Vacuum rhexis – A novel capsulorhexis technique for white cataracts

Capsulorhexis in white intumescent cataract is often associated with extension leading to radial tears or biradial extension “Argentinian flag sign” and associated complications. We describe a novel technique of managing this situation. Vacuum rhexis is performed with a 24 G bent cannula attached to a 10-ml syringe. The flap is lifted and then caught using 24 G cannula. The suction is manually controlled by the surgeon, and the rhexis is completed using circumferential movement. The chamber stability is well maintained as there is no leakage, and the bent tip gives excellent fulcrum for movement. The advantage of this technique is that a single port is used for maintaining the chamber stability and it needs no special surgical instruments. Vacuum rhexis is a novel surgical technique used for performing successful continuous curvilinear capsulorhexis (CCC) of adequate size in white and intumescent cataracts, with a consistent and predictable outcome.     

连续环形撕囊在压核排液后白色膨胀白内障术中的应用

目的:评价白内障术中破囊后,撕囊镊下压晶状体核,液化皮质充分流出(压核排液)后,在白色膨胀白内障中完成连续环形撕囊的临床应用效果。方法:对60例60眼皮质液化白色膨胀白内障随机分组。观察组30例患者,撕囊镊直接撕囊;治疗组30例患者,压核排液后进行撕囊。结果:在初步破囊时,有前囊膜自动裂向周边现象,观察组有9例,治疗组有10例,差异无统计学意义(P>0.05)。观察组连续环形撕囊的成功率为26.7%,治疗组撕囊成功率66.7%,差异有显著统计学意义(P<0.01)。观察组2例患者术中后囊自发破裂,治疗组无后囊破裂情况发生。结论:在白色膨胀白内障手术中,应用压核排液处理后,液化皮质的流出可消除晶状体核的上浮对前囊膜撕囊的影响,并可显著提高此类白内障中连续环形撕囊的成功率。     

Limited pars-plana vitrectomy for optimizing surgical outcome in subluxated cataracts undergoing femtosecond laser-assisted cataract surgery

We propose a technique for combined femto laser-assisted cataract surgery (FLACS) and limited vitrectomy from the pars-plana site for optimization of surgical results in subluxated cataracts. FLACS creates a free-floating, customised capsulotomy, minimizes stress on compromised zonules, and prechops the nucleus, effectively reducing the ultrasonic power as well as the forces required to chop the nucleus. The area of zonular dehiscence creates a direct communication between the irrigation fluid and the anterior vitreous, leading to its hydration. Trans-limbal vitrectomy creates a continuum between the liquefied vitreous and the main wound, leading to further vitreous loss, and exaggeration of the zonular weakness, while pars-plana vitrectomy avoids this by cutting the liquefied vitreous, near its attachment, thereby preventing further hydration and causing lesser stress to the zonules. A combination of these procedures, along with a capsule support device, gives favorable surgical outcomes in moderate to severe subluxations.     

Cataract surgery and Indigenous eye care: A review

Cataract remains the leading cause of blindness in Aboriginal and Torres Strait Islander peoples and is still a major cause of vision loss. The pathway of care to cataract surgery has many potential gaps and barriers. Although there has been a significant increase in services over the last few years, there is still the urgent need to facilitate timely and affordable cataract surgery. Particularly for public surgery there needs to be a significant decrease in waiting times for the clinical assessment of those needing surgery and for those on a surgical waiting list.     

The Impact of Cataract Surgery questionnaire: re‐evaluation using Rasch analysis

Purpose: The Impact of Cataract Surgery (ICS) questionnaire was designed to assess cataract surgery outcomes. The aim of this study was to describe the psychometric properties of the ICS questionnaire using the Rasch model in a cataract population. Methods: Ninety‐one patients waiting to undergo cataract surgery in the first or second eye at the Flinders Medical Centre, Adelaide, South Australia self‐administered the four‐item ICS questionnaire. Rasch analysis was performed to assess behaviour of response categories, ability to differentiate between participants’ visual abilities (person separation; minimum acceptable 2.0), if items measure a single underlying construct [i.e. unidimensionality assessed by fit statistics and further by principal components analysis (PCA)] and matching of item difficulty to participant ability (targeting; ideal < 0.5 logits). Adequate person separation was defined as basic requirement for a measure, failing which further assessment such as PCA was not performed. Results: The four‐item ICS questionnaire did not meet the required measurement properties (person separation zero). Response categories did not behave as intended, requiring the collapsing of categories for one item (read ordinary newspaper‐size print). One item misfit (estimating distance) indicating that it was not measuring the same construct as other items. However, person separation failed to improve following the deletion of this item. Targeting was ?0.46 logits, indicating that the item difficulty was well suited to the visual abilities of the participants. Conclusion: In its present form, the ICS is unsuitable for visual disability assessment in patients awaiting cataract surgery. Other, better visual function questionnaires are available and preferred.     

