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In an ageing population, efficiency improvements are required to assure future accessibility of cataract care. We aim to address remaining knowledge gaps by evaluating the safety, effectiveness, and cost-effectiveness of immediate sequential bilateral cataract surgery (ISBCS) versus delayed sequential bilateral cataract surgery (DSBCS). We hypothesised that ISBCS is non-inferior to DSBCS, regarding safety and effectiveness, and being superior in cost-effectiveness. We did a multicentre, non-inferiority, randomised controlled trial, which included participants from ten Dutch hospitals. Eligible participants were 18 years or older, underwent expected uncomplicated surgery, and had no increased risk of endophthalmitis or refractive surprise. Participants were randomly assigned (1:1) to either the ISBCS (intervention) group or DSBCS (conventional procedure) group, using a web-based system stratified by centre and axial length. Participants and outcome assessors were not masked to the treatment groups because of the nature of the intervention. The primary outcome was the proportion of second eyes with a target refractive outcome of 1·0 dioptre (D) or less 4 weeks postoperatively, with a non-inferiority margin of –5% for ISBCS versus DSBCS. For the trial-based economic evaluation, the primary endpoint was the incremental societal costs per quality-adjusted life-year. All analyses were done by a modified intention-to-treat principle. Costs were calculated by multiplying volumes of resource use with unit cost prices and converted to 2020 Euros (€) and US$. This study was registered with ClinicalTrials.gov, number NCT03400124, and is now closed for recruitment. Between Sept 4, 2018, and July 10, 2020, a total of 865 patients were randomly assigned to either the ISBCS group (427 [49%] patients; 854 eyes) or DSBCS group (438 [51%] patients; 876 eyes). In the modified intention-to-treat analysis, the proportion of second eyes with a target refraction of 1·0 D or less was 97% (404 of 417 patients) in the ISBCS group versus 98% (407 of 417) in the DSBCS group. The percentage difference was –1% (90% CI –3 to 1; p=0·526), thereby establishing non-inferiority for ISBCS compared with DSBCS. Endophthalmitis was not observed or reported in either group. Adverse events were comparable between groups, with only a significant difference in disturbing anisometropia (p=0·0001). Societal costs were €403 (US$507) lower with ISBCS than with DSBCS. The cost-effectiveness probability of ISBCS versus DSBCS was 100% across the willingness-to-pay range of €2500–80 000 (US$3145–100 629) per quality-adjusted life-year. Our results showed non-inferiority of ISBCS versus DSBCS regarding effectiveness outcomes, comparable safety, and superior cost-effectiveness of ISBCS. National cost savings could amount to €27·4 million (US$34·5 million) annually, advocating for ISBCS if strict inclusion criteria are applied. Research grant from The Netherlands Organization for Health Research and Development (ZonMw) and Dutch Ophthalmological Society.

Retinopathy, a common microvascular complication of type 1 diabetes, can lead to vision loss. Follow-up data from two studies show that intensive therapy in patients with type 1 diabetes was associated with a substantially reduced long-term risk of ocular surgery. Retinopathy, a common microvascular complication of type 1 diabetes, is a leading cause of vision loss worldwide. 1 In the Diabetes Control and Complications Trial (DCCT), 2 6.5 years of intensive therapy aimed at achieving glycemia as close to the nondiabetic range as safely possible, as compared with conventional therapy at the time, was associated with a 76% reduction in the onset of retinopathy and a 52% reduction in disease progression. In the subsequent long-term observational follow-up, the Epidemiology of Diabetes Interventions and Complications (EDIC) study, 3 the patients in the intensive-therapy group had a durable reduction in progression of microvascular and macrovascular . . .

