Second-eye Surgery Research Articles

Modeling utility of second-eye cataract surgery.

To study the impact on public health in terms of utility of various proportions of first-eye and second-eye cataract surgery. A model was used to study the impact on a population of a fixed cataract surgical rate (9,250 operations/1,000,000 people) with varying proportions of first-eye and second-eye cataract operations. The study population was the County of Blekinge with a known incidence of previous cataract surgery. The prevalence of cataract, the estimated need for cataract surgery, and the utility values were taken from the literature. The population was grouped by disability stage of cataract and previous cataract surgery in accordance with prevalence studies and data from a large national database on cataract surgery and patients' self-assessed visual function. The mortality rate was taken from real data for the study population. Given a fixed cataract surgical rate over a period of five years, a high percentage of second-eye cataract surgery (42 percent) resulted in a mean utility of 0.82239 in the population forty years of age and older and the corresponding number for a low percentage of second-eye cataract surgery (25 percent) was 0.82253. A high percentage of second-eye surgeries resulted in 421 more individuals who were well compared with a low percentage of second-eye surgeries. On the other hand, a low percentage of second-eye surgeries resulted in 152 fewer individuals with disability and 118 fewer individuals with dependence compared with a high percentage of second-eye surgeries. A high frequency of first-eye cataract surgeries instead of second-eye surgeries affects more individuals and means an optimized improvement of utility in a population. This should be recommended if the cataract surgical rate is very insufficient. If the cataract surgical rate is high, more second-eye surgeries should be performed to optimize quality of life to as many as possible.

Outcomes of sulcus implantation of Array multifocal intraocular lenses in second-eye cataract surgery complicated by vitreous loss

Purpose: To evaluate the outcomes of implantation of the Array ® multifocal intraocular lens (IOL) (model SA-40N, AMO) in the ciliary sulcus in second-eye cataract surgery complicated by vitreous loss. Setting: Department of Ophthalmology, Arrowe Park Hospital, Wirral, United Kingdom. Methods: This retrospective study comprised 15 patients who had complicated second-eye cataract surgery with loss of posterior capsule support leading to sulcus implantation of an Array multifocal IOL. The patients were recalled for assessment. Objective evaluation included uncorrected and corrected distance and near visual acuities, complications, and IOL centration. Subjective assessment was performed using a questionnaire that included the VF-14 index of visual function; the questions were related to satisfaction with vision, limitations from halos and glare, and the frequency of spectacle wear. Results: Fourteen eyes (93%) had postoperative visual improvement. The best corrected distance acuity was 6/12 or better in 11 eyes (73%). The best corrected near acuity was J2 or better in 12 eyes (80%). The IOL was well centered in 11 eyes (73%) and slightly decentered in 4 eyes (27%). Subjectively, patients indicated a high level of satisfaction with their distance and near vision. The VF-14 indicated high levels of visual function, with 73% of patients having a score higher than 90 (out of 100). Seventy-three percent of patients were not troubled by glare or halos, and 40% did not wear spectacles. Conclusion: Implantation of the Array multifocal IOL in the sulcus during complicated phacoemulsification led to good visual outcomes based on objective and subjective patient measures.

Cataract surgery in children with and without retinopathy of prematurity

Purpose: To report the outcomes of cataract surgery in children born prematurely who had or did not have retinopathy of prematurity (ROP). Setting: Seoul National University Hospital, Department of Ophthalmology, Seoul, Korea. Methods: Retrospective studies were conducted by reviewing the charts of 26 eyes of 14 premature infants with or without ROP that had cataract surgery. The patients' preoperative characteristics and postoperative visual outcomes were documented. Cataract surgery consisted of lensectomy, posterior capsulectomy, and anterior vitrectomy in patients younger than 2 years and primary posterior chamber intraocular lens (PC IOL) implantation or secondary PC IOL implantation in those 2 years or older. Postoperative optical correction in those younger than 2 years was by glasses or contact lenses. Results: Eight eyes of 5 patients had acute ROP; 4 eyes had stage 3, 2 had stage 2, and 2 had stage 1. Three eyes had transconjunctival cryotherapy for treatment of threshold ROP. First-eye cataract surgery were performed in children from 0.2 to 5.5 years old (mean 1.5 years) and second-eye surgery, in children from 1.8 to 12.1 years old (mean 4.3 years). Twenty eyes had implantation of a PC IOL. In 1 patient with stage 3+ ROP, Rush (plus) type, both eyes had combined cataract and scleral buckle encircling surgery. The mean follow-up after the last surgery was 1.4 years (0.5 to 3.1 years). At the last examination, the best corrected visual acuity was good fixation or better than 20/80 except in 2 eyes, 1 with esotropia and the other with a dense pupillary membrane. Conclusions: This is the first report of an encouraging surgical outcome for PC IOL implantation in premature infants with cataract regardless of the presence of ROP. However, if retinopathy is present and has progressed in the cataractous eye of a premature child, careful examination and timely surgical decisions are important.

