Journal of Cataract & Refractive Surgery

JCRS 2011: Looking back, looking ahead

2012-01-01

As 2012 begins, we reflect on a year of progress at the Journal of Cataract & Refractive Surgery and look ahead with excitement to the coming year. Every issue of JCRS is a product of innumerable hours of effort, and we wish to take this opportunity to thank all those who make JCRS the leading peer-reviewed anterior segment surgery journal. Each of us is a reader, and among these readers we also find authors, reviewers, editorial board members, office staff, advertisers, and publishers. Every person who touches the journal in one or another way has contributed something to its success, and to the efforts of each of these people, the journal is indebted.

Flaporhexis: Rapid and effective technique to limit epithelial ingrowth after LASIK enhancement

Steven E. Wilson, Marcony R. Santhiago — 2011-11-15

We describe a method of lifting and replacing the laser in situ keratomileusis (LASIK) flap to reduce the incidence of epithelial ingrowth beneath the flap after LASIK enhancement. In the rapid flaporhexis technique, the flap edge is opened by 1 clock hour with a Sinskey hook and the flap is peeled back after the exposed edge is grasped with a forceps. When necessary, further blunt retraction of the flap is performed with a triangular polyvinyl acetate sponge. After ablation and before the flap is replaced, a triangular sponge is used to clear epithelial remnants from the interface. This method consistently produces a smooth epithelial dissection and decreases the possibility that epithelium is retained beneath the flap.Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned.

Black-on-clear piggyback technique for a black occlusive intraocular device in intractable diplopia

2011-11-17

Black occlusive intraocular devices have been used successfully for intractable binocular diplopia. We describe a novel technique of implanting both a black occlusive device and a clear poly(methyl methacrylate) intraocular lens (IOL) in the capsular bag during phacoemulsification surgery. If the need should arise at a later date, this approach will allow safer and easier explantation of the black occlusive device, avoiding the need for IOL exchange.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Single versus double femtosecond laser pass for incomplete laser in situ keratomileusis flap in contralateral eyes: Visual and optical outcomes

2012-01-01

Purpose: To evaluate visual acuity, refractive outcomes, and anterior corneal higher-order aberrations (HOAs) after myopic laser in situ keratomileusis (LASIK) with uneventful single femtosecond laser pass versus double pass performed for intraoperative suction loss.Setting: Private refractive surgery center, Valencia, Spain.Design: Cohort study.Methods: After the LASIK flap was created with a single pass of an Intralase femtosecond laser in 1 eye and a double pass in the fellow eye, the ablation was performed with a Visx S2 laser. At 12 months, the refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, and anterior corneal HOAs were measured with 4.0 mm and 6.0 mm pupils.Results: The study enrolled 42 eyes (21 patients). Twelve months postoperatively, there were no statistically significant differences in any parameter studied including residual spherical equivalent (mean −0.05 diopter [D] ± 0.25 [SD] single pass; −0.03 ± 0.19 D double pass; P=.75), UDVA (mean 0.008 ± 0.057 logMAR single pass; 0.011 ± 0.046 logMAR double pass; P=.89), CDVA (mean −0.010 ± 0.040 logMAR single pass; −0.007 ± 0.037 logMAR double pass; P=.74), or anterior corneal HOAs. No eye lost 1 line of CDVA.Conclusions: Visual acuity, refractive outcomes, and anterior corneal HOAs were comparable between eyes after uneventful femtosecond laser single pass or double pass after suction loss affecting the pupillary area. A new femtosecond laser pass performed immediately after incomplete flap due to intraoperative suction loss provided good visual and optical outcomes.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Optical quality after myopic photorefractive keratectomy and laser in situ keratomileusis: Comparison using a double-pass system

2012-01-01

Purpose: To use a double-pass system to compare the optical quality after photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) for mild to moderate myopia.Setting: Universitat Politècnica de Catalunya, Terrassa, Barcelona Institute of Ocular Microsurgery, Barcelona, Spain.Design: Comparative case series.Methods: Optical quality was assessed with a clinical double-pass system preoperatively and 3 months after PRK or LASIK. The modulation transfer function (MTF), retinal image quality parameters (MTF cutoff frequency, Strehl ratio), and intraocular scattering (objective scatter index [OSI]) were calculated.Results: This study evaluated 34 eyes that had PRK and 55 eyes that had LASIK. Both PRK and LASIK had a statistically significant impact on retinal image quality, although no significant differences between the techniques were observed. The MTF at 30 cycles per degree decreased by a factor of 1.50 in the PRK group and by a factor of 1.32 in the LASIK group. The MTF cutoff frequency decreased by a factor of 1.04 in the PRK group and by a factor of 1.06 in the LASIK group. The Strehl ratio decreased by a factor of 1.10 and 1.07, respectively. Photorefractive keratectomy and LASIK increased the objective scatter index by factors of 1.48 and 1.57, respectively. Significant correlations between the preoperative refraction and the OSI were found.Conclusions: Retinal image quality was similarly reduced with PRK and LASIK, with no significant differences between the 2 methods. Some PRK patients had a residual refractive error that might have been related to corneal-wound healing still present 3 months postoperatively.Financial Disclosure: Dr. Arjona is an investor in and Drs. Güell and Pujol are investors in and consultants to Visiometrics S.L., Terrassa, Spain. None of the other authors has a financial or proprietary interest in any material or method mentioned.

Optical ray tracing–guided laser in situ keratomileusis for moderate to high myopic astigmatism

Silvia Schumacher, Theo Seiler, Arthur Cummings, Matthias Maus, Michael Mrochen — 2011-10-28

Purpose: To assess the efficacy, safety, and predictability of an individualized laser in situ keratomileusis (LASIK) ablation profile based on an optical ray-tracing algorithm to treat moderate to high myopic astigmatism.Setting: Ophthalmology centers in Zurich, Switzerland; Dublin, Ireland; and, Cologne, Germany.Design: Multicenter clinical trail.Methods: This 3-center study enrolled eyes with a manifest refraction sphere ranging from 0.50 to −10.25 diopters (D) and/or astigmatism ranging from 0.00 to −4.50 D. The intended outcome was plano in most eyes, undercorrection of 0.50 D in 1 eye, and undercorrection of 0.25 D in 2 eyes. Refractive outcomes were analyzed preoperatively and postoperatively at 1 day and 1 and 3 months.Results: The study enrolled 127 eyes (71 patients). The mean manifest refraction was −5.92 D ± 1.72 (SD). By 3 months postoperatively, 15 eyes had been lost to follow-up and 1 eye was excluded from analysis because of early retreatment. Of the remaining 111 eyes, 93 (83.8%) had an uncorrected distance visual acuity (UDVA) of 20/20 or better. The mean manifest refraction spherical equivalent (MRSE) in all eyes was 0.03 ± 0.30 D. In 97 (87.4%), the MRSE was within ±0.50 D and in 107 (96.4%), within ±1.00 D. No eye lost 2 or more lines of corrected distance visual acuity.Conclusions: The new optical ray-tracing algorithm for individualized LASIK ablation profiles to treat moderate to high myopic astigmatism was efficacious, safe, and predictable. The UDVA in eyes with high myopic astigmatism was better than in those treated with wavefront-guided LASIK.Financial Disclosure: Drs. Schumacher and Mrochen are paid scientific consultants to and Drs. Seiler and Cummings and Mr. Maus are members of the medical advisory board of Wavelight, Erlangen, Germany.

