Risk factors for retinal detachment following cataract surgery: the impact of posterior capsular rupture

Evaluation of intravitreal injections as a risk factor for capsular rupture during cataract surgery

OBJECTIVE

To determine whether previous intravitreal injections are an independent risk factor for posterior capsular rupture (PCR) during cataract surgery after adjusting for known risk factors.

DESIGN

Single-centre medical records analysis of a population-based cohort at a university-based referral centre. A retrospective cohort study has been conducted with inclusion of cataract surgeries done from January 1, 2005 to December 31, 2020 at the Department of Ophthalmology, Medical University of Graz, Austria.

PARTICIPANTS

All consecutive cataract surgeries done in patients of at least 18 years of age from January 1, 2005 to December 31, 2020 have been included.

METHODS

Association between previous intravitreal injections and PCR rates has been analysed through univariable and multivariable generalized estimating equations (GEE). Other investigated risk factors were age, combined surgery, pseudoexfoliation, surgeon's experience, and type of cataract surgery.

RESULTS

A statistically significant higher rate of posterior capsular rupture during cataract surgery has been found in patients with previous intravitreal therapy compared with patients with no history of intravitreal therapy (OR 1.27, 95% CI 1.10-1.46, p = 0.008). However, after adjusting for confounding risk factors, no statistically significant effect was seen (OR 1.04, 95% CI 0.89-1.21, p = 0.664).

CONCLUSION

We found no association between history of intravitreal injections and PCR during cataract surgery after adjusting for known risk factors. Further studies upon interactions between history of intravitreal injections and known risk factors for PCR, especially pseudoexfoliation, are needed.

Incidence and Outcomes of Recurrent Retinal Detachment after Cataract Surgery in Eyes with Prior Retinal Detachment Repair

OBJECTIVE

To investigate the incidence and outcomes of recurrent retinal detachment (RD) after cataract extraction (CE).

DESIGN

Retrospective case series.

SUBJECTS

Phakic eyes with RD that were successfully repaired with pneumatic retinopexy (PR), scleral buckle (SB), pars plana vitrectomy (PPV), or combined PPV/SB and subsequently underwent cataract surgery.

METHODS

A retrospective review of phakic eyes that underwent successful RD repair followed by subsequent cataract surgery between April 2012 and January 2023 was performed. Patients with multiple RD surgeries before CE and those with silicone oil tamponade before cataract surgery were excluded. Eyes that redetached were matched 1:2 with eyes that did not redetach after cataract surgery.

MAIN OUTCOME MEASURES

Incidence of redetachment after cataract surgery as well as visual and anatomic outcomes at 6 months after first redetachment and at the final visit.

RESULTS

Of 4833 phakic eyes at the time of initial RD, 1893 patients (39.2%) underwent cataract surgery. After applying exclusion criteria, 763 patients were included. The mean (standard deviation) duration of follow-up was 48.4 (29.1) months. The overall incidence of retinal redetachment after cataract surgery was 2.5% (19/763 eyes). The rate of redetachment based on the type of initial RD repair was 9.1% (1/11), 5.3% (2/38), 2.8% (9/317), and 1.8% (7/397) for PR, SB, PPV, and combined PPV/SB, respectively (P = 0.24). The median (interquartile range [IQR]; range) duration between the cataract surgery and first redetachment was 301 (104-1222; 8-2760) days. Single surgery anatomic success for the RD repair after cataract surgery was achieved in 17 eyes (89.5%) at 3 months and 14 eyes (73.7%) at 6 months and at the final visit. Final anatomic success rate for reattachment was 100% (19/19). The median (IQR) logarithm of the minimal angle of resolution visual acuity (VA) at the final visit was 1.00 (0.18-2.00, Snellen equivalent, 20/200) with significant worsening compared with vision after cataract surgery (0.18 [0.10-0.48], 20/30) (P = 0.001).

CONCLUSION

Recurrent RD was not uncommon in patients with a prior history of RD repair after CE. Reoperation resulted in relatively favorable anatomic success but there were declines in VA.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

BCLA CLEAR Presbyopia: Evaluation and diagnosis

It is important to be able to measure the range of clear focus in clinical practice to advise on presbyopia correction techniques and to optimise the correction power. Both subjective and objective techniques are necessary: subjective techniques (such as patient reported outcome questionnaires and defocus curves) assess the impact of presbyopia on a patient and how the combination of residual objective accommodation and their natural DoF work for them; objective techniques (such as autorefraction, corneal topography and lens imaging) allow the clinician to understand how well a technique is working optically and whether it is the right choice or how adjustments can be made to optimise performance. Techniques to assess visual performance and adverse effects must be carefully conducted to gain a reliable end-point, considering the target size, contrast and illumination. Objective techniques are generally more reliable, can help to explain unexpected subjective results and imaging can be a powerful communication tool with patients. A clear diagnosis, excluding factors such as binocular vision issues or digital eye strain that can also cause similar symptoms, is critical for the patient to understand and adapt to presbyopia. Some corrective options are more permanent, such as implanted inlays / intraocular lenses or laser refractive surgery, so the optics can be trialled with contact lenses in advance (including differences between the eyes) to better communicate with the patient how the optics will work for them so they can make an informed choice.

