Evaluation of Early Corneal Endothelial Cell Loss in Bimanual Microincision Cataract Surgery (MICS) in Comparison with Standard Phacoemulsification

Corneal Endothelial Cell Loss After Endocapsular and Supracapsular Phacoemulsification: The PERCEPOLIS Randomized Clinical Trial

PURPOSE

Subluxation techniques are superior to divide-and-conquer in procedure duration, pain, and ultrasound quantity, but their safety in endothelial cell loss (ECL) is unclear. This randomized single-blind noninferiority clinical trial aimed to determine whether subluxation supracapsular phacoemulsification techniques are inferior to a reference endocapsular technique (divide-and-conquer) regarding postoperative corneal ECL.

METHODS

Patients (aged18 years or older) with greater than +0.2 logarithm of the minimum angle of resolution best spectacle-corrected visual acuity and normal to severe density cataract were randomized to subluxation or divide-and-conquer phacoemulsification in 2015 to 2016. Follow-up with ophthalmic tests was conducted on day 4 and months 1, 3, and 12. The primary study outcome was ECL at all time points. Secondary study end points were operative variables, including effective phaco time and procedure duration. A clinically relevant noninferiority ECL limit was established on the basis of the literature.

RESULTS

In total, 292 patients (mean age, 73 yrs; 59% female) were randomized and underwent subluxation (n = 148) or divide-and-conquer (n = 144). Day 4 and month 1, 3, and 12 data were available for 243, 270, 275, and 198 patients, respectively. The unexpectedly high dropout at 12 months meant that the 12-month ECL data could only be assessed qualitatively. Surgery was successful in all patients. Subluxation was noninferior to divide-and-conquer in ECL. Effective phaco times were similar, but subluxation associated with shorter procedure duration.

CONCLUSIONS

The subluxation technique was noninferior to divide-and-conquer regarding postoperative ECL, at least in the first 3 months, and associated with reduced intervention time. Subluxation techniques may be suitable alternatives to endocapsular techniques.Clinical Trial Registration-URL: ClinicalTrials.gov. Unique identifier: NCT02535819.

Modified Trabeculectomy versus Glaucoma Drainage Implant Surgery: A Retrospective Comparative Study for Refractory Glaucoma Treatment

Purpose

To observe and compare the efficacy of modified trabeculectomy (TE), Ahmed drainage valve implantation (AGV), and EX-PRESS glaucoma shunt for refractory glaucoma (RG).

Methods

The study population of this retrospective study comprised 73 patients (76 eyes) who were suffering from RG and treated with modified TE, AGV, and EX-PRESS glaucoma shunt in our hospital from October 2012 to October 2020. The number of cases who underwent modified TE, AVG, and EX-PRESS glaucoma shunt was 36 (38 eyes). 19 (20 eyes), and 18 patients (18 eyes), respectively. The intraocular pressure (IOP), best-corrected visual acuity (BCVA), postoperative antiglaucoma medications, filter bubble morphology, anterior chamber depth (ACD), successful rate, and postoperative complications were recorded and statistically analyzed preoperative and 1 d, 1 w, 1 mon, 3 mon, 6 mon, and the end follow-up after operation.

Results

The BCVA differed insignificantly among the three cohorts before and 6 months after surgery. Compared to preoperative BCVA, the postoperative BCVA of the three groups had no statistical significance. An obvious reduction in IOP was observed in all the three group after operation (P < 0.05). An obvious decrease in antiglaucoma medications was observed after surgery in all the three groups (P < 0.05). The AGV group showed deeper ACD postoperatively, while no marked difference was found in postoperative ACD in the other two groups. The total success rates in modified TE and AGV groups were slightly higher than those in the EX-PRESS group. The three groups differed insignificantly in filter bubble morphology after operation.

Conclusion

Modified TE, AGV, and EX-PRESS glaucoma shunt showed equivalent efficacy for RG, which could validly reduce IOP and postoperative antiglaucoma medications. However, the success rates of modified TE and AGV were slightly higher than those of EX-PRESS glaucoma shunt in the last follow-up, and their complications were slightly less than those of the EX-PRESS glaucoma shunt.

