Viscoelastic, Optical, and Surgical Properties of Vitreous Body Replacement Hydrogels After Aging Compared to Porcine Vitreous Bodies And Silicone Oils.

Purpose: First- (monomers), second- (pre-gelated), and third- (in situ gelating after injection) generation hydrogels were previously introduced to replace the vitreous body after vitrectomy surgery. In this study, we evaluated the surgical, optical, and viscoelastic properties of vitreous body replacement hydrogels before and after an accelerated aging protocol previously applied to intraocular implants. Methods: Measurements of injection force, removal speed using a clinically established vitrectomy setup, as well as evaluation of forward light scattering and viscoelastic properties before and after an accelerated aging protocol were conducted. Results were compared to porcine and human vitreous bodies, as well as currently clinically applied lighter- and heavier-than-water silicone oils. Results: Removal speed of all tested hydrogels is substantially lower than the removal speed of porcine vitreous body (0.2 g/min vs. 2.7 g/min for the best performing hydrogel and porcine vitreous body, respectively). Forward light scattering in second-generation vitreous body replacement hydrogels was higher after the aging process than the straylight of the average 70-year-old vitreous body (9.4 vs. 5.5 deg2/sr, respectively). The viscoelastic properties of all hydrogels did not change in a clinically meaningful manner; however, trends toward greater stiffness and greater elasticity after aging were apparent. Conclusions: This study demonstrates surgical weaknesses of the hydrogels that need to be addressed before clinical use, especially low removal speed. Pre-linked hydrogels (second-generation) showed inferior performance regarding surgical properties compared to in situ gelating hydrogels (third-generation). Translational Relevance: This study highlights possible pitfalls regarding surgical and optical properties when applying vitreous replacement hydrogels clinically.

Evaluation of Parameters and Nozzle Tip Damage after Clinical Use of Three Hydrophilic Intraocular Lens Injector Models.

Purpose: To assess the nozzle tip damage and the parameters of three different hydrophilic intraocular lens (IOL) injector models. Methods: After routine cataract surgeries at the University Eye Hospital Heidelberg, all the used IOL injectors were collected from the operating room and sent to our laboratory. Nozzle tip damage was assessed under a microscope and graded as follows: no damage (grade 0), slight scratches (1), deep scratches (2), extensions (3), cracks (4), and bursts (5). Each damage grade was assigned a score from 0 to 5, and the total damage score for each injector system was calculated and compared. Nozzle tip parameters (diameters and areas), plunger tip parameters, and tip angles were also measured in each model. Results: The damage scores were (median, Q3-Q1): 1 (1-1) for Accuject, 1 (1-1) for Bluemixs, and 1 (1-1) for RayOne. There was no statistically significant difference in the damage scores between the study groups (P > 0.05). The outer cross-sectional vertical and horizontal diameters were 1.69 and 1.69 mm for Accuject, 1.69 and 1.69 mm for Bluemixs, and 1.70 and 1.71 mm for RayOne. Plunger tip areas were 0.78 mm2 for Accjuect, 0.74 mm2 for Bluemixs, and 0.43 mm2 for RayOne. Plunger tip area/inner cross-sectional area of the nozzle tip (%) was 31.2% for RayOne, 66.7% for Accuject, and 63.8% for Bluemixs. The tip angles for three injector models were 56° (Accuject), 56° (Bluemixs), and 44° (RayOne). Conclusions: All the injector models showed mild to moderate damage to the nozzle tip after IOL implantation, even with smaller diameter tips. RayOne resulted in the lowest ratio between plunger tip area and inner cross-sectional area of the nozzle tip and a better distribution of damage categories than the other two groups. All three injector models had relatively small tip parameters. If smaller incisions are required in certain patients, smaller tip parameters should be considered.

Forward Light Scattering of the Vitreous Gel After Enzymatic Aging: An In Vitro Model to Study Vitreous Opacification.

