End Of Cataract Surgery Research Articles

Descemet’s membrane detachment during cataract surgery: a case report

<p><strong>Background</strong>: Descemet’s membrane detachment is a possible complication after cataract surgery and has been reported to happen in 0.5% of cases after cataract surgery.<br /><strong>Case Presentation</strong>: A 77-year-old male patient underwent right eye cataract surgery and presented 2 weeks after surgery with decreased visual acuity (CF) in the operated right eye. There was generalized cornea edema and the Descemet’s membrane (DM) was noticed to be detached at 80% of the corneal surface. At 12 days postoperatively, a descemetopexy with intracameral air bubble was performed following the principles of endothelial keratoplasty. On follow-up, the visual acuity in the right eye was 6/7.5 with complete corneal clarity at 2 months.<br /><strong>Conclusion</strong>: Early recognition and surgical intervention of a DM detachment at cataract surgery are likely to enable<br />resolution without the need for a transplant. If suspected or identified at the end of surgery, anterior chamber air insertion is recommended. It is important to note that separated DM can mimic a retained anterior capsule flap. Care must be taken when considering removal of any clear membranes at the end of cataract surgery.</p>

Safety of intracameral application of moxifloxacin and dexamethasone (Vigadexa®) after phacoemulsification surgery

BackgroundIntracameral antibiotics, such as moxifloxacin and cefuroxime, are safe to corneal endothelial cells and effective prophylaxis of endophthalmitis after cataract surgery. Corneal endothelial cells decrease in density after cataract surgery. Any substance used in the anterior chamber may affect corneal endothelial cells and lead to a greater decrease in density. This study wants to determine the percentage of endothelial cell loss after cataract extraction by phacoemulsification with off-label intracameral injection of moxifloxacin and dexamethasone (Vigadexa®).MethodsAn observational retrospective study was performed. The clinical records of patients undergoing cataract surgery by phacoemulsification plus intracameral injection of Vigadexa® were analyzed. Endothelial cell loss (ECL) was calculated using preoperative and postoperative endothelial cell density. The relation of endothelial cell loss with cataract grade using LOCS III classification, total surgery time, total ultrasound time, total longitudinal power time, total torsional amplitude time, total aspiration time, estimated fluid usage, and cumulative dissipated energy (CDE) was studied using univariate linear regression analysis and logistic regression analysis.ResultsThe median loss of corneal endothelial cells was 4.6%, interquartile range 0 to 10.4%. Nuclear color and CDE were associated with increased ECL. ECL>10% was associated with age and total ultrasound time in seconds.ConclusionsThe endothelial cell loss after the intracameral use of Vigadexa® at the end of cataract surgery was similar to the reported in other studies of cataract surgery without the use of intracameral prophylaxis for postoperative endophthalmitis (POE). This study confirmed the association of CDE and nuclear opalescence grade with postoperative corneal endothelial cell loss.

Macular Edema and Serous Macular Detachment after a Standard Dose of Intracameral Cefuroxime.

Intracameral cefuroxime has been associated with postoperative macular edema and sub-retinal fluid. To date, nearly all published cases are attributed to errors in antibiotic dilution, leading to administration of supratherapeutic doses. We report three cases of postoperative macular edema and subretinal fluid following a standard dose of 1 mg/0.1 mL of cefuroxime at the end of cataract surgery. Distinguishing features of these cases were intraoperative zonular instability and history of vitrectomy. We hypothesize that certain factors may increase the risk of cefuroxime-associated retinal toxicity, including history of vitrectomy, zonular compromise, posterior capsular break, surgery for a secondary intraocular lens, and unicameral state. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:615-618.].

Management of cataracts secondary to intravitreal chemotherapy injections for retinoblastoma seeding.

To report our experience in the management of cataracts presumably due to intravitreal chemotherapy administration in eyes with vitreous disease associated with retinoblastoma. This retrospective study consisted of a cohort of five eyes of five retinoblastoma patients who developed cataracts secondary to intravitreal chemotherapy administration and who then underwent cataract surgery. All patients underwent lensectomy and anterior vitrectomy with/without intraocular lens implantation via clear corneal approach. All cases were administered intraoperative intravitreal melphalan (35-40 mcg) and topotecan (10-20 mcg) at the end of cataract surgery as a preventive measure against retinoblastoma spread. Injections were repeated as needed in monthly follow-ups. Main outcome measures were enucleation rate and disease-free survival time. The age at surgery ranged between 5 and 10 years. Follow-up time varied from 12 to 16 months. Treatment-free period before surgery ranged between 3 and 20 months. Time from last injection to cataract detection was: 2, 2, 10, 6, and 7 months; and time from last injection to cataract surgery was: 8, 3, 20, 7, and 15 months in cases 1-5, respectively. None of the eyes required enucleation. Tumor control was achieved in all patients at the end of follow-up. Injection of melphalan and topotecan into anterior parts of the vitreous may lead to cataract formation. This can be safely managed with lensectomy and anterior vitrectomy and the use of intravitreal administration of melphalan and topotecan at the conclusion of the surgery as a precautionary measure against the potential risk of extraocular spread.