Characteristics and Risk Factors for Rhegmatogenous Retinal Detachment Related to Endophthalmitis

Purpose: To evaluate the risk factors for the development of concurrent or delayed-onset rhegmatogenous retinal detachment (RRD) related to endophthalmitis as well as the anatomic and visual outcomes with subsequent RRD repair. Methods: In this retrospective case study, a 2-tailed t test (continuous) and Fisher exact test were used to determine statistical significance of the observed findings. The relative risk (RR) and 95% CIs were calculated to assess statistical significance. Results: Of the 170 patients included, 22 were found to have a concurrent or subsequent RRD. Initial treatment with pars plana vitrectomy (PPV) (RR, 3.544; 95% CI, 1.650-7.614), aphakia (RR, 4.150; 95% CI, 1.434-12.011), endogenous endophthalmitis (RR, 2.684; 95% CI, 1.065-6.764), and posterior synechiae (RR, 3.026; 95% CI, 1.408-6.505) were statistically significant risk factors for RRD. Anatomically successful repair was achieved in 77.7% of patients. Conclusions: In addition to preexisting risk factors, the initial treatment of endophthalmitis may be a significant risk factor for RRD development, with a higher incidence of subsequent RRD in patients who have PPV as the initial treatment for endophthalmitis.

The effect of intraocular lens and lens eye on the treatment of macular splits in high myopia

BACKGROUND

Macular retinoschisis in patients with high myopia is one of the main reasons for a decline in visual function and the perceived deformation of visual objects.

OBJECTIVE

This study aimed to investigate the therapeutic effect of cataract phacoemulsification and foldable intraocular lens implantation (FILI) combined with internal limiting membrane stripping (ILMS) in the treatment of macular retinoschisis in patients with high myopia.

METHODS

A total of 52 patients (55 eyes) who had been diagnosed with macular retinoschisis with high myopia between June 2019 and June 2020 were enrolled in the present study. Patients in the control group (25 eyes) received 23G vitreous surgery and macular ILMS and long-term inert gas (C3F8) filling of the vitreous cavity; patients in the research group (30 eyes) were additionally treated with cataract phacoemulsification and soft intraocular lens on the same treatment basis as the control group.

RESULTS

The difference in average BCVA between the control and the research groups was not statistically significant before the surgery (P> 0.05) but was statistically significant 12 months after the procedure (P< 0.05). The minimum foveal thickness was significantly decreased in the two groups after the surgery compared with before the procedure (P< 0.05).

CONCLUSION

Cataract phacoemulsification and FILI further improved the therapeutic effect of ILMS in the treatment of macular retinoschisis in patients with high myopia.

Incidence and Risk Factors for Retinal Detachment and Retinal Tear after Cataract Surgery: IRIS® Registry (Intelligent Research in Sight) Analysis

Objective

To report the incidence of and evaluate demographic, ocular comorbidities, and intraoperative factors for rhegmatogenous retinal detachment (RRD) and retinal tear (RT) after cataract surgery in the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight).

Design

Retrospective cohort study.

Participants

Patients aged ≥ 40 years who underwent cataract surgery between 2014 and 2017.

Methods

Multivariable logistic regression was used to evaluate demographic, comorbidity, and intraoperative factors associated with RRD and RT after cataract surgery.

Main Outcome Measures

Incidence and risk factors for RRD or RT within 1 year of cataract surgery.

Results

Of the 3 177 195 eyes of 1 983 712 patients included, 6690 (0.21%) developed RRD and 5489 (0.17%) developed RT without RRD within 1 year after cataract surgery. Multivariable logistic regression odds ratios (ORs) showed increased risk of RRD and RT, respectively, among men (OR 3.15; 95% confidence interval [CI], 2.99-3.32; P < 0.001 and 1.79; 95% CI, 1.70-1.89; P < 0.001), and younger ages compared with patients aged > 70, peaking at age 40 to 50 for RRD (8.61; 95% CI, 7.74-9.58; P < 0.001) and age 50 to 60 for RT (2.74; 95% CI, 2.52-2.98; P < 0.001). Increased odds of RRD were observed for procedure eyes with lattice degeneration (LD) (10.53; 95% CI, 9.82-11.28; P < 0.001), hypermature cataract (1.61; 95% CI, 1.06-2.45; P = 0.03), complex cataract surgery (1.52; 95% CI, 1.4-1.66; P < 0.001), posterior vitreous detachment (PVD) (1.24; 95% CI, 1.15-1.34; P < 0.001), and high myopia (1.2; 95% CI, 1.14-1.27; P < 0.001). Lattice degeneration conferred the highest odds of RT (43.86; 95% CI, 41.39-46.49; P < 0.001).

Conclusion

In the IRIS Registry, RRD occurs in approximately 1 in 500 cataract surgeries in patients aged > 40 years within 1 year of surgery. The presence of LD conferred the highest odds for RRD and RT after surgery. Additional risk factors for RRD included male gender, younger age, hypermature cataract, PVD, and high myopia. These data may be useful during the informed consent process for cataract surgery and help identify patients at a higher risk of retinal complications.

Financial Disclosures

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Retinal detachment after refractive lens exchange: A narrative review

Refractive lens exchange (RLE) allows to correct ametropias and presbyopia by replacing the crystalline lens with an extended depth of focus or multifocal intraocular lens (IOL). Retinal detachment (RD) is one of the most serious adverse events after RLE. This study aimed to review the evidence related to the risk of RD after RLE and clinical outcomes. A search using PubMed and a snowball search approach was conducted to identify articles and case reports. According to the literature, the risks of RD should be considered in patients <60 years old with axial lengths >23 mm. Only nine articles reported visual acuity (VA) after RD in RLE, and only 25% of eyes had a VA > 20/40. Considering that the decrease in VA might be uniform for all types of IOLs after RD, surgeons should focus on selecting the patient to prevent RD rather than on a particular IOL optical design based on the potential risk of DR.