Cataract surgical coverage and self-reported barriers to cataract surgery in a rural Myanmar population

Purpose: The aim of this study is to determine the cataract surgical coverage and investigate the barriers to cataract surgery as reported by those with cataract‐induced visual impairment in rural Myanmar. Methods: A cross‐sectional, population‐based survey of inhabitants 40 years of age and over from villages in the Meiktila District (central Myanmar); 2481 eligible participants were identified and 2076 participated. Data recording included corrected visual acuity, dilated slit lamp examination and stereoscopic fundus examination. Lens opacity was graded using the Lens Opacities Classification System III. Participants with cataract‐induced visual impairment (acuity < 6/18 in better eye) were also invited to respond to a verbal questionnaire about barriers to cataract surgery. Results: Cataract surgical coverage for visual acuity cut‐offs of <6/18, <6/60 and <3/60 was 9.74%, 20.11% and 22.3%, respectively, for people and 4.18%, 9.39% and 13.47%, respectively, for eyes. Cataract surgical coverage was higher for men than women, but gender was not associated with refusal of services. Of the 239 who responded to the extra questionnaire, 216 were blind or had low vision owing to cataract. Three quarters refused referral for surgery: cost and fear of surgery were the most frequently reported barriers. Conclusion: Cost plays a large role in the burden of cataract in this region. Implementation of educational programmes, reforms to local health service and subsidization of ophthalmic care may improve the uptake of cataract surgery.     

Barriers to Uptake of Free Pediatric Cataract Surgery in Malawi

Purpose: To examine the demographic, sociocultural and socioeconomic factors that prevent families of cataract blind children from accepting free pediatric cataract surgery in Malawi.

Methods: A total 58 parents of 62 children were recruited into the study. Of these, 53 parents partook in in-depth interviews and focus group discussions after the children were screened and the parents offered free cataract surgery. Overall, 37 parents accepted (acceptors) and 16 parents did not accept (non-acceptors) cataract surgery. All interviews were transcribed and iteratively analyzed. Household economic status was quantified using the Progress out of Poverty Index for Malawi.

Results: Acceptors were better off economically (p?=?0.13). Understanding of cataract, its causing blindness and impairment, as well as treatment options, by the decision makers in the families was poor. Decision-making involved a complex array of aspects needing consideration before accepting, of which distance to the health facility was a frequently mentioned barrier. Non-acceptors were more likely to come from twice the distance compared to acceptors (p?=?0.0098). Non-acceptors were more likely to be peasant (subsistence) farmers than acceptors (p?=?0.048). Non-acceptors were more likely to live in a house made of mud bricks with a roof of grass thatch (p?=?0.001). There was no significant difference in acceptance rate between educated and non-educated mothers (p?=?0.11). Intensive counseling as provided in this project increased the likelihood of accepting surgery.

Conclusion: Economic hardship and long distances to health facilities decrease acceptance even of free pediatric cataract surgical services, highlighting that just providing surgery free of cost may not be sufficient for the most economically disadvantaged in rural Africa.     

Different faces of the white cataract: A phaco surgeon’s perspective

Purpose: To develop a system of categorizing white cataracts so that the salient features, as would be pertinent to phacoemulsification surgery, could be recognized pre-operatively. Methods: Patients with total cataracts were carefully evaluated using slit-lamp biomicroscopy and slit-lamp photography. An attempt was made to determine whether pre-operative evaluation could ascertain the presence or absence of features of these cataracts that often cause surgical difficulties, namely, increased intralenticular pressure (ILP), milky cortex and brown nuclear colour. Results: Using a standardized method of biomicroscopic evaluation, it was found that the status of the ILP, cortex and nuclear colour could be determined consistently. Surgical strategies based on such a system of categorization has permitted white cataracts to be consistently managed using phacoemulsification. Conclusions: Systematic pre-operative evaluation and categorization of white cataracts based on the ILP, status of the cortex and nuclear colour can permit proper surgical planning and successful management of such cases with phacoemulsification.     

