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Mansoor Q, Qurashi N, Chen Y. A Modular Cataract Surgery Training Model Incorporating Human Factors and a Pedagogical Theory. Clin Ophthalmol 2024; 18:1171-1180. [PMID: 38711573 PMCID: PMC11073136 DOI: 10.2147/opth.s451594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 04/11/2024] [Indexed: 05/08/2024] Open
Abstract
Synopsis High volume cataract lists are cost-effective, reduce waiting times, and facilitate surgical teaching. We propose a stepwise training model that incorporates human factor principles and a reflective pedagogical approach, which has not been documented previously. Background/Aims Surgical training in ophthalmology is effective when a modular approach is utilised. High volume lists further enhance training by increasing exposure to a newer way of learning and working. We evaluated the efficiency and safety of trainee-assisted cataract surgery across a single NHS eye unit and an independent sector (IS) provider. Methods We examined results from audits of surgical efficiency and safety in trainee-assisted high-volume lists, including a single-centre comparative evaluation of consultant-only and trainee lists. The quantitative and qualitative information gained from these projects helped us to implement a modular, structured training programme that utilises a reflective cycle of pedagogy, suitable for any grade of trainee. Results Our projects included an audit following cataract surgery performed by a surgical trainee over a 5-month period, which showed excellent post-op refractive results and no cases of intra-operative and post-operative complications. A single-centre observational study demonstrated comparable surgical throughput and safety results for trainee and solo consultant high volume lists. Systemic and ocular complication rates were reported to be similar for low and medium risk cataract surgery among trainee supervised IS and NHS lists. Conclusion Cataract surgery outcomes and patient feedback support the effectiveness of the surgical training model. Combining Gibbs' reflective cycle of critical reflection with the International Council of Ophthalmology's principles helped us to develop the QM Model of modular teaching for cataract surgery, which we believe is suitable for utilisation in all surgical centres in the NHS and IS settings, for both low volume and high-volume surgical lists regardless of trainee experience.
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Affiliation(s)
- Qasim Mansoor
- Department of Ophthalmology, James Cook University Hospital, Middlesbrough, UK
- Teesside Newmedica Eye Health Clinic & Surgical Centre, Middlesbrough, UK
| | - Neda Qurashi
- Department of Ophthalmology, James Cook University Hospital, Middlesbrough, UK
| | - Yunzi Chen
- Department of Ophthalmology, James Cook University Hospital, Middlesbrough, UK
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Nuijts RMMA, Cochener-Lamard B, Szaflik JP, Mencucci R, Chiambaretta F, Behndig A. Safety of an Intracameral Fixed Combination for Mydriasis and Intraocular Anaesthesia During Cataract Surgery. Clin Ophthalmol 2024; 18:1103-1115. [PMID: 38686012 PMCID: PMC11057510 DOI: 10.2147/opth.s453257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/08/2024] [Indexed: 05/02/2024] Open
Abstract
Purpose To compare the safety of a standardized, commercially available intracameral combination of mydriatics and anesthetic (ICMA) with a reference topical mydriatic regimen for cataract surgery. Patients and Methods The safety results from two international, randomized, controlled clinical studies were combined to compare ICMA at the beginning of cataract surgery (ICMA group) to the reference topical mydriatic regimen (reference group). Data were collected on ocular and systemic adverse events, corneal and anterior chamber examination, endothelial cell density, retinal thickness and visual acuity. Analysis was performed on a pooled safety set from both studies, preoperatively and up to 1 month postoperatively. Results 342 patients received ICMA and 318 the reference topical regimen. Ocular adverse events were reported in 17.0% of patients in the ICMA group and 18.6% in the reference group. No difference was shown between groups in endothelial cell density (2208 ± 498 cells/mm2 for ICMA group versus 2241 ± 513 cells/mm2 for the reference group; p=0.547) and retinal thickness (change from baseline less than 50 µm in 94.7% versus 95.0% of patients, respectively) at 1 month postoperatively. At 1-day post-surgery, less patients in the ICMA group had moderate or severe (Grades 2 and 3) superficial punctate corneal staining (3.9% versus 7.0% for the reference group; p=0.064). Postoperatively, some ocular symptoms were also less frequently reported in the ICMA group. Best-corrected visual acuity increased in 96.0% of patients in the ICMA group and 95.8% in the reference group at 1 month. Conclusion ICMA injection at the beginning of cataract surgery was demonstrated to be safe and may also provide perioperative and postoperative advantages over the standard topical mydriatic regimen.
