Safety and Efficacy of Prostaglandin Analogues in the Immediate Postoperative Period after Uneventful Phacoemulsification.

Prostaglandin analogues (PGAs) have been associated with the development of pseudophakic macular edema (PME) in complicated cataract cases, but evidence on their effects in uncomplicated phacoemulsification remains controversial. This two-arm, prospective, randomised study included patients with glaucoma or ocular hypertension under PGA monotherapy who were scheduled for cataract surgery. The first group continued PGA use (PGA-on), while the second discontinued PGAs for the first postoperative month and reinitiated use afterwards (PGA-off). Topical non-steroidal anti-inflammatory drugs (NSAIDs) were routinely administered to all patients during the first postoperative month. The patients were followed up for three months and the primary outcome was PME development. Secondary outcomes were corrected distance visual acuity (CDVA), central and average macular thickness (CMT and AMT), and intraocular pressure (IOP). The analysis included 22 eyes in the PGA-on group and 33 eyes in the PGA-off group. No patient developed PME. CDVA was not significantly different between the two groups (p = 0.83). CMT and AMT showed a small but statistically significant increase until the end of follow-up (p < 0.001). Mean IOP values had no significant differences between the groups at each visit (p > 0.05). At the end of follow-up, the IOP values were significantly lower than baseline in both groups (p < 0.001). In conclusion, PGA administration with concomitant topical NSAIDs appears to be a safe practice in the early postoperative period of uncomplicated phacoemulsification.

Comparison of two protocols of diode laser transscleral cyclophotocoagulation in refractory glaucoma.

INTRODUCTION: Diode laser transscleral cyclophotocoagulation (DLTSCPC) remains the most commonly used cyclodestructive procedure. Nonetheless, there is no common consensus on a standardized technique. METHODS: In this prospective randomized pilot study we compare the "pop"-titrated and "slow-burn" DLTSCPC techniques for a follow-up period of 3 months. The major outcomes of this study were intraocular pressure (IOP) before and after the procedure and the incidence of adverse events. Furthermore, postoperative pain, postoperative intraocular inflammation and corrected distance visual acuity (CDVA) were evaluated. RESULTS: Mean baseline IOP decreased from 37.9 ± 12.7 mmHg in the pop group and 41.2 ± 9.6 mmHg in the slow-burn group to 20.3 ± 13.9 mmHg and 21.3 ± 13.4 mmHg at the final follow-up visit, corresponding to a 45.8 ± 31.7% and 46.3 ± 32.6% reduction respectively. 64.3% and 57.1% of patients had IOP ≥6 and≤ 21 mmHg in the pop and slow-burn groups respectively. The occurrence of adverse events was similar in both groups, with 1 case of hyphema in the pop group and 2 cases in the slow-burn group, and 1 case of hypotony in each group. Mean CDVA remained unchanged until the end of follow-up from 2.05 ± 0.84 to 2.04 ± 0.8 logMAR in the pop group and from 1.93 ± 0.78 to 1.89 ± 0.7 logMAR in the slow-burn group. Nonetheless, 4 eyes in each group encountered CDVA loss. Postoperative pain and inflammation were also similar between groups. DISCUSSION: At the 3rd postoperative month, safety and efficacy was similar in the two techniques. The relative ease of the slow-burn technique may make its application more appealing to ophthalmic surgeons beyond glaucoma specialists.

Ocular Surface Disease Signs and Symptoms in Patients with Pseudoexfoliative Glaucoma: A Case-Control Study.

PURPOSE: The present study evaluates the differences in the prevalence of the signs and symptoms of ocular surface disease (OSD) in patients with PEX glaucoma (PEXG), compared to other glaucoma types (non-PEXG). METHODS: Patients with non-PEXG and PEXG were prospectively examined for the presence and severity of OSD signs and questioned for symptoms using the OSDI (ocular surface disease index) questionnaire. RESULTS: 116 patients were prospectively enrolled (58 non-PEXG and 58 PEXG). PEXG subjects who were older, had lower central corneal thickness (CCT) values, at a more advanced glaucoma stage and required more IOP lowering drops. OSD signs were prevalent in both groups: conjunctival hyperemia (74.5% non-PEXG vs. 94.8% PEXG), eyelid redness (70.7% vs. 96.6%), conjunctival (74.1% vs. 93.1%) and corneal fluorescein staining (81% vs. 93.1%) and abnormal TFBUT (82.8% vs. 87.9%). When adjusted for potential confounders, (older age, thinner CCT, more advanced glaucoma in PEXG) eyelid redness remained the only parameter significantly associated with PEXG, being 11 times more likely to occur in this group (p = 0.037). CONCLUSION: Subjects with PEXG presented a higher frequency of signs of OSD compared to other glaucoma types. When accounting for confounding factors, the only difference between the groups was the significantly higher presence (11 times more likely) of eyelid redness in PEXG, suggesting, in addition to glaucoma treatment, the impact of PEX on ocular surface integrity.

