Intraocular Lens Unfurling Time Exponentially Decays with Increased Solution Temperature.

Purpose: Intraocular lens (IOL) unfurling can be a rate-limiting step in cataract surgery, limiting operative efficiency. Furthermore, inefficient unfurling has important implications for clinical outcomes. We examine the effects of solution temperature on IOL unfurling time using three in vitro models of the ocular environment. Methods: IOLs were injected into a 6-well plate filled with balanced salt solution (BSS), dispersive ophthalmic viscoelastic device (OVD), or cohesive OVD. Experiments were also performed in a plastic eye filled with dispersive or cohesive OVD. IOL unfurling time was recorded against the temperature of the respective solution. Results: IOL unfurling time decayed exponentially as solution temperature increased in all experiments, including the BSS-filled 6-well plate, the OVD-filled 6-well plate, and the OVD-filled plastic eye. IOLs failed to unfurl within 10 min at 10°C, below the glass transition temperature of the tested IOLs. Increasing solution temperature from 20°C to 30°C decreases IOL unfurling by greater than 2 min. Further heating to 40°C did not significantly decrease IOL unfurling time. Conclusion: Increased solution temperature rapidly decreases IOL unfurling time in vitro. IOLs do not unfurl within a clinically acceptable timeframe at or below their glass transition temperature. Increased BSS and/or OVD temperature may be a potential method to decrease IOL unfurling time in cataract surgery. However, future research is needed to elucidate potential consequences of warmed BSS and/or OVD on post-operative outcomes. This study demonstrates the potential for temperature regulation to decrease cataract surgery operative time and provides preliminary evidence to justify future clinical validation of this relationship.

During cataract surgery, a prosthetic intraocular lens (IOL) is inserted into the eye once the clouded lens is removed. The IOL must then unfurl before the procedure can proceed. When IOLs fail to unfurl or unfurl slowly, this can delay the operation and may even cause post-operative complications. Thus, we studied the effect temperature may have on IOL unfurling time to optimize this segment of the operation. We injected IOLs into solutions of saline (balanced salt solution) or ophthalmic viscoelastic device (OVD), two fluids injected into the eye during surgery. In both a well plate and a plastic eye, we found that increasing the temperature of the solution significantly affected IOL unfurling time. Specifically, heating the solution from refrigeration to room temperature decreased unfurling time from over 10 min to less than four. Heating to physiological temperature further decreased unfurling time to less than a minute. Our results show promise for potentially utilizing heated BSS and/or OVD to accelerate IOL unfurling and decrease cataract surgery operative time.

Clinical outcome of diffractive multifocal lens versus monofocal lens in post-laser in situ keratomileusis patients: A retrospective, comparative study.

Purpose: To compare the clinical outcomes of diffractive multifocal and monofocal lenses in post-laser in situ keratomileusis (LASIK) patients who underwent cataract surgery. Methods: This was a retrospective, comparative study of clinical outcomes that was conducted at a referral medical center. Post-LASIK patients who underwent uncomplicated cataract surgery and received either diffractive multifocal or monofocal lens were studied. Visual acuities were compared at baseline and postoperatively. The intraocular lens (IOL) power was calculated with Barrett True-K Formula only. Results: At baseline, both groups had comparable age, gender, and an equal distribution hyperopic and myopic LASIK. A significantly higher percentage of patients receiving diffractive lenses achieved uncorrected distance visual acuity (UCDVA) of 20/25 or better (80 of 93 eyes, 86% vs. 36 of 82 eyes, 43.9%, P = 1.0 x 105) and uncorrected near vision of J1 or better (63% vs. 0) compared to the monofocal group. The residual refractive error had no significant difference (0.37 ± 0.39 vs. 0.44 ± 0.39, respectively, P = 0.16) in these two groups. However, more eyes in the diffractive group achieved UCDVA of 20/25 or better with residual refractive error of 0.25-0.5 D (36 of 42 eyes, 86% vs. 15 of 24 eyes, 63%, P = 0.032) or 0.75-1.5 D (15 of 21 eyes, 23% vs. 0 of 22 eyes, P = 1.0 x 10-5) compared to the monofocal group. Conclusion: This pilot study shows that patients with a history of LASIK who undergo cataract surgery with a diffractive multifocal lens are not inferior to those who receive monofocal lens. Post-LASIK patients with diffractive lens are more likely to achieve not only excellent near vision, but also potentially better UCDVA, regardless of the residual refractive error.

Long-Term Outcome of Femtosecond Laser-Assisted Keratopigmentation: Using Intacs Channels for Precise Pigment Deposition Within the Cornea.

