Simultaneous Cataract Surgery Research Articles

Secondary acute angle closure glaucoma after 25-gauge pars plana vitrectomy for a macular hole: a case report

BackgroundPosterior synechiae of the iris rarely cause secondary angle-closure glaucoma after pars plana vitrectomy, mainly reported in cases with high postoperative inflammation. The face-down position with gas tamponade can cause acute angle-closure glaucoma in phakic eyes owing to relative pupillary block. This report presents a rare case of pseudophakic eye with secondary acute angle-closure glaucoma after 25-gauge pars plana vitrectomy and long-term vitreous gas tamponade for a macular hole.Case presentationA 61-year-old Japanese female patient presented with a chief complaint of right-sided visual impairment that had persisted for several months. Slit-lamp examination revealed deep anterior chamber and moderate nuclear sclerotic cataracts in both eyes. The axial length of the eye was 23.53 mm right eye and 24.05 mm left eye, and the fundus examination revealed a full-thickness macular hole (stage 3) in the right eye. The patient underwent simultaneous cataract surgery and pars plana vitrectomy with 7-mm diameter 3-piece monofocal intraocular lens implantation, internal limiting membrane peeling, and air tamponade. There were no complications during surgery. Due to non-closure of the macular hole, a second pars plana vitrectomy with internal limiting membrane inverted flap and SF6 gas tamponade was performed 13 days later. The patient maintained face-down position after both surgeries, and 6 days after the second surgery, intraocular pressure was elevated to 53 mmHg, and acute angle-closure glaucoma with iris bombe was diagnosed in the right eye. A laser peripheral iridotomy was performed, resulting in a deepened anterior chamber, normalized intraocular pressure, and a closed macular hole.ConclusionsThis case presents a rare occurrence of secondary acute angle-closure glaucoma in a pseudophakic eye after 25-gauge minimally invasive pars plana vitrectomy and SF6 gas tamponade for macular hole. The cause was presumed to be posterior synechiae of the iris or relative pupillary block due to forward pushing of the intracapsular intraocular lens by vitreous gas. In cases where surgery is repeated without achieving macular hole closure, necessitating long-term face-down position, where vitreous gas is retained for an extended period, or when a large-diameter intraocular lens is implanted, secondary acute angle-closure glaucoma should be considered. This applies even when the 25-gauge pars plana vitrectomy is performed not for a highly invasive proliferative diabetic retinopathy but for macular hole repair, especially if the patient has a pseudophakic eye.

RETINAL MIGRATION AND SURGICAL OUTCOME AFTER HEMI-TEMPORAL INTERNAL LIMITING MEMBRANE PEELING VERSUS CONVENTIONAL PEELING FOR MACULAR HOLE: A Multicenter, Randomized, Controlled Trial.

To investigate the anatomical changes and surgical outcomes of hemi-temporal internal limiting membrane (ILM) peeling and conventional ILM peeling for idiopathic macular hole (MH). This randomized controlled trial was conducted at 3 centers and included 50 participants with MHs of <400 µm in minimum diameter for a duration of <6 months. All participants had undergone vitrectomy with either hemi-temporal ILM peeling (Hemi group) or 360° ILM peeling (360° group) with an injection of 5% sulfur hexafluoride gas, with or without simultaneous cataract surgery, from July 2017 to January 2021. The rate of MH closure and distance of retinal migration were examined. Of 50 eyes randomized in the 3 centers, the Hemi group comprised 23 eyes, the 360° group 23 eyes, and 4 eyes were eliminated from final analysis. There was a significantly higher rate of primary MH closure in the 360° group (Hemi group: 73.9% vs. 360° group: 100%, P = 0.009). Retinal migration to the optic disk on the nasal side was significantly shorter in the Hemi group at 1, 3, and 6 months postoperatively than in the 360° group. There was no significant difference between the two groups in retinal migration to the optic disk on the temporal side. Nasal retinal migration in patients who underwent the hemi-temporal ILM peeling method was significantly less than in those who underwent the 360° ILM peeling method. However, less nasal retinal migration did not contribute to the MH closure rate.

Descemet Membrane Endothelial Keratoplasty for Endothelial Failure in Primary Angle Closure Suspects.

