Severe Intraocular lens tilt following the Yamane technique.

PURPOSE: To evaluate CT Lucia 602 intraocular lenses (IOLs) implanted in cases lacking capsular support, and explanted because of decentration/dislocation with subsequent pathological analysis. The main objectives were to a) document the status of haptics, and b) verify the presence of the "rotisserie" effect. SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. DESIGN: Case series with clinicopathological correlation. METHODS: 13 explanted CT Lucia 602 lenses were included, 12 implanted via the Yamane technique, and 1 that was iris-fixated. Four lenses were explanted between October 2020 and February 2022. Nine lenses, explanted between November 2022 and February 2024 also exhibited severe optic tilt, leading to explantation. A chart review was performed to obtain clinical information from each case. Explanted lenses underwent gross and microscopic examination for haptic status and rotation, in the dry state (room temperature) and after hydration (body temperature). RESULTS: Time between implantation and explantation was longer for lenses explanted before November 2022 (without severe tilt). Among the 26 haptics evaluated, 15 were deformed, 6 were broken, 2 were detached, and 3 were unremarkable. Four haptics of Yamane lenses explanted between November 2022 and February 2024 showed free rotation within the optic insertion, after hydration at body temperature. CONCLUSION: Anecdotal reports of the "rotisserie" effect of CT Lucia 602 lenses implanted via the Yamane technique appeared mostly during the second half of 2022, and suggested that affected lenses were from specific batches, which appears to be consistent with the findings of this study.

Carbon bursts inside a small aperture intraocular lens after Nd:YAG laser capsulotomy.

Purpose: The IC-8® Apthera™ (AcuFocus Inc.™, Irvine, California, USA) is the first small aperture intraocular lens (IOL) to receive FDA approval for presbyopia correction in the summer of 2022. It is a single-piece hydrophobic acrylic monofocal lens, which is placed in the capsular bag. In its center it carries a black circular mask (FilterRing™) with a diameter of 3.23 mm consisting of polyvinylidene fluoride and carbon black nanoparticles. In the center of this mask sits a 1.36 mm wide aperture. Thanks to this pinhole effect the IC-8® serves as an extended-depth-of-focus (EDOF) IOL and can be used in presbyopia correction.This report describes the case of a patient with an IC-8® implant who underwent Nd:YAG laser capsulotomy for posterior capsule opacification (PCO). The post laser checkup showed a dark central optical change within the IOL and the patient described optical phenomena as well as blurred central vision, which is why he received IOL exchange. The explanted IC-8® was sent to the Intermountain Ocular Research Center at the University of Utah for further analysis. Observations: A 56-year-old male underwent cataract surgery with implantation of a non-diffractive EDOF-IOL on the right and the IC-8® small aperture IOL on the left eye. On the left eye, the patient had received penetrating keratoplasty seven years prior to the cataract operation due to posttraumatic corneal scarring. The early checkups after cataract surgery showed a corrected distance visual acuity (CDVA) in the left eye of +0.1 logMAR in the first month. About 5 months after the operation, PCO was first described on the left eye leading to a decrease in visual acuity to +0.4 logMAR (CDVA). Due to PCO, Nd:YAG laser capsulotomy was conducted 5 months after the cataract operation on the left eye. 12 shots were applied at 2.7 mJ. The following appointments showed a continuously reduced visual acuity of +1.3 logMAR (uncorrected) on the left eye and the patient described blurry and 'swirled' central vision. By slightly tilting his head and thus not using the center of his optic axis, he would be able to see sharper. Slit lamp examination showed a small optical change inside the IC-8® IOL not resembling a pit but believed to be a small pocket of air. Due to the ongoing symptoms as well as the reduced VA, the seemingly damaged small aperture IOL was exchanged for a three-piece hydrophobic acrylic monofocal lens, which was also placed in the posterior chamber. The explanted IC-8® was sent to the Intermountain Ocular Research Center at the University of Utah for further analysis. Results from gross and light microscopic analysis showed that the change caused by the Nd:YAG laser application consisted of a localized optical area containing carbon black nanoparticles used for the circular mask within the IOL. Conclusions and importance: When dealing with PCO and performing Nd:YAG laser capsulotomy in eyes with an IC-8® IOL implant, the laser shots should be applied either inside the aperture or outside of the black circular mask of the IOL. Otherwise, the Nd:YAG laser can lead to bursts of carbon nanoparticles within the IOL which may cause optical phenomena as well as decreased visual acuity possibly resulting in an IOL exchange.

