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Indian Journal of Ophthalmology Apr 2021This study compares the vital parameters and pain experienced during phacoemulsification under peribulbar and topical anesthesia to determine the incidence of OCR. (Randomized Controlled Trial)
Randomized Controlled Trial
PURPOSE
This study compares the vital parameters and pain experienced during phacoemulsification under peribulbar and topical anesthesia to determine the incidence of OCR.
METHODS
One hundred six patients are enrolled for phacoemulsification in a prospective and randomized study. Fifty-two patients undergo surgery in a peribulbar block (Group PB) and 54 in topical anesthesia (Group TA). Mean arterial pressure (MAP) and pulse rate are recorded during a preoperative check-up and at four other steps of surgery. Pain experienced during surgery and on a postoperative day, 5, is graded with a verbal analogue scale. OCR defined as a decrease in pulse rate by greater than 20% is calculated. Chi-square test, Fisher's exact test, paired t test and the comparison of means give the statistical analysis. A value of P < 0.05 was taken as significant.
RESULTS
MAP readings at baseline versus MAP at other steps of surgery show a trend towards rising with a P value of < 0.05 in both groups. Pulse rate measured at all steps of surgery versus baseline pulse rate in Group TA shows P < 0.05. OCR is present in nine patients in peribulbar block verses eleven patients in topical anesthesia with P value of 0.687. The pain scores using verbal analogue scale were higher in Group TA compared with Group PB with a P < 0.0001.
CONCLUSION
Oculocardiac reflex can occur during phacoemulsification under both peribulbar block and topical anesthesia, and the difference is not significant.
Topics: Administration, Topical; Anesthesia, Local; Anesthetics, Local; Humans; Lidocaine; Pain Measurement; Pain, Postoperative; Phacoemulsification; Prospective Studies; Reflex, Oculocardiac
PubMed: 33727460
DOI: 10.4103/ijo.IJO_1019_20 -
The Cochrane Database of Systematic... Mar 2021Primary angle-closure glaucoma (PACG) is characterized by a rise in intraocular pressure (IOP) secondary to aqueous outflow obstruction, with relative pupillary block...
BACKGROUND
Primary angle-closure glaucoma (PACG) is characterized by a rise in intraocular pressure (IOP) secondary to aqueous outflow obstruction, with relative pupillary block being the most common underlying mechanism. There is increasing evidence that lens extraction may relieve pupillary block and thereby improve IOP control. As such, comparing the effectiveness of lens extraction against other commonly used treatment modalities can help inform the decision-making process.
OBJECTIVES
To assess the effectiveness of lens extraction compared with other interventions in the treatment of chronic PACG in people without previous acute angle-closure attacks.
SEARCH METHODS
We searched CENTRAL, MEDLINE, Embase, one other database, and two trials registers (December 2019). We also screened the reference lists of included studies and the Science Citation Index database. We had no date or language restrictions.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) comparing lens extraction with other treatment modalities for chronic PACG.
DATA COLLECTION AND ANALYSIS
We followed standard Cochrane methodology.
