Journal of Cataract & Refractive Surgery

Endophthalmitis

Emanuel Rosen — 2010-02-01

Endophthalmitis is the scourge of cataract surgeons but fortunately is a rare, although serious, event. Infection origin is almost always exogenous, which means the infecting organism gains access to the inner eye during surgery or early in the postoperative period. Asepsis and antisepsis are the keys to operative risk; ocular hygiene and topical antibiotic agents are the key to eliminating postoperative risk. Despite attempts to sterilize the ocular surface prior to surgical intervention, several studies have confirmed that bacterial contamination may survive the operative session and thereby gain access to the inner eye during surgery. Thereafter, wound security or lack of it may allow ingress of bacterial contamination, including suture presence or removal in the early postoperative period.

Double-bubble technique to facilitate Descemet membrane exposure in deep anterior lamellar keratoplasty

Jun Shimazaki — 2010-02-01

Safe and efficient exposure of Descemet membrane is the key to success in deep anterior lamellar keratoplasty. Although widely used, the big-bubble technique has the drawback of difficulty in maintaining appropriate needle insertion depth in the corneal stroma, resulting in injected air sometimes escaping to the peripheral cornea without separation of Descemet membrane. We describe a variation of the big-bubble technique in which air is injected into the anterior chamber before it is injected into the stroma. By observing the reflection created on the surface of the air, a needle can be inserted deep into the stroma without puncturing Descemet membrane. This allows safe and efficient separation of Descemet membrane. Moreover, air in the anterior chamber can be used as an indicator of successful Descemet membrane separation as air is shifted to the periphery with creation of the big bubble.Financial Disclosure: The author has no financial or proprietary interest in any material or method mentioned.

Crossed-swords, capsule-pinch technique for capsulotomy in pediatric and/or loose lens cataract extraction

Michael E. Snyder, Luke B. Lindsell — 2010-02-01

Puncturing the anterior capsule in a patient with a very soft lens, an elastic capsule, and/or deficient zonular countertraction can be challenging even with a sharp needle or blade. The crossed-swords, capsule-pinch technique capitalizes on opposing forces from 2 needles directed toward each other with a “pinch” of the capsule between their tips. This affords a controlled and facile puncture of the capsule without creating stress on the zonules or anteroposterior displacement of the lens.Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned.

Repositioning free laser in situ keratomileusis flaps

Amit Todani, Khalid Al-Arfaj, Samir A. Melki — 2010-02-01

We describe a protocol for adequate repositioning of free laser in situ keratomileusis (LASIK) corneal flaps created by a Moria M2 microkeratome even in the absence of fiduciary marks. In an enucleated porcine globe, a free flap was created by initially placing a longitudinal incision at the proposed hinge site followed by activating the forward pass of the automated microkeratome. A protocol was devised based on placement of a positioning dot on the free flap before the flap is retrieved from the microkeratome head. Preplaced surgical landmarks were used as a guide to determine the correct alignment of the free flap. Adequate orientation of the free flap to the stromal bed was achieved in 9 porcine eyes using the positioning dot method. The technique is applicable to the Moria M2 microkeratome only and must be validated for other types of keratomes.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Effectiveness of intracameral cefuroxime in preventing endophthalmitis after cataract surgery: Ten-year comparative study

2010-02-01

Purpose: To determine the differences in the endophthalmitis rates in cataract surgery before and after prophylactic use of intracameral cefuroxime.Setting: University Hospital Fundación Alcorcón, Madrid, Spain.Methods: This prospective study evaluated patients who had cataract surgery at a university eye center over a 10-year period (1999 to 2008). Since the protocol's approval by the Hospital Board in October 2005 to the end of the 10-year period, cataract patients were routinely treated with prophylactic intracameral cefuroxime. A database was used to measure the occurrence of endophthalmitis postoperatively. Then, the incidence of endophthalmitis before and after generalized use of prophylactic cefuroxime was compared. The effect of cefuroxime was evaluated by the relative risk.Results: From January 1999 to December 2008, 13 652 patients had cataract surgery. Forty-two cases of postoperative bacterial endophthalmitis were reported. The endophthalmitis rate was 0.30% (95% confidence interval [CI], 0.26%-0.35%) overall, 0.59% (95% CI, 0.50%-0.70%) from January 1999 to September 2005, and 0.043% (95% CI, 0.02%-0.06%) from October 2005 to December 2008. The relative risk was 0.07 (range 0.022 to 0.231; P<.05).Conclusion: Intracameral cefuroxime proved to be effective in reducing the risk for acute-onset endophthalmitis after cataract surgery.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Role of anterior capsule polishing in residual lens epithelial cell proliferation

Xialin Liu, Bing Cheng, Danyin Zheng, Yuhua Liu, Yizhi Liu — 2010-02-01

Purpose: To determine the role of anterior capsule polishing in residual lens epithelial cell (LEC) proliferation.Setting: Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China.Methods: Phacoemulsification was performed on pairs of human cadaver eyes. One eye of each pair had anterior capsule polishing; the fellow eye did not. Capsular bags with implanted intraocular lenses (IOLs) were incubated in culture. Specimens were observed and photographed under microscopy. For clinical comparison, both eyes of patients who had phacoemulsification and IOL implantation with anterior capsule polishing in 1 eye only were observed for 1 year postoperatively.Results: The study comprised 10 pairs of cadaver eyes and 20 eyes of 10 patients. One day after surgery, large patches of cells remained under the anterior capsule and the equatorial zone in the unpolished cadaver eyes and the anterior capsule was clear in the polished eyes. By 3 days in culture, many patches of dead cells had formed in the unpolished eyes. After 7 days in culture, cell growth was minimal in the unpolished eyes; however, robust cell proliferation was observed in the polished eyes. In the clinical comparison, there was no obvious difference in the mean subjectively assessed fibrotic posterior capsule opacification (PCO) score between polished eyes and unpolished eyes at 1 year.Conclusions: Anterior capsule polishing, although it removed many LECs, did not decrease residual cell growth and, conversely, enhanced cell proliferation in capsular bag cultures. This might explain why polishing does not reduce PCO in clinical studies.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Effect of intraocular lens asphericity on vertical coma aberration

