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Objectives: To report the outcomes of novel modified transepithelial phototherapeutic keratectomy (PTK) in treating band keratopathy (BK). Methods: A retrospective analysis was performed on patients who underwent PTK for BK at the Sussex Eye Laser Clinic, Nuffield Health, Brighton. Patients with BK obscuring the visual axis, affecting visual acuity, or causing discomfort were considered for PTK. All the patients underwent preoperative evaluation, including preoperative corneal topography and optical coherence tomography. Modified transepithelial PTK was performed without using EDTA for chelation or alcohol for epithelium debridement. Patients were followed up for one week and then every two weeks after that until two months. Preoperative and postoperative best corrected visual acuities (BCVA) were compared using a paired t -test. Results: We studied 15 eyes of nine patients undergoing novel PTK for BK. The mean age was 80 ± 5.73 years. The mean pre-treatment visual acuity was 0.68 ± 0.17 logMAR (range: 0.6 logMAR to 1 logMAR) and improved to 0.22 ± 0.09 logMAR ( p < 0.05), ranging from 0.18 to 0.48 logMAR at two months following PTK. None of the patients complained of ocular discomfort following the procedure. A repeat procedure was not required for any of these patients. Conclusions: Modified transepithelial PTK is an effective procedure for improving visual outcomes in patients with band keratopathy and should be considered for the treatment of band keratopathy.

Objectives: To analyse development of individual nontechnical skills (NTS) domains after undertaking a previously developed simulation-based training model and analyse the relationship between technical skills (TS) and NTS in ophthalmic surgery., Methods: The simulation-based training model involved a cataract surgery case complicated by intraoperative posterior capsule rupture. Cataract surgeons underwent the simulation twice, separated by a training intervention. Two blinded independent experts assessed participants' NTS using HUFOES, NOn-Technical Skills for Surgeons (NOTSS), and the OSATS global rating scale for TS. Paired t-tests assessed differences in individual NTS domains, with p < 0.05 indicating significance. The Pearson Product Moment Correlation Coefficient was used to assess the correlation between scores from each scoring system., Results: All NTS domains within HUFOES and NOTSS demonstrated statistically significant improvements secondary to the training intervention. Positive correlations were demonstrated between HUFOES and OSATS scores in the pre- and post-training simulations, r = 0.870 (p < 0.001) and r = 0.861 (p < 0.001), respectively. Positive correlations were also demonstrated between NOTSS and OSATS scores in pre- and post-training simulations, r = 0.849 (p < 0.001) and r = 0.757 (p = 0.001), respectively. Positive correlations were demonstrated between HUFOES and NOTSS scores; r = 0.979 (p < 0.001) (n = 17) and r = 0.959 (p < 0.001) for pre- and post-training simulations, respectively., Conclusion: All NTS domains contained within HUFOES and NOTSS demonstrated significant increases following the completion of the simulation-based training model. Positive correlations exist between an ophthalmic surgeon's TS and NTS. This is the first study to report these findings within ophthalmic surgery., (© 2024. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

The type and nature of refractive surgery procedures has greatly increased over the past few decades, allowing for almost all patient populations to be treated to extremely high satisfaction. Conventional photorefractive keratectomy involves the removal of the corneal epithelium through mechanical debridement or dilute alcohol instillation. An improvement to this method utilises laser epithelial removal in a single-step process termed transepithelial photorefractive keratectomy (transPRK). We explore the history of transPRK from its early adoption as a two-step process, identify different transPRK platforms from major manufacturers, and describe the role of transPRK in the refractive surgery armamentarium. This is a narrative review of the literature. This review finds that TransPRK is a safe and effective procedure that works across a variety of patient populations. Though often not seen as a primary treatment option when compared to other corneal-based procedures that offer a faster and more comfortable recovery, there are many scenarios in which these procedures are not possible. These include, but are not limited to, cases of corneal instability, previous refractive surgery, or transplant where higher-order aberrations can impair vision in a manner not amenable to spectacle or contact lens correction. We discuss refinements to the procedure that would help improve outcomes, including optimising patient discomfort after surgery as well as reducing corneal haze and refractive regression.

Purpose: To evaluate and compare the visual outcomes of an enhanced monofocal intraocular lens (IOL) with two different monofocal IOLs., Setting: Eye Clinic, Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy., Design: Prospective, single-center, single-masked, randomized controlled clinical study., Methods: The study included patients undergoing phacoemulsification and IOL implantation. Patients were consecutively randomized by block randomization and assigned in a 1:1:1 allocation ratio to three study arms to bilaterally receive Tecnis Eyhance™ (model ICB00) or Tecnis ® monofocal 1-piece (model PCB00) or Clareon ® monofocal (model CNA0T0), respectively. Monocular and binocular (both corrected and uncorrected) visual acuities for far, intermediate and near were registered and compared among groups at 3 months. To track changes in patient quality of life, the Catquest-9SF questionnaire was administered to each patient before and after cataract extraction., Results: Ninety patients (30 for each group) were enrolled. At 3 months follow-up, statistically significant differences for intermediate visual acuities were found between the three groups. Nonstatistically significant differences were observed for distance visual acuities and the changes in Catquest-9SF scores., Conclusion: Tecnis Eyhance™ provided better results in intermediate visual outcomes without adverse effects on patients' quality of life., (© 2024. The Author(s).)

