Intraoperative complications of cataract surgery in the very old

Age-related appearance of lamellar structures in lens capsule of cataractous eyes and its pathological significance

PURPOSE

To determine morphological changes in the lens capsule with aging.

SETTING

Hayashi Eye Hospital, Fukuoka, Japan.

DESIGN

Cross-sectional study.

METHODS

25 eyes from the older patient group (aged 80 years or older) and 25 eyes from the younger patient group (aged 65 years or younger) who were diagnosed with cataract and indicated for surgery were included in the study. After continuous curvilinear capsulorhexis, the anterior lens capsule was collected, immediately fixed, and processed for electron microscopy analysis. Backscattered electron images of the cross-section of the anterior lens capsule were observed under a scanning electron microscope. The ultrastructure of the anterior lens capsule was observed and compared between the groups. Factors associated with the occurrence of the lamellar structure were also identified, with the presence or absence of a lamellar structure as an objective variable and preoperative clinical characteristics as the explanatory variables.

RESULTS

50 eyes of 50 patients were included. In the younger patient group, 20 eyes (80%) had a homogeneous lens capsule, whereas 5 eyes had lamellar structures. By contrast, in the older patient group, 5 eyes had homogeneous structures, while the remaining 20 eyes (80%) had lamellar structures. 1 eye showed capsular delamination. The only significant factor for the occurrence of lamellar structures was age group ( P < .01, nominal logistic regression analysis).

CONCLUSIONS

Lamellar structures appear in the anterior capsule during aging. The appearance of lamellar structures indicates fragility of the lens capsule, which may, in turn, lead to capsular delamination or lens dislocation in some cases.

Determinants of the risk of intraoperative complications in phacoemulsification among patients with pseudoexfoliation

PURPOSE

The purpose of the study was to study the relationship between pseudoexfoliation (PES) and other predictors in the development of complications in cataract surgery by phacoemulsification in patients with PES.

METHODS

A retrospective cohort study of patients undergoing cataract surgery by phacoemulsification in the health area of Cee in northwestern Spain during the 2-year period from 2009 to 2010. Capsule rupture, choroidal hemorrhage, and vitreous loss were included as complications and intraoperative nucleus or lens dislocation as the independent variable. PES, age, hardness, type of cataract, myopia, preoperative visual acuity, antiplatelet use, anticoagulant uses, alpha agonist use, mydriasis prior to surgery, anterior chamber depth, and axial length were included as predictor variables. All predictive hierarchical models were tested using as a selection criterion the one minimizing the Akaike index.

RESULTS

A total of 551 patients were initially identified from hospital register, of which 48 were excluded due to the presence of an exclusion factor. After the initial selection, the final sample was 681 eyes of 503 patients. Of the 8192 possible models, a model with the following seven variables was selected: PES, steroid use, alpha agonist use, nuclear hardness, mydriasis, anterior chamber depth, and axial length. The selected model had an Akaike index of 435.4 and an area under the curve of 0.7895 corresponding to a sensitivity of 6.2% and a specificity of 98.5%.

CONCLUSION

PES, nuclear hardness, and alpha agonist use are risk factors strongly predictive of complications.

Accuracy of IOL power calculations in the very elderly

Background/objectives

To analyze the refractive predictability and outcomes of cataract surgery in the very elderly (≥85 years old).

Subjects/methods

A retrospective case-series performed at the Shiley Eye Institute, University of California San Diego, USA. Electronically pulled data of 2444 surgeries revealed 147 surgeries on 133 very elderly patients. Chart review was conducted for all very elderly and corresponding control patients (75–84 years old). The first operated eyes of patients with final best-corrected visual acuity ≥20/40, axial length (AL) 22–26 mm, and implanted SN60WF IOL were included. Patients with ocular comorbidities and/or intra- or post-operative complications were excluded. Prediction errors of refractive outcome and percentage of eyes within ±0.50D and ±1.00D were compared between the groups for the Holladay 1 and Barrett Universal II (Barrett) formulas. Logistic regression analysis for achievement of ±1.00D was conducted.

Results

Final analysis included 90 eyes (n = 44, very elderly, n = 46, control patients). Median absolute refractive error (MedAE) with Holladay 1, but not Barrett formula, was significantly higher in the older group (p = 0.02 and p = 0.07, respectively). The MedAE in the older group was lower using the Barrett compared to Holladay 1 (p = 0.02). Fewer older patients than younger patients achieved refraction within ±0.50D and ±1.00D from goal, using the Holladay 1 (p = 0.049 and p = 0.002 respectively). Logistic regression analysis supported the relationship between Holladay 1 predictive refractive error of >1.00D and patient’s age (p = 0.046).

Conclusions

Very elderly patients undergoing cataract surgery may be prone to reduced refractive precision, particularly with utilization of the Holladay 1 formula.

[Cataract Surgery in Very Old Patients]

BACKGROUND

In recent years, there has been an increase in the number of very old patients requiring a cataract operation. However, there is little information on the intraoperative complications and safety in these patients. For various reasons, operations on patients from age 85 may be demanding: dense nuclear cataract, narrow pupils, low count of endothelial cells, loose zonula, and other ocular or systemic diseases. The aim of this retrospective study was to compare very old to younger cataract patients with respect to intraoperative complications and the maturity of the cataract.

