Intraoperative subconjunctival steroid reduces the incidence of pseudophakic macular oedema: a cohort study of 20,066 consecutive phacoemulsification surgeries.

BACKGROUND/OBJECTIVES: Pseudophakic macular oedema remains the most common sight-threatening complication following cataract surgery. This study aims to assess the effect of intraoperative subconjunctival steroids on the rate of pseudophakic cystoid macular oedema. METHODS: A retrospective, observational database study of 20 066 consecutive phacoemulsification surgeries. The incidence of pseudophakic cystoid macular oedema was compared in eyes that did and did not receive intraoperative subconjunctival steroid injection during routine cataract surgery. RESULTS: Intraoperative subconjunctival injection of dexamethasone or betamethasone sodium phosphate significantly reduced the odds of developing pseudophakic cystoid macular oedema across the cohort (odds ratio: 0.67; 95% confidence interval: 0.46-0.98, p = 0.039). The effect of subconjunctival steroids on pseudophakic macular oedema remained independently associated on multivariate logistic regression analysis (p = 0.028). CONCLUSION: This study demonstrates that administration of intraoperative subconjunctival steroid injection is associated with a reduced incidence of pseudophakic cystoid macular oedema in routine, uncomplicated cataract surgery.

Developing refractive management recommendations for patients undergoing cataract surgery: A Delphi study.

PURPOSE: Currently, there are no UK optometric guidelines regarding the pre and postoperative refractive management of patients undergoing cataract surgery. This study used a Delphi method to gain consensus on best practice. METHODS: Eighteen recommendations targeted areas of concern/variability in advice that were highlighted in an earlier focus group study of refractive management for patients who had received cataract surgery. These covered three topics: preoperative target refraction discussions, postoperative refractive management and driving advice postoperatively. The recommendations were then developed using evidence from optometry and ophthalmology clinical expertise and the research literature. Eighteen recommendations underwent a process of agreement and modification using a Delphi study consisting of a panel of 22 highly experienced optometrists (N = 11, 25 years mean clinical experience) and ophthalmologists (N = 11, 17 years mean clinical experience) who rated and commented upon the importance and feasibility of each recommendation. The responses were considered by the research team and the recommendations modified and/or removed prior to a second Delphi round of responses to a modified series of recommendations. Consensus of opinion was defined as greater than 80% of panellists 'agreed' or 'strongly agreed' on the recommendation for both importance and feasibility. RESULTS: Fourteen of the 18 recommendations reached consensus in the first round. A second round of the Delphi method saw 17 modified recommendations scored and commented upon by 20 clinicians. Fifteen recommendations reached consensus after two rounds of the Delphi method. CONCLUSIONS: Recommendations to guide the pre and postoperative refractive management of patients undergoing cataract surgery were agreed between highly experienced optometrists and ophthalmologists using a 2-round Delphi method. Patients would benefit from consistent target refraction discussions, postoperative refractive management and driving advice, and recommendations were of particular benefit to less experienced optometrists.

Mitigation and management strategies for ocular events associated with tisotumab vedotin.

Tisotumab vedotin is a tissue factor-directed antibody-drug conjugate developed for treatment of recurrent or metastatic cervical cancer (r/mCC). In the pivotal phase 2 study innovaTV 204, 101 r/mCC patients received tisotumab vedotin. 138 ocular treatment-related AEs (TRAEs), predominantly Grade 1 or 2, were observed in 54 (53%) patients. The most common ocular TRAEs were conjunctivitis (26 patients [26%]), dry eye (23 patients [23%]), and keratitis (11 patients [11%]). Observed ocular TRAEs are hypothesized to be conjunctival and inflammatory in nature, resulting in signs and symptoms readily recognizable by patients and healthcare providers. Generally, ocular TRAEs were manageable with ophthalmic care (prophylactic and symptom management) and dose modifications. Of 138 ocular TRAEs, 118 (86%) resolved within 30 days after last dose of tisotumab vedotin. Median time to resolution was 0.7 months (interquartile range: 0.3-1.6). To help reduce the risk of ocular AEs, an eye care plan based on clinical trial experience was developed. This encompasses an oncology care team partnering with an eye care provider, incorporates eye exams at baseline (per trial mitigation measures) and prior to each dose, includes eye drops and cold packs, avoids contact lens use, and advises prompt referral for new or worsening ocular signs and symptoms. Moreover, dose modification guidelines have been developed to manage potential ocular AEs. Ocular AEs will require patient management strategies that may be new to oncology teams. Oncologists should become familiar with symptoms that typically arise, and eye care providers should be an integral part of the comprehensive care team treating patients receiving tisotumab vedotin. With diligent monitoring for early signs and symptoms, careful adherence to required eye care, pharmacologic intervention when ocular AEs arise, and dose modifications when needed, ocular AEs can be detected early and symptoms can be alleviated before any impact on vision, to ultimately help patients stay on therapy.

