Posterior Capsule Tear Research Articles

Wet Lab-Based Cataract Surgery Training Curriculum for the PGY 2/PGY 3 Ophthalmology Resident.

Studies have shown that structured cataract surgery training curricula are beneficial for resident surgeons-in-training, yet nearly one-third of US training programs do not have one, and public dissemination of said curricula are lacking. We created a microsurgical simulation center and accompanying structured training curriculum. Weekly lectures focused on the steps of cataract surgery, variations on technique, and complications. Each didactic was followed by a 1.5- to 2-hour time block with faculty supervision in the wet lab. Finally, to demonstrate proficiency, residents submitted a recorded video illustrating their competency within 1 week of the lecture. We reviewed videos and provided written feedback via a standardized form. Curriculum effectiveness was evaluated through formative feedback on the course itself and complication rates for resident-performed cataract surgery before and after implementation of the curriculum. The course was implemented in 4 consecutive academic years, allowing time for nine junior residents to participate in the course at least once before operating as a senior. The incidence of posterior capsule tears for senior residents decreased from 3.07% in the 4 years preceding curriculum implementation to 1.13% for the senior residents who completed the course at least once as juniors (p = .0571). Supervised wet lab sessions and submitted videos allowed faculty to identify surgically struggling residents early. Implementation of a cataract surgery training curriculum for junior ophthalmology residents provides a safe and effective environment to practice surgical techniques. Such a curriculum may decrease the complication rates of beginner surgeons.

Complications of cataract surgery in Wistar rats undergoing treatment with tamsulosin.

The aim of the study was to identify if there is a connection between the time of administration of alpha-blocker medication and cataract surgery complications. Furthermore, it was explored whether discontinuation of tamsulosin before cataract surgery influences the manifestations of intraoperative floppy iris syndrome in rats. An experimental study was conducted on 20 male Wistar rats aged 1.5–2 years (body mean weight 357 g), which were divided into four equal groups: Group 1, under tamsulosin hydrochloride 0.4 mg/day for 2 months; group 2, without any treatment in the first month, followed by tamsulosin; group 3, under tamsulosin for 1 month, followed by 1 month without any treatment; and group 4, control. The pupillary diameter was assessed before instillation of 0.5% tropicamide (mydriatic and cycloplegic agent), after 1 or 2 h from instillation and postoperatively. Furthermore, pupil constriction during surgery, the presence of floppy iris and prolapse of the iris following the main incision and during serum injection were also assessed. Other analyzed features included iris rupture, posterior capsule tear, vitreous loss, lens fragments in the vitreous, suprachoroidal bleeding and corneal haze. The iris dilator muscle thickness and the posterior epithelium was measured using light microscopy. In the control group, the largest pupillary diameters were indicated and in group 1, the smallest pupillary diameters were revealed. Statistically significant differences were indicated between group 1 and 2 and group 3 and 4. Floppy iris, iris prolapse in the main incision and during serum injection appeared at maximum frequency for group 1 with continuous treatment and low frequency for the control group. Lens fragments in the vitreous were present in the groups 1–3. Notably, intraoperative miosis had statistical relevance in group 1 and group 2. To conclude, the present findings suggested there is a clear connection between the time of administration of the alpha-blocker medication and most cataract complications. The results indicated that discontinuation of tamsulosin for one month largely reduces the manifestations of intraoperative floppy iris syndrome in rats, which may suggest to change preoperative treatment for benign prostatic hypertrophy with another class of drugs that do not interact with the iris receptors.

Intracameral moxifloxacin for endophthalmitis prophylaxis after cataract surgery: Cost-effectiveness analysis