Prevalence and outcome of lens capsule disruption IN routine canine cataract surgery: A retrospective study of 520 eyes (2012-2019)

OBJECTIVE

To investigate the prevalence and surgical outcome of lens capsule disruption (LCD) in dogs undergoing cataract removal.

ANIMALS STUDIED

Medical records of 924 eyes undergoing phacoemulsification were analyzed retrospectively.

PROCEDURES

Routine cataract surgeries with or without LCD were included. Any LCD other than routine anterior capsulorhexis was defined as LCD and classified according to location and etiology. Odds ratios (OR) were calculated for maintaining vision, implantation of an artificial intraocular lens (IOL), and enucleation.

RESULTS

In total, 520 eyes were included. A LCD occurred in 145 eyes (27.8%; 145/520) and affected the posterior (85.5%; 124/145), anterior (6.2%; 9/145), and equatorial lens capsule (4.8%; 7/145) and at multiple locations (3.4%; 5/145). The etiology of the LCD was spontaneous preoperative in 41 eyes (28.3%; 41/145), accidental intraoperative in 57 eyes (39.3%; 57/145), and planned in 47 eyes (32.4%; 47/145). Disruption did not increase the odds of enucleation (OR = 1.48, 95% confidence interval [CI] 0.56-3.67; p = .36). The presence of LCD significantly increased the risk of losing vision 1 year post-operatively (OR = 8.17, 95% CI 1.41-84.93; p = .007) associated with retinal detachment. However, this was not present at 2 years follow-up or in PCCC cases at any time point. An IOL was implanted in 108 eyes (108/145; 75.2%) with LCD and in 45/47 (95.7%) eyes with a PCCC.

CONCLUSION

Increased surgeon awareness of possible intraoperative, accidental LCDs is important, as LCDs were relatively common and associated with increased odds for vision loss after 1 year in the present study. A prospective study investigating the causes of intraoperative, accidental LCD is warranted.

Incidence and Risk Factors for Retinal Detachment Following Cataract Surgery at a Tertiary Center in Jeddah, Saudi Arabia

Introduction The incidence of retinal detachment in the general population is 0.08%, it has been reported to reach 0.7% or higher following cataract surgery. One of the most important risk factors for retinal detachment is posterior capsular rupture during cataract surgery. Additional risk factors include high myopia, history of ocular trauma, young age, male sex, and diabetes. In this study, we aimed to investigate the incidence and risk factors of retinal detachment following cataract surgery in patients treated at our hospital. Materials and methods This retrospective cohort study was conducted at King Abdulaziz University Hospital (KAUH), a tertiary center in Jeddah, Saudi Arabia. The medical records of 365 patients (365 eyes) who underwent cataract surgery from 2017 to 2021 were reviewed. Results The average age of the 365 patients was 63 years, and 47.7% (n=174) of patients were male. The incidence of retinal detachment was 3.3% (n=12). The risk of RD was 2.8 times higher for the right eye than for the left eye. The incidence of RD was significantly more in eyes with intraoperative posterior capsular rupture, zonular dehiscence, corneal trauma, and surgery combined with anterior vitrectomy than in other eyes. The most common complication of cataract surgery is corneal edema, which was observed in 22.7% of the eyes; our analysis revealed a significant relationship between corneal edema and the duration of surgery. Conclusion In our study, we highlighted the higher incidence of retinal detachment compared to those in other studies; most cases occurred one month postoperatively.

In-depth analysis of risk factors for pseudophakic retinal detachments and retinal breaks

Purpose

To provide a detailed analysis of risk factors for pseudophakic retinal detachments (PRD) and pseudophakic retinal breaks (PRB).

Materials and methods

We reviewed the medical records of cataract surgeries between 1996 and 2017 at a tertiary care hospital in Austria. A Cox proportional‐hazard regression model was used to analyse risk factors for PRD and PRB.

Results

Sixty‐five thousand six hundred and sixty‐two eyes (45 043 patients) underwent phacoemulsification, and 393 eyes (cumulative incidence 0.6%) were diagnosed with PRD (327 eyes) or PRB (66 eyes) during the follow‐up (median 7.1 years, range 0–21). Calculation of adjusted hazard ratios (HR) revealed a hierarchy of risk factors for either event including (from the highest to the lowest risk) posterior capsular rupture (PCR), patient age <65 years (compared with the age group >75 years), male gender and high myopia. Diabetes mellitus was associated with a lower risk. PCR was the strongest risk factor for PRD both in patients with and without perioperative vitrectomy (i.e. vitreous loss), but time to PRD was significantly reduced only following PCR with vitrectomy.

Conclusions

Posterior capsular rupture, young patient age, male gender and high myopia were risk factors for PRD, but diabetes mellitus was associated with a lower risk. PCR had the strongest association with PRD, regardless of the need for perioperative vitrectomy due to vitreous loss. Time to PRD was reduced in patients with PCR and vitrectomy compared with PCR without the need for vitrectomy or uneventful surgery.

