Semi-supervised segmentation of orbit in CT images with paired copy-paste strategy.

The segmentation of the orbit in computed tomography (CT) images plays a crucial role in facilitating the quantitative analysis of orbital decompression surgery for patients with Thyroid-associated Ophthalmopathy (TAO). However, the task of orbit segmentation, particularly in postoperative images, remains challenging due to the significant shape variation and limited amount of labeled data. In this paper, we present a two-stage semi-supervised framework for the automatic segmentation of the orbit in both preoperative and postoperative images, which consists of a pseudo-label generation stage and a semi-supervised segmentation stage. A Paired Copy-Paste strategy is concurrently introduced to proficiently amalgamate features extracted from both preoperative and postoperative images, thereby augmenting the network discriminative capability in discerning changes within orbital boundaries. More specifically, we employ a random cropping technique to transfer regions from labeled preoperative images (foreground) onto unlabeled postoperative images (background), as well as unlabeled preoperative images (foreground) onto labeled postoperative images (background). It is imperative to acknowledge that every set of preoperative and postoperative images belongs to the identical patient. The semi-supervised segmentation network (stage 2) utilizes a combination of mixed supervisory signals from pseudo labels (stage 1) and ground truth to process the two mixed images. The training and testing of the proposed method have been conducted on the CT dataset obtained from the Eye Hospital of Wenzhou Medical University. The experimental results demonstrate that the proposed method achieves a mean Dice similarity coefficient (DSC) of 91.92% with only 5% labeled data, surpassing the performance of the current state-of-the-art method by 2.4%.

OrbitNet-A fully automated orbit multi-organ segmentation model based on transformer in CT images.

The delineation of orbital organs is a vital step in orbital diseases diagnosis and preoperative planning. However, an accurate multi-organ segmentation is still a clinical problem which suffers from two limitations. First, the contrast of soft tissue is relatively low. It usually cannot clearly show the boundaries of organs. Second, the optic nerve and the rectus muscle are difficult to distinguish because they are spatially adjacent and have similar geometry. To address these challenges, we propose the OrbitNet model to automatically segment orbital organs in CT images. Specifically, we present a global feature extraction module based on the transformer architecture called FocusTrans encoder, which enhance the ability to extract boundary features. To make the network focus on the extraction of edge features in the optic nerve and rectus muscle, the SA block is used to replace the convolution block in the decoding stage. In addition, we use the structural similarity measure (SSIM) loss as a part of the hybrid loss function to learn the edge differences of the organs better. OrbitNet has been trained and tested on the CT dataset collected by the Eye Hospital of Wenzhou Medical University. The experimental results show that our proposed model achieved superior results. The average Dice Similarity Coefficient (DSC) is 83.9%, the value of average 95% Hausdorff Distance (HD95) is 1.62 mm, and the value of average Symmetric Surface Distance (ASSD) is 0.47 mm. Our model also has good performance on the MICCAI 2015 challenge dataset.

Combined endoscopic transethmoid and transconjunctival en bloc resection of optic nerve tumors in patients lacking functional vision.

Background: Surgical treatment of optic nerve tumors is challenging. The study's objective was to evaluate the efficacy of a combined endoscopic transethmoid and transconjunctival approach in patients without functional vision. Design: A retrospective, noncomparative case series. Methods: Retrospective data were collected from all patients who had undergone tumor resection using this approach at the authors' institution between 2015 and 2021. Preoperative assessments included magnetic resonance imaging and ophthalmological examinations, and re-assessments were conducted three months after surgery and regularly during the follow-up period. Results: Seventeen patients, mean age 35 ± 19.0 years, were enrolled. Of these, 64.7% presented with visual acuity (VA) of light perception or no light perception. Gross total resection was realized in all patients. The average decline in exophthalmos was 3.63 ± 1.93 mm. Tumor histopathological analysis identified 12 optic nerve sheath meningiomas and 5 optic gliomas. The mean follow-up time was 30 months during which there was no local recurrence in any of the patients. Conclusions: The combined endoscopic transethmoid and transconjunctival approach offers an additional choice for accessing optic nerve tumors. The procedure is both safe and effective and provides an alternative transcranial route to the orbit.

Optic chiasmatic potential by endoscopically implanted skull base microinvasive biosensor: a brain-machine interface approach for anterior visual pathway assessment.