Purpose: To propose an algorithm to facilitate lens-based surgery in keratoconus., Methods: A literature review was performed to prepare a software algorithm based on cone location, stability, best spectacle-corrected distance visual acuity (BSCVA) level and whether there is a clear or cataractous lens. The software usability was assessed through a 10-question questionnaire and two hypothetical keratoconus case histories (moderately simple and moderately complex) given to 15 trainees. The usability questionnaires were graded on a Likert scale (1 = strongly disagree to 5 = strongly agree) and two case histories (1 = very difficult to 7 = very easy)., Results: The algorithm can be found at https://www.sussexeyelaserclinic.co.uk/keratoconus/. Thirteen trainees completed the questionnaire. 91.9% would frequently use it; for 100%, it was easy to use independently without technical support; for 63.7%, it was strongly integrated; for 100%, it was consistent; 100% thought that most people would learn to use it quickly, 91.9% found the system not cumbersome to use, felt very confident to use it and need not learn a lot to use it. The first case was found easy by 63.7% and the second by 45%., Conclusion: We present an algorithm as a guide for lens-based surgery in stable and progressing keratoconus, which is classified based on cone location. This algorithm will help trainee and "non-specialist" ophthalmic surgeons understand the pre-operative planning for the surgery and referral to the "specialist" corneal surgeon, considering factors such as progression, BSCVA, keratometry, topography and apex location of the cone in keratoconus patients.

Purpose: To compare 5-year outcomes of toric intraocular lens (tIOL) or peripheral corneal relaxing incision (PCRI) for correction of keratometric astigmatism (K A ) between 0.75 and 2.5 diopters (D)., Methods: Setting: University Hospital. Design: Randomized clinical trial. Eighty eyes (80 participants) received either tIOL or PCRI. Patients were assessed preoperatively, 1-month, 1, and 5 years. Primary outcomes were uncorrected (UDVA) and best-corrected distance logMAR visual acuity (CDVA). Secondary outcomes were a manifest refractive sphere, refractive astigmatism (Ra), spherical equivalent (SEQ), K A & mean keratometry (K M ), and Quality-of-Life Impact of Refractive Correction (QIRC) scores., Results: There was no difference between the two groups in UDVA, CDVA, refractive sphere, K M , R A , and SEQ. K A reduced after 1 month in the PCRI group and remained stable until 5 years. From 1 to 5 years, the number of eyes with distance emmetropia (within ±0.13D) changed from 59% (20/34 eyes) to 32% (6/19 eyes) for tIOLs and from 43% (15/36 eyes) to 20% (4/21 eyes) for PCRIs with 32% (6/19 eyes) and 20% (4/21 eyes) showing >0.5D change in SEQ at 5-years respectively. Compared to 1-year, Ra significantly increased at 5 years in both groups with no difference between the groups. Mean overall QIRC scores were not different between the groups (tIOL: 49.88 ± 7.47; PCRI: 52.09 ± 7.02; p  = .18)., Conclusions: Although there was no difference between the overall visual and vision-related quality of life outcomes between tIOLs and PCRIs, an increase in refractive astigmatism and reduction in distance emmetropia with time was noted in both groups.

Despite the refinement of modern cataract surgery, postoperative inflammation still constitutes a substantial amount of visual morbidity worldwide. A surrogate for intraocular inflammation and blood-aqueous barrier breakdown can be objectively quantified by Laser flare photometry (LFP). This review outlines the utility of LFP in assessing the assessment of post-cataract surgery inflammation. It highlights the impact of preoperative pathological states such as uveitis and diabetes, intraoperative techniques, including efficient phacoemulsification and direct comparisons between postoperative anti-inflammatory regimes. There is a large interobserver variation in the subjective flare measurement after cataract surgery and the continued use of LFP amongst other objective, noninvasive measurements of intraocular inflammation, particularly in the further development of cataract surgery, is recommended., Competing Interests: The authors declare that there is no conflict of interest., (© The Author(s), 2023.)