Recurring themes during cataract assessment and surgery.

The aim of this review was to discuss frequently encountered themes such as cataract surgery in presence of age-related macular degeneration (AMD), dementia, Immediate Sequential Bilateral Cataract Surgery (ISBCS), discussing non-standard intraocular lens (IOL) options during consultation in the National Health Services (NHS) and the choice of the biometric formulae based on axial length. Individual groups of authors worked independently on each topic. We found that cataract surgery does improve visual acuity in AMD patients but the need for cataract surgery should be individualised. In patients with dementia, cataract surgery should be considered 'sooner rather than later' as progression may prevent individuals presenting for surgery. This should be planned after discussion of patients' best interests with any carers; multifocal IOLs are not proven to be the best option in these patients. ISBCS gives comparable outcomes to delayed sequential surgeries with a low risk of bilateral endophthalmitis and it can be cost-saving and efficient. Patients are entitled to know all suitable IOL options that can improve their quality of life. Deliberately withholding this information or pressuring patients to choose a non-standard IOL is inappropriate. However, one should be mindful of the not spending inappropriate amounts of time discussing these in the NHS setting which may affect care of other NHS patients. Evidence suggests Hoffer Q, Haigis, Hill-RBF and Kane formulae for shorter eyes; Barrett Universal II (BU II), Holladay II, Haigis and Kane formulae for longer eyes and BU II, Hill-RBF and Kane formulae for medium axial length eyes.

5 year incidence of YAG capsulotomy and PCO after cataract surgery with single-piece monofocal intraocular lenses: a real-world evidence study of 20,763 eyes.

OBJECTIVES: To evaluate the 3- and 5-year incidence of posterior capsule opacification (PCO) and neodymium-doped yttrium aluminium garnet (Nd:YAG) capsulotomy in patients following cataract surgery, comparing results for different single-piece acrylic hydrophilic and hydrophobic monofocal intraocular lens (IOL) models and other patient factors. PATIENTS AND METHODS: Electronic medical record data collected from seven United Kingdom (UK) National Health Service (NHS) ophthalmology clinics for routine, age-related (≥65 years) cataract surgeries that implanted single-piece acrylic monofocal IOLs during 2010-2013 were used to calculate 3- and 5-year incidence of Nd:YAG and PCO. IOL models of Alcon Acrysof, AMO Tecnis, Bausch & Lomb (B & L) Akreos, LenStec Softec, and Rayner Flex were analyzed. Pairwise comparisons were conducted between AcrySof IOLs and other IOLs using Bonferroni adjustment for multiplicity. Multivariate analyses were conducted adjusting for known confounders. RESULTS: The incidence of Nd:YAG capsulotomy ranged between 2.4-12.6% at 3 years and 5.8-19.3% at 5 years post-cataract surgery. Similarly, the incidence of PCO ranged between 4.7-18.6% at 3 years and 7.1-22.6% at 5 years. When comparing all of the single-piece IOLs, AcrySof demonstrated the lowest incidence rates for both PCO and Nd:YAG (P < 0.001 for each comparison). From adjusted logistic regression analysis, AcrySof were associated with lower 3- and 5-year odds of Nd:YAG and PCO incidence. CONCLUSIONS: Following cataract surgery with single-piece monofocal IOLs different incidence rates of PCO were observed with different IOLs. AcrySof IOLs were associated with significantly lower incidence of PCO requiring Nd:YAG treatment over periods of 3 and 5 years.