3D X-ray computed tomography in the analyses of intraocular lenses explanted because of postoperative opacification.

PURPOSE: To use X-ray computed tomography (CT) -which describes the acquisition and reconstruction of 2-dimensional X-ray transmission images to create a 3D representation of a specimen -in the analyses of intraocular lenses (IOLs) explanted because of optical opacification occurring postoperatively. SETTING: John A. Moran Eye Center, and Utah Nanofab, University of Utah, Salt Lake City, Utah. DESIGN: Laboratory study. METHODS: A hydrophilic acrylic and a silicone lens (the latter from an eye with asteroid hyalosis) explanted because of postoperative calcification, as well as a poly(methyl methacrylate) (PMMA) lens explanted because of snowflake degeneration underwent analysis under gross and light microscopy. Then, they were attached to an appropriate support and scanned under a Zeiss Xradia Versa X-ray microscope. After data acquisition, data segmentation was performed with a commercially available program to separate image data into components. RESULTS: Morphology, size/volume, and specific location of calcified deposits on the surface or within the substance of explanted IOLs could be demonstrated by X-ray CT within the entire volume of each lens with high contrast and resolution. The PMMA lens showed multiple spaces/fissures in relation to Nd:YAG pitting of the optic, and what appeared to be sheets of delaminated PMMA material at different levels within the optic substance. CONCLUSIONS: The key benefit of X-ray CT is that it can be performed without physically sectioning the specimen. This preliminary study demonstrates that this technology can be potentially useful in the imaging and analyses of explanted, opacified lenses.

Ex Vivo Histological Analysis of Corneas with Manually Implanted Intracorneal Stromal Ring Segments.

Backgrond: Intracorneal ring segments (ICRSs) are utilized to correct refractive changes impacting visual acuity, commonly implanted via femtosecond laser but can also inserted manually. Corneal deposits alongside the ICRS channels are seen commonly. Methods: This study explores the histological characteristics of corneal deposits following manual ICRS implantation, comparing them to previously published articles describing femtosecond laser-assisted cases. Results: This is a retrospective analysis of three cases involving manual ICRS implantation, accumulation of whitish deposits and later explanation of the corneas due to penetrating keratoplasty (PKP). Patient demographics, ocular history, and surgical details were collected. Histological analysis employed Hematoxylin and Eosin (H&E) and Masson's trichrome staining. Whitish deposits along ICRS tracts were observed in all cases, with minimal fibroblastic transformation of keratocytes adjacent to the segments. Comparing these cases of manual to femtosecond laser-assisted ICRS implantation, in most cases, similar deposits were identified, indicating the deposits' association with the stromal tissue reaction to the ring segment and not to the surgical technique. Conclusions: This study contributes insights into the histopathology of manually implanted ICRS, emphasizing the shared nature of deposits in both insertion methods. The findings highlight the link between deposits and the stromal tissue reaction to the ring segment, irrespective of the insertion technique.

Immunohistochemical findings of lens capsules obtained from patients with dead bag syndrome.

PURPOSE: To investigate the extracellular matrix and cellular components in lens capsules extracted from patients with dead bag syndrome (DBS) through immunohistochemistry. SETTING: Department of Ophthalmology, Wakayama Medical University School of Medicine, Wakayama, Japan, and Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah. DESIGN: Immunohistochemical experimental study. METHODS: 9 capsular bag specimens from DBS cases, as well as 2 control specimens from late-postoperative in-the-bag intraocular lens dislocation cases related to previous vitrectomy, pseudoexfoliation, and blunt trauma were included. They were processed for histopathology; unstained sections were obtained from each one and analyzed by immunohistochemistry targeting collagen type IV, laminin, vimentin, collagen type I, and fibronectin. RESULTS: Immunohistochemistry in DBS showed lens capsule stained for basement membrane components. The outer part of the anterior capsule that was split from the inner part was more markedly stained for type IV collagen as compared with the posterior part. Faint staining for fibrous posterior capsular opacification (PCO) components, for example, collagen type I and fibronectin, was detected in limited areas, but the major portion of the capsule was free from these components. Small spotty vimentin-positive materials, suggesting the presence of cell debris, were also detected in limited samples. CONCLUSIONS: Small amounts of fibrotic PCO components were detected in capsules extracted from patients with DBS, but their major parts were free from PCO components. Current findings suggest small amounts of lens epithelial cells were present after surgery and secreted fibrous components before undergoing cell death process.

