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There is a high variability in the use of postoperative eye protection among ophthalmologists. Postoperative eye protection treatment modalities include an eye shield, an eye patch, an ocular bandage, and instant vision. The aim of this study was to review and compare the evidence on the various options for eye protection.A systematic literature search was conducted, and original comparative articles that reported on subjective symptoms (e.g., foreign-body sensation, photophobia, tearing, and pain) and postoperative outcomes (e.g., tear film breakup time, best-corrected visual acuity, etc.) after usage of an eye protection method were included.Overall, 598 eyes across 8 articles were included. Included studies investigated ocular bandages (n = 6), eye patches (n = 4), instant vision (n = 2), and eye shields (n = 1) postoperatively. In 5 studies, patients receiving ocular bandages self-reported symptoms, including pain (n = 3), foreign-body sensation (n = 4), photophobia (n = 3), and tearing (n = 3), at a reduced or equivalent rate compared with other treatment modalities. With the ocular bandage, 3 studies reported increased tear film breakup time, and 1 study reported improvements in corneal wound healing compared with a control group. Two studies reported reduced tear film breakup time for the eye patch relative to the ocular bandage, and another study reported reduced tear film breakup time for instant vision compared with the eye patch.Patient-reported symptoms are acutely reduced for patients receiving an ocular bandage relative to instant vision following cataract surgery. Patients prefer receiving some form of postoperative protection as opposed to instant vision.

To track operative phases of cataract surgery over a resident's training to measure action times and frequencies as a surrogate for competency and skill progression.An n=1 panel study.We collected cataract surgery video recordings performed by a single resident between 2021-2022. Only full-length videos of adequate quality without supervisor intervention were included. The start and end times of 19 distinct operative phases of cataract surgery were manually labelled by a trained annotator. Timeseries analysis was employed to measure the direction and magnitude of trends in the resident's surgical timing for each action across their first year of training.The dataset comprised 100 videos spread across the resident's 6-760 cases. The median total time was 11.6min (interquartile range: 10.1min-14.4min), with overall speed increasing at a rate of 43.4s for every 10 videos (95% CI: 35.1s-52.7s). Nine operative phases significantly decreased in time throughout training. The main incision, phacoemulsification, and hydrodissection had the greatest improvements in speed relative to their average procedural time. There were an average 26.9 distinct operative actions (excluding idle periods) in each video (range: 20 to 50).This is the first study to quantitatively track operative times and frequencies across all relevant actions in cataract surgery and derive learning curves for each. Consistent with previous works, we found that a basic level of surgical competency is achieved after performing 80 cases. In addition, results from this study indicate that the next level in skill advancement towards surgical finesse occurs after 300 cases.

Purpose To compare the efficacy and safety of early versus later ab interno gelatin microstent placement with mitomycin C. Design Canada-wide, multicenter, retrospective propensity score-matched cohort study. Participants Two hundred seventy eyes (135 early cases and 135 later cases) with no prior incisional surgery. Methods Surgeons’ first 20 patients (early cases group), from 6 glaucoma surgeons across 4 Canadian sites, were matched 1:1 to patients with the closest propensity score from the later (21+) patients (later cases group). Main Outcome Measures Primary outcome was hazard ratio (HR) of failure of the early versus later cases groups, with failure defined as IOP of less than 6 mmHg with more than 2 lines of vision loss or more than 17 mmHg with no medications (complete success) on 2 consecutive visits despite in-clinic maneuvers (including needling) more than 1 month after surgery. Secondary outcomes were HRs for failure, defined as IOP outside the range of 6 to 14 mmHg and 6 to 21 mmHg with and without allowing for medications (qualified success), interventions, complications, and reoperations. Results Hazard ratio of failure for early versus later cases groups was 1.38 (95% confidence interval [CI], 0.97–1.96) for the IOP range of 6 to 17 mmHg, 1.29 (95% CI, 0.90–1.84) for 6 to 14 mmHg, and 1.48 (95% CI, 1.03–2.13) for 6 to 21 mmHg without medication and 0.95 (95% CI, 0.55–1.64), 0.95 (95% CI, 0.61–1.48), and 0.95 (95% CI, 0.52–1.75) for the same IOP ranges allowing for medications. Needling rates were 43.0% (early cases group) and 41.5% (later cases group). Complication rates after 1 month occurred in 9.6% (early cases group) and 11.1% (later cases group; P = 0.69). Reoperation rates were 14.8% (early cases group) and 8.1% (later cases group; P = 0.08). Conclusions There is some evidence for improved success in the later cases group. Similar needling rates, similar complication rates, and a slightly higher reoperation rate were found for the early cases group. The results suggest that this procedure can be adopted by existing surgeons with current training regimens, although they may see an improvement in their success outcomes over time.

