Nanofiber-based hydrogels with extracellular matrix-based synthetic peptides for the prevention of capsular opacification.

Nanofiber-based hydrogels (nanogels) with different, covalently bound peptides were used as an extracellular environment for lens epithelial cells (LECs) in order to modulate the capsular opacification (CO) response after lens surgery in a porcine eye model. Lenses were divided into 15 groups (n = 4 per group), the lens content was removed and the empty capsules were refilled with nanogel without peptides and nanogels with 13 combinations of 5 different peptides: two laminin-derived, two fibronectin-derived, and one collagen IV-derived peptide representing cell adhesion motifs. A control group of 4 lenses was refilled with hyaluronan. After refilling, lenses were extracted from the porcine eye and cultured for three weeks. LECs were assessed for morphology and alpha smooth muscle actin (αSMA) expression using confocal laser scanning microscopy. Compared to hyaluronan controls, lenses filled with nanogel had less CO formation, indicated by a lower αSMA expression (P = 0.004). Microscopy showed differences in morphological cell response within the nanogel refilled groups. αSMA expression in these groups was highest in lenses refilled with nanogel without peptides (9.54 ± 11.29%). Overall, LEC transformation is reduced by the presence of nanogels and the response is improved even further by incorporation of extracellular matrix peptides representing adhesion motifs. Thus, nanomaterials targeting biological pathways, in our case interactions with integrin signaling, are a promising avenue toward reduction of CO. Further research is needed to optimize nanogel-peptide combinations that fully prevent CO.

Changes in lens stiffness due to capsular opacification in accommodative lens refilling.

Accommodation may be restored to presbyopic lenses by refilling the lens capsular bag with a soft polymer. After this accommodative lens refilling prevention of capsular opacification is a requirement, since capsular opacification leads to a decreased clarity of the refilled lens. It has been hypothesized that capsular fibrosis causing the capsular opacification results in increased stiffness of the lens capsular bag, therewith contributing to a decrease in accommodative amplitude of the lens. However, the change in viscoelastic properties of refilled lenses due to capsular fibrosis has never been measured directly. In this study we examined natural lenses from enucleated porcine eyes and refilled lenses directly after refilling and after three months of culturing, when capsular fibrosis had developed, and determined their viscoelastic properties with a low load compression tester. Control refilled lenses were included in which capsular opacification was prevented by treatment with actinomycin D. We related lens stiffening to the degree of capsular opacification, as derived from the microscopic images taken with a confocal laser scanning microscope. Overall, the refilled lenses directly after refilling were softer than refilled lenses after three months of culturing, and refilled lenses treated with actinomycin D were softer compared with untreated refilled lenses. The degree of capsular opacification as assessed by microscopy corresponds to an increase in lens stiffness. This indicates that the viscoelastic properties of the refilled lens are influenced by capsular fibrosis and modulated by treatment of the lens epithelium. In conclusion, this study shows that the development of capsular fibrosis negatively affects the viscoelastic properties of isolated, cultured refilled lenses.

Prevention of posterior capsular opacification.

Posterior capsular opacification (PCO) is a common complication of cataract surgery. The development of PCO is due to a combination of the processes of proliferation, migration, and transdifferentiation of residual lens epithelial cells (LECs) on the lens capsule. In the past decades, various forms of PCO prevention have been examined, including adjustments of techniques and intraocular lens materials, pharmacological treatments, and prevention by interfering with biological processes in LECs. The only method so far that seems effective is the implantation of an intraocular lens with sharp edged optics to mechanically prevent PCO formation. In this review, current knowledge of the prevention of PCO will be described. We illustrate the biological pathways underlying PCO formation and the various approaches to interfere with the biological processes to prevent PCO. In this type of prevention, the use of nanotechnological advances can play a role.

Describing the corneal shape after wavefront-optimized photorefractive keratectomy.

