Surgical outcomes of intraocular lens iris suture fixation in eyes with residual capsule support.

PURPOSE: To evaluate the safety and refractive outcomes of eyes after intraocular lens (IOL) iris suture fixation (ISF). SETTING: Private practice, Los Angeles, California. DESIGN: Nonrandomized and unmasked retrospective chart review. METHODS: Eyes that underwent IOL exchange or repositioning with ISF with at least 270 degrees of capsular support were included. Eyes with less than 270 degrees of capsular support and eyes with iris damage were excluded. The primary outcome measures included incidence of cystoid macular edema (CME), IOL dislocation requiring refixation, and chronic inflammation. Secondary outcome measures included worsening intraocular pressure (IOP) control, retinal tear or detachment, worsening of corrected distance visual acuity (CDVA), and corneal decompensation. Refractive outcomes for 26 subgrouped eyes included mean and median spherical equivalent refraction accuracy (SERA), and percentage of eyes within 0.5 diopter (D) and 1 D of the refractive target. RESULTS: The study included 53 eyes of 50 patients. CME: 2/53 (3.8%), IOL dislocation requiring refixation: 2/53 (3.8%), chronic inflammation: 1/53 (1.9%), worsening IOP control: 5/53 (9.4%), retinal tear or detachment: 2/53 (3.8%). No patient experienced worsening of CDVA from baseline or corneal decompensation. Mean SERA ± SD -0.35 ± 0.29 D, median SERA -0.37 D. Of the 26 eyes subgrouped for refractive analysis, 73% were within 0.5 D and 100% were within 1 D of the desired refractive outcome. CONCLUSIONS: ISF can offer stability for sulcus-fixated IOLs provided there is some residual capsule support. Although there are measurable complications, there is a relatively low side effect profile. The refractive error tended to be myopic, indicating the need for further refinement of IOL power predictive formulas.

Epidemiology of Consumer-Product-Related Ocular Injuries in the Geriatric Population in the United States.

INTRODUCTION: The purpose of this study was to assess trends in consumer-product-related geriatric ocular injuries using National Electronic Injury Surveillance System (NEISS) data. Understanding the specific consumer products and settings coded in the NEISS dictionary that contribute to geriatric (≥ 65 years) ocular injuries, along with changing patterns during events like the COVID-19 pandemic, provides crucial insights for tailoring therapy and preventative strategies. This ultimately may reduce the burden of eye injuries on both older adults and healthcare systems. METHODS: This was a retrospective population-based cohort study. The NEISS database was used to study eye injuries in geriatric adults from 2010 to 2021. Patients were categorized by age groups (65-74, 75-84, 85-94, ≥ 95 years), and data on demographics, injury types, product categories, and COVID-19 impact were collected. Pearson's chi-squared test (with p < 0.001 taken to indicate significance) was used to assess differences in expected ratios between age groups. RESULTS: A total of 168,685 eye injury cases in adults aged 65 years and older were analyzed. Household items, tools, and gardening products accounted for over 75% of injuries. Most injuries occurred at home (65.3%). Contusions/abrasions (40.3%) and a foreign body (19.3%) were common diagnoses. Females had more household-item-related injuries, while males had more foreign body injuries. Regarding therapeutic disposition, 93.7% of all injuries were treated/examined and released, which showed a decreasing trend as age increased, while hospital admission/transfer rates increased with age. Compared to before COVID-19, the percentage of injuries during COVID-19 due to tools decreased (from 22.5% to 18.3%), while injuries due to gardening/lawn/landscaping/patio products increased (from 13.8% to 15.3%). CONCLUSIONS: Our study characterizes geriatric ocular injuries and COVID-19 impact, highlighting common products and locations. Different age groups showed different injury patterns. Understanding these trends can aid injury prevention strategies for consumers and healthcare providers. Demographics and injury frequencies differed based on age and sex. Future research should further explore post-COVID-19 trends.

Capsular phimosis with intraocular lens tilt and decentration.

