Anterior Chamber Intraocular Lens Implantation Versus Four-Flanged Scleral Fixation Technique for Patients With Loss of Capsular Support During Routine Cataract Surgery.

PURPOSE: To compare the outcomes of anterior chamber intraocular lens (AC-IOL) implantation versus the four-flanged scleral fixation technique in eyes with loss of capsular support during routine cataract surgery. METHODS: This was a retrospective cohort study of all patients in whom an IOL was implanted either during or after short-term aphakia due to loss of capsular and sulcus support in a routine cataract surgery with at least 6 months of follow-up time between 2015 and 2023 in a tertiary medical center in Israel. Two different IOL implantation techniques were compared: the implantation of an angle-supported ACIOL and four-flanged scleral fixation. Main outcome measures included postoperative complications such as pseudophakic bullous keratopathy, loss of intraocular pressure control and glaucoma, IOL subluxation, and retinal detachment. RESULTS: Sixty-five eyes of 65 patients were included in the study, 33 eyes in the AC-IOL group and 32 eyes in the flange group. Follow-up time was 29.92 ± 20.02 months in the AC-IOL group and 20.17 ± 15.56 months in the flange group (P = .087). Pseudophakic bullous keratopathy was observed in 10 (30.3%) patients in the AC-IOL group and in 1 (3.1%) patient in the flange group (P = .04). This association remained significant using survival analysis (P = .006). In 4 (12.1%) patients in the AC-IOL group, a glaucoma filtering procedure was performed to control the intraocular pressure compared with none in the flange group (P = .042). CONCLUSIONS: In the setting of loss of capsular support during routine cataract surgery, four-flanged scleral fixation showed an overall lower rate of complications and significantly reduced rate of subsequent surgical interventions. [J Refract Surg. 2024;40(8):e520-e526.].

Corneal pseudoectasia: a case series.

OBJECTIVE: To raise awareness of conditions that can tomographically mimic corneal ectasia and describe the actions required to avoid misdiagnosis. METHODS: We report a retrospective case series of seven patients presenting at two tertiary care centers in Israel with a presumed diagnosis of keratoconus or post-refractive ectasia. Upon further examination, the ectasia diagnosis was reconsidered and eventually ruled out. RESULTS: Included were ten eyes of seven patients. Cases included bilateral diffuse Salzmann's nodular degeneration, ophthalmoplegia with strabismus which precluded proper fixation during the acquisition of tomography images, two cases of incorrect Pentacam parameter settings, a patient with a history of hyperopic laser-assisted in situ keratomileusis (LASIK) treatment in one eye and myopic LASIK in the fellow eye, a case of old post-photorefractive keratectomy (PRK) stromal haze, and a patient with posterior polymorphous corneal dystrophy. CONCLUSIONS: Tomography patterns mimicking corneal ectasia can appear in patients without ectatic pathology. The comprehensive ophthalmologist should be aware of such cases as they may substantially alter the treatment course and prognosis of these patients.

Accuracy of Intraocular Lens Calculation Formulas for the Four-Flanged Fixation Technique in Eyes With No Capsular Support.

PURPOSE: To assess the refractive prediction error of four intraocular lens (IOL) calculation formulas in eyes that have undergone scleral fixation using the four-flanged technique. METHODS: This was a retrospective cohort analysis of patients who underwent scleral fixation using the four-flanged technique at the Shamir Medical Center between 2020 and 2021. Refractive prediction errors for four IOL prediction formulas (Barrett Universal II, Holladay 1, SRK/T, and Kane) were obtained by subtracting the predicted spherical equivalent from the postoperative spherical equivalent. Mean arithmetic refractive prediction error and mean absolute error were calculated and compared. RESULTS: Twenty-three eyes of 23 patients were included in the analysis. The Akreos AO60 IOL (Bausch & Lomb, Inc) was implanted in 9 eyes and the BunnyLens HP IOL (Hanita Lenses) in 14 eyes. Mean age was 72.84 ± 13.2 years. All formulas produced myopic mean arithmetic refractive prediction error. Mean arithmetic refractive error and mean absolute error were equal in absolute number. Mean arithmetic refractive prediction errors were -0.72 diopters (D) for Barrett Universal II, -0.61 D for Holladay 1, -0.77 D for SRK/T, and -0.94 D for Kane formulas. The refractive outcome differed significantly from the predicted refraction in all formulas. There were no statistically significant differences in prediction errors between the formulas. CONCLUSIONS: Refractive outcomes of the four-flanged fixation technique produced myopic results compared to the predicted refraction for all formulas tested. This suggests that the effective lens position is more anterior than in-the-bag IOL implantation. [J Refract Surg. 2022;36(10):668-673.].

