Vancomycin-Associated Hemorrhagic Occlusive Retinal Vasculitis: Clinical Characteristics of 36 Eyes.

PURPOSE: To expand understanding of presentation, diagnosis, and outcomes of hemorrhagic occlusive retinal vasculitis (HORV). DESIGN: Retrospective case series. PARTICIPANTS: Thirty-six eyes of 23 patients. METHODS: The American Society of Cataract and Refractive Surgery (ASCRS) and the American Society of Retina Specialists (ASRS) formed a joint task force to define clinical characteristics of HORV and to study its prevalence, cause, treatment, and outcomes. An online registry was established on both societies' web sites. Surveys were e-mailed to members of both societies soliciting cases of suspected HORV. A literature search was performed to uncover additional cases. MAIN OUTCOME MEASURES: Historical data including intraoperative characteristics, images, treatment regimens, and visual and anatomic outcomes. RESULTS: Characteristic findings of HORV included unremarkable postoperative day 1 undilated examination, delayed-onset painless vision loss, mild anterior chamber and vitreous inflammation, sectoral retinal hemorrhages in areas of ischemia, and predilection for venules and peripheral involvement. Based on predetermined diagnostic criteria, 36 eyes of 23 patients were diagnosed with HORV. All eyes received intraocular vancomycin via intracameral bolus (33/36), via intravitreal injection (1/36), or through the irrigation bottle (2/36). Patients sought treatment with HORV 1 to 21 days after surgery or intravitreal injection. Visual results usually were poor: 22 of 36 eyes (61%) had 20/200 or worse visual acuity and 8 of 36 eyes (22%) had no light perception (NLP). Neovascular glaucoma developed in 20 of 36 eyes (56%). Seven eyes received additional intravitreal vancomycin after surgery; 5 of these 7 eyes had NLP visual acuity at the most recent examination. Three eyes received intravitreal corticosteroids and had final visual acuities of 20/40, 20/70, and hand movements. CONCLUSIONS: Hemorrhagic occlusive retinal vasculitis is a rare, potentially devastating condition that can develop after cataract surgery or intraocular injection. All cases in this series were associated with intraocular vancomycin. Disease course and findings suggest that HORV is caused by a delayed hypersensitivity reaction to vancomycin. Early treatment with corticosteroids likely is beneficial. Subsequently, anti-vascular endothelial growth factor injections and panretinal photocoagulation are important to prevent neovascular glaucoma, a common complication. Avoidance of additional intravitreal vancomycin is recommended if HORV is suspected.

Aspheric intraocular lens selection based on corneal wavefront.

PURPOSE: To determine the feasibility of selectively targeting zero total postoperative spherical aberration by selecting the best fit aspheric intraocular lens (IOL) based on preoperative topographically derived corneal spherical aberration. METHODS: Candidates for cataract surgery were offered selection of aspheric IOLs based on corneal spherical aberration. The target postoperative total wavefront spherical aberration Z4,0 was set at zero. Corneal topographic spherical aberration Z4,0 was measured at the 6-mm optical zone, and one of three aspheric IOLs was chosen so the arithmetic sum of the corneal spherical aberration and pseudophakic spherical aberration came closest to zero. Postoperatively, total ocular wavefront was measured and statistical analysis performed to ascertain the accuracy of customized aspheric IOL selection. RESULTS: Thirty eyes of 18 patients were available for analysis. The SofPort Advanced Optics (Bausch & Lomb) lens was implanted in 1 eye, the AcrySof IQ (Alcon Laboratories Inc) in 11 eyes, and the Tecnis Z9000 or Z9002 (Advanced Medical Optics [AMO]) in 18 eyes. Total postoperative ocular spherical aberration for the entire population measured -0.013+/-0.072 microm (SofPort: +0.025 microm; AcrySof IQ: +0.010+/-0.053 microm; and Tecnis: -0.015+/-0.052 microm [P=.22]). For the entire population, mean absolute predictive error measured 0.058+/-0.056 microm (SofPort: 0.040 microm; AcrySof IQ: 0.052+/-0.040 microm; and Tecnis: 0.063+/-0.066 microm [P=.631). CONCLUSIONS: Customized selection of aspheric IOLs based on corneal wavefront is feasible and produces favorable results compared with studies of unselected patient populations implanted with aspheric IOLs.

