Showing papers in "Journal of Cataract and Refractive Surgery in 2013"

Correcting astigmatism with toric intraocular lenses: Effect of posterior corneal astigmatism

Abstract: Purpose To evaluate the impact of posterior corneal astigmatism on outcomes with toric intraocular lenses (IOLs). Setting Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA. Design Case series. Methods Corneal astigmatism was measured using 5 devices before and 3 weeks after cataract surgery. Toric IOL alignment was recorded at surgery and at the slitlamp 3 weeks postoperatively. The actual corneal astigmatism was calculated based on refractive astigmatism 3 weeks postoperatively and the effective toric power calculated with the Holladay 2 formula. The prediction error was calculated as the difference between the astigmatism measured by each device and the actual corneal astigmatism. Vector analysis was used in all calculations. Results With the IOLMaster, Lenstar, Atlas, manual keratometer, and Galilei (combined Placido–dual Scheimpflug analyzer), the mean prediction errors (D) were, respectively, 0.59 @ 89.7, 0.48 @ 91.2, 0.51 @ 78.7, 0.62 @ 97.2, and 0.57 @ 93.9 for with-the-rule (WTR) astigmatism (60 to 120 degrees), and 0.17 @ 86.2, 0.23 @ 77.7, 0.23 @ 91.4, 0.41 @ 58.4, and 0.12 @ 7.3 for against-the-rule (ATR) astigmatism (0 to 30 degrees and 150 to 180 degrees). In the WTR eyes, there were significant WTR prediction errors (0.5 to 0.6 diopters [D]) by all devices. In ATR eyes, WTR prediction errors were 0.2 to 0.3 D by all devices except the Placido–dual Scheimpflug analyzer (all P Conclusions Corneal astigmatism was overestimated in WTR by all devices and underestimated in ATR by all except the Placido–dual Scheimpflug analyzer. A new toric IOL nomogram is proposed. Financial Disclosure Drs. Koch, Weikert, and Wang received research support from Ziemer USA, Inc. Dr. Koch has a financial interest with Alcon Laboratories, Inc., Abbott Medical Optics, Inc., Optimedica Corp., and Ziemer USA, Inc. No other author has a financial or proprietary interest in any material or method mentioned.

Six-year incidence of endophthalmitis after cataract surgery: Swedish national study.

Abstract: Purpose To report the nationwide incidence and risk factors for endophthalmitis after cataract surgery in Sweden. Setting Swedish National Cataract Register containing reports on cataract operations from all Swedish ophthalmic surgical units. Design Prospective epidemiologic study. Methods Endophthalmitis case reports were collected from 2005 through 2010. Case and control parameters pertaining to patient characteristics and surgical technique were generated from the database. In addition, information from annual surveys regarding the topical prophylactic protocol was analyzed. Results The reports showed 135 endophthalmitis cases in 464 996 operations, equaling an incidence of 0.029%. Patient age over 85 years, perioperative communication with the vitreous and, above all, nonuse of intracameral cefuroxime showed a statistically significant association with endophthalmitis in the logistic regression. Short-term topical antibiotics given as add-on prophylaxis to the intracameral regimen before, after, or before and after the operation did not confer a clear-cut benefit. Groups with topical treatment were small, comprising 14% of the sample. Conclusions The incidence of endophthalmitis after cataract surgery in Sweden is declining, which appears to be explained by a fall in the frequency of major risk factors. Operating earlier in the cataract course, avoiding capsule breakage, and giving intracameral antibiotics universally should further reduce the endophthalmitis rate. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Toric intraocular lenses: Historical overview, patient selection, IOL calculation, surgical techniques, clinical outcomes, and complications

Abstract: We present an overview of currently available toric intraocular lenses (IOLs) and multifocal toric IOLs. Relevant patient selection criteria, IOL calculation issues, and surgical techniques for IOL implantation are discussed. Clinical outcomes including uncorrected visual acuity, residual refractive astigmatism, and spectacle independency, which have been reported for both toric IOLs and multifocal toric IOLs, are reviewed. The incidence of misalignment, the most important complication of toric IOLs, is determined. Finally, future developments in the field of toric IOLs are discussed.

Transepithelial corneal collagen crosslinking for progressive keratoconus: 24-month clinical results

Abstract: Purpose To assess the clinical results of transepithelial collagen crosslinking (CXL) in patients 26 years and younger with progressive keratoconus suitable for epithelium-off (epi-off) CXL. Setting Department of Ophthalmology, Siena University Hospital, Siena, Italy. Design Prospective case series. Methods The study included 26 eyes (26 patients) treated by transepithelial (epithelium-on) CXL. The mean age was 22 years (range 11 to 26 years) (10 younger than 18 years; 16 between 19 years and 26 years). Preoperative and postoperative examinations included uncorrected (UDVA) and corrected (CDVA) distance visual acuities, simulated maximum keratometry (K), coma and spherical aberration, and corneal optical coherence tomography optical pachymetry. The solution for transepithelial CXL (Ricrolin TE) comprised riboflavin 0.1%, dextran 15.0%, trometamol (Tris), and ethylenediaminetetraacetic acid. Ultraviolet-A treatment was performed with the Caporossi Baiocchi Mazzotta X Linker Vega at 3 mW/cm 2 . Results After relative improvement in the first 3 to 6 months, the UDVA and CDVA gradually returned to baseline preoperative values. After 12 months of stability, the simulated maximum K value worsened at 24 months. Coma aberration showed no statistically significant change. Spherical aberration increased at 24 months. Pachymetry showed a progressive, statistically significant decrease at 24 months. Fifty percent of pediatric patients were retreated with epi-off CXL due to significant deterioration of all parameters after 12 months of follow-up. Conclusions Functional results after transepithelial CXL showed keratoconus instability, in particular in pediatric patients 18 years old and younger; there was also functional regression in patients between 19 years and 26 years old after 24 months of follow-up. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Femtosecond laser–assisted cataract surgery