Factors affecting cataract surgery operating time among trainees and consultants.

PURPOSE: To define factors affecting cataract surgery operating time for operating room planning, optimizing throughput, enhancing patient experiences, minimizing costs, and allocating training time. SETTING: Epsom and St. Helier University National Health Service Trust, London, United Kingdom. DESIGN: Retrospective case series. METHODS: All patients who had primary manual phacoemulsification cataract surgery from January 1, 2012, to December 30, 2016, were included. Combined anterior and posterior segment procedures and surgeons with fewer than 50 cases were excluded. Anonymized data collected were demographics, anesthesia, operating time, surgeon grade, case complexity, pupil size, pupil expander or capsular tension ring (CTR) use, intraocular lens type, posterior capsule or zonular fiber rupture or dialysis, vitreous loss, and automated anterior vitrectomy. RESULTS: From 11 067 cases, 9552 (86.3%) had a recorded operating time. The mean ± SD operating times in minutes were as follows: consultants 19 ± 10, junior 30 ± 11, intermediate 27 ± 12, senior trainees 24 ± 10, and fellows 31 ± 11. Operating time was significantly shorter for topical than for sub-Tenon or general anesthesia, especially among trainees. Consultant operating time remained unchanged with increasing case complexity, except for high-complexity cases. Small pupils, pupil expander or CTR use, posterior capsule or zonular fiber rupture or dialysis with or without vitreous loss (mean 45 ± 23) were associated with increased operating times. Iris hooks were associated with greater increases in operating time than Malyugin rings (16 minutes versus 6 minutes; P < .001). There was a modest 3-minute decrease in operating time among consultants over 5 years. CONCLUSION: Cataract surgery operating time was significantly influenced by anesthesia type, surgeon grade, high case complexity, pupil size, pupil expander use/type, CTR use, and intraoperative complications.

Iris hooks versus a pupil expansion ring: Operating times, complications, and visual acuity outcomes in small pupil cases.

PURPOSE: To compare iris hooks and a pupil expansion ring (Malyugin ring) in eyes with a small pupil. SETTING: Epsom and St. Helier University National Health Service Trust, London, United Kingdom. DESIGN: Retrospective case series. METHODS: Patients who had primary phacoemulsification cataract surgery from January 1, 2012, to December 30, 2016, were included. Combined procedures and surgeons with fewer than 50 cases were excluded. Anonymized data were demographics, surgeon grade, case complexity, iris hooks or Malyugin ring use, posterior capsule rupture, zonular fiber rupture or dialysis, vitreous loss, operating time, postoperative complications, and visual acuity. RESULTS: Of the 9552 cases included, 425 (4.4%) had a small pupil, 314 of which required a pupil expansion ring and 95 iris hooks. Compared with no pupil expander, iris hooks were associated with an additional operating time of 14 minutes for consultants and 24 minutes for trainees. The pupil expansion ring was associated with an additional operating time of 4 minutes and 6 minutes, respectively. Neither pupil expander was associated with more intraoperative complications. The pupil expansion ring was associated with higher postoperative anterior uveitis and corneal edema rates. Pupil expander cases achieved equivalent visual acuity gains. CONCLUSIONS: The pupil expansion ring and iris hooks were safe and effective in minimizing intraoperative complications in eyes with a small pupil. The pupil expansion ring was faster to use than iris hooks. Monitoring for signs of postoperative anterior uveitis or cornea edema with careful insertion or removal of pupil expansion rings is advocated.

Updated cataract surgery complexity stratification score for trainee ophthalmic surgeons.

