Impact of First Eye versus Second Eye Cataract Surgery on Visual Function and Quality of Life

THE IMPACT OF BILATERAL VISION STATUS ON VISION-RELATED QUALITY OF LIFE IN PEOPLE WITH DIABETES MELLITUS

PURPOSE

To assess the impact of bilateral vision status on vision-related quality of life (VR-QOL) in patients with Type 2 diabetes in a Chinese cohort.

METHODS

Patients with presenting visual acuity (PVA) and VR-QOL data from the Fushun Diabetic Retinopathy Cohort Study were included. Vision-related quality of life was assessed using the National Eye Institute Visual Function Questionnaire-25. Monocular PVA (Snellen) was categorized into three levels for both the better-seeing eye and worse-seeing eye: 1) high PVA (H, > 6/18); 2) moderate PVA (M, 6/18-6/60); and 3) low PVA (L, < 6/60). Based on the monocular PVAs, six categories of bilateral vision status were defined (H-H, H-M, H-L, M-M, M-L, and L-L). The parameters of VR-QOL were analyzed between the groups.

RESULTS

A total of 1,717 patients were enrolled. For better-seeing eyes in the same PVA level, the Visual Function Questionnaire-25 composite score decreased significantly with declining PVA in the worse-seeing eye (H-M vs. H-L: 80.5 ± 17.9 vs. 73.6 ± 22.5, P = 0.01; M-M vs. M-L: 78.7 ± 19.6 vs. 69.1 ± 26.4, P = 0.01). Conversely, for worse-seeing eyes in the same PVA level, there was no significant difference in the Visual Function Questionnaire-25 composite score as PVA changed in the better-seeing eye (H-M vs. M-M, 80.5 ± 17.9 vs. 78.7 ± 19.6, P = 0.30; H-L vs. M-L: 73.6 ± 22.5 vs. 69.1 ± 26.4, P = 0.25).

CONCLUSION

The PVA of the worse-seeing eye in bilateral vision has a greater impact on VR-QOL in diabetic patients. Priority treatment may be considered for the worse-seeing eye for diabetic patients with different bilateral vision statuses, to better improve VR-QOL.

Comparative visual outcomes of the first versus second eye following small-incision lenticule extraction (SMILE)

BACKGROUND

This study aimed to compare the visual outcomes of the first operated eyes with those of the second operated eyes following small-incision lenticule extraction (SMILE).

METHODS

A total of 202 patients (404 eyes) underwent SMILE using the tear film mark centration method for myopia and myopic astigmatism correction. Baseline characteristics, objective optical quality, decentered displacement, induced corneal aberrations, and modulation transfer function (MTF) values were assessed. Linear regression analyzed the relationship between decentration and visual quality parameters, including corneal aberrations and MTF values.

RESULTS

No significant difference was observed in objective visual quality, efficacy, and safety indexes between the two groups (all P > 0.05). The average decentered displacement for the first and second surgical eyes was 0.278 ± 0.17 mm and 0.315 ± 0.15 mm, respectively (P = 0.002). The horizontal coma in the first surgical eyes were notably lower than in the second (P = 0.000). MTF values at spatial frequencies of 5, 10, 15, and 20 cycles/degree (c/d) were higher in the first surgical eyes compared to the second (all P < 0.05). Linear regression indicated that high-order aberrations (HOAs), root mean square (RMS) coma, spherical aberration, horizontal coma, vertical coma, and eccentric displacement were all linearly correlated. Furthermore, MTF values exhibited a linear relationship with eccentric displacement across these spatial frequencies.

CONCLUSIONS

There was no discernible difference in visual acuity, efficacy, or safety between the two operated eyes. Nonetheless, the first operated eyes exhibited reduced decentered displacement and demonstrated superior outcomes in terms of horizontal coma and MTF values compared to the second operated eyes following SMILE. The variations in visual quality parameters were linearly correlated with decentered displacement.

The association between cataract surgery and mental health in older adults: a review

BACKGROUND

Although cataract surgery has been proposed as a potentially modifiable protective factor for enhancing emotional well-being in cataract patients, studies examining the relationship between anxiety or depression and cataract surgery have yielded inconsistent findings. This review summarizes existing evidence to establish whether cataract surgery is associated with depression and anxiety in older adults.

METHODS

A literature search was conducted across PubMed, Medline, Web of Science, and Embase databases. An initial screening by abstracts and titles was performed, followed by a review and assessment of the methodological quality of the relevant full papers, and final inclusion of 44 studies were deemed eligible for inclusion in this review.

RESULTS

Among 44 included studies, 36 studies (81.8%) were observational studies concerning the association of cataract surgery or cataracts with anxiety or depression, four studies (9.1%) were interventional studies, and four studies (9.1%) were reviews. Cataract surgery notably enhances the mental health of individuals with impaired vision. However, the multifaceted nature of psychological well-being, influenced by various factors, suggests that cataract surgery may not address all aspects comprehensively. Additionally, preoperative anxiety and depression significantly impact cataract surgery outcomes.

CONCLUSION

Vision impairment in older adults is closely associated with increased symptoms of depression and anxiety. While surgical intervention for cataracts improves these symptoms, it might be less effective for mental disorders with multifactorial causes. Notably, anxiety or depression poses challenges to successful preoperative and intraoperative cataract surgeries.

Global estimates on the number of people blind or visually impaired by cataract: a meta-analysis from 2000 to 2020

BACKGROUND

To estimate global and regional trends from 2000 to 2020 of the number of persons visually impaired by cataract and their proportion of the total number of vision-impaired individuals.