Purpose: Manual small-incision cataract surgery (MSICS) has a major role in tackling cataract blindness in our country. Cauterization of sclera is one of the important steps performed in MSICS to have bloodless field during surgery. Only few studies have addressed the effect of cautery on post-operative astigmatism. The present study is designed to evaluate the effect of cautery on surgically induced astigmatism in Indian patients. Methods: The study was designed as a prospective randomized trial conducted in a tertiary health care institution over a period of 2 years. A total of 150 eyes were randomized into two groups. The study group (Group 1, n = 75) underwent MSICS with cauterization using wetfield bipolar cautery with 4 amperes power. In the control group (Group 2, n = 75), no cauterization was performed. Surgically induced astigmatism was calculated using Naesers polar value method and compared between these two groups up to 60 days post-operatively. Results: Data from 150 eyes were available for evaluation. The net post-operative astigmatic value was 1.01 ± 0.21, 1.04 ± 0.19, and 1.03 ± 0.22 D on the 1st, 7th, and 30th post-operative days, respectively, showing a stable trend in patients undergoing cauterization. In Group 2, the net post-operative astigmatic values observed were 0.47 ± 0.11 D, 0.54 ± 0.10, and 0.54 ± 0.09 D on the 1st, 7th, and 30th post-operative days, respectively. The mean value of surgically induced astigmatism at 2 months post-operatively with and without cautery was 0.60 ± 0.20 D at 90° and 0.47 ± 0.10 D at 90°. The difference was not statistically significant (P = 0.08). Conclusion: The results of this study show that the use of cautery in MSICS is not associated with a higher surgically induced post-operative astigmatism. The magnitude of surgically induced astigmatism decreases with time.

ObjectivesTo evaluate the development of posterior capsule opacification (PCO) and Nd:YAG capsulotomy rates following implantation of two hydrophobic acrylic IOLs.MethodsIn a randomized, controlled trial, 80 patients with bilateral senile cataract were implanted with the hydrophobic acrylic single-piece intraocular Lenses (IOLs) EyeCee One in one eye and iMics1 in the other. Outcomes of 39 patients (78 eyes) were evaluated after 3 years. Automated Quantification of After-Cataract (AQUA; for PCO occurrence), visual acuity, anterior fibrosis, capsule−optic edge interaction and distance between anterior and posterior capsule IOL surface were analysed.ResultsAfter a mean follow-up of 38 ± 1.95 months, Nd:YAG capsulotomy occurred at a rate of 15.4% and 46.2% in the EyeCee One and iMics1 groups, respectively (p < 0.01). Respective mean PCO scores measured by AQUA were 1.57 ± 1.63 and 2.45 ± 1.44 (p = 0.019). A distinct gap between the anterior capsule and the IOL optic was present in 89% of eyes implanted with EyeCee One and 13% of iMics1 eyes. A gap between the posterior capsule and the posterior surface of the lens was observed in 76% of EyeCee One eyes and 35% of iMics1 eyes.ConclusionsStudy findings suggest that PCO and Nd:YAG capsulotomy rates are significantly lower in eyes implanted with the EyeCee One IOL compared to the iMics1 IOL. Optic sharpness and lens material seem to be the decisive factors, while the stepped edge beneath the haptic junction appeared to be ineffective.

Objective To compare the efficacy of femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification surgery (CPS) in treating postvitrectomy cataracts. Methods Prospective randomized controlled study. Patients who underwent cataract surgery after pars plana vitrectomy (PPV) were randomly divided into the FLACS group and the CPS group. Preoperative data of all patients were collected to compare intraoperative complications, average phacoemulsification energy (AVE), effective phacoemulsification time (EPT), postoperative intraocular pressure, corneal endothelial cell density (ECD), and best corrected visual acuity (BCVA). Results A total of 92 eyes were included in the analysis, with 47 eyes in the FLACS group and 45 eyes in the CPS group. The intraoperative AVEs and EPTs in the FLACS group were both lower than those in the CPS group ( P  < 0.05). In the FLACS group, incomplete prechopping and incomplete capsulorhexis occurred in 3 eyes (3/47, 6.38%), and incomplete lens dislocation occurred in 1 eye (1/47, 2.13%). In the CPS group, incomplete lens dislocation occurred in 2 eyes (2/45, 4.44%), and anterior capsule tears occurred in 1 eye (1/45, 2.22%). There was no statistically significant difference in intraoperative complications between the two groups ( P  > 0.05). Postoperatively, intraocular pressure (IOP) was lower in both groups than preoperatively, and there was no statistically significant difference in intraocular pressure between the two groups at three months postsurgery ( P  > 0.05). Three months postoperatively, the ECD in the FLACS group was greater than that in the CPS group, with less average endothelial cell loss (ECL) than that in the CPS group ( P  < 0.01). The BCVA in both groups improved to varying degrees compared with the preoperative values, with the FLACS group performing better than the CPS group on the first postoperative day ( P  < 0.05). There was no statistically significant difference between the two groups at one week, one month, or three months postoperatively (all P  > 0.05). Conclusion FLACS is safe and effective for treating post-PPV cataracts and, compared with CPS, facilitates early postoperative recovery with no difference in final visual acuity. Residual silicone oil in the anterior chamber post-PPV may lead to certain specific outcomes for FLACS. Although it may not affect surgical results, it is still noteworthy.

