Leftover Astigmatism: The Missing Link Between Measured and Calculated Posterior Corneal Astigmatism.

PURPOSE: To quantify the total eye astigmatism that is not accounted for by measurement of anterior corneal astigmatism and posterior corneal astigmatism and knowledge of intraocular lens (IOL) astigmatism and assess whether it is correlated with candidate sources of or correlates with leftover astigmatism. METHODS: Vector subtraction of anterior corneal, posterior corneal, and IOL astigmatism from total eye astigmatism as represented by spectacle astigmatism to yield a value of "leftover" astigmatism that is neither corneal nor lenticular. This value was derived in a series of eyes following cataract surgery. This novel entity was examined for correlation with candidate sources of or correlates with leftover astigmatism. RESULTS: In 103 pseudophakic eyes with known IOL toricity, mean leftover astigmatism was 0.71 ± 0.43 diopters. This was significantly correlated with against-the-rule anterior corneal astigmatism (P < .001). CONCLUSIONS: Leftover astigmatism is clinically substantial. Because it is included in IOL cylinder power calculations based on refractive outcome, it may explain why methods of IOL cylinder power calculation using refractive outcome-based adjustments to anterior corneal astigmatism (previously described as adjustments for "posterior corneal astigmatism") are more successful than adjustment on the basis of measured posterior corneal astigmatism. [J Refract Surg. 2022;38(9):559-564.].

Accuracy of the Goggin Nomogram for 0.50 D Steps in Toric IOL Cylinder Power Calculation.

PURPOSE: To examine the accuracy of the cylinder power choice for toric intraocular lenses (IOLs) using the Goggin Nomogram, which adjusts anterior keratometric astigmatic power values for the likely effect of posterior corneal and non-corneal, non-lenticular astigmatism. METHODS: A consecutive, retrospective case series was based at the Queen Elizabeth Hospital and Ashford Advanced Eye Care in Adelaide, Australia. A total of 586 consecutive eyes of 586 patients underwent phacoemulsification surgery with implantation of a Zeiss AT TORBI 709MP or AT LISA Tri Toric 939 MP toric IOL, calculated using the Goggin Nomogram. The median absolute magnitude of error and geometric mean astigmatic correction index in consecutive eyes with toric IOL cylinder powers of 1.00 to 3.00 diopters (D) were analyzed. RESULTS: Overall, all eyes receiving IOL cylinder powers of 1.00 to 3.00 D inclusive had a median magnitude of error value of 0.19 D (IQR: 0.31) and astigmatic correction index value of 1.03 (IQR: 0.33). For eyes with with-the-rule, against-the-rule, and oblique astigmatism, the median magnitude of error was 0.18 D (interquartile range [IQR]: 0.29), 0.19 D (IQR: 0.31), and 0.17 D (IQR: 0.39), respectively, and the astigmatic correction index was 1.06 (IQR: 0.28), 1.01 (IQR: 0.35) and 1.08 (IQR: 0.32), respectively. CONCLUSIONS: Goggin Nomogram adjusted keratometry provided optimal refractive astigmatic outcome in IOL cylinder powers of 1.00 to 3.00 D in eyes with with-the-rule, against-the-rule, and oblique astigmatism. Goggin Nomogram adjusted keratometry compensates for both posterior corneal astigmatism and any other source of ocular astigmatism. [J Refract Surg. 2022;38(5):298-303.].

Materials in the vitreous during cataract surgery: nature and incidence, with two cases of histological confirmation.

BACKGROUND: To identify and classify materials in the vitreous observed during phacoemulsification cataract surgery (phaco). DESIGN: Prospective, consecutive, observational case series at one ophthalmic day surgery in Sydney, Australia. PARTICIPANTS: A total of 767 consecutive phaco cases. Cases were excluded if there was posterior capsule rupture or vitreous loss intraoperatively. METHODS: For each patient, age, gender, baseline corrected distance visual acuity, presence of pseudoexfoliation, nuclear sclerosis grade and phacoemulsification ultrasound time were recorded. The relationship between these variables and materials in the vitreous was evaluated with regression analysis. Two patients with materials in the vitreous developed an acute intraoperative rock-hard eye syndrome. In these two patients, pars plana needle aspiration of retrolenticular fluid was performed to re-establish normal intraocular pressure. Histology was undertaken to compare this fluid with known lens material retrieved from the Fluid Management System bags in two unrelated cases. MAIN OUTCOME MEASUREMENTS: Presence of materials in the vitreous during phaco. RESULTS: Materials in the vitreous were observed in either Berger's space or the anterior vitreous in 386 eyes (50.3% of cases); the majority was putatively lens material (46.5% of all cases). Pigment and ophthalmic viscoelastic device were seen in the anterior vitreous in 9.8% and 1.7% of cases, respectively. Logistic regression analysis demonstrated that higher nuclear sclerosis grade (P = 0.025), male gender (P = 0.003) and greater age (P = 0.016) were predictive of the presence of materials in the vitreous. Histological assessment with light microscopy and birefringence techniques identified the materials in the vitreous as lens material. CONCLUSION: Materials in the vitreous were seen in 50.3% of phaco cases. It has been histologically demonstrated that lens materials can be introduced into the anterior vitreous during phaco.

