Surgically induced miosis during phacoemulsification in patients with diabetes mellitus

Mydriasis Stability During Cataract Surgery in Patients with Systemic Comorbidities Using a Standardised Combination of Intracameral Mydriatics and Anaesthetic

BACKGROUND

This study aimed to evaluate mydriasis stability during cataract surgery in patients with systemic comorbidities such as diabetes mellitus (DM) and pseudoexfoliation syndrome (PXF) after a standardised combination of intracameral mydriatics and anaesthetic (SCIMA). Stable mydriasis is crucial for safe and effective phacoemulsification.

METHODS

Patients were included if they achieved pupil dilation ≥6.0 mm during the qualifying visit. A total of 103 patients were enrolled, divided into three groups: cataract with diabetes (C + DM group, n = 35), cataract with PXF (C + PXF group, n = 32), and cataract without those comorbidities (C group, n = 36). SCIMA was administered, and pupil diameters were measured at key surgical stages. Stability was defined as a pupil diameter of ≥6.0 mm without additional pharmacological intervention and no significant change in its diameter (≥3.0 mm).

RESULTS

Stable mydriasis was achieved in 90.3% of patients: 97.1% in the C + DM group, 90.6% in the C + PXF group, and 83.3% in the C group, with no statistically significant differences (p = 0.14).

CONCLUSIONS

SCIMA effectively maintains mydriasis stability during cataract surgery, even in patients with systemic comorbidities, ensuring greater surgical safety.

Cataract-1K Dataset for Deep-Learning-Assisted Analysis of Cataract Surgery Videos

In recent years, the landscape of computer-assisted interventions and post-operative surgical video analysis has been dramatically reshaped by deep-learning techniques, resulting in significant advancements in surgeons' skills, operation room management, and overall surgical outcomes. However, the progression of deep-learning-powered surgical technologies is profoundly reliant on large-scale datasets and annotations. In particular, surgical scene understanding and phase recognition stand as pivotal pillars within the realm of computer-assisted surgery and post-operative assessment of cataract surgery videos. In this context, we present the largest cataract surgery video dataset that addresses diverse requisites for constructing computerized surgical workflow analysis and detecting post-operative irregularities in cataract surgery. We validate the quality of annotations by benchmarking the performance of several state-of-the-art neural network architectures for phase recognition and surgical scene segmentation. Besides, we initiate the research on domain adaptation for instrument segmentation in cataract surgery by evaluating cross-domain instrument segmentation performance in cataract surgery videos. The dataset and annotations are publicly available in Synapse.

Pharmacological management of intra-operative miosis during cataract surgery

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.

Efficacy of Nepafenac versus Flurbiprofen in Maintaining Intraoperative Mydriasis During Phacoemulsification: A Comparative Study

Purpose

To compare the efficacy of topical nepafenac (0.1%) with flurbiprofen (0.03%) in maintaining intra-operative mydriasis during phacoemulsification surgery.

Patients and Methods

This study comprised of 160 patients, who were divided into two arms of 80 each (arms A and B) after randomisation. Pre-operatively, all patients received one drop of tropicamide 0.8% and phenylephrine 5% (combination), 4 times, at an interval of 15 minutes on the day of surgery. Thereafter, Nepafenac drop in arm A/Flurbiprofen drop in arm B was administered 4 times, at an interval of 15 minutes keeping a gap of 10 minutes between tropicamide-phenylephrine and any of the experimental drugs. Phacoemulsification was performed one hour after the administration of last drop. Both vertical and horizontal pupillary diameter were measured at three steps; immediately before the surgical incision (baseline), at the end of emulsification of nucleus (before irrigation and aspiration) and at the end of surgery (after stromal hydration).

