Polypseudophakia: from "Piggyback" to supplementary sulcus-fixated IOLs.

Polypseudophakia, the concept of using a second intraocular lens (IOL) to supplement an IOL that has already been placed in the capsular bag, was first used as a corrective measure where the power requirement was higher than that of available single IOLs. Subsequently, the technique was modified to compensate for post-operative residual refractive errors. In these early cases, an IOL designed for the capsular bag would be implanted in the sulcus.  Although these approaches were less than ideal, alternative means of correcting residual refractive errors were not without their limitations: IOL exchange can be traumatic to the eye and is not easily carried out once fibrosis has occurred, while corneal refractive surgical techniques are not suitable for all patients. Piggyback implantation was the term first coined to describe the use of two IOLs, placed together in the capsular bag. The term was later extended to include the procedure where an IOL designed for the capsular bag was placed in the sulcus. Unfortunately, the term piggyback has persisted even though these two approaches have been largely discredited. Intraocular lenses are now available which have been specifically designed for placement in the ciliary sulcus. As these newer IOLs avoid the many unacceptable complications brought about by both types of earlier piggyback implantation, it is time to employ a new terminology, such as supplementary IOL or secondary enhancement to distinguish between the placement of an unsuitable capsular bag IOL in the sulcus and the implantation of an IOL specifically designed for ciliary sulcus implantation. In addition to minimising possible complications, supplementary IOLs designed for the sulcus have expanded the options available to the ophthalmic surgeon. With these new IOLs it is possible to correct presbyopia and residual astigmatism, and to provide temporary correction of refractive errors in growing, or unstable, eyes. This article aims to review the literature available on supplementary IOL implantation in the ciliary sulcus and to summarise the evidence for the efficacy and safety of this intervention. KEY MESSAGES: What is known Polypseudophakia has been used for over 30 years to correct hyperopia or residual refractive error, but early techniques were associated with significant complications. What is new The development of specially designed sulcus-fixated supplementary IOLs significantly reduces the risks associated with these procedures, and has also opened up new opportunities in patient care. The reversibility of the procedure allows patients to experience multifocality, and to provide temporary and adjustable correction in unstable or growing eyes. The terms "secondary enhancement" or "DUET" to describe supplementary IOL implantation are preferential to "piggyback".

Potential environmental effect of reducing the variation of disposable materials used for cataract surgery.

PURPOSE: To analyze the cataract package variability in 1 country, Austria. SETTING: Austrian Departments of Ophthalmology. DESIGN: Cross-sectional study. METHODS: The cataract package components of 3 different Austrian hospitals were weighed and life cycle assessment on each product performed. This data was then extrapolated to the sales figures of the main Austrian cataract package suppliers to estimate the carbon footprint of all cataract packages used in Austria in 2021. RESULTS: There were 55 different cataract package compositions in use with an average weight of 0.7 kg. These compositions differ significantly in weight and composition considering that the smallest package was 57% lighter than the largest package. The size of the surgical drapes also showed considerable variation, with a difference of up to 71%. This is substantial, considering that drapes and covers account for about 53% of the package weight. CONCLUSIONS: There was a considerable variation in package composition and product size, which could provide opportunities to save carbon dioxide emissions in cataract surgery. If all Austrian eye departments were to reduce the material quantities and drape sizes to the lower third of the cataract packages used in the Austria in 2021, cataract package associated CO 2 emissions could be reduced by 34%.

Visual Outcomes and Patient Satisfaction After Bilateral Sequential Implantation of a Capsular Bag IOL and a Supplementary Sulcus-Fixated Trifocal IOL.

