Sherleen H. Chen

Cataract surgery and diabetes.

Purpose of review Recent studies have focused on interventions to minimize progression of retinal disease in diabetic patients undergoing cataract surgery. Here, we review the evidence for progression of diabetic retinal disease with cataract surgery and critically analyze the interventions proposed to minimize it. Recent findings Peri-operative intravitreal bevacizumab, sub-Tenons triamcinolone, and panretinal photocoagulation (PRP) after cataract surgery (instead of before) have been examined as ways to improve cataract surgery results in diabetic patients. The bevacizumab and triamcinolone results are promising, but the inclusion criteria are variable, the sample sizes are small, and the follow-up is short. Postsurgery PRP shows improved cataract surgery results in diabetics with more severe retinopathy up to 1 year after surgery. Summary Recent studies do not support the generalized conclusion that phacoemusification surgery causes progression of retinopathy and macular edema in all diabetic patients. In certain populations of diabetic patients undergoing cataract surgery, peri-operative triamcinolone and bevacizumab may blunt the progression of diabetic macular edema and diabetic retinopathy. The optimal timing of PRP in relation to cataract surgery in patients with more severe retinopathy warrants further evaluation.

Epithelial and fibrous downgrowth: mechanisms of disease

Epithelial downgrowth is a rare, but potentially devastating, complication of intraocular surgery and trauma. It has been suggested that the incidence is declining with modern surgical techniques, but further long-term analysis is needed to determine whether this in fact is true. While clinical observations and experimental studies have helped to elucidate factors involved in the development of this disease, a precise understanding of its pathogenesis is unknown. Given the difficult management and poor prognosis of this disease, further study and heightened clinical awareness are needed to better understand this disease process.

Solar Exposure and Residential Geographic History in Relation to Exfoliation Syndrome in the United States and Israel

IMPORTANCE Residential (geographic) history and extent of solar exposure may be important risk factors for exfoliation syndrome (XFS) but, to our knowledge, detailed lifetime solar exposure has not been previously evaluated in XFS. OBJECTIVE To assess the relation between residential history, solar exposure, and XFS. DESIGN, SETTING, AND PARTICIPANTS This clinic-based case-control study was conducted in the United States and Israel. It involved XFS cases and control individuals (all ≥ 60-year-old white individuals) enrolled from 2010 to 2012 (United States: 118 cases and 106 control participants; Israel: 67 cases and 72 control participants). MAIN OUTCOMES AND MEASURES Weighted lifetime average latitude of residence and average number of hours per week spent outdoors as determined by validated questionnaires. RESULTS In multivariable analyses, each degree of weighted lifetime average residential latitude away from the equator was associated with 11% increased odds of XFS (pooled odds ratio [OR], 1.11; 95% CI, 1.05-1.17; P < .001). Furthermore, every hour per week spent outdoors during the summer, averaged over a lifetime, was associated with 4% increased odds of XFS (pooled OR, 1.04; 95% CI, 1.00-1.07; P = .03). For every 1% of average lifetime summer time between 10 am and 4 pm that sunglasses were worn, the odds of XFS decreased by 2% (OR, 0.98; 95% CI, 0.97-0.99; P < .001) in the United States but not in Israel (OR, 1.00; 95% CI, 0.99-1.01; P = .92; P for heterogeneity = .005). In the United States, after controlling for important environmental covariates, history of work over water or snow was associated with increased odds of XFS (OR, 3.86; 95% CI, 1.36-10.9); in Israel, there were too few people with such history for analysis. We did not identify an association between brimmed hat wear and XFS (P > .57). CONCLUSIONS AND RELEVANCE Lifetime outdoor activities may contribute to XFS. The association with work over snow or water and the lack of association with brimmed hat wear suggests that ocular exposure to light from reflective surfaces may be an important type of exposure in XFS etiology.

Achieving Target Refraction after Cataract Surgery

PURPOSE To evaluate the difference between target and actual refraction after phacoemulsification and intraocular lens implantation at an academic teaching institutions Comprehensive Ophthalmology Service. DESIGN Retrospective study. PARTICIPANTS We examined 1275 eye surgeries for this study. METHODS All consecutive cataract surgeries were included if they were performed by an attending or resident surgeon from January through December 2010. Postoperative refractions were compared with preoperative target refractions. Patients were excluded if they did not have a preoperative target refraction documented or if they did not have a recorded postoperative manifest refraction within 90 days. MAIN OUTCOME MEASURES The main outcome measure was percentage of cases achieving a postoperative spherical equivalent ± 1.0 diopter (D) of target spherical equivalent. RESULTS We performed 1368 cataract surgeries from January through December of 2010. Of these, 1275 (93%) had sufficient information for analysis. Of the included cases, 94% (1196 of 1275) achieved ± 1.0 D of target refraction by 90 days after cataract surgery. CONCLUSIONS This paper establishes a new benchmark for a teaching hospital, where 94% of patients achieved within 1.0 D of target refraction after cataract surgery. The refractive outcomes after cataract surgery at this academic teaching institution were higher than average international benchmarks.

Pseudoexfoliation syndrome and cataract surgery.

Pseudoexfoliation syndrome (PXF) is characterized by the deposition of fibrillar extracellular matrix material in both anterior segment tissues of the eye and in nonocular tissues. PXF deposits in the iris, ciliary processes, cornea, and lens are associated with poor pupillary dilation, open-angle glaucoma, and nuclear cataract formation. These manifestations are especially important for the general ophthalmologist to consider when planning for cataract surgery. This review of PXF syndrome will focus on its effect on cataract surgery, including preoperative evaluation, surgical technique, postoperative complications, and visual outcomes. The classic anterior lens capsule deposits of PXF were first described and illustrated by the Finnish ophthalmologist, Lindberg, in 1917. Although other nomenclatures have been used, ‘‘pseudoexfoliation syndrome’’ is most commonly used term today to differentiate this condition from the true exfoliation of the lens capsule owing to trauma from infrared radiation and other sources. The exact composition of PXF material is unknown. It is believed to be produced by numerous cell types and distributed throughout the anterior chamber and onto the central anterior lens capsule and zonules via the aqueous humor. The PXF material is also found in extraocular connective tissues, including eyelid, heart, kidney, liver, and cerebral meninges. Therefore, PXF