Intracameral illuminator-guided advanced lens capsule polishing during cataract surgery in eyes with diabetic retinopathy

Automated Imaging of Cataract Surgery Using Artificial Intelligence

Objectives: This study proposes a state-of-the-art technology to estimate a set of parameters to automatically display an optimized image on a screen during cataract surgery. Methods: We constructed an architecture comprising two stages to estimate the parameters for realizing the optimized image. The Pix2Pix approach was first introduced to generate fake images that mimic the optimal image. This part can be considered a preliminary step; it uses training datasets comprising both an original microscopy image as the input data and an optimally tuned image by ophthalmologists as the label data. The second part of the architecture was inspired by ensemble learning, in which two ResNet-50 models were trained in parallel using fake images obtained in the previous step and unprocessed images. Each set of features extracted by the ensemble-like scheme was exploited for the regression of the optimal parameters. Results: The fidelity of our method was confirmed through relevant quantitative assessments (NMSE 121.052 ± 181.227, PSNR 29.887 ± 4.682, SSIM 0.965 ± 0.047). Conclusions: Subsequently, surgeons reassured that the objects to be highlighted on the screen for cataract surgery were faithfully visualized by the automatically estimated parameters.

Surgical time and efficacy of illuminated chopper-assisted cataract surgery involving miosis after femtosecond laser pretreatment

PURPOSE

To evaluate the efficacy of the illuminated chopper-assisted cataract surgery in terms of shortening the surgical time in eyes with miosis after femtosecond laser pretreatment.

METHODS

As retrospective study, three hundred thirty-six eyes of 336 consecutive patients who underwent the femtosecond laser and illuminated chopper-assisted cataract surgery were included. Cases with pupil less than 6 mm after femtosecond laser pretreatment were included in the miosis group. Pupil diameter, surgical time, and improved efficacy (100/surgical time×pupil size) were compared between eyes with and without miosis.

RESULTS

Of 336 eyes, 20 were included in the miosis group (6.0%). Pupil diameter was smaller in eyes with miosis than in those without miosis (5.23 ± 0.38 mm vs 7.35 ± 0.64 mm, p < 0.001); however, surgical time was not different (6.86 ± 0.73 min vs 6.60 ± 1.27 min, p = 0.071) between the two groups. Mechanical pupil dilations were not needed in any cases. As a result, improved efficacy was calculated to be higher in patients with miosis (2.83 vs 2.14, p < 0.001).

CONCLUSION

In terms of surgical time and improved efficacy, using the illuminated chopper simplified cataract surgery involving miosis after femtosecond laser pretreatment. The use of an illuminated chopper is expected to be a good solution for femtosecond laser-assisted cataract surgeries.

Learning Curve in Phaco Chop Cataract Surgery Using an Illuminated Chopper

Purpose: To confirm that the phaco chop method using an illuminated chopper (iChopper; Oculight, Seongnam, Korea) can reduce cataract surgery complications, and that even beginners can safely and effectively perform phaco chop.Methods: We retrospectively analyzed the medical records of the first 30 phaco chop cases using illuminated chopper of four cataract surgeons. Four ophthalmologists had a variety of empirical backgrounds, from those who have experienced more than 10,000 cataract surgery, to beginners who have experienced 20 cataract surgery.Results: Of the total 120 eyes, two eyes (1.67%) had posterior capsule rupture. The chopping method was changed from phaco chop to stop and chop in three eyes (2.5%) including one eye with brown cataract with pseudoexofoliation syndrome and two eyes with nuclear opacity grade ≥5.Conclusions: The rates of posterior capsule rupture of phaco chop using an illuminated chopper were very low in four surgeons with various experiences and who became proficient shortly in phaco chop.

Illuminated Chop Using an Illuminated Chopper in Cataract Surgery: on the Way to Minimal-energy Phacoemulsification

Purpose: To minimize ultrasound power use and surgical phaco time in illuminated chop cataract surgery.Methods: The charts of patients who underwent senile cataract surgery by a single surgeon were reviewed retrospectively. A conventional intracameral endoilluminator was used in a Stop & Chop group (n = 45), while an illuminated chopper was used in an illuminated chop (I-Chop) group (n = 71). EFX, a unitless value that roughly correlates with ultrasound energy during phacoemulsification, surgical phaco time, and changes in endothelial cell count were compared between the two groups and the ratio of zero phacoemulsification in the I-Chop group was evaluated.Results: EFX of the Stop & Chop and I-Chop groups was 18.08 ± 16.15 and 0.82 ± 3.53, respectively (p = 0.001), while the surgical phaco time was 185.08 ± 41.42 and 162.04 ± 49.65 seconds (p = 0.01). However, the endothelial loss did not differ in the two groups (7.03 ± 7.89 vs. 7.13 ± 9.47%, p = 0.76). In the I-Chop group, 56 (86%) eyes had zero phaco energy and patients with EFX >1 (n = 6) had more severe nuclear sclerosis grading (2.90 ± 0.71 vs. 4.5 ± 1.0; p = 0.001).Conclusions: The I-Chop group had lower EFX and shorter surgical phaco time than the Stop & Chop group. Illuminated chop using an illuminated chopper is one way to attain minimal phacoemulsification.