A 34-year-old woman with quiescent bilateral intermediate uveitis maintained on once-daily dexamethasone 0.1% eyedrops, complicated by left cataract and glaucoma controlled with a single antiglaucoma medication, presented for cataract surgery. Her left corrected distance visual acuity (CDVA) was 20/40 because of a posterior subcapsular lens opacity. The anterior chamber angles appeared closed in all 4 quadrants on gonioscopy. Ultrasound biomicroscopy (UBM) confirmed the gonioscopy findings and, in addition, revealed a crystalline lens thickness of 5.53 mm, normal ciliary body structure, and multiple localized chorioretinal scars with membranes over the pars plana region. She underwent left phacoemulsification, goniosynechiolysis, and in-the-bag implantation of a single-piece monofocal hydrophobic acrylic intraocular lens (IOL). On the first postoperative day, she achieved pinhole vision of 20/70 (-6 diopters [D] myopia to balance with the fellow eye). There was mild anterior chamber cellular activity and flare, consistent with postoperative inflammation. Her intraocular pressure (IOP) was 16 mm Hg without antiglaucoma therapy. She was advised to continue the prednisolone acetate 1% eyedrops 6 times daily and to reduce it to 4 times daily after a week for the next 4 weeks. At 1 month, she was refracted to 20/40 N5, and the eye was quiescent. Optical coherence tomography showed that the macular was normal. The topical steroids were gradually tapered to the preoperative level. However, a month later, she returned complaining of deteriorating vision while using twice-daily steroid eyedrops. Her CDVA was 20/60. Slitlamp examination revealed anterior capsule fibrosis and capsular phimosis, resulting in partial obstruction of the visual axis and mild decentration of the IOL superior temporally (Figure 1JOURNAL/jcrs/04.03/02158034-202310000-00013/figure1/v/2023-09-28T161738Z/r/image-tiff). The anterior segment was quiescent. The pupil could only be dilated to 4.5 mm despite the absence of posterior synechiae. Fundus examination revealed a normal-looking quiescent posterior segment. Her IOP was 16 mm Hg. UBM showed a thickened anterior capsule, intact zonular fibers, and a posteriorly bowed and decentered IOL within the capsular bag (Figure 2JOURNAL/jcrs/04.03/02158034-202310000-00013/figure2/v/2023-09-28T161738Z/r/image-tiff). She was referred for further management. Discuss how you would manage this problem, explaining your decisions. How would you be able to avoid the same problem when operating on her fellow eye?

Clinical outcomes and complications following intraocular lens exchange in the setting of an open or intact posterior capsule.

PURPOSE: To assess whether there are added risks when performing intraocular lens (IOL) exchange in the setting of an open posterior capsule (OPC) when compared with a closed posterior capsule (CPC) IOL exchange. SETTING: Private practice, Los Angeles, California. DESIGN: Nonrandomized and unmasked retrospective chart review. METHODS: Eyes undergoing IOL exchange solely to relieve optical symptoms, with open or intact posterior capsules, were included. Eyes undergoing IOL exchange due to IOL malposition or dislocation were excluded. Eyes with preexisting, uncontrolled glaucoma and inflammation and eyes with a visual potential worse than 20/40 (Snellen) were also excluded. The main outcome measures were the postoperative complications compared between the OPC and CPC groups. RESULTS: 90 eyes of 75 patients undergoing IOL exchange were included in this study; 38/90 eyes had an OPC, and 52/90 eyes had a CPC. 3/38 in the OPC group and 2/52 in the CPC group experienced worsening intraocular pressure control. 1/38 in the OPC group experienced chronic inflammation. 2/38 in the OPC group and 2/52 in the CPC group experienced cystoid macular edema. 1/52 in the CPC group experienced a retinal tear. Statistically or clinically significant differences in postoperative complications between the OPC and CPC groups were not found. CONCLUSIONS: In the hands of an experienced surgeon, IOL exchange with an OPC appear red to be just as safe as IOL exchange with a CPC; when deemed necessary, experienced surgeons may perform an IOL exchange safely in the presence of an OPC.

Development of a Patient-Reported Outcome Measure to Assess Symptoms Associated with Cataract Surgery and Intraocular Lens Implants.

