Case report: Topical pilocarpine ameliorated the accommodation loss and pupillary dilation after micropulse transscleral laser treatment.

BACKGROUND: The present study elucidates a common significant postoperative complication of micropulse transscleral laser treatment (mTLT) and explores its potential management strategies for younger patients with good central vision. CASE PRESENTATION: Three younger Chinese glaucoma patients with good central vision maintained high intraocular pressures (IOPs) (36, 25, and 30 mmHg) on maximally tolerated topical anti-glaucoma medications. All patients were treated with mTLT because of a higher risk of complications with filtering surgery. After the procedure, their best-corrected visual acuities were not significantly changed, IOPs were significantly decreased, and the number of topical anti-glaucoma medicines was gradually decreased. However, all patients complained about reduced near visual acuity (NVA) for 1-5 months. Slit-lamp examination revealed pupillary dilation, and binocular accommodative function examination indicated accommodation loss. After treatment with 2% topical pilocarpine, all patients reported an improvement in NVA. Among them, we could observe pupillary constriction, recovery of accommodation function, and improved NVA, even discontinuation of pilocarpine in Patient 2. CONCLUSION: In younger patients with good central vision, topical pilocarpine might ameliorate accommodation loss and pupillary dilation after mTLT.

Effect of topical pilocarpine on refractive surgery outcomes.

PURPOSE: To investigate the effect of topical pilocarpine on topical cycloplegia and on the results of refractive surgery. METHODS: The study included 100 eyes of 100 patients who underwent laser-assisted in situ keratomileusis. Group 1 comprised patients who wanted to undergo surgery on the same day after cycloplegic examination and were applied with 2% pilocarpine hydrochloride; group 2 comprised patients whose pupils spontaneously went into the natural position. Corneal thickness, mean refractive spherical equivalent (MRSE), uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), pupil diameter, pupil center shift and high-order aberrations (HOAs) were compared between the two groups. RESULTS: There were no statistically significant differences between the groups in respect of preoperative age, gender, corneal thickness, MRSE, UDVA and CDVA. The pupil diameter was not statistically significant between the groups. Pupil diameter after pilocarpine was not statistically significant when compared with the natural pupil diameter. There were no statistically significant differences in postoperative HOA between the two groups. CONCLUSIONS: The pupillary dilatation and the associated pupillary shift were reduced with pilocarpine. Postoperative refractive values and aberrations showed no difference between the groups.

Unilateral Malignant Glaucoma Postbilateral Implantable Collamer Lens: Effect of Miotics.

An implantable collamer lens® (ICL) V4c model (STAAR Surgical, Monrovia, CA, USA) was placed in the eye of a 31-year-old male patient with high myopia followed by the development of malignant glaucoma. After failing medical treatment for 5 days, a noncomplicated pars plana vitrectomy and anterior hyaloidectomy succeeded in breaking the aqueous misdirection. Sixteen months later, intraoperative miotics were purposefully withheld from the ICL surgery in the fellow eye and malignant glaucoma did not develop. Even though the patient's visual acuity postoperatively was 20/20, OU, a single small atrophic iris patch in the affected eye resulted in slightly more halos and glare in mesopic conditions as compared to the fellow eye. Earlier surgical intervention may have prevented iris ischemia and iridocorneal touch with its subsequent iris atrophy and resulted in an even more favorable visual outcome. Withholding intraoperative miotics during ICL surgery appeared to be beneficial in this case.

Acetylcholine chloride 1% usage for intraoperative cataract surgery miosis / Cloridrato de Acetilcolina 1% na obtenção da miose intraoperatória na cirurgia de catarata

Abstract Objective: To test the efficacy of Acetylcholine chloride use in obtaining intraoperative miosis on phacoemulsification cataract surgery. Methods: Patients with cataract diagnosis and elected for surgical phacoemulsification procedure were selected. All patients underwent conventional phacoemulsification procedure performed by a single surgeon and all patients had 0.2 ml of Acetylcholine chloride 1% irrigated in the anterior chamber at the end of the surgery. The pupillary diameter was measured immediately before the beginning of surgery, immediately before and two minutes after the use of acetylcholine chloride 1%. Results: A total of 30 eyes from 30 patients were included in the study. 18 were female, and mean age was of 69.5 years with a 7.2y standard deviation on the population study. The mean pupillary diameter immediately before the beginning of surgery was 7.5 mm with a standard deviation of 0.56 mm; the mean pupillary diameter immediately before the acetylcholine chloride 1% use (after the intraocular lens im-plantation) was 7.1 mm with a standard deviation of 0.57 mm. The mean pupillary diameter two minutes after the use of acetylcholine chloride 1% in the anterior chamber was 3.4 mm with standard deviation of 0.66 mm. The mean maximum action time of ACH chloride 1% was 64 seconds, with a standard deviation of 8 seconds. The mean intraocular pressure on the first postoperative day was 19.1 mmHg with a standard deviation of 2.45 mmHg. Conclusion: We conclude that acetylcholine chloride 1% is an important drug to obtaining intraoperative miosis in cataract surgery.

