Journal of Cataract & Refractive Surgery - Articles in Press

Matched comparison of rotational stability of 1-piece acrylic and plate-haptic silicone toric intraocular lenses in Asian eyes - Corrected Proof

Wei-Han Chua, Leonard H. Yuen, Jocelyn Chua, Gillian Teh, Warren E. Hill — 2012-02-02

Purpose: To evaluate and compare the postoperative rotational stability of a 1-piece acrylic toric intraocular lens (IOL) (Acrysof) and a plate-haptic silicone toric IOL (Staar) in Asian eyes.Setting: Singapore National Eye Centre, Singapore.Design: Prospective randomized control trial.Methods: Eyes of Chinese patients having cataract surgery were randomized to receive the acrylic toric IOL or the silicone toric IOL. Postoperatively, patients returned at 1 day, 1 week, and 1 and 3 months. The eyes were dilated and slitlamp retroillumination photography of the toric IOL was performed to assess rotational stability.Results: The acrylic IOL was implanted in 24 eyes and the silicone IOL in 26 eyes. The mean age of the patients was 68.2 years (range 42 to 82 years). The mean IOL rotation from baseline to 3 months postoperatively was 4.23 ± 4.28 degrees in the acrylic IOL group and 9.42 ± 7.80 degrees in the silicone IOL group; the difference was statistically significant (P=.01). Of the acrylic IOLs, 73% were rotated less than 5 degrees at 3 months; none was rotated more than 15 degrees at 3 months. The silicone toric IOLs showed greater rotational movement, with 37% being rotated less than 5 degrees and 21% being rotated more than 15 degrees.Conclusion: The acrylic toric IOL had better rotational stability than the silicone toric IOL.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Bilateral delayed nonpupillary block angle closure after insertion of phakic intraocular lens - Corrected Proof

Jean Chai, Romesh I. Angunawela, Shamira Perera, Donald Tan — 2012-02-02

We describe a case of nonpupillary block angle closure and discuss the possible mechanisms of this rare complication. A 41-year-old woman with low myopia (right eye: −2.75 −1.25 × 165; left eye: −3.50 −0.50 × 20) had bilateral implantation of a Visian Implantable Collamer Lens phakic intraocular lens (pIOL) (Staar Surgical Co.) at another facility. The preoperative anterior chamber depth (ACD) was 2.8 mm bilaterally. Two months postoperatively, she presented with pain in the right eye of 2 days duration.

Combined Descemet-stripping automated endothelial keratoplasty and phacoemulsification with toric intraocular lens implantation for treatment of failed penetrating keratoplasty with high regular astigmatism - Corrected Proof

Vincenzo Scorcia, Andrea Lucisano, Jacqueline Beltz, Massimo Busin — 2012-02-02

We present the case of a 57-year-old woman who had combined Descemet-stripping automated endothelial keratoplasty (DSAEK) and phacoemulsification with implantation of a toric intraocular lens (IOL). Surgery was intended to treat a cataract developing in a post-penetrating keratoplasty (PKP) eye with high astigmatism and endothelial decompensation. Six months after uneventful surgery, the cornea was clear and the corrected distance visual acuity was 20/20 with a refraction of +0.25 −1.00 × 10 (from −3.00 −8.50 × 12 preoperatively). The internal topography map (OPD-Scan) showed an IOL rotation of 4 degrees. The endothelial cell loss was 15% of the eye-bank value. Descemet-stripping automated endothelial keratoplasty combined with phacoemulsification and toric IOL implantation is a relatively simple and very effective procedure for eyes with endothelial failure and high post-PKP astigmatism. The speed of visual rehabilitation and final visual acuity achieved with this approach was superior to that obtained with other surgical procedures.Financial Disclosure: Dr. Busin received royalties from Moria in 2008, 2009, and 2010, and his travel expenses were partly reimbursed by Moria from 2005 to 2011. No other author has a financial or proprietary interest in any material or method mentioned.

Outcomes of cataract surgery in patients with neovascular age-related macular degeneration in the era of anti-vascular endothelial growth factor therapy - Corrected Proof

2012-01-27

Purpose: To evaluate the visual outcomes, choroidal neovascular complex status, and adverse events in patients with visually significant cataract and neovascular age-related macular degeneration (AMD) who had cataract surgery.Setting: Private practices, Beverly Hills, California, and New London, Connecticut, USA.Design: Case series.Methods: Data were abstracted from the medical records of patients with neovascular AMD treated by anti-vascular endothelial growth factor (anti-VEGF) therapy who had cataract surgery. The main outcome measures were Snellen corrected distance visual acuity (CDVA), perioperative adverse events, and status of the choroidal neovascular complex.Results: The study enrolled 30 eyes of 28 patients. The CDVA was 20/40 or better in 10% of eyes preoperatively and 40% postoperatively; 20/50 to 20/100 in 53% and 33%, respectively; and 20/200 or worse in 37% and 27%, respectively. The change in CDVA from preoperatively to postoperatively was statistically significant, with a mean change of 0.22 logMAR ± 0.27 (SD) at 2 months (P<.0001), 0.22 ± 0.36 logMAR at 6 months (P=.001), and 0.17 ± 0.54 logMAR at the last follow-up (P=.01). Patients received a mean of 0.32 injections per month postoperatively compared with 0.49 injections per month preoperatively. Perioperative macular adverse events did not occur in any eye.Conclusions: With regular evaluations and appropriate treatment with anti-VEGF agents, cataract surgery did not appear to be associated with an increased incidence of perioperative complications or macular adverse events.Financial Disclosures: Dr. Tabandeh is a consultant/advisor to Alcon and Allergan. Dr. Boyer is a consultant/advisor to Alcon, Allergan, Genentech, Regeneron, Novartis, Pfizer, and Optos and has received lecture fees from Allergan, Alcon, Genentech, and Pfizer. No other author has a financial or proprietary interest in any material or method mentioned.

Complications of inadvertent filtering blebs after cataract extraction - Corrected Proof

Sandra M. Johnson, Evan C. Pike, Eric G. Feinstein — 2012-01-24

We report 2 cases of inadvertent filtering blebs that developed vision-threatening complications many years after uneventful cataract extraction with scleral incisions. These inadvertent blebs can create complications similar to the intentionally produced blebs from trabeculectomy surgery; thus, follow-up and management should be handled in a similar manner.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Modified capsular tension ring implantation in eyes with traumatic cataract and loss of zonular support - Corrected Proof

