SPS-208 Cataract Surgery - Complications | ASCRS
2020 ASCRS Virtual Annual Meeting

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Papers in this Session
Expand each tab below to view the paper abstract for each paper within this session.
Dysphotopsias, Glare, Halo and Spiderweb Optical Effects from Different Intraocular Implant Lenses.
Author
Peter J. Cornell, MD, ABO

Purpose
Implant lenses can provide good results but can have unwanted optical aberrations. The incidence, type of aberration, treatments and comparison provide useful information when counseling patients about their lens options.

Methods
A chart review was performed of all eyes operated on by one surgeon over a 36-month period. 921 eyes of 506 patients were identified for analysis. All patients had preoperative explanations of possible optical aberrations, including positive and negative dysphotopsia, glare, halo and spiderweb effects. 58 eyes were identified with any of these symptoms noted at one-month visit, and those eyes were evaluated for the type of implant, the type of aberration and lens exchange frequency.

Results
58/921 eyes (7.1%) of 36 patients had optical aberrations, 8.8% of women and 4.5% of men. 8.5% of acrylic eyes had symptoms, 2.3% positive, 3.2% negative dysphotopsia, 1.2% glare, 1.2% halos. 6.3% of multifocal lenses had symptoms, 6.3% positive dysphotopsia, 2% glare. 11.8% EDOF eyes had symptoms, 2.3% positive, 0.8% negative dysphotopsia, 1.6% halos, 6.3% spiderweb effects, 0.8% glare. 3.8% accommodating lenses had symptoms, 0.6% positive dysphotopsia, 2.6% glare, 0.6% halos, no negative dysphotopsia. Silicone three piece eyes had no symptoms. Exchanges were 3 EDOF (spiderweb), 2 accommodating (halo) one multifocal (positive dysphotopsia) and one acrylic (negative dysphotopsia) lenses.

Conclusion
Patients need consent about optical aberrations including glare, halo, dysphotopsia, and spiderwebs. More women 8.8% than men 4.5% had symptoms. Symptoms were 7.8 % with acrylic lenses, 3.8% silicone accommodating lenses and 0% 3 piece silicone lenses. No multifocal or accommodating lenses had negative dysphotopsia. Some lenses required removal.
Long Term Clinical Outcome of in the Bag Intraocular Lens Implantation for Eyes with Posterior Capsule Rupture
Author
Masayuki Ouchi, MD, PhD

Purpose
To evaluate long-term clinical outcomes of in the bag implantation of intraocular lens (IOL) in case with posterior capsule rupture during cataract surgery.

Methods
Eleven eyes of 11cases with both posterior capsule rupture and satisfaction of certain conditions during cataract surgery were enrolled. All eyes underwent in the bag insertion of soft single-piece IOLs, and clinical outcomes were evaluated 1month, 1year, and 5years post-operatively.

Results
No cases was seen with IOL tilt, deviation nor falling into vitreous cavity. The mean corrected visual acuity was -0.04 +/- 0.20 (Log MAR) at 5 years post-operatively. The mean refractive error was -0.97+/- 0.67 diopter (D) at 5years post-operatively while -0.06 +/- 0.63 at 1year. No significant relation between refractive error at 5years post-operatively and axial length or pre-operative anterior chamber depth.

Conclusion
Soft single piece IOL implantation with selected eyes with ruptured posterior capsule can be safely performed and registered good refractive outcome until 1year post-operatively. However, it should be concerned about myopic shift in long follow up period.
Surgical Management of Uveitis-Glaucoma-Hyphema Syndrome
Authors
Abdelrahman M. Elhusseiny, MD
Richard K. Lee, MD, PhD
William E. Smiddy, MD, ABO

Purpose
To report outcomes of patients after intraocular lens (IOL) repositioning or exchange for the contemporary version of the uveitis-glaucoma-hyphema (UGH) syndrome

Methods
Design: A retrospective case-series Setting: University-based tertiary center Patients: Patients with UGH who underwent IOL repositioning or exchange by one surgeon. Intervention: IOL repositioning or exchange Main outcome measures: Best corrected visual acuity (BCVA) as a decimal fraction preoperatively and postoperatively after IOL repositioning or exchange. Clinical findings evaluated included the presence of uveitis, hyphema, elevated intraocular pressure (IOP), and other complications such as pigment dispersion or vitreous hemorrhage. The number of anti-inflammatory and glaucoma medications were assessed before and after IOL repositioning or exchange.