PURPOSE: To assess visual and refractive outcomes and patient satisfaction after bilateral sequential implantation of a primary capsular bag intraocular lens (IOL) and a supplementary sulcus-fixated trifocal IOL. METHODS: All patients had bilateral implantation of a mono-focal IOL in the capsular bag followed by a supplementary trifocal IOL (Sulcoflex 703F, Rayner Intraocular Lenses Limited) in the sulcus. Patients were evaluated for monocular uncorrected and corrected distance visual acuity, binocular uncorrected and corrected distance, intermediate and near visual acuity, photopic and mesopic contrast sensitivity, defocus curves, visual symptoms, spectacle independence, and patient satisfaction at 1 and 6 months postoperatively. RESULTS: Forty eyes of 20 patients were evaluated. Six months after surgery, mean binocular uncorrected visual acuity was -0.07 ± 0.06 logMAR for distance vision (range: -0.2 to 0.0 logMAR), -0.03 ± 0.17 logMAR for intermediate vision (range: -0.1 to 0.6 logMAR), and 0.09 ± 0.08 logMAR for near vision (range: -0.1 to 0.2 logMAR). All patients reported full spectacle independence after 6 months and no adverse events were reported for any of the patients. CONCLUSIONS: Sequential implantation of a monofocal IOL in the capsular bag and a supplementary trifocal IOL in the sulcus provides a safe and effective choice for patients who desire spectacle independence after cataract surgery. [J Refract Surg. 2021;37(2):105-111.].

The forceps-needle: Combining needle and grasping functions in a single instrument.

A new forceps-needle to facilitate intrascleral haptic fixation surgery is described. In an initial series of 10 cases, the forceps-needle was used to grasp and externalize the haptic of a 3-piece intraocular lens (IOL) for transscleral fixation. The site of perforation was marked at 180 degrees 2.0 mm away from the limbus. Then, the IOL with polypropylene haptics was folded and implanted partially into the anterior chamber. A transconjunctival, scleral tunnel of about 2.0 mm length parallel to the limbus was prepared with the forceps-needle on 1 side, with the second hand holding the leading haptic through a side-port incision. The end of the first haptic was grasped and externalized after which the end of the haptic was flanged. Subsequently, a second scleral tunnel was prepared with the forceps-needle, and the second haptic was externalized and flanged. All procedures could be performed without any intraoperative complication.

LIPEMIA RETINALIS DURING CHEMOTHERAPY WITH ADJUNCTIVE GLUCOCORTICOID TREATMENT IN A PATIENT WITH COLON CARCINOMA.

PURPOSE: The purpose of this report is to describe a case of lipemia retinalis due to decompensating hyperlipidemia that occurred during chemotherapy in a patient with metastatic colon carcinoma. METHODS: Retrospective case report. RESULTS: A 55-year-old non-insulin-dependent diabetic man with well-controlled hyperlipidemia presented himself with temporarily blurred vision in both eyes occurring during chemotherapy. He was found to have lipemia retinalis in his both eyes. Blood tests revealed elevated cholesterol and triglyceride levels exceeding 8,200 mg/dL. He received six cycles of FOLFIRI/bevacizumab and accompanying dexamethasone because of colon cancer with pulmonary metastases. Lipemia retinalis had resolved after a 6-week follow-up when chemotherapy was finished, and the patients' triglyceride and glucose levels decreased to normal values. CONCLUSION: Lipemia retinalis associated with visual impairment may occur during chemotherapy under accompanying treatment with dexamethasone. Even if patients with hyperlipidemia are metabolically well-controlled with oral medication, treatment with dexamethasone can potentially lead to decompensation of hyperlipidemia causing secondary lipemia retinalis.

Randomized controlled European multicenter trial on the prevention of cystoid macular edema after cataract surgery in diabetics: ESCRS PREMED Study Report 2.

PURPOSE: To compare the efficacy of perioperative treatment strategies, in addition to topical bromfenac 0.09% and dexamethasone 0.1%, to reduce the risk for developing cystoid macular edema (CME) after uneventful cataract surgery in diabetic patients. SETTING: Twelve European study centers. DESIGN: Randomized clinical trial. METHODS: Diabetic patients having phacoemulsification cataract surgery were randomly allocated to receive no additional treatment, a subconjunctival injection with 40 mg triamcinolone acetonide, an intravitreal injection with 1.25 mg bevacizumab, or a combination of both. The main outcomes were the difference in central subfield mean macular thickness, corrected distance visual acuity, and the incidence of CME and clinically significant macular edema within 6 and 12 weeks postoperatively. RESULTS: The study comprised 213 patients. At 6 and 12 weeks postoperatively, the central subfield mean macular thickness was 12.3 µm and 9.7 µm lower, respectively, in patients who received subconjunctival triamcinolone acetonide than patients who did not (P = .007 and P = .014, respectively). No patient who received subconjunctival triamcinolone acetonide developed CME. Intravitreal bevacizumab had no significant effect on macular thickness. CONCLUSIONS: Diabetic patients who received a subconjunctival injection with triamcinolone acetonide at the end of cataract surgery had a lower macular thickness and macular volume at 6 and 12 weeks postoperatively than patients who did not. Intravitreal bevacizumab had no significant effect.