Small-aperture corneal inlay for the correction of presbyopia: 3-year follow-up

2011-10-24

Purpose: To report the 3-year postoperative safety and efficacy outcomes of the Acufocus corneal inlay.Setting: University Eye Clinic, Paracelsus Medical University, Salzburg, Austria.Design: Prospective nonrandomized noncomparative cohort study.Methods: The corneal inlay was implanted in the nondominant eye of naturally emmetropic presbyopic patients. Refraction, uncorrected near (UNVA), intermediate (UIVA), and distance (UDVA) visual acuities; corrected distance visual acuity (CDVA); contrast sensitivity; visual fields; subjective patient satisfaction and symptoms; and operative and postoperative adverse events and complications were evaluated.Results: The study enrolled 32 patients. The mean UNVA improved from Jaeger (J) 6 preoperatively to J1 at 3 years and the mean UIVA, from 20/40 to 20/25, respectively. At 3 years, 97% of eyes had a UNVA of J3 or better and 91% had a UIVA of 20/32 or better. The mean UDVA was 20/20, with all eyes achieving 20/32 or better. Nine eyes (28.3%) lost 1 line of CDVA, 1 eye (3.1%) lost more than 2 lines (3.8 lines), and 3 eyes (9.3%) gained 1 line. No inlay was explanted, and no inflammatory reactions were observed. At 3 years, 15.6% of patients reported severe night-vision problems and 6.3% (versus 87.5% preoperatively) reported being dependent on reading glasses.Conclusions: These 3-year results support the safety and efficacy of the corneal inlay to correct presbyopia in naturally emmetropic presbyopic patients. However, despite a significant gain in UNVA and UIVA, 28.3% of patients lost 1 line of CDVA.Financial Disclosure: Acufocus, Inc., California, USA, financially supports the Research Foundation for Promoting Opthhalmology, Salzburg, Austria, as the clinical research center of the University Eye Clinic, Paracelsus Medical University, Salzburg. Dr. Grabner received travel expenses from Acufocus, Inc. Dr. Riha currently works as a clinical application specialist for Acufocus, Inc. Drs. Seyeddain, Hohensinn, Nix, Rückl, and Dexl have no financial or proprietary interest in any material or method mentioned.

Central vault after phakic intraocular lens implantation: Correlation with anterior chamber depth, white-to-white distance, spherical equivalent, and patient age

2012-01-01

Purpose: To compare the central postoperative vault of a phakic intraocular lens (pIOL) to correct myopia, myopic astigmatism, and hyperopia and identify ocular and lens parameters that might predict the vault amount.Setting: Fernández-Vega Ophthalmological Institute, Oviedo, Spain.Design: Cohort study.Methods: Three months after implantation of Implantable Collamer Lens pIOLs to correct myopia, hyperopia, and myopic astigmatism, central vault was measured using optical coherence tomography. Patients were divided into groups according to the preoperative anterior chamber depth (ACD) to compare the effects of ACD, white-to-white (WTW) distance, and lens diameter on postoperative pIOL vault.Results: Hyperopic pIOLs had statistically significantly lower vault followed by myopic pIOLs and toric pIOLs, which had a higher mean value and narrower range (260 to 860 μm). Measured vaults had a positive correlation with preoperative ACD (r = .32, P<.001) and WTW (r = .29, P<.001) and a negative correlation with preoperative spherical equivalent (SE) (r = −0.21, P<.001) and patient age (r = −0.12, P=.025). Eyes with a vault of 250 μm or less had a shallower ACD than eyes with a vault between 250 μm and 750 μm (mean difference −0.11 mm; P=.012) and those with a vault greater than 750 μm (mean difference −0.25 mm; P<.001).Conclusions: Central vaulting was lower in hyperopic eyes. Current nomograms for pIOL diameter selection based on ACD and WTW might yield ideal vault and may have to be adjusted for older patients, shallower ACD, lower WTW, and lower SE.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Rotational stability of a toric intraocular lens: Influence of axial length and alignment in the capsular bag

2011-11-07

Purpose: To evaluate the rotational stability of a toric intraocular lens (IOL) using purpose-designed software and to determine the influence of axial length (AL) and in-the-bag IOL alignment on IOL rotation.Setting: Iladevi Cataract & IOL Research Centre, Ahmedabad, India.Design: Prospective observational case series.Methods: This study enrolled eyes that had AcrySof toric IOL implantation. The AL was measured using optical coherence biometry or immersion A-scan biometry. Corneal astigmatism was determined by manual keratometry and topography. The IOL alignment was vertical, horizontal, or oblique. Rotational stability was measured using the purpose-designed software, and the mean absolute difference was determined. The effect of AL and IOL alignment on rotational stability was determined 6 months postoperatively.Results: The study evaluated 168 eyes (168 patients). The mean AL was 23.86 mm ± 1.63 (SD), (range 19.50 to 29.03 mm). The median IOL rotation was 0.3 degree from baseline to 1 week, 1.0 degree from 1 week to 1 month, 0.2 degree from 1 to 3 months, and 0.1 degree from 3 to 6 months. The maximum rotation occurred between 1 week and 1 month. There was a strong correlation between AL and IOL rotation at 6 months (r = 0.93, P<.001). The mean absolute difference at 6 months was not significantly different between the 3 axis placement categories when correlated with the rotation (P=.102, analysis of variance).Conclusions: Toric IOL rotation was greater in eyes with a longer AL. Alignment of the IOL in the capsular bag had no influence on rotation.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Comparison of clinical outcomes with 2 small-incision diffractive multifocal intraocular lenses

İzzet Can, Başak Bostancı Ceran, Gülizar Soyugelen, Tamer Takmaz — 2011-11-15

Purpose: To evaluate and compare the clinical results of 2 diffractive multifocal small-incision intraocular lenses (IOLs) implanted after biaxial microincision cataract surgery (MICS).Setting: Atatürk Training and Research Hospital, 2nd Ophthalmology Department, Ankara, Turkey.Design: Comparative case series.Methods: Eyes that had biaxial MICS with implantation of an Acri.Lisa 366D IOL (Group 1) or Acriva Reviol MFM 611 IOL (Group 2) were followed for at least 6 months postoperatively. Uncorrected distance (UDVA), intermediate (UIVA), and near (UNVA) visual acuities; corrected distance visual acuity; distance-corrected intermediate and near visual acuities; and contrast sensitivity measurements with and without glare were determined. Early and late complications and subjective complaints were recorded and evaluated.Results: The study enrolled 60 eyes of 32 patients. The preoperative and intraoperative data were comparable in the 2 IOL groups. There were no statistically significant postoperative differences in the mean spherical equivalent (Group 1, −0.30 diopter (D) ± 0.30 [SD]; Group 2, −0.26 ± 0.28 D; P=.584), mean UDVA (0.80 ± 0.14 and 0.86 ± 0.17, respectively; P=.158), and mean Jaeger UNVA (1.46 ± 0.73 and J 1.23 ± 0.50, respectively; P=.155). However, there was a significant difference in mean Jaeger UIVA (3.06 ± 0.90 and 2.23 ± 0.72, respectively; P=.000). Mesopic contrast sensitivity and the incidence of complications and dysphotopsia symptoms were not significantly different between the 2 IOL groups.Conclusions: Both IOLs provided excellent distance and near visual acuity and contrast sensitivity. The Group 2 IOL gave better intermediate distance results.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Comparison of a new-generation sectorial addition multifocal intraocular lens and a diffractive apodized multifocal intraocular lens