To analyze the feasibility and outcome of Descemet membrane endothelial keratoplasty (DMEK) for treatment of endothelial failure in primary angle closure suspect (PACS) eyes. Retrospective, single-center case series of eyes treated by DMEK for endothelial failure caused by PACS. Main study parameters were success rate of DMEK, best-corrected visual acuity, anterior chamber depth, central corneal thickness, and endothelial cell density. Mean follow-up time was 16 ± 13 months. Ten eyes of 9 patients receiving DMEK for the treatment of corneal endothelial failure because of PACS were included. Except for 2 eyes that had undergone cataract surgery, none of the eyes had previous ocular surgery. DMEK combined with cataract surgery was performed in 5 eyes, DMEK alone with second-step cataract surgery in 2 eyes. The eyes with corneal edema after cataract surgery received DMEK only. DMEK surgery was successful in nine out of 10 eyes, 1 patient required repeat DMEK because of primary graft failure. In the group of phakic eyes, mean preoperative internal anterior chamber depth was 1.74 ± 0.18 mm. In eyes with corneal edema, central corneal thickness was 849 ± 205 μm before DMEK surgery, and 517 ± 24 μm at the final postoperative visit (P = 0.002). DMEK is a feasible option in eyes with endothelial failure because of primary angle closure. In case of advanced corneal edema, a second-step procedure (first DMEK, second cataract surgery) is a possible approach if visibility of the lens is too poor for simultaneous cataract surgery.

Relationship between Image Quality and Reproducibility of Surgical Images in 3D Digital Surgery.

Objectives: Ophthalmic three-dimensional (3D) digital surgery can reproduce high-definition surgical images; however, 3D digital surgery is limited by recording capacities. We examined the relationship between the minimum image quality required to reproduce surgical images and recording capacity. Methods: Patients who underwent simultaneous vitrectomy and cataract surgery by the same surgeon using a 3D digital surgery system at Juntendo University Urayasu Hospital between February and October 2021 were evaluated. Various quality (Q) and frame rate (FR) settings were used for each case. Four vitreous surgeons evaluated the reproducibility of recorded images of macular manipulation for epiretinal membrane (ERM) and macular hole (MH) cases and those of peripheral retinal manipulation for rhegmatogenous retinal detachment (RRD) cases. The video bitrate and minimum settings required to reproduce surgical images and factors affecting surgical image reproducibility were examined. Results: A total of 129 eyes of 129 patients were observed. The minimum image quality required to reproduce surgical images was 11.67 Mbps. The Q and FR for periretinal processing and Q for macular manipulation affected surgical image reproducibility (p = 0.025, p = 0.019, and p = 0.07, respectively). The minimum recording settings required to obtain highly reproducible images were Q = 3 and FR = 40. The total file size for vitrectomy video recordings with these settings was as compact as 3.17 GB for 28 min. Conclusions: During 3D digital surgery, highly reproducible surgical images can be obtained with a small storage capacity using settings of at least Q = 3 and FR = 40.

Effect of topical bromfenac on intraretinal cystoid lesion in simultaneous cataract and idiopathic epiretinal membrane surgery

PurposeTo investigate the effect of topical nonsteroidal anti-inflammatory drugs (NSAIDs,) bromfenac on the intraretinal cystic lesions (IRC) when performing simultaneous cataract and idiopathic epiretinal membrane (iERM) surgery.MethodsThis study included patients with iERM who had been followed up for 6 months after vitrectomy, membrane removal, and concurrent cataract surgery. Eyes were treated with topical bromfenac or not. The baseline fluorescein angiography (FA) was obtained to assess the microvascular leakage (ML). Structural changes of macula, including IRC and central macular thickness (CMT) were assessed using optical coherence tomography (OCT). The main outcome measures were changes in IRCs and best-corrected visual acuity (BCVA) regarding FA findings.ResultsOne hundred eighteen eyes were included. IRC and ML were observed in 51 eyes (43.2%) and 63 eyes (53.4%), respectively. The IRC did not show any association with the ML. Of total, 29 eyes (24.6%) were treated with topical bromfenac (Group A). Compared to Group B, topical bromfenac did not show beneficial effects in aspect of preventions for the newly developed IRC and treatment for pre-existed IRC. Whether the ML existed or not, topical bromfenac did not show any different effect on the changes in BCVA and IRC.ConclusionWhen performing simultaneous cataract and ERM surgery, topical NSAIDs, bromfenac did not show beneficial effects on the preventions and treatment of IRC in both eyes with and without the ML.