Older Drivers and Cataracts: Measures of Driving Performance Before and After Cataract Surgery

Cataracts are the main cause of reversible vision impairment in older adults. An investigation examined how cataracts and cataract surgery affected driving performance and determined whether any changes in driving performance could be predicted by self-reported perceptions of driving and vision. Twenty-eight older participants with bilateral cataracts and eighteen age-matched control participants with normal vision were tested. All were licensed drivers. Driving and vision performance were measured before cataract surgery, after first-eye surgery, and again after second-eye surgery for the cataract participants and on three separate occasions for the control group. Driving performance was assessed on a closed-road circuit. Visual acuity and contrast sensitivity were also measured at each test session. Self-perceptions of vision and driving were assessed with the Activities of Daily Vision Scale (ADVS). The participants with cataracts had significantly poorer ( p <.05) driving performance at the first visit compared with the control participants for a range of measures of driving performance, which significantly improved to the level of the control participants following cataract extraction. Self-perceived changes in driving performance assessed with the ADVS were not strongly related to the actual changes in driving performance recorded. Together these findings indicate that participants with cataracts have poorer driving and vision performance than age-matched control participants and that cataract surgery can result in significant improvements in driving, which are not predicted by self-reported measures such as the ADVS.

Cost-utility analysis of cataract surgery in the second eye

Objective To perform a reference case cost-utility analysis of second-eye cataract surgery by using the current literature on cataract outcomes and complications. Design Computer-based econometric modeling. Methods Visual acuity data of patients treated and observed over a 4-month postoperative period were obtained from the U.S. National Cataract Patient Outcomes Research Team report. The results from this prospective study were combined with those of other studies that investigated the complication rates of cataract surgery to complete the cohort of patients and outcomes. These synthesized data were incorporated with time trade-off utility values, which accounted for prior successful cataract surgery in the fellow eye. Cost-utility determinations were made with decision analysis, and present value modeling was used to account for the time value of money and health state consequences. Main outcome measures The number of quality-adjusted life-years (QALYs) gained was calculated for the study group undergoing second-eye cataract surgery, assuming that the postoperative vision in the second eye was equivalent to the vision in the first eye after surgery (20/27). This was divided into the cost of the procedure to find the number of year 2001 nominal U.S. dollars spent per QALY gained. Results Second-eye cataract surgery, as compared with unilateral pseudophakia, resulted in a mean gain of 1.31 undiscounted QALYs per patient treated. A 3% annual discount rate, dependent on the duration of benefit, was used, yielding 0.92 discounted QALYs gained over a 12-year life expectancy. The mean discounted cost of treatment for each patient totaled $2509. The cost divided by the QALYs gained (benefit) resulted in $2727 per QALY gained for this procedure. Sensitivity analysis varying costs and utility values revealed a range from $2045 to $3649 per QALY gained. Conclusions Second-eye cataract surgery is an extremely cost-effective procedure when compared with other interventions across medical specialties. The cost-effectiveness of second-eye surgery diminishes only slightly from the $2023 per QALY gained from first-eye cataract surgery. This suggests that patients with good vision in one eye and visual loss from cataract in the fellow eye derive substantial benefit from cataract extraction.

Quality of life after first- and second-eye cataract surgery : Five-year data collected by the Swedish National Cataract Register

Purpose: To study the benefits of surgery and satisfaction with vision after first- and second-eye cataract surgery in comparable groups of patients. Setting: Clinics participating in the Swedish National Cataract Outcome Study from 1995 to 1999. Methods: A prospective observational study evaluated patients’ self-assessed visual function and satisfaction with vision before and 6 months after cataract extraction. Patients who had another cataract surgery in the fellow eye during the 6-month study were excluded. Data of 8595 patients having cataract extraction at participating clinics during the month of March for 1995 to 1999 were collected. Preoperative and intraoperative data were reported at the time of surgery. Final postoperative visual acuity was recorded. The Catquest questionnaire was completed before surgery and 6 months after surgery. Results: First-eye surgery was performed in 5570 patients and second-eye surgery, in 3025. Patient-assessed benefits of surgery and satisfaction with vision as defined by the Catquest was higher after second-eye surgery ( P < .001). The outcomes were studied in detail in patients with equal visual acuity in the fellow eye before and after surgery and without ocular comorbidity. The better outcome after second-eye surgery was most pronounced in patients with good or intermediate visual acuity in the fellow eye. Conclusion: The self-assessed visual outcomes and satisfaction with vision were better after second-eye surgery than after first-eye surgery in comparable groups of patients.

