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Kaur S, Kumari K, Gupta PC, Sukhija J. Pharmacological management of intra-operative miosis during cataract surgery. Indian J Ophthalmol 2023; 71:2656-2661. [PMID: 37417103 PMCID: PMC10491068 DOI: 10.4103/ijo.ijo_3384_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 03/25/2023] [Accepted: 03/27/2023] [Indexed: 07/08/2023] Open
Abstract
Cataract surgery requires a well-dilated and stable pupil for a good outcome. Unexpected pupillary constriction during surgery increases the risk of complication. This problem is more pronounced in children. There are now pharmacological interventions that help tackle this unforeseen happening. Our review discusses the simple and quick options available to a cataract surgeon when faced with this dilemma. As cataract surgical techniques continue to improvise and get faster, an adequate pupil size is of paramount importance. Various topical and intra-cameral drugs are used in combination to achieve mydriasis. Despite good pre-operative dilation, the pupil can be quite unpredictable during surgery. Intra-operative miosis limits the field of surgery and increases the risk of complications. For example, if the pupil size decreases from 7 mm to 6 mm, this 1 mm change in pupil diameter will lead to a decrease of 10.2 mm2 in the area of surgical field. Making a good capsulorhexis with a small pupil can be a challenge, even for an experienced surgeon. Repeated touching of the iris increases the risk of fibrinous complications. Removal of cataract and the cortical matter becomes increasingly difficult. Intra-ocular lens implantation in the bag also requires adequate dilation. When dealing with challenging cases like lens subluxation, pseudo-exfoliation, and zonular dehiscence, a small pupil further increases the risk and adversely affects the surgical outcome. Hence, achieving and maintaining adequate mydriasis throughout surgery is essential. This review highlights the risk factors for small pupils during surgery and current management strategies.
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Affiliation(s)
- Savleen Kaur
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kiran Kumari
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Parul Chawla Gupta
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jaspreet Sukhija
- Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Zeilinger J, Hienert J, Ruiss M, Pilwachs C, Findl O. Rotational stability of a new toric intraocular lens with an advanced optical profile. J Cataract Refract Surg 2023; 49:584-588. [PMID: 36745852 DOI: 10.1097/j.jcrs.0000000000001158] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/30/2023] [Indexed: 02/08/2023]
Abstract
PURPOSE To examine the rotational stability of a new toric intraocular lens (IOL), the TECNIS Eyhance Toric II, over a course of 3 months. SETTING Vienna Institute for Research in Ocular Surgery, Hanusch Hospital, Vienna, Austria. DESIGN Prospective unmasked single-center study. METHODS 50 eyes of 50 patients with cataract and regular corneal astigmatism ≥0.75 diopters (D) were included. The TECNIS Eyhance Toric II IOL was implanted in 1 eye of each study patient. Images of the alignment axis of the IOL were taken intraoperatively, as well as at 1 hour, 1 week, and 3 months postoperatively. For the measurement of toric IOL rotation, images were superimposed on the basis of ocular landmarks. Uncorrected and corrected distance (4 m) and intermediate (66 cm) visual acuities were assessed at the 3-month visit. RESULTS There was no significant difference in the rotational position between the intraoperative and 3 month timepoints, with a mean rotation of 1.34 ± 1.46 degrees, in 27 examined eyes. ( P = 0.313). No patients had to undergo repositioning of the toric IOL. A significant reduction of refractive cylinder occurred from preoperatively 1.8 ± 1.1 to 0.40 ± 0.42 D at the 3-month visit ( P = .001; n = 43). The corrected distance visual acuity improved significantly from 0.28 ± 0.16 logMAR preoperatively to -0.01 ± 0.13 logMAR at 3 months postoperatively ( P = .001; n = 43). CONCLUSIONS The TECNIS Eyhance Toric II showed a good visual performance with no significant rotation over a course of 3 months and, therefore, an excellent rotational stability. The intraocular lens showed a good safety profile with no adverse events.