Previous intravitreal injection as a risk factor of posterior capsule rupture in cataract surgery: a systematic review and meta-analysis

PURPOSE

Intravitreal injections and cataract surgery are two common procedures in the elderly. Posterior capsular rupture (PCR) is a rare but important complication of cataract surgery. We systematically reviewed the literature on previous intravitreal injections as a risk factor of PCR and performed meta-analyses to provide pooled summary risk estimates.

METHODS

We searched 13 literature databases on 1 June 2021 for studies evaluating the risk of PCR in eyes undergoing cataract surgery with data on previous intravitreal injections. Data extraction was made independently by two authors and discussed afterwards until reaching consensus. Random effects meta-analyses on the pooled odds ratio (OR) of PCR in eyes with previous intravitreal injections were made using MetaXL 5.3.

RESULTS

Six studies on 1 051 097 eyes undergoing cataract surgery were eligible for the qualitative and quantitative review. Previous history of intravitreal injections was present in 7034 eyes (majority was anti-VEGF). Our meta-analyses revealed that any previous intravitreal injection was a risk factor for PCR with an OR of 2.30 (95% CI 1.39-3.81). For each previous intravitreal injection, the risk of PCR was OR 1.04 (95% CI 1.01-1.08) (equivalent of relative risk ~1.04). In other words, risk of PCR increases by 4% for each previous intravitreal injection.

CONCLUSIONS

Previous intravitreal injection is a risk factor for PCR and should be taken into account when planning cataract surgery. However, to be regarded as a clinically significant risk of PCR, a substantial number of previous intravitreal injection (e.g. ≥10) should have been administered, considering that the a priori risk of PCR is very low (~1%).

POSTOPERATIVE POSTERIOR SEGMENT COMPLICATIONS AFTER BOSTON TYPE 1 KERATOPROSTHESIS: Incidence, Risk Factors, and Intermediate-Term Outcomes

PURPOSE

To identify the incidence of, risk factors for, and outcomes of posterior segment complications (PSC) after Boston Type 1 keratoprosthesis (KPro) implantation.

METHODS

Retrospective, consecutive case series of KPro procedures at the Stein Eye Institute. Data regarding ocular history, intraoperative details, postoperative management, and outcomes were collected. Eyes with at least one PSC (PSC group) were compared with eyes without PSC (No PSC group), and risk factors for PSC were determined.

RESULTS

Ninety-five PSC occurred in 69/169 eyes (40.8%), at a mean of 20.1 months after KPro implantation (0.01 complications/eye month). The median follow-up after KPro implantation was 44.0 months (range 3.0-174.4). The most common PSC were epiretinal membrane (16.6%), cystoid macular edema (12.4%), vitritis (11.2%), and retinal detachment (9.5%). Previous retinal detachment repair, concomitant intraocular lens removal, postoperative aphakia, and vitritis were risk factors for retinal detachment. Postoperative infectious keratitis was a risk factor for epiretinal membrane, cystoid macular edema, and vitritis. The posterior segment complication group had a significantly higher rate of eyes failing to maintain visual acuity ≥20/200 (HR = 2.28; 95% CI = 1.35-3.85) and KPro retention failure rate (HR = 1.66; 95% CI = 0.95-2.91).

CONCLUSION

Posterior segment complications occur in approximately 40% of eyes after KPro implantation, resulting in reduced visual outcomes and KPro retention.

Efficacy and complications of cataract surgery in high myopia

To evaluate the efficacy and complications of cataract surgery in high myopia, a comprehensive search query was conducted from January 2000 to August 2020. A total of 19 586 highly myopic eyes from 28 studies were included. Modern cataract surgery turns out efficacious in highly myopic eyes with significant improvement of visual acuity. However, phacoemulsification-related complications such as posterior capsular rupture (3.91%, 95% CI, 1.98%-6.37%), retinal detachment (1.74%, 95% CI, 1.36%-2.15%), progressed myopic traction maculopathy (5.07%, 95% CI, 1.80%-9.37%), capsular contraction syndrome (2.1%), intraocular lens dislocation (0.58%), and transient intraocular pressure elevation (28.15%, 95% CI, 20.29%-36.70%) occurred more frequently in the highly myopic population. Separate analyses were also conducted based on follow-up period. In conclusion, modern cataract surgery was effective for highly myopic cataract patients, whereas careful precautions and sufficient follow-ups were of great value because of higher incidences of intraoperative and postoperative complications.

Nd:YAG capsulotomy is not a risk factor for retinal detachment after phacoemulsification cataract surgery

PURPOSE

To evaluate the cumulative incidence and risk factors of pseudophakic retinal detachment (PRD) following phacoemulsification cataract surgery.

METHODS

Cataract surgeries performed between the years 2007 and 2016 at the Ophthalmology Unit of Kymenlaakso Central Hospital, Kotka, Finland, were included. The cumulative incidence of PRD was estimated through Kaplan-Meier analysis. Patient mortality was incorporated as one of the censoring events. Cox regression analyses were used to evaluate potential risk factors, including age, gender, intraocular lens (IOL) power and previous neodymium-doped yttrium aluminium garnet (Nd:YAG) laser capsulotomy.

