Efficacy and Adverse Event Profile of the iStent and iStent Inject Trabecular Micro-bypass for Open-angle Glaucoma: A Meta-analysis.

Aim: This meta-analysis explores the efficacy and adverse event profile of the iStent, an ab interno implant for the treatment of open-angle glaucoma. Methods: A systematic literature search of Ovid MEDLINE and EMBASE was used to identify peer-reviewed original studies that provided efficacy data on the first or second generation iStent for at least five eyes. Intraocular pressure (IOP) was the primary efficacy endpoint, while the number of medication classes was the secondary outcome. Weighted mean differences were reported for continuous endpoints, while a relative risk was computed for dichotomous variables. Review Results: The search revealed 545 results, of which 1767 eyes from 28 studies were included. The cohort age was 71.4 ± 5.4 years, and 44.9% of patients were male. There was a significantly greater IOP reduction after the use of two first-generation stents compared to one, irrespective of phacoemulsification status (p < 0.001). Additionally, there was a significantly greater IOP reduction following iStent alone relative to phaco-iStent for the first-generation iStent (p < 0.001) and the iStent inject (p < 0.001). For the first generation stent, combined phaco-iStent provided a greater level of IOP reduction (p < 0.001) and reduction in the number of medication classes relative to phacoemulsification alone (p < 0.001). In total, 22.5% of eyes that received iStent implantation sustained some type of adverse event. The most common adverse events were intraocular pressure elevation, stent blockage or obstruction, stent malposition and hyphema. Conclusion and Clinical Significance: Statistically significant differences in efficacy outcomes exist between different numbers of stents and the presence or absence of concurrent phacoemulsification.How to cite this article: Popovic M, Campos-Moller X, Saheb H, Ahmed IIK. Efficacy and Adverse Event Profile of the iStent and iStent Inject Trabecular Micro-bypass for Open-angle Glaucoma: A Meta-analysis. J Curr Glaucoma Pract 2018;12(2):67-84.

Midterm failure of combined phacoemulsification with trabecular microbypass stenting: Clinicopathological analysis.

A propagation of microinvasive glaucoma surgery (MIGS) techniques and devices has resulted in the availability of multiple new modalities for surgical intervention for open-angle glaucoma. As MIGS devices and methods approach a new phase in maturity, midterm failures will inevitably be reported. Although MIGS techniques prioritize safety, an understanding of the potential mechanisms of failure is paramount. In this case of a midterm failure of a trabecular microbypass, clinical findings and pathological correlates allow for a comprehensive understanding of the means by which MIGS devices might fail and offer the opportunity for intervention and potential prevention.

Visual and Refractive Outcomes in Manual versus Femtosecond Laser-Assisted Cataract Surgery: A Single-Center Retrospective Cohort Analysis of 1838 Eyes.