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Affiliation(s)
- Johannes Zeilinger
- From the Vienna Institute for Research in Ocular Surgery (VIROS), A Karl Landsteiner Institute, Hanusch Hospital, Vienna, Austria
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Simsek A, Toptan M. The evaluation of pupil diameter by using Sirius before and after phacoemulsification in healthy, diabetic and hypertension patients. Medicine (Baltimore) 2023; 102:e33223. [PMID: 37083801 PMCID: PMC10118319 DOI: 10.1097/md.0000000000033223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 02/16/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Pupil size can affect the selection of the ablation region in refractive surgery and intraocular lens design in cataract surgery. Therefore, the evaluation of pupil diameter (PD), one of the anterior segment parameters, is an important component of ophthalmological examination. MATERIAL AND METHODS Seventy-one healthy patients, 64 patients with Systemic Hypertension (HT), and 65 patients with Diabetes Mellitus (DM) scheduled for phacoemulsification were included in the study. PD was measured before and one month after surgery using combined Scheimpflug-Placido disk topography (Sirius, CSO Inc.). Preoperative PD values of the groups were compared. The PD of the groups was compared in the 1st month after surgery. Then, preoperative and postoperative pupil diameter values of the groups were compared. The effect of the surgery on the change in pupil diameter (effect value) in the groups was also examined. RESULTS Pre- and postoperative PD only differed significantly between the healthy and DM groups (P = .039 and P = .045, respectively). PD decreased in all three groups after phacoemulsification. Pre-and postoperative PD differed significantly in the healthy group (4.78 ± 0.94 and 3.01 ± 0.48 mm, respectively, P < .05). Pre- and postoperative PD values also differed significantly (4.69 ± 0.84 and 2.95 ± 0.42 mm, respectively, P < .05). In the DM group, Pre- and postoperative PD also differed significantly in the DM group (4.38 ± 1.08 and 2.82 ± 0.43 mm, respectively, P < .05). The effect values of PD changes differed in the healthy, DM, and HT groups (1.95, 1.41, and 2.28, respectively). Phacoemulsification was observed to have a greater effect on PD change in HT patients. CONCLUSIONS PD was smaller in DM patients than in the other groups. PD decreased in all three groups after phacoemulsification. This change should be remembered when planning cataract surgery for chronic metabolic patients.
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Affiliation(s)
- Ali Simsek
- Department of Ophthalmology, Harran University, School of Medicine, Sanliurfa, Turkey
| | - Müslüm Toptan
- Department of Ophthalmology, Harran University, School of Medicine, Sanliurfa, Turkey
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Foster GJL, Ayres B, Fram N, Khandewal S, Ogawa GSH, MacDonald SM, Miller KM, Snyder ME, Vasavada AR. Management of common iatrogenic iris defects induced by cataract surgery. J Cataract Refract Surg 2021; 47:522-532. [PMID: 32925648 DOI: 10.1097/j.jcrs.0000000000000411] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 07/18/2020] [Indexed: 11/26/2022]
Abstract
The proximity of the iris to the instruments and currents of cataract surgery makes iatrogenic damage to the iris a common complication of cataract surgery. This article discusses techniques to prevent or minimize this damage. When damage does occur, the surgeon must decide if, when, and how to repair the damage. Principles governing these decisions and techniques for repair are discussed. Figures and videos, included as online Supplemental Data files, illustrate cases of iatrogenic damage and repair techniques.
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Affiliation(s)
- Gary J L Foster
- From The Eye Center of Northern Colorado, PC (Foster), Fort Collins, Colorado, Ophthalmic Partners of PA (Ayres), Bala Cynwyd, Pennsylvania, Advanced Eye Care (Fram), Los Angeles, California, Baylor College of Medicine (Khandelwal), Houston, Texas, Eye Corps (MacDonald), Dallas, Texas, Tufts University School of Medicine (MacDonald), Boston, Massachusetts, Stein Eye Institute (Miller), University of California, Los Angeles, Los Angeles, California, Eye Associates of New Mexico, University of New Mexico (Ogawa), Albuquerque, New Mexico, Cincinnati Eye Institute (Snyder), Cincinnati, Ohio, USA; Iladevi Cataract & IOL Research Center (Vasavada) Ahmedabad, India
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Shibata Y. [Establishing Evidence for Use of Appropriate Medicines in the Operating Room]. YAKUGAKU ZASSHI 2021; 141:25-31. [PMID: 33390443 DOI: 10.1248/yakushi.20-00190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Various issues related to clinical use of medicines remain unclear, and pharmacists are expected to establish evidence for appropriate use of medicines. The present review summarizes our findings from three areas of research regarding the use of medicines in the operating room: 1) We evaluated the extent of extravasation injury due to thiopental (2.5 mg/100 μL) and propofol (1.0 mg/100 μL) at the macroscopic and histopathologic levels in a rat model. Thiopental, which causes tissue necrosis, can be classified as a "vesicant", and propofol can be classified as an "irritant". Moreover, warming strongly exacerbated the degeneration or necrosis induced by extravasation of thiopental. 2) The cytotoxicity of povidone-iodine solution (PVP-I) for ophthalmic use and that of polyvinyl alcohol-iodine solution (PAI) was compared using a human corneal epithelial cell line. Despite exhibiting equivalent antiseptic effects, the cytotoxicity of PVP-I diluted 16-fold was greater than that of PAI diluted 6-fold. After inactivation of iodine, the cytotoxicity of PVP-I persisted; therefore, to avoid corneal damage, antisepsis should be achieved with PAI. 3) The stability of 1 μg/mL adrenaline when used as an intraocular irrigating solution to maintain pupil dilation was evaluated. After mixing for 6 h, the adrenaline concentration was 65.2% (pH 8.0) of the initial concentration. Moreover, the low concentration of sodium bisulfite in the irrigating solution could have caused adrenaline reduction. Our results strongly suggest that intraocular irrigation solution containing adrenaline should be prepared just prior to use in surgery.