PATIENTS AND METHODS

This was a retrospective study on 4065 cataract patients treated in our department with IOL implantation with the corneal small incision technique between January 2015 and January 2018. The patients were split by age (from 85 and under 85).

RESULTS

Of the 4065 cataract operations, 10.6% (431/4065) were performed on patients aged at least 85, 1.7% (69/4065) on patients aged at least 90 and 0.1% (4/4065) on patients of at least 95 years. There were statistically significant differences between the younger and older patients with respect to pupil dilatation (4.6 vs. 6.0%), use of the capsule tension ring (0.4 vs. 0%) and in capsule staining (5.5 vs. 7.0%). There were no intraoperative complications (e.g. anterior capsule laceration) in patients aged at least 85 and in 0.71% of patients aged under 85; loss of vitreous fluid was recorded in none of the patients in the older group and in 0.41% of patients in the younger group.

CONCLUSION

Our study confirms that advanced age alone is not a contraindication for a cataract operation and is not associated with a greater rate of intraoperative complications. Cataract operations on very old patients are generally successful, but should be undertaken early - particularly on multimorbid patients or those with dementia - in order to support the psychological status. The age of the patient is irrelevant.

Residents' Learning Curve for Manual Small-Incision Cataract Surgery at Aravind Eye Hospital, India

PURPOSE

The goal of this study was to document the resident learning curve for manual small-incision cataract surgery (MSICS) and to identify implications for the design of ophthalmology residency programs aimed to train surgeons for developing countries.

DESIGN

Hospital-based retrospective cohort study.

PARTICIPANTS

All 38 residents entering 2 postgraduate residency programs at Aravind Eye Hospital, Madurai, in 2012 and 2013.

METHODS

Surgical complications and reoperations for all MSICSs performed by residents during the residency training period were evaluated using a computerized patient database. Multivariate logistic regression models were used to estimate the effect of the cumulative number of surgeries performed on incidence of intraoperative complications, postoperative complications, and reoperations, controlling for covariates.

MAIN OUTCOME MEASURES

Incidence of intraoperative and first-day postoperative complications of Oxford Cataract Treatment and Evaluation Team (OCTET) grades II and III and the incidence of reoperations. Analyses controlled for patient-, resident-, and residency program-level covariates.

RESULTS

The study evaluated 13 159 surgeries performed by the 38 residents between October 15, 2012, and August 24, 2016. The mean number of surgeries performed by a resident was 346.3 (standard deviation, 269.4). Three hundred forty-two eyes (2.60%) with at least 1 intraoperative complication, 234 eyes (1.78%) with at least 1 first-day postoperative complication, and 154 reoperations (1.17%) were observed. After controlling for baseline covariates, increasing surgical experience was associated with reduced risk of intraoperative and postoperative complications, as well as reoperations. The odds decreased by 17% (intraoperative complications), 12% (postoperative complications measured 1 day after surgery), and 7% (reoperations) per 100 additional surgeries performed. Patient-level factors such as older age, left eye surgery, and lower preoperative uncorrected visual acuity were found to be associated with higher risk of intraoperative complications (P < 0.01 for all).

CONCLUSIONS

The risk of surgical complications and reoperations in MSICS decreased steadily with surgical experience gained by resident surgeons. We recommend that ophthalmology residency programs in developing nations teaching MSICS provide opportunities to perform 300 surgeries or more by residents so as to achieve rates of intraoperative and postoperative complications of less than 2%.

The relationship between age and the intraoperative complication rate during phacoemulsification surgery

AIM

The aim of this study was to determine if aging is a factor that increases the intraoperative complication rate during phacoemulsification surgery.

MATERIALS AND METHODS

Patients who underwent phacoemulsification surgery were divided into three age groups according to World Health Organization classification, as follows: ≤ 59, 60-74, and ≥ 75 years. The intraoperative complications which occurred during the operation were recorded. Binary logistics regression analysis, Pearson’s correlation analysis, and Duncan’s (multiple range) test were used for statistical analysis.

RESULTS

In total, 789 patients who underwent phacoemulsification surgery at Nigde State Hospital, Ophthalmology Clinic between 01 July 2010 and 31 October 2012 were retrospectively reviewed, and intraoperative complications that occurred during surgery were recorded. Mean age of the patients was 68.98 years (range 38–93 years). In all, 132 (16.7 %) patients were aged ≤ 59 years, 406 (51.5 %) were aged 60 - 74 years, and 251 (31.8 %) were aged ≥ 75 years. The complication rates were 3.78 % in the ≤ 59-year-old age group, 5.17 % in the 60- to 74-year-old age group, and 5.30 % in the ≥ 75-year-old age group. Age did not have a significant effect on intraoperative complication rates during phacoemulsification surgery, according to binary logistic regression analysis (P = 0.58) and Pearson’s correlation analysis (P = 0.076). The incidence and risk of intraoperative complications in the age groups did not differ statistically (Duncan’s test, P = 0.18).