BackgroundTo assess the efficacy and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in uveitic glaucoma (UG).MethodsA retrospective interventional case series in which 33 eyes of 32 patients with UG underwent GATT with or without concomitant cataract extraction and intraocular lens implantation (CE/IOL) at three Canadian treatment centres from October 2015 to 2020. The main outcome measure was surgical success defined as an intraocular pressure (IOP) ≤18 mm Hg and at least one of the following: IOP within one mm Hg of baseline on fewer glaucoma medications as compared with baseline or a 30% IOP reduction from baseline on the same or fewer medications. Secondary outcome measures were IOP, medication usage and surgical complications.ResultsMean patient age (mean±SD) was 49±16 years (range: 18–79) and 44% were female. GATT was performed as a standalone procedure in 52% of cases and the remainder were combined with CE/IOL. Surgical success was achieved in 71.8% (SE: 8.7%) of cases. Mean preoperative IOP (±SD) was 31.4±10.8 mm Hg on a median of 4 medications. 59% of patients were on oral carbonic anhydrase inhibitors (CAIs) prior to surgery. After 1 year, average IOP was 13.8 mm Hg on a median 1 medication, with 6% of patients being on oral CAIs. No sight threatening complications occurred during surgery or follow-up.ConclusionGATT is an effective surgical strategy in the management of UG. This microinvasive conjunctival-sparing procedure should be considered early in these patients.

Microinvasive glaucoma surgery (MIGS) is a potentially safer and more efficacious method studied in patients with mild-to-moderate open-angle glaucoma requiring less invasive treatment goals; however, the literature on MIGS must be thoroughly evaluated. We conducted a review of MIGS by searching MEDLINE, EMBASE, and Cochrane CENTRAL. Primary efficacy indicators were reductions in intraocular pressure and topical medication use postoperatively. While all comparative randomized controlled trials assessing MIGS in English peer-reviewed journals were included, only observational studies with a target follow-up of at least one year and a high priority score were analyzed, resulting in a total of 3476 eyes across 20 trials. The mean age was 69.5 ± 2.9 years, 53.7% were female, and 77.4% were Caucasian. One study had last follow-up at less than one year, fifteen studies had follow-up extending 1-2 years, and four had longer than two years of follow-up. A pattern of more significant intraocular pressure and medication reduction was observed in patients who underwent MIGS (n = 2170) relative to control (n = 1306) interventions. iStent had the most literature supporting its efficacy, followed by Hydrus. The most common adverse events after MIGS implantation included stent obstruction, inflammation, and subsequent surgical intervention. Surgical complication rates and efficacy are favorable after MIGS. This review helps to consolidate the high-quality evidence that exists for various MIGS procedures and to identify gaps where further research is needed.

To evaluate the accuracy of 12 intraocular lens (IOL) power calculations: Barrett Universal II, EVO, Haigis, Hill-RBF version 2.0, Hoffer Q, Holladay 1, Holladay 2, Kane, Olsen, SRK/T, Super Formula and T2. In this retrospective consecutive case series, cataract extraction and IOL implantation cases in Toronto, Canada, were recruited between 2017 and 2019. Refractive predictions were compared to the observed 1-month postoperative spherical equivalent to determine the refractive error for each formula cohort. Subgroup analysis stratified eyes into short (≤ 22.5 mm)-, intermediate (22.5 mm-25.5 mm)- and long (≥ 25.5 mm)-axial length (AL) cohorts. The primary outcome was the percentage of cases within ± 0.50D of refractive error. Overall, 764 cataract cases were analyzed. Formulas with the highest percentage of eyes within ± 0.50D of refractive error, in decreasing order, were: Kane (77.7%), Barrett Universal II (77.4%), EVO (76.6%), T2 (76.4%), Super (75.9%), Holladay 1 (75.4%), Hill-RBF 2.0 (74.7%), SRK/T (72.6%), Hoffer Q (72.5%), Haigis (71.7%), Olsen (67.4%) and Holladay 2 (67.3%). For short-AL eyes, the Holladay 1 formula was most accurate (n = 69, 78.3% within ± 0.50D), and for long-AL eyes, the Barrett Universal II formula was most accurate (n = 116, 76.7% within ± 0.50D). Kane, Barrett, EVO, T2 and Super formulas led to a significantly lower mean absolute error compared to the open-source calculations with optimized lens constants (p-value

