Cataract Publications

Vingopoulos F, Kasetty M, Garg I, Silverman RF, Katz R, Vasan RA, Lorch AC, Luo ZK, Miller JB. Active Learning to Characterize the Full Contrast Sensitivity Function in Cataracts. Clin Ophthalmol 2022;16:3109-3118.Abstract
Background: To characterize contrast sensitivity function (CSF) in cataractous and pseudophakic eyes compared to healthy control eyes using a novel quantitative CSF test with active learning algorithms. Methods: This is a prospective observational study at an academic medical center. CSF was measured in eyes with visually significant cataract, at least 2+ nuclear sclerosis (NS) and visual acuity (VA) ≥ 20/50, in pseudophakic eyes and in healthy controls with no more than 1+ NS and no visual complaints, using the Manifold Contrast Vision Meter. Outcomes included Area under the Log CSF (AULCSF) and CS thresholds at 1, 1.5, 3, 6, 12, and 18 cycles per degree (cpd). A subgroup analysis as performed on cataract eyes with VA ≥ 20/25. Results: A total of 167 eyes were included, 58 eyes in the cataract group, 77 controls, and 32 pseudophakic eyes with respective median AULCSF of 1.053 (0.352) vs 1.228 (0.318) vs 1.256 (0.360). In our multivariate regression model, cataract was associated with significantly reduced AULCSF (P= 0.04, β= -0.11) and contrast threshold at 6 cpd (P= 0.01, β= -0.16) compared to controls. Contrast threshold at 6 cpd was significantly reduced even in the subgroup of cataractous eyes with VA ≥ 20/25 (P=0.02, β=-0.16). Conclusion: The novel qCSF test detected disproportionate significant contrast deficits at 6 cpd in cataract eyes; this remained significant even in the cataractous eyes with VA ≥ 20/25. CSF testing may enhance cataract evaluation and surgical decision-making, particularly in patients with subjective visual complaints despite good VA.
Bothun ED, Shainberg MJ, Christiansen SP, VanderVeen DK, Neely DE, Kruger SJ, Cotsonis G, Lambert SR, Lambert SR. Long-term strabismus outcomes after unilateral infantile cataract surgery in the Infant Aphakia Treatment Study. J AAPOS 2022;Abstract
PURPOSE: To characterize long-term strabismus outcomes in children in the Infant Aphakia Treatment Study (IATS). METHODS: This study was a secondary data analysis of long-term ocular alignment characteristics of children aged 10.5 years who had previously been enrolled in a randomized clinical trial evaluating aphakic management after unilateral cataract surgery between 1 and 6 months of age. RESULTS: In the IATS study, 96 of 109 children (88%) developed strabismus through age 10.5 years. Half of the 20 children who were orthophoric at distance through age 5 years maintained orthophoria at distance fixation at 10.5 years. Esotropia was the most common type of strabismus prior to age 5 years (56/109 [51%]), whereas exotropia (49/109 [45%]) was the most common type of strabismus at 10.5 years (esotropia, 21%; isolated hypertropia, 17%). Strabismus surgery had been performed on 52 children (48%), with 18 of these (35%) achieving microtropia <10Δ. Strabismus was equally prevalent in children randomized to contact lens care compared with those randomized to primary intraocular lens implantation (45/54 [83%] vs 45/55 [82%]; P = 0.8). Median visual acuity in the study eye was 0.56 logMAR (20/72) for children with orthotropia or microtropia <10Δ versus 1.30 logMAR (20/400) for strabismus ≥10Δ (P = 0.0003). CONCLUSIONS: Strabismus-in particular, exotropia-is common irrespective of aphakia management 10 years following infant monocular cataract surgery. The delayed emergence of exotropia with longer follow-up indicates a need for caution in managing early esotropia in these children. Children with better visual acuity at 10 years of age are more likely to have better ocular alignment.
