Journal of cataract and refractive surgery最新文献

Purpose: To develop and assess the utility of an ophthalmic viscosurgical device (OVD) manufactured with fluorescein-conjugated hyaluronic acid (conjHA).

Setting: Department of Biomedical Engineering and the Wilmer Eye Institute, Johns Hopkins University and School of Medicine, Baltimore, Maryland.

Design: Laboratory study.

Methods: ConjHA and unconjugated HA (unconjHA) at varied ratios were used to produce OVD (conjOVD) with varied fluorescence intensity. The conjHA:unconjHA ratio was optimized to maximize clarity under white light and fluorescence intensity under cobalt blue light (CBL), allowing for conditional visualization. The effect of conjugation on conjOVD viscosity was assessed by rotational rheometry. Intraocular lenses (IOLs) were immersed in conjOVD for 4 hours to assess staining of IOLs. A proof-of-concept study was performed in ex vivo porcine eyes. After injection and visualization, the OVDs were removed from the eyes by irrigation/aspiration (I/A).

Results: 0.5 mg/mL of conjHA (degree of substitution = 0.005) enabled robust fluorescence of conjOVD under CBL. Fluorescein conjugation did not significantly affect conjOVD viscosity ( P > .05 for mean difference in viscosity at all shear rates tested). No staining of IOLs was appreciated. ConjOVD was visualized under CBL when injected ex vivo and maintained clarity of the anterior chamber under white light. Importantly, conjHA enabled delineation of retained OVD after I/A.

Conclusions: Use of OVD composed of fluorescein-conjugated HA is a feasible method to enable conditional visualization of OVD intraoperatively without nonspecific staining of ocular structures. Further development of this technology may enable accelerated OVD removal in ocular surgery or decreased OVD retention postoperatively.

Topic: Topical nonsteroidal anti-inflammatory drugs (NSAIDs) for management of pain in patients after photorefractive keratectomy (PRK).

Clinical relevance: Pain after PRK is a major concern for both patients and surgeons. Although evidence supports the use of NSAIDs postoperatively, no consensus exists regarding the preferred regimen. The study aimed to compare the efficacy and safety of different topical NSAIDs.

Methods: This study was prospectively registered with PROSPERO (ID: CRD42023417651). A systematic search of electronic databases was performed, for randomized controlled trials reporting topical NSAIDs' outcomes of corneal re-epithelization, rescue analgesics intake, and pain in days 0 to 3 after PRK (postoperative days [PODs] 0 to 3). Studies were graded for risk of bias. Data were extracted, and standardized mean differences (SMDs) were evaluated in a network meta-analysis in accordance with the Cochrane's guidelines, to which a frequentist approach model was fitted. Transitivity was assessed using the net split method. Treatment effectiveness was ranked using forest plots based on comparison with placebo. P-scores (P) and league tables were used to examine combined direct and indirect comparisons.

Results: Of 1540 studies identified, 27 were included. These encompassed 2286 patients across 11 countries, evaluating 7 distinct topical NSAIDs. At POD0, ketorolac (P 0.764), flurbiprofen (P 0.763), and bromfenac (P 0.717) were the most efficient drugs overall and displayed significantly lower pain scores than placebo. Other than that, flurbiprofen held the highest rank for reported pain throughout, significantly outperforming placebo on POD1 (P 0.874, SMD -1.19, 95% CI -1.86 to -0.52), POD2 (P 0.882, SMD -1.05, 95% CI -1.82 to -0.27), and POD3 (P 0.939, SMD -1.14, 95% CI -2.1 to -0.18). Other NSAIDs were significantly better than placebo only on POD1 and POD0. Rescue analgesic intake analysis favored indomethacin (P 0.834, SMD -0.8, 95% CI -1.33 to -0.27), ketorolac, and diclofenac. Compared with placebo, re-epithelization was slowed to different significances with all NSAIDs but flurbiprofen (P 0.991, SMD -0.7, 95% CI -1.38 to -0.03).

