Immediately sequential bilateral cataract surgery versus delayed sequential bilateral cataract surgery: potential hospital cost savings

Objective: Cataract surgery represents a substantial cost to health care systems around the world. Canada's socialized medical system allows an opportunity to accurately track costing because of the institutional record keeping necessary for public reporting to provincial governments. Cataract surgical costs consist of medical costs, hospital costs, and social costs. Our study compared the hospital costs of immediately sequential bilateral cataract surgery (ISBCS) with delayed sequential bilateral cataract surgeries (DSBCS), minimizing other interfering variables.Design: Retrospective chart review with collection of associated costing information from the hospital.Participants: Twenty-two consecutive patients undergoing ISBCS with posterior chamber intraocular lens implantation and a randomly selected group of 22 patients undergoing similar DSBCS during the same period.Methods: Hospital costs were determined using the London Health Sciences Centre case-costing system. Average costs were calculated and compared statistically.Results: Average hospital costs were significantly reduced when performing ISBCS (p < 0.0001); 2 separate unilateral cataract surgeries totaled $ 1566.30, compared with $ 1059.10 for one bilateral cataract surgery (32.4% reduction). Pre- and post-operative in-hospital care accounted for a significant portion of this difference (54%), as 2 separate surgeries cost $547.92 compared with $273.96 for ISBCS.Conclusions: ISBCS provided considerable hospital cost savings compared to DSBCS.     

双眼先天性白内障同时手术的评价

目的 评价双眼同时手术治疗双眼先天性白内障的疗效。方法 通过对6例先天性白内障施行双眼同时手术,术后联合弱视训练进行分析。包括手术方式、手术操作、术后炎症反应、后囊膜浑浊、术后视力情况、脱盲、脱残情况等。结果 手术方式分单纯白内障吸出术、白内障吸出加人工晶状体植入、白内障囊外摘除加人工晶状体植入术。所有手术眼术后视力较术前均有提高,5例7眼术后出现前房纤维素样渗出、1例1眼出现人工晶状体前后膜,全部发生后囊膜混浊,但程度不等。需激光后囊切开的有3例6眼。经过手术前后对比,术后眼球震颤的程度都有减轻。结论 双眼先天性白内障同时手术是可行的,有利于避免遮盖导致的剥夺性弱视,利用双眼视的建立,减少全麻手术的风险。如果双眼先天性白内障视力均低于0.1,双眼无明显的差别,可以选择同时手术。     

糖皮质激素性白内障研究进展

长期全身或局部应用糖皮质激素可发生激素性白内障，激素性白内障作为后囊下白内障的一种类型．其组织形态学表现、临床特点等有其特殊性。有关激素性白内障的发病机制较复杂且不明，有多种假说．都不能很好地解释后囊下混浊的形成过程，因而在预防及治疗上无有效手段。一种新的观点认为，激素可能通过生长因子影响晶状体上皮细胞分化，导致激素性白内障形成，因此．研究生长因子对晶状体上皮细胞增殖和分化的影响，可能是研究激素性白内障发病机制一个新的方向．     

Apoptosis is a feature of TGFß‐induced cataract

Background : Studies in our laboratory have shown that transforming growth factor beta (TGFß) induces rodent lens epidielial cells to undergo aberrant growth and differentiation that reproduces morphological and molecular features of human anterior subcapsular cataract and posterior capsule opacification. In addition, features of apoptosis have been described in some forms of human cataract. In the present study we investigated apoptotic changes induced by TGFß in our rodent models. Methods : Lens epidielial explants and whole lenses from rats were cultured with TGFß. Morphological analysis and TUNEL were used to detect apoptotic changes. Transgenic mice expressing a self‐activating form of human TGFßI in the lens were included in the analysis. Results : TGFß‐induced cell loss in epithelial explants coincided with increased numbers of pyknotic nuclei. Some of these nuclei were TUNEL‐positive. Studies on lenses cultured with TGFß and lenses from transgenic mice showed that the subcapsular plaques that developed contained pyknotic nuclei and that many of these were TUNEL‐positive. Discussion : This study shows that cells develop morphological and molecular features of apoptosis in TGFß‐induced cataract models. This confirms that apoptosis can be included as another TGFß‐induced cellular change that mimics events in human cataract.     

