Visual outcomes comparing emmetropia versus mini-monovision following bilateral implantation of a non-diffractive extended vision intraocular lens:randomized trial.

PURPOSE: To compare visual outcomes and patient satisfaction following bilateral implantation of a non-diffractive extended vision intraocular lens(IOL) when targeting emmetropia versus mini-monovision. SETTING: Iladevi Cataract & IOL Research Centre,India. DESIGN: Prospective,randomized controlled trial. METHODS: Patients undergoing bilateral cataract surgery with an extended vision IOL(Vivity, Alcon Laboratories, USA) randomized to: group I- IOL implantation with emmetropic target in both eyes, or group II- IOL implantation with mini-monovision of -0.5 diopters(D). Outcome measures evaluated 6 months postoperatively were: unaided and corrected near visual acuity(UNVA, CNVA) at 40 centimeters(cm), unaided and corrected distance(UDVA, CDVA) and intermediate (UIVA, CIVA) visual acuity at 66cm. Mesopic contrast sensitivity, binocular defocus curve, patient reported spectacle independence questionnaire and satisfaction on the McAlinden questionnaire were also assessed. RESULTS: 70 patients enrolled in study. 34 and 33 patients in groups I and II completed follow-up. Binocular UNVA was significantly better in group II (0.26+0.05 vs 0.22+0.08 LogMAR, P=0.03). Reading add required in group II was significantly lower. UIVA (0.09+0.06 vs 0.07+0.08 LogMAR, P=0.15) and UDVA (0.02+0.04 vs 0.02+0.05 LogMAR, P=0.78) were not significantly different between groups. Mesopic contrast sensitivity was not significantly different between the groups. Binocular defocus curve showed significantly better mean visual acuities between -2.0 to -3.0 diopters in group II. Patients in both groups had high levels of spectacle independence, with no patient reporting dysphotopsia. CONCLUSION: Binocular UNVA was significantly better, with comparable UDVA and mesopic contrast sensitivity when targeting mini monovision with the non-diffractive extended vision IOL as compared to targeting binocular emmetropia.

FLACS vs conventional phacoemulsification by junior cataract surgeons: randomized trial.

PURPOSE: To report intraoperative performance and postoperative outcomes of femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification (PE) in the hands of junior surgeons. SETTING: Iladevi Cataract & IOL Research Centre, Ahmedabad, Gujarat, India. DESIGN: Prospective single-masked randomized controlled trial. METHODS: 320 eyes (320 patients) undergoing cataract surgery for uneventful cataracts in the hands of junior surgeons were randomized to Group 1-FLACS or Group 2-PE. Intraoperatively, cumulative dissipated energy (CDE) and fluid used were compared. Postoperatively, the following were compared: central corneal thickness (CCT) on day 1, 1 week, and 1 month; corneal clarity (day 1 and 1 week); anterior chamber inflammation (day 1 and 1 week); change in endothelial cell density (ECD) at 6 months postoperatively; and corrected distance visual acuity (CDVA) at 1 week and 1 month postoperatively. RESULTS: 157 and 158 patients in groups 1 and 2 analysed. Intraoperatively, CDE (5.41 ± 2.73 vs 8.83 ± 4.28 in Groups 1 and 2, P = .0001) and fluid used (79.33 ± 33.46 vs 101.82 ± 32.23 mL in Groups 1 and 2, P < .0001) were significantly lesser in Group 1. CCT was significantly higher in Group 2 on day 1 (550.96 ± 33.64 vs 587.70 ± 55.76 µm in Groups 1 and 2, P < .0001) and at 1 week postoperatively (527.94 ± 30.78 vs 545.11 ± 35.17 µm in Groups 1 and 2, P = .001). 72% of eyes had clear corneas on day 1 in Group 1 compared with 39% in Group 2 ( P = .01). Anterior chamber inflammation and CDVA were comparable. Change in ECD was significantly lower (9.3%) in Group 1 vs 12.7% in Group 2, P < .0001. CONCLUSIONS: FLACS showed lower intraoperative CDE, fluid usage, lesser increase in CCT, better early postoperative corneal clarity, and lesser change in ECD at 6 months postoperatively in the hands of junior surgeons during standard cataract surgery.

Late onset corneal decompensation following retained lens fragment in anterior chamber years after uneventful phacoemulsification.

PURPOSE: To report a case of late onset corneal decompensation following cataract surgery due to retained lens fragment in anterior chamber. OBSERVATIONS: A 65 year old female presented with complaint of gradual dimness of vision in left eye since 4 months. She underwent uneventful phacoemulsification with posterior chamber intraocular lens implantation elsewhere 4 years back. On examination, the CDVA in left eye was 20/200. Slit-lamp examination revealed corneal edema with Descemet's folds. She was diagnosed as pseudophakic bullous keratopathy and was being treated with topical steroids, cycloplegics and hyperosmolar agents for the same. She was also counseled about a lamellar corneal transplant. Posterior segment examination was within normal limits. Since the position of the IOL (sulcus versus bag) was not clearly seen ultrasound biomicroscopy (UBM) and anterior segment optical coherence tomography (AS-OCT) imaging was performed to try and better understand the possible cause for corneal decompensation. To our surprise, on both, UBM and ASOCT, a single, retained lens fragment was noted at 6 0'clock in the anterior chamber. AC wash was performed to remove the retained lens fragment. 3 months post AC wash corneal edema resolved completely with improvement in the BCVA to 20/40. CONCLUSION: AND IMPORTANCE: This case highlights the importance of a thorough clinical evaluation supplemented with imaging modalities in order to make a complete diagnosis and eventually achieve better outcomes for the patient. In any case of unexplained corneal edema, either in the early or late postoperative period, UBM and ASOCT can become very helpful to determine the underlying cause.