Mayank A. Nanavaty, David J. Spalton, John Marshall — 2010-02-01

Purpose: To analyze the effect of asphericity of intraocular lenses (IOLs) on vertical coma aberration after implantation of spherical, spherically neutral, and aspheric IOLs.Setting: Department of Ophthalmology, St. Thomas' Hospital, London, United Kingdom.Method: This observational study recruited patients from previous prospective randomized fellow-eye controlled studies comparing aspheric and spherical IOLs (3 spherical, 1 spherically neutral, and 2 aspheric IOLs). At postoperative follow-up visits, maximum pupil dilation was achieved and aberrometry was performed using an iTrace aberrometer with a pupil scan size of 5.0 mm. Data on Zernike coefficients Z(3,−1) (vertical coma), Z(3,+1) (horizontal coma), and Z(4,0) (spherical aberration) and on IOL power were extracted.Results: Two hundred eyes of 100 patients were recruited. Ninety-two eyes had a spherical IOL, 32 eyes had a spherically neutral IOL, and 76 eyes had an aspheric IOL. Vertical coma Z(3,−1) and spherical aberration Z(4,0) values were highest with the spherical IOLs and lowest with the aspheric IOLs (P = .0163 and P<.0001, respectively). There was no difference in horizontal coma aberration between the 3 IOL groups. There was no correlation between IOL power and vertical coma aberration (r2 = 0.0135, P = .1169).Conclusions: Conventional spherical IOLs induced more vertical coma than newer aspheric and spherically neutral IOLs. Vertical coma aberration enhances the depth of focus; thus, newer aspheric and spherically neutral designs of IOLs may negatively affect uncorrected near vision.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Assessment of toric intraocular lens alignment by a refractive power/corneal analyzer system and slitlamp observation

2010-02-01

Purpose: To assess the validity of an internal optical path difference map of a refractive power/corneal analyzer system in determining the alignment of toric intraocular lenses (IOLs).Settings: Private practices, Spring Hill, Brisbane, and Chermside, Australia.Methods: This retrospective study comprised patients with more than 1.5 diopters of preexisting corneal astigmatism who had phacoemulsification and AcrySof toric IOL implantation. Preoperatively, the surgical eye was marked at the slitlamp microscope using a 4-point technique. The desired IOL orientation was marked with a Mendez marker based on the steep corneal axis. The toric IOL axis was measured 3 weeks postoperatively by rotating the slitlamp beam to align with the IOL axis indicator marks and using the Internal OPD Map on the Nidek OPD-Scan system. Uncorrected (UDVA) and corrected (CDVA) distance visual acuities, residual refractive sphere, and residual keratometric and refractive cylinders were also measured at 3 weeks.Results: Postoperatively, the mean UDVA was 0.17 logMAR ± 0.18 (SD) and the mean CDVA, −0.01 ± 0.12 logMAR; 88.2% of eyes had a UDVA of 0.3 or better, and no eye lost lines of visual acuity. There was an 82.33% reduction in defocus equivalent and a 64.62% reduction in refractive cylinder. The mean IOL misalignment measured by slitlamp was 2.55 ± 2.76 degrees and by the internal map, 2.65 ± 1.98 degrees. The correlation between the 2 methods was highly significant (r = 0.99, P<.001).Conclusions: Both refractive power/corneal analyzer system and slitlamp observation were reliable and predictable methods of assessing IOL alignment. The 4-point preoperative marking technique yielded clinically acceptable, accurate toric IOL alignment.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Intraocular lens power calculation: Clinical comparison of 2 optical biometry devices

Tanja M. Rabsilber, Charlotte Jepsen, Gerd U. Auffarth, Mike P. Holzer — 2010-02-01

Purpose: To evaluate intraocular lens (IOL) power calculation using a new optical low-coherence reflectometry (OLCR) biometer and compare the results with those obtained with a partial coherence interferometry (PCI) optical biometer.Setting: International Vision Correction Research Centre, Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany.Methods: Biometry measurements in eyes of cataract patients were performed by the same examiner with an OLCR biometer (Lenstar LS 900/Allegro Biograph) and a PCI optical biometer (IOLMaster). After determination of axial length (AL), corneal radii values by keratometry (R1 and R2), and anterior chamber depth (ACD), power calculation for an AcrySof MA60AC IOL was compared between the 2 devices using 4 formulas and the corresponding IOL constants. The target was emmetropia.Results: One hundred eyes of 100 cataract patients (mean age 70.0 years ± 10.6 [SD]) were measured. Of the biometry parameters, the only statistically significant differences between the 2 devices were in R2 (mean difference 0.02 ± 0.05 mm), (R1 + R2)/2 (mean difference 0.01 ± 0.04 mm), and ACD (mean difference 0.05 ± 0.11 mm) (P .01, Wilcoxon test).Conclusion: The OLCR biometry device provided precise and valid measurements and thus can be used for the preoperative examination of cataract patients.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Magnetic resonance imaging of the anteroposterior position and thickness of the aging, accommodating, phakic, and pseudophakic ciliary muscle

Susan A. Strenk, Lawrence M. Strenk, Suqin Guo — 2010-02-01

Purpose: To quantify accommodative and age-related changes in the anteroposterior position and thickness of the ciliary muscle in phakic and pseudophakic eyes.Setting: Department of Surgery/Bioengineering, UMDNJ–Robert Wood Johnson Medical School, Piscataway; Institute of Ophthalmology and Visual Science UMDNJ–New Jersey Medical School, Newark, New Jersey; MRI Research, Inc., Middleburg Heights, Ohio, USA.Methods: Magnetic resonance images were taken of phakic and pseudophakic eyes.Results: The cohort comprised 32 phakic volunteers and 8 volunteers with a monocular intraocular lens (IOL) aged 22 to 91 years. No anteroposterior accommodative movement of the ciliary muscle apex occurred in either group. The muscle moved closer to the cornea with advancing age in phakic eyes; IOL implantation returned the muscle to a youthful position. An age-dependent increase in ciliary muscle anteroposterior thickness occurred that was not mitigated by IOL implantation. Muscle thickness increased with accommodation in only phakic eyes.Conclusions: Presbyopia-correction strategies cannot rely on accommodative anterior movement of the ciliary muscle. Forces on the uvea by crystalline lens–pupillary margin contact may increase with accommodation and lens growth, producing accommodative and age-dependent increases in muscle thickness and significant age-dependent anterior muscle displacement. Intraocular lens implantation removed these forces, allowing choroidal elasticity to restore the muscle to a youthful position; however, the increase in thickness was permanent and likely due to an age-dependent increase in connective tissue. This supports the geometric theory of presbyopia development and that the mechanical forces in human accommodation and presbyopia are very different from those in the rhesus monkey model.Financial Disclosure: S. A. Strenk and L. M. Strenk have a proprietary interest in the purpose-built eye coil. Dr. Guo has no financial or proprietary interest in any material or method mentioned.