Corneal Endothelial Cell Loss After PRESERFLO™ MicroShunt Implantation in the Anterior Chamber: Anterior Segment OCT Tube Location as a Risk Factor

INTRODUCTION

To analyze the effects of PRESERFLO on corneal endothelial cell density (ECD).

METHODS

Forty-six eyes that underwent PRESERFLO implantation were followed up for 12 months. Specular microscopy was performed preoperatively and at 1, 3, 6, and 12 months postoperatively to measure central ECD and mean monthly reduction (MMR). Anterior segment optical coherence tomography (AS-OCT) was applied to measure the tube-endothelium (TE < 200 μm, 201-500 μm, > 500 μm) distance. The relationship between TE distance and ECD was analyzed with a linear mixed-effects model.

RESULTS

Central ECD decreased significantly at 1 year (7.4%, p = 0.04), with an MMR of -15 ± 25 cells/mm². Regarding TE distance groups, there was an 18% ECD reduction in the < 200 μm group vs. 1% in the > 500 μm group (p = 0.08). Endothelial cell loss was related to TE distance (mean 482.9 ± 238 μm), with a higher rate at 1 month in comparison to 12 months for the same tube position in the anterior chamber (-174.8 ± 65.2 cells/mm² at 1 month vs. 30.2 ± 11.3 cells/mm² at 12 months, p < 0.01). From month 6, tubes located > 600 μm from the endothelium showed EC loss close to zero.

CONCLUSIONS

The PRESERFLO implant is associated with a loss of EC from the immediate postoperative period that continues over time at lower rates. A shorter TE distance appears to cause more severe ECD loss.

The Effects of Glaucoma and Glaucoma Therapies on Corneal Endothelial Cell Density

A healthy corneal endothelium is required for corneal clarity. Both the glaucoma disease state and its various forms of treatment can have adverse effects on the corneal endothelium. Both the presence of glaucoma and the magnitude of intraocular pressure elevation are related to endothelial cell loss (ECL). Topical medical therapy, laser procedures, and both traditional surgeries-trabeculectomy and tube-shunts-and newer minimally invasive glaucoma surgeries have variable effects on ECL. This review will summarize the reported effects of glaucoma and its treatment on ECL. Concerns for corneal endothelial cell health should be part of the decision-making process when planning glaucoma therapy for lowering intraocular pressure, with added caution in case of planned device implantation in eyes with preexisting ECL and low endothelial cell density at high risk for corneal endothelial decompensation.

Corneal Endothelial Cell Changes After Phacoemulsification Combined with Excisional Goniotomy with the Kahook Dual Blade or iStent: A Prospective Fellow-Eye Comparison

Purpose

To characterize changes in endothelial cell density and morphology following phacoemulsification combined with either excisional goniotomy with the Kahook Dual Blade (KDB-phaco) or first-generation iStent trabecular microbypass implantation (iStent-phaco).

Setting

A single clinical practice.

Methods

Twenty-one adult subjects from one center with visually significant cataract and mild-moderate open-angle glaucoma underwent KDB-phaco or iStent-phaco in one eye and the alternate procedure in the fellow eye as part of a prospective, multicenter, randomized trial. Specular microscopy and pachymetry were performed before and 6–29 months after surgery. Parameters analyzed included change from baseline of endothelial cell density (ECD), the coefficient of variation (CV), the percent of hexagonal cells (%HEX), and central corneal thickness (CCT).

Results

Baseline ECD, CV, %HEX, and CCT were similar between groups. A mean (standard deviation) of 18.2 (5.8) months postoperatively (range 12.5–28.7 months), the change from baseline in ECD was −90 ± 226 cells/mm² (−3.4%) in KDB-phaco eyes (p=0.083) and −239 ± 247 cells/mm² (−9.0%) in iStent-phaco eyes (p<0.001); the change in iStent-phaco eyes was significantly greater than in KDB-phaco eyes (p=0.013). The magnitude of Endothelial Cell Loss (ECL) was not correlated with length of postoperative follow-up time in either group. No significant differences in change from baseline in CV, %HEX, or CCT were noted with the exception of a decrease in %HEX in iStent-phaco eyes (p=0.017). No eyes manifested corneal edema, decompensation, or other cornea-related complications.

