Descemet Membrane Endothelial Keratoplasty as Treatment for Late-Onset Interface Fluid Syndrome After Laser In Situ Keratomileusis.

PURPOSE: We herein present Descemet membrane endothelial keratoplasty (DMEK) as an effective surgical means of treatment for the management of interface fluid syndrome (IFS) in a series of cases with distant history of laser in situ keratomileusis (LASIK). METHODS: Three cases from a single institution were included. All patients had documented IFS in the setting of history of LASIK. All 3 patients underwent DMEK for the treatment of IFS. Visual acuity, clinical findings, pachymetry, endothelial cell count, and anterior segment optical coherence tomography were recorded. RESULTS: We describe 3 cases of late-onset IFS that developed in eyes many years after LASIK (ranging from 15 to 31 years). All 3 patients had clinically significant corneal edema and evidence of poor endothelial function at the time of IFS diagnosis. DMEK was subsequently performed in each case. All 3 eyes showed resolution of corneal edema and improvement in best-corrected visual acuity after DMEK. CONCLUSIONS: DMEK can provide successful visual and anatomical recovery in patients who have had previous LASIK and experience late-onset IFS due to endothelial cell dysfunction.

Work Intensity of Postoperative Care Following Implantation of Presbyopia-Correcting versus Monofocal Intraocular Lenses.

Purpose: To compare the work intensity of postoperative care following implantation of presbyopia-correcting intraocular lenses (IOLs) to that of standard monofocal IOLs. Patients and Methods: This open-label, multicenter, comparative study retrospectively reviewed the case records of cataract surgery patients who underwent bilateral implantation of either presbyopia-correcting IOLs (presby-IOL group; N=177) or standard monofocal IOLs (monofocal group; N=177). Outcome measures included the total time the patient spent in the office, number of visits, mean duration of visits, and the number of procedures and diagnostic tests during the first postoperative year. Outcome measures were compared between the first 90 days and days 91-365 after surgery. Results: Mean (±SD) time spent in the office during the first postoperative year was 5:50 ± 3:35 hours (H:MM) over 6.6 ± 2.9 visits in the presby-IOL group, compared to 3:38 ± 1:36 hours over 4.9 ± 1.6 visits in the monofocal IOL group (p <0.001). During the first 90 days, a presby-IOL patient spent 40 minutes longer in the office than a monofocal IOL patient (3:39 ± 1:38 hours vs 2.59 ± 1:13 hours) (p <0.001). During days 91-365, time in the office was 1:32 hours longer (p <0.001), and the mean visit duration was 8 minutes longer for the presby-IOL patients (p=0.002) than those with monofocal IOL. In addition, the presby-IOL patients underwent more procedures and diagnostic tests (p ≤0.001) as compared with standard monofocal cataract surgery patients. Conclusion: Patients implanted with presbyopia-correcting IOLs require significantly more clinic time, diagnostic testing, and procedures postoperatively as compared with standard monofocal cataract surgery patients.

Interface fluid syndrome after LASIK surgery: retrospective pooled analysis and systematic review.

Interface fluid syndrome (IFS) is a complication associated with laser in situ keratomileusis (LASIK) surgery where a fluid pocket in the corneal stroma decreases visual acuity. A systematic review of IFS cases using PRISMA guidelines was performed yielding a total of 33 patients. 2 outcomes were selected for logistic regression analysis: final corrected distance visual acuity (CDVA) and need for surgical management. Results showed 33.3% of patients required surgery, 51.5% had their IFS resolve within 1 month or sooner, and 51.5% had final CDVA 20/25 or better. Higher presenting intraocular pressure (IOP) and duration of IFS ≤1 month was associated with higher odds of final CDVA 20/25 or better (adjusted odds ratio [aOR] 1.12, P = .04; aOR 7.71, P = .02, respectively). Endothelial cell dysfunction led to 17.55 greater odds for requiring surgical compared to medical management (aOR 0.36, P = .04). Presenting IOP and duration of IFS predicted final CDVA, while prior endothelial cell dysfunction predicted need for surgery.

Surgical decisions in the setting of zonulopathy.