Phacoemulsification of posterior polar cataracts.

Posterior polar cataracts present a unique challenge for the cataract surgeon. This review describes the steps a surgeon can take to overcome these challenges for the successful phacoemulsification of the posterior polar cataract. Proper preoperative examination and diagnostics will allow appropriate preoperative counseling and surgical planning to increase the likelihood of success. Specific techniques for each stage of the procedure are described, all with the aim of protecting the posterior capsule and preserving intraocular lens (IOL) fixation options. Posterior polar cataracts present dilemmas in preoperative evaluation, surgical management, and IOL fixation.

Persistent interface fluid syndrome.

We present an unusual case of persistent interface fluid that would not resolve despite normal intraocular pressure and corneal endothelial replacement with Descemet-stripping endothelial keratoplasty. Dissection, elevation, and repositioning of the laser in situ keratomileusis flap were required to resolve the interface fluid. Circumferential corneal graft-host margin scar formation acting as a mechanical strut may have been the cause of the intractable interface fluid.

Phacoemulsification of the rock-hard dense nuclear cataract: Options and recommendations.

We describe the essential steps in the successful phacoemulsification of the rock-hard, dense cataract. Appropriate and directed preoperative history, physical examination, and diagnostics allow the surgeon to select the best incision, anesthesia, and intended surgical technique for a given dense nuclear challenge. Hard nucleus-specific approaches for hydrodissection, pupil management, and zonular protection then allow the surgeon to approach the rock-hard nucleus with maximum safety. Dense nuclear dismantling options are then discussed in detail along with fluidic and power modulation considerations. Various specific phacoemusification machine settings for rock-hard cataracts from the authors representing several different phaco systems are then presented. The combination of these steps and considerations allow a more successful dense cataract removal and potential restoration of vision for patients. This paper represents the collective experience and advice of the Challenging and Complex Cataract Surgery Subcommittee.

Profile of clear corneal cataract incisions demonstrated by ocular coherence tomography.

PURPOSE: To examine the profile of clear corneal cataract incisions in the living eye using optical coherence tomography (OCT). SETTING: Private practice, Eugene, Oregon, USA. METHODS: The Zeiss Visante OCT anterior segment imaging system was used to study the profile of clear corneal cataract incisions, all in senior citizens. The OCT images of the operative eye were taken on the first postoperative day approximately 24 hours after surgery. The OCT images of clear corneal incisions were compared with an OCT image of a control eye, incisions without stromal hydration, and previous drawings of clear corneal incisions. RESULTS: In the images, the clear corneal incisions had an arcuate configuration rather than a straight line configuration, as previously indicated. This architecture appears to add greater stability as a result of a tongue-and-groove-like fit of the floor to the roof of the incision as well as an incision that is longer than the chord length that had previously been measured. Other findings include that stromal swelling, which facilitates sealing of these incisions by the endothelial pump, lasted for at least 24 hours. CONCLUSIONS: Results indicate an incision in the plane of the cornea with a chord length of at least 2.0 mm provides advantageous architecture for adequate self-sealing. Proper clear corneal incision construction resulted in an incision architecture that seemed to have increased stability and added safety, contributing to an absence of endophthalmitis for more than 10 years and 9000 cases in a single practice.

Scleral fixation without conjunctival dissection.

Scleral fixation of intraocular lenses (IOLs) and adjunctive capsular devices can be performed under the protection of a scleral flap. A modification of this technique uses a scleral pocket initiated through a peripheral clear corneal incision. Full-thickness passage of a double-armed suture through the scleral pocket and conjunctiva, with subsequent retrieval of the suture ends through the external incision for tying, facilitates scleral fixation. This modification offers several advantages over traditional methods: It eliminates the need for conjunctival dissection and scleral cauterization; a scleral pocket affords a greater surface area for suture placement through an ab externo or ab interno approach; retrieval of the sutures through the external corneal incision and subsequent tying allows the suture knot to pass under the protective roof of the scleral pocket, negating the need for suture knot rotation; and the architecture of the scleral pocket eliminates the need for sutured wound closure. Suture retrieval and scleral fixation through a corneoscleral pocket offers a refined method for fixation of IOLs and other intraocular adjunctive devices.