Epithelial transdifferentiation and cataract in the human lens

Anterior subcapsular cataracts cause a serious loss of vision and are normally associated with ocular trauma, inflammation or clinical skin conditions. They appear to be accompanied by epithelial cell growth and transdifferentiation where unscheduled production of a number of proteins, including alpha smooth muscle actin (alpha-sma), occurs. Clinical studies have also revealed an up-regulation of the TGFbeta signalling pathway in such cataracts. The present study, using phase contrast and immunofluorescent techniques, was undertaken to investigate the extent of alpha-sma expression in traumatic cataracts, in capsulorhexis specimens obtained during cataract surgery and in aged human lenses from donor eyes. The donor lenses were also exposed to trauma or TGFbeta in culture to observe their relative contribution to alpha-sma production. Dense anterior subcapsular cataracts were relatively rare (<1%), but all showed a pronounced up-regulation of alpha-sma, which was located both in anterior cells of normal appearance and in nucleated fibroblastic cells lying beneath the anterior epithelium. Surprisingly, more than 50% of capsulorhexis specimens from mature cataracts showed expression of alpha-sma, although to a limited extent. Alpha-sma was not expressed in any of the clear donor lenses and culture for 8 days in EMEM did not induce expression. Interestingly, unlike their young animal counterparts, human lenses failed to show the presence of alpha-sma when exposed to 10 ng ml(-1) TGFbeta. However, after culture, lenses with pre-existing cortical opacities did express alpha-sma, as did clear lenses subjected to injury or trauma. It appears that the greater the stress, the greater is the expression of alpha-sma. Cataract, and especially cortical cataract, should therefore be seen as associated with stress-induced signalling pathways in the lens that lead to the transdifferentiation of the anterior epithelial cells.     

Growth spurt in a lens with a posterior subcapsular cataract

Over a period of 5 years, the lenses of a patient with a unilateral posterior subcapsular cataract were documented using Scheimpflug slit-image photography. For the first time ever, a growth spurt was observed of the cataractous lens. It is postulated that this could be a reflection of either a mitotic spurt of the lens epithelium or a failure of compaction of the the deeper lens fibres.     

Benefits and risks of immediately sequential bilateral cataract surgery: a literature review

Immediately sequential bilateral cataract surgery (ISBCS) is a highly contended issue in ophthalmology, mainly due to the risk of bilateral endophthalmitis and financial penalties that many ophthalmologists face when performing simultaneous cataract surgeries. The purpose of this review is to understand the current status of the knowledge of ISBCS, mainly its benefits and risks and how they compare with the standard of care, delayed sequential bilateral cataract surgery. Evidence, although limited, increasingly supports ISBCS for providing faster rehabilitation, improved visual outcomes, and cost and time savings. Evidence does not support the fear of bilateral endophthalmitis resulting from the simultaneous procedure. However, stronger and greater evidence is needed before ISBCSs can be considered the standard of care. Where ISBCS can potentially create the most beneficial impact is in public eye health programmes in developing countries, but this has not yet been explored.     

双眼白内障摘除术后双眼视觉的测定

目的：了解双眼行白内障人工晶状体植入术后患者的双眼视功能恢复情况并探讨影响其恢复的因素。方法：对80例(160只眼)老年性白内障患者双眼均采用Phaco或小切口ECCE后房型人工晶状体植入术。术后检查矫正视力、同时视觉、融合功能及远、近距离立体视功能以及视网膜对应情况。结果：术后患者双眼矫正视力均≥0．3，其中矫正视力均≥0．5者76例(95％)，矫正视力均≥0．9者60例(75％)。术后均有同时视功能及一定的融合功能。近距离立体视检查：中心凹立体视(40″～60″)32例(占40％)，黄斑部立体视(80″-200″)30例(占37．5％)，周边部立体视(400″～800″)15例(占18．8％)，无立体视者3例(占3．7％)。远距离立体视中：中心凹立体视者65例(81．3％)，黄斑部立体视者12例(占15％)，周边部立体视者3例(占3．7％)。术后视网膜对应均正常。结论：双眼白内障摘除人工晶状体植入手术且双眼矫正视力均≥0．5者，均可较快地恢复一定程度的双眼视功能。     

