Journal of Cataract & Refractive Surgery

Ectasia risk: Barriers to understanding

William J. Dupps — 2012-05-01

Models should be as simple as possible, but not more so.Attributed to Albert Einstein This summer will mark the passage of 14 years since the first published reports of post-LASIK keratectasia appeared. Nearly a decade and a half and hundreds of reported cases later, a clear understanding of ectasia risk remains elusive.

Capsulorhexis rescue after peripheral radial tear-out: Quick-pull technique

2012-03-05

We describe a technique to rescue the continuous curvilinear capsulorhexis (CCC) in cases in which complete radial tears make it impossible to use normal traction forceps. A circumferential path and rapid movement are applied in the plane of the anterior capsule in the direction of the center pupil. This technique was used in 50 cases. In 47, the CCC could be completed; in 3, it could not and surgery was continued with low-parameter phacoemulsification. No other intraoperative complications occurred.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Modified technique for removal of Soemmerring ring and in-the-bag secondary intraocular lens placement in aphakic eyes

Dilraj S. Grewal, Surendra Basti — 2012-05-01

We describe modifications to previously described techniques for evacuation of Soemmerring ring during secondary intraocular lens (IOL) implantation in aphakic eyes following previous pediatric cataract surgery. A new anterior capsulotomy is initiated using a cystotome to incise the anterior capsule close to its attachment to the posterior capsule. A curved microscissor is used to cut circumferentially, completing the capsulotomy, and a dispersive ophthalmic viscoelastic device (OVD) is used to viscoexpress Soemmerring ring material from the capsular bag. A 2-handed maneuver is used to manually divide the Soemmerring ring. Finally, slow-motion phacoemulsification is used to emulsify and remove the pieces. Viscoexpression of fragments of Soemmerring ring is done if there is a posterior capsulotomy. The residual capsular bag is filled with OVD and a foldable 3-piece IOL injected into the bag and dialed in. This technique allows complete evacuation of Soemmerring ring and placement of a secondary IOL in the capsular bag.Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned.

Suture fixation of iris-claw intraocular lens

Amandeep S. Rai, Devesh K. Varma, Iqbal Ike K. Ahmed — 2012-03-19

We report a technique to surgically manage the damaged haptic of an iris-claw intraocular lens (IOL). An 89-year-old woman initially presented with a subluxated posterior chamber IOL that was exchanged for an Artisan iris-claw IOL. The IOL had been enclavated nasally and temporally, but it deenclavated nasally 4 weeks postoperatively. During surgery to reposition the IOL, 1 haptic of the nasal claw was seen to be damaged. It was sutured to the iris with 10-0 polypropylene using a CIF-4 needle. The postoperative outcome was good.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Refractive outcomes of laser-assisted subepithelial keratectomy for myopia, hyperopia, and astigmatism using a 213 nm wavelength solid-state laser

2012-03-14

Purpose: To study the visual and refractive outcomes after laser-assisted subepithelial keratectomy (LASEK) performed with a 213 nm solid-state laser for a broad range of refractive errors.Setting: Private practice, Jersey, United Kingdom.Design: Case series.Methods: The LASEK was performed using a Pulzar Z1 213 nm solid-state laser. Manifest refraction and uncorrected (UDVA) and corrected (CDVA) distance visual acuities were measured preoperatively and 2 and 6 months postoperatively. Accuracy, safety, efficacy, and stability were assessed at 6 months.Results: The study enrolled 245 eyes (134 patients). The preoperative spherical equivalent (SE) refractive errors ranged from −9.50 to +6.50 diopters (D); 24 eyes had more than 2.50 D of astigmatism. At 6 months, 60.4% of eyes were within ±0.25 D of the intended SE, 89.4% were within ±0.50 D, and 97.9% were within ±1.00 D. No eye lost 2 or more lines of CDVA; 95.5% of eyes were unchanged or gained 1 line. The mean cylinder power decreased from −0.98 ± 1.17 D to −0.14 ± 0.28 DC at 6 months. The mean SE was unchanged over the follow-up period; −0.01 ± 0.57 D and −0.01 ± 0.55 D at 2 months and 6 months, respectively.Conclusion: Laser-assisted subepithelial keratectomy performed using the 213 nm wavelength solid-state laser was safe, accurate, and effective for the treatment of myopia, hyperopia, and astigmatism.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Flap thickness in eyes with ectasia after laser in situ keratomileusis

J. Bradley Randleman, Carolyn B. Hebson, Paul M. Larson — 2012-03-19

Purpose: To measure central flap thickness in eyes with ectasia after laser in situ keratomileusis (LASIK) and to compare these values with estimated anticipated flap thickness based on mean published values for each device used for flap creation.Setting: Emory Vision at Emory University, Atlanta, Georgia, USA.Design: Retrospective comparative case series, using published data for controls.Methods: Confocal microscopic analysis was performed using the Confoscan 3 device to measure central flap thickness in eyes with ectasia after LASIK. Pre-LASIK records were evaluated for information, including basic patient demographics, preoperative corneal topographies, estimated anticipated flap thickness based on the mean average thickness values, and residual stromal bed (RSB) thickness calculations using measured and estimated flap thicknesses.Results: Fifty eyes of 29 patients were evaluated. The mean measured flap thickness was 138 μm ± 26 (SD) (range 90 to 220 μm). There were no significant differences between measured and estimated flap thicknesses (138 μm versus 135 μm; P=.5) or RSB thickness (329 μm versus 332 μm; P=.7), nor were there differences in flap thickness between eyes developing ectasia with normal corneal topographies and eyes with abnormal corneal topographies. One eye had a measured flap resulting in an unintended RSB thickness less than 250 μm; this eye also had abnormal topography.Conclusions: Measured central flap thickness was not thicker than estimated in most eyes developing ectasia after LASIK. Thus, excessively thick flaps do not appear to be a major contributing factor to the pathogenesis of ectasia after LASIK.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Comparison of central corneal thickness using optical low-coherence reflectometry and spectral-domain optical coherence tomography

