Lens Fragments Research Articles

Water Gonioscopy: A Technique for Intraoperative Visualization of the Anterior Chamber Angle.

Aim and objectiveTo describe a technique of lens-free gonioscopy that allows the anterior chamber angle to be visualized intraoperatively, without the use of a gonioscopy lens.BackgroundMinimally invasive glaucoma surgery (MIGS) is an increasingly popular treatment option for mild to moderate glaucoma. We describe a technique of lens-free gonioscopy that allows visualization of the anterior chamber angle without the use of a lens. This simple intraoperative technique may be used to inspect the placement of MIGS devices within the angle.TechniqueTo perform a water gonioscopy, the surgeon sits temporal to the eye. The patient's head is turned 20–45° away from the surgeon, and the operating microscope is tilted 15–30° toward the surgeon. A reservoir of balanced salt solution is allowed to collect in the crater formed by the nose bridge and the bony orbital rim, external to the corneal surface. This body of liquid obliterates the cornea–air interface and hence allows visualization of the anterior chamber. In contrast to gonioscopy using a gonioscopy lens, water gonioscopy offers a lower magnification, ultra-wide field of view for angle visualization.ConclusionWater gonioscopy is a useful technique that anterior segment surgeons might use for quick visualization of the anterior chamber angle without the need for additional equipment.Clinical significanceThis is a simple technique that surgeons can use to visualize the anterior chamber angles intraoperatively. It is especially useful for MIGS that are placed within the anterior chamber angle, but this technique may also be used during other anterior segment surgeries, such as visualizing the haptics of an anterior chamber intraocular lens or checking for retained lens fragments in the anterior chamber angles.How to cite this articleChiam N, Perara S. Water Gonioscopy: A Technique for Intraoperative Visualization of the Anterior Chamber Angle. J Curr Glaucoma Pract 2021;15(3):106–108.

Prostaglandin Release After Low-Energy Femtosecond Laser-Assisted Cataract Surgery Without Anti-Inflammatory Drug Premedication

To compare prostaglandin E2 (PGE-2) levels in the aqueous and pupil diameter in patients undergoing low-pulse energy femtosecond laser-assisted cataract surgery (LCS) without non-steroidal anti-inflammatory (NSAID) pretreatment with either fragmentation or capsulotomy performed first. Prospective, randomized, fellow-eye controlled comparison. This study was undertaken at the Department of Ophthalmology, Medical University of Vienna. The population consisted of 140 eyes of 70 patients with bilateral age-related cataract. Bilateral same-day LCS with either anterior capsulotomy before lens fragmentation (Caps-First) in one eye or vice versa (Frag-First) in a random sequence were performed. Aqueous was tapped 5 minutes after LCS and PGE-2 concentration was analyzed. Pupil diameters were recorded immediately before and after femtosecond laser pretreatment. The main outcome measure was PGE-2 concentrations in picograms/milliliter and pupil diameter in millimeters. Mean PGE-2 concentrations were 42.0 ± 63.7 pg/mL in the Caps-First group versus 71.8 ± 160.7 pg/mL with the Frag-First group (P=.186). Mean pupil diameters before and after pretreatment were 7.6 ± 0.8 mm and 7.6 ± 0.8 mm, respectively (P=.871). Mean PGE-2 concentrations and pupil diameters did not show any significant difference between time points or groups. Low-energy femtosecond laser pretreatment did not increase PGE-2 levels in the absence of NSAID pretreatment. This was independent of whether capsulotomy or fragmentation was performed first. Moreover, no pupillary miosis was observed.

Risk factors, complications, and outcomes of phacoemulsification cataract surgery complicated by retained lens fragments in Asian eyes: A 10-year retrospective study.