Conclusions: Flurbiprofen was favorable in pain scores on typically painful postoperative days and re-epithelization times. However, analgesics intake, a more objective outcome, suggested superiority of other NSAIDs. Inconsistencies may be explained by the small sample size. For clinical interpretation, NSAID effect sizes should be taken into consideration.

Purpose: To investigate the changing patterns of corneal endothelial cells and the associated factors in children with congenital ectopia lentis (CEL) after scleral-fixated intraocular lens (SF IOL) surgery.

Setting: Zhongshan Ophthalmic Center, Guangzhou, China.

Design: Retrospective study.

Methods: Patients were divided into the surgery group and the control group. Central endothelial cell density (ECD), coefficient of variation in cell size, the percentage of hexagonal cells (hexagonality), average cell size (AVG), and central corneal thickness were analyzed for both groups at baseline and each follow-up visit. Clinic characteristic, ocular parameters, IOL decentration, and IOL tilt of patients in the surgery group were collected. Multiple linear regression was performed to assess the potential associated factors for the postoperative changes in corneal endothelial cells in the surgery group.

Results: After 2-year follow-up, the decline of ECD was 17.8% (95% CI, -21.8 to -13.9) in the surgery group and -3.1% (95% CI, -5.2 to -1.0) in the control group ( P < .001), while the increase of AVG was 24.3% (17.1-31.6) in the surgery group and 2.7% (1.0 to 4.5) in the control group ( P < .001). Multivariate analysis showed that axial length (AL) ≥24 mm and white-to-white (WTW) <12.2 mm were significantly associated with greater loss of ECD (β = -241.41, 95% CI, -457.91 to -24.91, P = .030 and β = 251.63, 95% CI, 42.10-461.17, P = .020, respectively) and AL ≥24 mm was significantly positively associated with the increase of AVG (β = 34.81, 95% CI, 0.90-68.71, P = .044).

Conclusions: The SF IOL had a significant impact on corneal endothelium in children with CEL. More attention should be paid to monitor postoperative corneal endothelium change during long-term follow-up in CEL children, especially for those with longer AL and smaller WTW.

Purpose: To evaluate the stability of the postoperative vault of the implantable phakic contact lens (IPCL) 5 years after implantation.

Setting: Clínica de Ojos Dr. Nano, Olivos, Buenos Aires, Argentina.

Design: Retrospective case-series study.

Methods: Myopic patients operated with the IPCL for spherical correction in which preoperative data were compared with different scenarios of postoperative vault at 1, 3, and 5 years postoperatively. The main parameter to be evaluated was the vault obtained 5 years postoperatively.

Results: 140 eyes of 72 patients, aged 31.9 ± 2.8 years (21 to 50), were included. Most of the eyes (78.6%) obtained a vault between 250 μm and 750 μm, while in 15% of the eyes, it was less than 250 μm, and 6.4% were greater than 750 μm. The vault evaluated 1, 3, and 5 years postoperatively remained stable. Subcapsular cataracts were detected in 2 eyes, with vault <250 μm. A total of 50 eyes (35.7%) had cysts in the sulcus (5 cases in the group of eyes with vault >750 μm). No changes were detected in relation to intraocular pressure or endothelial cell count.

Conclusions: In eyes implanted with the IPCL over 5 years, it was observed that the vault remained stable over time. The proportion of eyes with cysts was higher in eyes with vaults larger than 750 μm.

Purpose: To investigate the factors affecting footplate position and its influence on vault characteristics after implantable collamer lens (ICL) implantation.

Setting: Hunan Provincial People's Hospital, Changsha, China.

Design: Retrospective case series.

Methods: This study included 124 patients (124 eyes). Ultrasound biomicroscopy (UBM) was performed to assess the iris and ciliary body morphologies and observe the footplate position. Using multiple linear regression, the relationship between various ocular and ICL parameters and the vault as well as the factors affecting the footplate distance (FD) were analyzed. Based on the FD, 3 groups were formed: group 1 (<500 μm), group 2 (500 to 1000 μm), and group 3 (>1000 μm). The distribution of the vault range postoperatively was observed for the 3 groups.