MAIN RESULTS
We identified eight RCTs with 914 eyes. We obtained data for participants meeting our inclusion criteria for these studies (PACG only, no previous acute angle-closure attacks), resulting in 513 eyes included in this review. The participants were recruited from a diverse range of countries. We were unable to conduct meta-analyses due to different follow-up periods and insufficient data. One study compared phacoemulsification with laser peripheral iridotomy (LPI) as standard care. Participants in the phacoemulsification group were less likely to experience progression of visual field loss (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.13 to 0.91; 216 eyes; moderate certainty evidence), and required fewer IOP-lowering medications (mean difference [MD] -0.70, 95% CI -0.89 to -0.51; 263 eyes; moderate certainty evidence) compared with standard care at 12 months. Moderate certainty evidence also suggested that phacoemulsification improved gonioscopic findings at 12 months or later (MD -84.93, 95% CI -131.25 to -38.61; 106 eyes). There was little to no difference in health-related quality of life measures (MD 0.04, 95% CI -0.16 to 0.24; 254 eyes; moderate certainty evidence), and visual acuity (VA) (MD 2.03 ETDRS letter, 95% CI -0.77 to 4.84; 242 eyes) at 12 months, and no observable difference in mean IOP (MD -0.03mmHg, 95% CI -2.34 to 2.32; 257 eyes; moderate certainty evidence) compared to standard care. Irreversible loss of vision was observed in one participant in the phacoemulsification group, and three participants in standard care at 36 months (moderate-certainty evidence). One study (91 eyes) compared phacoemulsification with phaco-viscogonioplasty (phaco-VGP). Low-certainty evidence suggested that fewer IOP-lowering medications were needed at 12 months with phacoemulsification (MD -0.30, 95% CI -0.55 to -0.05). Low-certainty evidence also suggested that phacoemulsification may have improved gonioscopic findings at 12 months or later compared to phaco-VGP (angle grading MD -0.60, 95% CI -0.91 to -0.29; TISA500 MD -0.03, 95% CI -0.06 to -0.01; TISA750 MD -0.03, 95% CI -0.06 to -0.01; 91 eyes). Phacoemulsification may result in little to no difference in best corrected VA at 12 months (MD -0.01 log MAR units, 95% CI -0.10 to 0.08; low certainty evidence), and the evidence is very uncertain about its effect on IOP at 12 months (MD 0.50 mmHg, 95% CI -2.64 to 3.64; very low certainty evidence). Postoperative fibrin reaction was observed in two participants in the phacoemulsification group and four in the phaco-VGP group. Three participants in the phaco-VGP group experienced hyphema. No data were available for progression of visual field loss and quality of life measurements at 12 months. Two studies compared phacoemulsification with phaco-goniosynechialysis (phaco-GSL). Low-certainty evidence suggested that there may be little to no difference in mean IOP at 12 months (MD -0.12 mmHg, 95% CI -4.72 to 4.48; 1 study, 32 eyes) between the interventions. Phacoemulsification did not reduce the number of IOP-lowering medications compared to phaco-GSL at 12 months (MD -0.38, 95% CI -1.23 to 0.47; 1 study, 32 eyes; moderate certainty evidence). Three eyes in the phaco-GSL group developed hyphemas. No data were available at 12 months for progression of visual field loss, gonioscopic findings, visual acuity, and quality of life measures. Three studies compared phacoemulsification with combined phaco-trabeculectomy, but the data were only available for one study (63 eyes). In this study, low-certainty evidence suggested that there was little to no difference between groups in mean change in IOP from baseline (MD -0.60 mmHg, 95% CI -1.99 to 0.79), number of IOP-lowering medications at 12 months (MD 0.00, 95% CI -0.42 to 0.42), and VA measured by the Snellen chart (MD -0.03, 95% CI -0.18 to 0.12). Participants in the phacoemulsification group had fewer complications (risk ratio [RR] 0.59, 95% CI 0.34 to 1.04), and the phaco-trabeculectomy group required more IOP-lowering procedures (RR 5.81, 95% CI 1.41 to 23.88), but the evidence was very uncertain. No data were available for other outcomes.
AUTHORS' CONCLUSIONS
Moderate certainty evidence showed that lens extraction has an advantage over LPI in treating chronic PACG with clear crystalline lenses over three years of follow-up; ultimately, the decision for intervention should be part of a shared decision-making process between the clinician and the patient. For people with chronic PACG and visually significant cataracts, low certainty evidence suggested that combining phacoemulsification with either viscogonioplasty or goniosynechialysis does not confer any additional benefit over phacoemulsification alone. There was insufficient evidence to draw any meaningful conclusions regarding phacoemulsification versus trabeculectomy. Low certainty evidence suggested that combining phacoemulsification with trabeculectomy does not confer any additional benefit over phacoemulsification alone, and may cause more complications instead. These conclusions only apply to short- to medium-term outcomes; studies with longer follow-up periods can help assess whether these effects persist in the long term.