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Affiliation(s)
- Yuuka Shibata
- Division of Patient Safety, Hiroshima University Hospital
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Ganesan N, Srinivasan R, Babu KR, Vallinayagam M. Risk factors for endothelial cell damage in diabetics after phacoemulsification. Oman J Ophthalmol 2019; 12:94-98. [PMID: 31198294 PMCID: PMC6561038 DOI: 10.4103/ojo.ojo_200_2017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND To assess the corneal endothelium, central corneal thickness and the factors associated with endothelial cell damage after phacoemulsification in diabetics in comparison with non-diabetics. METHODS It was a case control study with 80 eyes each in the diabetic group and the control group. Intraoperative mydriasis, effective phaco time (EPT) and postoperative inflammation were measured. Preoperative, 1st week, 6th week and 3rd month postoperative endothelial cell density (ECD), coefficient of variation (CV), hexagonality and central corneal thickness (CCT) were also measured using Konan noncon robo specular microscope (Model - NSP 9900). RESULTS In the control group, patients in the age group of 60-69 years were 3.8 times more at risk of ECL compared to patients in the age group of 50-59 years. Patients in whom EPT was ≥0.50 min, were 8.8 times more at risk of ECL when compared to patients in whom EPT <0.25 min. In the diabetic group, patients who had an inflammatory score of 1+ in the first postoperative week; also had 5.7 times more risk of ECL when compared to patients in whom the inflammatory score was 0.5+ in the first postoperative week. There was a significant increase in CV (p-0.03) and CCT (p-0.03), significant decrease in the hexagonality (p-0.01) and no statistically significant difference in the endothelial cell loss (ECL) (p-0.34) in diabetics after phacoemulsification when compared to controls. CONCLUSION The present study reveals postoperative inflammation as a risk factor for ECL in diabetics and not intraoperative mydriasis and EPT.
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Affiliation(s)
- Niruban Ganesan
- Cornea and Refractive Services, Aravind Eye Hospital, Puducherry, India
| | | | - K Ramesh Babu
- Department of Ophthalmology, JIPMER, Puducherry, India
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Popiela MZ, Young-Zvandasara T, Nidamanuri P, Moore T, Leccisotti A, Kumar V. Factors influencing pupil behaviour during femtosecond laser assisted cataract surgery. Cont Lens Anterior Eye 2019; 42:295-298. [DOI: 10.1016/j.clae.2018.10.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/15/2018] [Accepted: 10/15/2018] [Indexed: 11/29/2022]
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Visco D. Effect of phenylephrine/ketorolac on iris fixation ring use and surgical times in patients at risk of intraoperative miosis. Clin Ophthalmol 2018; 12:301-305. [PMID: 29440873 PMCID: PMC5804732 DOI: 10.2147/opth.s149522] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose To evaluate the effect of intracameral phenylephrine/ketorolac (1%/0.3%) during cataract surgery on the use of iris fixation ring and surgical time in patients with poor pupil dilation (≤5.0 mm) or intraoperative floppy iris syndrome (IFIS). Setting Private practice outpatient surgical center. Design This retrospective analysis was conducted from January 1, 2014 to October 7, 2015. Materials and methods The use of iris fixation rings was evaluated in a retrospective analysis of 46 patients who underwent cataract surgery from January 1, 2014, to October 7, 2015, and who were identified before surgery to be at risk for intraoperative miosis. The qualifying factors were presurgical examination of pupil dilation ≤5.0 mm after being administered topical tropicamide 1% and phenylephrine 2.5% or history of IFIS during surgery in the fellow eye. All patients received a 2-day preoperative course of topical nonsteroidal anti-inflammatory drugs (NSAIDs) and day-of-surgery preoperative dilation using topical cyclopentolate 1%, tropicamide 1%, and phenylephrine 10%. Phenylephrine/ketorolac 1%/0.3% (Omidria®) or epinephrine 1:1,000 with sulfites was added to the ophthalmic irrigation solution and delivered intracamerally at the start of the procedure and throughout surgery. The use of iris fixation rings and surgical time for each patient were captured for each group. Results Eighteen (50%) of the patients in the epinephrine group and no patients in the phenylephrine/ketorolac group required iris fixation ring insertion to maintain pupil dilation or to control IFIS (p=0.0034). Mean surgical time was significantly shorter in the group of patients who received phenylephrine/ketorolac (p=0.0068). Conclusion In this retrospective cohort analysis of patients with poorly dilated pupils and/or IFIS, the use of intracameral phenylephrine/ketorolac in patients at risk for intraoperative miosis resulted in significantly less iris fixation ring use and significantly shorter surgical time when compared with intracameral epinephrine use.
