Topical Recombinant Human Nerve Growth Factor (Cenegermin) for Neurotrophic Keratopathy: A Multicenter Randomized Vehicle-Controlled Pivotal Trial.

PURPOSE: To evaluate the efficacy and safety of topical cenegermin (recombinant human nerve growth factor) in patients with neurotrophic keratopathy. DESIGN: Multicenter, randomized, double-masked, vehicle-controlled trial. PARTICIPANTS: Patients with neurotrophic persistent epithelial defect with or without stromal thinning. METHODS: The NGF0214 trial, conducted among 11 sites in the United States, randomized 48 patients 1:1 to cenegermin 20 µg/ml or vehicle eye drops, 6 drops daily for 8 weeks of masked treatment. Follow-up was 24 weeks. Safety was assessed in all patients who received study drug. Efficacy was assessed by intention to treat. MAIN OUTCOME MEASURES: The primary end point was healing of the neurotrophic lesion (persistent epithelial defect or corneal ulcer) after 8 weeks of masked treatment. Masked central readers measured neurotrophic lesions in randomized clinical pictures, then assessed healing status conventionally (<0.5 mm of fluorescein staining in the greatest dimension of the lesion area) and conservatively (0-mm lesion staining and no other residual staining). Secondary variables included corneal healing at 4 weeks of masked treatment (key secondary end point), overall changes in lesion size, rates of disease progression, and changes in visual acuity and corneal sensitivity from baseline to week 8. RESULTS: Conventional assessment of corneal healing showed statistically significant differences at week 8: compared to 7 of 24 vehicle-treated patients (29.2%), 16 of 23 cenegermin-treated patients (69.6%) achieved less than 0.5 mm of lesion staining (+40.4%; 95% confidence interval [CI], 14.2%-66.6%; P = 0.006). Conservative assessment of corneal healing also reached statistical significance at week 8: compared to 4 of 24 vehicle-treated patients (16.7%), 15 of 23 cenegermin-treated patients (65.2%) achieved 0 mm of lesion staining and no other residual staining (+48.6%; 95% CI, 24.0%-73.1%; P < 0.001). Moreover, the conservative measure of corneal healing showed statistical significance at week 4 (key secondary end point). Compared to vehicle, cenegermin-treated patients showed statistically significant reductions in lesion size and disease progression rates during masked treatment. Cenegermin was well tolerated; adverse effects were mostly local, mild, and transient. CONCLUSIONS: Cenegermin treatment showed higher rates of corneal healing than vehicle in neurotrophic keratopathy associated with nonhealing corneal defects.

Optical Coherence Tomography Imaging of the Palisades of Vogt to Assist Clinical Evaluation and Surgical Planning in a Case of Limbal Stem-Cell Deficiency.

PURPOSE: To describe the use of volumetric optical coherence tomography (OCT) imaging to assist evaluation of a patient referred for autologous limbal stem-cell transplant. METHODS: This is a case report of a 50-year-old patient presenting with unilateral limbal stem-cell deficiency who was referred for autologous limbal stem-cell transplant. The presence of Salzmann nodules in the donor eye raised questions about the efficacy of transplantation, prompting examination of both eyes using volumetric OCT imaging to determine whether there were palisades of Vogt (POV) present. Image volumes were acquired in all clock hours and were compared against those of an age-matched normal subject. RESULTS: Palisades were found in both eyes, although in both eyes there were fewer palisade ridges, and those that were present were not as distinct as those of the normal subject. The OCT volumes also showed that stromal scarring was present only in the anterior stroma of the intended transplant eye. These findings suggested that the patient may be able to sustain a deep anterior lamellar keratoplasty without an autologous transplant, which would spare any insult to the opposing eye and require less surgery to restore vision in the affected eye. Nine months postsurgical follow-up revealed significant improvement in visual acuity and no scar tissue development. CONCLUSION: The OCT evaluation of the POV provides detailed information to the clinician that may assist in diagnosis and evaluation of patients before transplantation. Further development of this technique is necessary to make it clinically available.

Application of adipose-derived stem cells on scleral contact lens carrier in an animal model of severe acute alkaline burn.