儿童白内障双眼同时人工晶状体植入术

目的：研究特定环境条件下双眼先天性白内障手术同时完成并植入人工晶状体与两眼分开做的手术的安全性和手术效果比较。方法：总结1999年3月至12月在健康快车所做的143眼儿童白内障手术，分为46例92眼双服手术组和51例单眼手术组，两组手术并发症对比。结果：在严格无菌条件及好的手术条件下，双眼手术组与单眼手术组相比，术后并发症如玻璃体溢出，眼内炎，瞳孔区渗出膜等并无显著性增加。结论：双眼同时完成并植入人工晶状体的儿童白内障手术是安全的，减少了两次全麻的危险，具有一定的经济和社会效益。     

Immediately sequential bilateral cataract surgery in Down syndrome

The exponential increase in world population and average human lifespan is expected to result in geriatric population globally. The problem of preventable blindness due to cataract will increase manifold. Simultaneous Bilateral cataract surgery (SBCS) is a viable option in such subset of patients. Despite faster visual recovery, economic benefits to patients and health care providers, decreased risk of complications associated with General anaesthesia, there is significant resistance in accepting SBCS as a routine procedure. Bilateral endophthalmitis is the main deterrent in performing ISBCS. This case highlights successful ISBCS in 36 years old female patient with Down’s syndrome.     

视网膜色素变性并发白内障的临床表现与中性粒细胞/淋巴细胞计数比值的相关性

目的：评估视网膜色素变性(RP)并发白内障患者中性粒细胞与淋巴细胞计数比值(NLR),探讨其与RP并发白内障临床特征的相关性。

方法：回顾性研究。纳入2008-01/2018-12在我院接受白内障摘除手术的RP并发白内障患者79例125眼,排除发病年龄较早的RP并发白内障患者选取其中63例63眼纳入RP并发白内障组,另选取年龄、性别相匹配、同期行白内障摘除手术的年龄相关性白内障(ARC)患者63例63眼纳入ARC组。收集患者的临床资料及NLR值,分析RP并发白内障患者的临床表现与NLR相关性。

结果：RP并发白内障组患者NLR显著高于ARC组\〖1.79(1.32,2.27)vs 1.58(1.32,1.98),P=0.032\〗。NLR与后囊下白内障(PSC)严重程度、悬韧带薄弱程度、术前最佳矫正视力(>1LogMAR)相关。接收者操作特征(ROC)曲线分析显示,NLR≥1.36可预测RP并发较严重的PSC(>P1)(AUC=0.803,95%CI 0.672-0.934,P=0.002),NLR≥2.12可以预测RP并发白内障患者悬韧带薄弱(AUC=0.796,95%CI 0.665-0.928,P=0.002),NLR≥1.51可以预测术前较差的BCVA(AUC=0.667,95%CI 0.540-0.793,P=0.015)。

结论：RP并发白内障患者NLR明显高于ARC患者,且与RP并发白内障临床表现存在相关性。NLR可作为评估RP并发白内障临床表现严重程度的潜在预测指标。     

晶状体上皮细胞异常分化对皮质类固醇性白内障后囊下混浊的影响

目的 探讨地塞米松(DEX)对大鼠晶状体上皮细胞(LECs)分化的影响及其在皮质类固醇性白内障(GIC)后囊下混浊(PSO)形成中的作用.方法 大鼠双眼应用DEX 6个月,ELISA法检测各时段房水碱性成纤维细胞生长因子(bFGF)质量浓度的变化,行后囊膜铺片,观察组织学改变;不同浓度DEX作用于培养的大鼠LECs,采用RT-PCR和Western blot方法,检测LECs中β-晶状体蛋白表达的变化.结果 DEX组各时段房水bFGF质量浓度与正常对照相似(P＞0.05),部分后囊膜见上皮样细胞堆积,提示来自赤道部的LECs;DEX可抑制LECs中β-crystallin的表达,转录水平分别为0 mol/L组2.07,10-8 mol/L组1.48,10-7ml/L组1.06,10-6 mol/L组0.78,蛋白水平各组分别为1.38、1.03、0 60和0.45.结论 DEX抑制LECs分化可能在GIC的PSO形成中起重要作用.     