RESULTS

A total of 17 688 eyes of 12 003 patients were included. The mean patient age at surgery was 75.2 ± 9.1 years with 63.5% females (n = 11 228). During the mean follow-up time of 4.3 ± 2.7 years, 83 laterality-matched PRDs were registered (incidence 0.11% per year). Univariate analyses showed that age (HR 0.93; 95% CI 0.92-0.95), male gender (HR 3.99; 95% CI 2.52-6.33) and IOL power (HR 0.86; 95% CI 0.83-0.90) were significantly associated with PRD (p < 0.001 for all) and remained significant in a multivariate analysis. Neither univariate (HR 1.45; 95% CI 0.82-2.54, p = 0.201) nor multivariate (HR 1.03; 95%CI 0.57-1.88, p = 0.919) analyses showed any association between Nd:YAG capsulotomy and PRD.

CONCLUSIONS

Male gender, low IOL power and younger age were confirmed as risk factors for PRD after phacoemulsification surgery. Real-world evidence suggests that Nd:YAG capsulotomy does not increase the risk for PRD.

Prognostic Factors for Low Visual Acuity after Cataract Surgery with Vitreous Loss

Purpose

The purpose of this study is to find prognostic factors associated with low visual acuity in patients experiencing vitreous loss during cataract surgery.

Methods

A retrospective, noncomparative, interventional, case study of patients experiencing vitreous loss during cataract surgery. Data collected included demographics, best corrected visual acuity (BCVA), axial length (AL), presence of ocular comorbidity affecting central vision, timing of intraocular lens (IOL) implantation, position of the implanted lens, and the presence of corneal sutures. Low visual outcome was defined as BCVA < 20/40.

Results

Overall, 179 patients (60.3% males) with a mean age of 73 ± 12 years and axial length of 23.5 ± 1.3 mm with a mean follow-up of 12 ± 13 months were included. In multivariable logistic regression analysis, low visual outcome was independently associated with persisting postoperative complications (OR 6.25, 95% CI 1.378–30.9), preexisting ocular comorbidities (OR 4.45, 95% CI 1.1–18.00), and secondary intraocular lens (IOL) implant (OR 10.36, 95% CI 1.8–60.00). Conversely, pars plana vitrectomy (PPV) for dislocated fragments of lens material, age > 70 years, gender, axial length, degree of surgeon, corneal suturing, and anterior chamber lens implantation were not found to have significant associations with low visual outcomes (P > 0.05).

Conclusions

Low visual outcome after vitreous loss during cataract surgery was associated with ocular comorbidities, secondary IOL implantation, development of cystoid macular edema, and additional surgical complications.

Macrophage recruitment in immune-privileged lens during capsule repair, necrotic fiber removal, and fibrosis

Emerging evidence challenges the lens as an immune-privileged organ. Here, we provide a direct mechanism supporting a role of macrophages in lens capsule rupture repair. Posterior lens capsule rupture in a connexin 50 and aquaporin 0 double-knockout mouse model resulted in lens tissue extrusion into the vitreous cavity with formation of a “tail-like” tissue containing delayed regressed hyaloid vessels, fibrotic tissue and macrophages at postnatal (P) 15 days. The macrophages declined after P 30 days with M2 macrophages detected inside the lens. By P 90 days, the “tail-like” tissue completely disappeared and the posterior capsule rupture was sealed with thick fibrotic tissue. Colony-stimulating factor 1 (CSF-1) accelerated capsule repair, whereas inhibition of the CSF-1 receptor delayed the repair. Together, these results suggest that lens posterior rupture leads to the recruitment of macrophages delivered by the regression delayed hyaloid vessels. CSF-1-activated M2 macrophages mediate capsule rupture repair and development of fibrosis.

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Lens posterior rupture delays regression of the hyaloid vessels.

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Lens posterior rupture recruits macrophages delivered by the hyaloid vessels.

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Macrophages mediate necrotic fiber cell removal and capsule rupture sealing.

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CSF-1 activated M2 macrophages facilitate capsular rupture sealing by fibrosis.

Retinal Detachment After Endophthalmitis: Risk Factors and Outcomes

Purpose

To analyze the risk factors, clinical course, and visual and anatomic outcomes of retinal detachment (RD) after endophthalmitis.

Patients and Methods

This retrospective study included 108 patients diagnosed with endophthalmitis between August 2014 and May 2019 at a single tertiary referral center. Sixteen patients developed RD after endophthalmitis. Retrospective analysis was performed to compare the cohort of endophthalmitis alone versus the cohort that developed RD after endophthalmitis, with analysis of potential risk factors for RD after endophthalmitis and treatment outcomes.

Results

The incidence of RD after endophthalmitis was 14.8% (N=16/108). The median time to develop RD after endophthalmitis was 27 days (range: 1-581 days, IQR: 25.3). Thirteen (81.3%) cases of RD occurred less than 2 months after the diagnosis of endophthalmitis. The incidence of aphakia (p=0.023) and posterior synechia (PS) (p=0.014) were significantly higher in the RD group. The mean initial and final visual acuity (VA) of the endophthalmitis alone group was 1.9±0.8 logMAR and 1.2±1.0 logMAR (p<0.0001), respectively, and 1.9±0.9 logMAR and 1.3±1.2 logMAR (p=0.07) in the RD group, respectively. Enucleation or evisceration occurred in 31.3% of cases with RD after endophthalmitis. The rate of final retinal re-apposition for the RD cohort was 56.3%.

Conclusion

The anatomic and functional outcomes for RD after endophthalmitis remain poor, with significant risk for permanent vision loss. Aphakia and posterior synechiae were seen more often in cases with RD after endophthalmitis.