Conclusion

Both KDB-phaco and iStent-phaco are associated with postoperative ECL, with iStent-phaco producing significantly greater ECL than KDB-phaco. The clinical significance of these findings is unclear, and future studies are warranted to more robustly characterize long-term effects of glaucoma surgical procedures—with and without permanent implants—on ECD and corneal health and to develop evidence-based guidelines for the pre- and post-operative evaluation of corneal health in eyes undergoing glaucoma surgery.

Comparison of the selected parameters of the anterior segment of the eye between femtosecond laser-assisted cataract surgery, microincision cataract surgery, and conventional phacoemulsification: A case-control study

The purpose of our study was to compare the selected parameters of the anterior segment of the eye in patients after femtosecond laser-assisted cataract surgery (FLACS) with the results of microincision cataract surgery (MICS) and conventional phacoemulsification surgery (CPS). This single-center prospective randomized comparative observational study included 87 patients. Patients were randomly selected into group A (FLACS), group B (MICS) and group C (control group). All the surgeries were performed by the same experienced surgeon. Preoperative and postoperative parameters were evaluated: best-corrected visual acuity (BCVA), endothelial cell density (ECD), endothelial cell loss percentage (ECL%), central corneal thickness (CCT), central anterior and posterior corneal astigmatism induction, posterior corneal elevation map were measured. Intraoperative parameters: effective phacoemulsification time (EPT), balanced salt solution use (BSS use), total surgical time and suction time were analyzed. Examination was performed preoperatively and on the first, seventh day, one and six months postoperatively. The follow up period was 6 months. There was no statistically significant difference in BCVA, central anterior and posterior astigmatism induction between studied groups. The ECL% was statistically significant lower in the group A on the 7th day, 1 month and 6-months postoperatively (P < .05). The CCT was statistically significant lower in the group A and in the group B than in the group C on the 7th postoperative day (P = .002). However, in the 6 months follow-up there was no statistically significant difference in the CCT between studied groups (P = .133). We observed statistically significant difference in change of the posterior corneal elevation map at the periphery assessed within the 90° to 120°meridian range between group A, group B and group C at every timepoint postoperatively (P < .05). The EPT and BSS use were statistically significant lower whilst total surgery time was statistically significant higher in the FLACS group (P < .05). To conclude in the 6 months follow-up there was statistically significant difference found between eyes undergoing FLACS, MICS and CPS with respect to the posterior corneal elevation map assessed within the studied range, ECL%, EPT, BSS use and total surgery time. Postoperative BCVA, central anterior and posterior astigmatism induction, CCT were comparable between studied groups.

Corneal Endothelial Cell Loss and Morphometric Changes 5 Years after Phacoemulsification with or without CyPass Micro-Stent

PURPOSE

To characterize long-term changes in corneal endothelial cells after phacoemulsification with or without supraciliary Micro-Stent (Alcon) implantation in eyes with open-angle glaucoma (OAG) and visually significant cataract.

DESIGN

Three-year safety extension of a 2-year randomized clinical trial.

METHODS

Patients from the multicenter Study of an Implantable Device for Lowering Intraocular Pressure in Glaucoma Patients Undergoing Cataract Surgery (COMPASS) trial who underwent Micro-Stent implantation plus phacoemulsification (n = 282) or phacoemulsification alone (n = 67) were analyzed post hoc. Specular microscopy was used to assess endothelial cell loss (ECL), including changes from baseline in endothelial cell density (ECD), coefficient of variation, and percentage of hexagonal cells.