PURPOSE:To study the risk factors, visual outcomes, and sequelae of phacoemulsification surgery complicated by retained lens fragments (RLFs).METHODS:This single-center case–control study enrolled consecutive eyes complicated by RLF and compared them to age- and gender-matched uneventful cataract surgery cases at a tertiary care teaching hospital. Biometric, intraoperative, and postoperative data were collected. The primary outcome measures were risk factors, visual outcomes, and rate of postoperative complications.RESULTS:The study and control groups included 282 and 289 eyes, respectively. The estimated incidence of RLF was 1.47% during the study. We found a statistically higher risk of RLF among diabetics (P < 0.001), those with a history of intravitreal injections (P = 0.001), eyes with dense nuclear sclerosis, anterior capsular cataract (P < 0.001), and posterior polar cataract (P = 0.01). There was a statistically higher risk of RLF in eyes with a higher mean preoperative visual acuity (logarithm of the minimum angle of resolution) (P < 0.001) and in cases performed by trainees (P < 0.001). Most eyes in the RLF group (n = 207, 73.4%) retained their preoperative vision or experienced a one-line improvement in visual acuity and 14 eyes (5.3%) experienced more than one-line improvement in vision.CONCLUSION:Although RLFs are rare, they can affect the quality of postoperative vision and outcomes of complicated phacoemulsification surgery.

Two different approaches, posterior and anterior, during pars plana vitrectomy for retained lens fragments after cataract surgery

Two different approaches, posterior and anterior, during pars plana vitrectomy for retained lens fragments after cataract surgery

Rate of Posterior Capsule Rupture in Phacoemulsification Cataract Surgery by Residents with Institution of a Wet Laboratory Course

Abstract Purpose To determine if a structured surgical wet laboratory curriculum for ophthalmology residents reduced the rate of posterior capsule rupture (PCR) in phacoemulsification cataract surgery. Setting James A. Haley Veterans' Hospital, Tampa, FL. Design Retrospective cohort study. Methods The study assessed resident-performed phacoemulsification cataract cases from 2011 to 2017, after the creation of a wet laboratory course. Primary outcome measure was PCR. If present, timing of complication, dropped lens fragments, and the need for anterior vitrectomies were noted. Self-reported rates of PCR prior to institution of a wet laboratory course (2010–2011) were compared with cases done by residents who completed the course (2011–2017). Results A total of 3,445 cases were reviewed of which 2.44% (84 cases) noted PCR. Of these, 19% (16) had dropped lens fragments, and 60.7% (51) required anterior vitrectomy. Sixty-nine cases documented timing of PCR with the majority, 58%, occurring during phacoemulsification. When comparing rates of PCR in cases done prior to the presence of a wet laboratory course versus after, there was a significant reduction observed (5.20% before vs. 2.44% after). Conclusion In the presence of a wet laboratory curriculum, the rate of PCR decreased dramatically. The average rate was lower than those reported at other training programs (2.6–9.9%). Most PCR occurred during phacoemulsification, suggesting need for further focused instruction in this step.

Protecting the Corneal Endothelium during Cataract Surgery Using the Anterior Capsulorhexis Flap as a Corneal Protection Shield

Purpose: Classification and quantification of swirling lens fragments during phacoemulsification with or without using the capsulorhexis flap as an additional endothelial protective shield. Also, to determine the effects on endothelial cell count (ECC) and central corneal thickness (CCT) caused by fragments during cataract surgery. Methods: Patients with dense cataracts scheduled for surgery were randomized into study and control groups (2:1). In the study group, the anterior capsule ‘flap’ from the capsulorhexis was used as an endothelial protection shield during phacoemulsification. The control group underwent standard surgery. During surgery, intra-operative optical coherence tomography was performed to score swirling lens fragments that hit the corneal endothelium. CCT and ECC were measured at several time points before and after surgery. Results: In total, 176 fragments in 49 eyes of 49 patients came in contact with the corneal endothelium. The mean number of fragments was 2.8 in the study group and 4.8 in the control group. There was no statistically significant change of ECC between the groups. Mean CCT increased by 16.6 µm in the study group and by 42µm in the control group 1 day postoperatively. There was no significant difference between the groups regarding the increase in CCT. Conclusions: No significant benefit concerning ECC or CCT was found in the study group compared to the control group, meaning that we were not able to prove that using the capsulorhexis flap as a protection shield is a sufficient method of protecting the corneal endothelium.