Contrast, visibility, and color balance between the microscope versus intracameral illumination in cataract surgery using a 3D visualization system

Purpose:

To compare image resolution and depth between the microscope versus intracameral illumination images during 3D heads-up cataract surgery.

Methods:

We collected 25 consecutive patients who had cataract surgery using the 3D viewing system. Based on bright, contrast, visibility, and color balance, the digital images (RGB color and three monochromes) extracted at the same point of the procedures were compared between the two illuminations.

Results:

Contrast values of green and blue channels except for red channel and visibility values of all three channels were higher in the intracameral illumination images than in the microscope images (P < 0.001, t-test). Color balance values of both green/red and blue/red were higher in the intracameral illumination images than in the microscope images (P < 0.001, t-test).

Conclusion:

The digital images in the digitally assisted cataract surgery were enhanced by using the intracameral illumination. Considering the contrast and color balance in the 3D cataract surgery, the intracameral illumination may be better than the microscope illumination.

Light exposure from microscope versus intracameral illumination during cataract surgery

Purpose:

To evaluate light exposure from microscope versus intracameral illuminations to patient's and surgeon's retina during cataract surgery.

Methods:

Thirty consecutive patients who had cataract surgery using microscope and intracameral illuminations. At the point of the ocular of an operating microscope, optical illuminance and irradiance from the microscope illumination (60, 40, 20% intensity) and the intracameral illumination (60% intensity) were measured using a light meter and a spectrometer at a pause after lens capsule polishing in cataract surgery.

Results:

Average illuminance (lux) was 1.46, 0.66, 0.27, and 0.1 from 60%, 40%, 20% intensity microscope illuminations and 60% intracameral illumination. Average total spectral irradiance (μW/cm2) was 1.25, 0.65, 0.26, and 0.03 from 60%, 40%, 20% intensity microscope illuminations and 60% intracameral illumination.

Conclusion:

Microscope ocular illuminance and irradiance during cataract surgery were higher in the microscope illumination than in the intracameral illumination. It suggests that light exposure reaching patient's and surgeon's retina during cataract surgery is lower in the intracameral illumination than in the microscope illumination.

Intracameral endoilluminator-assisted phacoemulsification surgery in patients with severe corneal opacity

While phacoemulsification cataract surgery is a routine and safe procedure, clear visualization of the anterior segment is challenging in patients with corneal opacity. Illumination from the operating microscope can cause scattering and light reflection in a patient with corneal opacity. A frequent approach for these cases is cataract surgery with sequential or simultaneous corneal transplantation. This method has serious preoperative, intraoperative, and postoperative drawbacks, such as a long wait for a donor cornea, choroidal hemorrhage, and delayed visual rehabilitation. In this case series, the technique of intracameral endoilluminator-assisted phacoemulsification surgery in patients with severe corneal opacity was shown to provide better visualization and reduced scattering and reflection in patients with corneal opacity.

Macular photostress and visual experience between microscope and intracameral illumination during cataract surgery

PURPOSE

To evaluate macular photostress and visual experience between coaxial microscope illumination versus oblique intracameral illumination during cataract surgery.

SETTING

Gachon University Gil Hospital, Incheon, South Korea.

DESIGN

Prospective case series.

METHODS

Consecutive patients who had cataract surgery using microscope illumination and intracameral illumination were included. The patients were asked to complete a questionnaire (seeing strong lights, feeling photophobia, feeling startled (fright) when seeing lights, seeing any colors, seeing any instruments or surgical procedures, and estimating intraoperative visual function) designed to describe their cataract surgery experience. The images projected on the retina of the model eye (rear view) with artificial opaque fragments in the anterior chamber during simulating cataract surgery were compared between the 2 illumination types.

RESULTS

Sixty patients completed the questionnaire. Scores for strong lights, photophobia, fright, and color perception were significantly higher with microscope illumination than with intracameral illumination (all P < .001). More patients preferred the intracameral illumination (45 [75.0%]) to the microscope illumination (13 [21.7%]). In the rear-view images created in a model eye, only the bright microscope light in the center was seen without any lens image in the microscope illumination. However, in the intracameral illumination, the less bright light from the light pipe in the periphery and the lens fragments were seen more clearly.