Background: Visually evoked potential (VEP) is widely used to detect optic neuropathy in basic research and clinical practice. Traditionally, VEP is recorded non-invasively from the surface of the skull over the visual cortex. However, its trace amplitude is highly variable, largely due to intracranial modulation and artifacts. Therefore, a safe test with a strong and stable signal is highly desirable to assess optic nerve function, particularly in neurosurgical settings and animal experiments. Methods: Minimally invasive trans-sphenoidal endoscopic recording of optic chiasmatic potential (OCP) was carried out with a titanium screw implanted onto the sphenoid bone beneath the optic chiasm in the goat, whose sphenoidal anatomy is more human-like than non-human primates. Results: The implantation procedure was swift (within 30 min) and did not cause any detectable abnormality in fetching/moving behaviors, skull CT scans and ophthalmic tests after surgery. Compared with traditional VEP, the amplitude of OCP was 5-10 times stronger, more sensitive to weak light stimulus and its subtle changes, and was more repeatable, even under extremely low general anesthesia. Moreover, the OCP signal relied on ipsilateral light stimulation, and was abolished immediately after complete optic nerve (ON) transection. Through proof-of-concept experiments, we demonstrated several potential applications of the OCP device: (1) real-time detector of ON function, (2) detector of region-biased retinal sensitivity, and (3) therapeutic electrical stimulator for the optic nerve with low and thus safe excitation threshold. Conclusions: OCP developed in this study will be valuable for both vision research and clinical practice. This study also provides a safe endoscopic approach to implant skull base brain-machine interface, and a feasible in vivo testbed (goat) for evaluating safety and efficacy of skull base brain-machine interface.

Removal of Small Cavernous Hemangioma in Orbital Apex Through an Endoscopic Transethmoidal-Sphenoidal Approach.

OBJECTIVE: To investigate the feasibility, efficacy, and safety of an endoscopic transethmoidal-sphenoidal approach in removing a small cavernous hemangioma (CH) located in the deep lateral orbital apex. METHODS: This study involved 19 patients diagnosed with a CH located in the deep lateral orbital apex. All patients underwent an endoscopic transethmoidal-sphenoidal approach for removal of the CH. The best-corrected visual acuity (BCVA), visual field, and surgery-related complications were analyzed and compared. RESULTS: All tumors in this study were completely removed. The mean BCVA was LogMAR 0.97 ± 0.97 preoperatively and LogMAR 0.38 ± 0.64 postoperatively (p < 0.05). The mean visual field index was 52.26% ± 33.26% preoperatively and 75.47% ± 30.49% postoperatively (p < 0.05). The mean deviation index was -17.48 ± 12.43 dB preoperatively and -10.10 ± 10.85 dB postoperatively (p < 0.05), and the pattern standard deviation was 6.37 ± 3.77 dB preoperatively and 4.90 ± 3.56 dB postoperatively (p > 0.05). Four (21.1%) patients developed oculomotor limitations and two (10.5%) patients developed ptosis after surgery. All of these symptoms resolved spontaneously, and no other complications occurred. The mean follow-up time was 6.71 ± 3.89 months. CONCLUSION: The endoscopic transethmoidal-sphenoidal approach is an effective and minimally invasive treatment for removing small CH in the deep lateral orbital apex. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:1743-1749, 2022.

Management of chronic dacryocystitis cases after failed external dacryocystorhinostomy using endoscopic technique with a novel lacrimal ostium stent.

AIM: To demonstrate the outcomes of endoscopic endonasal dacryocystorhinostomy (En-DCR) with an novel lacrimal ostium stent (LOS) which was performed in patients with recurrent epiphora after failed external dacryocystorhinostomy (Ex-DCR) and analyze the causes of failed Ex-DCR. METHODS: From September 2015 and December 2017, the clinic data of 29 cases suffered from recurrent epiphora after failed Ex-DCR was reviewed. The LOS were implanted into the ostium at the end of the revisional surgery. The causes of failed Ex-DCR were analyzed before revisional surgeries. Outcome of revisional surgeries with the new device were evaluated as well. RESULTS: The major causes of failure of the external approach were synechiae formation in the nasal ostium (29/29), followed by inadequate removal of the bony wall (21/29), nasal synechiae formation between lateral wall of nose and middle turbinate (11/29), and the bone opening was not in good location (7/29). The rate of success after revisional surgery was 82.76%. Re-obstruction of the ostiums were found in 5 failed cases. CONCLUSION: Endoscopic approach with a novel LOS may be an effective procedure to manage recurrent epiphora after previous failed Ex-DCR surgery. Synechiae formation in the nasal ostium and inadequate removal of the bony wall were the major causes of failure of Ex-DCR.

