Correlation between visual acuity at discharge and on final follow-up in patients undergoing manual small incision cataract surgery

Purpose

The aim of this study was to determine the correlation between visual acuity on discharge and at final follow-up in patients undergoing manual small incision cataract surgery (MSICS) through outreach services of a tertiary care training center.

Methods

A prospective observational study was done to determine the correlation between visual acuity on postoperative day 1 and final follow-up (4-8 weeks) among various categories of surgeons and surgical complications in patients who underwent MSICS between January 2018 and March 2018. Proportions of patients benefitting from refractive correction were also analyzed.

Results

Of the 924 patients who underwent MSICS through outreach services during the study period 841 were eligible for the study. Follow-up rate at 4-8 weeks was 91%. Mean age was 61.6 (SD 9.2) years, 63% were females and 55% were operated by trainees. There was a positive correlation between visual acuity at day one and final follow-up with a Spearman's correlation coefficient of 0.375 and 0.403 for uncorrected (UCVA) and best corrected visual acuity (BCVA) respectively (P < 0.001). The correlation coefficient, while still positive, was lower for trainees (0.287), as compared to consultants (0.492). At least two lines of improvement in visual acuity on refractive correction were found in 77% of patients.

Conclusion

Visual acuity on the day of discharge may be a useful quality indicator of visual outcome for monitoring cataract surgical programs. However, a follow-up at 4-8 weeks is recommended for individual patient benefit and monitoring surgical quality especially in training hospitals.

Quality of vision after AMO Array multifocal intraocular lens implantation

PURPOSE

To evaluate safety and efficacy of Array SA40N multifocal intraocular lens (IOL) (AMO) implantation in cataract surgery.

SETTING

Helsinki University Eye Hospital, Helsinki, Finland.

METHODS

In this prospective randomized comparative trial, 80 patients scheduled for cataract surgery were selected based on preoperative counseling and randomized to have multifocal or monofocal IOL implantation. Fifty-three eyes of 35 patients received a multifocal IOL and 67 eyes of 40 patients, a monofocal IOL. The incidence of complications and visual outcome in the multifocal and monofocal IOL groups were compared. Quality of vision was measured by comparing the severity of visual symptoms (glare, halos, and cataract symptoms score), changes in functional impairment measured by a 7-item visual function test (VF-7), changes in global measures of vision (trouble and satisfaction with vision), and range of accommodation and contrast sensitivity.

RESULTS

Intraoperative and postoperative complications and adverse events were few and required no further surgical intervention. Both distance and near visual acuities were significantly better in the multifocal group than in the monofocal group; the difference was most prominent in distance corrected near acuity (P<.001). Thirty-five eyes (67.3%) in the multifocal group and 10 eyes (14.9%) in the monofocal group achieved a distance corrected near acuity of J6 (20/40) or better; 30 eyes (56.6%) and 19 eyes (28.4%), respectively, achieved a best corrected distance acuity of 20/20 or better. Glare symptoms decreased postoperatively in both groups but were slightly more common in the multifocal group. In contrast, halos were significantly more common at 1 month in the multifocal group (P<.001). Contrast sensitivity values were slightly lower with multifocal IOLs at almost all spatial frequencies, but the difference was not significant. The change in the quality of life postoperatively, measured with the VF-7, was significant and identical in both groups.

CONCLUSIONS

Pseudophakic eyes with multifocal IOLs had better distance and near acuity and range of accommodation than eyes with a monofocal IOL. Slightly lower contrast sensitivity and increased perception of halos by subjects with the multifocal IOL appear to be an acceptable compromise to enhanced near and distance vision.

Traumatic expulsive iridodialysis after small-incision sutureless cataract surgery

Phacoemulsification with intraocular lens (IOL) implantation was performed in the right eye of an 84-year-old woman using a small clear corneal incision. Ten weeks after surgery, the patient fell, which caused traumatic iridodialysis and hyphema with expulsion of the iris through the surgical corneal incision. Apart from a transient rise in intraocular pressure, no other complication was identified and the visual acuity returned to 20/20 within 2 months. The IOL remained in situ and undisturbed in the capsular bag, and the retina remained flat, suggesting that an IOL in the capsular bag may provide a stable barrier to prevent tissue loss from the posterior segment.

Manual multi-phacofragmentation through a 3.2 mm clear corneal incision

PURPOSE

To evaluate the postoperative astigmatism and complications after manual multi-phacofragmentation (MPF) cataract surgery through a 3.2 mm clear corneal incision (CCI).

SETTING

Department of Ophthalmology, Hospital General de Segovia, Segovia, Spain.