Purpose: To screen patients with a monofocal intraocular lens (IOL) for incidence of unaided 20/40 and 0.3 LogMAR for distance and near (pseudoaccommodation) and to find factors for pseudoaccommodation., Settings: University Hospitals Sussex NHS Foundation Trust, Brighton, United Kingdom., Design: Prospective study., Methods: This was a single-eye study ( ClinicalTrials.gov : NCT04011696). At 3 to 9 months, refraction, uncorrected and corrected distance and uncorrected near visual acuity (logMAR), spherical equivalent (SEQ), mesopic pupil size (PS), total eye spherical (Z 40 ), vertical coma (Z 3-1 ) aberrations, reading speed and smallest print size were assessed. Refractive astigmatism (RA) was classified as against-the-rule, with-the-rule, oblique and no astigmatism. Data on preoperative axial length (AL) and anterior chamber depth (ACD) were collected., Results: 29 patients (9.6%, 95% CI, 6.5-13.5) had pseudoaccommodation. In cases vs controls, median SEQ, PS, total Z 40 , Z 3-1 , reading speed, smallest print size, preoperative ACD, preoperative AL were: -0.39 vs 0.0 diopters; 3.62 vs 4.10 mm; 0.01 vs 0.02 μm; 0.018 vs 0.022 μm; 106 vs 133 words per minute; 0.30 vs 0.50 logMAR; 2.94 vs 3.13 mm, 23.4 vs 23.7 mm, respectively. RA was not different between the groups. Univariate analysis revealed preoperative ACD (odds ratio [OR], 0.38, 95% CI, 0.16-0.94, P = .04), SEQ (OR, 0.61, 95% CI, 0.42-0.88, P = .01), total Z 40 (OR, 0.0003, 95% CI, 0.00-0.39, P = .03) and PS (OR, 0.39, 95% CI, 0.22-0.69, P < .041) to be significant. Whereas multivariable logistic regression identified: preoperative AL (OR, 0.62, 95% CI, 0.42-0.91, P = .02), SEQ (OR, 0.49, 95% CI, 0.31-0.78, P = .01), Z 40 (OR, 0.00, 95% CI, 0.0-0.01, P = .01) and PS (OR, 0.41, 95% CI, 0.23-0.75, P = .01) to be significant., Conclusions: A combination of low myopic SEQ, lower Z 40 , shorter preoperative AL, and smaller PS increases the chances of pseudoaccommodation., (Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To establish consensus among experts in lens and refractive surgery to guide general ophthalmologists on issues related to presbyopia-correcting intraocular lenses (IOLs)., Design: A modified Delphi method to reach a consensus among experts., Methods: A steering committee formulated 105 relevant items grouped into four sections (preoperative considerations, IOL selection, intraoperative considerations, and postoperative considerations). The consensus was defined as ≥ 70% of experts agreeing with the evaluation of a statement., Results: Ten experts participated and completed all rounds of questionnaires (100% response rate). Of 68 items considered in the preoperative considerations, consensus was achieved in 48 (70.6%). There was a lack of consensus over IOL selection, the experts only agreed on the importance of the patient's habits for the optical IOL design selection. Of the 14 considerations related to intraoperative issues, the experts reached a consensus on 10 (71.4%). The postoperative considerations section reached the highest consensus in 10 items of 13 (76.9%)., Conclusions: Key recommendations for a diffractive multifocal IOL were a potential postoperative visual acuity > 0.5, a keratometry between 40-45 diopters, a pupil >2.8 mm under photopic conditions and <6.0 mm under scotopic conditions, a root mean square of higher order corneal aberrations <0.5 µm for 6-mm pupil size, while monofocal or non-diffractive IOLs should be considered for patients with coexisting eye disorders. A lack of agreement was found in the issues related to the IOL selection., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: To present the results of a study investigating the 3-year effectiveness and safety of the Clareon single-piece intraocular lens (IOL)., Setting: 19 multinational sites., Design: Prospective multicenter single-arm study., Methods: Patients were bilaterally implanted with Clareon IOLs. Assessments included uncorrected distance visual acuity, corrected distance visual acuity (CDVA), manifest refraction, tilt, decentration, applanation tonometry, and fundus examination, including glistenings and posterior capsule opacification (PCO) evaluation. The primary outcomes for effectiveness and safety were evaluated at 1 year and compared with ISO historical safety and performance endpoint (SPE) rates. Patients were followed for up to 3 years after implantation., Results: 424 eyes of 215 patients were implanted (n = 215 first eye, n = 209 second eye), and 183 patients completed the trial at 3 years (with 364 binocular and 1 monocular patient). At 1 year, the cumulative and persistent adverse event rates were below SPE targets, and 99.5% of eyes achieved a monocular CDVA of ≤0.3 logMAR (vs the SPE target of 92.5%). At 3 years, the mean monocular CDVA was -0.032, with 93.4% (341/365) of eyes achieving a CDVA of 0.1 logMAR or better, 100% of eyes presented with grade 0 glistenings ≤25 MV/mm 2 , and 92.9% of eyes (394/424) had either no PCO or clinically nonsignificant PCO., Conclusions: This study supports the long-term safety and effectiveness of the Clareon IOL. The visual outcomes were excellent and stable over the 3-year study period, PCO rates were very low, and 100% of IOLs had grade 0 glistenings., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of ASCRS and ESCRS.)

Objectives: To analyze the outcomes and complications of Descemet's membrane endothelial keratoplasty (DMEK) performed without prophylactic peripheral iridotomy (PI). Methods : Design: Retrospective study., Setting: Institutional, tertiary care eye hospital., Study Population: All patients who underwent DMEK or DMEK combined with phacoemulsification (DMEK triple) for Fuchs endothelial dystrophy, using a standardized protocol between August 2016 and July 2021, were included. Previous glaucoma surgery, laser PI, aphakia, or complicated pseudophakia were excluded., Main Outcome Measures: Primary outcomes: Incidence of pupillary block (PB)., Secondary Outcomes: Graft detachment (GD), rebubbling rates, uncorrected (UCDVA) and best corrected logMAR distance visual acuity (BCDVA), and endothelial cell loss (ECL) at six months. Data were analyzed using the chi-square test and stepwise backward regression analysis. Results : 104 eyes of 72 patients were included. Four eyes (3.8%) developed PB; in two of these cases, standard protocol was not followed. Overall minor GD occurred in 43.2% (n = 45); significant GD was present only in 7 eyes (6.6%). Overall slit lamp rebubbling rate was 30% (n = 35), though only four patients were rebubbled in theatre (3.8%). PB, GD, and rebubbling rates did not vary with the surgeon, surgery, or tamponade (air or SF6 gas). UCDVA, BCDVA, and ECL at 6 months were 0.29 ± 0.31, 0.20 ± 0.28, and 40.46 ± 20.36%, respectively. Conclusions : Compared to previously reported outcomes of DMEK with PI, our results of PI less DMEK using a standardized protocol have a similar incidence of pupillary block, graft detachment, and rebubbling, with comparable visual acuity and endothelial cell loss.

