Reasons for Early Ocular Hypertension after Uneventful Cataract Surgery

The Combination Usage of Dexamethasone and Prednisolone Versus Prednisolone Monotherapy for Inflammation and Intraocular Pressure After Cataract Surgery

Purpose The purpose of this study is to survey the anti-inflammatory effect of combined preoperative dexamethasone and postoperative prednisolone therapy and postoperative prednisolone therapy for cataract surgery. The intraocular pressure (IOP) change between groups was also examined. Methods A retrospective cohort study was practiced, and individuals who received cataract surgery were enrolled and categorized according to the anti-inflammation therapy. A total of 62 and 108 eyes were included in the combined and single groups, respectively. The primary outcomes were ocular hypertension and anterior chamber (AC) inflammation. The independent t-test and generalized linear model were used for the statistical analysis. Results There were 12 and 16 episodes of ocular hypertension in the combined and single groups, and the incidence of ocular hypertension was similar between groups (P = 0.203). In addition, there were four and seven AC inflammation events in the combined and single groups, and the incidences of AC inflammation were similar between groups (P = 0.335). Old age was correlated to a higher risk of developing ocular hypertension in the combined and single groups (both P < 0.05). Besides, higher myopia is related to higher ocular hypertension risk in the combined group (P = 0.038). Preoperative dry eye disease (DED) was associated with higher AC inflammation risk in the combined and single groups (both P < 0.05). Also, the high myopia was related to higher AC inflammation risk in the two groups (both P < 0.05). Conclusion The combination therapy of dexamethasone and prednisolone showed similar anti-inflammatory effects. The IOP changes between groups were similar.

Management and toxicological analysis of ocular hypertension after EyeCee® ONE intraocular lens implantation: a case series

BACKGROUND

The EyeCee® ONE intraocular lens (Nidek, Gamagori, Japan) has been withdrawn from the market due to a high number of reports of severe ocular hypertension (OHT) following phacoemulsification with implantation of this intraocular lens (IOL). In this case series, we report the results of a toxicological analysis and the surgical management of five patients with severe OHT following the implantation of defective EyeCee® ONE IOLs during cataract surgery.

CASES PRESENTATION

Five patients developed early, severe OHT refractory to maximal medical therapy following uneventful phacoemulsification (PCE) cataract surgery with implantation of an EyeCee® ONE IOL from a defective lot. Glaucoma filtering surgeries were required to control intraocular pressure (IOP). Toxicological analyses were carried out on the aqueous humor of one patient. IOP levels were monitored during postoperative follow-up, but three patients required postoperative adjustments (reintroduction of IOP-lowering therapy, goniopuncture or needling) in order to maintain IOP at satisfactory levels. Toxicological analysis revealed a high concentration of silicon in the aqueous humor of the patient from whom the sample was obtained.

CONCLUSIONS

These cases of OHT following cataract surgery with a defective IOL were of early onset severe, all requiring filtering surgery. The exact mechanism of this OHT has not been determined, but we did find high concentrations of silicon in the aqueous humor of one of these patients. Patients who received EyeCee® ONE IOLs during the same period of time should have their IOP and optic nerve monitored to detect any potential OHT or glaucoma that might appear over time.

Complications of high myopia: An update from clinical manifestations to underlying mechanisms

Background

High myopia is one of the major causes of visual impairment and has an ever-increasing prevalence, especially in East Asia. It is characterized by excessive axial elongation, leading to various blinding complications that extend beyond mere refractive errors and persist immovably after refractive surgery, presenting substantial public health challenge.

Main text

High myopia-related complications include lens pathologies, atrophic and tractional maculopathy, choroidal neovascularization, peripheral retinal degenerations and retinal detachment, and glaucoma and heightened susceptibility to intraocular pressure (IOP) elevation. Pathological lens changes characteristic of high myopia include early cataractogenesis, overgrowth of lens, weakened zonules, and postoperative capsular contraction syndrome, possibly driven by inflammatory pathogenesis, etc. Dome-shaped macula and cilioretinal arteries are two newly identified protective factors for central vision of highly myopic patients. These patients also face risks of open-angle glaucoma and IOP spike following intraocular surgery. Morphologic alternations of optic nerve in high myopia can complicate early glaucoma detection, necessitating comprehensive examinations and close follow-up. Anatomically, thinner trabecular meshwork increases this risk; conversely lamina cribrosa defects may offer a fluid outlet, potentially mitigating the pressure. Notably, anxiety has emerged as the first recognized extra-ocular complication in high myopia, with an underlying inflammatory pathogenesis that connects visual stimulus, blood and brain.