An 85-year-old man with a history of type 2 diabetes, pseudoexfoliation (PXF) in both eyes, and tamsulosin use was referred for the evaluation of a dense cataract in the right eye and a subluxated intraocular lens (IOL) in the left eye. Unfortunately, his surgery in the left eye was complicated by diffuse zonulopathy. The referring surgeon placed a 3-piece IOL in the sulcus. However, the passively fixated 3-piece IOL moved inferiorly causing monocular diplopia for over a year. Because the patient was pleased with the IOL immediately postoperatively, a refixation procedure was performed in the form of sulcus placement with iris suture fixation in the left eye. Fortunately, the iris-fixated IOL in the left eye has remained well centered and stable without cystoid macular edema (CME) or chronic inflammation for over 8 months. The patient is on no ocular medications and has no family history of glaucoma. He now needs cataract surgery in the right eye and is extremely apprehensive because of his difficult course in the left eye. The corrected distance visual acuity is 20/70 in the right eye and 20/25 in the left eye. Intraocular pressures (IOPs) measure 20 mm Hg in the right eye and 14 mm Hg in the left eye by Goldmann tonometry. Pachymetry is 536 µm in the right eye and 543 µm in the left eye. Pupils are round with minimal reactivity and without a relative afferent pupillary defect. Extraocular motility is normal in both eyes, and confrontation visual fields is full in both eyes. Gonioscopy reveals an angle open to the pigmented trabecular meshwork (PTM) in the right eye and the ciliary body in the left eye with 1+ PTM and without peripheral anterior synechia in both eyes. The retinal nerve fiber layer and macular optical coherence tomography are normal in both eyes. On slitlamp examination, pertinent findings include pseudoexfoliative changes at the pupillary margin with poor dilation of 3.5 mm in both eyes; the anterior chamber (AC) is shallow but adequate in the right eye and deep and quiet with rare pigmented cells in the left eye. There is a 5+ nuclear sclerotic cataract with pseudoexfoliative changes on the anterior capsule and no obvious phacodonesis in the right eye and a 3-piece posterior chamber IOL in the sulcus fixated to the iris with 10-0 polypropylene sutures at 6 and 12 o'clock without pseudophacodonesis in the left eye. Dilated fundus examination reveals a cup-to-disc ratio of 0.4 with healthy neuroretinal rims in both eyes, posterior vitreous detachments in both eyes, and no evidence of diabetic retinopathy in both eyes. All other findings are unremarkable. How would you counsel this patient regarding his risk factors for surgery in the right eye? What surgical maneuvers would you use to remove the cataract safely? How would you stabilize the IOL if the capsule bag becomes compromised due to zonulopathy?

Acute-onset postoperative endophthalmitis after cataract surgery performed by resident and attending physicians at a university teaching hospital.

PURPOSE: To evaluate acute-onset postoperative endophthalmitis following cataract surgery and to compare rates between resident and attending physician-performed cohorts. SETTING: Bascom Palmer Eye Institute, Miami, Florida. DESIGN: Retrospective chart review. METHODS: Records of patients diagnosed with endophthalmitis within 6 weeks of surgery performed by attending and resident physicians between January 1, 2015, and December 31, 2020, were reviewed. Total cataract volume was obtained from institutional records, and resident case totals were obtained from case logs. Endophthalmitis cases were obtained from billing records and confirmed with chart review. RESULTS: There were 22 cases of endophthalmitis among 32 505 cases (0.068%). Endophthalmitis occurred in 6 of 6447 (0.093%) resident cases and 16 of 26 058 (0.061%) attending cases ( P = .55). The most common bacterial isolates were coagulase-negative Staphylococcus (8/22, 36.3%) and Streptococcus species (3/22, 13.6%), with negative cultures in 10 (10/22, 45.5%). Initial treatment with vitreous tap and injection of intravitreal antibiotics was performed in 21 eyes (21/22, 95.4%) and vitrectomy with intravitreal antibiotic injection in one (1/22, 4.5%). Vitrectomy was performed secondarily in 9 patients (9/22, 40.9%). Corrected distance visual acuity (CDVA) at last follow-up was ≥20/40 in 13 eyes (13/22, 59%) and ≤hand motions in 3 eyes (3/22, 13.6%). CDVA (logMAR mean ± SD) was 1.22 ± 1.16 in resident and 0.49 ± 0.79 in attending cases ( P = .11). CONCLUSIONS: In the current study, acute-onset postoperative endophthalmitis developed infrequently following cataract surgery. The rates and visual outcomes of endophthalmitis were similar in resident and attending cases.

