Follow-Up Study of Over Three Years of Patients with Uveitis after Cataract Phacoemulsification: Outcomes and Complications

Purpose: To evaluate the rate and onset of intraoperative and postoperative complications post-phacoemulsification. Methods: One hundred sixty-two eyes of 145 patients with uveitis who underwent phacoemulsification between 2006 and 2009 were identified through surgical record review. Fifty-nine eyes of 46 patients met the inclusion criteria. Hazard ratio (HR) and Kaplan-Meier survival probability were calculated for each class of uveitis. Results: Macular edema (ME) resulted to be associated to chronic postoperative inflammation (r?=?0.6; p?=?0.00) and mostly related to patients who presented more than one postoperative relapse/year (r?=?0.2; p?=?0.02). Fuchs uveitis resulted to be a risk factor for posterior capsule opacification (PCO) (HR 3.36 IC95%1.0-10.5; p?=?0.03). Hypotony and elevated intraocular pressure (IOP) were detected in the anterior uveitis group (0.02 EY). Conclusion: The HR to develop ME was significantly related to chronic anterior uveitis. PCO and elevated IOP are most frequent in Fuchs uveitis. The postoperative visual acuity result was good among all the uveitis groups.     

Analysis and Outcomes of Cataract Surgery in Patients with Acquired Immunodeficiency Syndrome

Purpose: To investigate the surgical outcomes, complications and postoperative progression in HIV patients undergoing cataract surgery in a teaching hospital.

Methods: A retrospective cohort study of patients with HIV/AIDS who had cataract surgery from January 2000 until December 2011 at a tertiary referral multidisciplinary hospital in Singapore.

Results: We identified 44 eyes from 29 patients. Preoperatively, 41.3% had no ophthalmic manifestations of HIV/AIDS, while 16 eyes had quiescent cytomegalovirus retinitis (CMVR). Postoperatively, 1 eye developed new CMVR, while 1 eye had reactivation of previous CMVR. Of eyes with new or previous CMVR, 1 eye developed rhegmatogenous retinal detachment (RD) postoperatively. Only 3 eyes had prolonged postoperative inflammation. There were no cases of endophthalmitis or cystoid macular edema. Postoperative improvement of at least two Snellen lines was achieved in 86.6% of eyes.

Conclusions: Cataract surgery in HIV patients is generally safe, regardless of CD4 count, but their general and ocular health should be optimized preoperatively.     

Follow-Up Survey of Cataract Surgical Coverage and Barriers to Cataract Surgery at Nkhoma,Malawi

Purpose: Nkhoma Eye Hospital, Malawi provides high volume, high quality free cataract surgery to people in its catchment region of Central-Malawi. However, a previous survey in 2000 indicated that only 1 in 7 people with bilateral blindness from cataract had received surgery in a 10-mile radius of Nkhoma.

Methods: We conducted a population-based survey in 2006 in the 32 villages within a 10-mile radius of Nkhoma Hospital in people aged ≥ 40 years in order to investigate the cataract surgical coverage (CSC) and barriers to cataract surgery.

Results: The prevalence of blindness (visual acuity [VA] <3/60 in better eye) in 835 people aged ≥ 40 was 1.3% (95% CI 0.5–2.1), of which 36.4% was due to cataract. Overall, the CSC was 83.3%, and for eyes (VA<3/60) was 66.0%. The CSC was lower in females compared to males (73.3% vs. 100.0%. P?<?0.001). The most common barrier to surgery was cost (58%).

Conclusion: Our results demonstrate a 5-fold increase in coverage in the 6 years, primarily by increasing efficiency of the service provider and providing a community screening and referral service. Supporting the ophthalmic personnel with appropriate infrastructure and management has been central to this shift. Implementing an active case finding and referral mechanism has enabled this unit to provide regular high volume cataract surgery. There is a need to understand the factors influencing perceptions about cost as a barrier in this community and the disparity between need and access to services for women.     

Cataract Surgery in Retinitis Pigmentosa Patients

From the UCLA Retinitis Pigmentosa Registry, 30 patients with 54 aphakic eyes were studied in a retrospective analysis to evaluate the results of cataract surgery. Patients consisted of 19 men and 11 women, with an age range at the time of cataract surgery from 24 to 75 years (mean 47 years). After surgery all aphakic eyes showed some improvement in visual acuity; 83% of eyes demonstrated improvement in visual acuity of at least two lines on the Snellen chart, and 52% of eyes achieved a visual acuity of 20/50 or better. In all eyes, the postoperative visual field was unchanged when compared with the preoperative visual field. Subjectively, 83% of patients reported benefit from cataract surgery. Guidelines for the preoperative evaluation of retinitis pigmentosa (RP) patients with cataracts are presented.     