Abstract: Femtosecond laser-assisted cataract surgery provides surgeons an exciting new option to potentially improve patient outcomes and safety. Over the past 2 years, 4 unique laser platforms have been introduced into the marketplace. The introduction of this new technology has been accompanied by a host of new clinical, logistical, and financial challenges for surgeons. This article describes the evolution of femtosecond laser technology for use in cataract surgery. It reviews the available laser platforms and discusses the necessary modifications in cataract surgery technique and the logistics of incorporating a femtosecond laser into one's practice.

Multifocal intraocular lenses in cataract surgery: literature review of benefits and side effects.

Abstract: This literature review looks at the current status of multifocal intraocular lenses (IOLs) in cataract surgery. The results of implantation of multifocal IOLs of diffractive, refractive, and hybrid diffractive–refractive design are described with regard to uncorrected near and distance visual acuity and spectacle independence. The occurrence of photic phenomena and contrast sensitivity loss with multifocal IOLs are also addressed. Financial Disclosure Neither author has a financial or proprietary interest in any material or method mentioned.

Corneal endothelial cell loss and corneal thickness in conventional compared with femtosecond laser–assisted cataract surgery: Three-month follow-up

Abstract: Purpose To quantify changes in endothelial cell counts and corneal thickness measurements in patients having standard phacoemulsification compared with femtosecond laser–assisted cataract removal. Setting Ruhr University Eye Clinic, Bochum, Germany. Design Prospective randomized intraindividual cohort study. Methods One eye of each patient had standard phacoemulsification (control group) and the other eye had femtosecond laser–assisted phacoemulsification (study group), both with intraocular lens implantation. Pulsed ultrasound energy was used for phacoemulsification. Noncontact endothelial cell microscopy and corneal pachymetry were performed preoperatively and 1 day, 3 to 4 days, 7 to 10 days, 50 to 60 days, and 90 to 100 days postoperatively. Results The mean endothelial cell loss was 7.9% ± 7.8% (SD) 1 week postoperatively and 8.1% ± 8.1% 3 months postoperatively in the study group and 12.1% ± 7.3% and 13.7% ± 8.4%, respectively, in the control group. The mean relative change in corneal thickness from the preoperative values was −0.0% ± 1.9% at 1 day, 2.8% ± 1.8% at 1 week, and 3.3% ± 1.7% at 3 months in the study group and −0.9% ± 2.3%, 2.4% ± 1.5%, and 3.2% ± 1.4%, respectively, in the control group. Conclusion The femtosecond laser did not add to the endothelial damage caused by cataract surgery and might be beneficial in eyes with low preoperative endothelial cell values (eg, cornea guttata cases). Financial Disclosure Dr. Dick is a member of the medical advisory board of Optimedica Corp. No other author has a financial or proprietary interest in any material or method mentioned.

Visual outcomes and subjective experience after bilateral implantation of a new diffractive trifocal intraocular lens.

Abstract: Purpose - To assess clinical outcomes and subjective experience after bilateral implantation of a diffractive trifocal intraocular lens (IOL). Setting - Midland Eye Institute, Solihull, United Kingdom. Design - Cohort study. Methods - Patients had bilateral implantation of Finevision trifocal IOLs. Uncorrected distance visual acuity, corrected distance visual acuity (CDVA), and manifest refraction were measured 2 months postoperatively. Defocus curves were assessed under photopic and mesopic conditions over a range of +1.50 to -4.00 diopters (D) in 0.50 D steps. Contrast sensitivity function was assessed under photopic conditions. Halometry was used to measure the angular size of monocular and binocular photopic scotomas arising from a glare source. Patient satisfaction with uncorrected near vision was assessed using the Near Activity Visual Questionnaire (NAVQ). Results - The mean monocular CDVA was 0.08 logMAR ± 0.08 (SD) and the mean binocular CDVA, 0.06 ± 0.08 logMAR. Defocus curve testing showed an extended range of clear vision from +1.00 to -2.50 D defocus, with a significant difference in acuity between photopic conditions and mesopic conditions at -1.50 D defocus only. Photopic contrast sensitivity was significantly better binocularly than monocularly at all spatial frequencies. Halometry showed a glare scotoma of a mean size similar to that in previous studies of multifocal and accommodating IOLs; there were no subjective complaints of dysphotopsia. The mean NAVQ Rasch score for satisfaction with near vision was 15.9 ± 10.7 logits. Conclusions - The trifocal IOL implanted binocularly produced good distance visual acuity and near and intermediate visual function. Patients were very satisfied with their uncorrected near vision.