2012-03-21

Purpose: To assess intraobserver and interobserver reliability of central corneal thickness (CCT) measurements using optical low-coherence reflectometry (OLCR) technology and its agreement with spectral-domain optical coherence tomography (SD-OCT).Setting: Rio Hortega University Hospital, Valladolid, Spain.Design: Evaluation of diagnostic technology.Methods: To analyze OLCR intraobserver repeatability, 1 examiner obtained 4 successive measurements. To study interobserver reproducibility, a different examiner obtained another CCT measurement. To determine agreement with SD-OCT, the first examiner also obtained CCTs. Intraobserver and interobserver within-subject standard deviation (Sw), coefficient of variation (CVw), and limits of agreement (LoA) were obtained for OLCR reliability analysis; for study agreement, data were analyzed using the paired-sample t test and the LoA were calculated.Results: For OLCR intraobserver repeatability, the Sw and precision (1.96×Sw) were 2.33 and 4.56 μm, respectively. The intraobserver CVw was 0.42%. For interobserver reproducibility, the Sw and precision were 11.59 and 22.71 μm, respectively; the CVw was 2.10%. The mean difference between observers was −1.35 μm (95% confidence interval [CI], −3.97 to 1.26). The width of the LoA was 45.27 μm. The mean CCT difference between OLCR and SD-OCT was 5.68±11.46 μm (95% CI, 8.29-3.08 μm; P=.0001), and the width of the LoA was 44.93 μm.Conclusions: Optical low-coherence reflectometry technology provided reliable intraobserver and interobserver CCT measurements. Although OLCR underestimated the pachymetry by less than 6 μm compared with SD-OCT, its interchangeability fell within the range of interobserver reproducibility. Both noncontact pachymetry measurements seem to be clinically useful and may be used interchangeably with minimum calibration adjustment.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Visual outcomes and corneal changes after intrastromal femtosecond laser correction of presbyopia

Nardine Menassa, Anna Fitting, Gerd U. Auffarth, Mike P. Holzer — 2012-05-01

Purpose: To assess the effect of intrastromal femtosecond laser presbyopia treatment on uncorrected near visual acuity (UNVA) and corneal integrity over an 18-month period.Setting: Department of Ophthalmology, International Vision Correction Research Centre, University of Heidelberg, Heidelberg, Germany.Design: Clinical trial.Methods: The UNVA (at 40 cm), corneal pachymetry, and true net power were evaluated preoperatively and 1, 3, 6, 12, and 18 months after femtosecond intrastromal presbyopic treatment (Intracor). Endothelial cell density (ECD) was measured preoperatively and 3, 6, and 12 months postoperatively. Data were analyzed with the Wilcoxon test at a P=.01 level of significance.Results: The median UNVA improved significantly from 0.7 logMAR preoperatively to 0.4 logMAR, 0.2 logMAR, 0.2 logMAR, 0.3 logMAR, and 0.2 logMAR at 1, 3, 6, 12, and 18 months, respectively (all P<.001). The median corneal true net power increased significantly by 1.1 diopters (D) to 0.7 D, 0.8 D, 1.0 D, and 0.9 D, respectively (all P<.001); pachymetry showed no significant thinning postoperatively. There was no significant difference in ECD between preoperatively and postoperatively.Conclusions: Intrastromal femtosecond presbyopic treatment yielded a significant and stable gain of UNVA and corneal steepening without significant loss of endothelial cells or corneal thinning up to 18 months postoperatively. No significant regression of visual acuity or further corneal steepening occurred during the follow-up period.Financial Disclosure: Dr. Auffarth and Dr. Holzer received lecture and consulting fees from Technolas Perfect Vision GmbH. No author has a financial or proprietary interest in any material or method mentioned.

Visual simulation through different intraocular lenses in patients with previous myopic corneal ablation using adaptive optics: Effect of tilt and decentration

2012-05-01

Purpose: To evaluate visual quality differences between intraocular lenses (IOLs) in patients with previous myopic laser ablations and assess the impact of IOL decentration and tilt on visual quality.Setting: University of Valencia, Burjassot, Spain.Design: Cohort study.Methods: An adaptive optics visual simulator was used to simulate the wavefront aberration pattern of 1 aberration-correcting IOL (Acrysof IQ SN60WF), 1 aberration-free IOL (Akreos Adapt AO), and 1 spherical IOL (Triplato) under 5 IOL situations: centered, 0.2 mm and 0.4 mm decentered, and 2 degrees and 4 degrees tilted in eyes with simulated low or high myopic laser corneal ablations. Monocular distance visual acuity at 100%, 50%, and 10% contrast were measured.Results: Ten eyes of 10 patients were evaluated. When the IOLs were centered, the aberration-correcting IOL provided the best visual quality results in both groups. When the IOLs were misaligned, there was a decrease of visual quality with all simulated IOLs except the aberration-free IOL in the high myopia group. In the misaligned situations, all simulated IOLs obtained comparable visual quality results in both groups.Conclusions: The results suggest that in patients with previous myopic laser corneal ablation, aberration-correcting IOLs should be implanted. The decrease in visual quality when these IOLs are decentered or tilted demonstrates the importance of accurate implantation of these IOLs.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Accuracy of corneal power measurements by a new Scheimpflug camera combined with Placido-disk corneal topography for intraocular lens power calculation in unoperated eyes

Giacomo Savini, Piero Barboni, Michele Carbonelli, Kenneth J. Hoffer — 2012-03-05

Purpose: To assess the accuracy of the corneal power measurements with a new Scheimpflug camera combined with Placido-disk corneal topography (Sirius) (combined Scheimpflug camera–topographer) for intraocular lens (IOL) power calculation in unoperated eyes and compare the results with those by a validated corneal topographer (Keratron) (validated topographer).Setting: Private practice.Design: Case series.Methods: Consecutive patients having phacoemulsification and in-the-bag IOL implantation were studied. Intraocular lens power was calculated using the Hoffer Q, Holladay 1, and SRK/T formulas; the axial length, as measured by ultrasound immersion biometry; and 3 corneal power measurements: validated topographer simulated keratometry (K); combined Scheimpflug camera–topographer simulated K (derived from anterior corneal curvature only); combined Scheimpflug camera–topographer mean pupil power (derived from anterior and posterior corneal curvatures through ray tracing). The prediction error was calculated as the difference between the predicted refraction and the refraction measured 1 month postoperatively.Results: When the corneal power measurements from the combined Scheimpflug camera-topographer were used, the mean absolute error (MAE) ranged between 0.23 diopter (D) ± 0.24 (SD) (simulated K and Hoffer Q formula) and 0.33 ± 0.23 D (mean pupil power and SRK/T formula). There were no statistically significant differences between the MAE generated by the simulated Ks of the 2 devices with any of the 3 formulas.Conclusion: Both corneal power measurements (simulated K and mean pupil power) provided by the new combined Scheimpflug camera–topographer were successfully entered into third-generation IOL power calculation formulas in unoperated eyes.Financial Disclosure: Dr. Hoffer is the author of the Hoffer Q formula and owns the EyeLab, which sells Hoffer Programs. No other author has a financial or proprietary interest in any material or method mentioned.

