Editorial: Surgical advancements and innovations in cataract surgery for the complex patient No abstract available

Management of cataract in the setting of uveitis: a review of the current literature Purpose of review This review aims to cover the preoperative planning, intraoperative considerations, and postoperative management that aids in successful outcomes of patients with cataract and uveitis. Disease-specific management and pediatric management will also be addressed. Recent findings Dexamethasone implants appear to be a safe and effective addition to standard steroid treatment in decreasing the incidence of postoperative cystoid macular edema (CME). Intravitreal steroids and topical difluprednate have shown utility in CME treatment. Summary Cataract surgery in eyes with uveitis is generally safe and effective if inflammation is well controlled; however, complication rates are still higher than in eyes without uveitis. Future investigations should delineate outcomes for eyes with different etiologies of uveitis, and further research is needed to adequately control inflammation and avoid postoperative complications.

How much astigmatism to treat in cataract surgery Purpose of review Astigmatism correction in cataract surgery is a common surgical challenge. Although there are numerous approaches to its treatment during cataract surgery, there remains a lack of consensus on what level of postoperative astigmatism to target. We examine the literature to determine the effect of astigmatism on visual function and provide a recommendation on how much to treat in cataract surgery. Recent findings Distance visual acuity decreases as myopic, hyperopic, or mixed astigmatism increases. Near visual acuity decreases with hyperopic astigmatism but improves with myopic astigmatism. The effect of astigmatism is generally independent of axis; however, against-the-rule (ATR) astigmatism with mild myopia may benefit reading. A progressive ATR shift occurs with age whether or not an individual undergoes cataract surgery. In the presence of higher order aberrations, correction of astigmatism below 0.5 D shows minimal practical benefit. Presbyopia-correcting intraocular lenses (IOLs) are sensitive to astigmatism but achieve distance visual acuities similar to monofocal IOLs and reach their full near and/or intermediate potential when residual astigmatism 0.5 D or less. Summary In cataract surgery, we recommend correction to 0.5 D or less of postoperative residual astigmatism to achieve optimum visual function and patient satisfaction following cataract surgery.

Cataract surgery and intraocular pressure in glaucoma Purpose of review To review the current literature on the relationship between cataract extraction and intraocular pressure (IOP). Recent findings Cataract extraction can be an effective IOP lowering treatment for open and closed angle glaucoma as well as ocular hypertension. In comparative trials studying novel micro-invasive glaucoma surgeries in open angle glaucoma, the control group undergoing cataract extraction alone routinely achieved significant reductions in IOP and medication use postoperatively. Data from the Effectiveness in Angle Closure Glaucoma of Lens Extraction (EAGLE) trials have demonstrated that lens extraction is more effective at lowering IOP than peripheral iridotomy in patients with angle closure and should be considered as first line therapy. Additionally, patients in the ocular hypertension treatment study who underwent cataract extraction over the course of follow-up demonstrated significant IOP lowering sustained over 3 years. Summary Cataract extraction is an effective method to lower IOP in patients with glaucoma. Pressure lowering is more significant in eyes with narrow angles and those with higher baseline IOP levels. In eyes with angle closure, phacoemulsification alone can lower IOP, but when combined with GSL it may be even more effective. Recent large multicenter randomized trials have further elucidated the benefit of standalone cataract extraction to treat mild to moderate primary open angle glaucoma. Prospective and longitudinal studies that systematically investigate the variables that may influence degree and duration of IOP lowering post cataract extraction are lacking.

Cataract surgery in corneal transplantation Purpose of review Corneal diseases are often associated with lens opacity. The present article reviews the recent advances in the management of cataract and corneal transplant. Recent findings Thanks to the development of lamellar transplant techniques and the evolution of cataract surgery, we now have several strategies to address corneal diseases and cataract including ‘lamellar triple procedure’. Numerous precautions have been identified to have a successful surgery with good visual recovery. Summary Corneal diseases associated with cataract can be successfully managed using separate or combined surgical procedures, as appropriate. In most cases the intraocular lens power can be calculated with a predictable outcome.