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Affiliation(s)
- Rudy M M A Nuijts
- University Eye Clinic, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Béatrice Cochener-Lamard
- Ophthalmology Department, CHU Morvan, University Hospital of Brest, and University of Bretagne Occidentale (UBO), Brest, France
| | - Jacek P Szaflik
- Department of Ophthalmology, Medical University of Warsaw, Warszawa, Poland
| | - Rita Mencucci
- Eye Clinic, Department of Neurosciences, Psychology, Pharmacology, and Child Health, University of Florence, Florence, Italy
| | - Frédéric Chiambaretta
- Ophthalmology Department, CHU Gabriel Montpied, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Anders Behndig
- Department of Clinical Sciences/Ophthalmology, Umea University, Umea, Sweden
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Chua MJ, Varshney N, Eke T. Intracameral phenylephrine for surgical mydriasis and intraoperative floppy-iris syndrome: systemic adverse effects and optimal dose. J Cataract Refract Surg 2024; 50:187-194. [PMID: 37748029 PMCID: PMC10805356 DOI: 10.1097/j.jcrs.0000000000001319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 09/27/2023]
Abstract
Phenylephrine, a potent sympathomimetic, induces mydriasis via iris dilator muscle contraction. Intracameral (IC) phenylephrine has been successfully used in cataract surgery for initial mydriasis, maintaining mydriasis, and management of intraoperative floppy-iris syndrome. Serious systemic adverse events (mainly cardiovascular) have been described with topical phenylephrine drops, but we found very little evidence of such adverse events associated with IC phenylephrine use. However, we suspect under-reporting of such adverse events, as they may instead be ascribed to anxiety, positioning, anesthesia, etc. Optimal dosage/concentrations for IC phenylephrine use in different purposes have not been fully studied. In the absence of robust evidence, we suggest that lower but effective IC phenylephrine concentrations are used: a lower concentration (0.31%), in conjunction with an anticholinergic and lidocaine, may be used for initial mydriasis. For management of intraoperative floppy-iris syndrome, 0.31% may be effective, though a higher concentration (1% to 1.25%) may be required.
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Affiliation(s)
- Matthew J. Chua
- From the Department of Anaesthesia, Liverpool Hospital, Liverpool, Australia (Chua); East Kent Hospitals University NHS Foundation Trust, Canterbury, United Kingdom (Varshney); Department of Ophthalmology, Norfolk and Norwich University Hospital, Norwich, United Kingdom (Eke)
| | - Natasha Varshney
- From the Department of Anaesthesia, Liverpool Hospital, Liverpool, Australia (Chua); East Kent Hospitals University NHS Foundation Trust, Canterbury, United Kingdom (Varshney); Department of Ophthalmology, Norfolk and Norwich University Hospital, Norwich, United Kingdom (Eke)
| | - Tom Eke
- From the Department of Anaesthesia, Liverpool Hospital, Liverpool, Australia (Chua); East Kent Hospitals University NHS Foundation Trust, Canterbury, United Kingdom (Varshney); Department of Ophthalmology, Norfolk and Norwich University Hospital, Norwich, United Kingdom (Eke)
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4
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Dereń-Szumełda JK, Dorecka M, Zandecki Ł, Mrukwa-Kominek E. Effectiveness of a Standardized Combination of Intracameral Mydriatics and Anaesthetic on Mydriasis during Cataract Surgery with Coexisting Diseases. Life (Basel) 2023; 14:14. [PMID: 38276263 PMCID: PMC10817656 DOI: 10.3390/life14010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 01/27/2024] Open
Abstract
PURPOSE To examine the effectiveness of a standardized combination of intracameral mydriatics and anesthetic (SCIMA) on mydriasis in patients with coexisting diseases such as diabetes mellitus (DM) and pseudoexfoliation syndrome (PXF) during phacoemulsification. METHODS Patients with cataract were included in the study if they achieved pupil dilation diameter ≥ 6.0 mm after the administration of mydriatic eyedrops (ME) during the first visit (V1). During the second visit (V2), pupil size measurements were obtained for phacoemulsification surgery with SCIMA. Effective mydriasis was defined as a pupil diameter ≥ 6.0 mm just prior to capsulorhexis without the use of additional pupil dilating agents. The measurements after ME administration during V1 and after SCIMA use during V2 were compared. RESULTS 103 patients (103 eyes) were divided into 3 groups: cataract and DM (n = 35), cataract and PXF (n = 32), and cataract without DM or PXF (n = 36). SCIMA administration allowed the achievement of effective mydriasis (≥6.0 mm) in all groups (n = 103; 100%). Mydriasis was significantly larger (p ≤ 0.001) after ME (7.3 mm) than after SCIMA (6.8 mm) administration. CONCLUSIONS Patients with cataract and such comorbidities as DM or PXF are likely to achieve effective pharmacological mydriasis during cataract phacoemulsification after SCIMA application. Mydriasis after ME is slower and larger, while SCIMA is faster.