RESULTS

Preoperative ECDs in the microstent group (2,432.6 cells/mm² [95% confidence interval [CI], 2,382.8-2,482.4 cells/mm²]) were similar to those in the control group (2,434.5 cells/mm² [95% CI, 2,356.5-2,512.4 cells/mm²]) groups. ECL at months 48 and 60 was greater in the Micro-Stent group than in the control group. At month 60, the mean percent of changes in ECD was -20.4% (95% CI, -23.5% to -17.5%) in the Micro-Stent group and -10.1% (95% CI, -13.9% to -6.3%) in the control group. No statistically significant between-group changes from baseline in cellular morphology were observed. Nine adverse events were possibly related to ECL, including 3 eyes with transient focal corneal edema and 4 eyes that required Micro-Stent trimming due to protrusion.

CONCLUSIONS

In eyes with OAG, ECL after phacoemulsification is acute and stabilizes after 3 months, whereas ECL after phacoemulsification plus Micro-Stent implantation proceeds for at least 5 years. Clinical findings associated with ECL in these eyes were uncommon (3.3% of implanted eyes), suggesting that ECL is generally a subclinical phenomenon.

Ultrasound power and irrigation volume in different lens opacity grades: comparison of femtosecond laser-assisted cataract surgery and conventional phacoemulsification

OBJECTIVES

To compare the amount of ultrasound energy and irrigation volume in conventional phacoemulsification cataract surgery versus femtosecond laser-assisted phacoemulsification at different nuclear-cortical cataract grades.

METHOD

This was a prospective, consecutive, investigator-masked nonrandomized parallel cohort study. Patients were divided into 4 groups (Phaco1, Phaco2, Femto1 and Femto2) according to the surgical technique (conventional phacoemulsification [Group Phaco] or femtosecond laser-assisted cataract surgery [Group Femto]) and the Lens Opacity Classification System III (LOCS) grade (LOCS<11 [group 1] or LOCS≥11 [group 2]). The measured outcomes were effective phacoemulsification time (EPT), indicating the ultrasound energy, and balanced salt solution (BSS) use, indicating the irrigation volume, to indirectly estimate the damage to the corneal endothelium caused by the cataract surgery.

RESULTS

A total of 160 eyes from 109 patients were included: 87 eyes in Group Phaco, 73 eyes in Group Femto, 76 eyes in group 1 and 84 eyes in group 2. The EPT mean in Femto1 was 53% less (2.73±1.88, 0.1 to 8.65) than that in Phaco1 (5.80±2.86) (p=0.00) and in Femto2 (8.38±9.32) was 33% less than that in Phaco2 (12.55±8.38) (p=0.00). No significant differences in mean LOCS grades between the Phaco1 (8.21±1.44) and Femto1 (7.90±1.90) groups (p=0.73) or between the Phaco2 (13.15±2.55) and Femto2 (12.72±2.18) groups (p=0.95) were found. There were no significant differences in the mean BSS use between the Phaco1 (55.73±12.45) and Femto1 (59.37±10.93) groups (p=0.48) or between the Phaco2 (64.34±21.00) and Femto2 (65.71±17.60) groups (p=0.47).

CONCLUSIONS

Compared to conventional phacoemulsification at different nuclear-cortical cataract grades, femtosecond laser-assisted cataract surgery provides an EPT reduction but does not influence the BSS use.

A contralateral eye study comparing characteristics of corneal endothelial cells in bilateral keratoconus patients with unilateral corneal Vogt's striae

Purpose

The aim of this study was to analyze and compare corneal endothelial cell morphology and characteristics in bilateral keratoconus (KCN) patients with unilateral Vogt's striae.

Methods

Fifty patients aged 20–38 years were recruited in this cross-sectional contralateral eye study. In this study, corneal endothelial cell parameters were evaluated in patients with bilateral KCN and unilateral Vogt's striae using the Topcon SP2000P specular microscope (Topcon, Tokyo, Japan).