Scleral fixation using suture retrieval through a scleral tunnel.

Scleral fixation of intraocular lenses (IOLs) can be performed under the protection of a scleral flap. A variation of this technique uses a scleral tunnel for suture fixation to the eye. Passage of a double-armed suture through the roof of the scleral tunnel with subsequent retrieval of the suture ends through the external incision for tying facilitates scleral fixation. This modification offers several advantages: A scleral tunnel is easier to construct than a triangular flap and does not require suture closure. It affords a greater surface area for suture placement through an ab externo or ab interno approach. Tying each suture allows the suture knot to pass under the roof of the tunnel, eliminating the need for suture knot rotation. Suture retrieval and scleral fixation through a scleral tunnel incision offers a simplified and elegant method for fixation of IOLs and other intraocular adjunctive devices.

Intraocular pressure during phacoemulsification.

PURPOSE: To assess changes in intraocular pressure (IOP) during standard coaxial or bimanual microincision phacoemulsification. SETTING: Oregon Eye Center, Eugene, Oregon, USA. METHODS: Bimanual microincision phacoemulsification (microphaco) was performed in 3 cadaver eyes, and standard coaxial phacoemulsification was performed in 1 cadaver eye. A pressure transducer placed in the vitreous cavity recorded IOP at 100 readings per second. The phacoemulsification procedure was broken down into 8 stages, and mean IOP was calculated across each stage. Intraocular pressure was measured during bimanual microphaco through 2 different incision sizes and with and without the Cruise Control (Staar Surgical) connected to the aspiration line. RESULTS: Intraocular pressure exceeded 60 mm Hg (retinal perfusion pressure) during both standard coaxial and bimanual microphaco procedures. The highest IOP occurred during hydrodissection, ophthalmic viscosurgical device injection, and intraocular lens insertion. For the 8 stages of the phacoemulsification procedure delineated in this study, IOP was lower for at least 1 of the bimanual microphaco eyes compared with the standard coaxial phaco eye in 4 of the stages (hydro steps, nuclear disassembly, irritation/aspiration, anterior chamber reformation). CONCLUSION: There was no consistent difference in IOP between the bimanual microphaco eyes and the eye that had standard coaxial phacoemulsification. Bimanual microincision phacoemulsification appears to be as safe as standard small incision phacoemulsification with regard to IOP.

Clinical evaluation of the Crystalens AT-45 accommodating intraocular lens: results of the U.S. Food and Drug Administration clinical trial.

PURPOSE: To evaluate the 12-month U.S. phase II clinical trial results of the Crystalens AT-45 (eyeonics, Inc.) intraocular lens (IOL) used to provide uncorrected distance, intermediate, and near visual acuities in patients having cataract extraction and to compare in a substudy the contrast sensitivity and near visual acuity in patients with the Crystalens AT-45 IOL and those receiving a standard IOL. SETTING: Fourteen clinical sites throughout the U.S. for efficacy and 3 non-U.S. sites for safety and efficacy. METHODS: Patients 50 years or older had small-incision cataract extraction with implantation of the Crystalens AT-45 IOL. Unilateral implantation was followed by fellow-eye implantation. Postoperatively, uncorrected distance, near, and intermediate visual acuities were determined. Near and intermediate visual acuities were tested through a distance correction to eliminate potential pseudoaccommodative effects of residual myopia and corneal cylinder. A substudy tested contrast sensitivity under mesopic conditions with and without glare, as well as visual acuity in a subset of Crystalens AT-45 patients and a control group receiving a standard IOL. RESULTS: A total of 263 patients participated in the U.S. clinical trial and had 1 year of follow-up. Near visual acuities through the distance correction of 20/40 (J3) or better, monocularly and bilaterally, respectively, were seen in 90.1% and 100%; intermediate near visual acuities were seen in 99.6% and 100%. More than half the bilaterally implanted Crystalens AT-45 patients achieved uncorrected near acuity of 20/25 (J1) or better through the distance correction, and 84% achieved 20/32 (J2) or better. In the substudy, monocular near vision through the distance correction of 20/25 (J1) or better was seen in 50.4% with the Crystalens AT-45 IOL and in 4.7% with the standard IOLs. Mesopic contrast sensitivity results with and without glare for the Crystalens AT-45 were similar to those with standard monofocal IOLs. Nearly all patients (74 patients; 97.3%) who bilaterally were within 0.50 diopter of plano postoperatively achieved 20/32 (J2) or better uncorrected near, intermediate, and distance visual acuities. CONCLUSIONS: The Crystalens AT-45 accommodating IOL provided good uncorrected near, intermediate, and distance vision in pseudophakic patients. Contrast sensitivity with the Crystalens AT-45 was not diminished relative to standard monofocal IOLs, and near and intermediate visual performance was significantly better than with standard IOLs.