Preoperative cataract grading by Scheimpflug imaging and effect on operative fluidics and phacoemulsification energy

Donald R. Nixon — 2010-02-01

Purpose: To evaluate the power use, chamber stability, and surgical efficiency of a phacoemulsification system when cataracts were graded preoperatively using the Pentacam Nucleus Grading System (PNS) and adjustments were made in phaco parameters based on the cataract grade.Setting: Royal Victoria Hospital, Barrie, Ontario, Canada.Methods: Cataracts were graded using Scheimpflug imaging (Pentacam) in consecutive patients. In Group 1, surgery was performed with no change in parameters. In Group 2, adjustments were made preoperatively in fluidics and phaco power to reflect the cataract grade determined by Scheimpflug imaging. Parameters assessed in both groups included effective phaco time (EPT), balanced salt solution (BSS) use, and needle time to remove the cataract.Results: There were 200 patients in each group. Emulsification and aspiration of higher and lower grades of cataract took statistically significantly less EPT and BSS in Group 2 (preoperative parameter adjustments) than in Group 1. The needle time for the higher grades of cataract was statistically significantly less in Group 2. For cataracts of a middle grade (2 to 3; 63% of cases), there was no statistically significant difference between standard phaco settings and adjusted settings. The cataract was effectively aspirated in both groups.Conclusion: Preoperatively adjusting phaco parameters based on cataract grade helped improve overall efficiency by reducing the amount of energy and fluid used in the eye and reducing overall phaco time.Financial Disclosure: The author has no financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Comparison of endothelial cell loss after cataract surgery: Phacoemulsification versus manual small-incision cataract surgery: Six-week results of a randomized control trial

2010-02-01

Purpose: To compare endothelial cell loss in cataract surgery by phacoemulsification and by manual small-incision cataract surgery (SICS).Settings: Tertiary care ophthalmic center, India.Methods: A complete ophthalmologic examination and endothelial specular microscopy were performed preoperatively and 1 and 6 weeks postoperatively in patients having cataract surgery. The endothelial cell count (ECC) was calculated manually and automatically using an LSM 12000 specular microscope. Patients were randomly allocated to have SICS or phacoemulsification using a random number table. Phacoemulsification was performed using the stop-and-chop technique and SICS, by viscoexpression.Results: The study evaluated 200 patients, 100 in each group. The mean preoperative ECC by the manual counting method was 2950.7 cells/mm2 in the phacoemulsification group and 2852.5 cells/mm2 in the SICS group and by the automated counting method, 3053.7 cells/mm2 and 2975.3 cells/mm2, respectively. The difference at 6 weeks was 543.4 cells/mm2 and 505.9 cells/mm2, respectively, by the manual method (P = .44) and 474.2 cells/mm2 and 456.1 cells/mm2, respectively, by the automated method (P = .98). The corrected distance visual acuity at 6 weeks was better than 6/18 in 98.5% of eyes in the phacoemulsification group and 97.3% of eyes in the SICS group.Conclusion: There were no clinically or statistically significant differences in ECC loss or visual acuity between phacoemulsification and SICS, although there was a small difference in the astigmatic shift.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Intermediate results of sutureless intrascleral posterior chamber intraocular lens fixation

2010-02-01

Purpose: To report the intermediate multicenter results of a technique of sutureless intrascleral fixation of a standard 3-piece posterior chamber intraocular lens (PC IOL) in the ciliary sulcus.Setting: Four European ophthalmology centers.Methods: A technique for sutureless intrascleral fixation of the haptics of a standard 3-piece PC IOL was retrospectively evaluated. The technique uses standardized maneuvers to fixate the PC IOL without need for special haptic architecture or preparation or haptic suturing. All patients having IOL implantation by the technique were evaluated for preoperative status (visual acuity, refractive error, preexisting ocular conditions, optical biometry), postoperative status, complications, and need for further surgery.Results: The study evaluated 63 consecutive patients from 4 institutions (4 surgeons). The median follow-up was 7 months. Two dislocated PC IOLs (3.6%) were decentered; the other 61 IOLs (96.8%) were stable and well centered. There were no cases of recurrent dislocation, endophthalmitis, retinal detachment, or glaucoma.Conclusion: Fixation of PC IOL haptics in a limbus-parallel scleral tunnel provided exact centration and axial stability of the IOL and prevented distortion and subluxation in most cases.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Laser-assisted subepithelial keratectomy for bilateral hyperopia and hyperopic anisometropic amblyopia in children: One-year outcomes

William F. Astle, Peter T. Huang, Ismat Ereifej, Ania Paszuk — 2010-02-01

Purpose: To assess the refractive, visual acuity, and binocular results of laser-assisted subepithelial keratectomy (LASEK) in children with bilateral hyperopia or hyperopic anisometropic amblyopia.Setting: Nonhospital surgical facility and hospital clinic, Calgary, Alberta, Canada.Methods: This retrospective review comprised children with bilateral hyperopia or hyperopic anisometropic amblyopia who had LASEK. Refractive status, visual acuity, and binocular vision were assessed and recorded 2 months and 1 year postoperatively.Results: The mean spherical equivalent (SE) in all 72 hyperopic eyes (47 patients) was +3.42 diopters (D) (range 0.00 to +12.50 D) preoperatively and +0.59 D (range −1.25 to +2.00 D) 1 year postoperatively. After LASIK, 41.7% of eyes had improved corrected distance visual acuity (CDVA). No patient had reduced CDVA or loss of fusional ability; there was a 25.0% improvement in stereopsis at 1 year. The mean anisometropic difference in the hyperopic anisometropic amblyopia subgroup (18 eyes, 10 patients) was 4.39 D (range +1.75 to +7.75 D) preoperatively and +0.51 D (range 0 to +0.875 D) at 1 year. One year postoperatively, 83% of anisometropic eyes were within ±1.00 D of the fellow eye and 94.0% were within ±3.00 D. Postoperatively, 64.7% of eyes had improved CDVA with no reduced CDVA or loss of fusional ability; there was a 22% improvement in stereopsis at 1 year.Conclusion: Laser-assisted subepithelial keratectomy improved visual acuity in pediatric hyperopia with or without associated hyperopic anisometropic amblyopia.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Ocular blood-flow hemodynamics before and after application of a laser in situ keratomileusis ring

Miriam L. Conway, Mark Wevill, Alexandra Benavente-Perez, Sarah L. Hosking — 2010-02-01

Purpose: To evaluate blood-flow responses before and after microkeratome application.Setting: School of Life and Health Sciences, Aston University, Birmingham, United Kingdom.Methods: Hemodynamic responses were measured in eyes of healthy volunteers before and after transient elevation in intraocular pressure (IOP) resulting from microkeratome application. The IOP was elevated above 85 mm Hg for 90 seconds. Blood-flow responses were measured using color Doppler imaging, Heidelberg retinal flowmetry, and an ocular blood-flow analyzer.Results: The study included 10 eyes. There was no difference in ocular-perfusion measurements before or after IOP elevation using any measurement system.Conclusion: In normal healthy eyes, once suction was released, blood-flow responses returned immediately to normal levels.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Collagen crosslinking with riboflavin and ultraviolet-A in eyes with pseudophakic bullous keratopathy