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Affiliation(s)
- Denise Visco
- Eyes of York Cataract & Laser Center, York, PA, USA
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Kartasasmita AS, Arsih W, Switania A, Setiohadji B. The effectiveness of continuous intravitreal adrenaline as mydriatic adjuvant on pars plana vitrectomy in diabetic patient, a randomized clinical trial. REVISTA MEXICANA DE OFTALMOLOGÍA 2017. [DOI: 10.1016/j.mexoft.2016.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Goyal S, Hardin J, Uwaydat SH, Ellabban AA, Warner DB, Sallam AB. Review and update of cataract surgery in the diabetic eye. EXPERT REVIEW OF OPHTHALMOLOGY 2017. [DOI: 10.1080/17469899.2017.1351296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Sunali Goyal
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Cornea and External Diseases, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Joshua Hardin
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sami H. Uwaydat
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Retina, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | - David B. Warner
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Cornea and External Diseases, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ahmed B Sallam
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Retina, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Joshi RS. Phacoemulsification without preoperative mydriasis in patients with age-related cataract associated with type 2 diabetes. Clin Ophthalmol 2016; 10:2427-2432. [PMID: 27980391 PMCID: PMC5147406 DOI: 10.2147/opth.s122107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Aim To study the effect of intracameral injection of preservative-free lignocaine to induce pupil dilatation, without using any preoperative dilating eyedrops or intraoperative mydriatics in patients with age-related cataract associated with type 2 diabetes mellitus. Design This was a prospective, observational, and interventional case series conducted at a tertiary eyecare center in rural India. Materials and methods A total of 32 patients underwent phacoemulsification under topical anesthesia for visually significant cataract. Preoperative pupillary diameter was measured 3 days prior to surgical procedure under mydriatics (tropicamide 0.8%, phenylephrine hydrochloride 5%). Intraoperative pupillary dilatation was achieved by 1% intracameral lignocaine solution alone. Effective phacoemulsification time (EPT), total surgical time, and final pupillary diameter were recorded at the conclusion of surgery. Results The average duration of diabetes was 11.2 (range 5–25) years. There was no difference in dilatation by preoperative pupil-dilating drops (5.2±0.5 mm, range 3–8.3 mm) and intracameral 1% lignocaine during the surgical procedure (P=0.63). There was a negative correlation (r=−0.92) between diabetes duration and dilatation of pupils with dilating drops and intracameral lignocaine. The duration of the surgery, EPT, and phacoemulsification chop had statistically insignificant effects on mydriasis, while the grade of the nucleus had a statistically significant effect on mydriasis. Intracameral lignocaine had no significant effect on blood pressure or pulse. There were no surgical complications that could have compromised the visual outcome. None of the patients developed macular edema in a follow-up period of 3 months; 28 patients (87.5%) had best-corrected visual acuity from 20/30 to 20/20. Conclusion Intracameral lignocaine 1% provides sufficient mydriasis for the safe phacoemulsification of cataract in patients with type 2 diabetes of variable duration.
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Affiliation(s)
- Rajesh Subhash Joshi
- Department of Ophthalmology, Vasantrao Naik Government Medical College, Yavatmal, India
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Shibata Y, Kimura Y, Taogoshi T, Matsuo H, Kihira K. Stability of Adrenaline in Irrigating Solution for Intraocular Surgery. Biol Pharm Bull 2016; 39:879-82. [PMID: 27150155 DOI: 10.1248/bpb.b15-00916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Intraocular irrigating solution containing 1 µg/mL adrenaline is widely used during cataract surgery to maintain pupil dilation. Prepared intraocular irrigating solutions are recommended for use within 6 h. After the irrigating solution is admistered for dilution, the adrenaline may become oxidized, and this may result in a decrease in its biological activity. However, the stability of adrenaline in intraocular irrigating solution is not fully understood. The aim of this study was to evaluate the stability of adrenaline in clinically used irrigating solutions of varying pH. Six hours after mixing, the adrenaline percentages remaining were 90.6%±3.7 (pH 7.2), 91.1%±2.2 (pH 7.5), and 65.2%±2.8 (pH 8.0) of the initial concentration. One hour after mixing, the percentages remaining were 97.6%±2.0 (pH 7.2), 97.4%±2.7 (pH 7.5), and 95.6%±3.3 (pH 8.0). The degradation was especially remarkable and time dependent in the solution at pH 8.0. These results indicate that the concentration of adrenaline is decreased after preparation. Moreover, we investigated the influence of sodium bisulfite on adrenaline stability in irrigating solution. The percentage adrenaline remaining at 6 h after mixing in irrigating solution (pH 8.0) containing sodium bisulfite at 0.5 µg/mL (concentration in irrigating solution) or at 500 µg/mL (concentration in the undiluted adrenaline preparation) were 57.5 and 97.3%, respectively. Therefore, the low concentration of sodium bisulfite in the irrigating solution may be a cause of the adrenaline loss. In conclusion, intraocular irrigation solution with adrenaline should be prepared just prior to its use in surgery.