Resident experience with toric and multifocal intraocular lenses in a public county hospital system

2012-03-19

Purpose: To study the outcomes of toric and multifocal intraocular lens (IOL) implantation performed by resident surgeons.Setting: Parkland Health and Hospital System, Dallas, Texas, USA.Design: Case series.Methods: Patients seen between July 2008 and May 2011 and meeting inclusion criteria (including >1.0 diopter [D] of astigmatism in toric group and <0.75 D astigmatism in multifocal group) were offered implantation of the study IOLs. Major outcomes were uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) and, for the multifocal IOL, near visual acuity. Residents were surveyed about their knowledge regarding these IOLs.Results: Seventy-nine eyes of 60 patients received an Alcon Acrysof toric IOL. Eighteen eyes of 10 patients received an Alcon Acrysof Restor IOL. In the toric group, 57% of eyes achieved a postoperative UDVA of 20/25 or better and 90% achieved 20/40 or better. The CDVA was 20/25 or better in 92% of eyes. The mean refractive cylinder was 1.69 D preoperatively and 0.38 D postoperatively. In the multifocal group, 78% of patients achieved a UDVA of 20/25 or better and 94% achieved 20/40 or better. All patients had a CDVA of 20/25 or better. Near vision was Jaeger 3 or better in 94%. The survey showed that residents have a strong comfort level with preoperative and surgical techniques for premium IOLs after their experience in the residency setting.Conclusion: Residents in public county hospitals can be taught to use premium IOLs with good success rates, comparable to those in other published studies.Financial Disclosure: Dr. McCulley is a consultant to Alcon Laboratories, Inc., and Dr. Aggarwal is on the speaker's bureau for Alcon Laboratories, Inc. No author has a financial or proprietary interest in any material or method mentioned.

Evaluating teaching methods of cataract surgery: Validation of an evaluation tool for assessing surgical technique of capsulorhexis

2012-05-01

Purpose: To develop and assess the validity of an evaluation tool to quantitatively assess the capsulorhexis portion of cataract surgery performed by residents.Setting: University of California at Los Angeles (UCLA), Department of Ophthalmology, Jules Stein Eye Institute, Los Angeles, California, USA.Design: Masked prospective case series.Methods: Ophthalmology faculty members at UCLA were surveyed and literature was reviewed to develop a grading tool comprising 12 questions to evaluate surgical technique, including 4 from the Global Rating Assessment of Skills in Intraocular Surgery and 2 from the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric. Video clips of continuous curvilinear capsulorhexis (CCC) performed by 2 postgraduate year (PGY) 3 residents, 2 PGY 4 residents, and 2 advanced surgeons were independently graded in a masked fashion by a 7-member faculty panel.Results: Four questions had low interobserver variability and a significant correlation with surgical skill level (intraclass correlation coefficient >0.75; P<.05, analysis of variance; 42 observations). The 4 questions were visual Likert-scale questions grading flow of operation, set up for regrasp, commencement of flap and formation, and circular completion of the CCC.Conclusions: Surgical performance can be validly measured using an evaluation tool. However, not all evaluation questions produced reliable results. The reliability and accuracy of the measurements appear to depend on the form and content of the question. Studies to optimize assessment tools identifying the best questions for evaluating each step of cataract surgery may help ophthalmic educators more precisely measure outcomes for improving teaching interventions.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Peripheral refraction in pseudophakic eyes measured by infrared scanning photoretinoscopy

2012-03-19

Purpose: To obtain quantitative data of peripheral refractive errors in pseudophakic eyes including measurements up to ±45 degrees on the retina.Setting: University Eye Hospital, Tübingen, Germany.Design: Population-based cross-sectional study.Methods: Pseudophakic and phakic subjects were measured with a purpose-built scanning photorefractor. The instrument was improved over previous versions. It permits measurement of semicontinuous peripheral profiles over the central 90-degree field of the retina at a faster speed (4 s/scan).Results: Twenty-four pseudophakic and 43 phakic subjects were enrolled. The intraocular lenses (IOLs) induced a mean myopic shift of 2.00 diopters (D) at ±45 degrees of eccentricity in the vertical pupil meridian. Ray-tracing simulations with phakic eye and pseudophakic eye models agreed well with the experimental data. They showed that changes induced by IOLs were a consequence of an increase in astigmatism with eccentricity and a myopic shift in the spherical equivalent.Conclusions: The peripheral refractions in pseudophakic eyes were more myopic than in phakic eyes as a consequence of the optical design of the IOLs. Whether a more myopic refraction of approximately 2.00 D at 45 degrees has significant effects on visual performance must be tested. Perhaps there is room for improvement in the peripheral optics of IOLs.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Effects of a blue light–filtering intraocular lens on driving safety in glare conditions

Rob Gray, Warren Hill, Brooke Neuman, Diane Houtman, Richard Potvin — 2012-05-01

Purpose: To evaluate whether the previously established benefit of blue light–filtering intraocular lenses (IOLs) when driving in glare conditions is maintained in patients previously implanted with a blue light–filtering toric IOL.Setting: Department of Applied Psychology, Arizona State University, Mesa, Arizona, USA.Design: Comparative case series.Methods: The study comprised patients with a blue light–filtering toric IOL (test IOL) or an ultraviolet (UV)-only filtering nontoric IOL (control IOL). All patients had good visual acuity and a valid driver’s license. While wearing best spherocylindrical correction, patients performed left-turn maneuvers in front of oncoming traffic in a driving simulator. The safety margin was defined as the time to collision less the time taken to turn at an intersection with oncoming traffic. Measures were repeated with a glare source simulating low-angle sun conditions (daytime driving).Results: Of the 33 evaluable patients, 18 had a test IOL and 15 had a control IOL. In the presence of glare, patients with test IOLs had significantly greater safety margins (mean 2.676 seconds ± 0.438 [SD]) than patients with control IOLs (mean 2.179 ± 0.343 seconds) and significantly lower glare susceptibility (P<.05). In no-glare and glare conditions, patients with test IOLs had significantly lower glare susceptibility than patients with control IOLs.Conclusion: The blue light–filtering toric IOL produced a significantly greater reduction in glare disability than the UV-only filtering nontoric IOL and increased the ability of drivers to safely execute left turns in low-sun conditions.Financial Disclosure: Dr. Houtman is an employee of Alcon Laboratories, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Visual quality assessment in patients with orange-tinted blue light–filtering and clear ultraviolet light–filtering intraocular lenses