Modification of intraocular lens insertion using 4-flanged fixation with a standard cartridge and a 2.4 mm corneal incision in eyes with no capsular support.

A modification of intraocular lens (IOL) implantation, using the 4-flanged IOL fixation technique, through a 2.4 mm corneal incision using a standard cartridge and injector, is presented. An IOL with 4 eyelets is used, through which a 6-0 polypropylene suture is threaded on one side and then loaded into a provided cartridge and inserted to the anterior chamber through a 2.4 mm corneal incision. Using the handshake technique, the suture ends are eventually threaded through the eyelets and secured outside the eye with the creation of 4 flanges. This technique was used in 6 eyes of 5 consecutive patients with the absence of capsular support. During all follow-up visits, the IOLs were well centered and stable, and the flanges were buried in the sclera and covered with the conjunctiva. No complications were recorded. This modification simplifies the technique and reduces the well-known complications of large corneal incisions.

Intrascleral 4-flanged technique for in-the-bag intraocular lens subluxation.

PURPOSE: To present a series of cases in which the 4-flanged technique was used in the management of in-the-bag intraocular lens (IOL) subluxation. SETTING: Shamir Medical Center, Israel. DESIGN: Retrospective cohort analysis. METHODS: Included were consecutive cases with secondary IOL subluxation that underwent scleral fixation with the 4-flanged technique using 6-0 polypropylene and low temperature cautery. Surgeries were performed during September 2019 to April 2020. Postoperative IOL angle tilt was evaluated using high-resolution ocular coherence tomography. RESULTS: Eleven eyes of 11 patients were included. The mean age was 82.7 ± 5.5 years, and 60% were men. Pseudoexfoliation was noted in 82% of patients, and only 1 case was related to trauma. The mean corrected distance visual acuity (CDVA) postoperatively was within 1 line of the original presubluxation CDVA (0.55 ± 0.41 vs 0.54 ± 0.6 logMAR, P = .965). The mean postoperative IOL tilt was 5.78 ± 3.85 degrees. Surgery duration decreased from 70 ± 14 minutes to 39 ± 15 minutes (first to last operations). No intraoperative complications were reported. Postoperatively, transient intraocular pressure elevation, which resolved at 1 week, was recorded in 45% of cases. Cystoid macular edema, which resolved within a few months under topical treatment, was seen in 2 patients. CONCLUSIONS: Among a cohort of patients with secondary in-the-bag IOL subluxation, the 4-flanged technique was safe and resulted in satisfactory visual outcomes and a stable IOL position, with a short learning curve.

Clinical outcomes of Ankoris toric intraocular lens implantation using a computer-assisted marker system.