PURPOSE: To evaluate the therapeutic effect of human adipose-derived stem cells (hASCs) overlaid on a scleral contact lens (SCL) carrier in a rabbit model of ocular alkaline burn. MATERIALS AND METHODS: After inducing alkaline burn in 11 New Zealand white rabbits, hASCs cultured on SCLs were placed on the right eye of 5 rabbits, SCLs without cells were used in 5, and no treatment was applied in 1 eye. Each eye was examined and photographed for corneal vascularization, opacities, and epithelial defect in week 1, 2, and 4 after surgery. After 1 month, rabbits were killed and the corneas were removed and cut in half for electron and light microscopy examination. RESULTS: Human adipose-derived stem cells were attached to SCL surface and confluent easily. Human adipose-derived stem cells on SCL eyes showed smaller epithelial defect, less corneal opacity, corneal neovascularization relative to SCL eyes. Both groups showed no symblepharon. However, the cornea in the untreated eye was melted in 2 weeks and developed severe symblepharon. CONCLUSION: Human adipose-derived stem cells on SCL can reduce inflammation and corneal haziness in severe ocular alkaline burn injury in rabbits.

A cross-linked hyaluronan gel accelerates healing of corneal epithelial abrasion and alkali burn injuries in rabbits.

OBJECTIVE: To evaluate the efficacy of a chemically modified and cross-linked derivative of hyaluronan (CMHA-SX) for treatment of corneal epithelial abrasion and standardized alkali burn injuries. ANIMALS: Twelve female New Zealand white rabbits in two groups were used. PROCEDURES: Bilateral 6-mm diameter corneal epithelial abrasions were made in each of six rabbits in one group and 6-mm standardized alkali burn injuries were made in the second group. A 1% CMHA-SX formulation was applied topically four times per day in right eye of each rabbit for 1 week, and phosphate buffered saline (PBS) was placed in left (control) eye of each rabbit. The wound size was determined by staining with 1% fluorescein and photographed at the slit lamp with a digital camera at 0, 1, 2, 3 days postoperatively in the first group and 0, 1, 2, 3, 7, 12 days in the second group. Rabbit corneas were collected for histological examination on day 7 in the first group and day 12 in the second group. RESULTS: Closure of corneal wound in the abrasion model was complete in the CMHA-SX treated eye by 48 h. The wound closure rate and thickness of the central corneal epithelium in the CMHA-SX treated group was greater than in control eyes for both the abrasion and alkali burn injuries. Moreover, the CMHA-SX treated cornea exhibited better epithelial and stromal organization than the untreated control cornea. CONCLUSIONS: Chemically modified and cross-linked derivative of hyaluronan improved corneal wound healing and could be useful for treating noninfectious corneal injuries.

A Narrative Review of Microsporidial Infections of the Cornea.

Microsporidia are a rare and commonly misdiagnosed cause of corneal infection, accounting for approximately 0.4% of cases of microbial keratitis in some populations. Ocular microsporidiosis most often presents as either microsporidial keratoconjunctivitis (MKC) or microsporidial stromal keratitis (MSK). Though these two clinical entities exhibit similar symptomology, they are distinguished from one another by the time course for disease progression, findings on slit-lamp examination, and response to medical therapy. This review summarizes the current literature on the etiology and clinical presentation of microsporidial infections of the cornea and highlights ongoing developments in available diagnostic modalities and treatment regimens.

Late in-the-bag spontaneous intraocular lens dislocation: evaluation of 86 consecutive cases.

OBJECTIVE: As techniques for cataract surgery have evolved, spontaneous intraocular lens (IOL) dislocation has decreased overall. However, since 2006 the Intermountain Ocular Research Center has received an increased number of explanted IOLs within the capsular bag forwarded for pathologic evaluation. Late, spontaneous dislocation of IOLs results from zonular insufficiency and zonulysis that has been associated with pseudoexfoliation, trauma, and other risk factors. The findings of 86 consecutive cases of this complication, analyzed in the laboratory, are described. DESIGN: Retrospective case series. PARTICIPANTS: Eighty-six IOLs explanted within the capsular bag, submitted in formalin. METHODS: Standard light microscopy of specimens, as well as questionnaire sent to explanting surgeons and patient chart review, when available. MAIN OUTCOME MEASURES: Lens design, material, and abnormalities; capsular bag anomalies; patient demographic data; surgical dates; and presence or absence of known risk factors. RESULTS: This series included polymethyl methacrylate, silicone, and hydrophobic acrylic lenses, manufactured with both 1-piece and 3-piece designs. The mean time from surgery to spontaneous IOL dislocation was 8.5 years. The main conditions associated with the cases of IOL dislocation were as follows: pseudoexfoliation, 50%; prior vitreoretinal surgery, 19%; history of trauma, 6%; uveitis, 2%; and none or unknown, 23%. CONCLUSIONS: Patients with any type of IOL are at risk for late in-the-bag dislocation. Pseudoexfoliation and vitreoretinal surgery were the most common associated conditions in this series. Regardless of the presence of known risk factors, IOLs dislocated on average 8.5 years after phacoemulsification and IOL implantation.