Resumo Objetivo: Demonstrar a eficácia do cloridrato de acetilcolina 1% na obtenção da miose intraoperatória na cirurgia de catarata pela técnica de facoemulsificação. Métodos: Pacientes com diagnóstico de catarata e indicação de cirurgia foram selecionados para participar do presente estudo. Todos os pacientes foram operados pela técnica de facoemulsificação convencional pelo mesmo cirurgião, todos foram submetidos à aplicação de 0,2 ml do cloridrato de acetilcolina 1% na câmara anterior ao final do procedimento cirúrgico. A medida do diâmetro pupilar foi realizada imediatamente antes do início da cirurgia, imediatamente antes do uso do cloridrato de acetilcolina 1% e após 2 minutos. Resultados: Foram estudados 30 olhos de 30 pacientes, destes, 18 eram do sexo feminino, a média de idade do estudo foi de 69,5 anos com desvio padrão de 7,2 anos. A média do diâmetro pupilar imediatamente antes do início da cirurgia foi 7,55 mm com desvio padrão de 0,56mm, a média do diâmetro pupilar imediatamente antes do uso do cloridrato de acetilcolina 1% (após implante da lente intraocular no saco capsular) foi 7,1mm com desvio padrão de 0,57mm. A média do diâmetro pupilar após 2 minutos da aplicação da acetilcolina na câmara anterior foi de 3,4 mm com desvio padrão de 0,66mm. O tempo médio de ação máxima do medicamento foi de 64 segundos, com desvio padrão de 8 segundos. A média da pressão intraocular no primeiro dia do pós-operatório foi de 19,1 mmHg com desvio padrão de 2,45mmHg. Conclusão: O estudo acima mostrou que a acetilcolina apresenta boa eficácia na obtenção de miose intraoperatória na cirurgia de facoemulsificação, permitindo uma maior facilidade na confecções das suturas corneanas ou corneo-escleral, reduzindo a incidência de sinéquias anteriores periféricas. Concluimos que o cloridrato de acetilcolina 1% é um importante medicamento na obtenção da miose intraoperatória na cirurgia de catarata.

Acute Primary Angle Closure in the Fellow Eye as a Complication of Facedown Position After Vitrectomy Surgery.

PURPOSE: To report a case of acute primary angle closure that developed in the fellow eye rapidly after facedown position after vitrectomy surgery. PATIENTS AND METHODS: A 66-year-old female developed acute primary angle closure in the fellow eye approximately 1.5 hours after facedown position after vitrectomy surgery for macular hole. RESULTS: The intraocular pressure was controlled after treatment that included halting the facedown position, intravenous mannitol injection, and topical pilocarpine instillation. Facedown position was continued after laser peripheral iridotomy was performed. The intraocular pressure was controlled within normal range even after pilocarpine was withdrawn. CONCLUSIONS: Although rare, the potential risk of acute-angle closure should be explicitly explained to patients being considered for facedown position after vitrectomy. Prophylactic intervention, such as laser peripheral iridotomy, could be considered for anatomically predisposed eyes.

Intraoperative intracameral pilocarpine after capsular tension ring and capsule/iris hook insertion in pediatric eyes with subluxated cataract.

UNLABELLED: Capsular tension rings and iris hooks have proved to be useful devices in cataract surgery in cases of zonular weakness and dialysis. We describe the use of intracameral pilocarpine-induced pupillary miosis to couple the iris and the capsulorhexis edge with iris hooks during phacoemulsification in pediatric cases with posttraumatic subluxated cataractous lens. The coupled iris and capsule act as a single unit, eliminating the space between them and significantly reducing the possibility of vitreous or ophthalmic viscosurgical device passing through the zonular defect. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Nanoparticle cross-linked collagen shields for sustained delivery of pilocarpine hydrochloride.