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Affiliation(s)
- Yuuka Shibata
- Department of Pharmaceutical Services, Hiroshima University Hospital
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Storr-Paulsen A, Jørgensen JS, Norregaard JC, Thulesen J. Corneal endothelial cell changes after cataract surgery in patients on systemic sympathetic α-1a antagonist medication (tamsulosin). Acta Ophthalmol 2014; 92:359-63. [PMID: 23617291 DOI: 10.1111/aos.12140] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Allan Storr-Paulsen
- Department of Ophthalmology, Frederiksberg University Hospital, Frederiksberg, DenmarkRoskilde Eye Clinic, Roskilde, Denmark
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Corneal endothelial cell changes associated with cataract surgery in patients with type 2 diabetes mellitus. Cornea 2011; 30:749-53. [PMID: 21317781 DOI: 10.1097/ico.0b013e31820142d9] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Mori Y, Miyai T, Kagaya F, Nagai N, Osakabe Y, Miyata K, Amano S. Intraoperative mydriasis by intracameral injection of mydriatic eye drops:in vivoefficacy andin vitrosafety studies. Clin Exp Ophthalmol 2011; 39:456-61. [DOI: 10.1111/j.1442-9071.2010.02456.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Skarbez K, Priestley Y, Hoepf M, Koevary SB. Comprehensive Review of the Effects of Diabetes on Ocular Health. EXPERT REVIEW OF OPHTHALMOLOGY 2010; 5:557-577. [PMID: 21760834 PMCID: PMC3134329 DOI: 10.1586/eop.10.44] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Altan-Yaycioglu R, Gedik S, Pelit A, Akova YA, Akman A. Clinical Factors Associated With Floppy Iris Signs: A Prospective Study From Two Centers. Ophthalmic Surg Lasers Imaging Retina 2009; 40:232-8. [DOI: 10.3928/15428877-20090430-02] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
PURPOSE To determine whether intracameral mydriatics can redilate pupils that contract during phacoemulsification cataract surgery. METHODS A total of 80 patients were included in this prospective, randomized, double-blind study performed at Ornsköldsviks Hospital Eye Clinic. Of these, 60 patients had 0.6 microg/ml of epinephrine added to the balanced salt solution (BSS) used for irrigation and 20 patients did not. The patients in each group were randomized and given either an intracameral mydriatics (ICM) solution or placebo intracamerally after phacoemulsification and cortex cleaning. The pupil size was registered preoperatively, after cortex cleaning, 30 seconds after study injection, 2 mins after study injection and the day after surgery. RESULTS No clinically relevant differences were found preoperatively. In the epinephrine material a significantly longer operation time (p = 0.023) and more procedures requiring Vision Blue and Kelman-type tip in the placebo group might indicate diversity in the grade of cataract. There was a greater degree of contraction in the absence of epinephrine in the irrigation solution (2.3 +/- 1.0 mm in the ICM group and 3.2 +/- 0.7 mm in the placebo group) compared to in the presence of epinephrine. With no epinephrine ICM significantly redilated the pupils at 30 seconds (p < or = 0.001) as well as at 2 mins (p = 0.015). CONCLUSION We have shown that in cases with an intraoperative pupil contraction, ICM is effective in redilating the pupil. Insufficient adrenergic stimulation of the pupil dilator appears to be a major factor causing intraoperative pupil contraction during phacoemulsification cataract surgery.