Re-evaluating the assistant practitioner role in NHS England: Survey findings.

AIM AND BACKGROUND: In the absence of data providing an overview on the state of the assistant practitioner (AP) workforce, this study surveys trusts in NHS England with the aim of establishing how the role is viewed, used and managed. METHODS: Based on an earlier survey undertaken around a decade ago, an online questionnaire was sent to members of an assistant practitioner network, generating a response from over fifty different trusts, drawn from different regions and health care settings. RESULTS: The survey results highlight the increased use of assistant practitioners by trusts and in a more diverse range of clinical settings. This increase has been driven more by the apparent value of the APs in addressing issues of service design and quality, than by attempts to reduce costs through substitution and skill mix dilution. CONCLUSIONS: The AP role has retained value to nurse managers in developing and designing services, and indeed in establishing a career pathway for health care assistants. Most striking are future intentions to continue using APs, particularly within the context of the emerging nursing associate (NA) role. This suggests that the AP and NA are likely to be complementary rather than alternative roles. IMPLICATIONS FOR NURSING MANAGERS: Nurse managers might note the continuing use and value of the AP role, although as a means of improving design and quality as well as providing career opportunities for health care assistants, rather than as a way of saving labour costs. Clearly, the AP role has a future although there is scope to review its position in relation to the newly emerging nursing associate role.

Effect of Trypan Blue on Descemet Membrane Elasticity.

PURPOSE: To evaluate the effect of trypan blue on the elastic property of Descemet membrane (DM) by atomic force microscopy. METHODS: Human corneas (n = 10) were obtained from the Illinois Eye Bank (Chicago, IL). The DM was isolated and divided into two halves, one half was stained with ophthalmic trypan blue (Vision Blue, 0.06%, DORC International), whereas the unstained other half served as control. The DM samples were then tested using the atomic force microscope. Data were analyzed using the Hertz model for the evaluation of the Young modulus of elasticity. RESULTS: Atomic force microscopy showed higher cantilever deflection on trypan blue-stained DM compared with control, and the difference was statistically significant (P = 0.03). Force-distance curve analysis also revealed a statistically significant increase in the Young modulus of elasticity in the trypan blue-stained samples (10.5 ± 1.4 kPa) compared with the control (5.8 ± 0.8 kPa), (P < 0.0001). CONCLUSIONS: Our results suggest that trypan blue may decrease DM elasticity and consequently increase its stiffness. This may influence the graft adherence when used for endothelial keratoplasty.

Technology and Intraocular Lenses to Enhance Cataract Surgery Outcomes-Annual Review (January 2013 to January 2014).

PURPOSE: This article is aimed to provide a clinical update on recent developments in cataract surgical techniques, with specific focus on femtosecond laser technology. The article also focuses on recent improvements in the technology used in implanting intraocular lenses (IOLs). DESIGN: Literature review. METHODS: The authors conducted a review of literature available in the last 12 months in the English language using PubMed. The period used to conduct the literature search was from January 1, 2013, to December 31, 2013. The following search terms were used during the PubMed search: phacoemulsification, femtosecond laser, toric IOLs, multifocal IOLs, multifocal toric IOLs, manual small-incision cataract surgery, outcomes, surgically induced astigmatism, rotational stability, trifocal IOLs, laser cataract surgery, safety, and efficacy. RESULTS: This review incorporates selected original articles that provide fresh insights and updates on the fields of toric and multifocal IOLs, femtosecond laser cataract surgery, and manual small-incision cataract surgery. Particular attention has been paid to observational, randomized controlled clinical trials, experimental trials, and analyses of larger cohorts with prospective and retrospective study designs. Letters to the editor, unpublished works, and abstracts do not fall under the purview of this review. CONCLUSIONS: This review is not designed to be all-inclusive. It highlights and provides insights on literature that is most useful and applicable to practicing ophthalmologists.

Visual axis opacification after AcrySof intraocular lens implantation in children.

