Pseudoexfoliative Syndrome in Cataract Surgery-A Quality Register Study and Health Economic Analysis in the Split-Dalmatia County, Croatia.

PURPOSE: To investigate the impact of pseudoexfoliation (PEX) syndrome on intraoperative phacoemulsification (PHACO) parameters and assess the economic cost of PHACO surgery for cataracts in patients with and without PEX syndrome. METHODS: This was a retrospective quality register study on 5889 patients (6236 eyes) who underwent PHACO cataract surgery in the Eye Clinic, Clinical Hospital Centre Split, Croatia, over a 7-year period (May 2015 to December 2022), in accordance with the Guidelines of the Helsinki Declaration and approval from the Research Ethics Committee of the University Hospital Centre Split, Croatia. Inclusion criteria were patients with either presenile or senile cataract or cataract related to PEX syndrome who undertook PHACO procedure by the same experienced surgeon using the same PHACO device (Infiniti Vision System, Alcon Laboratories, Inc., Fort Worth, TX, USA). Eyes were categorized according to PEX presence- (PEX group) or absence (Group without PEX). The following recorded data about intraoperative PHACO parameters were collected: Cumulative Dissipated Energy (CDE), Ultrasound total time, PHACO time, torsional time, aspiration time, estimated fluid used, and duration of the surgical procedure. In the economic analysis, all PHACO parameters were considered, with a specific focus on the duration of the surgical procedure, costs associated with additional medical materials and devices, complications during surgery, and surgery procedure Diagnosis-Related Group (DRG) codes. RESULTS: A total of 4535 cases were eligible for inclusion in the study, 278 (6.13%) were diagnosed with PEX and 4257 (93.87%) had no PEX. Significantly higher PHACO parameters were observed in the PEX group. Similarly, a statistically significant increase in the values of all PHACO parameters was observed with the increase in nuclear lens density. Intraoperative complications were more frequent in the PEX group. Zonular weakness requiring the use of a capsular tension ring (CTR) and posterior capsular rupture occurred 30 and 13 times more often, respectively, in the PEX group. The expected cost of the PHACO procedure was found to be 1.4 times higher in patients with PEX, compared to those without PEX, for all types of nuclear cataract. CONCLUSIONS: All PHACO parameters are significantly higher in patients with PEX. The costs associated with PHACO surgery for cataracts are greater for patients with PEX and are not covered by the present DRG codes, which highlights the need to accordingly adjust the DRGs for PHACO procedures in PEX patients, in order to maintain the quality of healthcare provided for these vulnerable patients.

Albrecht von Graefe (1828-1870) and his contributions to the development of ophthalmology.

PURPOSE: The aim of this article is to show Albrecht von Graefe's contributions to the development of ophthalmology on the occasion of the 150th anniversary of his death. He is regarded as the greatest ophthalmologist of the 19th century. Modern and scientific ophthalmology owes its beginning to him. METHODS: Extensive literature research is made and contacts with institutions for history of medicine as well as medico-historians in the field of ophthalmology. RESULTS: His contributions to ophthalmology were multiple. Von Graefe was the first to introduce iridectomy in acute glaucoma treatment, initiated visual field testing and developed the first tonometer. He made the first classification of glaucoma. Von Graefe was the ophthalmologist who created a special knife for cataract surgery. He was also the first to use Helmholtz' ophthalmoscope. He founded the first ophthalmological society in the world and the second ophthalmology journal which has been published continously up to now. In 1852 he founded famous private eye clinic in Berlin, where he treated many eye patients and educated many prominent ophthalmologists. At the age of 29 he became associate professor of ophthalmology, the first with such a title in Germany. CONCLUSION: Albrecht von Graefe was founder of modern ophthalmology and separated it from surgery. Graefe's contacts, correspondency and meetings at ophthalmological congresses with his teachers, assistants, collegaues also contributed to international co-operation and internationalization in ophthalmology. Although Albrecht von Graefe died before 150 years, he still provokes great admiration and respect in the world of ophthalmology.