This review aimed to compare the outcomes of Descemet's membrane endothelial keratoplasty (DMEK) in combination with (category 1), before (category 2), or after cataract surgery (category 3) in patients with Fuchs' endothelial dystrophy (FED). Primary outcome was gain in best-corrected log of minimum angle of resolution (logMAR) visual acuity (BCVA). Secondary outcomes were graft detachment, rebubbling rates, rejection, failure, and endothelial cell loss (ECL). In category 1, 2, and 3, 12 studies (N = 1932) were included (five in category 1 [n = 696], one in category 2 [n = 286], and two in category 3 [n = 950], and the remaining four compared between two of the three categories). At 6 months, the gain in BCVA was 0.34 ± 0.04, 0.25 ± 0.03, and 0.38 ± 0.03 logMAR in category 1, 2, and 3, respectively. The difference was significant between categories 1 and 2 (Chi 2 = 11.47, P < 0.01) and categories 2 and 3 (Chi 2 = 35.53, P < 0.01). At 12 months, the gain in BCVA was 0.52 ± 0.05 and 0.38 ± 0.06 logMAR in categories 1 & 3 (Chi 2 = 14.04, P < 0.01). The rebubbling rates were 15%, 4%, and 10% (P < 0.01) and the graft detachment rates were 31%, 8%, and 13% (P < 0.01) in categories 1, 2, and 3, respectively. However, graft rejection, survival rates, and ECL at 12 months were not different between categories 1 and 3. There is low certainty evidence that gain in BCVA in category 1 was comparable to category 3 at 6 months; however, it was significantly better with category 3 at 12 months. Although rebubbling and graft detachment rates were highest in category 1, there was no significant difference in graft rejection, survival rates, and ECL. Further high-quality studies are likely to change the effect estimate and have an impact on the confidence of the estimate., Competing Interests: None

Purpose: To assess the proportion of maculopathy detectable only on optical coherence tomography (OCT) versus slit lamp indirect ophthalmoscopy (SLIO) during cataract assessment., Methods: Population: Consecutive patients attending cataract assessments., Data Collection: All patients underwent OCT and SLIO. SLIO findings were recorded before reviewing OCT. Scans were examined to compare with recorded SLIO findings., Primary Outcome: analyse the proportion of eyes with maculopathy missed by SLIO., Secondary Outcome: to assess the proportion of patients with maculopathy on OCT, the incidence of maculopathy in the fellow eye on OCT and proportion with cataracts too dense to allow SLIO or OCT., Results: Six hundred twenty-six patients were enroled. Eighty (12.8%) had maculopathy detectable only on OCT which included: 26 (4.2%) epiretinal membrane (ERM), 25 (4%) dry age-related macular degeneration (AMD), 19 (3%) vitreomacular traction (VMT), 5 (0.8%) lamellar macular hole (LMH), 2 (0.3%) cystoid macular oedema (CMO) and 1 (0.2%) wet AMD. 166 (26.5%) had maculopathy on OCT, of which only 48 (7.7%) had known history of maculopathy. In fellow eyes, 29 (4.6%) had significant findings and 29 (4.6%) were unable to have SLIO or OCT due to dense cataract., Conclusions: A quarter of the patients had occult maculopathy. One-tenth of the occult maculopathy were missed without OCT, with ERM, dry AMD, VMT, LMH, CMO and wet AMD being the primary missed diagnosis. Less than 5% had occult maculopathy in fellow eye, and <5% had dense cataracts where neither SLIO nor OCT was not possible., (© 2022. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Objectives: To develop and implement a simulation-based training model for the management of posterior capsule rupture (PCR) from a non-technical skills (NTS) perspective, and analyse changes in participant's NTS and technical skills (TS)., Methods: The simulation-based training model consisted of two identical PCR simulations with NTS stressors applied, separated by a predominantly NTS focussed training intervention. Participants' TS and NTS were evaluated by two blinded assessors using the Objective Structured Assessment of Technical Skill (OSATS) global rating scale and the HUman Factors in intraoperative Ophthalmic Emergencies Scoring System (HUFOES) respectively. Paired t-tests were used to establish the difference in mean HUFOES and OSATS scores between initial and repeat simulations; p < 0.05 indicated statistical significance. McGaghie's model of translational outcomes for simulation-based learning was used to establish the simulation model's educational status., Results: Seventeen cataract surgeons of varying training grades participated in the simulation-based training model. NTS improved with statistical significance; mean HUFOES scores increased from 48.7 ± 16.6 to 59.2 ± 14.8 (p < 0.001). Mean OSATS scores increased without statistical significance from 16.0 ± 7.3 to 17.9 ± 8.3 (p = 0.07). This simulation model achieved Level 1 (internal acceptability) and Level 2 (contained effects) according to McGaghie's model., Conclusions: This novel simulation-based training model was designed to improve the NTS required for managing intraoperative PCR, through the provision of an interactive training session. Statistically significant improvements in participants' NTS in combination with statistically insignificant improvements in TS demonstrate that the simulation-based training model has specificity within the NTS domain., (© 2022. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