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Hayashi K, Hayashi H. Pupil size before and after phacoemulsification in nondiabetic and diabetic patients. J Cataract Refract Surg 2005; 30:2543-50. [PMID: 15617922 DOI: 10.1016/j.jcrs.2004.04.045] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2004] [Indexed: 11/21/2022]
Abstract
PURPOSE To evaluate the changes in pupil size before and after phacoemulsification surgery in nondiabetic and diabetic patients and determine whether there is an association between preoperative pupil size and postoperative pupil size. SETTING Hayashi Eye Hospital, Fukuoka, Japan. METHODS In this study, 315 nondiabetic patients and 71 diabetic patients scheduled for phacoemulsification were recruited consecutively. The pupil area and pupil diameter were measured preoperatively and approximately 3 days and 1 month postoperatively using an infrared pupillometer and Colvard pupillometer, respectively. The simple association between preoperative and postoperative pupil size and between pupil size and age were evaluated. RESULTS The mean pupil area in the nondiabetic group and diabetic group decreased significantly 3 days postoperatively and returned to approximately preoperative levels at 1 month. Strong associations were found between preoperative pupil area and diameter and the area and diameter at 3 days and 1 month in both groups. Younger age was weakly associated with larger pupils in the nondiabetic group. The pupil size in the diabetic group was smaller than in the nondiabetic group, although the difference was not significant preoperatively. The pupil size became smaller with increasing severity of diabetic retinopathy. CONCLUSIONS Pupil size decreased immediately after phacoemulsification but returned to approximately preoperative levels by 1 month postoperatively in nondiabetic and diabetic patients. There was a strong association between preoperative and postoperative pupil size. The pupil size in diabetic patients was significantly smaller than in nondiabetic patients postoperatively.
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Khokhar S, Pangtey MS, Soni. Surgical Peculiarities in Type II Diabetic Cataracts During Phacoemulsification. Ophthalmic Surg Lasers Imaging Retina 2003. [DOI: 10.3928/1542-8877-20030301-04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Mirza SA, Alexandridou A, Marshall T, Stavrou P. Surgically induced miosis during phacoemulsification in patients with diabetes mellitus. Eye (Lond) 2003; 17:194-9. [PMID: 12640406 DOI: 10.1038/sj.eye.6700268] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
PURPOSE To assess the incidence of surgically induced miosis during phacoemulsification in diabetic patients. METHODS A total of 76 patients with diabetes mellitus were compared to 76 age- and race-matched controls. A combination of cyclopentolate 1%, phenylephrine 2.5% and diclofenac sodium 0.1% was applied topically 60, 45 and 30 min before surgery. Adrenaline mixed with buffered saline solution was used for irrigation during surgery. The procedure included phacoemulsification and implantation into the bag of a foldable acrylic implant. Measurements of the horizontal pupillary diameter were taken at three stages: before corneal incision, after phacoemulsification, and at the end of surgery. The duration of phacoemulsification was also recorded. RESULTS Surgically induced miosis or dilation of the pupil was defined as constriction or dilation noted at any interval during surgery. The pairs of diabetic-control were grouped into three groups: those in which constriction was noted, those in which dilation was noted, and those in which there was no change in pupil size during the procedure. Surgically induced miosis was noted more often in the diabetics (McNemar's test, chi(2), P=0.016). The mean pupil size at the beginning of surgery was 7.38 (+/-0.95) mm in the diabetics as compared to 7.65 (+/-0.89) mm in the control group. No statistically significant difference was noted between the two groups (paired t-test, P=0.07). The mean (+/-SD) duration of phacoemulsification in the diabetic group was 2.31 (+/-1) min as compared to 2.05 (+/-0.82) min in the control group. No statistically significant difference was found between the two groups (paired t-test, P=0.08). CONCLUSION Surgically induced miosis occurred more often in the diabetics. Therefore, it is advisable that phacoemulsification in this group of patients is undertaken by an experienced surgeon.
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Affiliation(s)
- S A Mirza
- Birmingham and Midland Eye Centre, City Hospital, UK
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Lam PTH, Poon BTM, Wu WK, Chi SCC, Lam DSC. Randomized clinical trial of the efficacy and safety of tropicamide and phenylephrine in preoperative mydriasis for phacoemulsification. Clin Exp Ophthalmol 2003; 31:52-6. [PMID: 12580895 DOI: 10.1046/j.1442-9071.2003.00600.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To compare the mydriatic effect and safety between different concentrations of tropicamide and phenyle-phrine in preoperative mydriasis for phaco-emulsification. METHODS Two hundred and seventeen consecutive eyes in the same number of Chinese patients undergoing phaco-emulsification under local or topical anaesthesia in a university-based eye hospital were analyzed. Patients were randomized into two groups by cluster randomization, each group receiving a different preoperative mydriatic regimen. Regimen A consisted of tropicamide 1.0% with phenylephrine 2.5%, and Regimen B consisted of tropicamide 0.5% with phenylephrine 0.5%. The main outcome measures were horizontal pupillary diameter, systolic, diastolic and pulse pressure and pulse rate. RESULTS The group who received Regimen A attained a mean horizontal pupillary diameter of 7.00 +/- 1.06 mm. Their pupils were significantly larger than those receiving Regimen B (6.61 +/- 1.03 mm, P = 0.007). No untoward cardiovascular effects were noted in either groups. CONCLUSION Regimen A attained better preoperative mydriasis for phacoemulsification than Regimen B. Both regimens were safe with regard to their cardiovascular effects. The combination of tropicamide 1.0% and phenylephrine 2.5% is recommended as preoperative mydriatic for phacoemulsification in Chinese patients who have darkly pigmented irides.
