Daily tonometric curves after cataract surgery

Reduced Posology of an Ophthalmic Hydrogel Containing Dexamethasone/Netilmicin to Prevent and Treat Ocular Inflammation After Cataract Surgery: Efficacy and Tolerability

INTRODUCTION

To demonstrate efficacy and safety of an ophthalmic hydrogel formulation of netilmicin/dexamethasone, containing xanthan gum twice a day (b.i.d.) versus netilmicin/dexamethasone eye drops four times a day (q.i.d) to treat inflammation and prevention of infection after cataract surgery.

METHODS

Patients undergoing phacoemulsification with intraocular lens implantation (IOL) were randomised in two groups: group 1, twice daily (b.i.d.) dexamethasone 0.1%/netilmicin 0.3% (Netildex) ophthalmic gel; group 2, four times daily (q.i.d.) dexamethasone 0.1%/netilmicin 0.3% (Netildex) eye drops. Both treatments were administered for 14 days after surgery. Patients were evaluated before surgery, on the day of surgery and at 1, 7, 15 and 60 postoperative days. The primary efficacy endpoint was evaluation of cellularity and flare in the anterior chamber through slit-lamp biomicroscopy 7 days after surgery. Secondary endpoints included: presence of signs/symptoms of postoperative ocular inflammation and incidence of infection.

RESULTS

One hundred seventy-three patients were randomised and 168 were evaluable. Flare and cellularity were resolved at day 7 in 92.5% of patients and almost completely by day 15. In both intent to treat (ITT) and per-protocol (PP) populations, the efficacy analysis demonstrated that the gel formulation administered twice a day was non-inferior to the eye drops administered four times a day. For ITT analysis, the lower limit of the 97.5% confidence interval (- 0.0535) was greater than the non-inferiority limit of -0.10. For the PP analysis, the lower limit of the 97.5% confidence interval (- 0.0526) was greater than the non-inferiority limit of - 0.10. The patient's global tolerability and reported symptoms were similar between treatment groups. No microbial load and no safety events were observed.

CONCLUSIONS

Efficacy of the gel reduced posology (twice a day) is not inferior to four times a day eye drops. Both treatments were well tolerated and efficacious. The new reduced posology hydrogel formulation may improve patient compliance and quality of life.

TRIAL REGISTRATION

Eudract: 2016-0021138-63; ClinicalTrial.gov: NCT029738880.

Changes in intraocular pressure after intraocular eye surgery-the influence of measuring technique

AIM

To investigate the changes in intraocular pressure (IOP) before and after intraocular surgery measured with Goldmann applanation tonometry (GAT) and pascal dynamic contour tonometry (PDCT), and assessed their agreement.

METHODS

Patients who underwent trans pars plana vitrectomy (TPPV) with or without cataract extraction (CE) were included. The IOP was measured in both eyes with GAT and PDCT pre- and postoperatively, where the non-operated eyes functioned as control.

RESULTS

Preoperatively, mean IOP measurements were 16.3±6.0 mm Hg for GAT and 12.0±2.8 mm Hg for PDCT for the operated eyes. Postoperatively, the mean IOP dropped to 14.3±5.6 mm Hg for GAT (P=0.011) and rose up to 12.7±2.6 mm Hg for PDCT (P=0.257). Bland-Altman analysis showed a poor agreement between GAT and PDCT with a mean difference of 2.9 mm Hg preoperatively and 95% limits of agreement ranging from -3.2 to 9.0 mm Hg. Postoperatively, the mean difference was 1.2 mm Hg with 95% limits of agreement ranging from -8.3 to 10.7 mm Hg. There were no significant differences between the TPPV and TPPV+CE group, except when measured with PDCT postoperatively (P=0.012).