Topics: Chronic Disease; Disease Progression; Glaucoma, Angle-Closure; Humans; Lens, Crystalline; Phacoemulsification; Quality of Life; Randomized Controlled Trials as Topic; Visual Acuity
PubMed: 33759192
DOI: 10.1002/14651858.CD005555.pub3 -
JAMA Ophthalmology Jul 2023The efficacy and safety of femtosecond laser-assisted cataract surgery is well documented. An important requirement for decision makers is the evaluation of the...
IMPORTANCE
The efficacy and safety of femtosecond laser-assisted cataract surgery is well documented. An important requirement for decision makers is the evaluation of the cost-effectiveness of femtosecond laser-assisted cataract surgery (FLACS) over a sufficiently long horizon. Evaluating the cost-effectiveness of this treatment was a preplanned secondary objective of the Economic Evaluation of Femtosecond Laser Assisted Cataract Surgery (FEMCAT) trial.
OBJECTIVE
To estimate the cost utility of FLACS compared with phacoemulsification cataract surgery (PCS) on a 12-month time horizon.
DESIGN, SETTING, AND PARTICIPANTS
This multicenter randomized clinical trial compared FLACS with PCS in parallel groups. All FLACS procedures were performed using the CATALYS precision system. Participants were recruited and treated in ambulatory surgery settings in 5 university-hospital centers in France. All consecutive patients eligible for a unilateral or bilateral cataract surgery 22 years or older with written informed consent were included. Data were collected from October 2013 to October 2018, and data were analyzed from January 2020 to June 2022.
INTERVENTIONS
FLACS or PCS.
MAIN OUTCOMES AND MEASURES
Utility was measured through the Health Utility Index questionnaire. Costs of cataract surgery were estimated by microcosting. All inpatient and outpatient costs were collected from the French National Health Data System.
RESULTS
Of 870 randomized patients, 543 (62.4%) were female, and the mean (SD) age at surgery was 72.3 (8.6) years. A total of 440 patients were randomized to receive FLACS and 430 to receive PCS; the rate of bilateral surgery was 63.3% (551 of 870). The mean (SD) costs of cataract surgery were €1124.0 (€162.2; US $1235) for FLACS and €565.5 (€61.4; US $621) for PCS. The total mean (SD) cost of care at 12 months was €7085 (€6700; US $7787) in participants treated with FLACS and €6502 (€7323; US $7146) in participants treated with PCS. FLACS yielded a mean (SD) of 0.788 (0.009) quality-adjusted life-years (QALYs), and PCS yielded 0.792 (0.009) QALYs. The difference in mean costs was €545.9 (95% CI, -434.1 to 1525.8; US $600), and the difference in QALYs was -0.004 (95% CI, -0.028 to 0.021). The incremental cost-effectiveness ratio (ICER) was -€136 476 (US $150 000) per QALY. The cost-effectiveness probability of FLACS compared with PCS was 15.7% for a cost-effectiveness threshold of €30 000 (US $32 973) per QALY. At this threshold, the expected value of perfect information was €246 139 079 (US $270 530 231).
CONCLUSIONS AND RELEVANCE
The ICER of FLACS compared with PCS was not within the $50 000 to $100 000 per QALY range frequently cited as cost-effective. Additional research and development on FLACS is needed to improve its effectiveness and lower its price.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT01982006.
Topics: Humans; Female; Aged; Male; Visual Acuity; Laser Therapy; Cataract Extraction; Phacoemulsification; Cataract; Lasers
PubMed: 37200037
DOI: 10.1001/jamaophthalmol.2023.1716 -
Clinical Interventions in Aging 2016The aim of this study was to compare the results of phacoemulsification through a small pupil using minimal iris manipulation versus phacoemulsification through a... (Comparative Study)
Comparative Study Randomized Controlled Trial
PURPOSE
The aim of this study was to compare the results of phacoemulsification through a small pupil using minimal iris manipulation versus phacoemulsification through a well-dilated pupil.