Pharmacologic interventions for mydriasis in cataract surgery

Pharmacologic interventions for mydriasis in cataract surgery

Acute Endophthalmitis after Cataract Surgery: Clinical Characteristics and the Role of Intracameral Antibiotic Prophylaxis

To evaluate the clinical characteristics and investigate the role of surgical antibiotic prophylaxis (SAP) in acute endophthalmitis cases after cataract surgery. Retrospective, consecutive case series. A total of 126 patients referred to a tertiary center from 2007 to 2015 for acute endophthalmitis after unilateral cataract surgery. All patients who underwent a vitreous biopsy were included. Clinical and microbiology data were reviewed, and associations with visual outcome were analyzed using multivariate logistic regression. Data regarding SAP via intracameral injection were also retrieved. Bacterial culture results and visual acuity outcome. Bacterial growth was observed in 92 of 126 cases (73%). Among these positive cultures, 49 (53.3%), 29 (31.5%), and 13 (14.1%) were coagulase-negative staphylococci, other gram-positive, and gram-negative bacteria, respectively. Among the 77 gram-positive strains tested, 76 (98.7%) were vancomycin-sensitive; among the 12 gram-negative strains tested, all 12 (100%) were ceftazidime-sensitive. Best achieved visual acuity outcome was ≥20/40 Snellen in 77 of 114 cases (67.5%). On multivariate analysis, we found an association between visual outcome of worse than 20/40 Snellen and a positive culture of more virulent bacteria (gram-negative and other gram-positive groups) and presentation with light perception or worse, with an odds ratio of 3.3 and 3.0, respectively. A subgroup of 25 cases (19.8%) developed endophthalmitis despite receiving a SAP by cefuroxime at the end of cataract surgery. Two-thirds of the patients in this endophthalmitis cohort experienced a visual outcome of ≥20/40 Snellen. Efficacy of primary treatment with vancomycin combined with ceftazidime is supported by this study. A subgroup treated prophylactically with cefuroxime demonstrated that SAP alone does not prevent endophthalmitis. This highlights the importance of surgical factors in the prevention of postoperative endophthalmitis.

Efficacy and Side Effects of Intracameral Moxifloxacin as Prophylaxis after Cataract Surgery

Purpose: To determine the efficacy of intracameral moxifloxacin at the end of cataract surgery.
 Methods: Retrospective record based study. Study was based on a consecutive case series of patients who had cataract surgery during 2009 through 2019 in the Department of Ophthalmology at Maharishi Vashishth State Medical College, Basti (India). Intracameral preservative free moxifloxacin injection was given at the conclusion of surgery to most patients. Standardized operating room and sterilization protocols were used. All The medical records were reviewed for the 8 weeks after surgery. Post-operative endophthalmitis rate was computed using the number of cases of postoperative endophthalmitis as the numerator and the number of cataract surgeries as the denominator.
 Results: Of the 10,108 surgeries performed during study period, 2012 (19.9%) involved intracameral moxifloxacin injection. No adverse drug reactions were reported from administration of intracameral antibiotics during the study period. The post-operative endophthalmitis rate in patient who had not received intracameral antibiotic injection was 0.06%. There was no endophthalmitis case reported in patients who had received intracameral moxifloxacin injection as prophylaxis.
 Conclusion: The results of this study support the use if intracameral moxifloxacin as a routine prophylaxis for endophthalmitis after cataract surgery. Especially in rural setting as the patients postoperative instruction compliance is poor and many patients are lost to follow-ups sue to different reasons.

Intracameral injection of triamcinolone acetonide to treat macular edema in pseudophakia

The study aimed to evaluate the effectiveness of intracameral injection of triamcinolone acetonide (TA) on macular edema before and after cataract surgery. Intracameral injection of TA was performed at the end of cataract surgery in patients with macular edema before cataract surgery. We also performed intracameral injection of TA to treat macular edema in other pseudophakic eyes. In the patient receiving intracameral injection of TA during cataract surgery, central macular thickness decreased from 351 to 272 μm at 1 month after cataract surgery. In 2 patients who had secondary intraocular lens (IOL) implantation using retropupillary fixation of the iris claw IOL, intracameral TA injection successfully reduced central macular thickness, although 1 patient was refractory to intravitreal TA injection. Intracameral injection of TA seems to be more familiar to cataract surgeons and is an effective treatment for macular edema in pseudophakic eyes.