Endoscopic Transconjunctival Deep Lateral Wall Decompression for Thyroid-associated Orbitopathy: A Minimally Invasive Alternative: Transconjunctival Endoscopic with Wall Decompression for TAO.

PURPOSE: To investigate the feasibility, efficacy, and safety of endoscopic transconjunctival transorbital deep lateral wall decompression for thyroid-associated orbitopathy (TAO). DESIGN: Prospective single-surgeon interventional case series. METHODS: Twenty-two patients (39 orbits) diagnosed with thyroid-associated orbitopathy without dysthyroid optic neuropathy were enrolled in this study. All patients underwent endoscopic transconjunctival transorbital deep lateral wall decompression for proptosis reduction. The data, including measurement on exophthalmometry, volumetric change on computed tomography, and surgery-related complications, were analyzed. RESULTS: We observed a proptosis reduction (mean, 3.42 ± 0.87 mm; range, 2.10-5.52 mm) and a corresponding decrease in the bony volume of the greater wing of the sphenoid bone (mean, 1.89 ± 0.81 cm3; range, 0.56-3.79 cm3) postoperatively. Preexisting diplopia improved in 5 patients (22.73%). Transient zygomaticotemporal hypoesthesia developed in all patients, and cerebrospinal fluid leakage occurred in 1 orbit (2.56%). No patient complained of temporal hollowing, oscillopsia, or new-onset or worsening diplopia during follow-up. CONCLUSIONS: Endoscopic transconjunctival transorbital deep lateral wall decompression is an effective and minimally invasive treatment for proptosis reduction in patients with thyroid-associated orbitopathy. The surgery-related complications with this technique were fewer compared with traditional approaches.

Self-Cross-Linked Hyaluronic Acid Hydrogel in Endonasal Endoscopic Dacryocystorhinostomy: A Randomized, Controlled Trial.

PURPOSE: To investigate whether self-cross-linked HA hydrogel fill stimulates wound mucosal regeneration and its epithelialization around the ostia to improve long-term ostial patency in endonasal endoscopic dacryocystorhinostomy (En-DCR). METHODS: One hundred and ninety-two patients with unilateral primary chronic dacryocystitis (PCD) were randomized divided into 2 groups: group A (the HA hydrogel group) and group B (the control group). All patients underwent En-DCR. The HA hydrogel group received HA hydrogel filling the ostium at the end of the surgery and the control group received no treatment. The mucosal epithelialization of the wound, the formation of granulation, the formation of scars, and the success rate of ostial patency were compared. RESULTS: Our study included 82 patients in group A and 79 patients in group B. At the 2-week follow up, 74 patients (90.2%) in the group A had a healed ostium with a lining of intact epithelial mucosa. It was higher when compared with 56 patients (70.9%) in group B (X2 = 9.698, P < 0.05). At the 12-month follow up, Granulation were present in 7.3% of patients in group A which was significantly lower than the 19.0% of patients in group B (X2 = 4.831, P < 0.05). No statistical difference was found with scars formation between 2 groups (X2 = 1.607, P = 0.205). The success rate of ostial patency was 89.0% (73/82) in group A and 77.2% (61/79) in group B. The success rate was much higher in group A than group B (X2 = 4.02, P < 0.05). CONCLUSION: Self-cross-linked HA hydrogel may enhance the success rate of En-DCR for PCD by promoting mucosal epithelial healing and preventing excessive granulation.

Endoscopic transnasal canaliculorhinostomy for refractory common canalicular obstruction with an unidentifiable lacrimal sac.

AIM: To describe the role of endoscopic transnasal canaliculorhinostomy (ETC) in refractory common canalicular obstruction (CCO) associated with an absent or unidentifiable lacrimal sac. METHODS: The records of patients with refractory CCO who underwent ETC at the Eye Hospital of Wenzhou Medical University from October 2007 to December 2016 were retrospectively reviewed. RESULTS: Fifty-six patients (56 eyes) with refractory CCO were recruited into the study. Eight patients were excluded due to the presence of a residual lacrimal sac or failure to complete the follow-up duration. The anatomic and functional success rates were both 85.4% (41/48) at a mean follow-up of 18.6mo. Five cases failed as a result of ostial synechia and two failed because of ostial obstruction by granulation. Postoperative complications included mild nasal bleeding in 5 cases, dried nasal feeling in 8 cases, and olfactory dysfunction in 4 cases. CONCLUSION: Although being surgically challenging, ETC has comparable findings to its external approach counterpart or conjunctivodacryocystorhinostomy (CDCR) with Jones tube. And it may prove to be a novel alternate surgical technique for patients with refractory CCO without identifiable lacrimal sac.

