Femtosecond laser-assisted cataract surgery with bimanual technique: learning curve for an experienced cataract surgeon.

PURPOSE: To describe the intraoperative complications and the learning curve of microincision cataract surgery assisted by femtosecond laser (FLACS) with bimanual technique performed by an experienced surgeon. METHODS: It is a prospective, observational, comparative case series. A total of 120 eyes which underwent bimanual FLACS by the same experienced surgeon during his first experience were included in the study; we considered the first 60 cases as Group A and the second 60 cases as Group B. In both groups, only nuclear sclerosis of grade 2 or 3 was included; an intraocular lens was implanted through a 1.4-mm incision. Best-corrected visual acuity (BCVA), surgically induced astigmatism (SIA), central corneal thickness and endothelial cell loss (ECL) were evaluated before and at 1 and 3 months after surgery. Intraoperative parameters, and intra- and post-operative complications were recorded. RESULTS: In Group A, we had femtosecond laser-related minor complications in 11 cases (18.3%) and post-operative complications in 2 cases (3.3%); in Group B, we recorded 2 cases (3.3%) of femtosecond laser-related minor complications with no post-operative complications. Mean effective phaco time (EPT) was 5.32 ± 3.68 s in Group A and 4.34 ± 2.39 s in Group B with a significant difference (p = 0.046). We recorded a significant mean BCVA improvement at 3 months in both groups (p < 0.05) and no significant SIA nor corneal pachymetry changes in the two groups during the follow-up (p > 0.05). Finally, we found significant ECL in both groups with a significant difference between the two groups (p = 0.042). CONCLUSIONS: FLACS with bimanual technique and low-energy LDV Z8 is associated with a necessary initial learning curve. After the first adjustments in the surgical technique, this technology seems to be safe and effective with rapid visual recovery and it helps surgeons to standardize the crucial steps of cataract surgery.

Bimanual femtosecond laser-assisted cataract surgery compared to standard bimanual phacoemulsification: A case-control study.

PURPOSE: To evaluate the efficacy and safety of bimanual, low-energy femtosecond laser-assisted cataract surgery with 1.4-mm microincisions compared to standard bimanual phacoemulsification (bimanual microincision cataract surgery). DESIGN: Prospective, non-randomized comparative case series. METHODS: Bimanual femtosecond laser-assisted cataract surgery with microincisions was performed on 80 eyes (Group A) with the low-energy Ziemer LDV Z8; a matched case-control series of 80 eyes performed with standard bimanual microincision cataract surgery technique was selected for comparison (Group B). All interventions were performed by the same experienced surgeon. Intraoperative parameters were recorded as well as intra- and postoperative complications. Best corrected visual acuity, surgically induced astigmatism, central corneal thickness and endothelial cell count were evaluated before surgery and at 1 and 3 months post intervention. RESULTS: The mean effective phaco times were 3.79 ± 2.19 s (Group A) and 4.49 ± 1.84 s (Group B) (p = 0.041). No major intra- or postoperative complications occurred. An overall significant mean best corrected visual acuity improvement was noted at 3 months, but was not statistically different between the groups. No significant changes were observed for surgically induced astigmatism or corneal pachymetry. A significant loss of endothelial cell count in both groups was detected at 3 months, with Group A reporting a significantly lower endothelial cell count loss compared to Group B (p = 0.009). CONCLUSION: Bimanual, low-energy femtosecond laser-assisted cataract surgery with 1.4-mm microincisions by an expert surgeon was proven to be safe and effective in this study. This technique has advantages compared with standard bimanual microincision cataract surgery in terms of endothelial preservation.

Postoperative diffuse opacification of a hydrophilic acrylic intraocular lens: analysis of an explant.

PURPOSE: We describe the clinicopathological and ultrastructural features of an opaque single-piece hydrophilic acrylic intraocular lens (IOL) explanted from a patient. METHOD: The main outcome of this report is the documentation of calcium deposits confirmed by surface analysis. The decrease in visual acuity was due to the opacification of the IOL. The opacification involved both the optic plate and the haptics. RESULTS: The analysis at the scansion electron microscope revealed that the opacity was caused by the deposition of calcium and phosphate within the lens optic and haptics. CONCLUSION: This is the first case about the opacification of an Oculentis L-313. The opacification was characterized by calcium and phosphate deposition probably due to a morphological alteration of the posterior surface of the IOL.

Work-Related Eye Injuries: A Relevant Health Problem. Main Epidemiological Data from a Highly-Industrialized Area of Northern Italy.