Electron microscopy analysis of femtosecond laser-assisted capsulotomy before and after lens fragmentation

Studying anterior lens capsule cutting edge profiles from femtosecond laser-assisted capsulotomy procedures performed before and after lens fragmentation. Twenty eyes (10 patients) with age-related cataract underwent femtosecond laser-assisted surgery (FLACS) using the Ziemer Z8 platform. First step of laser surgery was either capsulotomy (group first) or fragmentation (group second). One eye of each patient was assigned randomly, the second eye treated with the different sequence of procedures. After anterior capsule removal, tissue was fixed in cacodylate-buffered solution and cutting-edge profiles were analysed using scanning electron microscopy (SEM). All cases had cataract grade 2 and 3 based on LOCS III grading. SEM analysis showed more smooth edges in the first group, especially in cases with pseudoexfoliation (P = 0.037); more tags and bridges and a significant number of staggered cutting patterns (7 out of 10 cases) in the second group. All cases evolved the same microgroves with “valleys and mountains “ as signs of the photodisruption process. Femtosecond laser capsulotomy should be performed before lens fragmentation minimizing the rate of cutting errors. Especially in eyes with advanced cataract, as intracapsular pressure may increase due to lens fragmentation without anterior capsular opening.

The Effect of Prophylactic 360-degree Barrier Laser Photocoagulation during Vitrectomy for Dropped Lens Fragments

The Effect of Prophylactic 360-degree Barrier Laser Photocoagulation during Vitrectomy for Dropped Lens Fragments

Indications for surgical management of retained lens fragments.

Retained lens fragments are a relatively rare occurrence after cataract surgery. While no definite guidelines for the surgical management or timing of surgery of this complication exist, surgery is indicated for patients with large lens fragments, persistent inflammation, secondary glaucoma, corneal edema, retinal tears or detachments, and associated endophthalmitis. The aim of this review is to summarize the current surgical management of retained lens material. The Intelligent Research in Sight registry database of 2.26 million patients who underwent cataract surgery in the US indicated that 0.18% (1 in 563) had secondary removal of retained lens fragments in the anterior chamber in the operating room within 1 year of the original cataract surgery. The risk of returning to the operating room for retained lens material removal was greater among men, smokers, patients with Medicaid or military insurance, and those who had complex cataract surgery. Medical management with topical corticosteroids or observation may be considered for small lens fragments, but surgical removal remains the mainstay of the treatment for large lens fragments. Retained lens fragments following cataract surgery may result in various vision-threatening complications. Understanding the risk factors, diagnosis, and surgical management of retained lens fragments are critical to preserving good visual outcomes. Vitrectomy is effective in patients with posterior nuclear fragments, retinal detachment, endophthalmitis, or uncontrolled glaucoma not responding to medical management. The best timing for surgery for retained lens fragments should be further investigated in a prospective study.

HYDROGEL INSERT MISMATCH - A RARE CAUSE OF FAILED FEMTOSECOND LASER Assisted CATARACT SURGERY

Background: Femtosecond laser-assisted cataract surgery (FLACS) offers high level of precision and automates the three major steps of cataract surgery - corneal incisions, anterior capsulotomy and lens fragmentation. An ideal dock is required for optimal outcomes in FLACS. However dock failure can occur due to various factors. Here, we report a case of failed FLACS due to mismatch of hydrogel insert. Case description: FLACS with toric intraocular lens (IOL) implantation was planned in right eye for a 57 year old male who was diagnosed with immature cataract in that eye. Due to mismatch between the corneal curvature and the hydrogel insert, multiple attempts were required to achieve dock which resulted in folds on the hydrogel insert, causing incomplete anterior capsulotomy and nuclear fragmentation. During surgery, capsulorhexis and nuclear fragmentation was completed manually. Rest of the surgery was uneventful. Conclusion: The choice of hydrogel insert should depend on the corneal curvature. Appropriate usage of hydrogel insert based on the keratometry readings will result in enhanced outcomes.

Ceftazidime and Vancomycin Deposits after Intravitreal Injection in a Vitrectomized Eye

A 62-year-old man was referred on suspicion of exogenous endophthalmitis 3 weeks after pars plana vitrectomy to remove retained lens fragments, following a complicated phacoemulsification 2 months before presentation. Five days prior to his referral, endophthalmitis was suspected, and he underwent a vitreous tap and received intravitreal injections of ceftazidime and vancomycin. Left posterior segment examination showed multiple, diffuse, whitish, preretinal deposits, without chorioretinal lesions or vascular involvement (Fig A). OCT conducted through the lesions confirmed the preretinal location (Fig B). After 1 week, the deposits had reduced in size and number, and migrated inferiorly (Fig C). After 4 weeks, the deposits had resolved completely (Fig D). (Magnified version of Fig A-D is available online at www.aaojournal.org). Supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.