Ocular parameter changes after phacoemulsification in pseudoexfoliative eyes: case-control study.

PURPOSE: To assess changes of angle morphometric parameters, anterior chamber depth (ACD), intraocular pressure (IOP), and endothelial cell density (ECD) after uneventful phacoemulsification in eyes with pseudoexfoliation syndrome (PEX) compared with those in eyes without PEX and to evaluate the effect of these changes on effective lens position and postoperative refraction. SETTING: Papageorgiou Hospital, Thessaloniki, Greece. DESIGN: Prospective case-control study. METHODS: Angle opening distance, trabecular-iris space area, and scleral spur angle width were measured using anterior segment optical coherence tomography. ACD was assessed using IOLMaster and ECD using specular microscopy. All parameters were evaluated at baseline and 2 months postoperatively. RESULTS: 42 patients (42 eyes) with PEX and 39 patients (39 eyes) without PEX who underwent uneventful phacoemulsification were enrolled. All angle parameters and ACD increased significantly after phacoemulsification in both groups ( P < .001), with no statistically significant difference between them ( P > .05). Percentile change in ACD was greater in PEX eyes ( P = .017). Regarding the mean refractive prediction error, no statistically significant differences were found between the study groups ( P = .68). A statistically significant trend toward hyperopic shift was noted in the PEX group ( P = .039). IOP and ECD diminished postoperatively in both groups, with no statistically significant difference between the study groups ( P = .09 and P = .22, respectively). CONCLUSIONS: PEX, compared with non-PEX eyes, demonstrated a greater anterior chamber deepening and a hyperopic shift after phacoemulsification. These could be related to the zonular laxity in eyes with PEX and imply that PEX eyes may require a modified target refraction to achieve the desired refractive outcome.

Validation of the Digital Eye Strain Questionnaire and pilot application to online gaming addicts.

INTRODUCTION: 'Digital eye strain' (DES) is a clinical syndrome with eyesight symptoms related to continuous engagement in front of a screen-enabled digital device. With use of these devices constantly on the rise, the related symptoms have become prominent, even in younger ages. This study describes the process of validating the Digital Eye Strain Questionnaire (DESQ), a thirteen-item self-report scale in a yes-no format designed to offer a measure of complaints related to digital eye strain syndrome (DES). METHODS: The validation process included 150 outpatients with no long-standing eye disease who were examined for various eye complaints and 50 outpatients who were diagnosed with gaming addiction according to WHO ICD-11 clinical criteria. All participants filled in a demographics questionnaire, the DESQ, the Computer Vision Syndrome Questionnaire (CVS-Q) and the Problematic Internet Use Questionnaire-9 (PIUQ-9). RESULTS: Principal component analysis of categorical variables confirmed the proposed three-factor DES structure with a total of 61.02% of explained variance and Cronbach's alpha equal to.94. Concurrent validity was assessed by comparing the results of the DESQ to the CVS-Q while convergent validity was assessed by examining correlations of the DESQ with results from the PIUQ-9 questionnaire. In all cases the DESQ demonstrated excellent reliability and validity. CONCLUSIONS: Results indicate that the DESQ questionnaire can be employed to reliably measure the symptomatology of digital eye strain in clinical populations who present either with eye issues or with excessive use of the gaming and screen-enabled devices in general.

Personality of patients with central serous chorioretinopathy.