[The efficacy of the fixed drug combination dorzolamide 2%/timolol 0.5% in patients with primary open angle glaucoma]. / Ucinkovitost fiksne kombinacije dorzolamid 2%/timolol 0,5% kod bolesnika s primarnim glaukomom otvorenog kuta.

The aim was to investigate the effectiveness of the fixed drug combination dorzolamide 2%/timolol 0.5% as monotherapy, substitutive and as adjunctive therapy in patients with primary open angle glaucoma. 130 patients were divided in three different study groups and treated by the combination dorzolamide 2%/timolol 0.5% as monotherapy, substitutive therapy and additional therapy. After three months using fixed combination dorzolamide 2%/timolol 0.5%, the mean IOP decreased by 5.6 mmHg. After prescribing substitutive therapy with fixed drug combination dorzolamide 2%/timolol 0.5% for 3 months, the intraocular preassure increased by 0.13 mmHg. Three months after the treatment with fixed combination dorzolamide 2%/timolol 0.5% as an additional antiglaucomatous drug, we have noticed a decrease of the mean IOP of 3.28 mmHg. Itching and soarness were reported by 43% patients. In conclusion, glaucoma drug therapy with fixed drug combination dorzolamide 2%/timolol 0.5% achieves effective lowering of intraocular preassure levels as monotherapy or as adjunctive therapy. As a substitutive therapy, the combination had the same IOP lowering effect. Simple drug administration and good drug tolerance indicate the effectiveness of the same drug.

Phacoemulsification in eyes with posterior polar cataract.

The aim of the study was to evaluate the results of phacoemulsification in eyes with posterior polar cataract and to assess the risk factors for posterior capsular rupture during phaco surgery. This prospective study included 13 patients (14 eyes) undergoing phacoemulsification surgery with intraocular lens implantation. Intact posterior capsule was present in 10 (71.5%) eyes, posterior capsular rupture in 4 (28.5%) eyes, one of them with vitreal loss and requiring anterior vitrectomy. Of the eyes with intact posterior capsule, 5 (35%) had capsular plaque which was removed by gentle aspiration; in one case posterior capsulorrhexis was performed to remove the plaque; and postoperative capsule was clear in 4 (28.5%) eyes. In 3 eyes with capsular rupture, there was soft nucleus and capsular opacification greater than 3 mm in diameter, and the patients were under 40 years old. One capsular rupture occurred in dense cataract. The incidence of posterior capsular rupture in our study was 28.5%; other authors reported the incidence between 7.1% and 36%. Many different techniques have been described by other surgeons to avoid capsular rupture; however, in our opinion, posterior capsular rupture could not be avoided in some cases. In our study, the risk factors for capsular rupture in posterior polar cataract were soft nucleus with large capsular opacification and younger patient age. Our results of visual acuity after phacoemulsification in posterior polar cataracts are consistent with those reported by other authors: in 9 eyes, visual acuity was 0.8 or more (Snellen chart), and in 5 eyes there was no satisfactory improvement of visual acuity, probably due to amblyopia because the majority of the cataracts were unilateral. Accordingly, phacoemulsification in posterior polar cataracts, when done carefully, leads to good postoperative results and good visual improvement in most cases.

[Clinico-epidemiological analysis of choroidal melanoma in Split Area, Croatia]. / Klinicko-epidemioloska analiza melanoma zilnice u splitskom podrucju u Hrvatskoj.