A case of inferior rhegmatogenous Descemet's membrane detachment after stromal hydration in cataract surgery

We describe the uncommon case of an inferior rhegmatogenous Descemet's membrane detachment (DMD) from stromal hydration at the side port during cataract surgery that was successfully treated with pneumodescemetopexy and head posturing. A temporally located, transverse and inferior, DMD was noted during stromal hydration. An air bubble was inserted at the end of cataract surgery. This failed to appose the detached Descemet's membrane against the overlying stroma because of the inferior location of the detachment and the superior position of the bubble without appropriate head positioning. Corneal edema persisted with an associated visual acuity of counting fingers. Two weeks after initial cataract surgery, a further air bubble with appropriate head positioning (Trendelenburg, ie, feet up and head down) for 6 hours was performed. The patient's corneal edema and associated poor vision almost completely resolved within the 6 hours of air bubble reinsertion and appropriate head positioning. His corrected distance visual acuity remains at 6/6.

Safety and efficacy of intracameral injection of dexamethasone and moxifloxacin at the end of cataract surgery

Safety and efficacy of intracameral injection of dexamethasone and moxifloxacin at the end of cataract surgery

Randomized controlled European multicenter trial on the prevention of cystoid macular edema after cataract surgery in diabetics: ESCRS PREMED Study Report 2

To compare the efficacy of perioperative treatment strategies, in addition to topical bromfenac 0.09% and dexamethasone 0.1%, to reduce the risk for developing cystoid macular edema (CME) after uneventful cataract surgery in diabetic patients. Twelve European study centers. Randomized clinical trial. Diabetic patients having phacoemulsification cataract surgery were randomly allocated to receive no additional treatment, a subconjunctival injection with 40mg triamcinolone acetonide, an intravitreal injection with 1.25mg bevacizumab, or a combination of both. The main outcomes were the difference in central subfield mean macular thickness, corrected distance visual acuity, and the incidence of CME and clinically significant macular edema within 6 and 12weeks postoperatively. The study comprised 213 patients. At 6 and 12weeks postoperatively, the central subfield mean macular thickness was 12.3μm and 9.7μm lower, respectively, in patients who received subconjunctival triamcinolone acetonide than patients who did not (P = .007 and P = .014, respectively). No patient who received subconjunctival triamcinolone acetonide developed CME. Intravitreal bevacizumab had no significant effect on macular thickness. Diabetic patients who received a subconjunctival injection with triamcinolone acetonide at the end of cataract surgery had a lower macular thickness and macular volume at 6 and 12weeks postoperatively than patients who did not. Intravitreal bevacizumab had no significant effect.

Comparative analysis of the safety and efficacy of intracameral cefuroxime, moxifloxacin and vancomycin at the end of cataract surgery: a meta-analysis

BackgroundCurrent practice methods are unclear as to the most safe and effective prophylactic pharmacotherapy and method of delivery to reduce postoperative endophthalmitis occurrence.MethodsA systematic review and meta-analysis using Meta-analysis of...

Pharmacologic interventions for mydriasis in cataract surgery

Pharmacologic interventions for mydriasis in cataract surgery

Intracameral ketorolac concentration at the beginning and end of cataract surgery following preoperative topical ketorolac administration

PurposeTo evaluate the intracameral concentration of ketorolac tromethamine (ketorolac) at the beginning and end of cataract surgery following preoperative topical administration.SettingSanta Barbara Surgery Center, Santa Barbara, CA, USA.DesignThis was a pre–post, interventional, single-arm study.Patients and methodsPatients undergoing cataract extraction and lens replacement (CELR) were eligible. Written informed consent was obtained from 14 patients who were prescribed topical ophthalmic ketorolac according to the surgeon’s usual practice beginning the day prior to surgery. The surgeon withdrew 100 μL of aqueous humor from the operative eye immediately prior to the initial surgical incision and again just prior to final anterior chamber reinflation and wound closure. Ketorolac concentrations in the intracameral fluid samples were measured.ResultsThirteen of 14 patients used four doses of ketorolac the day prior to surgery as directed, and one patient used three doses. On the day of surgery, all 14 patients administered one drop of topical ketorolac on awakening and one drop after arriving at the surgery center. Preoperative ketorolac concentrations for the 12 patients from whom samples were collected ranged from 4.9 to 369 ng/mL. End-of-procedure sample concentrations ranged from <1.0 (the lower limit of quantification [LLOQ]) to 6.32 ng/mL, with eight of 12 patients having ketorolac levels below the LLOQ.ConclusionAt-home compliance with topical ketorolac was good, with 92.9% of patients using it as directed. Following CELR, levels of ketorolac in the aqueous humor were low, and 66.7% of patients had undetectable levels.