CONCLUSIONS

In a view of the patients' visual experience, oblique intracameral illumination caused less subjective photostress and was preferred over coaxial microscope illumination. Objective findings from the model-eye experiment correlated to the result of visual experience.

Intraoperative Complications of Cataract Surgery Using Intracameral Illumination in the Elderly over 75 Years

Purpose

To evaluate intraoperative complications and utilization of adjunctive devices between microscope and intracameral illuminations during cataract surgery in the elderly over 75 years.

Design

A retrospective, consecutive, interventional case series Participants. Two hundred eighty-six eyes of 184 patients older than 75 years who underwent cataract surgery using microscope and intracameral illuminations.

Methods

A chart review was performed on an advanced cataract surgery group of 141 consecutive cases in which the intracameral illumination was used and on a standard cataract surgery group of 145 consecutive cases in which the intracameral illumination was not used.

Main Outcome Measures

Intraoperative complications (posterior capsule rupture, radial tear of the anterior capsule, dropped nucleus, or sulcus-implanted/sclera-fixated IOL) and utilization of adjunctive devices (pupil expansion device or anterior capsule staining).

Results

The frequency of use of the pupil expansion device was lower in the advanced cataract surgery group than that in the standard cataract surgery group (0.7% vs 6.9%; p=0.007). Furthermore, the rates of a posterior capsule rupture and at least one intraoperative complication were lower in the advanced cataract surgery group than those in the standard cataract surgery group (0.7% vs 4.8%; p=0.067) (0.7% vs 7.6%; p=0.004).

Conclusions

In the current cohort of patients over 75 years, the rate of intraoperative complications was lower when using the intracameral illumination than that when using the conventional method. Cataract surgery using intracameral illumination would be good option for elderly people.

Phacoemulsification using a chisel-shaped illuminator: enhanced depth trench, one-shot crack, and phaco cut

PURPOSE

To evaluate the efficacy and outcomes of intracameral illuminator-assisted nucleofractis technique in cataract surgery.

METHODS

Since June 2012, this novel technique has been performed in all cataract cases by one surgeon (approximately 300 cases of various densities). Trenching continues until the posterior plate white reflex between an endonucleus and an epinucleus is identified (enhanced depth trench). After trenching, cracking is initiated with minimal separation force, and completion of cracking is confirmed by posterior capsule reflex (one-shot crack). With followability enhanced by an elliptical phaco mode, the divided nucleus is efficiently cut into small fragments by a chisel-shaped illuminator (phaco cut).

RESULTS

We have not experienced any capsular bag or zonular complications, and the effective phacoemulsification time seemed to be shorter than that with the conventional technique.

CONCLUSIONS

This technique simplifies the complete division of the nucleus, which is the most challenging step in safe and efficient phacoemulsification.

Intracameral illuminator-assisted advanced cataract surgery combined with 23-gauge vitrectomy in eyes with poor red reflex

PURPOSE

To evaluate the efficacy and outcomes of intracameral illuminator-assisted advanced cataract surgery combined with 23-gauge vitrectomy in eyes with a poor red reflex.

SETTING

Department of Ophthalmology, Gachon University Gil Hospital, Incheon, Korea.

DESIGN

Interventional case series.

METHODS

Surgeon-controlled intracameral illumination was used for visualization during combined cataract surgery and 23-gauge vitrectomy. The main outcome measures were causes of the poor red reflex, value of the intracameral illuminator in specific cataract steps, and intraoperative and postoperative complications.

RESULTS

The study comprised 17 patients (17 eyes). The main causes of a poor red reflex were vitreous hemorrhage in 8 eyes, vitreous opacity in 6 eyes, and corneal opacity, bullous retinal detachment, and globe deviation in 1 eye each. Horizontal or oblique intracameral illumination minimized the amount of corneal scatter and reflection of the illuminating light and provided high-quality intraoperative lens images in most surgical steps. In addition, excellent visibility of the lens capsules facilitated the removal of almost all lens epithelial cells from the capsular bag. In all eyes, completion of the capsulorhexis and in-the-bag implantation of an intraocular lens were accomplished. In 1 eye, a radial anterior capsule tear occurred during irrigation/aspiration. Postoperatively, the rate of anterior capsule opacification was 11.8% (2/17 eyes) and of posterior capsule opacification, 23.5% (4/17 eyes).

CONCLUSIONS

Surgeon-controlled intracameral illumination provided excellent imaging and almost 360-degree visualization of the lens capsule structures. This capability can be used for challenging cataract surgery combined with vitrectomy in eyes with a poor red reflex.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.