A randomised, prospective study of 'off-the-shelf' use of toric intraocular lenses for cataract patients with pre-existing corneal astigmatism in the NHS.

BACKGROUND/OBJECTIVES: To compare visual and refractive outcomes of monofocal intraocular lenses (IOLs) with limbal relaxing incisions (LRI) with 'off-the-shelf' use of toric IOLs (TIOLs), with a fixed 2-dioptre cylinder (DC) correction, for cataract patients with pre-existing corneal astigmatism in a public-sector setting. SUBJECTS/METHODS: Seventy-seven patients (77 eyes, first treated eye) with visually significant cataract and pre-operative corneal astigmatism ≥2.00 DC were randomised to receive either 'off-the-shelf' TIOLs, with a fixed 2.00 DC cylinder correction (39 eyes), or monofocal IOLs (38 eyes) with LRIs. The concept of fixing the cylindrical correction was to minimise costs, allow a full TIOL bank to be available and eliminate the need for individual TIOL ordering. Outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA) and refraction. Astigmatic changes were evaluated using the Alpins vector method. RESULTS: Mean UDVA improved from logMAR 0.88 (SD 0.56)[~20/150] pre-operatively to 0.18 (SD 0.19)[~20/30] post-operatively in TIOL group, versus 0.82 (SD 0.55)[~20/130] to 0.27 (SD 0.15)[~20/40] in monofocal/LRI group (P = 0.02; 95% CI: -0.17, -0.01). Mean CDVA improved from logMAR 0.40 (SD 0.26)[~20/50] to 0.01 (SD 0.12)[~20/20] in TIOL group, and 0.41 (SD 0.38)[~20/40] to 0.06 (SD 0.12)[~20/25] in LRI group (P = 0.07; 95% CI: -0.11, 0.01). Average post-operative refractive cylinder in TIOL group was 1.35 DC (SD 0.84 DC) and in LRI group 1.91 DC (SD 1.07 DC) (P = 0.01; 95% CI: -1, -0.12). Mean difference vector magnitude was 1.92 DC (SD 1.08 DC) in LRI group and 1.37 DC (SD 0.84 DC) in TIOL group (P = 0.02; 95% CI: 0.11, 0.99). CONCLUSIONS: TIOLs with a fixed 2.00 DC correction during cataract surgery may improve UDVA, reduce post-operative cylinder and result in a more reliable astigmatic correction compared with monofocal IOLs with LRIs.

Acute dacryocystitis in a 2-year old child caused by pantoea.

A previously healthy 23-month-old girl was admitted for the management of an acute unilateral dacryocystitis following accidental contact with dog faeces. No periocular trauma was reported. Microbiological investigation showed a multiresistant strain of Pantoea species to be the responsible pathogen. The infection responded to a course of oral Clindamycin and Ciprofloxacin, in combination with Chloramphenicol eye drops. This is the first report of an acute dacryocystitis sustained by this microorganism.

Pigment deposits on hydrophilic intraocular lenses after phacoemulsification cataract surgery.

A heterogeneous group of conditions can cause changes to the intraocular lens (IOL) during or after implantation in uneventful cataract surgery. We describe a series of 5 patients presenting distinctive deposits on the surface of hydrophilic intraocular lenses, implanted during routine cataract surgery, with a follow-up of 1 to 24 months. Disposable forceps were found to be the source of the pigmented marks when used to hold the lens during the injector loading process. At the slit-lamp examination, the pigments were located in the centre of the lens optic, easily detectable. Although involving the visual axis, none of the patients were visually affected. To our knowledge, this is the first time such unusual occurrence has been described. The reported case-series shows the importance of in-house follow-up after cataract surgery.

Corneal limbal marking in the treatment of myopic astigmatism with the excimer laser.

