant shortage of ophthalmologists and eye surgical services is the chief, but not sole cause. Yorston highlighted four additional major obstacles that deter people from receiving cataract surgery in developing countries. These barriers are (i) a lack of awareness about cataract and its treatment, (ii) a negative perception of the quality of locally available health services, (iii) problems with transportation to health-care facilities, and (iv) the inability to afford the direct and indirect costs arising from surgery. During the past three decades, China’s explosive economic growth and development have been apparent and impressive to all. However, the benefits of this extraordinary economic transformation have been largely reaped in China’s urban centres, and have not been shared by the rural population. Perhaps in no area is this gap in living standard more apparent than in health care. An important public health statistic is the so-called, cataract surgical rate (CSR), which represents the number of cataract operations annually performed per one million of population. As would be expected, the highest rates are seen in those countries with the highest gross domestic product (GDP) (Table 1). Astonishingly, however, China’s CSR is among the lowest in the world, and on a par with African countries with extremely low GDPs. This glaring discrepancy is all the more disappointing considering that economic reforms have resulted in a 10-fold rise in China’s GDP since 1978. An epidemiological survey in the late 1980s estimated that at least 5 million people suffered from bilateral blindness in China, and that cataract was responsible for 50% of these cases. According to the WHO, in developing countries a CSR of 1000 is necessary simply to treat the new cases of cataract blindness arising every year. For China, the current population of 1.3 billion, translates into 1.3 million new cases of cataract blindness per year. With such a deficient CSR, China’s burden of cataract blindness will continue to grow at an epidemic rate until access to surgery can be increased. To underscore the severity of the problem, even a tripling of China’s current CSR would barely make a dent in the country’s huge backlog of cataract blindness.