2012-01-24

Purpose: To evaluate the outcomes of implantation of a Cionni modified capsular tension ring (CTR) and a posterior chamber intraocular lens (PC IOL) in patients with traumatic cataract and loss of zonular support.Setting: Eye Clinic II, Haydarpasa Numune Education and Research Hospital, Istanbul, Turkey.Design: Case series.Methods: Eyes with traumatic cataract and loss of zonular support had phacoemulsification with implantation of a foldable IOL and a 1- or 2-eyelet modified CTR. Preoperative features, preoperative and postoperative corrected distance visual acuity (CDVA), intraoperative performance, IOL position, and complications were evaluated.Results: The study enrolled 16 eyes (16 patients). The mean CDVA was 0.89 logMAR ± 0.41 (SD) preoperatively and 0.33 ± 0.43 logMAR at the last postoperative examination (P=.001). Postoperatively, the mean spherical equivalent was −0.23 diopter (D) (range −1.50 to +1.00 D) and the mean postoperative astigmatism, 1.59 D (range 0.50 to 4.00 D). Eight eyes (50.0%) had phacodonesis preoperatively; no eye had pseudophacodonesis postoperatively. Preoperatively, 10 eyes (62.5%) had symptomatic decentration. Two eyes (12.5%) had asymptomatic nonprogressive decentration in the early postoperative period; no eye had symptomatic decentration throughout the follow-up. Three eyes (18.8%) preoperatively and 1 eye (6.2%) postoperatively had vitreous in the anterior chamber. Four eyes (25.0%) required anterior vitrectomy. Other complications were symptomatic posterior capsule opacification in 8 eyes (50.0%) and transient increased intraocular pressure in 2 eyes (12.5%).Conclusion: The use of a modified CTR preserved the capsular bag and resulted in good PC IOL centration with few significant complications in patients with traumatic cataract and loss of zonular support.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Idiopathic peripheral necrotizing keratitis after femtosecond laser in situ keratomileusis - Corrected Proof

Marissa G. Bucci, Gregory J. McCormick — 2012-01-24

We report a case of necrotizing peripheral keratitis after laser in situ keratomileusis (LASIK) using the low-energy Femto LDV femtosecond laser in a 31-year-old helicopter pilot with no history of medical or ocular disease. The severe peripheral flap inflammation resulted in stromal necrosis that was unresponsive to intensive topical steroid but improved rapidly on oral prednisone. The uncorrected distance visual acuity was maintained at 20/15 in both eyes, and the flaps were left undisturbed rather than attempting a more aggressive intervention such as a flap lift with culture and antibiotic irrigation. Identification of sterile corneal infiltration must be distinguished from infectious etiologies as the treatment is distinctly different. Although increased corneal infiltration has been reported with increasing femtosecond laser energy level for flap creation, to our knowledge this is the first report of necrotizing sterile corneal infiltration after LASIK with the low-energy femtosecond laser.Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned.

Modulation of central corneal thickness by various riboflavin eyedrop compositions in porcine corneas - Corrected Proof

2012-01-24

Purpose: To evaluate the modulatory effect of various riboflavin 0.1% and 0.2% compositions on the central corneal thickness (CCT) in fresh porcine corneas.Setting: Department of Ophthalmology, Johannes Gutenberg University of Mainz, Mainz, Germany.Design: Experimental study.Methods: The CCT in freshly enucleated porcine globes was measured by ultrasound pachymetry before and after (if applicable) deepithelialization and every 10 minutes thereafter during 120 minutes of eyedrop application. In Groups 1 and 2 (controls), no eyedrops were applied. In Groups 3 and 4, isotonic riboflavin eyedrops were used. In Groups 5 to 9, hypotonic riboflavin eyedrops were given. In Groups 10 and 11, preparations for transepithelial crosslinking were applied. In Groups 2 to 9, deepithelialization was performed. The final CCT in the groups was compared by analysis of variance.Results: One hundred ten freshly enucleated porcine globes were used. The mean final CCT compared with preoperative values was 97% ± 4% (SD) in Group 1, 91% ± 4% in Group 2, 66% ± 5% in Group 3, 151% ± 13% in Group 4, 65% ± 2% in Group 5, 105% ± 3% in Group 6, 120% ± 4% in Group 7, 130% ± 4% in Group 8, 132% ± 4% in Group 9, 114% ± 2% in Group 10, and 114% ± 4% in Group 11. The differences between Group 1 and each of Groups 3, 4, 5, 7, 8, and 9 were statistically significant (P<.05).Conclusion: There was considerable variation in the final CCT as a result of varying riboflavin eyedrop compositions.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Reliability and repeatability of swept-source Fourier-domain optical coherence tomography and Scheimpflug imaging in keratoconus - Corrected Proof

Eszter Szalai, András Berta, Ziad Hassan, László Módis — 2012-01-20

Purpose: To evaluate the repeatability and reliability of a recently introduced swept-source Fourier-domain anterior segment optical coherence tomography (AS-OCT) system and a high-resolution Scheimpflug camera and to assess the agreement between the 2 instruments when measuring healthy eyes and eyes with keratoconus.Setting: Department of Ophthalmology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary.Design: Evaluation of diagnostic test or technology.Methods: Three consecutive series of anterior segment images were taken with AS-OCT (Casia SS-1000) followed by rotating Scheimpflug imaging (Pentacam high resolution). Axial keratometry in the steep and flat meridians and astigmatism values were recorded. Pachymetry in the apex, center, and the thinnest position and anterior chamber depth (ACD) measurements were also taken.Results: This study enrolled 57 healthy volunteers (57 eyes) and 56 patients (84 eyes) with keratoconus. Significant difference was found in all measured anterior segment parameters between normal eyes and keratoconic eyes (P<.05). In keratoconic eyes, the difference between repeated measurements was less with AS-OCT than with Scheimpflug imaging in every keratometry and astigmatism value, in apical thickness, and in ACD. For keratometry, the thinnest and central pachymetry measurement repeatability was better in healthy eyes than in keratoconic eyes with both instruments. In general, the mean difference between AS-OCT and Scheimpflug imaging was higher in cases of keratoconus.Conclusions: Significant differences in keratometry, pachymetry, and ACD results were found between AS-OCT and Scheimpflug imaging. However, the repeatability of the measurements was comparable.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Patient-perceived pain during laser in situ keratomileusis: Comparison of fellow eyes - Corrected Proof

Hala El Rami, Ali Fadlallah, Daoud Fahd, Sharbel Fahed — 2012-01-20

Purpose: To compare pain scores during laser in situ keratomileusis (LASIK) between first-eye surgery and second-eye surgery.Setting: Private practice, Beirut, Lebanon.Design: Cohort study.Methods: Sequential bilateral LASIK was performed between January 2010 and January 2011 by the same surgeon using a Schwind Amaris excimer laser. Hemodynamics and intraocular pressure (IOP) were monitored intraoperatively. Patients graded their pain perception on a 4-point scale after the completion of each eye’s surgery.Results: The study enrolled 154 patients. The first surgery was performed in the right eye in 106 patients and in the left eye in 48 patients. Patients reported discomfort during suction (mean pain score 0.80 ± 0.56 [SD]). More pain was reported during second-eye surgery by 74% of patients; 2% reported more pain in the first eye, and 24% reported equal pain in both eyes. The mean pain score was 0.63 ± 0.35 in the first eye and 0.93 ± 0.51 in the second eye (P=.01). Pain was higher during second-eye surgery whether the procedure was started in the right eye or in the left eye. Systolic blood pressure was also higher during second-eye surgery (P=.001). There was no statistically significant difference in diastolic blood pressure, heart rate, IOP, or suction-ring pressure.Conclusions: Patients had more pain during second-eye LASIK for reasons that are not clear. A psychological explanation or regional sensitization processes are potential factors and should be studied.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Collagen crosslinking and toric iris-claw phakic intraocular lens for myopic astigmatism in progressive mild to moderate keratoconus - Corrected Proof

