Paul Rosen

Effect of cataract surgery on the corneal endothelium: Modern phacoemulsification compared with extracapsular cataract surgery

PURPOSE To investigate whether modern phacoemulsification surgery results in more damage to the corneal endothelium than extracapsular cataract extraction (ECCE), and to examine which preoperative, operative, and postoperative factors influence the effect of cataract surgery on the endothelium. DESIGN Randomized controlled trial. PARTICIPANTS Five hundred patients 40 years or older were randomized into 2 groups (ECCE, 249; phacoemulsification, 251). METHODS Central corneal endothelial cell counts, coefficient of variation of cell size, and hexagonality were assessed before surgery and up to 1 year postoperatively. MAIN OUTCOME MEASURE Endothelial cell count. RESULTS Four hundred thirty-three patients completed the trial. The initial preoperative mean cell count for the entire sample was 2481 (standard error [SE]: 18.6), reduced at 1 year postoperatively to 2239 (SE: 23.5). An average 10% reduction in cell count was recorded by 1 year postoperatively. There was no such change in hexagonality or in the coefficient of variation. There was no significant difference in overall percentage cell loss between the 2 treatment groups. Factors associated with excessive cell loss (> or =15% by 1 year) were a hard cataract (odds ratio [OR]: 2.1, 95% confidence limits: 1.1-4.1; P = 0.036), age (OR: 1.04, P = 0.005), and capsule or vitreous loss at surgery (OR: 2.38, P = 0.106). Phacoemulsification carried a significantly higher risk (OR: 3.7, P = 0.045) of severe cell loss in the 45 patients with hard cataracts relative to ECCE (52.6% vs. 23.1%; chi-square test, P = 0.041), with both procedures achieving similar postoperative visual acuity outcomes. CONCLUSIONS No significant difference in overall corneal endothelial cell loss was found between these 2 operative techniques. The increased risk of severe cell loss with phacoemulsification in patients with hard cataracts suggests that phacoemulsification may not be the optimal procedure in these cases, and that ECCE should be preferred.

Original articleEffect of cataract surgery on the corneal endothelium: Modern phacoemulsification compared with extracapsular cataract surgery☆

PURPOSE To investigate whether modern phacoemulsification surgery results in more damage to the corneal endothelium than extracapsular cataract extraction (ECCE), and to examine which preoperative, operative, and postoperative factors influence the effect of cataract surgery on the endothelium. DESIGN Randomized controlled trial. PARTICIPANTS Five hundred patients 40 years or older were randomized into 2 groups (ECCE, 249; phacoemulsification, 251). METHODS Central corneal endothelial cell counts, coefficient of variation of cell size, and hexagonality were assessed before surgery and up to 1 year postoperatively. MAIN OUTCOME MEASURE Endothelial cell count. RESULTS Four hundred thirty-three patients completed the trial. The initial preoperative mean cell count for the entire sample was 2481 (standard error [SE]: 18.6), reduced at 1 year postoperatively to 2239 (SE: 23.5). An average 10% reduction in cell count was recorded by 1 year postoperatively. There was no such change in hexagonality or in the coefficient of variation. There was no significant difference in overall percentage cell loss between the 2 treatment groups. Factors associated with excessive cell loss (> or =15% by 1 year) were a hard cataract (odds ratio [OR]: 2.1, 95% confidence limits: 1.1-4.1; P = 0.036), age (OR: 1.04, P = 0.005), and capsule or vitreous loss at surgery (OR: 2.38, P = 0.106). Phacoemulsification carried a significantly higher risk (OR: 3.7, P = 0.045) of severe cell loss in the 45 patients with hard cataracts relative to ECCE (52.6% vs. 23.1%; chi-square test, P = 0.041), with both procedures achieving similar postoperative visual acuity outcomes. CONCLUSIONS No significant difference in overall corneal endothelial cell loss was found between these 2 operative techniques. The increased risk of severe cell loss with phacoemulsification in patients with hard cataracts suggests that phacoemulsification may not be the optimal procedure in these cases, and that ECCE should be preferred.

Postoperative intraocular lens rotation: a randomized comparison of plate and loop haptic implants.