Increasing incidence of cataract surgery: population-based study.

Abstract: Purpose To estimate the incidence of cataract surgery in a defined population and to determine longitudinal cataract surgery patterns. Setting Mayo Clinic, Rochester, Minnesota, USA. Design Cohort study. Methods Rochester Epidemiology Project (REP) databases were used to identify all incident cataract surgeries in Olmsted County, Minnesota, between January 1, 2005, and December 31, 2011. Age-specific and sex-specific incidence rates were calculated and adjusted to the 2010 United States white population. Data were merged with previous REP data (1980 to 2004) to assess temporal trends in cataract surgery. Change in the incidence over time was assessed by fitting generalized linear models assuming a Poisson error structure. The probability of second-eye cataract surgery was calculated using the Kaplan-Meier method. Results Included were 8012 cataract surgeries from 2005 through 2011. During this time, incident cataract surgery significantly increased ( P P P Conclusion Incident cataract surgery steadily increased over the past 32 years and has not leveled off, as reported in Swedish population-based series. Second-eye surgery was performed sooner and more frequently, with 60% of residents having second-eye surgery within 3 months of first-eye surgery. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Comparison of bifocal and trifocal diffractive and refractive intraocular lenses using an optical bench.

Abstract: Purpose To assess the differences in optical performance of 9 multifocal IOLs using the same optical bench and to propose a possible comparison for surgeons. Setting Rothschild Foundation, Paris, France. Design Experimental study. Methods Nine IOLs (Acrysof Restor +3.0 diopter [D] SN6AD1, Acrysof Restor +4.0 D SN60D3, Acrysof aspheric monofocal SN60WF, Acri.Lisa 366D, Finevision Micro F, Tecnis ZM900, and Rezoom, Diffractiva Diff-s, and Lentis Mplus +3.0 D) were tested using the same optical bench that complies with International Organization for Standardization standard 11979 requirements. The through-focus modulation transfer functions (MTFs) were compared, and the image of the United States Air Force (USAF) target was taken while each IOL was at far, intermediate, and near focal points. Results The through-focus MTF of the trifocal IOL showed a peak in the intermediate range that was not present with monofocal and bifocal IOLs. The USAF target images showed similar resolution with all IOLs for far focal points. Diffractive IOLs showed better resolution for near focal points, and the only sharp image in the intermediate range was obtained using the trifocal IOL. Conclusion There was a significant difference in the degree of near, intermediate, and distance quality of the image with the various types of multifocal IOLs in vitro. Intermediate vision was more prominent with the trifocal IOL. Financial Disclosure Dr. Gatinel has a proprietary interest in the optical frame used (Patent WO2011092169 [A1] 2011-08-04). Dr. Houbrechts has no financial or proprietary interest in any material or method mentioned.

Decreased postoperative endophthalmitis rate after institution of intracameral antibiotics in a Northern California eye department.

Abstract: Purpose To evaluate post-cataract-surgery endophthalmitis rates in relation to changing practice patterns in antibiotic administration. Setting Kaiser Permanente, Diablo Service Area, California. Design Ecological time-trend study. Methods During 2007 through 2011, 3 time periods were identified based on increasing adoption of intracameral injections after phacoemulsification cataract surgery. In 2007, patients primarily received postoperative antibiotic drops without intracameral injection. During 2008 and 2009, in addition to the surgeons’ usual postoperative topical drop regimen, patients received intracameral cefuroxime unless contraindicated by allergy or posterior capsule rupture (PCR). During 2010 and 2011, all patients received an intracameral injection of cefuroxime, moxifloxacin, or vancomycin while topical antibiotics were used according to surgeon preference. The rates of postoperative endophthalmitis during these 3 periods were calculated. Also evaluated separately were consecutive patients without PCR from a subgroup of 3 surgeons who used intracameral injection alone without perioperative topical antibiotics. Results Nineteen cases of endophthalmitis occurred in 16 264 cataract surgeries. The respective rates per 1000 during the 3 time periods (2007, 2008 and 2009, 2010 and 2011) were as follows: 3.13 (95% confidence interval [CI], 1.43-5.93); 1.43 (95% CI, 0.66-2.72); 0.14 (95% CI, 0-0.78). One case of endophthalmitis was observed in 2038 patients without PCR who received intracameral injection only without topical antibiotics (rate per 1000: 0.49; 95% CI, 0.01-2.73). Conclusions The adoption of intracameral antibiotic injection coincided with a decline in the rate of postoperative endophthalmitis, and a low infection rate was observed with intracameral injection alone. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Effectiveness and safety of femtosecond laser–assisted lens fragmentation and anterior capsulotomy versus the manual technique in cataract surgery