Results

The difference in pupillary diameter between two groups, was statistically insignificant for vertical diameter (P = 0.08) and horizontal diameter (P = 0.28) at the start of surgery. On the other hand, pupillary diameter difference was statistically significant after emulsification of nucleus and at the end of surgery as well when both vertical (P < 0.05) and horizontal diameter (P < 0.05) were considered. The total reduction in pupillary diameter (both vertically and horizontally) was significantly less in the Nepafenac as compared to Flurbiprofen group (P < 0.05). Analysis of mean cumulative dissipated energy did not document any appreciable difference between the two groups. Phacoemulsification time analysis yielded statistically significant results (P = 0.004) between the Nepafenac and Flurbiprofen group.

Conclusion

In the present study, topical Nepafenac (0.1%) proved to be more efficacious in maintaining intra-operative mydriasis during phacoemulsification surgery as compared to topical Flurbiprofen (0.03%).

[Mechanical dilation of the pupil and its possible applications in femtosecond laser-assisted cataract surgery]

In certain cases intraoperative pupil dilation during cataract surgery may be necessary to improve the visualization of intraocular structures and assure the atraumatic nature of surgical manipulations. The article reviews a wide range of pupil expanders, their historical aspects and possibilities of their application in modern cataract surgery.

Cataract surgery in small pupils

This paper presents the review of historical aspects and the current state-of-the-art in various pupil dilatation methods to be used in cataract surgery. The surgical algorithm in managing small pupil cases should include topical and intraocular mydriatics, appropriately selected viscosurgical device and mechanical dilatation with instruments, iris hooks, and/or pupil expanders.

Recent advances in small pupil cataract surgery

PURPOSE OF REVIEW

To highlight the existing and emerging cataract surgery trends in patients with insufficient mydriasis. Discuss the latest pharmacological approaches for pre and intraoperative pupil dilatation. Present the variety of newest pupil expansion devices; critically review their advantages and possible limitations to be considered by the surgeon.

RECENT FINDINGS

The intracameral use of various mydriatic combinations augmenting the preoperative mydriatic instillations is currently gaining popularity in cataract surgery. Two main options are available: bolus injection of pharmacological agent or its constant irrigation during the phacoemulsification procedure. The former is aimed to expand the pupil, whereas the latter is mostly preventing the pupil from constriction. Introduction of femtosecond-assisted cataract surgery, apart from some benefits was followed by a variety of adverse effects including prostaglandin release into the aqueous humor causing pupil constriction. Preoperative administration of nonsteroidal anti-inflammatory drugs at least 1 day prior to surgery significantly decreases the chance of pupil constriction after laser energy is applied to the eye. However, pupil expansion devices may be needed in up to 10% of cases. Following the success of the Malyugin ring (MicroSurgical Technology Inc., Redmond, Washington, USA) several manufacturers introduced pupil expansion devices of various designs. They are differing with materials, pupillary margin fixation mechanisms, and easiness of manipulations during implantation and removal.

SUMMARY

Combination of proper use of pre and intraoperative pharmacological pupil dilatation protocols combined with pupil expander rings allow for well tolerated and effective cataract surgery in the vast majority of patients with insufficient mydriasis.

Visual outcomes, efficacy, and surgical complications associated with intracameral phenylephrine 1.0%/ketorolac 0.3% administered during cataract surgery

Aim

The purpose of this study was to compare visual outcomes, surgical time, and perioperative surgical complications after intracameral use of either phenylephrine/ketorolac (P/K) or epinephrine (Epi) during cataract surgery.

Methods

This was a single-center, retrospective case review of patients undergoing cataract surgery from August to November 2015. Of the 641 eyes of 389 patients who underwent cataract surgery, 260 eyes were administered phenylephrine 1.0%/ketorolac 0.3% and 381 eyes received Epi in the irrigation solution intraoperatively. All patients received a topical nonsteroidal anti-inflammatory drug regimen (bromfenac 0.07%, nepafenac 0.3%, or ketorolac 0.5%) for 3 days before surgery and topical tropicamide 1.0%, cyclopentolate 1.0%, and phenylephrine 2.5% on the day of surgery.