Surgery after corneal grafts

There is one available donor per 70 patients so we need to identify those whose vision would benefit from corneal transplantation and minimize risks that could jeopardize corneal graft survival possibility1.The two leading causes of graft failure post Penetrating Keratoplasty (PKP) are graft rejection and secondary glaucoma development. The existence of preoperative glaucoma increases two to three times the chances of graft rejections in any corneal transplantation2,3. The 10‐year Cornea Donor Study also confirmed that pre‐existing glaucoma is a risk factor for graft failure4. The 3‐year graft survival rate has been shown to be 71% in patients with preop glaucoma and 89% in patients without preop glaucoma5.In cases following Descemet Striping Endothelial Keratoplasty (DSAEK), Ocular Hypertension (OHT) ranges in otherwise healthy eyes from 29 to 47% and increases to 43 to 54% in cases with pre‐existing glaucoma or high‐risk eyes. Glaucoma can be presented in up to 15% in post‐DSAEK cases which increases twice the relative risk of rejection. Concurrent gonio‐synechiolysis is considered an additional risk factor whereas 18.6% of high IOP cases considered as secondary to steroid administration. Acute raise in IOP can be attributed in pupillary block at an estimated rate of 13%6,7.In cases of Descemet Membrane Endothelial Keratoplasty (DMEK) OHT or intraocular pressure (IOP) elevation is presented to 6.5 up to 11.1% and de novo glaucoma can be found from 2.8 to 6.5%, whereas progression of pre‐existing glaucoma is less than 2.5%8. In cases with simultaneous DMEK and cataract surgery there is greater likelihood of post‐op OHT or glaucoma. In DMEK cases the early postoperative increase in pressure is usually due to a combination of anterior (inferior) and posterior (superior) pupillary blocks when patient is sitting upright9.The late post‐DMEK IOP increase is attributed to Blockage of TM by inflammatory cells, PAS formation or steroid use. However, steroid‐induced glaucoma post‐DMEK is not as common as that in post‐PKP or post‐DSAEK due to the shortest steroid regime post‐DMEK cases. Treatment methods include medical treatment, trabeculectomy or tubes. Some cases with Xen®10 and Micropulse cyclodidode11 laser have been reported in endothelial cases, however with little degree of evidence.Controversy still exists to which surgical procedure is the best for graft survival and IOP control, as well as when is the best time of the surgery in patients with pre‐existing glaucoma, before, simultaneously or after, and if needed, graft surgery. Certainly a “try not to create glaucoma” strategy needs always to be followed by not producing additional iatrogenic risk factors with improved technique(s) and by respecting the tissue(s).

Prospective Study of Canaloplasty and Trabeculotomy Performed by Trainees.

To evaluate outcomes of new adopters of the OMNI® Surgical System (Sight Sciences, Inc.) by prospectively evaluating intermediate-term outcomes of patients operated by trainees. This was a prospective study of surgeries performed by trainees on patients with open angle glaucoma undergoing simultaneous cataract surgery and ab interno canaloplasty and trabeculotomy using the OMNI Surgical System. Pre-operative intraocular pressure (IOP) and number of glaucoma medications were recorded. Only patients with a minimum of 6-month follow up were included. Baseline IOP was used to separate subjects into two groups: Group 1 (IOP ≥18 mmHg) and Group 2 (IOP <18 mmHg). Mean decrease in IOP and medications was calculated and compared with paired t-tests for the overall sample as well as the subgroups. Success was defined as those with a ≥20% reduction from pre-operative IOP or with an IOP ≤18 mmHg and ≥6 mmHg and on the same or fewer number of medications while not requiring additional surgery. Adverse events were also recorded. Forty-two eyes of 31 patients were included. Mean pre-operative IOP was 17.2 ± 4.8 mmHg and mean number of medications was 2.4 ± 1.2. The primary endpoint was reached in 83.3% of patients at 12 months. IOP was reduced by 22.3% to 13.4 ± 2.4 (p<0.001). Mean number of medications decreased to 1.7 ± 1.6 (p<0.001). Group 1 mean IOP decreased 35.4% from 22.2 ± 4.6 mmHg to 14.3 ± 2.8 mmHg (p<0.001). Group 2 mean number of medications decreased from 2.3 ± 1.1 to 1.6 ± 1.5 (p<0.001). When operated on by the novice MIGS surgeon, the OMNI device provides effective IOP and glaucoma medication reduction with minimal adverse events. Efficacy and safety of the device in the hands of trainees was comparable to experienced glaucoma surgeons suggesting its ease of adoption.

A quality analysis of internet patient information for immediate, sequential, bilateral cataract surgery (ISBCS).

Due to surgical capacity pressures, induced by the COVID-19 pandemic, immediate bilateral simultaneous cataract surgery (ISBCS) has been utilised increasingly throughout the U.K. This surgical method comes with both novel risks and benefits, so the consent process must be modified. Prior randomised trials have demonstrated that appropriate online information may act as an adjunct to the surgical consent process. This study aims to assess the quality of available internet information for ISBCS. Terms searched were 'bilateral cataract surgery patient information', 'double cataract surgery patient information', and 'immediate sequential bilateral cataract surgery patient information'. The Google search engine was used. The DISCERN instrument and JAMA benchmarks were used to assess healthcare information for quality. The Flesch Reading Ease Score (FRE), Flesch Kincaid Grade (FKG) Level and Gunning Fog Score (GFS) were used to assess for readability. HONcode certification was used to assess transparency and quality. Forty-six websites were found. The average DISCERN score was 41.3, meaning a "fair" quality which is below what many patients would anticipate discovering when trying to find information. National Healthcare Service websites had higher DISCERN scores than private healthcare-provided websites (p < 0.01; 95% CI: 1.13-1.88.). Fair patient information for ISBCS has been demonstrated. Specific internet information sources with appropriate information should be further developed, with cited sources, and patients signposted to them if felt appropriate.

Internal limiting membrane flap with viscoelastic device for lamellar hole surgery with no postoperative positioning.

