Late Presentation of Pseudophakic Macula Edema from Oral Kinase Inhibitors: A Case Series and Literature Review.

Introduction: Two cases of late presentation (>5 years) of bilateral pseudophakic macula edema related to oral tyrosine kinase inhibitors are described. These cases are the first of their type in the published literature. A review of ocular inflammatory complications of tyrosine kinase inhibitors in the current literature is explored. Case Presentation: Case 1 is an 83-year-old female who has been stable on ibrutinib (Imbruvica®) for chronic lymphocytic leukemia. She presented with bilateral blurred vision from severe cystoid macula edema, 7 years following routine cataract surgery. She was treated with intravitreal steroids with complete resolution without relapse. Case 2 is a 76-year-old female who was on therapy for polycythemia vera with ruxolitinib (Jakafi®). She presented with bilateral blurred vision from mild cystoid macula edema, 6 years following routine cataract surgery. She responded well to topical steroids without relapse. In both cases, oral tyrosine kinase inhibitor agents were presumed to be the underlying cause and were ceased. Over the last 5 years, there have been increasing reports in the literature of the inflammatory effects of tyrosine kinase inhibitors on the retina, uvea, and optic nerve. Conclusion: Late presentation of pseudophakic macula edema following routine cataract surgery is rare. Such presentations should prompt investigation of chronic use of systemic medications, especially oral kinase inhibitors. Patients who must remain on these agents require ongoing ophthalmologic assessment in view of their long-term inflammatory side effects.

Delayed Bacterial Endotheliitis and Endophthalmitis 11 Years after Cataract Surgery.

Infective endophthalmitis is an uncommon complication following intraocular surgery. Chronic endophthalmitis may present some time after intraocular surgery, making the diagnosis challenging. Cutibacterium acnes is a well-recognised causative agent of these chronic infections. Practitioners should be aware of the conditions required to culture this slow-growing organism. We report a case of delayed low-grade endophthalmitis presenting 11 years after cataract surgery. Cutibacterium acnes and Staphylococcus warneri were cultured from Descemet's membrane biopsy following three failed previous attempts at microbiological studies. Clinical features of the infection included discrete white granules on the iris, endothelium, and within the capsular bag of the patient's right eye. The patient presented with no signs of systemic infection and the left eye was normal on examination. Bullous keratopathy, secondary to endothelial dysfunction was a feature of this infection. This retrospective case report illustrates the prolonged periods for which Cutibacterium acnes can remain latent before causing clinical signs. While uncommon, endothelial involvement may occur and clinicians should consider low-grade infective endophthalmitis in cases with corneal oedema.

Pigmented Nevus of the Caruncle and Plica Semilunaris: A Case Report.

Conjunctival nevi are benign, heterogenous tumors that uncommonly arise from the lacrimal caruncle and plica semilunaris. We present a case of a patient diagnosed and managed for an unusual, pigmented nevus of the left caruncle involving the plica. An 84-year-old woman presented with a rapidly growing, pigmented lesion in her left nasal canthus. Examination demonstrated a raised, dark, pigmented area arising from the left caruncle and seeming to involve the plica semilunaris without scleral extension. The lesion was completely excised for histopathology, which confirmed the diagnosis of a compound nevus with pigment incontinence. Given the unfavorable anatomical position and prognostic significance in the case of malignancy, pigmented caruncular lesions should be thoroughly investigated with a low threshold for surgical removal.

Visual and Refractive Efficacy of Panoptix Toric Intraocular Lens in a Clinical Setting.