Retinal detachment after phacoemulsification in refractive surgery clinics: a large series analysis with variable follow-up during 16 years

PURPOSE

To determine the long-term incidence of pseudophakic retinal detachment (PRD) after phacoemulsification and the weight of the main risk factors in the appearance of such complication in a large sample. To implement a customized formula and a software calculation program able to quantify the risk of suffering PRD applicable to all lens extraction patients.

METHODS

Retrospective cumulative risk analysis conducted on 178,515 eyes operated under similar conditions in a group of refractive surgery clinics (Clínica Baviera SL) located in a relatively limited geographical area (Spain). A survival analysis was performed and the data were modelled using the Weibull regression to determine the risk over a period of 16 years and to estimate the association of different risk factors: sex, age, axial length (AXL) of the eye, intraoperative posterior capsule rents (PCR), and YAG laser capsulotomies. The resulting estimates were translated into a predictive equation for hazard rates and survival probabilities. Later, an application was developed to make prediction available for the clinical community in order to estimate the potential risk of any hypothetical case before lens surgery.

RESULTS

Globally, 1521 (0.85%) cases of PRD were diagnosed during the period. The risk for PRD was significantly greater in males (5.48 [2.94-10.2]; p < 0.001), in long eyes (1.24 [1.21-1.26]; p < 0.001), and also after posterior capsule rents (13.97 [11.61-16.82]; p < 0.001). Posterior capsule rupture increased the risk of PRD up to fourteen times.

CONCLUSIONS

From weaker to stronger impact, age, axial length, sex, and intraoperative posterior capsule rent were significant risk factors for the appearance of PRD after lens extraction.

Clinical outcomes of management of posterior capsule rupture with air bubble techniques

AIM

To introduce a new surgical technique, air-bubble technique for the management of posterior capsule rupture (PCR) and to evaluate the safety and efficacy of the technique.

METHODS

A retrospective case series analysis of 24 eyes of 24 patients, in which the air bubble technique was used for the management of PCR, was performed. Once PCR occurred, a dispersive ophthalmic viscosurgical device (OVD) was injected into the tear. And small volumes (0.2-0.3 mL) of air bubbles were injected beneath the OVD. The air bubble served as a physical barrier and supported the posterior capsule.

RESULTS

After surgery, none of the patients had serious complications during the follow-up period of 1y. Extension of the PCR size occurred in only 2 cases, and additional OVD injection was required only in 3 cases. Air bubbles imparted great stability to the nuclear pieces and the posterior capsule.

CONCLUSION

The air-bubble technique may be considered a safe and effective procedure for managing a PCR. It may be of value to the inexperienced cataract surgeon.

What Is the Cost of a Posterior Capsule Rupture Complication?

BACKGROUND AND OBJECTIVE

To examine the cost of a posterior capsule rupture (PCR) in patients who underwent planned phacoemulsification.

PATIENTS AND METHODS

Retrospective review of 8,113 cataract surgeries performed between January 2014 and December 2017 at one academic institution. The rate of PCR was 0.55%, and 34 patients with PCR who met inclusion criteria were identified. Investigators evaluated the added operating room time required to manage PCR, subsequent surgeon visits beyond the typical average, referrals to other specialties, further imaging, and additional required surgeries.

RESULTS

Patients with PCR had an additional 2.76 (standard deviation [SD] ± 3.27) postoperative encounters and 3.06 (SD ± 3.78) visits to another subspecialty. Operating room time was found to average 61.43 minutes (range: 21 to 191 minutes) at an additional cost of $455.48 (SD ± $407.37). Additional visits, imaging, and procedures added $655.59 (SD ± $767.21). The total additional average cost was $1,111.07 (SD ± $1,021.20) per PCR.

CONCLUSION

Posterior capsular ruptures impose a substantial cost burden on the health care system. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:444-447.].

Posterior Capsule Rupture during Cataract Surgery in Eyes Receiving Intravitreal anti-VEGF Injections

PURPOSE

To examine the risk of posterior capsule rupture (PCR) during phacoemulsification cataract surgery in patients who received intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections prior to surgery.

METHODS

A retrospective study was conducted of cataract surgeries at the Sue Anschutz-Rodgers UCHealth Eye Center from January 1, 2014, through December 31, 2018. The primary outcome was the occurrence of PCR during surgery. Other variables of interest included age, race, sex, ocular comorbidities, diabetes, mature cataract, primary surgeon, injection frequency and type, and date of most recent injection. Predictors of PCR were assessed using logistic regression with generalized estimating equations to account for correlation between patient eyes. Additional sub-analysis was performed on eyes with PCR with and without anti-VEGF injection history to compare intraoperative characteristics, post-operative complications, and visual outcomes.

RESULTS

In total 10,327 cataract surgeries were included in the analysis, and 308 of these eyes received anti-VEGF injections prior to surgery. Of the 308 eyes that received anti-VEGF injections, eight (2.6%) had a PCR during surgery compared to 45 of 10,019 eyes (0.5%) that did not receive injections (unadjusted OR = 5.9, 95% CI: 2.8-12.7, p < .0001). Males and diabetics were more likely to have received injections and had higher rates of PCR, so these variables were adjusted for in the multivariate analysis of the association between injections and PCR (adjusted OR = 4.7, 95% CI: 2.1-10.4, p-value = 0.0001). Eyes with mature cataracts and those that underwent surgery with a resident as the primary surgeon were also at higher risk of PCR, but these variables were not associated with the anti-VEGF injection. Injection frequency, time between most recent injection and surgery, and type of anti-VEGF agent were not significantly associated with PCR.

