The Asia-Pacific Journal of Ophthalmology

  • Current Issue

    July/August 2017 - Volume 6 - Issue 4
    Special Issue on Cataract & IOLs
    pp: 307-400
    Guest Editors-in-Chief: Jorge Alió, David Chang



The Continuing Evolution of Cataract Surgery Chang, David F.
We are delighted this month to devote an entire issue of the Asia-Pacific Journal of Ophthalmology (APJO) to cataract surgery. While planning this issue, it was interesting for me to reflect on the state of cataract surgery 35 years ago when i performed my first case as a resident. My training progression took me first through intracapsular cataract extractions without an intraocular lens (iol), to manual extracapsular cataract extractions (ECCE) with a pos-terior chamber iol, and finally to phacoemulsification with a nonfoldable polymethylmethacrylate (PMMa) posterior chamber IOL. That I learned and performed all 3 procedures as a second year resident in 1982‒1983 is remarkable in hindsight. at that time, the daunting transition from manual ECCE to phaco was like moving from checkers to chess and for the rest of that decade, many questioned what was gained by doing phaco when we still had to enlarge the incision to implant a PMMa iol.
Cataract Surgery: From Today’s Standards to Future Progress Alió, Jorge L.
Cataract surgery is indeed the most frequently performed surgical procedure in the human being. Having said that, it still needs to be practiced much more widely in underdeveloped countries as cataract is still one of the main causes of blindness worldwide. With this, cataract surgery is a social and medical need, a surgical service to our communities and on a worldwide basis a hugely relevant issue as it will become a necessity in most human beings as they reach an adequate age to develop cataracts.

Review Article

Endophthalmitis Prophylaxis for Cataract Surgery Haripriya, Aravind; Baam, Zervin R.; Chang, David F.
Endophthalmitis after cataract surgery is a rare but potentially devastating complication. There is great variability in endophthalmitis prophylaxis practice patterns worldwide. Treatment varies globally and is based on the microbiological profile and availability of formulations. Periocular povidone-iodine antisepsis is universally adopted and considered the standard of care in most practices. Perioperative topical antibiotics are also very popular despite the lack of level 1 evidence confirming efficacy. Based on growing observational evidence, routine intracameral antibiotic prophylaxis is increasing, especially where approved commercial intraocular preparations are available. This review updates recent trends and evidence regarding endophthalmitis prophylaxis and the preferred choice of intracameral antibiotics.
IOL Power Calculation in Short and Long Eyes Hoffer, Kenneth J.; Savini, Giacomo
An analysis of the studies published in the past 50 years reveals that the Haigis, Hoffer Q, and Holladay 2 formulas are the best options for intraocular lens power prediction in short eyes (<22 mm). In long eyes (>26 mm), the Barrett Universal II, Haigis (with optimized

