Impact of Aspheric Monofocal Intraocular Lens Implantation on Uncorrected Intermediate Visual Acuity: a Combined Analysis.

Purpose: To evaluate binocular intermediate visual acuity (IVA), depth of focus, and other visual outcomes achieved with a monofocal aspheric intraocular lens (IOL) using pooled data from 2 randomized, double-masked, controlled trials. Patients and Methods: The studies conducted at 32 sites included patients aged ≥22 years with bilateral cataracts, preoperative corneal astigmatism 1.0 D, and lens power 18.0-25.0 D. Patients received bilateral AcrySof IQ IOLs (SN60WF). Primary endpoint data were collected at month 6. Binocular uncorrected and corrected distance visual acuity (UDVA and CDVA) at 4 m, binocular uncorrected and corrected IVA (UIVA and DCIVA) at 66 cm, manifest refraction spherical equivalent (MRSE), and binocular defocus curve at 4 m were assessed under photopic conditions. Validated questionnaires were used to assess spectacle use and quality of vision. Results: Of 233 patients who received SN60WF, 228 had visual acuity data at 6 months. Under photopic conditions, 51% of the eyes had pupils >4 mm, 40% had pupils 3-4 mm, and 9% had pupils <3 mm. Mean ± SD UDVA and CDVA were -0.019 ± 0.110 and -0.088 ± 0.082 logMAR, respectively. Mean ± SD UIVA and DCIVA were 0.125 ± 0.145 and 0.196 ± 0.139 logMAR, respectively. UIVA and DCIVA of 20/32 or better were achieved by 83% (188/228) and 71% (162/228) of patients, respectively. Mean ± SD MRSE was -0.007 ± 0.404 D for the first eye and 0.036 ± 0.371 for the second eye. The defocus curve demonstrated binocular vision of 0.24 logMAR or better from +1.2 to -1.5 D. Spectacle independence for distance and intermediate vision was reported by 86% and 41% of the patients, respectively. Based on questionnaires, 61%, 79%, and 65% of the patients did not experience starbursts, halos, or glare. Conclusion: A monofocal aspheric IOL (SN60WF) assessed in a large, pooled study provided excellent distance vision and clinically functional intermediate vision.

Reducing topical drug waste in ophthalmic surgery: multisociety position paper.

This position article on reducing topical drug waste with ophthalmic surgery was written by the Ophthalmic Instrument Cleaning and Sterilization Task Force, comprising representatives of the ASCRS, American Academy of Ophthalmology, American Glaucoma Society, and Outpatient Ophthalmic Surgery Society. Drug waste significantly increases the costs and carbon footprint of ophthalmic surgery. Surgical facilities should be permitted to use topical drugs in multidose containers on multiple patients until the manufacturer's labeled date of expiration, if proper guidelines are followed. Surgical patients requiring a topical medication not used for other patients should be allowed to bring that partially used medication home for postoperative use. These recommendations are based on published evidence and clarification of policies from multiple regulatory and accrediting agencies with jurisdiction over surgical facilities. Surveys suggest that most ambulatory surgery centers and hospitals performing cataract surgery are wasting topical drugs unnecessarily.

Diagnosis and management of postrefractive surgery ectasia.

Postrefractive surgery ectasia is a serious, sight-threatening complication seen after the following procedures: laser in situ keratomileusis, photorefractive keratectomy, small-incision lenticule extraction, radial keratotomy, and/or arcuate keratotomy. Specific risk factors may include age, corneal thickness, degree of refractive error, corneal topographic changes including irregular astigmatism, percent tissue ablation, and residual stromal bed. Biomarkers may be a new option to help indicate who is at greatest risk for ectasia. Visual aids including spectacles or contacts lenses are often required to achieve optimal vision. Collagen crosslinking is the only treatment believed to stop progression of ectasia and prevent keratoplasty. Other surgical options may include topography-guided phototherapeutic keratectomy and intrastromal corneal ring segments. Ultimately, an "ounce of prevention is a pound of cure," so careful preoperative screening and ultimately offering the safest and most effective treatments for patients is arguably the most important job of the refractive surgeon.

Expert consensus on the identification, diagnosis, and treatment of neurotrophic keratopathy.