METHODS

A systematic review and meta-analysis of published population studies and gray literature from 2000 to 2020 was carried out to estimate global and regional trends. We developed prevalence estimates based on modeled distance visual impairment and blindness due to cataract, producing location-, year-, age-, and sex-specific estimates of moderate to severe vision impairment (MSVI presenting visual acuity <6/18, ≥3/60) and blindness (presenting visual acuity <3/60). Estimates are age-standardized using the GBD standard population.

RESULTS

In 2020, among overall (all ages) 43.3 million blind and 295 million with MSVI, 17.0 million (39.6%) people were blind and 83.5 million (28.3%) had MSVI due to cataract blind 60% female, MSVI 59% female. From 1990 to 2020, the count of persons blind (MSVI) due to cataract increased by 29.7%(93.1%) whereas the age-standardized global prevalence of cataract-related blindness improved by -27.5% and MSVI increased by 7.2%. The contribution of cataract to the age-standardized prevalence of blindness exceeded the global figure only in South Asia (62.9%) and Southeast Asia and Oceania (47.9%).

CONCLUSIONS

The number of people blind and with MSVI due to cataract has risen over the past 30 years, despite a decrease in the age-standardized prevalence of cataract. This indicates that cataract treatment programs have been beneficial, but population growth and aging have outpaced their impact. Growing numbers of cataract blind indicate that more, better-directed, resources are needed to increase global capacity for cataract surgery.

Immediately sequential bilateral cataract surgery

PURPOSE OF REVIEW

This review aims to clarify the advantages and disadvantages of immediately sequential bilateral cataract surgery (ISBCS) based on recent studies, illustrate the safety of this approach, the cost-effectiveness, and present the importance of inclusion protocols for the best results.

RECENT FINDINGS

In recent studies, the authors found no evidence of an increased risk of bilateral devastating complications such as endophthalmitis with ISBCS based on descriptive evidence compared to delayed sequential bilateral cataract surgery (DSBCS). Furthermore, recent studies on cost analyses showed that ISBCS resulted in fewer costs and significant cost savings to third-party payers, patients, and society compared to DSBCS.

SUMMARY

The ISBCS surgical approach decreases hospital visits, reduces costs, and provides rapid visual rehabilitation and neuro adaptation. The risk of bilateral simultaneous complications is now recognized to be very rare with intracameral antibiotics and compliance with correct protocols. With new generations of optical biometry and lens calculation formulas, refractive surprises are occasional for normal eyes. However, refractive surprise is controversial, especially in the implantation of presbyopia correction intra-ocular lenses, which must be evaluated carefully in the ISBCS approach.

An update on immediate sequential bilateral cataract surgery

PURPOSE OF REVIEW

The aim of this study was to present an overview of recent publications and opinions in the field of same-day bilateral cataract surgery.

RECENT FINDINGS

A Cochrane review was published comparing immediate sequential bilateral cataract surgery (ISBCS) and delayed sequential bilateral cataract surgery (DSBCS) with regard to safety outcomes, costs and cost-effectiveness. In addition, several large database studies provided more information on incidences of rare complications such as unilateral and bilateral endophthalmitis rates.

SUMMARY

Recently available evidence showed that ISBCS is an effective and cost-effective alternative to DSBCS. Nonetheless, additional (randomized) registry studies, randomized controlled trials and cost-effectiveness studies are needed to evaluate bilateral endophthalmitis rates, refractive outcomes and cost-effectiveness of ISBCS compared with DSBCS.

Immediate sequential bilateral surgery versus delayed sequential bilateral surgery for cataracts

BACKGROUND

Age-related cataract affects both eyes in most cases. Most people undergo cataract surgery in both eyes on separate days, referred to as delayed sequential bilateral cataract surgery (DSBCS). An alternative procedure involves operating on both eyes on the same day, but as two separate procedures, known as immediate sequential bilateral cataract surgery (ISBCS). Potential advantages of ISBCS include fewer hospital visits for the patient, faster visual recovery, and lower healthcare costs. Nevertheless, concerns exist about possible bilateral, postoperative, sight-threatening adverse effects with ISBCS. Therefore, there is a clear need for evaluating evidence regarding the safety, effectiveness, and cost-effectiveness of ISBCS versus DSBCS.

OBJECTIVES

To assess the safety of ISBCS compared to DSBCS in people with bilateral age-related cataracts and to summarise current evidence for the incremental resource use, utilities, costs, and cost-effectiveness associated with the use of ISBCS compared to DSBCS in people with bilateral age-related cataracts (primary objectives). The secondary objective was to assess visual and patient-reported outcomes of ISBCS compared to DSBCS in people with bilateral age-related cataracts.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register; 2021, Issue 5); Ovid MEDLINE; Ovid Embase; the ISRCTN registry; ClinicalTrials.gov; the WHO ICTRP; and DARE and NHS EED on the CRD Database on 11 May 2021. There were no language restrictions. We limited the searches to a date range of 2007 onwards.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) to assess complications, refractive outcomes, best-corrected distance visual acuity (BCDVA) and patient-reported outcome measures (PROMs) with ISBCS compared to DSBCS. We included non-randomised (NRSs), prospective, and retrospective cohort studies comparing ISBCS and DSBCS for safety assessment, because of the rare incidence of important adverse events. To assess cost-effectiveness of ISBCS compared to DSBCS, we included both full and partial economic evaluations, and both trial-based and model-based economic evaluations.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures and assessed risk of bias for NRSs using the ROBINS-I tool. For cost-evaluations, we used the CHEC-list, the CHEERS-checklist, and the NICE-checklist to investigate risk of bias. We assessed the certainty of evidence with the GRADE tool. We reported results for economic evaluations narratively.