Хирургическое лечение при повреждении задней капсулы хрусталика после лазерного витреолизиса

Damage to the posterior capsule of the lens after laser vitreolysis causes the formation of traumatic cataracts and a decrease in visual acuity. The search for surgical methods of treating such complications is relevant. Purpose. To develop and improve the technique of posterior capsulorexis during phacoemulsification and implantation of IOL combined with vitrectomy in the presence of an initial injury of the posterior lens capsule. Material and methods. Clinical case - a patient came to the clinic with complaints about a decrease in visual acuity and quality after laser vitreolysis performed in another clinic. Observed the damage of the posterior capsule of the lens. The operation was performed according to the developed technique. Results. A method of primary posterior capsulorexis during phacoemulsification and implantation of IOL after vitreolysis, combined with vitrectomy, is proposed. Achieved high visual acuity after the operation, OD=1.0. Conclusions. 1) The developed technique of primary posterior capsulorexis is safe and allows partially preserving the posterior capsule of the lens, while forming a «window» in the area of damage, and implanting the IOL into a capsule bag. 2) The installation of scleral ports during primary posterior capsulorexis makes it possible to successfully combine this operation with vitrectomy and prevent the displacement of lens fragments to the fundus. Key words: сataract, posterior capsulorexis, laser vitreolysis, phacoemulsification, pseudophakia, IOL, vitrectomy, vitreous body.

Incidence and complications of retained lens fragment in the anterior chamber after uneventful cataract surgery in a United Kingdom tertiary center.

To analyze the outcomes of retained lens fragment (RLF) in the anterior chamber after uneventful cataract surgery. Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom. Retrospective, observational cross-sectional study. A single-center, retrospective review was performed to identify patients who underwent RLF removal after uneventful phacoemulsification surgery between October 2012 and November 2018; 122 eyes from 121 patients were identified. Patient characteristics, clinical findings, visual outcomes, and need for subsequent surgical procedure were recorded. Main outcomes were change in corrected distance visual acuity (CDVA), and number and risk factors associated with additional surgery following RLF removal. One hundred twenty-two RLF over a total of 98 467 uneventful phacoemulsification surgeries were identified, with an incidence of 1 (0.124%) in 807 operations. The mean CDVA improved significantly after RLF removal from 0.32 to 0.26 logMAR (SD 0.26) (P = .001). Six eyes (4.9%) had persistent corneal edema that required endothelial keratoplasty (EK) after a mean of 13 months after RLF removal (SD 12 months; median 8; range 4 to 35). Risk factors for EK include α-receptor blocker use (odds ratio [OR], 6.75; 95% CI, 1.069, 42.63), increased interval (month) between cataract surgery and diagnosis of RLF (OR, 1.29; CI: 1.080, 1.541), increased interval between cataract surgery and RLF washout (OR, 1.28; CI, 1.075, 1.522), and RLF diagnosis on gonioscopy (OR, 10.60; CI, 1.885, 59.59). RLF is a rare complication of uneventful cataract surgery and appears more frequently in challenging cataract cases and myopic eyes. CDVA improved significantly after RLF removal, but approximately 1 in 20 eyes needed additional surgery-mainly EK for corneal decompensation.

Semi-Automated Extraction of Lens Fragments via a Surgical Robot Using Semantic Segmentation of OCT Images with Deep Learning - Experimental Results in ex vivo Animal Model.

The overarching goal of this work is to demonstrate the feasibility of using optical coherence tomography (OCT) to guide a robotic system to extract lens fragments from ex vivo pig eyes. A convolutional neural network (CNN) was developed to semantically segment four intraocular structures (lens material, capsule, cornea, and iris) from OCT images. The neural network was trained on images from ten pig eyes, validated on images from eight different eyes, and tested on images from another ten eyes. This segmentation algorithm was incorporated into the Intraocular Robotic Interventional Surgical System (IRISS) to realize semi-automated detection and extraction of lens material. To demonstrate the system, the semi-automated detection and extraction task was performed on seven separate ex vivo pig eyes. The developed neural network exhibited 78.20% for the validation set and 83.89% for the test set in mean intersection over union metrics. Successful implementation and efficacy of the developed method were confirmed by comparing the preoperative and postoperative OCT volume scans from the seven experiments.

