A Schlemm Canal Microstent for Intraocular Pressure Reduction in Primary Open-Angle Glaucoma and Cataract: The HORIZON Study.

OBJECTIVE: To compare cataract surgery with implantation of a Schlemm canal microstent with cataract surgery alone for the reduction of intraocular pressure (IOP) and medication use after 24 months. DESIGN: Prospective, multicenter, single-masked, randomized controlled trial. PARTICIPANTS: Subjects with concomitant primary open-angle glaucoma (POAG), visually significant cataract, and washed-out modified diurnal IOP (MDIOP) between 22 and 34 mmHg. METHODS: Subjects were randomized 2:1 to receive a single Hydrus Microstent (Ivantis, Inc, Irvine, CA) in the Schlemm canal or no stent after uncomplicated phacoemulsification. Comprehensive eye examinations were conducted 1 day, 1 week, and 1, 3, 6, 12, 18, and 24 months postoperatively. Medication washout and MDIOP measurement were repeated at 12 and 24 months. MAIN OUTCOME MEASURES: The primary and secondary effectiveness end points were the proportion of subjects demonstrating a 20% or greater reduction in unmedicated MDIOP and change in mean MDIOP from baseline at 24 months, respectively. Hypotensive medication use was tracked throughout the course of follow-up. Safety measures included the frequency of surgical complications and adverse events. RESULTS: A total of 369 eyes were randomized after phacoemulsification to Hydrus Microstent (HMS) and 187 to no microstent (NMS). At 24 months, unmedicated MDIOP was reduced by ≥20% in 77.3% of HMS group eyes and in 57.8% of NMS group eyes (difference = 19.5%, 95% confidence interval [CI] 11.2%-27.8%, P < 0.001). The mean reduction in 24-month unmedicated MDIOP was -7.6±4.1 mmHg (mean ± standard deviation) in the HMS group and -5.3±3.9 mmHg in the NMS group (difference = -2.3 mmHg; 95% CI, -3.0 to -1.6; P < 0.001). The mean number of medications was reduced from 1.7±0.9 at baseline to 0.3±0.8 at 24 months in the HMS group and from 1.7±0.9 to 0.7±0.9 in the NMS group (difference = -0.4 medications; P < 0.001). There were no serious ocular adverse events related to the microstent, and no significant differences in safety parameters between the 2 groups. CONCLUSIONS: This 24-month multicenter randomized controlled trial demonstrated superior reduction in MDIOP and medication use among subjects with mild-to-moderate POAG who received a Schlemm canal microstent combined with phacoemulsification compared with phacoemulsification alone.

Glaucoma diagnostic accuracy of ganglion cell-inner plexiform layer thickness: comparison with nerve fiber layer and optic nerve head.

PURPOSE: To determine the diagnostic performance of macular ganglion cell-inner plexiform layer (GCIPL) thickness measured with the Cirrus high-definition optical coherence tomography (HD-OCT) ganglion cell analysis (GCA) algorithm (Carl Zeiss Meditec, Dublin, CA) to discriminate normal eyes and eyes with early glaucoma and to compare it with that of peripapillary retinal nerve fiber layer (RNFL) thickness and optic nerve head (ONH) measurements. DESIGN: Evaluation of diagnostic test or technology. PARTICIPANTS: Fifty-eight patients with early glaucoma and 99 age-matched normal subjects. METHODS: Macular GCIPL and peripapillary RNFL thicknesses and ONH parameters were measured in each participant, and their diagnostic abilities were compared. MAIN OUTCOME MEASURES: Area under the curve (AUC) of the receiver operating characteristic. RESULTS: The GCIPL parameters with the best AUCs were the minimum (0.959), inferotemporal (0.956), average (0.935), superotemporal (0.919), and inferior sector (0.918). There were no significant differences between these AUCs and those of inferior quadrant (0.939), average (0.936), and superior quadrant RNFL (0.933); vertical cup-to-disc diameter ratio (0.962); cup-to-disc area ratio (0.933); and rim area (0.910), all P>0.05. CONCLUSIONS: The ability of macular GCIPL parameters to discriminate normal eyes and eyes with early glaucoma is high and comparable to that of the best peripapillary RNFL and ONH parameters. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Computer clinical decision support that automates personalized clinical care: a challenging but needed healthcare delivery strategy.