CONCLUSION

The IOP is reduced after surgery when measured with GAT and remained stable when measured with PDCT. However, the agreement between GAT and PDCT is poor. Although PDCT may be a more accurate predictor of the true IOP, it seems less suitable for daily use in the clinical practice.

iStent with Phacoemulsification versus Phacoemulsification Alone for Patients with Glaucoma and Cataract: A Meta-Analysis

Background

Minimally invasive glaucoma surgeries (MIGS) have attracted significant attention, as they have been reported to lower intra-ocular pressure (IOP) and have an excellent safety profile. The iStent is an example of a minimally invasive glaucoma device that has received particular attention due to its early and wide spread utilization. There is a growing body of evidence supporting its use at the time of phacoemulsification to help lower IOP. However, it is still not clear how much of the IOP lowering effect can be attributed to the iStent, the crystalline lens extraction or both when inserted concurrently at the time of phacoemulsification. This has been an important issue in understanding its potential role in the glaucoma management paradigm.

Purpose

To conduct a systematic review and meta-analysis comparing the IOP lowering effect of iStent insertion at the time of phacoemulsification versus phacoemulsification alone for patients with glaucoma and cataracts.

Methods

A systematic review was conducted utilizing various databases. Studies examining the IOP lowering effect of iStent insertion in combination with phacoemulsification, as well as studies examining the IOP lowering effect of phacoemulsification alone were included. Thirty-seven studies, reporting on 2495 patients, met the inclusion criteria. The percentage reduction in IOP (IOPR%) and mean reduction in topical glaucoma medications after surgery were determined. The standardized mean difference (SMD) was computed as a measure of the treatment effect for continuous outcomes taking into account heterogeneity. Fixed-effect and random-effect models were applied.

Results

A 4% IOP reduction (IOPR%) from baseline occurred following phacoemulsification as a solo procedure compared to 9% following an iStent implant with phacoemulsification, and 27% following 2 iStents implants with phacoemulsification. Compared with cataract extraction alone, iStent with phacoemulsification resulted in significant reduction in the post-operative IOP (IOPR%) (SMD = -0.46, 95% CI: [-0.87, -0.06]). A weighted mean reduction in the number of glaucoma medications per patient was 1.01 following phacoemulsification alone compared to 1.33 after one iStent implant with phacoemulsification, and 1.1 after 2 iStent implants with phacoemulsification. Compared to cataract extraction alone, iStent with cataract extraction showed a significant decrease in the number of glaucoma medications (SMD = -0.65, 95% CI: [-1.18, -0.12]). Funnel plots suggested the absence of publication bias.

Conclusion

Both iStent implantation with concurrent phacoemulsification and phacoemulsification alone result in a significant decrease in IOP and topical glaucoma medications. In terms of both reductions, iStent with phacoemulsification significantly outperforms phacoemulsification alone.

Efficacy of selective laser trabeculoplasty in phakic and pseudophakic eyes

PURPOSE

To compare the efficacy of selective laser trabeculoplasty (SLT) in phakic and pseudophakic eyes in open-angle glaucoma and ocular hypertension.

MATERIALS AND METHODS

Charts of 28 pseudophakic eyes and 60 phakic eyes that underwent 360-degree SLT were retrospectively reviewed. Patients were examined at 1, 3, 6, and 12 months. Treatment success was defined as ≥20% intraocular pressure (IOP) reduction, with no additional medications, laser, or glaucoma surgery. Mean IOP change, mean percentage of IOP reduction, and success rates for phakic and pseudophakic eyes were compared.

RESULTS

Mean percentage of IOP reduction post-SLT at 1-, 3-, 6-, and 12-month visits were 21.4%, 25.8%, 24.8%, and 23.7%, respectively, in the pseudophakic group and 22.8%, 25.0%, 25.7%, and 21.2%, respectively, in the phakic group. Success rates ranged between 60% and 64% in the pseudophakic group and between 58% and 73% in the phakic group. No statistically significant differences in IOP change, percentage of IOP reduction, and success rate were seen between the groups at any of the post-SLT visits (P>0.05).

CONCLUSIONS

Application of 360-degree SLT seems to be an efficient and safe treatment option for the management of phakic and pseudophakic open-angle glaucoma and ocular hypertension.

Long-term change in intraocular pressure after extracapsular cataract extraction with posterior chamber intraocular lens implantation versus phacoemulsification with posterior chamber intraocular lens implantation in Indians

Purpose:

The purpose of the study is to evaluate the long-term changes in intraocular pressure (IOP) after extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens (PCIOL) implantation versus phacoemulsification with PCIOL implantation in otherwise normal cataract patients in India.

