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To analyze and compare the efficiency of three phaco-emulsifying machines by evaluating parameters related to fluidics and ultrasound time (UST). Pilot, prospective, observational, comparative study conducted at the “Mediterranea” Clinic Ophthalmology Operative Unit, Naples, Italy. A total of 145 consecutive cases of phacoemulsification were included in the study. Patients were randomized into 4 arms and operated using three phaco-emulsifying machines in 4 configurations equipped with three different infusion systems. The phaco machines were: (1) Centurion ® , with and without the Active Sentry ® handpiece (Alcon), (2) Stellaris Elite™ (Bauch & Lomb), and (3) Whitestar Signature ®  Pro (Johnson & Johnson). The primary outcomes were UST and fluid aspiration volume. Centurion, with and without Active Sentry, required less UST compared to other phaco machines ( P  < 0.001). Furthermore, Centurion required lower values of intraocular pressure (IOP) to complete the procedure and aspirated less fluid compared to the Stellaris Elite. No statistical differences in UST, aspirated fluid, and IOP have been found between Centurion and Centurion with Active Sentry. Centurion, with and without Active Sentry required lower UST and IOP for cataract removal compared to Stellaris Elite and Whitestar Signature Pro. Less fluid is necessary to complete the procedure compared to the Stellaris Elite.

AimTo assess the safety and efficacy of microinterventional endocapsular nuclear fragmentation in moderate to severe cataracts.MethodsThis was a prospective single-masked multisurgeon interventional randomised controlled trial (ClinicalTrials.gov NCT02843594) where 101 eyes of 101 subjects with grade 3‒4+ nuclear cataracts were randomised to torsional phacoemulsification alone (controls) or torsional phacoemulsification with adjunctive endocapsular nuclear fragmentation using a manual microinterventional nitinol filament loop device (miLOOP group). Outcome measures were phacoemulsification efficiency as measured by ultrasound energy (cumulative dispersed energy (CDE) units) and fluidics requirements (total irrigation fluid used) as well as incidence of intraoperative and postoperative complications.ResultsOnly high-grade advanced cataracts were enrolled with more than 85% of eyes with baseline best corrected visual acuity (BCVA) of 20/200 or worse in either group. Mean CDE was 53% higher in controls (32.8±24.9 vs 21.4±13.1 with miLOOP assistance) (p=0.004). Endothelial cell loss after surgery was low and similar between groups (7‒8%, p=0.561) One-month BCVA averaged 20/27 Snellen in miLOOP eyes and 20/24 in controls. No direct complications were caused by the miLOOP. In two cases, capsular tears occurred during IOL implantation and in all remaining cases during phacoemulsification, with none occurring during the miLOOP nucleus disassembly part of the procedure.ConclusionsMicrointerventional endocapsular fragmentation with the manual, disposable miLOOP device achieved consistent, ultrasound-free, full-thickness nucleus disassembly and significantly improved overall phaco efficiency in advanced cataracts.Trial registration numberNCT02843594

To compare a modified phacoemulsification tip with the established micro tip, in terms of temperature at the corneal wound, efficiency, and chatter events, using the Centurion® Vision system. Eighty porcine eyes were randomized into 4 groups: 1)sleeveless conventional 45D MiniFlared ABS® Kelman tip (1.1-mm incision); 2)sleeveless new modified 45D ABS® INTREPID® balanced tip(1.1-mm incision); 3) Kelman tip with own sleeve (2.2-mm incision); 4)Balanced tip with modified 4-rib sleeve (2.2-mm incision). Measurements were taken with 2 settings: longitudinal(power 40% and 70%) and torsional mode (power 40% and 100%). Peak temperatures were measured 0, 10, 30, and 60 seconds after continuous ultrasound power. For the efficiency test, porcine lens nuclei were formalin soaked and cut into 2.0 mm3 cubes. Efficiency and chatter were examined. In all longitudinal settings, the sleeveless groups(1 and 2) showed lower temperatures than the sleeved groups(3 and 4) (P = 0.003). In 100% torsional mode, groups 3 and 4 produced significantly different temperatures(37.13 ± 1.44 and 35.14 ± 0.54, respectively; P = 0.007).The efficiency, in a 100% power torsional setting, was13.52 ± 2.60 sec for group 4, and 44.45± 14.75 sec for group 3 (P<0.001). The two different bare tips show no significant differences in thermogenesis. However, the balanced tip with sleeve produces lower temperaturesat100% torsional power and better efficiency than the Kelman tip.