METHODS

In a retrospective study, 50 eyes of 50 patients had cataract surgery by MPF. Patients were divided into 3 groups according to type of cataract. This technique uses a racquet-shaped nucleotome, a spatula, and 2 manipulators, right and left, for nuclear fragments. With these instruments, the nucleus is fragmented into multiple small pieces that are extracted from the anterior chamber. Astigmatism was evaluated before surgery and 7 days and 1 and 3 months after surgery by Gaussian distribution (P <.05). Intraoperative and postoperative complications were recorded.

RESULTS

Mean postoperative astigmatism was 0.77 diopters (D) +/- 0. 29 (SD) at 7 days, 0.47 +/- 0.22 D at 1 month, and 0.21 +/- 0.22 D at 3 months. During surgery, 2 cases (4%) of slight transient intracameral bleeding in the anterior chamber occurred. After surgery, 5 eyes (10%) had corneal edema, 2 (4%) had iritis, and 3 (6%) had ocular hypertension.

CONCLUSION

Using MPF, soft and hard nuclei can be removed through a 3.2 mm CCI. The astigmatic results were favorable and the complications few.

A comparison of visual performance between a rigid PMMA and a foldable acrylic intraocular lens

PURPOSE

To examine post-operative visual outcomes when using micro-incision surgery and a three-piece, foldable acrylic intraocular lens (IOL) and when using small-incision surgery and a one-piece, rigid polymethyl-methacrylate (PMMA) IOL.

METHODS

Phacoemulsification and IOL implantation was conducted by one surgeon on 86 subjects (aged 50-89 years) with cataracts. Of these subjects, 67 completed the study. Subjects were implanted either with a foldable IOL (n = 38) or a rigid IOL (n = 29). Best corrected Snellen visual acuity and contrast sensitivity (2-28 cycles/degree) were measured approximately 2 months post-operatively. Comparisons were made between the pseudophakic groups and an additional group of 28 age-matched, normal subjects (aged 58-81 years). Non-parametric (Kruskal-Wallis and Mann-Whitney U) as well as parametric (ANOVA and Pearson) statistics tests were used in the analysis of results.

RESULTS

All pseudophakes had corrected visual acuity of 6/9 or better. There were no significant differences in visual acuity (Kruskal-Wallis, p = 0.61) or contrast sensitivity (ANOVA, p = 0.33) between the three groups. The mean residual refractive error of the foldable IOL group was hypermetropic in comparison with the rigid IOL group but not significant at the 99% level of probability (Mann-Whitney U, p = 0.02). There was no significant difference in astigmatism between the groups.

CONCLUSIONS

Implanting a foldable acrylic IOL gave no post-operative benefit in visual acuity and contrast sensitivity to pseudophakes over a less expensive rigid PMMA IOL, within this post-operative period. This study did not provide a comparison between the two lenses regarding post-operative complications, in particular the important long-term complication of posterior capsular opacification (PCO). Until and if any particular advantage of a given IOL in reduced incidence of PCO is confirmed, it appears more economical to implant the conventional rigid PMMA IOL using small-incision surgery.

Efficacy of synthetic and biological bioadhesives in scleral tunnel phacoemulsification in eyes with high myopia

PURPOSE

To study the efficacy of a synthetic (cyanoacrylate) and a biological (fibrinogen) bioadhesive in sealing scleral tunnel incisions in cataract surgery.

SETTING

Private institution with academic orientation.

METHODS

This controlled clinical study comprised 126 eyes with high myopia (axial length > 28.0 mm) divided into three groups based on method of incision closure 10-1 nylon anchor suture; cyanoacrylate (Histoacryl); fibrinogen (Tissucol). Phacoemulsification was done through a double-valved scleral tunnel incision with an 8.0 mm arc. In all eyes, a hyperconcave, 7.0 mm optic, posterior chamber intraocular lens was implanted.

RESULTS

Mean induced astigmatism at 12 weeks was 0.18 diopter (D) in the suture group, 0.50 D in the cyanoacrylate group, and 0.43 D in the fibrinogen group. The difference between the bioadhesive groups and the suture group was not significant. A mild inflammatory reaction occurred in the cyanoacrylate group. In the fibrinogen group, 3 eyes developed postoperative hypotony requiring reclosing of the incision with sutures and 5 eyes developed intraoperative hypotony requiring suture closure. These eyes were not included in the refractive analysis. These complications led to the suspension of the fibrinogen portion of the study after uneventful use of the bioadhesive in 26 eyes.

CONCLUSION

The results of this study indicate that bioadhesives, especially synthetic ones such as cyanoacrylate, are an effective alternative to sutures in scleral tunnel cataract surgery. Future improvements in bioadhesives could extend their application to other ocular incision types.

