As cataract surgery continues improving in safety and predictability, and surgeons increasingly face pressure to be more efficient in adapting to downward pressure on reimbursements, the traditional post-op regimen is being scrutinized for any time or cost savings that can be found. A recent study published in Journal of Cataract & Refractive Surgery validated the use of telemedicine and remote monitoring tools, particularly for screening purposes, to lower costs and increase the efficiency of care but stopped short of advocating for a retooling of traditional in-person assessments.

The systematic review involved data from 14 studies published across multiple databases. The selection criteria focused on papers relating specifically to remote care applications in postoperative cataract patient management. Of the included studies, four were randomized controlled trials and 10 were observational studies, comprising a total of 2,681 patients from various geographic locations.

The researchers assessed several remote care technologies, including telephone consultations, automated calls, messaging and mobile applications. After reviewing patient data, here are the conclusions they drew about each:

• Telephone consultations. These were commonly used for follow-up screenings and effectively maintained patient care without the need for in-person visits. However, they had limitations in terms of not being able to provide assessments of visual acuity directly. While they can’t replace traditional post-op care, the researchers suggested telephone consults may be most appropriately used as a screening tool in uncomplicated cases. 

• Automated calls. Similar to telephone consultations, automated calls effectively managed post-op care by reminding patients about medication schedules or follow-up appointments, which helped increase adherence to postoperative instructions. In the two studies that assessed this remote care method, automated calls showed 88.7 percent decision-making accuracy. However, one limitation of these types of calls is that they “capture subjective information and lack objective data on visual acuity and refractive status,” the researchers pointed out.

Whether human-led or automated, the researchers noted in their paper that telephone calls “offer a safe alternative for postoperative cataract care, avoiding long travel distances or accommodating systemic diseases that impair travel.” Both interventions were also well-received by patients.

• Messaging. In the two studies that deployed this method, communicating with patients via text or secure messaging applications improved medication and follow-up appointment adherence in the early postoperative period. However, the researchers warned that “two-way messaging may increase workload due to the potential for generating a high volume of responses.” 

• Mobile applications. Three digital tools to assess visual acuity were reviewed in this study: the Boost Cataract app, the Dyop chart and Easee web-based tool. However, the included studies presented some variability in results using these applications compared to conventional methods. Easee showed particular promise in assessing visual acuity and other critical outcomes, though the application lacks precision compared with traditional VA measurement methods. Nonetheless, the researchers relayed that “since the primary aim of a postoperative visual acuity check is the early detection of potential complications, the Easee tool may serve as a useful screening instrument for identifying patients with sight-impacting complications.” They also noted that the app isn’t yet proven to be reliable for predicting post-op refraction outcomes, as a previous study demonstrated its tendency to overestimate residual refractive errors.

While initial evidence from these studies suggests that these interventions may be able to replace portions of in-person postoperative care, the scant amount of published studies, along with inconsistencies in quality and study designs, complicates the formulation of concrete guidelines for clinical use, the researchers wrote in their paper.

“Despite these challenges,” they concluded, “the growing interest in digital and remote care indicates a potential shift in cataract care delivery. Clinicians may consider digital remote screening to complement their traditional postoperative follow-up, but further research is essential for validation and to clarify the role of these interventions within the care pathway.” They also noted that “expected advancements in artificial intelligence are likely to expand the impact of digital care within ophthalmology.”

^{1. Wanten JC, Segers MHM, Kleijnen J, Bauer NJC, Nuijts R. Efficacy of remote care in cataract surgery: A systematic review. J Cataract Refract Surg. March 12, 2025. [Epub ahead of print].}

More Negative Effects from Smoking

Decades of research has proven that cigarette smoking increases one’s risks for various life-threatening diseases, but some users may not experience any detrimental issues. However, habitual smoking changes the body’s homeostasis in negative ways that are unnoticeable to the user, especially in the eyes. 

Although most clinicians think of elevated age-related macular degeneration and cataract risk when considering the ocular hazards, smokers with no history of eye disease or systemic diseases can have significantly worse ocular surface health compared to non-smokers.

Smoking tobacco is detrimental to a patient’s health. Not only does it impact the respiratory and cardiovascular systems, but it negatively affects the integrity of the ocular surface. Research has shown that there is significantly lower nerve fiber density in smokers vs. non-smokers. Also, neuromas were larger and of greater total area in smokers compared to non-smokers. 

In a recent study conducted at the Singapore Eye Research Institute, researchers examined the ocular morphology of smokers and non-smokers.¹ Each subject was chosen based on their medical history. If a patient had a previous eye surgery, a current eye disease and/or systemic disease, then they were excluded from the study. A total of 250 smokers and 272 non-smokers were identified.