PURPOSE: To report the clinical outcomes of patients who underwent cataract surgery with implantation of Ankoris monofocal toric intraocular lens (IOL) (PhysIOL SA, Liège, Belgium) using the Zeiss Callisto Eye (Carl Zeiss AG, Dublin, CA). METHODS: We conducted a retrospective case series of patients who underwent routine cataract extraction and implantation of Ankoris toric IOL using the Zeiss Callisto eye between January 2018 and December 2018 by four senior surgeons. Patients' medical records were reviewed, and clinical outcomes including postoperative refraction, visual acuity outcomes, IOL position and deviation from planned axis were collected. RESULTS: Fifty-six eyes of 56 patients were included, 48% were female, and the mean age was 70 ± 8 years. Patients with pseudoexfoliation syndrome, glaucoma or keratoconus were excluded from the study. Pre-operative mean corneal astigmatism was 2.38 ± 0.78 diopters (D), and mean implanted IOL cylindrical power was 3.06 ± 1.07 D. IOL rotation 30 days postoperatively was within 5° in 82% of eyes and between 6° and 10° in 10.8% of eyes. Mean postoperative refractive astigmatism 30 days postoperatively was 0.22 ± 0.36 D; in 84% of eyes the postoperative refractive astigmatism was ≤ 0.50 D. IOL rotation significantly increased between day 1 to day 7 postoperatively (1.91 ± 3.15° to 3.18 ± 3.3°, P = 0.001). However, no significant rotation had occurred between day 7 and day 30 postoperatively (P = 0.093). CONCLUSION: Cataract surgery with implantation of Ankoris monofocal toric IOL using the Zeiss Callisto Eye marking system is predictable and effective in reducing refractive astigmatism.

Laser in situ keratomileusis in myopic patients with congenital nystagmus.

PURPOSE: To evaluate the results of laser in situ keratomileusis (LASIK) and IntraLASIK in the treatment of myopic patients with nystagmus. METHODS: Eight patients with congenital nystagmus (16 eyes), aged 23 to 49 years, had LASIK surgery. Corneal flaps were created using the Bausch & Lomb Hansatome microkeratome or the IntraLase femtosecond laser. The ablations were performed with the Bausch & Lomb excimer laser with an active tracking system. In some patients, the eyes were fixated with forceps or a fixation ring during laser ablation. RESULTS: The refractive errors were corrected in all cases. There was no decentration or loss of best corrected visual acuity greater than 1 line. In 56% of the eyes, the postoperative uncorrected visual acuity was better than the best spectacle-corrected visual acuity (BSCVA). The BSCVA improved in 62.5% of the eyes. The overall visual performance improved in all patients. One patient who did not drive before surgery became eligible for a driver's license after surgery. CONCLUSIONS: Selected patients with myopia and congenital nystagmus may benefit from laser refractive surgery. Laser refractive surgery may be safely and accurately performed using the Hansatome microkeratome or the IntraLase femtosecond laser and an active tracking system with or without mechanical fixation. The BSCVA may improve in certain patients postoperatively.

[Evaluation of efficacy, safety and stability of lasik-zyoptix as compared to lasik-planoscan in myopia patients with or without astigmatism].

AIM: To compare the efficacy, safety and stability of laser in-situ keratomileusis (LASIK) Zyoptix and PlanoScan (PS) systems for the surgical correction of myopia with and without astigmatism. METHODS: In this retrospective study we analyzed the results of 198 eyes of 99 patients (randomly chosen) who underwent LASIK Zyoptix treatment and 198 eyes of 99 patients (randomly chosen) who underwent LASIK PlanoScan standard ablation treatment. Patients were followed for a period of 12 months after treatment. All surgeries were performed with the Bausch & Lomb Technolas 217z. Data on uncorrected (UCVA) and best spectacle-corrected (BSCVA) visual acuity, efficacy, predictability, stability and safety were analyzed. RESULTS: Mean preoperative spherical error in the Zyoptix group was -7.16 D (range= 0 to -16.50, SD = 3.21) and in the PS group -5.31 D (range= 0 to -16.50, SD=3.13). Mean preoperative cylinder was -1.30 D (range= -0.25 to 5.00, SD=0.99) and -1.17 D (range= -1 to -4.00, SD=0.85) respectively. Mean spherical deviation from expected at 1 year in the Zyoptix group was -0.13 D (range= -1.75 to 2, SD=0.73) and in the PS group -0.16 D (range= -4.50 to 2, SD = 0.75). Mean cylinder at 1 year was -0.69 D (range= -0.50 to 0.75, SD= -0.13) and -0.69 D (range = 0 to -2.25, SD = 0.46) respectively. At 1 year, the UCVA in the Zyoptix group was 6/12 or better, 6/7.5 or better and 6/6 or better in 87%, 60% and 27% respectively, and in the PS group 92%, 64% and 39% respectively. CONCLUSIONS: Both treatments can safely and effectively treat myopia and astigmatism with stable results up to one year. Zyoptix was found to show better outcomes in terms of safety and efficacy.