MAIN RESULTS

We included 14 studies in the review; two RCTs, seven NRSs, and six economic evaluations (one study was both an NRS and economic evaluation). The studies reported on 276,260 participants (7384 for ISBCS and 268,876 for DSBCS) and were conducted in Canada, the Czech Republic, Finland, Iran, (South) Korea, Spain (Canary Islands), Sweden, the UK, and the USA. Overall, we considered the included RCTs to be at 'high to some concerns' risk of bias for complications, 'some concerns' risk of bias for refractive outcomes and visual acuity, and 'high' risk of bias for PROMs. The overall risk of bias for NRSs was graded 'serious' regarding complications and 'serious to critical' regarding refractive outcomes.  With regard to endophthalmitis, we found that relative effects were estimated imprecisely and with low certainty, so that relative estimates were not reliable. Nonetheless, we found a very low risk of endophthalmitis in both ISBCS (1/14,076 participants) and DSBCS (55/556,246 participants) groups. Based on descriptive evidence and partially weak statistical evidence we found no evidence of an increased risk of endophthalmitis with ISBCS. Regarding refractive outcomes, we found moderate-certainty (RCTs) and low-certainty (NRSs) evidence there was no difference in the percentage of eyes that did not achieve refraction within 1.0 dioptre of target one to three months after surgery (RCTs: risk ratio (RR) 0.84, 95% confidence interval (CI) 0.57 to 1.26; NRSs: RR 1.02, 95% CI 0.60 to 1.75). Similarly, postoperative complications did not differ between groups (RCTs: RR 1.33, 95% CI 0.52 to 3.40; NRSs: 1.04, 95% CI 0.47 to 2.29), although the certainty of this evidence was very low for both RCTs and NRSs. Furthermore, we found low-certainty (RCTs) to very low-certainty (NRSs) evidence that total costs per participant were lower for ISBCS compared to DSBCS, although results of individual studies could not be pooled. Only one study reported on cost-effectiveness. This study found that ISBCS is cost-effective compared to DSBCS, but did not measure quality-adjusted life years using preferred methods and calculated costs erroneously. Finally, regarding secondary outcomes, we found limited evidence on BCDVA (data of two RCTs could not be pooled, although both studies individually found no difference between groups (very low-certainty evidence)). Regarding PROMs, we found moderate-certainty evidence (RCTs only) that there was no difference between groups one to three months after surgery (standardised mean difference -0.08, 95% CI -0.19 to 0.03).

AUTHORS' CONCLUSIONS

Current evidence supports there are probably no clinically important differences in outcomes between ISBCS and DSBCS, but with lower costs for ISBCS. However, the amount of evidence is limited, and the certainty of the evidence was graded moderate to very low. In addition, there is a need for well-designed cost-effectiveness studies.

The impact of phacoemulsification surgery on vision-related quality of life in senile cataract patients

BACKGROUND

Phacoemulsification surgery may have beneficial effects on the quality of life of patients with senile cataract. These effects can be evaluated with the help of questionnaires and tests.

PURPOSE

To evaluate the effect of the phacoemulsification surgery on the vision-related quality of life (VR-QOL) in patients with senile cataract using the 25-item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) and functional independence measure (FIM) tests.

METHODS

The data collection was prospective. NEI-VFQ-25 and FIM tests were measured by a masked ergo-therapist. The patients who underwent phacoemulsification surgery were included in this study. Mean best-corrected visual acuity (BCVA), NEI-VFQ-25 and FIM scores were compared in the preoperative period and at least 3 months after the surgery according to demographic properties including gender, age, education status, as well as the BCVA level and laterality.

RESULTS

Preoperative mean BCVA and NEI-VFQ-25 composite scores improved significantly (p < 0.001 and p = 0.001, respectively). All NEI-VFQ-25 subscale scores except the general health (p = 0.235) and driving (p = 0.226) showed a significant postoperative increase. The postoperative NEI-VFQ-25 composite scores showed a significant increase in all subgroup analyses (p < 0.05 for all). Patients with poorer BCVA, bilateral surgery, and low education status had lower preoperative NEI-VFQ-25 composite scores than the patients with better BCVA, unilateral surgery, and high education status (p = 0.026, p = 0.016, and p = 0.032, respectively). All FIM scores were similar in the preoperative and postoperative periods regardless of subgroup analyses (p > 0.05 for all).

CONCLUSION

Phacoemulsification surgery can provide a satisfying improvement in VR-QOL in patients with cataracts. As a valid and reliable test, the NEI-VFQ-25 scale can be used to measure the visual function after the ocular surgeries.

Efficacy and complications of cataract surgery in high myopia

To evaluate the efficacy and complications of cataract surgery in high myopia, a comprehensive search query was conducted from January 2000 to August 2020. A total of 19 586 highly myopic eyes from 28 studies were included. Modern cataract surgery turns out efficacious in highly myopic eyes with significant improvement of visual acuity. However, phacoemulsification-related complications such as posterior capsular rupture (3.91%, 95% CI, 1.98%-6.37%), retinal detachment (1.74%, 95% CI, 1.36%-2.15%), progressed myopic traction maculopathy (5.07%, 95% CI, 1.80%-9.37%), capsular contraction syndrome (2.1%), intraocular lens dislocation (0.58%), and transient intraocular pressure elevation (28.15%, 95% CI, 20.29%-36.70%) occurred more frequently in the highly myopic population. Separate analyses were also conducted based on follow-up period. In conclusion, modern cataract surgery was effective for highly myopic cataract patients, whereas careful precautions and sufficient follow-ups were of great value because of higher incidences of intraoperative and postoperative complications.

