Eyeworld

167 EW INTERNATIONAL April 2017 significant difference between the level of depressive symptoms before and after cataract surgery, which was significantly increased before surgical intervention and signifi- cantly decreased after. An analysis of the impact of the visual acuity of the non-operated eye on the symptoms of depression showed that the level of visual acuity of the non-operated eye significantly affects depressive symptoms before and after cataract surgery. Therefore, visual acuity is a very important factor in reducing depressive symptoms in older pa- tients," Dr. Jovanovic said. EW References 1. Nyunt MSZ, et al. Criterion-based validity and reliability of the geriatric depression screening scale (GDS–15) in a large validation sample of community living Asian older adults. Aging Ment Health. 2009;13:376–82. 2. Freeman EE, et al. Cataract–related vision loss and depression in a cohort of patients awaiting cataract surgery. Can J Ophthalmol. 2009;44:171–6. 3. To KG, et al. The impact of cataract surgery on depressive symptoms for bilateral cataract patients in Ho Chi Minh City, Vietnam. Int Psychogeriatr. 2014;26:307–13. Editors' note: Dr. Jovanovic has no financial interests related to her com- ments in this article. Contact information Jovanovic: drsvetlanajovanovic@yahoo.com A total of 435 patients took part in the trial, which included 234 (53.8%) male and 201 (46.2%) female patients, ranging in age from 62 to 95 years. Patients were chosen if they had been diagnosed with senile cataracts and required first-eye cataract surgery. The study excluded patients who had already had first- eye cataract surgery or those with other ocular or systemic diseases. Preoperatively, there were 387 patients (88.9%) with visual acuity within the range of 0.1–0.3 and 48 patients (11%) within the range of 0.4–0.6. After cataract surgery, 12 pa- tients (2.8%) had visual acuity in the 0.1–0.3 range, 90 patients (20.7%) were in the 0.4–0.7 range, and 333 patients (76.6%) achieved visual acu- ity of 0.8–1.0. Visual acuity in the non-operated eye was in the range of 0.1–0.5 in 246 patients (56.6%) and 0.6–1.0 in 189 patients (43.5%). The Wilcoxon rank sum test showed a significant difference in visual acu- ity before and after cataract surgery (P<.001). The GDS-15 scale before surgery showed a high level of mild (197 patients, 45.29%) and moderate (94 patients, 21.61%) depressive symptoms and also showed the relative number of patients without depressive symptoms (105 patients, 24.14%). After cataract surgery, the GDS-15 scale showed the distribu- tion of patients with symptoms of depression to be mild (108 patients, 24.83%), moderate (38 patients, 8.74%), and a significant increase in individuals with non-depressive symptoms (278 patients, 63.91%). Wilcoxon rank-sum test showed a statistically significant difference (P<.003) between the pre- and post- operative GDS-15 outcomes. Statistically significant differenc- es were also seen in GDS-15 scores among different depressive symp- toms before and after cataract sur- gery, as follows: without symptoms (P<.003), mild symptoms (P<.002), moderate symptoms (P<.001), and severe symptoms (P<.004). The Kruskal-Wallis test indicated that the level of visual acuity in the non-op- erated eye plays an important role in depressive symptoms before (P<.002) and after (P<.001) cataract surgery. Further statistical analysis established that there was no sig- nificant difference between the sex of patients and their level of visual acuity or between sex and depressive symptoms before and after cataract surgery. The GDS has been shown to be reliable in differentiating depressed from non-depressed adults. 1 Several studies have shown a close correla- tion between a patient's level of visual acuity and depression before and after cataract surgery. One such study that investigated depression in 672 preoperative cataract pa- tients using the Visual Function-14 questionnaire showed that patients with lower visual acuities were more likely to show signs of depression. 2 It revealed statistically significant evi- dence that the relationship between visual acuity and depression was me- diated by greater reported difficulty on Visual Function-14 (P<.05). Unlike the present study's outcomes, visual acuity in the non-operated eye did not seem to have the same impact on depression as first eye surgery did, according to the results of a recent study in which investigators demonstrated no significant difference in depres- sive symptoms between cataract patients who underwent first-eye or bilateral cataract surgery. 3 While the study noted a small but significant difference in depressive symptoms between pre- and post-cataract sur- gery (P =.04) performed in the first eye and a greater decrease in depres- sive symptoms in women compared to men (P =.01), contrast sensitivity, visual acuity, and stereopsis were not significantly associated with change in the depressive symptoms score. "Our study shows that a sig- nificant difference exists between the loss of visual acuity and the occurrence of depressive symptoms before and after first-eye cataract surgery in elderly patients. The level of visual acuity of the non-operat- ed eye is an important element in the level of depressive symptoms as well. We showed a statistically Phased continued from page 165 of viscoelastic material was added to open the bag further, and once completely open, the lens could be pushed and rotated from its position in the sulcus to inside the capsular bag, where he was able to center it perfectly. In a second case, Dr. Morkos presented a young woman who had surgery 2.5 years earlier and was also complaining of unsatisfactory vision and monocular diplopia. Having located the white mark, he began his dissection through the two para- centeses and cleared the posterior capsule, dissecting the capsular bag open from different sides. The rhexis was found to be smaller than opti- mal, which explained the difficulty the first surgeon might have had to implant inside the bag. He enlarged the rhexis using scissors and capsu- lorhexis forceps. He found the artifi- cial lens in an upside-down position, flipped it to the proper orientation, and dialed the lens inside the capsu- lar bag. The patient's vision mark- edly improved after surgery, and her eye has stayed quiet postoperatively with the same, original lens centered inside the bag. In another instance, zonular dehiscence led to significant lens displacement in one of Dr. Morkos' patients. He cut the IOL partially into its center and explanted it, allowing for more space inside the eye for intraoperative maneuvers, as he expected the surgery to be some- what more complex. Opening the capsular bag was more difficult in this patient, requiring some patience because of the highly cumbersome and tedious manipulation. However, once the capsule began to open, as Dr. Morkos had already emphasized, opening up the remainder was eas- ier. He identified the zonular defect at the lower nasal quadrant and was able to insert a capsular tension ring into the capsular bag and safely implant a new IOL. Finally, a child who had had his congenital cataract removed 8 years earlier with a posterior rhex- is and vitrectomy presented with visual problems due to repeated IOL displacements after several attempts at repositioning. Dr. Morkos was able to pry open the tightly closed capsular bag with a blade and vitre- ous scissors, abandoning his usual technique due to the difficulty of the case. He used a vitreous cutter to extract Soemmerring's ring and vitreous bands. A new IOL was then implanted into the newly formed capsular bag, which is stable and central 8 years on. "The telltale white lines along the capsule give a clear landmark to the edge of the anterior capsu- lotomy. After severing the tight adhesions that surround the ante- rior capsule, the use of mechanical and viscodissection help reopen the closed capsular bag. The cap- sulorhexis can be widened, and capsular tension rings can be used to manage existing zonular dialysis. Then, the surgeon can decide to use the same or a new IOL inside the newly opened capsular bag, where it remains stable and perfectly central- ized," Dr. Morkos said. EW Editors' note: Dr. Morkos has no finan- cial interests related to his comments. Contact information Morkos: fathyfawzy@alwatany.net.eg

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