合并葡萄膜炎者的白内障手术

葡萄膜炎白内障手术较单纯老年性白内障手术更具挑战性.葡萄膜炎白内障通常由慢性炎症或长期使用糖皮质激素所致,明确病因诊断、完善眼科检查、充分控制炎症和精细手术操作对获得视力改善相当重要.对严重的葡萄膜炎患者,控制炎症的关键是全身或局部糖皮质激素使用联合免疫抑制剂,免疫抑制剂可有助于充分控制眼内炎症,减少使用糖皮质激素的副作用.在活动性炎症完全控制3个月后行超声乳化白内障吸除联合人工晶状体植入术,绝大多数患者可获得视力改善.     

Long-Term Efficacy and Rotational Stability of AcrySof Toric Intraocular Lens Implantation in Cataract Surgery

Purpose

To evaluate the long-term efficacy and rotational stability of the AcrySof toric intraocular lens (IOL) in correcting preoperative astigmatism in cataract patients.

Methods

This prospective observational study included 30 eyes from 24 consecutive patients who underwent implantation of an AcrySof toric IOL with micro-coaxial cataract surgery between May 2008 and September 2008. Outcomes of visual acuity, refractive and keratometric astigmatism, and IOL rotation after 1 day, 1 month, 3 months, and long-term (mean, 13.3±5.0 months) follow-up were evaluated.

Results

At final follow-up, 73.3% of eyes showed an uncorrected visual acuity of 20/25 or better. The postoperative keratometric value was not different from the preoperative value; mean refractive astigmatism was reduced to -0.28±0.38 diopter (D) from -1.28±0.48 D. The mean rotation of the toric IOL was 3.45±3.39 degrees at final follow-up. One eye (3.3%) exhibited IOL rotation of 10.3 degrees, the remaining eyes (96.7%) had IOL rotation of less than 10 degrees.

Conclusions

Early postoperative and long-term follow-up showed that implantation of the AcrySof toric IOL is an effective, safe, and predictable method for managing corneal astigmatism in cataract patients.     

Barriers for Poor Cataract Surgery Uptake among Patients with Operable Cataract in a Program of Outreach Screening and Low-cost Surgery in Rural China

Aims: To identify the reasons for poor uptake of cataract surgery in a program of outreach screening and low-cost surgery in Pucheng County, a rural area in northwestern China.

Methods: Detailed interviews with a semi-structured questionnaire were conducted by telephone or face-to-face for participants who had been advised to attend a low-cost cataract surgery program but did not schedule the surgery within 3 months after the initial screening.

Results: Among 432 eligible subjects, 355 (82.2%) were interviewed (mean age 70.6?±?6.6 years, 73.8% female). A total of 138 subjects (38.9%) were interviewed by phone and 217 (61.1%) were interviewed face-to-face. Lack of family support (n?=?106, 29.9%) and failure to understand the need for surgery (n?=?96, 27.0%) were the two main reasons for not undergoing cataract surgery. Other factors included fear of surgery (n?=?62, 17.5%), lack of faith in doctors (n?=?36, 10.1%), financial constraints (n?=?25, 7.0%) and lack of transportation (n?=?4, 1.1%).

Conclusion: The principal barriers to low-cost cataract surgery uptake in rural China included lack of family support and failure to understand the need for surgery. Education targeting entire families to eliminate these barriers and development of community support systems at the family level are required to achieve greater uptake of low-cost cataract surgery programs in rural China.     

Household Preferences for Cataract Surgery in Rural India: A Population-based Stated Preference Survey

Abstract

Purpose: Cataract surgery is provided both by the private and public sector in India. Free cataract surgery (with minimal amenities) funded through subsidies/reimbursements by government and non-governmental organizations is provided for underprivileged and poor patients, especially in rural areas. However, no evidence exists whether this free surgery is used by those who could afford to pay and are willing to pay for cataract surgery. So, understanding willingness to pay and preferences for cataract surgery in the population can have important policy implications.

Methods: A cross-sectional survey of 1272 households from four randomly drawn rural household clusters in Theni district, Tamilnadu state, India was conducted. Respondents from households were presented with scenarios (with and without free surgery availability) to elicit their willingness to pay and preferences for cataract surgery.

Results: Of those willing to undergo surgery; 696 (57%) were willing to undergo paid surgery, 148 (12%) only free surgery, and 378 (31%) paid surgery if no free surgery was available. In a multinomial logit model, household wealth measures, income variables and family history of cataract surgery largely distinguished the preferences. Good understanding of cataract and its intervention only marginally influenced preference for paid surgery.