2011-11-14

Purpose: To compare visual, refractive, and satisfactory outcomes between a new-generation sectorial addition multifocal intraocular lens (IOL) (Lentis Mplus LS-312; study group) and a diffractive apodized multifocal IOL (Restor SN6AD1; control group).Setting: Private practice, Driebergen, and Department of Ophthalmology, Academic Medical Center, Amsterdam, The Netherlands.Design: Comparative case series.Methods: Refractive and visual outcomes at near and distance, patient satisfaction, and dysphotopsia scores were recorded 3, 6, and 12 months postoperatively.Results: The study group comprised 90 eyes and the control group, 143 eyes. Three months postoperatively, the mean uncorrected distance visual acuity (UDVA) was not statistically significantly different between the study group and the control group (0.04 ± 0.15 logMAR [SD] versus 0.06 ± 0.25 logMAR). The control group had significantly better uncorrected near visual acuity than the study group at 30 cm (0.05 ± 0.14 logMAR versus 0.15 ± 0.08 logMAR) and 40 cm (0.05 ± 0.14 versus 0.16 ± 0.21) (P<.01 and P<.03, respectively). Patients in the control group were more satisfied with their vision (P<.001). Dissatisfaction was related to younger age at surgery and male sex (P<.0001 and P<.033 respectively). Dysphotopsia occurred in approximately 18% of cases in both groups.Conclusions: The new sectorial addition multifocal IOL performed comparably to the diffractive apodized multifocal IOL in terms of UDVA and the presence of dysphotopsia. The diffractive apodized multifocal IOL performed better at 30 cm and 40 cm reading distances and had higher patient satisfaction.Financial Disclosure: Dr. Lapid-Gortzak has received speaker’s fees from Alcon, Simovision, Oculentis, and Medtechnika. Dr. Lapid-Gortzak and Dr. van der Meulen have received an unrestricted research grant from Oculentis. Dr. van Velthoven has received speaker’s fees from Novartis (Netherlands). Drs. van der Linden, Nieuwendaal, and Mourits have no financial or proprietary interest in any material or method mentioned.

Development of a questionnaire to assess the relative subjective benefits of presbyopia correction

2011-11-14

Purpose: To develop a standardized questionnaire of near visual function and satisfaction to complement visual function evaluations of presbyopic corrections.Setting: Eye Clinic, School of Life and Health Sciences, Aston University, Midland Eye Institute and Solihull Hospital, Birmingham, United Kingdom.Design: Questionnaire development.Methods: A preliminary 26-item questionnaire of previously used near visual function items was completed by patients with monofocal intraocular lenses (IOLs), multifocal IOLs, accommodating IOLs, multifocal contact lenses, or varifocal spectacles. Rasch analysis was used for item reduction, after which internal and test–retest reliabilities were determined. Construct validity was determined by correlating the resulting Near Activity Visual Questionnaire (NAVQ) scores with near visual acuity and critical print size (CPS), which was measured using the Minnesota Low Vision Reading Test chart. Discrimination ability was assessed through receiver-operating characteristic (ROC) curve analysis.Results: One hundred fifty patients completed the questionnaire. Item reduction resulted in a 10-item NAVQ with excellent separation (2.92), internal consistency (Cronbach α = 0.95), and test–retest reliability (intraclass correlation coefficient = 0.72). Correlations of questionnaire scores with near visual acuity (r = 0.32) and CPS (r = 0.27) provided evidence of validity, and discrimination ability was excellent (area under ROC curve = 0.91).Conclusion: Results show the NAVQ is a reliable, valid instrument that can be incorporated into the evaluation of presbyopic corrections.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Informed consent for cataract surgery: Patient understanding of verbal, written, and videotaped information

Anita N. Shukla, Mary K. Daly, Paul Legutko — 2011-11-07

Purpose: To determine the effectiveness of verbal, written, and videotaped descriptions of cataract surgery on patients’ understanding of the risks, benefits, and treatment alternatives.Setting: Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.Design: Randomized prospective study.Methods: Patients eligible for cataract surgery were randomized into 1 of 4 arms of the informed consent process as follows: Group 1, conventional verbal information; Group 2, conventional verbal information plus second-grade reading level brochure; Group 3, conventional verbal information plus eighth-grade reading level brochure; Group 4, conventional verbal information plus American Academy of Ophthalmology DVD Understanding Cataract Surgery: Patient Education DVD Featuring an Aid to Informed Consent. After the informed consent process, patients in each group completed a 12-question questionnaire discussing the surgical procedure, its benefits, its foreseeable and unforeseeable risks, and the alternatives to cataract surgery. Scores in each group were calculated as the number of correct responses out of 12 questions.Results: Patients in Group 2 (mean score 10.8 ± 1.29 [SD]) and Group 4 (mean score 10.56 ± 1.44) scored significantly higher than patients in Group 1 (mean score 7.68 ± 2.80) or Group 3 (mean score 9.08 ± 1.60). Previous cataract surgery and education level had no significant influence on recall of the informed-consent process.Conclusions: Concise informed consent information sheets at lower reading grade levels and videotape presentation optimized patient understanding of the risks, benefits, and treatment alternatives to cataract surgery. The cost–benefit of these results is important because better patient understanding has the potential to decrease the risk for indemnity payments awarded because of inadequate informed consent.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Effect of blue-light filtering on multifocal visual-evoked potentials

2011-10-17

Purpose: To perform an objective functional assessment of the impact of blue-light filters on cortical processing to evaluate the potential side effects of the filters on higher tier visual function at the neural level.Setting: Department of Ophthalmology, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.Design: Cohort study.Methods: Multifocal pattern-reversal visual-evoked potentials (multifocal VEPs) were recorded monocularly in pseudophakic patients with a clear intraocular lens (IOL) under 2 conditions: (1) stimulus perception through a yellow filter with the filter characteristics of an AF-1 YA-60BB IOL (blue filtering); (2) stimulus perception through a neutral filter that homogeneously attenuates the effective stimulus intensity as under the blue-light filtering condition but independent of the wavelength (neutral filtering). Second-order kernel multifocal VEPs were extracted for 60 visual field locations, and amplitude and latency effects were determined for 6 stimulus eccentricities.Results: The study evaluated 20 patients. Typical multifocal VEPs were obtained for the blue-light and neutral filtering conditions at all eccentricities. No significant effects on amplitudes were obtained, and a subtle latency effect (<0.5 millisecond delay for neutral filtering; P<.02) did not reach significance in an eccentricity-specific analysis.Conclusions: The induced short-term change in the spectral composition of the visual stimulus left neural activity at the level of the primary visual cortex largely unaffected, providing an objective account of the integrity of visual processing under this condition.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Effect of povidone–iodine concentration and exposure time on bacteria isolated from endophthalmitis cases