Purpose: Symptomatic vitreous opacifications, so-called floaters, are difficult to objectively assess majorly limiting the possibility of in vitro studies. Forward light scattering was found previously to be increased in eyes with symptomatic floaters. Using an objective setup to measure forward light scattering, we studied the effects of enzymatically digesting the components of the vitreous body on straylight to develop an in vitro model of vitreous opacifications. Methods: Fifty-seven porcine vitreous bodies were digested using hyaluronidase, collagenase, trypsin, and bromelain, as well as using a combination of hyaluronidase + collagenase and hyaluronidase + bromelain. A modified C-Quant setup was used to objectively assess forward light scattering. Results: Depletion of hyaluronic acid majorly increased vitreous straylight (mean increase 34.4 deg2/sr; P = 0.01), whereas primarily digesting the vitreous gel with collagenase or trypsin did not significantly affect straylight. When collagenase or bromelain is applied in hyaluronic acid depleted vitreous gels, the increase in forward light scattering is reversed partially. Conclusions: The age-related loss of hyaluronic acid primarily drives the increase in vitreous gel straylight induced by conglomerates of collagen. This process can be reversed partially by digesting collagen. This in vitro model allows the objective quantification and statistical comparison of straylight burden caused by vitreous opacities and, thus, can serve as a first testing ground for pharmacological therapies, as demonstrated with bromelain.

Quantification of Straylight Induced by Silicone Oil Adherent to Intraocular Lenses of Different Materials.

PURPOSE: A complication of using silicone oil as an intraocular endotamponade is its adhesion to intraocular lenses (IOLs). Forward light scattering is a measure to quantify the optical disturbance caused by adherent oil droplets. We tested the straylight caused by silicone oil adhesion to different IOLs and examined whether an approved cleaning solution, F4H5, reverses the induced straylight. DESIGN: An experimental study. METHODS: Two hydrophobic acrylic IOL models and 1 hydrophilic model with a hydrophobic surface (n = 8 per model: 24 lenses) had straylight measured before contact with silicone oils, providing a baseline for subsequent testing: 12 lenses with lighter-than-water silicone oil (Siluron 2000) and 12 with heavier-than-water oil (Densiron 68). The final measurement was performed after cleansing with F4H5 when we used scanning electron and light microscopy to detect surface changes. RESULTS: Straylight was majorly increased in IOLs with adherent silicone oil (baseline vs adherent oil median 3.1 [2.1, 3.9] and 39.7 [22.7, 87.8] deg2/sr, respectively; P < .001). No difference was seen between heavier- and lighter-than-water silicone oils. Between IOL types, induced straylight varied significantly, with 1 hydrophobic model reaching the highest average straylight. F4H5 significantly reduced straylight values in all IOL types (median 9.4 [5.4, 13.8] deg2/sr). The microscopy revealed surface changes on the IOLs even after cleaning. CONCLUSIONS: Silicone oil adhesion to IOLs can induce amounts of straylight known to cause severe optical disturbance. F4H5 cleansing solution reversed straylight values to only slightly increased values. We found no difference in straylight formation between the lighter- and heavier-than-water silicone oils.

Forward Light Scattering of First to Third Generation Vitreous Body Replacement Hydrogels after Surgical Application Compared to Conventional Silicone Oils and Vitreous Body.

To treat certain vitreoretinal diseases, the vitreous body, a hydrogel composed of mostly collagen and hyaluronic acid, must be removed. After vitrectomy surgery, the vitreous cavity is filled with an endotamponade. Previously, pre-clinical hydrogel-based vitreous body substitutes either made from uncrosslinked monomers (1st generation), preformed crosslinked polymers (2nd generation), or in situ gelating polymers (3rd generation) have been developed. Forward light scattering is a measure of Stray light induced by optical media, when increased, causing visual disturbance and glare. During pinhole surgery, the hydrogels are injected into the vitreous cavity through a small 23G-cannula. The aim of this study was to assess if and to what extent forward light scattering is induced by vitreous body replacement hydrogels and if Stray light differs between different generations of vitreous body hydrogel replacements due to the different gelation mechanisms and fragmentation during injection. A modified C-Quant setup was used to objectively determine forward light scattering. In this study, we found that the 1st and 3rd generation vitreous body replacements show very low stray light levels even after injection (2.8 +/- 0.4 deg2/sr and 0.2 +/- 0.2 deg2/sr, respectively) as gel fragmentation and generation of interfaces is circumvented. The 2nd generation preformed hydrogels showed a permanent increase in stray light after injection that will most likely lead to symptoms such as glare when used in patients (11.9 +/- 0.9 deg2/sr). Stray light of the 2nd generation hydrogels was 3- and 2-fold increased compared to juvenile and aged vitreous bodies, respectively. In conclusion, this significant downside in the forward light scattering of the 2nd generation hydrogels should be kept in mind when developing vitreous body replacement strategies, as any source of stray light should be minimized in patients with retinal comorbidities.