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Affiliation(s)
| | - Mariola Dorecka
- Department of Ophthalmology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-514 Katowice, Poland;
| | - Łukasz Zandecki
- Collegium Medicum, Jan Kochanowski University of Kielce, Żeromskiego 5, 25-369 Kielce, Poland;
| | - Ewa Mrukwa-Kominek
- Faculty of Medical Sciences in Katowice, Medical University of Silesia, Poniatowskiego 15, 40-055 Katowice, Poland;
- Department of Ophthalmology, Kornel Gibiński University Clinical Center, Ceglana 35, 40-514 Katowice, Poland
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5
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Kaur S, Kumari K, Gupta PC, Sukhija J. Pharmacological management of intra-operative miosis during cataract surgery. Indian J Ophthalmol 2023; 71:2656-2661. [PMID: 37417103 PMCID: PMC10491068 DOI: 10.4103/ijo.ijo_3384_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/25/2023] [Accepted: 03/27/2023] [Indexed: 07/08/2023] Open
Abstract
Cataract surgery requires a well-dilated and stable pupil for a good outcome. Unexpected pupillary constriction during surgery increases the risk of complication. This problem is more pronounced in children. There are now pharmacological interventions that help tackle this unforeseen happening. Our review discusses the simple and quick options available to a cataract surgeon when faced with this dilemma. As cataract surgical techniques continue to improvise and get faster, an adequate pupil size is of paramount importance. Various topical and intra-cameral drugs are used in combination to achieve mydriasis. Despite good pre-operative dilation, the pupil can be quite unpredictable during surgery. Intra-operative miosis limits the field of surgery and increases the risk of complications. For example, if the pupil size decreases from 7 mm to 6 mm, this 1 mm change in pupil diameter will lead to a decrease of 10.2 mm2 in the area of surgical field. Making a good capsulorhexis with a small pupil can be a challenge, even for an experienced surgeon. Repeated touching of the iris increases the risk of fibrinous complications. Removal of cataract and the cortical matter becomes increasingly difficult. Intra-ocular lens implantation in the bag also requires adequate dilation. When dealing with challenging cases like lens subluxation, pseudo-exfoliation, and zonular dehiscence, a small pupil further increases the risk and adversely affects the surgical outcome. Hence, achieving and maintaining adequate mydriasis throughout surgery is essential. This review highlights the risk factors for small pupils during surgery and current management strategies.
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Affiliation(s)
- Savleen Kaur
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kiran Kumari
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Parul Chawla Gupta
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jaspreet Sukhija
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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6
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Kęcik D, Grabska-Liberek I, Jurowski P, Mrukwa-Kominek E, Omulecki W, Romanowska-Dixon B, Szaflik JP, Romaniuk W, Szaflik J, Kopacz D, Mianowska K. Pupil diameter during cataract surgery after intracameral injection of the first ready-to-use combination of mydriatics and anaesthetic at the beginning of surgery in patients with a preoperative pupil diameter <6 mm. Acta Ophthalmol 2023; 101:e81-e87. [PMID: 35974455 PMCID: PMC10087216 DOI: 10.1111/aos.15218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 06/07/2022] [Accepted: 07/19/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE We evaluated, in a real-life setting, the effect of Mydrane® (ready-to-use combination of tropicamide, phenylephrine hydrochloride and lidocaine, injected into the anterior chamber at the beginning of cataract surgery to induce mydriasis and intraocular anaesthesia) on the pupil diameter during cataract surgery in patients with a preoperative pupil diameter <6 mm after the use of topical mydriatics. METHODS We collected and analysed the data of 59 consecutive patients whose pupils dilated to a diameter <6 mm after the administration of mydriatic eye drops during the preoperative visit and who received Mydrane® during cataract surgery. RESULTS In the group of 59 patients with a preoperative pupil diameter <6 mm after topical mydriatics, cataract surgery was performed in 36 patients (61.0%) using only Mydrane® to obtain mydriasis, with no additional drug or medical device. The mean pupil diameters in this group (36 of 59) during the preoperative assessment after topical mydriatics and just before capsulorhexis when Mydrane® was injected during surgery were 5.1 ± 0.74 and 6.15 ± 1.14 mm. Additional drugs were used in 23 patients (39%). In this group, the mean pupil diameters after topical mydriatics and just before capsulorhexis using Mydrane® were 4.58 ± 1.06 and 5.6 ± 1.26 mm, respectively. CONCLUSION In a real-life setting, the mean pupil diameter achieved during cataract surgery after the intracameral injection of Mydrane® in patients with a preoperative pupil diameter <6 mm was over 1 mm larger than the mean pupil diameter after topical mydriatics, despite the trauma caused by the operation.