A patient with history of previous right eye penetrating keratoplasty for viral keratitis presented with an inferonasal graft melt, loose sutures and a flat anterior chamber (AC) in the same eye. B-scan ultrasound revealed 360° choroidal detachment. Cyanoacrylate adhesive and bandage contact lens were placed to restore ocular integrity. About 5 weeks after the procedure, the glue was found inside the AC with healed corneal melt. An emergency procedure was planned to remove the intraocular glue to prevent long-term toxicity. During the procedure, glue was found adherent to the intraocular lens (IOL), which necessitated an IOL exchange. Following the procedure, the eye settled well with residual scarring and an uncorrected visual acuity of 6/60, which improved to 6/18 with a pinhole. We discuss this case of late dislocation of the glue into the AC, which was managed with an IOL exchange highlighting a rare complication of corneal glueing., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Acute hydrops is a rare complication of corneal ectatic disease, which occurs secondary to Descemet membrane break. Spontaneous resolution of this condition is associated with longstanding ocular discomfort and corneal scar. Intracameral gas/air injection with or without corneal suturing, anterior segment ocular coherence tomography (ASOCT)-guided drainage of intrastromal fluid, and penetrating keratoplasty are some of the described surgical interventions to manage this condition. The purpose of our study was to assess the effect of full-thickness corneal suturing as a solo treatment in the management of acute hydrops. A total of five patients with acute hydrops received full-thickness corneal sutures perpendicular to their Descemet break. A complete resolution of symptoms and corneal oedema was observed between 8 to 14 days post-operation with no complications. This technique is simple, safe, and effective in the management of acute hydrops and saves patients from a corneal transplant in an inflamed eye.

Competing Interests: There are no conflicts of interest.

Introduction: Multifocal intraocular lens (IOLs) are used to restore vision at different focal distances. The technology of multifocal IOLs is continually advancing. Optical aberrations a property of lenses that causes spreading of light over a region resulting in a blurred or distorted image. This study aims to systematically review investigator measured and patient reported optical aberrations following implantation of multifocal IOLs during phacoemulsification surgery to treat presbyopia in adults., Methods and Analysis: We will conduct an electronic database search for randomised controlled trials, prospective non-randomised studies, observational studies in Ovid MEDLINE, Ovid EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus and ClinicalTrials.gov in March 2021. Eligibility criteria will include quantitative articles written in English and containing data on optical aberrations. Two independent reviewers will screen titles and abstracts and extract data from full texts, reporting outcomes according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data extraction of key characteristics will be completed using customised forms. Methodological quality will be assessed using Cochrane Handbook 6.2., Ethics and Dissemination: Ethics approval is not required for this review, as it will only include published data. Findings will be published in a peer-reviewed journal and disseminated across ophthalmic networks. We anticipate that the findings of this work will be of interest to multiple stakeholders: people who have undergone cataract surgery, eye health professionals, ophthalmic surgeons, device manufacturers and policy-makers. It will also inform researchers to where there are gaps in evidence and identify areas for future research., Prospero Registration Number: CRD42021271050., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Purpose: To assess the subjective validity of a cost-effective and adaptable cataract surgery simulation technique using basic technology., Methods: We devised and filmed a range of simulation techniques that mimic steps of phacoemulsification cataract surgery using various "everyday" basic materials. This video was combined in a "parallel" fashion with live cataract surgery so that all steps of surgery were simulated. Subsequently, we distributed an online subjective validation questionnaire on Google Forms with the embedded simulation video in a generic invitation that was forwarded via email and/or text messages/WhatsApp messenger amongst Ophthalmologists of all grades within our regions (Kent, Surrey and Sussex, London and Wales Postgraduate Deaneries)., Results: Face validity: 66 (99%) participants agreed that the explanations in the video were clear and 53 (79%) concurred with the realistic feel of simulated technique. Instrumentation and adaptations demonstrated were deemed user friendly and conducive to replicate by 99% participants. Content validity: 60 (90%) of participants agreed the techniques described in the video reflected the technical skills required to train cataract surgeons. Forty-nine (74%) agreed that the simulation techniques were relevant for acquiring other generic and transferable microsurgical and manual dexterity skills., Conclusions: We demonstrated subjective validity of our cost-effective cataract simulation technique. Our model can be used as an adjunct to intraocular and virtual reality training for cataract surgery by removing the barrier of cost and improved exposure to real instruments used in cataract surgery., (© 2021. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

This study aimed to assess the surface quality of cap, stroma and lenticular surfaces created using low-energy femtosecond laser lenticule extraction (Ziemer FEMTO LDV Z8). Twenty-four porcine eyes were divided into four groups (n = 6 each): two with optimal laser power (32%) with posterior curvature equivalent to a spherical correction of -2D and -5D, respectively and the other two with high power (64%) with spherical correction of -2D and -5D respectively. Samples were analysed using scanning electron microscopy (SEM). Surface morphology was evaluated using a standard scoring system; surface relief, surface regularity, extent and position of irregularities were graded by four independent clinicians. Eyes with 32% power and -2D correction had significantly less size of the irregular area than those with -5D; however, no significant difference was found between the two groups with 64% power. When comparing eyes with -2D correction, the size of the irregular area was lesser with 32% power. Surface relief was lesser with -5D correction with 32% power than 64% power. Low-energy femtosecond laser lenticule extraction (Ziemer FEMTO LDV Z8) produces good surface quality results. There is a tendency for smoother surface stromal quality with lower power settings than a higher power., (© 2022. The Author(s).)