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Affiliation(s)
- Philip T H Lam
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, People's Republic of China.
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Pittasch D, Lobmann R, Behrens-Baumann W, Lehnert H. Pupil signs of sympathetic autonomic neuropathy in patients with type 1 diabetes. Diabetes Care 2002; 25:1545-50. [PMID: 12196425 DOI: 10.2337/diacare.25.9.1545] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Pupillary autonomic neuropathy is considered an early sign of the development of systemic autonomic neuropathy. Sympathetic denervation is related to the duration of diabetes and the development of systemic autonomic dysfunction. We investigated pupil responsiveness to directly and indirectly acting sympathomimetics in type 1 diabetic patients with and without long-term complications, defined as cardiac autonomic neuropathy (CAN), peripheral sensomotor neuropathy, retinopathy, and nephropathy, and in healthy subjects. RESEARCH DESIGN AND METHODS A total of 47 randomly chosen type 1 diabetic patients and 20 healthy subjects were selected for this study. Patients were divided into groups determined by whether they had long-term diabetic complications. Pharmacological tests were performed with cocaine 4%, epinephrine 1%, and pholedrine 5% eye drops. Horizontal pupil diameter (HPD) was measured at the beginning of the pharmacological tests and at defined time points after instillation of the eye drops. RESULTS Statistical analysis showed a significantly smaller HPD in the patients before instillating eye drops (P = 0.011). In particular, the HPD was significantly smaller in the patient group without CAN when compared with healthy subjects (P = 0.004). Maximal cocaine reaction was diminished in the complication group (P < 0.001). Epinephrine test, visual acuity, ocular pressure, and HbA(1c) did not differ in patients with or without long-term complications. The noncomplication group showed no significant differences in pupillary responses as compared with healthy subjects. The complication group showed a smaller HPD (P = 0.022), reduced pupillary responses in the cocaine (P = 0.037) and pholedrine tests (P < 0.001), and anisocor pupil sizes after instillation of the eye drops (P = 0.034). CONCLUSIONS Our results clearly show that sympathetic denervation does exist in the pupil of diabetic patients and that it can be rapidly assessed using the cocaine test. These data and the results of the epinephrine test suggest a mixed pre- and postganglionic dysfunction of the sympathetic plexus. The significant smaller HPD in patients without CAN compared with that of healthy subjects could be a sign for early involvement of the pupil function before cardiac manifestation of systemic autonomic diabetic neuropathy.
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Affiliation(s)
- Daniel Pittasch
- Department of Endocrinology and Metabolism, Otto-von-Guericke-Universität Magdeburg, Magdeburg, Germany
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Zaczek A, Olivestedt G, Zetterström C. Visual outcome after phacoemulsification and IOL implantation in diabetic patients. Br J Ophthalmol 1999; 83:1036-41. [PMID: 10460771 PMCID: PMC1723171 DOI: 10.1136/bjo.83.9.1036] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS To follow visual acuity (VA) and progression of diabetic retinopathy (DR) after phacoemulsification in diabetic patients with different stages of DR and controls. METHODS This prospective study included 27 diabetic patients with no or mild to moderate non-proliferative DR; 25 patients with moderate to severe non-proliferative, or proliferative DR; and 22 non-diabetic controls. All patients underwent uncomplicated, phacoemulsification surgery, with implantation of a heparin-surface modified (HSM) poly(methylmethacrylate) (PMMA) intraocular lens (IOL) into the capsular bag. Colour fundus photographs and fluorescein angiograms (FA) were taken at 1 week (baseline), 3 months, and 1 year postoperatively to determine stability or progression of DR. RESULTS The VA of 46 diabetic eyes (88%), was improved 1 year after surgery and only six eyes (12%) were unchanged or worse. 41 diabetic eyes (79%) achieved a VA of 0.5 or better and 11 eyes (21%) had a final VA lower than 0.5. Significantly lower final corrected VA was found 1 year after surgery in eyes with advanced DR (median 0.5; range 0.1-1.0) compared with controls (1.0; 0.1-1.0) and eyes with no or mild to moderate DR (1.0; 0.1-1.0). Eyes with mild to moderate DR and clinically significant macular oedema (CSMO) 1 week postoperatively had a lower final VA than those without CSMO. Angiographic cystoid macular oedema (CMO) was detected with FA in 15% of all diabetic eyes 1 week postoperatively. 41 eyes (79%) showed no change or improvement of the retinal status 1 year after cataract surgery. Progression was found in 11 eyes (21%), mainly in eyes with mild to moderate DR and moderate to severe DR. Eyes with an indication for laser photocoagulation at baseline showed a significantly higher rate of progression of DR after surgery than those without indication for laser treatment. CONCLUSION The final visual outcome was improved in the majority of diabetic eyes. Eyes with CSMO at the time of surgery had the worst prognosis regarding postoperative VA.