PURPOSE: To develop a standardized patient-reported outcome measure of visual perceptions and symptoms for implanted premium and monofocal intraocular lenses (IOLs). DESIGN: Observational study before and after IOL implants to assess the measure and symptom experience. PARTICIPANTS: Adults scheduled for binocular implantation of the same IOL type completed the survey at baseline prior to surgery (n = 716) and postoperatively (n = 554). Most respondents were female (64%), White (81%), 61 or older (89%), and had some college or more education (62%). METHODS: Administration was by web survey with mail follow-up and phone reminders. MAIN OUTCOME MEASURES: Frequency, severity, and level of symptom bother in the last 7 days for 14 symptoms: (1) glare, (2) hazy vision, (3) blurry vision, (4) starbursts, (5) halos, (6) snowballs, (7) floaters, (8) double images, (9) rings and spider webs, (10) distortion, (11) light flashes with eyes closed, (12) light flashes with eyes open, (13) shimmering images, and (14) dark shadows. RESULTS: The median correlation among having 14 symptoms at baseline was only 0.19. Mean uncorrected binocular visual acuity improved from a preoperative value of 0.47 logarithm of the minimum angle of resolution (logMAR; Snellen 20/59) to a postoperative value of 0.12 (20/26) and best-corrected binocular visual acuity improved from 0.23 logMAR (20/34) preoperative to 0.05 logMAR (20/22) postoperative. The most bothersome symptoms were reduced after surgery: preoperative/postoperative glare (84%/36%), blurry vision (68%/22%), starbursts (66%/28%), hazy vision (63%/18%), snowballs (55%/17%), and halos (52%/22%). All symptoms decreased significantly (P < 0.0001) from before to after surgery except for dark crescent-shaped shadows (4%/4%). The percentage of symptoms rated as quite a bit or extremely bothersome declined from before to after surgery except for dark crescent-shaped shadows (29%/32%): blurry vision (54%/15%), snowballs (52%/14%), glare (49%/15%), and halos (46%/14%). Having monofocal IOL implants was associated with significantly more reduction in halos, starbursts, glare, and rings and spider webs, but less improvement in self-reported general vision. CONCLUSIONS: This study provides support for the 37-item Assessment of IntraOcular Lens Implant Symptoms (AIOLIS) instrument for use to assess symptoms and general perceptions of vision in clinical studies and clinical care. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Symptoms and Satisfaction Levels Associated with Intraocular Lens Implants in the Monofocal and Premium IOL Patient-Reported Outcome Measure Study.

PURPOSE: To develop a questionnaire with standardized questions and images about visual symptoms and satisfaction administered before and after cataract surgery with monofocal and various (premium) intraocular lenses (IOLs). DESIGN: A prospective, observational study of cataract surgery patients completing a self-administered questionnaire preoperatively and postoperatively at 4 to 6 months. PARTICIPANTS: Five hundred fifty-four patients with plans to undergo implantation of the same IOL in both eyes on separate occasions in 20 ophthalmology practices. METHODS: An 86-item questionnaire with standardized images assessed the following 14 symptoms: glare, blurry vision, starbursts, hazy vision, snowballs, halos, floaters, double images, rings and spider webs, light flashes with eyes closed, distortion, light flashes with eyes open, shimmering images, and dark crescent-shaped shadows. MAIN OUTCOME MEASURES: Symptom severity and level of symptom bother, satisfaction with vision, quality of vision, and ability to see without corrective lenses or eyeglasses. RESULTS: Except for dark crescent-shaped shadows, the report of visual symptoms significantly decreased postoperatively. Best uncorrected binocular visual acuity improved from 0.47 (20/59 Snellen visual acuity values) ± 0.35 logarithm of the minimum angle of resolution (logMAR) preoperatively to 0.12 (20/26 Snellen visual acuity values) ± 0.12 logMAR postoperatively. Patients' ratings of intermediate vision as good to excellent improved significantly from 12% preoperatively to 71% postoperatively, and patients' ratings of distance vision improved from 8% preoperatively to 85% postoperatively. After surgery, 84% reported that they were somewhat, very, or completely satisfied with their vision. Most patients (88%) reported that they could see pretty well, very well, or perfectly well without corrective lenses after surgery. CONCLUSIONS: The Assessment of IntraOcular Lens Implant Symptoms questionnaire can be used across a wide variety of IOLs to evaluate visual symptoms and satisfaction with a growing segment of the market, premium IOLs, that target intermediate and near vision, in addition to distance vision. Compared to patients receiving monofocal IOLs, patients receiving premium IOLs appear to be more challenging to satisfy because of their requirements for distance, intermediate, and near vision, and their desire to be free of eyeglasses postoperatively. This instrument provides a structured, uniform tool for regulators, researchers, and ophthalmologists in everyday practice to gain insights into patients' experiences. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Surgical Correction for Late Postoperative Subluxation of a Diffractive Optic Multifocal IOL, Capsule Bag and Capsule Tension Ring Complex: Case Report.