2010-02-01

Purpose: To evaluate the safety and efficacy of corneal collagen crosslinking (CXL) in patients with painful pseudophakic bullous keratopathy (PBK).Setting: University of São Paulo, São Paulo and Sadalla Amin Ghanem Eye Hospital, Joinville, Santa Catarina, Brazil.Methods: This prospective study included consecutive eyes with PBK that had CXL. After a 9.0 mm epithelial removal, riboflavin 0.1% with dextran 20% was applied for 30 minutes followed by ultraviolet-A irradiation (370 nm, 3 mW/cm2). Therapeutic contact lenses were placed for 1 week. Corneal transparency, central corneal thickness (CCT), and ocular pain were assessed preoperatively and 1 and 6 months postoperatively. Statistical analysis was by paired t tests.Results: Fourteen patients (14 eyes) with a mean age 71.14 years ± 11.70 (SD) (range 53 to 89 years) were enrolled. Corneal transparency was better in all eyes 1 month after surgery. At 6 months, corneal transparency was similar to preoperative levels (P = .218). The mean CCT was 747 μm preoperatively and 623 μm at 1 month; the decrease was statistically significant (P<.001). At 6 months, the mean CCT increased to 710 μm, still significantly thinner than preoperatively (P = .006). Pain scores at 6 months were not significantly different than preoperatively (P = .066).Conclusions: Corneal CXL significantly improved corneal transparency, corneal thickness, and ocular pain 1 month postoperatively. However, it did not seem to have a long-lasting effect in decreasing pain and maintaining corneal transparency in patients with PBK.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Clinical performance of a handheld digital infrared monocular pupillometer for measurement of the dark-adapted pupil diameter

Jay C. Bradley, Karl C. Bentley, Aleem I. Mughal, Sandra M. Brown — 2010-02-01

Purpose: To compare the accuracy of a handheld infrared digital pupillometer and digital infrared photography for measurement of the dark-adapted pupil diameter.Setting: Department of Ophthalmology and Visual Sciences, Texas Tech University Health Sciences Center, Lubbock, Texas, USA.Methods: The right horizontal pupil diameter in healthy volunteers was measured using a NeurOptics PLR-200 pupillometer and then videographed using the infrared function of a CyberShot video camera after 2 minutes and 5 minutes dark adaptation at 1 lux ambient illumination. The best still image was extracted from the video file, and the horizontal pupil diameter was determined by comparison against an internal photographic length standard using digital image software. Accommodation and alertness were controlled during testing.Results: The mean horizontal pupil diameter by infrared photography after 2 minutes of dark adaptation by subject age was 7.71 mm for ages 20 to 29 years, 6.80 mm for ages 30 to 39 years, 6.53 mm for ages 40 to 49 years, 5.94 mm for ages 50 to 59 years, and 6.01 mm for ages 60 to 69 years. The mean difference (infrared photography minus pupillometer) was +0.09 mm (range +0.30 to −0.14 mm) at 2 minutes of adaptation and +0.07 mm (range +0.25 to −0.13 mm) at 5 minutes.Conclusions: The pupillometer accurately measured the horizontal pupil diameter at 1 lux, with no measurement more than 0.3 mm different from infrared photography measurements. The pupillometer had a slight negative bias that is unlikely to introduce an error greater than 0.5 mm in clinical measurements.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Visual function after monocular implantation of apodized diffractive multifocal or single-piece monofocal intraocular lens: Randomized prospective comparison

Guiqiu Zhao, Jing Zhang, Yang Zhou, Liting Hu, Chengye Che, Nan Jiang — 2010-02-01

Purpose: To compare visual function after phacoemulsification with implantation of a multifocal intraocular lens (IOL) or a monofocal IOL.Setting: Department of Ophthalmology, Affiliated Hospital of Qingdao University Medical College, Qingdao, Shandong, China.Methods: This study comprised patients with unilateral cataract who had phacoemulsification with implantation of an AcrySof ReSTOR SA60D3 multifocal IOL (multifocal group) or an AcrySof SA60AT single-piece monofocal IOL (monofocal group). Postoperative visual function, including uncorrected (UDVA) and corrected (CDVA) distance visual acuity; uncorrected (UNVA), corrected (CNVA), and distance-corrected near visual acuity; and contrast sensitivity were evaluated 1 week, 1 month, and 6 months postoperatively. Patient-reported vision and spectacle independence in the 2 groups were also compared.Results: Of the 161 eyes, 72 were in the multifocal group and 89 were in the monofocal group. The multifocal group had statistically significant better UNVA than the monofocal group from 1 week postoperatively to the final follow-up and statistically significant better CNVA at 6 months (both P<.05). There were no statistically significant differences in UDVA or CDVA between the 2 groups over the 6-month follow-up. The multifocal group had statistically significantly better pseudoaccommodation than the monofocal group; the monofocal group had significantly better contrast sensitivity (both P<.05). Patients with the multifocal IOL reported being more satisfied than those with the monofocal IOL.Conclusions: The multifocal IOL provided better near visual acuity and more spectacle independence than the monofocal IOL.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Assessing the accuracy of intracameral antibiotic preparation for use in cataract surgery

David Lockington, Hugh Flowers, David Young, David Yorston — 2010-02-01

Purpose: To evaluate 2 local dilution protocols to assess the accuracy and variability of intracameral antibiotic dosage in cataract surgery.Setting: Tennent Institute of Ophthalmology, Glasgow, United Kingdom.Methods: Ten ophthalmic operating room nurses from 2 local hospitals participated. Oven-dried analytical grade potassium chloride (KCl) was used as a surrogate for cefuroxime. Solutions intended for intracameral use (1.0 mg in 0.1 mL) were prepared according to the 2 protocols. Twenty samples were obtained for each protocol. Ten analytical chemists also performed both dilutions. Concentrations of KCl in each 0.1 mL sample were analyzed by flame photometry.Results: Thirty samples were obtained for each protocol. The median dose after dilution was 1.17 mg (range 0.62 to 1.77 mg) for protocol 1 and 2.05 mg (range 0.52 to 7.25 mg) for protocol 2. The median was significantly higher for protocol 2 (P < .001). There was also greater variability with protocol 2.Conclusions: This study shows that the mathematical accuracy of a dilution protocol does not ensure dosage accuracy in the clinical scenario. Inadequate mixing in a 1.0 mL syringe was probably responsible for the inaccuracy of protocol 2, indicating that small-volume syringes should not be used for mixing. However, protocol 1 had an acceptable range of variability. Replication of this study could evaluate other protocols and address concerns regarding the accuracy of intracameral antibiotic preparations.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Uveal and capsular biocompatibility of an intraocular lens with a hydrophilic anterior surface and a hydrophobic posterior surface