Outcomes of Femtosecond Laser-Assisted Cataract Surgery Compared to Conventional Phacoemulsification in Eyes with Pseudoexfoliation Syndrome.

OBJECTIVE: To compare the outcomes including complications, in a large cohort of eyes with pseudoexfoliation syndrome that underwent Femtosecond Laser-Assisted Cataract Surgery (FLACS) versus conventional phacoemulsification. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 513 eyes from 366 patients with pseudoexfoliation syndrome that underwent cataract surgery between April 1, 2014, and December 31, 2018. METHODS: Charts were reviewed for preoperative examination findings, intraoperative complications, and post-operative outcomes. Best-corrected visual acuity (BCVA) was measured by logMAR and compared between groups at one month and the final follow-up visit. RESULTS: Of 513 eyes, 71 (13.8%) underwent FLACS, and 442 (86.2%) eyes underwent conventional cataract surgery. Between the two groups, there was no difference in the incidence of vitreous prolapse, capsular tear, pupillary expansion device usage, capsular tension support device usage, or postoperative cystoid macular edema (p > .05 for all). At the final visit, there was no significant difference in BCVA between FLACS and conventional phacoemulsification groups (mean logMAR 0.26 vs. 0.25, p = .87). CONCLUSIONS: When comparing FLACS and conventional phacoemulsification in eyes with pseudoexfoliation syndrome, no difference was seen in the incidence of complications. BCVA was comparable between the two groups. Zonular weakness significantly increased the risk of complications in both groups.

Refractive Outcomes in Fuchs' Endothelial Corneal Dystrophy: Conventional and Femtosecond Laser-Assisted Cataract Surgery.

PURPOSE: To investigate the refractive outcomes of eyes with Fuchs' endothelial corneal dystrophy (FECD) following phacoemulsification. METHODS: This is a retrospective chart review of patients with FECD who underwent phacoemulsification. Manifest refraction at the early postoperative period (1-6 weeks) and late postoperative period (3-12 months) was collected. The spherical equivalent (SE) and variance of SE from target in diopters (D) were analyzed. RESULTS: A total of 219 eyes from 175 FECD patients (73 FLACS, 146 conventional phacoemulsification) were included. In the early postoperative period, when comparing variance from intended target, 62% (n=126) had a SE variance of ≤0.5 D, 22% (n=44) >0.5 D and ≤1 D, and 17% (n=34) >1 D. In the late postoperative period, 62% (n=85) had a SE variance of ≤0.5 D, 19% (n=26) >0.5 D and ≤1 D, and 20% (n=27) >1 D. There was no difference in the variance of SE comparing FLACS versus conventional phacoemulsification in either the early postoperative period (p=0.78) or the late postoperative period (p=0.29). CONCLUSION: Patients with mild-to-moderate FECD had favorable refractive outcomes with phacoemulsification. There was no difference in refractive outcomes in eyes with FECD between the group that underwent FLACS versus the group that underwent conventional phacoemulsification.

The Economic Impact of Presbyopia.