Data was collected using in vivo confocal microscopy to examine corneal changes, and tear break-up time, ocular surface and corneal staining, corneal sensitivity and Schirmer tests were used to evaluate the ocular surface. An Ocular Surface Disease Index questionnaire was provided to each subject to assess any symptoms they may be experiencing.

“In the present study, we reported that smoking has adverse effects on corneal nerve and ocular surface health, evidenced by the significantly worse corneal nerve metrics, larger corneal neuromas size and area, higher dendritic cell density and count along with reduced elongation,” stated the authors in their paper. Here are some of their findings:

• The corneal nerve fiber density, branch density, fiber length, total branch density, fiber area and fractal dimension were all significantly lower for smokers compared to non-smokers in the study.
• Corneal neuromas were found in more smokers than non-smokers (18.8 percent vs. 4.2 percent).
• Dendritic cell density was significantly higher for smokers, who had a count of 14.64 ±9.34 (compared to 12.02 ±10.07 in non-smokers), with significantly lower elongation for smokers.
• The researchers noted that the results for smokers led to higher Oxford scores and reduced tearfilm breakup time measurements. The mean Oxford score for smokers was 0.7 ±0.04, which was significantly higher than non-smokers (0.52 ±0.04). Researchers recorded a mean time of 4.99 ±2.54 seconds for smokers when measuring their tear break-up time. Compared to non-smokers (5.82 ±4.10 seconds), smokers had significantly lower tear-film breakup time. These results suggest that smokers have a more compromised ocular surface, even if they’re healthy.

“Our research highlights the potential risks associated with smoking in relation to ocular surface integrity and can potentially be a consequence for the management of ocular surface disorders in smokers,” concluded the authors.”

^{1. Anam A, Yu M, Liu C, et al. Smoking negatively impacts ocular surface and corneal nerve metrics. Ocular Surface. March 13, 2025. [Epub ahead of print].}

Risk Factors for Reops After Cataract Surgery

Cataract surgery is extremely safe, but as with any surgery, there are several factors that can increase the risk for complications or poorer outcomes. One metric used to assess surgical quality is the rate of return to the operating room. Unplanned returns are associated with increased costs and resource use as well as short- and long-term morbidity. To get a better picture of cataract surgery performed by residents, fellows and attendings, researchers at the Wilmer Eye Institute conducted a retrospective study on more than 32,000 cases.¹ By identifying key risk factors, their findings can help provide a framework for reducing surgical complications.

The study included patients aged ≥40 years who underwent cataract surgery between 2019 and 2022. Researchers used statistical modeling to identify the rate of unplanned return to the OR and most common reasons for it.

In the study cohort, 0.5 percent of eyes had an unplanned return to the OR within 21 days of cataract surgery. The most common reason was retained lens fragments (50 percent of incidents). Patients who returned to the OR had worse mean best corrected visual acuity preoperatively (20/100 vs. 20/50 for controls) and at the last follow up visit (20/50 vs. 20/30 for controls). The researchers identified a significantly higher rate of unplanned OR return for patients who underwent complex cataract surgery and for those with prior tamsulosin use.

“This study provides new information on the postoperative course after cataract surgery and a framework for surgeons to consider the risk factors for reoperation and the appropriate preoperative preparation to limit intraoperative complications and provide more accurate patient education on postoperative risks,” the researchers concluded in their AJO paper. They called for multicenter studies examining the rate of unplanned reoperation.

^{1. Suazo MK, Hamza Khan MM, Akhlaq A, et al. Unplanned return to the operating room after cataract surgery. Am J Ophthalmol 2025. [Epub ahead of print].}

Air Pollution Linked to Diabetic Retinopathy Rates

Ambient air pollution may exacerbate ocular conditions in various ways; however, there has been somewhat limited comprehensive research on the effects of various pollutants. In a new study conducted in China, researchers evaluated the association between multiple air pollutants and the incidence of five vision-threatening ocular diseases: cataracts, glaucoma, macular degeneration, diabetic retinopathy and retinal detachment.¹ They found exposure to high levels of particulate matter (PM) were associated with increases in diabetic retinopathy and retinal detachments. The findings were reported in American Journal of Ophthalmology.

A total of 114,930 participants were included. Annual average concentrations of nitrogen oxides, nitrogen dioxide and particulate matter with diameters <2.5µm (PM2.5) and <10µm (PM10) were assessed using land use regression models.