Moussa O, Frank T, Valenzuela IA, Aliancy J, Gong D, De Rojas JO, Dagi Glass LR, Winn BJ, Cioffi GA, Chen RWS. Efficacy of Preoperative Risk Stratification on Resident Phacoemulsification Surgeries. Clin Ophthalmol 2022;16:2137-2144.Abstract
Purpose: To evaluate efficacy of a novel risk stratification system in minimizing resident surgical complications and to evaluate whether the system could be used to safely introduce cataract surgery to earlier levels of training. Materials and Methods: This is a retrospective cross-sectional study on 530 non-consecutive cataract cases performed by residents at Columbia University. Risk scores, preoperative best corrected visual acuity (BCVA), intraoperative complications, postoperative day 1 (POD1), and month 1 (POM1) exam findings were tabulated. The relationship between risk scores and POD1 and POM1 BCVA was modeled using linear regression. The relationship between risk scores and complication rates was modeled using logistic regression. Logistic regression was used to model the rates of complications across different levels of training. Rates of complications were compared between diabetic versus non-diabetic patients using t-tests. Results: Risk scores did not have significant association with intraoperative complications. Risk scores were predictive of corneal edema (OR = 1.36, p = 0.0032) and having any POM1 complication (OR = 1.20, p = 0.034). Risk scores were predictive of POD1 (β = 0.13, p < 0.0001) and POM1 (β = 0.057, p = 0.00048) visual acuity. There was no significant association between level of training and rates of intraoperative (p = 0.9) or postoperative complications (p = 0.06). Rates of intraoperative complication trended higher among diabetic patients but was not statistically significant (p = 0.2). Conclusion: Higher risk scores were predictive of prolonged corneal edema but not risk of intraoperative complications. Our risk stratification system allowed us to safely introduce earlier phacoemulsification surgery.
Chang DS-T, Jiang Y, Kim JA, Huang S, Munoz B, Aung T, He M, Foster PJ, Friedman D. Cataract progression after Nd:YAG laser iridotomy in primary angle-closure suspect eyes. Br J Ophthalmol 2022;Abstract
BACKGROUND/AIMS: Prophylactic laser peripheral iridotomy (LPI) is performed in primary angle-closure suspect (PACS) eyes to prevent acute angle-closure attacks. However, accelerated cataractogenesis is a potential risk of the procedure that may result in decreased visual acuity. We aimed to assess the long-term impact of LPI on cataract formation in Chinese PACS. METHODS: In the Zhongshan Angle Closure Prevention Trial, eligible bilateral PACS participants received LPI in one randomly selected eye, while the fellow eye remained untreated. Cataract was graded using the Lens Opacity Classification System III, and progression was defined as an increase in grade by at least two units in any category or cataract surgery. RESULTS: In total, 889 participants were randomly assigned to LPI in one eye only (mean age 59±5 years, 83% female). At 72 months, treated eyes had slightly higher average nuclear grades (p<0.001). However, there were no differences between eyes for predefined cataract progression (cumulative probability at 72 months: 21.2% in LPI vs 19.4% in control, p=0.401) or cataract surgery (1% for both). While LPI-treated eyes had a 10% higher risk of progression over 6 years (HR=1.10 (95% CI 0.88 to 1.36)), this was not statistically significant. Visual acuity at 72 months was similar in treated and untreated eyes (p=0.43). CONCLUSION: Although lenses were graded on average as slightly more opaque in laser-treated eyes, prophylactic neodymium:yttrium-aluminum-garnet LPI did not cause significant cataract progression. Our results suggest that LPI treatment of asymptomatic narrow angles does not increase the risk of developing clinically meaningful cataract worsening over time. TRIAL REGISTRATION NUMBER: ISRCTN45213099.
VanderVeen DK, Oke I, Nihalani BR. Deviations From Age-Adjusted Normative Biometry Measures in Children Undergoing Cataract Surgery: Implications for Postoperative Target Refraction and IOL Power Selection. Am J Ophthalmol 2022;239:190-201.Abstract
PURPOSE: To evaluate whether pediatric eyes that deviate from age-adjusted normative biometry parameters predict variation in myopic shift after cataract surgery. METHODS: This is a single institution longitudinal cohort study combining prospectively collected biometry data from normal eyes of children <10 years old with biometry data from eyes undergoing cataract surgery. Refractive data from patients with a minimum of 5 visits over ≥5 years of follow-up were used to calculate myopic shift and rate of refractive growth. Cataractous eyes that deviated from the middle quartiles of the age-adjusted normative values for axial length and keratometry were studied for variation in myopic shift and rate of refractive growth to 5 years and last follow-up visit. Multivariable analysis was performed to determine the association between myopic shift and rate of refractive growth and factors of age, sex, laterality, keratometry, axial length, intraocular lens power, and follow-up length. RESULTS: Normative values were derived from 100 eyes; there were 162 eyes in the cataract group with a median follow-up of 9.6 years (interquartile range: 7.3-12.2 years). The mean myopic shift ranged from 5.5 D (interquartile range: 6.3-3.5 D) for 0- to 2-year-olds to 1.0 D (interquartile range: 1.5-0.6 D) for 8- to 10-year-olds. Multivariable analysis showed that more myopic shift was associated with younger age (P < .001), lower keratometry (P = .01), and male gender (P = .027); greater rate of refractive growth was only associated with lower keratometry measures (P = .001). CONCLUSIONS: Age-based tables for intraocular lens power selection are useful, and modest adjustments can be considered for eyes with lower keratometry values than expected for age.