Influence of Subclinical Corneal Edema on Contrast Sensitivity in Fuchs Endothelial Corneal Dystrophy.

PURPOSE: The aim of this study was to compare visual function, with a focus on contrast sensitivity, between patients with Fuchs endothelial corneal dystrophy (FECD) with and without subclinical corneal edema. METHODS: In this cross-sectional, observational, single-center study, 46 pseudophakic eyes of 31 patients with FECD were divided into 2 groups depending on the presence of subclinical corneal edema. All eyes presented with a Krachmer grade of 5 and no clinical corneal edema. The criteria for subclinical corneal edema were loss of regular isopachs, displacement of the thinnest point, and focal posterior surface depression in Scheimpflug tomography. If more than 1 criterion was present, subclinical corneal edema was diagnosed. The corrected distance visual acuity, contrast sensitivity (Pelli-Robson chart and CSV-1000 test with optional glare), and straylight were measured. The differences between both groups were analyzed using clustered Wilcoxon rank-sum tests. RESULTS: The corrected distance visual acuity and the contrast sensitivity, measured with a Pelli-Robson chart, were significantly inferior in eyes with subclinical corneal edema compared with eyes without subclinical edema ( P < 0.05). At all spatial frequencies, eyes with subclinical edema demonstrated lower contrast sensitivity with a statistically significantly reduction in total contrast sensitivity when tested with ( P = 0.005) and without ( P = 0.002) glare. The straylight did not significantly differ between both groups ( P > 0.05). CONCLUSIONS: The corrected distance visual acuity and contrast sensitivity were significantly reduced in FECD eyes with subclinical corneal edema compared with those with no subclinical edema. This decrease in visual quality may be considered when evaluating the need for surgical intervention at earlier stages of FECD.

Late central graft detachment due to double endothelial layer after repeat Descemet membrane endothelial keratoplasty.

Purpose: To report late central graft detachment after repeat Descemet membrane endothelial keratoplasty (DMEK) without visual reduction. Observations: A 71-year-old patient with Fuchs' endothelial corneal dystrophy received a DMEK in his left eye. At 11 month post-operatively, a subtotal graft detachment was noted. Due to increasing corneal edema with vision loss, the first DMEK was removed and a repeat-DMEK was performed. At four months post repeat-DMEK, the graft was fully adherent to the posterior stroma. There was no significant corneal edema, and the best corrected visual acuity was 20/25. At 16-months after repeat-DMEK, a central graft detachment was noted, but there was no concurrent corneal edema or any loss of visual acuity. The mean density of the central endothelial cells was measured at 842 cells/mm2. Given the lack of corneal edema, visual reduction or subjective visual complaint, the graft detachment was followed-up for up to 20-months post repeat-DMEK with no further intervention, where the central cornea remained clear. Conclusions and Importance: To our knowledge, this is the first report of a central repeat-DMEK graft detachment that occurred 16 months after surgery despite initial attachment. Interestingly, there was no concurrent corneal edema or vision reduction. We describe a potential mechanism for clear central cornea in the presence of a central graft detachment after repeat-DMEK.

Impact of Lens Opacity on Optical Coherence Tomography Angiography Metrics.