European multicenter trial of the prevention of cystoid macular edema after cataract surgery in nondiabetics: ESCRS PREMED study report 1.

PURPOSE: To compare the efficacy of a topical nonsteroidal antiinflammatory drug, topical corticosteroid, and a combination of both drugs to prevent the occurrence of cystoid macular edema (CME) after cataract surgery in nondiabetic patients. SETTING: Twelve European study centers. DESIGN: Randomized clinical trial. METHODS: Nondiabetic patients having uneventful cataract surgery were included in this study. Patients were randomized to receive topical bromfenac 0.09% twice daily for 2 weeks or dexamethasone 0.1% 4 times daily with 1 drop less per day every following week, or a combination of both. The primary outcome was the difference in central subfield mean macular thickness 6 weeks postoperatively. Secondary outcome measures included corrected distance visual acuity as well as the incidence of CME and clinically significant macular edema (CSME) within 6 weeks and 12 weeks postoperatively. RESULTS: This study comprised 914 patients. Six weeks postoperatively, the central subfield mean macular thickness was 288.3 µm, 296.0 µm, and 284.5 µm in the bromfenac group, dexamethasone group, and combination treatment group, respectively (overall P = .006). The incidence of clinically significant macular edema within 12 weeks postoperatively was 3.6%, 5.1%, and 1.5%, respectively (overall P = .043). CONCLUSION: Patients treated with a combination of topical bromfenac 0.09% and dexamethasone 0.1% had a lower risk for developing CSME after cataract surgery than patients treated with a single drug.

Anti-vascular endothelial growth factor for unilateral acute idiopathic maculopathy.

PURPOSE: To describe a case of unilateral acute idiopathic maculopathy (UAIM) response to intravitreal therapy with aflibercept (Eylea). METHODS: Retrospective case report. RESULTS: A 36-year-old woman with sudden visual impairment and central scotoma was found to have a UAIM in her left eye. Three weeks after continuous worsening of her visual acuity and central scotoma, the patient was treated with intravitreal injections of aflibercept. The visual acuity increased and the macula lesion regressed, causing macula scarring after 2 injections. CONCLUSIONS: Intravitreal injections of aflibercept could be a therapy option in patients with UAIM without signs of spontaneous resolution of the clinical manifestations and visual improvement.

Capsular bag-fixated and ciliary sulcus-fixated intraocular lens centration after supplementary intraocular lens implantation in the same eye.

PURPOSE: To assess capsular bag and sulcus intraocular lens (IOL) centration in eyes that had implantation of a sulcus-fixated supplementary IOL anterior to a preexisting capsular bag IOL. SETTING: Academic Teaching Hospital of St. John, Vienna, Austria. DESIGN: Retrospective case series. METHODS: A sulcus-fixated supplementary IOL (Sulcoflex) was implanted anterior to a preexisting capsular bag IOL. The geometric center of preexisting capsular bag IOLs and newly implanted sulcus-fixated IOLs was evaluated at least 12 months postoperatively and in relation to the geometric center of the pupil and limbus. RESULTS: The study comprised 48 eyes of 43 patients with a mean follow-up of 25 months (range 12 to 84 months). The mean decentration of the capsular bag-fixated IOL was 0.29 mm ± 0.02 (SEM) when compared with the limbus and 0.29 ± 0.03 mm when compared with the dilated pupil. The mean decentration of the sulcus-fixated IOL was 0.23 ± 0.02 mm in relation to the limbus and 0.22 ± 0.02 mm when in relation to the dilated pupil. Sulcus-fixated supplementary IOLs showed significantly better centration than bag-fixated IOLs when compared with the limbus and with the pupil (both P = .03, paired t test). CONCLUSIONS: Implantation of a sulcus-fixated supplementary IOL resulted in good centration of capsular bag-fixated IOLs and ciliary sulcus-fixated IOLs. However, ciliary sulcus-fixated IOLs achieved significantly better centration.

Intraindividual comparison of capsule behavior of 2 hydrophobic acrylic intraocular lenses during a 5-year follow-up.