The Additive Value of Foveal OCT-Based Biometry to Fundus Biomicroscopy for Detecting Macular Pathology Prior to Cataract Surgery

PURPOSE

To assess the additive value of foveal swept-source optical coherence tomography (OCT)-based biometry to the preoperative fundus examinations for diagnosing macular abnormalities in patients scheduled for cataract surgery.

DESIGN

Diagnostic testing evaluation.

METHODS

Consecutive patients 50 years of age and older planned for cataract surgery from one institution were retrospectively enrolled. All patients underwent foveal swept-source OCT, and macular spectral domain (SD) OCT scans before pupil dilation as well as dilated fundus biomicroscopy examination. The effectiveness of fundus biomicroscopy examinations, foveal swept-source OCT scans, and the combination of both in identifying macular diseases was analyzed with macular spectral-domain OCT scans as reference.

RESULTS

Seventy-eight of the eligible 442 eyes (442 patients) were excluded because of noninterpretable macular spectral-domain OCT OCT scans or foveal swept-source OCT scans. The remaining 364 eyes of 364 patients (mean age 73.59±9.26 years [range 49-96], 172 males) formed the study group. Fundus biomicroscopy alone vs fundus biomicroscopy with the addition of foveal swept-source OCT yielded 36% vs 63% sensitivity, 94% vs 72% specificity, 79% vs 58% positive predictive value (PPV), and 71% vs 76% negative predictive value (NPV), respectively. This diagnostic improvement was significant compared with fundus biomicroscopy alone (P = 2.98^-8).

CONCLUSION

Combined fundus biomicroscopy and foveal swept-source OCT scans improved the detection of macular abnormalities prior to cataract surgery but it was inferior to macular spectral-domain OCT scans. Additional studies to assess the cost-effectiveness of adding foveal swept-source OCT scan in comparison to macular spectral-domain OCT scan to the preoperative cataract evaluation are required.

Open globe injuries: Epidemiology, visual and surgical predictive variables, prognostic models, and economic cost analysis

BACKGROUND

Open globe injuries (OGI) represent a visually and economically devastating cause of vision loss. We examined the epidemiology, predictive variables, prognostic models, and economic cost of surgically managed OGI.

METHODS

A retrospective tertiary centre study from 2008 to 2018 of 155 consecutive OGI in individuals aged 16 and older was performed. Medical records review, application of Ocular Trauma Score (OTS) and Classification and Regression Tree Analysis (CART) and cost analysis were undertaken. Key outcomes measured were visual acuity, number of operating theatre visits, prognostication using OTS and CART and estimated costs.

RESULTS

Younger males at work with inadequate protective eyewear (89.1%) and falls in the elderly were overrepresented. Inferior visual outcomes were associated with a more severe OTS score, a larger injury zone, increasing age, the presence of retinal detachment, extraocular muscle involvement, intraocular foreign body, and globe rupture (R²  = 0.723, p < 0.001). Multiple operating theatre visits were required in the presence of retinal detachment, lens or orbit involvement, work-related injury, globe rupture, and a history of previous intraocular surgery (R²  = 0.0423, p < 0.001). Both OTS and CART prognosticated outcomes (p < 0.001). The OTS predicted for no vision (no light perception/enucleation/evisceration) and profound visual loss (worse than 6/120; specificity: both 100%, sensitivity: 88.2% and 88%) whereas the CART predicted for visual survival (light perception or better) and minimal-to-severe visual loss (6/120 or better; specificity: 88.5% and 81.7% , sensitivity: 97.7% and 100%). Estimated annual OGI cost for Australia was AUD48.1-60.5 million (USD37.3-47.0 million).

CONCLUSIONS

The total cost of OGI is immense with young males and the elderly being disproportionately affected. Implementation of targeted government legislation and public health preventative measures may be cost-effective in ameliorating the significant burden.

Implementing ICHOM standard set for cataract surgery at IPO-Porto (Portugal): clinical outcomes, quality of life and costs

BACKGROUND

This paper fills a gap in the applied research field, for a local context, by addressing the topics of describing cataract surgery' clinical outcomes; quality of life (QoL); and costs of the patients treated after the implementation of the ICHOM standard set.

METHODS

This is a retrospective observational study using real-world data (RWD). We included all patients subjected to cataract surgery at the Portuguese Institute of oncology - Porto (IPO-Porto), Portugal, after 3 months follow up period completed between 5th June 2017 and 21st May 2018. The following inclusion criteria: corrected visual acuity of ≤ 6/10 or other significant visual disturbance due to lens opacity or the existence of a large anisometropia. A circuit was implemented based on the ICHOM standard for cataract, to measure clinical variables (e.g. visual acuity) and QoL (CATQUEST-9SF) before and after surgery, and cost of treatment. The results were explored by means of a paired-sample t-test, considering normality assumptions.

RESULTS

Data refers to 268 patients (73 P25-P75:32-95 years old), regarding 374 eyes. The cataract surgery had a positive effect on visual acuity (p < 0.001), refraction (right and left cylinder; p < 0.001) and all QoL dimensions. The vast majority of patients, around 98%, reported improvements in QoL. Based on IPO-Porto administrative records, the direct cost of treating cataracts (per eye) is of 500€, representing a total cost of 187,000€ for the number of patients operated herein.

CONCLUSION

This study reports the successful implementation of the ICHOM standard set for cataracts in a Portuguese institution and confirms that cataract surgery provides a rapid visual recovery, with excellent visual outcomes and minimal complications in most patients, while also having a positive impact on patients' quality of life.