Results

Mean length of surgery (LOS) was 15.4±0.6 minutes. Although a positive correlation was noted between patient age and LOS (p<0.001), P/K was associated with a decrease in the LOS, when controlled for age quartiles. A statistically significant lower incidence of complications (1.1%) was observed with P/K use than Epi (4.5%; p=0.018). Among surgeons who used mydriatic-assist devices more frequently, P/K use was associated with a reduction in the use of these devices (p<0.001). When controlling for age quartile, patients of age groups 69–76 and 76–92 years who received P/K had significantly better uncorrected visual acuity at postoperative day 1 than those receiving Epi (p=0.003).

Conclusion

Intracameral use of phenylephrine 1.0%/ketorolac 0.3% during cataract surgery may be effective in maintaining mydriasis. It appears to be superior to intracameral Epi at reducing intraoperative and postoperative complications, need for pupillary dilating devices, and surgical time.

The differential pupillary response to 2.5% phenylephrine in patients taking tamsulosin

PURPOSE

To determine if a pharmacological test could be developed to determine iris dilator dysfunction in patients taking tamsulosin.

METHODS

Patients taking tamsulosin and controls were recruited from the Urology and Ophthalmology clinics at the Montefiore Medical Center. The patient's right eye (OD) was dilated with phenylephrine hydrochloride 2.5% and tropicamide 1%. The patient's left eye (OS) was dilated with tropicamide 1% alone. Forty minutes after dilation, pupillary diameter was measured in both eyes.

RESULTS

Thirty-eight tamsulosin subjects and 43 controls met the inclusion criteria for the study. The tamsulosin-treated patients dilated less with phenylephrine than controls (0.61±0.4 vs. 1.10±0.45 mm, respectively P<0.001). Receiver operating characteristic curves comparing maximal pupillary dilation versus differential pupillary dilation in tamsulosin patients relative to controls shows a greater area under the curve for differential dilation (0.8 vs. 0.6, respectively). A correlation between smooth muscle dysfunction and length of time on tamsulosin was observed. Patients using tamsulosin for <1 month had an average OD-OS difference of 0.85±0.5 mm. Patients who were on tamsulosin for >1 month had an average OD-OS difference of 0.52±0.32 mm (P<0.01, Mann-Whitney).

CONCLUSION

Patients treated with tamsulosin demonstrated a significantly decreased iris dilatory response to the selective adrenergic effects of phenylephrine compared to controls. Additionally, it appears that longer duration of exposure to tamsulosin increases the likelihood of dilator dysfunction.

Corneal endothelial cell changes after cataract surgery in patients on systemic sympathetic α-1a antagonist medication (tamsulosin)

PURPOSE

  The purpose of this study was to assess the incidence of intraoperative floppy iris syndrome (IFIS) and the morphology of the corneal endothelium after cataract extraction in Caucasian male patients exposed to the α-1a adrenergic receptor antagonist tamsulosin.

METHODS

  In a clinical prospective study, 23 male patients (23 eyes) treated with tamsulosin due to benign prostatic hyperplasia and 25 male patients (25 eyes) with no tamsulosin treatment had cataract surgery. The divide-and-conquer technique was used with the Infinity OZil(®) machine. A combination of Healon and Healon5 was used in all patients, but the use of additional Vision Blue, iris retractors or intracameral phenylephrine in the tamsulosin group was at the discretion of the surgeon. The endothelial cell density, variation in endothelial cell size (CV), percentage of hexagonal cells and central corneal thickness (CCT) were recorded at baseline and at 3 months postoperatively.

RESULTS

  In the tamsulosin-treated group, 19 of 23 eyes (83%) developed IFIS, compared with no IFIS in the control group. Compared with the control group, the tamsulosin group showed significantly less dilatation at the start of the operation, significant miosis during surgery and significantly greater corneal endothelial cell loss 3 months postoperatively (12% versus 3%; p< 0.001).

CONCLUSION

  Intraoperative floppy iris syndrome during cataract surgery is significantly associated with tamsulosin-treated male patients. Patients on tamsulosin showed less preoperative dilatation, significant miosis during surgery, and had significantly greater postoperative endothelial cell loss compared with nontreated patients despite recommended precautions.