Endoscopic Transethmosphenoid Optic Canal and Orbital Apex Decompression for Patients With Traumatic Orbital Apex Syndrome.

PURPOSE: The aim of this study was to evaluate the efficacy, feasibility, and safety of the endoscopic optic canal and orbital apex decompression for patients with traumatic orbital apex syndrome. DESIGN: Retrospective, noncomparative case series. METHOD: Thirty-one patients (31 eyes) with traumatic orbital apex syndrome underwent endoscopic transethmosphenoid optic canal and orbital apex decompression at the Eye Hospital of Wenzhou Medical University from May 1st, 2012 to May 1st, 2018. In each case, the indication of surgery was that patient with traumatic orbital apex syndrome failed to respond to corticosteroids. Patients were followed up to 6 months after surgery. Best corrected visual acuity, visual field, ptosis, ophthalmoplegia, hypoesthesia, and pupil before and after surgery were compared. RESULT: All patients presented visual decline (including 5 patients with no light perception), ptosis, ophthalmoplegia, diplopia, pupil dysfunction, and visual field defect, and 20 of them also presented hypoesthesia. Nineteen of 31 (61.3%) patients gained improvement of best-corrected visual acuity after surgery, 7 of them gained 20/20 BCVA, and visual field showed improvement in 20 patients. Ptosis and ophthalmoplegia of all patients recovered in various degree; diplopia also relieved relatively. The function of the pupil was also improved in most patients (27/31, 87.1%). The improvement of hypoesthesia was also observed in most patients. No serious complications occurred. CONCLUSION: Endoscopic transethmosphenoid optic canal and orbital apex decompression seems to be a feasible, efficient, and safe approach for traumatic orbital apex syndrome patients.

Combined External, Endoscopic, Endonasal-Assisted En Bloc Resection of Malignant Tumors From the Lacrimal Drainage System.

PURPOSE: The aim of this study is to describe a minimally invasive technique of en bloc resection of malignant tumors from lacrimal drainage system (LDS). METHODS: This was a noncomparative, retrospective chart review of the clinical and pathologic findings of patients presenting with a LDS malignant tumor who underwent endoscopic prelacrimal recess approach with a small external incision for en bloc excision of the LDS. RESULTS: A total of 12 patients from April 2010 to July 2017 were reviewed in this study. Of the 12 patients, 7 were males. The mean age was 51 years (range, 38-66 years), and all cases were unilateral. Histopathology revealed 3 adenoid cystic carcinomas, 2 squamous cell carcinomas, 2 melanomas, and 1 each of papilloma with carcinoma, papillary squamous cell carcinoma, mucoepidermoid carcinoma, B-cell lymphoma, and natural killer/T-cell lymphoma. Epiphora and a mass were the most common presentations. Adjuvant radiotherapy was given in 6 cases after surgery. Eleven patients remain alive and mean disease-free survival time was 25 months (range, 3-78 months). Two cases with malignant melanoma showed recurrence and 1 patient died of metastatic involvement. CONCLUSION: Endoscopic endonasal approach combined with a small external incision is efficient method for the management of tumors arising from the LDS.

Navigation-Guided Endoscopy Combined with Deep Lateral Orbitotomy for Removal of Small Tumors at the Lateral Orbital Apex.

