Annals of the American Thoracic Society

Topic: To evaluate the complication rates of different intraocular lens (IOL) placement methods in adults with inadequate capsular bag support. Clinical Relevance: The surgical correction of inadequate capsular bag support for the IOL harbors several challenges, and there is a wide range of surgical procedures. Methods: For the purpose of this meta-analysis, surgical methods were grouped based on the location of IOL placement: (1) anterior chamber (AC) placement; (2) iris fixation, which included prepupillary or retropupillary placement of an iris-claw IOL, or iris suturing of an IOL; and (3) scleral fixation, which included scleral sutured and sutureless techniques. Only studies comparing the results of 2 or more different placement methods were analyzed. The study protocol has been registered in the PROSPERO database (CRD42023458557). Results: 15 studies were included in the final analysis, which reported results of 1247 eyes. The overall complication rate was nonsignificantly lower in iris fixation (4.4%; 95% CI, 3.6%-5.4%, P = .150) than in AC placement (7.4%; 95% CI, 6.4%-7.9%) and scleral fixation (7.4%; 95% CI, 6.5%-8.4%). Transient corneal edema was the most common complication in AC placement (29.9%; 95% CI, 2.4%-57.5%, P < .001), compared with scleral fixation (11.9%; 95% CI, 2.6%-21.2%) and iris fixation (4.1%; 95% CI, 0.8%-7.3%). Vitreous hemorrhages were more frequently reported after scleral fixation (8.5%; 95% CI, 6.3%-11.2%, P = .006) than in AC placement (5.4%; 95% CI, 3.4%-8.5%) and iris fixation (1.4%; 95% CI, 0.4%-4.2%), and so was IOL decentration/dislocation (8.9%; 95% CI, 6.7%-11.8%, P = .047 compared with 1.1%; 95% CI, 0.4%-3.4% and 4.0%; 95% CI, 2.2%-7.3%, respectively). Conclusions: The risks associated with particular techniques should be taken into account in preoperative counseling and planning postoperative treatment.

Purpose: To investigate the anterior segment morphology in cataracts with Retinitis Pigmentosa (RP). Setting: XXXX (anonymized for review) University Hospital. Design: A retrospective matched case-control study. Methods: The analysis included 28 eyes of 28 patients with cataracts and RP and 28 eyes of 28 patients with cataracts but without RP, matched for age and sex. Lens thickness, anterior lens curvature (Front R), posterior lens curvature, anterior chamber depth (ACD), anterior chamber width, central corneal thickness (CCT), white-to-white distance (WTW), corneal curvature, and axial length (AL) were compared between the groups. Data were obtained from preoperative evaluations conducted before cataract surgery. The same set of comparisons was also conducted for 18 eyes of 18 patients with cataracts and RP and 18 eyes of 18 patients with cataracts but without RP, matched for age, sex, and AL. Cases including missing data, categorized as Emery–Little classification grade 4 or above, or those with a history of acute angle closure were excluded. Results: In the age- and sex-matched analysis, cataracts with RP showed significantly a thicker lens, steeper Front R, shallower ACD, thinner CCT, and shorter AL. In the analysis matched by age, sex, and AL, cataracts with RP had a thicker lens, steeper Front R, and larger WTW. Conclusions: Cataracts with RP demonstrated centripetal swelling of the lens, centrifugal corneal thinning, and AL shortening. A decrease in tension between the lens and eyeball wall due to zonular weakness in the RP may lead to swelling of the lens and horizontal flattening of the eyeball.

Purpose: To evaluate the risk of zonular dialysis (ZD) in fellow eye phacoemulsification cataract surgery and to identify risk factors, including prior first eye ZD. Setting: 8 United Kingdom National Health Service clinical centers. Design: Retrospective database study. Methods: Overall risk of ZD in the fellow eye was calculated and the odds ratio (OR) for the various risk factors was reported, including first eye ZD. The main outcome measures were the risk and the predictors of intraoperative ZD in the fellow eye. Results: There was a total of 66 288 patients. At the time of the first surgery, the mean age of patients was 75.3 ± 10.2 years and 39.2% were male. Intraoperative ZD occurred during the first eye surgery in 333 patients (0.5%) and the fellow eye in 349 patients (0.5%). The risk of fellow eye developing ZD in patients with first eye ZD was higher than in patients without first eye ZD: 23 of 333 patients (6.9%) vs 326 of 65 955 patients (0.5%) (unadjusted OR 14.9, P < .001). In the adjusted logistic regression model, first eye ZD was the most significant risk factor (OR 13.3, 95% confidence interval [CI] 8.2-21.7). Other significant covariates of ZD in the fellow eye were pseudoexfoliation (OR 6, 95% CI 3.8-9.7), previous pars plana vitrectomy (OR 4.5, 95% CI 1.1-18.5), and poor pupillary dilation (OR 2.2, 95% CI 1.4-3.3). Conclusions: The most important risk factor for the development of ZD in the fellow eye during cataract surgery was the occurrence of ZD in the first eye. These findings have implications for patient counseling and surgery allocation.