2011-10-10

Purpose: To determine the in vitro susceptibility of post-cataract surgery endophthalmitis bacterial isolates to different concentrations of povidone–iodine at different exposure times.Setting: Poostchi Ophthalmology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.Design: Experimental study.Methods: Ocular-fluid samples obtained from patients diagnosed with postoperative endophthalmitis were submitted to a microbiology laboratory for culture. One milliliter of microbial isolate suspension with a McFarland standard turbidity of 0.5 was mixed with 1 mL of 1%, 2%, 5%, and 10% povidone–iodine solutions. After 1 minute, 5 minutes, and 15 minutes of exposure at 37°C, each solution was transferred to appropriate culture media and incubated at 37°C for 24 hours.Results: Organisms were isolated in 30 (68%) of the 44 patients evaluated. Coagulase-negative Staphylococcus was identified in 14 cases (47%), Streptococcus species in 8 cases (27%), Staphylococcus aureus in 5 cases (17%), Bacillus cereus in 2 cases (6%), and Pseudomonas aeruginosa in 1 case (3%). Higher povidone–iodine concentrations and longer exposure times were more effective than lower povidone–iodine concentrations or shorter exposure in preventing growth of bacterial isolates. The most effective regimens were 5% povidone–iodine for 15 minutes and 10% povidone–iodine for at least 5 minutes. With a high bacterial load, 13% of bacterial isolates remain viable after exposure to 10% povidone–iodine, even with a long exposure time.Conclusion: Results indicate that using 5% povidone–iodine for 15 minutes or 10% povidone–iodine for 5 minutes can prevent the growth of most post-cataract surgery endophthalmitis bacterial isolates.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Desktop auxiliary apparatus for A-scan ultrasound: Repeatability and validity

Hongfei Huang, Xiaohu Ding, Decai Wang, Xiangfu Yang, Dandan Wang, Mingguang He — 2011-11-14

Purpose: To evaluate the intraobserver repeatability and validity of biometric measurements with a newly developed auxiliary A-scan ultrasound apparatus at a rural clinic.Setting: Rural county hospital in China.Design: Evaluation of diagnostic technology.Methods: Patients awaiting surgery for age-related cataract were consecutively enrolled for preoperative A-scan biometric measurements. The applanation A-scan was performed by 2 experienced nurses, with 1 using the conventional handheld method and the other using the new method with the auxiliary desktop apparatus. Two consecutive measurements were performed with each method. The 95% limits of agreement (LoA) and Bland-Altman plot were used to assess and compare the intersession measurement repeatability between the 2 methods.Results: Data for 75 eyes of 75 consecutive patients were available for analysis. The mean age of the patients was 74.3 years ± 7.4 (SD); 40.0% were men. The desktop method had a smaller standard deviation and coefficient of variance than the conventional handheld method for both measurement sessions. For intersession repeatability, the desktop method had a narrower 95% LoA range than the handheld method for all the biometry parameters. The axial length (AL) obtained with the desktop method was significantly longer than that with the handheld method (23.32 mm versus 23.14 mm; P<.01).Conclusion: The newly developed auxiliary device had better intraobserver repeatability and more accurate AL measurements than the conventional handheld method, making it a better option for preoperative biometric measurement of cataract patients.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Refractive shift in pseudophakic eyes during the second decade of life

Rupal H. Trivedi, M. Edward Wilson, Dipankar Bandyopadhyay — 2012-01-01

Purpose: To evaluate the refractive shift in pseudophakic eyes of children after their 10th birthday.Setting: Storm Eye Institute, Charleston, South Carolina, USA.Design: Case series.Methods: One eye of each patient with at least 2 refractions at a minimum of a 1-year interval after the 10th birthday was analyzed.Results: One hundred fourteen pseudophakic eyes (114 patients) were identified. The mean initial refraction was −0.65 diopter (D) ± 2.27 (SD) and the mean final refraction, −1.78 ± 2.82 D. The mean shift in refraction was −1.13 ± 1.36 D; the mean shift in refraction per year was −0.30 ± 0.38 D. Postoperative refraction could be predicted by regression analysis (P<.001). There was a myopic shift in refraction in 86.8% of eyes; 64.0% of eyes had up to a 0.50 D myopic shift per year. Age at the time of intraocular lens (IOL) implantation (before or after 10 years of age) did not influence the refractive shift in pseudophakic eyes of children after their 10th birthday. However, the refractive shift was significantly different between black patients and white patients (P=.006). In unilateral cases, 27 eyes had refraction data available for the fellow eye. The mean refractive shift per year was −0.19 D in the operated eye and −0.22 D in the fellow eye (P=.67).Conclusion: A myopic shift in refraction continued in children after 10 years of age, which has important implications for the use of multifocal IOLs in preteens and teenagers and for IOL power selection.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Association of biometric factors with anterior chamber angle widening and intraocular pressure reduction after uneventful phacoemulsification for cataract

2011-11-07

Purpose: To evaluate anterior chamber biometric factors associated with the degree of angle widening and intraocular pressure (IOP) reduction after phacoemulsification.Setting: University of California, San Francisco, California, USA.Design: Case series.Methods: Anterior chamber parameters obtained by anterior segment coherence tomography were compared preoperatively and 3 months postoperatively. Measurements included the angle opening distance 500 μm anterior to the scleral spur (AOD500), trabecular–iris space area 500 μm from the scleral spur (TISA500), iris curvature (I-Curv), anterior chamber angle (ACA), trabecular–iris space area, anterior chamber volume, anterior chamber width, and lens vault (LV).Results: The study enrolled 73 eyes. The mean patient age was 77.45 years ± 7.84 (SD); 65.75% of patients were women. From preoperatively to 3 months postoperatively, the mean AOD500 increased significantly (0.254 ± 0.105 to 0.433 ± 0.108 mm) and the mean IOP decreased significantly (14.97 ± 3.35 to 12.62 ± 3.37 mm Hg) (P<.001). The reduction in IOP was correlated with the increase in AOD500 (r = 0.240, P=.041) and preoperative LV (r = 0.235, P=.045). After adjusting for related factors, AOD500 widening was positively correlated with LV (β = 0.458, P=.044) and I-Curv (β = 0.235, P=.043) and negatively correlated with preoperative TISA500 (β = −0.269, P=.025) and ACA (β = −0.919, P=.027).Conclusions: Surgically induced AOD widening was significantly correlated with anterior chamber biometric factors. Preoperative LV appears to be a significant factor in angle widening and IOP reduction after phacoemulsification.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Preoperative iris configuration and intraocular pressure after cataract surgery

Shilpi Pradhan, Christopher T. Leffler, Martin Wilkes, Muneera A. Mahmood — 2011-11-15

Purpose: To determine predictors of long-term intraocular pressure (IOP) after cataract surgery.Setting: Hunter Holmes McGuire Veterans Administration Hospital, Richmond, Virginia, USA.Design: Case series.Methods: Clinical variables, IOP by applanation tonometry, anatomic features on anterior segment optical coherence tomography (AS-OCT), and gonioscopy were assessed before and after uneventful cataract surgery in eyes with open filtration angles. Multivariate linear regression of preoperative measurements was used to predict the mean IOP from 2 to 18 months postoperatively.Results: The study enrolled 77 eyes (77 patients). Prediction of the mean postoperative IOP improved when up to 4 preoperative IOP values were averaged (r2 = 0.20) compared with using the final preoperative IOP value only (r2 = 0.13). The mean iris cross-sectional area decreased after surgery, from 3.84 mm2 to 3.70 mm2 (P=.01). The mean convex hull of the iris segments also decreased, from 5.05 mm2 to 4.19 mm2 (P<.001). The mean postoperative IOP was independently predicted by the preoperative average IOP, primary open-angle glaucoma, and the convex hull of cross-sectional iris segments (P=.001, model r2 = 0.38) or iris cross-sectional area (P=.003, model r2 = 0.36). Phacoemulsification parameters, incision type, and anterior chamber angle and depth did not predict postoperative IOP.Conclusions: Averaging up to 4 preoperative IOP values improved postoperative IOP predictions. A high iris cross-sectional area or convex hull of the iris segments on AS-OCT was associated with lower postoperative IOP. These findings might help identify patients who are likely to have the largest IOP drop after cataract surgery.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Homeostatic response of intraocular pressure in the early period after sutureless phacoemulsification