PURPOSE: To evaluate the impact of lens opacity on the reliability of optical coherence tomography angiography metrics and to find a vessel caliber threshold that is reproducible in cataract patients. METHODS: A prospective cohort study of 31 patients, examining one eye per patient, by applying 3 × 3 mm macular optical coherence tomography angiography before (18.94 ± 12.22 days) and 3 months (111 ± 23.45 days) after uncomplicated cataract surgery. We extracted superficial (SVC) and deep vascular plexuses (DVC) for further analysis and evaluated changes in image contrast, vessel metrics (perfusion density, flow deficit and vessel-diameter index) and foveal avascular area (FAZ). RESULTS: After surgery, the blood flow signal in smaller capillaries was enhanced as image contrast improved. Signal strength correlated to average lens density defined by objective measurement in Scheimpflug images (Pearson's r: -.40, p: .027) and to flow deficit (r= -.70, p < .001). Perfusion density correlated to the signal strength index (r = .70, p < .001). Vessel metrics and FAZ area, except for FAZ area in DVC, were significantly different after cataract surgery, but the mean change was approximately 3-6%. A stepwise approach in extracting vessels according to their pixel caliber showed a threshold of > 6 pixels caliber (∼20-30 µm) was comparable before and after lens removal. CONCLUSION: In patients with cataract, OCTA vessel metrics should be interpreted with caution. In addition to signal strength, contrast and pixel properties can serve as supplementary quality metrics to improve the interpretation of OCTA metrics. Vessels with ∼20-30 µm in caliber seem to be reproducible.

Functional and Morphological Responses to Fluocinolone Acetonide 0.19 mg in Noninfectious Uveitic Macular Edema Evaluated as the Area-Under-the-Curve.

Purpose: This study investigated the impact of baseline clinical and optical coherence tomography (OCT) factors on the response to a 0.19-mg fluocinolone acetonide (FAc) implant in patients with noninfectious uveitic macular edema evaluated by the area under the curve over 24 months. Methods: A retrospective study was conducted of eyes of patients with noninfectious uveitic macular edema undergoing FAc treatment, with follow-up from baseline to 24 months. The area under the curve (AUC) of best-corrected visual acuity (BCVA) and the central macular thickness (CMT) were calculated using the trapezoidal rule. Clinical and OCT data at the time of FAc administration were collected, and associations with AUC of BCVA and CMT changes were investigated. Results: Twenty-three patients were enrolled. BCVA and CMT significantly improved after FAc implantation (P < 0.05). AUCBCVA and AUCCMT were 0.41 ± 0.33 logarithm of minimal angle of resolution/6 months and 320.15 ± 321.64 µm/6 months, respectively. Better baseline BCVA (coefficient [coef.] = 0.83, P < 0.001) and macular thickness reduction after FAc administration (coef. = -0.0001, P < 0.05) were associated with better BCVA after FAc treatment. In contrast, baseline OCT biomarkers such as ellipsoid zone reflectivity and choroidal vascularity index, sex, or disease duration before FAc injection showed no correlation with AUCBCVA and AUCCMT (P > 0.05). The younger the patient at the time of FAc injection, the greater the reduction in CMT (coef. = 1.76, P < 0.05). Conclusions: Among all clinical and morphological baseline factors, Baseline BCVA was the strongest predictor for AUCBCVA, while no association with baseline OCT features was observed. Overall, improvement of BCVA and CMT after FAc injection was maintained over 24 months. This study is registered in the German Clinical Trials Register under the DRKS-ID: DRKS00024399.

Comparison of a Presbyopia-Correcting Supplementary Intraocular Lens Combination and a Capsular-Bag Lens: An In Vitro Study.

We evaluated the optical quality of two approaches to trifocality: polypseudophakia versus monopseudophakia. The combination (polypseudophakia) of a monofocal Basis Z B1AWY0 and AddOn Trifocal A4DW0M intraocular lens (IOL) was compared to using one Basis Z Trifocal B1EWYN IOL, all from 1stQ GmbH. In both approaches, we measured modulation transfer function (MTF) and Strehl Ratio (SR) values at 3.0 and 4.5 mm pupil sizes. We determined the through-focus (TF) MTF at 25, 50 and 100 lp/mm for the 3 mm aperture. United States Air Force (USAF) target images were recorded. MTF measurement of the trifocal lens and the combined monofocal and trifocal AddOn IOL showed good performance at the far and near focus for the 3 mm aperture. For the 4.5 mm aperture the MTF improved for the far focus but decreased for the intermediate and near focus. TF MTF showed better contrast at the far focus for the polypseudophakic setup but at the expense of the efficiency at the near focus. However, the USAF chart images revealed only minimal differences between both approaches. The optical quality of the polypseudophakic approach was not affected by the presence of two IOLs instead of one and proved to be comparable with the performance of one capsular-bag-fixated trifocal IOL. Differences between the single vs. two-lens approach seen in the TF MTF analysis could be attributed to the optical design that varied between the trifocal models.