Glaucoma is a common progressive eye disorder which remains the second leading cause of blindness worldwide. Current therapy involves frequent administration of eye drops which often results in poor patient adherence and therapeutic outcomes. The aim of this study was to overcome these limitations by developing a novel nanoparticle cross-linked collagen shield for sustained delivery of pilocarpine hydrochloride (PHCl). Three metal oxide nanoparticles (NPs); titanium dioxide (TiO2), zinc oxide (ZnO) and polyvinylpyrrolidone (PVP) capped zinc oxide (ZnO/PVP), were evaluated for their cytotoxicity as well as shield transparency before selecting ZnO/PVP NPs as the ideal candidate. Cross-linked collagen shields were then characterized for their mechanical strength, swelling capacity and bioadhesive properties, with ZnO/PVP NP cross-linked shields showing the most favorable characteristics compared to plain films. The shield with the best properties was then loaded with PHCl and in vitro release of zinc ions as well as PHCl was measured without and with further cross-linking by ultraviolet irradiation. The concentration of zinc ions released was well below the IC50 rendering them safe for ocular use. Moreover, collagen shields cross-linked with ZnO/PVP NPs released PHCl over a period of 14 days offering a promising sustained release treatment option for glaucoma.

Anterior segment changes after pilocarpine and laser iridotomy for primary angle-closure suspects with Scheimpflug photography.

PURPOSE: To assess changes in Scheimpflug-based measurements of the anterior segment after pilocarpine administration and prophylactic laser peripheral iridotomy in narrow anterior chamber angles. METHODS: Thirty-seven eyes in 37 patients with occludable angles were included in this prospective interventional case series. Primary angle-closure suspects (iridotrabecular contact in 3 quadrants or more) were enrolled. Patient evaluation included indentation gonioscopy, Goldmann tonometry, and optic nerve examination. The mean of 3 consecutive Pentacam measurements was taken at baseline, 45 minutes after 2% pilocarpine administration, and 1 month after laser peripheral iridotomy (LPI). Anterior chamber angle (ACA), anterior chamber volume (ACV), anterior chamber depth (ACD), pupil diameter, central corneal thickness, and intraocular pressure were measured. RESULTS: ACV increased significantly after LPI (from a mean ± standard error of 94.6 ± 3.6 mm(3) to 108.8 ± 3.4 mm(3), P<0.001), as did the ACA (26.7 ± 0.9 degrees to 28.2 ± 0.8 degrees, P<0.001). Central corneal thickness decreased significantly after LPI (558.1 ± 5.3 µm to 552.6 ± 5.7 µm, P=0.018). Central ACD increased slightly after LPI, but this was not statistically significant (2.13 ± 0.05 mm to 2.15 ± 0.05 mm, P=0.109). Pupil diameter and intraocular pressure also did not change significantly after LPI. After pilocarpine, the ACV decreased significantly (by 4.3 ± 1.3 mm(3), P=0.009), as did the central ACD (by 0.1 ±0.02 mm, P<0.001) and the pupil diameter (by 0.74 ± 0.06 mm, P<0.001). CONCLUSIONS: Scheimpflug photography demonstrates significant anterior segment changes after pilocarpine and after LPI in primary angle-closure suspects.

Effect of primary posterior continuous curvilinear capsulorrhexis with posterior optic buttonholing on pilocarpine-induced IOL shift.

PURPOSE: To assess intraocular lens (IOL) shift along the visual axis induced by ciliary muscle contraction with pilocarpine after cataract surgery and to compare primary posterior continuous curvilinear capsulorrhexis (CCC) and posterior optic buttonholing with IOLs implanted in the bag. SETTING: Department of Ophthalmology, Medical University of Vienna, Vienna, Austria. DESIGN: Clinical trial. METHODS: Eyes with age-related cataract had cataract surgery with implantation of a nonaccommodating IOL (AF-1 YA-60BB). Surgery was performed with primary posterior CCC and posterior buttonholing in 1 eye (study eyes) and with conventional in-the-bag implantation in the contralateral eye (control eyes). After a minimum of 6 months postoperatively, the anterior chamber depth was assessed with partial coherence interferometry before and after application of pilocarpine 2.0% and, after a washout interval of 1 week, before and after the application of cyclopentolate 1.0%. RESULTS: Forty eyes of 20 patients were enrolled. A slight backward shift of the IOL (+78 µm) in study eyes and in control eyes (+118 µm) was detected after pilocarpine application (both P<.05). No significant difference in IOL shift was found between study eyes and control eyes (P=.19). CONCLUSIONS: Combined primary posterior CCC and posterior optic buttonholing did not affect IOL shift during pharmacologically stimulated ciliary muscle contraction compared with in-the-bag implanted IOLs. Capsule fibrosis diminished with primary posterior CCC but did not seem to be the only limiting factor in the accommodative IOL shift. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Miotics after modern cataract surgery are history.

