Quantification of Postoperative Inflammation in Laser and Surgical Procedures for Glaucoma with Laser Flare Photometry: A Review of the Literature.

PURPOSE: To review the application of laser flare photometry (LFP) in the objective quantification of aqueous flare (anterior chamber inflammation) post laser and surgical procedures for glaucoma. METHODS: A search was undertaken using the following: PubMed (all years), the Web of Science (all years), Ovid MEDLINE (R) (1980 to 30 March 2023), Ovid MEDLINE (R) Daily Update 30 March 2023, MEDLINE and MEDLINE non-indexed items, Embase (1980-2021, week 52), Ovid MEDLINE (R) and Epub Ahead of Print, in-Process & Other Non-Indexed Citations and Daily (1980 to 30 March 2023), CENTRAL (including Cochrane Eyes and Vision Trials Register), metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrial.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (www.who.int/ictrp/search/en). Search terms included "aqueous flare," "anterior chamber inflammation," "tyndallometry," "laser flare photometry" combined with "laser," "iridotomy," "trabeculoplasty," "cataract surgery," "phacoemulsification," "glaucoma surgery," "minimally invasive glaucoma surgery," "trabeculectomy," "aqueous shunt," "glaucoma drainage" and "cyclophotocoagulation." RESULTS: The majority of studies utilizing laser flare photometry in grading flare have been post laser trabeculoplasty. The degree of flare produced varies according to the type of glaucoma laser or surgery performed, with filtration procedures and glaucoma drainage devices having marked and prolonged detectable levels. Aqueous flare in cyclodestructive procedures positively correlated with intraocular pressure (IOP) reduction. CONCLUSION: In comparison to clinician grading, laser flare photometry provides a more objective measure of post-surgical inflammation in eyes that have undergone laser and surgery for glaucoma. Further research is warranted into how this instrument can be utilized to identify eyes at high risk of failure and other adverse outcomes after glaucoma surgery.

Factors influencing aqueous flare after cataract surgery and its evaluation with laser flare photometry.

Despite the refinement of modern cataract surgery, postoperative inflammation still constitutes a substantial amount of visual morbidity worldwide. A surrogate for intraocular inflammation and blood-aqueous barrier breakdown can be objectively quantified by Laser flare photometry (LFP). This review outlines the utility of LFP in assessing the assessment of post-cataract surgery inflammation. It highlights the impact of preoperative pathological states such as uveitis and diabetes, intraoperative techniques, including efficient phacoemulsification and direct comparisons between postoperative anti-inflammatory regimes. There is a large interobserver variation in the subjective flare measurement after cataract surgery and the continued use of LFP amongst other objective, noninvasive measurements of intraocular inflammation, particularly in the further development of cataract surgery, is recommended.

Six year outcomes of combined phacoemulsification surgery and endoscopic cyclophotocoagulation in refractory glaucoma.

PURPOSE: This study is to describe the 6-year results of combined phacoemulsification surgery and endoscopic cyclophotocoagulation (Phaco-ECP) surgery in patients with uncontrolled glaucoma and no previous glaucoma surgery. METHODS: This is a retrospective case series of 84 eyes. The primary outcome measure was intraocular pressure (IOP) reduction 6 years postoperatively. Secondary outcome measures were the cumulative probability of failure of the surgical procedure at 6 years. Failure was defined as IOP higher than 21 mm Hg or lower than 6 mm Hg or IOP not reduced by 20% from baseline at the 1, 2, 3, 4, 5, or 6-year time points or further laser or other surgery to reduce IOP at any timepoint. RESULTS: There was a statistically significant decrease in mean IOP from 18.9 mmHg pre-operatively to 13.7, 12.8, 13.0, 12.7, 12.5, and 12.3 mmHg at the 1, 2, 3, 4, 5, and 6 years post-operatively respectively (p < 0.001). Fifty-seven (68%) reached criteria for failure by 6 years. In 36% of cases, this was due to inadequate IOP control, whereas 32% required further laser or surgery. When we excluded patients who only had selective laser trabeculoplasty rather than further surgery, the failure rate reduced to 51%. Eleven percent had a post-operative complication, 2.4% requiring further surgical intervention. CONCLUSIONS: At 6 years postoperatively, combined phaco-ECP achieved a significant reduction in IOP in patients with uncontrolled glaucoma and no previous drainage surgery. Significant complications were uncommon, but 68% was classified as surgical failures by the six year point.