Diffractive optic intraocular lenses (IOLs) require near perfect centration for best performance. A patient with a multifocal IOL and pseudoexfoliation developed late marked subluxation of the capsule bag, capsule tension ring and multifocal IOL complex. The surgical challenge was to fixate and recenter the diffractive optic IOL in order to restore normal quality vision; traditional surgical methods are not adequate for repositioning IOLs of this nature. A unique surgical plan that included three-point radially oriented suture fixation of an existing standard capsule tension ring (CTR) was conceived and was successful in achieving the patient's goal of maintaining spectacle independence by returning his vision to previous levels with a well-centered multifocal IOL.

Results of the United States Food and Drug Administration Clinical Trial of the CustomFlex Artificial Iris.

PURPOSE: To evaluate safety and efficacy of a custom-manufactured artificial iris device (CustomFlex Artificial Iris; HumanOptics AG) for the treatment of congenital and acquired iris defects. DESIGN: Multicenter, prospective, unmasked, nonrandomized, interventional clinical trial. PARTICIPANTS: Patients with photophobia, sensitivity secondary to partial or complete congenital or acquired iris defects, or both. METHODS: Eyes were implanted from November 26, 2013, to December 1, 2017, with a custom, foldable artificial iris by 1 of 4 different surgical techniques. Patients were evaluated 1 day, 1 week, and 1, 3, 6, and 12 months after surgery. At each examination, slit-lamp findings, intraocular pressure, implant position, subjective visual symptoms, and complications were recorded. Corrected distance visual acuity (CDVA) and endothelial cell density (ECD) were measured at 3, 6, or 12 months as additional safety evaluations. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was used to assess health-related quality of life affected by vision. The Global Aesthetic Improvement Scale was used to assess cosmetic results. MAIN OUTCOME MEASURES: Photosensitivity, glare, visual symptoms, NEI VFQ-25 score, Global Aesthetic Improvement Scale rating, prosthesis-related adverse events, intraocular lens (IOL)-related adverse events, and surgery-related adverse events 12 months after surgery. RESULTS: At the 12-month postoperative examination, a 59.7% reduction in marked to severe daytime light sensitivity (P < 0.0001), a 41.5% reduction in marked to severe nighttime light sensitivity (P < 0.0001), a 53.1% reduction in marked to severe daytime glare (P < 0.0001), and a 48.5% reduction in severe nighttime glare (P < 0.0001) were found. A 15.4-point improvement (P < 0.0001) in the NEI VFQ-25 total score was found, and 93.8% of patients reported an improvement in cosmesis as measured by the Global Aesthetic Improvement Scale 12 months after surgery. No loss of CDVA of > 2 lines related to the device was found. Median ECD loss was 5.3% at 6 months after surgery and 7.2% at 12 months after surgery. CONCLUSIONS: The artificial iris surpassed all key safety end points for adverse events related to the device, IOL, or implant surgery and met all key efficacy end points, including decreased light and glare sensitivity, improved health-related quality of life, and satisfaction with cosmesis. The device is safe and effective for the treatment of symptoms and an unacceptable cosmetic appearance created by congenital or acquired iris defects.

Diffractive optic intraocular lens exchange: indications and outcomes.