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Affiliation(s)
- Dariusz Kęcik
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
| | - Iwona Grabska-Liberek
- Department of Ophthalmology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Piotr Jurowski
- Department of Eye Diseases, Medical University of Lodz, Lodz, Poland
| | - Ewa Mrukwa-Kominek
- Department of Ophthalmology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Wojciech Omulecki
- Department of Ophthalmology, Medical University of Lodz, University Hospital No 1, Lodz, Poland
| | - Bożena Romanowska-Dixon
- Department of Ophthalmology and Ocular Oncology, Jagiellonian University Medical College, Cracow, Poland
| | - Jacek P Szaflik
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
| | - Wanda Romaniuk
- Department of Ophthalmology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Jerzy Szaflik
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
| | - Dorota Kopacz
- Department of Ophthalmology, Medical University of Warsaw, Warsaw, Poland
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7
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Zaluski S, Amzallag T, Bouchut P, Pinsard L, Theron JP, Tellouck-Morincomme J, Baffert S. Perioperative time and economic impact of an intracameral combination of mydriatics and anaesthetics in routine cataract surgery. Eur J Ophthalmol 2023; 33:239-246. [PMID: 35570572 DOI: 10.1177/11206721221101359] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE The aim of this study was to compare the perioperative time and economic impact of a licensed intracameral anaesthetic/mydriatic combination (Mydrane) during routine cataract surgery. METHODS A real-life, prospective, comparative study was performed in 3 clinical centres in France. Preoperative, surgical, and post-operative times were determined for two mydriasis strategies using conventional preoperative mydriatics/anaesthetics eye drops (control regimen) or Mydrane administered at time of surgery. Staff, surgery schedules and drugs utilisation were collected over 12 surgery half-days. The total cost of each strategy was estimated based on treatment cost and nursing costs. RESULTS The analysis included 112 routine cataract surgeries (57 surgeries using Mydrane and 55 using the topical regimen) without protocol deviations or complicated surgery. Overall, the mean time between administration of the first mydriatic eye drops or Mydrane and the end of the surgery was 27.4 ± 21.1 min in the Mydrane group vs. 90.3 ± 30.4 min in the control group (P < 0.0001). The total time of the procedure (from admission to discharge) was not significantly different between groups (P = 0.1611). On average, the extra cost of drugs per patient in the Mydrane group (€5.81) was almost balanced by the reduced nursing time (€5.57) with some variations between centres, due to different organisation including staff resource and consumable. CONCLUSIONS The Mydrane strategy produced perioperative nursing time saving and cost reduction provided that adaptation and reorganisation of routine cataract surgery are implemented.
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Affiliation(s)
- Serge Zaluski
- Polyclinique St Roch, Cabestany, France.,VISIS ophthalmological centre, Perpignan, France
| | | | | | - Loïc Pinsard
- Polyclinique St Roch, Cabestany, France.,VISIS ophthalmological centre, Perpignan, France
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Ripa M, Cuffaro G, Savastano MC, Grieco G, Rizzo S, Ricci F. Efficacy of the intracamerally administered mydriatics for cataract surgery in patients with primary open-angle glaucoma. Eur J Ophthalmol 2022; 33:1380-1389. [PMID: 36579807 DOI: 10.1177/11206721221146676] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE To compare Mydrane®, mydriatic eye drops, and Mydriasert® in terms of pupil site stability, surgical time, visual field, and anterior chamber configuration modifications among patients with primary open-angle glaucoma (POAG) during cataract extraction surgery. METHODS Retrospective analysis of sixty patients with POAG and cataract who underwent elective cataract extraction. All patients underwent routine ophthalmic examinations, including automatic visual field examination, anterior chamber configuration, specular microscopy, and arterial blood pressure measurement prior to surgery, and 24 h and 30 days postoperatively. All cataract surgeries were video-recorded and all measurements were performed using a media player. Patients divided into groups 1, 2, and 3 (n = 20 in each group) received topical mydriatic eye drops, Mydriasert®, and an intracameral injection of Mydrane®, respectively, immediately after the first incision. RESULTS The mean change in pupil size from just before capsulorhexis to the end of surgery was 0.43 ± 0.09, 0.42 ± 0.08, and 0.36 ± 0.02 mm in groups 1, 2, and 3, respectively. The mean surgery duration was similar among all the groups. The baseline main cell density slightly decreased at 24 h and remained stable for 30 days postoperatively. The mean deviation and pattern standard deviation remained stable at 1 month after surgery. At 24 h after surgery, the nasal irido-corneal angle, temporal-iridocorneal angle, and anterior chamber depth increased compared with the baseline, remaining stable for 30 days after surgery. CONCLUSIONS Mydrane® produced adequate and stable mydriasis as effectively as produced by Mydriasert® and topical eye drops.