Engelhard SB, Haripriya A, Namburar S, Pistilli M, Daniel E, Kempen JH. Dropped Nucleus during Cataract Surgery in South India: Incidence, Risk Factors, and Outcomes. Ophthalmic Epidemiol 2022;29(3):271-278.Abstract
PURPOSE: To determine incidence, risk factors for, and outcomes of dropped nucleus (DN) during cataract surgery. METHODS: This is a matched case-control study at the Aravind Eye Hospital in Madurai, India. Out of 184 consecutive DN cases, 171 were included. The case immediately preceding the DN case by the same surgeon served as matched concurrent control. The proportion of cataract surgeries with DN was calculated with a 95% confidence interval (CI). Conditional logistic regression was used to generate odds ratios for potential risk factors. RESULTS: Among 415,487 consecutive cataract surgeries, incidence risk of DN was 0.044% [95% CI 0.038%, 0.051%], or 0.44 per 1,000 surgeries in 52 months. Significant preoperative risk factors were posterior polar cataract (adjusted odds ratio [aOR] 21.73, p = .003); suspected loose zonules (aOR 8.85, p < .001); older age (aOR 1.57, p = .001); and presence of diabetes mellitus (aOR 1.79, p = .03). Associated intraoperative complications included zonular dialysis (OR 34.49, p < .001), vitreous disturbance (OR 193.36, p < .001), and posterior capsule rent (OR 384.39, p < .001). Phacoemulsification and manual small incision cataract surgery did not significantly differ in DN incidence. DN most commonly occurred during nucleus removal (35.1%) or during/immediately following hydrodissection (24.0%). Visual outcomes of DN were worse than controls on average, but 51.9% achieved visual acuity 20/40 or better at 1 month. CONCLUSIONS: DN occurred rarely, with low absolute risk even when a strong risk factor was present. Nearly all cases followed posterior capsular rent or zonular dialysis, usually with observed vitreous loss. In spite of increased risk of postoperative complications in the DN group, the majority achieved favorable results.
Böhm M, Müller M, Paul J, Hemkeppler E, Kohnen T. Intraoperative OCT versus Scheimpflug and Swept-Source OCT measurements for anterior eye parameters. J Cataract Refract Surg 2021;Abstract
PURPOSE: To compare agreement of anterior segment parameter measurements using an intraoperative optical coherence tomography (iOCT) of a femtosecond laser (LenSx) during interface docking to the eye to preoperative Scheimpflug-tomography (Pentacam AXL) and swept-source optical coherence tomography (IOL Master 700). SETTING: Department of Ophthalmology, Goethe University, Frankfurt, Germany. DESIGN: Retrospective study. METHODS: Ninty-five eyes of 66 patients who had planned OCT-guided femtosecond laser-assisted lens surgery were included. Anterior segment measurements were performed in mydriasis prior to surgery using Scheimpflug-tomography and swept-source optical coherence tomography. After surgery iOCT images were analysed using a modification of the FIJI image processing program. Outcome measures included external anterior chamber depth (ACD), central corneal thickness (CCT) and central lens thickness (LT). RESULTS: The ACD measured with the iOCT was -0.011±0.126mm smaller (p=0.389) than with theswept-source OCT and -0.059±0.185mm than with the Scheimpflug-tomography (p=0.003). The swept-source OCT measures a -0.047±0.146mm smaller ACD than the Scheimpflug-tomography (p=0.002). The measurements of CCT using the iOCT and the Scheimpflug-tomography (-0.705±20.837μm, p=0.742) and the LT measurements of swept-source OCT and iOCT (-0.050±0.089mm, p<0.001) show no clinically relevant difference. Just the ACD between the iOCT and the Scheimpflug-tomography shows a clinically relevant difference. CONCLUSION: The comparison of the anterior segment parameters of intraoperative optical coherence tomography with swept-source optical coherence tomography showed no clinically relevant differences regarding the ACD and the lens thickness. However, Scheimpflug-tomography versus intraoperative optical coherence tomography measures a small clinically relevant difference for ACD.