Effect of iris registration on outcomes of LASIK for myopia with the VISX CustomVue platform.

PURPOSE: To compare visual outcomes after LASIK using the VISX STAR S4 CustomVue, with and without Iris Registration technology. METHODS: In this retrospective study, LASIK was performed on 239 myopic eyes, with or without astigmatism, of 142 patients. Iris registration LASIK was performed on 121 eyes and non-iris registration LASIK was performed on 118 eyes. Primary outcome measures were uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), and manifest refraction. RESULTS: At 6 months, the mean values for UCVA (logMAR) were 0.00 +/- 0.09 in the iris registration group and -0.01 +/- 0.11 in the non-iris registration group (P = .587). Seventy-nine percent of eyes in the iris registration group had UCVA of 20/20 or better compared to 78% in the non-iris registration group (P = .518). Ninety-two percent of eyes in the iris registration group and 90% in the non-iris registration group were within +/- 0.50 diopters (D) of emmetropia (P = .999). Mean postoperative absolute change in total root-mean-square higher order aberrations in the iris registration group and non-iris registration group was 0.22 microm and 0.19 microm, respectively (P = .6). At 3 months, the mean magnitude of error of surgically induced astigmatism was -0.09 in the iris registration group and -0.04 in the non-iris registration group (P = .25). CONCLUSIONS: Wavefront-guided LASIK with the VISX STAR S4 CustomVue laser system, independent of iris registration status, is effective, safe, and predictable. Under well-controlled surgical conditions, this study did not find any statistical significance supporting the better achievement of visual acuity, astigmatism correction, or the lesser induction of higher order aberrations using iris registration in comparison to a non-iris registration system.

Ulcerative keratitis in gastrointestinal stromal tumor patients treated with perifosine.

PURPOSE: Perifosine is a novel alkylphospholipid with antiproliferative properties attributed to protein kinase B inhibition. The authors describe a form of ulcerative keratitis in 5 patients with advanced gastrointestinal stromal tumor (GIST) enrolled in a phase I/II trial of perifosine in combination with imatinib. DESIGN: Interventional case series. PARTICIPANTS: Five patients (1 man, 4 women) with imatinib-resistant metastatic GIST who received a combination of imatinib and perifosine orally. METHODS: The medical records were reviewed retrospectively. MAIN OUTCOME MEASURES: Ocular toxicity and ulcerative keratitis associated with perifosine. RESULTS: The ocular symptoms included redness, irritation, tearing, photophobia, and a gradual decrease in vision. Slit-lamp biomicroscopy in each case revealed a peripheral, paralimbal, ring-shaped, superficial corneal stromal infiltration and ulcerative keratitis, reminiscent of the autoimmune keratitis in conditions such as rheumatoid arthritis. The ulcerative keratitis was unilateral in 3 and bilateral in 2 patients; it was National Cancer Institute grade II (symptoms interfering with function but not interfering with activities of daily living) in all patients. All 5 patients had imatinib-resistant metastatic GIST and had continued on the highest dose of imatinib tolerated and initiated therapy with perifosine 100 mg daily or 900 mg weekly. A combination of topical steroids, topical antibiotics, and lubricating drops were used to manage ulcerative keratitis. In the first 3 patients, ulcerative keratitis initially was treated with topical antibiotics without improvement, but subsequently they improved significantly after topical steroids were added. CONCLUSIONS: A vision-threatening form of ulcerative keratitis may occur in patients taking perifosine. It is possible that imatinib in combination with perifosine contributes to this corneal toxicity; however, the authors are unaware of this ocular toxicity having been reported for imatinib when used without perifosine. The visual loss associated with perifosine may be reversible if detected and treated early and with judicious early use of topical steroids, topical antibiotic coverage, and lubrication.