Dominantly inherited posterior subcapsular cataract

We report on a family in which many family members show dominantly inherited posterior subcapsular cataract (PSC). While PSC is not a particularly uncommon finding, especially from the influence of congenital, systemic disease, ocular disease and toxic factors, reports of genetically determined PSC are comparatively few in the ophthalmic literature.     

小切口囊袋内手法劈核术用于硬核白内障的临床观察

目的探讨双进路圈垫式劈核技术在硬核白内障手术中的临床应用效果。方法应用圈垫器，采用双进路囊袋内劈核对眼硬核白内障患者行小切口白内障摘除及人工晶体植入术。结果术后一周裸眼视力≥0．6者269眼占57．7％；角膜内皮细胞丢失率3．07％。术后一月裸眼视力≥0．6者288眼占61．8％；角膜内皮细胞丢失率4．93％。术后半年裸眼视力≥0．6者293眼占62．9％：角膜内皮细胞丢失率5．05％。结论对于Ⅳ级以上硬核白内障，应用双进路圈垫劈核方法．不仅具有小切口的特点，且操作安全，术后视力恢复快并发症少。     

前囊下性白内障患者晶状体上皮细胞基质金属蛋白酶-3的表达意义

目的：探讨基质金属蛋白酶-3(matrix metalloproteinase-3,MMP-3)在前囊下性白内障患的晶状体上皮细胞(lens epithelial cells,LECs)中的表达及意义。方法：采用SP免疫组织化学染色法,测定21例前囊下性白内障、18例核性白内障和10例正常晶状体上皮细胞中MMP-3的表达情况,并进行阳性细胞细胞计数。结果：MMP-3在前囊下性白内障品状体上皮细胞中有表达,而在核性白内障和正常晶状体上皮细胞中均无表达。结论：MMP-3可能是调节细胞外基质(extracellular matrix,ECM)降解的重要因素而参与前囊膜下性白内障的形成。     

Resident-performed immediate sequential bilateral cataract surgery during the COVID-19 pandemic

Purpose:To assess visual outcomes and patient satisfaction for senior resident-performed immediate sequential bilateral cataract surgery (ISBCS) versus delayed sequential bilateral cataract surgery (DSBCS) during the COVID-19 pandemic, when minimizing healthcare-related exposures for patients and providers are paramount.Methods:This was a pilot retrospective cohort study of all ISBCS and DSBCS patients who underwent senior resident-performed cataract surgery from May to September 2020 at a single academic institution. Outcome measures were final corrected distance visual acuity (CDVA), final manifest refraction (MRx), intraoperative and postoperative complications rates, total number of visits, and patient satisfaction assessed postoperatively by telephone questionnaire.Results:Twenty-two eyes of 14 patients and 56 eyes of 28 patients underwent senior resident-performed ISBCS and DSBCS, respectively. Final CDVA was 20/25 or better in 21 (95%) ISBCS and 51 (91%) DSBCS eyes (P = 0.670). Deviation of final MRx from target refraction was within 0.50 D in 17 (77%) ISBCS and 47 (84%) DSBCS eyes (P = 0.522). There was no significant difference in intraoperative (P = 1.000) or postoperative (P = 1.000) complications. ISBCS patients averaged 3.5 fewer visits than DSBCS patients (5.9 vs 9.5, P < 0.001). All ISBCS and 20 DSBCS patients (87%) reported they were “very satisfied” or “satisfied” with their experience (P = 0.701). Five of six senior residents responded that they preferred performing ISBCS over DSBCS.Conclusion:This early experience suggests that senior resident-performed ISBCS is as safe and effective as DSBCS, with the added benefit of averaging fewer in-person visits. Residency programs should consider offering senior resident-performed ISBCS to select patients during the COVID-19 pandemic.