Abstract: Purpose To evaluate the effectiveness and safety of cataract surgery using femtosecond laser–assisted lens fragmentation and anterior capsulotomy versus manual cataract surgery. Setting MaxiVision Eye Hospital, Begumpet, Hyderabad, India. Design Randomized controlled open-label multisurgeon prospective trial. Methods Patients (at least 18 years old) were randomized to femtosecond laser–assisted lens prefragmentation and capsulotomy or manual capsulorhexis and standard phacoemulsification. Measured outcomes were effective phacoemulsification time (EPT), surgeon-assessed ease of phacoemulsification, mean phaco energy, mean phaco time, balanced salt solution volume, capsulotomy precision, and adverse event rates. Results Fifty-six eyes had the femtosecond laser procedure, and 63 had manual cataract surgery. The mean EPT was significantly lower in the laser group (5.2 seconds ± 5.7 [SD]) than in the manual group (7.7 ± 6.0 seconds) ( P =.025). There was a significant difference in the mean phaco energy between the 2 groups (13.8% ± 10.3% in laser group; 20.3% ± 8.1% in manual group) ( P P Conclusion The femtosecond laser platform was effective and safe in cataract surgery, reducing EPT and the mean phaco energy during lens fragmentation and providing precise and reproducible capsulotomies. Financial Disclosure Dr. Reddy has received travel and research grants from Technolas Perfect Vision GmbH, Dr. Kandulla is an employee of Technolas Perfect Vision GmbH (a Bausch & Lomb company), and Dr. Auffarth has received travel and research grants as well as lecture fees from Technolas Perfect Vision GmbH/Bausch & Lomb.

Contrast sensitivity basics and a critique of currently available tests.

Abstract: The ability to distinguish contrast plays an important role in patients' everyday vision. Contrast sensitivity testing can identify many ocular diseases. Testing the peak of contrast sensitivity function provides a useful clinical adjunct to standard visual acuity assessments. This article reviews the basics of contrast sensitivity. It also describes the currently available contrast sensitivity tests and compares their reliability, advantages, and disadvantages. Financial Disclosure Drs. Spaeth and Richman have developed and patented a contrast sensitivity test titled the Spaeth/Richman Contrast Sensitivity test. Dr. Wirostko has no financial or proprietary interest in any material or method mentioned.

Posterior corneal elevation and back difference corneal elevation in diagnosing forme fruste keratoconus in the fellow eyes of unilateral keratoconus patients.

Abstract: Purpose To evaluate posterior corneal elevation and back difference corneal elevation in patients with keratoconus in 1 eye and forme fruste keratoconus in the fellow eye. Setting Kudret Eye Hospital, Ankara, Turkey. Design Case-control study. Methods This study retrospectively reviewed patients with keratoconus in 1 eye and forme fruste keratoconus in the fellow eye and eyes of normal subjects. All subjects were evaluated with a rotating Scheimpflug imaging system (Pentacam), including sagittal and tangential anterior curve analysis, keratometry, and posterior elevation. The back difference elevation values were extrapolated from the difference maps of the Belin-Ambrosio enhanced ectasia display of the Scheimpflug system. The receiver operating characteristic (ROC) curves were analyzed to evaluate the sensitivity and specificity of the parameters. Results The corneal power, pachymetric progression index, and posterior corneal elevation (posterior elevation and back difference elevation) measurements were statistically significantly higher in eyes with keratoconus or forme fruste keratoconus than in eyes of normal control subjects ( P Conclusions Back difference elevation was better than posterior elevation in diagnosing forme fruste keratoconus. However, as sole parameters, both had limited sensitivity and specificity to differentiate between forme fruste keratoconus eyes and normal control eyes. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Visual outcome of cataract surgery; Study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery

Abstract: Purpose To analyze the visual outcome after cataract surgery. Setting Cataract surgery clinics in 15 European countries. Design Database study. Methods Data were drawn from case series of cataract extractions reported to the European Registry of Quality Outcomes for Cataract and Refractive Surgery database. These data were entered into the database via the Web by surgeons or by transfer from existing national registries or electronic medical record systems. The database contains individual anonymous data on preoperative, intraoperative, and postoperative measurements. Results Data on 368 256 cataract extractions were available for analysis. The best visual outcome was achieved in age groups 40 to 74 years, and men showed a higher percentage of excellent vision (1.0 [20/20] or better) than women. A corrected distance visual acuity (CDVA) of 0.5 (20/40) or better and of 1.0 (20/20) or better was achieved in 94.3% and 61.3% of cases, respectively. Ocular comorbidity and postoperative complications were the strongest influences on the visual outcome; however, surgical complications and ocular changes requiring complex surgery also had a negative influence. Deterioration of visual acuity after the surgery (n= 6112 [1.7% of all cases]) was most common in patients with a good preoperative visual acuity. Conclusions The visual outcomes of cataract surgery were excellent, with 61.3% of patients achieving a corrected distance visual acuity of 1.0 (20/20) or better. Age and sex influenced the visual outcomes, but the greatest influences were short-term postoperative complications, ocular comorbidity, surgical complications, and complex surgery. A weakness of the study could be that some of the data is self-reported to the registry. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Handshake technique for glued intrascleral haptic fixation of a posterior chamber intraocular lens

Abstract: We describe a technique for easy externalization of the haptics for glued intrascleral fixation of a posterior chamber intraocular lens (IOL). The “handshake” technique is a modification of the glued-IOL procedure in which the IOL haptic is bimanually transferred from one glued IOL forceps to another under direct visualization in the pupillary plane. The modification provides better intraocular maneuverability throughout the surgery and extends applicability of the technique to challenging cases that require haptic manipulation, such as IOL drop and haptic slippage. It also provides the intraoperative advantage of a well-formed globe throughout the surgery. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Endophthalmitis prophylaxis in cataract surgery : Overview of current practice patterns in 9 European countries