Results: Ciliary sulcus angle and FD significantly affected the vault (adjusted R2 = 0.190, F = 6.763, P < .001), with FD being the most important factor influencing the vault (β = -0.383, P < .001). Postoperative UBM revealed that the footplate was located at different positions in the posterior chamber, with the majority (52%) being located on the ciliary body. The mean size of the 4 footplate orientations was 0.88 ± 0.24 mm. Multiple linear regression analysis revealed that ciliary body thickness (CBT), iris curvature (IC), and ICL iris contact length (IRCL) significantly influenced the FD (adjusted R2 = 0.373, F = 11.432, P < .001). The vault range differed significantly among the 3 groups (X 2 = 32.33, P < .001).

Conclusions: Different postoperative ICL footplate positions significantly affect the vault. CBT, IC, and IRCL can alter the position of the footplate from the expected position. This study provides reference for ICL size selection and vault prediction.

Topic: To systematically compare the effectiveness of conventional phacoemulsification surgery (CPS) and low-energy femtosecond laser-assisted cataract surgery (FLACS) in patients with cataract.

Clinical relevance: Cataract surgery is a common procedure, and comparing different techniques such as CPS and low-energy FLACS is crucial for optimizing patient outcomes.

Methods: The PubMed, Web of Science, MEDLINE, EMBASE, and Cochrane library databases were searched for clinical trials. Outcomes of procedure time, effective phacoemulsification time, balanced salt solution usage, cumulative dissipated energy, mean change of corrected distance visual acuity, endothelial cells reduction, central corneal thickness (CCT), and aqueous cytokine level were evaluated. The effect measures were weighted mean differences with 95% CI. The protocol was registered at the Prospective Register for Systematic Reviews (registration number CRD42023420173).

Results: 11 studies were included in this meta-analysis, of which 1680 eyes were analyzed (637 eyes in the low-energy FLACS group and 1043 eyes in the CPS group). Low-energy FLACS demonstrated significantly fewer reductions in endothelial cell count at 6 months ( P < .001) compared with CPS. It also exhibited a shorter effective phacoemulsification time ( P < .001) and less balanced salt solution usage ( P < .001). However, there were no differences in cumulative dissipated energy, corrected distance visual acuity, CCT changes, or aqueous cytokine levels between the 2 groups.

Conclusions: Both low-energy FLACS and CPS are effective in treating cataracts, but low-energy FLACS may offer advantages such as reduced phacoemulsification time and less endothelial cell loss.

Purpose: To investigate predictive factors for redislocation in patients with recurrent intraocular lens (IOL) dislocation after secondary scleral-fixated IOL (SF IOL) surgery.

Setting: 2 tertiary referral hospitals.

Design: Retrospective case series.

Methods: Patients undergoing SF IOL surgery were grouped into redislocation and no-redislocation groups. Medical records of consecutive patients who underwent SF IOL surgery between June 2014 and December 2019 at 2 tertiary referral centers were reviewed. Data regarding patient demographics, treatment factors, anatomical and functional outcomes, and postoperative complications were recorded.

Results: 237 eyes of 225 patients (169 [75.1%] men) were included. The redislocation group was more likely to have a younger mean age at the initial SF IOL surgery (redislocation vs no-redislocation, 55.4 vs 62.0 years, respectively; P = .008), have a prior history of a previous suture break (23 eyes, 52.3% vs 1 eye, 0.5%; P < .001), and have undergone the initial SF IOL surgery using <1 mm-sized side-port incisions (17 eyes, 38.6% vs 32 eyes, 16.5%; P = .002) than was the no-redislocation group. In addition, the redislocation group had a higher occurrence of complications ( P < .001). Multivariate regression revealed that younger age, left eye involvement, aphakic status before the surgery, unremarkable primary IOL dislocation cause, need for ocular hypertension treatment and glaucoma surgery, and no large incision during the initial surgery were significantly (all P < .05) associated with redislocation.