PURPOSE: To describe a long-term outcome of a new technique using the femtosecond laser to assist with keratopigmentation (corneal tattooing). METHOD: Nineteen eyes of 18 patients with a history of significant visual disability related to iris defects underwent femtosecond laser-assisted keratopigmentation (FAK) for functional restoration of their visual disabilities. Postoperative visual acuity and symptomatic resolution were collected during their postoperative visits. RESULTS: After FAK surgery, all patients had improvement in their previous visual-related symptoms. Eighteen of 19 eyes (94%) had improvement in their best-corrected Snellen visual acuity. Eight of 19 eyes (42%) had at least 1 line improvement, 8 of 19 eyes (42%) had at least 2 lines of improvement, and 2 of 19 eyes (10%) had at least 3 lines improvement. The average follow-up period was approximately 60 months. CONCLUSIONS: The FAK technique offers a long-term effective and safe technique for visual disabilities and improves visual acuity in patients with various traumatic iris defects.

Rate of pseudophakic cystoid macular edema using intraoperative and topical nonsteroidal antiinflammatory drugs alone without steroids.

PURPOSE: To determine the rate of postoperative cystoid macular edema (CME) in patients undergoing cataract surgery treated with intraoperative intracameral and postoperative topical nonsteroidal antiinflammatory drugs (NSAIDs) without steroids. SETTING: Academic outpatient surgery center Wake Forest Baptist Health in Bermuda Run, NC. DESIGN: Retrospective cohort study. METHODS: A retrospective chart review was performed. Patients were identified through a medical record search tool using criteria of the Current Procedural Terminology code (66984), a single surgeon, and a date range from January 1, 2016, through December 31, 2017. Medical records were reviewed to determine intraoperative and postoperative medication regimen, visual outcome, and development of postoperative CME. Patients with a history of uveitis, diabetic macular edema, retinal vein occlusions, epiretinal membranes, vitreomacular traction, or any prior macular edema were excluded. In addition, any patients with less than 6 weeks of postoperative follow-up were excluded. RESULTS: Overall, 824 patient records were reviewed, and the analysis included 504 eyes. Of these, 2 eyes developed postoperative CME (rate = 0.40%, 95% CI 0.0005 to 0.0143). CONCLUSIONS: The rate of CME in patients treated with intraoperative and postoperative NSAIDs without steroids was low and below the historical rates derived from a literature review of CME development with the use of steroids.

Incidence of cystoid macular edema following routine cataract surgery using NSAIDs alone or with corticosteroids / Incidência de edema macular cistóide após cirurgia de catarata de rotina com a utilização de AINEs isoladamente ou com corticosteroides

ABSTRACT Purpose: To evaluate the rate of cystoid macular edema development among cataract surgery patients on four different therapeutic regimens. Methods: The present study is a retrospective analysis of 5,380 eyes following uncomplicated phacoemulsification at Wake Forest University. The study period went from July 2007 to December 2012. Patients received one of four regimens, as follows: postoperative generic ketorolac 0.4% and prednisolone 1%, postoperative name-brand ketorolac 0.45% and prednisolone 1%, postoperative bromfenac 0.09% and prednisolone 1%, preoperative and postoperative bromfenac 0.09% alone. A statistical analysis was performed to assess the differences in rate of cystoid macular edema development among the four different therapeutic regimens. The diagnosis of cystoid macular edema required worsening of vision and evidence of increased macular thickness on optical coherence tomography. Results: The overall rate of cystoid macular edema was 0.82%. Treatment by postoperative generic ketorolac 0.45% and prednisolone 1% demonstrated the highest rate of cystoid macular edema development (2.20% of the cases). Postoperative name-brand ketorolac 0.45% and prednisolone 1% exhibited intermediate rates of cystoid macular edema development (0.90% of the cases). Postoperative administration of bromfenac 0.09% and prednisolone 1% exhibited intermediate rates of cystoid macular edema development (0.44% of the cases). Preoperative and postoperative bromfenac 0.09% alone resulted in the lowest rate of cystoid macular edema development (0.09% of the cases). The rate of cystoid macular edema was significantly lower when bromfenac was used alone vs. either regimen where ketorolac and prednisolone were used (OR 0.043, 95% CI 0.002 to 0.312; p<0.001). Conclusions: Post-cataract surgery cystoid macular edema developed less frequently following topical non-steroidal anti-inflammatory drugs regimen compared to the other therapies evaluated. Bromfenac, without corticosteroids, achieved lower rates of cystoid macular edema vs. various combinations of non-ste­roidal anti-inflammatory drugs with corticosteroids.