Background/aimTo compare visual and refractive outcomes, changes in intraocular pressure (IOP), and complications of femtosecond laser-assisted cataract surgery (FLACS) to conventional phacoemulsification surgery (CPS) in paired eyes from the same patients.MethodsThis is a secondary analysis of an intraindividual, randomised, controlled clinical trial including 110 paired eyes from 55 patients that were randomised into either FLACS or CPS groups. Outcomes were recorded at baseline and postoperatively during a 3-month follow-up period.ResultsUncorrected distance visual acuity and corrected distance visual acuity were similar between FLACS and CPS over the follow-up period (p>0.05). The mean absolute refractive error was not significantly different between the two groups at postoperative month 1 (POM1) (0.3±0.2 D in FLACS vs 0.4±0.3 D in CPS, p=0.18) and month 3 (POM3) (0.3±0.3 D in FLACS vs 0.3±0.3 D in CPS, p=0.71). IOP was statistically higher in the FLACS group on postoperative day 1 (20.6±5.7 mm Hg for FLACS and 18.0±4.9 mm Hg for CPS, p=0.01). However, it was similar between the two groups subsequently (p>0.05). Intraoperatively, one case of posterior capsular block syndrome was observed in the FLACS group. Postoperatively, one case of newly developed glaucoma was observed in the FLACS group and one case of retinal tears in the CPS group.ConclusionThe 3-month postoperative refractive and visual outcomes were comparable between FLACS and CPS in paired eyes from the same patients. Complication rate was low in the study population.

Purpose: This study aimed to evaluate the effect of using the lubricated eyelid speculum on the overall pain perception by the subject patients who underwent cataract surgery by phacoemulsification technique under topical anesthesia. Methods: A prospective interventional randomized comparative study was conducted at the tertiary eye care center, wherein adult patients scheduled for bilateral cataract surgery with phacoemulsification techniques under topical anesthesia were randomized to undergo surgery with two different modes of eyelid speculum insertion, either with or without lubrication of the eyelid speculum. Fifty percent of the patients underwent surgery with eyelid speculum without lubrication, and 50% with lubrication of the eyelid speculum. The primary outcome was to compare the level of overall pain perception among the subject patients of the two groups by using the Visual Analogue Scale (VAS) in the immediate postoperative period. Results: The study included 130 patients who underwent bilateral cataract surgery (n = 260 eyes) under topical anesthesia, wherein n = 130 eyes underwent surgery using lubricated eyelid speculum and n = 130 eyes underwent surgery with dry eyelid speculum. Pain perception score assessed on the VAS (0-10 cm) ranged from 0.5 to 6, with a mean ± standard deviation of 2.06 ± 1.12. A significant correlation was found with two different methods of eyelid speculum insertion with reduced overall pain perception in patients with the use of lubricated eyelid speculum compared to the dry eyelid speculum (P = 0.0001). Conclusion: The overall pain perception associated with cataract surgery performed by phacoemulsification technique under topical anesthesia can be further minimized by lubricating the eyelid speculum prior to insertion for exposing the globe.