PURPOSE: To develop a procedure for describing wavefront-optimized photorefractive keratectomy (PRK) corneas and to characterize PRK-induced changes in shape. METHODS: We analyzed preoperative and postoperative corneal elevation data of 41 eyes of 41 patients (mean [±SD] age, 38 [±11] years) who underwent a myopia-correcting (preoperative spherical equivalent refraction -3.9 [±1.5] diopters) wavefront-optimized PRK, assessed with Scheimpflug imaging. Zernike polynomials were fitted to the elevation data. The diameter of the greatest corneal zone that could be analyzed and the number of Zernike orders needed to make a reliable fit were determined, based on the fitting error. The PRK-induced changes in corneal shape were studied. RESULTS: All subjects could be included for analysis of zones up to 6 mm in diameter. This was 90, 83, and 44% for 7, 8, and 9 mm, respectively. The number of Zernike orders (terms) needed for an accurate fit ranged from four (15) for a 4-mm analyzed zone diameter to eight (45) for 8 mm. For the anterior surface, the spherical aberration term decreased significantly (p < 0.01) after PRK for the 4-mm analyzed zone diameter (-0.09 µm), remained unchanged for 5 mm (+0.01 µm; p = 0.56), and increased significantly for 6 mm (+0.40 µm) and above (p < 0.01). There was no significant change in any other higher-order Zernike term, but the square root of the sum of the squares of all higher-order terms increased significantly for all analyzed zone diameters. Photorefractive keratectomy did not influence the posterior corneal shape. CONCLUSIONS: The cornea after wavefront-optimized PRK can be described as accurately as a healthy cornea and with a similar number of Zernike polynomials. The anterior corneal shape changes significantly after treatment, whereas the posterior corneal shape remains unchanged. The observed effect of wavefront-optimized ablation on the spherical aberration term depends on the diameter of the analyzed zone.

Barriers to and facilitators of sports participation in people with visual impairments.

We examined barriers to and facilitators of sports participation in people with visual impairments. Participants registered at Royal Visio, Bartiméus, and the Eye Association were invited to complete a questionnaire (telephone or online). Six hundred forty-eight of the invited participants (13%) completed the questionnaire, and 63% of the respondents reported sports participation. Walking (43%), fitness (34%), and cycling (34%) were frequently mentioned sports. Costs, lack of peers/buddies, and visual impairment were negatively associated with sports participation, whereas higher education and computer (software) use were positively associated. The most important personal barrier was visual impairment; transport was the most important environmental barrier. Active participants also mentioned dependence on others as a personal barrier. The most important personal facilitators were health, fun, and social contacts; support from family was the most important environmental facilitator. To improve sports participation in people with visual impairments, the emphasis in a sports program should be on the positive aspects of sports, such as fun, health, and social contacts.

Relationship between contrast sensitivity and spherical aberration: comparison of 7 contrast sensitivity tests with natural and artificial pupils in healthy eyes.

PURPOSE: To find a contrast sensitivity test that can be used clinically to evaluate interventions aimed at minimizing spherical aberration and determine the circumstances under which these tests should be performed. SETTING: Laboratory of Experimental Ophthalmology, University of Groningen, Groningen, The Netherlands. METHODS: Contrast sensitivity tests were performed using 2 experimental designs. Design 1 was with a natural pupil under mesopic and photopic conditions. Design 2 was with a 5.0 mm artificial pupil after cycloplegia under photopic conditions only. Two computerized tests (vertical sine-modulated gratings [VSG] and Holladay circular sine-modulated patterns [HACSS]) and 5 chart tests (Pelli-Robson, acuity-measuring letter charts at low contrast [2.5% and 10%], VectorVision, and edge contrast sensitivity) were used. Spherical aberration was assessed with a Hartmann-Shack wavefront analyzer. RESULTS: Forty-nine healthy subjects aged 20 to 35 years (n = 24) and 55 to 70 years (n = 25) participated. Design 2 showed a significant relationship between contrast sensitivity and spherical aberration with the HACSS at 3 cycles per degree (cpd) (P = .03) and 6 cpd (P = .01) and with the VSG at 6 cpd (P = .01). Design 1 yielded no significant relationships. CONCLUSIONS: Using an artificial pupil, a relationship between contrast sensitivity and spherical aberration was established with the VSG and HACSS tests but not with the chart tests. No test showed a relationship using natural pupils under either lighting condition. Chart tests are unsuitable for uncovering contrast sensitivity differences related to differences in spherical aberration, as typically found in healthy phakic eyes.

Long-term prevention of capsular opacification after lens-refilling surgery in a rabbit model.