Hand hygiene and instrument sanitization in ophthalmology clinics Purpose of review This article reviews the various challenges in infection control in eye clinics and successful measures taken to prevent nosocomial infections. Recent findings The Center for Disease Control recommends hand-washing when hands are visibly soiled, and after direct contact with patients, and inanimate objects such as medical equipment. Published studies have identified poor hygiene in clinical settings as a major cause of nosocomial outbreaks, particularly in cases of epidemic keratoconjunctivitis (EKC). Some studies of EKC outbreaks are able to support direct observation of hygiene lapses with molecular analysis that can match viral strains on particular instruments to those found in infected patients. Although most studies are about adenoviral infection and tonometer use, researchers have found viral and bacterial loads on other common surfaces, indicating a need for further research. Summary Proper hygiene in eye clinics requires special attention because of the potential to examine many patients at a time and because multiple instruments are often used during a single exam. Studies reinforce the link between hygiene and outbreak prevention, and more research can be done to determine the specific links between certain instruments and nosocomial infections.

Methods for achieving adequate pupil size in cataract surgery Purpose of review Cataract surgery is the most common surgical procedure performed worldwide. Small pupils have been an eternal challenge for cataract surgeons; insufficient pupil dilation is associated with increased complication rates, including capsule rupture, vitreous loss, iris trauma or postoperative inflammation. The aim of the current review is to present the methods for pupil dilation and the risk factors for a small pupil in a cataract patient. Recent findings Risk factors for intraoperative small pupil include diabetes, intraoperative floppy iris syndrome, pseudoexfoliation syndrome, receiving glaucoma medications, having undergone previous ocular surgery and iris sphincter sclerosis from aging. There is a wide range of options to manage the small pupil, including pharmacological treatment, mechanical stretching, dilation with iris hooks or pupil expanders. We recommend a stepwise approach for intraoperative pupil dilation, from pharmacological mydriasis to pupil expanders. Summary The current article discusses risk factors for a small pupil and the methods for pupil dilation in a cataract patient. Every cataract surgeon needs to be ready to cope with a small pupil, both manifesting preoperatively and intraoperatively.

Iris reconstruction suturing techniques Purpose of review When patients have large iris defects, they may experience debilitating glare, halos, and unfavorable cosmetic appearance. Surgical iris reconstruction can alleviate these symptoms. This article will review current suturing techniques for iris reconstruction, as well as the benefits and drawbacks to various suturing methods. Alternative reconstructive methods are also discussed. Recent findings One of the earliest iris suturing methods described was the McCannel technique. This technique allows direct suturing of the iris using three incisions. The Siepser slipknot is another method used in closed chamber iris suturing techniques. This knot, and its recent modifications, utilizes a sliding knot, which is created outside the eye and slid into place atop the iris defect. The cerclage iris suture, in which small bites are taken around the pupillary circumference, is especially useful when treating a mydriatic pupil. Recently, a number of surgeons have adapted these techniques and developed novel suturing strategies to address complex ocular conditions. Summary The various iris suturing methods, as well as alternative techniques including cautery, corneal tattooing, and iris prosthetics, each have unique benefits, providing surgeons with a wide array of tools for iris reconstruction.

Scleral fixation of intraocular lenses Purpose of review To review current, effective and more popular techniques for scleral fixation of intraocular lens (IOLs) and IOL–capsular bag complex. Recent findings Scleral fixation of IOLs became popular, originally with sutured scleral fixated IOLs and later the Scharioth technique of intrascleral haptic fixation. This was further developed as the Glued IOL technique which enjoys widespread adoption all over the world. Recently the Yamane technique has also become popular and is being widely adopted as well. Summary Scleral fixated IOLs have evolved in the last 2 decades with technical modifications, extended indications and improvised instrumentation. Though sutured and sutureless techniques have been growing equally, the sutureless scleral fixation techniques have attracted special interest. Reduced suture-related complications, technical ease and high-quality functional outcomes may be possible reasons. Sutureless capsular bag fixation also has distinct advantages.