CONCLUSIONS

History of intravitreal anti-VEGF injections was associated with higher odds of PCR during cataract surgery.

Incidence of rhegmatogenous retinal detachment after bag-in-the-lens IOL implantation: extended follow-up in a larger cohort of patients

PURPOSE

To report the incidence of rhegmatogenous retinal detachment (RRD) and associated risk factors after cataract surgery using the bag-in-the-lens (BIL) intraocular lens (IOL) implantation technique.

SETTING

Department of Ophthalmology, Antwerp University Hospital, Belgium.

DESIGN

Prospective cohort study.

METHODS

All consecutive BIL IOL surgeries performed between January 2001 and December 2010 were included, with the exclusion of combined procedures and IOL exchanges. The incidence of RRD was reported first in the total cohort, then in a subgroup of patients with 1 year to 5 years of follow-up, and finally in the group remaining after exclusion of all risk factors, except gender. Risk factors associated with RRD were examined using multiple Cox regression analysis with a random intercept.

RESULTS

Rhegmatogenous RD was diagnosed in 36 eyes (1.06%) of 3385 BIL cases, with a mean follow-up of 48.28 ± 40.05 months (range 0 to 195 months). The 2-year cumulative RRD incidence rate was 0.66% (17 cases in 1024 eyes; 0.00% in patients without risk factors). The 5-year cumulative RRD incidence rate was 1.17% (26 cases in 931 eyes; 0.15% without risk factors). Five risk factors were confirmed: male sex, age less than 60 years at the time of surgery, axial length 25.0 mm or greater, a history of contralateral RD, and intraoperative surgical complications.

CONCLUSIONS

The incidence of RRD after BIL IOL implantation is comparable with that of lens-in-the-bag (LIB) implantation. This larger study provided a longer follow-up and suggested that RRD incidence is even lower than that previously reported. This study also confirmed intraoperative surgical complications as an additional risk factor for RRD development, as already described with LIB implantation.

Retinal detachment following cataract phacoemulsification-a review of the literature

A link between cataract surgery and rhegmatogenous retinal detachment (RRD) has long been considered. Indeed, pseudophakic retinal detachment (PPRD) forms a substantial and increasing proportion of RRD. We reviewed the literature to answer the following questions: what is the incidence of PPRD in eyes following phacoemulsification cataract surgery and how does its risk change over time following surgery? We also sought to assess how the risk is modified by intraoperative factors (operative complications, surgeon grade, subsequent laser capsulotomy), intrinsic eye-related factors (laterality, myopia, previous RRD, previous trauma, previous PVD) and patient factors (sex, age, ethnicity, affluence, systemic comorbidities). Secondarily we asked how the incidence of PPRD after phacoemulsification compares with the RRD incidence in the general population and how identified risk factors contribute to the pathophysiology of PPRD. A search of the Medline and Ovid databases was conducted for relevant publications from 1990 onwards using defined search terms with pre planned inclusion and exclusion criteria. The 10-year PPRD incidence after phacoemulsification was identified as being between 0.36 and 2.9%. This decreases over time to 0.1-0.2% annually but remains above the general population. The PPRD risk is further elevated by (in order of decreasing effect) intraoperative vitreous loss, increasing axial length, younger age, male sex and trainee operating surgeons. The PPRD risk after phacoemulsification is approximately ten times the general population's RRD risk. This risk is modified by the interplay of a hierarchy of risk factors, of which intraoperative vitreous loss, myopia, age and sex have the biggest effect.

Current Trends in Modern Visual Intraocular Lens Enhancement Surgery in Stable Keratoconus: A Synopsis of Do's, Don'ts and Pitfalls

Keratoconus is a relatively common ectatic, non-inflammatory corneal disorder that involves gradual visual deterioration through progressive alteration of the shape of the cornea. The corneal thinning, irregular astigmatism and higher order aberrations that occur as the disease progresses pose major challenges in the visual rehabilitation of such patients. This paper summarizes the current literature regarding the results of visual enhancement procedures in patients with stable keratoconus treated with standalone anterior or posterior chamber phakic intraocular lens implantation and monofocal, toric or multifocal toric intraocular lens implantation following phacoemulsification for age-related cataract extraction or refractive lens exchange.

Long-term outcomes of patients with myopic traction maculopathy after phacoemulsification for incident cataract

PURPOSE

To evaluate the long-term effect of cataract surgery on highly myopic patients with myopic traction maculopathy (MTM) and the risk factors associated with MTM progression.

METHODS

Highly myopic patients with cataract and MTM were included. Phacoemulsification surgery was performed on patients who had vision loss below 20/63 and were willing to operation. Exclusion criteria included full thickness macular hole, foveal/retinal detachment, history of vitreoretinal surgery, myopic choroidal neovascularization, macular chorioretinal atrophy, peripheral lattice degeneration, incomplete follow up, or intraoperative complications. All patients underwent a complete ophthalmological examination. Optical coherence tomography examinations and microperimetry examinations were performed.

RESULTS

A total of 229 patients (mean age: 57 ± 6 years) were recruited, including 179 operated patients and 50 unoperated patients. Both the best corrected visual acuity (BCVA) and macular sensitivity (MS) were significantly improved after cataract surgeries throughout the follow-up period (p = 0.000). No difference was found in the proportion of MTM staging and in the rate of resolving/stable or progressive MTM (p = 0.757) between the operated and the unoperated groups. Of all patients, those with S2 to S4 MTM at baseline had significantly higher risk of progressive MTM (p < 0.001). Patients with absence of posterior vitreous detachment or with longer axial length at baseline had higher risks of progressive MTM.