How to deliver best care in various clinical settings remains a vexing problem. All pertinent healthcare-related questions have not, cannot, and will not be addressable with costly time- and resource-consuming controlled clinical trials. At present, evidence-based guidelines can address only a small fraction of the types of care that clinicians deliver. Furthermore, underserved areas rarely can access state-of-the-art evidence-based guidelines in real-time, and often lack the wherewithal to implement advanced guidelines. Care providers in such settings frequently do not have sufficient training to undertake advanced guideline implementation. Nevertheless, in advanced modern healthcare delivery environments, use of eActions (validated clinical decision support systems) could help overcome the cognitive limitations of overburdened clinicians. Widespread use of eActions will require surmounting current healthcare technical and cultural barriers and installing clinical evidence/data curation systems. The authors expect that increased numbers of evidence-based guidelines will result from future comparative effectiveness clinical research carried out during routine healthcare delivery within learning healthcare systems.

Special Commentary: Using Clinical Decision Support Systems to Bring Predictive Models to the Glaucoma Clinic.

Advances in the field of predictive modeling using artificial intelligence and machine learning have the potential to improve clinical care and outcomes, but only if the results of these models are presented appropriately to clinicians at the time they make decisions for individual patients. Clinical decision support (CDS) systems could be used to accomplish this. Modern CDS systems are computer-based tools designed to improve clinician decision making for individual patients. However, not all CDS systems are effective. Four principles that have been shown in other medical fields to be important for successful CDS system implementation are (1) integration into clinician workflow, (2) user-centered interface design, (3) evaluation of CDS systems and rules, and (4) standards-based development so the tools can be deployed across health systems.

Pseudoexfoliation and Cataract Syndrome Associated with Genetic and Epidemiological Factors in a Mayan Cohort of Guatemala.

The Mayan population of Guatemala is understudied within eye and vision research. Studying an observational homogenous, geographically isolated population of individuals seeking eye care may identify unique clinical, demographic, environmental and genetic risk factors for blinding eye disease that can inform targeted and effective screening strategies to achieve better and improved health care distribution. This study served to: (a) identify the ocular health needs within this population; and (b) identify any possible modifiable risk factors contributing to disease pathophysiology within this population. We conducted a cross-sectional study with 126 participants. Each participant completed a comprehensive eye examination, provided a blood sample for genetic analysis, and received a structured core baseline interview for a standardized epidemiological questionnaire at the Salama Lions Club Eye Hospital in Salama, Guatemala. Interpreters were available for translation to the patients' native dialect, to assist participants during their visit. We performed a genome-wide association study for ocular disease association on the blood samples using Illumina's HumanOmni2.5-8 chip to examine single nucleotide polymorphism SNPs in this population. After implementing quality control measures, we performed adjusted logistic regression analysis to determine which genetic and epidemiological factors were associated with eye disease. We found that the most prevalent eye conditions were cataracts (54.8%) followed by pseudoexfoliation syndrome (PXF) (24.6%). The population with both conditions was 22.2%. In our epidemiological analysis, we found that eye disease was significantly associated with advanced age. Cataracts were significantly more common among those living in the 10 districts with the least resources. Furthermore, having cataracts was associated with a greater likelihood of PXF after adjusting for both age and sex. In our genetic analysis, the SNP most nominally significantly associated with PXF lay within the gene KSR2 (p < 1 × 10-5). Several SNPs were associated with cataracts at genome-wide significance after adjusting for covariates (p < 5 × 10-8). About seventy five percent of the 33 cataract-associated SNPs lie within 13 genes, with the majority of genes having only one significant SNP (5 × 10-8). Using bioinformatic tools including PhenGenI, the Ensembl genome browser and literature review, these SNPs and genes have not previously been associated with PXF or cataracts, separately or in combination. This study can aid in understanding the prevalence of eye conditions in this population to better help inform public health planning and the delivery of quality, accessible, and relevant health and preventative care within Salama, Guatemala.

Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.