To propose a novel technique of an internal limiting membrane (ILM) flap using ophthalmic viscoelastic device (OVD) with no requirement for postoperative head posture for the treatment of lamellar macular hole (LMH) repair. A retrospective analysis of 16 consecutive eyes of LMH patients who underwent vitrectomy with ILM flap with OVD. Best-corrected visual acuity (BCVA), central macular thickness (CMT), simultaneous cataract extraction, and ellipsoid zone disruption preoperatively and at the final follow-up were compared. The mean age was 73.19 ± 7.26 years, and ten patients (62%) were females. The mean follow-up was 5.06±1.43 months (range 3-6). For all patients, BCVA was significantly improved at the final visit, from 0.65±0.36 logMAR units to 0.42±0.29 (p < 0.001). None of the patients had visual loss. Six patients had epiretinal membrane (ERM) foveoschisis, and the rest had LMH with epiretinal proliferation. Both subgroups presented a significant improvement in their BCVA with a trend for better improvement in the latter (p=0.09). Ellipsoid zone disruption was seen in 7 patients including one patient with a macular scar. There was no significant effect of ellipsoid zone disruption on the final BCVA (p=0.33). Twelve eyes (75%) underwent simultaneous cataract extraction. Mean BCVA at the final postoperative visit improved regardless of whether the eyes underwent simultaneous cataract surgery (p=0.39). CMT was also significantly improved at the final visit, from 200.06±46.8 μm preoperatively to 305.00±85.5 μm (p<0.001). No full-thickness macular holes were developed postoperatively. No intraoperative or postoperative complications were observed. Treatment of LMH with ILM flap with OVD showed promising anatomical and functional results with no postoperative head position requirements.

Comparison of the Effectiveness of Intravitreal Bevacizumab Injections with and without Simultaneous Cataract Surgery in Diabetic Patients with Macular Edema.

Intravitreal bevacizumab (IVB), often injected during cataract surgery, is currently the main treatment for diabetic macular edema. This retrospective study aimed to compare the effectiveness of IVB injections alone and during cataract surgery in patients with diabetic macular edema. We examined 43 eyes in 40 patients who underwent cataract surgery with simultaneous IVB injections 3-12 months after IVB injections alone. Best-corrected visual acuity and central subfield macular thickness (CMT) were measured 1-month post-injection. The CMTs of the same eyes with IVB-only first and combined-treatment procedures later were 384 ± 149 vs. 315 ± 109 μm pretreatment (p = 0.0002), and after 1 month, they were 319 ± 102 vs. 419 ± 183 μm (p < 0.0001). In the IVB-only procedure, 56.1% of eyes had CMT < 300 μm 1 month after the injection compared to 32.5% after the combined treatment. Therefore, on average, when IVB was administered during cataract surgery, CMT increased, whereas after IVB injection alone, it effectively decreased. More prospective trials with large sample sizes are needed to evaluate the effectiveness of IVB injection performed simultaneously with cataract surgery.

Cost Drivers of Endothelial Keratoplasty: A Time-Driven Activity-Based Costing Analysis

To determine cost drivers of endothelial keratoplasty (EK) through evaluation of surgical costs and procedure length based on type of EK, use of preloaded grafts, and performance of simultaneous cataract surgery. This study was an economic analysis of EKs at a single academic institution using time-driven activity-based costing methodology (TDABC). EK surgical cases, including Descemet Membrane Endothelial Keratoplasty (DMEK) and Descemet Stripping Automated Endothelial Keratoplasty (DSAEK), at the University of Michigan Kellogg Eye Center from 2016 to 2018 were included in the analysis. Data and inputs were obtained via the electronic health record and from prior literature. Simultaneous cataract surgeries were included and separately categorized for analysis. EK expenses were determined with TDABC, a method for cost calculation that incorporates the time that key resources are used and each resource's associated cost rate. Main outcome measures included surgery length (in minutes) and day-of-surgery costs. There were 559 EKs included, 355 DMEK and 204 DSAEK. Fewer DSAEKs had simultaneous cataract extraction (47, 23%) than DMEK (169, 48%). Of the DMEKs, 196 (55%) utilized preloaded corneal grafts. DMEK cost $392.31 less [95% confidence interval ($251.05, $533.57), P < 0.0001] than DSAEK and required 16.94 fewer minutes [(14.16, 19.73), P < 0.0001]. DMEK cases that utilized preloaded corneal grafts cost $460.19 less [($316.23, $604.14), P < 0.0001] and were 14.16 minutes shorter [(11.39, 16.93), P < 0.0001]. In multivariate regression, preloaded graft use saved $457.19, DMEK (compared to DSAEK) saved $349.97, and simultaneous cataract surgery added $855.17 in day-of-surgery costs. TDABC cost analysis identified a day-of-surgery cost and surgical time reduction associated with the use of preloaded grafts for DMEK, DMEK compared to DSAEK, and isolated EK compared to EK combined with cataract surgery. This study provides an improved understanding of surgical cost drivers and margin incentivization, which may explain trends and indirectly influence patient care decisions in cornea surgery practices.