[Lasik in myopic patients with congenital nystagmus].

PURPOSE: To present the results of IntraLASIK treatment in myopic patients with nystagmus. METHODS: Four patients, ranging in age from 25 to 49 years, with congenital nystagmus (8 eyes), underwent IntraLASIK surgery. Corneal flaps were made by Intralase femtosecond laser. In some patients, the eyes were fixated with forceps or a fixation ring during the laser ablation. In all patients, the effect of involuntary eye movements was neutralized by an active tracking system. RESULTS: The refractive errors were corrected in all cases. There was no decentration or loss of best corrected visual acuity by more than 1 line. In 3 of 8 eyes, the post-operative uncorrected visual acuity (UCVA) was equal or better than the best spectacles corrected visual acuity (BSCVA) preoperatively. Four of the 8 eyes retained or improved their BSCVA. CONCLUSIONS: Some patients with myopia and nystagmus may benefit from laser refractive surgery. By using the Intralase femtosecond laser and an active tracking system with or without mechanical fixation, laser refractive surgery may be safely and accurately performed in selected cases of nystagmus. Certain patients improve their BSCVA postoperatively.

[Increase in posterior segment depth in eyes with corneal opacities].

AIM: Studies in animals and in humans demonstrate an increase in axial length and induced myopia in eyes with early onset corneal scars. The purpose of this study was to compare the total ocular axial length and the length of the anterior and the posterior segments, in eyes with unilateral central corneal opacification with the unaffected fellow eyes. Elongation of the eye and progressive myopia, may lead to both anisometropia and amblyopia. METHODS: In six patients with unilateral corneal opacification that developed at an early age, complete eye examinations with refraction were performed. Ocular axial measurements were determined by A-mode ultrasound. RESULTS: The mean ocular length was greater in eyes with central corneal opacities compared with the fellow eyes (27.53 vs. 23.38 mm; p < 0.003), due to elongation of the posterior segment (19.75 mm vs. 15.87 mm; p<0.008). No significant change was found in the length of the anterior segments. CONCLUSIONS: Our study showed an ipsilateral increase in the posterior segment length in patients with unilateral corneal opacification which had occurred in childhood. The cause is unknown but may be due to altered visual input. Progressive myopia in corneal leukoma is a factor to be taken into account in the follow-up and treatment of patients with central corneal opacities that occurred in childhood.

Peripheral sterile corneal infiltrates after refractive surgery.

PURPOSE: To report 5 eyes of peripheral sterile corneal infiltrates after refractive surgery. SETTING: Department of Ophthalmology, Soroka University Medical Center, Beer-Sheva, Israel, and Enaim Ophthalmological Center, Jerusalem, Israel. METHODS: Three patients had bilateral refractive procedures for correcting myopia. The procedures included laser epithelial keratectomy in 2 eyes, laser in situ keratomileusis (LASIK) in 2 eyes using a keratome, and LASIK in 1 eye using femtosecond laser. RESULTS: All the patients complained of ocular pain between 1 and 3 days after the procedure. A ring stromal infiltrate peripheral to the flap edge with intact epithelium and an intervening clear zone between the peripheral corneal infiltrates and the limbus was observed in 5 eyes without anterior chamber reaction. All cases improved after several days of topical steroid and antibiotic treatment and systemic steroid. Final visual acuity was 20/25 or better in all cases. CONCLUSIONS: The exact mechanism of this complication is still unknown, which can be confused with infectious keratitis. It is important to maintain a high degree of suspicion for infectious keratitis because the management is very different. The potential outcome can be much worse if the keratitis is due to an infectious etiology which can appear after all types of refractive laser procedures.