Purpose: To assess the flattening of central, paracentral, and peripheral cones following non-accelerated (non-A-CXL) and accelerated (A-CXL) epithelium-off corneal cross-linking with 10 times higher intensity., Methods: In this multicenter study of 200 eyes (100 in each group), following 10 minutes of soak time with riboflavin 0.1%, continuous CXL was performed for 30 minutes (intensity: 3 mW/cm 2 , fluence: 5.4 J/cm 2 ) in the non-A-CXL group and 3 minutes (intensity: 30 mW/cm 2 , fluence: 5.4 J/cm 2 ) in the A-CXL group. Anterior and posterior cone flattening were compared at 12 months. Multiple regression analysis was performed to establish correlation of age, sex, cone location, and preoperative maximum keratometry (Kmax) values with postoperative flattening at 12 months., Results: In the non-A-CXL and A-CXL groups, central cones were the steepest, followed by paracentral and peripheral cones. Both groups showed significant flattening in central (1.54 ± 1.94 and 1.09 ± 1.79 diopters [D]) and paracentral (0.62 ± 1.59 and 0.55 ± 0.98 D) cones only. In the non-A-CXL group, there was a positive correlation between postoperative flattening and preoperative Kmax values, whereas paracentral and peripheral cone locations were negatively related. In the A-CXL group, only paracentral location was negatively correlated to postoperative flattening and showed posterior cone steepening at 12 months., Conclusions: Although central cones were the steepest in both groups, there was no difference in postoperative flattening between the groups for all cone locations. In the non-A-CXL group, postoperative flattening was proportional to preoperative Kmax values in central cones and was less with paracentral and peripheral locations. With A-CXL, postoperative flattening was less only with paracentral location. In the A-CXL group, significant posterior cone steepening was noticed only in paracentral cones. [ J Refract Surg . 2022;38(5):310-316.] .

An 89-year-old man with multiple episodes of inferior corneal oedema and low-grade anterior segment inflammation over 18 months was diagnosed and managed as viral keratitis; however, the episodes kept recurring every time treatment, vis-à-vis topical steroids, were tapered or stopped. History of cataract surgery few months prior to onset of the symptoms, lack of other features of viral keratitis, such as keratic precipitates and inferior corneal oedema in the presence of slight pupillary peaking led to the suspicion of either a retained lens fragment (RLF) or other possible iatrogenic insult. This was confirmed by anterior segment optical coherence tomogram, which revealed the RLF in inferior angle; this was removed surgically as an emergency procedure. This resulted in significant improvement in the corneal oedema, as well as marked symptomatic relief confirmed by the patient., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

This study aimed to assess the anterior corneal wavefront aberrations, keratometry, astigmatism vectors and pupil size between Pentacam HR® (Oculus Optikgeraete GmbH, Wetzlar, Germany) and iTrace® (Tracey Technologies Corp., Houston, TX, USA). In this observational study, 100 eyes (50 healthy volunteers) were scanned in mesopic light condition with a Pentacam HR® and iTrace®. Anterior corneal aberrations (spherical aberration (Z40), vertical coma (Z3 − 1), horizontal coma (Z3 + 1)), keratometry in the flattest (K1) and steepest meridian (K2), mean astigmatism, astigmatic vectors (J0 and J45), and pupil size were measured. We found a significant difference in Z40 (Pentacam®: +0.30 ± 0.11 µm and iTrace®: −0.03 µm ± 0.05 µm; p < 0.01) with no correlation between the devices (r = −0.12, p = 0.22). The devices were in complete agreement for Z3 − 1 (p = 0.78) and Z3 + 1 (p = 0.39), with significant correlation between the machines (r = −0.38, p < 0.01 and r = −0.6, p < 0.01). There was no difference in K1, K2 and mean astigmatism. J0 was negative with both devices (against-the-rule astigmatism), but there was no correlation. J45 was negative with the Pentacam HR® (more myopic oblique astigmatism) but significantly correlated between the devices. Pupil size was smaller with Pentacam HR® (p < 0.01). In summary, these devices cannot be used interchangeably. Corneal Z40 was significantly different with more negative Z40 with iTrace® compared to Pentacam HR®. iTrace® operates with lower illumination, giving larger pupil size than Pentacam HR®, which uses intense blue light during measurement. No correlation was found for J0. Pentacam HR® had a trend to record more negative J45 (myopic oblique astigmatism).