constants), Olsen, and SRK/T formulas provide the most accurate outcomes for intraocular lens power prediction.
Intraocular Lens Power Calculation in Eyes After Laser In Situ Keratomileusis or Photorefractive Keratectomy for Myopia Abulafia, Adi; Hill, Warren E.; Wang, Li; Reitblat, Olga; Koch, Douglas D.
Intraocular power calculation is challenging for patients who have previously undergone corneal refractive surgery. The sources of prediction errors for these eyes are well known; however, the numerous formulas and methods available for calculating intraocular lens power in these cases are eloquent testimony to the absence of a definitive solution. This review discusses some of the available methods for improving the accuracy for predicting the refractive outcome for these patients. It focuses mainly on the methods available on the American Society of Cataract and Refractive Surgery (ASCRS) online calculator and provides some practical guidelines for cataract surgeons who encounter these challenging cases.
Multifocal Intraocular Lenses and Extended Depth of Focus Intraocular Lenses Breyer, Detlev R.H.; Kaymak, Hakan; Ax, Timon; Kretz, Florian T.A.; Auffarth, Gerd U.; Hagen, Philipp R.
Presbyopia and cataract patients’ desire for increased spectacle independence after surgery is one of the main drivers for the development of multifocal intraocular lenses (MIOLs) and extended depth of focus (EDOF) intraocular lenses (IOLs). As education, biometry, diagnostics, surgical techniques, and MIOL/EDOF IOL designs have improved over the past decade, an increasing number of cataract surgeons have become cataract-refractive surgeons to help address this need. There is not 1 single MIOL/EDOF IOL, however, that suits all patients’ needs. The wide variety of MIOLs and EDOF IOLs, their optics, and their respective impact on our patients’ quality of vision have to be fully understood to choose the appropriate IOL for each individual; MIOL/EDOF IOL surgery has to be customized. This review article looks at the different optical aspects and clinical consequences of MIOLs/EDOF IOLs to help surgeons find an appropriate solution for each of their individual patients.
Accommodating Intraocular Lenses Pepose, Jay S.; Burke, Joshua S.; Qazi, Mujtaba A.
With an explosive increase in the world-wide prevalence of presbyopia, development of an accommodating intraocular lens with expansive accommodative amplitude remains the Holy Grail in lens based refractive surgery. A dynamic change in the dioptric power of the eye can be accomplished by various strategies alone or in combination, including changes in the position, shape, or refractive index of a single or dual optic intraocular lens (IOL). This article reviews the cumulative advances in these various lens designs, as well as clinical outcomes and complications of those that have been implanted in man. The challenges that remain in each category are also highlighted
Supplementary IOLs: Monofocal and Multifocal, Their Applications and Limitations Manzouri, Bita; Dari, Maria-Laura; Claoué, Charles
Supplemental intraocular lenses (IOLs) have been developed to replace IOLs designed for in-the-bag placement being used as “piggy-back” IOLs in the sulcus due to unacceptable complications. The new IOLs have unique platform designs to avoid these complications. As a result, a new nomenclature is needed to describe the 4 scenarios when supplemental IOL use is now indicated.
The Complexities of Negative Dysphotopsia Geneva, Ivayla I.; Henderson, Bonnie A.
The appearance of a dark shadow in the temporal periphery, otherwise known as negative dysphotopsia, continues to be a problem for some patients after routine uncomplicated cataract surgery. Etiologies include type and design of intraocular lens (IOL), anatomical features and dimensions of the eye, pupil size, angle kappa, relationship of the optic to the anterior capsule, and the position of the optic/haptic junction of the IOL. Although the primary etiology remains controversial, it is clear that the cause is multifactorial. All of the factors should be considered when attempting to prevent or treat this phenomenon.
Intraocular Lens Explantation After Cataract Surgery: Indications, Results, and Explantation Techniques Fernández-Buenaga, Roberto; Alió, Jorge L.
Intraocular lens (IOL) explantation after uneventful cataract surgery is rare but associated with a high risk of complications. In the past few years, the number of published reports about IOL explantation has grown significantly and most of them focus on explantation surgery due to spontaneous late IOL in-the-bag dislocations. This is related to the growth of the pseudophakic population, first as a result of longer lifespans, and second, because the improvements in safety and accuracy of phacoemulsification surgery have led to an increased number of phacorefractive procedures performed in younger patients. The improvement in phacoemulsification surgery goes in tandem with higher patient demands and expectations of the surgery. Therefore, incorrect lens power or patients who fail to neuroadapt to multifocal IOLs are also well-recognized indications for IOL explantation and exchange. IOL opacification, although it was an epidemic in the past especially associated with certain IOL models, is currently still occurring even with some new IOL models. The outcomes of explantation surgeries are analyzed in this review separately according to the reason for explantation. Finally, the main reported IOL explantation techniques are reviewed as well.
Intrascleral IOL Fixation Jacob, Soosan
Intrascleral sutureless intraocular lens (IOL) fixation utilizes direct haptic fixation within the sclera in eyes with deficient capsular support. This has advantages of long-term stability, good control of tilt and decentration, and lesser pseudophakodonesis. This review summarizes various techniques for intrascleral haptic fixation, results, complications, adaptations in special situations, modifications of the technique, combination surgeries, and intrascleral capsular bag fixation techniques (glued capsular hook).
Combined Cataract/DSEK/DMEK: Changing Expectations Price, Francis W. Jr; Price, Marianne O.
Endothelial keratoplasty (EK) has revolutionized corneal transplant surgery by providing rapid visual recovery and improved visual outcomes. In parts of the world with Fuchs endothelial dystrophy, many patients may present with both cataracts and corneal degeneration requiring surgery. Other forms of endothelial decompensation may also present with cataracts. The staging or combination of transplant surgery and cataract surgery depend on both the abilities of the surgeon and the surgical techniques being considered. We currently use phacoemulsification to remove cataracts and routinely perform both cataract surgery and EK with topical anesthesia. The decision to perform either combined or staged cataract and transplant surgery depends upon the examination of the eye including assessment of the anterior chamber depth and the status of the anterior surface of the cornea, which affects the ability to reliably assess keratometry. Additional considerations include the type of lens implant to use, the desired refractive outcome, and the patient’s preference about whether to undergo 1 or 2 surgical procedures per eye.
Femtosecond Laser-Assisted Cataract Surgery, Technology, Outcome, Future Directions and Modern Applications Hooshmand, Joobin; Vote, Brendan J.
Since its introduction in 2009 femtosecond laser-assisted cataract surgery (FLACS) has promised to revolutionise cataract surgery. Despite its promise, the assessment of FLACS’s perceived benefits has proven to be far more complicated than initially might have been thought. Most studies to date have not provided validation of FLACS technology as a clinically significant advancement on our current techniques. We review FLACS technology and outcomes including detailed analysis of safety, efficacy, cost effectiveness and future prospects using data from the literature and our own published clinical experience.