2012-01-20

Purpose: To report the long-term results of combined collagen crosslinking (CXL) and toric phakic intraocular lens (pIOL) implantation to correct myopic astigmatism in patients with progressive mild to moderate keratoconus.Setting: Instituto de Microcirugia Ocular, Barcelona, Spain.Design: Case series.Methods: From November 2006 to July 2009, CXL was performed in eyes with proven progressive keratoconus. Once refraction and topography stabilized, toric Artiflex/Artisan pIOL implantation was performed to correct residual myopic astigmatism. A complete ophthalmologic examination, including manifest refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, biomicroscopy, tonometry, fundoscopy, keratometry, corneal tomography, and central endothelial cell count (ECC), was performed before each procedure and postoperatively at 3 months and at yearly intervals up to 5 years. Main outcome measures were accuracy and stability of the spherical equivalent (SE) and cylinder, keratometry, UDVA (efficacy), CDVA (safety), central ECC, and complications.Results: The median follow-up in the 9 patients (17 eyes) was 36.9 months ± 15.0 (SD). The median interval between CXL and pIOL implantation was 3.9 ± 0.7 months. Fourteen eyes (82%) were within ±0.50 diopter (D) of the attempted SE correction and 13 eyes (76%) were within ±1.00 D of the attempted cylinder correction. The mean difference in simulated keratometry between preoperatively and the last follow-up was 0.17 ± 0.45 D (range −0.55 to 1.45 D). The postoperative UDVA was 20/40 or better in 16 eyes (94%). No eye lost lines of CDVA. No significant decrease in central ECC occurred (P>.05).Conclusion: Combined CXL and toric iris-claw pIOL implantation effectively and safely corrected myopic astigmatism in progressive mild to moderate keratoconus.Financial Disclosure: Dr. Güell is a consultant to Ophtec. No other author has a financial or proprietary interest in any material or methods mentioned.

Topical–intracameral anesthesia without preoperative mydriatic agents for Descemet-stripping automated endothelial keratoplasty and phacoemulsification cataract surgery with intraocular lens implantation - Corrected Proof

Thomas J. Oberg, Shameema Sikder, Adam J. Jorgensen, Mark D. Mifflin — 2012-01-20

We describe a technique for a new triple procedure comprising phacoemulsification and intraocular lens (IOL) implantation followed immediately by Descemet-stripping automated endothelial keratoplasty (DSAEK). It is performed under topical anesthesia, with dilation accomplished using methylparaben-free lidocaine 1% with no added epinephrine. In a case series of 32 patients, adequate dilation was achieved and no patient reported significant intraoperative discomfort. No operative or postoperative complications were encountered, and visual rehabilitation was quick and satisfactory. Topical anesthesia eliminated the risks associated with retrobulbar and peribulbar blocks, as well as the risks associated with general anesthesia. Intracameral dilation with preservative-free lidocaine 1% provided adequate and short-lived dilation, alleviating the need for intraoperative pharmacologic constriction when transitioning from IOL implantation to DSAEK.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Results of laser in situ keratomileusis performed using solid-state laser technology - Corrected Proof

2012-01-16

Purpose: To evaluate and report the visual, refractive, and aberrometry outcomes of laser in situ keratomileusis (LASIK) to correct low to moderate myopia using a commercial solid-state laser.Setting: Oftalmar, Medimar International Hospital, Alicante, Spain.Design: Prospective case series.Methods: This study evaluated consecutive eyes with low to moderate myopia that had LASIK performed using a Pulzar Z1 solid-state laser. Visual, refractive, and aberrometry changes as well as potential complications were evaluated.Results: The study enrolled 60 eyes (34 patients). The mean follow-up was 8.5 months (range 6 to 13 months). There was a significant improvement in logMAR uncorrected distance visual acuity (UDVA) postoperatively (P<.01). No significant change was detected in logMAR corrected distance visual acuity (CDVA) (P=.21). The postoperative logMAR UDVA was 0.1 (approximately 20/25) or better in 57 eyes (95.00%). The mean overall efficacy index was 0.99 and the mean safety index, 1.02. Postoperatively, 1 eye (1.67%) lost lines (1 line) of CDVA. The postoperative spherical equivalent was within ±0.50 diopter in 58 eyes (96.67%). There was a small, but statistically significant increase in the primary coma root mean square (0.17 μm) and in the magnitude of primary spherical aberration (0.09 μm). No severe complications occurred.Conclusion: Laser in situ keratomileusis using the solid-state laser provided predictable correction of low to moderate myopia, minimizing the induction of higher-order aberrations and preserving CDVA.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Epidemiology of postoperative endophthalmitis in an Asian population: 11-year incidence and effect of intracameral antibiotic agents - Corrected Proof

Colin S.H. Tan, Hon Kiat Wong, Francine P. Yang — 2012-01-16

Purpose: To describe the incidence of postoperative endophthalmitis after cataract surgery in a multiethnic Asian population over an 11-year period, compare the endophthalmitis rates before and after the use of intracameral antibiotic agents, and identify potential risk factors for endophthalmitis.Setting: Department of Ophthalmology, Tan Tock Seng Hospital, Singapore.Design: Cohort study.Methods: The incidence and risk factors for postoperative endophthalmitis in patients who had cataract surgery over 11 years were reviewed. Subconjunctival antibiotic agents only were administered over 7 years; in the subsequent 4 years, intracameral cefazolin (1.0 mg/0.1 mL) was used.Results: The overall incidence of postoperative endophthalmitis in 50 177 was 0.042%. Over the 7 years without intracameral antibiotics, the endophthalmitis rate was 0.064% (19/29 539). With the use of intracameral cefazolin, the incidence decreased to 0.01% (2/20 638) (multivariate odds ratio [OR], 13.6; 95% confidence interval [CI], 3.15-58.58; P<.001). The independent risk factors for endophthalmitis were age (OR, 1.05; 95% CI, 1.01-1.09; P=.025) and male sex (0.06% versus 0.02%; OR, 2.96; 95% CI; 1.15-7.65; P=.025).Conclusions: There was a significant reduction in the rate of postoperative endophthalmitis in a multiethnic Asian population with the use of intracameral cefazolin. Men and older patients were at a higher risk for endophthalmitis.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Long-term visual outcome after cataract surgery: Comparison of healthy eyes and eyes with age-related macular degeneration - Corrected Proof

Eva Mönestam, Britta Lundqvist — 2012-01-16

Purpose: To compare the long-term longitudinal visual acuity outcomes after cataract surgery in eyes with age-related macular degeneration (AMD) at surgery and eyes without comorbidity.Setting: University-based eye clinic.Design: Longitudinal cohort study.Methods: Patients having cataract surgery were evaluated over 1 year. A clinical eye examination and corrected distance visual acuity (CDVA) measurement were performed preoperatively and postoperatively as well as 5 and 10 years postoperatively for eligible patients. The patients were divided into functional groups depending on postoperative signs of macular degeneration and postoperative CDVA.Results: The study evaluated 810 patients. The rate of CDVA decline with age was faster in AMD patients than in patients without comorbidity. The slope of the visual acuity decline was similar in the 2 subgroups with AMD (almost normal CDVA and reduced CDVA postoperatively). After adjustment for age, there was a mean loss of 2.3 logMAR letters in patients with no comorbidity and 6.4 letters in patients with AMD at surgery for each decade of increasing age. More than 75% of AMD patients had better CDVA 10 years after surgery than before surgery.Conclusions: Patients with signs of AMD at cataract surgery had a longitudinally worse visual outcome than patients without clinical signs of AMD. However, there is no reason to discourage patients with concurrent visually significant cataract and AMD from having surgery because most AMD patients had better CDVA 10 years after surgery than before surgery.Financial Disclosure: Neither author has a financial or proprietary interest in any material or method mentioned.