INTRODUCTION: Central serous chorioretinopathy (CSC) is a disease of the retina that is a frequent cause of mild to moderate visual impairment. The disease can be precipitated by psychosocial stress and hypercortisolism while full remission will often be spontaneous within a few months. Risk factors have included male gender, increased plasma cortisol due to other conditions or steroid use and Type A behavior. METHODS: This is a cross-sectional study comparing three research groups that included 100 CSC patients, 200 healthy volunteers, and 200 patients with other ophthalmic disease on their results in the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ). RESULTS: CSC patients differed from the other subjects on increased high Neuroticism-Anxiety, low Sociability, and high Aggression-Hostility. CONCLUSIONS: Since high Neuroticism is related to increased cortisol levels only in males, and high Aggression-Hostility is related to increased cortisol response, these findings point to the possibility of a robust neurobiological background to the etiopathogenesis of CSC that merits further research. The association of Type A behavior with CSC may be a spurious one and its widespread reference in ophthalmology texts should be re-examined.

Patient Adherence to Glaucoma Treatment During the COVID-19 Pandemic.

Introduction In medicine, patient adherence refers to the degree to which a patient correctly follows medical advice, and it most commonly pertains to medication or drug compliance. Patient adherence to glaucoma treatment has been a frequent and serious issue that is associated with adverse long-term outcomes. The purpose of this study was to determine the factors that are associated with adherence to glaucoma treatment among patients during the ongoing coronavirus disease 2019 (COVID-19) pandemic. Methods This was a cross-sectional study involving 100 consecutive glaucoma outpatients who were interviewed based on the modified version (ARMS2-COVID) of the original Adherence to Refills and Medications Scale 2 (ARMS2) that examined adherence to medication. Length of treatment and disease onset along with basic demographic details (gender, age, socioeconomic status, and educational levels) of the patients were also recorded. Results The COVID-19 pandemic has disproportionally impacted patients of older age (p=0.033) and lower educational levels (p<0.001) with regard to their ability to follow their treatment plan regardless of the duration of previous treatment. Conclusions Based on our findings, in order to ensure higher levels of patient adherence among patients of older age with limited education, more planning will be required, aided by appropriate educational interventions and proactive patient follow-ups.

Peripapillary Choroidal Neovascular Membrane Secondary to Sarcoidosis-Related Panuveitis: Treatment with Aflibercept and Ranibizumab with a 50-month Follow-Up.

A case of peripapillary choroidal neovascular membrane (PCNM) secondary to sarcoidosis-related panuveitis successfully treated with anti-vascular endothelial growth factor (anti-VEGF) agents and systemic immunomodulatory therapy is reported. Diagnosis and follow-up were based on fundoscopic, optical coherence tomography as well as fluorescein angiography findings. A 45-year-old female patient presented with sudden onset bilateral blurring of vision. Fundoscopy revealed bilateral granulomatous panuveitis with solitary peripheral granuloma in the right eye and PCNM in the left eye. Diagnostic work-up including conjunctival biopsy confirmed the diagnosis of sarcoidosis. Topical and systemic corticosteroids controlled the inflammation. Within 4 weeks, PCNM showed rapid enlargement (best-corrected visual acuity [BCVA]: 6/60) with foveal involvement. Monthly intravitreal aflibercept injections and systemic methotrexate were administered. After 5 aflibercept injections, anatomical and functional improvement was noted (BCVA: 6/6). Due to aflibercept unavailability, further treatment included ranibizumab injections. During a 50-month follow-up period, every anti-VEGF injection was followed by total NV regression and 6/6 BCVA. Both aflibercept and ranibizumab appear to be effective in the treatment of PCNM secondary to sarcoidosis.

Comparison of Chemokine CXCL-1 and Interleukin-6 Concentrations in the Subretinal Fluid and Vitreous in Rhegmatogenous Retinal Detachment.

Purpose: Comparison of IL-6 and CXCL-1 concentrations and CXCL-1/IL-6 ratio correlations with clinical parameters (RRD extent, duration, and proliferative vitreoretinopathy - PVR-grade) between subretinal fluid (SRF) and vitreous during rhegmatogenous retinal detachment (RRD) complicated with PVR.Methods: A total of 71 eyes of 71 patients with primary RRD possibly complicated with PVR were included; 36 eyes treated with scleral buckling and 35 eyes with pars-plana vitrectomy. Enzyme-Linked Immuno-sorbent Assay was employed for CXCL-1/IL-6 measurement (ng/ml).Results: Correlation analysis between mean CXCL-1/IL-6 ratio and clinical parameters revealed non-significant results. CXCL-1/IL-6 ratio was significantly elevated in phakic eye vitreous. Optimum circumstances for elevated chemokine levels during RRD were considerable extent (2-3-quadrant) and duration (29-60-day) complicated with PVR C.Conclusions: SRF appears to be characterized by greater chemokine concentrations while vitreous retains several structural characteristics that may assist in investigating inflammation and improving understanding of underlying pathophysiological mechanisms during RRD complicated with PVR.