Clinical decision-making is based on knowledge, expertise, and authority, with clinicians approving almost every intervention-the starting point for delivery of "All the right care, but only the right care," an unachieved healthcare quality improvement goal. Unaided clinicians suffer from human cognitive limitations and biases when decisions are based only on their training, expertise, and experience. Electronic health records (EHRs) could improve healthcare with robust decision-support tools that reduce unwarranted variation of clinician decisions and actions. Current EHRs, focused on results review, documentation, and accounting, are awkward, time-consuming, and contribute to clinician stress and burnout. Decision-support tools could reduce clinician burden and enable replicable clinician decisions and actions that personalize patient care. Most current clinical decision-support tools or aids lack detail and neither reduce burden nor enable replicable actions. Clinicians must provide subjective interpretation and missing logic, thus introducing personal biases and mindless, unwarranted, variation from evidence-based practice. Replicability occurs when different clinicians, with the same patient information and context, come to the same decision and action. We propose a feasible subset of therapeutic decision-support tools based on credible clinical outcome evidence: computer protocols leading to replicable clinician actions (eActions). eActions enable different clinicians to make consistent decisions and actions when faced with the same patient input data. eActions embrace good everyday decision-making informed by evidence, experience, EHR data, and individual patient status. eActions can reduce unwarranted variation, increase quality of clinical care and research, reduce EHR noise, and could enable a learning healthcare system.

Systemic Disease and Ocular Comorbidity Analysis of Geographically Isolated Federally Recognized American Indian Tribes of the Intermountain West.

BACKGROUND: The American Indian Navajo and Goshute peoples are underserved patient populations residing in the Four Corners area of the United States and Ibupah, Utah, respectively. METHODS: We conducted a cross-sectional study of epidemiological factors and lipid biomarkers that may be associated with type II diabetes, hypertension and retinal manifestations in tribal and non-tribal members in the study areas (n = 146 participants). We performed multivariate analyses to determine which, if any, risk factors were unique at the tribal level. Fundus photos and epidemiological data through standardized questionnaires were collected. Blood samples were collected to analyze lipid biomarkers. Univariate analyses were conducted and statistically significant factors at p < 0.10 were entered into a multivariate regression. RESULTS: Of 51 participants for whom phenotyping was available, from the Four Corners region, 31 had type II diabetes (DM), 26 had hypertension and 6 had diabetic retinopathy (DR). Of the 64 participants from Ibupah with phenotyping available, 20 had diabetes, 19 had hypertension and 6 had DR. Navajo participants were less likely to have any type of retinopathy as compared to Goshute participants (odds ratio (OR) = 0.059; 95% confidence interval (CI) = 0.016-0.223; p < 0.001). Associations were found between diabetes and hypertension in both populations. Older age was associated with hypertension in the Four Corners, and the Navajo that reside there on the reservation, but not within the Goshute and Ibupah populations. Combining both the Ibupah, Utah and Four Corners study populations, being American Indian (p = 0.022), residing in the Four Corners (p = 0.027) and having hypertension (p < 0.001) increased the risk of DM. DM (p < 0.001) and age (p = 0.002) were significantly associated with hypertension in both populations examined. When retinopathy was evaluated for both populations combined, hypertension (p = 0.037) and living in Ibupah (p < 0.001) were associated with greater risk of retinopathy. When combining both American Indian populations from the Four Corners and Ibupah, those with hypertension were more likely to have DM (p < 0.001). No lipid biomarkers were found to be significantly associated with any disease state. CONCLUSIONS: We found different comorbid factors with retinal disease outcome between the two tribes that reside within the Intermountain West. This is indicated by the association of tribe and with the type of retinopathy outcome when we combined the populations of American Indians. Overall, the Navajo peoples and the Four Corners had a higher prevalence of chronic disease that included diabetes and hypertension than the Goshutes and Ibupah. To the best of our knowledge, this is the first study to conduct an analysis for disease outcomes exclusively including the Navajo and Goshute tribe of the Intermountain West.

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.

Laser in situ keratomileusis versus lens-based surgery for correcting residual refractive error after cataract surgery.