Presbyopia is the world's number one cause of vision loss with more than 1 billion individuals affected globally. The total global costs associated with correcting near vision impairment due to uncorrected presbyopia have been estimated at $30.8 billion for a comprehensive eye care model. Both cost to the patient and cost to society, which is greater in low-income countries relative to high-income areas, should be considered. Ultimately, surgical correction of the nonaccommodating dysfunctional natural lens may provide the "cure" for presbyopia. Presbyopia-correcting intraocular lenses (IOLs) may provide better visual acuity and fewer adverse effects. Patients are pursuing cataract surgery at a younger and younger age. Although this expands the viable pool for lens exchange, this younger group of patients has extreme demands and has a much more scrutinizing frame of reference for comparison (a milder cataract). Thus, they are at a much higher risk for dissatisfaction and have a much higher chance of noticing potential adverse effects from multifocal IOLs. Setting appropriate expectations and thoroughly educating patients preoperatively helps create a partnership with the patient and a strong foundation for a successful surgical outcome. A cure for presbyopia has always been considered the holy grail of ophthalmology. In 2021, ophthalmologists are moving closer to achieving this goal while also creating a safer, more productive, cost-effective solution to presbyopia on an individual and on a global level. [J Refract Surg. 2021;37(6 Suppl):S17-S19.].

Outcomes of toric intraocular lens implantation after femtosecond laser and traditional cataract surgery.

CLINICAL RELEVANCE: Having an understanding of the refractive outcomes of different forms of cataract surgery will assist optometrists in explaining the implication of such procedures to patients being referred for such procedures. BACKGROUND: The purpose of this study was to compare the refractive outcomes after toric intraocular lens implantation between femtosecond laser-assisted cataract surgery and traditional phacoemulsification. METHODS: This retrospective non-randomised case series included 114 eyes of 92 consecutive patients (59 male and 55 female) aged 71.65 ± 10.46-years (range 57 to 92-years), who underwent either femtosecond laser-assisted cataract surgery (using two laser platforms) (group 1) or traditional phacoemulsification (group 2) between August 2013 and September 2015. Pre-operative keratometric values, the attempted refraction from the biometry platform and the toric intraocular lens web-based calculator, and the one month post-operative manifest refraction were assessed to evaluate the refractive outcomes of the two groups. RESULTS: Mean pre-operative topographic corneal astigmatism was -1.94 ± 0.73 D (range 0.91 to 4.61 D) and -1.98 ± 0.60 D (range 1.07 to 3.43 D) for groups 1 and 2, respectively (p > 0.05). Mean axial length was 24.22 ± 0.73-mm (range 21.78 to 29.30-mm) and 24.60 ± 1.09-mm (range 21.82 to 25.95-mm) for groups 1 and 2, respectively (p > 0.05). Multivariate vector analysis of the remaining refractive error between the two groups (desired refraction minus achieved refraction) revealed no statistically significant difference (p > 0.05). Analysis within each group demonstrated a higher accuracy of refractive outcomes for the femtosecond laser-assisted cataract surgery eyes (p < 0.05) when compared to the traditional phacoemulsification (p > 0.05). CONCLUSION: Femtosecond laser-assisted cataract surgery and traditional phacoemulsification demonstrate similar refractive outcomes after toric intraocular lens implantation, while femtosecond laser-assisted cataract surgery seems to provide a slightly higher accuracy.

Long-term outcomes of riboflavin photodynamic antimicrobial therapy as a treatment for infectious keratitis.

PURPOSE: To report the long-term outcomes of three patients with infectious keratitis treated with riboflavin photodynamic antimicrobial therapy (PDAT). OBSERVATIONS: Case series reporting three patients with infectious keratitis unresponsive to standard medical treatment who underwent riboflavin photodynamic antimicrobial therapy (PDAT) as an adjunct therapy. One male and two female patients were treated, the median age of presentation was 58 years (range, 29-79 years). The organisms isolated and treated were Pseudomonas aeruginosa, Mycobacterium chenolae, and Curvularia spp. Different risk factors to develop corneal infection ulcers were identified, including corneal abrasion in a contact lens user, history of penetrating keratoplasty with chronic use of topical corticosteroids, and organic trauma. The median follow-up was 47 months (range 37-54 months), and there were no complications secondary to riboflavin PDAT treatment. Two cases underwent optical penetrating keratoplasty after infection was resolved and ocular surface was quiet for at least 3 years. CONCLUSIONS AND IMPORTANCE: Riboflavin PDAT can be used as an adjunct treatment in infectious keratitis to strengthen the corneal collagen fibers, delay keratolysis, and allow more time for antimicrobials to work and this way prevent a corneal perforation.

Dry Eye Disease: Consideration for Women's Health.