Predicting changes in cataract surgery health outcomes using a cataract surgery appropriateness and prioritization instrument

Objective

Determine whether items in a cataract surgery appropriateness and prioritization questionnaire can predict change in best corrected visual acuity (BCVA) and health related quality of life (HRQOL) following cataract surgery.

Methods

313 patients with a cataract in Ontario, Canada were recruited to participate. BCVA was measured using the Snellen chart. HRQOL was measured using a generic instrument (EQ5D), a visual functioning instrument (Catquest-9SF), and an appropriateness and prioritization instrument (17 items). Outcomes were measured preoperatively and 3–6 months postoperatively. Descriptive statistics were used to describe demographics and outcomes. For each appropriateness and prioritization questionnaire item, a one-way ANOVA was used to compare group means of the change in BCVA, EQ5D, and Catquest-9SF.

Results

Participants had a mean age of 69 years and were 56% female. BCVA improved in 81%, EQ5D in 49.6%, and Catquest-9SF score in 84% of patients. Improvement in both BCVA and Catquest-9SF scores were found in 68.5% of patients. The ANOVA showed a statistically significant association between a change in BCVA and the ability to participate in social life, and a statistically significant association between a change in Catquest-9SF and glare, extent of impairment in visual function, safety and injury concerns, ability to work and care for dependents, ability to take care of local errands, ability to assist others and ability to participate in social life.

Conclusions

Almost all patients had improved BCVA and/or visual functioning after surgery. Seven variables from the cataract appropriateness and prioritization instrument were found to be predictors of improvement in Catquest-9SF measuring visual functioning.

Association of Visual Impairment With Risk of Incident Dementia in a Women's Health Initiative Population

Importance

Dementia affects a large and growing population of older adults. Although past studies suggest an association between vision and cognitive impairment, there are limited data regarding longitudinal associations of vision with dementia.

Objective

To evaluate associations between visual impairment and risk of cognitive impairment.

Design, Setting, and Participants

A secondary analysis of a prospective longitudinal cohort study compared the likelihood of incident dementia or mild cognitive impairment (MCI) among women with and without baseline visual impairment using multivariable Cox proportional hazards regression models adjusting for characteristics of participants enrolled in Women's Health Initiative (WHI) ancillary studies. The participants comprised community-dwelling older women (age, 66-84 years) concurrently enrolled in WHI Sight Examination (enrollment 2000-2002) and WHI Memory Study (enrollment 1996-1998, ongoing). The study was conducted from 2000 to the present.

Exposures

Objectively measured visual impairment at 3 thresholds (visual acuity worse than 20/40, 20/80, or 20/100) and self-reported visual impairment (determined using composite survey responses).

Main Outcomes and Measures

Hazard ratios (HRs) and 95% CIs for incident cognitive impairment after baseline eye examination were determined. Cognitive impairment (probable dementia or MCI) was based on cognitive testing, clinical assessment, and centralized review and adjudication. Models for (1) probable dementia, (2) MCI, and (3) probable dementia or MCI were evaluated.

Results

A total of 1061 women (mean [SD] age, 73.8 [3.7] years) were identified; 206 of these women (19.4%) had self-reported visual impairment and 183 women (17.2%) had objective visual impairment. Forty-two women (4.0%) were ultimately classified with probable dementia and 28 women (2.6%) with MCI that did not progress to dementia. Mean post-eye examination follow-up was 3.8 (1.8) years (range, 0-7 years). Women with vs without baseline objective visual impairment were more likely to develop dementia. Greatest risk for dementia was among women with visual acuity of 20/100 or worse at baseline (HR, 5.66; 95% CI, 1.75-18.37), followed by 20/80 or worse (HR, 5.20; 95% CI, 1.94-13.95), and 20/40 or worse (HR, 2.14; 95% CI, 1.08-4.21). Findings were similar for risk of MCI, with the greatest risk among women with baseline visual acuity of 20/100 or worse (HR, 6.43; 95% CI, 1.66-24.85).

Conclusions and Relevance

In secondary analysis of a prospective longitudinal cohort study of older women with formal vision and cognitive function testing, objective visual impairment appears to be associated with an increased risk of incident dementia. However, incident cases of dementia and the proportion of those with visual impairment were low. Research is needed to evaluate the effect of specific ophthalmic interventions on dementia.

Influence of cataract surgery for the first or second eye on vision-related quality of life (VR-QOL) and the predictive factors of VR-QOL improvement

PURPOSE

To assess improvements in vision-related quality of life (VR-QOL) in patients undergoing their first or second eye cataract surgery, as well as clinical factors related to VR-QOL.

STUDY DESIGN

Prospective case series.

METHODS

We examined 282 patients undergoing their first (222) or second (60) eye cataract surgery. VR-QOL was evaluated before and after surgery using the 25-item National Eye Institute visual function questionnaire (VFQ-25), along with the best-corrected visual acuity (BCVA), uncorrected visual acuity, and the lens opacities classification system III (LOCSIII). The resulting VFQ-25 subscale scores were compared between patients undergoing their first or second eye cataract surgery, including multiple regression analysis.

RESULTS

The mean VFQ-25 composite score (CS) was 71.5 ± 14.2 before and 84.0 ± 10.2 after the first eye cataract surgery and 73.5 ± 12.7 before and 85.4 ± 10.2 after the second eye cataract surgery. VFQ-25 scores improved significantly, with reduced disparity among patients after surgery in both groups. Preoperative CS was related to the preoperative sum of the BCVA (standardized partial regression coefficient (β) =  - 0.254, P < 0.001). Improvement in the CS was related to a preoperative poor BCVA (β = 0.203, P < 0.001), low CS (β =  - 0.693, P < 0.001), and high general health score (β = 0.118, P = 0.025).