Effect of topical anesthetic agents and ethanol on corneoepithelial wound healing in an ex vivo whole-globe porcine model - Corrected Proof

2012-01-16

Purpose: To assess the impact of topical anesthetic agents and ethanol on ocular surface wound healing using an ex vivo whole-globe porcine model.Setting: Department of Ophthalmology, Inselspital, University of Bern, Bern, Switzerland.Design: Experimental study.Methods: Standardized corneoepithelial lesions (5.0 mm diameter, 40 μm depth) were created with excimer laser light in freshly enucleated porcine eyes. The globes (6 per group) were exposed to different concentrations of ethanol (2.0% to 99.0%), cocaine (2.0% to 10.0%), procaine hydrochloride (0.4%), tetracaine (0.5% to 1.0%), or lidocaine (2.0%), 3 drops/hour for 3 hours. Control solutions were physiologic saline, balanced salt solution, and tissue-culture medium. After 20 to 26 hours, wound-healing response was compared by measuring the diameter of each corneoepithelial lesion.Results: The mean diameter of corneoepithelial lesions exposed to physiologic saline decreased from 4.78 mm ± 0.19 (SD) to 4.44 ± 0.17 mm between 20 and 26 hours. After 24 hours, the mean lesion size, compared with physiological saline, was larger after cocaine 5.0% (5.20 ± 0.26 mm) and 10.0% (5.39 ± 0.12 mm), tetracaine 0.5% (5.59 ± 0.35 mm) and 1.0% (5.55 ± 0.27 mm), and procaine hydrochloride 0.4% (5.76 ± 0.12 mm), but not after lidocaine 2.0% (5.01 ± 0.17 mm). Balanced salt solution, tissue-culture medium, ethanol 2.0% to 99.0%, and cocaine 2.0% did not inhibit the wound-healing response.Conclusions: In an ex vivo whole-globe porcine model, lidocaine 2.0% and cocaine 2.0% were the least toxic anesthetic agents. At all concentrations, ethanol had no impact on wound healing.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Using artificial intelligence to predict the risk for posterior capsule opacification after phacoemulsification - Corrected Proof

2012-01-13

Purpose: To apply artificial intelligence models to predict the occurrence of posterior capsule opacification (PCO) after phacoemulsification.Setting: Farabi Eye Hospital, Tehran, Iran.Design: Clinical-based cross-sectional study.Methods: The posterior capsule status of eyes operated on for age-related cataract and the need for laser capsulotomy were determined. After a literature review, data polishing, and expert consultation, 10 input variables were selected. The QUEST algorithm was used to develop a decision tree. Three back-propagation artificial neural networks were constructed with 4, 20, and 40 neurons in 2 hidden layers and trained with the same transfer functions (log-sigmoid and linear transfer) and training protocol with randomly selected eyes. They were then tested on the remaining eyes and the networks compared for their performance. Performance indices were used to compare resultant models with the results of logistic regression analysis.Results: The models were trained using 282 randomly selected eyes and then tested using 70 eyes. Laser capsulotomy for clinically significant PCO was indicated or had been performed 2 years postoperatively in 40 eyes. A sample decision tree was produced with accuracy of 50% (likelihood ratio 0.8). The best artificial neural network, which showed 87% accuracy and a positive likelihood ratio of 8, was achieved with 40 neurons. The area under the receiver-operating-characteristic curve was 0.71. In comparison, logistic regression reached accuracy of 80%; however, the likelihood ratio was not measurable because the sensitivity was zero.Conclusion: A prototype artificial neural network was developed that predicted posterior capsule status (requiring capsulotomy) with reasonable accuracy.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Serious ocular complications of cosmetic iris implants in 14 eyes - Corrected Proof

2012-01-13

Purpose: To report the presentation and subsequent management of a series of patients presenting with cosmetic iris implants.Setting: New York Eye and Ear Infirmary, New York, New York, USA.Design: Case series.Methods: In this evaluation of patients with NewColorIris cosmetic iris implants, data collected included patient demographics, visual acuity, intraocular pressure (IOP), endothelial cell count, and slitlamp examination findings at presentation. Medical and surgical interventions and the postoperative course were recorded.Results: Fourteen eyes of 7 patients (ages 22 to 60; 71% men) were identified. Nine eyes (64%) presented with decreased visual acuity, 7 (50%) had elevated IOP, 5 (36%) had corneal edema, and 5 (36%) had anterior uveitis. All 14 eyes had explantation of the iris prosthesis (range 4 to 33 months after placement). The minimum follow-up after implant removal in all eyes was 2 months (range 2 to 28 months). Intraoperative complications included suprachoroidal hemorrhage during explantation in 1 eye. Postoperative complications included corneal edema (8 eyes), cataract (9 eyes), and increased IOP/glaucoma (7 eyes). Secondary surgeries included Descemet-stripping automated endothelial keratoplasty (5 eyes), cataract extraction with intraocular lens placement (7 eyes), trabeculectomy (3 eyes), glaucoma drainage implant placement (3 eyes), and penetrating keratoplasty (1 eye).Conclusions: The cosmetic iris implants may result in severe ocular morbidity. Complications in our series included uveitis, glaucoma, corneal edema, and decreased visual acuity. Although explantation helped stabilize symptoms, additional medical and surgical intervention to control IOP and corneal decompensation was required in many cases.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Delayed-onset interface fluid syndrome after laser in situ keratomileusis secondary to combined cataract and vitreoretinal surgery - Corrected Proof

Sang Beom Han, Se Joon Woo, Joon Young Hyon — 2011-12-26

A 40-year-old man with a history of laser in situ keratomileusis (LASIK) 13 years earlier had combined cataract extraction and vitreoretinal surgery due to rhegmatogenous retinal detachment and posterior subcapsular cataract. Two weeks postoperatively, he complained of painless visual blurring. Diffuse interface haze was observed, and antiinflammatory treatment including topical steroid and cyclosporine was started. One week later, visual blurring had not improved and intraocular pressure was 27 mm Hg. Interface haze, fluid collection, and flap edema were observed and confirmed by spectral-domain anterior segment optical coherence tomography. After discontinuation of the steroid and addition of IOP-lowering medication, visual acuity and interface fluid collection and haze improved. This case illustrates that interface fluid syndrome can develop more than 10 years after LASIK, triggered by ocular hypertension and inflammation after intraocular surgery.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Evaluation of variables affecting intraoperative aberrometry - Corrected Proof