Results
The study included 14 pseudophakic eyes. The median time at the onset of UGH after CE/IOLimplantation was 7.5 years. IOL repositioning or exchange was perfromed at a mean duration of 8.1± 8.7 months after onset of UGH. The mean BCVA was improved from 0.45±0.26 preoperatively after onset of UGH syndrome to 0.76±0.22 (p=0.016) after IOL repositioning or exchange. Among the 14 eyes, uveitis, elevated IOP, and hyphema were present preoperatively in 13, 13, and 6 eyes, respectively. Uveitis and hyphema resolved in all cases after IOL surgery. The mean IOP was reduced from 26.4±4.5 mmHg on 1.7±1.1 drops preoperatively to 14.7±4.9mmHg on 0.8±1.08 drops postoperatively (p=0.01)

Conclusion
IOL repositioning or exchange is an effective treatment in many cases for medically-resistant UGH syndrome.
Toxic Anterior Segment Syndrome Outbreak (TASS) Associated with Automatic Washers in 3 Canadian Clinics (No Audio)
Authors
Simon P. Holland, MD, FRCS
Magdalena Wirth, MD
Mukhtar Bizrah, MBBS, FRCOphth

Purpose
Investigation of TASS clusters in 3 clinics 2018-9 to identify any common factors. TASS outbreaks are difficult to investigate due to multiple steps and products involved in re-processing of instruments, and typically small sample sizes. All clinics used the same automatic washer QuickRinse (QR).

Methods
Ten incident cases of TASS from three separate facilities were summarized using descriptive epidemiology. A chart review of 3:1 controls to cases was conducted to examine a variety of intra-operative exposures. Odds ratios for exposure variables, along with corresponding 95% confidence intervals and two-tailed Fisher Exact p-values, were calculated. Site observations of the three implicated facilities were conducted. Fluid from the final wash from the automatic washer was tested using the LAL gel-clot test (Pryosate LAL).

Results
All clinics reported at least one case in the same week with one clinic reporting all 6 cases on the same day. None of the exposures studied significantly influenced the risk of developing TASS at the 5% level of significance consistent with the small sample size. Observational epidemiology showed that endotoxins detected from an automated flushing device (QuickRinse,QR) were a probable cause at all the three clinics. Endotoxin was above recommended levels in all clinics that also made improvements to standard operating procedures for re-processing instruments

Conclusion
TASS outbreaks are often multifactorial, primarily related to issues with ophthalmic instrument re-processing. This research presents one of few case-control studies conducted during TASS outbreaks. Endotoxin detected in a widely used unregulated automated flushing device is of concern.
Clinical Assessment of Surgical Treatment of Acute Postoperative Endophthalmitis
Author
Nadezhda A. Pozdeyeva, MD

Purpose
clinical assessment of efficacy of acute postoperative endophthalmitis treatment

Methods
27 patients (27 eyes) with acute postoperative endophthalmitis were operated during the period from April 2016 till September 2019. 27 patients were enrolled in this study. 19 clinical cases were after cataract phacoemulsification, 7 – after vitreoretinal surgery, and 1 – after intravitreal injection of ranibizumab. Mean age of patients was 57.8±16.3 years. Vitreoretinal surgery with intravitreal injection of antibiotics was performed during 2-4 hours since acute postoperative endophthalmitis was diagnosed.

Results
10 cases of post-cataract endophthalmitis amounted to 0,068% of all performed lens extraction (without preventive intracameral antibiotics). Presence of culture in aqueous humor samples was proven only in 9 of 27 patients. Presence of culture in the vitreous samples was proven in 18 of 27 patients: St epidermidis - in 9, St aureus – in 3, Ent faecalis – in 2, Moraxella lacunata, Acinetobacter, Esch coli, Ent faecium – in 1 case. In 5 of 12 patients methicillin-resistant culture of Staphylococcus were revealed. No Vancomycin-resistant cultures were identified. At discharge vision was recover in 26 of 27 patients. CDVA achieved up 0,32±0,2. In 6 months CDVA was 0.38±0.26 in 21 patients.

Conclusion
These data prove prevalence of gram-positive culture among the reasons of acute postoperative endophthalmitis. Urgently performed vitreoretinal surgery with intravitreal injection of antibiotics allows to restore visual functions in cases of acute postoperative endophthalmitis.
Small Incision Cataract Surgery Intra-Operative Complications Study Analysis of 18775 Eyes
Authors
Ruchita Manaktala, DOMS, DNB
Karan Bhatia, DOMS, DNB

Purpose
To analyse the intra-operative complications of Small Incision Cataract Surgery (SICS).

Methods
18,775 eyes who underwent SICS at a tertiary level teaching eye hospital in India from January 2017 to December 2018 by consultants and trainees were retrospectively analysed for intra-operative complications.