To evaluate differences in preoperative measurements and refractive outcomes between ultrasound and optical biometry when using the Barrett Universal II intraocular lens (IOL) power formula. In this consecutive case series, cataract extraction and IOL implantation cases from two surgical centers in Toronto, Canada, were recruited between January 2015 and July 2017. Differences between ultrasound (applanation or immersion A-scan) and optical biometry (IOLMaster 500) were compared for axial length (AL), anterior chamber depth and refractive outcomes. The primary outcome was the percentage of cases in each cohort within ± 0.50D of refractive error. In total, 527 cataract cases underwent IOLMaster testing. Of these, 329 eyes (62.4%) were also measured by applanation A-scan, and the other 198 eyes (37.6%) received immersion A-scan testing. Applanation ultrasound led to 5.8%, 16.0% and 46.4% of eyes within ± 0.25D, ± 0.50D and ± 1.00D of refractive error, respectively, whereas the IOLMaster 500 led to 48.5%, 77.1% and 94.9%, respectively (n = 293, ± 0.50D: p

The Icare HOME (TA022, Icare Oy, Vanda, Finland) is rebound tonometer recently approved by the US Food and Drug Administration in March 2017 designed for self-measurement of intraocular pressure (IOP). IOP remains a major modifiable risk factor for glaucoma progression; however, IOP measurements typically occur through single office measurements on Goldmann applanation tonometry (GAT) and do not always reveal the complete picture of patient's IOP patterns and daily fluctuations, which are important for accurate diagnosis and evaluation. Numerous studies have now compared the efficacy of the Icare HOME to that of GAT. The objective of this article is to review the existing literature surrounding the Icare HOME tonometer and its efficacy as a self-tonometer in comparison to GAT. The available literature has shown promising results in its accuracy of measuring IOP but suggests cautious usage in patients with central corneal thicknesses or IOP ranges that are outside of a certain range. This article will also provide details and example cases for when the Icare HOME may be most clinically useful.

Purpose To determine the efficacy, risk factors for failure, and adverse events of a standalone novel ab externo SIBS microshunt with mitomycin C (MMC) during 1-year follow-up. Design Retrospective, interventional case series. Subjects Glaucomatous eyes with an intraocular pressure (IOP) above target and/or progressing on maximally tolerated medical therapy. Methods Consecutive patients with open-angle glaucoma (OAG) and no previous filtering surgery received an ab externo SIBS microshunt with MMC from July 2015 to November 2017. Main outcome measures were proportion of eyes at 1-year with (1) no 2 consecutive IOP readings >17 mm Hg or clinical hypotony without (complete) or with glaucoma medications (qualified); and (2) at least a 20% reduction from decision IOP. Secondary outcomes included upper IOP thresholds of 14 mm Hg and 21 mm Hg with and without a 20% IOP reduction from baseline, median IOP, medications, risk factors for failure, interventions, complications, and reoperations. Results A total of 164 eyes in 132 patients were included. Complete success was achieved in 76.9% of eyes, qualified success in 92.5%. Complete success was 75.6% for an upper IOP cut-off of 14 mm Hg and 76.9% for 21 mm Hg, and qualified success was 91.9% and 92.5%. MMC dose of 0.2 vs 0.4-0.5 mg/mL (hazard ratio [HR] 2.51; 95% CI 1.12-5.65) and primary open-angle glaucoma vs secondary open-angle glaucoma (SOAG) (HR 2.51; 95% CI 1.01-6.23) represented the only risk factors for failure in multivariable analysis. Needling was performed in 8.5% of eyes. Two eyes received surgical revision, and 1 a reoperation. Conclusions One-year results of the ab externo SIBS microshunt demonstrated promising rates of qualified and complete success, decreased drop use, few complications, and infrequent postoperative interventions.