Dry eye disease (DED) is a multifactorial disorder of the ocular surface and tear homeostasis that can result in discomfort, pain, and visual disturbance. Untreated, DED can become chronic, progressive, and significantly affect an individual's quality of life. Women are disproportionately affected by DED, are diagnosed at a younger age, and experience more severe symptoms compared with men. DED is associated with a wide range of comorbid conditions; there is a strong association between DED and autoimmune disorders, especially those that affect women at many times the rate of men. Treatment response questionnaires indicate women respond better to a wellness model of treatment for DED than men. Furthermore, women's health care-seeking behaviors provide opportunities for general practitioners, specialists, and women's health centers to help identify women with DED or at risk for DED for referral to an eye care specialist. This review of the prevalence of DED in women, and gender and sex-specific aspects of DED, highlight a significant opportunity for action. Earlier diagnosis and treatment of this common but burdensome condition could significantly improve a woman's quality of life.

Comparison of phacoemulsification parameters between manual and femtosecond laser-assisted cataract surgery.

OBJECTIVE: To compare the nucleus removal time (NRT) and cumulative dissipated energy (CDE) outcomes of traditional phacoemulsification and femtosecond laser-assisted cataract surgery (FLACS) performed by cornea attendings and fellows. DESIGN: Prospective nonrandomized comparative study. PARTICIPANTS: A total of 410 eyes of 410 patients. METHODS: Nucleus removal time and CDE were recorded from patients who underwent cataract surgery using either FLACS (Catalys, LenSx, or Victus) or traditional phacoemulsification technique performed by 3 cornea attendings and 4 cornea fellows. One-way analysis of variance with Bonferroni post hoc tests and unpaired t tests were used to determine the differences between groups. RESULTS: There was no statistically significant difference in cataract grade between groups. NRT was significantly lower only when using the Catalys system compared with the LenSx and Victus platforms and the traditional surgery, in both the attending group (p = 0.006, p = 0.002, p < 0.000, respectively) and the fellow group (p = 0.049, p = 0.038, p = 0.011, respectively). With respect to CDE, there was no significant difference when using the laser systems compared with the traditional surgery in both attending and fellow groups (p > 0.05). NRT and CDE were significantly higher in the fellow group (NRT = 269.10 ± 117.67, CDE = 7.30 ± 4.83) compared with the attending group (NRT = 218.87 ± 109.67, CDE = 5.76 ± 3.66) in traditional cases; however, in FLACS cases, there was no significant difference in NRT and CDE between the fellow group and the attending group. CONCLUSIONS: Inexperienced surgeons seem to require more time and use more ultrasound energy during traditional phacoemulsification when compared with experienced surgeons. The use of FLACS seems to significantly improve the NRT of experienced and inexperienced surgeons.

The Effect of NSAID Pretreatment on Aqueous Humor Prostaglandin E2 Concentration in Eyes Undergoing Femtosecond Laser-Assisted Capsulotomy.

PURPOSE: To assess aqueous humor concentration of prostaglandin E2 (PGE2) after capsulotomy creation using a femtosecond laser (FLAC) in patients pretreated with short-term topical ketorolac versus patients without pretreatment. METHODS: This prospective study comprised consecutive patients scheduled to undergo cataract surgery using a femtosecond laser platform to perform only capsulotomies. An identical protocol for preoperative mydriasis was used for all the eyes included in the study, while aqueous humor was extracted from the anterior chamber of all patients immediately after the initial side port incision. ELISA was performed to quantify aqueous humor PGE2. The patients were divided into 2 groups; in group 1, the patients received short-term topical ketorolac preoperatively, while the patients in group 2 did not receive NSAID pretreatment. RESULTS: Twenty eyes of 20 patients were included in the study (10 eyes in each group). Mean concentration of aqueous humor PGE2 after FLAC was 392.16 ± 162.00 pg/ml and 622.63 ± 331.84 pg/ml for groups 1 and 2, respectively. A statistically significant difference in aqueous humor PGE2 concentration between the two groups (p < 0.05) was demonstrated, with the eyes that received ketorolac pretreatment demonstrating a lower concentration of PGE2. CONCLUSION: Short-term topical use of ketorolac prior to FLAC seems to prevent excessive release of PGE2 in the anterior chamber of the eyes that received NSAID pretreatment when compared to the eyes that did not receive NSAIDs preoperatively.