CONCLUSION

Age has no effect on the rate of intraoperative complications during phacoemulsification surgery.

Clinical outcomes of cataract surgery in very elderly adults

OBJECTIVES

To investigate the clinical outcomes of cataract surgery elderly adults.

DESIGN

Retrospective cohort study.

SETTING

Two clustered hospitals.

PARTICIPANTS

Two hundred seven individuals aged 90 and older who underwent cataract surgery for primary senile cataracts.

MEASUREMENTS

Best-corrected preoperative and postoperative Snellen visual acuity, type of cataract, surgical techniques, preoperative systemic or ocular comorbidities, and intraoperative and postoperative complications were assessed. Improvement of visual acuity was defined as a decrease in logMAR acuity of 0.1. Factors associated with visual outcome within 6 months after surgery were identified using logistic regression modeling. The duration of postoperative survival was calculated.

RESULTS

In the 207 participants (mean age 92.0 ± 2.1), 79.7% achieved visual improvement after cataract surgery. Forty-eight percent (mean age 97.4 ± 2.8) were alive on December 31, 2012. The most common systemic comorbidities were hypertension (66.2%), diabetes mellitus (25.1%), and myocardial infarction (19.8%). Age-related macular degeneration (AMRD) (15.9%), glaucoma (10.6%), and myopic degeneration (5.3%) were the three most common ocular comorbidities. Uncomplicated cataract surgery was performed in 87.0% cases. The most common complications were vitreous loss (8.2%), posterior capsular rupture (7.2%), and zonular rupture (4.8%). Participants with AMRD (P = .001, odds ratio (OR) = 4.77, 95% confidence interval (CI) = 1.86-12.26) and vitreous loss (P = .001, OR = 12.86, 95% CI = 2.71-61.10) were less likely to achieve postoperative visual improvement.

CONCLUSION

Despite a high prevalence of systemic and ocular comorbidities in very elderly adults, good clinical outcomes of cataract surgery were attainable. ARMD and vitreous loss were associated with a lower chance of postoperative visual improvement.

Results of cataract surgery in the very elderly population

AIM

The aim of our study was to retrospectively evaluate the effectiveness and safety of cataract surgery and intraocular lens implantation (IOL) for patients aged 90 years or older, whom we define as "very elderly."

METHODS

The study involved a total number of 122 patients (122 eyes) with senile cataracts. The mean age of patients was 91.2 ± 2.3 years (range 90-100 years old). Phacoemulsification (phaco) was done on 113 of 122 eyes, and 9 of 122 eyes had extracapsular cataract extraction (ECCE). Postoperative visual acuity and intraocular pressure (IOP) were analyzed on the first postoperative day, 3 months after surgery, and 6 months after surgery.

RESULTS

Best corrected visual acuity (BCVA) improved in 100 of 122 eyes (82.0%). BCVA remained the same in 20 of 122 eyes (16.4%) and decreased in 2 of 122 eyes (1.6%), mainly because of coexisting age-related macular degeneration (AMD). The BCVA 3 months after surgery was ≥0.8 in 23 of 122 eyes (18.9%), between 0.5 and 0.7 in 28 of 122 eyes (22.3%), and between 0.2 and 0.4 in 33 of 122 eyes (27.1%). We found significant implications of cataract surgery on decreasing IOP in the studied group of patients suffering from glaucoma compared to the patients without glaucoma.

CONCLUSION

Advanced age is not a contraindication for cataract surgery. The results of the study showed that when systemic conditions are stable, both phaco and ECCE with IOL for very elderly patients are effective and safe.

Cataract surgery in patients older than 90 years of age

OBJECTIVE

The aim of this study was to examine whether differences exist after cataract surgery is performed in patients over and under 90 years of age.

STUDY DESIGN

Retrospective, nonrandomized study.

PARTICIPANTS

Cataract surgery was performed in 21 patients (31 eyes) who were older than 90 years of age and in 45 patients (70 eyes) who were younger than 90 years of age.

METHODS

The medical records of all patients who underwent cataract surgery between January 2005 and September 2010 at Dokkyo Medical University Koshigaya Hospital were reviewed. Factors evaluated included systemic disease, changes in systemic condition, surgical time, preoperative and postoperative visual acuity, corneal endothelial cell density, and intraoperative complications.

RESULTS

The group of patients older than 90 years of age experienced greater occurrences of systemic disease (p < 0.05; χ(2) test) and intraoperative changes in systemic conditions (p < 0.001; χ(2) test). These patients also had significantly lower preoperative visual acuity (p < 0.001; Student t test). No differences were noted between the 2 age groups in surgical time, postoperative visual acuity, preoperative corneal endothelial cell density, or intraoperative complications.

CONCLUSIONS

Poorer cataract surgery outcome results were noted in patients older than 90 years due to systemic disease and intraoperative changes in systemic condition. Factors that need to be taken into consideration prior to performing cataract surgery in older patients include age, systemic disease, and the likelihood of intraoperative changes in systemic condition.