PURPOSE: To evaluate and compare the 5-year postoperative anterior (ACO) and posterior capsule opacification (PCO), the occurrence of glistenings, and the level of anterior capsule retraction after implantation of 2 designs of 1-piece hydrophobic acrylic IOLs. SETTING: Hospital St. John, Vienna, Austria. DESIGN: Randomized controlled prospective case series. METHODS: Patients had an Acrysof SA60AT IOL (Group A) implanted in 1 eye and a Tecnis ZCB00 IOL (Group B) implanted in the fellow eye. At 1, 3, and 5 years, the PCO level was evaluated with the Evaluation of Posterior Capsule Opacification software. The level of ACO and capsule retraction was graded subjectively. Glistenings were scored as present or not present. RESULTS: Fifty eyes of 25 patients were evaluated after 5 years. No significant differences in PCO scores were found between the 2 groups at all follow-up visits (1 year: 0.06 ± 0.12 [SD] versus 0.07 ± 0.13, P = .35; 3 years: 0.23 ± 0.36 versus 0.22 ± 0.32, P = .66; 5 years: 0.36 ± 0.41 versus 0.36 ± 0.54, P = .98). A significant increase in PCO score was found between 3 and 5 years (P < .01). Anterior capsule opacification was present in Group A and Group B in 18.0% and 2.7% of eyes (P = .03), in 92.0% and 24.0% of eyes, and in 100% and 52% of eyes (P < .01) at 1, 3, and 5 years, respectively. Glistenings (5 years 100%) were observed in Group A. CONCLUSION: Both IOLs had a comparable PCO rate 5 years after surgery, although more ACO and retraction as well as glistenings were observed in Group A.

Intraindividual comparative analysis of capsule opacification after implantation of 2 single-piece hydrophobic acrylic intraocular lenses models: Three-year follow-up.

PURPOSE: To compare the 3-year postoperative anterior (ACO) and posterior (PCO) capsule opacification and the level of anterior capsule retraction after implantation of 2 single-piece hydrophobic acrylic intraocular lens (IOL) models. SETTING: Hospital of St. John of God, Vienna, Austria. DESIGN: Comparative randomized controlled double-blind clinical trial. METHODS: Eyes with bilateral cataract were evaluated. Each patient had an Acrysof SA60AT (interrupted optic edge) IOL implanted in 1 eye (Group A) and a Tecnis ZCB00 (continuous optic edge) IOL implanted in the fellow eye (Group B). One and 3 years postoperatively, PCO was evaluated using Evaluation of Posterior Capsule Opacification software and the ACO level and capsule-retraction level were evaluated and graded subjectively. RESULTS: The study evaluated 100 eyes of 50 patients ranging from 61 to 80 years. Postoperatively, there were no statistically significant differences in PCO between Group A and Group B at 1 year (0.06 ± 0.12 [SD] and 0.07 ± 0.13, respectively; P = 4.35) or 3 years (0.23 ± 0.36 and 0.22 ± 0.32, respectively; P = .66). In Group A and Group B, ACO was present in 18.0% of eyes and 2.7% of eyes, respectively, at 1 year (P = .03) and in 92.0% and 24.0%, respectively, at 3 years (P < .01). Capsule phimosis (18.0% at 1 year; 30.0% at 3 years) and glistenings (66.0% at 1 year; 86.0% at 3 years) were observed in Group A only. CONCLUSION: Both IOLs had similarly low PCO rates 3 years postoperatively, although more ACO and capsule retraction were observed in eyes with the interrupted optic edge IOL.

Anterior and posterior capsular opacification with the Tecnis ZCB00 and AcrySof SA60AT IOLs: a randomised intraindividual comparison.