PURPOSE: To evaluate visual axis opacification after AcrySof intraocular lens (IOL) (Alcon) implantation in pediatric eyes. SETTING: Iladevi Cataract and IOL Research Centre, Ahmedabad, India. METHODS: This prospective study evaluated 103 consecutive eyes of 72 children with congenital cataract. Two groups were formed based on age at surgery: Group 1, younger than 2 years, and Group 2, older than 2 years. All eyes in Group 1 (n = 37) had primary posterior continuous curvilinear capsulorhexis (PCCC) with anterior vitrectomy. In Group 2 (n = 66), management of the posterior capsule was assigned randomly to no PCCC (Group 2A, n = 37) or PCCC (Group 2B, n = 29). The PCCC group was further randomized into 2 subgroups: no vitrectomy (Group 2BN, n = 14) or vitrectomy (Group 2BV, n = 15). The primary outcome measures were visual axis opacification and the resulting need for a secondary procedure. Statistical analysis was performed using SPSS for Windows (version 11.0.1). RESULTS: The mean age of the patients was 5.2 years +/- 5.0 (SD) (range 0.2 to 16.0 years) and the mean follow-up, 2.3 +/- 0.9 years (range 1.0 to 4.0 years). Overall, 41 eyes (39.8%) developed visual axis opacification and 14 (13.6%) required secondary intervention. In Group 1, 4 eyes (10.8%) developed visual axis opacification and 3 (8.1%) had a secondary pars plana vitrectomy. In Group 2A, 31 eyes (83.8%) developed posterior capsule opacification (PCO) and 10 eyes (27.7%) had secondary intervention. Children 8 years or younger at the time of surgery developed significantly greater PCO than older children (P =.01). Five eyes (37.5%) in Group 2BN had opacification of the anterior vitreous face, 1 of which required a secondary procedure. One eye (6.7%) in Group 2BV had visual axis opacification that did not require a secondary procedure. CONCLUSIONS: AcrySof IOL implantation with appropriate management of the posterior capsule maintained a clear visual axis in 60.2% of eyes. Of the 39.8% of eyes with visual axis opacification, 13.6% had visually significant opacification and required a secondary procedure.

Diagnosis and management of congenital cataract with preexisting posterior capsule defect.

PURPOSE: To establish and evaluate the diagnostic signs, intraoperative performance, and postoperative outcomes in children with congenital cataract with a preexisting posterior capsule defect (PCD). SETTING: Iladevi Cataract & IOL Research Centre, Ahmedabad, India. METHODS: This study evaluated 400 consecutive eyes that had congenital cataract surgery, of which 27 (20 children) had a confirmed preexisting PCD. Seven children had bilateral defects. The preoperative diagnostic signs of PCD under maximum pupil dilation included well-demarcated, thick defect margins; white dots on the posterior capsule; and white dots in the anterior vitreous that moved with the degenerated vitreous like a fish tail (fish-tail sign). Hydrodissection was not attempted. Bimanual irrigation/aspiration and 2-port anterior vitrectomy were performed. The mean follow-up was 17.9 months +/- 16.96 (SD). RESULTS: The mean age of the 16 boys and 4 girls with a PCD was 21.98 +/- 33.33 months. Nineteen eyes (70.3%) had total white mature cataract. In 7 eyes (25.92%), the preexisting PCD was converted into a posterior capsulorhexis. Twenty eyes (74.07%) had an AcrySof MA30BA intraocular lens (IOL) implanted in the bag and 4 eyes (14.81%), in the sulcus. Three eyes (11.11%) were left aphakic. The visual axis remained clear in all eyes, and the IOL was well centered in 24 eyes (88.88%). CONCLUSION: Establishing the diagnostic signs of PCD with the eye fully dilated and carefully planning the surgery produced satisfactory technical and visual outcomes.

Anterior vitreous face behavior with AcrySof in pediatric cataract surgery.

PURPOSE: To describe anterior vitreous face behavior when AcrySof (Alcon, Fort Worth, TX) intraocular lenses come in contact with the anterior vitreous face after posterior continuous curvilinear capsulorhexis without anterior vitrectomy in pediatric patients undergoing cataract surgery. METHODS: This study comprised 14 eyes of 12 children whose mean age was 9.6 years (range, 2.3 to 16.0). All eyes underwent primary posterior continuous curvilinear capsulorhexis without anterior vitrectomy and had AcrySof IOLs implanted in the bag. Changes on the anterior vitreous face were documented, and visual acuity was recorded. Statistical analysis was performed using Student group t and Mann Whitney tests. RESULTS: Mean length of follow-up was 21.1 +/- 7.4 months (range, 15.0 to 36 months). Nine eyes (64.3%) had a clear visual axis, whereas 5 eyes (35.7%) developed anterior vitreous face changes. Of those with anterior vitreous face changes, 60% (3 of 5) eyes showed a fine meshwork-like reticular response termed "anterior vitreous reticular response" (AVR); 20% (1 of 5) eyes showed a scaffold response; and 20% (1 of 5) eyes showed a mixed response at the last follow-up examination. The difference in visual acuity before and after the development of the AVR response was not significant (P =.712). The mean age of patients with eyes having a clear visual axis was 12.1 +/- 2.3 years (median = 11.0; range, 9.1 to 16.0), and the mean age of patients with eyes having anterior vitreous face changes was 5.1 +/- 3.4 years (median = 3.6; range, 2.3 to 11.6) (P =.0098). CONCLUSION: The results suggest that when the AcrySof intraocular lenses come in contact with the anterior vitreous face, they produce the AVR response during the early postoperative period in younger eyes. This does not seem to have any significant impact on visual acuity.