Abstract: Data on practice patterns for prophylaxis against infectious postoperative endophthalmitis (IPOE) during cataract surgery in 9 European countries were searched in national registers and reviews of published surveys. Summary reports assessed each nation's IPOE rates, nonantibiotic prophylactic routines, topical and intracameral antibiotic use, and coherence to the European Society of Cataract & Refractive Surgeons (ESCRS) 2007 guidelines. Although the reliability and completeness of available data vary between countries, the results show that IPOE rates differ significantly. Asepsis routines with povidone-iodine and postoperative topical antibiotics are generally adopted. Use of preoperative and perioperative topical antibiotics as well as intracameral cefuroxime varies widely between and within countries. Five years after publication of the ESCRS guidelines, there is no consensus on intracameral cefuroxime use. Major obstacles include legal barriers or persisting controversy about the scientific rationale for systematic intracameral cefuroxime use in some countries and, until recently, lack of a commercially available preparation.

Optical patient interface in femtosecond laser–assisted cataract surgery: Contact corneal applanation versus liquid immersion

Abstract: Purpose To compare 2 optical patient interface designs used for femtosecond laser–assisted cataract surgery. Setting Optimedica Corp., Santa Clara, California, USA, and Centro Laser, Santo Domingo, Dominican Republic. Design Experimental and clinical studies. Methods Laser capsulotomy was performed during cataract surgery with a curved contact lens interface (CCL) or a liquid optical immersion interface (LOI). The presence of corneal folds, incomplete capsulotomy, subconjunctival hemorrhage, and eye movement during laser treatment were analyzed using video and optical coherence tomography. The induced rise of intraocular pressure (IOP) was measured in porcine and cadaver eyes. Results Corneal folds were identified in 70% of the CCL cohort; 63% of these had areas of incomplete capsulotomies beneath the corneal folds. No corneal folds or incomplete capsulotomies were identified in the LOI cohort. The mean eye movement during capsulotomy creation (1.5 sec) was 50 μm with a CCL and 20 μm with an LOI. The LOI cohort had 36% less subconjunctival hemorrhage than the CCL cohort. During suction, the mean IOP rise was 32.4 mm Hg ± 3.4 (SD) in the CCL group and 17.7 ± 2.1 mm Hg in the LOI group. Conclusions Curved contact interfaces create corneal folds that can lead to incomplete capsulotomy during laser cataract surgery. A liquid interface eliminated corneal folds, improved globe stability, reduced subconjunctival hemorrhage, and lowered IOP rise. Financial Disclosure Drs. Talamo, Culbertson, Batlle, Feliz, and Palanker are consultants to and Messrs. Gooding, Angeley, Schuele, Marcellino, and Andersen, and Ms. Essock-Burns are employees of Optimedica Corp., Sunnyvale, California, USA.

Transepithelial corneal collagen crosslinking for progressive keratoconus in a pediatric age group.

Abstract: Purpose To evaluate the effectiveness and safety of transepithelial corneal collagen crosslinking (CXL) in children with keratoconus and the refractive changes induced by this treatment. Setting Ophthalmology Department, Ain-Shams University Hospitals, Cairo, Egypt. Design Prospective comparative case series. Methods Patients younger than 18 years with bilateral keratoconus had transepithelial CXL with the use of transepithelial riboflavin. The other eye was used as a control and was treated conservatively. The uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and corneal tomography at 12 months were the main outcome measures. Results The mean age of the 22 patients (22 eyes) was 15.7 years ± 2.1 (SD). After transepithelial CXL, the improvement in the mean UDVA was statistically significant (from 0.95 ± 0.34 logMAR to 0.68 ± 0.45 logMAR) (P .05). The mean simulated keratometry (K) decreased by a mean of 2.03 diopters (D), with mean flattening of the apical K by 2.20 D; both results were statistically significant (P .05), with mean steepening of the apical K by 2.9 D (P Conclusion Preliminary results of transepithelial CXL in children with keratoconus were encouraging, with no evidence of progression of keratoconus over 12 months. Financial Disclosure The author has no financial or proprietary interest in any material or method mentioned.

Characteristics influencing outcomes of corneal collagen crosslinking for keratoconus and ectasia: implications for patient selection.