Smartphone apps are becoming increasingly popular in ophthalmology, one specific area of their application being toric intraocular lens (IOL) surgery for astigmatism correction. Our objective was to identify, review and objectively score smartphone apps applicable to toric IOL calculation and/or axis alignment. This review was divided into three phases. A review was conducted on four major app databases (phase I): National Health Service (NHS) Apps Library, Google Play Store, Apple App Store and Amazon Appstore. A systematic literature review (phase II) was conducted to identify studies for included apps in phase I of our study. Keywords used in both searches included: "toric lens", "toric IOL", "refraction", "astigmatism", "ophthalmology", "eye calculator", "ophthalmology calculator" and "refractive calculator". Included apps were objectively scored (phase III) by three independent reviewers using the mobile app rating scale (MARS), a validated tool that ranks the quality of mobile health apps using a calculated mean app quality (MAQ) score. Phase I of our study screened 2428 smartphone apps, of which six apps for toric IOL calculation and four apps for axis marking were eligible and were selected for quantitative analysis. Phase II of our study screened 477 studies from PubMed, Medline and Google Scholar. Three studies validating two apps (toriCAM, iToric Patwardhan) in a clinical setting as adjunct tools for preoperative axis marking were identified. Phase III ranked Toric Calculator for iPhone (Apple iOS, MAQ 4.13; average MAQ 3.34 ± 0.54) as the highest-scoring toric IOL calculator, and iToric Patwardhan (Android OS, MAQ 4.13; average MAQ 3.41 ± 0.44) was the highest-scoring axis marker in our study. Our review identified and objectively scored ten smartphone apps available for toric IOL surgery adjuncts. Toric Calculator for iPhone and iToric Patwardhan were the highest-scoring toric IOL calculator and axis marker, respectively. Current literature, though limited, suggests that axis marking smartphone apps can achieve similar levels of misalignment reduction when compared to digital systems.

Aim: To compare intraocular lens (IOL) calculation methods not requiring refraction data prior to myopic laser-assisted in situ keratomileusis (LASIK) and radial keratotomy (RK)., Methods: In post-LASIK eyes, the methods not requiring prior refraction data were Hagis-L; Shammas; Barrett True-K no-history; Wang-Koch-Maloney; 'average', 'minimum' and 'maximum' IOL power on the American Society of Cataract and Refractive Surgeons (ASCRS) IOL calculator. Double-K method and Barrett True-K no-history, 'average', 'minimum' and 'maximum' IOL power on ASCRS IOL calculator were evaluated in post-RK eyes. The predicted IOL power was calculated with each method using the manifest postoperative refraction. Arithmetic and absolute IOL prediction errors (PE) (implanted-predicted IOL powers), variances in arithmetic IOL PE and percentage of eyes within ±0.50 and ±1.00 D of refractive PE were calculated., Results: Arithmetic or absolute IOL PE were not significantly different between the methods in post-LASIK and post-RK eyes. In post-LASIK eyes, 'average' showed the highest and 'minimum' showed the least variance, whereas 'average' and 'minimum' had highest percentage of eyes within ±0.5 D and 'minimum' had the highest percentage of eyes within ±1.0 D. In the post-RK eyes, 'minimum' had highest variance, and 'average' had the least variance and highest percentage of eyes within ±0.5 D and ±1.0 D., Conclusion: In post-LASIK and post-RK eyes, there are no significant differences in IOL PE between the methods not requiring prior refraction data. 'Minimum' showed least variance in PEs and more chances of eyes to be within ±1.0 D postoperatively in post-LASIK eyes. 'Average' had least variance and more chance of eyes within ±1.0 D in post-RK eyes., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To compare uniocular and binocular visual acuity, wavefront aberrations, and defocus curves using the TECNIS Eyhance (Johnson & Johnson) and RayOne (Rayner) intraocular lenses (IOLs)., Methods: In this prospective, randomized, comparative study, 50 patients (100 eyes) were randomized to receive the same IOL bilaterally (ClinicalTrials.gov Identifier: NCT04175951). Follow-up visits were at 1 and 3 to 9 months postoperatively. Primary outcome measures were uncorrected distance (UDVA) and uncorrected intermediate (UIVA) visual acuity (logMAR) at 66 cm. Secondary outcome measures were corrected distance (CDVA) and distance-corrected intermediate (DCIVA) visual acuity at 66 cm, manifest refraction, spherical (Z 4 0 ) and vertical coma (Z 3 -1 ) aberrations (total, internal eye, and corneal) at normal pupil size, defocus curves, and Catquest 9SF and Glare and Halos questionnaire on Likert scale (1 = no glare and halos and 4 = continuous)., Results: Uniocular UDVA ( P = .02), UIVA ( P = .02), and binocular UIVA ( P < .01) and uniocular ( P = .01) and binocular ( P < .01) DCIVA were better with the TECNIS Eyhance IOL at 3 to 9 months. At 3 to 9 months, both uniocular and binocular defocus curves were significantly broader with the TECNIS Eyhance IOL between -0.50 and -3.00 diopters (D). For total and internal eye, there was a statistically but clinically insignificant difference in Z 4 0 with the TECNIS Eyhance IOL. Rasch scores improved (TECNIS Eyhance: 2.04 ± 1.34 to 2.91 ± 0.81 and RayOne:1.61 ± 1.35 to 2.97 ± 0.16) at 3 to 9 months. Refraction, Z 3 -1 , glare, and halos were not different., Conclusions: The TECNIS Eyhance IOL provided better DCIVA and broader defocus curves than the RayOne IOL. There was no difference in CDVA or patient-reported outcomes. Although there were some differences in aberrations when measured with normal pupil size, they were not clinically significant. [ J Refract Surg . 2022;38(1):10-20.] .