Conclusion: A larger number of people were willing to pay when free surgery was not available. Free surgery may be crowding out surgery for which costs can be recovered. With non-cataract causes of blindness in the Indian population also requiring attention, this has implications for allocation of scarce resources.     

Cataract Surgery with Primary Lens Implantation in Children with Chronic Uveitis

Purpose: To evaluate the evolution of chronic uveitis in children undergoing cataract surgery with primary intraocular lens (IOL) implantation.

Methods: Twelve children with chronic uveitis underwent cataract surgery with primary posterior chamber intraocular lens (IOL) implantation.

Results: Fourteen eyes were implanted with a foldable hydrophobic acrylic IOL. The mean follow-up was 35.39 months (8.72–69.57). The mean BCDVA before surgery and at the end of follow-up was 1.11 (0.40–2.30; SD: 0.57) and 0.48 (0–3; SD: 0.77; p=0.007) respectively. The mean oral corticosteroids dosage after surgery and at the end of follow-up was 0.80 mg/kg/day (SD: 0.37) and 0.17 mg/kg/day (SD: 0.24; p=0.001) respectively. All patients except one were treated with methotrexate. Four patients (5 eyes) were additionally treated with anti-tumor necrosis factor agent.

Conclusions: Cataract surgery with primary posterior chamber hydrophobic IOL implantation is possible and leads to a good visual recovery in cases of pediatric chronic uveitis. This surgery requires aggressive anti-inflammatory management with immunosuppressive drugs to control inflammation and reduce the corticosteroids dosage.     

Manual small-incision cataract surgery under topical anesthesia for post-uveitis complicated cataract

Purpose:Cataract development is a common sequelae associated with uveitis. Despite phacoemulsification being the popular method of cataract surgery today, manual small-incision cataract surgery (MSICS) may still be a safe and effective alternative because of several inherent benefits. There is not much literature and studies on the efficacy and safety of MSICS under topical anesthesia in complicated cataract in patients with uveitis. We aimed to study the safety and visual outcome of MSICS under topical anesthesia for post uveitis complicated cataract.Methods:This was a retrospective observational study. The electronic medical records of adult patients who underwent MSICS under topical anesthesia for post uveitis cataract were reviewed. The records were reviewed and analyzed for preoperative clinical characteristics and visual acuity, intraoperative complications and postoperative visual acuity, and complications.Results:A total of 71 eyes of 59 patients were taken for final analysis. The average age of patients was 59.9 years. There was improvement in the best corrected visual acuity by 0.7 logMAR (P value <0.0001). Average follow-up period was 9.8 months. The mean gain in visual acuity in eyes that received preoperative steroids was 0.6 logMAR compared to the eyes that did not receive steroids (0.71 logMAR). The difference was not statistically significant (P = 0.407). Complications seen during long-term follow-up were recurrence (15.5%), cystoid macular edema (7%), Epiretinal membrane (8.5%), and posterior capsular opacification (5.5%).Conclusion:With proper technique and precautions, MSICS can be safely and comfortably performed under topical anesthesia even in complicated cataracts with excellent visual and safety outcomes.     

Cataract Surgery Complications in Uveitis Patients: A Review Article

ABSTRACT

Uveitis is a leading causes of blindness worldwide, and the development of cataracts is common due to both the presence of intraocular inflammation and the most commonly employed treatment with corticosteroids. The management of these cataracts can be very challenging and often requires additional procedures that can compromise surgical results. The underlying disease affects a relatively young population at higher risk of complications. Preoperative control of inflammation/quiescent disease for at least three months is generally accepted as the minimum amount of time prior to surgical intervention. Phacoemulsification with intraocular lens is the preferred method for surgery, with some studies showing improvement in visual acuity in over 90% of patients. The most common postoperative complications include macular edema, posterior capsule opacification, recurrent or persistent inflammation, glaucoma, epiretinal membrane and IOL deposits, or dislocation. Despite the potential complications, cataract surgery in uveitis patients is considered a safe and successful procedure.     

Combined Cataract Extraction and Glaucoma Surgery

An approach to the surgical management of eyes with concomitant cataract and glaucoma is outlined, and the author's experience in 73 consecutive cases is described. Cataract extraction alone is recommended when glaucomatous damage is minimal, and the intraocular pressure is controlled with a low-dose, well-tolerated medical regimen. When the glaucoma is uncontrolled on maximum tolerable medical therapy and poses an immediate threat to vision, a two-stage procedure of filtering surgery with subsequent cataract extraction is preferred. Between these two extremes of glaucoma control are those cases for which a combined operation is felt to be indicated, especially when cataract surgery is planned in an eye with borderline glaucoma control and/or moderate to advanced glaucomatous damage. The preferred combined approach is cataract extraction with a guarded filtering procedure, and a simplified technique to accomplish this is described.     