PURPOSE: To evaluate and compare the efficacy and safety of laser in situ keratomileusis (LASIK) versus lens-based surgery (intraocular lens [IOL] exchange or piggyback IOL) for correcting residual refractive error after cataract surgery. SETTING: Private eye center, Salt Lake City, Utah, USA. METHODS: This retrospective study included 57 eyes of 48 patients who had LASIK (28 eyes) or lens-based correction (29 eyes) for residual refractive error after cataract surgery. The visual and refractive outcomes were evaluated at a mean follow-up of 20 to 24 months. RESULTS: In the LASIK group, the mean spherical equivalent (SE) was reduced from -1.62 +/- 0.80 diopters (D) preoperatively to +0.05 +/- 0.38 D postoperatively in myopic eyes and from +0.51 +/- 1.25 D to +0.19 +/- 0.35 D in hyperopic eyes. Ninety-two percent of eyes were within +/-0.50 D of intended correction. In the lens group, the mean SE was reduced from -3.55 +/- 2.69 D preoperatively to -0.20 +/- 0.50 D postoperatively in myopic eyes and from +2.07 +/- 2.38 D to +0.07 +/- 0.85 D in hyperopic eyes. Eighty-one percent of eyes had postoperative SE within +/-0.50 D of the intended correction. The UCVA improved significantly in both groups. No eye lost more than 1 line of BSCVA. With a similar length of follow-up, no significant difference in postoperative SE was found between the 2 groups (P = .453). CONCLUSIONS: The results showed efficacy, safety, predictability, and merits of LASIK and lens-based approaches for correcting different types of residual refractive error after cataract surgery.

Corticocapsular cleavage during phacoemulsification: Viscodissection versus hydrodissection. Miyake-Apple view analysis.

PURPOSE: To compare the corticocapsular separation created by viscodissection and by hydrodissection using Miyake-Apple video-photographic analysis. SETTING: University-based center. METHODS: Fourteen cadaver eyes were randomized to hydrodissection (Group 1, n=7) or viscodissection (Group 2, n=7). Twelve eyes were prepared for Miyake-Apple viewing. One eye in each group was prepared to simulate a closed chamber. On Miyake-Apple viewing, corticocapsular separation was graded from 0 to 3 after hydrodissection/viscodissection and at the sculpting, nuclear division, and early and late fragment removal stages. The surgeon's subjective impression of the mechanical cushion effect was noted. Histopathology of the capsular bag was performed in 4 eyes in each group to determine the amount of residual lens epithelial cells (LECs). RESULTS: More space was created and maintained between the capsule and cortex in Group 2 than in Group 1. The mean scores in Groups 1 and 2 were endpoint of hydrodissection/viscodissection 1.92+/-0.38 and 2.58+/-0.38, respectively (P=.05); sculpting, 1.6+/-0.42 and 2.3+/-0.45, respectively (P=.05); nuclear division, 0.9+/-0.42 and 1.5+/-0.35, respectively (P=.13); early fragment removal, 0.6+/-0.22 and 1.0+/-0, respectively (P=.04); and late fragment removal, 0.1+/-0.22 and 0.4+/-0.22, respectively (P=.17). Although only early fragment removal achieved statistical significance, the surgeon's impression confirmed greater cushion effect with viscodissection. Residual LECs in the 2 groups were comparable. CONCLUSION: Viscodissection as an adjunct to hydrodissection created and maintained greater corticocapsular separation than hydrodissection alone during phacoemulsification.

Intraoperative performance and postoperative outcomes of endocapsular ring implantation in pediatric eyes.