Retrospective analysis of actual LASIK flap diameter compared with microkeratome ring size performed by different surgeons.

PURPOSE: To evaluate the difference in the diameter between microkeratome ring and actual laser in situ keratomileusis (LASIK) flap size by 4 different surgeons using 3 different microkeratomes in comparison to preoperative keratometry. SETTING: Gimbel Eye Centre, Calgary, Alberta, Canada. METHODS: A retrospective analysis of 6667 consecutive LASIK surgeries performed at the Gimbel Eye Centre between 1998 and 2002 was conducted. The study compared the difference in the actual LASIK flap diameter and microkeratome ring size for 3 Hansatome microkeratomes indicated by serial numbers 2230, 3048, and 3084 in comparison to the preoperative keratometry. The surgeries were performed by 4 surgeons from the Centre. RESULTS: A statistically significant correlation was found between the actual flap size and the microkeratome ring size. The deviation increased with corneal steepness (#2230: r = 0.45, P<.001; #3048: r = 0.28, P<.001; #3084: r = 0.23, P<.001). The mean difference between actual flap size and the microkeratome ring size was 0.647 mm, 0.808 mm, and 0.916 mm for Hansatome microkeratome #2230, #3048, and #3084, respectively. The actual flap was larger than the microkeratome ring size in 92.8%, 93.8%, and 97.4% of eyes, respectively. The mean difference between microkeratome ring size and measured LASIK flap size was consistently significantly different (P<.0001) per surgeon for all microkeratomes. CONCLUSIONS: Estimation of the flap size is an important issue while selecting ring size and planning the treatment zone. In this study, the actual flap size was larger than the ring size for all surgeons and all 3 Hansatome microkeratomes. Higher preoperative keratometry values achieved larger flaps than those with lower keratometry values.

Cu/Zn superoxide dismutase plays important role in immune response.

Activation of macrophages leads to the secretion of cytokines and enzymes that shape the inflammatory response and increase metabolic processes. This, in turn, results in increased production of reactive oxygen species. The role of Cu/Zn superoxide dismutase (SOD-1), an important enzyme in cellular oxygen metabolism, was examined in activated peritoneal elicited macrophages (PEM) and in several inflammatory processes in vivo. LPS and TNF-alpha induced SOD-1 in PEM. SOD-1 induction by LPS was mainly via extracellular signal-regulated kinase-1 activation. Transgenic mice overexpressing SOD-1 demonstrated a significant increase in the release of TNF-alpha and of the metalloproteinases MMP-2 and MMP-9 from PEM. Disulfiram (DSF), an inhibitor of SOD-1, strongly inhibited the release of TNF-alpha, vascular endothelial growth factor, and MMP-2 and MMP-9 from cultured activated PEM. These effects were prevented by addition of antioxidants, further indicating involvement of reactive oxygen species. In vivo, transgenic mice overexpressing SOD-1 demonstrated a 4-fold increase in serum TNF-alpha levels and 2-fold stronger delayed-type hypersensitivity reaction as compared with control nontransgenic mice. Conversely, oral administration of DSF lowered TNF-alpha serum level by 4-fold, lowered the delayed-type hypersensitivity response in a dose-dependent manner, and significantly inhibited adjuvant arthritis in Lewis rats. The data suggest an important role for SOD-1 in inflammation, establish DSF as a potential inhibitor of inflammation, and raise the possibility that regulation of SOD-1 activity may be important in the treatment of immune-dependent pathologies.