METHODS
This prospective randomized control (comparative) study comprised 78 patients (group I) with a maximally dilated pupil size of ≤4.00 mm and 45 patients (group II) with dilated pupil size of ≥7.00 mm. In group I patients, only viscodilation and minimal push-and-pull iris stretching with two collar-button iris-retractor hooks were utilized without iris manipulation. Phacoemulsification was performed by two senior surgeons and the technique used consisted of either stop and chop or quick chop, infusion/aspiration of lens cortex, capsular bag refill with ocular viscoelastic devices, and implantation of an acrylic foldable intraocular lens. Patients were examined on the first day and 1 month postoperatively.
RESULTS
Forty-six eyes of group I patients had pseudoexfoliation syndrome, eleven eyes had previous glaucoma surgery, 14 eyes had angle-closure or open-angle glaucoma, and seven eyes had posterior synechiae with iritis. In group I patients, the mean pupil size measured under an operating microscope was 3.2 mm preoperatively, 4.3 mm after viscoelastic and mechanical pupil dilation, and 4.1 mm at the end of a surgical procedure. Rupture of the zonular fibers occurred in six patients of group I and the intraocular lens was implanted in the sulcus. Small iris-sphincter rupture and small hemorrhages occurred in four eyes during pupillary manipulation, but they were not evident at the end of the surgery. In group II patients, no intraoperative complications occurred. Signs of significant corneal edema and iritis were observed more frequently in group I eyes (26 eyes and 20 eyes, respectively) on the first postoperative day in comparison with group II eyes (ten eyes and six eyes, respectively). Intraocular pressure was <20 mmHg in all eyes of both groups. One month postoperatively, the pupil was round and reactive to light, the anterior chamber was quiet, and the cornea was clear in all eyes. The best-corrected visual acuity on Snellen chart was 20/40 (Monoyer's scale) or better in both groups.
CONCLUSION
Phacoemulsification through a small pupil using minimal iris manipulation can be safe and exhibits the same results as those obtained with phacoemulsification through normal pupils.
Topics: Aged; Aged, 80 and over; Cataract; Exfoliation Syndrome; Female; Glaucoma, Open-Angle; Greece; Humans; Intraocular Pressure; Intraoperative Complications; Iris; Iritis; Lens Implantation, Intraocular; Male; Middle Aged; Phacoemulsification; Prospective Studies; Pupil; Visual Acuity
PubMed: 27274213
DOI: 10.2147/CIA.S97254 -
Indian Journal of Ophthalmology Jun 2021We herein describe a novel device to contain droplets and aerosols during phacoemulsification. We modified the silicon phaco test chamber into an aerosol containment...
We herein describe a novel device to contain droplets and aerosols during phacoemulsification. We modified the silicon phaco test chamber into an aerosol containment chamber (ACC) by shortening the chamber and making a pear-shaped opening at one aspect of its tip. The ACC was fitted over phaco tip such that 4-5 mm of phaco tip and sleeve was exposed. When the phaco tip and irrigation port are inside the anterior chamber during phacoemulsification, the portion of the modified chamber remains around the clear corneal tunnel in an enclosing manner that contains aerosols and droplets.
Topics: Aerosols; Anterior Chamber; Humans; Phacoemulsification
PubMed: 34011751
DOI: 10.4103/ijo.IJO_3478_20 -
Open Veterinary Journal Aug 2023A cataract is one of the underlying causes of blindness in animals. Phacoemulsification is the standard procedure in cataract surgery for humans and animals. This...
BACKGROUND
A cataract is one of the underlying causes of blindness in animals. Phacoemulsification is the standard procedure in cataract surgery for humans and animals. This procedure has been used to restore vision in cataracts in a variety of animals. However, this technique is difficult in very small animals, such as rodents, due to their small eyes.