2012-01-01

Purpose: To determine the homeostatic response of postoperative intraocular pressure (IOP) by analyzing postoperative IOP trends after sutureless phacoemulsification.Setting: Asan Medical Center, Seoul, South Korea.Design: Comparative case series.Methods: Normotensive eyes were treated with sutureless phacoemulsification with in-the-bag posterior chamber IOL (PC IOL) implantation. The patients were randomly divided into 3 groups according to the intended immediate postoperative IOP as follows: Group 1, IOP less than 10 mm Hg; Group 2, IOP 10 to 21 mm Hg; Group 3, IOP over 21 mm Hg. The surgeon intentionally attempted supranormal, normal, or subnormal pressurization. The IOP was measured immediately after surgery and 2 hours, 4 hours, 1 day, 1 week, and 1 month postoperatively.Results: Group 1 included 88 eyes (27.8%), Group 2 included 130 eyes (41.2%), and Group 3 included 98 eyes (31.0%). The mean IOP immediately after surgery was 6.4 mm Hg ± 2.0 (SD), 14.5 ± 3.2 mm Hg, and 27.0 ± 4.6 mm Hg, respectively, with significant differences between the 3 groups (P<.05). However, the IOP values were nearly normalized in the 3 groups 2 to 4 hours postoperatively. Twenty-eight eyes (8.9%) had an IOP lower than 5 mm Hg immediately after surgery in the absence of incision leakage. There were no postoperative complications related to hypotony. Thirty-one eyes (9.8%) had an IOP of at least 30 mm Hg immediately after surgery; the IOP normalized by 1 day postoperatively.Conclusion: In normal eyes that had uneventful sutureless phacoemulsification with in-the-bag PC IOL implantation, immediate postoperative high or low IOP did not affect the return to baseline levels.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Intrastromal corneal ring segments for advanced keratoconus and cases with high keratometric asymmetry

Mohammad I. Khan, Anas Injarie, Mohammed Muhtaseb — 2011-11-07

Purpose: To report the safety and efficacy of intrastromal corneal ring segment (ICRS) implantation to manage keratoconus.Setting: Singleton Hospital Abertawe Bro Morgannwg University NHS Trust, Swansea, United KingdomDesign: Case series.Methods: Intacs SK ICRS were implanted manually for moderate to severe keratoconus and contact lens intolerance or ineffectiveness. Postoperative examinations were at 2 and 4 weeks; 3, 6, 9, and 12 months; and every 6 months thereafter. Outcome measures included uncorrected (UDVA) and corrected (CDVA) distance visual acuities, refraction, corneal topography, and slitlamp examination.Results: This study enrolled 31 eyes (29 patients; mean age 30 years). The mean UDVA was significantly better 12 months postoperatively (0.88 logMAR) than preoperatively (1.40 logMAR) (P=.001), as was the mean CDVA (0.29 logMAR versus 0.44 logMAR) (P=.04). The mean spherical equivalent was −6.57 diopters (D) preoperatively and −2.84 D at 12 months (P=.01). The mean keratometry (K) reading decreased from 52.07 D (range 45.9 to 63.1 D) to 46.15 D (range 39.2 to 52.9 D) for K1 (P<.0001) and from 57.9 D (range 52.5 to 69.7 D) to 51.2 D (range 46.8 to 58.3 D) for K2 (P<.0001). There were no intraoperative complications; however, 6 patients had segment extrusion.Conclusion: Implantation of ICRS was useful in managing keratoconus, producing up to 12.00 D of corneal flattening, which improved CDVA and allowed contact lens tolerance in all cases.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Toxicity comparison of intraocular azithromycin with and without a bioadhesive delivery system in rabbit eyes

2011-11-14

Purpose: To determine whether the addition of a bioadhesive drug-delivery system to topical azithromycin induces intraocular inflammation and damage when introduced intraocularly by different approaches and in varying doses.Setting: John A. Moran Eye Center, Salt Lake City, Utah, USA.Design: Experimental study.Methods: Commercial topical azithromycin 1.0% was duplicated, including the benzalkonium chloride, but without inclusion of the Durasite bioadhesive drug-delivery system. Injections of 50 μL, 25 μL, and 10 μL of the antibiotic solutions were administered in a masked fashion to 2 rabbits; 1 eye (study eye) in each rabbit was randomized to receive azithromycin with the delivery system and the fellow eye (control eye) to receive azithromycin without the delivery system. Two rabbits had topical drops of each solution placed after a 2.8 mm incision was created. Masked slitlamp examinations, pachymetry, and intraocular pressure (IOP) were determined 1 day and 2 days postoperatively. The animals were humanely killed, and the endothelial density and histopathology were examined.Results: The IOP (P<.001), pachymetry (P<.001), and signs of inflammation (P=.38 to .003) were consistently higher in the study eye, especially at the 50 μL dose, than in the control eye. This was confirmed by histopathology.Conclusion: If the drug-delivery system gains access to the anterior chamber, it may cause substantial corneal edema and inflammation, even at low doses and after topical administration.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Changes in intraocular lens surface roughness during cataract surgery assessed by atomic force microscopy

2011-11-07

Purpose: To analyze the changes in optic surface roughness before and after injection of various intraocular lens (IOL) models using atomic force microscopy (AFM).Settings: Departments of Ophthalmology, Medical University of Graz, General Hospital Linz and University Hospital Basel; Upper Austria University, School of Applied Health and Social Sciences, Linz, Austria.Design: Experimental study.Methods: The morphology and surface roughness of 3 hydrophobic acrylic IOLs from different manufacturers were analyzed by AFM in liquid using the tapping mode. First, AFM was performed on IOLs taken from the original package without further manipulation. In a second step, under sterile conditions, an experienced cataract surgeon loaded the IOLs into the appropriate injection system and pushed them through a system resembling an IOL implantation in cataract surgery; this was followed by AFM evaluation. Finally, 3 samples of a preloaded hydrophilic acrylic IOL taken from the original cartridge were compared with 3 samples that were pushed through the implantation system.Results: Comparison of the arithmetic mean, standard deviation, root mean square, and surface skewness of the IOLs before and after injection showed a significant increase in surface roughness (P<.05).Conclusions: Standard application procedures of IOLs may alter the IOL surface. Increases in the surface roughness of IOLs may influence postoperative posterior capsule opacification. Further studies are necessary to evaluate the interfacial properties of IOLs.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Assessment of a single-piece hydrophilic acrylic IOL for piggyback sulcus fixation in pseudophakic cadaver eyes