Xiao-Dan Huang, Ke Yao, Zheng Zhang, Yidong Zhang, Yao Wang — 2010-02-01

Purpose: To evaluate the uveal and capsular biocompatibility of intraocular lenses (IOLs) with a hydrophilic anterior surface and a hydrophobic posterior surface in a rabbit model.Setting: Eye Center, Affiliated Second Hospital, College of Medicine, Zhejiang University, Hangzhou, China.Methods: Modified silicone IOLs were produced by grafting 2-methacryloyloxyethyl phosphorylcholine (MPC) onto the anterior IOL surface using a plasma technique. A contact-angle test characterized the hydrophilicity of the IOL surface; physical and optical properties were determined by State Food and Drug Administration (SFDA) standards. Rabbits had phacomulsification and implantation a modified silicone IOL, a control silicone IOL, or a hydrogel IOL. Postoperative inflammation was assessed by aqueous flare measurement, and PCO was evaluated by software analysis. Three months after surgery, attached cells on extracted IOLs were evaluated by light microscopy; PCO was evaluated by Miyake-Apple technique. Histologic sections of globes were used to assess lens epithelial cells (LECs) and extracellular matrix in the capsular bag.Results: Contact angle data showed the MPC-modified IOL had a hydrophilic anterior surface and hydrophobic posterior surface. The properties of the modified IOLs met SFDA standards. There was no statistical difference in aqueous flare between the IOL groups at any time. The modified and control IOLs had less PCO than the hydrogel IOLs (P<.05). There were fewer cells on modified IOLs than on silicone IOLs (P<.05). The LECs and cortical remnants on modified IOLs had a rapid, fibroblastic appearance at the optic periphery; the center was clear.Conclusions: Results suggest that the MPC-modified IOL has excellent uveal and capsule biocompatibility from hydrophilic anterior surface and hydrophobic posterior surface properties, respectively.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Transmission spectrums and retinal blue-light irradiance values of untinted and yellow-tinted intraocular lenses

Masaki Tanito, Tsutomu Okuno, Yoshihisa Ishiba, Akihiro Ohira — 2010-02-01

Purpose: To record and compare the spectral transmission characteristics of foldable untinted and yellow-tinted intraocular lenses (IOLs) and evaluate the protective effects against retinal damage by sunlight.Setting: Shimane University Faculty of Medicine, Izumo, Japan.Methods: The study evaluated 3 untinted IOLs (SA60AT, VA-60BBR, AU6 K) and 3 yellow-tinted IOLs (SN60AT, YA-60BBR, AU6 N) of 3 lens powers (+10.0 diopters [D], +20.0 D, and +30.0 D). Spectral transmittance in the wavelength range of 300 to 800 nm was measured using a spectrophotometer through 2.5 mm and 4.5 mm diameter apertures. Retinal hazard indices, including blue-light irradiance and maximum permissible exposure duration per day (tmax) for viewing sunlight, were calculated.Results: The untinted IOLs completely absorbed ultraviolet (UV) light and nearly completely absorbed transmitted visible light at wavelengths longer than 440 nm. Yellow-tinted IOLs absorbed more in the blue-light range (400 to 500 nm) than untinted IOLs. The blue-light irradiance was 34.2% to 56.0% lower with the SN60AT IOL than with the SA60AT IOL, 35.2% to 48.4% lower with the YA-60BBR IOL than with the VA-60BBR IOL, and 16.8% to 22.9% lower with the AU6 N IOL than with the AU6 K IOL. Blue-light irradiance values of SN60AT and YA-60BBR IOLs decreased as the lens power increased.Conclusions: Compared with aphakic eyes, UV-blocking untinted IOLs reduced the blue-light irradiance value by 60%; yellow-tinted IOLs conferred an additional 17% to 56% reduction. The difference in lens power was significantly related to the blue-light irradiance value of some yellow-tinted IOLs.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Age-related changes in the transmission properties of the human lens and their relevance to circadian entrainment

2010-02-01

Purpose: To characterize age-related changes in the transmission of light through noncataractous human lenses.Setting: Department of Ophthalmology, Glostrup Hospital, Glostrup, Denmark.Methods: The spectral transmission of white light was measured along the visual axis in the most central part of the lens in vitro in intact human donor lenses over a wide range of ages.Results: The study evaluated 28 intact human donor lenses of 15 donors aged 18 to 76 years. Increasing age was associated with gradually decreasing transmission at all visible wavelengths, most prominently at shorter wavelengths. Empirical formulas describing the age-related loss of transmission were created for each spectral color. At 480 nm, the absorption peak for melanopsin, transmission decreased by 72% from the age of 10 years to the age of 80 years.Conclusion: The age-related decrease in spectral transmission through the human lens could be modeled by a simple algorithm that may be useful in the design of intraocular lenses that mimic the characteristics of the human lens and in studies of color vision, psychophysics, and melanopsin activation.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Wave aberration of human eyes and new descriptors of image optical quality and visual performance

Marco Lombardo, Giuseppe Lombardo — 2010-02-01

The expansion of wavefront-sensing techniques redefined the meaning of refractive error in clinical ophthalmology. Clinical aberrometers provide detailed measurements of the eye's wavefront aberration. The distribution and contribution of each higher-order aberration to the overall wavefront aberration in the individual eye can now be accurately determined and predicted. Using corneal or ocular wavefront sensors, studies have measured the interindividual and age-related changes in the wavefront aberration in the normal population with the goal of optimizing refractive surgery outcomes for the individual. New objective optical-quality metrics would lead to better use and interpretation of newly available information on aberrations in the eye. However, the first metrics introduced, based on sets of Zernike polynomials, is not completely suitable to depict visual quality because they do not directly relate to the quality of the retinal image. Thus, several approaches to describe the real, complex optical performance of human eyes have been implemented. These include objective metrics that quantify the quality of the optical wavefront in the plane of the pupil (ie, pupil-plane metrics) and others that quantify the quality of the retinal image (ie, image-plane metrics). These metrics are derived by wavefront aberration information from the individual eye. This paper reviews the more recent knowledge of the wavefront aberration in human eyes and discusses the image-quality and optical-quality metrics and predictors that are now routinely calculated by wavefront-sensor software to describe the optical and image quality in the individual eye.Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned.

Enhanced effect of double-stacked intrastromal corneal ring segments in keratoconus

Brad H. Feldman, Terry Kim — 2010-02-01

We present a patient with poor visual acuity and contact lens intolerance due to advanced keratoconus who had femtosecond-assisted placement of two 0.35 mm intrastromal corneal ring segments (ICRS) in the right eye. Postoperatively, both rings migrated inferiorly and overlapped each other in a double-stacked formation. This resulted in a dramatic central shift of the cone and flattening of the inferior paracentral cornea with significant improvement in vision. To our knowledge, this is the first report of double-stacked ICRS in a human cornea and raises the possibility that significantly thicker segments may provide enhanced anatomic and visual effects in some keratoectatic patients.Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned.