Purpose: Trifocal Intraocular Lenses (IOLs) were developed to provide patients with effective near, intermediate and distance vision, thus minimizing spectacle dependency. Residual astigmatism has previously been shown to impact unaided visual acuity across all distances; therefore, to optimise the expected outcomes, consideration of preoperative corneal astigmatism is essential. The purpose of this study was to provide a real-world, multi-site review of visual and refractive outcomes in eyes undergoing implantation with the Panoptix Trifocal toric IOL platform. Patients and Methods: This study represents a two-fold approach. Patients who had previously undergone routine cataract removal and IOL insertion with the Panoptix Toric IOL were retrospectively analysed for routine efficacy and safety endpoints ("Retrospective Cohort"). Data was retrieved from the preoperative, surgical and postoperative visits (range 2-6 weeks). A further subset of patients undergoing lens removal and bilateral Panoptix Toric IOL insertion were identified at surgery ("Qualitative Cohort"). These patients underwent additional testing inclusive of quality of vision questionnaire and bilateral defocus curve. Results: A total of 466 eyes of 254 patients were included in the retrospective cohort. Between 91% and 98% of eyes, respectively, were within 0.50D and 1.00D of target. Mean absolute difference from Spherical Equivalent (SE) target was 0.22 ± 0.24Ds. Following surgery, 94% of eyes demonstrated a refractive astigmatism of 0.50D or less. Further, 61% eyes achieved uncorrected distance visual acuity (UDVA) of 20/20 or better, increasing to 94% achieving 20/32 or better. Seventy percent of eyes unilaterally achieved N5 unaided and 66.0% achieved N8 or better at intermediate. In the qualitative cohort, no patient described any symptom as significant or requested explant. Conclusion: In a real-world setting, the PanOptix toric trifocal IOL continues to demonstrate refractive accuracy and good visual performance at all focal distances. This IOL also exhibited good quality of vision, with minimally bothersome visual disturbances or photic phenomena.

The Latest Evidence with Regards to Femtosecond Laser-Assisted Cataract Surgery and Its Use Post 2020.

Femtosecond laser-assisted cataract surgery (FLACS) was introduced with the hope of making cataract surgery safer and making the refractive result more predictable. It is only in the last four years that level 1 prospective randomised controlled trials (RCT) using current technology have been published. These, along with a meta-analysis of recent studies have shown that there seems to be little long-term visual benefit when using FLACS with monofocal lenses. The promised decrease in ultrasound energy required to remove a cataract has not been consistently demonstrated. There is level one evidence that the rate of posterior capsular rupture is less with FLACS using modern software. The round capsulotomy may be of increasing importance with the uptake of toric, multifocal and extended depth of focus lenses where a predictable capsulotomy size and precise placement of the lens becomes more important.

Posterior capsular complication rates with femtosecond laser-assisted cataract surgery: a consecutive comparative cohort and literature review.

PURPOSE: The aim of the study was to determine whether femtosecond-assisted laser cataract surgery (FLACS) reduces the posterior capsular complication (PCC) rate compared to manual cataract surgery when performed by an experienced surgeon. PATIENTS AND METHODS: We reviewed 2,021 consecutive FLACS procedures between 1 June 2012 and 30 August 2017. All cases of posterior capsular rupture (PCR) with or without vitreous prolapse or zonular dialysis (ZD) that prevented an in-the-bag placement of the intraocular lens were included. Risk factors were noted and outcomes documented. RESULTS: Six eyes of 2,021 (0.3%) who underwent FLACS had either a PCR or ZD. One eye (0.25%) of 403 eyes that had manual cataract surgery had a PCR. There was no significant difference in outcomes. Risk factors included advanced age, dense nuclei, pseudoexfoliation and small pupil. Only a single case in the FLACS series may have been directly attributed to the FLACS procedure. CONCLUSION: This study provides evidence that there is no significant difference in the PCC rate between FLACS and manual cataract surgery in the hand of an experienced surgeon who performs >350 cases annually. This low rate of complications may be achieved by less experienced surgeons adopting FLACS.

Reviewing the visual benefits of femtosecond laser-assisted cataract surgery: Can we improve our outcomes?

Femtosecond laser-assisted cataract surgery (FLACS) was introduced in 2009 and has increasingly been incorporated into surgical practice. The automation of three key aspects of cataract surgery was expected to deliver a significant improvement in both refractive and safety outcomes. The published literature has not yet shown consistent refractive improvement above conventional techniques. The purpose of this paper is to review current FLACS refractive outcomes and explore factors that may have contributed to the current findings and whether future improvements are possible.

Visual and refractive outcomes following implantation of a new trifocal intraocular lens.