Different patterns in the corneal endothelial cell loss after pars plana and pars limbal insertion of the Baerveldt glaucoma implant

To assess corneal endothelial cell (CE) loss after pars plana (PP) and pars limbal (PL) insertion of a Baerveldt glaucoma implant (BGI). Retrospective multicenter interventional comparative study. We studied central CE loss for 5 years after BGI surgery in 192 eyes. The prevalence of bullous keratopathy (BK) was greater in the PL cohort than in the PP cohort (P=.003). The CE loss after simultaneous PP vitrectomy and tube insertion into the vitreous cavity was 11.9% in the first year, which was greater than that of 2.9% in eyes where the tube was inserted simply into the vitreous cavity after a prior vitrectomy (P=.046). The annual percentage CE loss after the first year decreased unidirectionally in both of those groups and was 1.3% and 1.0% in the fifth year, respectively (P < .001). For limbal insertion, the CE loss in the simple PL cohort was biphasic, decreasing from 10.5% in the first year to 7.0% in the fifth year. Simultaneous cataract and BGI surgery enhanced the CE loss slightly in the first year in the PP and PL cohorts to 13.0% and 14.0%, respectively. However, these increases were not significant (P=.816 and .358, respectively). Low preoperative CE density (P < .001) and insertion site (P=.020) were significant risk factors for the development of BK. CE loss in the PL and PP cohorts was biphasic and unidirectional, respectively. The difference in annual CE loss became evident over time. PP tube implantation may be advantageous when the preoperative CE density is low.

The Effect of Intravitreal Bevacizumab Injection in Wet Age-Related Macular Degeneration Patients with Cataract Surgery

This study was design to evaluate the efficacy of cataract surgery with simultaneous intravitreal bevacizumab injection for wet age-related macular degeneration. Of the patients who underwent anti-vascular endothelial growth factor injections, cataract surgery was performed in 24 eyes (control group), and simultaneous intravitreal bevacizumab injection was performed in 27 eyes (bevacizumab group). Best corrected visual acuity, ocular tonometry, anterior chamber inflammation, and central subfield macular thickness were measured at baseline and 1 week, 1 month, 3 months, and 6 months after surgery. The mean central subfield macular thickness increased 1 month postoperatively in the control group (&lt;i&gt;p&lt;/i&gt; = 0.02), whereas there was no significant change in the bevacizumab group. When the preoperative and postoperative differences between the two groups were compared at each time point, the mean best corrected visual acuity improved in the bevacizumab group at 3 months after surgery (&lt;i&gt;p&lt;/i&gt; = 0.045), and the mean central subfield macular thickness was more decreased in the bevacizumab group at 1 month after surgery compared to that of the control group (&lt;i&gt;p&lt;/i&gt; = 0.032). Additional anti-vascular endothelial growth factor injection was performed after surgery at 1.56 ± 2.05 months and 2.52 ± 2.01 months, in the control and bevacizumab groups, respectively (&lt;i&gt;p&lt;/i&gt; = 0.047). Simultaneous cataract surgery and intravitreal bevacizumab injection is considered an effective treatment since it reduces central subfield macular thickness in the short term, and it can delay the timing of additional anti-vascular endothelial growth factor injections after surgery.

Commentary: Treatment of postoperative cystoid macular edema in vitrectomized eyes: An enigma.