Results

In the current study, there were no significant differences in corneal endothelial cell parameters including endothelial cell density (ECD), hexagonal cell ratio (HEX), and coefficient of variance of cell size (CV) between the KCN groups with and without Vogt's striae, [(2968.34 ± 276.65 vs. 2980.05 ± 253.30, P = 0.618), (51.88 ± 13.57 vs. 53.24 ± 9.31, P = 0.658), and (32.50 ± 5.40 vs. 32.97 ± 4.07, P = 0.467), respectively]. Also, among study groups with and without Vogt's striae, ECD did not correlate with anterior chamber depth (ACD) [(P = 0.564, r = 0.09), (P = 0.219, r = −0.18), respectively], maximum keratometry (Kmax) [(P = 0.215, r = 0.18), (P = 0.898, r = 0.02), respectively], and central corneal thickness (CCT) [(P = 0.989, r = −0.02), (P = 0.643, r = −0.07), respectively].

Our results showed significant differences in corrected and uncorrected distance visual acuity (UDVA), cycloplegic refractive error components (calculated by vectorial analysis), CCT, and Kmax between two study groups (all P < 0.05) except for J₄₅ (Jackson cross cylinder, axes at 45 and 135°) (P = 0.131).

Conclusions

We were not able to find the statistically significant differences in ECD, HEX, and CV between KCN eyes with and without Vogt's striae. Despite clinical and tomographic results, it seems that Vogt's striae cannot cause deterioration in the corneal endothelial morphology.

Usefulness of Surgical Media Center as a Cataract Surgery Educational Tool

Purpose. This study retrospectively analyzed cataract surgeries to examine the usefulness of Surgical Media Center (SMC) (Abbott Medical Optics Inc.), a new cataract surgery recording device, for training of cataract surgery. Methods. We studied five hundred cataract surgeries conducted with a phacoemulsification system connected to the SMC. After surgery, the surgical procedures were reviewed, with changes in aspiration rate, vacuum level, and phaco power displayed as graphs superimposed on the surgical video. We examined whether use of SMC is able to demonstrate the differences in technique between experienced and trainee operators, to identify inappropriate phacoemulsification techniques from analyzing the graphs, and to elucidate the cause of intraoperative complications. Results. Significant differences in the time taken to reach maximum vacuum and the speed of increase in vacuum during irrigation and aspiration were observed between experienced and trainee operators. Analysis of the graphs displayed by SMC detected inappropriate phacoemulsification techniques mostly in cases operated by trainee operators. Conclusions. Using SMC, it was possible to capture details of cataract surgery objectively. This recording device allows surgeons to review cataract surgery techniques and identify the cause of intraoperative complication and is a useful education tool for cataract surgery.

Comparison of corneal endothelial changes following phacoemulsification with transversal and torsional phacoemulsification machines

AIM

To compare and evaluate the phacoemulsification parameters and postoperative endothelial cell changes of two different phacoemulsification machines, each with different modes, but also to assess the relationship between postoperative endothelial cell loss and the phacoemulsification parameters, as well as the other factors in both groups.

METHODS

This prospective observational study was comprised of consecutive eligible cataract patients operated with phacoemulsification technique performed by the same surgeon using either a WHITESTAR Signature Ellips FX (transversal, group 1) or Infiniti OZil IP (torsional, group 2) machine.

RESULTS

The study included 86 patients. Baseline characteristics in the groups were similar. The median nuclear sclerosis grade was 3 (2-4) in the first group and 2 (2-4) in the second group (P=0.265). Both groups had similar phacoemulsification needle times (group 1: 60.63±36 s; group 2: 55.98±30 s; P=0.789). The percentage of endothelial cell loss 30d after surgery ranged from 3% to 15% with a median of 7% in group 1, and from 2% to 13% with a median of 6% in group 2; however, there was no statistically significant difference between the groups (P=0.407). Hexagonality (P=0.794) and the coefficient of variation (CV; P=0.142) did not differ significantly between the groups before and 30d after surgery. A significant positive correlation was found between the endothelial cell loss and nuclear sclerosis grade (group 1: P<0.001; group 2: P<0.001) and between the endothelial cell loss and average phacoemulsification power (group 1: P=0.007; group 2: P=0.008).

CONCLUSION

Both of these machines were efficient, with similar endothelial cell loss. This endothelial cell loss was related to the increased nuclear sclerosis grade and increased phacoemulsification power.