Materials and Methods:

The study was conducted in the Department of Ophthalmology, King George's Medical College, Lucknow between August 2000 and August 2001. One hundred and seventeen eyes of 115 patients were included in the study. 84 patients were randomly selected for ECCE with PCIOL implantation (ECCE group) and 31 patients were selected for phacoemulsification with PCIOL implantation (Phaco group). IOP was measured pre-operatively and post-operatively, from the 1^st month to the 12^th month. Statistical significance was indicated by P > 0.05.

Results:

There was a mean fall in IOP of 2.70 mm Hg (19.74%) in the ECCE group and 2.74 mm Hg (20.57%) in the phaco group. The decrease in the mean post-operative IOP from baseline was statistically significant (P > 0.01) at the end of 2 months in both groups. There was no statistically significant difference in post-operative IOP at any visit between groups (P < 0.05, all post-operative visits). After 4^th monthpost-operatively, the IOP was mostly stable, but it was significantly lower than the pre-operative IOP.

Conclusion:

Significant IOP reduction may be expected after cataract surgery with either ECCE or phacoemulsification with IOL implantation. The lowering of IOP became statistically significant at about 2 months post-operatively, but became almost stable after the 4^th month.

The efficacy of selective laser trabeculoplasty versus argon laser trabeculoplasty in pseudophakic glaucoma patients

INTRODUCTION

This study evaluated and compared the efficacy of selective laser trabeculoplasty (SLT) and argon laser trabeculoplasty (ALT) in terms of intraocular pressure (IOP)-lowering effects in pseudophakic patients at various time points after treatment. The primary aim was to compare the efficacy of SLT and ALT in reducing the IOP of pseudophakic glaucoma patients who recently underwent successful cataract extraction surgery. The secondary endpoint was to determine the percentage of SLT and ALT patients whose IOP was successfully reduced by at least 15% from baseline.

PATIENTS AND METHODS

This study was a follow-up of a prospective randomized clinical trial. Fifty-two eyes from 52 glaucoma patients with uncontrolled IOP who had previously undergone successful phacoemulsification-assisted cataract excision surgery with intracapsular lens implantation were randomly assigned to treatment with either ALT (n = 30) or SLT (n = 22). Fifteen patients were excluded due to adverse events encountered during the study, leaving a total of 18 and 19 patients in the ALT and SLT groups, respectively. IOP measurements were carried out at scheduled intervals until 12 months post-laser treatment.

RESULTS

There were no significant differences in the IOP-lowering effects between the two methods at any time point during the follow-up period. The greatest differences between the two groups were observed at 1 week posttreatment and at the 3-month time point, but neither reached a level of significance. At the final checkup, the mean IOP reduction from baseline was 3.23 mmHg in the ALT group and 4.30 mmHg in the SLT group (P = 0.269). At that visit, six (35.3%) patients in the ALT group and 15 (75%) patients in the SLT group had a reduction of ≥15% from their baseline IOP.

CONCLUSION

SLT and ALT are equally effective in their IOP-lowering capabilities in new pseudophakic glaucoma patients during the first 12 months after treatment.

Changes in intraocular pressure after clear corneal phacoemulsification in normal patients

Purpose:

To evaluate changes in intraocular pressure (IOP) after clear corneal phacoemulsification (CCP) in normal patients.

Materials and Methods:

A prospective study including 273 normal patients selected for cataract extraction by CCP. Intraocular pressure was recorded on the 15^th day, l^st, 2^nd, 3^rd month and 6 months after surgery.

Statistical Analysis:

For statistical analysis, Epi Info was used to determine the statistical significance of changes in IOP.