Results
Out of the 18775 eyes, 1390 eyes (7.4%) had complications. Higher rates of complications were seen in trainee surgeons (80.7%, n=1122). Of the complications seen, Posterior capsular rent (PCR) was most common (69.4%, n=965), followed by zonular dialysis (10.5%, n=146). Iridodialysis was seen in 7.6% eyes (n=106), premature entry was seen in 6.7% eyes (n=93), descemet's membrane detachment was seen in 2.2% eyes (n=30), nucleus drop was seen in 1.8 % eyes (n=25), intra-ocular lens drop was seen in 0.9% eyes (n=12) , button hole was seen in 0.6% eyes (n=8) and expulsive haemorrhage was seen in 0.4 % eyes (n=5).

Conclusion
Intra-operative complications were observed more in the trainee surgeons. PCR was the most common complication noted.
Clinical and Economic Burden Associated with Posterior Capsule Rupture in Cataract Surgery - a Targeted Literature Review
Authors
Lawrence Woodard, MD
Hang Cheng, MSc
Divyesh Thakker, MS
Amanda Henry, MSc
Javed Shaikh, MS

Purpose
Despite advances in cataract surgery, posterior capsule rupture (PCR) remains a serious complication. PCR may require additional surgical interventions, leading to an additional burden on healthcare systems. The purpose of this study was to review published scientific evidence on clinical and economic burden associated with PCR.

Methods
A targeted literature search using Medline® (including Medline In-process), Embase® and Cochrane databases using a predefined search strategy was conducted (search period: 2000 to 22nd February 2019). Additionally, a grey literature search was also performed. Studies reporting on incidence of PCR during cataract surgery, complications of PCR, and the costs and resource use associated with PCR were included.

Results
PCR incidence varied across regions: UK (0.53-5.10%), USA (0.36-3.05%), Canada (0.45%), Europe (2.09-10.71%), Egypt (23.30%) and Asia (0.19-8.00%). PCR with vitreous loss required unplanned vitrectomies (1%-4%). Unplanned vitrectomies added significant costs to healthcare systems and were associated with risk for complications. Reportedly, ~23% of PCR cases failed to achieve post-operative visual acuity of ≤0.30 logMAR, and 31% cases suffer from visual loss. PCR cases had higher post-operative follow-up visits, longer follow-up duration, higher number of secondary surgeries required compared to uncomplicated cataract surgeries, leading to incremental cost burden on healthcare systems.

Conclusion
Cataract surgeries complicated by PCR pose a significant clinical and economic burden, with increased risk of developing complications such as Cystoid Macular Edema, Retinal Detachment, Endophthalmitis, and impaired visual outcomes leading to additional burden on the healthcare systems worldwide.
Diagnosis and Management of Persistent Non-Infectious Uveitis after Cataract Surgery.
Authors
Soifer a Matias, MD
Hazem Mousa, MD
Victor L. Perez, MD

Purpose
Cataract Surgery is a safe procedure. Yet there are patients that develop Uveitis after the process and this is a challenge for the ophthalmologist. The study purpose is to review the persistent Uveitis following Cataract Surgery that attended our clinic to assess the etiology, characteristics and management algorithm to approach this disease.

Methods
Retrospective chart review of 30 patients attended at the Foster Center for Ocular Immunology between 2017 and 2019 that presented with persistent uveitis after Cataract Surgery for longer than 1 month. Exclusion criteria were existence of a past history that could otherwise explain the incidence of the uveitis. We analyzed patient demographics, Visual Acuity, Uveitic complications, anterior chamber cells, IOP, pre- operative, intra-operative, and post-operative factors, laboratory panels and diagnostic tests to assess the etiology, along with the medical and surgical interventions performed during the follow up.

Results
Mean age: 64. Female:Male ratio: 3.3. Presentation was unilateral in 65%. 94% had Iritis, while 6% Panuveitis. Average time from Surgery to uveitis was 1.5 months. Etiologies were 2 (7%) Uveitis-Glaucoma-Hyphema, 1 (3%) retained lens fragment and 27 (90%) idiopathic cases. UBM was done in 50% of patients, and 10% had abnormal results. Main complications were glaucoma in 50% and CME in 30%. Management was topical in 96% and only 4% required systemic treatment. 10% required a surgical intervention. On follow up, none of them had worsening number of anterior chamber cells. Subanalysis of the idiopathic uveitis revealed that 82% happened in African American patients, and 73% of them were ANA+

Conclusion
The management of the persistent uveitis after surgery should include a UBM to rule out retained lens fragments and IOL disorders. With only topical treatment, the majority of patients had a good prognosis, but 10% needed a surgery. Main complications were glaucoma and CME. 90% of cases were idiopathic, mainly of african american descent and ANA+.
Incidence of Endophthalmitis in Patients Undergoing Phacoemulsfication without the Use of Intracameral Antibiotics
Authors
Rohit Om Parkash, MS
Shruti Mahajan, MS
Tushya O. Parkash, MS

Purpose
To evaluate the incidence of endophthalmitis following phacoemulsification surgery from January 2016 to August 2019

Methods
Retrospective single-center, cross-sectional study was done at Dr Om Parkash Eye Institute,India wherein 24567 consecutive phacoemulsification surgeries were observed for endophthalmitis. Strict preoperative and intra operative asepsis of surgical field and sealing of wound was done. All patients were given temporal limbal incision and patching was done for minimum 4 hours to allow epithelial healing. Special care was taken to facilitate post operative compliance of instructions by patients. No intra cameral antibiotics were used. Patients with acute post operative endophthalmitis were recognised during 6 weeks from the day of surgery.