Conclusions: Younger age, left eye involvement, postoperative complications such as ocular hypertension and glaucoma, and techniques without large incisions increase the risk of redislocation. Conversely, lower risk factors include unremarkable surgery causes and a history of aphakic conditions.

Purpose: To assess the cost-effectiveness of the treatment of low corneal astigmatism (≤1.5 diopters) at the moment of cataract surgery.

Setting: Qvision, Ophthalmology Department, VITHAS Almería Hospital, Spain.

Design: Economic evaluation.

Methods: A decision tree was used to assess the cost-effectiveness of implanting spherical vs toric intraocular lenses (IOLs) or spherical lens combined with the following corneal incisions: limbal-relaxing incisions conducted manually (M-LRI) or assisted by femtosecond laser (F-LRI), arcuate keratotomies conducted manually (M-AK) or assisted by femtosecond laser (F-AK), and intrastromal arcuate keratotomies (F-iAK). Outcomes of cost were selected from a patient perspective considering the gross cost of each one of the surgeries at European centers, and the effectiveness variable was the probability of achieving a visual acuity of 20/20 postoperatively. A sensitivity analysis was conducted to assess the uncertainty considering the evidence retrieved from the transition probabilities of the model, effectiveness, and cost.

Results: F-AK or toric IOLs were the most effective treatments, increasing an 16% or 9%, respectively, in the percentage of eyes attaining 20/20 vision. The M-LRI, F-iAK, and F-LRI procedures were strongly dominated while the M-AK and toric IOL were weakly dominated by the F-AK. A patient with low corneal astigmatism would need to be willing to pay 360€ (95% CI, 231-1224) with F-AK and 472€ (95% CI, 149-4490) with toric IOLs for a 10% increase in the probability of achieving 20/20 vision.

Conclusions: From patient perspective, F-AK was generally the most cost-effective treatment, although toric IOLs can dominate in some countries.

In May 2023, a 36-year-old carpenter complained of a sudden decrease in visual acuity in both eyes after his fourth COVID-19 vaccination. He underwent extensive evaluation by ophthalmological, neurological, and internal medicine specialists elsewhere, which was unremarkable, except for a computed tomography scan of his brain showing minor occipital calcifications. In 2021, he had been diagnosed with anterior basement membrane dystrophy and treated with phototherapeutic keratectomy (PTK) of the left eye, leading to significant postoperative haze. On referral in July 2023, slitlamp examination showed significant anterior basement membrane dystrophy in the right eye, whereas the left eye had an extensive central scar in the anterior stroma, measuring up to 6 mm in width and 140 µm in depth (Figures 1-3JOURNAL/jcrs/04.03/02158034-202410000-00017/figure1/v/2024-09-18T130724Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202410000-00017/figure2/v/2024-09-18T130724Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202410000-00017/figure3/v/2024-09-18T130724Z/r/image-tiff). His corrected distance visual acuity was 20/80 in his right eye and 20/200 in his left eye, with a manifest refraction of -0.50 -3.75 × 170 and +0.00 -4.75 × 180, respectively. Corneal Scheimpflug topography showed regular corneal astigmatism of 3.3 diopters (D) and 5.5 D in the right and left eyes, respectively, with a corneal thickness of 550 and 566 µm (Figure 4JOURNAL/jcrs/04.03/02158034-202410000-00017/figure4/v/2024-09-18T130724Z/r/image-tiff). The Schirmer tear test was 20-20 mm. Fundoscopy, electrophysiological testing, and retinal optical coherence tomography (OCT) showed no abnormalities. The patient mentioned he had Crohn disease, managed with ustekinumab (a monoclonal antibody inhibitor of cytokines interleukin [IL]-12 and IL-23), but he had discontinued it because of the apparent remission of the disease. Attempts to improve visual acuity involved a soft bandage contact lens in the right eye, which was discontinued after 2 days because of the occurrence of a small corneal infiltrate that healed with a short course of topical antibiotics. Unfortunately, because of his vision, he cannot perform his tasks as a carpenter anymore. Which is your recommended treatment for both eyes?