PURPOSE: To reduce capsular opacification by a peri-surgical treatment of the lens capsule with drugs in an in vivo rabbit model. Lens-refilling surgery is a potential therapeutic intervention to treat patients with a cataract lens. The lens material is replaced with an injectable (bio)polymer that retains the natural mechanical and optical lens properties, therewith allowing accommodation. The occurrence of capsular opacification mediated by lens epithelial cells negatively affects accommodation and vision and should be avoided in this lens restoration approach. METHODS: An in vivo rabbit animal model was used with lens replacement with a silicone-based gel-like polymer and concurrent treatment of the lens epithelium with drugs. A case-study approach was applied as both drug combinations and implantation times were varied. The following drugs were investigated for their potential to prevent capsular opacification long-term: actinomycin D, methotrexate, paclitaxel and Tween-20. All were administered in a hyaluronic acid vehicle. The rabbits were clinically followed for periods up to 4 years postimplantation. Eyes, corneas and lenses were analysed post-mortem using MRI and confocal microscopy. RESULTS: Treatment combinations containing actinomycin D generally led to the least appearance of capsular fibrosis. The use of Tween-20 or paclitaxel without actinomycin D resulted in much earlier and pronounced fibrotic responses. The aspect of capsular opacification was highly variable in individual animals. Application of the drugs in a hyaluronic acid vehicle appeared to be a safe method that spared the corneal endothelium. CONCLUSION: The feasibility of long-term prevention of fibrosis over a period of more than 4 years has been demonstrated in lens refilling in the rabbit model.

Development of a ciliary muscle-driven accommodating intraocular lens.

PURPOSE: To develop a ciliary muscle-driven accommodating intraocular lens (IOL) that has a large and predictable range of variable power as a step toward spectacle independence. SETTING: Department of Physics and Medical Technology, VU University Medical Center, Amsterdam, The Netherlands. METHODS: A concept IOL that has a rotating focus mechanism and a mechanical frame that can operate within the range of ciliary muscle contraction of a typical 60-year-old human eye was designed. Prototypes were made to test the IOL's mechanical performance in an enucleated pig's eye using a laboratory lens-stretching device that mimics the action of the human ciliary muscle. Changes in focal length during stretching were measured by laser-based ray tracing and a videocamera system. To rotate the 2 lenses in the IOL with variable optical power, a frame that allows the displacement and force of the ciliary muscle to be transferred by the capsular bag was designed. RESULTS: Ray tracing showed that the modulation transfer function (MTF) of the IOL in different accommodative states did not deviate to a great extent from the MTF of a monofocal IOL. During stretching experiments, the prototype IOL achieved 8.0 diopters of accommodation. CONCLUSIONS: Evaluation of an accommodating IOL that meets the requirements for a spectacle-independent solution to presbyopia showed that the mechanical and optical designs must be further optimized to improve optical quality and functionality.

Changes in spherical aberration after lens refilling with a silicone oil.

PURPOSE: It may be possible to restore accommodation to presbyopic human eyes by refilling the lens capsular bag with a soft polymer. In the present study, optical changes were measured that occurred in a pig eye model after the refilling of the capsular bag. METHODS: The optical power and spherical aberration in 10 isolated pig lenses were measured under different conditions. They were first determined by using a scanning laser ray-tracing technique over an effective pupil size of 6 mm. Second, the contours of the anterior and posterior lens surface were photographed, and a mathematical ray-tracing was performed by using a polynomial fit through the digitized surface contours, to determine optical power and spherical aberration. Third, the lenses were refilled with a silicone oil until their preoperative lens thickness was reached, and scanning laser ray-tracing, contour photography, and mathematical ray-tracing were repeated. Comparisons between the measurements were made to determine how the change from a gradient refractive index to a homogeneous refractive index influenced spherical aberration. The influence of the change in lens contour on spherical aberration after lens refilling was also studied. RESULTS: The natural lenses had a higher lens power than the refilled lenses (49.9 +/- 1.5 D vs. 36.8 +/- 1.5 D; P < 0.001). Moreover, there was a change in sign from negative spherical aberration before lens refilling (-3.6 D) to positive spherical aberration after lens refilling (7.9 D; P < 0.001). The comparison between scanning laser ray-tracing of the natural lens and mathematical ray-tracing of the photographed surface contours of the natural lens to determine the effect of refractive index substitution (i.e., replacement of a gradient refractive index by a homogeneous refractive index) showed a significant change in spherical aberration from -3.6 +/- 2.0 to 11.0 +/- 2.1 D (P < 0.001). The change in lens contour did not result in a significant change in spherical aberration (P = 0.08) before and after lens refilling with an equal refractive index. CONCLUSIONS: The lower lens power of refilled pig lenses compared to natural lenses was due to the lower refractive index of the refill material. Refilling pig lenses with the silicone oil used in this study resulted in an increase in spherical aberration. This increase was mainly caused by the change from a gradient refractive index to a homogeneous refractive index. The change in lens curvature after lens refilling did not result in an increase in spherical aberration. The influence of lens refilling on spherical aberration of human lenses must be determined in similar experiments in human eyes.