Optical coherence tomography angiography in children with spontaneously regressed retinopathy of prematurity.

PURPOSE: To assess optical coherence tomography angiography (OCTA) parameters in children born preterm who developed spontaneously regressed retinopathy of prematurity (sr-ROP, group 1), or had no ROP (PreT, group 2), compared with term-born age-matched controls (group 3). METHODS: Cross-sectional comparative case series. Children aged 6-8 years had a complete ocular examination and OCT and OCTA imaging (Optovue RTVue AVANTI instrument). Foveal avascular zone (FAZ) area, FAZ perimetry, and vascular density in three slabs were measured automatically, and foveal depth was measured manually by two graders. RESULTS: Groups 1, 2, and 3 (26, 32, and 34 eyes respectively) did not differ in age or gender, but differed in gestational age and birth weight. Both inner retinal thickness and foveal depth differed significantly between group 1 and 2, as did vascular density in the superficial and deep vascular plexus. VA, FAZ area, and perimetry were distinct in all three groups. VA correlated positively with FAZ area and foveal depth, negatively with vascular density. CONCLUSION: OCTA parameters reveal microvascular changes that distinguish eyes with sr-ROP from premature eyes without ROP, as does visual acuity. It is not possible to infer if the cause is the presence of retinopathy or the different severity of retinal immaturity.

Reoperations After Cataract Surgery: Is the Incidence Predictable Through a Risk Factor Stratification System?

Introduction The objective of the study was to quantify the number of procedures needed to achieve the best possible surgical outcome, depending on the number and type of risk factors identified. Methods Two independent observers reviewed the medical records of 1,502 patients who underwent phacoemulsification surgery, during a two-year period (January 1, 2014 to December 31, 2015). Preoperative risk factors were documented according to the stratification system used. Based on the total risk score, each case was allocated to one of four risk groups with 0, 1-2, 3-5, and >6 total risk factors, respectively. All qualitative and quantitative characteristics were gathered and included in a multivariate analysis. Results A total of 1,792 eyes were included. Αge over 88 years, low cooperation ability with the patient, and surgeries performed by residents tended to have more often complications, while white/intumescent cataract, iridodonesis/phacodonesis, α1 blockers intake, and male gender are risk factors positively associated with more than one surgery. Conclusions Risk factors tend to be prognostic for possible intraoperative complications. The number of procedures needed for the best possible surgical outcome seems to depend on these preoperative risk factors. A stratification method increases the level of awareness of the surgeon, and therefore may decrease the number of complications and even procedures while enhancing the "safe" practice and skills of residents.

Safety and efficacy of hypertonic saline solution (5%) versus placebo in the treatment of postoperative corneal edema after uneventful phacoemulsification: a randomized double-blind study.

PURPOSE: To evaluate safety and efficacy of hypertonic saline solution administration after uneventful cataract surgery. DESIGN: Prospective double-blind randomized study METHODS: In total, 183 eyes of 183 patients undergoing phacoemulsification were randomly allocated into two equal groups. Treatment group (TG) subjects received single-dose hypertonic (NaCl 5%) solution 4 times daily for 14 days, while placebo group (PG) received single dose of normal saline solution (0.9%) at the same frequency in addition to ordinary postoperative treatment. All patients underwent assessment of central corneal thickness (CCT), endothelial cell density (ECD), best-corrected visual acuity (BCVA), clinical staging of postoperative corneal edema and questionnaire regarding the procedure success and impact on patient's life. Measurements were taken at baseline and 1, 4, 9 and 30 days following surgery. RESULTS: CCT increased by 134.67 ± 94.51 µm (25.1 ± 19.4%) on postoperative day 1, without any difference between study groups (p = 0.58). Corneal edema showed a significant recession in TG compared to PG on day 4, in terms of both pachymetry (10.73% vs 7.39%, p = 0.004), BCVA (BCVATG = 0.64 ± 0.24 [logMARTG = 0.25 ± 0.3], BCVAPG = 0.56 ± 0.23 [logMARPG = 0.33 ± 0.3], p = 0.04) and clinical staging (p = 0.02). Similar results were recorded on postoperative day 9 in subjects demonstrating marked corneal edema on the first postoperative day. Endothelial cell loss showed no statistically significant difference between study groups (p = 0.48). No adverse events were recorded in relation to treatment. More patients in the TG (92.4% vs 57.1% in the PG) reported a subjectively clear vision 1 week postoperatively (p = 0.04). CONCLUSION: The use of 5% hypertonic saline solution is found to be a safe and effective adjunct in the management of postoperative corneal edema after uneventful phacoemulsification, achieving rapid corneal clearance and expediting a good visual outcome, especially in cases with marked postoperative edema.