PURPOSE: To study the intraoperative performance and postoperative outcomes of Cionni modified capsule tension ring (CTR) and intraocular lens (IOL) implantation in the capsular bag in pediatric eyes with ectopia lentis. SETTING: John A. Moran Eye Center, Salt Lake City, Utah, USA. METHODS: Thirty-five eyes (22 children) with ectopia lentis and visually significant cataract that had lens aspiration and in-the-bag implantation of single-piece AcrySof IOL and Cionni CTR were included. Single- and double-eyelet CTRs were used. The rings were sutured to the sclera using 9-0 or 10-0 polypropylene (Prolene) sutures. Preoperative and postoperative best corrected visual acuity (BCVA), intraoperative performance, IOL centration, and complications were studied. RESULTS: The mean patient age was 8.2 years +/- 5.1 (SD) and the median follow-up, 28 months. A double-eyelet CTR was implanted in 12 eyes and a single-eyelet CTR, in 23 eyes. The mean BCVA at the final follow-up (0.37 +/- 0.25 logMAR, 33 eyes) was significantly better than preoperatively (0.78 +/- 0.42 logMAR, 28 eyes) (P = .003). At the last examination, the BCVA was 20/40 or better in 16 eyes (45.7%). Three eyes (8.5%) required resuturing for IOL decentration. Nineteen eyes (54.3%) had a secondary procedure for posterior capsule opacification. Other complications included anterior capsule opacification (2.85%), cystoid macular edema (5.71%), chronic uveitis (5.71%), and vitreous prolapse (2.85%). CONCLUSION: Implantation of the Cionni CTR and single-piece AcrySof IOL in the capsular bag in pediatric eyes with subluxated lenses was safe and effective and led to a stable IOL with few significant complications.

Exfoliation Syndrome and Cataract Surgery.

Cataract extraction in exfoliation syndrome requires careful preoperative assessment and planning. Knowledge of the degree of pupil dilation and zonular integrity are essential for safely perform cataract surgery in these eyes. Capsule rhexis should be 5.5 mm and all intraoperative maneuvers should be designed to minimize zonular stress. The surgeon should be versatile in various nuclear disassembly techniques and consider use of capsular support devices when warranted. Cortical cleanup should proceed via a tangential approach and attempts should be made to removal residual lens epithelial cells so as to minimize postoperative capsular contraction syndrome.

Long-term outcomes for pediatric patients having transscleral fixation of the capsular bag with intraocular lens for ectopia lentis.

PURPOSE: To report the long-term outcomes of transscleral fixation of capsular tension rings (CTR) with intraocular lens (IOL) placement in pediatric patients with ectopia lentis. SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. DESIGN: Retrospective case series. METHODS: Pediatric patients requiring lens extraction with transscleral capsular bag fixation with a CTR and IOL for ectopia lentis between January 2006 and January 2016 were analyzed. RESULTS: Thirty-seven patients (67 eyes) who had transscleral fixation of the capsular bag using a CTR fixated with 9-0 or 10-0 polypropylene (Prolene), 8-0 polytetrafluoroethylene (Gore-Tex), or 9-0 nylon were identified. The mean age at time of surgery was 7.25 years (2 to 18 years) and the mean follow-up was 35.3 months (0.25 to 120 months). The proportion of eyes showing improvement in corrected distance visual acuity (CDVA) postoperatively was 78.5%, which demonstrated significance with a 95% confidence interval. In the immediate postoperative period, 1 eye developed a hyphema and 1 eye required IOL repositioning. Long-term complications included posterior capsule opacification in 35 eyes (52%) and uveitis-glaucoma-hyphema syndrome in 1 eye (1.5%). Three eyes (4.4 %) required IOL repositioning for spontaneous delayed IOL dislocation, 2 sutured with 8-0 polytetrafluoroethylene at postoperative month 8 and postoperative year 3 and 1 sutured with 9-0 polypropylene at postoperative year 7. CONCLUSION: Transscleral fixation of the capsular bag using a CTR improved CDVA and provided IOL stability in pediatric patients with ectopia lentis.

Visual function, digital behavior and the vision performance index.