Posterior corneal shape: Comparison of height data from 3 corneal topographers.

PURPOSE: To compare the ability of 3 clinical corneal topographers to describe the posterior corneal shape. SETTING: University Medical Center Groningen, the Netherlands. DESIGN: Prospective observational study. METHODS: Corneas of healthy participants were measured twice with a dual Scheimpflug instrument (Galilei G2), a scanning-slit system (Orbscan IIz), and a single Scheimpflug instrument (Pentacam HR). Height data describing the posterior corneal shape were fit with Zernike polynomials. Mean values with standard deviations (SD), test-retest variability (coefficient of repeatability [CoR]), and interdevice variability were determined for the defocus Z(2,0), astigmatism Z(2,-2) and Z(2,2), and higher-order terms coma Z(3,-1) and Z(3,1), trefoil Z(3,-3) and Z(3,3), and spherical aberration Z(4,0) coefficients for 5.5 mm and 8.0 mm diameters. RESULTS: For the 5.5 mm diameter, CoRs ranged from 0.3 to 4.3 µm with the dual Scheimpflug instrument, 1.6 to 5.2 µm with the scanning-slit system, and 0.3 to 2.0 µm with the single Scheimpflug instrument. The CoR was similar for the Scheimpflug instruments (P = .43) but poorer for the scanning-slit system (P < .001). The CoRs of the Scheimpflug instruments were smaller than the corresponding population SD for defocus, cardinal astigmatism, coma, and spherical aberration. The scanning-slit system failed to provide 8.0 mm diameter data. There was a significant bias (interdevice variability) between the Scheimpflug instruments in the higher-order coefficients at both diameters. CONCLUSIONS: Repeatability in assessing the posterior corneal shape was generally good for the Scheimpflug instruments but poor for the scanning-slit system. Interdevice variability between the Scheimpflug instruments compromised the interchangeability of higher-order coefficients. For astigmatism, CoR and 95% limits of agreement of the Scheimpflug instruments typically corresponded to 0.1 diopter per astigmatism term.

Accommodative lens refilling in rhesus monkeys.

PURPOSE: Accommodation can be restored to presbyopic human eyes by refilling the capsular bag with a soft polymer. This study was conducted to test whether accommodation, measurable as changes in optical refraction, can be restored with a newly developed refilling polymer in a rhesus monkey model. A specific intra- and postoperative treatment protocol was used to minimize postoperative inflammation and to delay capsular opacification. METHODS: Nine adolescent rhesus monkeys underwent refilling of the lens capsular bag with a polymer. In the first four monkeys (group A) the surgical procedure was followed by two weekly subconjunctival injections of corticosteroids. In a second group of five monkeys (group B) a treatment intended to delay the development of capsular opacification was applied during the surgery, and, in the postoperative period, eye drops and two subconjunctival injections of corticosteroids were applied. Accommodation was stimulated with carbachol iontophoresis or pilocarpine and was measured with a Hartinger refractometer at regular times during a follow-up period of 37 weeks in five monkeys. In one monkey, lens thickness changes were measured with A-scan ultrasound. RESULTS: In group A, refraction measurement was possible in one monkey. In the three other animals in group A, postoperative inflammation and capsular opacification prevented refraction measurements. In group B, the maximum accommodative amplitude of the surgically treated eyes was 6.3 D. In three monkeys the accommodative amplitude decreased to almost 0 D after 37 weeks. In the two other monkeys, the accommodative amplitude remained stable at +/-4 D during the follow-up period. In group B, capsular opacification developed in the postoperative period, but refraction measurements could still be performed during the whole follow-up period of 37 weeks. CONCLUSIONS: A certain level of accommodation can be restored after lens refilling in adolescent rhesus monkeys. During the follow-up period refraction measurements were possible in all five monkeys that underwent the treatment designed to prevent inflammation and capsular opacification.