[Hydrophobic surface properties of hydrophilic acrylic lenses do not protect against calcification]. / Hydrophobe Oberflächeneigenschaften hydrophiler Acryllinsen schützen nicht vor Kalzifikation.

BACKGROUND: Opacification through calcification of hydrophilic acrylic intraocular lenses is a serious complication of cataract surgery, which usually results in explantation of the lens. In the process of calcification, the intraocular lens material plays a crucial role: calcification only occurs in hydrophilic acrylic lenses. Hydrophobic acrylic lenses show no crystal formation within the polymer. Hydrophilic acrylic lenses from some manufacturers have hydrophobic surface properties. The question arises as to what influence these surface properties have on the risk of calcification. OBJECTIVE: The present study investigated whether the hydrophobic surface properties of hydrophilic acrylic lenses can prevent calcification. MATERIAL AND METHODS: Using an electrophoretic in vitro model of calcification, two hydrophilic lenses with hydrophobic surface properties were compared to two hydrophilic lenses and a hydrophobic negative control to determine the risk of calcification. The lenses were then analyzed by optical microscopy, Alizarin Red and Von Kossa staining, scanning electron microscopy (SEM) and energy dispersive X­ray spectroscopy (EDX). RESULTS: All four hydrophilic lens models showed calcification within the polymer. No difference was found between the hydrophilic lenses and the hydrophilic lenses with hydrophobic surface properties in terms of crystal formation. The hydrophobic negative control showed no calcification. CONCLUSION: The investigation conducted in this study under standardized conditions could show that hydrophobic surface properties of hydrophilic acrylic lenses do not protect against calcium phosphate crystal formation within the polymer. There also is a risk of calcification in these lens models.

Development of a standardized in vitro model to reproduce hydrophilic acrylic intraocular lens calcification.

Opacification through calcification of hydrophilic acrylic intraocular lenses (IOL) is a severe complication after cataract surgery. Causing symptoms that range from glare through to severe vision loss, the only effective therapy is explantation of the opacified IOL so far. Although IOL calcification is a well-described phenomenon, its pathogenesis is not fully understood yet. The purpose of the current study was to develop a laboratory model to replicate IOL calcification. Calcification could be reproduced using a horizontal electrophoresis and aqueous solutions of calcium chloride and disodium hydrogen phosphate. The analysis of the in vitro calcified IOLs was performed using light microscopy, Alizarin Red and Von Kossa staining, scanning electron microscopy, energy dispersive x-ray spectroscopy and electron crystallography using transmission electron microscopy and electron diffraction. The presented laboratory model could be used to identify hydrophilic IOLs that are at risk to develop calcification and to assess the influence of associated risk factors. In addition, it can serve as a research tool to further understand this pathology.

Clinical Outcomes in Patients After Duet Procedure for Reversible Trifocality Using a Supplementary Trifocal Intraocular Lens.