BACKGROUND: Neurotrophic keratopathy (NK) is a relatively uncommon, underdiagnosed degenerative corneal disease that is caused by damage to the ophthalmic branch of the trigeminal nerve by conditions such as herpes simplex or zoster keratitis, intracranial space-occupying lesions, diabetes, or neurosurgical procedures. Over time, epithelial breakdown, corneal ulceration, corneal melting (thinning), perforation, and loss of vision may occur. The best opportunity to reverse ocular surface damage is in the earliest stage of NK. However, patients typically experience few symptoms and diagnosis is often delayed. Increased awareness of the causes of NK, consensus on when and how to screen for NK, and recommendations for how to treat NK are needed. METHODS: An 11-member expert panel used a validated methodology (a RAND/UCLA modified Delphi panel) to develop consensus on when to screen for and how best to diagnose and treat NK. Clinicians reviewed literature on the diagnosis and management of NK then rated a detailed set of 735 scenarios. In 646 scenarios, panelists rated whether a test of corneal sensitivity was warranted; in 20 scenarios, they considered the adequacy of specific tests and examinations to diagnose and stage NK; and in 69 scenarios, they rated the appropriateness of treatments for NK. Panelist ratings were used to develop clinical recommendations. RESULTS: There was agreement on 94% of scenarios. Based on this consensus, we present distinct circumstances when we strongly recommend or may consider a test for corneal sensitivity. We also present recommendations on the diagnostic tests to be performed in patients in whom NK is suspected and treatment options for NK. CONCLUSIONS: These expert recommendations should be validated with clinical data. The recommendations represent the consensus of experts, are informed by published literature and experience, and may improve outcomes by helping improve diagnosis and treatment of patients with NK.

Evolving Guidelines for Intracameral Injection.

PURPOSE: To review evidence and provide guidelines on intracameral (ICM) injection techniques and monitoring. MATERIALS AND METHODS: A review of published literature on ICM injection and intravitreal injections formed the basis for roundtable deliberations by an expert panel of ophthalmologists. RESULTS: ICM injection as a way to deliver medications is growing in popularity. However, there is limited published literature and no standard approach to best practices for ICM injections, particularly when not accompanying another surgical procedure. Fortunately, there is long clinical experience with ICM manipulation and a large body of evidence surrounding intravitreal injections that has provided important guidance. The expert panel formulates several concrete guidelines and many suggested techniques to help physicians safely and effectively employ ICM injections. CONCLUSIONS: This committee addressed the many considerations surrounding ICM injection of drugs or implants and agree that it is a safe and effective surgical procedure when performed with appropriate training and according to established safe practices.

Eyelid and scleral necrosis following bare iridium-192 seed for retinoblastoma.

A 2 1/2-year-old girl with a history of bilateral retinoblastoma underwent primary enucleation of the right eye and was referred for further management of persistent tumor in the fellow eye. Previous treatment of the left eye included external beam radiotherapy, systemic chemotherapy, laser photocoagulation, cryotherapy, and direct scleral application of a bare iridium-192 radioactive seed. Examination revealed focal full-thickness necrosis of the left upper and lower eyelid and a large inferonasal viable retinoblastoma tumor with overlying retinal detachment. Systemic chemotherapy and direct laser photocoagulation were administered. Four months after presentation, the patient developed focal scleral necrosis with 360 degrees hemorrhagic choroidal detachment. Enucleation was performed and histopathologic examination demonstrated full-thickness scleral necrosis with adjacent viable retinoblastoma tumor cells. Follow-up examinations showed no evidence of recurrent or metastatic tumor. This case is the first report of scleral necrosis following combined modality treatment of retinoblastoma.

Local anesthesia with intravenous sedation for surgical repair of selected open globe injuries.

PURPOSE: To report factors associated with the use of local anesthesia with intravenous sedation (local anesthesia/sedation) rather than general anesthesia for surgery for open globe injuries in adult reparable eyes. DESIGN: Retrospective, nonrandomized, comparative case series. METHODS: Medical records were reviewed of all patients with open globe injuries repaired at Bascom Palmer Eye Institute between 1995 and 1999. "Adult reparable eyes" (eyes in patients >/=18 years of age, not treated with primary enucleation or evisceration, followed up >/=2 months) were included. RESULTS: In all, 220 eyes of 218 patients met inclusion criteria. General anesthesia was employed in 80 of 200 (36%) and local anesthesia/sedation in 140 of 220 (64%). Patients who had local anesthesia/sedation were significantly more likely to have an intraocular foreign body (31% vs 14%; P =.010, chi-square test), better presenting visual acuity (1.8 logMAR [logarithm of the minimum angle of resolution] units vs 2.5 logMAR units; P <.001, t test), more anterior wound location (75% corneal/limbal vs 65%; P =.003, chi-square), shorter wound length (6.3mm vs 10.8mm; P <.001, t test), and dehiscence of previous surgical wound (26% vs 12%; P =.021, chi-square) and were significantly less likely to have an afferent pupillary defect (22% vs 51%; P <.001, chi-square). There was no anesthesia-related complication in either group. The local anesthesia/sedation group had a shorter mean operating time than did the general anesthesia group (78 minutes vs 117 minutes; P <.001, t test). The general anesthesia group had a longer mean follow-up than the local anesthesia/sedation group (20.2 months vs 13.9 months, respectively; P =.002, t test). Change in visual acuity between the presenting and final examinations was similar for open globe injuries repaired with general anesthesia compared with local anesthesia/sedation (0.94 vs 0.72 logMAR units of visual acuity, respectively; P =.16, t test). CONCLUSIONS: Local anesthesia/sedation is a reasonable alternative to general anesthesia for selected patients with open globe injuries.