2012-05-01

Purpose: To evaluate potential differences in the quality of vision after implantation of a blue light–filtering intraocular lens (IOL) and an ultraviolet (UV) light–filtering IOL.Setting: Department of Ophthalmology, Ruhr-University, Bochum, Germany.Design: Prospective randomized cohort study.Methods: Patients with age-related cataract had bilateral standardized small-incision Kelman phacoemulsification-based cataract surgery with implantation of a blue light–filtering IOL (Oculaid PC 440Y Orange Series) in 1 eye and a UV light–filtering IOL (Oculaid PC 430 Elite Series) in the other eye. Outcome measures included scotopic and photopic corrected distance visual acuity (CDVA) and photopic uncorrected distance visual acuity (UDVA), color discrimination, and contrast sensitivity with and without glare. A questionnaire was used to assess patient satisfaction. Postoperative follow-up visits were scheduled at 1, 3, and 6 months.Results: Twenty-two patients (44 eyes) completed the study. There were no statistically significant differences in UDVA, CDVA, or contrast sensitivity with or without glare between the 2 IOL groups. Color discrimination was significantly decreased in eyes with blue light–filtering IOLs compared with UV light–filtering IOLs, except along the red–green axis (P=.118). No subjective differences in color or light perception were found.Conclusions: Both IOL types provided similar postoperative visual function except color perception, which was slightly better in eyes with a clear IOL. Although differences were not clinically significant, information about potential disturbances in color vision might be provided before implanting an orange blue light–filtering IOL.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Comparison of the effect of torsional and microburst longitudinal ultrasound on clear corneal incisions during phacoemulsification

2012-05-01

Purpose: To compare incision integrity after clear corneal microcoaxial phacoemulsification using longitudinal and torsional ultrasound (US).Setting: Iladevi Cataract & IOL Research Centre, Ahmedabad, India.Design: Prospective randomized experimental clinical trial.Methods: Part 1 comprised an experimental study of rabbit eyes. Group 1 received longitudinal US. Group 2 received torsional US. The right eye of each rabbit served as a control. Samples were processed for histomorphology and collagen I denaturation by immunofluorescence. Part 2 comprised a clinical trial of patients. Group 1 received torsional US. Group 2 received longitudinal US. At the end of surgery, trypan blue 0.0125% was instilled. After 2 minutes, 0.1 mL of aqueous was aspirated and its optical density measured.Results: In part 1, incision histomorphology was comparable in both modalities. Collagen denaturation tests (immunofluorescence, dot blot analysis) showed no irregularity in collagen arrangement in either group. In Group 2, Descemet membrane was detached and endothelial cells were minimal at the roof of the incision. In part 2, trypan blue ingress into the anterior chamber was significantly greater in Group 1 than in Group 2 (mean 3.40 + 0.6 log units versus and 3.77 + 0.82 log units) (P<.007).Conclusions: Incision histomorphology in the torsional group showed minimal Descemet membrane detachment and minimal endothelial cell loss at the roof of the incision. Minimal ingress of trypan blue into the anterior chamber was observed with torsional US, indicating better wound integrity than with longitudinal US.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Straylight measurements as an indication for cataract surgery

2012-05-01

Purpose: To assess adding straylight measurements to the indication for cataract surgery.Setting: Onze Lieve Vrouwe Hospital, Amsterdam, and Zonnestraal Eye Clinic, Hilversum, The Netherlands.Design: Prospective interventional cohort study.Methods: Before and after cataract extraction, corrected distance visual acuity (CDVA) and straylight were recorded in all patients. Subjective complaints were documented by the 39-item National Eye Institute Visual Function Questionnaire (NEI VFQ-39) and a straylight questionnaire.Results: The population comprised 217 patients with a mean age of 72 years ± 9.12 (SD) (range 29 to 90 years). Preoperatively, the mean straylight was 1.55 ± 0.29 log(s) and the mean CDVA, 0.28 ± 0.21 logMAR. Visual acuity and straylight showed little correlation (R2 = 0.08). The mean postoperative improvement in CDVA was 0.26 ± 0.20 logMAR (range −0.12 to 1.12 logMAR) and in straylight, 0.31 ± 0.32 log(s) (range −0.50 to 1.27 log[s]). The preoperative breakeven point (50% chance of postoperative improvement) was 0.06 logMAR for CDVA and 1.29 log(s) for straylight. Preoperative and postoperative questionnaires showed straylight had almost the same influence as visual acuity on quality of vision.Conclusions: Straylight and visual acuity measure different aspects of quality of vision and influenced subjective visual quality almost equally. When straylight was added to preoperative considerations of cataract extraction, postoperative results were more predictable.Financial Disclosure: The Netherlands Academy of Arts and Sciences has a proprietary interest in the C-Quant Straylight meter. No author has a financial or proprietary interest in any material or method mentioned.

Outcomes of pediatric cataract surgery in anterior persistent fetal vasculature

2012-05-01

Purpose: To report the intraoperative performance and postoperative outcomes in eyes with anterior persistent fetal vasculature (PFV).Setting: Iladevi Cataract & IOL Research Centre, India, and Filatov Institute Odessa, Ukraine.Design: Prospective interventional case series.Methods: Eyes with anterior PFV had surgery using a standardized surgical technique. Plaque peeling was used for small plaques and partial excision for larger plaques. In eyes in which the entire lens converted into a fibrovascular tissue, extensive capsulectomy with anterior 2-port limbal vitrectomy was performed. Microphthalmic eyes had no intraocular lens implantation.Results: This study comprised 33 eyes. The mean age at surgery was 6.30 months ± 5.16 (SD). Microcornea was observed in 10 eyes (30.3%). Within the morphology of cataract, 10 eyes (30.3%) had the lens converted into fibrovascular mass, of which 4 had associated prominent ciliary process. Anterior continuous curvilinear capsulorhexis (CCC) and manual posterior CCC were performed in 23 eyes (69.7%) and 3 eyes (9.1%), respectively. Intraoperatively, posterior capsule plaque was seen in 20 eyes (60.6%). In 31 eyes (93.9%), 2-port limbal anterior vitrectomy was performed and in 2 eyes (6.1%), pars plana vitrectomy was performed. Intraocular lens implantation was performed in 16 eyes (48.5%); 17 eyes (51.5%) were left aphakic. Visual axis obscuration was observed in 6 eyes (18.2%). At the 3-year follow-up, visual acuity remained stable in 11 eyes (33.3%) and improved in 22 eyes (66.6%).Conclusion: The results suggest that good visual outcomes can be obtained in PFV eyes after surgical intervention, with an acceptable rate of serious postoperative complications.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Visual function through 4 contact lens–based pinhole systems for presbyopia