Prior pars plana vitrectomy and its association with adverse intraoperative events during cataract surgery.

To evaluate the risk of intraoperative complications during cataract surgery in eyes with a prior vitrectomy. A retrospective review of data from our cataract surgery registry of all patients undergoing cataract surgery between 2014 and 2018 at the University of Colorado Hospital. Univariate and multivariate analyses were conducted, accounting for intra-patient correlation in subjects who underwent two cataract surgeries. The three main outcomes of interest, zonulopathy, posterior capsule (PC) tears and dropped lens fragments, were analysed for their association with prior pars plana vitrectomy (PPV) and clinical characteristics of patients such as history of prior intravitreal injection and surgeon level of experience. 10 540 eyes of 6447 patients were included in the analysis. 371 (3.5%) eyes had a prior PPV. Eyes with a prior PPV experienced more zonulopathy during cataract surgery (adjusted OR 2.2, 95% confidence interval: 1.3-3.7, p = 0.002). Combined phacoemulsification/PPV were significantly more likely to experience all 3 complications, and this effect was even greater for eyes with a prior PPV. All complications were rare; however, there was a significant association with prior PPV and intraoperative zonulopathy. Cataract surgeons must be aware of a patient's prior vitrectomy and plan accordingly for the increased risk of intraoperative complications.

Anterior Chamber Retained Lens Fragments After Cataract Surgery: A Case Series and Narrative Review.

IntroductionRetained lens fragments in the anterior chamber following cataract extraction (CE) with phacoemulsification are rare but can lead to significant patient morbidity. Our study aimed to identify risk factors associated with retained lens fragments.MethodsPatients who underwent cataract surgery and subsequently identified to have retained lens fragments in the anterior segment were included. Incidence per year, patient demographics, visual acuity, ocular biometrics, surgical technique, surgeon performing CE, and outcomes were collected retrospectively and compared to a control group.ResultsTwenty-four patients were identified with retained lens fragments, with an incidence of 0.10%. The mean age was 76 years ±6.72 (60–80) compared to 63 ±11.41 (22–86) in the control group (p <0.001). Patients with UDVA 20/150 or worse experienced a greater average improvement in visual acuity compared to patients with UDVA better than 20/150 (logMAR 0.46 vs logMAR 0.05). The mean intraocular pressures before (CE), after CE but before fragment removal, and following fragment removal were 14 mmHg ±2.59, 19 mmHg ±8.20, and 11 mmHg ±2.75, respectively. Twenty-two patients presented with inferiorly located fragments. Statistically significant biometrics include mean anterior chamber depth (3.1 mm ±0.37 vs 3.33 mm ±0.39, p = 0.01) and lens thickness (4.77 mm ±0.44 vs 4.35 mm ±0.44, p = <0.001). Yearly incidence rates per surgeon ranged from 0.00% to 0.85%. In 2003 and 2004, one surgeon had significantly higher incidence rates (0.31 and 0.40%) compared to the average combined rate of all surgeons throughout the study (0.10), with p values of 0.001 and 0.003, respectively. The mean number of days between CE and fragment removal was 26 ±40 (1–138).ConclusionIncreased patient age, shallow anterior chamber depth, and thick lens may be risk factors for retained lens fragments. There may be additional surgeon-specific risk factors. Phacoemulsification technique (Divide-and-Conquer versus Horizontal Chop) showed no significant difference.

PSU1 An Umbrella Review Comparing the Safety and Effectiveness of Femtosecond Laser-Assisted Cataract Surgery with Manual Cataract Surgery

Femtosecond laser-assisted cataract surgery (FLACS) automates corneal incision, capsulotomy, and lens fragmentation steps of manual cataract surgery (MCS) which may provide advantages in clinical effectiveness and safety outcomes. A narrative umbrella review of systematic reviews and meta-analyses (MAs) was conducted to summarize the totality of evidence available for clinical effectiveness and safety outcomes.