Intrastromal corneal ring segments for post-LASIK ectasia complicated by persistent pain

Marcus C. Neuffer, Vasudha Panday, Charles Reilly — 2010-02-01

A 33-year-old man who was 2 years post laser in situ keratomileusis was found to have corneal ectasia. He was intolerant of rigid gas-permeable contact lenses and eventually chose to have placement of intrastromal corneal ring segments (ICRS) (Intacs) in the right eye. Two ICRS were implanted without complication, and postoperative examination showed improved visual acuity and decreased corneal elevation on scanning-slit tomography imaging. However, over the following 2 months, he complained of persistent pain in the right eye. Confocal microscopy showed a corneal nerve touching the superonasal ICRS. The ICRS was removed, and shortly thereafter the patient's pain resolved.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Brevundimonas vesicularis keratitis after laser in situ keratomileusis

Jesse S. Pelletier, Takeshi Ide, Sonia H. Yoo — 2010-02-01

A 45-year-old woman developed a corneal infiltrate 14 months after laser in situ keratomileusis (LASIK) enhancement in the left eye. The LASIK flap was lifted, scraped, and irrigated with fortified vancomycin and ceftazidime. Scraped samples were cultured and grew Brevundimonas vesicularis. The patient remained on topical ceftazidime until improvement was noted and was then switched to topical levofloxacin. The keratitis resolved on antibiotic agents with strong gram-negative coverage and a steroid. To our knowledge, this is the first report of a B vesicularis ocular infection.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Toxic anterior segment syndrome after cataract surgery

Eun Jung Jun, Sung Kun Chung — 2010-02-01

We report a case of toxic anterior segment syndrome (TASS) that developed after cataract surgery. A 78-year-old woman had uneventful phacoemulsification via a clear corneal incision with implantation of an acrylic intraocular lens. One day postoperatively, diffuse corneal edema and anterior chamber inflammation were evident. Topical antibiotic and steroid eyedrops were prescribed. The anterior chamber reaction decreased considerably, but corneal edema persisted. After a thorough investigation, the antiseptic solution used to soak surgical instruments before subsequent surgery was identified as the source of the problem.Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned.

Accommodating intraocular lens implantation in an epikeratophakia patient

Phillips Kirk Labor, Teresa Ignacio, Maureen Johnson, Linda Janku-Lestock — 2010-02-01

We report a case of implantation of the Crystalens AT-45SE and AT-52SE intraocular lenses in a highly myopic patient who had bilateral epikeratophakia surgery 15 years previously. Lessons learned from the first eye were taken into consideration when selecting the dioptric power for the fellow eye. With secondary interventions and meticulous lens calculations, the final outcomes were excellent and equivalent, allowing the patient to achieve uncorrected distance and intermediate visual acuities of 20/25 and near visual acuity of 20/50 in both eyes. To our knowledge, this is the first reported case of accommodating lens implantation in an epikeratophakic eye.Financial Disclosure: Dr. Labor and Ms. Janku-Lestock have no financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Iris fingerprinting: New method for improving accuracy in toric lens orientation

Robert H. Osher — 2010-02-01

Since the day that the Alcon toric intraocular lens (IOL) was approved, I have been searching for a better solution for orienting the IOL with greater accuracy. Using a marking pen has been a suboptimal approach because the mark is an inexact estimation that seems counterintuitive to the precision that defines contemporary refractive cataract surgery. Moreover, the mark can easily diffuse 10 degrees or even disappear entirely by the time the surgeon sits down to operate.

Late loss of corneal endothelial density with refractive iris-claw IOLs

Paul U. Fechner — 2010-02-01

I report a case of loss of corneal endothelial density between 12 years and 20 years after iris-claw intraocular lens (IOL) implantation in the phakic eyes of a myopic patient. In 1991, Fechner et al. reported on 127 eyes of 70 patients in whom the iris-claw IOL had been implanted between November l986 and November 1991. Seventeen of the eyes had experienced considerable loss of corneal endothelial density that was correlated with 3 parameters: shallow anterior chamber, high IOL power (ie, a thick IOL), and older age. In 1991, the company changed the myopia iris-claw IOL to a slightly flatter design, the Artisan myopia IOL (Ophtec BV).

Cataract Surgical Problem: February consultation #1

Samuel Masket — 2010-02-01

Recently (3 months ago), a 69-year-old woman had uneventful cataract surgery with implantation of a Crystalens HD intraocular lens (IOL) (Bausch & Lomb) in the right eye. Shortly afterward, similar surgery was performed in the left eye. However, according to the history, the vision in the left eye was poor initially and the IOL required repositioning on the first postoperative day. Nevertheless, vision in the left eye remains poor and the patient requests improvement.

February consultation #2

Steven J. Dell — 2010-02-01

The complication in the left eye is typically referred to as Z-syndrome; however, it is essentially a consequence of capsule contraction in the presence of the highly deformable Crystalens IOL. The hallmarks of this condition are new noncorneal astigmatism, a tilted IOL with 1 haptic forward and the other back, striae in the posterior capsule, and capsulorhexis ovalization. Some patients report eye pain, perhaps related to zonular tension. End-to-end capsule contraction forces the IOL into a Z-configuration. Causes of this condition include retained lens cortex with an exuberant healing response, inadequate postoperative antiinflammatory medication, preoperative hyperopia, and a decentered or poorly sized capsulorhexis. Smaller capsular bags in hyperopic eyes can place the IOL in a greater state of flexion with stored potential energy. An overly large capsulorhexis will provide inadequate anterior capsule coverage, possibly leading to forward movement of 1 plate. A very small capsulorhexis leaves behind far more anterior lens epithelial cells, leading to capsule phimosis.

February consultation #3

Anita Nevyas-Wallace — 2010-02-01

Although the 3.00 diopters (D) of noncorneal astigmatism probably stem from the Z-shaped misalignment, neither the astigmatism nor the marked Z-configuration explains the CDVA of only 20/30. Macular optical coherence tomography (OCT) and a retinal consultation are indicated preoperatively, and the patient must understand that surgical intervention would be expected to improve the UDVA but not the CDVA.

February consultation #4

Mitchell A. Jackson — 2010-02-01

In this case, capsule contraction and fibrosis are causing long-axis compression with asymmetric folding at the haptic–optic junction, which is typically seen with the Crystalens IOL. This Z-deformation can induce up to 4.00 D of asymmetric pseudophakic astigmatism. Keratometry readings are spherical, confirming a pseudophakic or noncorneal etiology for the astigmatism. The persistent striae in the posterior capsular bag at 3 months also suggest a shift in IOL position. Of note, the details of the IOL repositioning 1 day postoperatively, which did not improve vision, are not disclosed. Either way, repositioning the IOL should have corrected the problem because it was performed on the first postoperative day and capsule fibrosis had not yet developed.

February consultation #5

Uday Devgan — 2010-02-01

The Crystalens HD IOL requires meticulous surgery. This includes ensuring accuracy in IOL power calculation, using a consistent surgical technique, and achieving the desired refractive outcome without inducing significant astigmatism. When these criteria are met, this IOL model can give a wide range of sharp vision and lessen spectacle dependence.

February consultation #6

Steven G. Safran — 2010-02-01

The lenticular astigmatism in this case is an invariable result of asymmetric IOL vault (Z-syndrome) associated with the Crystalens. The syndrome may be caused by transient or gradual forces that deform the IOL, which may take on an asymmetric shape that persists. Transient forces may be due to an early postoperative wound leak or eye rubbing, which may occur during sleep. Gradual deformation may be caused by asymmetric capsule contraction associated with faulty haptic placement, zonule deficiency, capsule damage, retained cortex, or LEC-induced fibrosis. An oversized or eccentric capsulorhexis can contribute to the problem.