Purpose: To analyze the dependence between corneal endothelial cell loss by Aqualase® cataract surgery and the nuclear opalescence grade of the lens. Patients and Methods: A total of 100 eyes of 92 patients were enrolled in this prospective, single-center study. Patients were randomly assigned to the Aqualase (50 eyes) or the phacoemulsification group (50 eyes). The nuclear density was classified with the Lens Opacities Classification System III. All procedures were performed by the same surgeon. Preoperatively and 1 week postoperatively, endothelial cell counts were obtained using a noncontact specular microscope (Konan, Japan). Results: (1) Aqualase group: the group of patients with a nuclear density of 1-2 (17 patients) showed no significant endothelial cell loss (4.1%, p = 0.163). The endothelial cell loss in grade 3 cataracts (28 eyes) was 13.9% (p = 0.004) and in grade 4 cataracts (5 eyes) 69.1% (p = 0.043), being statistically significant in both groups. (2) Phacoemulsification group: in nuclear density groups 1 and 2, endothelial cell loss was 6.3% (p = 0.41), in group 3 it was 17.6% (p = 0.001) and in group 4 it was 14.9% (p = 0.08). Only in nuclear opalescence grade 4 there was a significant difference between the Aqualase and the phacoemulsification procedure (p = 0.008). Conclusion: Endothelial cell loss by Aqualase technology depends strongly on the nuclear opalescence grade. In low- and medium-density cataracts, Aqualase does not seem to provoke significant endothelial cell loss. Due to very high endothelial loss in hard nuclei, Aqualase is unsuitable for these cataracts.

Background: Posterior capsule opacification (PCO) is still a major long-term complication of modern cataract surgery. We evaluated the impact of sharp-edged intraocular lenses (IOLs) with different haptic designs made from the same hydrophobic acrylic material on posterior and anterior lens capsule opacification. Setting: Eye clinic of Kaunas University of Medicine, Lithuania. Prospective randomised clinical study. Methods: Seventy-four eyes of 74 patients scheduled for cataract surgery were included in a prospective randomised clinical study. Thirty-seven eyes of 37 patients received a three-piece acrylic hydrophobic (AcrySof, MA3OBA, Alcon) IOL; and thirty-seven eyes of 37 patients received a one-piece acrylic hydrophobic (AcrySof, SA3OAL, Alcon) IOL. Visual acuity, anterior capsule opacification (ACO), capsular folds, capsulorrhexis/optic overlapping and posterior capsule opacification (PCO) were evaluated. ACO was assessed subjectively. PCO values in the entire IOL optic area and in the central 3 mm optic zone were assessed using a photographic image-analysis system (EPCO2000). Follow-ups were performed postoperatively at 1 day, 6 months, 1 year and 2 years. Results: There were no significant differences in best corrected visual acuity, grade of ACO and capsulorrhexis/optic overlapping between IOL types during the follow-up period. Patients in the one-piece acrylic hydrophobic IOL group more frequently presented with capsular folds behind the IOL optic area than those in the three-piece IOL group. In the three-piece acrylic hydrophobic IOL group, PCO values (mean (SD)) of the entire IOL optic area were significantly lower six months postoperative (three-piece: 0.002 (0.009); one-piece: 0.007 (0.017); p = 0.04), one year postoperative (three-piece: 0.004 (0.016); one-piece: 0.026 (0.041); p = 0.001) as well as one year postoperative in the central 3 mm optic zone (three-piece: 0.000 (0.0002); one-piece: 0.019 (0.049); p = 0.001). However, two years postoperative, the PCO values of the groups did not show significant differences (entire IOL optic area: three-piece, 0.136 (0.223); one-piece, 0.154 (0.190); p = 0.18; central zone: three-piece, 0.023 (0.065); one-piece: 0.020 (0.039); p = 0.44). Conclusion: The 2 year follow-up after cataract surgery showed no significant difference in ACO and PCO development between three-piece and one-piece acrylic hydrophobic intraocular lenses.

To compare the surgical outcomes of manual sutureless small-incision extracapsular cataract surgery (MSICS) with versus without a conjunctival flap for the treatment of cataracts. Prospective, randomized comparison of 220 consecutive patients with visually significant cataracts. Tertiary level eye clinic. 220 consecutive patients with cataracts. Patients assigned randomly to receive either SICS with a conjunctival flap or without one. Operative time, surgical complications, surgically induced astigmatism. Both surgical techniques achieved comparable surgical outcomes with comparable complication rates. The operative time was markedly less in group without flap (mean duration of 7.67 ± 1.45 min) than in group with flap (mean duration of 11.46 ± 1.69 min) ( p value <0.001). In the group without a flap intraoperative pupillary miosis was significantly greater ( p value 0.039) and on postoperative day 1, there were greater patients with a subconjunctival bleed involving greater than one quadrant of the bulbar conjunctiva ( p value <0.0001). Also, post operative conjunctival retraction and consequent wound exposure was also significantly higher in this group ( p value 0.026). However, the rate of other serious complications like any postop hyphaema, conjunctival bleb formation, iris prolapse, tunnel stability, shallow anterior chamber, post operative uveitis, malpositioned IOL, retinal detachment, cystoid macular edema, endophthalmitis were comparable in both. Both MSICS with and without a conjunctival flap achieved good surgical outcomes with comparable complication rates. But flapless MSICS is significantly faster. However it may be associated with higher intraoperative miosis and greater postoperative wound exposure.