2012-03-19

Purpose: To evaluate the effects of different contact lens–based artificial pupil designs on visual performance.Setting: University of Valencia, Burjassot, Spain, and University of Manchester, Manchester, United Kingdom.Design: Comparative case series.Methods: Presbyopic patients were evaluated using 4 artificial pupil designs in the nondominant eye. Binocular uncorrected distance visual acuity (UDVA), binocular corrected distance visual acuity (CDVA), binocular uncorrected near visual acuity (UNVA), binocular distance-corrected near visual acuity (DCNVA), defocus curve, binocular distance, and near contrast sensitivity under photopic and mesopic conditions, and stereoacuity were measured after contact lens fitting.Results: The mean UDVA and CDVA ranged from 0.04 ± 0.05 (SD) to −0.01 ± 0.04 logMAR and from −0.02 ± 0.05 to −0.05 ± 0.03 logMAR, respectively. The UNVA and DCNVA ranged from 0.37 ± 0.11 to 0.42 ± 0.20 logMAR and from 0.35 ± 0.17 to 0.38 ± 0.12 logMAR, respectively. The difference in binocular distance contrast sensitivity was statistically significant between the pinhole systems and the control group (distance-corrected patients without pinhole lens) for 6 cycles per degree (cpd), 12 cpd, and 18 cpd; for near vision, differences were also significant for 3 cpd at the 2 luminance levels (P .05).Conclusions: Soft contact lens apertures provide good visual acuity at distance, functional intermediate vision, and poor near visual acuity and stereoacuity. An improvement in visual performance with decreasing pupil diameter was not found.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Long-term effect of phacoemulsification on intraocular pressure using phakic fellow eye as control

2012-02-27

Purpose: To investigate the long-term effect of phacoemulsification on intraocular pressure (IOP) in patients with ocular hypertension and open-angle glaucoma.Setting: Three multispecialty ophthalmology practices and one glaucoma specialty group.Design: Retrospective comparative case series.Methods: Review of medical records of patients with open-angle glaucoma or ocular hypertension who had had unilateral phacoemulsification (without other prior or concurrent ophthalmic procedure) with the fellow eye remaining phakic at least 3 years postoperatively.Results: Preoperatively, the IOP in the surgical and fellow eyes in the 29 patients was 15.66 mm Hg ± 3.33 (SD) and 15.64 ± 4.23 mm Hg (P=.98), respectively. Postoperatively, it was 13.56 ± 2.04 mm Hg and 14.92 ± 2.85 mm Hg, respectively, at 4.5 months (P=.06); 14.88 ± 3.20 mm Hg and 15.27 ± 3.19 mm Hg, respectively, at 1 year (P=.67); 14.16 ± 2.61 mm Hg and 14.95 ± 2.79 mm Hg, respectively, at 2 years (P=.37); and 14.68 ± 3.44 mm Hg and 14.68 ± 2.68 mm Hg at 3 years (P=1.00), respectively. There was no significant difference in the mean number of IOP-lowering medications used in the surgical eyes (1.96 ± 1.40) and fellow eyes (2.08 ± 1.44) postoperatively (P=.77).Conclusions: In a cohort of ocular hypertensive and glaucoma patients, uncomplicated phacoemulsification had no significant IOP-lowering effect compared with the phakic fellow eye for up to 3 years postoperatively. There was also no difference between the mean number of postoperative IOP-lowering medications used in the surgical and fellow eyes.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Outcomes of Descemet membrane endothelial keratoplasty in phakic eyes

2012-05-01

Purpose: To determine the clinical outcomes of isolated Descemet membrane transplantation (ie, Descemet membrane endothelial keratoplasty [DMEK]) in phakic eyes.Setting: Tertiary referral center.Design: Cohort study.Methods: Phakic eyes from a larger group of consecutive eyes that had DMEK for Fuchs endothelial dystrophy were examined. The examination included corrected distance visual acuity (CDVA), subjective and objective refractions, endothelial cell density (ECD), and intraoperative and postoperative complications at 1, 3, and 6 months.Results: The study enrolled 52 phakic eyes from a group of 260 DMEK eyes. Of the phakic eyes, 69% reached a CDVA equal to or better than 20/40 (≥0.5) within 1 week and 85% reached equal to or better than 20/25 (≥0.8) at 6 months. Compared with an age-matched control group of pseudophakic eyes, phakic eyes had a similar visual rehabilitation rate, final visual outcome, mean ECD at 6 months (1660 cells/mm2 ± 470 [SD]), minor hyperopic shift (+0.74 diopter), and graft detachment rate (4%). Visual acuity equal to or better than 20/13 (≥1.5) was limited to phakic eyes, suggesting better optical quality with the crystalline lens in situ. Temporary mechanical angle-closure glaucoma due to air-bubble dislocation behind the iris was the main complication (11.5%). Two eyes (4%) required phacoemulsification after DMEK.Conclusions: In phakic eyes, DMEK may give excellent visual outcomes without an increased risk for complications. Visual acuities equal to or better than 20/13 (≥1.5) may indicate that the almost anatomic repair after DMEK is associated with near perfect optical quality of the transplanted cornea.Financial Disclosure: Dr. Melles is a consultant to D.O.R.C. International/Dutch Ophthalmic USA. No author has a financial or proprietary interest in any material or method mentioned.

Riboflavin injection into the corneal channel for combined collagen crosslinking and intrastromal corneal ring segment implantation

Aylin Kılıç, Gunhal Kamburoglu, Arsen Akıncı — 2012-03-19

Purpose: To evaluate the effectiveness of intracorneal riboflavin injection for combined collagen crosslinking (CXL) and intrastromal corneal ring segment (ICRS) implantation.Setting: Kudret Eye Hospital, Ankara, Turkey.Design: Noncomparative case series.Methods: Keratoconic eyes had combined ICRS (Intacs) implantation and transepithelial CXL with 20% alcohol application and riboflavin injection into the corneal channel. Outcome measures were uncorrected (UDVA) and corrected (CDVA) distance visual acuities, sphere, cylinder, and keratotomy (K) readings.Results: The study enrolled 131 eyes (105 patients) with a mean follow-up of 7.07 months ± 4.66 (SD). The mean improvement was 0.26 ± 0.16 logMAR in UDVA and 0.24 ± 0.16 logMAR in CDVA (both P<.05). The mean manifest spherical refraction decreased from −3.87 ± 4.55 diopters (D) to −1.25 ± 2.31 D, the mean manifest cylinder improved from −3.89 ± 1.97 D to −2.27 ± 2.18 D, and the mean K reading improved from 50.50 ± 5.26 D to 46.03 ± 4.51 D (all P<.05). There were no intraoperative or postoperative complications.Conclusions: Combined ICRS and CXL treatment with intracorneal riboflavin injection was effective in keratoconic eyes. Intracorneal riboflavin injection into the tunnel was safe and may provide more penetration without epithelial removal.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Evaluation of transepithelial stromal riboflavin absorption with enhanced riboflavin solution using spectrophotometry