Jack Stringham, Jeff Pettey, Randall J. Olson — 2011-12-26

Purpose: To understand some of the variable refractive changes that occur during routine cataract surgery that could affect the accuracy and effectiveness of intraoperative aberrometry as it relates to the postoperative refractive state.Setting: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA.Design: Comparative case series.Methods: Phase 1 of this study assessed the cylinder induced by 2 eyelid speculums (open wire and closed wire) with corneal topographic images from participants without cataract. Phase 2 assessed the refractive change in cylinder, its axis, and the spherical equivalent (SE) in cataract patients within 1 hour of cataract surgery compared with 1 week after surgery. These measurements were taken using wavefront aberrometry, manual refraction, and corneal topography.Results: Phase 1 evaluated 99 corneal topographic images from 5 participants. The presence of a speculum induced erratic changes in cylinder and a statistically significant difference in axis when comparing the open-wire speculum and the closed-wire speculum (both P<.0001). In phase 2, which evaluated 10 patients, there was a significant change in the SE within 1 hour of cataract surgery compared with 1 week after surgery (P=.039).Conclusion: Cataract surgery induced changes in cylinder, its axis, and the SE. This suggests that decisions based on intraoperative aberrometry may be inaccurate.Financial Disclosure: Dr. Olson has been a consultant to Abbott Medical Optics, Inc., Becton, Dickinson and Co., and Allergan, Inc., and has received grant support from Abbott Medical Optics, Inc. and Allergan, Inc. No author has a financial or proprietary interest in any material or method mentioned.

Impact of phacoemulsification on failure of trabeculectomy with mitomycin-C - Corrected Proof

2011-12-22

Purpose: To evaluate whether phacoemulsification after trabeculectomy affects postoperative intraocular pressure (IOP).Setting: Kumamoto University, Kumamoto, Japan.Design: Cohort study.Methods: The medical records of patients with primary open-angle glaucoma or exfoliation glaucoma who had trabeculectomy with mitomycin-C were reviewed. The primary endpoints were condition A (persistent postoperative IOP 21 mm Hg or higher or additional glaucoma procedures with or without medications) and condition B (postoperative IOP 18 mm Hg or higher or additional glaucoma procedures with or without medications). Multivariable analysis was performed using the Cox proportional hazards model.Results: The records of 178 patients (178 eyes) were reviewed. The mean follow-up was 37.0 months. For condition A, the probability of treatment success at 1 year, 2 years, and 3 years was 97.9%, 95.0%, and 92.7%, respectively. For condition B, the corresponding probabilities of success were 92.3%, 84.1%, and 81.8%. Thirty-seven patients (37 eyes) had phacoemulsification after trabeculectomy; 10 of those patients had phacoemulsification within 1 year after trabeculectomy. Multivariate analysis showed that a higher IOP before trabeculectomy was a significant risk factor for condition A and condition B (P=.01 and P=.0006, respectively); phacoemulsification within 1 year after trabeculectomy was significantly associated with trabeculectomy failure for condition B (P=.04).Conclusion: Postoperative IOP in eyes with previous trabeculectomy may be affected by the IOP before trabeculectomy and phacoemulsification within 1 year after trabeculectomy.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Optical modeling of a corneal inlay in real eyes to increase depth of focus: Optimum centration and residual defocus - Corrected Proof

Juan Tabernero, Pablo Artal — 2011-12-19

Purpose: To determine the optimum position to center a small-aperture corneal inlay and the effect of residual defocus in the surgical eye to maximize depth of focus.Setting: Laboratorio de Óptica, Universidad de Murcia, Murcia, Spain.Design: Cohort study.Methods: Personalized eye models were built using actual data (corneal topography, eye length, ocular aberrations, and eye alignment). A small aperture 1.6 mm in diameter was placed at the corneal plane in each model. The monochromatic and polychromatic Strehl ratios were calculated as a function of the pinhole position. Different residual defocus values were also incorporated into the models, and the through-focus Strehl ratios were calculated.Results: Sixteen eye models were built. For most subjects, the optimum location of the aperture for distance vision was close to the corneal reflex position. For a given optimized centration of the aperture, the best compromise of depth of focus was obtained when the eyes had some residual myopic defocus (range −0.75 to −1.00 diopter [D]). Strehl ratio values were over 0.1 for far distance, which led to visual acuities better than 20/20. The depth of focus was 2.50 D with a mean near visual acuity of Jaeger 1 or better.Conclusions: In eyes with little astigmatism and aberrations, the optimum centration of the small aperture was near the corneal reflex position. To improve optical outcomes with the inlay, some small residual myopia and correction of corneal astigmatism might be required.Financial Disclosure: Dr. Artal is a consultant to Acufocus, manufacturer of the Acufocus Kamra corneal inlay. Dr. Tabernero has no financial or proprietary interest in any material or method mentioned.

Staining the capsule in congenital aniridic eyes - Corrected Proof

Michael E. Snyder — 2011-12-19

Capsule dyes have been an important tool in the ophthalmic surgeon’s armamentarium. Since Horiguchi et al.’s initial report on the use of indocyanine green (ICG) dye (IC Green, Akorn, Inc.) for staining the anterior capsule, the use of capsule dyes has gained wide acceptance. Uses besides staining the anterior capsule for capsulorhexis have been described. Khng and Snyder reported the use of ICG dye to aid visualization of the anterior capsule during insertion of an iris prosthetic device in the capsular bag since the device precludes red reflex visualization of the capsule margin. Indocyanine green dye has been available in the United States for decades as a cardiac and ophthalmic angiographic imaging adjunct, although its intraocular use has remained “off label.”

Wavefront analysis and Zernike polynomial decomposition for evaluation of corneal optical quality - Corrected Proof

Cristina M. Oliveira, Andreia Ferreira, Sandra Franco — 2011-12-16

Wavefront-guided excimer laser refractive surgery and new customized intraocular lens and contact lens designs are major clinical applications of corneal wavefront analysis. Other therapeutic applications include corneal disorders, conventional excimer laser refractive surgery, incisional techniques and cataract surgery, corneal transplantation, intrastromal corneal ring segment implantation, and crosslinking therapy. Basic data regarding corneal wavefront aberrations, such as distribution in the population and changes with aging, are essential for understanding the nature of each aberration and correcting it. Corneal aberrometry also improved our comprehension of the optical effects of the aforementioned topics while helping us assess the success of the procedures. Zernike polynomials are representations of the higher- and lower-order aberrations of the cornea, allowing a mathematical approach to their determination. Polynomials are used to model individual components of the wavefront in familiar terms. This article reviews the current knowledge of the wavefront aberrations of the human cornea and analyzes studies in the fields of anterior segment surgery and/or therapy, diseases, and optical quality in the context of this knowledge.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Femtosecond laser settings for keratoconic corneas - Corrected Proof

Hassan Hashemi, Masoomeh Mohebbi, Shiva Mehravaran — 2011-12-16

Femtosecond lasers and their many applications have improved the safety, efficiency, predictability, and speed of many corneal surgical procedures. Currently, Abbott Medical Optics is offering the fifth-generation of the Intralase FS laser and there are other available options by companies including Wavelight/Alcon, Zeimer, Carl Zeiss Meditec, and Technolas Perfect Vision. The Smarttech 150 by Schwind will soon join this list. When compared, femtosecond lasers have similar central wavelength and pulse duration characteristics. Their differences arise primarily from a relatively wide range of repetition rates (80 kHz to 5 MHz) and pulse energy (10 nJ to 5 μJ), which could explain some of the pros and cons with each device. Other differences lie in the design of the device, consumables, and software.