Secondary pigmentary glaucoma following cosmetic laser treatment to alter iris colour.

Cosmetic alteration of iris colour with implants, along with its secondary complications, is already well described in the literature. However the use of cosmetic iris laser is relatively novel. We report on a rare case of bilateral secondary pigmentary glaucoma, in a young patient who underwent such a treatment to cause a change in iris pigmentation. Data on the safety of such procedures are lacking. Ophthalmic healthcare professionals should be aware of the potentially devastating consequences and encourage caution in patients seeking this novel treatment.

Confidence of UK Ophthalmology Registrars in Managing Posterior Capsular Rupture: Results from a National Trainee Survey.

INTRODUCTION: To establish the level of confidence amongst UK ophthalmology specialist registrars (residents) in managing posterior capsule rupture (PCR) during cataract surgery. METHODS: An online nine-item questionnaire was distributed to all registrars, recruited nationwide via regional representatives. Data collected included stage of training, number of completed cataract operations, cumulative PCR rate, number of PCRs independently managed, understanding of vitrectomy settings and fluidic parameters and access to simulation. Respondents self-evaluated their confidence in managing PCR with vitreous loss. RESULTS: Complete responses were obtained from 248 registrars (35% response rate). Mean number of phacoemulsification procedures performed was 386. For senior registrars (OST 6-7), 35 out of 70 (50%) felt confident to manage PCR independently and 55 out of 70 (78.6%) were either quite confident or very confident at deciding when to implant an intraocular lens during PCR management. Lower confidence levels were noted for junior trainees (OST 1-2). Over 65% of survey respondents had access to relevant simulation. CONCLUSIONS: Our results represent the largest UK survey analysing the confidence of PCR management amongst registrars. Confidence improves with duration of training and increased exposure to management of PCR. However, 50% of senior registrars still lacked confidence to independently manage PCR and vitreous loss. A specific competency-based framework, potentially using a simulator or simulating a PCR event, incorporated into the curriculum may be desirable.

Ciliary Body and Iris Metastases With Anterior Chamber Angle Infiltration: A Rare Complication From Invasive Ductal Breast Cancer.

A 54-year-old woman who presented with photopsia was found to have elevated intraocular pressure in both eyes and optic disc cupping in the right eye. Angle infiltration was noted on gonioscopy. She was previously been diagnosed with metastatic breast cancer. This case report describes a rare case of glaucoma as a complication of ciliary body and iris metastases secondary to invasive ductal breast cancer.

Correction: Efficacy of toric intraocular lens implantation with high corneal astigmatism within the United Kingdom's National Health Service.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Efficacy of toric intraocular lens implantation with high corneal astigmatism within the United Kingdom's National Health Service.