Purpose: To compare the efficiencies of the Active Sentry handpiece at low intraocular pressure (IOP) (20 mm Hg) with the Ozil handpiece at high IOP (50 mm Hg). Setting: Private practice (Medford, Oregon). Design: Single-site, prospective, double-arm, randomized, contralateral eye study. Methods: The first operated eye was randomized to receive phacoemulsification with either the Active Sentry handpiece at 20 mm Hg (Active Sentry group) or the Ozil handpiece at 50 mm Hg (Ozil group). The second operated eye was assigned to the other group. Outcome measures included phacoemulsification time, total aspiration time, aspiration time during phacoemulsification, fluid use, cumulative dissipated energy, total torsional time, total longitudinal time, and central corneal thickness. Results: 36 participants (72 eyes) completed the study. Mean total aspiration time was 90.1 ± 16.4 seconds in the Active Sentry group and 85.1 ± 17.0 seconds in the Ozil group (P > .05). Mean aspiration time during phacoemulsification was 40.9 ± 8.5 seconds in the Active Sentry group and 40.4 ± 8.8 seconds in the Ozil group (P > .05). Mean total phacoemulsification time was 29.5 ± 7.3 seconds in the Active Sentry group and 31.0 ± 7.4 seconds in the Ozil group (P > .05). Mean total fluid volume was 32.8 ± 4.6 mL in the Active Sentry group and 33.8 ± 6.0 mL in the Ozil group (P > .05). Conclusions: The results of this study suggest that the efficiencies of the Active Sentry handpiece at low IOP settings and the Ozil handpiece at high IOP are similar.

Purpose: To compare the prediction errors (PEs) of several thick intraocular lens (IOL) formulas with a thin lens approach using variations of the same paraxial vergence calculation formula. Setting: Department of Ophthalmology, Randers Regional Hospital, Denmark. Design: Prospective, noninterventional study. Methods: Optical low coherence reflectometry biometry was prospectively and consecutively performed in 132 eyes with subsequent phacoemulsification and insertion of the same aspheric IOL model. Clinical refraction was performed 2 months postoperatively. Retrospectively, the same paraxial vergence formula was used and only the methods were varied for calculating the postoperative IOL position, thickness, and curvatures to construct 4 formulas: Næser I formula based on thick lens calculation using the manufacturer's cutting card information, Næser II formula based on thick lens calculation using calculated IOL data from open sources, Næser III formula based on thick lens calculation and a fixed IOL thickness of 0.62 mm, and Næser IV formula based on thin lens calculation with fixed IOL position 0.31 mm anterior to the postoperative capsule. Each formula was optimized separately, hereby assuring a mean error of zero. The PE was defined as the difference between the measured and predicted spherical equivalent refraction. Results: Mean absolute error amounted to 0.30 ± 0.26 diopters for all 4 formulas with no statistically significant difference. PE averaged zero for short, normal, and long eyes. Conclusions: The additional optical information provided by thick IOL calculations seems insignificant compared with other sources of error, related to the accuracy of IOL manufacturing, crystalline lens refractive index, and postoperative refraction.