Incidence and influence of posterior capsule striae on the development of posterior capsule opacification after 1-piece hydrophobic acrylic intraocular lens implantation - Corrected Proof

2011-12-12

Purpose: To determine the incidence of intraoperative posterior capsule striae after implantation of a 1-piece hydrophobic acrylic intraocular lens (IOL), study the clinical impact on the patients’ vision, and assess whether the presence of posterior capsule striae increases the risk for posterior capsule opacification (PCO).Setting: Iladevi Cataract & IOL Research Centre, Ahmedabad, India.Design: Case-control study.Methods: Part 1 of this study evaluated consecutive adult eyes having cataract surgery performed using standardized techniques with in-the-bag 1-piece hydrophobic acrylic IOL implantation. Posterior capsule striae details were noted at the end of surgery. Part 2 was a case-control study comprising all patients with intraoperative striae and an age- and biometry-matched control group without striae, which was selected on a 1:1 ratio.Results: Intraoperative posterior capsule striae were observed in 68 (13.6%) of 500 eyes. A single stria was seen in 43 eyes [63.2%], and multiple striae were seen in 25 eyes [36.7%]). There was no significant difference in logMAR corrected distance visual acuity at baseline (P=.881) or at 3 years (P=.191) between cases and controls. At 3 years, there was no statistically significant between-group difference in the median Evaluation of Posterior Capsule Opacification score or area values in the capsulorhexis margin (P=.36 and P=.39, respectively) or in the central 3.0 mm optic area (P=.40 and P=.42, respectively).Conclusion: The incidence of posterior capsule striae was 13.6%. Intraoperative striae did not influence visual acuity or the development of PCO at the 3-year follow-up.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Final incision size after implantation of a hydrophobic acrylic aspheric intraocular lens: New motorized injector versus standard manual injector - Corrected Proof

David Allen, Maged Habib, David Steel — 2011-12-12

Purpose: To assess the impact on incision size of IOL implantation using a new motorized intraocular lens (IOL) injector versus a standard manual injector.Setting: Cataract Treatment Centre, Sunderland Eye Infirmary, Sunderland, United Kingdom.Design: Comparative case series.Methods: All patients received an Acrysof SN60WF IOL implanted using a D cartridge and an Autosert motorized injector at fast speed, an Autosert motorized injector at slow speed, or a manual Monarch injector. Each group had a range of preimplantation incision sizes (1.9 mm, 2.0 mm, 2.1 mm, 2.2 mm, 2.3 mm). Incision gauges were used to measure the incision width before and immediately after IOL implantation.Results: The study recruited 256 patients. All incisions that were 1.8 mm at the commencement of surgery increased in size by the end of irrigation/aspiration. The motorized injector used with a fast speed (4.4 mm/sec) caused significantly less incision enlargement than the manual injector for all preimplantation incision sizes tested (P<.02). For 4 of the 5 preimplantation incision size subgroups, the motorized injector used at slow speed (1.5 mm/sec) produced less incision stretch than the manual injector, although the difference did not reach statistical significance.Conclusion: The motorized injector was easy to use, and its use with an injection speed of 4.4 mm/sec caused significantly less incision enlargement than the manual injector during IOL implantation.Financial Disclosure: Drs. Allen and Steele have received travel and lodging reimbursement from Alcon Laboratories, Inc., Fort Worth, Texas, USA, which also provided the motorized implantation device for evaluation purposes. Dr. Habib has no financial or proprietary interest in any material or method mentioned.

Effect of preoperative duration of stromal edema in bullous keratopathy on early visual acuity after endothelial keratoplasty - Corrected Proof

2011-12-08

Purpose: To clarify the relationship between visual acuity after Descemet-stripping automated endothelial keratoplasty (DSAEK) and the preoperative duration of stromal edema.Setting: Yamaguchi University Hospital, Yamaguchi, Japan.Design: Comparative case series.Methods: Patients who had DSAEK were divided into 2 groups based on whether the preoperative duration of stromal edema was less than 12 months (Group A) or more than 12 months (Group B). No patient had postoperative conditions that might have affected postoperative visual outcomes. Postoperatively, the corrected distance visual acuity (CDVA) was measured and the morphology of the anterior cornea evaluated by in vivo laser confocal microscopy.Results: The postoperative CDVA in Group A ranged from 20/50 to 20/16 at 3 months and from 20/66 to 20/16 at 6 months; the maximum CDVA was 20/40 to 20/13. The postoperative CDVA in Group B ranged from 20/66 to 20/40 at 3 months and 6 months; the maximum CDVA was 20/66 to 20/33. The structure of the anterior cornea was normal in patients in Group A but was abnormal with fibroblastic cells in the anterior stroma in patients in Group B.Conclusions: Patients with a preoperative duration of stromal edema of more than 12 months had pathologic changes in the corneal stroma that may have adversely affected visual acuity after DSAEK. Given that stromal edema, including that associated with bullous keratopathy, has been proposed to be a progressive condition, DSAEK may be most effective when performed early after the onset of edema, before the occurrence of pathologic changes in the stroma.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Intraoperative performance and postoperative outcome comparison of longitudinal, torsional, and transversal phacoemulsification machines - Corrected Proof

Panos G. Christakis, Rosa M. Braga-Mele — 2011-12-08

Purpose: To compare the intraoperative performance and postoperative outcomes of 3 phacoemulsification machines that use different modes.Setting: Kensington Eye Institute, Toronto, Ontario, Canada.Design: Comparative case series.Methods: This chart and video review comprised consecutive eligible patients who had phacoemulsification by the same surgeon using a Whitestar Signature Ellips-FX (transversal), Infiniti-Ozil-IP (torsional), or Stellaris (longitudinal) machine.Results: The review included 98 patients. Baseline characteristics in the groups were similar; the mean nuclear sclerosis grade was 2.0 ± 0.8. There were no significant intraoperative complications. The torsional machine averaged less phacoemulsification needle time (83 ± 33 seconds) than the transversal (99 ± 40 seconds; P=.21) or longitudinal (110 ± 45 seconds; P=.02) machines; the difference was accentuated in cases with high-grade nuclear sclerosis. The torsional machine had less chatter and better followability than the transversal or longitudinal machines (P<.001). The torsional and longitudinal machines had better anterior chamber stability than the transversal machine (P<.001). Postoperatively, the torsional machine yielded less central corneal edema than the transversal (P<.001) and longitudinal (P=.04) machines, corresponding to a smaller increase in mean corneal thickness (torsional 5%, transversal 10%, longitudinal 12%; P=.04). Also, the torsional machine had better 1-day postoperative visual acuities (P<.001).Conclusions: All 3 phacoemulsification machines were effective with no significant intraoperative complications. The torsional machine outperformed the transversal and longitudinal machines, with a lower mean needle time, less chatter, and improved followability. This corresponded to less corneal edema 1 day postoperatively and better visual acuity.Financial Disclosure: Dr. Braga-Mele was a consultant to Abbott Medical Optics, Alcon Laboratories, Bausch & Lomb, and Allergan at the time the study was performed. Neither author has a financial or proprietary interest in any material or method mentioned.