This experimental study aimed to guide cataract surgeons in selecting suitable intraocular lens (IOL) injectors by evaluating the in vitro resistance force during IOL ejection and assessing associated injector damage across modern injector models. Twenty-five injectors from five manufacturers were tested using + 20 diopter lenses. IOLs were ejected into petri dishes, and resistance forces were continuously recorded with an automated digital force gauge. Parameters including maximum force and the area under the curve (AUC) were analyzed. After each ejection, injector nozzle tips were examined microscopically and graded for damage using the HeiScore. Significant differences in resistance forces were found among injector models ( p  < 0.05), with maximum forces ranging from 4.39 ± 0.45 N to 25.71 ± 6.62 N. The AUC also showed significant variability, indicating differing levels of force required for IOL delivery. No ejection complications occurred, though one injector model exhibited markedly higher nozzle damage compared to others. These findings demonstrate substantial variability in resistance and durability among modern IOL injectors and underscore the importance of understanding these differences to ensure safe, controlled, and efficient IOL implantation in cataract surgery.

Purpose To compare the efficacy and safety of capsule support hooks and iris hooks in stabilizing the capsular bag during cataract surgery in patients with significant zonular weakness. Methods This retrospective comparative study included 46 eyes of 39 patients with zonular weakness exceeding 90 degrees who underwent cataract surgery at a tertiary clinic. Patients were divided into two groups due to intraoperative usage of capsule support hooks (Group 1) or iris hooks (Group 2) for capsular stabilization. Intraoperative complications such as capsular tears and vitreous loss, as well as postoperative visual outcomes and intraocular lens (IOL) centration, were evaluated. Results There was no significant difference in terms of postoperative visual acuity and intraocular pressures between the two groups ( p  = 0.370, p  = 0.250 respectively). Anterior capsular tear occurred in 4 eyes in the iris hook group compared to none in the capsule support hook group ( p  = 0.017). Vitreous loss was observed in 4 eyes in the capsule hook group and 7 eyes in the iris hook group ( p  = 0.122). Cystoid macular edema developed in 1 patient in each group ( p  = 0.849). Conclusions Capsule support hooks provide a safer and more stable option for capsular stabilization for zonular weakness during cataract surgery with a lower incidence of intraoperative complications compared to iris hooks. Despite their higher cost and limited availability, capsule support hooks should be preferred to enhance surgical outcomes and patient safety. Iris hooks, while less optimal, remain a viable alternative when capsule support hooks are not available.

Background Theatre activity is a major source of hospital waste, accounting for 21–30% of total output, and is 3–6 times more energy-intensive than any other hospital department. Cataract remains the leading cause of blindness worldwide, and cataract surgery is the most commonly performed surgical procedure worldwide, but to date has received little analysis in this field. The aim of this study was to evaluate the carbon impact of streamlining single-use packs, and transitioning from single-use items, to reusable equivalents in cataract surgery. Methods A focus group and prospective audit was carried out to identify single-use pack items for streamlining. A bottom-up, process-based carbon footprint analysis was conducted of single-use items and reusable alternatives using activity data provided by the suppliers and greenhouse gas (GHG) conversion factors from the UK Government GHG Conversion Factors for Company Reporting database. Results Total carbon savings from streamlining was 935 kgCO2e/year, and switching, was 309 kgCO2e/year. Single-use items had a 27 times greater carbon footprint than reusable equivalents (322 kgCO2 vs. 12 kgCO2e respectively). A net carbon saving was achieved from 19 or more re-uses of the reusable items compared to single-use equivalents. Conclusions This study provides evidence of carbon emissions savings both from streamlining disposable instruments in cataract surgical packs, and from switching from single-use to reusable instruments. Mitigation strategies targeting hotspots in resource intensive areas will be an important aspect of reducing the climate burden of surgery. Change in practice and policy is required in all surgical specialities to realize net zero carbon healthcare.

This study tried to compare the clinical outcomes of femtosecond laser-assisted astigmatic keratotomy (FSAK) and toric intraocular lens (IOL) implantation for astigmatism correction and identify factors affecting the efficacy of FSAK and toric IOL implantation in astigmatism correction. This retrospective case series comprised patients with corneal astigmatism ranging between 0.5 D and 4.5 D. Patients underwent FSAK or toric IOL implantation for cataract treatment and correction of astigmatism at the Samsung Medical Center, a tertiary surgical center, between April 2016 and December 2018. All patients underwent examination before and at three months after the surgery for comparative evaluation of refractive astigmatism, corneal high order aberrations and irregularity index. The astigmatism correction was analyzed by the Alpins method. Subgroup analysis of preoperative factors was based on the extent of target-induced astigmatism (TIA), the degree of astigmatism, and astigmatism classification based on topography. Thirty-one eyes underwent toric IOL implantation and 35 eyes underwent FSAK. The refractive astigmatism was significantly decreased in both toric IOL ( P  = 0.000) and FSAK group ( P  = 0.003). The correction index (CI) of refractive astigmatism was 0.84 ± 0.39 in the toric IOL and 0.71 ± 0.60 in the FSAK group. There was no difference between the two groups ( P  = 0.337). The CI of the FSAK group was significantly lower than in the toric IOL group when TIA was more than 1.5 D ( P  = 0.006), when correcting against-the-rule ( P  = 0.017), and limbus-to-limbus astigmatism ( P  = 0.008). In conclusion, toric IOL implantation is an effective and safe procedure for correcting preoperative astigmatism in cataract surgery in the short-term observation.