Development of an accommodating intra-ocular lens--in vitro prevention of re-growth of pig and rabbit lens capsule epithelial cells.

Cataract surgery is routinely performed to replace the clouded lens by a rigid polymeric intra-ocular lens unable to accommodate. By implanting a silicone gel into an intact capsular bag the accommodating properties of the natural lens can be maintained or enhanced. The implantation success of accommodating lenses is hampered by the occurrence of capsular opacification (PCO) due to lens epithelial cell (LEC) growth. In order to prevent LEC proliferation, a treatment regime using actinomycin D, cycloheximide and water was developed. The effectiveness of treatment was analyzed using an in vitro, MTT-based cell culture system and an ex vivo pig eye model in which the implanted lens-in-the-bag is cultured as a whole. LEC were exposed to treatment solutions for 5 min, then the cells were allowed to recover and to re-colonize the substratum. MTT conversion by cells was transiently inhibited by cycloheximide dissolved in water and by water alone. Exposure to actinomycin D resulted in a lasting inhibition of MTT conversion and consequently cell proliferation. These in vitro data could not be fully reproduced in the ex vivo pig eye model due to essential differences between both models. Treatment with actinomycin D containing solutions, however, resulted in a nearly complete absence of cells on the capsular wall. The pig eye model is a promising approach to further evaluate the effects of peri-surgical treatment during the accommodating intra-ocular lens implantation.

Artificial crystalline lens.

If presbyopia is caused by hardening of the crystalline lens, replacing it with a material with mechanical properties similar to the young crystalline lens should restore accommodative ability. Such a silicone material has been developed. Refilling the capsular bag with this material results in 3 to 5 D of accommodation in primates in response to pilocarpine.

Effects of peptide ratios in nanofibre-based hydrogels for the prevention of capsular opacification.

PURPOSE: To moderate the capsular opacification (CO) response after lens surgery, an experimental study was performed in which nanofibre-based hydrogels (nanogels) with different ratios of attached peptides were applied to provide extracellular matrix-related cues for lens epithelial cells (LECs) in a porcine eye model. METHODS: The lens content was removed, and the capsules were refilled with nanogel. Lenses were divided into two groups, the first group (n = 34) was refilled with nanogels containing different ratios of two laminin-derived peptides (IKVAV + YIGSR), and the latter group (n = 26) was refilled with nanogel combinations of a fibronectin-derived and a type IV collagen-derived peptide (RGDS + DGEA). Two lenses were refilled with culture medium to investigate the effect of the medium on LECs. After refilling, lenses were extracted and cultured for 3 weeks. Lens epithelial cells (LECs) were assessed for morphology and alpha-smooth muscle actin (αSMA) expression using confocal laser scanning microscopy. RESULTS: Differences were seen in cell morphology between lenses refilled with nanogels with IKVAV + YIGSR and RGDS + DGEA peptides. In nanogels with IKVAV + YIGSR peptides, differences in LEC morphology were largest when ratios between the peptides were unequal, whereas LEC responses from the RGDS + DGEA refilled groups showed variation in LEC morphology dependent on the total quantity of mixed-in peptides. The culture medium did not induce proliferation or transformation of LECs. CONCLUSIONS: Ratios and concentrations of cell adhesion-mediating peptides both can direct the LEC response, depending on the adhesion molecules of origin, by influencing LEC proliferation and transformation. Nanogels with incorporated peptides may be tuned towards CO prevention.

Influence of stereoscopic vision on task performance with an operating microscope.