PURPOSE: We report the clinical outcomes of patients who had primary lens implantation in the capsular bag and subsequently a supplementary trifocal lens implanted in the ciliary sulcus (duet procedure) to create reversible trifocality. DESIGN: Retrospective interventional case series. METHODS: This single-center clinical study included 25 patients who had undergone either refractive lens exchange for presbyopia correction or cataract surgery. All had lens removal by phacoemulsification and duet procedure to achieve reversible trifocality. Preoperatively and 3 months postoperatively, uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) were assessed, as well as uncorrected near visual acuity (UNVA), distance corrected near visual acuity (DCNVA), and corrected near visual acuity (CNVA). At the postoperative examination, uncorrected intermediate visual acuity (UIVA), distance corrected intermediate visual acuity (DCIVA), and corrected intermediate visual acuity (CIVA), defocus curve testing, and dysphotopsia evaluation were also performed. RESULTS: Monocular UDVA and CDVA improved from 0.71 ± 0.43 logarithm of the minimum angle of resolution (logMAR) and 0.12 ± 0.16 logMAR preoperatively to 0.04 ± 0.10 logMAR and -0.01 ± 0.09 logMAR postoperatively. Monocular UNVA and DCNVA were both 0.06 ± 0.08 logMAR and UIVA and DCIVA 0.00 ± 0.10 logMAR and -0.02 ± 0.10 logMAR postoperatively. Monocular defocus curve testing revealed a visual acuity of 0.2 logMAR or better from +0.75 to -3.5 diopters. CONCLUSIONS: Duet procedure using a trifocal supplementary intraocular lens provided excellent results for far, near, and intermediate distance, comparable to those reported for capsular bag fixated trifocal intraocular lenses. The duet procedure offers the advantage of an exit strategy in cases with a future loss of function or side effects associated with the optics.

Intravitreal 0.19 mg Fluocinolone Acetonide Implant in Non-Infectious Uveitis.

The efficacy of the 0.19-mg fluocinolone acetonide (FAc) intravitreal implant (ILUVIEN) in the treatment of non-infectious uveitic macular edema (UME) was assessed on twenty-six patients (34 eyes) with non-infectious UME between 2013 and 2020, in a mean follow-up of 18 ± 19.3 (mean ± SD) months. Macular edema was resolved in 24 (70.6%) cases. Five of these eyes had a relapse after 23.2 ± 14 months. Three FAc reinjections were performed and a drying of the macula was observed. After FAc implantation, 24 eyes (70.6%) were completely dry; central retinal thickness (CRT) decreased in 6 eyes (17.6%), but residual intraretinal fluid was still evident. In 20 eyes (58.5%), visual acuity (VA) improved (from +1 to +5 lines) and remained stable in 9 eyes (26.5%). Thirty eyes (88.2%) were pseudophakic at baseline and four were phakic. Three of these eyes had a cataract prior to therapy and the other developed a cataract 2.5 years after the FAc implant was administered. There was an overall increase in intraocular pressure (IOP; +4.4 ± 3.7 mmHg) and eye drops were required in three eyes. The FAc implant led to long-term improvements in mean CRT and VA, and that the side-effect profile was manageable in a clinical setting in patients with non-infectious UME.

The Development and Status of Eye Banking with Special Focus on the Commitment of LIONS Clubs. / Entwicklung und Stand des Hornhautbankings unter besonderer Berücksichtigung des Engagements von LIONS Clubs.

BACKGROUND: Ever since the first successful keratoplasty in 1905, there has been a need to store corneas for transplantation. R. Townley Paton founded the first eye bank in New York in 1944. With Helen Keller's call in 1925 for LIONS to "constitute themselves Knights of the Blind in the crusade against darkness", LIONS Clubs International has become involved in the establishment of eye banks worldwide. This paper presents the development of eye banking in general and with special attention to the support offered by LIONS Clubs. METHODS: Selective literature search through PubMed, Google Scholar and Google in close cooperation with the LIONS Eye Banks already established in Germany, LIONS Clubs International (USA) and the Julius Hirschberg Society (Austria). Analysis focused on the founding processes of 6 German eye banks and their current services. RESULTS: Filatov was the first to keep donor eyes in a cool, moist container for a few days. In 1973, Summerlin et al described the technique of organ culture for donor corneas, and McCarey & Kaufman described a liquid storage medium in 1974. LIONS Clubs International and their organisational structure first supported an eye bank in the US in 1952, outside America in Hong Kong in 1962 and in Germany in 1969. Funding is provided across all levels of LIONS as network support and material resources. In general, staff funding is not provided. Of the 88 eye banks operating worldwide today, 44 are called LIONS Eye Banks. 6 of the current 26 eye banks in Germany are operating under LIONS sponsorship and run by departments of ophthalmology at university medical centres. Although the number of transplants has increased in recent years due to new surgical techniques, the number of patients waiting for donor tissue is also growing as a result of the broadening indication. CONCLUSIONS: Even today, the availability of donor corneas limits patient care. Eye banks help to meet the need for donor corneas. However, the techniques and technical equipment of eye banks must undergo continuous improvement. The local, national and international network of LIONS Clubs can assist in establishing these in order to facilitate legal requirements and structural developments. This support frequently lasts for many years, often triggers additional public commitment and is thus also a supporting element for the future development of eye banking in Germany.