PURPOSE: To evaluate and compare the 1-year postoperative levels of posterior capsule opacification (PCO) as well as the level of anterior capsule retraction and opacification (ACO) after implantation of two single-piece hydrophobic acrylic intraocular lens (IOL) models. METHODS: Randomised, controlled, prospective and double-blind study including 148 eyes of 74 patients (age range, 61-80 years) with bilateral senile cataract. Each patient underwent surgery with implantation of an AcrySof SA60AT (Group A) in one eye and Tecnis ZCB00 (Group B) in the fellow eye by the same experienced surgeon. Lens allocation to the first or second operated eye followed a randomisation process. At 12 months postoperatively, the PCO level was evaluated with the Evaluation of Posterior Capsule Opacification software, whereas the level of ACO and capsule retraction was evaluated and graded subjectively. RESULTS: All surgeries were uneventful. The mean PCO scores were 0.10 ± 0.17 and 0.21 ± 0.89 in Groups A and B, respectively, with no statistically significant differences between the groups (p=0.47). No significant correlation was found between the PCO scores in Groups A and B (r=0.16, p=0.17). Regarding ACO, it was present in 15 eyes (20.3%) and two eyes (2.7%) in Groups A and B, respectively (p=0.37). Capsular phimosis (13 eyes, 17.6%) was only observed in Group A. CONCLUSIONS: Both IOLs had a similar low rate of PCO 1 year after surgery. However, there seems to be a difference in the anterior capsule behaviour between both IOL models.

Influence of scleral buckling surgery with encircling band on subfoveal choroidal thickness in long-term observations.

PURPOSE: The aim of this study is the presentation of subfoveal choroidal thickness with enhanced depth imaging spectral-domain optical coherence tomography (EDI-OCT) several months after scleral buckling with encircling band surgery. METHODS: 48 patients who underwent scleral buckling with encircling band surgery for unilateral rhegmatogenous retinal detachment were included in the retrospective observational study. The mean time from scleral buckling surgery to the final EDI-OCT examination was 22±6.7 months. We compare choroidal thickness between operated and fellow eyes. RESULTS: In all patients, the macula was detached before the surgery. The subfoveal choroidal thickness in 48 treated eyes was 260.9±45.8 µ m (range 155-383 µ m) and in the fellow eyes was 217.5±36.7 µ m (range 98-326 µ m). The subfoveal choroidal thickness of eyes after scleral buckling surgery in long-term EDI-OCT examination was significantly thicker (P<0.001) than in fellow eyes. CONCLUSIONS: The subfoveal choroid in eyes undergoing encircling band surgery was significantly thicker than in fellow eyes. We suspect that this may be the result of reduced choroidal blood flow. It also seems that the width and size of the material used in scleral buckling surgery may affect a change in the choroid circulation and increase subfoveal choroidal thickness.

Biocompatibility of hydrophilic acrylic, hydrophobic acrylic, and silicone intraocular lenses in eyes with uveitis having cataract surgery: Long-term follow-up.

PURPOSE: To evaluate the long-term uveal and capsular biocompatibility of 5 intraocular lenses (IOLs) in eyes with uveitic cataract. SETTING: Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. DESIGN: Comparative case series. METHODS: Patients with uveitis of various origin were consecutively recruited for cataract surgery (1998-2006) and received 1 of 3 hydrophilic acrylic IOLs (Hydroview, AcrySof MA60BM, or Injectacryl F3000), a silicone IOL (CeeOn 911), or a hydrophilic acrylic IOL with heparin surface modification (BioVue(3)). A 7-year follow-up was performed in the Hydroview, AcrySof, and CeeOn groups. Visual acuity, anterior chamber flare measurements, specular microscopy, biomicroscopy, and fundoscopy were performed postoperatively at 6 months and 1, 2, and 3 years. RESULTS: The study enrolled 136 eyes of 115 patients. There were no significant differences in anterior chamber flare results between the 5 groups. The Hydroview group had the highest grade and the CeeOn IOL and AcrySof groups had the lowest grade of posterior capsule opacification. The BioVue(3) and Injectacryl IOLs had good uveal biocompatibility. Patients in all groups had better visual acuity postoperatively. CONCLUSIONS: Overall, patients with uveitis benefited from cataract surgery. The long-term results indicate that all sharp-edged hydrophilic and hydrophobic IOLs performed well in eyes with uveitis. Higher uveal biocompatibility was achieved with the modern hydrophilic acrylic IOLs than with the hydrophobic acrylic IOL. Modern hydrophilic acrylic IOLs seem to be a good option in these cases. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Evaluation of anterior-segment inflammation and retinal thickness change following cataract surgery.