Complications of foldable intraocular lenses requiring explantation or secondary intervention--2007 survey update.

The tenth annual survey of complications associated with foldable intraocular lenses (IOLs) requiring explantation or secondary intervention was sent to members of the American Society of Cataract and Refractive Surgery and the European Society of Cataract and Refractive Surgeons. Preoperative data about visual acuity, patient signs and symptoms, and complications requiring IOL removal were evaluated. Complications were then tabulated for each of the following major foldable IOL groups: 1-piece (plate) silicone, 1-piece hydrophobic acrylic with haptics, 3-piece silicone, 3-piece hydrophobic acrylic, 3-piece hydrophilic acrylic (hydrogel), 3-piece unknown, multifocal acrylic, and multifocal silicone. One hundred forty-two surveys were returned for evaluation. Dislocation/decentration, incorrect IOL power, glare/optical aberrations, and IOL calcification were the most common reasons for removing foldable IOLs. Good surgical technique, accurate IOL power measurements, and high manufacturing standards for foldable IOL materials and designs are the most important factors in preventing complications.

Corneal profile analysis after Descemet stripping endothelial keratoplasty and its relationship to postoperative hyperopic shift.

PURPOSE: To evaluate changes in the corneal profile after Descemet stripping endothelial keratoplasty (DSEK) using anterior segment optical coherence tomography (AS-OCT) analysis and to describe its relationship to a dynamic postoperative hyperopic shift. SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, USA. METHODS: In this retrospective observational study, 9 eyes had DSEK and were followed with manifest refractions and AS-OCT analysis. To assess changes in the thickness of the cornea, measurements for each AS-OCT image were taken at the vertex of the cornea, at 1.5 mm on each side of the vertex, and at the distal edges of the graft. RESULTS: Patients were followed for a mean of 134 days (range 46 to 228 days). Monthly Graft thinning rates were 5.2 microm per month at the vertex, 7.9 microm per month 1.5 mm from the vertex, and 26 microm per month at the edges, with the edges thinning significantly faster than the cornea vertex (P = .0024) and the points on either side of the 3.0 mm visual axis (P = .0018). The mean spherical equivalent (SE) showed an initial hyperopic shift that decreased over the ensuing 100 to 200 days postoperatively. The mean monthly postoperative SE change was -0.25 diopter (D) with a mean preoperative to postoperative SE change of +1.26 D. CONCLUSIONS: The donor graft underwent changes after DSEK, which may account for the induced hyperopia and its diminishment over time via changes in the posterior corneal curvature. Results suggest that intraocular lenses be targeted to -1.00 to -1.25 D of myopia for combined DSEK and cataract procedures.

Risk for uveitis after laser in situ keratomileusis in patients positive for human leukocyte antigen-B27.

PURPOSE: To assess the incidence of, risk for, and visual outcomes of acute anterior uveitis (AAU) in human leukocyte antigen (HLA)-B27 positive patients who had laser in situ keratomileusis (LASIK). SETTING: University-based center. METHODS: This study comprised 46 eyes of 23 HLA-B27 positive patients with a 5-year follow-up. Data on episodes of uveitis were reviewed retrospectively and the incidence rates calculated for LASIK and non-LASIK eyes. Kaplan-Meier survival probabilities were calculated for uveitis occurring during the final 36 to 60 months of the study. Survival probabilities between LASIK and non-LASIK eyes were compared. RESULTS: Twenty eyes (10 patients) had LASIK a mean of 36 months+/-2 (SD) after the diagnosis of HLA-B27. In the HLA-B27 positive patients, the incidence rates of uveitis between eyes that had and eyes that did not have LASIK were not significantly different. The incidence rates of uveitis after LASIK did not differ significantly between eyes with and eyes without episodes of uveitis before LASIK (P=.135). The probability of an eye having no episode of uveitis in the fourth and fifth year of follow-up was not significantly different between eyes that had LASIK and those that did not (P=.668). CONCLUSIONS: The occurrence rate of post-LASIK AAU in the HLA-B27 positive population was not higher than the general incidence in a similar HLA-B27 population without previous LASIK. A previous episode of uveitis did not appear to increase the risk for uveitis after LASIK in HLA-B27 positive patients.

Phakic intraocular lenses.