Purpose: To evaluate the safety and efficacy of limbal relaxing incisions for the correction of corneal astigmatism during phacoemulsification. Methods: Fifty eyes of 37 patients (mean age 66.5 years, range: 45 to 80 years) with cataract and coexisting topographic astigmatism were included in the study. Eyes were randomly divided into two groups: eyes that underwent cataract surgery with limbal relaxing incisions (cataract LRI group) and eyes that underwent cataract surgery only (control group). All limbal relaxing incisions were performed during phacoemulsification. Best spectacle-corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), and corneal topography were recorded preoperatively and 1, 3, and 6 months postoperatively. Results: A statistically significant improvement in BSCVA was seen in the cataract LRI eyes from 0.9±0.7 preoperatively to 0.1±0.1 at 1, 3, and 6 months postoperatively (P<.01). A statistically significant improvement in BSCVA was seen in control eyes from 0.8±0.6 before surgery to 0.2±0.2 at 1, 3, and 6 months after surgery (P<.01). No difference in postoperative BSCVA was noted between the groups. A statistically significant reduction in the mean topographic astigmatism was seen in the cataract LRI eyes from 1.93±0.58 diopters (D) preoperatively to 1.02±0.60 D 6 months postoperatively (P<.05). The control eyes did not show a statistically significant change in topographic astigmatism. Conclusions: Limbal relaxing incisions performed during phacoemulsification surgery appear to be a safe, effective, and stable procedure to reduce pre-existing corneal astigmatism. [J Refract Surg. 2007;23:499–504.]

Cataract prevalence increases with age. As the world's population ages, cataract-induced visual dysfunction and blindness is on the increase. This is a significant global problem. The challenges are to prevent or delay cataract formation, and treat that which does occur. Genetic and environmental factors contribute to cataract formation. However, reducing ocular exposure to UV-B radiation and stopping smoking are the only interventions that can reduce factors that affect the risk of cataract. The cure for cataract is surgery, but this is not equally available to all, and the surgery which is available does not produce equal outcomes. Readily available surgical services capable of delivering good vision rehabilitation must be acceptable and accessible to all in need, no matter what their circumstances. To establish and sustain these services requires comprehensive strategies that go beyond a narrow focus on surgical technique. There must be changes in government priorities, population education, and an integrated approach to surgical and management training. This approach must include supply of start-up capital equipment, establishment of surgical audit, resupply of consumables, and cost-recovery mechanisms. Considerable innovation is required. Nowhere is this more evident than in the pursuit of secure funding for ongoing services.

Recent American College of Cardiology/American Heart Association guidelines on statin initiation on the basis of total atherosclerotic cardiovascular disease risk argue that the preventive effect of statins on cardiovascular events outweigh the side effects, although this is controversial. Studies indicate a possible effect of statin therapy on reducing risk of lens opacities. However, the results are conflicting. The Simvastatin and Ezetimibe in Aortic Stenosis study (NCT00092677) enrolled 1,873 patients with asymptomatic aortic stenosis and no history of diabetes, coronary heart disease, or other serious co-morbidities were randomized (1:1) to double-blind 40 mg simvastatin plus 10 mg ezetimibe versus placebo. The primary end point in this substudy was incident cataract. Univariate and multivariate Cox models were used to analyze: (1) if the active treatment reduced the risk of the primary end point and (2) if time-varying low-density lipoproteins (LDL) cholesterol lowering (annually assessed) was associated with less incident cataract per se. During an average follow-up of 4.3 years, 65 patients (3.5%) developed cataract. Mean age at baseline was 68 years and 39% were women. In Cox multivariate analysis adjusted for age, gender, prednisolone treatment, smoking, baseline LDL cholesterol and high sensitivity C-reactive protein; simvastatin plus ezetimibe versus placebo was associated with 44% lower risk of cataract development (hazard ratio 0.56, 95% confidence interval 0.33 to 0.96, p = 0.034). In a parallel analysis substituting time-varying LDL-cholesterol with randomized treatment, lower intreatment LDL-cholesterol was in itself associated with lower risk of incident cataract (hazard ratio 0.78 per 1 mmol/ml lower total cholesterol, 95% confidence interval 0.64 to 0.93, p = 0.008). In conclusion, randomized treatment with simvastatin plus ezetimibe was associated with a 44% lower risk of incident cataract development. This effect should perhaps be considered in the risk-benefit ratio of statin treatment.