RESUMO Objetivo: Avaliar a taxa de desenvolvimento do edema macular cistóide em pacientes submetidos à cirurgia de catarata em quatro esquemas terapêuticos diferentes. Métodos: O presente estudo é uma análise retrospectiva de 5.380 olhos após facoemulsificação não complicada na Wake Forest University. O período do estudo foi entre julho de 2007 e dezembro de 2012. Os pacientes receberam um dos quatro esquemas: cetorolaco genérico pós-operatório 0,4% e prednisolona 1%, cetorolaco 0,45% pós-operatório e prednisolona 1%, bromfenac 0,09% e a prednisolona 1% pós-operatório, bromfenaco 0,09% no pré-operatório e isoladamente no pós-operatório. Uma análise estatística foi realizada para avaliar as diferenças na taxa de desenvolvimento do edema macular cistóide entre os quatro diferentes regimes terapêuticos. O diagnóstico de edema macular cistóide exigiu uma piora da visão e uma evidência de aumento da espessura macular na tomografia de coerência óptica. Resultados: A taxa global de edema macular cistóide foi de 0,82%. O tratamento com cetorolaco genérico pós-operatório 0,45% e prednisolona 1% demonstrou a maior taxa de desenvolvimento de edema macular cistóide (2,20% dos casos). O cetorolaco 0,45% e a prednisolona 1% no pós-operatório exibiram taxas intermediárias de desenvolvimento de edema macular cistóide (0,90% dos casos). A administração de bromofenac 0,09% e de prednisolona 1% no pós-operatório apresentou taxas interme­diárias de desenvolvimento de edema macular cistóide (0,44% dos casos). O bromfenac 0,09% no pré e pós-operatório isoladamente resultou na menor taxa de desenvolvimento de edema macular cistóide (0,09% dos casos). A taxa de edema macular cistóide foi significativamente menor quando o bromfenac foi utilizado isoladamente em relação ao esquema onde cetorolaco e a prednisolona foram usados (OR 0,043, 95% CI 0,002 a 0,312; p<0,001). Conclusões: O edema macular cistóide pós-cirurgia de catarata desenvolveu-se com menor frequência após o tratamento tópico de medicamentos anti-inflamatórios não esteroidais, comparado às outras terapias avaliadas. Bromfenac, sem corticosteróides, alcançou taxas mais baixas de edema macular cistóide vs. Várias combinações em comparação com as várias combinações de drogas anti-inflamatórias não esteroidais com corticosteróides.

Incidence of cystoid macular edema following routine cataract surgery using NSAIDs alone or with corticosteroids.

PURPOSE: To evaluate the rate of cystoid macular edema development among cataract surgery patients on four different therapeutic regimens. METHODS: The present study is a retrospective analysis of 5,380 eyes following uncomplicated phacoemulsification at Wake Forest University. The study period went from July 2007 to December 2012. Patients received one of four regimens, as follows: postoperative generic ketorolac 0.4% and prednisolone 1%, postoperative name-brand ketorolac 0.45% and prednisolone 1%, postoperative bromfenac 0.09% and prednisolone 1%, preoperative and postoperative bromfenac 0.09% alone. A statistical analysis was performed to assess the differences in rate of cystoid macular edema development among the four different therapeutic regimens. The diagnosis of cystoid macular edema required worsening of vision and evidence of increased macular thickness on optical coherence tomography. RESULTS: The overall rate of cystoid macular edema was 0.82%. Treatment by postoperative generic ketorolac 0.45% and prednisolone 1% demonstrated the highest rate of cystoid macular edema development (2.20% of the cases). Postoperative name-brand ketorolac 0.45% and prednisolone 1% exhibited intermediate rates of cystoid macular edema development (0.90% of the cases). Postoperative administration of bromfenac 0.09% and prednisolone 1% exhibited intermediate rates of cystoid macular edema development (0.44% of the cases). Preoperative and postoperative bromfenac 0.09% alone resulted in the lowest rate of cystoid macular edema development (0.09% of the cases). The rate of cystoid macular edema was significantly lower when bromfenac was used alone vs. either regimen where ketorolac and prednisolone were used (OR 0.043, 95% CI 0.002 to 0.312; p<0.001). CONCLUSIONS: Post-cataract surgery cystoid macular edema developed less frequently following topical non-steroidal anti-inflammatory drugs regimen compared to the other therapies evaluated. Bromfenac, without corticosteroids, achieved lower rates of cystoid macular edema vs. various combinations of non-ste-roidal anti-inflammatory drugs with corticosteroids.

Continuous intracameral phenylephrine-ketorolac irrigation for miosis prevention in femtosecond laser-assisted cataract surgery: Reduction in surgical time and iris manipulation.