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Affiliation(s)
- Matteo Ripa
- Ophthalmology Unit, 18654"Fondazione Policlinico Universitario A. Gemelli IRCCS", Rome, Italy.,9371Department of Ophthalmology, Catholic University "Sacro Cuore", Rome, Italy
| | - Giovanni Cuffaro
- Ophthalmology Unit, 18654"Fondazione Policlinico Universitario A. Gemelli IRCCS", Rome, Italy.,9371Department of Ophthalmology, Catholic University "Sacro Cuore", Rome, Italy
| | - Maria Cristina Savastano
- Ophthalmology Unit, 18654"Fondazione Policlinico Universitario A. Gemelli IRCCS", Rome, Italy.,9371Department of Ophthalmology, Catholic University "Sacro Cuore", Rome, Italy
| | - Giulia Grieco
- Ophthalmology Unit, 18654"Fondazione Policlinico Universitario A. Gemelli IRCCS", Rome, Italy.,9371Department of Ophthalmology, Catholic University "Sacro Cuore", Rome, Italy
| | - Stanislao Rizzo
- Ophthalmology Unit, 18654"Fondazione Policlinico Universitario A. Gemelli IRCCS", Rome, Italy.,9371Department of Ophthalmology, Catholic University "Sacro Cuore", Rome, Italy.,Consiglio Nazionale delle Ricerche, Istituto di Neuroscienze, Pisa, Italy
| | - Francesco Ricci
- Ophthalmology Unit, 18654"Fondazione Policlinico Universitario A. Gemelli IRCCS", Rome, Italy.,9371Department of Ophthalmology, Catholic University "Sacro Cuore", Rome, Italy
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9
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Uy HS, Cruz FM, Kenyon KR. Efficacy of a hinged pupil expansion device in small pupil cataract surgery. Indian J Ophthalmol 2021; 69:2688-2693. [PMID: 34571616 PMCID: PMC8597469 DOI: 10.4103/ijo.ijo_2857_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Purpose: To evaluate the efficacy and safety of a hinged pupil expansion device (PED) in eyes with small pupils undergoing phacoemulsification. Methods: In this prospective, multicenter, interventional case series of 57 eyes with suboptimal pharmacologic pupil dilation (<5 mm diameter), a hinged PED (I-Ring, Beaver-Visitec International, Waltham, MA) was applied to facilitate surgical visualization during cataract surgery. The pupil diameters (PD) were measured at different stages of the procedure and at the 1-month follow-up visit. Rate of successful intraoperative PED deployment, pupil size, and shape were assessed. Results: The mean patient age was 70.5 ± 12.1 years. The I-Ring PED was successfully applied in all eyes. The mean PD at various stages were 4.1 ± 1.1 mm (dilation with eye drops only preoperatively), 4.3 ± 1.1 mm (dilation after intracameral epinephrine and ophthalmic viscoelastic device), 6.80 ± 0.00 mm (with PED applied), and 5.7 ± 1.1 mm (end of surgery). A statistically significant difference (P < 0.001) was observed between the mean PD with intracameral medications and with PED application. Postoperative circular pupil was observed in 54 of 57 eyes (94.7%) and the mean eccentricity index (n = 57 eyes) was 0.11 ± 0.22. No significant adverse events were observed. Conclusion: The I-Ring PED safely and effectively provided and maintained adequate pupil expansion and surgical visualization in eyes with small pupils undergoing cataract surgery. Postoperatively 95% of eyes attained circular pupils. This hinged PED is an additional instrumentation option for the safe and effective expansion of inadequately sized pupils during cataract surgery.
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Affiliation(s)
- Harvey S Uy
- Peregrine Eye and Laser Institute, Makati City; Department Ophthalmology and Visual Sciences, University of the Philippines, Manila, Philippines
| | - Franz M Cruz
- Peregrine Eye and Laser Institute, Makati City; Department Ophthalmology and Visual Sciences, University of the Philippines, Manila, Philippines
| | - Kenneth R Kenyon
- Department of Ophthalmology, New England Eye Centre, Tufts University School of Medicine, Boston, MA, USA
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10
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Simons RWP, Rondas LUE, van den Biggelaar FJHM, Berendschot TTJM, Visser N, de Crom RMPC, Nuijts RMMA. Cost analysis of mydriasis strategies in cataract surgery care in the Netherlands. J Cataract Refract Surg 2021; 47:982-990. [PMID: 33577273 DOI: 10.1097/j.jcrs.0000000000000577] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/30/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate the economic impact of an intracameral mydriatics and anesthetic agent (ICMA), topical mydriatics, and a mydriatic ocular insert in cataract patients. SETTING One public hospital in the Netherlands. DESIGN Prospective cohort study. METHODS Resource use data were collected from a healthcare and societal perspective on the day of surgery. Other outcome parameters included pupil size, surgeon satisfaction, postoperative pain, and Catquest-9SF scores. RESULTS A total of 368 patients were included, the mean costs per patient were €506 in the ICMA group (n = 122), €474 in the ocular insert group (n = 115), and €451 in the topical group (n = 131). The acquisition cost of ICMA was highest and resulted in longer surgical time. After correction for an imbalance in the distribution of fast and slow surgeons, the mean costs in the ocular insert and topical groups were comparable (€450 vs €444). There was no statistically significant difference in the use of additional mydriatics intraoperatively (P = .521). The mean ratio of pupil size to white-to-white distance was lower in the ICMA group during all intraoperative measurements (P < .001) but similar between the topical and ocular insert groups (P range .11-.82). CONCLUSIONS In the investigated setting in the Netherlands, ICMA was the most costly strategy. In addition, pupil size was lowest in the ICMA group but did not result in more additional mydriasis measures intraoperatively. The ocular insert was comparable with topical mydriatics in costs and pupil size. Implementation of ICMA could be considered when availability of nurses or physical space for perioperative care is limited.