PURPOSE: To assess indications and outcomes of surgical exchange of diffractive optic multifocal and extended depth-of-focus intraocular lenses (IOLs) in favor of monofocal IOLs. SETTING: Private practice, Los Angeles, California. DESIGN: Retrospective chart review. METHODS: All cases of diffractive optic IOL exchange between June 2007 and October 2020 for diffractive optic dysphotopsia (DOD) (ie, light-induced concentric circles and spider web patterns), poor visual quality, or night vision symptoms were evaluated retrospectively regarding surgical indications, comorbidities, surgical methods, surgical complications, and visual outcomes. Ocular surface disease and ametropia were managed prior to consideration of IOL exchange. RESULTS: The charts of 64 eyes of 46 patients were included. 53/64 (83%) had DOD, 50/64 (78%) experienced reduced quality of vision, and 12/64 (19%) complained of night vision difficulties. 27/64 (42%) of eyes had no ocular comorbidities; 15/64 (23%) of eyes had more than 1 comorbid condition, and 12/64 (19%) were post-laser refractive surgery. Laser posterior capsulotomy had been performed in 15/64 (23%) of eyes. There were a variety of inciting diffractive optic IOLs and various monofocal exchange lenses and fixation techniques were used based on symptoms, comorbidities, and status of the posterior capsule. After IOL exchange, all eyes were relieved of DOD, and all eyes had improved or unchanged corrected distance visual acuity. CONCLUSIONS: Diffractive optic IOLs may induce unsatisfactory visual outcomes. However, in this large series of IOL exchanges, DOD and reduced visual function can be overcome with exchange for a monofocal IOL, despite comorbidities or an open posterior capsule.

Clinical and histopathological findings in the dead bag syndrome.

PURPOSE: To describe the findings of a recently described syndrome, the dead bag syndrome, in which the capsular bag appears to be clear many years postoperatively, becoming diaphanous and floppy and unable to support the intraocular lens (IOL) within it. SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah. DESIGN: Case series with clinicopathological correlation. METHODS: Of 10 cases suspected to represent a dead bag syndrome, 8 IOLs and 7 capsular bags were removed because of subluxation or dislocation. The 7 capsular bags available for analysis were fixed in formalin and submitted to histopathological examination (hematoxylin-eosin and Masson trichrome stains). The associated explanted IOLs in 5 cases were also examined microscopically. RESULTS: Histopathologic examination of the 7 capsular bags showed capsular thinning and/or splitting. Lens epithelial cells (LECs) were completely absent on 2 specimens, whereas the other 5 specimens had rare LECs on the inner surface of the capsule. Explanted IOLs were 3-piece silicone IOLs or single-piece hydrophobic acrylic IOLs. 1 IOL optic showed a small amount of granular pigment deposition, but the optics of the other 4 IOLs were unremarkable. CONCLUSIONS: In this syndrome, there seems to be an absence of secondary proliferation of LECs and fibrotic changes. The capsule shows some signs of degradation, such as thinning and/or splitting. Weakness of zonular attachments seems to be an associated finding, with subsequent in-the-bag IOL dislocation. Further studies are necessary to ascertain the etiology of this condition.

Femtosecond laser-assisted intraocular lens exchange.

Intraocular lens (IOL) exchange in patients with anterior capsule contraction resulting from phimosis can complicate IOL exchange as the fibrotic anterior capsule must be cut to gain access to the IOL. Maintaining curvilinear capsulotomy is particularly important when the desired outcome is bag-to-bag IOL exchange. Similarly, when the posterior capsule is open, properly sized curvilinear anterior capsulotomy will allow for optic capture and further stability of the exchanged IOL. Secondary capsulotomy size ranged from 4.9 to 5.0 mm, and the energy was set at 4 to 10 µJ depending on diffusiveness of the anterior capsule. The femtosecond laser was adapted to create a secondary anterior capsulotomy to facilitate IOL exchange.

Temporary ab interno suture cyclopexy for closing a cyclodialysis cleft during cataract surgery.

Cyclodialysis clefts are often associated with ocular hypotony and attendant maculopathy. However, these clefts create an alternative aqueous outflow pathway that can be useful to maintain intraocular pressure (IOP) at physiologic levels under some conditions. At normal levels of IOP, they might prevent glaucoma damage and avoid maculopathy of hypotony. Indeed, historically, cyclodialysis was a planned surgical method for managing glaucoma, and more recently, a minimally invasive glaucoma surgery device that created a small-stented cyclodialysis was in use until removed from the market for unrelated concerns. Cataract surgery in the presence of a cleft, however, might be complicated by extensive fluid misdirection through the cleft with resultant large suprachoroidal effusion. A technique of ab interno temporary suture cyclopexy was devised for a patient needing cataract surgery with an existing traumatic cyclodialysis cleft that was vital for long-term management of IOP. The suture was used to close the cleft transiently during surgery and was removed at the close of the procedure to reestablish patency and preserve the cleft.