Development of a reliable preoperative risk stratification system for phacoemulsification.

PURPOSE: To present a statistically validated risk classification system for intraoperative complications in cataract surgery. SETTING: 2nd Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece. DESIGN: Prospective observational study. METHODS: All patients underwent phacoemulsification surgery by experienced, high-volume surgeons for cases with intraoperative complications. The presence of several risk factors was statistically assessed with the help of multiple correspondence analysis to determine the more reliable rank categorization for severity and to calculate a total risk score. RESULTS: This study included 1572 consecutive patients. The proposed system had 3 risk groups and a no-risk group and had high statistical reliability. A comparison of this system against a previously asserted empirical system showed higher internal reliability. CONCLUSIONS: Previous efforts to construct a risk classification system for intraoperative complications in cataract surgery have been empirically defined and tested against practice-as-usual. The system in this study quantified risk more accurately and provided an experienced clinician with a reliable means of assessing the preoperational likelihood of intraoperative complications.

A comparative study of depressive symptomatology among cataract and age-related macular degeneration patients with impaired vision.

Vision impairment remains an important cause of disability with the leading being age-related cataract (ARC) and age-related macular degeneration (ARMD) with depression symptoms often reported in vision impairment. This is a cross-sectional survey of two groups of fifty patients with ARC and ARMD and no prior psychiatric history on depressive symptomatology. Results indicate that ARMD patients scored higher on the BDI-II than ARC patients, in line with their poorer prognosis. Female patients with ARMD, living alone, with a higher number of other comorbid health issues, are more likely to have more depressive symptomatology. ARMD patients scored higher in the items related to pessimism for the future, feelings of past failure and feelings of self-dislike. There is a need for liaison psychiatry services to be readily available in patients with suspected ARC and ARMD coming forward with substantial vision loss. ARMD patients in particular tend to be more pessimistic and blame themselves for the progression of their disease. This should be taken into consideration with patient education on the causes of the disease and more effort should be undertaken to instill hope. The impact of vision loss on psychic status is related to disease prognosis and not only current state.

Safety of air tamponade versus corneal hydration for sealing clear corneal incisions in cataract surgery.

PURPOSE: To compare safety of wound hydration to anterior chamber air tamponade for securing watertight closure of clear corneal incisions, during uneventful cataract surgery. METHODS: Prospective, comparative case-control series. Patients undergoing phacoemulsification were assigned to receive either anterior chamber air bubble (Group A) or intrastromal wound hydration with balanced salt solution (Group B) at the end of the procedure. Two high-volume surgeons operated equal number of cases in each group employing identical surgical technique, except for corneal side incision management. Patients were assessed pre- and postoperatively at day 1, day 4, day 9, and day 30 after surgery. RESULTS: One hundred eyes of 100 patients were enrolled, of which 2 were lost to follow-up. The two groups were comparable in terms of preoperative risk factor assessment, baseline central corneal thickness (CCT), preoperative endothelial cell density, as well as cumulative dissipated energy and duration of phacoemulsification (p > 0.05). Mean CCT and best-corrected visual acuity were better in Group B on the first postoperative day, but did not differ between the two groups at all other timepoints. Surgically induced astigmatism was comparable in the two groups (p > 0.05). Endothelial cell density loss at 1 month postoperatively was greater in Group A (34.06%) compared to Group B (16.45%). CONCLUSIONS: Wound sealing with intrastromal hydration proved to be safer than air tamponade in terms of preserving endothelial cell density and function.

The Role of Nutrition in Primary Open Angle Glaucoma: A Multivariate Analysis.