Post-operative cystoid macular edema (PCME) is a sight-threatening complication that could affect visual recovery following a successful ocular surgery. Irvine–Gass syndrome, that is, PCME following cataract surgery has extensively been studied. The incidence of clinical CME following phacoemulsification ranges from 0.2% to 2.35%.[1] The incidence of PCME following vitrectomy for vitreous floaters, rhegmatogenous retinal detachment (RRD), and the epiretinal membrane (ERM) has been found to be around 5%, 10–25%, and 13–47%, respectively.[1-4] Although the exact pathophysiology of PCME remains debatable, the most probable cause seems to be subclinical low-grade inflammation. Studies have shown that the levels of cytokines and prostaglandins are elevated in such eyes, leading to blood–aqueous barrier breakdown and consequent fluid accumulation.[1-4] Pole et al.[2] described the optical coherence tomography (OCT) characteristics of PCME after RRD surgery. These included fovea-involving diffuse CME, which involved all four macular quadrants and cysts in the inner nuclear and outer plexiform layers. In untreated eyes, the cysts may coalesce into larger irregular, polygonal-shaped cavities. CME may resolve spontaneously but cause disorganization and atrophy of the retinal layers. Several risk factors for the development of PCME following vitrectomy have been identified. Risk factors following RRD surgery include old age, cataract surgery, macula-off RRD, longer duration, pre-existing proliferative vitreoretinopathy changes (C or higher), intra-operative retinectomy, and multiple surgeries.[12] Risk factors following ERM removal surgery include old age, cataract surgery, stage 4 ERM, and the presence of pre-existing intraretinal cysts.[34] The post-operative tamponading agent did not influence the development of PCME in either pathology.[1-4] To date, there has been no consensus on the treatment for PCME. Its management is often complex due to its recurring nature. The various available treatment options include topical steroid and non-steroidal anti-inflammatory drug (NSAID) drops; intravitreal anti-vascular endothelial growth factor (VEGF) and triamcinolone acetonide (TA) injections; intravitreal dexamethasone and fluocinolone implants; suprachoroidal triamcinolone injection; and posterior subtenon and trans-tenon retrobulbar triamcinolone injection. The efficacy of topical treatment in previously vitrectomized eyes is usually limited.[12] Similarly, anti-VEGF injections also tend to be less effective in vitrectomized eyes due to faster clearance and reduced half-life.[12] Intravitreal triamcinolone acetonide (IVTA) injection has been found to be better than anti-VEGF injections in improving macular thickness and visual acuity.[2] However, the mean elimination half-life in vitrectomized eyes is merely 3.2 days compared to 18.6 days in non-vitrectomized eyes.[5] On the contrary, the vitreoretinal pharmacokinetic profiles of dexamethasone and fluocinolone implants in vitrectomized eyes are similar to that in non-vitrectomized eyes. Intravitreal dexamethasone implant has been found to be an effective treatment option for eyes with PCME following vitrectomy for RRD and even endophthalmitis.[67] Eyes that underwent vitrectomy for ERM compared to RRD, presence of subretinal fluid, intact outer retinal layers, and worse baseline best-corrected visual acuity (BCVA) have higher chances of visual improvement. Owing to the recurrent nature of the disease, multiple injections are often needed.[6] Intravitreal fluocinolone acetonide implant has been shown to achieve persistent functional and anatomical improvement with long recurrence-free periods. Miguel–Escuder et al.[8] suggested that it could be considered as a therapeutical option in eyes with refractory PCME following vitrectomy. Suprachoroidal TA injection with the help of custom-made needles is another treatment option. Due to its unique position, the suprachoroidal space serves as a drug reservoir with slow drug washout and better absorption. Animal model-based pharmacokinetic studies have shown that a 12-fold higher drug concentration can be achieved in the retina along with reduced entry drug in the anterior chamber, thus reducing the risk of intraocular pressure rise and cataract formation.[9] Trans-Tenon’s retrobulbar TA infusion has also been used successfully for the management of refractory diabetic macular edema (DME) in vitrectomized eyes. The described technique included making an incision in the conjunctiva and the Tenon’s capsule in the inferotemporal quadrant followed by infusion of 40 mg triamcinolone acetonide with a 25-gauge curved blunt cannula into sub-Tenon’s space under topical anesthesia.[10] Posterior subtenon triamcinolone (PST) injections have classically been used for the management of intermediate uveitis. It has been shown to provide a sustained high level of TA in the vitreous cavity level along with low systemic TA levels that cannot alter the systemic cortisol levels.[11] We congratulate the authors for their manuscript evaluating the efficacy and safety of PST for the treatment of chronic PCME in vitrectomized eyes.[12] However, prospective randomized studies with a larger sample size are required to compare the efficacy with other treatment modalities. Because simultaneous complicated cataract surgery is itself a risk factor for the development of PCME, eyes with nucleus drop should be excluded. Additionally, the management of a raised intraocular pressure in the steroid responder eyes may be challenging, because the depot of TA in the posterior subtenon location is difficult to remove completely.

Surgical Results of Trabeculectomy among Groups Stratified by Prostaglandin-Associated Periorbitopathy Severity