Prevention and Control of Perioperative Incision Infection in Patients Undergoing Day Cataract Surgery

Purpose： To explore the effects of the prevention and control of perioperative incision infection on the quality of day cataract surgery. Methods： The nursing care and efficacy of 5087 patients un- dergoing day cataract surgery between October 2012 and Oc- tober 2013 were retrospectively reviewed. The disinfection and isolation guidance was established for perioperative prevention and control of infection, topical administration of ocular a- gents, reexamination and healthcare instruction, and alterna- tive measures were taken. Results： All 5087 patients successfully underwent day surgery of phacoemulsification combined with intraocular lens im- plantation. All cases recovered without incision infection.     

Cataract Surgery in Patients with Diabetes: Management Strategies

ABSTRACT

Diabetes is a chronic systemic disease that affects nearly one in eight adults worldwide. Ocular complications, such as cataract, can lead to significant visual impairment. Among the worldwide population, cataract is the leading cause of blindness, and patients with diabetes have an increased incidence of cataracts which mature earlier compared to the rest of the population. Cataract surgery is a common and safe procedure, but can be associated with vision-threatening complications in the diabetic population, such as diabetic macular edema, postoperative macular edema, diabetic retinopathy progression, and posterior capsular opacification. This article is a brief review of diabetic cataract and complications associated with cataract extraction in this population of patients.     

视网膜母细胞瘤并发白内障的手术效果

目的：分析视网膜母细胞瘤（Rb）患儿并发白内障的诊断时间、手术时间,手术方式以及手术效果,并评估其行白内障手术的时机和安全性。方法：回顾性分析2010年1月至2016年12月在北京儿童医院、北京同仁医院和泉州市儿童医院行白内障摘除术的Rb患儿23例（25眼）。其中男11例（11眼）,女12例（14眼）。7眼行透明角膜25G切口,18眼行睫状体平坦部25G或者27G巩膜微切口。随访1～72个月,平均（24±16）个月。统计手术时间,术前Rb治疗方式及次数,术后眼底检查是否有肿瘤复发或转移。结果： 患儿平均手术年龄（35±19）个月。自确诊Rb到发现白内障的时间（中位数）为19 个月,发现白内障到白内障手术时间（中位数）为5个月,最后一次Rb治疗到行白内障手术的时间（中位数）是10个月。行白内障摘除术前全身化疗22例（102次）,局部光凝12眼（62次）,眼内注药11眼（19次）,放疗1眼（1次）,眼外冷冻6眼（10次）,玻璃体切割手术17眼（20次）。2眼在Rb治疗过程中不能查见眼底,而眼B超检查示肿瘤复发,故行白内障手术,术后局部激光治疗复发肿瘤,随访期内未再复发。23眼为肿瘤局限钙化后行白内障手术,术后19眼无肿瘤复发及转移,未做治疗;4眼出现肿瘤晚期并发症（1眼继发青光眼,2 眼前房出血,1 眼眼内肿瘤复发）,行眼球摘除术。术后行病理检查,摘除眼未见眼球外有Rb转移。结论：对于Rb患儿,必要的白内障手术为眼底检查提供了清晰的视野。对于肿瘤局限钙化病情稳定的患眼,在无肿瘤生长的角膜或者睫状体平坦部做切口行白内障手术是安全的。     

Dry Eye After Cataract Surgery and Associated Intraoperative Risk Factors

Purpose

To investigate changes in dry eye symptoms and diagnostic test values after cataract surgery and to address factors that might influence those symptoms and test results.

Methods

Twenty-eight eyes from 14 patients with preoperative dry eye (dry eye group) and 70 eyes from 35 patients without preoperative dry eye (non-dry eye group) were studied prospectively. In each group, we measured values such as tear break-up time (tBUT), Schirmer I test (ST-I), tear meniscus height (TMH), and subjective dry eye symptoms (Sx), and evaluated the postoperative changes in these values. We also evaluated the influence of corneal incision location and shape on these values. The correlations between these values and microscopic light exposure time and phacoemulsification energy were investigated.