Corneal biomechanical properties and intraocular pressure measurement in Marfan patients - Corrected Proof

2011-12-08

Purpose: To compare the biomechanical properties of the cornea and intraocular pressure (IOP) between patients with Marfan syndrome and age-matched controls.Setting: Departments of Ophthalmology and Genetics, Bakirkoy Maternity and Children Diseases Hospital, and Beyoglu Eye Education and Research Hospital, Istanbul, Turkey.Design: Cross-sectional study.Methods: This study comprised patients with Marfan syndrome (study group) and healthy individuals (control group). The study group was subdivided into patients with ectopia lentis and patients without ectopia lentis. In the right eye of each patient, the corneal hysteresis (CH), corneal resistance factor (CRF), Goldman-correlated IOP, and corneal-compensated IOP were recorded.Results: Overall, the mean CH, CRF, Goldman-correlated IOP, and corneal-compensated IOP were not significantly different between the study group and the control group. The mean CH was 9.9 mm Hg ± 1.2 (SD) in study eyes with ectopia lentis and 11.2 ± 1.5 mm Hg in study eyes without ectopia lentis (P=.016); the mean CRF was 8.2 ± 1.8 mm Hg and 11.3 ± 1.9 mm Hg, respectively (P<.001). The mean Goldman-correlated IOP was 11.7 ± 2.7 mm Hg in study eyes with ectopia lentis and 16.2 ± 4.3 in study eyes without ectopia lentis (P=.003); the mean corneal-compensated IOP was 13.5 ± 4.1 mm Hg and 15.6 ± 3.8 mm Hg, respectively (P=.07).Conclusion: The CH, CRF, and Goldman-correlated IOP were significantly lower in the Marfan syndrome eyes with ectopia lentis than in the Marfan syndrome eyes without ectopia lentis.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

One-year visual outcomes and patient satisfaction after surgical correction of presbyopia with an intracorneal inlay of a new design - Corrected Proof

2011-12-06

Purpose: To evaluate the safety and efficacy of the third-generation Kamra corneal inlay (ACI 7000PDT) implanted monocularly in corneal pockets of emmetropic presbyopic patients to improve near and intermediate vision.Setting: University Eye Clinic, Paracelsus Medical University, Salzburg, Austria.Design: Cohort study.Methods: The corneal inlay was implanted in the nondominant eye over the line of sight by creating a corneal pocket with a femtosecond laser. The minimum postoperative follow-up was 12 months. Distance, intermediate, and near visual acuities were assessed over the follow-up. Other examinations included slitlamp evaluation, central keratometry, computerized corneal topography, endothelial cell count, and central corneal thickness. Patients completed satisfaction questionnaires preoperatively and 3, 6, and 12 months postoperatively.Results: The study evaluated 24 patients. After a mean follow-up of 12 months, 92% of patients read Jaeger (J) 3 or better with the surgical eye, the mean binocular uncorrected near visual acuity improved from J5 preoperatively to J2, and the mean binocular uncorrected intermediate visual acuity was 20/20 (67% ≥ 20/20). At 12 months, the mean uncorrected distance visual acuity was 20/20 in the surgical eye and 20/16 binocularly. Patients reported no change in distance vision, and their need for reading glasses decreased significantly (P<.001). No inlay was explanted and or recentered during the reported follow-up.Conclusion: The new corneal inlay was a safe and effective treatment for presbyopia over a 1-year follow-up.Financial Disclosure: Dr. Riha is a surgical advisor to Acufocus, Inc., Irvine, California, USA. No other author has a financial or proprietary interest in any material or method mentioned.

Repeatability of intraoperative central corneal and residual stromal thickness measurement using a handheld ultrasound pachymeter - Corrected Proof

Dan Z. Reinstein, Timothy J. Archer, Marine Gobbe — 2011-12-02

Purpose: To determine and compare the repeatability of intraoperative central corneal thickness (CCT) and residual stromal bed thickness measurements using a handheld ultrasound (US) pachymeter.Setting: London Vision Clinic, London, United Kingdom.Design: Comparative evaluation of a diagnostic test or technology.Methods: This study comprised eyes that had laser in situ keratomileusis retreatment by flap lift in which handheld US pachymetry (Corneo-Gage Plus 50 MHz) had been performed intraoperatively. In each case, 5 consecutive measurements were obtained centrally immediately before and after the flap was lifted. The within-eye repeatability was calculated as the standard deviation of the 5 repeated measurements for the CCT measurements and the central residual stromal thickness (RST) measurements.Results: The study evaluated 134 eyes (79 patients). The mean CCT was 467 μm ± 40 (SD) (range 393 to 577 μm). The repeatability of CCT measurements was 6.83 μm, the coefficient of repeatability was 13.40 μm, and the coefficient of variation (CoV) was 1.46%. The mean central RST was 335 ± 46 μm (range 259 to 465 μm). The repeatability of central RST measurements was 4.91 μm, the coefficient of repeatability was 9.62 μm, and the CoV was 1.46%.Conclusion: The repeatability of intraoperative handheld US pachymetry was similar between measurements of CCT and measurements of central RST; the CoV was 1.46% in both cases.Financial Disclosure: Dr. Reinstein is a consultant to Carl Zeiss Meditec AG, Jena, Germany, and has a proprietary interest in the Artemis technology (Arcscan, Inc., Morrison, Colorado, USA), through patents administered by the Cornell Center for Technology Enterprise and Commercialization, Ithaca, New York, USA. Mr. Archer and Dr. Gobbe have no financial or proprietary interest in any material or method mentioned.

Ultrasound-induced corneal incision contracture survey in the United States and Canada - Corrected Proof

2011-12-02

Purpose: To ascertain factors associated with corneal incision contracture (wound burn) secondary to phacoemulsification in the United States and Canada.Setting: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA, and University of Toronto, Toronto, Ontario, Canada.Design: Cross-sectional study.Methods: Through state and provincial societies, members were queried as to cataract surgery practices during the previous 3 years as well as the specifics associated with each case of wound burn, if any, encountered during that period.Results: Eight hundred forty-two cataract surgeons reported on 920 095 surgeries and 341 wound burns (raw incidence 0.037%). After a multivariate analysis, the wound burn incidence was significantly inversely associated with the surgeon’s surgical volume (45% decrease per doubling of volume; 95% confidence interval, 38%-55%; P<.001), the surgical approach (P<.001), and the ophthalmic viscosurgical device (OVD) used (P=.004). Machine or ultrasound modality used, region of the U.S. or Canada, and incision size were not related to wound burn.Conclusion: Phacoemulsification-induced wound burn can be reduced by experience, by the approach used in nucleus disassembly, by choice of OVD, and most important, by not using ultrasound when the anterior chamber is filled with OVD.Financial Disclosure: Dr. Braga-Mele is a consultant to Abbott Medical Optics, Inc., Alcon Laboratories, Inc., and Bausch & Lomb. Dr. Olson has been a consultant to Abbott Medical Optics, Inc., Becton, Dickinson and Co., and Allergan, Inc. He has received grant support from Abbott Medical Optics, Inc. and Allergan, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Long-term pathologic follow-up of obsolete design: Choyce Mark VIII anterior chamber intraocular lens - Corrected Proof