Original Study - Clinical

Evaluation of Corneal Endothelial Cell Loss After Uncomplicated Phacoemulsification Cataract Surgery With Intracameral Phenylephrine Teoh, Li Sar; Foo, Siu Wan; Mansurali, Vanessa Naseem; Ang, Ee Ling, Md Noh, Umi Kalthum; Bastion, Mae-Lynn Catherine
Purpose: to study the effects of intracameral phenylephrine 1.5% on corneal endothelial cell loss and morphological changes in patients who had uneventful phacoemulsification surgery.

Design: a double-blind randomized controlled trial.Methods: this study comprised 295 patients who were randomized into the intracameral (icM) mydriatic group or topical mydriatic group. central corneal endothelial cell density (Ecd), coefficient of variation (cV), and percentage of hexagonal cells were measured preoperatively and postoperatively at 1 week, 6 weeks, and 3 months with specular mi-croscope.

Results: there was no significant difference in endothelial cell density and endothelial cell loss between the topical and icM mydriatic groups. at 3 months, the mean endothelial cell density in the icM group was 2129.76 ± 423.53 cells/mm2 and 2100.54 ± 393.00 cells/mm2 in the topi-cal group (P = 0.539). the endothelial cell loss was 18.60 ± 12.79% in the icM group and 19.44 ± 11.24% in the topical group (P = 0.550). no significant difference was seen in the percentage of hexagonal cells and coefficient of variation of patients between the 2 groups.

Conclusions: intracameral phenylephrine was not associated with increased risk of postoperative endothelial cell loss or morphological changes. it can be safely injected into the anterior chamber for pupil dila-tation before phacoemulsification cataract surgery.
Prevalence and Factors Associated With Second Eye Cataract Surgery and the Trend in the Time Interval Between the Two Eye Surgeries Based on the Malaysian National Eye Database Ho, Shu Fen; Adnan, Tassha Hilda bin; Goh, Pik Pin
Purpose: To study the prevalence of second eye cataract surgery (SECS), trend in time interval between subsequent surgeries over the years, and factors associated with sEcs utilization among patients who underwent cataract surgeries in the Ministry of Health (MOH), Malaysia.

Design: Secondary cross-sectional analysis of the Malaysian National Eye Database (NED) data.

Methods: The Malaysian cataract surgery registry collected data on patients who had cataract surgery from 2002–2004 and 2007–2012. Data collected included demography, operative events, time interval between 2 surgeries, and postoperative visual outcomes. descriptive analysis was performed.

Results: Total surgeries increased from 11,954 in 2002 to 30,265 in 2012 with a proportionate increase in SECS (30.7% in 2002 to 34.3% in 2012). Poor vision (<6/12) was reduced from 81.1% to 14.2% after surgery. With improved data capturing, missing data reduced from 29.22% to 1.05%. The time interval between surgeries was 10.58 months in 2002 and 14.49 months in 2012. Malays (40.2%) and those aged 61–70 years (38.1%) had the highest number of SECs. Those aged 40–50 years (10.96 months) and with poorer vision (9.97 months) had the shortest time interval between the 2 surgeries. The commonest surgical method was phacoemulsification (72.3%). Negeri Sembilan State had the highest SECS rate (35.91%) and Melaka had the shortest interval between surgeries (10.15 months).

Conclusions: Despite an increase in the number of SECS, the time interval is still long. Poor presenting second eye vision and disparity among different states warrants the health authority’s attention and intervention.
APJO Express

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