A variability in statistical complexity exists across the ophthalmology literature. This review investigates the frequency of statistical methods in ophthalmology articles and aims to determine dif...

Cataract is a common cause of reversible blindness. Visual acuity alone is not enough to assess appropriateness for surgery, prioritization, and outcomes. Catquest-9SF questionnaire evaluates patients' self-assessed visual function as related to daily tasks. We summarize and assess the validity of Catquest-9SF as a patient-reported outcome questionnaire to determine its suitability for clinical use. Thirteen studies with sample sizes ranging 102-10,886 (total n = 15,289) undertaken from 2009 to 2018 were included. Catquest-9SF showed unidimensionality, ordered response thresholds, and acceptable precision in all studies. Nine studies had significant mistargeting (range 0.66 to -2.04); the tasks being easy relative to the respondent ability in most studies. Two studies had misfitting items. We conclude Catquest-9SF is a valid and reliable tool to measure visual function in patients with cataract in various populations. Because results can be population specific, it is recommended that Catquest-9SF be validated in a new population before it is incorporated in routine practice.

Eliminating low-yield testing can reduce the burden on modern healthcare systems. Our purpose is to determine whether routine preoperative assessment impacts the incidence of perioperative complications in ophthalmic surgery. We conducted a comprehensive search of Ovid MEDLINE, EMBASE, and Cochrane Library databases to identify studies investigating the incidence of perioperative complications following any preoperative assessment (Registration#164008). Four randomized controlled trials (RCTs) and 5 observational studies were selected for inclusion. Risk of bias assessment revealed a lack of masking and insufficient statistical power in RCTs, and confounding in observational studies. Routine preoperative testing, including laboratory tests, electrocardiogram, and imaging studies, did not decrease the incidence of adverse events or risk of perioperative ocular and systemic complications in most studies. Two cohort studies (one retrospective, one prospective) suggested that patients with certain preexisting health conditions were at increased risk for adverse events perioperatively. Another retrospective study found a lower risk of complications in high-risk patients who underwent evaluation. While patients with comorbidities may be at increased risk of adverse events, the role of preoperative assessment is not well delineated in this population. Further study is required to determine the comparative safety, effectiveness, and implementation of alternative assessment tools.

Preoperative fasting is routinely performed to prevent anaesthesia-related pulmonary aspiration. To capture patients' experiences with preoperative fasting, a 13-item questionnaire was developed and validated using Rasch analysis and shortened to 6 items. This extension study aims to assess this questionnaire's ability to discriminate between participants with a short versus long duration of fasting and early versus late day surgery.Single-centred cross-sectional study.Subjects were recruited via consecutive sampling of cataract patients on surgery day at Kensington Eye Institute in Toronto from February to December 2019.A validated preoperative fasting questionnaire was administered. Discriminative ability was assessed by comparing responses in patients scheduled for surgery in the morning (8:00 am-12:00 pm) versus afternoon (12:00 pm-3:30 pm) and fasting for short (≤8 hours) versus long (8 hours) duration. Diagnostic ability of the 6-item questionnaire relative to the 13-item questionnaire was assessed with receiver operating characteristics curve analysis.A total of 164 patients (mean age 70.8 ± 10.0 years; 57% female) were included. Total scores of patients having surgery in the morning were greater (i.e., less fasting-related burden) than in the afternoon (p = 0.04). There was no significant difference in scores between patients fasting for a short versus long duration (p0.05). Receiver operating characteristics curve analysis showed excellent diagnostic ability of the 6-item questionnaire relative to the 13-item version (area under the curve = 0.964).The 6-item questionnaire for fasting-related burden has excellent discriminative ability between early versus late surgery patients. The time fasting while awake may be a more relevant predictor of fasting-related burden relative to the total duration of fasting.

Given the lack of policy standardization in Canada, this systematic review investigates the optimal duration of preoperative fasting in cataract surgery. A literature search was conducted on Ovid MEDLINE, with potential articles screened by 2 independent authors. The primary endpoint was the incidence of aspiration. Overall, 231 articles were screened, of which 6 were eligible. Two studies found no cases of aspiration in over 35 000 patients who underwent cataract surgery without preoperative fasting, some with intravenous sedation (50% in 1 series, less than 1% in the second). A survey of the British Ophthalmic Anaesthesia Society found that over 50% of centres did not require fasting before cataract surgery. Only 1 included report discussed a case of aspiration pneumonitis following cataract surgery with general anaesthesia and 14hours of preoperative fasting. In closing, further evidence is needed to delineate the risk of pulmonary aspiration based on fasting time in cataract surgery.