The province of Modena is one of the most industrialized areas of Northern Italy. The medical records of the Ophthalmological Emergency Department (OED) of Modena University Hospital were studied: there were 13,470 OED accesses in 2014 and in 754 cases that an occupational eye injury occurred. The frequency of work-related eye injuries (3‰) was lower compared to other published studies, but the absolute number is still relevant, showing the need for more adequate prevention, especially in metal work, construction work, and agriculture, where the worst prognoses were observed. Intervention programs must be implemented as early as possible in the working life, considering that the frequency in younger workers is about double that of the oldest age class (3.5‰ vs. 1.8‰), and special attention should also be given to foreigners, who have a 50% higher injury risk. Furthermore, the planning of specific interventions for eye-injured workers may be useful, considering that a previous injury does not appear to encourage the adoption of preventive interventions, and a subgroup of eye-injured workers have a potential risk for new injuries. Finally, the data presented here indicates how OED records, integrated with specific occupational information, can be applied for studies on work-related eye injuries.

Long-term analysis of IOL stability of the Lewis technique for scleral fixation.

PURPOSE: To demonstrate that in case of absence of capsular support intraocular lens (IOL) scleral fixation is both effective and stable over years. METHODS: A total of 13 eyes from 13 patients who underwent an IOL scleral fixation according to Lewis suturing technique between January 2001 and December 2008 were studied. Patients underwent a complete ophthalmologic evaluation. The IOL stability was assessed using slit-lamp and anterior segment optical coherence tomography (AS-OCT) examination. The IOL stability was evaluated in terms of centration and tilting. All the knots were photographed and their integrity assessed. RESULTS: Follow-up was 60-129 months. Eleven knots appeared evident and undamaged, 6 knots were eroded, and 9 knots were not detectable. All IOLs were stable in the sulcus. Two patients presented a slight decentration of the IOL at the slit-lamp examination, while the AS-OCT demonstrated slight tilting of the lenses in 4 patients. CONCLUSIONS: The Lewis technique for IOL scleral fixation is an optimal surgical technique in case of absence of capsular support. No IOL luxation in the vitreous chamber has been reported; only 2 of the 10 patients with at least one eroded knot presented a minimal decentration of the lens with no influence on visual acuity. Although knot erosion is not an uncommon occurrence, IOL remains stable in the long term, probably due to a fibrotic process around the suture, and the IOL haptics, which prevent IOL dislocation.

Clinical risk management in eye outpatient surgery: a new surgical safety checklist for cataract surgery and intravitreal anti-VEGF injection.

BACKGROUND: A database study to test a new model of surgical safety checklist for eye surgery in the outpatient operating room, especially for cataract surgery and intravitreal anti-VEGF injections. METHODS: WHO Surgical Safety Checklist analysis, and changes to obtain a customized surgical safety checklist for eye surgery. Testing of the new checklist in the outpatient operating room of the Institute of Ophthalmology, University of Modena during a period of 4 months (January-April 2011). All cataract surgery and intravitreal anti-VEGF operations were included in the study, and controlled by the new surgical safety checklist. The percentage of answers to each safety check was calculated to obtain an estimate of adherence to our new checklist. RESULT: Eight hundred and forty nine procedures (390 cataract, 452 anti-VEGF injections, seven combined surgery) were analyzed. The study showed a high level of adherence to the majority of the safety checks in the checklist. Important differences were identified in consent confirmation (correct confirmation in 99.76 %, no confirmation in 0.24 %), surgical site marking (correct marking in 99.29 %, no marking in 0.71 %), patient cooperation during operation (95.17 % of patients were cooperative, 4.83 % of patients were uncooperative), adherence to antibiotic prophylaxis (correct prophylaxis in 93.17 %, no prophylaxis in 6.83 %), critical situation during surgical procedures (no critical situation in 91.76 %, critical situation in 8.24 %) CONCLUSION: The study showed a high level of adherence to the checklist. A surgical safety checklist could improve the management of an eye surgery operating room.

Clear corneal incisions in bimanual microincision cataract surgery: long-term wound-healing architecture.

