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M.Phil. / One of the most important causes of blindness worldwide is cataracts. A constant struggle exists among cataract ophthalmic surgeons to minimize surgically induced astigmatism (SIA) and thus to ensure a better uncorrected visual acuity (VA) for the patient after surgery. Different techniques have been tried to accomplish a 100% success rate of 6/6 vision after surgery, but one of the greatest hurdles in this struggle is high corneal astigmatism before surgery. One of the more successful techniques used to reduce corneal astigmatism after surgery is the opposite clear corneal incision (OCCI) technique. In this technique, the surgeon makes two equally long cuts through the clear part of the cornea opposite each other on the steepest meridian of the cornea. When the wounds heal, they form scar tissue, pulling the cornea flatter along this meridian and thus reducing the corneal astigmatism.

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Cataract surgery is one of the most common procedures performed in the entire world. Cataracts are inevitable in anyone who live to old age and as the global population continues to age, the number of cataract surgeries that are expected to be performed each year is only expected to increase. The procedure is also one of the oldest and has matured a substantial amount since its first utilization but it is still not perfect. It is crucial that we continue to improve to procedure in pursuit of improved post-operative outcomes for patients. In this study, a delayed phacoemulsification after the femtosecond laser anterior capsulotomy and lens fragmentation was introduced into the procedure with the hypothesis that this may allow the cataract to hydrate and soften, leading to an intraoperative reduced phacoemulsification power and a post-operative preservation of the corneal endothelium in grade 4 nuclear cataracts. This study is a new study with very little data collected so far but it is planned that we will initially perform the procedure on 10 patients with bilateral grade 4 cataracts. Each patient will have the new procedure done on one eye and then the typical cataract surgery procedure done on the other eye to be used as a statistical comparator. This thesis specifically explores the concept of introducing a delay between the capsulotomy and the phacoemulsification process and the safety and feasibility of such procedure in practice. The new procedure, so far, has been performed on one patient with the surgery data for the other eye currently pending. Relevant data such as cumulative dissipated energy and intraocular pressures were recorded during and after the surgery for future comparisons. Without a complete set of data, a statistical conclusion cannot be made about the efficacy of the new procedure, but as addressed in this thesis, the procedure has been concluded to be safe and feasible with a good post-operative outcome.

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Purpose: To compare the effect of topical prednisolone acetate 1% (PA) used after routine cataract surgery to the effect of difluprednate 0.05% (DFBA) used for the same indication on intraocular pressure (IOP). Methods: An electronic query was created to gather information from all cataract surgeries between January 2010 and January 2015 within the electronic health record database at Barnet Dulaney Perkins, a multicenter, multiphysician private practice in Phoenix, Arizona. Information collected included age, sex, diabetes status, glaucoma history, medication regimen (use of PA or DFBA), and IOP before surgery, 5-10 days postoperatively (TP1) and 3-6 weeks postoperatively (TP2). Postoperative IOP measurements were compared to baseline IOP measurement in each patient. Results: Regardless of steroid used, all patients in this study experienced an increase in IOP within TP1 and returned to baseline IOP (+/- 2.0 mmHg) by TP2. Patients who received DFBA showed a statistically significant increase in IOP at TP1 compared to those on PA (P<0.001) with the mean IOP an average 0.60 mmHg higher (95% CI = 0.3, 0.9). The odds ratio of a clinically significantly increased IOP at TP1 (defined as overall IOP >= 21 mmHg and an increase of >= 10 mmHg) in DFBA-treated patients was 1.84 (95% CI = 1.4, 2.6). In patients treated with PA, 3% reached a significantly increased IOP, compared to 4.4% of patients in the DFBA group (P<0.05). Risk factors for increased IOP were identified, and include advanced age (>75) (P<0.005) and a history of glaucoma (P<0.001). Conclusion: In postoperative cataract patients, use of DFBA increased the risk of a clinically significant IOP increase.