PURPOSE: To determine the extent to which stereoscopic depth perception influences the performance of tasks executed under an operating microscope. SETTING: Laboratory of Experimental Ophthalmology, University Medical Center Groningen, the Netherlands. DESIGN: Experimental study. METHODS: Medical students were assigned (on the basis of their stereoacuity) to a stereo-sufficient group (depth perception ≤240 seconds of arc [arcsec]) or stereo-deficient group (≥480 arcsec). They performed a bead-stringing task (a mockup surgical test) under an operating microscope or a task on a cataract surgery simulator. The stereo-sufficient subjects also performed the bead-stringing task under artificial stereo-deficient conditions (binocular and monocular viewing). RESULTS: The study comprised 77 medical students. The stereo-sufficient subjects performed both tasks faster than the stereo-deficient subjects and artificially stereo-deficient subjects (P ≤ .024). In addition, a within-group analysis established that the stereo-sufficient subjects were faster at the bead-stringing task with stereoscopic viewing than under artificial stereo-deficient conditions with binocular viewing (P ≤ .011). CONCLUSIONS: Having stereovision resulted in better initial performance on certain tasks involving the use of an operating microscope or cataract surgery simulator. However, this study did not show that stereo deficiency necessarily results in an inability to perform such tasks properly. Hence, it was not evident that for admission to an ophthalmology residency program, stereovision should be judged more stringently than other traits. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Polymer refilling of presbyopic human lenses in vitro restores the ability to undergo accommodative changes.

PURPOSE: Because presbyopia is thought to be accompanied by increased lens sclerosis this study was conducted to investigate whether refilling the capsule of the presbyopic human lens with a soft polymer would restore the ability of the lens to undergo accommodative changes. METHODS: Accommodative forces were applied to natural and refilled lenses by circumferential stretching through the ciliary body and zonular complex. Nine natural lenses and 10 refilled lenses from donors ranging in age from 17 to 60 years were studied. Two refill polymers with a different Young's modulus were used. The lens power was measured by a scanning laser ray-tracing technique, and lens diameter and lens thickness were measured simultaneously while the tension on the zonules was increased stepwise by outward pull on the ciliary body. RESULTS: In the natural lenses the older lenses were not able to undergo power changes with stretching of the ciliary body, whereas in the refilled lenses, all lenses showed power changes comparable to young, natural lenses. The refilled human lenses had a higher lens power than the age-matched natural lenses. The Young's modulus of the polymers influenced the lens power change when measured with the ciliary body diameter increased by 4 mm. CONCLUSIONS: Refilling presbyopic lenses with a soft polymer enabled restoration of lens power changes with mechanical stretching. Because sclerosis of the lens is an important factor in human presbyopia, refilling the lens during lens surgery for cataract could enable restoration of clear vision and accommodation in human presbyopia.

Effect of infusion bottle height on lens power after lens refilling with and without a plug.

PURPOSE: To evaluate the influence of intraoperative infusion bottle height on the power of refilled pig lenses. SETTING: Research Laboratory, Pharmacia Intraocular Lens Manufacturing Plant, Groningen, The Netherlands. METHODS: This study comprised 2 groups of pig eyes. In 1 group, the lens was refilled with silicone oil using a plug to close the capsulorhexis; in the other group, no plug was used. The anterior chamber depth, lens thickness, and vitreous chamber depth were measured by A-scan ultrasound. The total refraction was measured with a Hartinger refractometer. Measurements were performed with the infusion bottle at 0 cm, 25 cm, 50 cm, 75 cm, and 100 cm above eye level. Calculations using a model eye were performed to evaluate the change in lens power based on empirical data. RESULTS: The mean change in the power of refilled lenses caused by varying the height of the infusion bottle was 1.8 diopters. Lenses refilled with a plug had a thickness similar to that of natural lenses. Lenses refilled without a plug were significantly thinner (P<.05). The power of lenses refilled with a plug was significantly higher that of lenses refilled without a plug (P<.05). CONCLUSIONS: During lens refilling, infusion bottle height influenced the resulting lens power. Using a plug to close the capsulorhexis resulted in refilled lens dimensions similar to those of the natural lens.

Quality of care from the perspective of the cataract patient. QUOTE cataract questionnaire.