BACKGROUND: Independence from all optical aids, and freedom from unwanted symptoms, following cataract and lens surgery remains the ultimate goal of both patient and surgeon. The development of trifocal IOL technology provides an ever-increasing range of options. The purpose of our study is to understand the predictability, safety and efficacy of a new trifocal intraocular lens (IOL) following cataract or refractive lens exchange (RLE) surgery. METHODS: This was a retrospective consecutive case series of patients undergoing cataract extraction or RLE followed by implantation of the Alcon IQ Panoptix IOL. Pre and postoperative refractive and visual parameters were recorded and evaluated. As the cohort followed a normal distribution, standard parametric tests were used. Paired t-test was used to compare the difference between target and postoperative refractive errors. The incidence of intraoperative and postoperative complications was also reported. RESULTS: The IOL was implanted in 66 eyes of 33 patients. Mean postoperative spherical equivalent (SE) refraction was -0.08 ± 0.25 dioptres (D). This was not significantly different from the target refraction (p = 0.841). Sixty-five percent of patients were within ± 0.25 D of the target SE refraction with 100% within ± 0.50 D of intended correction. Mean postoperative uncorrected distance visual acuity (UDVA) was 0.01 ± 0.10 LogMAR. All patients achieved an unaided distance acuity of 20/40 or better postoperatively. Binocularly, 100% saw 0.20 LogMAR or better at near without correction and 88.9% achieved this level for uncorrected intermediate visual acuity. No intraoperative complications were noted. Five patients complained of moderate haloes in the early postoperative period. CONCLUSION: The AcrySof IQ Panoptix IOL provides functional uncorrected visual acuity at distance, intermediate and near positions. Our results remain equivalent with existing trifocal IOL outcomes and provide surgeons with a further IOL alternative for the patient motivated to obtain true spectacle independence. Surgeons should consider individual reading and working requirements when counselling patients preoperatively to optimise postoperative patient satisfaction.

Evaluation of Toric Intraocular Lenses in Patients With Low Degrees of Astigmatism.

PURPOSE: This study aimed to describe the efficacy of toric intraocular lenses (IOLs) in patients with low degrees of corneal astigmatism. DESIGN: Retrospective case series was undertaken. METHODS: Patients with low amounts of corneal astigmatism who were treated with either a toric monofocal lens (SN6AT2 Toric, n = 76) or a toric multifocal lens (SND1T2 +3.00, n = 44) were reviewed. Eyes were evaluated preoperatively and 3 months postoperatively. Refraction and visual outcomes were monitored. RESULTS: Patients (69.7%) in the monofocal toric group obtained refractive cylinder less than 0.25 diopters (D) compared with 70.5% of the multifocal toric group. Both toric groups showed a statistically significant reduction in refractive cylinder after surgery (P = 0.001). Monofocal (66.7%) and multifocal (68.2%) toric patients achieved uncorrected distance visual acuity of 20/20 or better. CONCLUSIONS: This represents the first article to investigate the use of low-power toric IOLs in patients with less than 1.25 D of corneal cylinder. Before the development of low-power toric IOLs, patients with low to moderate amounts of astigmatism required concurrent intraoperative adjustments or additional forms of treatment to benefit from cataract and IOL surgery. Evidence suggests that the toric T2 IOL now removes this barrier, providing consistent, accurate refractive and astigmatic results, and enables these patients to achieve excellent outcomes with a single treatment across IOL platforms. Larger studies will help to consolidate our results.

Use of an anterior chamber maintainer in the surgical management of traumatic hyphaemas.

Surgical intervention in traumatic hyphaemas becomes necessary when high intraocular pressure (IOP) is intractable and there is persistent corneal staining. Anterior chamber (AC) washout and elimination of blood clots have been described previously using one paracentesis. We describe the value of creating two paracenteses. The first one is made in the lower temporal quadrant and accommodates a 20-gauge anterior chamber maintainer (ACM) that is connected to a bottle of Balanced Salt Solution. The second paracentesis is made in an upper quadrant and serves to evacuate liquefied blood and blood clots. With an ACM in place, the fluctuations of intraoperative IOP are minimized and the AC depth is stabilized throughout the operation. The risk of renewed bleeding is reduced because of the continuous positive intraoperative IOP. The ACM is an important tool in the surgical management of traumatic hyphaemas because it facilitates AC washout and reduces iatrogenic damage to the iris and corneal endothelium.