PURPOSE: To determine whether the addition of phenylephrine 1.0%-ketorolac 0.3% (Omidria) to the irrigation solution during femtosecond laser-assisted cataract surgery (FLACS) reduces surgical time and the need for pupil expansion devices compared with the irrigation solution containing epinephrine. SETTING: Wake Forest Baptist Eye Center, Winston-Salem, North Carolina, USA. DESIGN: Retrospective case series. METHODS: Data were collected from consecutive patients. One group had epinephrine 1 µg/mL in the irrigating solution and the other group, had phenylephrine and ketorolac 4 mL added to 500 mL irrigation solution instead of epinephrine. All patients received preoperative topical bromfenac 2 days before surgery. The same surgeon performed all procedures using the same laser (Catalys) and operative conditions. Endpoints were surgical time and the use of pupil expansion devices. RESULTS: Data were collected from 200 consecutive patients, 100 in each group. Patient demographics, including a mean baseline pupil size of 7.1 mm, were similar between the groups. Mean surgical times were significantly reduced in the phenylephrine-ketorolac group versus the epinephrine group (8.1 minutes versus 9.4 minutes) (P = .007). When eyes requiring a pupil expansion device were eliminated, there was still a significant reduction in surgical time for phenylephrine-ketorolac versus epinephrine (8.1 minutes versus 9.0 minutes) (P = .018). Two eyes (2%) in the phenylephrine-ketorolac group and 12 eyes (12%) in the epinephrine group required a pupil expansion device (P = .009). CONCLUSION: These data support the hypotheses that using phenylephrine and ketorolac reduces FLACS time and the need for pupil expansion devices.

Small-incision Descemet stripping automated endothelial keratoplasty: a comparison of small-incision tissue injector and forceps techniques.

PURPOSE: To describe a novel, small-incision, no-fold Descemet stripping automated endothelial keratoplasty (DSAEK) graft injector and to compare complications, visual acuity, and endothelial cell loss with a forceps technique. METHODS: An Institutional Review Board-approved, interventional, nonrandomized, consecutive case series analysis of 175 eyes undergoing DSAEK for Fuchs dystrophy and bullous keratopathy. The injector arm is prospective, and the forceps arm is retrospective. Seventy grafts were performed with a DSAEK graft injector, and 105 grafts were performed using a small-incision forceps technique. Preoperative and postoperative visual acuities at 3 and 6 months, 6-month endothelial cell counts, and complications, including graft dislocation, failure, and rejection, were recorded. Fifty-seven of 232 eyes met exclusion criteria for previous incisional corneal or glaucoma surgery. RESULTS: There were 4 eyes (5.7%) in the injector group and 29 eyes (27.6%) in the forceps group that required a re-bubble procedure because of graft detachment. One graft (1.4%) failed in the injector group and 7 grafts (6.5%) failed in the forceps group. Excluding eyes with other ocular comorbidities (43), in the injector group 74% were 20/40 or better at 6 months and 100% were 20/60 or better. In the forceps group, 72% were 20/40 or better at 6 months and 98% were 20/60 or better. Six-month postoperative endothelial cell counts were available for 84 (46 injector and 38 forceps) eyes, with an average cell loss of 28.3% in the injector group and 44.1% in the forceps group. CONCLUSIONS: DSAEK is an effective treatment of endothelial dysfunction. Surgical technique is important to limit endothelial cell loss and prevent complications, such as graft dislocation. The injector device has several advantages over the trifold forceps technique, including decreased endothelial cell loss, graft dislocation rate, and graft failure rate, and it reduces the DSAEK learning curve. DSAEK graft injectors likely will have a role in the future of endothelial keratoplasty.

Three-millimeter incision descemet stripping endothelial keratoplasty using sodium hyaluronate (healon): a survey of 105 eyes.