Anxiety in cataract surgery: pilot study

Purpose: To quantify the anxiety provoked by cataract surgery and establish whether the preoperative stage, the day of surgery, or the outcome was associated with unduly high anxiety. Setting: Moorfields Eye Hospital, London, United Kingdom. Methods: A cross-sectional survey of adult patients having cataract surgery under local anesthesia was done. The Hospital Anxiety and Depression (HAD) scale and a Visual Analog Scale (VAS) were used to quantify the patients’ anxiety. Of the 108 patients enrolled, 38 were surveyed at the preassessment clinic, 36 at the day ward (operation day), and 34 at the postoperative clinic. For each stage, the patients were divided into groups: first-eye cataract surgery, second-eye cataract surgery, and combined (first- and second-surgery patients). Results: The average patient in the combined group found the preassessment stage to be more anxiety provoking than the operation day or the postoperative visit. The median HAD scale scores were 5, 4, and 2, respectively, and the median VAS anxiety scores, 4, 2, and 1.75. The HAD anxiety scores in the combined group were significantly different between the operation day and the postoperative visit ( P < .05, Mann-Whitney U) but not between the preassessment and operation day. The VAS scores showed no significant differences among the 3 stages of treatment in the combined group. Different anxiety trends were found between the first- and second-surgery groups. Conclusion: The average patient was not unduly anxious about cataract surgery.

Topical anesthesia for cataract surgery: a population-based perspective

Purpose To analyze the anesthetic regimen and sedation in a population-based cohort of unselected cataract surgery cases operated on with the goal of maximizing the percentage of patients with topical anesthesia and no sedation. Setting Department of Ophthalmology, Norrlands University Hospital, Umeå, Sweden. Methods This prospective observational population-based study comprised all patients having cataract surgery during a 1 year period at 1 institution. Data were collected from the patients’ records, which were standardized. Outcome measures were use of preoperative sedation, type of anesthesia, intraoperative complications, and adverse events. Results The study comprised 890 cases performed by 4 surgeons. Seventy-two percent of patients had no sedation and topical anesthesia only. All patients except 1 who had previous cataract surgery with topical anesthesia chose the same method for their second-eye surgery. The rate of posterior capsule rupture was in the expected range for a population with high incidences of pseudoexfoliation and mature cataract. Conclusions It is possible to achieve a high percentage of effective topical anesthesia for cataract surgery in a population-based setting. The findings have implications for cost-containment in health services.

Outcomes of cataract surgery in monocular patients

Purpose To determine the best corrected visual acuity (BCVA) outcomes and surgical complications in a consecutive series of functionally monocular patients who had phacoemulsification and intraocular lens (IOL) implantation. Setting University-based referral practice, Los Angeles, California, USA. Methods The medical records of 93 monocular patients who had phacoemulsification and IOL implantation between December 1991 and February 1999 were reviewed. Patients were considered to be monocular if Snellen BCVA in their fellow eye (the eye not having surgery) was worse than 20/200. Recorded were demographic information, anesthesia method, additional surgery, IOL model, preoperative and postoperative BCVA, reason for poor vision in the unoperated eye, co-morbidities in the operated eye, intraoperative and postoperative complications, length of follow-up, and postoperative procedures. Results Mean patient age was 72 years and mean follow-up, 6 months. Thirteen patients (14%) were monocular from complications of surgery. Eighty patients (86%) were monocular because of medical eye conditions. Ocular co-morbidities were present in 75% of eyes having surgery. Preoperative median BCVA was 20/60. Median BCVA was 20/30 by the final scheduled follow-up examination and 20/25 by the final follow-up examination. Thirty-seven percent of eyes were correctable to 20/20 or better, and 67% were correctable to 20/40 or better. Two eyes lost BCVA by the final scheduled postoperative examination, and 3 eyes lost BCVA by the final follow-up examination. Final BCVA of worse than 20/40 was always related to preexisting macular or optic-nerve pathology. There were 16 intraoperative or early postoperative complications. The most common (3 eyes) was posterior capsule plaque that could not be removed by capsule polishing. Twenty eyes (22%) had subsequent surgical procedures, the most common being laser posterior capsulotomy. No patient who was monocular from surgical complications had similar problems with second-eye cataract surgery. Conclusions Best corrected visual acuity, the standard measure of efficacy in cataract surgery, improved a median of 3 to 4 Snellen lines. The safety of the procedure, as evidenced by the small number of patients who lost BCVA or experienced surgical complications, was satisfactory. Functionally monocular patients are likely to have ocular co-morbidities, some of which may limit the final visual outcome of surgery.