Historically, visual acuity has been the benchmark for visual function. It is used to measure therapeutic outcomes for vision-related services, products and interventions. Quantitative measurement of suboptimal visual acuity can potentially be corrected optically with proper refraction in some cases, but in many cases of reduced vision there is something else more serious that can potentially impact other aspects of visual function such as contrast sensitivity, color discrimination, peripheral field of view and higher-order visual processing. The measurement of visual acuity typically requires stimuli subject to some degree of standardization or calibration and has thus often been limited to clinical settings. However, we are spending increasing amounts of time interacting with devices that present high-resolution, full color images and video (hereafter, digital media) and can record our responses. Most of these devices can be used to measure visual acuity and other aspects of visual function, not just with targeted testing experiences but from typical device interactions. There is growing evidence that prolonged exposure to digital media can lead to various vision-related issues (eg, computer vision syndrome, dry eye, etc.). Our regular, daily interactions (digital behavior) can also be used to assess our visual function, passively and continuously. This allows us to expand vision health assessment beyond the clinic, to collect vision-related data in the whole range of settings for typical digital behavior from practically any population(s) of interest and to further explore just how our increasingly virtual interactions are affecting our vision. We present a tool that can be easily integrated into digital media to provide insights into our digital behavior.

TREK-1 channels regulate pressure sensitivity and calcium signaling in trabecular meshwork cells.

Mechanotransduction by the trabecular meshwork (TM) is an essential component of intraocular pressure regulation in the vertebrate eye. This process is compromised in glaucoma but is poorly understood. In this study, we identify transient receptor potential vanilloid isoform 4 (TRPV4) and TWIK-related potassium channel-1 (TREK-1) as key molecular determinants of TM membrane potential, pressure sensitivity, calcium homeostasis, and transcellular permeability. We show that resting membrane potential in human TM cells is unaffected by "classical" inhibitors of voltage-activated, calcium-activated, and inwardly rectifying potassium channels but is depolarized by blockers of tandem-pore K+ channels. Using gene profiling, we reveal the presence of TREK-1, TASK-1, TWIK-2, and THIK transcripts in TM cells. Pressure stimuli, arachidonic acid, and TREK-1 activators hyperpolarize these cells, effects that are antagonized by quinine, amlodipine, spadin, and short-hairpin RNA-mediated knockdown of TREK-1 but not TASK-1. Activation and inhibition of TREK-1 modulates [Ca2+]TM and lowers the impedance of cell monolayers. Together, these results suggest that tensile homeostasis in the TM may be regulated by balanced, pressure-dependent activation of TRPV4 and TREK-1 mechanotransducers.

Intraocular lens exchange due to incorrect lens power.

PURPOSE: To evaluate patients who had intraocular lens (IOL) exchange for unexpected postoperative refractive errors, determine the sources associated with the errors, and derive an empiric approach to estimating the power for IOL exchange. DESIGN: Retrospective review of interventional case series. PARTICIPANTS: Twenty-two eyes that underwent IOL exchange for correcting unexpected refractive errors after cataract surgery with IOL implantation were reviewed. INTERVENTION: All the IOLs for IOL exchange were placed in-the-bag. The same type of IOLs was used for original IOL implantation and IOL exchange in 91% (20/22) of eyes. MAIN OUTCOME MEASURES: Uncorrected visual acuity, best spectacle-corrected visual acuity (BSCVA), refraction, and reasons for IOL exchange. The equation derived from refractive change and change in IOL power was developed to calculate IOL power for exchange. RESULTS: Of the 22 cases, the identified reasons were keratometry errors in 5 (23%) and incorrect axial length (AL) determination in 3 (14%). In 3 other cases, a wrong IOL was implanted. After IOL exchange, 82% (18/22) of eyes were within +/-0.50 diopters (D) and 86% (19/22) within +/-1.00 D of emmetropia. Uncorrected visual acuity was 20/40 or better in 82% of eyes, and BSCVA was 20/40 or better in 95% (21/22) of eyes. The correlation between change of refraction and IOL power was significant (P<0.002). CONCLUSIONS: Among the identified causes, incorrect corneal power determination was the most frequent reason for incorrect IOL power implantation, followed by error in AL measurement and inserting a wrong IOL. The pre-exchange refraction can be used theoretically to calculate the IOL power for exchange.

Small-incision iris fixation of foldable intraocular lenses in the absence of capsule support.