Moxifloxacino, cefuroxima e vancomicina intracameral: espectro de atividade, preparo, segurança e eficácia

In Brazil, the greatest barrier to the routine intracameral use of prophylactic antibiotics at the end of cataract surgery is the lack of a commercially available antibiotic preparation for intracameral use approved by the National Sanitary Surveillance Agency (ANVISA). The Literature Review Group of the Brazilian Society for Cataract and Refractive Surgery (ABCCR/BRASCS) chose this topic for update aiming to review aspects regarding the spectrum of activity, dosage, preparation, safety and efficacy of moxifloxacin, cefuroxime, and vancomycin, which are deemed the safest antibiotics for intracameral use.

Intracameral cefuroxime in the prevention of postoperative endophthalmitis: an experience from Hong Kong.

The purpose was to study the effect of introducing intracameral cefuroxime, which was compounded by a hospital pharmacy, on postoperative endophthalmitis in a tertiary eye centre in Hong Kong. All cases that underwent cataract surgeries over a 12-year period (January 2004 to December 2015) were included. The routine use of intracameral cefuroxime at the end of cataract surgery was introduced at our centre after April 2010. All cefuroxime aliquots were prepared by the hospital pharmacy using an aseptic compounding technique. The rates of postoperative endophthalmitis before April 2010 (Group 1, no intracameral cefuroxime) and after April 2010 (Group 2, routine use of intracameral cefuroxime) were compared. A total of 30,428 eyes (7,332 in Group 1 and 23,096 in Group 2) were studied. Eight cases developed postoperative endophthalmitis (1.09 in 1000; 0.11%) in Group 1 whereas no cases developed endophthalmitis (0%) in Group 2. The rate of reduction was statistically significant (p < 0.0001). Seven out of eight cases of endophthalmitis were confirmed by positive culture. Organisms identified were Group G Streptococcus (two cases), Group B Streptococcus, Staphylococcus aureus, Serratia marcescens, and coagulase-negative Staphylococcus (two cases). Antibiotic susceptibility testing results were available in six cases. Four out of six organisms were susceptible to the penicillin group. No adverse events related to the use of intracameral cefuroxime were encountered. The use of intracameral cefuroxime could significantly reduce the rate of postoperative endophthalmitis in a tertiary centre in Hong Kong. The use of aseptic compounding to prepare cefuroxime aliquots by hospital pharmacy appeared to be safe and efficacious.

Efficacy and cost-effectiveness of intracameral vancomycin in reducing postoperative endophthalmitis incidence in Australia.

Endophthalmitis is a rare but devastating postoperative complication of cataract surgery. We aimed to describe the incidence of acute postoperative endophthalmitis in an Australian population over a 14-year period. This was a retrospective longitudinal cohort study performed at Westmead Hospital, a major tertiary hospital in Sydney, Australia. Patients who had acute postoperative endophthalmitis within 6 weeks of their cataract surgery at Westmead Hospital were included. Endophthalmitis cases from 2000 to 2014 were identified from computerized diagnostic coding. These were cross-referenced with the cataract surgery list over this time period. The routine use of intracameral vancomycin at the end of cataract surgery was introduced in Westmead Hospital in 2004. We quantified the incidence of acute postoperative endophthalmitis pre and post the routine use of intracameral vancomycin. A total of 14 805 cataract cases were performed at Westmead Hospital from 2000 to 2014. Seventeen cases of endophthalmitis were within 6 weeks post cataract surgery performed at Westmead Hospital. In the period 2000 to 2003, the incidence of postoperative endophthalmitis was 0.43% (11/2539). From 2004 to 2014, there was a dramatic decrease in the incidence of postoperative endophthalmitis to 0.049% (6/12 266, P < 0.0001). There has been a nine-fold reduction in the rate of acute postoperative endophthalmitis with the use of intracameral vancomycin in cataract surgery. Post-cataract surgery endophthalmitis is now a relatively rare cause of endophthalmitis in this Australian population. Our study supports the routine use of intracameral vancomycin as postoperative endophthalmitis prophylaxis.

Microbiology of corneal wounds after cataract surgery: biofilm formation and antibiotic resistance patterns.