PURPOSE: Femtosecond laser-assisted cataract surgery (FLACS) has emerged as an alternative to manual cataract surgery (MCS) for corneal incision and capsulorhexis creation, as well as nuclear fragmentation. This study compares postoperative refractive and visual outcomes in eyes receiving MCS or FLACS. DESIGN: Single-center, comparative, retrospective cohort analysis. PARTICIPANTS: Consecutive eyes receiving FLACS and MCS from July 1, 2012, to July 31, 2015, at a single tertiary care center. METHODS: Demographic data, ocular history, preoperative measurements and biometry, and postoperative surgical results were retrospectively obtained and statistically analyzed using a generalized linear mixed model adjusting for differences in baseline characteristics and within-patient correlation. A 2-tailed P value <0.05 was considered statistically significant throughout the study. MAIN OUTCOME MEASURES: Percentage of eyes achieving absolute error (AE) ≤0.5 diopters (D). Secondary outcomes included percentage of eyes with AE ≤0.25 D and ≤1.0 D, and percentage of distance-targeted eyes achieving uncorrected distance visual acuity (UDVA) of 20/20 or better, 20/25 or better, and 20/30 or better. RESULTS: A total of 883 eyes received MCS and 955 received FLACS among 1089 patients. Some 82.6% of FLACS eyes and 78.8% of MCS eyes had ≤0.5 D of AE at 3 weeks, representing an adjusted odds ratio (OR) of 1.28 (95% confidence interval [CI], 0.98-1.66) of FLACS relative to MCS being within target. Some 97.1% of FLACS and 97.2% of MCS eyes had ≤1.0 D of AE (OR, 0.96; 95% CI, 0.57-1.60) and 49.3% of FLACS and 46.3% of MCS eyes, ≤0.25 D of AE (OR, 1.13; 95% CI, 0.91-1.39). Factors predictive of a favorable refractive outcome included axial length between 22 and 24.8 mm, receiving a toric intraocular lens, less preoperative cylinder, and greater preoperative average keratometry. There was no significant difference in the percentage of patients targeted for distance who achieved UDVA of 20/20 or better (P = 0.30), 20/25 or better (P = 0.06), or 20/30 or better (P = 0.66) vision. CONCLUSIONS: Postoperatively, there was no statistically significant difference found between eyes undergoing FLACS and eyes undergoing MCS with respect to refractive and visual outcomes.

Wang-Koch formula for optimization of intraocular lens power calculation: Evaluation at a Canadian center.

PURPOSE: To externally validate the Wang-Koch method for optimization of intraocular lens (IOL) formulas. SETTING: TLC Laser Eye Centre, Mississauga, Ontario, Canada. DESIGN: Retrospective case series. METHODS: Consecutive cataract patients with an axial length (AL) of 25.0 mm or longer were recruited. The predicted postoperative spherical equivalents (SEs) calculated from the Holladay 1 formula were compared with the 3-week postoperative SEs to yield prediction errors for Wang-Koch adjusted and unadjusted ALs. A mixed linear model was used to compare the proportion of eyes with a prediction error of ±0.25 diopter (D) or worse, ±0.50 D or worse, and ±1.00 D or worse between groups. The secondary outcomes of mean absolute error and median absolute error were also analyzed. A subgroup analysis was performed based on AL subgroups. RESULTS: Two hundred sixty-two eyes were selected for inclusion with a balanced sex distribution, a mean age of 62.49 years ± 9.13 (SD), and a preoperative AL of 26.49 ± 1.10 mm. Subgroup prediction error comparisons of ±0.50 D or worse favored unadjusted eyes with ALs between 25.0 mm and 26.0 mm (n = 105; P < .001), no difference in eyes with ALs between 26.0 mm and 27.0 mm (n = 91; P = .43), adjusted eyes with ALs between 27.0 mm and 28.0 mm (n = 36; P = .003), and adjusted eyes with ALs of 28.00 mm or longer (n = 30; P < .001). CONCLUSION: The Wang-Koch adjustment should only be applied in eyes with ALs longer than 27.0 mm that have IOL power calculation with the Holladay 1 formula.

Refractive predictability of a 3-piece intraocular lens platform versus its 1-piece counterpart.