PM10 was linked to a 9-percent increase in retinal detachment incidence in the myopic population and PM2.5 was linked to an 8-percent increase in glaucoma incidence in the nonmyopic population. High PM10 exposure was associated with a 61 percent higher risk of diabetic retinopathy in the myopic group.

Despite the widespread concern about PM2.5, the researchers suggest that PM10 might play an even more significant role in certain ocular diseases, such as diabetic retinopathy and retinal detachment.

While PM2.5 particles are more likely to penetrate into the respiratory system, the study suggests that, due to the larger article size, PM10 substances might have a more direct impact on the ocular surface. As an example, for diabetic retinopathy the pathophysiology may involve increased oxidative stress, inflammation, endothelial dysfunction and elevated cytokines induced by hyperglycemia, which could lead to microvascular damage in the retina, the authors explained.

“Although myopia is known to confer a protective advantage against diabetic retinopathy, our study found PM10 exposure increased risks in low-to-moderately myopic populations,” the researchers wrote. “This observation hints at the possibility that the stimulatory influence of PM10 on VEGF may potentially outweigh the protective effect imparted by axial elongation in patients with low-to-moderate myopia.”

The impact of PM10 on diabetic retinopathy was more pronounced in individuals with low-to-moderate myopia than in those with high myopia. High PM10 exposure also correlated with a 67 percent higher risk of retinal detachment and a 44 percent higher risk of macular degeneration in the low-to-moderate myopic population.

For the purposes of public health, the authors suggest that current air quality guidelines may need to be revisited, particularly pollutants such as PM10, which have been shown to have detrimental effects on eye health.

“This highlights the importance of incorporating ocular health considerations into air quality management strategies,” the authors say.

^{1. Wang Z, Yu Y, Ye Y, et al. Associations between ambient air pollution and five common vision-threatening ocular diseases in middle-aged and older adults: a large prospective cohort study. Am J Ophthalmol. March 3, 2025. [Epub ahead of print.]}

OCTA Gives New View of SLT Outcomes

OCT scans of anterior segment structures, while not yet commonplace, are increasingly finding clinical applications. Anterior segment OCT angiography, however, has far fewer uses outside of research settings. Perhaps a new method could one day become a routine post-op safety check after  selective laser trabeculoplasty, based on findings recently published in the journal Vision.¹

Russian researchers assessed microcirculation characteristics of the irises of patients with primary open-angle glaucoma via OCTA scans immediately after SLT. The investigation included 31 eyes of 31 patient  (32.2 percent female; mean age 70.7 years) who all received standard SLT plus OCTA examination preoperatively and at day one and day seven postop. The researchers found from their data that iris vessel density increased significantly the day after SLT, followed by a decrease back to baseline level at one week. A significant correlation was also observed between the percentage change in iris vessel density the day following the procedure and intraocular pressure change at three months.

In the discussion section of their paper on the work, the researchers describe how the vascularity change of the iris was not detectable with slit lamp examination, instead representing a subclinical phenomenon. Following this, the researchers propose several potential reasons for the observed transitory increase in iris vessel density. One explanation may be collateral iris damage induced by the laser beam, since the laser beam runs tangentially to the iris surface and can touch the iris during pulses. However, as the operator typically controls the profile of the laser spot during manipulation to keep it round and avoid interaction of the beam with the iris surface, the authors excluded the role of direct iris damage.

A second possibility is indirect hyperemia of the iris induced by activating biological signaling pathways and the expression of biologically active molecules produced by the trabecular meshwork. Finally, a third explanation may be inflammation being part of cyclitis caused by ciliary body damage; this seems possible, the authors contend, because of the large spot used in SLT, which may cover part of the ciliary body.

However, they do note, “in general, the results of our study suggest that, although inflammation of anterior eye segment seems to be present in eyes after SLT, it plays no, or only a minor role, as the mechanism of action of SLT.” This is because despite anterior segment inflammation causing transient IOP decreases, it would not influence long-term SLT outcomes, since inflammation and transitory IOP reduction regress a few days after SLT.

The authors also propose that “since patients with a greater increase in iris vessel density show poorer long-term outcomes, the next-day increase in iris vascularity may be used as a biomarker for SLT prognostication.” As a result, “the assessment of iris vascularity after SLT may be used to predict which patients will have an unsatisfactory outcome of SLT,” they suggest. While this idea is an interesting proposed new method to evaluate iris safety after SLT, researchers will continue to explore its validity; in time, however, it may become a way to check for problems postoperatively. 

^{1. Maltsev DS, Kulikov AN, Kazak AA. Iris microcirculation after selective laser trabeculoplasty: A pilot optical coherence tomography angiography study. Vision 2025;9:1:21.}