PURPOSE: To determine whether preoperative marking of the limbal cornea improves treatment of myopic astigmatism with the excimer laser. METHODS: Retrospective study on 108 eyes with myopic astigmatism that underwent LASIK or laser epithelial keratomileusis (LASEK) with the Technolas 217 (Bausch & Lomb) excimer laser. Preoperative limbal marking was performed in 47 eyes (marked group). The 12-month results were used for refractive and visual analysis. RESULTS: The achieved cylinder reduction, spherical reduction, and refractive predictability were similar for the marked and unmarked groups in the overall study collective, in the LASIK and LASEK subgroup analysis, and in a higher astigmatism (> 1.25 diopters) subgroup analysis. Limbal marking showed no influence on the refractive results, and vector analysis showed no significant difference in angle of error among groups. CONCLUSIONS: Corneal limbal marking failed to improve the refractive outcome in LASIK and LASEK for myopic astigmatism.

Retinal straylight and complaint scores 18 months after implantation of the AcrySof monofocal and ReSTOR diffractive intraocular lenses.

PURPOSE: To evaluate retinal straylight and patient complaint scores 18 months after implantation with the AcrySof ReSTOR diffractive multifocal intraocular lens (IOL) (Alcon Laboratories Inc). METHODS: Retinal straylight was measured with the C-Quant (Oculus Optikgeräte GmbH) system in 40 eyes implanted with the AcrySof ReSTOR IOL (SA60D3) and in 40 eyes implanted with the AcrySof SA60AT monofocal IOL. Complaint scores were assessed by a questionnaire in both groups of patients at three different lighting conditions--day light, dimmed light, and at night. RESULTS: Seventy-five percent of eyes (30/40) of the ReSTOR group and 80% of eyes (32/40) of the SA60AT control group showed a retinal straylight value within or better than the normal range. No statistically significant differences between groups were found (P = .790). Patients of the ReSTOR group showed significantly more complaint scores at all assessed lighting conditions: increasing factors were 1.53, 2.02, and 2.66, for day light, dimmed light, and night, respectively (P < .0001). Comparing the amount of straylight, the multifocal group had 20% more straylight, albeit not significant at the 1% level. CONCLUSIONS: The AcrySof ReSTOR IOL showed similar retinal straylight values compared to the monofocal IOL. Subjectively, patients with the diffractive IOL claimed significantly more glare for all light conditions, especially at night.

Phacoemulsification in eyes with extreme axial myopia.

PURPOSE: To determine the outcomes of phacoemulsification of age-related cataract in eyes with extreme axial myopia. SETTING: Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom. METHODS: This consecutive case series of eyes with an axial length (AL) greater than 30.0 mm was identified retrospectively. Surgical procedure details, complications, and refractive outcome were recorded. The incidence of postoperative retinal detachment (RD) was assessed in a subgroup of eyes without previous RD or vitrectomy. RESULTS: One hundred seventy-seven eyes (124 patients) were identified from a dataset of 6882 cataract procedures; 21 eyes had previous RD or vitrectomy. Intraoperative complications were posterior capsule tear (5 eyes, 2.8%), zonular dehiscence (3 eyes, 1.7%), and anterior capsule tear (2 eyes, 1.1%). At a median follow-up of 25.4 months, 2 (1.3%) of 156 eyes without previous RD or vitrectomy developed RD. The median biometry prediction error in the 156 eyes (88.1%) with an intraocular lens (IOL) was 0.88 diopter (D) (range 0.00 to 5.75 D); 83 eyes (53.2%) were within +/-1.00 D. The median biometry prediction error was greater in the 61 eyes that received a negative-power IOL (1.38 D) than in the 95 eyes that received a plano or positive-power IOL (0.68 D) (P<.001). CONCLUSIONS: The incidence of complications after phacoemulsification in eyes with extreme axial myopia was similar to that in previously reported unselected case series. The refractive outcome showed a hyperopic error that increased with AL, an effect that was primarily the result of the eyes that received a negative-power IOL.

The practice of dacryocystorhinostomy (DCR) surgery by ophthalmologists in the United Kingdom (UK).

