Prevention and management of refractive prediction errors following cataract surgery.

Patient satisfaction after modern day cataract surgery requires excellent surgical technique but increasingly demands superior refractive outcomes as well. In many cases, there exists an expectation from patients, as well as surgeons, to achieve emmetropia after cataract surgery. This is particularly true in patients electing premium intraocular lens technology to correct astigmatism and presbyopia to minimize spectacle dependence. Despite continued advances in preoperative and intraoperative diagnostics, refractive planning, and surgical technology, residual refractive error remains a primary source of dissatisfaction after cataract surgery. The need to enhance refractive outcomes and treat residual astigmatic or spherical refractive errors postoperatively becomes paramount to meeting the expectations of patients in their surgical outcome. This article reviews the potential preoperative and intraoperative pitfalls that can be the source of refractive error, the various options to enhance refractive outcomes, and potential future technologies to limit residual refractive error after cataract surgery.

Medical and surgical management of the small pupil during cataract surgery.

As cataract surgery continues to evolve, the intraoperative small pupil continues to pose challenges to even the most experienced cataract surgeon. Several steps can be taken preoperatively to decrease the chance of intraoperative miosis. Even so, the problem of miosis during cataract surgery remains a relatively common occurrence. This paper discusses many steps, both preoperative and intraoperative, that can make surgery technically easier and safer, thus maximizing the postoperative outcomes and patient satisfaction. Complications associated with small-pupil cataract surgery, risk factors for intraoperative miosis, the preoperative and intraoperative management of the small pupil during cataract surgery, and postoperative care are reviewed.

Ultra-high resolution optical coherence tomography for differentiation of ocular surface squamous neoplasia and pterygia.

OBJECTIVE: To assess the use of an ultra-high-resolution (UHR) optical coherence tomography (OCT) as an adjuvant diagnostic tool in distinguishing ocular surface squamous neoplasia (OSSN) and pterygia. DESIGN: Prospective case series. PARTICIPANTS: Thirty-four eyes of 34 patients with conjunctival lesions clinically suspicious for OSSN or pterygia. METHODS: All patients were photographed and then imaged with a custom-built UHR OCT device. Subsequently, each patient underwent excisional or incisional biopsy with histopathologic diagnosis. MAIN OUTCOME MEASURES: Comparison of preoperative UHR OCT images and the corresponding histopathologic specimen; comparison of epithelial thickness between the 2 groups as measured by UHR OCT. RESULTS: Preoperative UHR OCT images of OSSN demonstrated similarities to the histopathologic specimens. Both optical and pathologic specimens showed a thickened layer of epithelium, often with an abrupt transition from normal to neoplastic tissue. Likewise, preoperative UHR OCT images of patients with pterygia were well correlated with the histopathologic specimens. As opposed to OSSN, both UHR OCT and pathologic images of pterygia demonstrated a normal thin epithelium, with underlying thickening of the subepithelial mucosal layers. Differences in the measured epithelial thickness on UHR OCT between OSSN and pterygia were statistically significant, with an average epithelial thickness of 346 µm (standard deviation [SD], 167) in OSSN patients and 101 µm (SD, 22) in pterygium patients (P<0.001). By receiver operating characteristic curve, the sensitivity and specificity of UHR OCT for differentiating between OSSN and pterygia was found to be 94% and 100%, respectively, using a cutoff value of 142 µm. CONCLUSIONS: Ultra-high-resolution OCT may show promise as a noninvasive diagnostic tool to evaluate ocular surface lesions. In addition to a statistically significant difference in epithelial thickness, a significant degree of morphologic correlation with the histopathologic results demonstrates its potential in evaluating ocular surface squamous neoplasia and pterygia.

Epithelial ingrowth after Descemet stripping automated endothelial keratoplasty: description of cases and assessment with anterior segment optical coherence tomography.

PURPOSE: To describe 5 cases of epithelial ingrowth after Descemet stripping automated endothelial keratoplasty (DSAEK) and the use of anterior segment optical coherence tomography (AS-OCT) to describe the areas of ingrowth. METHODS: Five cases with epithelial ingrowth after DSAEK were examined with commercially available AS-OCT and/or a novel custom-built ultrahigh resolution (UHR) AS-OCT. Argon laser photocoagulation was also used to confirm epithelial ingrowth on the iris surface. Pathological evidence of epithelial ingrowth was noted in an eye that underwent corneoscleral grafting for extensive ingrowth through a fistulous tract. RESULTS: Epithelial ingrowth was solely in the graft-host interface in 1 case and in both the interface and retrocorneal and iris surfaces in 4 cases. Argon laser photocoagulation on the iris confirmed epithelial ingrowth in 4 cases. The areas of epithelial ingrowth were imaged in 1 case with the Visante AS-OCT and in 3 cases with an UHR-OCT. In 1 case, block excision with corneoscleral grafting was required. CONCLUSIONS: Epithelial ingrowth can occur after DSAEK. This series reports 5 cases of epithelial ingrowth into the interface and/or the retrocorneal surface after DSAEK. Imaging with AS-OCT, specifically the UHR-OCT, and argon laser photocoagulation can help confirm the diagnosis. UHR-OCT imaging of the interface and retrocorneal surfaces can provide clues to the origin of epithelial ingrowth. Four cases were observed. One case underwent corneoscleral grafting with histological confirmation of epithelial ingrowth.