PURPOSE: To investigate the physiological retinal response to uneventful cataract surgery using conventional time-domain (TD-OCT) and current spectral-domain optical coherence tomography (SD-OCT) in combination with an assessment of the anterior chamber inflammatory reaction by laser flare/cell meter (LCFM). METHODS: Thirty-four patients scheduled for cataract surgery were included in this prospective pilot study. Retinal parameters were examined according to a standardized examination procedure using TD-OCT (Stratus; Carl Zeiss Meditec, Dublin, California, USA) and SD-OCT (Cirrus; Carl Zeiss Meditec) devices. The inflammatory reaction of the anterior chamber was measured by LFCM (Kowa FC-1000, Kowa Co. Ltd, Tokyo, Japan). Examinations were carried out preoperatively and at day 2, week 1 and week 4 postoperatively. RESULTS: A slight decrease of central retinal thickness values was identified at day 2 postoperatively followed by an increase of these parameters at week 4. LFCM showed peak values in all patients at day 2 postoperatively with a constant decrease at the following visits. No visible pathological retinal changes were seen after surgery. CONCLUSION: A biphasic retinal response after surgery could be shown with SD-OCT and TD-OCT technology. By using the advantages of rasterscanning mode, SD-OCT technology is superior to TD-OCT imaging in the investigation of the physiological retinal response to cataract surgery.

New supplementary intraocular lens for refractive enhancement in pseudophakic patients.

PURPOSE: To assess the efficacy and safety of implanting a secondary intraocular lens (IOL) in the ciliary sulcus to correct pseudophakic ametropia. SETTING: Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. METHODS: This prospective nonrandomized study included patients who had implantation of a secondary IOL (Sulcoflex 653L) to correct residual refractive error after phacoemulsification with IOL implantation in the capsular bag. After implantation of the secondary IOL in the ciliary sulcus, visual and refractive outcomes were evaluated. Inflammation was measured with a laser flare-cell meter. The position and rotation of the IOLs were documented at all control visits, and Scheimpflug images were taken. Postoperative follow-up was at 1 week and 1, 6, 12, and 17 months. RESULTS: Twelve eyes of 10 patients were evaluated. The mean spherical equivalent decreased from -1.25 diopters (D) +/- 0.25 (SD) (range -2.00 to +4.00 D) preoperatively to -0.25 +/- 0.40 D (range -0.50 to +0.25 D) postoperatively. Uncorrected distance visual acuity improved in all cases. There were no significant intraoperative or postoperative complications. CONCLUSIONS: Sulcus implantation of the secondary IOL to correct pseudophakic refractive error was safe and predictable. The IOL was well tolerated in all eyes. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Efficacy and tolerability of preservative-free and preserved diclofenac and preserved ketorolac eyedrops after cataract surgery.

PURPOSE: To compare the anti-inflammatory efficacy and subjective tolerability of preservative-free and preserved diclofenac 0.1% and preserved ketorolac 0.5% eye drops for prophylaxis and management of inflammation after cataract surgery. DESIGN: Prospective, randomized, investigator-masked, parallel-group, comparative clinical trial. METHODS: One hundred two patients who underwent small-incision phacoemulsification cataract surgery in an institutional setting were assigned randomly to receive preservative-free diclofenac sodium 0.1% (Voltaren ophtha SDU; Novartis Pharma), preserved diclofenac sodium 0.1% (Voltaren ophtha; Novartis Pharma), or preserved ketorolac tromethamine 0.5% (Acular; Pharm Allergan) eyedrops 4 times daily for 4 weeks after surgery. During the 1-month follow-up, anterior chamber flare and mean foveal thickness were evaluated for objective comparison of the anti-inflammatory effect. Ocular tolerability was assessed by observer-based grading of conjunctival hyperemia and ocular discomfort, as well as obtaining subjective ratings of ocular tolerability on a visual analog scale. Distance and near visual acuity and intraocular pressure served as safety measures. RESULTS: All 3 formulations demonstrated equal anti-inflammatory efficacy as measured by reduction of anterior chamber flare after surgery and prevention of postoperative macular edema. Patients treated with preservative-free diclofenac eyedrops reported significantly better subjective tolerability values (P = .001), were classified as having less ocular discomfort (P < .001), and experienced earlier reduction of postoperative conjunctival hyperemia (P = .029). CONCLUSIONS: Anti-inflammatory efficacy was comparable for all 3 agents. However, preservative-free diclofenac 0.1% eyedrops exhibited a significantly better postoperative subjective and objective tolerability when compared with preserved eyedrops containing ketorolac or diclofenac.