Contrast sensitivity and measuring cataract outcomes.

Clinical research has demonstrated the the continuous decline of the contrast sensitivity with age results from increasing spherical aberration of the human crystalline lens. Replacing the crystalline lens with appropriate modeled pseudophakic lens can provide superior contrast sensitivity and functional vision. As advances in the technology allow cataract and refractive surgeons to address higher-order optical aberrations, the measurement of functional vision becomes increasingly critical as a gauge of the progress. Contrast sensitivity testing is assuming a prominent place in the evaluation of surgical modalities because it reflects functional vision, correlates with visual performance, and provide a key to understanding optical and visual processing of images.

Refractive lens surgery.

This article compares methods of axial length measurement for determining intraocular lens power and describes bimanual micro incision phacoemulsification for refractive lens exchange and routine cataract surgery, which offers an enormous advantage of maintaining a more stable intraocular environment during lens removal. This advantage may be especially important in high myopes who are at a greater risk for retinal detachment following lens extraction.

Targeted Next-Generation Sequencing Analysis of a Pendred Syndrome-Associated Thyroid Carcinoma.

Pendred syndrome is an autosomal recessive disorder characterized by hearing loss and goiter and is caused by bi-allelic mutations (homozygous or compound heterozygous) of the PDS (SLC26A4) gene. The incidence of Pendred syndrome is 7.5-10/100,000 in the general population, and it carries a 1 % risk of developing thyroid carcinoma. Herein, we report a case of a patient with Pendred syndrome who developed a follicular variant of papillary thyroid carcinoma (FVPTC)-that is approximately at an odd of 1/1,000,000. Targeted next-generation sequencing with ThyroSeq v2 was performed on the tumor, and only a TP53 mutation (TP53 p.R175H) was identified. The mutation was limited to the tumor nodule of FVPTC as shown by immunohistochemistry. This report represents the first extensive molecular study of a Pendred syndrome-associated thyroid carcinoma. The evidences support that thyroid carcinomas arising from dyshormonogenetic goiter require additional genetic alteration in addition to the purported thyroid-stimulating hormone (TSH) overstimulation. It is intrigue to note that the mutant p53 is involved in the development of a low-grade malignant thyroid tumor as FVPTC in this patient.

Cataract surgery and nonsteroidal antiinflammatory drugs.

Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. These medications have been found to reduce pain, prevent intraoperative miosis, modulate postoperative inflammation, and reduce the incidence of cystoid macular edema (CME). Whether used alone, synergistically with steroids, or for specific high-risk eyes prone to the development of CME, the effectiveness of these medications is compelling. This review describes the potential preoperative, intraoperative, and postoperative uses of NSAIDs, including the potency, indications and treatment paradigms and adverse effects and contraindications. A thorough understanding of these issues will help surgeons maximize the therapeutic benefits of these agents and improve surgical outcomes. FINANCIAL DISCLOSURE: Proprietary or commercial disclosures are listed after the references.

The physics of phaco: a review.