2011-11-24

We analyzed an enucleated eye that was blind and painful from a 66-year-old patient implanted with a Tennant modification of the Choyce Mark VIII anterior chamber intraocular lens (IOL) as a secondary procedure in 1978. The eye developed glaucoma, with implantation of an Ahmed valve in 2006. Gross and light microscopic analyses showed corneal decompensation and vascularization, peripheral anterior and posterior synechiae, iris thinning, significant changes in the iris pigmented layer, fibrous tissue on the anterior surface of the iris, and Soemmerring ring formation in the periphery of capsular bag remnants. In addition, there was severe attenuation of the nerve fiber layer and extensive cupping of the optic disc. The IOL surface was overall smooth and regular, without warping of the footplates, and was partially covered by clumps of various cell elements, including giant cells intermixed with pigment. This study represents the longest clinicopathologic correlation report on this IOL.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Surgical management of traumatic LASIK flap dislocation with macrostriae and epithelial ingrowth 14 years postoperatively - Corrected Proof

Derick G. Holt, Shameema Sikder, Mark D. Mifflin — 2011-11-24

Fourteen years after uneventful laser in situ keratomileusis (LASIK), a 59-year-old woman presented after suffering blunt trauma to her left eye 5 weeks earlier. The injury resulted in traumatic flap dislocation, epithelial ingrowth, and significant macrostriae. Following epithelial removal, the flap was hydrated with sterile water, facilitating reduction of the macrostriae and reapproximation without the need for suture placement. The postoperative course was uneventful, and at 1 month, the epithelial ingrowth and macrostriae had resolved and the uncorrected distance visual acuity was 20/30. This case represents the longest documented interval from LASIK surgery to traumatic flap dislocation. We describe our surgical approach to the management of this type of injury and present a video illustrating the technique.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Risk factors for vitreous complications in resident-performed phacoemulsification surgery - Corrected Proof

Preston H. Blomquist, Marlene E. Morales, Liyue Tong, Chul Ahn — 2011-11-21

Purpose: To identify risk factors for intraoperative vitreous complications in resident-performed phacoemulsification surgery.Setting: Two urban public county hospitals.Design: Case series.Methods: Phacoemulsification cataract surgeries performed by residents between January 4, 2005, and January 8, 2008, were retrospectively reviewed. Clinical characteristics of patients with and without intraoperative vitreous complications were compared and independent factors associated with vitreous complications identified using univariate and multivariate analysis.Results: Of 2434 cases meeting inclusion criteria, there were 92 vitreous complications (3.8%). On univariate analysis, significant preoperative risk factors for vitreous complications included older age (P=.020), poor preoperative corrected distance visual acuity (CDVA) (P=.007), left eye (P=.043), history of trauma (P=.045), prior pars plana vitrectomy (P=.034), dementia (P=.020), phacodonesis (P=.014), zonule dehiscence (P<.0001), posterior polar cataract (P=.037), white/mature cataract (P=.005), dense nuclear sclerotic cataract (P=.0006), and poor red reflex (P=.002). Factors that remained significant on multivariate analysis were older age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.05), poor preoperative CDVA (OR, 1.52; 95% CI, 1.14-2.03), left eye (OR, 1.63; 95% CI, 1.05-2.51), prior pars plana vitrectomy (OR, 1.88; 95% CI, 1.01-3.51), dementia (OR, 3.65; 95% CI, 1.20-11.17), and zonule dehiscence (OR, 8.55; 95% CI, 3.92-18.63).Conclusion: Elements of the preoperative history and examination can identify patients at higher risk for intraoperative complications during resident-performed phacoemulsification surgery.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Modulation transfer function and optical quality after bilateral implantation of a +3.00 D versus a +4.00 D multifocal intraocular lens - Corrected Proof

2011-11-21

Purpose: To determine whether the improvement in intermediate vision after bilateral implantation of an aspheric multifocal intraocular lens (IOL) with a +3.00 diopter (D) addition (add) occurs at the expense of optical quality compared with the previous model with a +4.00 D add.Setting: Department of Ophthalmology, University of São Paulo, São Paulo, Brazil.Design: Prospective randomized double-masked comparative clinical trial.Methods: One year after bilateral implantation of Acrysof Restor SN6AD1 +3.00 D IOLs or Acrysof Restor SN6AD3 +4.00 D IOLs, optical quality was evaluated by analyzing the in vivo modulation transfer function (MTF) and point-spread function (expressed as Strehl ratio). The Strehl ratio and MTF curve with a 4.0 pupil and a 6.0 mm pupil were measured by dynamic retinoscopy aberrometry. The uncorrected and corrected distance visual acuities at 4 m, uncorrected and distance-corrected near visual acuities at 40 cm, and uncorrected and distance-corrected intermediate visual acuities at 50 cm, 60 cm, and 70 cm were measured.Results: Both IOL groups comprised 40 eyes of 20 patients. One year postoperatively, there were no statistically significant between-group differences in the MTF or Strehl ratio with either pupil size. There were no statistically significant between-group differences in distance or near visual acuity. Intermediate visual acuity was significantly better in the +3.00 D IOL group.Conclusion: Results indicate that the improvement in intermediate vision in eyes with the aspheric multifocal + 3.00 D add IOL occurred without decreasing optical quality over that with the previous version IOL with a +4.00 D add.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Transepithelial corneal collagen crosslinking: Bilateral study - Corrected Proof

Massimo Filippello, Edoardo Stagni, David O’Brart — 2011-11-21

Purpose: To evaluate the efficacy of transepithelial collagen crosslinking (CXL) in patients with bilateral progressive keratoconus.Setting: Outpatient ophthalmic clinic.Design: Cohort study.Methods: Patients with a history of bilateral progressive keratoconus were recruited. The worst eye was treated with transepithelial CXL, while the fellow eye was left untreated as a control. Transepithelial CXL was performed by applying an enhanced riboflavin solution (riboflavin 0.1%, dextrane T500 with trometamol [Tris-hydroxymethyl aminomethane] and EDTA [ethylenediaminetetraacetic] sodium salt) on the intact corneal epithelium for 30 minutes before irradiation with ultraviolet A (370 nm at 3 mW/cm2) for 30 minutes. Follow-up was 18 months in all eyes.Results: The study enrolled 20 patients. Transient hyperemia and mild foreign-body sensation occurred in 8 eyes (40%) after treatment; both resolved after 24 hours. In treated eyes, there were statistically significant improvements in uncorrected and corrected visual acuity and topography-derived keratometry, cone apex power, and higher-order aberrations (P<.05). In untreated control eyes, there was a general trend toward worsening of these parameters. No complications were reported.Conclusions: Transepithelial CXL treatment appeared to halt keratoconus progression, with a statistically significant improvement in visual and topographic parameters. The treatment was safe and well tolerated. Its noninvasive nature makes it potentially useful in cases in which epithelial debridement is ideally avoided, such as pediatric cases, uncooperative patients, and thin corneas with thicknesses nearing 380 μm.Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.