2011-11-07

Purpose: To evaluate a single-piece hydrophilic acrylic intraocular lens (IOL) designed for sulcus fixation in a piggyback configuration in postmortem pseudophakic human eyes.Setting: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.Design: Experimental study.Methods: Pseudophakic human cadaver eyes were imaged by high-frequency ultrasound (Artemis) to assess the overall position of the primary IOL and the sulcus diameter. The piggyback IOL (Sulcoflex) was then injected into the ciliary sulcus of these eyes. After fixation in formalin, they were reevaluated by high-frequency ultrasound for assessment of IOL fixation, fit, centration, tilt, and clearance from the primary IOL and intraocular structures and analyzed after sectioning.Results: Data could be obtained from 11 eyes, all in which the primary IOL was located in the capsular bag. Different foldable IOLs and different degrees of Soemmerring ring formation were represented. The piggyback IOL could be injected and positioned in the ciliary sulcus and had overall appropriate centration and minimum or no tilt. Clearance between the 2 IOLs ranged from 232 to 779 μm, mostly depending on the thickness of the primary IOL. Direct assessment of the sulcus-fixated haptics showed no disturbances to the ciliary processes.Conclusions: The new IOL has large optic and overall diameters, smooth and undulating haptics, and a convex–concave optic profile. Results show that these characteristics minimize the possibility of interaction with the primary IOL and uveal tissues, decreasing the likelihood of optical aberrations and pigmentary dispersion.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Recurrent iris cyst discharge

Rana Altan-Yaycioglu, Handan Canan, Yonca A. Akova — 2011-11-14

A 23-year-old woman with the diagnosis of anterior uveitis in the left eye was referred to our clinic. Circumferential midzonal iris epithelial cysts were observed in the right eye and corneal endothelial pigment precipitates and diffuse pigment discharge in the anterior chamber of the left eye. Topical prednisolone acetate was prescribed. After 2 days, hyperemia and pain decreased in the left eye and started in the right eye. During the following 3 months, the patient experienced 3 similar episodes, which resulted in diffuse pigment deposition in the anterior chamber angles. Intraocular pressure (IOP) elevation was observed after 1 week and 3 weeks in the left eye and right eye, respectively. Topical antiglaucomatous medication was prescribed. Nine months after the last episode, the uncorrected distance visual acuity was 20/20 and the IOP was 15 mm Hg bilaterally. The iris showed diffuse transillumination, and the pupils were unresponsive to light.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Reversible opacification of a hydrophilic acrylic intraocular lens

Choul Yong Park, Roy S. Chuck — 2011-11-11

A 56-year-old woman with diabetic retinopathy and chronic myelogenous leukemia had phacoemulsification cataract removal and hydrophilic acrylic intraocular lens (IOL) (Akreos MI-60) implantation in both eyes. One month after surgery, significant IOL opacity and severe cystoid macular edema were observed in both eyes. After bilateral intravitreal injection of bevacizumab (Avastin) to control macular edema, central clearing of the IOL opacity was observed in both eyes. Two months after the injection, the IOL opacity had almost disappeared from both eyes. To our knowledge, this is the first case of early postoperative bilateral IOL opacity in a hydrophilic acrylic IOL cleared after anti-vascular endothelial growth factor (VEGF) intravitreal injection. The role of anti-VEGF therapy in clearing IOL opacification requires further investigation.Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned.

Lenticular meridional astigmatism secondary to iris mesectodermal leiomyoma

K.V. Chalam, Carolee M. Cutler Peck, Sandeep Grover, Ravi Radhakrishnan — 2012-01-01

A 61-year-old African American man presented with decreased vision of 2 months duration. Examination revealed a significant lenticular astigmatism and sectoral cataract as a result of an amelanotic iris lesion. Slitlamp optical coherence tomography (OCT) revealed angle crowding. An excisional biopsy was performed along with phacoemulsification in the right eye, with intraocular lens implantation for meridional lenticular astigmatism. Histopathology and histoimmunochemistry confirmed a diagnosis of uveal mesectodermal leiomyoma. Lenticular astigmatism may be a subtle sign of an anterior segment tumor. Anterior segment slitlamp OCT is an effective tool in diagnosing as well as monitoring small interval changes in these types of tumors.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Microbial contamination of ultrasound biomicroscopy probes: Evaluation of cross-infection risk

Nicholas P. Bell, Aashish Anand, Audrey Wanger, Thomas C. Prager — 2011-11-14

Ultrasound biomicroscopy (UBM) is being used increasingly in cataract and refractive surgery to evaluate phacomorphic lenses, dislocated intraocular lenses, misplaced haptics, sulcus-to-sulcus measurements for implantable Collamer lenses (ICLs), ciliary body cysts before ICL implantation, retained lens fragments, and anterior effusions. In a previous report, biometry apparatus grew pathogenic flora despite routine disinfection with alcohol swabs, suggesting the risk for cross-contamination if the equipment is not sterilized. Ultrasound biomicroscopy probes may have the same risk because of identical disinfection methods. Recently, the ClearScan cover (ESI, Inc.), a U.S. Food and Drug Administration-approved sterile bag, has been developed as a more comfortable and less traumatic alternative to the open-shell/gel technique for UBM. This study investigates microbial inoculation of the sterile bag covers after single use and whether this contamination carries a realistic risk for cross-infection.

Creating a feedback loop to improve cataract surgery outcomes

Paul B. Greenberg, Victoria L. Tseng, Wen-Chih Wu, Curtis E. Margo — 2011-10-24

Numerous studies assess cataract surgery outcomes, identify risk factors for poor outcome, and define target areas that need improvement. However, these studies fail to address a more fundamental question: Is there any evidence that monitoring cataract surgery outcomes improves the quality of future care? The few studies that have investigated this have small numbers (N<505), are retrospective, and focus on residency training programs, which limits their generalizability.

Brown discoloration of acrylic multifocal, monofocal, and blue light–filtering IOLs

Albert T. Milauskas — 2012-01-01

It has been 20 years since I first detected and reported browning or discoloration of silicone intraocular lenses (IOLs) made by Staar, Iolab, and Allergan. It is ironic that I have detected and now report browning in an acrylic multifocal IOL (Restor) and monofocal IOL (Acrysof) (both Alcon Laboratories, Inc.) and an aspheric blue light–filtering IOL (PY-60AD, Hoya Surgical Optics GmbH). These are the first observed and reported cases of these IOLs that have become discolored brown after implantation. There were reports of discolored IOLs in 2007 and 2008. These IOLs were stained blue; 1 from inadvertent use of methylene blue instead of trypan blue and 1 from the systemic use of a drug to treat urinary tract infection (Prosed DS) that contains methylene blue. Both IOLs were made of silicone. The discolored IOLs in this study were observed over a 2-month period. A total of 10 discolored IOLs were observed in 6 patients, 2 men and 4 women. Two patients were operated on at my facility and the other 4 had been operated on at multiple other sites. The exact date of implantation in the latter patients could not be ascertained. The timeframe for implantation appears to be between 6 months and 8 years. In the 2 patients operated on at my facility, the implantations were done in 2006 (Acrysof) and 2010 (PY-60AD).

Refractive Surgical Problem: January consultation #1

Sonia H. Yoo — 2012-01-01

A 51-year-old man who had previous penetrating corneal transplantation (penetrating keratoplasty [PKP]) for keratoconus in the right eye presented to his primary ophthalmologist 2 years later with a visually significant cataract. Because of high and relatively symmetric astigmatism, the patient had phacoemulsification with implantation of an Acrysof IQ toric intraocular lens (IOL) (SN60T7, Alcon Laboratories, Inc.) to correct post-PKP astigmatism.