Herein, we provide guiding principles and a systematic approach to the analysis of comparative clinical data for clinicians. Although not every possible measure or statistical test is discussed, co...

To evaluate the accuracy of 12 intraocular lens (IOL) power calculations: Barrett Universal II, EVO, Haigis, Hill-RBF version 2.0, Hoffer Q, Holladay 1, Holladay 2, Kane, Olsen, SRK/T, Super Formula and T2.In this retrospective consecutive case series, cataract extraction and IOL implantation cases in Toronto, Canada, were recruited between 2017 and 2019. Refractive predictions were compared to the observed 1-month postoperative spherical equivalent to determine the refractive error for each formula cohort. Subgroup analysis stratified eyes into short (≤ 22.5 mm)-, intermediate (22.5 mm-25.5 mm)- and long (≥ 25.5 mm)-axial length (AL) cohorts. The primary outcome was the percentage of cases within ± 0.50D of refractive error.Overall, 764 cataract cases were analyzed. Formulas with the highest percentage of eyes within ± 0.50D of refractive error, in decreasing order, were: Kane (77.7%), Barrett Universal II (77.4%), EVO (76.6%), T2 (76.4%), Super (75.9%), Holladay 1 (75.4%), Hill-RBF 2.0 (74.7%), SRK/T (72.6%), Hoffer Q (72.5%), Haigis (71.7%), Olsen (67.4%) and Holladay 2 (67.3%). For short-AL eyes, the Holladay 1 formula was most accurate (n = 69, 78.3% within ± 0.50D), and for long-AL eyes, the Barrett Universal II formula was most accurate (n = 116, 76.7% within ± 0.50D). Kane, Barrett, EVO, T2 and Super formulas led to a significantly lower mean absolute error compared to the open-source calculations with optimized lens constants (p-value: 0.001-0.042).The Kane formula was the most accurate formula for the overall analysis. The Holladay 1 calculation was most accurate for short-AL cases, whereas the Barrett Universal II was superior for long-AL eyes.

In patients with both cataract and glaucoma, the ophthalmologist may choose to treat both conditions in the same operative encounter. Combined cataract extraction, IOL implantation, and Hydrus microstent insertion offers the patient visual rehabilitation, better control of glaucoma, and the benefit of not having to return to the OR for a second procedure. The Hydrus microstent (HMS) is a minimally invasive glaucoma surgery (MIGS) that bypasses the trabecular meshwork and provides a scaffold for Schlemm’s canal. By avoiding a filtering procedure, one can also avoid the known serious complications associated with blebs, but in exchange for decreased IOP lowering.

In patients with both cataract and glaucoma, the ophthalmologist may choose to treat both conditions in the same operative encounter. Combined cataract extraction, IOL implantation, and iStent insertion offers the patient visual rehabilitation, better control of glaucoma, and the benefit of not having to return to the OR for a second procedure. The iStent inject is a minimally invasive glaucoma surgery (MIGS) that bypasses the trabecular meshwork. It consists of a flange with a central lumen, a thorax that resides in the trabecular meshwork and a head that resides in Schlemm’s canal. The head contains a total of 4 outflow orifices. By avoiding a filtering procedure, one can also avoid the known serious complications associated with blebs, in exchange for decreased IOP-lowering.

In patients with both cataract and uncontrolled glaucoma, the ophthalmologist may choose to treat both conditions in the same operative encounter. Combined cataract extraction, IOL implantation, and glaucoma shunt surgery offer the patient visual rehabilitation, better control of glaucoma, and the benefit of not having to return to the OR for a second procedure. With the search for increasingly less invasive surgical options, the PreserFlo MicroShunt is a small, non-valved shunt that is thought to have has less risks of hypotony when compared to traditional glaucoma filtering procedures, all the while achieving low postoperative target pressures.