To determine the cost-effectiveness of intracameral moxifloxacin compared with traditional antibiotic prophylaxis in preventing endophthalmitis after cataract surgery. Theoretical surgical center in the United States. Evaluation of technology. The incremental cost-effectiveness ratios (ICER) and incremental cost-utility ratios (ICUR) were calculated for patients having cataract surgery with traditional antibiotic prophylaxis (perioperative topical antibiotics) compared with perioperative topical antibiotics with intracameral moxifloxacin. The base case was a healthy binocular 73-year-old man having first-eye cataract surgery. The incidences and costs were derived from PubMed English literature searches, Medicare reimbursement rates, and average wholesale prices. All costs and benefits were adjusted 3% per annum and for inflation to 2017 United States dollars. Deterministic and probabilistic sensitivity analyses were performed to assess uncertainty. Compared with traditional prophylaxis, an adjuvant 500μg intracameral moxifloxacin (for $20) was cost-saving from a societal perspective in the base case; in probabilistic sensitivity analyses, all the values were within the societal willingness-to-pay threshold of $50 000/quality-adjusted-life-years (QALYs), and 6142 (61%) of 10 000 iterations were cost-saving. From a healthcare sector perspective, intracameral moxifloxacin was cost-effective, with an ICUR of $8275/QALY. In cases with posterior capsule tears, a $20 intracameral moxifloxacin was cost-saving. From a societal perspective in the U.S., a topical perioperative antibiotic with a 500μg intracameral moxifloxacin costing $22 dollars or less was cost-effective and cost-saving. From a healthcare sector perspective, a $20 intracameral moxifloxacin was cost-effective but not cost-saving. Adjuvant intracameral moxifloxacin had greater effectiveness in improving QALYs than topical antibiotics.

Femtosecond laser-assisted cataract surgery for the white cataract.

To report the capsulotomy and lens fragmentation outcomes of white cataracts managed with the femtosecond laser (FL). Outcomes of a prospective, observational consecutive case series of white cataracts (June 2012-November 2016) that underwent FL-assisted cataract surgery (FLACS) (Victus, Bausch+Lomb, Munich, Germany) at the Singapore National Eye Centre were audited. Data collected:patient demographics, type of white cataract, levelness of docking, anterior capsule position following laser, completeness of capsulotomy and fragmentation, best-corrected visual acuity (BCVA) at 1 month, intraoperative complications. Outcome measures: capsulotomy integrity, fragmentation capability and BCVA at 1 month. 58 eyes of 54 patients underwent FLACS. White cataract types included dry white (24 eyes), intumescent (28 eyes) and Morgagnian (6 eyes). Docking was level in 22 eyes (38.6%). Following FL, the anterior capsule level dropped in 20 eyes (34.5%). Incomplete capsulotomies occurred in 10 eyes (17.2%). Lens fragmentation attempted in 38 eyes was effective or partially effective in 31 eyes (81.6%). No anterior or posterior capsule tears occurred. LogMAR BCVA at 1 month was 0.073 (SD 0.09). Risk factors for incomplete capsulotomy were Morgagnian cataract and lens thickness (multiple logistic regression, p<0.01 andp=0.03, respectively). The main complication of FLACS in white cataracts was incomplete capsulotomy (17.2%), significantly associated with Morgagnian cataracts and increased lens thickness. Lens fragmentation was effected in four-fifths of white cataracts but should be avoided in Morgagnian cataracts due to possible overlap of the lens fragmentation plan and the anterior capsule.

Intraoperative difficulties, complications and self-assessed visual function in cataract surgery.

To study associations between intraoperative difficulties and changes in patient-perceived and postoperative visual function and visual satisfaction after cataract surgery. Swedish multicenter, prospective, cross-sectional, nonrandomized, National Cataract Register study. A total of 10979 patients (n=10979) who underwent cataract surgery from 2008 to 2011 completed the Catquest-9SF questionnaire before and 3months postoperatively. Using Rasch analysis, we converted the nonparametric grading of the answers to parametric data and performed parametric statistical analyses. Multiple regression models were used to examine possible predictors associated with self-assessed visual function after cataract surgery. Greater improvement in self-assessed visual function was seen in patients in whom trypan blue dye was used; those without a posterior capsular tear or an ocular comorbidity; and those who were younger, female and had low preoperative corrected distance visual acuity (CDVA) or high postoperative CDVA compared with their counterparts. Significantly higher self-assessed postoperative visual function was seen in patients in whom trypan blue dye was used and those with no posterior capsular tear or ocular comorbidity and no use of capsular hooks; and those who were younger and had low preoperative or high postoperative CDVA compared with their counterparts. The risk of general dissatisfaction after cataract surgery was significantly greater in patients with a posterior capsule tear, ocular comorbidity or low postoperative CDVA, and those in whom mechanical pupillary stretching was performed. Several intraoperative difficulties, posterior capsular tear, ocular comorbidity, age, gender, and preoperative and postoperative CDVAs affect patient improvement and self-assessed visual function after cataract surgery.