OBJECTIVES: To determine the efficacy of toric intraocular lens (TIOL) implantation in cataract surgery patients with high levels of pre-operative corneal astigmatism and ocular co-morbidities in a state funded, National Health Service (NHS) hospital. METHODS: Retrospective cohort study involving consecutive cases of TIOL implantation in cataract surgery with over 3.00DC of pre-operative corneal astigmatism. Subjects were implanted with the Tecnis TIOL (Abbot Medical Optics) with capsular tension ring stabilisation using the Callisto system (Carl Zeiss Meditec). Visual acuity and refraction were assessed at 4-6 weeks post-operatively. Vector analysis was used to calculate the intended refractive correction, surgically induced refractive correction (SIRC), correction ratio (CR), error of magnitude (EM) and error vector (EV). RESULTS: Sixty-six eyes of forty-seven subjects aged 73.8 ± 11.9 were included. Eyes with ocular co-morbidities included dry age-related macular degeneration (n = 13), amblyopia (n = 7), high myopia (n = 7), glaucoma (n = 6), previous corneal transplantation (n = 2), nanophthalmos (n = 2) and corneal scarring (n = 1). Pre-operative corneal astigmatism was 4.25 ± 1.69DC (range 3.00-12.00), post-operative refractive astigmatism was 1.31 ± 1.05DC (range 0.00-6.50DC) and post-operative unaided visual acuity was 0.25 ± 0.19 LogMAR. Vector analysis demonstrated an SIRC of 4.08 ± 1.39DC, CR = 1.1 ± 0.3, EM -0.4 ± 1.0 and EV of 1.23 ± 0.72. CONCLUSIONS: The results demonstrate the efficacy of TIOL implantation in patients with high corneal astigmatism and provide strong evidence advocating their use in cataract surgery within a state funded hospital eye service. Refractive astigmatism was significantly lower than the pre-operative corneal astigmatism and a low error vector was achieved relative to the magnitude of correction.

Learning styles and the prospective ophthalmologist.

PURPOSE: Understanding the learning styles of individual trainees may enable trainers to tailor an educational program and optimise learning. Surgical trainees have previously been shown to demonstrate a tendency towards particular learning styles. We seek to clarify the relationship between learning style and learned surgical performance using a simulator, prior to surgical training. METHODS: The Kolb Learning Style Inventory was administered to a group of thirty junior doctors. Participants were then asked to perform a series of tasks using the EyeSi virtual reality cataract surgery simulator (VR Magic, Mannheim, Germany). All completed a standard introductory programme to eliminate learning curve. They then undertook four attempts of level 4 forceps module binocularly. Total score, odometer movement (mm), corneal area injured (mm(2)), lens area injured (mm(2)) and total time taken (seconds) recorded. RESULTS: Mean age was 31.6 years. No significant correlation was found between any learning style and any variable on the EyeSi cataract surgery simulator. CONCLUSION: There is a predominant learning style amongst surgical residents. There is however no demonstrable learning style that results in a better (or worse) performance on the EyeSi surgery simulator and hence in learning and performing cataract surgery.

Primary intraocular lymphoma.

Primary intraocular lymphoma (PIOL) is an ocular malignancy that is a subset of primary central system lymphoma (PCNSL). Approximately one-third of PIOL patients will have concurrent PCNSL at presentation, and 42-92% will develop PCNSL within a mean of 8-29 months. Although rare, the incidence has been rising in both immunocompromised and immunocompetent populations. The majority of PIOL is diffuse large B-cell lymphoma, though rare T-cell variants are described. Recently, PIOL has been classified by main site of involvement in the eye, with vitreoretinal lymphoma as the most common type of ocular lymphoma related to PCNSL. Diagnosis remains challenging for ophthalmologists and pathologists. PIOL can masquerade as noninfectious or infectious uveitis, white dot syndromes, or occasionally as other neoplasms such as metastatic cancers. Laboratory diagnosis by cytology has been much aided by the use of immunocytochemistry, flow cytometry, biochemical finding of interleukin changes (IL10:IL6 ratio > 1), and cellular microdissection with polymerase chain reaction amplification for clonality. Use of several tests improves the diagnostic yield. Approaches to treatment have centered on systemic methotrexate-based chemotherapy, often with cytarabine (Ara-C) and radiotherapy. Use of intravitreal chemotherapy with methotrexate (0.4 mg/0.1 mL) is promising in controlling ocular disease, and intravitreal rituximab (anti-CD20 monoclonal antibody) has also been tried. Despite these advances, prognosis remains poor.