Results
The incidence of post operative endophthalmitis was 0.0081% in 24567 patients undergoing phacoemulsification surgery between January 2016 to August 2019

Conclusion
The strict adherence to pre operative, intra operative and post operative protocols negates the use of Intracameral antibiotics.
Clinical Outcomes of Surgical Management of Positive Dysphotopsia
Authors
Nicole R. Fram, MD, ABO
Samuel Masket, MD

Purpose
Positive dysphotopsia (PD) is a debilitating reaction to uncomplicated cataract surgery causing unwanted optical images such as light arcs, streaks, glare, halo or starbursts. It is related to the internal reflection of the square edge optic and index of refraction. This study examines the clinical outcomes of surgical intervention to treat PD.

Methods
Nonrandomized retrospective review of 56 eyes of 47 patients (13 male, 33 female) mean age 66 years, having surgical management for PD between 2013 and 2019 in a private practice setting by surgeons SM and NF (Advanced Vision Care, Los Angeles, CA, USA). Thirty seven of 56 eyes (66.1% %) had isolated PD, and 19 of 56 eyes (33.9%) had a combination of ND (dark temoporal arc) and PD. Inclusion criteria: Visual acuity of 20/30 or better, no significant corneal, retinal or optic nerve pathology, no dislocated IOLs. Exclusion criteria: Corneal, macular or optic nerve disease, multifocal dysphotopsia alone (defined pattern of halos and starbursts while looking at a point source of light).

Results
Fifty six procedures were performed to treat PD with 9 failures. Of the 9 failures, 4 eyes had an additional IOL exchange with success. Five failures had no additional surgery. Of note, no patients were worsened by the surgical intervention. The material of the inciting IOLs were hydrophobic acrylic in 79%(44/56);Hydrophilic acrylic 7%(4/56),silicone in 9%(5/56) cases,and copolymer 5%(3/56). IOL materials successful in the alleviation of PD using IOL exchange were as follows: 20/33 silicone (87.8%), 15/21 copolymer (76.2%), and 2/2 PMMA (100%). Specifically, IOL exchange for acrylic to silicone or acrylic to copolymer the percentages of improvement are 87% and 88%, respectively.

Conclusion
PD treatment is challenging with little neuroadaptation. Although miotic therapy is helpful, resolution is rare. Further, there are no true square posterior edge IOLs in the US. Fortunately, changing the IOL material has been successful in alleviating symptoms of PD. Silicone appears to be the most effective IOL material to treat PD in all comers.
Objective Quantification of Optical Scatter before and after Nd:YAG Capsulotomy Using a Double Pass Technique
Authors
Mujtaba A. Qazi, MD, ABO
Jay S. Pepose, MD, PhD, ABO

Purpose
To evaluate the utility of the HD Analyzer metrics to quantify visual improvement following Nd:YAG capsulotomy.

Methods
High (HC) and low (LC) contrast best spectacle-corrected distance visual acuity (BCVA) and HD Analyzer evaluation was performed on patients with mild to moderate posterior capsular opacification (PCO). Differences between pre- and post-operative measurements were calculated, along with the correlation of HD Analyzer metrics to changes in visual acuity.

Results
Following Nd:YAG capsulotomy, there was statistically significant improvement in HC- and LC-BCVA, decrease in optical scatter, and corresponding improvement in Strehl ratio and HD Analyzer values at all contrast levels tested (p≤0.05). Pearson test showed a high correlation between the improvement in HC-BCVA (r=0.78) and LC-BCVA (r=0.70) to the improvement in Objective Scatter Index (OSI). There was a higher correlation of pre-op HC-BCVA and LC-BCVA to pre-op OSI (r2=0.61 and 0.49, respectively) than of pre-op HC-BCVA and LC-BCVA to the subjective PCO grading score (r2<0.20).

Conclusion
The HD Analyzer provides objective measurements of light scatter that can assist with PCO grading and prediction of improvement of visual quality after ND:YAG laser capsulotomy, with higher accuracy than grading based upon slit lamp observation alone.

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