Surgical Simulation Training Reduces Intraoperative Cataract Surgery Complications Among Residents.

This retrospective consecutive case series examined whether training on a surgical simulator reduces intraoperative complication rates among novice ophthalmology residents learning cataract surgery. Beginning July 2014, training on the Eyesi simulator became mandatory for novice postgraduate year 3 ophthalmology residents before live cataract surgery at our institution. Complication rates of the 11 simulator-trained residents (study group) were compared with their immediate 11 simulator-naive predecessors (comparison group). Only straightforward cataract cases (according to standardized preoperative criteria) where postgraduate year 3 residents served as the primary surgeon were included. Complication data were obtained from Morbidity and Mortality records and compared using Fisher exact test. A survey was administered to the residents to gauge the perceived utility of simulation training. The simulator-trained group (n = 501 cataract cases) and the simulator-naive comparison group (n = 454 cases) were analyzed. The complication rate in the simulator group was 2.4% compared with 5.1% in the comparison group (P = 0.037, Fisher exact test). Both the mean posterior capsule tear rate and vitreous prolapse rate in the simulator group were 2.2% compared with 4.8% in the comparison group (P = 0.032, Fisher exact test). The survey had a response rate of 100% (11/11), and 91% (10/11) of respondents felt that the training was "extremely worthwhile" and should be mandatory. The addition of surgical simulation training was associated with a significantly reduced rate of complications, including posterior capsule tears and vitreous prolapse, among novice postgraduate year 3 residents. There is a perceived utility among residents to incorporate virtual simulation into surgical training.

Open-sky capsulorrhexis in triple procedure: with or without trypan blue?

not available.

Outcomes and complication rates of primary resident-performed cataract surgeries at a large tertiary-care county hospital

To identify the preoperative risk factors, intraoperative events, and postoperative complications increasing the risk for poor visual outcomes in resident-performed cataract surgeries at a tertiary-care county hospital. Ben Taub General Hospital, Houston, Texas, USA. Retrospective case series. Resident-performed cataract surgeries were analyzed for risk factors, comorbidities, and intraoperative and postoperative complications. The main outcome measures were preoperative and postoperative uncorrected distance visual acuity and corrected distance visual acuity (CDVA), which were correlated with preoperative demographics, intraoperative and postoperative events, and resident training level. The data were subdivided into cases without events and cases with events to determine which complications led to poor visual outcomes. The study analyzed 1290 resident-performed cataract surgeries. The mean visual acuity improved significantly after surgery in all patients (P<.001), with 80.5% of patients without complications and 70.7% with complications attaining a CDVA of 20/40 or better (P<.002). Poor visual outcomes were associated with α-antagonist use (P=.043) and pseudoexfoliation syndrome (P=.001). The most common intraoperative complications were vitreous loss (6.7%) and posterior capsule tear (7.0%). The mean postoperative visual acuity did not vary by trainee year, and the rate of dropped nucleus during surgery declined as residents progressed in training (P<.05). All other complication rates were similar between levels of training. Despite more complicated cataracts and advanced comorbidities, primary resident-performed cataract surgery in a tertiary-care county hospital system achieved visual outcomes and complication rates similar to those found in other training hospitals.

Intraocular surgery - assessment and transfer of skills using a virtual-reality simulator.

Intraocular surgery - assessment and transfer of skills using a virtual-reality simulator.

Push and Pull Method for Small Incision Cataract Surgery in Small Pupil: An Innovative Technique

A significant number of patients who present for cataract surgery have pupils that do not respond adequately despite several pharmacological attempts with different mydriatic agents. Most of the current available surgical maneuvers for enlarging the pupil and preventing its intraoperative constriction are not safe enough. They can lead to an increased risk of iris sphincter tear, bleeding, iris damage, posterior capsule tears, and loss of the vitreous body. The postoperative complications can include an atonic pupil of irregular shape leading to poor visual and cosmetic result. Large pupils postoperatively are associated with glare and a reduced depth of focus. We present our innovative technique “Push and pull method “for small incision cataract surgery in small pupils. This push and pull method of pupillary dilatation minimizes the likelihood of iris sphincter tears, thereby leading to no postoperative irregular dilated pupil and glare and better visual outcome.