Age related cataracts are one of the major causes of loss of vision worldwide. Approximately 20 million people in the United States have their vision obstructed by cataracts and 500,000 new cases are diagnosed annually. The treatment for cataract is surgical extraction. The surgery is more than 95% successful in significantly improving vision. Because of continual advancements in cataract surgery, it is almost exclusively performed as an outpatient procedure and involves the administration of local anesthesia. For the most part patients are fully conscious during the procedure and it is imperative that they remain still. In the elderly, fear of loss of vision related to cataract surgery is second only to the fear of death. Although studies have shown that the average cataract patient is not unduly anxious regarding cataract surgery, anxiety is a known entity. An increase in anxiety can cause a patient to be restless, jittery, and agitated, all of which can cause unanticipated movement and hence a deleterious outcome. People are social beings. Interaction with and among other people provides and conveys support, comfort, and reassurance. Touch, specifically hand holding, has been shown to decrease anxiety and stress in multiple situations. It is minimally invasive, safe, reassuring and could allow patients to communicate during procedures where verbal communication, if done without parameters, as in cataract surgery, could be devastating. The findings of this study failed to reveal a significant difference in post op anxiety scores in either the treatment group or the non treatment group. However, subjectively, those people who received hand holding strongly agreed that hand holding helped to decrease anxiety during the procedure. The physician rating for patient compliance did not reveal a significant level of increase with the intervention during surgery. Again, subjectively, the majority of patients strongly agreed that hand holding did help them to be more compliant to the surgeon’s request. None of the participants that received hand holding felt an intrusion of personal space during the treatment. Results strongly suggest, at least subjectively, that hand holding is beneficial in decreasing anxiety, increasing compliance to intraoperative request, and is much welcomed, beneficial nursing intervention. / Thesis / Master

Objectives: The objectives of study were to (i) examine the regional differences in methods of performing cataract surgery across different jurisdictions in Australia and New Zealand (ii) identify risk factors for post-operative endophthalmitis and (iii) explore the implication of changes in surgical practice on the number of cases of post-operative endophthalmitis and resultant net cost to health system. Methods: Cataract surgeons across Australia and New Zealand were surveyed about their demographics, surgical techniques, use of pre- and post-operative antibiotics and antiseptics and cases of post-operative endophthalmitis. Statistical analysis was conducted to determine the regional variations in the use of methods of chemoprophylaxis and surgical practices. Multivariate Poisson regression was performed to identify factors associated with the incidence of post-operative endophthalmitis. A cost analysis was conducted to determine the impact of an increased use of chemoprophylatic treatment on the number of cases of post-operative endophthalmitis and net cost savings to the health system from its use. In addition, the results of the current survey of surgical practices of cataract surgeons was compared with those from an earlier survey conducted approximately 10 years ago. Result: The response to the survey of ophthalmologists was 82%, but after excluding ophthalmologists who did little or no cataract surgery, the study sample comprised 540 participants of the 896 who were initially sent the survey. Participating cataract surgeons reported 162,120 cataract surgeries and 92 cases of post-operative endophthalmitis, an incidence rate of 0.056%. Regional variations were found in the methods of chemoprophylaxis and surgical techniques. / Chloramphenicol was the most frequently used topical antibiotic in Australia, while neomycin was used by majority of cataract surgeons in New Zealand. The only notable change found over the past decade was a sharp fall in use of subconjunctival antibiotics from 75% to 45% in the current survey. A slight increase in use of post-operative topical antibiotics was noticed. Subconjunctival injection of antibiotics was the only form of chemoprophylaxis associated with a reduction in incidence of endophthalmitis. Results from this survey indicated that cataract surgeons routinely using corneal or limbal incisions had an incidence of endophthalmitis considerably higher than those surgeons routinely using scleral wounds, whilst surgeons routinely using temporally sited wounds had almost half the incidence of endophthalmitis compared to surgeons using superior wounds. The cost implications of subconjunctival gentamycin injection for chemoprophylaxis were examined. Additional costs of subconjunctival antibiotics were subtracted from the reduced cost of treating fewer cases endophthalmitis. There would potentially be a net saving to the Australian health system of $ 110,354 if all cataract surgeons used subconjunctival chemoprophylaxis. Conclusion: Regional variation in chemoprophylaxis and surgical techniques did not entirely explain differences in post-operative endophthalmitis incidence. Subconjunctival antibiotics would only need to reduce the incidence of endophthalmitis by 15% for it to be cost-effective.