Resident Cataract Surgery: Review of a Rural Teaching Hospital's Experience

A retrospective review of all intracapsular cataract operations (499 eyes) performed at The Mary Imogene Bassett Hospital from July 1973 to January 1980 revealed that 72% (359) were performed by Albany Medical Center Ophthalmology residents as part of their third-year training affiliation. The residents' operative results (94.9% with postoperative 20/20 to 20/40 visual acuity in age group 55 to 64 years) and complication rates (vitreous loss 4.2%) were similar to the data from the 1975 report of the cataract survey of the American Academy of Ophthalmology and Otolaryngology's Phacoemulsification Committee. Details of the program and data are presented. The results show that residents can perform supervised cataract surgery at the same risk to the patient as reported in the 1975 compilation of 400 participating Academy ophthalmologists.     

Cataract surgery in Australia: a profile of patient-centred outcomes

BACKGROUND: Few studies have addressed quality of life or satisfaction outcomes for patients undergoing cataract surgery, particularly in Australia. The purpose of this study was to describe a sample of patients undergoing cataract surgery in typical metropolitan practices in Sydney, with a particular focus on the impact upon quality of life and satisfaction with vision. METHODS: One hundred and eleven patients were recruited prior to surgery and followed through 3 months postoperatively. Patients reported basic demographic information, VF-14 visual disability and SF-36 quality of life information, along with the degree of satisfaction and trouble with vision they experienced. Surgeons' records provided information about type and severity of cataract, refractive error, ocular comorbidity and visual acuity. RESULTS: Patients enjoyed strongly significant improvement in visual acuity, disability, trouble and satisfaction with vision, with a median postoperative Snellen acuity of 6/7.5, and 82% within 1 D refraction. Not wearing glasses was the most commonly stated patient goal for undergoing surgery. Prior to surgery 23% of all driving patients did so illegally due to poor vision; after surgery 21% of non-drivers began driving again, all legally. Nonetheless, quality of life did not improve. Those who failed to achieve improvements in satisfaction with vision were more likely to be female, have lower educational attainment or have high visual function preoperatively. Change in visual acuity was not predictive. CONCLUSIONS: The findings from this study indicate that cataract surgery outcomes in Australia compare well with international standards, and emphasize the inadequacy of visual acuity to measure relevant surgical outcomes. Increased preoperative counselling may be required in those groups less likely to attain high levels of satisfaction. Finally, the role of cataract surgery to improve quality of life must be investigated further, as this is the ultimate goal of the procedure.     

Cataract Surgery in HIV Seropositive Patients: Long-Term Follow-Up

Purpose: To study epidemiology and clinical findings of cataract in HIV+ patients.

Methods: A total of 32 HIV+ patients, 11 with uveitis/retinitis before surgery and 21 without, mean follow-up 44.9 ± 36.6 months, and 114 HIV- patients, 57 with uveitis/retinitis before surgery and 57 without, were retrospectively compared.

Results: Visual acuity improved in all HIV+ patients (p < 0.001), who were younger (p = 0.01) and more frequently males (p = 0.027). HIV+ patients with uveitis prior surgery improved less (p = 0.046) than HIV- (p < 0.001); their anterior chamber inflammation was similar to baseline. Male sex (p = 0.005), younger age (p < 0.001), dyslipidaemia (p = 0.058), HBV+ (p = 0.037), and unilateral cataract (p = 0.001) were more frequent in HIV+ patients with senile cataract, but they showed the same postoperative course as HIV- patients.

Conclusion: Cataract surgery in HIV+ patients is safe and effective. Uveitis prior to surgery did not significantly affect the postoperative course. Systemic comorbidities are more frequent in HIV+ patients with senile cataract than in HIV- subjects.     

