CLINICAL SCENARIO: An 82-year-old female with no apparent ocular problems, except fora brunescent cataract, underwent phacoemulsification with intraocular-lens (IOL) implantation. Postoperative medication consisted solely of antibiotic-steroid eye drops. One day after uneventful surgery, the patient developed severe pain, poor vision, and redness in the operated eye. Visual acuity was counting fingers at 1 meter. The eye had ciliary injection, grade 4 flare and cells, a small hypopyon, fibrin extending from the corneal wound, and a mildly edematous cornea. Intraocular pressure (IOP) was 24 mm Hg. Exudates behind the IOL were noted, but visualization was poor. Anterior-chamber and vitreous taps revealed gram-positive cocci. Could the ophthalmologist have prevented this complication? CLINICAL QUESTION: Among patients undergoing cataract extraction, what is the most effective regimen that can reduce the risk of endophthalmitis? SEARCH METHOD: A Medline search was performed using the keywords "endophthalmitis," "cataract," and "prevention." The search was limited to randomized controlled trials (RCT). No studies were found that compared endophthalmitis rates using different perioperative prophylactic measures. Most studies reported used substitute outcome measures such as periocular bacterial load, intraocular penetration of antibiotics, and anterior-chamber contamination. After reviewing the abstracts, only one RCT was considered relevant to the clinical question CITATION: Soto AM, Mendivil MP. The effect of topical povidone-iodine, intraocular vancomycin, or both on aqueous humor cultures at the time of cataract surgery. Ophthalmol 2001; 131:293-300. (Author)
PHACOEMULSIFICATION, VANCOMYCIN, POVIDONE-IODINE

Surgical Technique: The technique involves creating a central crater, flipping the nucleus out into the supracapsular space, and creating another crater through the posterior surface that will eventually connect with the anterior crater to produce a central hole. The donut-shaped nucleus is then chopped and the fragments are aspirated with greater ease. Results: The technique was performed successfully in seven eyes of six patients with only minor problems. Phacoemulsification times were longer than usual because of the additional sculpting, but clinical results were not adversely affected. Conclusion: For dense or hard cataracts for which the surgeon anticipates a tough posterior plate, this technique is a safe alternative to the usual chopping techniques.
Human ; Male ; Female ; Aged ; Middle Aged ; CATARACT ; PHACOEMULSIFICATION ; SCLEROSIS

Objective: This study compared the effectiveness of prophylactic administration of topical ketorolac tromethamine 0.5% and nepafenac 0.1% on maintaining mydriasis during phacomulsification. Methods: This is a prospective, randomized, double-masked comparative study involving adult cataract patients given topical NSAIDs (ketorolac or nepafenac) or balanced salt solution (control) prior to phacoemulsification and capsular bag intraocular-lens (IOL) implantation at a tertiary hospital. Horizontal and vertical diameters of pupil were measured at different stages of cataract surgery and the mean values were compared across the three groups. Results: A total of 47 eyes of 44 cataract surgery patients, 13 males and 34 females, with a mean age of 66.04 ± 8.87 years, were included in the study. The mean horizontal and vertical diameters of the three groups were similar at the start of surgery. Significant differences were seen after IOL implantation, with the nepafenac group having the largest mean diameters in both horizontal (p = 0.012) and vertical (p = 0.012) pupil measurements. Conclusion Topical nepafenac has been shown to be a more effective inhibitor of miosis during phacoemulsification and provides a more stable mydriatic effect throughout the surgical procedure compared to topical ketorolac and placebo.
Cataract ; Phacoemulsification ; Mydriasis ; Ketorolac

Objective: To determine the efficacy of the Wong incision in providing wound seal compared to stromal wall hydration in clear cornea phacoemulsification in cadaveric porcine eyes. Method: This was an in vitro comparative experimental study using ten porcine eyes. All eyes were randomly assigned to the stromal wall hydration (control) or the Wong incision group (experimental). A side port was made and the anterior chamber formed with viscoelastic device. The main incision was made 180 degrees away. In the experimental group, a Wong incision was made first anterior to the main incision. Phacoemulsification surgery with IOL insertion was simulated. The main incision was sealed by hydration. The anterior chamber (AC) was infused with balanced salt solution (BSS) through an AC maintainer and leakage of fluid from the main incision was assessed. Samples from the AC were taken before and after tryphan blue drip and were sent for analysis by UV spectrophotometry. Trypan blue was dripped over the main incision and the whole eyeball was sent for histopathology. Results: There was a significant increase in density from the pre-dye to the post-dye AC samples of the control (0.0052 to 0.0074, p=0.01) and the experimental groups (0.0076 to 0.0094, p=0.02), although the final samples showed an optical density comparable to pure BSS, indicating that there was no significant amount of trypan blue detected in both groups. On histology, trypan blue staining was not seen in the incision tracts of both groups. After infusing the AC with BSS, there was outward wound leakage in all eyes of the control group and none in the experimental group. Conclusion The Wong incision was as effective as the lateral stromal wall hydration in preventing fluid influx. Furthermore, the Wong incision showed a more stable wound seal against outward wound leakage in an in-vitro porcine model of clear corneal phacoemulsification.
Phacoemulsification

Objective: To detect and characterize retinoblastoma susceptibility gene (RB1) mutations in tumor samples collected from Filipino patients with retinoblastoma. Methods: Six tumor samples were obtained from Filipino patients diagnosed with retinoblastoma. DNA was extracted from the tumor samples and exons 13-21 of the RB1 gene were amplified by polymerase chain reaction (PCR). PCR amplification products were subsequently purified and sequenced. Mutation detection and characterization were done by alignment of obtained sequences to the RB1 reference sequence from NCBI GenBank using Bioedit® software. The identified mutations were correlated with clinical presentation and family history. These mutations were also compared to known mutations reported in the RB1 Gene Mutation Leiden Open Variation Database (LOVD). Results: Mutations were detected in two out of the six samples. In a patient with unilateral disease and no family history, two mutations were identified: a novel CGT>AGT (Arginine → Serine) missense mutation in position c.1861 of exon 19 and a previously reported CGA>TGA (Arginine → STOP) nonsense mutation in position c. 1735 of exon 18. A possible large exonic deletion was identified in a case of unilateral disease with no family history. Conclusion We were able to identify both novel and known mutations in the RB1 gene of Filipino retinoblastoma cases using DNA sequencing techniques. These techniques may be applied to further characterize the genetic mutations of Filipino retinoblastoma cases and their families in developing a rational method of genetic testing for early diagnosis and counseling.
Retinoblastoma ; Genes, Retinoblastoma