Abstract: PURPOSE: To determine preoperative patient characteristics that may predict topography and visual acuity outcomes of corneal collagen crosslinking (CXL). SETTING: Cornea and refractive surgery practice. DESIGN: Cohort study. METHODS: Crosslinking was performed in eyes with keratoconus or corneal ectasia. Multiple regressionandoddsratioanalyseswereperformedtodetermineindependentpredictors ofchanges in topography-derived maximum keratometry (K) and corrected distance visual acuity (CDVA) 1 year postoperatively. Preoperative characteristics included sex, age, uncorrected distance visual acuity (UDVA), CDVA, maximum keratometry (K), corneal thickness, corneal haze, disease group, and cone location. Postoperative improvement in maximum K was defined as flattening of 2.0 diopters (D) or more and worsening as steepening of 1.0 D or more. Improvement in CDVA was defined as a gain of 2 lines or more and worsening as a loss of 1 line or more. RESULTS: The study comprised 104 eyes (66 keratoconus; 38 corneal ectasia). Eyes with a preoperative CDVA of 20/40 or worse were 5.9 times (95% confidence interval [CI], 2.2-6.4) more likely to improve 2 Snellen lines or more. Eyes with a maximum K of 55.0 D or more were 5.4 times (95% CI, 2.1-14.0) more likely to have topographic flattening of 2.0 D or more. No preoperative characteristics significantly predicted worsening of visual acuity or corneal topography. CONCLUSIONS: Patients with worse preoperative CDVA and higher K values, particularly with a CDVA of 20/40 or worse or a maximum K of 55.0 D or more, were most likely to have improvement after CXL. No preoperative characteristics were predictive of CXL failure.

Efficacy and safety of prophylactic intracameral moxifloxacin injection in Japan.

Abstract: Purpose To report endophthalmitis rates after cataract surgery and the incidence of complications after intracameral moxifloxacin injection. Setting Nineteen clinics in Japanese institutions. Design Retrospective survey cohort study. Methods The number of surgeries and endophthalmitis cases in the past 4 years before and after the introduction of intracameral moxifloxacin was evaluated. The survey was performed by mail or interview in February 2013. Results All institutions used total-replacement administration rather than small-volume injection. At 3 institutions, 50 to 100 μg/mL moxifloxacin; at 9 institutions, 100 to 300 μg/mL moxifloxacin; and at 7 institutions, 500 μg/mL moxifloxacin was administered. The highest concentration (500 μg/mL) was administered in 14 124 cases. Endophthalmitis cases occurred 1 month or sooner postoperatively in 8 of 15 958 cases (ie, 1 in 1955) without intracameral moxifloxacin administration and in 3 of 18 794 cases (ie, 1 in 6265) with intracameral moxifloxacin administration. Conclusions Intracameral moxifloxacin (50 to 500 μg/mL) administration decreased the risk for endophthalmitis by 3-fold. In more than 18 000 cases, moxifloxacin administration of 500 μg/mL or less did not result in severe complications, such as toxic anterior segment syndrome or corneal endothelial cell loss. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Visual outcomes and patient satisfaction in 9366 eyes using a refractive segmented multifocal intraocular lens

Abstract: Purpose To report the effectiveness, patient satisfaction, and complication rate with a zonal refractive intraocular lens (IOL) in a high volume of patients. Setting Private clinic, London, United Kingdom. Design Case series. Methods Retrospective data of patients with binocular Lentis Mplus IOLs were analyzed. The main outcome measures were uncorrected distance visual acuity (UDVA), uncorrected near visual acuity (UNVA), corrected distance visual acuity, manifest refraction, patient satisfaction, and complications. One-month, 3-month, and 6-month data were analyzed. Results The study comprised 9366 eyes of 4683 patients. The mean spherical equivalent changed from +1.73 diopters (D) ± 3.37 (SD) preoperatively to −0.02 ± 0.60 D at 3 months and +0.03 ± 0.60 D at 6 months. Ninety-five percent of patients achieved a binocular UDVA of 6/7.5 (0.1 logMAR) or better 3 months postoperatively. The mean binocular UNVA was 0.155 ± 0.144 logMAR and 0.159 ± 0.143 logMAR at 3 months and 6 months, respectively. Severe dysphotopsia requiring an IOL exchange occurred in 55 eyes. Patient satisfaction was high, with 97.5% of patients willing to recommend the procedure. Conclusions The zonal refractive IOL provided excellent distance and near visual acuity. The postoperative complication rate was clinically acceptable, and patient satisfaction high. Financial Disclosure Dr. Schallhorn is a consultant to Abbott Medical Optics, Inc. No author has a financial or proprietary interest in any material or method mentioned.

Femtosecond laser-assisted intrastromal arcuate keratotomy to reduce corneal astigmatism

Abstract: Purpose To report the initial results of intrastromal arcuate keratotomy performed with a femtosecond laser to treat corneal astigmatism. Setting Department of Ophthalmology, Paracelsus Medical University, Salzburg, Austria. Design Interventional case series. Methods Patients with corneal astigmatism (naturally occurring or after cataract surgery) were treated with an iFS femtosecond laser to perform paired arcuate cuts on the steep axis completely placed within the corneal stroma. Patients were followed for 6 months after surgery. Preoperative and postoperative (1-day, 1-week, and 1-, 3-, and 6-month) examinations included corrected and uncorrected visual acuities, manifest refraction, corneal topography, endothelial cell count, and corneal pachymetry. A subjective questionnaire was used to evaluate patient satisfaction. Results The study enrolled 16 patients. No perforations occurred, and all incisions were placed at the planned locations. After a 6-month follow-up, the mean refractive cylinder was reduced significantly from 1.41 diopters (D) ± 0.66 (SD) to 0.33 ± 0.42 D ( P P =.002). There was excellent refractive and topographic stability over time. The endothelial cell density was unchanged. Patient satisfaction was very high. Conclusion The femtosecond laser allowed the effective creation of precise, purely intrastromal, arcuate incision patterns with an excellent safety profile, rapid recovery, and stability of vision without the known risks associated with incisions that penetrate Bowman membrane. Financial Disclosure Dr. Binder is a paid consultant to Abbott Medical Optics, Inc. Dr. Grabner has received travel grants in the past and has at times served as medical advisor to Abbott Medical Optics, Inc., Santa Ana, California, USA. No other author has a financial or proprietary interest in any material or method mentioned.