OBJECTIVE To compare the postoperative rotation of plate and loop haptic implants of spherical power to ascertain the optimal design appropriate for toric intraocular lenses (IOLs). DESIGN Randomized, controlled trial. PARTICIPANTS Forty-eight patients attending for routine cataract surgery by phacoemulsification. METHOD Patients with cataract as the only ocular disease were randomly implanted with plate or loop haptic implants after uncomplicated phacoemulsification. The baseline position of the IOL was determined from a video frame acquired at the conclusion of surgery. Postoperative IOL position was documented using digital retroillumination images at 2 weeks and 6 months after surgery. Capsular fusion patterns were recorded using slit-lamp biomicroscopy. Correlation of IOL rotation with axial length, capsular contraction, and fusion was attempted. MAIN OUTCOME MEASURES Early IOL rotation, occurring between surgery and 2 weeks after surgery, was graded as mild (<10 degrees), moderate (10 degrees < to <30 degrees), or severe (>30 degrees) by a semiobjective online comparison of the images. Late IOL rotation, occurring between 2 weeks and 6 months, was measured more precisely using software developed specifically for the study. RESULTS Twenty-three patients were allocated the loop haptic and 25 the plate haptic IOL. The groups were comparable for demographic variables and numbers of patients excluded from analysis (P > 0.05). Five (24%) of 21 of plate haptic IOLs underwent severe early rotation compared to 2 (9%) of 22 loop haptics (P = 0.36). The median late rotation was 6.8 degrees for loop haptics compared to 0.6 degrees for plate haptics (P = 0.0073). Between 2 weeks and 6 months, anticlockwise rotation had occurred in 16 (89%) of 18 loop haptic IOLs compared to 11 (52%) of 21 plate haptic IOLs (P = 0.0081). CONCLUSIONS Plate haptic IOLs show greater rotational stability than do loop haptics made from polypropylene once capsular fusion has taken place. Loop haptics invariably rotate anticlockwise after 2 weeks.

Evidence-based guidelines for cataract surgery: Guidelines based on data in the European Registry of Quality Outcomes for Cataract and Refractive Surgery database

In March 2008, the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) commenced. This 3-year project was cofunded by the European Union (EU) and the European Society of Cataract & Refractive Surgeons (ESCRS). The ESCRS became the lead partner in the project with 11 national societies as associated partners. The aims of the project were to improve treatment and standards of care for cataract and refractive surgery and to develop evidence-based guidelines for cataract and refractive surgery across Europe. Surgeons from all participating societies contributed to the database, which contained data on 820,000 cataract surgeries in November 2011. The present guidelines are based on data entered from January 1, 2009, to August 28, 2011 (523,921 cataract extractions). The guidelines include only those steps in the cataract surgery process that can be analyzed by the database.

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.

Ophthalmological screening for von Hippel-Lindau disease

Forty seven individuals (from 16 kindreds) without prior evidence of retinal hae-mangiomas underwent full ophthalmological assessment as part of a comprehensive screening programme for Von Hippel-Lindau disease. Ten were known to be affected on the basis of non-ocular involvement and 37 were at 50% risk of having the abnormal gene. Seventeen angiomas were detected in 14 individuals (six affected patients and eight at risk relatives). Regular detailed ophthalmological assessment is important for all patients with von Hippel-Lindau disease and for relatives at risk of inheriting the abnormal gene.

Iris-claw intraocular lenses to correct aphakia in the absence of capsule support.