To report the role of prostaglandin-associated periorbitopathy (PAP) severity in the surgical effectiveness of trabeculectomy (LEC). Retrospective observational case series. A total of 139 consecutive eyes of 139 Japanese subjects (74 men, 65 women; mean age ± standard deviation, 65.7 ± 10.6 years) who underwent LEC were included. All had primary open-angle glaucoma (POAG), no history of conjunctival incisional surgery, completed all postoperative visits for 12 months, and information on the PAP severity using the Shimane University PAP Grading System (SU-PAP). Data were collected from a medical chart review at 2 hospitals. Comparison of surgical success rates among groups stratified by SU-PAP grades 0 to 3 by survival curve analysis using the definitions of failure based on surgical intervention other than laser suture lysis (LSL), intraocular pressure (IOP) reduction below 20%, postoperative IOP exceeding 15 mmHg (definition A) or 12 mmHg (definition B), and a postoperative IOP below 6 mmHg. Twelve months postoperatively, the success rates of grades 0, 1, 2, and 3 were 86%, 68%, 40%, and 0%, respectively, for definition A (P < 0.0001, log-rank test) and 86%, 61%, 36%, and 0%, respectively, for definition B (P < 0.0001). Interventions other than LSL (P < 0.0001, Cochran-Armitage trend test), IOP reduction less than 20% (P= 0.010), and IOP exceeding 15 mmHg (P= 0.016) or 12 mmHg (P < 0.0001) were associated with surgical failure; IOP under 6 mmHg was not (P= 0.31). The proportional hazard model for definition A showed that compared with grade 0, grade 2 (risk ratio [RR], 5.82, P= 0.0043) and grade 3 (RR, 12.2, P= 0.0003) were associated with surgical failure. For definition B, grade 1 (RR, 3.53, P= 0.040), grade 2 (RR, 6.65, P= 0.0021), and grade 3 (RR, 12.0, P= 0.0003) were associated with surgical failure. Differences in age, gender, preoperative IOP and medications, refractive error, and simultaneous cataract surgery were not associated with surgical failure in both models. The preoperative presence of severe PAP worsens the 1-year success rate of LEC in patients with POAG. To retain the surgical effectiveness, treating physicians should prevent patients from progressing to severe PAP, an avoidable side effect, by switching or stopping the causative medications. Proprietary or commercial disclosure may be found after the references.

Risk factors for ocular hypotony after XEN Gel Stent implantation

PurposeTo investigate the incidence of postoperative hypotony, and risk factors for the development of hypotony in eyes who had undergone XEN Gel Stent implantation.MethodsIn this retrospective, single-centre case series, medical records of 170 consecutive eyes who had undergone XEN Gel Stent implantation with or without simultaneous phacoemulsification for primary or secondary open angle glaucoma were analysed. Primary outcome parameters were the incidence of postoperative hypotony and potential risk factors for its development, and secondary parameters were pre- and postoperative visual acuity, intraocular pressure (IOP), and number of IOP-lowering eye drops.ResultsPostoperative hypotony ≤ 6 mmHg occurred in 57% of eyes. Hypotony was without complications in 70.1%, 13.4% had transient complications with spontaneous resolution, and 16.5% had complications requiring treatment. Mean visual acuity logMAR before surgery accounted for 0.47 ± 0.46 in all eyes and 0.47 ± 0.48 at the 4-week visit. There was no significant difference of BCVA in the group of eyes with and without postoperative hypotony before and after surgery. The mean IOP before surgery was 24.6 ± 8.4 mmHg and decreased significantly to 18.4 ± 10.2 after 4 weeks.Eyes with an axial length over 24.3 mm had a threefold increased risk for postoperative hypotony (OR 3.226, 95% confidence interval 1.121–9.279). This risk was decreased in eyes with simultaneous cataract surgery (OR 0.483, 95% confidence interval 0.258–0.903).ConclusionIn our sample, postoperative hypotony was a common complication after XEN Gel Stent implantation, but serious, persistent complications were rare. A longer axial length predisposes the eye for the development of hypotony.

Descemet Membrane Endothelial Keratoplasty (DMEK) for Severe Verrucous Posterior Polymorphous Corneal Dystrophy with Uncommon Clinical and Ultrastructural Findings.

To report a case of severe verrucous posterior polymorphous corneal dystrophy (PPCD) and cataract, which was treated with Descemet membrane endothelial keratoplasty (DMEK) and simultaneous cataract surgery as a triple procedure (Triple-DMEK). A 62-year-old female patient presented to our department for co-evaluation of advanced PPCD with cataract and progressive light sensitivity in both eyes. The clinical examination demonstrated unusual clinical findings with prominent verrucous lesions on the posterior surface of the cornea without corneal decompensation. We performed a Triple-DMEK in case of simultaneous cataract. The corneal tissue was examined by light and transmission electron microscopy. Intraoperatively, it was difficult to remove the verrucous structures completely after classical descemetorhexis. Light microscopic examination demonstrated epithelium-like transformation of the corneal endothelium by immunostaining (cytokeratin AE1/3 staining). Transmission electron microscopy revealed thickening of Descemet's membrane (18.5 to 30.0 µm). The anterior banded layer had a normal structure and was slightly thickened (3.5 to 5.5 µm). A normal posterior non-banded layer (PNBL) was observed but thinned (2.5 to 4.0 µm) or missing. It was followed by an altered PNBL with abnormal fibrillary inclusions, which was strongly and variably thickened (11.0 to 24.5 µm). The corneal endothelium was degenerated, partially absent, and epithelial-like altered. The nodular lesions were found to consist of a few degenerated cells that were embedded in an amorphous extracellular matrix interspersed with collagen fibers, which were not arranged in regular lamellae, forming the corneal stroma. The occurrence of pigment granules among the cellular debris suggested that the cells were endothelial cells. The corrected distance visual acuity improved from 20/50 to 20/30 in the right eye (+ 0.00/- 1.75/157°) and from 20/60 to 20/30 in the left eye (+ 0.00/- 1.75/33°), with significant improvement in light sensitivity. The clinical and ultrastructural findings seem to be an unusual variant of the typical characteristic appearance of a PPCD. This case demonstrates that Triple-DMEK is feasible even in very advanced dystrophic changes of the posterior corneal surface, with good morphological and functional results.