Tariq A. Alhamad, David P.S. O'Brart, Naomi A.L. O'Brart, Keith M. Meek — 2012-05-01

Purpose: To assess transepithelial stromal riboflavin absorption with an enhanced riboflavin solution (riboflavin 0.1%, 15% dextran T500 with trometamol (Tris-[hydroxymethyl]aminomethane) and sodium ethylenediaminetetraacetic acid by analyzing light-transmission properties of ex vivo rabbit corneas.Setting: School of Optometry and Vision Sciences, Cardiff, Wales.Design: Experimental study.Methods: The enhanced riboflavin drops (Ricrolin TE) were applied every 3 minutes for 1 hour to 12 corneas (4 with intact epithelium, 4 with superficial scratches, 4 with 8.0 mm epithelial debridement). As a comparison, riboflavin drops without the enhancers (riboflavin 0.1%, 20% dextran T500) (normal riboflavin group) were applied to 12 corneas (4 with intact epithelium, 4 with superficial scratches, 4 with central epithelial debridement). A control group of 4 corneas with intact epithelium received balanced saline 0.9%. To assess enhanced riboflavin absorption, light-transmission spectra of the corneas were analyzed with a spectrophotometer.Results: The spectra in corneas with intact epithelium in both riboflavin groups and in eyes with superficial scratches treated with normal riboflavin were similar to controls. Those with enhanced riboflavin and superficial scratches showed a homogeneous yellow discoloration of the cornea with a dip in light transmission between 400 and 490 nm, similar to that of the enhanced riboflavin solution. This was also seen, albeit of a greater magnitude, with complete epithelial removal, with eyes receiving enhanced riboflavin having a greater dip in transmission than eyes receiving normal riboflavin.Conclusions: Administration of enhanced riboflavin and superficial epithelial scratches allowed sufficient riboflavin stromal absorption to homogeneously alter the transmission spectra of rabbit corneas. This did not occur to the same extent with an intact epithelium or normal riboflavin with superficial scratches.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Fibrinoid reaction after lens extraction in rabbit eyes

Guy J. Ben Simon, Gili Kenet, Abraham Spierer — 2012-03-26

Purpose: To measure the inflammatory reaction in the anterior chamber after lens extraction in a rabbit model and to evaluate the effect of nonsteroidal antiinflammatory drugs (NSAIDs) or steroids on the amount of inflammation as measured by fibrinogen levels in the aqueous humor.Setting: Animal laboratory, Goldschleger Research Institute, Tel Aviv University, Sheba Medical Center, Ramat Gan, Israel.Design: Experimental study.Materials: Twenty-six eyes of New Zealand white rabbits had lens extraction surgery. One day later, aqueous humor (∼0.1 mL) was withdrawn from the anterior chamber and examined for fibrinogen concentration. Control rabbits received no treatment (9 eyes) or artificial tear eyedrops (5 eyes). One study group received NSAID drops (diclofenac) (6 eyes), and another study group received steroid drops (dexamethasone–neomycin) (6 eyes). All rabbits were treated hourly for 9 applications. Aqueous humor (∼0.1 mL) was withdrawn from the anterior chamber and examined for fibrinogen concentration 1 day later. Fibrinogen levels were also measured in the aqueous in 8 unoperated eyes.Results: Steroid-treated eyes achieved the lowest inflammatory score, followed by NSAID eyes, artificial tears eyes, and untreated eyes. The mean fibrinogen concentrations in the aqueous humor were 69.1 mg% untreated, 52.0 mg% artificial tears, 18.5 mg% NSAIDs, and 2.8 mg% steroids (P=.002).Conclusions: Measurement of aqueous fibrinogen after lens extraction surgery in a rabbit animal model was simple and provided a useful parameter for precise evaluation of postoperative intraocular reaction. Steroids and NSAIDs were effective in reducing postoperative inflammation. Steroids reduced inflammation to almost undetectable values.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Biaxial microincision cataract surgery versus conventional coaxial cataract surgery: Metaanalysis of randomized controlled trials

2012-03-19

A comprehensive literature search of Cochrane Library, PubMed, and Embase was performed to identify relevant prospective randomized controlled trials (RCTs) comparing biaxial microincision cataract surgery (MICS) and conventional coaxial phacoemulsification. A metaanalysis was performed on the following outcome measures: effective phacoemulsification time (EPT), phacoemulsification power (%), corrected distance visual acuity (CDVA), surgically induced astigmatism (SIA), laser flare photometry value, percentage of endothelial cell loss, change in central corneal thickness (CCT), and complications. Eleven RCTs describing a total of 1064 eyes were identified. There were no significant differences between the techniques in CDVA, mean percentage of endothelial cell loss, laser flare photometry value, CCT change, and intraoperative and postoperative complications. However, EPT was statistically significantly shorter and the mean phaco power was statistically significantly lower in the biaxial group than in the coaxial group, and biaxial MICS induced less SIA.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Suction loss during thin-flap femto-LASIK: Management and beneficial refractive effect of the epithelium

2012-03-14

We report the case of a 42-year-old man who experienced loss of suction during thin-flap femto-laser in situ keratomileusis, leading to a stromal step in the superior cornea where the cutting was stopped. The procedure was converted to photorefractive keratectomy 2 weeks later. Management of the loss of suction and the beneficial role played by the epithelium postoperatively on the refractive outcomes are discussed.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Successful argon laser photocoagulation of diffuse epithelial ingrowth following concomitant persistent pupillary membrane removal and phacoemulsification

2012-03-05

A 57-year-old woman had concomitant surgery of persistent pupillary membrane removal and uneventful phacoemulsification through the same temporal clear corneal incision in her left eye. Short axial lengths (right eye, 21.08 mm; left eye, 20.39 mm) with shallow angles were noted bilaterally, and other findings were not remarkable. The patient experienced angle-closure attacks 3 and 7 months postoperatively. At the second angle-closure attack, diffuse epithelial ingrowth was observed. The epithelial ingrowth covered the intraocular lens surface in the interpupillary area, the iris surface surrounding the pupil, and the temporal anterior chamber angle, but did not reach the corneal endothelial incision. After observation of iris blanching with laser photocoagulation, argon laser photocoagulation was applied to the epithelium covering the iris and angle 7 times during the following month. The epithelial ingrowth was completely removed and did not recur during the 36-month follow-up.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Intrastromal corneal ring segment implantation for irregular astigmatism after laser in situ keratomileusis

Daniel Elies, Jose Luis Güell, Oscar Gris, Diego Aristizábal Montes — 2012-05-01

We describe the case of a 56-year-old man with a previously decentered laser in situ keratomileusis ablation in his right eye that induced associated vision-threatening problems. After intrastromal corneal ring segment implantation, both topography and visual acuity significantly improved.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Refractive Surgical Problem: May consultation #1

Sonia H. Yoo — 2012-05-01

A 48-year-old white man came for cataract evaluation because of gradual vision loss in the left eye. He had had photorefractive keratectomy (PRK) in both eyes and radial keratotomy (RK) enhancement in the right eye in 1992. Before PRK, the left eye had a refraction of −4.00 +0.50 × 141 and keratometry was 41.87/42.25. Six months after PRK, the refraction in the left eye was +0.75 +0.75 × 62.