PURPOSE: To evaluate the indications, postoperative visual efficacy, and complication rate after intraocular implantation of an iris‐claw aphakic intraocular lens (IOL). SETTING: Oxford Eye Hospital, Oxford, United Kingdom. DESIGN: Case series. METHODS: This chart review comprised eyes with no capsule support that had anterior iris‐fixation IOL implantation for aphakia between 2001 and 2009. RESULTS: The study comprised 116 eyes (104 patients). Iris‐claw IOLs were inserted during primary lens surgery in 18 eyes (15.5%), during an IOL exchange procedure for dislocated posterior chamber IOLs in 19 eyes (16.4%), and as a secondary procedure in 79 eyes (68.1%). The mean follow‐up was 22.4 months (range 3 to 79 months). The final corrected distance visual acuity (CDVA) was 6/12 or better in 68.9% of all eyes and in 47 of 53 eyes (88.7%) with no preoperative comorbidity. Complications included wound leak requiring resuturing in 2.6% of eyes, postoperative intraocular pressure rise in 9.5% of eyes (glaucoma escalation 0.8%), and cystoid macular edema in 7.7% of eyes (0.8% chronic). Iris‐claw IOL subluxation occurred in 6.0% of eyes from 5 days to 60 months postoperatively; all the IOLs were repositioned. Corneal decompensation occurred in 1.7% of eyes; 0.8% had retinal detachments. CONCLUSIONS: Iris‐claw IOL implantation for aphakia gave a good visual outcome and can be used for a wide range of indications. Postoperative complication rates were comparable to, if not better than, those with conventional anterior chamber IOLs. Correct implantation technique is critical in avoiding postoperative IOL subluxation. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Visual outcome of cataract surgery; Study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery.

Purpose To analyze the visual outcome after cataract surgery. Setting Cataract surgery clinics in 15 European countries. Design Database study. Methods Data were drawn from case series of cataract extractions reported to the European Registry of Quality Outcomes for Cataract and Refractive Surgery database. These data were entered into the database via the Web by surgeons or by transfer from existing national registries or electronic medical record systems. The database contains individual anonymous data on preoperative, intraoperative, and postoperative measurements. Results Data on 368 256 cataract extractions were available for analysis. The best visual outcome was achieved in age groups 40 to 74 years, and men showed a higher percentage of excellent vision (1.0 [20/20] or better) than women. A corrected distance visual acuity (CDVA) of 0.5 (20/40) or better and of 1.0 (20/20) or better was achieved in 94.3% and 61.3% of cases, respectively. Ocular comorbidity and postoperative complications were the strongest influences on the visual outcome; however, surgical complications and ocular changes requiring complex surgery also had a negative influence. Deterioration of visual acuity after the surgery (n= 6112 [1.7% of all cases]) was most common in patients with a good preoperative visual acuity. Conclusions The visual outcomes of cataract surgery were excellent, with 61.3% of patients achieving a corrected distance visual acuity of 1.0 (20/20) or better. Age and sex influenced the visual outcomes, but the greatest influences were short‐term postoperative complications, ocular comorbidity, surgical complications, and complex surgery. A weakness of the study could be that some of the data is self‐reported to the registry. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Indentation microsurgery: Internal searching for retinal breaks

Breaks responsible for rhegmatogenous retinal detachments in 78 eyes could not be seen preoperatively owing to opacities in the media, previous buckling or other causes. Deep kinetic indentation of the sclera combined with endoillumination enabled retinal breaks to be identified during closed microsurgery in 95% of these eyes, and retinal reattachment was eventually achieved in 85%.

Pupillary capture after combined management of cataract and vitreoretinal pathology

Purpose: To report the incidence, pathogenesis, and management of pupillary capture after combined phacoemulsification with intraocular lens (IOL) implantation and vitreoretinal surgery. Setting: Oxford Eye Hospital, The Radcliffe Infirmary, Oxford, United Kingdom. Methods: This retrospective case review comprised 12 patients who developed pupillary capture after combined phacoemulsification, IOL implantation, and pars plana vitrectomy (PPV). Eleven IOLs were implanted in the capsular bag, and 1 was sulcus fixated. All patients had a long‐acting gas tamponade and were advised to lie face down postoperatively. All patients subsequently had IOL repositioning using a bimanual technique. Results: The incidence of pupillary capture was 8.95% and occurred a mean of 3.25 weeks postoperatively. At least 6 clock hours of the pupillary margin were captured by the optic except in 1 case in which the pupillary capture was total. Half the patients had posterior capsule opacification that required a neodymium:YAG laser capsulotomy after IOL repositioning. Conclusions: The incidence of pupillary capture after combined phacoemulsification, IOL implantation, PPV, and injection of long‐acting gas was high. This complication can be minimized by creating a smaller capsulorhexis, having the patient maintain a strict face‐down position, securing wound closure, and injecting an air bubble into the air chamber to push the iris–lens diaphragm posteriorly.