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Affiliation(s)
- Rob W P Simons
- From the University Eye Clinic Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands (Simons, Rondas, van den Biggelaar, Berendschot, Visser, de Crom, Nuijts); Department of Ophthalmology, Zuyderland Medical Center Heerlen, Sittard-Geleen, the Netherlands (Visser, de Crom, Nuijts)
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11
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Kaur S, Korla S, Ram J, Gupta PC, Sukhija J. Intracameral anesthetic mydriatic (ICAM) assisted pediatric cataract surgery. Eur J Ophthalmol 2021; 32:11206721211006575. [PMID: 33781116 DOI: 10.1177/11206721211006575] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To assess the efficacy and safety of intracameral mydriatic and anesthetic combination for pupillary dilation in pediatric cataract surgery. METHODS This prospective series included children <12 years, with visually significant unilateral or bilateral cataracts planned for cataract surgery with/without intraocular lens implantation. At the beginning of surgery, 0.025 ml of a combination of phenylephrine hydrochloride (0.31%), tropicamide (0.02%), and lidocaine hydrochloride (1%) was injected intracamerally. The efficacy of the combination was tested by achieving capsulorhexis and intraocular lens implantation without additional mydriatics. RESULTS We recruited 13 patients (16 eyes) with a mean age of 4.1 ± 3.9 years. The mean pupillary diameter changed increased from 1.92 to 5.68 mm after injection of one unit (0.025 ml) of drug (p < 0.0001). There was a strong positive correlation of the pupillary dilation with axial length (R = 0.86) and horizontal corneal diameter (R = 0.81). Seventy-five percent patients had a pupillary diameter >6 mm and surgery could be completed successfully in all cases without additional mydriatics. In all cases, pupil dilated as the surgery progressed. No adverse event to the drug was noted. CONCLUSIONS Intracameral mydriatic-anesthetic combination is an effective and safe way to obtain stable mydriasis in pediatric cataract surgery.
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Affiliation(s)
- Savleen Kaur
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shagun Korla
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jagat Ram
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Parul Chawla Gupta
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jaspreet Sukhija
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Sarkar S, Kasturi N, Bardoloi N. Minimizing topical medication in cataract surgery. TNOA JOURNAL OF OPHTHALMIC SCIENCE AND RESEARCH 2021. [DOI: 10.4103/tjosr.tjosr_61_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Assessment of the duration of surgery and patient turnover after the incorporation of a standardized intracameral combination of mydriatics and anesthetics for cataract surgery. J Cataract Refract Surg 2020; 46:1487-1494. [DOI: 10.1097/j.jcrs.0000000000000306] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Labetoulle M, Behndig A, Tassignon MJ, Nuijts R, Mencucci R, Güell JL, Pleyer U, Szaflik J, Rosen P, Bérard A, Chiambaretta F, Cochener-Lamard B. Safety and efficacy of a standardized intracameral combination of mydriatics and anesthetic for cataract surgery in type-2 diabetic patients. BMC Ophthalmol 2020; 20:81. [PMID: 32126990 PMCID: PMC7055021 DOI: 10.1186/s12886-020-01343-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/14/2020] [Indexed: 01/19/2023] Open
Abstract
Background Cataract surgery in diabetics is more technically challenging due to a number of factors including poor intraoperative pupil dilation and a higher risk of vision threatening complications. This study evaluates the safety and efficacy of an intracameral combination of 2 mydriatics and 1 anesthetic (ICMA, Mydrane) for cataract surgery in patients with well-controlled type-2 diabetes. Methods Post-hoc subgroup analysis of a phase 3 randomized study, comparing ICMA to a conventional topical regimen. Data were collected from 68 centers in Europe and Algeria. Only well-controlled type-2 diabetics, free of pre-proliferative retinopathy, were included. The results for non-diabetics are also reported. The primary efficacy variable was successful capsulorhexis without additional mydriatic treatment. Postoperative safety included adverse events, endothelial cell density and vision. Results Among 591 randomized patients, 57 (9.6%) had controlled type 2 diabetes [24 (42.1%) in the ICMA Group and 33 (57.9%) in the Topical Group; intention-to-treat (ITT) set]. Among diabetics, capsulorhexis was successfully performed without additional mydriatics in 24 (96.0%; modified-ITT set) patients in the ICMA Group and 26 (89.7%) in the Topical Group. These proportions were similar in non-diabetics. No diabetic patient [1 (0.5%) non-diabetics] in the ICMA Group had a significant decrease in pupil size (≥3 mm) intraoperatively compared to 4 (16.0%; modified-ITT set) diabetics [16 (7.3%) non-diabetics] in the Topical group. Ocular AE among diabetics occurred in 2 (8.0%; Safety set) patients in the ICMA Group and 5 (16.7%) in the Topical Group. Endothelial cell density at 1 month postoperatively was similar between groups in diabetics (P = 0.627) and non-diabetics (P = 0.368). Conclusions ICMA is effective and can be safely used in patients with well-controlled diabetes, with potential advantages compared to a topical regimen including reduced systemic risk, better corneal integrity and reduced risk of ocular complications. Trial registration The trial was registered at (reference # NCT02101359) on April 2, 2014.