High-speed cannula detachment into the eye during hydrodissection.

Detachment of a hydrodissection cannula during a phacoemulsification procedure appeared to produce no adverse sequelae during surgery. Day 1 postoperatively, two nonpenetrating hemorrhagic retinal lesions were identified; there was no evidence of posterior capsular perforation. Day 6 postoperatively, the pupil was temporally peaked by a fine vitreous strand running to the main-port incision in the superotemporal cornea. This was divided with Nd:YAG laser, and argon laser was applied to encircle the two retinal lesions. Postoperative uncorrected visual acuity remained 6/4 at day 1, day 6, and week 4 (3 weeks after laser application) follow-up visits. Surgeons must accept responsibility for confirming the integrity of the cannula and syringe connection before beginning hydrodissection, which can be highly destructive to intracameral structures.

Acute intraoperative rock-hard eye syndrome and its management.

PURPOSE: To evaluate the use of pars plana needle aspiration of retrolenticular fluid in the immediate management of an acute intraoperative rock-hard eye syndrome (AIRES). SETTING: Private practice, Sydney, Australia. DESIGN: Retrospective case series. METHODS: Data over an 18-month period were collected to evaluate efficacy, complications, and visual outcomes in patients who had pars plana needle aspiration for management of AIRES, which is an acute intraoperative shallowing of the anterior chamber and a marked increase in intraocular pressure (IOP) during phacoemulsification cataract surgery but without evidence of a choroidal hemorrhage. Preoperative and postoperative (1 day, 1 week, and 1 month) data were evaluated. Resolution of AIRES and postoperative posterior segment status, IOP, and corrected distance visual acuity (CDVA) were the main outcome measures. RESULTS: Acute intraoperative rock-hard eye syndrome occurred in 6 (1.45%) of 413 surgeries. All 6 patients were women with a mean age of 81 years. Four patients had dense nuclear cataracts. In each case, the anterior chamber depth and IOP normalized immediately after pars plana needle aspiration and the procedure concluded uneventfully. Mild vitreous hemorrhage was observed in 1 patient postoperatively. At 1 month, the IOP was normal in 5 of 6 cases, while the CDVA was 20/12 in 5 of 6 cases. CONCLUSION: Although the etiology of AIRES is iatrogenic, immediate resolution was achieved uneventfully with pars plana needle aspiration, which appears to be a safe management technique with satisfactory outcomes.

LESCs: Lateralizing Eyelid Sleep Compression Study.

PURPOSE: To study the hypothesis that in normal patients, changes in eyelid elasticity may occur asymmetrically and in relation to the side on which the individual sleeps. DESIGN: Prospective, consecutive, single-center study within a large, tertiary-referral ophthalmology department within a university hospital. METHODS: This prospective study was carried out consecutively on 262 normal patients. The 3 inclusion criteria were 1) age≥55 years, 2) absence of facial nerve palsy, and 3) absence of eyelid trauma or surgery. Immediately before the ocular plastic surgeon assessed the patient, each patient was questioned in a separate consulting room by the attending orthoptist as to his or her customary side of sleeping. After detailed explanation, the "history-masked" ocular plastic surgeon then assessed the patient's upper eyelid laxity, the main outcome measurement. This was performed by asking the seated patient to look down and then gently grasping the upper eyelids close to the eyelid margin, just medial to the lateral commissure. The ocular plastic surgeon, with thumbs pronated, simultaneously distracted both upper eyelids superiorly, laterally, and anteriorly. The measured separation of the upper eyelid from the globe conjunctiva was obtained using calipers. Eyelid laxity grading was designated as grade 1: 0 to 1.9 mm; grade 2: 2.0 to 3.9 mm; grade 3: 4 to 9 mm; and grade 4: floppy. RESULTS: Two hundred sixty-two patients (58% females) who consecutively satisfied the selection criteria were evaluated, of which 70.22% (183/262) patients had significantly greater laxity of the upper eyelid that corresponded to the side on which they customarily slept. An unpaired t test used to compare the eyelid laxity between the sleeping side and nonsleeping side was statistically significant (p<0.001). CONCLUSION: Normal patients demonstrate a correlation between the side on which they historically or customarily sleep and the laxity of their ipsilateral upper eyelid.