February consultation #7

John F. Doane — 2010-02-01

The diagnosis in this case is acute asymmetric vault or Z-syndrome of the Crystalens accommodating pseudophakic IOL. It appears that during the initial surgeries, the IOL should not have been implanted in the current orientation in the left eye. Adequate anterior capsule in front of the plate haptics prevents the hinge–optic junction from flexing anteriorly. That the patient had poor vision so soon after surgery highlights why training courses for this IOL recommend not implanting the IOL unless there is adequate anterior capsule coverage overlying the plate haptics. Regarding adequate coverage, a 7.0 mm continuous curvilinear capsulorhexis (CCC) is probably the upper limit to afford proper posterior vaulting of the IOL. My guess is that the inferonasal anterior capsule edge is 8.0 mm or greater and there is insufficient capsule to cause the nasal plate-hinge apparatus to vault posteriorly.

February consultation #8

William Trattler — 2010-02-01

Shortly after the launch of the initial version of the Crystalens IOL, surgeons noted the occurrence of Z-syndrome. Modifications were made to stiffen the haptics with the goal of reducing the incidence of the syndrome. However, even with the haptic modifications, the syndrome has occurred with the most recent versions of the IOL.

February consultation #9

Jeff Horn — 2010-02-01

The Z-syndrome in the left eye has been associated with the Crystalens IOL. This IOL should be positioned so that both hinged haptics are vaulted posteriorly. If the IOL vaults anteriorly on 1 side only, a Z-configuration results. Patients with the syndrome typically present with decreased vision and a manifest refraction showing increased myopic astigmatism resulting from IOL tilting.

February consultation #10

Jay S. Pepose — 2010-02-01

This patient presents 3 months postoperatively with classic Z-syndrome; the temporal plate haptic is vaulted posteriorly, the nasal plate haptic is vaulted anteriorly, and there is marked noncorneal astigmatism along the long axis of the IOL. Judging by the loss of iris pigment temporally and residual cortical material superiorly, this appears to have been a difficult case that required an attempt at IOL repositioning 1 day postoperatively.

February consultation #11

Jeffrey Whitman — 2010-02-01

I used to be a fan of lasering around the hinge area if I could find a cuff of fibrosis to lyse. I now often consider going back to reopen the bag with viscodissection. I then free the loops at the equator with a Sinskey hook and rotate the IOL 90 degrees. I then place a CTR over the IOL to ensure the capsule is well opened. Within 1 to 2 weeks, I open the posterior capsule and lyse any fibrous bands over the hinge area. My success with this technique is higher than with the laser alone, although the surgery can be difficult and tedious.

Corneal hysteresis changes in diabetic eyes

Afsun Şahin, Atilla Bayer — 2010-02-01

In their recent article, Goldich et al. found that corneal hysteresis (CH), corneal resistance factor (CRF), and central corneal thickness were significantly higher in diabetic eyes than in healthy eyes and CH was claimed to be related to the corneal stiffness. However, we found significantly lower CH values in diabetic eyes than in eyes of healthy subjects. We believe that the statements that equate a higher CH with increased corneal stiffness are at best speculative in this context. Corneal hysteresis can increase or decrease with stiffening depending on the behavior of the viscous material element, so the change in CH alone has too many undefined degrees of freedom to say anything more than that CH is increased.

Reply

Yakov Goldich, Yaniv Barkana, Isaac Avni, David Zadok — 2010-02-01

We agree that CH is more a measurement parameter specific to the Ocular Response Analyzer (ORA; Reichert, Inc.) than a well-defined physical property of the cornea and that much remains to be understood about the relationship between parameters measured by the ORA and their relative contribution to corneal elasticity and rigidity. We also agree that further studies of larger cohorts are needed to identify CH's role in the diagnosis of corneal disorders. For example, while some studies show decreased CH with increasing age, others report the opposite. The same ambiguity exists in our study and the study by Şahin et al. concerning CH and diabetes. Regarding these 2 studies, different results may be the result of specific differences. For example, in our study, patients were significantly older. We included only one eye per patient, whereas Şahin et al. included both eyes without statistically accounting for between-eye correlation (we think this is a methodological flaw).

Chopper and side-port incision leakage

Devesh Varma, Iqbal Ike K. Ahmed — 2010-02-01

Liyanage et al. should be commended for attempting to study incisional leakage and potential anterior chamber stability during cataract surgery, although the latter was not formally studied. Unfortunately, the study has several methodological issues, including a very rudimentary method to measure irrigation and aspiration volume (graduations on irrigation bottle and aspiration bag, respectively). Measuring volume differences using a strain gauge might have been more precise.

Reply

Brian C. Little — 2010-02-01

We thank Varma and Ahmed for their helpful comments. While anterior chamber stability was not formally studied in this paper, the closed-system model of phacoemulsification implies that incisional leakage is related to anterior chamber instability.

Comparison of femtosecond laser and mechanical microkeratome for flap thickness accuracy

Kenneth Lipstock — 2010-02-01

In their article comparing flap thickness results with 2 microkeratomes and a femtosecond laser, Rosa et al. focused discussion of the results on (1) how far the flap measurements differed from the targeted flap thickness and (2) the effect on flap thickness measurement of waiting 20 minutes after femtosecond flap creation to measure the stromal bed. The results showed a mean deviation from target that was greatest for the femtosecond laser when measured immediately after flap creation but least for the femtosecond laser when measured 20 minutes after flap creation. They theorized that temporary stromal dehydration after femtosecond flap creation may account for the difference when the readings were 20 minutes apart.

Reply

Joaquim N. Murta, Andreia M. Rosa — 2010-02-01

We agree with Lipstock that flap SD and range are very important in flap thickness evaluation. Accordingly, we included that information in our article. Despite the fact that the femtosecond laser has been regarded as more accurate than blade microkeratomes, there are important differences between the intended and obtained flap thicknesses, as we and other authors have shown, possibly resulting in a thinner than recommended residual stromal thickness. The programmed (target) flap thickness should not be used to calculate the residual stromal thickness, and therefore accurate subtraction pachymetry is critical when performing femtosecond laser in situ keratomileusis.

Comparison of fluidics systems of phacoemulsification machines

Terence Devine — 2010-02-01

The recent article by Han and Miller is, in my opinion, flawed and potentially misleading. The study attempts to draw several clinically relevant observations based on a comparison of the fluidics systems of 3 machines. However, it tested each of the 3 machines with the Alcon handpiece, needle, and sleeve. Each manufacturer's handpiece, needles, and sleeves are designed for its system and produce various degrees of resistance to inflow and outflow. The Alcon handpiece, needle, and sleeve used in the study are not recommended for use with the Stellaris system.