January consultation #2

Michael W. Belin — 2012-01-01

This case highlights the potential problems associated with the use of advanced IOLs (toric and multifocal) concomitant with or after full-thickness corneal transplantation. In general, I avoid these IOLs because the corneal transplant has a finite survival and if a repeat transplant is required (as in this case), you are left with a refractive dilemma. When possible, I prefer post-PKP corneal refractive surgery to deal with residual refractive errors. The exceptions could be a very elderly recipient, where the risk for rejection is lower and the expected graft survival may exceed the life expectancy of the patient, or (as in this case) patients with keratoconus, where overall graft survival is quite high. This case also highlights the risk that any surgical intervention or manipulation could induce a graft reaction/rejection. Although not mentioned, it is imperative to increase the steroid coverage during and after such procedures.

January consultation #3

Anthony Aldave — 2012-01-01

Options for management of corneal endothelial failure after PKP include repeat PKP, endothelial keratoplasty, and keratoprosthesis implantation. The decision on the most appropriate treatment modality depends on several factors, including historical factors (eg, number of previous graft failures, spectacle-corrected or contact lens–corrected vision before graft failure, patient's ability to successfully wear a contact lens before graft failure), anatomic factors (eg, significant corneal stromal opacification, presence of an intracapsular toric IOL), and other factors that would complicate the performance of DSEK (eg, peripheral anterior synechiae, anteriorly positioned tube shunts, presence of an anterior chamber IOL, aphakia, partial or complete aniridia).

January consultation #4

George Kymionis — 2012-01-01

Treatment of post-PKP corneal astigmatism has always been a challenge to ophthalmic surgeons. The introduction of refractive procedures, such as laser in situ keratomileusis (LASIK), femtosecond-assisted arcuate keratotomies, and toric IOL implantation, has offered effective approaches to manage this problem.

January consultation #5

Sophie X. Deng — 2012-01-01

The key issue in this case is astigmatic management. The implantation of the high-power toric IOL makes the eye have an inherent 3.00 diopters (D) of cylinder at the corneal plane. There are 3 possible approaches to rehabilitate the patient's vision. The first is a traditional PKP. The combination of the astigmatism from the repeat corneal transplantation and from the toric IOL will lead to challenging postoperative astigmatic correction. The curvature of the corneal plane would have to be adjusted to offset the astigmatism induced by the toric IOL. This is achievable as long as the axis of the toric IOL is known.

January consultation #6

Hassan Hashemi — 2012-01-01

In this case, several questions come to mind. First is whether continued medical treatment and a therapeutic contact lens (TCL) would resolve the visual problems or whether surgical treatment is needed. The corneal edema and irregular epithelium indicate corneal decompensation. Although medical treatment and TCL wear can alleviate the pain, they may have no effect on visual rehabilitation. I believe the patient should be treated surgically.

January consultation #7

Siamak Zarei-Ghanavati — 2012-01-01

The overall picture suggests that the visual loss is caused by graft edema secondary to endothelial failure. Although the irregular astigmatism on topography is a concern, the patient achieved 20/25 CDVA after cataract surgery. Thus, the astigmatism is probably the result of epithelial irregularity secondary to edema. In-office epithelial debridement followed by topography of the deepithelialized cornea could differentiate epithelial irregularity from true corneal irregularity. Because the patient was satisfied after cataract surgery (before graft failure), he could have DSAEK. I make my main incision in the steep meridian and expect an approximate 1.00 D hyperopic shift postoperatively.

January consultation #8

Kemal Ozulken — 2012-01-01

Some surgical options to treat graft failure can yield good visual outcomes. Repeat PKP and endothelial keratoplasty, in particular DSAEK, are alternatives. A serious drawback of repeat PKP is the slow visual recovery resulting from large and unpredictable refractive changes; the implanted toric IOL should also be taken into consideration because refractive changes after PKP regraft are inevitable. The repeat PKP and IOL exchange can be performed at the same time or as a 2-stage procedure consisting of repeat PKP followed months later by IOL exchange. The first alternative avoids an additional surgery and allows rapid recovery of vision; however, it may result in large refractive errors because of the inability to predict the IOL power correctly. The risks of this procedure include posterior capsule rupture and vitreous prolapse during surgery. The main advantage of a 2-stage procedure is that it provides patients with refractive errors closer to emmetropia. Its disadvantages include a delay in visual acuity and an increased risk for graft failure. In the case of a 2-stage procedure, all sutures should be removed to better determine the final corneal shape and better plan for astigmatic surgery before IOL exchange. In addition to the risks of simultaneous surgery, there is a risk for endothelial dysfunction from trauma, which can result in recurrence of graft failure with the 2-stage procedure.

January consultation #9

Francis W. Price — 2012-01-01

With the toric IOL in place, a PKP regraft would lead to induced astigmatism even if the transplant were perfectly spherical. If the regraft were not spherical, it would lead to complex astigmatism in combination with the IOL. Therefore, placement of an endothelial keratoplasty under the failed PKP is a better choice if the patient had acceptable visual and refractive results before PKP failure, which this patient did. This case is a great example of why toric IOLs should be implanted after PKP only when the PKP failure can be treated with endothelial keratoplasty.

Risk stratification and assessment in cataract surgery

Tom K.H. Butler — 2012-01-01

I believe the classification system for preoperative risk stratification for cataract surgery proposed by Gupta et al. is flawed in that no account of cumulative risk is made. Narendran et al. highlight the odds ratio (OR) and cumulative probability of vitreous loss with each risk factor and demonstrate that there is increasing risk with each additional risk factor present. Although the simple system proposed by Gupta et al. is appealing, it takes no account of this, which may falsely reassure.

Reply

Abha Gupta, Jas Singh, Bal Dhillon — 2012-01-01

The cataract classification we described is a simple guide to surgical complexity rather than an attempt to quantify a risk for a specific complication, ie, posterior capsule rupture. Although this complication may be a surrogate of surgical complexity, it was our aim to tailor the 3-point CC grade to a specific training task(s). To use the example Dr. Butler describes, a 70-year-old patient with pseudoexfoliation may require iris hooks and a capsular tension ring, which demands specific surgical skills and familiarity with these devices. In contrast, a 90-year-old patient with glaucoma, controlled intraocular pressure, and background diabetic retinopathy may not require any additional surgical skills compared with a younger patient without these comorbidities. In the event of a posterior capsule rupture, the consultant trainer would be expected to actively assist and/or complete the surgical procedure depending on the experience and capability of the trainee.

Oval capsulorhexis and its advantages

Gianluca Carifi — 2012-01-01

Singh et al.’s recent article on oval capsulorhexis for posterior polar cataract associated with preexisting capsule defect highlights important points in the surgical management, as well as providing some very educational videos. Surprisingly, the authors used sulcus-fixated intraocular lenses (IOLs) in only 2 cases. They preferred the endocapsular implantation in most cases, even without converting the defect into a posterior circular continuous capsulorhexis (PCCC). Any type of IOL can be placed inside the capsular bag if a posterior capsule rupture can be converted successfully into a PCCC. A sulcus-fixated IOL represents the safest option for unstable posterior capsule rupture. In addition, a 3-piece IOL can be placed in the bag when the optic can be securely captured through the anterior capsulorhexis.