Cataract in central Sri Lanka: cataract surgical coverage and self-reported barriers to cataract surgery

Purpose:  To determine the cataract surgical coverage and investigate the barriers to cataract surgery in the Kandy District of central Sri Lanka.
Methods:  A population-based, cross-sectional ophthalmic survey of the inhabitants of rural villages in central Sri Lanka was conducted; there were 1721 eligible subjects and 1375 participated (79.9% participation rate). The recorded data included age, gender, education, district, corrected visual acuity, dilated slit-lamp examination and stereoscopic fundus examination. Lens opacity was graded using the Lens Opacities Classification System III. Participants with cataract-induced visual impairment (acuity <6/18 in the better eye) were also invited to respond to a verbal questionnaire about barriers to cataract surgery.
Results:  Cataract surgical coverage per individual for visual acuity cut-offs of <6/18, <6/60 and <3/60 was 41.9%, 76.8% and 82.7%, respectively; and per eye was 34.0%, 60.3% and 65.2%, respectively. Cataract surgical coverage was higher for men than women, and two-thirds refused referral for surgery, for the following reasons: no desire to improve vision, fear of surgery and lack of awareness were the most frequently reported barriers.
Summary:  Cataract surgical coverage in central Sri Lanka is higher than that in neighbouring developing regions. Surgical uptake may be improved through better community education.     

利用手术模拟器提高眼科青年医师白内障手术技能在临床教学中的应用

如何提高医学临床实践教学质量是目前医学临床教育面临的重要课题,高端医学模拟技术在医学临床教育中应用为解决这一困难提供了有效的方法,我们专门介绍眼内手术模拟器的组成、使用方法、在眼科临床白内障手术培训中的优缺点、作为一种新的眼科临床手术培训模式,在提高青年眼科医师白内障手术技能方面显示了良好的前景。     

Outcomes and Barriers to Uptake of Cataract Surgery in Rural Northern China: The Heilongjiang Eye Study

Purpose: To report visual outcomes and barriers to uptake of cataract surgery among subjects of all ages in Mingshui County, Heilongjiang Province, China.

Methods: Cluster sampling was used to select a cross-sectional sample of people living in the Heilongjiang Province. Each subject underwent a participant interview, presenting and best-corrected vision measurements and an ocular examination. Visual outcomes and barriers to uptake of cataract surgery were assessed among subjects undergoing cataract surgery. Individuals who needed cataract surgery were interviewed regarding barriers.

Results: Of 11,787 subjects, 10,384 eligible participants underwent visual acuity (VA) testing and a basic eye examination (88.1% response rate). The cross-sectional sub-sample of 21 participants receiving cataract surgery had a median age of 63 years. Six eyes undergoing surgery at the county hospital with conventional intracapsular and extracapsular cataract extraction without an intraocular lens implant were aphakic, and 15 eyes (71.4%) undergoing surgery at tertiary care hospitals were pseudophakic. Seven eyes (33.3%) had corrected VA?≥?20/60, and nine eyes (42.9%) had presenting VA?≥?20/60. Approximately 28.6% (6/21) had poor outcomes. The principal causes of presenting blindness after cataract surgery were refractive error/uncorrected aphakia and posterior capsular opacification. Cost was the most common barrier (73.9%) to uptake of cataract surgery.

Conclusions: Cataract surgical outcomes in northern China were poor. The principal barrier to uptake of cataract surgery was cost. These findings call for the establishment of cataract surgical services that are of high quality, affordable, and sensitive to high-risk groups.     

Cataract surgery in aged patients:phacoemul-sification or small-incision extracapsular cataract surgery

AIM:To evaluate the effects and safety of phacoemu-lsification(Phaco) or small-incision extracapsular cataract surgery(SICS) and intraocular lens(IOL) implantation for aged patients.METHODS:Totally 137 aged patients(149 eyes) underwent cataract operation in the case of stable systemic condition,the blood pressure less than 160/95mmHg,blood glucose less than 8mmol/L,and under the help of electrocardiogram surveillance by anesthesiologists during the operation.106 aged patients(114 eyes) underwent Phaco while 31 aged patients(35 eyes) underwent SICS.The postoperative visual acuity,corneal endothelial cell loss,surgery time and major complications were observed and analyzed retrospectively.RESULTS:The best-corrected visual acuity(BCVA) of ≥0.6 was achieved in 135 eyes(92.6%) at 1 month postoperatively(χ2=259.730,P<0.001).For aged patients,both Phaco and SICS could significantly improve visual acuity with no significant difference(χ2=4.535,P>0.05).Postoperative corneal endothelial cell loss was 18.6%,in PHACO group,the rate was 18.5%;in SICS group,the rate was 19.0%,the difference of which was no significant(χ2=0.102,P >0.05).The surgery time was different in two groups.No severe complications occurred.CONCLUSION:Both Phaco and SICS combined with IOL implantation for aged patients are effective and safe.Before surgery,detailed physical examination should be performed.When the systemic condition is stable,cataract surgery for aged patients is safe.     