Corneal endothelial cell loss and corneal thickness in conventional compared with femtosecond laser-assisted cataract surgery: three-month follow-up

PURPOSE

To quantify changes in endothelial cell counts and corneal thickness measurements in patients having standard phacoemulsification compared with femtosecond laser-assisted cataract removal.

SETTING

Ruhr University Eye Clinic, Bochum, Germany.

DESIGN

Prospective randomized intraindividual cohort study.

METHODS

One eye of each patient had standard phacoemulsification (control group) and the other eye had femtosecond laser-assisted phacoemulsification (study group), both with intraocular lens implantation. Pulsed ultrasound energy was used for phacoemulsification. Noncontact endothelial cell microscopy and corneal pachymetry were performed preoperatively and 1 day, 3 to 4 days, 7 to 10 days, 50 to 60 days, and 90 to 100 days postoperatively.

RESULTS

The mean endothelial cell loss was 7.9% ± 7.8% (SD) 1 week postoperatively and 8.1% ± 8.1% 3 months postoperatively in the study group and 12.1% ± 7.3% and 13.7% ± 8.4%, respectively, in the control group. The mean relative change in corneal thickness from the preoperative values was -0.0% ± 1.9% at 1 day, 2.8% ± 1.8% at 1 week, and 3.3% ± 1.7% at 3 months in the study group and -0.9% ± 2.3%, 2.4% ± 1.5%, and 3.2% ± 1.4%, respectively, in the control group.

CONCLUSION

The femtosecond laser did not add to the endothelial damage caused by cataract surgery and might be beneficial in eyes with low preoperative endothelial cell values (eg, cornea guttata cases).

Phakic anterior chamber lenses in very high myopia: an 18-month follow up

BACKGROUND

To evaluate the efficacy and tolerance of two different foldable anterior chamber phakic intraocular lenses for high myopia.

DESIGN

A prospective interventional case series at the Eye Clinic, Kartal Training and Research Hospital, Istanbul, Turkey.

PARTICIPANTS

Sixty-two eyes of 31 patients received iris-claw lens (group 1) (Artiflex AC 401, Ophtec), and 43 eyes of 22 patients received angle-supported lens (group 2) (I-Care, Corneal).

METHODS

The mean preoperative spherical equivalents for group 1 and group 2 were -12.13 D and -18.95 D, respectively. Endothelial cell density was measured at day 1 and at 1, 3, 6, 12 and 18 months for follow ups.

MAIN OUTCOME MEASURES

  Percentage change in endothelial cell density and improvement in visual acuity.

RESULTS

At the 18-months follow up, uncorrected visual acuity improved to logMAR 0.37 ± 0.23 from 1.60 ± 0.10 in group 1, and logMAR 0.47 ± 0.14 from 0.70 ± 0.20 in group 2; best spectacle corrected visual acuity improved to logMAR 0.23 ± 0.22 from logMAR 0.36 ± 0.14) in group 1, and logMAR 0.29 ± 0.18 from logMAR 0.50 ± 0.20) in group 2 (P<0.001, in both groups). Mean decreased endothelial cell density was 241 cells/mm(2) (8.61%) and 223 cells/mm(2) (8.42%) at 18 months follow up in group 1 and 2, respectively (P=0.17) but significant in comparison to preoperative values for both groups (P<0.001).

CONCLUSIONS

Although both iris-claw and angle-supported lenses offer good refractive outcomes significant endothelial cell density was observed at 18 months follow up.

Relationship between endothelial cell loss and microcoaxial phacoemulsification parameters in noncomplicated cataract surgery

Purpose

To assess the relationship between postoperative endothelial cell loss and microcoaxial phaco parameters using Ozil IP (Alcon Laboratories, Inc, Fort Worth, TX) in noncomplicated cataract surgery.

Methods

In this prospective observational study, 120 consecutive cases of cataract patients with different grades of nuclear hardness underwent microcoaxial phacoemulsification through a 2.2-mm clear corneal incision. An Alcon Infinity Vision System with Ozil IP (Alcon Laboratories) was used with an Ozil torsional handpiece and a Kelman-style 45° phacoemulsification tip. Patients underwent preoperative and postoperative central endothelial cell counts.