Despite its unparalleled success in the field of surgery, the precise mechanism of ultrasonic phacoemulsification cataract extraction remains controversial. We review the relevant peer-reviewed literature on the subject of power generation and tip-tissue interactions to clarify the current status of our knowledge. We conclude that phacoemulsification most likely operates by a combination of mechanisms, including direct action of the vibrating tip against tissue and indirect cavitational effects. Surgeons will benefit from understanding the physical principles underlying phacoemulsification because they will be better able to evaluate the performance of various parameters and different machine settings.

Surgical glove-associated diffuse lamellar keratitis.

PURPOSE: To demonstrate a potential cause of a prolonged epidemic of diffuse lamellar keratitis (DLK). METHOD: This retrospective review analyzed an epidemic of diffuse lamellar keratitis over a 3-year period in a single surgery center. Altering the brand of surgical gloves used during surgery was associated with an elimination of the DLK epidemic. Optical microscopy, scanning electron microscopy-energy dispersive spectroscopy (SEM-EDS), and Fourier transform infrared (FTIR) spectroscopy were performed on both brands of surgical gloves to allow for comparisons and determine possible surface contaminants responsible for the DLK outbreaks. RESULTS: The incidence of DLK during the epidemic ranged from 2% to 38% on a quarterly basis for the 3-year period. A change in the brand of surgical gloves resulted in a cessation of DLK. Surface analysis of both brands of gloves revealed extensive silicone oil contamination on the internal and external surfaces of the DLK-associated gloves and insignificant amounts of silicone oil on the external surface of the DLK-free gloves. CONCLUSION: Silicone oil contamination of surgical gloves appears to be associated with epidemic DLK.

Cataract surgery in the small eye.

UNLABELLED: The surgical management of cataract in the small eye presents the ophthalmic surgeon with numerous challenges. An understanding of the anatomic classification in addition to a thorough preoperative assessment will help individualize each case and enable the surgeon to better prepare for the obstacles that might be encountered during surgery. Small eyes are especially challenging in terms of intraocular lens (IOL) calculations and possible current limitations of available IOL powers, which could necessitate alternative means of achieving emmetropia. Surgical strategies for minimizing complications and maximizing good outcomes can be developed from knowledge of the anatomic differences between various small-eye conditions and the pathologies that may be associated with each. A thorough understanding of the challenges inherent in these cases and the management of intraoperative and postoperative complications will ensure that surgeons approaching the correction of these eyes will achieve the best possible surgical results. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Prospective randomized trial of an anterior surface modified prolate intraocular lens.

PURPOSE: We compare the contrast sensitivity obtained with an anterior surface modified prolate intraocular lens with the contrast sensitivity obtained with a standard spherical intraocular lens. METHODS: Patients presenting for cataract surgery in one eye were randomized to receive either the Tecnis Z9000 intraocular lens (Pharmacia) or the AMO AR40e Opti-Edge intraocular lens (AMO). Sine wave grating contrast sensitivity testing under mesopic and photopic conditions served as the principal outcome measure. RESULTS: The Tecnis Z9000 intraocular lens provided statistically significantly better contrast sensitivity at 1.5 and 3 cycles per degree under mesopic conditions and at 6, 12 and 18 cycles per degree under photopic conditions. CONCLUSION: The use of a modified prolate intraocular lens during cataract surgery has the potential to improve contrast sensitivity under both mesopic and photopic conditions.

Refractive lens exchange with the array multifocal intraocular lens.

PURPOSE: To study the safety and efficacy of refractive lens exchange as a refractive surgery modality in the presbyopic population. SETTING: Oregon Eye Institute, Eugene, Oregon, USA. METHODS: This retrospective review of patient charts included patient selection, preoperative evaluation, management of astigmatism, surgical technique, postoperative visual outcome, and complications. The study included 68 eyes comprising 32 bilateral and 4 unilateral refractive lens exchanges. RESULTS: All patients having bilateral refractive lens exchange achieved an uncorrected binocular visual acuity of 20/40 and J5 or better 1 to 3 months postoperatively. More than 90% achieved an uncorrected binocular visual acuity of 20/30 and J4 and nearly 60%, of 20/25 and J3. CONCLUSION: Refractive lens exchange was a safe and effective refractive surgery modality in presbyopic patients.