Orbital infarction syndrome secondary to rhino-orbital mucormycosis in a case of COVID-19: Clinico-radiological features

Orbital infarction syndrome is an uncommon pathology with devastating consequences. It is frequently secondary to atherothrombotic phenomena in the internal carotid artery. We report a case of a 66-year-old male with uncontrolled diabetes and use of systemic steroids for COVID-19, who presented with a sudden loss of vision in the left eye, with total ophthalmoplegia and diffuse opacification of the retina. On imaging, he was found to have features of rhino-orbital cellulitis with ischemia of the orbital tissue secondary to isolated ophthalmic artery obstruction (OAO) with a patent internal carotid artery. KOH mount of deep nasal swab was confirmatory of mucor. This is the first reported case of orbital infarction syndrome in the setting of COVID-19.     

Cataract surgery in aged patients: phacoemul-sification or small-incision extracapsular cataract surgery

AIM: To evaluate the effects and safety of phacoemu- lsification (Phaco) or small-incision extracapsular cataract surgery (SICS) and intraocular lens (IOL) implantation for aged patients. METHODS: Totally 137 aged patients (149 eyes) underwent cataract operation in the case of stable systemic condition, the blood pressure less than 160/95mmHg, blood glucose less than 8mmol/L, and under the help of electrocardiogram surveillance by anesthesiologists during the operation. 106 aged patients (114 eyes) underwent Phaco while 31 aged patients (35 eyes) underwent SICS. The postoperative visual acuity, corneal endothelial cell loss, surgery time and major complications were observed and analyzed retrospectively. RESULTS: The best-corrected visual acuity(BCVA) of ≥0.6 was achieved in 135 eyes (92.6%) at 1 month postoperatively (χ2=259.730, P＜0.001). For aged patients, both Phaco and SICS could significantly improve visual acuity with no significant difference (χ2=4.535,P＞0.05). Postoperative corneal endothelial cell loss was 18.6%, in PHACO group, the rate was 18.5%; in SICS group, the rate was 19.0%, the difference of which was no significant (χ2=0.102, P>0.05). The surgery time was different in two groups. No severe complications occurred. CONCLUSION: Both Phaco and SICS combined with IOL implantation for aged patients are effective and safe. Before surgery, detailed physical examination should be performed. When the systemic condition is stable, cataract surgery for aged patients is safe.     

Cataract surgery in patients with age-related maculopathy: preoperative diagnosis and postoperative visual acuity

PURPOSE: To report the reliability in detecting age-related maculopathy (ARM) lesions before cataract surgery and postoperative visual acuity (VA) in cataract surgery patients with ARM. METHODS: Medical records of surgical patients in a large public hospital, west of Sydney, were reviewed retrospectively. Detection of ARM lesions was compared before and after surgery to determine sensitivity and specificity of preoperative diagnoses. Postoperative VA was assessed 4 weeks after surgery. RESULTS: Data were available for 721/784 eyes (92.0%) of 656 patients aged 60 years or older. ARM lesions were detected in 98 eyes (13.6%) before and 92 eyes (12.8%) after surgery. Sensitivities for detecting late ARM lesions, soft drusen and retinal pigment epithelium abnormalities preoperatively were 100%, 94% and 69%, respectively. Corresponding specificities were 100%, 100% and 77%, respectively. Postoperative VA achieved or remained 6/12 or better in 81.6% of eyes. CONCLUSION: A high sensitivity and specificity in detecting late ARM lesions and soft drusen preoperatively, and a good postoperative VA outcome is achievable in patients with preoperative early ARM lesions.