Results:

The mean age of 96 women and 177 men was 71 ± 12 years. The mean IOP before surgery was 14.18 ± 3.4 mmHg. Our patients showed a mean decrease in IOP of 2.25 mmHg (16%) compared to preoperative values. Change in IOP was not related to lens thickness (P = 0.12), but significantly correlated with change in anterior chamber depth (ACD) (P = 0.002). The postoperative IOP was inversely related to preoperative ACD (P = 0.012). Age, sex and axial length were not significantly related to IOP reduction (P = 0.2–0.5)

Conclusion:

CCP was associated with a statistically significant reduction in IOP. The exact mechanism by which cataract surgery results in IOP reduction is unclear. CCP can be performed with the intent of achieving better IOP control.

Cataract surgery to lower intraocular pressure

Cataract and glaucoma are common co morbidities. Cataract surgery is frequently performed in patients with glaucoma. In this study, a review of literature with search terms of cataract, glaucoma and intraocular pressure is followed by evaluation and synthesis of data to determine the effect of cataract surgery on intraocular pressure. Cataract surgery seems to lower intraocular pressure on a sustained basis, especially in patients with higher preoperative intraocular pressure. The mechanism of action of these finds remains speculative.

Modified extracapsular extraction versus endocapsular phacoemulsification: intraoperative and immediate postoperative events

The clinical events and variations in intraocular pressure (IOP) that occur in endocapsular phacoemulsification technique were compared to the modified extracapsular extraction technique during the intraoperative and immediate postoperative periods. Phacoemulsification technique caused less corneal edema, less ocular discomfort and fewer postoperative complications than the modified extracapsular extraction technique. The observed increase in postoperative IOP, especially in the case of phacoemulsification, makes pressure monitoring mandatory, as well as the use of ocular hypotensive agents when the IOP exceeds acceptable limits.

Comparative efficacy of acetazolamide and apraclonidine in the control of intraocular pressure following phacoemulsification

PURPOSE

The purpose of our study was to compare the effects of systemically administered acetazolamide and topical apraclonidine 0.5% in the control of intraocular pressure (IOP) following phacoemulsification of senile cataracts.

SETTING

The study was conducted on patients affected by cataract and followed at the Department of Ophthalmology.

METHODS

Seventy-eight eyes in 78 patients were selected. Twenty-six eyes were randomly assigned to postoperative treatment with topical apraclonidine 0.5%, 26 received oral acetazolamide and the remaining 26 received no hypotensive treatment (control group). Statistical analyses were performed mainly by means of analyis of variance.

RESULTS

IOPs measured 24 h after surgery were significantly (p = 0.01) lower in the apraclonidine group compared to the control group.

CONCLUSIONS

Our double-blind prospective study conducted on patients randomly assigned to treatment with apraclonidine or acetazolamide shows that the former drug is undoubtedly effective in the prevention of IOP increases following phacoemulsification. IOPs recorded in patients treated with this drug were lower than those observed in the acetazolamide and the control groups. Considering the lower risk of toxicity associated with topical administration, apraclonidine 0.5% seems to be preferable to oral acetazolamide in this postoperative setting.

Dexamethasone-netilmicin: a new ophthalmic steroid-antibiotic combination. Efficacy and safety after cataract surgery

PURPOSE

The purpose of this study was to evaluate both efficacy and safety of a new ophthalmic steroid-antibiotic fixed combination containing dexamethasone and netilmicin in the postsurgical management of cataract surgery.

METHODS

In total, 223 patients were randomly treated with dexamethasone 1 mg/ml plus netilmicin 3 mg/ml (n=148), or dexamethasone 1 mg/ml plus tobramycin 3 mg/ml (n=75, TOBRADEX) four times in a day for 7+/-1 days starting immediately after surgery. Efficacy (anterior chamber (AC) inflammation, conjunctival hyperaemia, corneal and lid oedema, ocular infection, pain, photophobia and tearing) and safety (burning, stinging, blurred vision, intraocular pressure, and visual acuity) were analysed in the operated eye after 1 and 7+/-1 days. A follow-up visit was performed at day 14+/-2. The extent of AC inflammation, measured by slit-lamp according to a standard scoring system, was used as primary efficacy parameter.

RESULTS

At the primary end point (day 7) both fixed combinations were equally effective in reducing postoperative inflammation. The safety profile of the dexamethasone/netilmicin combination was excellent with no evidence of poor local tolerance or adverse reaction.