Corneal endothelial cell changes associated with cataract surgery in patients with type 2 diabetes mellitus

PURPOSE

To investigate the corneal endothelial cell density and morphology in patients with and without diabetes after phacoemulsification with intraocular lens implantation.

METHODS

A clinical prospective study including 30 patients with type 2 diabetes and 30 control patients without diabetes scheduled to undergo cataract surgery. No difference in preoperative age was observed between the 2 groups (P = 0.90). Sample size was based on a power calculation (power 0.90; P = 0.05). The patients without diabetes had a casual blood glucose test performed to disclose undetected diabetes. The patients with diabetes had a serum glycosylated hemoglobin (HbA1c) test performed to reveal the glycemic control. The endothelial cell density, variation in endothelial cell size (CV), percentage of hexagonal cells, and central corneal thickness (CCT) were recorded at baseline and at 3 months postoperatively.

RESULTS

The mean decrease in endothelial cell density at 3 months in the diabetic group was 154 cells per square millimeter (6.2%) and 42 cells per square millimeter (1.4%) in the control group. The difference in cell loss between the 2 groups was significant (P = 0.04). A significant decrease in the percentage of hexagonal cells was also seen in the diabetic group (P = 0.01). There was no statistically significant change in CV or CCT. Visual acuity increased significantly and equally in the 2 groups.

CONCLUSIONS

The present study reveals a significantly greater loss of corneal endothelial cells in a diabetic group under good glycemic control, compared with nondiabetic group 3 months after phacoemulsification. The morphological changes in the endothelial cells in patients with well-controlled diabetes were not reflected in impaired function as judged by CCT.

Management of Intraoperative Miosis during Pediatric Cataract Surgery using Healon 5

Purpose:

We describe a technique for achieving pupillary dilatation in order to manage and counteract intraoperative miosis during pediatric cataract surgery using viscoadaptive viscoelastic (sodium hyaluronate 2.3%).

Materials and Methods:

The technique of viscomydriasis was used in six eyes with pediatric cataracts with intraoperative pupillary miosis.

Results:

Pupillary dilatation was achieved and maintained in all eyes throughout cataract surgery. All the surgical steps including anterior and posterior capsulorrhexis and aspiration were performed successfully.

Conclusions:

Viscomydriasis is a simple and effective technique for the management of intraoperative pupillary miosis during cataract surgery in pediatric eyes.

Clinical features, complications, and incidence of intraoperative floppy iris syndrome in patients taking tamsulosin

PURPOSE

To evaluate the intraoperative findings, complication rates, effect of intracameral adrenaline, and incidence of intraoperative floppy iris syndrome (IFIS) in patients using tamsulosin.

METHODS

In this prospective nonrandomized observational study, 858 eyes of 774 patients who had phacoemulsification between August 2005 and November 2006 were evaluated. Duration and preoperatively discontinuing time of tamsulosin intake were questioned. Preoperative pupil size, intraoperative iris behavior, progressive miosis, adrenalin usage, and complications were recorded.

RESULTS

The incidence of IFIS was 1.6% and IFIS was seen in 14 of the 18 eyes of patients using tamsulosin (77.8%). One eye had floppy iris only, 2 eyes had floppy iris and intraoperative miosis, 3 eyes had floppy iris and iris prolapse, and 8 eyes had all three signs of IFIS. IFIS was seen in 7 of the 10 eyes where intracameral adrenaline was used, and in 7 of the 8 eyes without adrenaline (p=0.588). Intraoperative miosis was seen only in 3 of the 10 eyes with adrenaline and in 7 of the 8 eyes without adrenaline (p=0.025). Posterior capsule rupture occurred in 1 of the eyes with IFIS and in 5 eyes focal iris stromal atrophy caused by prolapse was seen.

CONCLUSIONS

IFIS occurred in 1.6% of cases having phacoemulsification. Intracameral adrenaline usage did not change the IFIS occurrence rate, but it seemed to be effective in preventing intraoperative miosis. There are still many questions about IFIS, and there is need for future studies strengthening the understanding of IFIS.