PURPOSE: The aim of this study was to investigate the usefulness of a long-acting miotic (physostigmine) after phacoemulsification in preventing peripheral anterior synechiae (PAS), lens dislocation, and high postoperative intraocular pressure. METHODS: This was a prospective randomized controlled trial of 400 patients (400 eyes) scheduled for phacoemulsification. Patients were randomly assigned either to receive a single application of physostigmine ointment directly after phacoemulsification or not. The main outcome measures were the change of intraocular pressure (IOP) before and after surgery, number of extra outpatient clinic visits within 4 weeks postoperatively, verbal rating pain scale (VRS), status of the angle by gonioscopy, and best corrected visual acuity (BCVA). RESULTS: There was no significant difference in IOP and BCVA between both groups. There were more patients who reported a VRS score of more than 3 in the physostigmine group (P=0.021). PAS or (anterior) lens dislocation was not observed. CONCLUSION: In eyes without co-morbidity, the routine use of physostigmine ointment has lost its rationale.

Pediatric intraoperative floppy iris syndrome associated with persistent pupillary membrane.

Intraoperative floppy iris syndrome (IFIS) occurring during cataract surgery in adults has been widely reported in association with tamsulosin and other α-1(a) adrenergic antagonists; however, only one case of pediatric IFIS has been previously reported and was associated with congenital cataract. We report a case of a 1-month old girl with IFIS associated with bilateral persistent pupillary membranes without cataracts and the use of preoperative topical phenylephrine and pilocarpine for IFIS prophylaxis.

Outcomes of reenclavation of subluxated iris-fixated phakic intraocular lenses: comparison with primary surgery outcomes.

PURPOSE: To study the outcomes of successful reenclavation of subluxated iris-fixated phakic intraocular lenses (pIOLs). SETTING: Tertiary eyecare referral center. METHODS: Interventional case series comprised eyes with a subluxated Verisyse pIOL that had successful reenclavation of 1 haptic. A comparison of outcomes between primary pIOL implantation surgery and subsequent reenclavation was performed. The parameters were uncorrected (UDVA) and corrected (CDVA) distance visual acuity and the quantitative endothelial changes preoperatively and postoperatively at 1 week and 1, 3, and 6 months. RESULTS: Nine eyes of 6 patients were evaluated. Disenclavation was spontaneous in 6 eyes (66.6%) and posttraumatic in 3 eyes (33.3%). The mean UDVA and CDVA at 6 months were comparable between primary surgery and reenclavation. The subluxation and subsequent reenclavation did not cause statistically significant endothelial cell loss; endothelial cell loss after reenclavation was comparable to that after primary surgery (P = .953). CONCLUSION: Successful subluxation of iris-fixated pIOLs did not cause significant damage to the ocular structures or lead to serious complications.

Laserinterferometric measurements of accommodative changes in the position of an optic-shift intraocular lens.

PURPOSE: To measure optically and pharmacologically induced movement of an optic-shift intraocular lens (HumanOptics 1CU). METHODS: The change in position as well as the accommodative effect of the 1CU was determined using an anterior chamber laser interferometer (Zeiss ACMaster) in 15 eyes of 9 patients. Accommodation was induced by optical stimulus and pharmacologically by pilocarpine 2%. RESULTS: The mean forward movement due to optical-induced accommodation stimulation was 5 +/- 14 microm (range: -10 to + 40 microm). Pharmacological stimulation with 2% pilocarpine caused mean anterior movements of 93 +/- 162 microm (range: -321 to +/- 402 microm). CONCLUSIONS: A maximum accommodative effect of 0.50 diopters was measured with this method. This relatively small accommodative effect of the 1CU is in agreement with other studies. Pharmacologically induced optic shift differs significantly from optically induced shift and allows no conclusion on a clinically expected accommodative effect.