CONCLUSION

Cataract surgery generally improves the BCVA and MS of highly myopic patients with MTM. Preoperative vitreoretinal adhesion, longer axial length, and S2 to S4 MTM are risk factors for progressive MTM. A long-term follow-up on the development of MTM is recommended.

A 21-Year Study of Vitreoretinal Surgery for Aphakic Retinal Detachment: Long-Term Surgical Outcomes and Complications

PURPOSE

To determine the characteristics and outcomes of primary retinal detachment (RD) surgery in aphakic patients.

DESIGN

Retrospective case series.

PARTICIPANTS

Sixty eyes with primary aphakic RD (ARD) in 51 patients.

METHODS

A consecutive series of patients who underwent vitreoretinal surgery for primary rhegmatogenous ARD was analyzed retrospectively between 1997 and 2018 at Moorfields Eye Hospital.

MAIN OUTCOME MEASURES

Best-corrected visual acuity (BCVA), surgical outcomes, and complications.

RESULTS

Mean BCVA improved from 1.31 to 1.08 logarithm of the minimum angle of resolution (logMAR; P = 0.081) over a mean follow-up period of 8.2 years. Macula-off retinal detachments showed significantly improved BCVA from 1.72 to 1.1 logMAR (P = 0.007). Mean age was 38.8 years, and the most common cause of aphakia was congenital cataract surgery (55%). The macula was attached in 45% eyes, and grade C proliferative vitreoretinopathy (PVR) was present in 12%. Operations performed were vitrectomy (88%), combined vitrectomy and scleral buckle (8%), and encirclement (3%). The final anatomic success rate was 88%, and PVR was a significant predictor of redetachment (P = 0.03; odds ratio, 20.7; 95% confidence interval, 2.8-152.2). Raised intraocular pressure was the most common postoperative complication at 30%, with a rate of de novo postoperative glaucoma of 6.7% at final follow-up.

CONCLUSIONS

We report high rates of primary and overall anatomic success for surgery in ARD surgery. Grade C PVR was a positive predictor for surgical failure. Final visual outcomes were limited by ocular comorbidity, and we report significant improved visual outcomes for macula-off ARD.

Relationships between retinal break locations and the shapes of the detachments

Purpose

Detecting primary breaks and confirming detachment preoperatively are important. Lincoff stated that retinal detachments progress according to gravity; his law has become popular. We evaluated Lincoff’s law with a slight modification to determine whether it remains suitable for present cases independent of refractive error and previous cataract surgery.

Patients and methods

Group 1 included superior region detachments not exceeding the 12 o’clock midline; the original break was within 1 1/2 clock hours of the highest detachment border. Group 2 included shallow inferior detachment; the original break corresponded to the more spread side of the 6 o’clock midline. Group 3 detachments were beyond 12 o’clock; the original break was within a triangle with a 12 o’clock apex (A) or within 1 1/2 hours of 12 o’clock (B); (A) and (B) were stated in the original report. Another five classifications were applied for small numbers of detachments. Consecutive initial rhegmatogenous retinal detachment surgery patients were included; medical records and detachment charts were examined. Eyes were classified into categories and rates were calculated. Eyes that had never undergone previous cataract surgery besides those in which the macula remained attached were divided into groups at a −6 D cutoff (Groups 1, 2, and 3[B]); we compared groups in each category. We compared phakic eyes, pseudophakic eyes, and eyes ruptured at the posterior capsule (Groups 1, 2, and 3[B]).

Results

Finally, 747 eyes were categorized. In Groups 1, 2, 3(A), and 3(B), corresponding rates were 92, 86, 70, and 89%, respectively. Between the above and below −6 D groups, there was no significant difference in rate in any category. There were no significant differences between phakic, pseudophakic, and ruptured eyes.

Conclusion

Lincoff’s law was suitable for the present cases and independent of refractive error and previous cataract surgery.

Risk factors for retinal breaks during macular hole surgery

Purpose

To identify risk factors for retinal breaks during macular hole (MH) surgery.

Patients and methods

This retrospective, observational, comparative study included the medical records of 364 consecutive patients (382 eyes) who underwent vitrectomy for MH at Toho University Sakura Medical Center between January 2012 and May 2017. The patients comprised 135 men and 229 women with mean age 67.6±8.0 years. Six eyes with a pre-existing retinal tear treated by laser photocoagulation before MH surgery were excluded. Data on sex, age, presence or absence of lattice degeneration, axial length (measured using an IOL Master^®), preoperative refraction, whether or not combined lens extraction/vitrectomy had been performed, whether or not the lens was pseudophakic before vitrectomy, and whether or not a posterior vitreous detachment had been created intraoperatively were collected. The lattice degeneration status was classified as none (0), treated using laser photocoagulation (1), or untreated (2).

Results

The only item identified in logistic regression analysis with the backward elimination method to be a significant risk factor for retinal breaks during MH surgery was the presence of lattice degeneration (P<0.001).

Conclusion

Ophthalmologists should be aware of the increased risk of retinal breaks during MH surgery in eyes with lattice degeneration. Intraoperative retinal breaks may be less likely to occur in eyes with lattice degeneration treated by photocoagulation preoperatively.