Conclusions

High myopia induces multiple ocular and potential mental health complications, underscoring the need to develop more effective strategies to improve both physical and emotional well-being of these patients, among which anti-inflammation might possibly represent a promising new target.

The effect of axial length on the short-term outcomes of cataract surgery combined with ab interno trabeculotomy

PURPOSE

Minimally invasive glaucoma surgery is safer and effective surgical modality for patients with glaucoma. To compare the effect of axial length (AL) on the surgical outcomes of combined cataract surgery and ab interno trabeculotomy (phaco-LOT), a retrospective, non-randomized comparative study was performed.

METHODS

In total, 458 eyes of 458 open-angle glaucoma patients who underwent phaco-LOT and were followed-up without any intervention for at least 6 months were enrolled. All were divided into a long-AL group (AL ≥ 26.0 mm, 123 eyes) and a not-long-AL group (AL < 26.0 mm, 335 eyes). The principal outcomes were the changes in intraocular pressure (IOP) and medication scores. We also sought a correlation between postoperative IOP spike and hyphema.

RESULTS

Significant postoperative reductions in IOP and medication scores were apparent in all subjects. The IOP reductions were significant at all timepoints in the not-long-AL group, but not until 1 month postoperatively in the long-AL group, and the IOP change was significantly lower in the long-AL group from postoperative day 1 to 3 months. On subanalysis of subjects by age, the microhook used, the pre-operative IOP, and the medication score, a significantly higher incidence of IOP spike was observed in the long-AL group in weeks 1 and 2 (both p < 0.05), but this did not correlate with hyphema status, implying that a different mechanism was in play.

CONCLUSION

Phaco-LOT was effective regardless of AL, but the postoperative IOP decrease was lower and the early postoperative incidence of IOP spike was higher in long-AL eyes.

Surgical and Perioperative Considerations for the Treatment of Cataract in Eyes with Glaucoma: A Literature Review

Cataract surgery in the presence of glaucoma poses certain challenges that need to be addressed to offer the maximum benefit without complications. In this paper, we are reviewing the preoperative assessment, surgical options, the planning, and postoperative care. Cataract surgery can help reduce the intraocular pressure alone or combined with MIGS. When performed in patients with glaucoma, it can transiently increase the intraocular pressure and later on decrease the IOP to levels lower than the postoperative. The preoperative IOP and biometric characteristics are the main predictors of the postoperative course of IOP. The combination of cataract surgery with trabeculectomy remains controversial, in terms of best timing of each operation.

Schlemm Canal and Trabecular Meshwork Features in Highly Myopic Eyes With Early Intraocular Pressure Elevation After Cataract Surgery

PURPOSE

To investigate the morphologic features of the Schlemm canal and trabecular meshwork in highly myopic eyes with early intraocular pressure (IOP) elevation after cataract surgery.

DESIGN

Retrospective case-control study.

METHODS

Eighty-eight highly myopic eyes of 88 patients after uneventful cataract surgery were included, 31 of which had early postoperative IOP elevation and 57 of which did not. The morphologic features of the Schlemm canal and trabecular meshwork, collected with swept-source optical coherence tomography before surgery, were reviewed. Backwards stepwise multiple linear regression was used to investigate the anatomic risk factors for early IOP elevation in highly myopic eyes.

RESULTS

Highly myopic eyes with early postoperative IOP elevation had smaller Schlemm canal vertical diameter and area, as well as smaller trabecular meshwork thickness and width, in each quadrant than the non-elevation group. There was no significant difference in Schlemm canal horizontal diameter between the IOP elevation and non-elevation groups. In the highly myopic eyes, average Schlemm canal vertical diameter, Schlemm canal area, trabecular meshwork thickness, and width were all correlated negatively with the IOP elevation. A multivariate analysis showed that average Schlemm canal vertical diameter (β = -0.262, P = .004) and trabecular meshwork thickness (β = -0.173, P < .001) were significantly associated with early transient IOP elevation in highly myopic cataract eyes.