Purpose: To improve the accuracy of intraocular lens (IOL) power calculation formulas by modifying the effective lens position (ELP) equations for patients with Marfan syndrome (MFS) and ectopia lentis (EL) undergoing in-the-bag IOL implantation. Setting: Eye and ENT Hospital of Fudan University, Shanghai, China. Design: Retrospective cohort study. Methods: The formula-specific ELP was obtained from the SRK/T, T2, Holladay 1, and HofferQ formulas. The back-calculated ELP was obtained based on the vergence formula using preoperative biometry, postoperative refraction, and IOL power. The generalized linear models (GLMs) or gradient boosting machines were used to predict ELP or ELP error. Results: 255 patients (255 eyes) were assigned randomly into a training set and a validation set (7:3 ratio). Linear correlation identified axial length (AL), corneal height, and white-to-white distance as predictors of ELP and ELP error for patients with shorter AL (AL ≤24 mm). For those with longer AL (AL >24 mm), AL and the central corneal radius were identified as the primary predictors. Incorporating these predictors into the modified ELP formula significantly improved the accuracy in the validation set, including SRK/T, T2, Haigis, Holladay 1, and HofferQ formulas. The improvement was more pronounced in patients with shorter AL. In addition, the GLM-modified formulas outperformed both the Barrett Universal II and Kane formulas. The accuracy across different ocular dimensions was comparable among the modified formulas, based on which an online calculator was developed. Conclusions: Using the more accurately predicted ELP can significantly improve the accuracy of existing formulas in patients with MFS.

PURPOSE: To investigate the pharmacological accommodative changes of the anterior segment and its impact on the circumferential anterior chamber angle (ACA) after implantable collamer lens (ICL) implantation using swept-source optical coherence tomography (SS-OCT). SETTING: Eye and ENT Hospital, Fudan University, Shanghai, CHINA. DESIGN: Prospective randomized contralateral eye study. METHODS: Eight men and 24 women (mean age, 28.2 ± 5.8 years; range, 19–42 years); 64 eyes were included at 3 months after ICL implantation. One eye per patient was randomly assigned to undergo tropicamide instillation (mydriasis group), and the contralateral eye underwent pilocarpine instillation (miosis group). SS-OCT examinations were performed before and after instillation to measure angle parameters. Trabecular-iris angle 500 (TIA500), angle opening distance 500 (AOD500), trabecular-iris space area (TISA500), angle opening distance circumference area 500 (AODA500), trabecular-iris circumference volume 500 (TICV500), and central vault (ICL to crystalline lens [ICL-L]) were evaluated. RESULTS: Relative to baseline levels, TIA500, AOD500, and TISA500 values all increased significantly in both groups (all P < 0.01). AODA500 and TICV500 values increased by 19.7% and 12.1%, respectively, in the mydriasis group (all P < 0.001), and these values similarly increased by 23.4% and 27.7%, respectively, in the miosis group (all P < 0.001). After instillation, the ICL-L decrease in the miosis group was significantly larger than that in the mydriasis group (P = 0.004). Mean AOD500, TISA500, and TICV500 in the miosis group were significantly larger than those in the mydriasis group (all P ≤ 0.036), especially at 8 and 10 o’clock (all P ≤ 0.014). Correlation analyses indicated that the increase in anterior chamber angle parameters was positively correlated with the change in ICL-L for both groups. CONCLUSIONS: Pilocarpine induced a more significant increase in ACA than tropicamide, because of different mechanism of anterior segment changes. We recommend circumferential meridian scan to assess angle status.

Purpose: To investigate the accuracy of three distinct postoperative toric intraocular lens (TIOL) rotational stability measurement methods. Setting: Department of Ophthalmology and Optometry, Medical University of Vienna, Austria. Design: Single-center, prospective, interventional clinical trial. Methods: 128 eyes of 81 patients with age-related cataract received a hydrophobic acrylic TIOL Clareon CNW0T3-9. To evaluate rotational stability, three distinct assessment methods were used: (Rotix) comparing the TIOL axis at the end of surgery (EoS) to 1 week (1w) and 6 months (6m) postoperatively using reference vessels at the sclera, (Slit-lamp) comparing the intended axis (IA) with the axis at 1w and 6m using slit-lamp photography using the horizontal axis as a reference and (Casia) comparing the IA with the axis at 1w and 6m using the axis determination tool of a swept-source anterior segment optical coherence tomographer (Casia 2). Results: Mean absolute rotation from EoS/IA to 6m differed significantly among Rotix (1.33± 1.99° [0.01;19.80]), Casia (2.88± 2.64° [0.00; 19.00]), and Slit-lamp (4.38± 3.38° [0.02;19.38]), as indicated by Friedman's test (X2=71.852, p<0.001). Bland-Altman coefficients (CoR) of repeatability indicated the closest agreement of results between Casia and Rotix, with a CoR of ±3.95°, followed by Slit-lamp and Casia (±6.82°), and lastly, between the Slit-lamp and Rotix (±7.19°). Conclusion: When assessing true TIOL rotational stability, it is imperative to use fixed anatomical landmarks as reference and establish a baseline at the end of surgery. When assessing TIOL rotation along the horizontal axis, considering cyclorotation of the eye is crucial and must not be underestimated.