Intraoperative floppy-iris syndrome: Do we know everything about it?

We report a case of bilateral phacoemulsification for nuclear cataract in a 76-year-old man. The patient took tamsulosin for 4 months and stopped the medication 1 year before the cataract surgery. Phacoemulsification in the left eye was uneventful. One week later, phacoemulsification was performed in the same manner in the right eye, which demonstrated the 3 signs of the intraoperative floppy-iris syndrome (IFIS). Postoperative examinations revealed iris stromal atrophy and an irregular pupil in this eye. This case raises many questions: Why was IFIS seen in 1 eye only? Is the intake and stopping time of tamsulosin important to the occurrence of IFIS? Is intracameral adrenaline effective in preventing IFIS? Future studies are needed to increase our understanding of IFIS.

Does diabetic retinopathy increase the incidence of intraoperative complications of phacoemulsification surgery?

PURPOSE

To evaluate the rates of intraoperative and early postoperative complications (IEPC) and the duration of phacoemulsification (DOP) in the eyes with and without diabetic retinopathy and the effect of oral and topical nonsteroidal anti-inflammatory agents (NSAIDs) on surgically induced miosis (SIM).

MATERIALS AND METHODS

Phacoemulsification was applied to 50 eyes with proliferative diabetic retinopathy (PDR), 50 eyes with nonproliferative diabetic retinopathy (NPDR), and 50 eyes with no other ocular findings. NSAIDs were used perioperatively. The parameters evaluated were IEPC, DOP and the effect of NSAIDs on SIM.

RESULTS

The rates of IEPC and the DOP were significantly higher in the PDR group compared with the NPDR and control groups. Diabetes mellitus (DM) type had no significant effect on these parameters. The rate of SIM was higher in the eyes with PDR compared with the eyes with NPDR and the controls despite use of NSAIDs.

CONCLUSION

Our results indicates that eyes with PDR are significantly more prone to IEPC, while the type of DM is not a predictor factor. DOP is longer in the eyes with PDR. In spite of NSAID use, SIM is more commonly observed in eyes with PDR.

Floppy iris behaviour during cataract surgery: associations and variations

AIM

To assess the association of floppy iris behaviour during cataract surgery with use of alpha-1-antagonists and diabetes mellitus.

METHODS

1842 eyes of 1786 patients undergoing phacohoemulsification surgery were prospectively enrolled. The use of commonly prescribed alpha-1-antagonists and the presence or absence of diabetes mellitus were noted. The occurrence of any of the features of the intraoperative floppy iris syndrome (IFIS) was noted by surgeons blinded to the patient's history.

RESULTS

57% of patients receiving tamsulosin showed features of IFIS compared with 1% of the non-tamsulosin group (p<0.001). Of these, more than half the patients manifested the syndrome in an incomplete form. Only 1 of the 51 patients receiving other alpha-1-antagonists had IFIS. Diabetes was also not associated with IFIS (p = 1).

CONCLUSIONS

Tamsulosin is significantly associated with floppy iris behaviour during cataract surgery. But not all of these patients will necessarily show all or any features of IFIS. The floppy iris syndrome is likely to represent a continuum of severity. Various undefined factors, diabetes not being one of them, may have a contributory role. Non-selective alpha-1-antagonists are unlikely to be associated with IFIS.

α1-Adrenergic Receptor Antagonists and the Iris: New Mechanistic Insights into Floppy Iris Syndrome