CONCLUSIONS

VR-QOL improved after the first and second eye surgery. Many VFQ-25 subscales were related to the BCVA or LOCSIII scores. Low preoperative VR-QOL and BCVA were related to an improved postoperative VR-QOL.

Cost-effectiveness of immediate versus delayed sequential bilateral cataract surgery in the Netherlands (the BICAT-NL study): study design of a prospective multicenter randomised controlled trial

Background

Cataract surgery is one of the most frequently performed types of surgery. Most patients suffer from bilateral cataract and while cataract surgery of only one eye is effective in restoring functional vision, second-eye surgery leads to further improvements in health-related quality of life, and is cost-effective. At present, most patients undergo cataract surgery in both eyes on separate days as recommended in national guidelines, referred to as delayed sequential bilateral cataract surgery (DSBCS). An alternative procedure involves operating both eyes on the same day, but as separate procedures, known as immediately sequential bilateral cataract surgery (ISBCS). The aim of this study is to evaluate the effectiveness and costs of ISBCS compared to DSBCS, in order to test the hypothesis that ISBCS is non-inferior to DSBCS in terms of effectiveness and superior to ISBCS in terms of cost-effectiveness.

Methods/design

Multicenter non-inferiority randomised controlled clinical trial. Patients (18 years or older) with bilateral cataract and an indication for bilateral cataract surgery with an expected uncomplicated intraoperative and postoperative course are included in the study. Patients are randomly assigned to either ISBCS or DSBCS. The primary endpoint is the proportion of patients with a refractive outcome in the second eye within 1.0 dioptre from the target refraction, at 4 weeks after surgery. Secondary outcomes include corrected and uncorrected distance visual acuity, complications, patient reported outcomes (PROMs), cost-effectiveness, and budget impact. Follow-up visits are planned at 1 week after first-eye surgery and 4 weeks after second-eye surgery. At 3 months after first-eye surgery, the occurrence of complications is checked and patients fill in a final questionnaire.

Discussion

This study protocol describes the design of a multicenter non-inferiority randomised controlled trial. Current studies on ISBCS often lack information on safety regarding refractive outcomes. In addition, there is a lack of well-designed cost-effectiveness studies using established methods. The BICAT-NL study will provide more insight in refractive and cost-effectiveness outcomes for ISBCS compared to DSBCS.

Trial registration

This study was prospectively registered at Clinicaltrials.gov on January 17th 2018. (Identifier: NCT03400124.

Advanced ophthalmic nurse practitioners: the potential to improve outcomes for older people with cataracts

An ageing population has led to a substantial increase in the prevalence of visual impairments, which can compromise lifestyle, health and general physical and psychological well-being. Age-related cataracts can have a negative effect on older people's quality of life but can be corrected by surgery. It is imperative that older people have access to cataract surgery and, given government objectives of NHS efficiency gains, advanced level nurse practitioners have the potential to increase capacity for and access to cataract surgery. This article outlines the aetiology of cataracts, developments in ophthalmic nursing and the broadened scope of practice of advanced ophthalmic nurse practitioners (AONPs). It explores how the AONP is well-placed to provide high quality care to the older person who requires cataract surgery. Professional drivers for role development are explored in relation to older people.

Effect of Unilateral Endothelial Keratoplasty on Vision-Related Quality-of-Life Outcomes in the Descemet Endothelial Thickness Comparison Trial (DETECT): A Secondary Analysis of a Randomized Clinical Trial

Importance

Vision-related quality of life can be a valuable outcome for some interventions in ophthalmology. In the primary Descemet Endothelial Thickness Comparison Trial (DETECT), Descemet membrane endothelial keratoplasty (DMEK) had superior postoperative visual acuity compared with ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK). It is of interest to determine whether this trend extends to quality of life.

Objective

To determine the effect of UT-DSAEK and DMEK on vision-related quality of life.

Design, Setting, and Participants

A prespecified secondary analysis of a 2-surgeon patient- and outcome-masked randomized clinical trial was conducted at the Casey Eye Institute in Portland, Oregon, and Byers Eye Institute in Palo Alto, California. The study was conducted between January 20, 2015, and April 26, 2017. DETECT enrolled 38 individuals and included 50 eyes with isolated endothelial dysfunction; for this analysis, the second eye from a single participant was excluded along with any questionnaires in the first eye after second eye surgery for evaluation of 38 eyes at baseline and 3 months and 26 eyes at 12 months. Mean (SD) baseline visual acuity was 0.35 (0.31) logMAR in the DMEK arm and 0.28 (0.22) logMAR in the UT-DSAEK arm. Each arm consisted of 19 participants: 18 individuals with Fuchs dystrophy and 1 participant with pseudophakic bullous keratopathy.

Interventions

Study eyes were randomized to receive either UT-DSAEK or DMEK.

Main Outcomes and Measures

Responses to the National Eye Institute (NEI) Visual Function Questionnaire-39 (VFQ-39) administered at baseline and 3 and 12 months postoperatively were analyzed using the NEI-defined traditional subscales and composite score on a 100-point scale and with a Rasch-refined analysis.

Results

There were more women in both arms of the study (UT-DSAEK, 12 [63%]; DMEK, 11 [58%]); mean (SD) age was 68 (11) years in the UT-DSAEK arm and 68 (4) years in the DMEK arm. Overall, study participants experienced a 9.1-point improvement in NEI VFQ-39 composite score at 3 months compared with baseline (N = 38; 95% CI, 4.9-13.3; P < .001), and an 11.6-point improvement at 12 months compared with baseline (n = 26; 95% CI, 6.8-16.4; P < .001). Eyes randomized to DMEK had 0.9 points more improvement in NEI VFQ-39 composite score at 3 months compared with UT-DSAEK after controlling for baseline NEI VFQ-39 (95% CI, -6.2 to 8.0; P = .80).