Vitrectomie pour luxation postérieure de fragments cristalliniens après chirurgie de la cataracte : étude comparative

To evaluate and to compare functional outcomes and complication rates of the same-day versus delayed pars plana vitrectomy (PPV) for intravitreal retained lens fragments after cataract surgery. Retrospective comparative series of 135 eyes with retained lens fragments that underwent PPV between August 2014 and July 2016. Sixty-two eyes received same-day PPV (group 1) and seventy-three eyes underwent delayed PPV (group 2). Outcome measures included best-corrected visual acuity (BCVA) at 6 months and postoperative complications. The mean time to PPV in group 2 was 4.3±5.3 days. Mean axial length, lens fragment size and surgical technique were comparable in both groups. At 6 months, BCVA was 0.27±0.40 logMAR in group 1, and 0.35±0.30 logMAR in group 2, with no significant difference (P=0.205). Fifty-one (82.2%) eyes in group 1 and 53 (72.6%) eyes in group 2 achieved BCVA of+0.30 logMAR (20/40) or better (P=0.183). The most common complications were macular edema, elevated intraocular pressure>25mmHg, and retinal detachment occurring respectively in 10 (16.1%) eyes, 4 (6.4%) eyes and one eye (1.6%) in group 1 and 11 (15.0%) eyes, 5 (6.8%) eyes and 2 (2.7%) eyes in group 2. Overall, the complication rate was similar in both groups (P=1). Our study shows that visual acuity outcomes and complication rates were similar regardless of timing of the PPV. The optimal timing of surgery remains a multifactorial decision involving patient preferences, transportation, surgeon availability and severity of the initial presentation.

Perioperative pupil size in low-energy femtosecond laser-assisted cataract surgery.

To assess potential changes in pupil size during femtosecond laser-assisted cataract surgery (FLACS) using a low-energy laser system. The pupil sizes of eyes undergoing FLACS were measured using the Ziemer LDV Z8 by extracting images from the laser software after each of the following steps: application of suction, lens fragmentation, and capsulotomy. Furthermore, the pupil diameters were measured based on preoperative surgical microscope images and after releasing the suction. Paired t-test and the two one-sided tests (TOST) procedure were used for statistical analyses. The horizontal and vertical pupil diameters were compared in each of the steps with preoperative values. Data were available for 52 eyes (52 patients, mean age 73.4 years, range 51-87 years). The equivalence between mean preoperative pupil size and status immediately after femtosecond laser treatment was confirmed (p<0.001; 95% confidence interval [-0.0637, 0.0287] for horizontal and p<0.001; 95% CI [-0.0158, 0.0859] for vertical diameter). There was statistically significant horizontal and vertical enlargement of pupil diameters between 0.15 and 0.24 mm during the laser treatment steps as compared with preoperative values (all p values <0.001). No progressive pupil narrowing was observed using low-energy FLACS. Although a suction-induced, slight increase in pupil area became apparent, this effect was completely reversible after removing the laser interface.

Comparison of cumulative dispersed energy between conventional phacoemulsification and femtosecond laser-assisted cataract surgery with two different lens fragmentation patterns

The purpose of the study is to compare the total ultrasound power used between eyes undergoing different lens fragmentation patterns of femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification surgery (CPS). A total of 506 patient eyes underwent preoperative grading of lens opacity using the Lens Opacity Classification System III (LOCSIII). The eyes were divided into two subgroups: subgroup 1 had a LOCSIII grade of 1–3, and subgroup 2 had a LOCSIII grade of 4–6. The eyes underwent FLACS (LenSx) for clear corneal wound, capsulotomy, and lens fragmentation. Either a grid pattern or radial pattern was used for lens fragmentation. The eyes received one of the following three treatments: (1) CPS without femtosecond laser assistant, (2) FLACS with a grid pattern (FGP) lens fragment, or (3) FLACS with a quadrant pattern (FQP) lens fragment. The mean cumulative dispersed energy (CDE) for each subgroup and treatment was evaluated. The mean CDE was lower in the two FLACS groups (1.21±1.91 in FGP and 1.22±1.92 in FQP) than that in the CPG group (2.67±2.84). In subgroup 1, CDE was higher in the CPG group (1.54±1.18) as compared with the FLACS groups (0.16±0.31 in FGP and 0.74±1.17 in FQP; P<0.001). In subgroup 2, CDE was higher in the CPG (6.47±3.46) as compared with the FLACS groups (2.74±2.21 in FGP and 5.34±2.17 in FQP; P<0.001). CDE was lower in the two FLACS groups than that in the CPS group, and CDE was the lowest with FGP in both subgroups 1 and 2.