Prevalence of corneal astigmatism before cataract surgery in Chinese patients

Abstract: Purpose To assess the demographics and distribution of corneal astigmatism before cataract surgery in Chinese patients Setting State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China Design Clinic-based cross-sectional study Methods From July 2009 to May 2011, preoperative bilateral partial coherence interferometry (IOLMaster) was performed in consecutive patients having cataract surgery Patient demographics and keratometric data were recorded Results The mean age of the 2849 patients (4831 eyes) was 7056 years ± 955 (SD); there was a predominance of women patients (640%) The mean axial length was 2358 ± 113 mm The mean corneal astigmatism in this cohort was 101 D (range 005 to 659 D) Corneal astigmatism was between 025 D and 125 D in 677% of eyes, 125 D or higher in 275% eyes, and less than 025 D in 48% of eyes Astigmatism was with the rule in 251% of eyes, against the rule (ATR) in 582% of eyes, and oblique in 167% of eyes The mean steep keratometry measurement was 4476 ± 156 D Against-the-rule astigmatism increased significantly with older age Conclusions Corneal astigmatism largely fell between 025 D and 125 D in these predominantly elderly female Chinese patients, and ATR astigmatism increased with age Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned

Early postoperative safety and surgical outcomes after implantation of a suprachoroidal micro-stent for the treatment of open-angle glaucoma concomitant with cataract surgery.

Abstract: Purpose To evaluate the safety of a new suprachoroidal device, the Cypass micro-stent, for the surgical treatment of open-angle glaucoma (OAG) implanted in conjunction with cataract surgery. Setting Multicenter clinical study. Design Prospective interventional case series. Methods This is an interim report of an ongoing safety study. Patients with OAG glaucoma (Shaffer grade 3 and 4) who were also candidates for cataract surgery in the affected eye had standard phacoemulsification followed by micro-stent implantation in the supraciliary space. Included were patients with uncontrolled (≥21 mm Hg, Cohort 1) or controlled (<21 mm Hg, Cohort 2) medicated intraocular pressure (IOP) at baseline. Glaucoma medications were discontinued at surgery and resumed at the discretion of each investigator. Measures included adverse events/complications and postoperative changes in IOP or medication. Results The mean baseline medicated IOP was 21.1 mm Hg ± 5.91 (SD); the mean number of IOP-lowering medications was 2.1 ± 1.1 (N = 184). There were no major events such as retinal or choroidal detachment or endophthalmitis. The most common complications were transient early hypotony (13.8%) and transient IOP increase (10.5%). Uncontrolled patients (n = 57) had a 37% IOP reduction (P<.001), with more than a 50% reduction in glaucoma medications at 6 months (P<.001). Intraocular pressure–controlled patients (n = 41) had a 71.4% reduction in glaucoma medications (P<.001). Conclusion Initial clinical experience with the new micro-stent showed a low rate of surgical complications with concomitant decreases in IOP and/or glaucoma medications. Financial Disclosure Drs. Hoeh, Ahmed, Swaantje Grisanti, Salvatore Grisanti, Grabner, Nguyen, Rau, and Yoo are clinical investigators for Transcend Medical; Dr. Ahmed is a consultant to Transcend Medical; Dr. Ianchulev is an employee of Transcend Medical.

Management of the subluxated crystalline lens.

Abstract: The surgical management of ectopia lentis presents the ophthalmic surgeon with numerous challenges and options. From the clinical evaluation to the surgical approach, ectopia lentis patients require additional methodologies, techniques, and devices to ensure the best possible outcome. The continued refinement of surgical techniques and adjunctive prosthetic devices has led to incremental improvements in the ability to achieve successful in-the-bag placement and centration of intraocular lenses while reducing complications. A thorough understanding of the challenges inherent in ectopia lentis cases and the management of intraoperative complications will ensure that surgeons approaching the correction of these eyes will achieve the best possible surgical results.

Complications and visual outcomes after glued foldable intraocular lens implantation in eyes with inadequate capsules.