Discharging routine phacoemulsification patients at one week

The reduction of surgically induced astigmatism and rapid refractive stabilisation after phacoemulsification have been well studied and often lead to reduced follow-up. In this prospective study we reviewed a cohort of 100 patients discharged with a refractive prescription at their 1 week post-operative appointment following routine sutureless phacoemulsification through a corneal or scleral section. The aim was to assess the incidence of late pathology and need for review. Eighty-eight patients attended for review between 3 and 4 months post-operatively, of whom 8 (9.1%) who had been symptomatic had already visited ophthalmic casualty. Nine (10.2%) benefited from the follow-up appointment: 4 were given a new refractive prescription that increased their Snellen visual acuity by 1 line; the other 5 were all symptomatic or had incidental findings. We feel that provided there is easy access to the eye department, early discharge with or without refraction is justifiable as those with surgically related pathology at any stage are symptomatic.

Phacoemulsification and lens implantation after pars plana vitrectomy

OBJECTIVE

This study aimed to describe the intraoperative and postoperative complications and visual acuity outcomes of patients undergoing Kelman phacoemulsification (KPE) and intraocular lens (IOL) implantation after pars plana vitrectomy (PPV).

DESIGN

The study design was a retrospective review of a consecutive surgical series.

PARTICIPANTS

Forty-four eyes of 43 patients who underwent surgery at the Jules Stein Eye Institute, Los Angeles, California, or Advanced Vision Care, West Hills, California, were studied.

INTERVENTION

Office records, referring retina specialists' records, and operative reports were reviewed for demographic information, indications for PPV, preoperative cataract severity, unplanned intraoperative events and complications, early and late postoperative complications, and postoperative visual acuities.

MAIN OUTCOME MEASURES

Complications and postoperative visual acuities were measured.

RESULTS

The mean interval from PPV to KPE was 20 months. The mean interval from KPE to final examination was 19 months. Primary indications for PPV included development of a macular epiretinal membrane, macular hole, proliferative diabetic retinopathy, retinal detachment, vitreous abscess, and vitreous hemorrhage. The degree of nuclear sclerosis in postvitrectomy eyes was greater than that in typical cataract eyes (P = 0.00002). The most common intraoperative problem was the discovery of a posterior capsule plaque. In a few cases, surgery was made difficult by unusual fluctuations in anterior chamber depth and lens zonule instability. The most common early postoperative complication was corneal edema; the most common late complication was the need for neodymium:YAG (Nd:YAG) laser posterior capsulotomy. An IOL was implanted in every eye. There were no retinal detachments. Median visual acuity improved from 20/125 before cataract surgery to 20/40 6 weeks after surgery to 20/30 on final examination. Visual acuity of 20/40 or better was achieved by 63.6% of eyes at 6 weeks and by 72.7% of eyes by final examination.

CONCLUSIONS

Kelman phacoemulsification and IOL implantation can be performed safely after PPV. Intraoperative and postoperative complications are uncommon. Pre-existing posterior segment pathology limits the ultimate improvement in visual acuity, but substantial gains in visual acuity are realized by most patients.

Outcomes of small incision cataract surgery

PURPOSE

To compare cataract surgery outcome measures 4 months postoperatively and determine their association with changes in the eye's functional state.

SETTING

Department of Ophthalmology, Helsinki University Central Hospital, Finland.

METHODS

This longitudinal study comprised 219 consecutive patients having first-eye or second-eye cataract surgery by one surgeon. In most patients, the technique consisted of small-incision cataract surgery with in-the-bag intraocular lens implantation. Patients were interviewed and clinical data obtained preoperatively and 4 months postoperatively. Adverse events occurring within 24 hours and 4 months postoperatively were compared with changes in global measures of vision. Surgical success in terms of surgically induced astigmatism (SIA) was measured at 4 months using vector analysis of the changes in astigmatism and defining the extent to which the surgical goal was achieved. The association between the surgical astigmatism goals and global measures of vision was analyzed.

RESULTS

The percentage of patients showing improvement 4 months after first-eye cataract surgery varied by outcome measure: Snellen visual acuity (95.0%), VF-14 score (89.4%), satisfaction with vision (80.1%), self-reported trouble with vision (75.8%), and cataract symptoms (75.1%). Changes in Snellen acuity after second-eye cataract surgery were similar but VF-14 changes were significantly less than after first-eye surgery. Changes in global measures of vision were also better after first-eye surgery. The correlation between the change in VF-14 score and global measures of vision was stronger than between the change in Snellen acuity and the same general outcome measures. A good correlation was also seen between the changes in VF-14 scores and cataract symptoms. Mean SIA in all eyes was 0.2 diopter (D) +/- 0.7 (SD); 91.2% were within +/- 1.0 D of preoperative values. Failure to achieve surgical astigmatism goals was not associated with patients in whom global measures of vision did not improve, nor was there a correlation between adverse events occurring within 24 hours or 4 months postoperatively and global measures of vision. The only association was between ocular comorbidity or potential risk factors of phacoemulsification and adverse events seen within 24 hours and at 4 months.