PURPOSE OF REVIEW: Recent advances in the design and material of phakic intraocular lenses have made them very predictable, safe and effective. The use of these lenses in refractive surgery is expected to increase very significantly in the near future. The aim of this review is to update the reader regarding the recent advances reported on this topic during 2007. RECENT FINDINGS: Several new studies demonstrate the superior visual outcomes of phakic intraocular lenses over other refractive surgeries in patients with moderate and high myopia, with or without astigmatism, especially in the areas of visual quality and contrast sensitivity. In addition, other studies have reviewed the long-term complications of different designs of phakic intraocular lenses, such as endothelial cell loss, cataract formation and the risks of retinal detachment and choroidal neovascularization. New anterior segment imaging and measurement technologies such as very high frequency ultrasound, optical coherence tomography and Scheimpflug imaging provide valuable information about anterior segment anatomy and may allow custom-designed phakic intraocular lenses with proper sizing. SUMMARY: Long-term concerns with endothelial cell loss and cataract formation remain. Proper sizing and positioning are important and possible with new imaging modalities. Improved design, safety, predictability and visual quality of phakic intraocular lenses make them invaluable for the correction of severe ametropias.

Fourth-generation fluoroquinolone-resistant mycobacterial keratitis after laser in situ keratomileusis.

We report a case of mycobacterial keratitis resistant to fourth-generation fluoroquinolones after laser in situ keratomileusis (LASIK) with fourth-generation fluoroquinolone prophylaxis. While receiving moxifloxacin post LASIK, the patient was diagnosed with moxifloxacin-resistant Mycobacterium chelonae keratitis. Culture susceptibilities revealed isolates resistant to moxifloxacin and gatifloxacin, and treatment with topical amikacin and clarithromycin with oral doxycycline and clarithromycin along with flap amputation was necessary to control the infection. This case demonstrates the potential limitations in the coverage of these antibiotic agents.

Prospective randomized trial of wavefront-guided laser in situ keratomileusis with the CustomCornea and CustomVue laser systems.

PURPOSE: To compare visual function, safety, and higher-order aberrations (HOAs) after wavefront-guided laser in situ keratomileusis (LASIK) with the LadarVision CustomCornea (Alcon Laboratories, Inc.) and Star S4 CustomVue (Visx) laser systems. SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. METHODS: Seventy-eight eyes of 39 patients with myopia with or without astigmatism were randomized for LASIK treatment in 1 eye with the CustomCornea laser; the other eye was treated with the CustomVue laser. Patients were followed for 6 months after surgery. The primary outcome measures were uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), manifest refraction, and changes in HOAs. RESULTS: At 6 months, the mean logarithm of the minimum angle of resolution (logMAR) UCVA was -0.0135 +/- 0.07 (SD) in the CustomVue group and 0.0417 +/- 0.12 in the CustomCornea group (P = .023). Eighty-eight percent of eyes in the CustomVue group had 20/20 or better UCVA compared with 67% in the CustomCornea group (P<.02). At 6 months, 91% of eyes in the CustomVue group and 79% in the CustomCornea group were within +/-0.50 diopter (D) of emmetropia (P<.1); 88% and 50%, respectively, were within +/-0.25 D (P<.001). Both platforms led to a small increase in total HOAs. The CustomVue system reduced trefoil and induced less of an increase in total HOAs, whereas the CustomCornea platform increased trefoil but induced less of an increase in spherical aberrations and coma. CONCLUSIONS: Both laser systems were effective, safe, and predictable. Wavefront-guided LASIK with the CustomVue system resulted in better visual acuity, with more eyes having 20/20 acuity than in the CustomCornea group.

Therapeutic effect of macular grid photocoagulation in treatment of nonexudative age-related macular degeneration.