May consultation #2

Majid Moshirfar, Gene Kim — 2012-05-01

Intraocular lens power calculation after refractive surgery has become a challenging problem for most clinicians. The inability to correctly measure the true corneal power after laser photoablation is the primary problem. The preoperative and postoperative information for this patient illustrates the aforementioned issue. The changes in the keratometry (K) readings and spherical equivalent (SE) after PRK are −2.64 D and +4.87 D, respectively.

May consultation #3

Kemal Ozulken — 2012-05-01

The number of patients who have had keratorefractive surgery is increasing every year, which in turn increases the number of post-refractive surgery patients who will require cataract surgery. New-generation IOLs and biometry calculation methods are raising surgeon and patient expectations of refractive accuracy. A common goal today is to minimize refractive errors and reduce dependence on spectacles.

May consultation #4

Warren E. Hill — 2012-05-01

This was a PRK treatment before Food and Drug Administration approval in the United States, and it is unusual to have meaningful historical data from 20 years ago. Having this information is especially helpful because there appears to be an element of lens-induced myopia.

May consultation #5

George D. Kymionis — 2012-05-01

Accurate prediction of IOL power in eyes with previous corneal refractive surgery represents a challenging task that we are facing far more frequently. Because it has not been proven which proposed method works best in all eyes, surgeons should use as many methods as there are data available for and carefully evaluate the results.

May consultation #6

Eric D. Donnenfeld — 2012-05-01

Intraocular lens calculation after corneal refractive surgery is one of the most difficult management issues for the cataract surgeon. In addition, IOL calculation is more difficult after RK than after PRK or LASIK. After RK, I first assess the visual fluctuation seen during the day and aim to give the patient slight myopia at the most hyperopic point due to the continued hyperopic progression in these patients.

May consultation #7

Anat Galor — 2012-05-01

My current algorithm for IOL calculation after myopic PRK or LASIK is to select an IOL based on the flat or central Pentacam value. In this case, if emmetropia were the desired outcome, using 38.20 D as the K value and 28.4 mm as the axial length, the SRK/T formula would predict placing a 13.50 D IOL. I would then use the intraoperative wavefront aberrometer to refine the IOL selection. If the 2 measurements were in good agreement, I would generally target an SE between −0.50 D and −0.75D based on the wavefront aberrometer output.

Flaporhexis

Wolfgang A. Pfaeffl — 2012-05-01

In their recent article, Wilson and Santhiago describe lifting a previous laser in situ keratomileusis (LASIK) flap for an enhancement procedure that they call flaporhexis. The reader is encouraged to read the methods sections of the articles by Davis et al. and Febbraro et al., both cited by Wilson and Santhiago, to decide what is new in their description.

Reply: Flaporhexis

Steven E. Wilson — 2012-05-01

Dr. Pfaeffl's primary concern appears to be precedence in describing the technique. We first described our method in 2000 after developing it at the University of Washington in 1998 and using it in hundreds of patients. Our recent article provided a more detailed description of the method and its nuances. In addition, the new video with the article provides additional instruction regarding the utility of the triangular sponge as a blunt flap dissection instrument when performing the flaporhexis method. We believe this method will remain useful for enhancements performed after LASIK using femtosecond lasers or microkeratomes. It is our hope that our article and Dr. Pfaeffl's letter and this response will encourage surgeons performing LASIK to try this superior LASIK enhancement method.

Back to the surface?

Emil William Chynn, Jyoti Puri, Patricia Villaroel, Elias Almeida — 2012-05-01

Wilson and Santhiago recently reported on flaporhexis, which they describe as a new technique to lift the laser in situ keratomileusis (LASIK) flap during enhancement surgery. The stated advantage of this technique is that it “produces a smooth epithelial dissection and deceases the possibility that epithelium is retained beneath the flap.”

Reply: Back to the surface?

Steven E. Wilson, Marcony R. Santhiago — 2012-05-01

As we mentioned in the article, we have not had to re-lift a flap for clinically significant epithelial ingrowth since we began using this technique to lift the flap in 1998. This includes hundreds of cases. Anyone getting 1% or more epithelial ingrowth after LASIK enhancement should reevaluate the method they are using. Occasionally, we have seen a few epithelial pearls, as sometimes occurs in all LASIK cases—primary or enhancement, femtosecond laser or microkeratome—but these are not clinically significant. We have not used the side-cut-only flap enhancement method described by Güell et al. We did mention PRK in our article: “Very rarely, the wound healing at the flap edge and between the flap and underlying bed is so strong, the surgeon cannot lift the flap even when an iris spatula is used to dissect the interface. In this case, photorefractive keratectomy with mitomycin-C can be used to safely perform enhancement.” Of course, we also use PRK with mitomycin-C if we are concerned about residual posterior stromal bed after LASIK enhancement or with LASIK flaps with buttonholes or other irregularities, as we originally described in 1998. We never hesitate to use PRK with mitomycin if we have any concerns about the safety of a LASIK flap re-lift retreatment but prefer the increased patient comfort, faster visual recovery, and more predictable refractive outcome of LASIK retreatment over surface ablation when it can be safely performed. We, and others in comparative prospective trials, have never seen any utility in LASEK over PRK except to kill more keratocytes and thereby possibly trigger an even greater stromal wound-healing response.

Let us be clear: A cornea has no axis; a cornea has meridians

Catharina A. Eggink, Johannes R.M. Cruysberg — 2012-05-01

We fully agree with Dr. Rosen that the term axis (eg, on-axis incision) in incisional refractive surgery is misleading and that lens surgery incisions intended to be effective in neutralizing preexisting astigmatism should be placed on the steep corneal meridian. However, the last sentence of the editorial might be confusing as it might suggest that axis is again used for corneal power.