CASE DESCRIPTION
A 4-year-old male domestic chinchilla was presented with cloudiness in the lenses for 1 month. The ophthalmic examination revealed cataracts (oculus uterque: both eyes). Positive dazzle reflex oculus sinister; left eye (OS) and negative reflex oculus dexter; right eye (OD) were noted. The electroretinography was low amplitude OS whereas a flat waveform presented OD. In this case, cataract surgery was performed using phacoemulsification without intraocular lens implantation OS. Postoperative, the chinchilla was alert and could jump on and jump off the ledge in a house. When the veterinarian approached closely to OS, the chinchilla displayed an erect body posture and open eyes, whereas the chinchilla was ignored when the veterinarian doing the same OD. The chinchilla was alert and had improved vision observe by this chinchilla can jump on and jump off the ledge in his house throughout the follow-up period 18 months later.
CONCLUSION
In this chinchilla, phacoemulsification was successfully performed and resulted in better overall vision. The chinchilla was alert and could jump on and jump off the ledge in a house after cataract surgery throughout the follow-up period of 18 months.
Topics: Animals; Humans; Male; Phacoemulsification; Chinchilla; Cataract; Postoperative Period
PubMed: 37701661
DOI: 10.5455/OVJ.2023.v13.i8.10 -
Eye (London, England) Dec 2020To evaluate the changes in the corneal endothelial cell parameters and macular thickness after intraocular application of epinephrine [Formula: see text] and... (Randomized Controlled Trial)
Randomized Controlled Trial
Comparison of the effects of 1/10,000 and 1/100,000 concentrations of intracameral epinephrine on corneal endothelium and macular thickness after uncomplicated phacoemulsification.
PURPOSE
To evaluate the changes in the corneal endothelial cell parameters and macular thickness after intraocular application of epinephrine [Formula: see text] and epinephrine[Formula: see text].
METHODS
In this study, 210 eyes from 210 patients with age-related cataracts who underwent uncomplicated surgery were included. For all patients, specular microscopy of the corneal endothelium and macular OCT were performed before surgery and 3 months after the surgery. Patients were divided randomly into three groups: without drug (control group), epinephrine [Formula: see text], and epinephrine[Formula: see text]. Three months after the surgery, specular microscopy of the cornea and macular OCT measurements were performed. Measurements were compared between the three groups. Postoperative measurements were also compared with those measurements obtained before surgery.
RESULTS
All the three groups showed a statistically significant decrease in the endothelial cell density after surgery; the reduction in endothelial cell density in the epinephrine [Formula: see text] group was significantly more than those of the other two groups (P value < 0.001). Hexagonality of endothelial cells was significantly reduced in the three groups after the surgery, the epinephrine [Formula: see text] group had more reduction compared with both other groups (P values < 0.001). All the three groups showed a statistically significant increase in the macular thickness after the surgery (P values < 0.001). The mean increase in the macular thickness in the epinephrine [Formula: see text] group was significantly more than those of the other two groups (P values < 0.05).
CONCLUSION
Toxicity of the drug to many endothelial cell parameters and macula was reduced with decreasing concentration of epinephrine to [Formula: see text].
Topics: Cataract Extraction; Cell Count; Endothelial Cells; Endothelium, Corneal; Epinephrine; Humans; Phacoemulsification
PubMed: 32127653
DOI: 10.1038/s41433-020-0812-5 -
Indian Journal of Ophthalmology Nov 2022Manual small-incision cataract surgery (MSICS) is a cost-effective alternative to phacoemulsification and extracapsular cataract extraction (ECCE) for cataract surgery....