Microscopic analysis of preinsertion cutting modalities on custom, flexible iris prostheses.

PURPOSE: To determine the induced edge effects of different clinically used device postmanufacture modification styles and modalities on custom iris implants. SETTINGS: An academically affiliated multispecialty private practice group and an academic medical center. DESIGN: Laboratory study. METHODS: Sample custom iris prostheses were cut using patterns, blades, and surgical instruments described in the literature. The cut edges were evaluated with slitlamp microscopy, light microscopy, and scanning electron microscopy. RESULTS: Disposable blades yielded smoother cuts than scissors. Trephine blade brand significantly affected the cut surface smoothness of the silicone matrix. Meshwork-embedded prostheses had some irregular sharp edges where the mesh fibers were cut with all modalities, although these were worse with scissors and one tested trephine brand compared with the other. Pseudoiridectomies and scissor cuts created sharp points and corners in the device periphery. CONCLUSIONS: Postmanufacture modifications of iris implants should be minimized. The cut margins of the fiber-free implants have fewer sharp edges and may be preferable for sulcus placement. In-the-bag device placement may mitigate clinical impact of sharp edges and corners. These practices may help to minimize inflammatory sequelae postimplantation.

Rotational stability of a new hydrophobic acrylic intraocular lens platform.

PURPOSE: To evaluate rotational stability for ease of rotation of a new intraocular lens (IOL) platform with 4 haptics in an ex vivo model and compare it with a control single-piece lens with 2 open loops. SETTING: Intermountain Ocular Research Center, John A. Moran Eye Center, University of Utah, Salt Lake City, Utah. DESIGN: Experimental study. METHODS: 10 human cadaver eyes were prepared as per the Miyake-Apple technique. After injection of the test or control lens, clockwise and counterclockwise rotations were attempted with a hook, with and without an ophthalmic viscosurgical device in place. Ease of rotation was scored as (1) very easy, (2) easy, (3) difficult, and (4) very difficult. Rotation of the entire eye containing test or control IOL was also performed with a multipurpose rotator (2 minutes; 220 revolutions per minute) to evaluate its effect on IOL alignment. RESULTS: There were statistically significant differences regarding ease of rotation between test and control lenses in all 4 scenarios, with rotation being more difficult with the test lens ( P < .05, Wilcoxon signed-rank test). No change in the alignment of test or control lenses was observed after eye rotation with the multipurpose rotator. CONCLUSIONS: The new IOL platform showed greater rotational stability than the control lens in this model, owing to design features such as 4 small arcs of contact between the haptics and the bag equator, a bulge at the distal end of each haptic, and arcuate haptics with curvatures oriented toward each other.

Complications of foldable intraocular lenses requiring explantation or secondary intervention: 2022 survey with update of long-term trends.

PURPOSE: To assess the complications that resulted in the explantation or secondary intervention with foldable intraocular lenses (IOLs). SETTING: University setting, Salt Lake City, Utah. DESIGN: Survey study. METHODS: For the 25th consecutive year, surgeons were surveyed regarding complications associated with foldable IOLs requiring explantation or secondary intervention over the 2022 calendar year. These forms were made available online using the ASCRS and ESCRS websites and a fax-on-demand service. Surgeons completed 1 survey for each foldable IOL requiring explantation or secondary intervention. Further analysis determined complication trends related to specific IOL styles, materials, and types over the past 16 years (2007 to 2022). RESULTS: 103 completed surveys were returned in 2022 contributing to a total of 1627 tabulated surveys since 2007. In the 2022 survey, dislocation/decentration continued to be the most common complication overall. Glare/optical aberrations was a common complication associated with multifocal IOLs continuing a 16-year trend. In addition, hydrophilic acrylic IOLs as well as some silicone lenses in eyes with asteroid hyalosis demonstrated calcification as the most common complication necessitating explantation. CONCLUSIONS: Dislocation/decentration remains the leading cause of explantation in most IOL types. Glare/optical aberrations continue to be an associated complication of multifocal IOLs suggesting this ongoing issue has yet to be resolved with this type of IOL. In addition, calcification of hydrophilic acrylic lenses and silicone lenses is a rare event but continues to occur.