Reply

Kiranjit Singh, Vikas Mittal, Harmit Kaur — 2012-01-01

Dr. Carifi pointed out 3 main issues with the oval capsulorhexis. First, the IOL should be placed in the capsular bag only after converting the posterior capsule rupture into a PCCC. Second, the sulcus-fixated IOL whose optics were captured with oval capsulorhexis could lead to IOL instability. Third, the diaphragm between anterior and posterior segments created by an oval capsulorhexis is weaker than that created by a small capsulorhexis. Our opinion on these issues is as follows:

Steroid depot injection versus postoperative steroid eyedrops to prevent inflammation and macular edema after cataract surgery

Saurabh Kamal — 2012-01-01

In the recent article by Dieleman et al., the methods and discussion were not adequate. First, measuring foveal thickness at 4 weeks is too early to detect all cases of macular edema, which peaks at 4 to 6 weeks and may develop several months after the surgery, as discussed in the article. Moreover, only 1% of macular edema cases show a significant decrease in vision and subsequent improvement can occur in 3 to 12 months in 80%. Hence, all patients might not have come for extra clinic visits, making the follow-up inadequate and not representative.

Reply

Myrthe Dieleman, Peter de Waard — 2012-01-01

We appreciate the interest and comments of Dr. Kamal. To respond to the first comment, we agree that measurement of foveal thickness after 4 weeks is too early to detect all cases of macular edema. In our study, the postoperative follow-up visits were scheduled in accordance with our standard postoperative evaluations; therefore, the measurements were taken 4 weeks after cataract extraction. We tried to account for this by reviewing patients’ records after 6 months to determine the number of visits for post-cataract clinical macular edema after the last study visit. We agree with Dr. Kamal that we certainly could have missed some cases, but this applies to both groups. If we had measured 6 weeks after cataract extraction or at another fixed time point, we also could have missed some cases. Moreover, the percentage of patients with post-cataract macular edema depends on the definition used. Currently, there is no validated or universally accepted method for reporting post-cataract (clinical) macular edema, as discussed in our article.

Prevention of post cataract–surgery cystoid macular edema with nepafenac

David B. Glasser — 2012-01-01

The recent article by Miyake et al. on post cataract–surgery cystoid macular edema left me with questions about study design and financial disclosures. The results are not surprising given that fluorometholone 0.1% is known to have poor corneal penetration and would not be expected to have significant effects on the posterior segment. Why not compare nepafenac with a steroid with better penetration, one that is more commonly used as part of the post cataract–surgery regimen (eg, prednisolone acetate 1.0%), another nonsteroidal agent with proven penetration and efficacy in treatment or prevention of postoperative cystoid macular edema, or an inert control?

Reply

Kensaku Miyake, Ichiro Ota, Goichiro Miyake, Jiro Numaga — 2012-01-01

We agree with Dr. Glasser that the intraocular penetration of topical fluorometholone is lower than that of other steroids. We performed a similar study in which we compared the effects of diclofenac and fluorometholone in preventing postoperative breakdown of the blood–aqueous barrier and cystoid macular edema. We also compared the above-mentioned effects of diclofenac and betamethasone. We observed that diclofenac was more effective than the steroid and that betamethasone induced elevation in intraocular pressure in postoperative pseudophakic eyes. We based the design of the present study on these findings. The most essential reason for selecting fluorometholone as the control drug was its similarity in appearance to nepafenac; this enabled us to perform a double-masked scientific comparison. Placebos with no active antiinflammatory effects were not used for ethical reasons.

Assessing the value of simulator training on residency performance

Ayman Naseri, David F. Chang — 2012-01-01

Many residency programs, including ours at the University of California San Francisco, have acquired surgical simulator technology without persuasive peer-reviewed evidence to quantify its value in improving resident education and outcomes. Studies such as the one by Belyea et al. attempting to document the value of simulator training are important because of the significant cost of the technology relative to the budgets of most residency programs. However, we are concerned that the study design and results do not adequately support the conclusions.

Reply

David A. Belyea, Sarah E. Brown, Lamise Z. Rajjoub — 2012-01-01

We thank Drs. Naseri and Chang for their comments on our article and their contribution to the discussion of the role of surgical simulators in ophthalmology resident training. Our study investigated the effect of simulator training on intraoperative surgical performance, and its primary findings were statistically significant improvements in phacoemulsification time, phacoemulsification power, and adjusted phacoemulsification time.

Editorial Board

2012-01-01

Masthead

2012-01-01

Visual Acuity Chart

2012-01-01

Journal of Cataract & Refractive Surgery

JCRS 2011: Looking back, looking ahead

Flaporhexis: Rapid and effective technique to limit epithelial ingrowth after LASIK enhancement

Black-on-clear piggyback technique for a black occlusive intraocular device in intractable diplopia

Single versus double femtosecond laser pass for incomplete laser in situ keratomileusis flap in contralateral eyes: Visual and optical outcomes

Optical quality after myopic photorefractive keratectomy and laser in situ keratomileusis: Comparison using a double-pass system

Optical ray tracing–guided laser in situ keratomileusis for moderate to high myopic astigmatism

Small-aperture corneal inlay for the correction of presbyopia: 3-year follow-up

Central vault after phakic intraocular lens implantation: Correlation with anterior chamber depth, white-to-white distance, spherical equivalent, and patient age

Rotational stability of a toric intraocular lens: Influence of axial length and alignment in the capsular bag

Comparison of clinical outcomes with 2 small-incision diffractive multifocal intraocular lenses

Comparison of a new-generation sectorial addition multifocal intraocular lens and a diffractive apodized multifocal intraocular lens

Development of a questionnaire to assess the relative subjective benefits of presbyopia correction

Informed consent for cataract surgery: Patient understanding of verbal, written, and videotaped information

Effect of blue-light filtering on multifocal visual-evoked potentials

Effect of povidone–iodine concentration and exposure time on bacteria isolated from endophthalmitis cases

Desktop auxiliary apparatus for A-scan ultrasound: Repeatability and validity

Refractive shift in pseudophakic eyes during the second decade of life

Association of biometric factors with anterior chamber angle widening and intraocular pressure reduction after uneventful phacoemulsification for cataract

Preoperative iris configuration and intraocular pressure after cataract surgery

Homeostatic response of intraocular pressure in the early period after sutureless phacoemulsification

Intrastromal corneal ring segments for advanced keratoconus and cases with high keratometric asymmetry

Toxicity comparison of intraocular azithromycin with and without a bioadhesive delivery system in rabbit eyes

Changes in intraocular lens surface roughness during cataract surgery assessed by atomic force microscopy

Assessment of a single-piece hydrophilic acrylic IOL for piggyback sulcus fixation in pseudophakic cadaver eyes

Recurrent iris cyst discharge

Reversible opacification of a hydrophilic acrylic intraocular lens

Lenticular meridional astigmatism secondary to iris mesectodermal leiomyoma

Microbial contamination of ultrasound biomicroscopy probes: Evaluation of cross-infection risk

Creating a feedback loop to improve cataract surgery outcomes

Brown discoloration of acrylic multifocal, monofocal, and blue light–filtering IOLs

Refractive Surgical Problem: January consultation #1

January consultation #2

January consultation #3

January consultation #4

January consultation #5

January consultation #6

January consultation #7

January consultation #8

January consultation #9

Risk stratification and assessment in cataract surgery

Reply

Oval capsulorhexis and its advantages

Reply

Steroid depot injection versus postoperative steroid eyedrops to prevent inflammation and macular edema after cataract surgery

Reply

Prevention of post cataract–surgery cystoid macular edema with nepafenac

Reply

Assessing the value of simulator training on residency performance

Reply

Editorial Board

Table of Contents

Masthead

Visual Acuity Chart