The effect of cataract extraction on the contractility of ciliary muscle.

PURPOSE: To evaluate the changes in the pilocarpine-induced contractility of the ciliary muscle in eyes with presbyopia before and after cataract extraction using ultrasound biomicroscopy (UBM). DESIGN: Prospective interventional case series. METHODS: A clear corneal phacoemulsification and posterior chamber intraocular lens (AcrySof SA60AT; Alcon Laboratories, Fort Worth, Texas, USA) was implanted in 23 eyes in 15 subjects. UBM was performed with and without instilling 2% pilocarpine, as well as before and two months after cataract extraction. The mean (+/- standard deviation) age was 65.33 +/- 6.09 years (range, 56 to 75 years). The increase in the axial length of the ciliary body (CBAXL) was used as a surrogate indicator of the centripetal ciliary muscle contraction during accommodation. Images of the ciliary body were compared visually using Adobe Photoshop 7.0 (Adobe Systems Inc., San Jose, California, USA). RESULTS: The CBAXL value with and without pilocarpine before cataract extraction was 1.708 +/- 0.165 mm and 1.689 +/- 0.187 mm, respectively, which was not significantly different (P = .261). The CBAXL value with and without pilocarpine after cataract extraction was 1.998 +/- 0.375 mm and 1.675 +/- 0.279 mm, respectively, which was significantly different (P < .001). The visually compared configurations of the changes in the ciliary body were compatible with the analysis of the measured parameters. CONCLUSIONS: Pilocarpine induced only subtle movement of the ciliary body before cataract surgery. However, after cataract extraction, it induced significant centripetal movement of the ciliary body compared with that without pilocarpine. This shows that a lenticular sclerotic component may influence both lens movement and the contractility of the ciliary muscle, and is believed to be related to the presbyopia.

Barrier qualities of the mouse eye to topically applied drugs.

The mouse eye displays unusually rapid intraocular pressure (IOP) responses to topically applied drugs as measured by the invasive servo-null micropipette system (SNMS). To learn if the time course reflected rapid drug transfer across the thin mouse cornea and sclera, we monitored a different parameter, pupillary size, following topical application of droplets containing 40 microM (0.073 microg) carbachol. No miosis developed from this low carbachol concentration unless the cornea was impaled with an exploring micropipette as used in the SNMS. We also compared the mouse IOP response to several purinergic drugs, measured by the invasive SNMS and non-invasive pneumotonometry. Responses to the previously studied non-selective adenosine-receptor (AR) agonist adenosine, the A(3)-selective agonist Cl-IB-MECA and the A(3)-selective antagonist MRS 1191 were all enhanced to varying degrees, in time and magnitude, by corneal impalement. We conclude that the thin ocular coats of the mouse eye actually present a substantial barrier to drug penetration. Corneal impalement with even fine-tipped micropipettes can significantly enhance entry of topically-applied drugs into the mouse aqueous humor, reflecting either direct diffusion around the tip or a more complex impalement-triggered change in ocular barrier properties. Comparison of invasive and non-invasive measurement methods can document drug efficacy at intraocular target sites even if topical drug penetration is too slow to manifest convincing physiologic effects in intact eyes.

Phase transition water-in-oil microemulsions as ocular drug delivery systems: in vitro and in vivo evaluation.

Microemuslion (ME)-based phase transition systems were evaluated for ocular delivery of pilocarpine hydrochloride (model hydrophilic drug). These used two non-ionic surfactants, sorbitan mono laurate and polyoxyethylene sorbitan mono-oleate with ethyl oleate (oil component) and water. These systems undergo phase change from ME to liquid crystalline (LC) and to coarse emulsion (EM) with a change in viscosity depending on water content. This study selected five formulations containing aqueous phase at 5% (w/w) (ME 5%), 10% (w/w) (ME 10%), 26% (w/w) (LC), 85% (w/w) (O/W EM) and 100% (solution) with the model drug at 1% (w/w). Incorporation of pilocarpine hydrochloride did not affect the phase behaviour. The viscosity was increased initially with dilution from ME 5% to ME 10% then LC, indicating structuring of the system, before being reduced in the EM formulation. Drug release depended on the viscosity with lower release rates obtained from formulations with high viscosity. The miotic response and duration of action were greatest in case of ME and LC formulations indicating high ocular bioavailability. Thus, phase transition ME is promising for ocular drug delivery as it provides the fluidity with its viscosity being increased after application increasing ocular retention while retaining the therapeutic efficiency.