Impaired visual function after cataract surgery assessed using the Catquest questionnaire

PurposeTo evaluate and explain why some patients report more difficulties performing everyday activities 6 months after a cataract extraction than they did before surgery. SettingCataract surgeons from 4 departments of ophthalmology affiliated with the National Swedish Cataract Outcome Register. MethodsPatients were recruited from those having cataract extraction during March 1995, 1996, or 1997 at the participating units. Only patients who completed Catquest questionnaires before and after surgery and were evaluated to have a “no-benefit” outcome were included. The no-benefit outcomes were analyzed by using medical records and surgeon opinions. Possible and/or probable reasons for the outcome were identified. ResultsSeveral possible and/or probable reasons were identified as a single reason or combined with other reasons. The 5 most frequent reasons were ocular co-morbidity in the operative eye, anisometropia after surgery, problems with the nonoperative eye during follow-up, low disability score sum before surgery (no difficulties), and postoperative complications. ConclusionIn about a third of the cases, the no-benefit outcome could probably have been avoided by better planning for both eyes; that is, both eyes should have surgery within a short time and waiting for second-eye surgery in cases with anisometropia should be avoided.

Outcomes of small incision cataract surgery

Purpose: To compare cataract surgery outcome measures 4 months postoperatively and determine their association with changes in the eye's functional state.Setting: Department of Ophthalmology, Helsinki University Central Hospital, Finland.Methods: This longitudinal study comprised 219 consecutive patients having first-eye or second-eye cataract surgery by one surgeon. In most patients, the technique consisted of small-incision cataract surgery with in-the-bag intraocular lens implantation. Patients were interviewed and clinical data obtained preoperatively and 4 months postoperatively. Adverse events occurring within 24 hours and 4 months postoperatively were compared with changes in global measures of vision. Surgical success in terms of surgically induced astigmatism (SIA) was measured at 4 months using vector analysis of the changes in astigmatism and defining the extent to which the surgical goal was achieved. The association between the surgical astigmatism goals and global measures of vision was analyzed.Results: The percentage of patients showing improvement 4 months after first-eye cataract surgery varied by outcome measure: Snellen visual acuity (95.0%), VF-14 score (89.4%), satisfaction with vision (80.1%), self-reported trouble with vision (75.8%), and cataract symptoms (75.1%). Changes in Snellen acuity after secondeye cataract surgery were similar but VF-14 changes were significantly less than after first-eye surgery. Changes in global measures of vision were also better after first-eye surgery. The correlation between the change in VF-14 score and global measures of vision was stronger than between the change in Snellen acuity and the same general outcome measures. A good correlation was also seen between the changes in VF-14 scores and cataract symptoms. Mean SIA in all eyes was 0.2 diopter (D) ± 0.7 (SD); 91.2% were within ±1.0 D of preoperative values. Failure to achieve surgical astigmatism goals was not associated with patients in whom global measures of vision did not improve, nor was there a correlation between adverse events occurring within 24 hours or 4 months postoperatively and global measures of vision. The only association was between ocular comorbidity or potential risk factors of phacoemulsification and adverse events seen within 24 hours and at 4 months.Conclusion: Estimates of the proportion of patients benefiting from cataract surgery varied with the outcome measure used to determine benefit. The change in the VF-14 score was a better measure than Snellen acuity of the benefit of cataract surgery.

Cataract Surgery in One Eye or Both: A Billion Dollar per Year Issue

To measure the relative effect of cataract surgery in the second eye compared with the first eye on functional impairment, satisfaction, and vision problems. Seventy-five randomly selected ophthalmologists in three cities in the United States were enrolled in a National Study of Cataract Outcomes. They, in turn, referred eligible, sequential patients scheduled for first-eye cataract surgery. Interviews were conducted at enrollment, 4 months after first-eye surgery, and 12 months after first-eye surgery. An attempt was made to conduct a special, preoperative interview of those patients scheduled to undergo second-eye surgery before the 4-month interview. Each interview included administration of the VF-14 (a 14-item questionnaire that assessed visual function), as well as questions about symptoms possibly related to cataract, "trouble with vision," and satisfaction with vision. Seven hundred seventy-two patients were enrolled in the study, and interview data to 12 months were obtained from 669 (86%) patients. Of these patients, 243 (36%) underwent cataract extraction in the second eye during the 12-month period of observation. Overall, subjects who underwent cataract surgery in both eyes during the 12-month period had 61% greater improvement in VF-14 score (P < 0.001), 27% more decline in trouble with vision (P < 0.001), and 24% greater improvement in satisfaction with vision (P < 0.001) compared with those who underwent surgery in only one eye. Cataract surgery in the second eye of patients with bilateral cataract is associated with clinical and statistically significant improvement in functional impairment, trouble with vision, and satisfaction with vision.