PURPOSE: To devise a comprehensive cataract surgery complexity score system for the selection of appropriate cases for trainees using evidence-based, validated risk factors for posterior capsule rupture, patient-specific factors, and complexity stratification recommendations to minimize complications, optimize outcomes, and maximize patient safety. SETTING: Epsom and St. Helier University National Health Service Trust, London, United Kingdom. DESIGN: Retrospective cohort study. METHODS: Patients having primary phacoemulsification cataract surgery from January 1, 2011 until December 31, 2016 were included; combined corneal, glaucoma, or posterior segment procedures were excluded. Anonymized data on demographics, pupil size, pupil expander use, intraoperative and postoperative complications, and postoperative distance visual acuity were extracted. Patients were stratified by complexity score and surgeon grade (consultant, junior, intermediate, and senior trainee, and fellow). RESULTS: From 11 468 included cases, 8200 (71.5%) had a complexity score. Small pupil, pupil expander use, iris damage during phacoemulsification, zonular dialysis, postoperative raised intraocular pressure, and corneal edema (odds ratio, 3.17; 95% confidence interval, 2.05-4.92) were significantly associated with increasing complexity. Appropriate case allocation by complexity and surgeon grade resulted in no association between posterior capsule rupture and complexity score. Increasing complexity scores were associated with lower postoperative distance visual acuity. CONCLUSIONS: The updated evidence-based comprehensive cataract complexity score system is a useful tool for the stratification of case complexity and guides appropriate case selection to match trainee experience. Higher complexity scores were associated with greater intraoperative and postoperative complications and lower postoperative distance visual acuity. Patients with higher scores should be made aware of the guarded prognosis when obtaining consent.

Three-year incidence of Nd:YAG capsulotomy and posterior capsule opacification and its relationship to monofocal acrylic IOL biomaterial: a UK Real World Evidence study.

PURPOSE: To evaluate 3-year incidence of Nd:YAG capsulotomy and PCO and compare the effect of different IOL materials. METHODS: Data were retrospectively collected from seven UK ophthalmology clinics using Medisoft electronic medical records. Eyes from patients ≥65 years undergoing cataract surgery with implantation of acrylic monofocal IOLs during 2010-2013 and 3-year follow-up were analysed. Nd:YAG capsulotomy and PCO incidence proportions were reported for 3 IOL cohorts: AcrySof, other hydrophobic and hydrophilic acrylic IOLs. Unadjusted/adjusted odds ratios (OR) of Nd:YAG capsulotomy were calculated through logistic regression for non-AcrySof cohorts versus AcrySof. A sub-group analysis in single-piece IOLs (>90% of sample eyes) was also performed. RESULTS: The AcrySof cohort included 13,329 eyes, non-AcrySof hydrophobic 19,025 and non-AcrySof hydrophilic 19,808. The 3-year Nd:YAG capsulotomy incidence (95% CI) for AcrySof (2.4%, 2.2-2.7%) was approximately two times lower than non-AcrySof hydrophobic IOLs (4.4%, 4.1-4.7%) and approximately fourfold lower than non-AcrySof hydrophilic IOLs (10.9%, 10.5-11.3%). Trends were similar in PCO incidence (AcrySof: 4.7%; non-AcrySof hydrophobic: 6.3%; non-AcrySof hydrophilic: 14.8%). Also in the analysis restricted to single-piece IOLs, the pattern remained (2.4% vs 5.1% vs. 10.9%, respectively). Adjusted regression analysis showed a approximately two and fivefold increased odds of Nd:YAG for non-AcrySof hydrophobic and hydrophilic acrylic IOLs respectively vs. AcrySof IOLs. Nd:YAG capsulotomy ORs were similar and remained statistically significant in the single-piece IOL sub-group. CONCLUSIONS: Real-world evidence shows that within 3 years following implantation, AcrySof IOLs are significantly superior in reducing Nd:YAG capsulotomy and PCO incidence compared to other hydrophilic and hydrophobic acrylic IOLs.

Intraocular pressure effects of common topical steroids for post-cataract inflammation: are they all the same?