Reply: Let us be clear: A cornea has no axis; a cornea has meridians

Emanuel S. Rosen — 2012-05-01

I am grateful to Dr. Eggink for her further clarification of the terminology that should apply to the cornea, which indeed has meridians and no axes. The purpose of my editorial was to rectify the prevalent use of the term axis in JCRS manuscripts in particular and elsewhere in general usage when applied to the cornea. I trust the comments will enhance that message.

Optimized constants for an ultraviolet light-adjustable intraocular lens

Sheridan Lam — 2012-05-01

In their paper on the refractive outcome with the light-adjustable intraocular lens (IOL) (Calhoun Vision, Inc), Conrad-Hengerer et al. reported that in their series of 125 eyes, 52% were within 0.50 diopters (D) of the target refraction prior to the first adjustment, using the SRK/T formula with an optimized A constant.

Reply: Optimized constants for an ultraviolet light-adjustable intraocular lens

H. Burkhard Dick, Ina Conrad-Hengerer, Fritz Hengerer, Wolfgang Haigis — 2012-05-01

We appreciate Dr. Lam's comments about the promise of the light-adjustable IOL. This IOL allows the surgeon to correct residual spherical refractive error and astigmatism after cataract surgery noninvasively by shining a spatially profiled beam of ultraviolet (365 nm) light on the IOL.

Other factors in PCO prevention

Okihiro Nishi — 2012-05-01

In their recent article, Kavoussi et al. hypothesized that capsular bag clarity may be due to constant irrigation of the capsular bag compartment by the aqueous humor, which may contain factors that stabilize residual lens epithelial cells (LECs). This hypothesis appears to need further consideration.

Reply: Other factors in PCO prevention

Liliana Werner, Nick Mamalis, Shaheen C. Kavoussi — 2012-05-01

In our article, we advanced the hypothesis that IOL designs maintaining an open or expanded capsular bag are associated with bag clarity and that constant irrigation of the capsular bag inner compartment by the aqueous humor may play an important role in this finding. Dr. Nishi highlights that the lack of contact between LECs and the IOL helps prevent LEC proliferation. Indeed, in cadaver eye studies, we have observed that anterior capsule opacification (ACO) and fibrosis tend to occur in areas where the anterior capsule comes in contact with the IOL optic, which accounts for large amounts of ACO developing with plate silicone IOLs. Also, an IOL strategy to prevent ACO involves design features that prevent significant contact between the anterior capsule and the optic surface, which has been incorporated in at least 2 IOL designs: the Concept 360 (Corneal Laboratoire) and the Synchrony (Visiogen/Abbott Medical Optics, Inc.). Dr. Nishi also highlights that constant irrigation by the aqueous humor prevents cytokines that may be involved in stimulating LEC proliferation from reaching a threshold concentration level within the bag compartment. According to previous work by Dr. Nishi and coauthors, one such cytokine is IL-1.

Advantages of bevel-down technique

I. Howard Fine — 2012-05-01

The study by Kim et al. comparing bevel-down phacoemulsification and bevel-up phacoemulsification is seriously flawed because of the use of bevel-down sculpting. Sculpting is essentially a shaving technique and to do bevel-down shaving is the equivalent of using a snow plow with the plow attached to the vehicle backward.

Editorial Board

2012-05-01

Masthead

2012-05-01

Visual Acuity Chart

2012-05-01

Journal of Cataract & Refractive Surgery

Ectasia risk: Barriers to understanding

Capsulorhexis rescue after peripheral radial tear-out: Quick-pull technique

Modified technique for removal of Soemmerring ring and in-the-bag secondary intraocular lens placement in aphakic eyes

Suture fixation of iris-claw intraocular lens

Refractive outcomes of laser-assisted subepithelial keratectomy for myopia, hyperopia, and astigmatism using a 213 nm wavelength solid-state laser

Flap thickness in eyes with ectasia after laser in situ keratomileusis

Comparison of central corneal thickness using optical low-coherence reflectometry and spectral-domain optical coherence tomography

Visual outcomes and corneal changes after intrastromal femtosecond laser correction of presbyopia

Visual simulation through different intraocular lenses in patients with previous myopic corneal ablation using adaptive optics: Effect of tilt and decentration

Accuracy of corneal power measurements by a new Scheimpflug camera combined with Placido-disk corneal topography for intraocular lens power calculation in unoperated eyes

Resident experience with toric and multifocal intraocular lenses in a public county hospital system

Evaluating teaching methods of cataract surgery: Validation of an evaluation tool for assessing surgical technique of capsulorhexis

Peripheral refraction in pseudophakic eyes measured by infrared scanning photoretinoscopy

Effects of a blue light–filtering intraocular lens on driving safety in glare conditions

Visual quality assessment in patients with orange-tinted blue light–filtering and clear ultraviolet light–filtering intraocular lenses

Comparison of the effect of torsional and microburst longitudinal ultrasound on clear corneal incisions during phacoemulsification

Straylight measurements as an indication for cataract surgery

Outcomes of pediatric cataract surgery in anterior persistent fetal vasculature

Visual function through 4 contact lens–based pinhole systems for presbyopia

Long-term effect of phacoemulsification on intraocular pressure using phakic fellow eye as control

Outcomes of Descemet membrane endothelial keratoplasty in phakic eyes

Riboflavin injection into the corneal channel for combined collagen crosslinking and intrastromal corneal ring segment implantation

Evaluation of transepithelial stromal riboflavin absorption with enhanced riboflavin solution using spectrophotometry

Fibrinoid reaction after lens extraction in rabbit eyes

Biaxial microincision cataract surgery versus conventional coaxial cataract surgery: Metaanalysis of randomized controlled trials

Suction loss during thin-flap femto-LASIK: Management and beneficial refractive effect of the epithelium

Successful argon laser photocoagulation of diffuse epithelial ingrowth following concomitant persistent pupillary membrane removal and phacoemulsification

Intrastromal corneal ring segment implantation for irregular astigmatism after laser in situ keratomileusis

Refractive Surgical Problem: May consultation #1

May consultation #2

May consultation #3

May consultation #4

May consultation #5

May consultation #6

May consultation #7

Flaporhexis

Reply: Flaporhexis

Back to the surface?

Reply: Back to the surface?

Let us be clear: A cornea has no axis; a cornea has meridians

Reply: Let us be clear: A cornea has no axis; a cornea has meridians

Optimized constants for an ultraviolet light-adjustable intraocular lens

Reply: Optimized constants for an ultraviolet light-adjustable intraocular lens

Other factors in PCO prevention

Reply: Other factors in PCO prevention

Advantages of bevel-down technique

Editorial Board

Masthead

Table of Contents

Visual Acuity Chart