Manual small-incision cataract surgery (MSICS) is a cost-effective alternative to phacoemulsification and extracapsular cataract extraction (ECCE) for cataract surgery. The surgical technique in MSICS is heterogeneous, and the maximum variation exists in incision and nucleus delivery techniques. Many studies on various incisions are available, and most of them are dedicated to surgically induced astigmatism (SIA), utility, and visual outcomes. The nucleus delivery techniques have less-extensive literature available. They can be divided into "pulling" techniques like phacosandwich technique, fish hook technique, and vectis delivery and "pushing" techniques like viscoexpression or hydroexpression with irrigating vectis/Blumenthal's MiniNuc technique. Postoperative surgical-induced astigmatism is comparable in all techniques. The authors describe a pushing technique which does not raise the pressure of the anterior chamber and can be utilized with variable-sized and irregularly shaped nuclear fragments. It has universal application, especially when the size of the incision is getting smaller in MSICS and phacofragmentation is being used as an adjunct to reduce the incision size. It can be used in situations like posterior polar cataracts, where pressure variations in the anterior chamber can be dangerous.
Topics: Humans; Astigmatism; Cataract Extraction; Lens Implantation, Intraocular; Phacoemulsification; Cataract
PubMed: 36308159
DOI: 10.4103/ijo.IJO_1606_22 -
Indian Journal of Ophthalmology Nov 2022Cataract extraction is one of the most common surgical procedures performed worldwide. Manual small-incision cataract surgery (MSICS) is a popular technique of cataract... (Review)
Review
Cataract extraction is one of the most common surgical procedures performed worldwide. Manual small-incision cataract surgery (MSICS) is a popular technique of cataract extraction. Full economic evaluation of different techniques is of value to policy makers. This was a systematic review of published literature to present a brief overview of evidence available in respect of economic evaluation measures like cost effectiveness, cost utility, and cost parameters in cataract patients regarding MSICS. The data on these was sparse and heterogeneous. Direct costs of MSICS were lower than phacoemulsification (PE): $25.55 (PE) to $17.03 (MSICS) in India, $15 (MSICS) to $70 (PE) in Nepal, and $62.25 (MSICS) to $104.15 (PE) in Thailand. The cost utility analysis for MSICS demonstrated savings of $79.57 (INR6175) per gain in LogMAR BCVA, $8.91 (INR691) per QALY gained and $1.42 (INR110) per VF 14 score increment in India. Incremental cost-effectiveness ratio (ICER) $368.20 (13,215.50 Baht) for MSICS was better than $489.30 (17,561.70 Baht) for PE in Thailand. ICER for femto laser-assisted cataract surgery (FLACS) compared to was €10,703 in femtosecond laser-assisted versus phacoemulsification cataract surgery (FEMCAT) study. The corrected ICER for PE against MSICS is €146.50. The limited data available demonstrates that MSICS is the most cost-effective technique among FLACS, PE, and MSICS. MSICS scores over other existing alternatives of cataract extraction from cost-effectiveness and cost-minimization approaches. Further research is required in this area.
Topics: Humans; Cataract Extraction; Phacoemulsification; Cataract; Lens Implantation, Intraocular; Ophthalmology
PubMed: 36308093
DOI: 10.4103/ijo.IJO_1266_22 -
Middle East African Journal of... 2014Since the introduction of sutureless clear corneal cataract incisions, the procedure has gained increasing popularity worldwide because it offers several advantages over... (Review)
Review
Since the introduction of sutureless clear corneal cataract incisions, the procedure has gained increasing popularity worldwide because it offers several advantages over the traditional sutured scleral tunnels and limbal incisions. Some of these benefits include lack of conjunctival trauma, less discomfort and bleeding, absence of suture-induced astigmatism, and faster visual rehabilitation. However, an increasing incidence of postoperative endophthalmitis after clear corneal cataract surgery has been reported. Different authors have shown a significant increase up to 15-fold in the incidence of endophthalmitis following clear corneal incision compared to scleral tunnels. The aim of this report is to review the advantages and disadvantages of clear corneal incisions in cataract surgery, emphasizing on wound construction recommendations based on published literature.
Topics: Astigmatism; Cornea; Corneal Endothelial Cell Loss; Humans; Lens Implantation, Intraocular; Microsurgery; Phacoemulsification; Vision Disorders; Wound Healing
PubMed: 24669142
DOI: 10.4103/0974-9233.124084