Corneal endothelium protection provided by ophthalmic viscosurgical devices during phacoemulsification: experimental study in rabbit eyes.

PURPOSE: To compare the protection of the corneal endothelium provided by a cohesive and a dispersive ophthalmic viscosurgical device (OVD) against damage from torsional ultrasound and simulated lenticular debris during phacoemulsification. SETTING: University setting, Salt Lake City, Utah. DESIGN: Experimental study. METHODS: 15 New Zealand rabbits were included. After incision, each eye received cohesive or dispersive OVD (ProVisc or Viscoat). 10 1.0 mm beads were injected to simulate lenticular debris. The Intrepid Balanced tip (Centurion Ozil handpiece) was inserted into the anterior chamber, and 60% torsional ultrasound with 50 mL/min flow, 70 mm Hg intraocular pressure, and 600 mm Hg vacuum was applied (20 seconds). Cumulative dissipated energy (CDE) was noted. After euthanasia and enucleation, corneas were removed, stained with trypan blue/alizarin red, and photographed (5 ×400 magnification photos and 1 overview photograph from each cornea). ImageJ was used to evaluate cell damage and loss. RESULTS: CDE was 4.70 ± 0.26 and 4.64 ± 0.10 in the cohesive and dispersive OVD groups, respectively ( P = .8647). The analysis of the ×400 photographs showed that the percentage of intact cells was statistically higher in the dispersive OVD group ( P = .0002), whereas the percentages of damaged and lost cells were statistically higher in the cohesive OVD group ( P = .0002 and .0059, respectively). Overview photographs revealed the presence of residual OVD on the endothelium, especially in the dispersive group. CONCLUSIONS: In this experimental study using a rabbit model, the corneal endothelium protection provided by the dispersive OVD was superior to that provided by the cohesive OVD.

Wave-like calcification on the posterior surface of an acrylic hydrophilic bag-in-the-lens (BIL) implant.

Purpose: To report secondary opacification of a hydrophilic bag-in-the-lens (BIL) which is a rare manifestation that can happen years after initial surgery. Observations: We describe a case of a prominent wave-like, rippled opacification on the posterior surface of the BIL. The opacification was composed of calcium deposits and seems to start in the periphery as a ring and progresses to the centre of the posterior surface. Due to the specific design of the BIL, there is direct contact between the BIL and the posterior chamber, both with the space of Berger, and the anterior hyaloid, particularly in this very hyperopic eye. Conclusions and importance: Abnormal fluid flow and stagnation in an unusual retrolenticular space is a possible explanation for this unusual pattern of posterior surface opacification.

Effect of simulated lenticular debris on corneal endothelial cells: experimental study in rabbit eyes.

PURPOSE: To evaluate mechanical damage of simulated lenticular debris on corneal endothelial cells during phacoemulsification. SETTING: University setting, Salt Lake City, Utah. DESIGN: Experimental study. METHODS: 12 New Zealand rabbits underwent bilateral surgery. After incision, 10 1.0 mm beads were injected into the anterior chamber of test eyes to simulate lenticular debris. A balanced salt solution was injected into the contralateral eyes with the same injector. The Intrepid Balanced Tip of the Centurion Ozil handpiece was inserted into the anterior chamber, and 60% torsional ultrasound was applied for 20 seconds with 50 mL/min flow, 70 mm Hg intraocular pressure, and 600 mm Hg vacuum. Cumulative dissipated energy (CDE) was noted. After euthanasia and enucleation, the corneas were removed, stained with trypan blue/alizarin red, and photographed in a standardized manner (×400 photographs from 5 specific areas and 1 overview photograph from each corneal button). The ImageJ program was used to evaluate cell damage and loss in the photographs. RESULTS: CDE was 4.64 ± 0.19 for test eyes with beads and 4.66 ± 0.17 for control eyes without beads ( P = .58). The percentage of intact cells was statistically higher in the control group ( P = .0005), whereas the percentages of damaged and lost cells were statistically higher in the test group ( P = .0010 and .0005, respectively). This was observed in the analysis of the ×400 photographs and overview photographs. CONCLUSIONS: This study suggests that lenticular debris swirling around the anterior chamber may cause significant damage to the corneal endothelium, providing further insight on mechanisms of damage during phacoemulsification.