Antibiotic prophylaxis in cataract surgery - An evidence-based approach.

Various protocols are being followed for endophthalmitis prophylaxis in cataract surgery, and this subject continues to be a matter of debate. We summarize the most recent evidence-based studies on this topic with additional stress on intracameral (IC) antibiotic prophylaxis. Here, we discuss several large, international clinical studies which discuss the efficacy, adoption, safety, cost, and newer trends in antibiotic prophylaxis. Majority of these studies report a significant reduction in endophthalmitis rates with IC antibiotic prophylaxis. Efficacy data have been reported for IC cefuroxime, vancomycin, and moxifloxacin. Surgeons are now looking for alternatives to vancomycin for IC prophylaxis because of its association with the rare but sight-threatening complication of hemorrhagic occlusive retinal vasculitis. A recent large clinical study shows convincing efficacy with IC moxifloxacin prophylaxis. Two large studies have also reported significant endophthalmitis reduction following use of IC antibiotic prophylaxis, in eyes with posterior capsule tear which are at highest risk for infection. Except for one randomized controlled trial, there is a lack of prospective data on this subject; however, considering the complexity of performing such studies, surgeons have to rely on the mounting evidence from other recent big data studies. Availability of approved intraocular antibiotic formulations will see a much higher adoption in the future.

Preliminary Results of Femtosecond Laser-assisted Cataract Surgery in a Private Clinic in Iran.

Purpose:To report the preliminary results of femtosecond laser-assisted cataract surgery in Iranian patients.Methods:This prospective case series included 21 eyes of 21 patients with cataract. Mean patient age was 66.7 ± 10 years. The patients underwent femtosecond-laser assisted cataract surgery (VICTUS Femtosecond Laser Platform: Bausch + Lomb) and intraocular lens (IOL) implementation in Bina Eye Hospital, Tehran, Iran between May and October, 2014. Visual outcomes, intraocular pressure (IOP), and complications were evaluated three months after surgery.Results:Mean preoperative best-spectacle corrected visual acuity (BSCVA) was 0.40 ± 0.21 logMAR which significantly improved to 0.02 ± 0.03 logMAR three months postoperatively (P < 0.001). Mean preoperative IOP was 17.88 ± 2.70 mmHg which significantly decreased to 12.5 ± 1.51 mmHg three months after operation (P < 0.001). Mean duration of operation for these patients was 29.30 ± 8 minutes and mean femtosecond laser process time was 4.20 ± 2 minutes. In terms of complications, 9 patients developed fine subconjunctival hemorrhage and eye redness and 2 patients had mild corneal edema which all subsided within less than 7 days. Serious complications such as anterior or posterior capsule tears were not encountered.Conclusion:Femtosecond laser-assisted cataract surgery is a relatively new method of cataract

A modified-simple technique of removing the lens cortex during cataract surgery

We describe here a surgical technique of removing the remaining cortex after phacoemulsification without performing the conventional irrigation/aspiration (I/A) procedure. In this technique, the remaining cortex attached to the posterior capsule was separated and dissected into several pieces by continuous irrigation with balanced salt solution, which was supplied through a syringe attached to a bent, blunt-tip needle. Approximately, 10 s of manual irrigation separated most of the remaining cortex from the posterior capsule. Then, the capsular bag was inflated with an ophthalmic viscoelastic device (OVD), and this pushed the separated cortex toward the capsular fornix mechanically. An intraocular lens was inserted into the capsular bag, following which the remaining cortex and OVD were removed concomitantly using an automated I/A handpiece. This technique is a simple and easy maneuver to remove the cortex from all areas, including the subincisional area, and reduce the possibility of a posterior capsule tear.

SURGICAL AND FUNCTIONAL RESULTS OF 27-GAUGE VITRECTOMY COMBINED WITH COAXIAL 1.8 MM MICROINCISION CATARACT SURGERY: A Consecutive Case Series.