Case Series: Overnight Wear of Scleral Lens for Persistent Epithelial Defects.

SIGNIFICANCE: This case series demonstrates successful use of PROSE (Prosthetic Replacement of the Ocular Surface Ecosystem) for overnight wear among patients with persistent epithelial defects, while exploring the efficacy of using PROSE reservoir for autologous hematopoietic products during treatment. PURPOSE: This case series proposes a strategic approach to the treatment of refractory cases of persistent epithelial defect via overnight PROSE device wear. CASE REPORTS: We followed three patients with persistent epithelial defect treated with PROSE devices and observed expedited defect resolution and improvement in best-corrected visual acuity over the course of 2 to 4 weeks. In addition to moxifloxacin and preservative-free saline, autologous hematopoietic products were added to the reservoir of two patient's PROSE devices. Patients were advised to wear their PROSE device at all times except for lens cleaning and replacement of reservoir contents every 12 hours. CONCLUSIONS: Together, these cases demonstrated the safety and efficacy of overnight wear of PROSE devices in the treatment of refractory persistent epithelial defect (PED).

Comparison of Corneal Endothelial Cell Loss Between Two Femtosecond Laser Platforms and Standard Phacoemulsification.

PURPOSE: To analyze and compare the changes in endothelial cell density (ECD) and cumulative dissipated energy (CDE) in patients having cataract surgery with two different femtosecond laser platforms and standard phacoemulsification. METHODS: This prospective non-randomized comparative study included patients scheduled to undergo cataract extraction using femtosecond laser-assisted cataract surgery (FLACS) (60 eyes) or standard phacoemulsification (60 eyes) between September 2013 and March 2016. The main outcome measures were CDE and percentage of endothelial cell loss. Comparative analysis of CDE and percentage of endothelial cell loss between the two phacoemulsification platforms with respect to conventional and FLACS techniques was performed. RESULTS: The CDE and the 1-month mean percentage of endothelial cell loss was 6.11 ± 3.52 and 9.06% ± 8.77% in the standard phacoemulsification group and 4.65 ± 3.61 and 6.00% ± 8.02% in the FLACS group, respectively (P = .039). In the subgroup analysis based on cataract grading, the CDE was significantly less in the FLACS group compared to the standard phacoemulsification group in both the early and advanced cataract group (P = .002). The percent decrease in endothelial cell loss was statistically lower in the FLACS group when compared to the standard phacoemulsification group in the advanced cataract subgroup (P = .02). CONCLUSIONS: FLACS pretreatment resulted in a decrease in CDE and less endothelial cell loss when compared to standard phacoemulsification. The decrease in endothelial cell loss was more prominent in the denser cataract group; thus, FLACS may be most beneficial in those cases. There was no significant difference in results between the two laser platforms. [J Refract Surg. 2017;33(10):708-712.].

Effects of Short-term Preoperative Topical Ketorolac on Pupil Diameter in Eyes Undergoing Femtosecond Laser-Assisted Capsulotomy.

PURPOSE: To assess pupil diameter before and after femtosecond laser-assisted capsulotomy in patients who were pretreated with a short-term topical nonsteroidal anti-inflammatory drug (NSAID) (ketorolac) versus those without pretreatment. METHODS: This prospective, randomized, observational case series included consecutive patients scheduled to undergo cataract extraction using the Catalys femtosecond laser platform (Abbott Medical Optics, Inc., Santa Ana, CA) to perform only capsulotomies. The same protocol for preoperative medical mydriasis was used for all patients, whereas pupil diameter was assessed using a surgical ruler immediately before and 3 minutes after femtosecond laser-assisted capsulotomy. The patients were divided into two groups: one received short-term topical ketorolac preoperatively and the other did not receive NSAID pretreatment (control). RESULTS: A total of 42 eyes of 42 patients (1 eye per patient) were included in the study. Mean pupillary miosis was 0.79 ± 1.08 and 1.57 ± 1.19 mm for the ketorolac and control groups, respectively. There was a statistically significant decrease in pupil diameter for both groups individually (P < .05). There was also a statistically significant difference between the two groups (P < .05) with the induced miosis in the eyes that did not receive topical NSAIDs prior to cataract extraction being twofold greater when compared with the miosis of the eyes that received ketorolac pretreatment. CONCLUSIONS: Short-term topical use of ketorolac prior to femtosecond laser-assisted cataract surgery seems to induce significantly less pupillary miosis in comparison to eyes that did not receive NSAID pretreatment. NSAID use is advised prior to femtosecond laser-assisted cataract surgery to minimize pupil miosis-related surgical difficulties or complications during cataract extraction. [J Refract Surg. 2017;33(4):230-234.].