Abstract: Purpose To evaluate the complications and visual outcomes of glued intrascleral-fixated foldable intraocular lens (IOL) in eyes with deficient capsules. Setting Dr Agarwal's Eye Hospital and Eye Research Centre, Chennai, India. Design Case series. Methods Data were evaluated from the records of patients with a primary glued foldable IOL for intraoperative capsular loss or subluxated lens or secondary glued foldable IOL for aphakia. Exclusion criteria included preoperative glaucoma, aniridia, macular scar, traumatic subluxation, combined surgeries, incomplete operative medical records, and postoperative follow-up less than 6 months. The intraoperative and postoperative complication rates, reoperation rate, and visual outcomes were analyzed. Results The study comprised 208 eyes (185 patients). The mean follow-up was 16.7 months ± 10.2 (SD). The intraoperative complications were hyphema (0.4%), haptic breakage (0.4%), and deformed haptics (0.9%). Early complications occurred in 29 eyes (13.9%) and included corneal edema (5.7%), epithelial defect (1.9%), and grade 2 anterior chamber reaction (2.4%). Late complications occurred in 39 eyes (18.7%) and included optic capture (4.3%), IOL decentration (3.3%), haptic extrusion (1.9%), subconjunctival haptic (1.4%), macular edema (1.9%), and pigment dispersion (1.9%). Reoperation was required in 16 eyes (7.7%). Haptic position was altered in eyes with IOL decentration. Corrected distance visual acuity (CDVA) improved or remained unchanged in 84.6% of eyes. The postoperative CDVA was 20/40 or better and 20/60 or better in 38.9% and 48.5% of eyes, respectively. Conclusions The foldable glued-IOL procedure showed satisfactory visual outcomes without serious complications. Intraocular lens decentration was due to haptic-related problems. Financial Disclosure Dr. Agarwal is a paid consultant to Staar Surgical Co. No author has a financial or proprietary interest in any material or method mentioned.

Effective corneal collagen crosslinking in advanced cases of progressive keratoconus.

Abstract: Purpose To evaluate the 1-year results of corneal collagen crosslinking (CXL) in mild to moderate cases and advanced cases of progressive keratoconus. Setting Department of Ophthalmology, University Medical Center Utrecht, the Netherlands. Design Retrospective cohort study. Methods Eyes with progressive keratoconus had CXL between January 2010 and April 2011. Patients were divided into 2 subgroups as follows: Group 1, mild to moderate keratoconus with a preoperative maximum keratometry (K) of less than 58.0 diopters (D), and Group 2, advanced keratoconus with a maximum K of 58.0 D or more. Visual acuity, refraction, and elevation-based topography were evaluated at baseline and 12 months after CXL. Results The study comprised 53 eyes of 42 patients. In the overall group, progression was halted in 48 eyes (91%). The CXL-induced corneal flattening occurred in 11 (42%) of 26 eyes in Group 1 and 20 (74%) of 27 eyes in Group 2. Five of 7 keratoconus indices improved 12 months after CXL. The failure rate was comparable in the subgroups (3 eyes in Group 1, 2 eyes in Group 2). No major complications occurred in either subgroup. Conclusions Stabilization after CXL was achieved in mild to moderate cases and advanced cases of progressive keratoconus. The amount of failure was comparable in the 2 subgroups. The CXL-induced flattening was more pronounced in the advanced subgroup. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Comparison of the maximum applicable stretch force after femtosecond laser-assisted and manual anterior capsulotomy.

Abstract: Purpose To objectively measure the strength of the capsulotomy performed with a femtosecond laser-assisted technique or performed manually in a pig-eye laboratory study. Setting International Vision Correction Research Centre, Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany. Design Experimental study. Methods Ten fresh pig eyes were randomly assigned to femtosecond laser–assisted capsulotomy or manual capsulotomy. The capsule was immersed in hyaluronic acid, and retractors were fixed in the capsule opening with a pull-force measuring device. The force necessary to break the capsulotomy was measured in millinewtons (mN); the maximum stretching ratio was also assessed. Results The observed mean rupture force (ie, maximum amount of force measured immediately before tissue rupture) was 113 mN ± 12 (SD) in the laser-assisted procedure and 73 ± 22 mN in the manual procedure ( P P Conclusion In this laboratory pig-eye study, femtosecond laser–assisted capsulotomy resulted in a significantly stronger anterior capsule opening than the standard manually performed capsulotomy. Financial Disclosure Drs. Auffarth, Reddy, and Holzer have received research and travel grants from Technolas Perfect Vision GmbH. Mr. Ritter is an employee of Technolas Perfect Vision GmbH, Munich, Germany.

Intraocular pressure variation during femtosecond laser-assisted cataract surgery using a fluid-filled interface.

Abstract: Purpose To evaluate intraocular pressure (IOP) during femtosecond laser–assisted cataract surgery using a fluid-filled interface. Setting Ruhr University Eye Clinic, Bochum, Germany. Design Prospective clinical trial. Methods The absolute IOP was measured with a modified Schiotz tonometer before and after laser-assisted cataract surgery with and without a fluid-filled interface (Liquid Optics interface, Catalys Precision Laser System). Results The study evaluated 100 eyes. Tonometry and laser cataract surgery were completed successfully in all eyes. The mean preoperative IOP was 15.6 mm Hg ± 2.5 (SD). Upon application of the suction ring and vacuum, the mean IOP rose to 25.9 ± 5.0 mm Hg and remained nearly constant after the laser procedure (27.6 ± 5.5 mm Hg). After removal of the suction ring, the mean IOP was 19.1 ± 4.4 mm Hg. The IOP 1 hour after surgery was not significantly higher than the preoperative values. Conclusions The results indicate a minor increase in IOP using the fluid-filled interface. This is in strong contrast to substantially higher values reported in the literature with flat and curved applanating contact interfaces. Financial Disclosure Dr. Dick is a member of the Medical Advisory Board and a paid consultant to Optimedica, Sunnyvale, California, USA. No other author has a financial or proprietary interest in any material or method mentioned.