To investigate outcomes after coaxial 1.8 mm microincision cataract surgery combined with 27-gauge vitrectomy (MICVIT) in eyes with vitreoretinal disease and age-related cataract. A single-center, retrospective case series study of 62 subjects (62 eyes) with a mean age of 70 years who underwent combined microincision phacoemulsification, intraocular lens implantation, and 27-gauge vitrectomy during the 12-month period to January 2015. Intraoperative and postoperative complications, and visual results were the main outcome measures. The mean follow-up period was 6 months (range 2-10 months). Intraoperative findings were retinal break (9.7%) and one posterior capsule tear (1.6%). No cases required corneal or scleral suture, or conversion to larger-gauge vitrectomy. Postoperative complications consisted of posterior capsule opacification (8%), elevated intraocular pressure >30 mmHg (6.4%), retinal detachment (1.6%), and fibrin reaction (1.6%). There were no cases of hypotony (<9 mmHg), intraocular lens decentration, or postoperative endophthalmitis. Visual acuity improved 3 Early Treatment of Diabetic Retinopathy Study (EDTRS) score lines from 0.48 ± 0.4 logMAR (20/60) preoperatively to 0.17 ± 0.23 logMAR (20/30) at final postoperative visit (P = 0.001). Findings suggest 27-gauge vitrectomy combined with microincision phacoemulsification and intraocular lens implantation is feasible, safe, and effective as a 1-step surgical procedure for the management of vitreoretinal pathologies and concurrent cataract.

Laser-assisted cataract surgery versus standard ultrasound phacoemulsification cataract surgery.

Cataract is the leading cause of blindness in the world, and cataract surgery is one of the most commonly performed operations in the Western world. Preferred surgical techniques have changed dramatically over the past half century with associated improvements in outcomes and safety. Femtosecond laser platforms that can accurately and reproducibly perform key steps in cataract surgery, including corneal incisions, capsulotomy and lens fragmentation, are now available. The potential advantages of laser-assisted surgery are broad, and include greater safety and better visual outcomes through greater precision and reproducibility. To compare the effectiveness of laser-assisted cataract surgery with standard ultrasound phacoemulsification cataract surgery by gathering evidence on safety from randomised controlled trials (RCTs). We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 4), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to May 2016), EMBASE (January 1980 to May 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to May 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en) and the U.S. Food and Drugs Administration (FDA) website (www.fda.gov). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 10 May 2016. We included randomised controlled trials where laser-assisted cataract surgery was compared to standard ultrasound phacoemulsification cataract surgery. We graded the certainty of the evidence using GRADE. Two review authors independently screened the search results, assessed risk of bias and extracted data using the standard methodological procedures expected by Cochrane. The primary outcome for this review was intraoperative complications in the operated eye, namely anterior capsule and posterior capsule tears. The secondary outcomes were visual acuity (corrected distance visual acuity (CDVA) and uncorrected distance visual acuity (UDVA)), refractive outcomes, quality of vision (as measured by any validated visual function score), postoperative complications and cost-effectiveness. We included 16 RCTs conducted in Germary, Hungary, Italy, India, China and Brazil that enrolled a total of 1638 eyes of 1245 adult participants. Overall, the studies were at unclear or high risk of bias. In 11 of the studies the authors reported financial links with the manufacturer of the laser platform evaluated in their studies. Five of the studies were within-person (paired-eye) studies with one eye allocated to one procedure and the other eye allocated to the other procedure. These studies were reported ignoring the paired nature of the data.The number of anterior capsule and posterior capsule tears reported in the included studies for both laser cataract surgery and manual phacoemulsification cataract surgery were low. There were four anterior capsule tears and one posterior capsule tear in 1076 eyes reported in 10 studies (2 anterior capsule tears in laser arms, 2 anterior capsule tears and 1 posterior capsule tear in standard phacoemulsification arms). We are very uncertain as to the effect of laser-assisted surgery compared to standard phacoemulsification surgery with respect to these two outcomes. For postoperative cystoid macular oedema and elevated postoperative intraocular pressures, again the evidence was inconclusive (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.20 to 1.68; 957 eyes, 9 studies, low certainty evidence; and OR 0.57, 95% CI 0.11 to 2.86; 903 eyes, 8 studies, low certainty evidence).We found little evidence of any important difference in postoperative visual acuity between laser-assisted and standard phacoemulsification arms. There was a small advantage for laser-assisted cataract surgery at six months in CDVA. However, the mean difference (MD) was -0.03 logMAR (95% CI -0.05 to -0.00; 224 eyes, 3 studies, low certainty evidence) which is equivalent to 1.5 logMAR letters and is therefore, clinically insignificant. No studies reported patient-reported outcome measures such as visual function.There were no data reported on costs or resource use but three studies reported the time taken to do the surgery. There was little evidence of any major difference between the two procedures in this respect (MD 0.1 minutes, 95% CI -0.02 to 0.21; 274 eyes, low certainty evidence). The evidence from the 16 randomised controlled trials RCTs included in this review could not determine the equivalence or superiority of laser-assisted cataract surgery compared to standard manual phacoemulsification for our chosen outcomes due to the low to very low certainty of the evidence available from these studies. As complications occur rarely, large, adequately powered, well designed, independent RCTs comparing the safety and efficacy of laser-assisted cataract surgery with standard phacoemulsification cataract surgery are needed. Standardised reporting of complications and visual and refractive outcomes for cataract surgery would facilitate future synthesis. Data on patient-reported outcomes and cost-effectiveness are needed. Paired-eye studies should be analysed and reported appropriately.