OBJECTIVE: To compare the refractive outcomes of a 3-piece acrylic intraocular lens (IOL) with its 1-piece counterpart after phacoemulsification with in-the-bag implantation. DESIGN: Retrospective chart review. PARTICIPANTS: One-hundred twenty-six eyes of 95 patients were analyzed in the study, including 60 eyes of 43 patients receiving a 3-piece IOL and 66 eyes of 52 patients receiving a 1-piece IOL. METHODS: Randomized chart review of all patients who underwent uncomplicated phacoemulsification with in-the-bag IOL implantation with either a 3-piece hydrophobic acrylic IOL (Tecnis ZA9003) or a 1-piece hydrophobic acrylic IOL (Tecnis ZCB00) between 2006 and 2014 in a tertiary ophthalmology care centre in Mississauga, Ontario. Preoperative visual acuity and refraction, anterior chamber depth, axial length, IOL design and power, predicted refraction, postoperative visual acuity, and refraction were recorded. RESULTS: Mean absolute error was 0.40 ± 0.27 in the ZA9003 group and 0.39 ± 0.35 in the ZCB00 group, with no statistically significant difference between the 2 IOLs (p = 0.86). Mean arithmetic error was 0.11 ± 0.47 D in the ZA9003 group and 0.01 ± 0.47 D in the ZCB00 group (p = 0.019). In the ZA9003 group, 23 (38%), 42 (70%), and 52 (87%) of 60 eyes were within 0.25, 0.50, and 0.75 D, respectively, of predicted postoperative refraction. In the ZCB00 group, 32 (48%), 46 (70%), and 56 (85%) of 66 eyes were within 0.25, 0.50, and 0.75 D, respectively, of predicted postoperative refraction (p = 0.2836, p = 1.00, p = 0.8044). CONCLUSIONS: The ZA9003 and the ZCB00 have similar mean absolute error and thus appear to have similar refractive predictability.

Efficacy and Safety of Femtosecond Laser-Assisted Cataract Surgery Compared with Manual Cataract Surgery: A Meta-Analysis of 14 567 Eyes.

TOPIC: To investigate the efficacy and safety of femtosecond laser-assisted cataract surgery (FLACS) relative to manual cataract surgery (MCS). CLINICAL RELEVANCE: It is unclear whether FLACS is more efficacious and safe relative to MCS. METHODS: A literature search of MEDLINE, EMBASE, and Scopus from 2007 to March 2016 was conducted. Studies containing both FLACS and MCS arms that reported on relevant efficacy and/or safety parameters were included. Weighted mean differences (WMDs) and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. RESULTS: From 2802 screened articles, 14 567 eyes from 15 randomized controlled trials and 22 observational cohort studies were included. For primary visual and refractive outcomes, no statistically significant difference was detected between FLACS and MCS in uncorrected distance visual acuity (WMD, -0.02; 95% CI, -0.04 to 0.01; P = 0.19), corrected distance visual acuity (WMD, -0.01; 95% CI, -0.02 to 0.01; P = 0.26), and mean absolute error (WMD, -0.02; 95% CI, -0.07 to 0.04; P = 0.57). In terms of secondary surgical end points, there was a statistically significant difference in favor of FLACS over MCS for effective phacoemulsification time (WMD, -3.03; 95% CI, -3.80 to -2.25; P < 0.001), capsulotomy circularity (WMD, 0.16; 95% CI, 0.11-0.21; P < 0.001), postoperative central corneal thickness (WMD, -6.37; 95% CI, -11.88 to -0.86; P = 0.02), and corneal endothelial cell reduction (WMD, -55.43; 95% CI, -95.18 to -15.69; P = 0.006). There was no statistically significant difference between FLACS and MCS for total surgery time (WMD, 1.25; 95% CI, -0.08 to 2.59; P = 0.07), capsulotomy circularity using a second formula (WMD, 0.05; 95% CI, -0.01 to 0.12; P = 0.10), and corneal endothelial cell count (WMD, 73.39; 95% CI, -6.28 to 153.07; P = 0.07). As well, there was a significantly higher concentration of prostaglandins after FLACS relative to MCS (WMD, 198.34; 95% CI, 129.99-266.69; P < 0.001). Analysis of safety parameters revealed that there were no statistically significant differences in the incidence of overall complications between FLACS and MCS (RR, 2.15; 95% CI, 0.74 to 6.23; P = 0.16); however, posterior capsular tears were significantly more common in FLACS versus MCS (RR, 3.73; 95% CI, 1.50-9.25; P = 0.005). CONCLUSIONS: There were no statistically significant differences detected between FLACS and MCS in terms of patient-important visual and refractive outcomes and overall complications. Although FLACS did show a statistically significant difference for several secondary surgical outcomes, it was associated with higher prostaglandin concentrations and higher rates of posterior capsular tears.