BACKGROUND: To investigate the effect of prophylactic subthreshold laser macular grid photocoagulation on drusen area and to evaluate the visual outcome and incidence of choroidal neovascularization in patients with soft drusen maculopathy. METHODS: In a nonrandomized nonmasked clinical trial, 18 patients (36 eyes) with bilateral soft drusen maculopathy were studied. For each patient, one eye was treated with 48 subthreshold (invisible end-point) applications of 532-nm KTP-laser in a macular grid pattern and the fellow eye was observed. Soft drusen areas were calculated and compared between the two groups at baseline and follow-up visits at 3, 6, 12, and 30 months of therapy. Best corrected visual acuity was also compared in observed and laser-treated eyes. Reduction of drusen area, change in visual acuity, and rate of CNV were assessed in both groups. RESULTS: At baseline, there was no significant difference in the mean drusen surface area between the two groups (P = 0.90). The mean surface area of soft drusen in treated eyes was 6.51 mm(2) after 30 months and 7.58 mm(2) (P = 0.50) in the control eyes. There was a trend towards reduction in the mean soft drusen area after 30 months from baseline in laser-treated eyes (6.51 vs. 6.97 mm(2)). In treated eyes, there was no statistically significant difference between the mean best corrected visual acuity at the baseline (0.28 logMAR) and after 30 months (0.32 logMAR) (P = 0.40). CONCLUSION: Subthreshold macular grid photocoagulation with 532-nm KTP-laser did not seem to reduce drusen surface area significantly and did not improve best corrected visual acuity after 30 months. No exudative lesion developed in laser-treated eyes.

Intraoperative Optical Coherence Tomography-Assisted Descemet Stripping Automated Endothelial Keratoplasty for Anterior Chamber Fibrous Ingrowth.

PURPOSE: Here, we present the first reported case of intraoperative optical coherence tomography (OCT)-assisted Descemet membrane stripping automated endothelial keratoplasty (DSAEK) in a patient with anterior segment fibrous ingrowth. METHODS: A 61-year-old woman with corneal edema and chronic angle-closure glaucoma secondary to fibrous ingrowth after 2 glaucoma shunt device implantations underwent dissection and removal of anterior chamber fibrous ingrowth and DSAEK. The surgical techniques using intraoperative OCT and outcome are described. RESULTS: Intraoperative OCT provided a clear dissection plane of the fibrous membranes in the anterior chamber and view of their relation to the iris and corneal endothelium, despite an opacified cornea. The placement of the donor lenticule and absence of interface fluid were also verified intraoperatively. The postoperative course was uncomplicated with satisfactory outcome. CONCLUSIONS: We conclude that intraoperative OCT is a useful tool during DSAEK surgery, particularly in complicated cases such as anterior segment fibrous ingrowth and significant corneal edema.

Femtosecond laser-assisted decagonal deep anterior lamellar keratoplasty.

OBJECTIVE: To assess the use of a new polygonal trephination pattern for deep anterior lamellar keratoplasty (DALK) assisted by femtosecond laser. DESIGN: Prospective, nonrandomized clinical study. METHODS: Twenty-four eyes underwent decagonal DALK. All except 1 had advanced keratoconus. A laser was used to create decagonal cuts on both donor and recipient corneas. All patients were assessed for uncorrected visual acuity, best spectacle-corrected visual acuity (BCVA), and keratometry by Pentacam pre- and postoperatively. RESULTS: All eyes were treated successfully without intraoperative complications. All patients were followed for 18 months. Mean ± SD of postoperative BCVA was 0.26 ± 0.16 (logarithm of minimal angle of resolution), and there was a significant improvement in BCVA after 6 months. At 18 months, mean ± SD postoperative average K was 44.48 ± 0.87 D, which was significantly lower than preoperative average K (58.42 ± 12.1). Postoperative astigmatism at 18 months (mean ± SD: 1.82 ± 0.67) was significantly lower than that at 6 months (mean ± SD: 3.27 ± 0.81) (p = 0.001). CONCLUSIONS: Use of the decagonal trephination profile was effective to perform DALK. This study showed promising visual and refractive results. Longer follow-up, larger pool of patients, and comparative studies are necessary to determine advantages and optimal surgical settings of this technique.

Diagnosis and management of opacified silicone intraocular lenses in patients with asteroid hyalosis.

UNLABELLED: We analyzed 3 calcified silicone IOLs from 2 patients with a history of asteroid hyalosis. In both cases, posterior capsule opacification had been diagnosed and a laser capsulotomy performed before referral. Subsequently, both IOLs were exchanged with hydrophobic acrylic IOLs that were placed in the sulcus. The IOL exchange was challenging due to the open capsule. Light microscopy demonstrated that the white deposits on the explanted IOLs formed an almost confluent crust in some areas, interspersed with clear areas on the posterior optic surfaces. The findings in our cases and in other reported cases may affect the choice of IOL in the presence of asteroid hyalosis. Also, ophthalmologists may consider deferring laser posterior capsulotomy treatment in a calcified silicone IOL to facilitate an IOL exchange procedure. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.