Initial experience using a femtosecond laser cataract surgery system at a UK National Health Service cataract surgery day care centre

ObjectivesTo describe the initial outcomes following installation of a cataract surgery laser system.SettingNational Health Service cataract surgery day care unit in North London, UK.Participants158 eyes of 150 patients undergoing laser-assisted...

Femtosecond laser–assisted cataract surgery in complex cases

To describe the use of the femtosecond laser in complex cataract cases. Department of Ophthalmology, University of Colorado, Aurora, Colorado, USA. Retrospective case series. This was a single-center retrospective review of consecutive complex cataract surgery cases in which the Lensx femtosecond laser was used between October 2012 and February 2015. Complex cases were defined as white cataracts, dense brunescent cataracts, or cataracts in which zonulopathy was identified preoperatively. Outcome measures included an assessment of the capsulotomy, surgical complications, and postoperative corrected distance visual acuity (CDVA). Thirty-four eyes of 34 patients were included in this study; 27 had white cataract, 3 had dense brunescent cataract, and 6 had zonulopathy (2 of these also had white cataract). Three patients had an incomplete capsulotomy, and 3 had small radial tears in the anterior capsule. Four patients (11.7%) developed posterior capsule tears during phacoemulsification; 1 of these subsequently had pars plana vitrectomy for a retained lens fragment. Twenty-eight (97%) of 29 patients had a postoperative CDVA of 20/40 or better. Three patients were identified with comorbidities that limited postoperative CDVA. One patient developed postoperative cystoid macular edema. The femtosecond laser was useful in the surgical approach to patients with complex cataracts, especially for the creation of the capsulotomy. None of the authors has a financial or proprietary interest in any material or method mentioned.

Evaluation of Cataract Surgery Outcomes at the Ban Phaeo Mobile Eye Clinic, Thailand

Purpose: To evaluate the quality and efficacy of the Ban Phaeo Mobile Eye Clinic (BPMEC) model in providing cataract surgery to rural Thailand.Methods: Retrospective review of 4-week postoperative visual acuity (VA) of 7040 patients receiving unilateral cataract surgery at 75 sites from October 2008 to March 2011. BPMEC conducted screening, surgery, and follow-up at partnering local hospitals that otherwise do not offer eye care. The primary outcome was achievement of VA ≥20/70, which was secondarily analyzed by cataract extraction method (phacoemulsification, phaco, or extracapsular cataract extraction, ECCE) and intraocular lens (IOL) type (foldable acrylic or rigid polymethylmethacrylate).Results: Preoperatively, 249 eyes (4%) had uncorrected VA ≥20/70. Four weeks postoperatively, 5957 (85%) had VA ≥20/70, 3288 (47%) had VA ≥20/40, and 69 (1%) were lost to follow-up. Phaco was performed in 6324 eyes (90%), 1581 (25%) receiving foldable IOLs. A total of 1403 eyes (89%) undergoing phaco with a foldable IOL had postoperative VA ≥20/70, compared to 4058 (85%) and 496 (69%) of those undergoing phaco with a rigid IOL (p < 0.05) and ECCE with a rigid IOL (p < 0.001), respectively. Overall, 37 eyes were left aphakic. Reported intraocular complications included zonular dehiscence (37 eyes), retained lens fragment (2 eyes), wound leakage (1 eye), and posterior capsule tear (1 eye).Conclusions: The 4-week uncorrected postoperative VAs met the World Health Organization’s quality target of VA ≥20/70 for eyes undergoing phaco and were comparable to those published by an urban hospital in Bangkok.