PURPOSE: To report visual outcomes and complications of modified McCannel iris suture fixation of small-incision foldable acrylic intraocular lenses (IOLs) for aphakia in the absence of capsule support. DESIGN: Retrospective interventional case series. PARTICIPANTS: Forty-six patients who underwent foldable acrylic IOL implantation using peripheral iris suture fixation for aphakia in the absence of capsule support. METHODS: Data from 46 patients who underwent iris fixation of a foldable acrylic IOL were retrospectively evaluated for underlying diagnoses, surgical history, clinical results, and complications. MAIN OUTCOME MEASURES: Postoperative best-corrected visual acuity (BCVA), spherical equivalent, and surgical complications. RESULTS: Best-corrected visual acuity improved from 20/100 to 20/50 (P = 0.01), with 97% of eyes maintaining or improving BCVA after a mean (+/- standard deviation) follow-up of 24.1+/-12.4 months. Complications included transient low-grade uveitis (3 [6.5%]), transient pigment dispersion (3 [6.5%]), IOL dislocation (2 [4.3%]), elevated intraocular pressure (1 [2.2%]), and retinal detachment (1 [2.2%]). No new cases of cystoid macular edema or worsening of glaucoma occurred. CONCLUSION: Small-incision peripheral iris fixation of 3-piece acrylic foldable IOLs in the absence of capsule support appears to be an effective technique with few severe adverse events.

Phacotrabeculectomy: assessment of outcomes and surgical improvements.

PURPOSE: To evaluate the outcomes and progress after phacotrabeculectomy at the same clinical setting and/or performed by the same surgeon over the past decade. SETTING: Eye Institute of Utah, Salt Lake City, Utah, USA. METHODS: This retrospective study included 60 eyes of 43 patients who had phacotrabeculectomy at a single institute between 1999 and 2005. A modified phacotrabeculectomy surgical technique was used that included a 2-site incision approach, fornix-based flap, use of mitomycin-C, acrylic intraocular lens implantation, sutured scleral and conjunctival flaps, and sutured temporal clear corneal incision. RESULTS: Over a mean 30-month follow-up, 57 of the 60 eyes (95%) achieved intraocular pressure (IOP) control (

New capsular tension segment with 2-point fixation for zonular weakness.

We describe clinical applications and surgical techniques for a new type of capsular tension segment (CTS) for use during cataract surgery. The Ambati CTS is distinguished from other CTS devices by having 2 eyelets close to each other, which allows it to distribute tension to 2 points, avoiding too much stress at a single point on the anterior capsulotomy, which prevents peaking of the capsulorhexis, and potentially reducing the risk for anterior capsule tear. Two of these CTS devices could possibly be used to provide 4-point fixation of a capsular bag in eyes with near-complete zonular instability. We describe 4 cases and 2 surgical techniques for implanting the new CTS, 1 technique in an adult patient with zonular weakness secondary to trauma and the other in 3 children with subluxated lenses due to Marfan syndrome.

Analysis of intraocular lens power calculation for eyes with previous myopic LASIK.

PURPOSE: To evaluate the effectiveness of a manual keratometry (K) adjusted value for intraocular lens (IOL) power calculation in patients who underwent cataract surgery following previous myopic LASIK. METHODS: Sixteen eyes of 14 consecutive patients who underwent cataract surgery after previous LASIK were evaluated retrospectively. All IOL powers were calculated using an adjusted K value (K minus 1.0 diopter [D]) with the Binkhorst II formula aiming for -0.75 to -1.00 D final refraction. Additionally, the IOL power for each eye was retrospectively calculated using K, refractive-derived K, and adjusted K with the Binkhorst II, Holladay I, and SRK/T formulas. The final refraction was used as a criterion of accuracy of each approach. RESULTS: Uncorrected visual acuity > or = 20/40 was achieved in 14 (87.5%) of 16 eyes. The mean postoperative spherical equivalent refraction was -0.41 +/- 0.57 D (range: +0.50 to -2.00 D). Twelve (75%) of 16 eyes were within +/- 0.50 D of emmetropia and 15 (94%) of 16 eyes were within +/- 1.00 D. No eye was > +1.00 D. CONCLUSIONS: Using an adjusted K with the Binkhorst II formula, aiming for -0.75 to -1.00 D, and with the Holladay I formula, aiming for -0.50 to -1.00 D, measuring K with a regular manual keratometer permits determination of an IOL power after myopic LASIK without the need of preoperative LASIK refractive data.