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Affiliation(s)
- A Zaczek
- St Erik's Eye Hospital, Karolinska Institutet, Stockholm, Sweden
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Zaczek A, Zetterström C. Posterior capsule opacification after phacoemulsification in patients with diabetes mellitus. J Cataract Refract Surg 1999; 25:233-7. [PMID: 9951670 DOI: 10.1016/s0886-3350(99)80132-1] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE To compare posterior capsule opacification (PCO) after phacoemulsification and implantation of heparin-surface-modified (HSM) poly(methyl methacrylate) (PMMA) intraocular lenses (IOLs) in the capsular bag in patients with diabetes mellitus with that in a control group. SETTING St. Erik's Eye Hospital, Stockholm, Sweden. METHODS This prospective study comprised 26 patients with diabetes mellitus and 26 control patients without diabetes. Those with glaucoma, exfoliation syndrome, uveitis, and pupil size smaller than 6.0 mm after dilation were excluded. All patients received the same standardized phacoemulsification procedure with implantation of an HSM PMMA IOL in the capsular bag. Posterior capsule opacification was scored 1 and 2 years after surgery by evaluating retroillumination images taken with a Scheimpflug camera (Nidek Anterior Eye Segment Analysis System) after pupil dilation with phenylephrine 10% and cyclopentolate 1%. The PCO density behind the IOL optic was graded clinically from 0 to 4 (0 = none, 1 = minimal, 2 = mild, 3 = moderate, 4 = severe) and scored using the Evaluation of Posterior Capsule Opacification medical software developing system. RESULTS No differences in PCO were found between the diabetic and control groups 1 year after surgery. The total PCO score was significantly less in diabetic than in control eyes 2 years after surgery (P < .05, Mann-Whitney). In addition, progression of PCO from 1 year to 2 years after surgery was significantly less in diabetic groups with different stages of diabetic retinopathy than in the control group (P < or = .05, Kruskal-Wallis analysis of variance and multiple comparisons). CONCLUSION The rate of PCO after phacoemulsification was statistically significantly lower in patients with diabetes mellitus than in those without diabetes.
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Affiliation(s)
- A Zaczek
- St. Erik's Eye Hospital, Karolinska Institute, Stockholm, Sweden
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Zaczek A, Zetterström C. Aqueous flare intensity after phacoemulsification in patients with diabetes mellitus. J Cataract Refract Surg 1998; 24:1099-104. [PMID: 9719970 DOI: 10.1016/s0886-3350(98)80104-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To prospectively compare the postoperative blood-aqueous barrier breakdown induced by phacoemulsification and implantation of a heparin-surface-modified poly(methyl methacrylate) intraocular lens in the capsular bag in eyes with different stages of diabetic retinopathy (DR) and a control group. SETTING St. Erik's Eye Hospital, Karolinska Institute, Stockholm, Sweden. METHODS Aqueous flare intensity was measured preoperatively and 1 day, 1 week, and 3 months postoperatively in 21 nondiabetic control patients (Group 1), 20 diabetic patients with no or mild-moderate nonproliferative DR (Group 2), and 19 diabetic patients with advanced DR (moderate-severe, severe nonproliferative, and proliferative DR) who were divided into groups: without clinically significant macular edema (CSME), 7 eyes (Group 3), and with CSME, 12 eyes (Group 4). RESULTS Before surgery, flare intensity in Group 4 was significantly higher than in Groups 1 and 2 (P < .05). Surgical trauma increased flare values 1 day postoperatively in all groups. One week after surgery, Groups 1 and 4 had flare intensity significantly higher than preoperatively (P < .05). Recovery of flare occurred 3 months postoperatively in all groups except Group 2, in which it occurred 1 week after surgery. One day postoperatively, only Group 4 had significantly higher flare than Group 1 (P < .05). One week and 3 months after surgery, Group 4 had significantly higher flare intensity than Groups 1 and 2 (P < .05). The duration of phacoemulsification in Groups 2 and 4 was significantly longer than in Group 1 (P < .05). Operating time was significantly longer than in Group 1 only in Group 4 (P < .05). CONCLUSION Eyes with advanced stages of DR and with CSME had the highest flare intensity after cataract surgery.
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Affiliation(s)
- A Zaczek
- St. Erik's Eye Hospital, Karolinska Institute, Stockholm, Sweden
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