PURPOSE: To report a Descemet stripping automated endothelial keratoplasty (DSAEK) insertion technique using sodium hyaluronate (Healon) and describe complication rates, visual acuity, and endothelial cell counts. METHODS: A retrospective analysis of 105 eyes in 91 patients undergoing DSAEK. Ninety-three eyes had Fuchs endothelial dystrophy, 11 had bullous keratopathy, and 1 had iridocorneal endothelial (ICE) syndrome. We noted pre- and postoperative visual acuity at 3 and 6 months, endothelial cell counts, and complications, including graft detachment rates. Thirty-six of 141 eyes met exclusion criteria of prior incisional corneal, glaucoma, or retinal surgery. RESULTS: Because of graft detachment, 29 of 105 eyes (28%) required a re-bubble procedure at day 1 or week 1. Five of 105 grafts (4.8%) failed. Of note, in the last 35 cases, there were no graft failures and 5 detachments (14%). Twenty-eight percent of patients were 20/40 or better preoperatively compared with 49% at 3 months and 52% at 6 months. Excluding eyes with other ocular comorbidities (34), 62% were 20/40 or better at 3 months and 72% were 20/40 or better at 6 months. Postoperative endothelial cell counts were available for 52 eyes with an average cell loss of 44% at an average of 9.4 months. CONCLUSIONS: DSAEK is an effective treatment for endothelial dysfunction, but the learning curve is steep. Anterior chamber stability, graft positioning, and small incision insertion are advantages to our technique. Disadvantages include a relatively high endothelial loss and dislocation rate. Minimizing endothelial cell loss and graft dislocation continue to be important goals for successful DSAEK.

Accurate intraocular lens power calculation after myopic laser in situ keratomileusis, bypassing corneal power.

PURPOSE: To describe a novel method for calculating intraocular lens (IOL) power after myopic laser in situ keratomileusis (LASIK) without using the inaccuracies of the post-LASIK corneal power. SETTING: Department of Ophthalmology, Wake Forest University Eye Center, Wake Forest University School of Medicine, Winston Salem, North Carolina, USA. METHODS: This retrospective chart review comprised 9 eyes of 9 patients who had phacoemulsification after LASIK using our method for IOL calculation. This new method assumes the patient never had myopic LASIK to calculate IOL power and then targets the IOL at the pre-LASIK amount of myopia. The pre-LASIK keratometry values, pre-LASIK manifest refraction, and the current axial length are placed in the Holladay formula, bypassing the post-LASIK corneal power. In theory, assuming that the patient had satisfactory LASIK results, the correct IOL can then be determined. RESULTS: The mean spherical equivalent postoperative refraction was +0.03 diopter (D) +/- 0.42 (SD) (range -0.625 to +0.75 D). In all 9 eyes, our method consistently chose the most accurate and precise IOL compared with other methods. CONCLUSIONS: The new method of calculating IOL power after LASIK provided excellent results and the most accurate and precise results to date.

Effect of environmental factors on myopic LASIK enhancement rates.

PURPOSE: To determine whether environmental factors affect laser in situ keratomileusis (LASIK) enhancement rates. SETTING: Wake Forest University Eye Center, Winston-Salem, North Carolina, USA. METHODS: This retrospective chart review comprised 368 consecutive eyes of 191 myopic patients who had LASIK by the same surgeon (K.A.W.). All patients had surgery in 2000 with the Visx Star S2 excimer laser. Refractive outcome, visual acuity, and enhancement rates were monitored closely for 1 year. Fifty-seven eyes (15.5%) had an enhancement procedure. Using enhancement procedure or percentage of correction as the outcome measure, factors that were suspected to affect LASIK results and the need for enhancement were examined; specifically, age, eye, sex, pachymetry, corneal curvature (K), preoperative spherical equivalent, ablation depth, and environmental factors (procedure room temperature, procedure room relative humidity, outdoor temperature, and outdoor relative humidity). RESULTS: Using univariate and multivariate analysis, LASIK enhancement rates strongly correlated with the following variables: procedure room humidity (P =.003; odds ratio [OR] = 1.093; 95% confidence intervals [CI], 1.030-1.160), 2-week preoperative mean outdoor humidity (P =.011; OR = 1.054; 95% CI, 1.012-1.096), outdoor temperature (P =.0059; OR = 1.039; 95% CI, 1.011-1.068), and age (P =.0497; OR = 1.034; 95% CI, 1.001-1.070). The percentage of correction strongly correlated with the following variables: procedure room humidity (P =.021), 2-week preoperative mean outdoor humidity (P =.001), outdoor temperature (P =.0052), and room temperature (P =.017). CONCLUSIONS: The 2-week-preoperative mean outdoor relative humidity, procedure room relative humidity, outdoor temperature, and procedure room temperature may have to be considered during LASIK planning. The effect of these environmental variables on LASIK outcomes warrants further evaluation.

Ocular surface injury from a microwave superheated liquid.

PURPOSE: To describe the ocular surface injury resulting from a microwave superheated liquid. METHODS: Case report. RESULTS: A 40-year-old man sustained an ocular surface injury from a microwave superheated liquid. The injury resulted in limbal stem cell damage requiring an autograft limbal stem cell transplantation. CONCLUSIONS: We are unaware of previous reports of microwave superheated liquids resulting in ocular injury. Microwave superheating of liquids is a potential ocular danger that should be brought to the attention of both ophthalmologists and their patients.