PURPOSE: To evaluate the efficacy, feasibility, and safety of the navigation-guided endoscopy combined with deep lateral orbitotomy for removal of small tumors at the lateral orbital apex. DESIGN: A retrospective, noncomparative case series. METHODS: Retrospective analysis of ten patients (10 eyes) with small tumors at the lateral orbital apex comprised navigation-guided endoscopy combined with deep lateral orbitotomy at the Eye Hospital of Wenzhou Medical University from November 2015 to November 2017. In each case, the indication of surgery was existing or imminent visual impairment due to the tumor. The removal was believed to be complete if the mass was removed intactly during the surgery. The tumor character was confirmed by pathological examination after surgery. Patients were followed up to 3 months after surgery. Best corrected visual acuity before and after surgery was compared. RESULTS: All tumors were completely removed by the navigation-guided endoscopic approach. The mean preoperative best corrected visual acuity was 6/15 (95% confidence interval (95% CI) 6/40-6/8.5), and the mean postoperative best corrected visual acuity was 6/10 (95% CI 6/15-6/7.5). 5 of 7 (71%) patients with vision loss gained visual improvement in different degrees after surgery, and the rest of the patients had preoperative best corrected visual acuity. Visual field of all patients also improved. 8 cavernous hemangiomas and 2 schwannomas were confirmed postoperatively by pathology. 4 patients accompanied with limitation of eye abduction, which recovered spontaneously in an average of 4 weeks. No other serious complications occurred. CONCLUSIONS: Navigation-guided endoscopy combined with deep lateral orbitotomy seems to be a feasible, efficient, and safe approach for removing small tumors at the lateral orbital apex. This trial is registered with ChiCTR1800019244.

Endoscopic Transnasal Removal of Cavernous Hemangiomas of the Optic Canal.

PURPOSE: To assess the feasibility and efficacy of endoscopic transnasal removal of cavernous hemangiomas of the optic canal. DESIGN: Retrospective, noncomparative case series. METHODS: Eleven consecutive patients (11 eyes) with cavernous hemangioma of the optic canal underwent endoscopic trans-ethmoidal-sphenoidal removal of the tumor at the Eye Hospital of Wenzhou Medical University from January 2009 to March 2016. In each case, the indication for surgery was decreased visual acuity due to the tumor. The removal was believed to be complete if the tumor was removed en bloc during the surgery. A mucoperiosteal flap was used to cover the defect in the optic nerve sheath after tumor removal. The tumor was pathologically confirmed to be cavernous hemangioma after surgery. The mean follow-up time was 9.9 ± 5.5 months. Visual acuity before and after surgery was compared. RESULTS: All tumors were completely removed by the endoscopic approach. The best-corrected visual acuity (BCVA) improved after surgery in all patients. The mean preoperative BCVA was 6/30 (95% confidence interval [CI] 6/60-6/20) and the mean postoperative BCVA was 6/10 (95% CI 6/12-6/7.5). All patients showed cerebrospinal fluid rhinorrhea, which resolved with strict bed rest. Other complications included hyposmia in 2 patients; nasal bleeding in 3 patients, which resolved spontaneously; and temporary headache. CONCLUSIONS: Endoscopic trans-ethmoidal-sphenoidal approach is a feasible option for cavernous hemangiomas of the optic canal.

Endoscopic transethmoidal approach with or without medial rectus detachment for orbital apical cavernous hemangiomas.

PURPOSE: To determine the indications for the addition of a transcaruncular approach along with detachment of the medial rectus muscle during the removal of small apical cavernous hemangiomas using an endoscopic transethmoidal approach. DESIGN: Retrospective, noncomparative case series. METHODS: Multicenter study of 12 patients with apical orbital tumors removed using an endoscopic transethmoidal approach. The decision to detach the medial rectus muscle with the addition of a transcaruncular approach was made during surgery for tumors largely lateral to the medial rectus muscle. Tumors adjacent to the medial orbital wall were removed via an endoscopic transethmoidal approach alone. RESULTS: Seven tumors were removed via an endoscopic transethmoidal approach combined with medial rectus muscle detachment, whereas 5 patients underwent removal without detachment of the medial rectus. All patients had visual impairment. Complete excision of the hemangiomas was achieved in all patients and tumor size ranged from 6 × 5 mm to 20 × 12 mm. The mean postoperative follow-up time was 11.8 ± 4.3 months. At final follow-up, the best-corrected visual acuity improved in 11 patients. Three patients had transient horizontal diplopia resulting from partial paralysis of the medial rectus muscle after detachment during surgery. CONCLUSIONS: The endoscopic transethmoidal approach with or without medial rectus detachment is a promising approach for selected small cavernous hemangiomas located at the deep medial orbital apex. Detachment of the medial rectus muscle can be a useful technique for tumors located largely lateral to the medial rectus muscle. Further studies will be required to demonstrate the safety and efficacy of this technique.

The effect of hinge location on corneal sensation and dry eye after LASIK: a systematic review and meta-analysis.