CONCLUSIONS

A smaller vertical diameter of Schlemm canal and a thinner trabecular meshwork are 2 anatomic risk factors for early IOP elevation after cataract surgery in highly myopic eyes.

Systemic anti-inflammatory therapy aided by double-headed nanoparticles in a canine model of acute intraocular inflammation

Novel approaches circumventing blood-ocular barriers in systemic drug delivery are lacking. We hypothesize receptor-mediated delivery of curcumin (CUR) across intestinal and ocular barriers leads to decreased inflammation in a model of lens-induced uveitis. CUR was encapsulated in double-headed polyester nanoparticles using gambogic acid (GA)-coupled polylactide-co-glycolide (PLGA). Orally administered PLGA-GA₂-CUR led to notable aqueous humor CUR levels and was dosed (10 mg/kg twice daily) to adult male beagles (n = 8 eyes) with induced ocular inflammation. Eyes were evaluated using a semiquantitative preclinical ocular toxicology scoring (SPOTS) and compared to commercial anti-inflammatory treatment (oral carprofen 2.2 mg/kg twice daily) (n = 8) and untreated controls (n = 8). PLGA-GA₂-CUR offered improved protection compared with untreated controls and similar protection compared with carprofen, with reduced aqueous flare, miosis, and chemosis in the acute phase (<4 hours). This study highlights the potential of PLGA-GA₂ nanoparticles for systemic drug delivery across ocular barriers.

Early transient intraocular pressure spike after cataract surgery in highly myopic cataract eyes and associated risk factors

PURPOSE

To investigate the incidence of the early transient intraocular pressure (IOP) spike after cataract surgery in eyes with highly myopic cataract (HMC) and associated risk factors.

METHODS

Consecutive patients treated with phacoemulsification were recruited. IOP was measured before and 1 day, 3 days, 1 week and 3 months after surgery. Axial length (AL) and anterior chamber depth (ACD) were recorded, and optic disc tilt, rotation and beta-zone peripapillary atrophy (β-PPA) were measured from fundus photographs taken 1 week after surgery. Backward stepwise multiple linear regression was used to investigate the risk factors for early transient IOP spike in the HMC group.

RESULTS

Finally, 94 eyes of 94 HMC patients and 67 eyes of 67 age-related cataract (ARC) controls were included in analysis. The incidence of early IOP spike was 10% in the ARC group and 28% in the HMC group (OR=3.277, p<0.05) at 1 day after surgery. In the HMC group with IOP spikes, more males were seen and affected eyes showed longer AL, shallower ACD, greater optic disc tilt, and larger β-PPA than those without (all p<0.05). Multivariate analysis showed that sex, AL, ACD, and area of β-PPA were significantly associated with an early transient IOP spike in HMC eyes (all p<0.05).

CONCLUSIONS

Highly myopic eyes are more susceptible to early transient IOP spike after cataract surgery, and male sex, longer AL, shallower ACD, and greater β-PPA are associated risk factors.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02182921.

Injectable drug depot engineered to release multiple ophthalmic therapeutic agents with precise time profiles for postoperative treatment following ocular surgery