Effect of endocyclophotocoagulation on refractive outcomes in angle-closure eyes after phacoemulsification and posterior chamber intraocular lens implantation.

PURPOSE: To compare postoperative refractive outcomes in angle-closure eyes having phacoemulsification and intraocular lens (IOL) implantation with or without endocyclophotocoagulation (ECP). SETTING: Single tertiary-level ophthalmology practice. DESIGN: Retrospective comparative study. METHODS: Primary angle-closure suspect (PACS), primary angle-closure (PAC), or primary angle-closure glaucoma (PACG) eyes that had phacoemulsification and IOL implantation with or without ECP from 2012 to 2014 were studied. Clinical data collected included axial length (AL), minimum and maximum keratometry (K) values, corneal powers, anterior chamber depth (ACD), corneal white-to-white (WTW), implanted IOL power, and postoperative manifest refraction. The Holladay 1 formula was used for IOL calculations. Primary and secondary outcome measures were the mean absolute error (MAE) and mean arithmetic error, respectively. RESULTS: Sixty-eight eyes with ECP and 71 eyes without ECP were included. There were no statistically significant differences between the 2 groups in age, sex, eye side, ethnicity, AL, minimum or maximum keratometry values, ACD, WTW, or implanted IOL power. The MAE was lower in the non-ECP group (0.47 ± 0.32D versus 0.62 ± 0.43D; P = .0285). The mean arithmetic error showed a more myopic result in the ECP group (-0.54 ± 0.53D versus -0.26 ± 0.52D; P = .0017). CONCLUSION: In this study, patients with PACS, PAC, or PACG having phacoemulsification and IOL implantation with ECP had decreased predictability of the postoperative refraction and a small myopic shift compared with those without ECP. FINANCIAL DISCLOSURE: Dr. Ahmed is a consultant to Alcon, Advanced Medical Optics, Bausch & Lomb, and Carl Zeiss. None of the other authors has a proprietary or financial interest in any material or method mentioned.

Fusarium keratitis in Mexico.

PURPOSE: To describe the clinical characteristics, diagnosis, treatment, and visual outcome of 61 cases of Fusarium keratitis in Mexico. METHODS: Retrospective, comparative study of 61 patients with clinically and culture-confirmed Fusarium keratitis, who were attended at an eye hospital in Mexico City from 1981 to 2001. RESULTS: Fusarium solani was the main causal agent in 83.6% of cases. Trauma history was observed in 57.4% and a history of agricultural activity in 34.4%. Signs were redness (100%), epithelial defects (98.3%), superficial corneal ulcer (95.1%), anterior chamber inflammation (91.8%), and satellite infiltrates (75.4%). In 50% of cases, the treatment was topical ketoconazole 2%; in 34.2% of cases, additional topical antifungal preparations were used. A total of 77% of patients improved and 23% worsened. Conjunctival flap was indicated in 4 of 61 patients (6.5%), and 14 of 61 patients (23%) underwent penetrating keratoplasty. Two of 61 patients were treated with tectonic keratoplasty. Evisceration surgeries were practiced in 14 of 61 patients (22.9%). The final visual acuity after medical or medical/surgical therapy, was no light perception (NLP) in 19 patients (33.33%), light perception (LP) to hand movements (HM) in 18 patients (31.57%), 20/400 to 20/200 in 1 patient (1.75%), 20/150 to 20/60 in 5 patients (8.77%), and 20/40 to 20/20 in 14 patients (24.56%). Four patients were lost to follow-up. CONCLUSIONS: Fusarium is the most common cause of fungal keratitis in Mexico. Most cases (43/54, 79.6%) improved with topical antifungal therapy (either monotherapy or combined). We suggest surgical therapy with conjunctival flap or penetrating keratoplasty in advanced cases, when there has been poor response to medical therapy or a very low final visual acuity.