Conclusions and Relevance

Improvement in vision-related quality of life was not shown to be greater with DMEK compared with UT-DSAEK.

Trial Registration

ClinicalTrials.gov identifier: NCT02373137.

The Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: Report 7, immediate sequential bilateral cataract surgery in the UK: Current practice and patient selection

BACKGROUND

Cataract extraction is the most frequently performed surgical intervention in the world and demand is rising due to an ageing demography. One option to address this challenge is to offer selected patients immediate sequential bilateral cataract surgery (ISBCS). This study aims to investigate patient and operative characteristics for ISBCS and delayed bilateral cataract surgery (DSCS) in the UK.

METHODS

Data were analysed from the Royal College of Ophthalmologists' National Ophthalmology Database Audit (NOD) of cataract surgery. Eligible patients were those undergoing bilateral cataract extraction from centres with a record of at least one ISBCS operation between 01/04/2010 and 31/08/2018. Variable frequency comparison was undertaken with chi-square tests.

RESULTS

During the study period, 1073 patients had ISBCS and 248,341 DSCS from 73 centres. A higher proportion of ISBCS patients were unable to lie flat (11.3% vs. 1.8%; p < 0.001), unable to cooperate (9.7% vs. 2.7%; p < 0.001); underwent general anaesthesia (58.7% vs. 6.6% (p < 0.001)); had brunescent/white/mature cataracts (odds ratio (OR) 5.118); no fundal view/vitreous opacities (OR 8.381); had worse pre-operative acuity 0.60 LogMAR ISBCS vs. 0.50 (first) and 0.40 (second eye) DSCS and were younger (mean ages, 71.5 vs. 75.6 years; p < 0.001). Posterior capsular rupture (PCR) rates adjusted for case complexity were comparable (0.98% ISBCS and 0.78% DSCS).

CONCLUSIONS

ISBCS was performed on younger patients, with difficulty cooperating and lying flat, worse pre-operative vision, higher rates of known PCR risk factors and more frequent use of general anaesthesia than DSCS in centres recorded on NOD.

Association of Social Support Network Size With Receipt of Cataract Surgery in Older Adults

Importance

Cataract-related vision impairment is an important public health issue that tends to affect older adults. Little is known about the association between older adults' social support networks and their likelihood of receiving cataract surgery.

Objective

To determine if older adults with smaller social support networks are less likely to receive cataract surgery.

Design, Setting, and Participants

Retrospective cohort study. The National Health and Aging Trends Study, a nationally representative US survey, administered annually from 2011 to 2015 to a cohort of Medicare beneficiaries 65 years and older with no cataract surgery prior to the start of the study.

Main Outcomes and Measures

Multivariable logistic regression was performed to evaluate if the number of persons in an individual's social support network influenced whether that individual received cataract surgery during a given year of the study.

Results

Overall, 3448 participants were interviewed from 2011 to 2015 for a total of 9760 observations. Of these observations, 3084 (weighted, 38.81%; 95% CI, 37.28-40.35) were aged 70 to 74 years, 5211 (weighted, 52.32%; 95% CI, 50.19-54.44) were women; 5899 (weighted, 78.53%; 95% CI, 76.29-80.61) were white, 2249 (weighted, 9.55%; 95% CI, 8.45-10.78) were black, 537 (weighted, 7.18%; 95% CI, 5.88-8.73) were Hispanic, and 303 (weighted, 4.74%; 95% CI, 3.56-62.9) reported other races. Medicare beneficiaries with smaller social support networks (0-2 individuals) were less likely to receive cataract surgery in a given year (adjusted odds ratio, 0.60; 95% CI, 0.37-0.96) than those with larger support networks (≥3 individuals). The adjusted predicted proportion of Medicare beneficiaries undergoing cataract surgery was 4.7% (95% CI, 2.7%-6.7%) and 7.5% (95% CI, 6.9%-8.1%) for those with small and large social support networks, respectively. Having fewer non-spouse/partner family members in the support network was associated with decreased odds of receiving cataract surgery (adjusted odds ratio, 0.60; 95% CI, 0.43-0.85), but having spouses/partners (adjusted odds ratio, 0.97; 95% CI, 0.77-1.22) and nonfamily members (adjusted odds ratio, 0.90; 95% CI, 0.72-1.11) did not have a significant association.

Conclusions and Relevance

Medicare beneficiaries with fewer non-spouse/partner family members in their social support networks were less likely to receive cataract surgery. These findings suggest that attention should be given to patients with smaller support networks to ensure that they receive cataract surgery when it is indicated.

Refractive outcomes following cataract surgery in patients who have had myopic laser vision correction

Objective

Prediction errors are increased among patients presenting for cataract surgery post laser vision correction (LVC) as biometric relationships are altered. We investigated the prediction errors of five formulae among these patients.

Methods and analysis

The intended refractive error was calculated as a sphero-cylinder and as a spherical equivalent for analysis. For determining the difference between the intended and postoperative refractive error, data were transformed into components of Long's formalism, before changing into sphero-cylinder notation. These differences in refractive errors were compared between the five formulae and to that of a control group using a Kruskal-Wallis test. An F-test was used to compare the variances of the difference distributions.