CONCLUSIONS

A new fixed combination of dexamethasone and netilmicin was effective and safe in controlling ocular inflammation after cataract surgery.

Anterior chamber depth, iridocorneal angle width, and intraocular pressure changes after uneventful phacoemulsification in eyes without glaucoma and with open iridocorneal angles

PURPOSE

To investigate the influence of uneventful phacoemulsification on anterior chamber depth (ACD), iridocorneal angle (ICA) width, and intraocular pressure (IOP) in nonglaucomatous eyes with open ICA preoperatively.

SETTING

Beyoglu Eye Education and Research Hospital, Istanbul, Turkey.

METHODS

Fifty-three eyes of 49 patients were evaluated for 6 months postoperatively. The nonparametric Wilcoxon signed rank test was used to compare preoperative and postoperative IOP, ACD, and ICA width. Univariate and multivariate regression analyses were used to evaluate the relationships between IOP, ACD, and ICA width and between preoperative patient characteristics.

RESULTS

The mean preoperative IOP of 15.1 mm Hg +/- 2.8 (SD) dropped postoperatively to 13.4 +/- 3.4 mm Hg at 1 day, 13.3 +/- 2.6 mm Hg at 1 week, 13.2 +/- 3.1 mm Hg at 1 month, 13.3 +/- 2.7 mm Hg at 3 months, and 14.1 +/- 2.5 mm Hg at 6 months (P<.05). The mean preoperative ICA grade of 2.97 +/- 0.72 increased to 3.55 +/- 0.48 at 1 week and 3.68 +/- 0.45 at 1 month (P<.05). The mean preoperative ACD of 3.06 +/- 0.49 mm increased to 3.57 +/- 0.47 mm at 4 weeks, 3.69 +/- 0.32 mm at 1 month, and 3.70 +/- 0.36 mm at 3 months (P<.05). The IOP decrease was not correlated with the changes in ICA width or ACD. Multiple regression analysis showed preoperative IOP was the single predictor of the postoperative IOP drop (P<.001).

CONCLUSIONS

In nonglaucomatous eyes with an open ICA preoperatively, uneventful phacoemulsification reduced IOP, increased ACD, and widened the ICA. The changes were statistically significant over 6 months.

Ultrasound activates the TM ELAM-1/IL-1/NF-kappaB response: a potential mechanism for intraocular pressure reduction after phacoemulsification

PURPOSE

Elevated intraocular pressure (IOP), the major causal risk factor for glaucoma, often decreases after cataract removal by phacoemulsification ultrasound. In this study, the hypothesis that ultrasound energy propagated through a fluid medium induces a stress response with the potential to lower IOP was investigated.

METHODS

Normal and glaucomatous trabecular meshwork (TM) cell culture lines were initiated from tissue isolated from human cadaveric eyes or trabeculectomy specimens. Cultured cells were treated for 60 seconds with a phacoemulsification ultrasound probe set to a power of 70%. Activation of the TM cell-specific stress response was assayed by enzyme-linked immunosorbent assay (ELISA) and immunolocalization.

RESULTS

Normal TM cell cultures did not release detectable levels of the stress response protein, IL-1alpha, into their culture medium. In contrast, IL-1alpha was easily detected after treatment with ultrasound energy. Consistent with earlier findings, glaucomatous TM cells produced IL-1alpha constitutively, and the level of expression was increased after treatment with phacoemulsification ultrasound. As was previously demonstrated, the stress-regulated transcription factor NF-kappaB was present in the cytoplasm of normal cells, but in the nucleus of glaucomatous cells. After treatment with ultrasound energy, NF-kappaB translocated to the nucleus in the normal cells. Endothelial leukocyte-adhesion molecule (ELAM)-1 was not detected in normal TM cells, but was constitutively present on glaucomatous TM cells, consistent with findings in previous work. ELAM-1 expression was induced in normal cells by ultrasound treatment.

CONCLUSIONS

A potentially IOP-lowering stress response is induced in TM cells by ultrasound. The findings suggest that this response may be induced clinically during cataract removal by phacoemulsification, and may be one mechanism responsible for the reduction in IOP that often follows this procedure.