Reply

Young Keun Han, Kevin M. Miller — 2010-02-01

In preparing our response, we thought it might be useful to investigate publications by Devine in the area of phacoemulsification to see what expertise and biases he brings to this discussion. A search of the National Library of Medicine database revealed 3 peer-reviewed publications since 1975, 2 of which are in the ophthalmic literature. Of these, one is an instrument/technique report and the other a letter to the editor. The letter is a rebuttal of work by Mackool and Sirota, similar to Devine's rebuttal of our work. A sentence from this letter starts, “Two other concerns are that the Millennium was apparently not tested with its Custom Control software and that the friction tests were performed with manual decentration.…” We have an interest in the thermal effects of phacoemulsification equipment and a few peer-reviewed publications resulting from this work. We agree with most of what Mackool and Sirota published; however, Devine's statement suggests a Bausch & Lomb bias. Our PubMed search revealed that Devine had no publications on the topic of phacoemulsification equipment. We discovered how difficult it is to run fair, reproducible, and unbiased experiments on this equipment when we first got into the laboratory.

Positioning patients with severe kyphosis during cataract surgery

Soon-Phaik Chee — 2010-02-01

Muthialu et al. are to be commended for their innovative technique of using a parachute-like harness to securely strap the patient postured in the Trendelenburg position. However, they acknowledge that because of the limited leg room under the stacked up head and neck supports, the surgeon has to be seated superiorly rather than temporally, which is the preferred approach.

Reply

Thomas Oetting — 2010-02-01

Chee's strategy for patient positioning seems simple and elegant using this table. With severe kyphosis, we have found that the curve of the spine is so low under the head (when the head is horizontal) that we cannot get our feet under the bed for a temporal approach. It sounds as though this bed and position allow a temporal approach, which I think would be preferred.

Black iris-claw intraocular lens for cosmesis

Graham Belovay, Iqbal Ike K. Ahmed — 2010-02-01

In reply to the cataract surgical problem pertaining to cosmetic surgical options for a no-light-perception eye with a subluxated white cataract, many useful options were given. However, one option that should be considered is an opaque black iris-claw intraocular lens (IOL) (Ophtec BV) that can be enclavated to the iris (). This avoids the potentially risky prospect of removing the subluxated rock-hard cataract and does not require complex intraocular maneuvers or the need to suture the IOL to the sclera. A 5.0 mm corneal or scleral incision is required. The surgery can be performed under topical anesthesia and is very quick and well tolerated. We have found the use of iris-claw IOLs for phakic or aphakic purposes to be a very effective platform for lens fixation in complex situations.

Early publication on intraoperative retinoscopy

Richard J. Mackool — 2010-02-01

In their study concerning the use of intraoperative retinoscopy for intraocular lens (IOL) power estimation, Patwardhan et al. cited another report that used autorefractive optical biometry for IOL power calculation. They also reported the deficiencies of the latter method compared with intraoperative retinoscopy. The authors apparently overlooked my original publication on the subject of intraoperative retinoscopy for IOL power calculation, a technique that I have been using for approximately 30 years.

Early flap dislocation with perioperative brimonidine use in laser in situ keratomileusis

Mohammad H. Nowroozzadeh — 2010-02-01

In their article about flap dislocation, Muñoz et al. state that topical brimonidine prevents the formation of subconjunctival hemorrhages after femtosecond laser in situ keratomileusis (LASIK) but significantly increases the risk for early flap dislocation. I offer some plausible explanations for the observed flap dislocation.

Editorial Board

2010-02-01

Visual Acuity Chart

2010-02-01

Journal of Cataract & Refractive Surgery

Endophthalmitis

Double-bubble technique to facilitate Descemet membrane exposure in deep anterior lamellar keratoplasty

Crossed-swords, capsule-pinch technique for capsulotomy in pediatric and/or loose lens cataract extraction

Repositioning free laser in situ keratomileusis flaps

Effectiveness of intracameral cefuroxime in preventing endophthalmitis after cataract surgery: Ten-year comparative study

Role of anterior capsule polishing in residual lens epithelial cell proliferation

Effect of intraocular lens asphericity on vertical coma aberration

Assessment of toric intraocular lens alignment by a refractive power/corneal analyzer system and slitlamp observation

Intraocular lens power calculation: Clinical comparison of 2 optical biometry devices

Magnetic resonance imaging of the anteroposterior position and thickness of the aging, accommodating, phakic, and pseudophakic ciliary muscle

Preoperative cataract grading by Scheimpflug imaging and effect on operative fluidics and phacoemulsification energy

Comparison of endothelial cell loss after cataract surgery: Phacoemulsification versus manual small-incision cataract surgery: Six-week results of a randomized control trial

Intermediate results of sutureless intrascleral posterior chamber intraocular lens fixation

Laser-assisted subepithelial keratectomy for bilateral hyperopia and hyperopic anisometropic amblyopia in children: One-year outcomes

Ocular blood-flow hemodynamics before and after application of a laser in situ keratomileusis ring

Collagen crosslinking with riboflavin and ultraviolet-A in eyes with pseudophakic bullous keratopathy

Clinical performance of a handheld digital infrared monocular pupillometer for measurement of the dark-adapted pupil diameter

Visual function after monocular implantation of apodized diffractive multifocal or single-piece monofocal intraocular lens: Randomized prospective comparison

Assessing the accuracy of intracameral antibiotic preparation for use in cataract surgery

Uveal and capsular biocompatibility of an intraocular lens with a hydrophilic anterior surface and a hydrophobic posterior surface

Transmission spectrums and retinal blue-light irradiance values of untinted and yellow-tinted intraocular lenses

Age-related changes in the transmission properties of the human lens and their relevance to circadian entrainment

Wave aberration of human eyes and new descriptors of image optical quality and visual performance

Enhanced effect of double-stacked intrastromal corneal ring segments in keratoconus

Intrastromal corneal ring segments for post-LASIK ectasia complicated by persistent pain

Brevundimonas vesicularis keratitis after laser in situ keratomileusis

Toxic anterior segment syndrome after cataract surgery

Accommodating intraocular lens implantation in an epikeratophakia patient

Iris fingerprinting: New method for improving accuracy in toric lens orientation

Late loss of corneal endothelial density with refractive iris-claw IOLs

Cataract Surgical Problem: February consultation #1

February consultation #2

February consultation #3

February consultation #4

February consultation #5

February consultation #6

February consultation #7

February consultation #8

February consultation #9

February consultation #10

February consultation #11

Corneal hysteresis changes in diabetic eyes

Reply

Chopper and side-port incision leakage

Reply

Comparison of femtosecond laser and mechanical microkeratome for flap thickness accuracy

Reply

Comparison of fluidics systems of phacoemulsification machines

Reply

Positioning patients with severe kyphosis during cataract surgery

Reply

Black iris-claw intraocular lens for cosmesis

Early publication on intraoperative retinoscopy

Early flap dislocation with perioperative brimonidine use in laser in situ keratomileusis

Editorial Board

Visual Acuity Chart

TOC