Management of cataract surgery in Lowe syndrome.

To evaluate the ophthalmic and anesthesiologic management of cataract surgery in children with Lowe syndrome receiving lens removal, the development and management of secondary glaucoma. This retrospective case series included 12 eyes of 6 children with genetically verified Lowe syndrome receiving cataract removal. Information regarding the type and duration of surgery and total anesthesia time were recorded. Additionally, intra- and postoperative complications were noted as well as clinical examinations such as visual acuity and funduscopy. All children received simultaneous bilateral cataract surgery at the mean age of 8.98±3.58wk. Lensectomy combined with posterior capsulotomy and anterior vitrectomy was performed in all children. The mean time for cataract surgery per eye was 35.83±8.86min, whereas the total time of surgery was 153.33±22.11min. The mean extubation time and duration at recovery room was 42.33±22.60min and 130.00±64.37min, respectively. During surgery, a decrease of oxygen saturation below 93% was found in only one child. During the postoperative follow-up, nystagmus (6 children) and strabismus (5 children) was commonly found in contrast to no case of visual axis opacification. Secondary glaucoma developed in five eyes of three children, which was treated with topical eye drops in only one child. A trabeculectomy was performed in both eyes of one child, whereas removal of syechia and an iridectomy in one eye of one child. Bilateral simultaneous cataract surgery under general anesthesia is a safe surgical procedure in Lowe syndrome children. The glaucoma screening with intraocular pressure measurements is crucial in the postoperative management of Lowe syndrome patients to avoid additional visual impairment.

Сравнительная эффективность и безопасность ранибизумаба и афлиберцепта в лечении неоваскулярной вмд в сочетании с хирургией катаракты

Aim. To perform a comparative analysis of the safety and efficacy of intravitreal injection (IVI) of ranibizumab and aflibercept with simultaneous phacoemulsification of cataract (FEC) and implantation of an intraocular lens (IOL) in patients with a combination of neovascular AMD and senile cataract. Methods. A comparative study was performed in 52 patients. IVI of ranibizumab and aflibercept was carried out by random sampling. Methods of clinical, OCT morphometric and immunological examination of tear in dynamics were used. Results. On the 31st day of follow-up, there was an increase in BCVA by an average of 3 lines, a decrease in the thickness of the retina in the macula the height and extent of subretinal fluid and pigment epithelium detachment, according to OCT. A decrease in the concentration of VEGF and TNFαwas detected in the tear. There was no statistically significant difference between ranibizumab and aflibercept. Conclusion. Simultaneous cataract surgery and administration of anti-VEGF drugs is an effective and safe method of treatment in patients with combined pathology. Key words: cataract surgery; neovascular age-related macular degeneration; anti-VEGF drugs; ranibizumab; aflibercept.

Indications and Results of Emergency Penetrating Keratoplasty With Simultaneous Cataract Surgery ("Triple-PKP à Chaud").

The purpose of this study was to analyze the indications and clinical results of emergency penetrating keratoplasty with simultaneous cataract surgery ("Triple-PKP à chaud"). This study included all subjects who underwent Triple-PKP à chaud between 2006 and 2020 at the Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar in Germany. Data obtained from patient records were retrospectively analyzed. Triple-PKP à chaud was successfully performed in 27 of 29 eyes with a mean age of 66.0 ± 19.9 years. Previous surgery was performed in 20 eyes (69.0%), most frequently amniotic membrane transplantation in 11 eyes (37.9%) and previous keratoplasty in 9 eyes (31.0%). The most common indication was infectious keratitis (62.1%). In 27 subjects (93.1%), capsulorhexis was performed using the open-sky technique. The most frequent intraoperative complication was positive vitreous pressure (24.1%). In 2 eyes (6.9%), no intraocular lens implantation was performed because of posterior capsule rupture. The preoperative uncorrected visual acuity improved from 2.2 ± 0.6 logMAR (range = 3.0-0.7 logMAR) to 1.3 ± 0.7 logMAR (range = 3.0-0.18 logMAR) postoperatively ( P < 0.001). Common postoperative complications were suture loosening (44.4%) and corneal epithelial defects (33.3%). Repeat keratoplasty was necessary in 14 eyes (51.9%), including 9 eyes (64.2%) within 12 months postoperatively. The mean graft survival was 12.2 ± 17.9 months (range = 1-69 mo). Triple-PKP is also feasible in emergency conditions. Nevertheless, the surgery is associated with an increased risk of intraoperative and postoperative complications. Combined surgery should, therefore, only be performed in severely diseased eyes with progressed stage of cataract.