Purpose: To evaluate visual and refractive outcomes in eyes with a history of radial keratotomy (RK) implanted with the second-generation light-adjustable lens (LAL). Setting: Private practice, multiple locations. Design: Retrospective, consecutive case series. Methods: Eyes with a history of RK that underwent cataract surgery with implantation of the LAL and were targeted for emmetropia prior to lock-in were included. Data on the type and number of prior refractive surgeries were collected, in addition to the timing and number of postoperative adjustments. The primary outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and the percentage (%) of eyes within ±1.00 diopter (D), ±0.50 D, and ±0.25 D and of their refractive target. Results: 94 eyes from 77 patients were included. 28% (n = 26) were a history of 4-cut RK, 12% (n = 11) were 6-cut RK, 55% (n = 52) were 8-cut RK, and 5% (n = 5) were 16-cut RK. Overall, 82% (n = 77) of all eyes achieved 20/25 UDVA or better, 74% (n = 70) of all eyes achieved UDVA of 20/20 or better, and 94% (n = 88) were correctable to 20/20 or better postoperatively. For refractive outcomes, 98% (n = 92) of eyes were within ±1.00 D of target, 88% (n = 83) were within ±0.50 D, and 69% (n = 65) were within ±0.25 D of preoperative refractive target. Conclusions: Patients with a history of RK achieved favorable visual and refractive outcomes with the LAL. Postoperative light adjustments should be delayed to allow for refractive stabilization. The LAL is a promising option for post-RK patients who are motivated to obtain favorable uncorrected acuity after cataract surgery.

Purpose: To assess a new objective deep learning model cataract grading method based on swept-source optical coherence tomography (SS-OCT) scans provided by the Anterion. Setting: Single-center study at the Rothschild Foundation, Paris, France. Design: Prospective cross-sectional study. Methods: All patients consulting for cataract evaluation and consenting to study participation were included. History of previous ocular surgery, cornea or retina disorders, and ocular dryness were exclusion criteria. Our CATALYZE pipeline was applied to Anterion image providing layerwise cataract metrics and an overall clinical significance index (CSI) of cataract. Ocular scatter index (OSI) was also measured with a double-pass aberrometer (OQAS) and compared with our CSI. Results: 548 eyes were included, 331 in the development set (48 with cataract and 283 controls) and 217 in the validation set (85 with cataract and 132 controls) of 315 patients aged 19 to 85 years (mean ± SD: 50 ± 21 years). The CSI correlated with the OSI (r 2 = 0.87, P < .01). CSI area under the receiver operating characteristic curve (AUROC) was comparable with OSI AUROC (0.985 vs 0.981 respectively, P > .05) with 95% sensitivity and 95% specificity. Conclusions: The deep learning pipeline CATALYZE based on Anterion SS-OCT may be a reliable and comprehensive objective cataract grading method.

Purpose: To investigate the light transmission (LT) of UV-A and green light through infected corneas saturated with riboflavin or rose bengal in an ex vivo porcine model for infectious keratitis. Setting: University of Zurich and EMPA. Design: Laboratory study. Methods: Ex vivo porcine eyes (n=162) were divided into three groups: control eyes, eyes infected with Staphylococcus aureus, and eyes infected with Pseudomonas aeruginosa. Corneas remained either uninfected, or were infected with S. aureus, and P. aeruginosa, respectively, and were either left untreated, or were instilled with 0.1% riboflavin or 0.1% rose bengal. Corneal buttons were prepared, and corneal LT was measured at 365 nm and 522 nm using a spectrophotometer. LTs were calculated and compared. Transmission electron microscopy (TEM) was used to visualize structural damage and bacteria within infected corneas. Results: Riboflavin-saturated corneas infected by S. aureus or P. aeruginosa (LT = 0.77% [0.41-1.87] and 0.81% [0.23, 1.46]) exhibited 3.18-fold and 3.02-fold lower LTs than uninfected corneas (LT = 2.45% [2.15, 5.89]) (both p-values < 0.001). No LT difference was found between rose bengal-saturated corneas infected by S. aureus or P. aeruginosa and uninfected corneas (all LTs = 0.01% [0.01-0.01]; both p-values = 0.08). TEM showed bacteria on corneal stroma borders and occasionally inside the stroma. Conclusion: Our results indicate that the amount of light arriving at the corneal endothelium is substantially reduced in infected corneas. The total fluence of clinical PACK-CXL protocols can be safely increased substantially while maintaining a low risk of corneal endothelial damage.