Results

In the dry eye group, there were significant aggravations in Sx at 2 months postoperatively and in TMH at 3 days, 10 days, 1 month, and 2 months postoperatively, compared with preoperative values. All dry eye test values were significantly worse after cataract surgery in the non-dry eye group. With regard to incision location, there was no difference in tBUT, Sx, ST-I, or TMH in either the dry eye group or the non-dry eye group at any postoperative time point. Regarding incision shape, there was no difference in tBUT, Sx, ST-I or TMH at any postoperative time point in the dry eye group. In the superior incision sub-group of the non-dry eye group, tBUT and Sx were worse in the grooved incision group at day 1. In the temporal incision sub-group of the non-dry eye group, Sx were worse in the grooved incision group at 1 day, 3 days, and 10 days postoperatively. In both groups, significant correlations were noted between microscopic light exposure time and dry eye test values, but no correlation was noted between phacoemulsification energy and dry eye test values.

Conclusions

Cataract surgery may lead to dry eye. A grooved incision can aggravate the symptoms during the early postoperative period in patients without dry eye preoperatively. Long microscopic light exposure times can have an adverse effect on dry eye test values.     

Outcomes of Cataract Surgery in Ocular Cicatricial Pemphigoid

Abstract

Purpose: To report the outcomes of cataract surgery in ocular cicatricial pemphigoid (OCP). Setting: L. V. Prasad Eye Institute, Hyderabad, India. Design: Retrospective, interventional case series.

Methods: Patients diagnosed with OCP who had undergone cataract surgery were included. Staging of disease, type of surgery, pre- and postoperative best-corrected visual acuity (BCVA), and number and duration of topical and systemic medications were recorded. Complications and any exacerbation or worsening of disease were noted.

Results: Nine eyes of 7 patients (3 male, 4 female) were included in the study, with mean age of 60.44?±?2.6 years (range 56–64 years). Follow-up ranged from 6 months to 10 years (mean 52.9?±?46.25 months). Surgery performed was extracapsular cataract extraction with posterior chamber intraocular lens implantation (n?=?5) or phacoemulsification with posterior chamber intraocular lens implantation (n?=?4). Best-corrected visual acuity improved by more than 2 lines in 6 of 9 (66.67%) eyes, which remained stable till the last follow-up. Three eyes had no visual improvement due to corneal scar in 2 patients and preexisting posterior staphyloma in 1 eye. Disease progression was noted in 2 of 9 operated eyes by one stage at the end of 1 year.

Conclusion: In this series, cataract surgery could be safely performed with no major intra- or postoperative complications. While the surgical intervention itself was not associated with acute exacerbations of inflammation, progression of disease was noted in some cases over time. In spite of ongoing disease, cataract surgery in OCP was associated with stable visual outcomes.     

Long-Term Follow-Up of Patients with Birdshot Retinochoroidopathy Treated with Systemic Immunosuppression

Purpose: Birdshot retinochoroidopathy (BRC) is a rare uveitis syndrome of presumed autoimmune etiology. Therapy with systemic and periocular corticosteroids is of inconsistent efficacy, attendant with numerous potential long-term side effects. Corticosteroid-sparing strategies with agents such as cyclosporine A or azathioprine have been suggested for this disease. Methods: We retrospectively reviewed the medical charts of patients with BRC who were evaluated consecutively at a tertiary-care, referral-based North American uveitis clinic over a 15-year period. Results: Eleven Caucasian patients (22 eyes) were diagnosed with BRC, representing approximately 1% of all cases seen at the uveitis clinic. HLA-A29 was positive in all 11 patients. We elected to treat five patients with azathioprine, methotrexate, cyclosporine A, mycophenolate mofetil, and/or IvIg, as well as systemic or periocular corticosteroid injections. The median period of follow-up for the five treated patients was six years (range: 8 months–13 years). Inflammation was reduced or stabilized in five of five patients. Conclusion: Although the definitive strategy for the management of BRC is unknown, control of intraocular inflammation and preservation of vision is possible with corticosteroid-sparing immunosuppressive agents.     

Cataract surgery in a case of carotid cavernous fistula

A carotid-cavernous fistula (CCF) is an abnormal communication between the cavernous sinus and the carotid arterial system. The ocular manifestations include conjunctival chemosis, proptosis, globe displacement, raised intraocular pressure and optic neuropathy. Although management of CCF in these patients is necessary, the ophthalmologist may also have to treat other ocular morbidities such as cataract. Cataract surgery in patients with CCF may be associated with many possible complications, including suprachoroidal hemorrhage. We describe cataract extraction surgery in 60-year-old female with bilateral spontaneous low-flow CCF. She underwent phacoemulsification via a clear corneal route under topical anesthesia and had an uneventful postoperative phase and recovered successfully. Given the various possible ocular changes in CCF, one must proceed with an intraocular surgery with caution. In this communication, we wish to describe the surgical precautions and the possible pitfalls in cataract surgery in patients with CCF.