In order to maintain manual dexterity and surgical skills, trainees are encouraged to partake in regular simulation. Current options for intraocular surgical simulation require specialist microscopic equipment which is expensive and requires access to simulation facilities. A set of core simulation exercises and basic surgical skills of performing the corneal incisions, capsulorhexis, improving the manual dexterity, and suturing were identified, discussed, and agreed among authors before designing this simulation exercise. In this paper, we propose a smartphone-based, low-cost, low-tech model with corresponding exercises for intraocular simulation that can be used at home for the above-mentioned surgical skill set. This model provides an easy, portable, and reproducible method of simulation and can serve as an adjunct to patient-facing surgical training, especially in the current pandemic, where the excess to the simulation facilities or setup of these facilities may be difficult., Competing Interests: None

Purpose: To assess whether pars plana vitrectomy (PPV) is an aerosol-generating procedure (AGP) in an ex vivo experimental model., Methods: In this ex vivo study on 10 porcine eyes, optical particle counter was used to measure particles ≤10 μm using cumulative mode in the six in-built channels: 0.3 μm, 0.5 μm, 1 μm, 2.5 μm, 5 μm and 10 μm aerosols during PPV. Two parts of the study were as follows: (1) to assess the pre-experimental baseline aerosol count in the theatre environment where there are dynamic changes in temperature and humidity and (2) to measure aerosol generation with 23-gauge and 25-gauge set-up. For each porcine eye, five measurements were taken for each consecutive step in the experiment including pre-PPV, during PPV, fluid-air exchange (FAX) and venting using a flute with 23-gauge set-up and a chimney with 25-gauge set-up. Therefore, a total of 200 measurements were recorded., Results: With 23-gauge and 25-gauge PPV, there was no significant difference in aerosol generation in all six channels comparing pre-PPV versus PPV or pre-PPV versus FAX. Venting using flute with 23-gauge PPV showed significant reduction of aerosol ≤1 μm. Air venting using chimney with 25-gauge set-up showed no significant difference in aerosol of ≤1 μm. For cumulative aerosol counts of all particles measuring ≤5 μm, compared with pre-PPV, PPV or FAX, flute venting in 23-gauge set-up showed significant reduction unlike the same comparison for chimney venting in 25-gauge set-up., Conclusion: PPV and its associate steps do not generate aerosols ≤10 μm with 23-gauge and 25-gauge set-ups., Competing Interests: Competing interests: MAN: research grants from Alcon Laboratories, USA; European Society of Cataract & Refractive Surgery; Johnson & Johnson, USA; NuVision Biotherapies, UK; Rayner Intraocular lenses, UK. Lecture fees from Alcon Laboratories, USA. Consultant to Hoya. Travel grant from Alcon Laboratories, USA & Bausch & Lomb, USA., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

The aim of this review was to discuss frequently encountered themes such as cataract surgery in presence of age-related macular degeneration (AMD), dementia, Immediate Sequential Bilateral Cataract Surgery (ISBCS), discussing non-standard intraocular lens (IOL) options during consultation in the National Health Services (NHS) and the choice of the biometric formulae based on axial length. Individual groups of authors worked independently on each topic. We found that cataract surgery does improve visual acuity in AMD patients but the need for cataract surgery should be individualised. In patients with dementia, cataract surgery should be considered 'sooner rather than later' as progression may prevent individuals presenting for surgery. This should be planned after discussion of patients' best interests with any carers; multifocal IOLs are not proven to be the best option in these patients. ISBCS gives comparable outcomes to delayed sequential surgeries with a low risk of bilateral endophthalmitis and it can be cost-saving and efficient. Patients are entitled to know all suitable IOL options that can improve their quality of life. Deliberately withholding this information or pressuring patients to choose a non-standard IOL is inappropriate. However, one should be mindful of the not spending inappropriate amounts of time discussing these in the NHS setting which may affect care of other NHS patients. Evidence suggests Hoffer Q, Haigis, Hill-RBF and Kane formulae for shorter eyes; Barrett Universal II (BU II), Holladay II, Haigis and Kane formulae for longer eyes and BU II, Hill-RBF and Kane formulae for medium axial length eyes., (© 2021. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Evaluation and recommendation of the scoring systems for technical skills (TS) and non-technical skills (NTS) assessments in ophthalmic surgery. A literature search was performed between December 2019 and May 2020. Studies describing the development or validation of TS or NTS scoring systems in ophthalmic surgery were included. Only scoring systems for completion by hand were included. The primary outcome was the validity and reliability status for each scoring system. The secondary outcome was recommendation based on modified Oxford Centre for Evidence-Based Medicine guidelines. Nineteen and five scoring systems were identified for TS and NTS respectively. TS scoring systems exist for cataract surgery (including the steps of phacoemulsification and paediatric cataract surgery) ptosis, strabismus, lateral tarsal strip, vitrectomy, and intraocular surgery in general. NTS scoring systems apply to cataract surgery or ophthalmic surgery in general. No single scoring system satisfied all validity and reliability measures. The recommended TS scoring systems are 'International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubrics' (ICO-OSCAR) for phacoemulsification, strabismus and paediatric cataract surgery, and 'Objective Structured Assessment of Cataract Surgical Skill' (OSACSS). Non-Technical Skills for Surgeons (NOTSS), Observational Teamwork Assessment for Surgery (OTAS) and Anaesthetists Non-Technical Skills (ANTS) are recommended for NTS. There is a paucity of NTS scoring systems. Further research is required to validate all scoring systems to consistent standards. Limitations of the assessment tools included infrequent quantification of face and content validity, and inconsistency in terminology and statistical methods between studies.