In patients with both cataract and glaucoma, the ophthalmologist may choose to treat both conditions in the same operative encounter. Combined cataract extraction, IOL implantation, and gonioscopy-assisted transluminal trabeculotomy (GATT) offers the patient visual rehabilitation, better control of glaucoma, and the benefit of not having to return to the OR for a second procedure. GATT is a minimally invasive glaucoma surgery (MIGS) that allows for the removal of a portion of trabecular meshwork, which is the site of outflow resistance in primary open-angle glaucoma. Avoiding a filtering procedure prevents the known serious complications associated with blebs. However, it is recommended to avoid GATT in patients on anticoagulation that cannot be reversed preoperatively.

The XEN gel stent is a minimally invasive glaucoma procedure that creates a filtering bleb without the need for tissue dissection. It is thought to have fewer risks of hypotony when compared to traditional glaucoma filtering procedures, all the while achieving moderately low postoperative target pressures.

In cases requiring secondary IOL implantation in eyes lacking capsular support, ACIOL, scleral-fixated PCIOL, and iris-sutured PCIOL are all viable options. An ACIOL offers the advantage of simplicity but has to be properly sized and is held in place with angle-supported haptics that can cause damage to the corneal endothelium, inflammation, or posterior synechiae formation. A scleral-fixated PCIOL and iris-sutured PCIOL have the advantage of keeping the IOL away from the corneal endothelium and avoiding a 6 mm wound, though require longer operating time, significant technical expertise, and can tilt causing iris chaffing, inflammation, hyphema, and elevated intraocular pressure. There are also instances where the sutures break requiring reoperation. In cases where a complete capsulectomy has previously been performed, an intrascleral haptic-fixated IOL is a good option. It avoids scleral sutures but is subject to tilt and decentration and can be technically challenging. It is highly recommended to use a three-piece IOL with robust haptics.

GATT is a minimally invasive glaucoma surgery (MIGS) that allows for the removal of a portion of trabecular meshwork, which is the site of outflow resistance in primary open angle glaucoma. Avoiding a filtering procedure prevents the known serious complications associated with blebs. However, it is recommended to avoid GATT in patients on anticoagulation that cannot be reversed preoperatively.

IMPORTANCE: Some ophthalmologists may be reluctant to prescribe oral carbonic anhydrase inhibitors, given the potential for life-threatening systemic adverse reactions. OBJECTIVE: To conduct a population-based analysis of the safety of oral or topical carbonic anhydrase inhibitors in clinical care. DESIGN, SETTING, AND PARTICIPANTS: This matched longitudinal cohort study took place in Ontario, Canada. Consecutive patients older than 65 years who were prescribed an oral or topical carbonic anhydrase inhibitor in Ontario, Canada, between January 1, 1995, and January 1, 2020, were identified. Patients were matched 1-to-1 based on age, sex, and diabetes status. Time zero was defined as the date of the first identified prescription for the medication, and the primary analysis focused on the first 120 days of follow-up. MAIN OUTCOMES AND MEASURES: The primary end point was a severe complicated adverse event of either Stevens-Johnson syndrome, toxic epidermal necrolysis, or aplastic anemia. RESULTS: Overall, 128 942 matched patients initiated an oral or topical carbonic anhydrase inhibitor during the 25-year study period. The mean (SD) age was 75 (6.6) years, 71 958 (55.8%) were women, and 25 058 (19.4%) had a diagnosis of diabetes. The oral and topical carbonic anhydrase inhibitor groups had similar baseline demographics. Patients prescribed an oral carbonic anhydrase inhibitor had an absolute risk of a severe complicated adverse event of 2.90 per 1000 patients, whereas patients prescribed a topical carbonic anhydrase inhibitor had an absolute risk of 2.08 per 1000 patients. This difference was equivalent to a risk ratio of 1.40, with a number needed to harm of 1 in 1220 patients (95% CI, 1.12-1.74; P = .003). This generally low risk was replicated in multivariable regression controlling for confounding factors. Additional risk factors for a severe complicated adverse event included patients with more comorbidities and those with more frequent clinic contacts. CONCLUSIONS AND RELEVANCE: The risk of a serious adverse reaction following prescription of an oral or topical carbonic anhydrase inhibitor was low and similar between agents. Given the low risk of severe adverse reactions, this population-level analysis supports reconsidering the reluctance toward prescribing an oral carbonic anhydrase inhibitor.