Understanding the role of adrenergic receptors in iris biology has gained widespread interest due to the recently described intraoperative floppy iris syndrome sometimes encountered during cataract surgery. alpha(1)AR-mediated iris dilator smooth muscle contraction occurs via alpha(1a)ARs whereas alpha(1b)ARs mediate iris arteriolar contraction. Because alpha(1)AR antagonists are first-line therapy for benign prostatic hyperplasia and lower urinary tract symptoms, more elderly patients requiring cataract surgery now receive these drugs. After reviewing intraoperative floppy iris syndrome, strengths/weaknesses of supporting data, and reviewing iris biology, a case is made that rather than being drug specific (alpha(1)AR antagonists), intraoperative floppy iris syndrome may represent the "tip of the iceberg." Relaxed iris dilator muscle resistant to adrenergic agonists should be expected with clinical drugs shown to relax the iris dilator (e.g., antagonists at alpha(1)AR, endothelin-A, angiotensin receptors, nitric oxide donors such as nitrates), and/or diseases associated with endothelial dysregulation (e.g., congestive heart failure, diabetes, hypertension). Rather than a rare, unexpected, unpredictable syndrome due to one drug, a careful medical history should elucidate intraoperative floppy iris syndrome predisposition. Just as anticoagulants are discontinued prior to elective surgery, conservative management of elderly patients suggests discontinuation of drugs that relax iris dilator muscle, in consultation with the patient's primary physician, should be considered prior to cataract surgery.

Combined Pars Plana Vitrectomy and Phacoemulsification With Intraocular Lens Implantation in Severe Proliferative Diabetic Retinopathy

BACKGROUND AND OBJECTIVE

To evaluate the results of combined vitrectomies and intraocular lens implantations in cases of proliferative diabetic retinopathy.

PATIENTS AND METHODS

Data from procedures on 117 eyes (91 patients) undergoing combined pars plana vitrectomy, phacoemulsification, and intraocular lens implantation for the complications of proliferative diabetic retinopathy were analyzed retrospectively. Follow-up ranged from 8 to 64 months (median = 25 months).

RESULTS

Retinal tears were the most frequent intraoperative problems (19%). Limited postoperative fibrin formation occurred in 22% of eyes. Within 6 months, 7% developed glaucoma and 2% showed new anterior segment rubeosis. Overall, 10% underwent secondary surgical procedures as follows: lavage for hemorrhage (n = 3), silicone oil exchange after 7 days for focal rebleeding (n = 1), silicone oil surgery for retinal detachment after gas resorption (n = 1), and lavage for late vitreous hemorrhage (7 to 13 months) (n = 4). Half of the secondary procedures were necessitated within 3 months of the original surgery.

CONCLUSIONS

Combined surgery in proliferative diabetic retinopathy is safe and effective. It should be considered when lens opacities are either present or likely to develop soon.

Intraoperative floppy iris syndrome associated with tamsulosin

PURPOSE

To assess the incidence and possible causative factors of a newly recognized syndrome, the intraoperative floppy iris (IFIS).

SETTING

Clinical practices in Los Altos and San Rafael, California, USA.

METHODS

A retrospective chart review of consecutive cataract surgeries performed in a 2-surgeon practice over a 12-month period (706 eyes; 511 patients) was used to assess the percentage of cataract patients on systemic sympathetic alpha-1 antagonist medications as well as the percentage of patients who manifested the IFIS. A separate prospective study of 900 consecutive cases (741 patients) performed by another surgeon was used to determine the incidence of IFIS and the percentage of these patients who were taking alpha-1 antagonist medications.

RESULTS

Three percent (16/511) of the patients in the retrospective study, representing 3.0% (25/706) of the total eyes, were taking tamsulosin (Flomax) for benign prostatic hypertrophy. The overall prevalence of IFIS was 2.0% (10/511 patients). The syndrome was noted intraoperatively in 63.0% (10/16) of the tamsulosin patients but in none of the 11 patients on other systemic alpha-1 blockers. In the prospective study of 900 consecutive cataract surgeries, the prevalence of IFIS was 2.2% (16/741 patients). Ninety-four percent (15/16) of the IFIS patients were taking or had taken systemic tamsulosin. Twenty-six patients (36 eyes) in the 2 studies had IFIS associated with systemic tamsulosin. Sphincterotomies and mechanical pupil stretching were ineffective in maintaining adequate pupil dilation in this surgical population.

CONCLUSION

Intraoperative floppy iris syndrome occurred in approximately 2% of a cataract surgery population and appeared to be caused by tamsulosin, a systemic sympathetic alpha-1A antagonist medication that is the most frequently prescribed medication for benign prostatic hypertrophy.