Choroidal melanoma is the most common primary intraocular malignant tumour in adults. The aim of the study was to examine epidemiological characteristics of choroidal melanoma in Split-Dalmatia County from 1990 to 2009. In this retrospective study, data on 46 patients from medical documentation of the University Department of Ophthalmology, Split University Hospital Center, were analyzed. According to 2001 census, the Split-Dalmatia County population was 467,676 inhabitants. The incidence of choroidal melanoma was 0.49 per 100,000 inhabitants, which is somewhere in the middle of the incidence between south and north Europe. Choroidal melanoma most commonly appeared in the 7th decade of life. The average dimensions of choroidal melanoma (basis x height) were 13.4 x 8.0 mm. Histopathologic findings according to Callender classification showed the following types of melanoma: epithelioid cell type 8%, spindle cell type 40%, and mixed type 52%. The most common forms of therapy were enucleation 47.8% and brachytherapy 28.3%, which means that patients presented relatively late when choroidal melanoma advanced in size. The Split-Dalmatia County has 1/10 of the Croatian population, so it could be supposed that approximately 25 new cases of malignant melanoma of the choroid are discovered annually in Croatia. For early detection of the disease, regular and complete checkups are necessary, especially in presbyopic population. Study results enabled better evaluation of the disease and better planning of ophthalmologic service in the treatment of this serious eye disease.

Acute bilateral cataract with phacomorphic glaucoma in a girl with newly diagnosed type 1 diabetes mellitus.

The authors present a rare case of acute bilateral cataract with phacomorphic glaucoma in a girl with newly diagnosed type 1 diabetes mellitus without a known history of ocular problems. Within 3 months after the diagnosis of diabetes mellitus, she presented with high intraocular pressure. Her visual acuity was limited to hand motions. The patient required immediate surgical intervention. Postoperatively, the intraocular pressure normalized and bilateral visual acuity was 6/6.

The effect of travoprost 0.004% as an adjuvant to timolol 0.5% therapy.

The aim of the study was to compare the efficacy of travoprost 0.004% eye drops added to therapy with timolol 0.5%. The study included 40 patients (80 eyes) with open angle glaucoma and intraocular pressure (IOP) above 18 mm Hg treated with topical beta blocker (timolol 0.50% twice a day). Travoprost 0.004% was added to timolol 0.5% therapy once daily in the evening. Follow up examinations were scheduled at 7 days, one month and three months. IOP lowering was achieved in all patients. Substantial lowering of 2.42 mm Hg was achieved after the first week of treatment. Further lowering and stabilization of IOP was recorded at three months, with total IOP decrease of 3.97 mm Hg; the difference was statistically significant (chi2=6.7743; p<0.01). At three months, target IOP was recorded in 64 eyes (16.4+/-0.7 mm Hg) and failed to be achieved in 16 eyes (21.1+/-2.3 mm Hg). Mild hyperemia was found in two patients and discrete hyperemia in 26 patients. Burning sensation associated with the use of travoprost 0.004% eye drops was reported by 68 patients. In conclusion, the use of travoprost 0.004% eye drops resulted in successful lowering of IOP and achievement of target IOP.

[Additive therapy with carboanhydrase inhibitors for open angle glaucoma previously treated with timolol 0.5% drops]. / Dodatno lijecenje glaukoma otvorenog kuta inhibitorima karboanhidraze na vec postojece lijecenje timololom.

Inhibitors of carboanhydrase (ICA) in the form of dorzolamide 2% drops and brinzolamide 1% drops are in use for 8-10 years, with a significant intraocular pressure (IOP) lowering effect. The goal of the present study was to obtain precise data on the efficacy of local ICA in conjunction with timolol 0.5% drops, and to evaluate the incidence of side effects. This was a prospective study that lasted 2 years and included 110 patients. Initial IOP values, before therapy with ICA, amounted to 19 +/- 8.4 mm Hg in group A and 20.5 +/- mm Hg in group B. Although the results obtained demonstrated statistically significant lowering of IOP (in group A by 4.5 +/- 2.4 mm Hg, and in group B by 4.6 +/- 2.1 mm Hg) after therapy with ICA, the difference between the groups was not found. Dorzolamide more frequently caused local side effects like aching, itching and pain in the eye. Aditional lowering of lOP in our patients was somewhat greater than reported before (4.6:4.3). Side effects (itching, aching, pain) were three times more frequent in the group treated with dorzolamide than reported by other authors; this difference could be due to patient age, as our patients were mostly elderly people and the data are subjective. The results of this study suggested the effectiveness of additional local therapy with ICA in patients with open angle glaucoma.