Purpose: To assess 5-year trends in the rate of immediate sequential bilateral cataract surgery (ISBCS) and surgeon characteristics associated with performing ISBCS. Setting: 100% Medicare Fee-For-Service beneficiaries from 2018 to 2022. Design: Cross-sectional study. Methods: ISBCS cases were identified among patients aged 65 years or older undergoing bilaterally performed cataract surgery (BPCS). Cochrane Armitage trend test was used to assess patient and surgeon characteristics over time. Multivariate logistic regression was used to evaluate surgeon characteristics associated with performing ISBCS. Results: Among 1 190 169 BPCS, 3954 (0.33%) were ISBCS. Quarterly ISBCS rate increased from 2.12 to 5.5 per 1000 BPCS (P < .001). Among 10 290 surgeons, 1119 (10.87%) performed ISBCS on some patients. Proportion of surgeons performing ISBCS per 1000 cataract surgeons increased from 15.63 during the first quarter of 2018 to 26.55 during the last quarter of 2022 (P < .001). Among the ISBCS surgeons, the proportion of ISBCS cases per 1000 BPCS doubled from 17.20 in 2018 to 35.50 in 2022 (P < .001). On multivariate analysis, surgeons in the highest surgical volume quartile (odds ratio [OR], 1.21; 95% CI, 1.01-1.45; Ref: lowest quartile), recent graduates (0 to 10 years: OR, 2.43; 95% CI, 1.87-3.15; Ref: ≥ 31 years), and surgeons in the West (OR, 2.408; 95% CI, 2.052-2.826; Ref: South) had higher odds of performing ISBCS. Conclusions: There was an increased rate of ISBCS possibly suggesting greater interest among patients and surgeons. Although the overall ISBCS rate remained low, the number of surgeons performing ISBCS increased. Higher volume surgeons, recent graduates, and those practicing in the West were more likely to perform ISBCS.

Purpose: To introduce a newly developed digital platform and compare its reliability and agreement with paper-based questionnaires for assessing quality of vision before and after cataract surgery. Setting: University-affiliated ophthalmology department and private clinic. Design: Prospective, randomized trial with parallel design of 1:1 allocation ratio without masking. Methods: Between 11/2021 and 6/2023, patients from a preoperative cataract clinic, aged ≥21 years, with cataracts in both eyes and internet access were randomly assigned by “ALEA” software to complete Catquest-9SF and Quality-of-Vision (QoV) questionnaires before surgery and after second eye surgery via paper or a newly developed digital European Registry of Quality Outcomes in Cataract and Refractive Surgery (EUREQUO) platform. Statistical analyses evaluated agreement between methods, and validation was by Rasch analysis. Results: Half (183/364, 50.3%) of the enrolled patients were allocated to digital questionnaires. After exclusion due to technical issues, missing questions, and withdrawal, 307/364 patients remained, of whom 159 (51.8%) filled in digital questionnaires. Half of all patients (n=154) underwent sequential surgeries on both eyes after a minimum one-month interval. Seventy-two (72/154, 46.8%) completed postoperative questionnaires. Comparative analysis found no significant differences between paper and digital methods. Catquest-9SF and QoV questionnaires demonstrated good precision and reliability (Rasch analysis). Postoperative vision improved at an average of 2.82 logits. Conclusion: The newly developed digital EUREQUO platform for patient assessment of quality of vision before and after cataract surgery with the Catquest-9SF and QoV questionnaires, offers a reliable alternative to traditional paper-based questionnaires, enhancing convenience for patients and providers.