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Affiliation(s)
- Marc Labetoulle
- Service d'Ophtalmologie, Hôpital Bicêtre, APHP, Université Paris Sud, Le Kremlin-Bicêtre, 94275, Paris, France.
| | | | | | - Rudy Nuijts
- University Eye Clinic, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Rita Mencucci
- A.O.U. Careggi, Clinica Oculistica, Università degli Studi di Firenze, Florence, Italy
| | | | - Uwe Pleyer
- Universitäts-Augenklinik, Charité Campus Virchow-Klinik, Berlin, Germany
| | - Jacek Szaflik
- Department of Ophthalmology, Medical University of Warsaw, Warszawa, Poland
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Tropicamide/Phenylephrine/Lidocaine Intracameral Injection: A Review in Cataract Surgery. Clin Drug Investig 2020; 39:1133-1139. [PMID: 31471864 DOI: 10.1007/s40261-019-00843-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Tropicamide 0.02%/phenylephrine 0.31%/lidocaine 1% injectable solution (Mydrane®) is the first fixed-dose mydriatic/anaesthetic combination approved for intracameral use in adults undergoing cataract surgery. In a phase 3 trial in this setting, intracameral tropicamide/phenylephrine/lidocaine was at least as effective as a standard topical regimen of tropicamide plus phenylephrine in enabling successful capsulorhexis without the use of additional mydriatics. The intracameral preparation, which is administered via a single injection, provides rapid and sustained mydriasis through to the end of surgery, with recipients spending around half as long in preoperative/surgery rooms as standard topical regimen recipients in the phase 3 study. Moreover, significantly more of the intracameral than topical regimen recipients were free from pain or pressure in the eye/orbit before intraocular lens (IOL) implantation and had an IOL implanted without complications. Intracameral tropicamide/phenylephrine/lidocaine also displayed mydriatic efficacy in patients with diabetes in this trial. Overall, the preparation was generally well tolerated, with no serious adverse events leading to hospitalization or permanent vision loss. Thus, tropicamide/phenylephrine/lidocaine injectable solution is an emerging option for mydriasis/anaesthesia in adults undergoing cataract surgery.
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Abstract
PURPOSE OF REVIEW Routine prophylaxis for adverse events following cataract surgery is evolving. Prior reliance on topical eyedrop instillation by patients is giving way to surgeon directed injections at the time of cataract surgery. The benefit of this new approach is assured delivery of drugs in standardized doses which should optimize the healing process and reduce the incidence of untoward events with higher confidence. RECENT FINDINGS Adoption rates of intracameral antibiotic injection amongst European and American cataract surgeons is increasing. Techniques to inject periocular corticosteroid for routine inflammation prophylaxis are also in development. In combination with intraoperative pharmacologic dilation, a drop-free modality can be achieved. SUMMARY Intraoperative injections offer the patient and surgeon assured drug delivery and hold promise to avoid the pitfalls of patient adherence, incorrect topical instillation, and topical drop-associated corneal issues.
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Affiliation(s)
- Neal H Shorstein
- Departments of Ophthalmology and Quality, Shorstein - Kaiser Permanente, Oakland, California; Department of Ophthalmology, Myers - Northwestern University, Chicago, IL
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Grzybowski A, Brockmann T, Kanclerz P, Pleyer U. Dexamethasone Intraocular Suspension: A Long-Acting Therapeutic for Treating Inflammation Associated with Cataract Surgery. J Ocul Pharmacol Ther 2019; 35:525-534. [DOI: 10.1089/jop.2019.0072] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Andrzej Grzybowski
- University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
- Institute for Research in Ophthalmology, Foundation for Ophthalmology Development, Poznan, Poland
| | - Tobias Brockmann
- Department of Ophthalmology, Campus Virchow Klinikum, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | | | - Uwe Pleyer
- Department of Ophthalmology, Campus Virchow Klinikum, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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de Faria A, Giorgi R, Cohen Salmon M, Bonnel S, Holweck G, Le Corre A, Chazalon E. [Same-eye comparison of pupillary dilation with an intraoperative standardized intracameral combination of mydriatics (Mydrane®) versus a preoperative ophthalmic (Mydriasert®) in standard cataract surgery in non-diabetic patients (French translation of the article)]. J Fr Ophtalmol 2019; 42:1068-1077. [PMID: 31668379 DOI: 10.1016/j.jfo.2019.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/26/2018] [Accepted: 02/04/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Cataract surgery is the most commonly performed surgery in the world, and its success depends in part on the quality of mydriasis. PURPOSE To compare, for the same eye, the pupillary dilation obtained with Mydrane® (standardized intracameral solution of 0.02% tropicamide, combined with 0.31% phenylephrine and 1% lidocaine) intraoperatively versus Mydriasert® (0.28mg tropicamide insert and 5.4mg phenylephrine) with a contact time between 45 and 60 minutes in the preoperative period. METHODS Single center prospective study from November 2016 to January 2018 at the Laveran Army Instructional Hospital in Marseille. Patients referred for surgery were dilated at the preoperative consultation with Mydriasert®. The pupillary diameter after 45-60 minutes of contact with the insert was manually measured, by two different examiners, through the "iris image" tab of the Pentacam® elevation topography. Patients were dilated on the day of their cataract surgery with 0.2cc of Mydrane® injected in the anterior chamber through a paracentesis. Thirty seconds later, prior to injection of viscoelastic, an eye photograph was taken by screen capture. The pupillary diameter was evaluated by two different examiners with to the Piximeter 5.9 metrology software. The difference in pupil dilation between Mydriasert® and Mydrane® was tested with the paired series Student t-test. RESULTS In total, 111 eyes of 82 patients were included. Mydriasert® achieved a mean pupillary dilation of 7.21±0.79mm. The mydriasis obtained with Mydrane® averaged 6.35±0.8mm. This difference of 0.86mm was statistically significant (P<0.001) with a confidence interval of 95% [-0.97; -0.74]. CONCLUSION On average, Mydrane® dilates the pupil less than Mydriasert®. However, the mydriasis obtained with Mydrane® remains comfortable for the performance of the capsulorhexis. It helps save preoperative time and affords additional anesthetic to the cataract surgery. Nevertheless, the use of Mydriasert® is beneficial when extra mydriasis is required.