Objective: To assess whether dietary habits can be associated with the presence of primary open angle glaucoma (POAG), while taking into account hereditary factors and metabolic disease.Methods: A case-control study of 100 POAG patients and 100 controls who were queried on their dietary habits. A nonlinear canonical correlation analysis is employed to assess and plot the relationships between the measured variables.Results: Controls had lower consumption of sweets containing processed sugar and avoided eating visible fat on their meat or meat sausages (which tend to contain high amounts of meat fats not plainly obvious) while consuming pure fruit juice and pears more frequently.Conclusions: Dietary habits and practices may have both research and clinical significance in POAG; Caffeine, processed sugar and animal fat appear to have noteworthy negative effects and while caffeine has been researched extensively, more research is needed in the negative role of the other two factors. Other important dietary factors that may be implicated is fruit fiber and various fruit antioxidants and flavonoids.

Hypertension is the Prominent Risk Factor in Cataract Patients.

Background and objectives: The purpose of this study is to determine the impact of the most prominent cardiovascular and metabolic risk factors in patients undergoing cataract surgery. Materials and Methods: The study included 812 consecutive patients undergoing unilateral, uneventful cataract surgery by means of phacoemulsification, at the 2nd Department of Ophthalmology, Medical School, Aristotle University of Thessaloniki, Greece, during a calendar year. Patients were assessed for the type of cataract and the presence of three diseases, under pharmacological treatment, that have been reported as risk factors for the development of cataract (arterial hypertension, diabetes mellitus, and dyslipidemia). Results: There was a statistically significant difference between the types of cataract and individual risk factors (p < 0.001). Hypertension was the most frequentrisk factor, ranging from 43.8% in patients with subcapsular cataracts, 24.3% in patients with nuclear cataracts, 28.6% in patients with cortical cataracts, and 27.6% in patients with mixed type cataracts. There was a statistically significant difference as to the total number of risk factors per cataract type (p < 0.001); almost all patients with subcapsular cataracts had at least one risk factor (98.4%) while this percentage was 90.5% for patients with mixed cataracts, 85.7% for patients with cortical cataracts, and78.6% for patients with nuclear cataracts. Conclusions: Diabetes mellitus did not have a large incidence in our sample as a single risk factor, while hypertension did. This finding raises the importance of early detection of hypertension, a cardiovascular condition that typically progresses undetected for a number of years.

The role of sex in intraoperative floppy-iris syndrome.

PURPOSE: To compare the incidence of intraoperative floppy-iris syndrome (IFIS) between male and female patients undergoing phacoemulsification cataract surgery, evaluate risk factors for its appearance in each sex, and assess any differences in the final visual outcomes. SETTING: 2nd Department of Ophthalmology, Aristotle University of Thessaloniki, Greece. DESIGN: Comparative retrospective case-control study. METHODS: Cataract patients with recorded IFIS of any severity occurring over 4 years in a tertiary care ophthalmic center during phacoemulsification surgery were identified and enrolled in a multivariate analysis. RESULTS: The study comprised 3811 eyes of 3213 patients. Of the 1678 female patients (1937 eyes) undergoing cataract surgery, IFIS was observed in 25 eyes (1.29%), whereas the incidence of IFIS in male eyes during the same period was statistically significantly higher (97 [5.17%] of 1874 eyes) (P < .0001). No statistically significant difference in age was found between male patients (72.92 years ± 6.5 [SD]) and female patients (72.04 ± 7.1 years) (P = .56). An intake of α1-receptor blockers was identified in 70 (72.2%) of 97 male IFIS cases and in none of the 25 female IFIS cases (P < .0001). The posterior capsule rupture rate was significantly higher in 7 (28%) of the 25 female IFIS cases compared with 9 (9.28%) of the 97 male IFIS cases (P = .02). The posterior capsule rupture incidence and final corrected distance visual acuity (with spectacles) were shown to correlate with the IFIS severity grade only in female patients (P < .001 and P = .02, respectively). CONCLUSIONS: Although the incidence of IFIS is rarer in female patients, it might significantly affect an increase in the intraoperative events rate and affect the final visual outcome correlating with the severity grade of its appearance. Predisposing risk factors differ between the sexes and surgeons should always be aware of the potentially catastrophic consequences of unforeseen IFIS.