PURPOSE: To examine the potential of a questionnaire (QUOTE Cataract) to measure quality of care from the perspective of cataract patients in quality-assurance or improvement programs. SETTING: Department of Ophthalmology, University Hospital Maastricht, Maastricht, University Hospital Groningen, Groningen, and Rotterdam Eye Hospital, Rotterdam, The Netherlands. METHODS: Cataract patients (N = 540) who had cataract surgery 2 to 8 months previously rated 31 quality-of-care aspects in terms of importance (range 0, not important, to 10, extremely important) and performance (0 = yes, 1 = no). An arithmetic combination of the 2 parameters was used to generate quality-impact factors (Q) (range 0, best quality of care, to 10, this aspect needs improvement according to every respondent). The goal was to identify bottlenecks in the quality of care. RESULTS: Patients scored aspects concerning patient education as the most important quality aspects. The top 3 quality-impact factors were to inform patients what to do in emergency situations (Q = 3.39), inform patients about the risks of treatment (Q = 3.00), and minimize the number of ophthalmologists to 1 per patient (Q = 2.79). CONCLUSIONS: The QUOTE Cataract Questionnaire effectively measured quality of care in cataract surgery patients in different hospital settings and provided practical information for quality-assurance programs.

Preservation of enucleated porcine eyes for use in a wet laboratory.

PURPOSE: To design a method to preserve enucleated porcine eyes for use in a wet laboratory. SETTING: Laboratory of Experimental Ophthalmology, University Medical Center Groningen, the Netherlands. DESIGN: Experimental study. METHODS: Porcine eyes were preserved using 15 methods including salt solutions, anterior chamber infusion fluids, tap water, mineral water, air, and topical glycerol on the cornea. The central corneal thickness (CCT) was measured by A-scan ultrasound over 3 days. Differences between increases in CCT were compared using repeated-measures multivariate analyses of variance. Also, lenses from eyes preserved in tap water were extracted and the lens epithelial cell morphology was studied. RESULTS: There was a significant interaction between the preservation method and CCT over 3 days (P<.001). Post hoc tests showed that the CCT in the sodium chloride (NaCl) 10.0% and tap-water groups increased significantly less than with 4 other preservation methods. However, preservation in NaCl 10.0% resulted in unusable shrunken coriaceous lenses. Addition of glycerol did not decrease the CCT. Lens epithelial cells from eyes preserved in tap water for 48 hours appeared to be intact but lost cell organization. CONCLUSIONS: Of the 15 tested methods to preserve porcine eyes, tap water (mineral content 1.79 mmol/L) resulted in the least corneal swelling. It is not necessary to use more expensive anterior chamber infusion fluids or other salt solutions. FINANCIAL DISCLOSURE: Neither author has a financial or proprietary interest in any material or method mentioned.

Prevention of capsule opacification after accommodating lens refilling: pilot study of strategies evaluated in a monkey model.

PURPOSE: To test 2 strategies to prevent capsule opacification after accommodating lens refilling in a rhesus monkey model. SETTING: Animal laboratory and laboratory of European university medical centers. DESIGN: Experimental study. METHODS: Six rhesus monkeys had refilling of the lens capsular bag. In the first strategy, before it was filled with a silicone polymer, the capsular bag was treated with noncommercial sodium hyaluronate 1.0% containing cytotoxic substances. In the second strategy, the capsular bag was filled with clinically used sodium hyaluronate 1.0% (Healon) after treatment with actinomycin-D. Slitlamp inspection was performed during a follow-up of 40 to 50 weeks. After enucleation, magnetic resonance images were obtained and confocal fluorescence imaging was performed. RESULTS: Using the first strategy, capsule opacification developed in all eyes. Using the second strategy, 1 monkey did not develop capsule opacification after a 9-month follow-up. In a second monkey, the lens capsule remained clear for 3 months, after which the hyaluronate refill material was exchanged with a silicone polymer and capsule opacification developed. Combining these results with those in a previous study, the difference in opacification between silicone and sodium hyaluronate as refilling materials was statistically significant (P<.01). CONCLUSIONS: That no capsular bag fibrosis occurred in the presence of hyaluronate suggests that the properties of hyaluronate are the reason that remaining lens epithelial cells do not develop into fibrotic cells. The choice of a suitable lens-refilling material prevents the development of capsule opacification. FINANCIAL DISCLOSURE: Mr. Terwee was an employee of Abbott Medical Optics B.V. during the study period. No other author has a financial or proprietary interest in any material or method mentioned.