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Affiliation(s)
- A de Faria
- Ophthalmology, HIA Laveran, Marseille, France.
| | - R Giorgi
- Department of Public Health (BIOSTIC), hôpital la Timone, APHM, Marseille, France
| | | | - S Bonnel
- Ophthalmology, HIA Laveran, Marseille, France
| | - G Holweck
- Ophthalmology, HIA Laveran, Marseille, France
| | - A Le Corre
- Ophthalmology, HIA Laveran, Marseille, France
| | - E Chazalon
- Ophthalmology, HIA Laveran, Marseille, France
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Same-eye comparison of pupillary dilation with an intraoperative standardized intracameral combination of mydriatics (Mydrane®) versus a preoperative ophthalmic (Mydriasert®) in standard cataract surgery in non-diabetic patients. J Fr Ophtalmol 2019; 42:e339-e348. [DOI: 10.1016/j.jfo.2019.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/24/2019] [Accepted: 06/16/2019] [Indexed: 11/21/2022]
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Guell J, Behndig A, Pleyer U, Jaulerry S, Rozot P, Pisella PJ, Robert PY, Lanzl I, Pourjavan S, Aguiar C, Fernandez J, Grabner G, Mencucci R, Chiambaretta F, Labetoulle M. Systemic exposure to intracameral vs topical mydriatic agents: in cataract surgery. Clin Ophthalmol 2019; 13:811-819. [PMID: 31118559 PMCID: PMC6501990 DOI: 10.2147/opth.s189671] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective The objective of this study was to compare systemic exposure to tropicamide/phenylephrine following intracameral or topical administration before cataract surgery. Patients and methods Mydriatics exposure was calculated in patients randomized to intracameral fixed combination of mydriatics and anesthetic ([ICMA]: tropicamide 0.02%, phenylephrine 0.31%, and lidocaine 1%, N=271) or mydriatic eye drops ([EDs]: tropicamide 0.5% and phenylephrine 10%, N=283). Additional doses were permitted if required. Mydriatic plasma levels were determined by mass spectrometric HPLC in 15 patients per group before and after administration. Results Most ICMA patients (73.6%) received a single dose (200 µL) representing an exposure to tropicamide of 0.04 mg and phenylephrine of 0.62 mg. None of these patients received additional mydriatics. In the control group (three administrations), the exposure was 0.45 (11.3-fold higher than ICMA) and 10.2 (16.5-fold higher) mg. When additional ED was used in this group (9.2% of patients), it was 37.5-fold higher for tropicamide (10 drops, 1.5 mg) and 54.8-fold higher for phenylephrine (10 drops, 34 mg) than the recommended ICMA dose. Tropicamide plasma levels were not detectable at any time point in ICMA patients while it was detectable in all ED patients at 12 and 30 minutes. Phenylephrine was detectable in 14.3% of ICMA patients compared to all ED patients at least at one time point. More ED patients experienced a meaningful increase in blood pressure and/or heart rate (11.2% vs 6.0% of ICMA patients; P=0.03). Conclusion Systemic exposure to tropicamide/phenylephrine was lower and cardiovascular (CV) effects were less frequent with ICMA. This could be of particular significance in patients at CV risk.
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Affiliation(s)
- Jose Guell
- Cornea and Refractive Surgery Unit, Instituto de Microcirugía Ocular, Barcelona, Spain,
| | - Anders Behndig
- Department of Clinical Science/Ophthalmology, Umeå University Hospital, Umeå, Sweden
| | - Uwe Pleyer
- Universitäts-Augenklinik, Charité Campus Virchow-Klinik, Berlin, Germany
| | | | | | | | | | - Ines Lanzl
- Chiemsee Augen Tagesklinik, Prien, Germany
| | | | | | | | - Gunther Grabner
- Universitätsklinik Für Augenheilkunde Und Optometrie, Der Paracelsus, Austria
| | - Rita Mencucci
- AOU Careggi, Clinica Oculistica, Università Degli Studi di Firenze, Firenze, Italy
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