Wishart TFL, Flokis M, Shu DY, Das SJ, Lovicu FJ. Hallmarks of lens aging and cataractogenesis. Exp Eye Res 2021;210:108709.Abstract
Lens homeostasis and transparency are dependent on the function and intercellular communication of its epithelia. While the lens epithelium is uniquely equipped with functional repair systems to withstand reactive oxygen species (ROS)-mediated oxidative insult, ROS are not necessarily detrimental to lens cells. Lens aging, and the onset of pathogenesis leading to cataract share an underlying theme; a progressive breakdown of oxidative stress repair systems driving a pro-oxidant shift in the intracellular environment, with cumulative ROS-induced damage to lens cell biomolecules leading to cellular dysfunction and pathology. Here we provide an overview of our current understanding of the sources and essential functions of lens ROS, antioxidative defenses, and changes in the major regulatory systems that serve to maintain the finely tuned balance of oxidative signaling vs. oxidative stress in lens cells. Age-related breakdown of these redox homeostasis systems in the lens leads to the onset of cataractogenesis. We propose eight candidate hallmarks that represent common denominators of aging and cataractogenesis in the mammalian lens: oxidative stress, altered cell signaling, loss of proteostasis, mitochondrial dysfunction, dysregulated ion homeostasis, cell senescence, genomic instability and intrinsic apoptotic cell death.
Rosenblatt TR, Vail D, Ludwig CA, Al-Moujahed A, Pasricha MV, Ji MH, Callaway NF, Moshfeghi DM. Fall risk in patients with pseudophakic monovision. Can J Ophthalmol 2021;Abstract
OBJECTIVE: Vision changes can precipitate falls in the elderly resulting in significant morbidity and mortality. We hypothesized that pseudophakic monovision and ensuing anisometropia and aniseikonia impact elderly fall risk. This study assessed fall risk in patients with pseudophakic monovision, pseudophakic single vision distance (classic cataract surgery), and cataracts with no surgery. DESIGN: Retrospective single-institution cohort study PARTICIPANTS: Patients with bilateral cataracts diagnosed at 60 years of age or older who underwent bilateral cataract surgery (monovision or single vision distance) or did not undergo any cataract surgery (n = 13 385). Patients with unilateral surgery or a fall prior to cataract diagnosis were excluded. METHODS: Data were obtained from the Stanford Research Repository. Time-to-fall analysis was performed across all 3 groups. Primary outcome was hazard ratio (HR) for fall after second eye cataract surgery or after bilateral cataract diagnosis. RESULTS: Of 13 385 patients (241 pseudophakic monovision, 2809 pseudophakic single vision, 10 335 no surgery), 850 fell after cataract diagnosis. Pseudophakic monovision was not associated with fall risk after controlling for age, sex, and myopia. Pseudophakic single-vision patients had a decreased time to fall compared with no-surgery patients (log rank, p < 0.001). Older age at cataract diagnosis (HR =1.05, 95% confidence interval [CI] 1.04-1.06, p < 0.001) or at time of surgery (HR = 1.05, 95% CI 1.03-1.07, p < 0.001) increased fall risk, as did female sex (HR = 1.29, 95% CI 1.10-1.51, p = 0.002) and preexisting myopia (HR = 1.31, 95% CI 1.01-1.71, p = 0.046) among nonsurgical patients. CONCLUSIONS: Pseudophakic monovision did not impact fall risk, but pseudophakic single vision may increase falls compared with patients without cataract surgery.