The efficacy of topical corticosteroids as ocular anti-inflammatory agents following cataract surgery is well-documented. They also help to prevent a number of complications associated with post-operative ocular inflammation, including corneal edema and cystoid macular edema. However, topical corticosteroids are associated with side effects, such as increased intraocular pressure (IOP). Indeed, corticosteroid-induced ocular hypertension and the potential for steroid-induced glaucoma remain the leading drawbacks of topical corticosteroid therapy. Some individuals are known to experience a high degree of IOP elevation with low doses or short durations of treatment with topical corticosteroids. Careful monitoring of IOP in such individuals is essential. Few randomized, controlled studies are available on the comparative safety and efficacy of common topical corticosteroids in the treatment of post-operative ocular inflammation. Furthermore, the lack of consistent reporting criteria for clinically significant IOP increases across clinical studies makes meaningful comparisons among corticosteroids difficult. This review aims to examine data from available published studies, including studies in steroid responders, to determine whether topical corticosteroids are the same in terms of their effect on IOP. Early generation corticosteroids, such as dexamethasone and prednisolone, are more likely to result in clinically significant increases in IOP. Newer corticosteroids, such as rimexolone and the retro-metabolically designed corticosteroid, loteprednol etabonate, offer similar anti-inflammatory efficacy to older corticosteroids with less effect on IOP. However, randomized controlled trials of newer corticosteroids are needed. The proportion of patients exhibiting an increase of ≥10 mmHg IOP in clinical studies has emerged as the most clinically relevant parameter for ophthalmologists to consider when deciding on which topical corticosteroid to use.

Automated keratometry in routine cataract surgery: comparison of Scheimpflug and conventional values.

PURPOSE: To compare the mean keratometry (K) readings obtained with a conventional automated keratometer (IOLMaster) and a Scheimpflug keratometer (Pentacam) in eyes having preoperative assessment for routine cataract surgery. SETTING: Epsom and St. Helier University Hospitals, London, United Kingdom. DESIGN: Evaluation of diagnostic technology. METHODS: Mean K values were obtained with the conventional and Scheimpflug keratometers. The following Scheimpflug readings were evaluated: anterior K, true net power, and Holladay equivalent K measured at 1.0 to 7.0 mm corneal diameters. Mean readings for each type of keratometry were compared. Bland-Altman plots were used to determine the 95% limits of agreement (LoA) for the conventional and Scheimpflug keratometers. RESULTS: The mean conventional K was statistically significantly greater than the mean Scheimpflug K for true net power and equivalent K at 1.0 mm, 2.0 mm, 3.0 mm, and 4.0 mm corneal diameters. The mean conventional K was significantly less than the equivalent K at 5.0 mm, 6.0 mm, and 7.0 mm. The smallest mean difference was for equivalent K at 4.5 mm (0.02 diopters [D]). The smallest 95% LoA were -0.68 to 1.16 D (equivalent K at 5.0 mm) and -0.91 to 0.95 D (equivalent K at 4.5 mm). CONCLUSIONS: Overall, the equivalent K at 4.5 mm had the closest match with the conventional K values. The degree of interdevice variability with the conventional keratometer was lowest for the equivalent K at 4.5 mm and 5.0 mm, although this variability would be sufficient to influence intraocular lens power selection.

Scheimpflug keratometry versus conventional automated keratometry in routine cataract surgery.

PURPOSE: To evaluate keratometry (K) readings obtained with an automated keratometer (IOLMaster) and Scheimpflug imaging (Pentacam) in eyes having routine cataract surgery and to compare the predicted and actual refractive outcomes. SETTING: Epsom/St. Helier University Hospitals, London, United Kingdom. METHODS: In this retrospective study, the mean absolute prediction errors (MAEs) were obtained for automated keratometry and Scheimpflug keratometry: true net power, anterior K, and equivalent K [corrected] values for 1.0 to 7.0 mm corneal diameters. Eyes were divided into lower delta K (mean 1.15 diopters [D]) and higher delta K (mean 2.13 D) groups and lower preoperative astigmatism (mean 0.83 D) and higher preoperative astigmatism (mean 2.55 D) groups to determine notable trends. RESULTS: The study evaluated 29 eyes. The lowest MAE was 0.424 D +/- 0.421 (SD) for Scheimpflug equivalent [corrected] K at 3.0 mm; the second lowest was 0.452 +/- 0.359 D for automated keratometry, which had the smallest SD overall. The difference was not statistically significant. In the lower delta K and astigmatism groups, the automated keratometer had the lowest MAE and smallest standard deviation. In the higher groups, there was a trend toward increased accuracy for the Scheimpflug equivalent [corrected] K values at 3.0 mm. CONCLUSION: In this small study, Scheimpflug imaging was not superior to automated keratometry overall, but the data suggest a trend toward increased accuracy of Scheimpflug equivalent [corrected] K values in eyes with more irregular corneas. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.