A multi-drug delivery platform is developed to address current shortcomings of post-operative ocular drug delivery. The sustained biodegradable drug release system is composed of biodegradable polymeric microparticles (MPs) incorporated into a bulk biodegradable hydrogel made from triblock copolymers with poly(ethylene glycol) (PEG) center blocks and hydrophobic biodegradable polyester blocks such as poly(lactide-co-glycolide) (PLGA), Poly(lactic acid) (PLA), or Poly(lactide-co-caprolactone) (PLCL) blocks. This system is engineered to flow as a liquid solution at room temperature for facile injection into the eye and then quickly gel as it warms to physiological body temperatures (approximately 37 °C). The hydrogel acts as an ocular depot that can release three different drug molecules at programmed rates and times to provide optimal release of each species. In this manuscript, the hydrogel is configured to release a broad-spectrum antibiotic, a potent corticosteroid, and an ocular hypotensive, three ophthalmic therapeutic agents that are essential for post-operative management after ocular surgery, each drug released at its own timescale. The delivery platform is designed to mimic current topical application of postoperative ocular formulations, releasing the antibiotic for up to a week, and the corticosteroid and the ocular hypotensive agents for at least a month. Hydrophobic blocks, such as PLCL, were utilized to prolong the release duration of the biomolecules. This system also enables customization by being able to vary the initial drug loading to linearly tune the drug dose released, while maintaining a constant drug release profile over time. This minimally invasive biodegradable multi-drug delivery system is capable of replacing a complex ocular treatment regimen with a simple injection. Such a depot system has the potential to increase patient medication compliance and reduce both the immediate and late term complications following ophthalmic surgery.

STATEMENT OF SIGNIFICANCE

After ocular surgery, patients routinely receive multiple medications including antibiotics, steroids and ocular hypotensives to ensure optimal surgical outcomes. The current standard of care for postoperative treatment after ocular surgery involves using eye drops daily, which has limited effectiveness mainly due to poor patient adherence. To improve patient experience and outcomes, this article presents the first thermoresponsive hydrogel able to release multiple drug molecules for the application of post-operative treatment following ocular surgery. By varying the parameters such as hydrogel type and polymer hydrophobicity, the drug release profile, duration and dosage can finely be tuned. The approach presented in this article can readily be applied to other applications by simply changing the drug loaded in the drug delivery system.

Recovery after cataract surgery

Cataract surgery is the most common ophthalmological surgical procedure, and it is predicted that the number of surgeries will increase significantly in the future. However, little is known about the recovery after surgery. The first aim of this study was to evaluate the prevalence, severity and duration of pain and other ocular discomfort symptoms experienced after cataract surgery. The other objectives were to identify the factors associated with lower postoperative patient satisfaction and to measure the effect of cataract surgery on patients' health-related quality of life (HRQoL) and visual function in everyday life. The study design was a prospective follow-up study. The course of the recovery and the presence of ocular symptoms were evaluated by interviewing the patients via a questionnaire at 1 day, 1 week, 6 weeks and one year after surgery The visual functioning in everyday life was measured with Visual Functioning Index VF-7 and Catquest-9SF-questionnaires and furthermore the HRQoL was measured with the 15D-instrument before surgery and at 12 months after surgery. The patients returned the questionnaires by mail and were interviewed in the hospital on the day of the surgery. The same patients filled-in all the questionnaires. The patient reports were used to collect the data on medical history. A total of 303 patients were approached at Kuopio University Hospital in 2010-2011 and of these 196 patients were eligible and willing to participate, with postoperative data being available from 186 (95%) patients. A systematic review article was included in the study procedure and it revealed the wide range in the reported incidence of postoperative ocular pain. Some of the identified randomized controlled studies reported no or only minor pain whereas in some studies significant pain or pain lasting for several weeks has been described in more than 50% of the study patients. In the present study setting, pain was reported by 34% during the first postoperative hours and by approximately 10% of patients during the first six weeks after surgery. During the early recovery in the hospital, only a minority of the patients reporting pain were provided with pain medication. The ocular discomfort symptoms such as itchiness, burning, foreign-body sensation and tearing were common both before (54%) and after surgery (38-52%). These symptoms can also be described as painful symptoms and are often difficult to distinguish from ocular pain. The symptoms are also typical of ocular surface disease, and some patients may benefit from the postoperative administration of tear substitutes. The patients reporting postoperative ocular symptoms were less satisfied with the treatment outcome at 12 months after surgery (p = 0.001) compared to the patients who experienced no symptoms. Those patients reporting less disability in visual functioning before surgery were more satisfied than patients with more reported disability. The HRQoL improved significantly after cataract surgery (p = 0.002). However, when compared to an age-and gender-standardized control population, in cataract subjects the HRQoL remained slightly worse both before and at 12 months after surgery.