Differences in energy expenditure for conventional and femtosecond-assisted cataract surgery using 2 different phacoemulsification systems.

PURPOSE: To compare the mean cumulative dissipated energy (CDE) in patients having femtosecond laser-assisted or conventional phacoemulsification cataract surgery using 2 different phacoemulsification platforms. SETTING: Bascom Palmer Eye Institute, Miami, Florida, USA. DESIGN: Prospective comparative nonrandomized clinical study. METHODS: Consecutive patients were scheduled to have femtosecond laser-assisted cataract surgery with the Lensx laser or conventional phacoemulsification using an active-fluidics torsional platform (Centurion) or torsional platform (Infiniti). The mean CDE and cataract grade were recorded. RESULTS: The study comprised 570 eyes (570 patients). There was no statistically significant difference in mean age (P = .41, femtosecond group; P = .33, conventional group) or cataract grade (P = .78 and P = .45, respectively) between the active-fluidics and gravity-fluidics platforms. In femtosecond cases (145 eyes), the mean CDE (percent-seconds) was 5.18 ± 4.58 (SD) with active fluidics and 7.00 ± 6.85 with gravity fluidics; in conventional cases (425 eyes), the mean CDE was 7.77 ± 6.97 and 11.43 ± 9.12, respectively. In both femtosecond cases and conventional cases, the CDE was lower with the active-fluidics platform than with the gravity-fluidics platform (P = .029, femtosecond group; P < .001 conventional group). With both fluidics platforms, the mean CDE was significantly lower in the femtosecond group than in the conventional group (both P < .001). CONCLUSIONS: The active-fluidics phacoemulsification platform achieved lower CDE values than the gravity-fluidics platform for conventional cataract extraction. Femtosecond laser pretreatment with the active-fluidics platform further reduced CDE.

Toxic Anterior Segment Syndrome: Inadvertent Administration of Intracameral Lidocaine 1% and Phenylephrine 2.5% Preserved With 10% Benzalkonium Chloride During Cataract Surgery.

PURPOSE: To report 3 patients with corneal decompensation and anterior uveitis within 24 hours of cataract surgery from a single ambulatory surgery center using intracameral lidocaine HCl 1% and phenylephrine 2.5% inadvertently preserved with 10% benzalkonium chloride. METHODS: This case series describes 3 patients who underwent traditional cataract extraction with a significant decrease in visual acuity in the immediate postoperative period resulting in secondary surgical intervention for corneal decompensation in 2 patients. RESULTS: All 3 patients experienced a dramatic decrease in visual acuity on the day of surgery, ranging from 20/400 to light perception. They were treated with topical steroids and sodium chloride, with stabilization of vision at 20/60 in 1 patient. The remaining 2 patients did not recover with medical management. One underwent Descemet stripping automated endothelial keratoplasty with placement of the corneal graft on top of Descemet membrane, which could not be removed secondary to extensive fibrosis. The third patient underwent penetrating keratoplasty secondary to deep corneal scarring. CONCLUSIONS: This is the first case series of toxic anterior segment syndrome occurring secondary to the use of benzalkonium chloride-preserved intracameral lidocaine and phenylephrine. Clinicians should remain alert to this phenomenon, and should refrain from using intracameral preservatives during cataract surgery.