Knee Injury-rugby

HISTORY: A 20 year old collegiate rugby player sustained a right knee injury. A defender struck the front of his right knee resulting in hyperextension and an audible pop. He was unable to ambulate off of the field. Initial exam revealed a dislocated knee which was reduced on the field. He was taken to the ED where a CT angiogram ruled out vascular injury. He was provided with an immobilizer, crutches and was referred to a sports medicine trained orthopedic surgeon. PHYSICAL EXAM: Examination in clinic demonstrated a marked effusion. Passive range of motion showed flexion to 50 degrees, and hyperextension into mild recurvatum. Varus and valgus stress revealed increased laxity for both. Lachman’s was markedly positive. He demonstrated a complete foot drop with 0/5 strength for dorsiflexion, eversion, and extensor hallicus longus (EHL). Plantarflexion and inversion had full strength. Sensory testing showed diminished light-touch over the lateral lower leg and the dorsum of the foot. DIFFERENTIAL DIAGNOSIS: 1. Anterior cruciate ligament (ACL) tear 2. Posterior cruciate ligament (PCL) tear 3. Medial collateral ligament (MCL) tear 4. Lateral collateral ligament (LCL) tear 5. Sciatic nerve injury 6. Common peroneal nerve injury 7. Superficial peroneal nerve injury 8. Deep peroneal nerve injury TESTS AND RESULTS: Right Knee MRI: -ACL tear -PCL tear -LCL tear -Popliteus tendon tear -Posterior lateral capsule tear -Both gastrocnemius tears -Posterior capsule tear FINAL WORKING DIAGNOSIS: -ACL tear, PCL tear, LCL tear, Popliteal tendon tear, posterior capsule tears, gastrocnemius tears, and a common peroneal nerve injury TREATMENT AND OUTCOMES: 1. The patient underwent arthroscopic reconstruction of his ACL and PCL, open LCL reconstruction, posterior lateral corner reconstruction, and a common peroneal nerve decompression. 2. He is undergoing physical therapy and he has advanced his range of motion back to normal. He continues to work on his quadriceps strength, hip flexor strength, balance and neuromotor control of the knee. 3. The patient experienced improved sensation in the peroneal nerve distribution and slight EHL activation at 52-days post surgery. This has continued to improve and the patient is able to dorsiflex, evert and activate his EHL against resistance at four months post surgery. Sensation is much improved.

Femtosecond laser–assisted cataract surgery versus standard phacoemulsification cataract surgery: Outcomes and safety in more than 4000 cases at a single center

To compare the intraoperative complications and safety of femtosecond laser-assisted cataract surgery and conventional phacoemulsification cataract surgery. Single center. Prospective consecutive comparative cohort case series. Eyes had femtosecond laser-assisted cataract surgery (study group) or phacoemulsification (control group) by 1 of 5 surgeons. The technique comprised manual corneal incisions and capsulorhexis or laser-assisted anterior capsulotomy, lens fragmentation, corneal incisions, phacoemulsification, and intraocular lens implantation. The study group comprised 1852 eyes and the control group, 2228 eyes. Patient demographics were similar between groups. There was a significant improvement in vacuum/docking attempts, surface recognition adjustments, treatment, and vacuum time during the laser procedure in the study group. Anterior capsule tears occurred in 1.84% of eyes in the study group and 0.22% of eyes in the control group (P < .0001). There was no difference in the incidence of anterior capsule tears between the first half and second half of laser-assisted cases. Anterior capsulotomy tags occurred in 1.62% study group eyes. There was no significant difference in posterior capsule tears between the 2 groups (0.43% versus 0.18%). The incidence of significant intraoperative corneal haze and miosis was higher and the effective phacoemulsification time significantly lower in the study group (P < .001). Significant intraoperative complications likely to affect refractive outcomes and patient satisfaction were low overall. The 2 cataract surgery techniques appear to be equally safe. Although anterior capsule tears remain a concern, the safety of femtosecond-assisted cataract surgery in terms of posterior capsule complications was equal to that of phacoemulsification. No author has a financial or proprietary interest in any material or method mentioned.