Agarwal K, Hatch K. Femtosecond Laser Assisted Cataract Surgery: A Review. Semin Ophthalmol 2021;36(8):618-627.Abstract
Femtosecond laser assisted cataract surgery (FLACS) offers a level of precision, accuracy and customization that is not possible with manual phacoemulsification (MP). With the increase of patient expectations and premium intraocular lens utilization in the era of refractive cataract surgery, predictability and accuracy has become of utmost importance. FLACS has four main functions: creation of a consistently sized round capsulotomy, treatment of keratometric astigmatism with arcuate incisions, construction of clear corneal incisions, and fragmentation and/or softening of the lens. However, FLACS may have limitations due to suction loss, incomplete capsulotomy or poor pupillary dilation. Patient selection and surgeon experience is critical. This review article will focus on the various platforms available for FLACS, the steps in cataract surgery it can perform, and overall advantages and limitations of the technology.
Moustafa GA, Borkar DS, Eton EA, Koulisis N, Kloek CE, Kloek CE, Kloek CE. Healthcare disparities contribute to missed follow-up visits after cataract surgery in the USA: results from the perioperative care for intraocular lens study. BMJ Open 2021;11(3):e038565.Abstract
OBJECTIVE: To identify factors that contribute to missed cataract surgery follow-up visits, with an emphasis on socioeconomic and demographic factors. METHODS: In this retrospective cohort study, patients who underwent cataract extraction by phacoemulsification at Massachusetts Eye and Ear between 1 January and 31 December 2014 were reviewed. Second eye cases, remote and international patients, patients with foreign insurance and combined cataract cases were excluded. RESULTS: A total of 1931 cases were reviewed and 1089 cases, corresponding to 3267 scheduled postoperative visits, were included. Of these visits, 157 (4.8%) were missed. Three (0.3%) postoperative day 1, 40 (3.7%) postoperative week 1 and 114 (10.5%) postoperative month 1 visits were missed. Age<30 years (adjusted OR (aOR)=8.2, 95% CI 1.9 to 35.2) and ≥90 years (aOR=5.7, 95% CI 2.0 to 15.6) compared with patients aged 70-79 years, estimated travel time of >2 hours (aOR=3.2, 95% CI 1.4 to 7.4), smokers (aOR=2.7, 95% CI 1.6 to 4.8) and complications identified up to the postoperative visit (aOR=1.4, 95% CI 1.0 to 2.1) predicted a higher rate of missed visits. Ocular comorbidities (aOR=0.7, 95% CI 0.5 to 1.0) and previous visit best-corrected visual acuity (BCVA) of 20/50-20/80 (aOR=0.4, 95% CI 0.3 to 0.7) and 20/90-20/200 (aOR=0.4, 95% CI 0.2 to 0.9), compared with BCVA at the previous visit of 20/40 or better, predicted a lower rate of missed visits. Gender, race/ethnicity, language, education, income, insurance, alcohol use and season of the year were not associated with missed visits. CONCLUSIONS: Medical factors and demographic characteristics, including patient age and distance from the hospital, are associated with missed follow-up visits in cataract surgery. Additional studies are needed to identify disparities in cataract postoperative care that are population-specific. This information can contribute to the implementation of policies and interventions for addressing them.
Ma KK, Luo ZK. Novel Method to Determine Target Refraction in Cataract Surgery for Patients Dependent on Therapeutic Scleral Lenses. Eye Contact Lens 2021;47(6):352-355.Abstract
OBJECTIVES: To evaluate a novel approach to determine the refractive target for patients undergoing cataract surgery who are dependent on therapeutic scleral lenses, to avoid the need for postoperative scleral lens replacement. METHODS: Retrospective single-surgeon case series. The target refraction for intraocular lens selection was determined by considering the effective scleral lens system power. This was calculated by adding the known scleral lens spherical power to the difference between the scleral lens base curve and the average keratometry value. RESULTS: Six eyes from three patients with moderate myopia or emmetropia with ocular graft versus host disease dependent on therapeutic scleral lenses underwent cataract surgery with intraocular lens selection based on this method. All six eyes had corrected visual acuities of 20/30 or better while wearing their previous scleral lenses at the postoperative week 1 visit. All six eyes resumed full-time scleral lens use 1 week after phacoemulsification and did not require scleral lens replacement. CONCLUSIONS: Using this method, patients requiring therapeutic scleral lenses can quickly experience optimal vision, comfort, and ocular surface protection 1 week after cataract surgery. These patients can continue to use their existing scleral lenses and avoid the costs and burdens associated with lens replacement.