Results

22 eyes post LVC and 19 control eyes were included for analysis. Comparing both groups, there were significant differences in the postoperative refractive error (p=0.038). The differences between the intended and postoperative refractive error were greater in post LVC eyes than control eyes (p=0.012), irrespective of the calculation method for the intended refractive error (p<0.01). The mean difference between the intended and postoperative refractive error was relatively small, but its variance was significantly greater among post LVC eyes than control eyes (p<0.01). Among post LVC eyes, there were no significant differences between the mean intended target refraction and between the intended and postoperative refractive error using five biometry formulae (p=0.76).

Conclusion

Biometry calculations were less precise for patients who had LVC than patients without LVC. No particular biometry formula appears to be superior among patients post LVC.

Differences in Cataract Surgery Rates Based on Dementia Status

BACKGROUND

Cataract surgery substantially improves patient quality of life. Despite the rising prevalence of dementia in the US, little is known about use of cataract surgery among this group.

OBJECTIVE

To evaluate the relationship between dementia status and cataract surgery.

METHODS

Using administrative insurance claims for a representative sample of 1,125,387 US Medicare beneficiaries who received eye care between 2006 and 2015, we compared cataract surgery rates between patients with and without dementia via multivariable regression models to adjust for patient characteristics. Main outcome measures were annual rates of cataract surgery and hazard ratio and 95% confidence interval (CI) for receiving cataract surgery.

RESULTS

Cataract surgery was performed in 457,128 patients, 23,331 with a prior diagnosis of dementia. 16.7% of dementia patients underwent cataract surgery, compared to 43.8% of patients without dementia. 59 cataract surgeries were performed per 1000 dementia patients annually, versus 105 surgeries per 1000 nondementia patients. After adjusting for patient characteristics, dementia patients were approximately half as likely to receive cataract surgery compared to nondementia patients (adjusted HR = 0.53, 95% CI 0.53-0.54). Among the subset of patients who received a first cataract surgery, those with dementia were also less likely to receive second-eye cataract surgery (adjusted HR = 0.87, 95% CI 0.86-0.88).

CONCLUSION

US Medicare patients with dementia are less likely to undergo cataract surgery than those without dementia. This finding has implications for quality of care and dementia progression. More information is necessary to understand why rates of cataract surgery are lower for these patients, and to identify conditions where benefits of surgery may outweigh risks.

Evaluating Refractive Outcomes after Cataract Surgery

PURPOSE

To compare methods for evaluating refractive outcomes after cataract surgery to detect outliers.

DESIGN

Case series database study of the evaluation of diagnostic technology.

PARTICIPANTS

Consecutive patients who had uneventful cataract operations over a 5-year period.

METHODS

The intended and postoperative refractive outcome and differences between these were analyzed as a spherical equivalent, cylinder, and spherocylinder. The average keratometry and differences between steep and flat keratometric meridians were used to calculate the intended refractive error.

MAIN OUTCOME MEASURES

Outliers were defined as patients for whom the difference between the intended and postoperative refractive errors was more than 3 standard deviations (SDs) away from the mean.

RESULTS

A total of 9000 patients were included. Twelve patients had missing data and were excluded. The mean intended refractive outcome was -0.12+0.12×2 (95% lower confidence limit [LCL], -1.94+1.06×44; 95% upper confidence limit [UCL], +0.77+1.05×140). The actual postoperative refractive error was -0.30+0.47×6 (95% LCL, -2.36+1.31×36; 95% UCL, +1.00+1.18×148) with a difference from the intended of -0.18+0.35×7 (95% LCL, -1.91+1.22×38; 95% UCL, +0.75+1.09×145). Treating the components of the refractive error independently, outliers were observed in 82 eyes (0.91%) based on the sphere, 46 eyes (0.51%) based on the spherical equivalent, 115 eyes (1.28%) based on treating the cylinder as a scalar, and 76 eyes (0.85%) based on treating the cylinder as a vector. When the differences between the intended and postoperative refractive errors were calculated as a compound spherocylinder, outliers were observed for 233 eyes (2.59%).

CONCLUSIONS

Treating the intended refractive outcome as a spherocylinder improves the precision for detecting clinically significant refractive outliers.

The impact of first and second eye cataract surgeries on falls: a prospective cohort study

Purpose

The purpose of this study was to investigate the impact of the first and second eye cataract surgeries on the risk of falls in participants with bilateral cataract and to determine which changes in visual measures are associated with changes in the number of falls throughout the cataract surgery process.

Patients and methods

Fifty-five older adults with bilateral cataract aged 55+ years were assessed at three time points during the cataract surgery process, and they completed a falls diary. Two separate generalized estimating equation-negative binomial models were undertaken to assess changes in the number of falls before first eye cataract surgery, between first and second eye surgeries, and after second eye cataract surgery and which changes in visual measures were associated with changes in the number of falls.

Results

After adjusting for potential confounding factors, the risk of falls decreased by 54% (incidence rate ratio (IRR) =0.458, 95% CI=0.215-0.974, p=0.04) after first eye cataract surgery only, compared with the period before first eye surgery. The risk of falls decreased by 73% (IRR =0.268, 95% CI =0.114-0.628, p=0.002) after second eye cataract surgery, compared with the period before first eye surgery. Improved binocular visual acuity (IRR =5.488, 95% CI =1.191-25.282, p=0.029) and contrast sensitivity (IRR =0.257, 95% CI =0.070-0.939, p=0.040) were associated with a decrease in the number of falls.

Conclusion

The study found that first and second eye cataract surgeries reduced the risk of falls among a cohort of bilateral cataract patients with relatively good baseline vision. This suggests that timely first and second eye cataract surgeries could play an important role in reducing the burden due to falls among older adults with cataract.