Stability and Visual Outcomes of the Capsulotomy-Fixated FEMTIS-IOL After Automated Femtosecond Laser-Assisted Anterior Capsulotomy.

PURPOSE: To evaluate stability and performance of a new monofocal anterior capsulotomy-fixated intraocular lens (IOL) (FEMTIS; Teleon Surgical B.V., Spankeren, Netherlands) after femtosecond laser-assisted cataract surgery (FLACS). DESIGN: Prospective, multicenter, interventional, noncomparative case series. METHODS: FLACS with FEMTIS IOL was performed in 336 eyes of 183 cataract patients with fixation of the IOL to the anterior capsulotomy followed up for 12 months. Examination included uncorrected distance visual acuity (UDVA), best-corrected visual acuity (CDVA), subjective refraction, IOL centration, posterior capsule opacification (PCO), and investigators' satisfaction questionnaire. RESULTS: At 12 months, mean IOL rotation was 1.50 ± 1.76 degrees and decentration 0.14 ± 0.14 mm from baseline (day of surgery). Mean horizontal IOL tilt was 0.70 ± 0.60 degrees and vertical 1.15 ± 1.06 degrees relative to the baseline (crystalline lens). Mean distance between IOL and iris was 0.32 mm to 0.36 mm for all measured meridians. Mean UDVA was 0.12 ± 0.14 logMAR (range -0.20 to 0.54 logMAR), mean CDVA -0.01 ± 0.09 logMAR (range -0.30 to 0.20 logMAR). Mean spherical equivalent was 0.35 ± 0.53 diopter (D) and 98% of eyes (n = 235) were within ±1.0 D. Median PCO score was 1 with an Nd:YAG laser rate of 3.1% after 12 months. Most surgeons were very satisfied (median score: 1) with surgery and implanted IOL. CONCLUSIONS: Implantation of FEMTIS IOL provided excellent visual and stable refractive outcomes. IOL decentration was very low compared to other published studies and showed an exceptional high in-the-bag stability over a 12-month period. This lens benefits from femtosecond laser capsulotomies. It can be positioned very predictably and offers an optimal platform for toric and multifocal IOL optics.

Reversibility of the duet procedure: Bilateral exchange of a supplementary trifocal sulcus-fixated intraocular lens for correction of a postoperative refractive error.

PURPOSE: We present the case of a 49-year old female who underwent bilateral exchange of a supplementary trifocal sulcus-fixated intraocular lens (IOL) to correct a residual refractive error. Six months beforehand, she had been treated for hyperopia, astigmatism and presbyopia with a duet procedure to create reversible trifocality. OBSERVATIONS: Refractive lens exchange with combined implantation of a monofocal toric IOL into the capsular bag and a trifocal supplementary IOL into the ciliary sulcus (duet procedure) had been performed in both eyes. Decreased uncorrected distance visual acuity due to the refractive outcome of -0.75 diopter sphere (DS)/-0.25 diopter cylinder (DC)x10° for the right eye and -1.0DS for the left eye as well as the perception of photic phenomena were inacceptable for the patient. In the second operations, we exchanged the supplementary IOLs to correct the residual refractive error and achieve the target refraction of emmetropia. UDVA increased from 0.50 logMAR in both eyes prior to the IOL exchange to -0.22 logMAR in the right eye and -0.20 logMAR in the left eye. Binocular uncorrected near and intermediate visual acuity were -0.10 logMAR and 0.00 logMAR respectively after exchanging the sulcus-fixated supplementary IOLs, allowing for complete spectacle independence. CONCLUSIONS: This case demonstrates one of the most important benefits of the duet procedure: the possibility, if necessary, to easily remove or exchange the supplementary IOL from the ciliary sulcus. The duet procedure offers a safe treatment option in the event of postoperative complications like residual refractive error or intolerance to a multifocal optic.