BACKGROUND: The aim of this meta-analysis is to investigate the possible effect of hinge location on corneal sensation and dry eye syndrome after laser-assisted in situ keratomileusis (LASIK). METHODS: A comprehensive literature search was conducted in the PubMed, EMBASE, and Cochrane Controlled Trials Register to identify potentially relevant randomized controlled trials (RCTs) of comparing the effects of horizontal-hinge flaps and vertical-hinge flaps on corneal sensation and dry eye after LASIK. Meta-analyses were performed for corneal sensation, tear break-up time (TBUT), Schirmer's I test and corneal fluorescein staining (CFS) at 1 week, 1, 3, and 6 months postoperatively. RESULTS: Eight RCTs (657 eyes) investigating the effects of hinge location on the corneal sensation and dry eye syndrome after LASIK were identified. The results showed that the horizontal-hinge group causes less loss of sensation than the vertical-hinge group, and the difference was significant at 3-month postoperative (p = 0.01). The TBUT value was significantly larger and a lower percentage of patients with CFS in the horizontal-hinge group than in the vertical-hinge group at 1-month postoperative (p = 0.007 and p = 0.01, respectively) and 3-month (p = 0.03 and p = 0.009, respectively); Schirmer's I test values were also higher in the horizontal-hinge group, but the difference did not reach statistically significance at each postoperative period. CONCLUSIONS: According to the available data, we suggest that hinge location may have some effect on corneal sensation and dry eye syndrome after LASIK at the early postoperative period. However, there was no significant difference between the groups at 6 months after surgery. Further well-organized, prospective, randomized studies involving more patients are warranted.

A meta-analysis of primary external dacryocystorhinostomy with and without mitomycin C.

OBJECTIVE: To assess the efficacy and safety of local application of intraoperative mitomycin C (MMC) at the osteotomy site in primary external dacryocystorhinostomy (EX-DCR). METHODS: A comprehensive literature search of the Cochrane Library, PubMed and Embase was undertaken to identify relevant trials comparing EX-DCR with MMC (MMC group, from 0.2-1.0 mg/mL) and without MMC (control group). A total of nine randomized controlled trials (RCTs) were selected and a meta-analysis performed on the results of success rates, which were defined as patency of the nasolacrimal canal and symptomatic improvement. Statistical analysis was performed using RevMan 5.0 software. RESULTS: Nine RCTs reporting on a total of 562 DCRs including patients in the age range 30-57 years were included in the meta-analysis. However, the total number of males and females could not be determined as only four RCTs reported on this aspect. There was a significantly higher success rate in the MMC group in comparison with the control group (odds ratio, OR, 2.11; 95% confidence interval, CI, 1.19-3.74, P = 0. 01). In two RCTs, the mean osteotomy size 6 months postoperatively was significantly larger in the MMC group than in the control group (about 27mm(2) in the MMC group versus about 12mm(2) in the control group in the first study, and about 22mm(2) in the MMC group versus about 18mm(2) in the control group in the second study, P < 0.005). No intraoperative or postoperative complications except two cases with delayed healing of the external skin wound were recorded in the MMC group. CONCLUSION: Intraoperative MMC application seems to be a safe adjuvant that could reduce the closure rate of the osteotomy site after primary EX-DCR. Further well-organized, prospective, randomized studies involving larger patient numbers divided into subgroups for different concentrations of locally applied MMC are warranted.

Biaxial microincision cataract surgery versus conventional coaxial cataract surgery: metaanalysis of randomized controlled trials.

UNLABELLED: A comprehensive literature search of Cochrane Library, PubMed, and Embase was performed to identify relevant prospective randomized controlled trials (RCTs) comparing biaxial microincision cataract surgery (MICS) and conventional coaxial phacoemulsification. A metaanalysis was performed on the following outcome measures: effective phacoemulsification time (EPT), phacoemulsification power (%), corrected distance visual acuity (CDVA), surgically induced astigmatism (SIA), laser flare photometry value, percentage of endothelial cell loss, change in central corneal thickness (CCT), and complications. Eleven RCTs describing a total of 1064 eyes were identified. There were no significant differences between the techniques in CDVA, mean percentage of endothelial cell loss, laser flare photometry value, CCT change, and intraoperative and postoperative complications. However, EPT was statistically significantly shorter and the mean phaco power was statistically significantly lower in the biaxial group than in the coaxial group, and biaxial MICS induced less SIA. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.