[Use of antiglaucoma therapy to reduce acute intraocular pressure rise following neodymium: YAG laser iridotomy in angle-closure glaucoma patients]. / Lokalna terapija glaukoma u redukciji akutnog povisenja intraokularnog tlaka u bolesnika s glaukomom zatvorenog kuta nakon neodymium: YAG laserske iridotomije.

AIM: To evaluate the efficacy of topical antiglaucoma therapy in reducing acute intraocular pressure (IOP) elevation after neodymium: Yag laser iridotomy. PATIENTS AND METHODS: Primary angle-closure glaucoma (PACG) eyes were randomized to receive premedication with latanoprost and pilocarpine, brimonidine 0.2% and pilocarpine or only with pilocarpine before Yag laser iridotomy. Postoperative IOP changes were compared with Wilcoxon signed-ranks test using the fellow eyes in each group. RESULTS: Postoperative pressure spikes were significantly lower in the groups of patients with local antiglaucoma therapy with pilocarpine than in the control group. Mean elevation of IOP was less in the groups of patients with local antiglaucoma therapy with pilocarpine at 2 hours postoperatively. CONCLUSION: Local antiglaucoma therapy may reduce the acute IOP rise following Yag laser iridotomy in PACG eyes.

Objective measurement of intraocular lens movement and dioptric change with a focus shift accommodating intraocular lens.

PURPOSE: To objectively measure the shift and refractive change of the 1CU accommodating intraocular lens (IOL) (HumanOptics) and compare them to that of a monofocal AcrySof MA30 IOL (Alcon Laboratories) in the fellow eye. SETTING: Ophthalmology Department, St. Thomas' Hospital, London, United Kingdom. METHODS: Thirty patients who had bilateral cataract surgery 18 to 24 months previously with a 1CU IOL prospectively randomly allocated to 1 eye and an AcrySof MA30 monofocal IOL to the other eye were examined. Distance correction, near vision, reading fluency, near point, and defocus to minus spheres were measured. Intraocular lens shift to an accommodative stimulus following instillation of pilocarpine 4% was measured with the ACMaster. Refractive change between distance and near was measured with the Tracey wavefront analyzer. RESULTS: Of the original 30 patients recruited, complete measurements could only be obtained for 20. There was no significant difference in near visual function with either IOL. A small anterior movement of the 1CU was seen with accommodation 0.010 mm +/- 0.028 (SD). After pilocarpine 4% instillation, a forward movement of 0.220 +/- 0.169 mm was seen with the 1CU compared to a backward movement of 0.028 +/- 0.095 with the MA30. There was no significant correlation between distance corrected near visual acuity and IOL movement. No change in spherical equivalent between distance and near was seen on wavefront analysis of either IOL. CONCLUSIONS: Small forward movement of the 1CU IOL was seen with accommodation and increased following pilocarpine, compared to the posterior movement of the MA30 IOL. The amount of the IOL shift was not sufficient to provide useful near vision, but the difference suggests that the engineering concept behind the 1CU IOL is valid.

Pharmacological-induced haptic changes and the accommodative performance in patients with the AT-45 accommodative IOL.

PURPOSE: To investigate the accommodative performance of the AT-45 (eyeonics Inc, Aliso Viejo, Calif) using three-dimensional ultrasound biomicroscopy. METHODS: The AT-45 haptic region was visualized in vivo 1 month after surgery in four patients using an in-house developed three-dimensional ultrasound biomicroscope. Haptic changes, axial shift, and accommodation amplitude were determined under pharmacologically induced accommodation. RESULTS: The angulation, depending on the accommodation state, could be distinguished and analyzed. In vivo a mean change in haptic angulation of 3.3 +/- 3.3 degrees (range: 0 degrees to 7 degrees) and a mean forward shift of 0.13 +/- 0.08 mm (range: 0.05 to 0.2 mm) were observed for the AT-45 using pharmacologically induced accommodation. A mean accommodative amplitude of 0.44 +/- 0.24 diopters (D) (range: 0.25 to 0.75 D) was found using a Hartinger coincidence refractometer. CONCLUSIONS: Minimal angulation changes and axial movements of the AT-45 have been demonstrated using pharmacological stimulation and objective measurement methods. The mechanical performance of the AT-45 in these eyes does not appear to provide the range of accommodation necessary for close work.