To evaluate the bacterial flora of corneal wounds at the end of cataract surgery before intracameral antibiotic use and to determine agents to treat postoperative endophthalmitis, the potential for biofilm formation, and antibiotic resistance. This cross-sectional clinical study included patients who underwent cataract surgery using the phacoemulsification technique without any complications. The hemifacial skin, periocular area, eyelids and eyelashes were washed with 10% povidone-iodine and the conjunctiva was washed with 5% povidoneiodine before cataract surgery. After uncomplicated surgery, a wipe sample was taken from the bulbar conjunctival surface, corneal surface, and wound rim before administering intracameral antibiotics. All samples were plated on blood agar, MRS agar, M17 agar, calcium-lactate agar, plate-count agar, and Sabouraud-dextrose agar. Biofilm formation was evaluated by microtitre plates and the Congo red-agar method. Antimicrobial resistance patterns of isolates were determined by the agar-disk diffusion method. We recruited 50 patients and studied 55 eyes, obtaining 34 isolates from the cultures of 16 eyes. Isolated organisms were coagulase-negative staphylococci (CoNS) (35.3%), Bacillus cereus (29.4%) and Pseudomonas spp. (5.9%). We obtained isolates from 64% of diabetic cases and 20% of non-diabetic cases, (p=0.002). It was observed that 21 out of 34 isolates produced a weakly positive biofilm, 8 were moderately positive, three were strongly positive, and two isolates were biofilm negative. Of the CoNS strains four of the 11 were resistance to four or more antibiotics. Microorganisms that remained at the end of cataract surgery had the capacity to produce biofilm and had high antibiotic resistance. Appropriate preoperative disinfection is very important and adequate disinfection and suitable antibiotics should be kept in mind for avoiding endophthalmitis, especially for diabetic patients. Biofilm is one of the major factors affecting the virulence of bacteria, and further studies into prevention of biofilm formation are required in this area.

Increased Uptake of Intracameral Antibiotic Prophylaxis in Europe

PurposeTo determine the use of intracameral cefuroxime at the end of cataract surgery across Europe since the beneficial results were first reported by the ESCRS Endophthalmitis Study Group in 2007 and examine the reasons for the different practice patterns identified.MethodsThe ESCRS conducted a survey of 250 ophthalmic surgeons across Europe regarding their awareness of the ESCRS study and seeking the reasons for their current use or non‐use of i/c antibiotics in their cataract surgery. Simultaneously, data on practice patterns for prophylaxis were searched in the main European countries concentrating on the uptake of the i/c route and the reasons for the switch.ResultsIn the ESCRS survey, 74% always/usually use i/c antibiotics and 82% of these use cefuroxime. Lack of need, protocol, or concerns re adverse events related to the absence of an approved product, accounted for non‐use. Only 8% would not use i/c cefuroxime whether commercially available or not. Germany has the lowest use and the highest cataract volume whilst France has the next highest volume and the most rapid conversion due to Government guidelines introduced in 2011. The approval of a product of i/c cefuroxime for use in cataract surgery by the EMA (European Medicines Agency) in 2012 eliminated the risks of errors of dilution, diluent, contamination or TASS and is largely responsible for the major shift to the i/c route.ConclusionsThe landmark ESCRS Study results of 2007 heralded a worldwide increase in the use of i/c antibiotic for the prevention of postoperative endophthalmitis following cataract surgery. Subsequent studies all over the world have validated these results ‐ where the rate was high it got much lower, where it was low it got even lower with almost no adverse events.

Intracameral cefuroxime and the incidence of post-cataract endophthalmitis: an Israeli experience.

The European Society of Cataract & Refractive Surgeons (ESCRS) study reported a decrease in endophthalmitis rates from 0.34 % to 0.08 % with the use of intracameral cefuroxime. The purpose of this study was to compare the endophthalmitis rates before and after the introduction of intracameral cefuroxime (ICC) routinely at the end of cataract surgery. A retrospective consecutive cohort study. We compared the rates of endophthalmitis between the years 2000-2006, and the years 2007-2014, after the pivotal publication of the ESCRS. Data collected included age, gender, culture results, initial and final visual acuity, and complications. Only patients that presented with endophthalmitis following cataract surgery performed at the two centers were included. Twenty-two cases of endophthalmitis occurred between the years 2000 and 2006, out of 26,663 cataract operations performed at the two centers, a rate of 0.083 %. Ten cases occurred between the years 2007 and 2014 out of 29,431 cataract operations, a rate of 0.034 %. The difference was statistically significant (p = 0.03) CONCLUSIONS: The introduction of prophylactic use of intracameral cefuroxime was associated with a significant reduction in post-operative endophthalmitis rates in our centers. We strongly recommend adoption of this routine by for all cataract operations except when contraindicated.