PURPOSE: To study the practice of dacryocystorhinostomy (DCR) surgery by ophthalmologists in the United Kingdom (UK) looking at the evaluation techniques used, surgical variations, and follow-up management of DCR cases. METHODS: A mail-shot questionnaire was designed and distributed to every UK consultant ophthalmologist on the specialist register held by the Royal College of Ophthalmologists. The questionnaire consisted of eight questions and an image of a typical DCR candidate so respondents could illustrate details of their surgical incision. The data received was entered into a database and analyzed with the SPSS statistical package. The variation in incisions was divided into various sub-types and quantified accordingly. The chi-square test and analysis of variance (ANOVA) were used to calculate significance, which was set at p < 0.05. RESULTS: A response rate of over 75% was achieved amongst the 800 questionnaires dispatched, almost one-third of which perform DCR surgery. Of these, almost 50% were non-lacrimal specialists. The majority never use the endonasal approach, with 59% never performing preoperative nasal endoscopy. Most respondents use a standard incision 10-15 mm long with routine silicone intubation. Lacrimal specialists tended to remove tubes earlier (week 4 to 8) and suture posterior flaps more often than non-specialists. Significant differences in practice were found between lacrimal and non-lacrimal specialists in most parameters, in addition to differences between members and non-members of the National Oculoplastic Surgery Society. CONCLUSIONS: A minimum of 200 DCR surgeons are practicing in the UK where almost 50% are non-lacrimal specialists. Marked variations exist in the perioperative DCR practice.

Rotational stability of the AcrySof SA60TT toric intraocular lenses: a cohort study.

BACKGROUND: To evaluate the rotational stability of the three types of AcrySof SA60TT toric intraocular lenses (Alcon, Switzerland) in cataract surgery after the first postoperative week. METHODS: A retrospective study of 44 eyes in 33 patients. All patients underwent similar uncomplicated phacoemulsification cataract surgery. Seven eyes with corneal astigmatism of less than 1.5 D were implanted with the AcrySof SA60T3 intraocular lens. Seventeen eyes with astigmatism between 1.5 D and 2.25 D received the SA60T4 intraocular lens, and 20 eyes with more than 2.25 D of corneal astigmatism received the SA60T5 intraocular lens. Intraoperatively, the axis of the toric lens was aligned to the steepest axis of the corneal astigmatism. Main outcome measure was the postoperative position of the lens, assessed at 1 week and 3 months, using a specially designed angle measuring eyepiece for the slit lamp. RESULTS: There was no significant difference in the rotational stability of the three types of toric intraocular lenses. Overall, the postoperative rotation was within 5 degrees in 95% and within 2 degrees in 68% of eyes. The mean absolute rotation was 2.2 +/- 2.2 degrees. No lens showed more than 9 degrees of rotation, and no lens required secondary repositioning. There was no trend for either clockwise or anti-clockwise rotation. The surgical procedure did not change the corneal astigmatism. CONCLUSION: Once placed to it's position, each of the three types of the AcrySof SA60TT toric intraocular lenses demonstrate rotational stability in the capsular bag.

Modified Ruiz procedure for reducing high astigmatism after penetrating keratoplasty.

PURPOSE: To evaluate the refractive, keratometric, and visual outcomes of a modified Ruiz procedure in patients with high astigmatism after penetrating keratoplasty (PKP). METHODS: Retrospective cohort study with 26 eyes of 24 patients. A modified Ruiz incision pattern was used. Two paired arcuate incisions, centered on the preoperative cylinder axis, were performed over 2 o'clock hours (60 degrees) within the graft. The median optical zone was 4.5 mm (range, 3-5 mm). Subsequently, 4 radial cuts were made. The depth of all cuts was 90%-95% of the central corneal thickness. The follow-up time was 3 months. RESULTS: The mean preoperative subjective cylinder was 8.75 +/- 3.05 D, decreasing to 5.31 +/- 3.12 D postoperatively. Three months after the procedure, 53.8% of the eyes had <5.0 D of refractive astigmatism and 47% of eyes had <5.0 D of keratometric astigmatism. For the refractive data, the mean correction index was 1.95; the mean index of success was 1.27. The mean reduction in spherical equivalent was 1.95 D (60.5%). The mean best-corrected visual acuity (BCVA) was 0.61 and did not change significantly. Three eyes gained 2 or more lines of BCVA, and 1 eye lost 2 or more lines of BCVA. There was no difference in subgroup analysis of eyes treated with 4- (13 eyes) or 5-mm (12 eyes) optical zones. CONCLUSIONS: The modified Ruiz procedure is an effective method to reduce high astigmatism after PKP. However, the results were widely scattered, and the patients need to be informed about the unpredictable outcome and its consequences.