Results

The study included 120 cases of age-related cataract whose mean age (standard deviation [SD]) was 59.68 years (9.47). There was a highly statistically significant endothelial cell loss (P < 0.001). The endothelial cell loss ranged 11–1149 cells/mm² with a median (interquartile range) of 386 cells/mm² (184.5–686 cells/mm²). The percentage of postoperative ECLoss% ranged from 0.48% to 47.8% with a median (interquartile range) of 15.4% (7.2% to 26.8%). A significant positive correlation was found between the ECLoss% and different phaco parameters. The Spearman’s rank-order correlation coefficient values, rho, (ρ) were as follows: CDE (ρ = 0.425), aspiration time (ρ = 0.176), and volume (ρ = 0.278). Also, ECLoss% was significantly correlated with the grade of nuclear opalescence (Kendall’s tau τ = 0.42).

Conclusion

Microcoaxial phacoemulsification was efficient in removing noncomplicated cataracts; however a statistically significant endothelial cell loss was noted, especially with increased nuclear hardness. This endothelial cell loss was mostly related to the increased cumulative dissipated energy (CDE), aspiration time, and volume of balanced salt solution used.

Comparison of bimanual and micro-coaxial phacoemulsification with torsional ultrasound

PURPOSE

To evaluate the efficacy and postoperative outcomes of bimanual and micro-coaxial phacoemulsification with torsional ultrasound.

METHODS

In this prospective randomized series, eyes with age-related cataract were randomly divided into bimanual phacoemulsification and micro-coaxial phacoemulsification groups. Data included preoperative and postoperative corrected distance visual acuity (CDVA), central/temporal corneal thickness, endothelial cell density and intraoperative ultrasound time, cumulative dissipated energy and balanced salt solution volume.

RESULTS

The study evaluated 89 patients (89 eyes). When compared between micro-coaxial and bimanual phaco groups, ultrasound time (57 ± 24 second versus 85 ± 40 second, p < 0.01), cumulative dissipated energy (10 ± 7 versus 14 ± 7, p = 0.01) and balanced salt solution volume (55 ± 19 ml l versus 75 ± 20 ml, p < 0.01) were significantly lower in micro-coaxial phaco group. At 1 day, there were no statistically significant differences in CDVA (p = 0.68) or central corneal thickness (p = 0.48) between two groups; temporal corneal thickness was statistically significantly thicker in bimanual phaco group (1247 ± 123 μm) than that in micro-coaxial phaco group (1108 ± 131 μm, p = 0.01). There were no statistically significant differences in CDVA, central/temporal corneal thickness, or endothelial cell density between two groups 30 days postoperatively (all p values >0.05).

CONCLUSION

With rapid visual rehabilitation and comparable endothelial cell loss, both bimanual and micro-coaxial phacoemulsification procedures with torsional ultrasound are efficient for moderate nuclear cataract extraction.

In vivo confocal microscopic evaluation of keratic precipitates and endothelial morphology in Fuchs' uveitis syndrome

PURPOSE

To evaluate the endothelial cell layer in patients with Fuchs' uveitis syndrome (FUS) with respect to the type and distribution of keratic precipitates (KP), endothelial cell morphology, and endothelial cell density (ECD), using in vivoconfocal microscopy (IVCM).

METHODS

Forty eyes of 40 patients (mean age of 32.2 ± 12.5 years) with the clinical diagnosis of FUS were evaluated with IVCM (Confoscan 3.0, Vigonza, Italy). KP were classified as type I (small, round), type II (stippled), type III (dendritiform), and type IV (globular). When >1 KP type was present, differentiation between the predominant and less frequent KP was made as 'primary' and 'secondary'. ECD was measured and compared with age-matched 60 control subjects. Endothelial blebs were classified as small (3-10 μm) or large (>10 μm).