Pseudophakic Dysphotopsia: Review of Incidence, Cause, and Treatment of Positive and Negative Dysphotopsia.

We reviewed the literature concerning positive dysphotopsia (PD) and negative dysphotopsia (ND) regarding cause, incidence, and clinical and surgical management. In addition, we summarized our surgical experience in managing dysphotopsia. A PubMed review, limited to English language articles, yielded 149 citations; multifocal (diffractive optic) and phakic intraocular lens (IOL) dysphotopsia were excluded. Overall, 39 articles were determined to be relevant for the objectives of this investigation. Regarding PD, 7 articles corroborated that the cause of PD is related primarily to internal reflection of oblique light rays that strike the square (truncated) edge of the IOL and are reflected onto the retinal surface. No round-edged foldable IOLs are available in the United States at this time, although IOLs modified with a round anterior edge and square posterior edge show a trend toward decreased incidence of PD. High index of refraction (I/R), surface reflectivity, and IOL optic design are additional causative factors for PD. Regarding the authors' surgical experience, changing the optic material to have a lower I/R improved PD symptoms in the large majority of patients. The cause of ND seems to be multifactorial and less well understood, with some disparity between clinical and laboratory findings. Four articles that explore using ray-tracing optical modeling suggest an "illumination gap," in which some temporally incident light rays to the nasal retina pass anterior to the IOL and some are refracted posteriorly by the IOL, resulting in a gap and resultant temporal shadow. However clinically, ND is associated invariably with well-centered in-the-bag IOLs. Other implicating factors include nasal anterior capsule override, haptic orientation, large-angle κ value, and high hyperopia. Persistent ND has been treated successfully or reduced with reverse (anterior) optic capture, sulcus IOL placement, piggyback IOLs, and neodymium:yttrium-aluminum-garnet nasal capsulectomy. Two articles reference a new optic edge designed to capture the anterior capsulotomy, mimicking reverse optic capture. Persistent dysphotopsia after cataract surgery is a significant cause for patient dissatisfaction. The cause and management of both ND and PD are of significance, and new IOL designs and alternative surgical strategies may help to mitigate these unintended side effects of IOL implantation.

Surgical management of positive dysphotopsia: U.S. perspective.

PURPOSE: To evaluate clinical outcomes of intraocular lens (IOL) exchange for intolerable positive dysphotopsia (PD). SETTING: Private practice, Advanced Vision Care, Los Angeles, California, USA. DESIGN: Retrospective review, case series. METHODS: Fifty-six eyes of 46 pseudophakic patients requiring surgical management of PD between 2013 and 2019 were reviewed. Thirty-seven eyes had PD alone and 19 had combined negative dysphotopsia and PD. INCLUSION CRITERIA: corrected distance visual acuity of 20/30 or better without significant corneal, retinal, or optic nerve pathology. EXCLUSION CRITERIA: corneal, macular, or optic nerve disease and multifocal dysphotopsia alone (defined patterns of concentric multiple halos or spider web patterns when looking at a point source of light). Primary outcome measure was improvement or resolution of self-reported PD symptoms by 3 months postoperatively. Secondary outcome measures included analysis of intraocular lenses (IOLs) that induced PD for IOL material, index of refraction, and edge design. RESULTS: IOL materials successful in the alleviation of PD symptoms were as follows: 20 (87.8%) of 33 silicone, 15 (76.2%) of 21 copolymer, and 2 poly(methyl methacrylate) (100%). However, when considering IOL exchange for an acrylic to silicone optic or acrylic to collamer optic, the percentages of improvement are indistinguishable at 87% and 88%, respectively. CONCLUSIONS: PD symptoms might be improved by changing the IOL material and, therefore, index of refraction. Although edge design plays an important role in etiology, changing the IOL material to a lower index of refraction may prove to be an effective surgical strategy to improve intolerable PD.