CONCLUSION

Estimates of the proportion of patients benefiting from cataract surgery varied with the outcome measure used to determine benefit. The change in the VF-14 score was a better measure than Snellen acuity of the benefit of cataract surgery.

Cataract patients in a defined Swedish population 1986-1990. VIII. Postoperative astigmatism, intraocular pressure and visual acuity

PURPOSE

Cataract surgery is often followed by a certain amount of astigmatism that changes in the postoperative period. However, there are large variations in both size and changes of the postoperative astigmatism. I have analysed the variations and the influence of different explanatory variables on the postoperative astigmatism.

METHODS

Data for all patients undergoing cataract surgery from 1986 up to and including 1990 in the Lund Health Care District were prospectively recorded. Except for cases operated on with both keratoplasty and cataract, all cases were included in the study. The different explanatory variables considered included sex, age, preoperative axial length, preoperative average keratometry, preoperative intraocular pressure, glaucoma history, diabetes history, uveitis history (including both anterior and posterior uveitis), and a history of rheumatoid arthritis.

RESULTS

Besides age and sex, several variables significantly influenced the development of size and/or change in the postoperative astigmatism. They were preoperative astigmatism (polar value), preoperative intraocular pressure, and whether or not the cataract patient had an insulin dependent diabetes. Phacoemulsification as extraction mode, the location of the incision, complications at surgery, and whether or not a sphincterotomy was performed also influenced the two parameters of astigmatism. It was also important whether or not the operation was performed by a high volume surgeon.

CONCLUSION

In this material, the most important predisposing factors for rapid changes in the postoperative astigmatism were large preoperative astigmatism (polar value), young age, low preoperative intraocular pressure, if an ECCE were chosen as the extraction type, and the surgeon. The same variables and, in addition, if the location of the incision was anterior to the limbus were the most important explanatory variables in generating an early, large with-the-rule astigmatism.

Corneal endothelial function after extracapsular cataract extraction and phacoemulsification

PURPOSE

To compare the morphology and function of the corneal endothelium in the early postoperative period after extracapsular cataract extraction (ECCE) and phacoemulsification.

SETTING

University Eye Clinic of Trieste, Italy.

METHODS

In this prospective, randomized study of patients scheduled for cataract surgery, 40 patients were divided into two groups of 20 patients each. Group 1 had ECCE and Group 2, phacoemulsification; both had capsular bag intraocular lens (IOL) implantation. Preoperatively and 7 and 30 days postoperatively, a complete ophthalmological examination, endothelial specular microscopy, ultrasonic pachymetry, and anterior segment fluorophotometry were done. Visual acuity, endothelial cell density, cell size variation coefficient, corneal thickness, endothelial permeability coefficient, and endothelial pump function were studied.

RESULTS

Visual acuity was better 7 days after phacoemulsification than after ECCE, but no differences were observed after 30 days. No significant differences in postoperative loss of endothelial cells were found between the two groups. Coefficient of variation in size, corneal thickness, and endothelial permeability significantly increased in both groups 7 days postoperatively, but only in the ECCE group 30 days postoperatively; the differences between the two groups were statistically significant. Endothelial pump function significantly increased after 7 days in only the phacoemulsification group.

CONCLUSIONS

Functional endothelial failure occurred in the early period after ECCE. Phacoemulsification seemed to minimize postoperative functional damage to the endothelium.

Prospective evaluation of early visual and refractive effects with small clear corneal incision for cataract surgery

PURPOSE

To evaluate the early postoperative visual and refractive effects of a 3.25 mm clear corneal self-sealing incision with foldable intraocular lens implantation.

SETTING

The Eye Institute of Utah, Salt Lake City.

METHODS

Visual acuity and refraction in 50 eyes of 50 consecutive patients having clear corneal phacoemulsification were prospectively evaluated at 30 minutes, 1 day, 1 week, and 1 and 3 months postoperatively.

RESULTS

Uncorrected visual acuity of 20/40 or better was obtained in 38% of eyes 30 minutes after surgery, 52% at 1 day, and 89% at 3 months. There was no significant refractive cylinder change (P = .093). Visual rehabilitation and refractive stability were rapid, and induced astigmatism was low. A strong positive correlation was found between refraction at 30 minutes and that at 3 months after surgery (R = .5788, P = .0003). The visual and refractive examination performed 30 minutes after surgery could help early detection of incorrect IOL power selection.

CONCLUSION

The low induced astigmatism, excellent early visual acuity, and lack of surgical complications support the concept and justify the use of small temporal corneal incisions for cataract surgery.