RESULTS

In 36 (90.0%) cases with FUS, more than one KP type was observed with IVCM. Type III (dendritiform) KP was the most frequently observed primary KP type (85.0%), followed by type II (stippled) KP (15.0%). Secondary KP included type II (58.3%), type IV (globular) (27.8%), and type III (13.9%). The mean endothelial cell density of eyes with FUS (2588 ± 396 cells/mm(2)) was significantly lower than that of control subjects (2930 ± 364 cells/mm(2)) (t-test; P<0.001). Eyes with FUS had lower proportion of hexagonal cells and higher percentage of polymegethism compared with the uninvolved contralateral eyes. Endothelial blebs (21 small, 16 large blebs) were observed in 37 (92.5%) eyes.

CONCLUSIONS

FUS is characterized by dendritiform KP and is associated with decreased ECD and altered endothelial cell morphology.

Comparison of endothelial changes and power settings between torsional and longitudinal phacoemulsification

PURPOSE

To compare the intraoperative and postoperative outcomes of conventional longitudinal phacoemulsification and torsional phacoemulsification.

SETTING

Department of Ophthalmology, University of Leipzig, Germany.

DESIGN

Randomized single-center clinical trial.

METHODS

Eyes with senile cataract were randomized to have phacoemulsification using the Infiniti Vision System and the torsional mode (OZil) or conventional longitudinal mode. Primary outcomes were corrected distance visual acuity (CDVA) and central endothelial cell density (ECD), calculated according to the Conference on Harmonisation-E9 Guidelines in which missing values were substituted by the median in each group (primary analysis) and the loss was then calculated using actual data (secondary analysis). Secondary outcomes were ultrasound (US) time, cumulative dissipated energy (CDE), and percentage total equivalent power in position 3. Postoperative follow-up was at 3 months.

RESULTS

The mean preoperative CDVA was 0.41 logMAR in the torsional group and 0.38 logMAR in the longitudinal group, improving to 0.07 logMAR postoperatively in both groups. The mean ECD loss was 7.2% ± 4.6% in the torsional group (72 patients) and 7.1% ± 4.4% in the longitudinal group (76 patients), with no statistically significant differences in the primary analysis (P = .342) or secondary analysis (P = .906). The mean US time, CDE, and percentage total equivalent power in position 3 were statistically significantly lower in the torsional group (98 patients) than in the longitudinal group (94 patients) (P<.001).

CONCLUSION

The torsional mode was as safe as the longitudinal mode in phacoemulsification for age-related cataract.

Bimanual microincisional cataract surgery technique and clinical outcome

Bimanual microincisional cataract surgery has been introduced recently as a technique for cataract surgery and it is gaining interest of many cataract surgeons in the world. Over the last few years many changes were made in the phacoemulsification machines and the intraocular lenses design which allowed bimanual microincisional cataract surgery to be safer and more efficient. The purpose of this review is to introduce the technique of bimanual microincisional cataract surgery and to review all the prospective randomized studies comparing bimanual microincisional cataract surgery and standard phacoemulsification in term of safety and efficacy parameters.

Documentation of capsular opacification and incomplete cell migration barrier formation by ThinOptX IOL using Miyake-Apple view

The purpose of this study was to evaluate the in situ relationship of ThinOptX intraocular lens (IOL) in a cadaveric donor eye with posterior capsular opacification (PCO), following report of high PCO rates with this IOL. A cadaveric donor eye implanted with ThinOptX IOL and received at our eye bank was fixed in 10% formalin after retrieval of corneoscleral button. The globe was sectioned at equator and evaluated from the posterior (Miyake-Apple) view. Complete iridectomy was performed and IOL evaluated from the anterior (surgeon's) view. The IOL was well centered in the bag. A thick (Grade 4) Sommering ring was seen with centripetal extension across the IOL edge margin. The anterior capsule showed fibrosis and distortion of the capsulorrhexis margin. It seems from our findings that in some cases, the edge of the ThinOptX IOL may not provide an adequate barrier to epithelial cell migration and PCO formation. This can have clinical implications which need evaluation in large clinical and histopathological studies.