PURPOSE: To evaluate bimanual microincision cataract surgery (MICS) clear corneal incision (CCI) architectural features over the long-term using anterior segment optical coherence tomography (AS-OCT). DESIGN: Case series. SETTING: Institute of Ophthalmology, University of Modena, Modena, Italy. METHODS: Patients who had uneventful bimanual MICS in the previous 2 to 16 months were examined using AS-OCT. Images were used to measure corneal thickness, incision length, incision angle, incidence of epithelial or endothelial gaping, misalignment, Descemet membrane detachment, and posterior wound retraction. RESULTS: Fifty-two eyes (33 patients) were enrolled. Mean incision length and incision angle were, respectively, 1427.91 µm and 31.19 degrees for the right hand, 1440.63 µm and 31.54 degrees for the left hand, 1474.13 µm and 31.27 degrees for temporal incisions, and 1394.41 µm and 31.46 degrees for nasal CCIs. Posterior wound retraction was the only architectural feature found. Its prevalence was 7.10% at 2 to 3 months, 31.8% at 4 to 11 months, and 33.3% at 12 months. Fifty-three percent of posterior wound retractions were in 1.8 mm CCIs and 47% in 1.4 mm CCIs. CONCLUSIONS: Bimanual MICS was not related to particular morphologic features of CCIs. The enlargement of 1 incision or construction of the incision with the dominant or the nondominant hand did not affect long-term wound architecture. Posterior wound retraction was the only architectural feature; however, its prevalence seems substantially lower than with other surgical techniques.

Bottle cork and cap injury to the eye: a review of 34 cases.

AIM: To describe our series of bottle cork and cap injuries to the eye in order to report the visual impairment and clinical outcomes observed in 34 cases over an 8-year period. METHODS: Retrospective review of the database of the Ophthalmology Institute of Modena from January 1999 to September 2007. All patients presented with closed-globe injury according to Kuhn et al.'s classification. All the cases were caused by sparkling wine: white in 24 cases and red in ten cases. RESULTS: The incidence varied between six and two cases a year (average 3.89). Bottle cork and cap injuries represent 11% of all injuries admitted to our department in the period considered in our series. In details: nine patients recovered totally, 22 patients recovered partially, three patients had a severe visual outcome (

Capsulorhexis phimosis after bimanual microphacoemulsification and in-the-bag implantation of the Akreos MI60 intraocular lens.

An 80-year-old woman with corticonuclear cataract had cataract extraction by bimanual microphacoemulsification and in-the-bag implantation of the Akreos MI60 (Bausch & Lomb) intraocular lens (IOL). After 6 months, a complete capsulorhexis phimosis developed and surgery was performed to open and reduce the phimosis, with complete functional recovery. In the fellow pseudophakic eye, an acrylic hydrophobic Acri. Smart 48S (Acri.Tec) IOL had been implanted without complications. We conclude that a capsulorhexis phimosis may occur a few months after uneventful cataract surgery and in-the-bag implantation of the Akreos MI60 IOL.

Bimanual microphacoemulsification and Acri. Smart intraocular lens implantation combined with vitreoretinal surgery.

PURPOSE: To assess the efficacy and safety of bimanual microphacoemulsification combined with vitrectomy in eyes with clinically evident cataract and vitreoretinal pathology. SETTING: Institute of Ophthalmology of the University of Modena and Reggio Emilia, Modena, Italy. METHODS: This prospective case series comprised 19 consecutive patients with clinically significant cataract who were scheduled for vitrectomy. Bimanual microphacoemulsification was performed, and an Acri. Smart 46 S hydrophobic acrylic intraocular lens (IOL) with a 6.0 mm optic (Acri.Tec, Inc.) was implanted in the capsular bag. Immediately after, standard 3-port vitrectomy was performed. RESULTS: The prevailing vitreoretinal pathology was retinal detachment, with 1 case of macular pucker and 1 case of macular hole. In all cases, the IOL was implanted in the capsular bag. There were no intraoperative complications during the cataract surgery or vitrectomy. Follow-up 1, 15, 30, 90, and 180 days after surgery showed significant visual recovery in all cases. The mean endothelial loss was 10.05%+/-2.01% (SD). In 3 cases that had tamponade with heavy silicone oil, progressive posterior capsule opacification occurred 6 months after surgery. CONCLUSIONS: Bimanual microphacoemulsification combined with vitrectomy was effective and safe. The microincisions and 19-gauge instruments provided excellent chamber resistance that simplified surgical maneuvers in eyes that might have a distorted fundus reflection and increased zonular laxity. The Acri. Smart 46 S IOL, which can be injected through a 2.0 mm incision, provided good fundus visibility during vitrectomy and good maneuverability up to the extreme periphery without resulting in glare or distracting reflections for the surgeon.

Bimanual microphacoemulsification versus coaxial miniphacoemulsification: prospective study.

PURPOSE: To compare the outcomes of bimanual microphacoemulsification and coaxial miniphacoemulsification and assess the potential advantages of the former over the latter. SETTING: Institute of Ophthalmology, University of Modena, Modena, Italy. METHODS: In a controlled prospective clinical trial, 100 eyes of 50 patients with nuclear or corticonuclear cataract of grade 2 to 4 on the Lens Opacities Classification System III had phacoemulsification. Fifty eyes were randomized to have surgery by the bimanual technique and 50, by the coaxial technique. All surgeries were performed by the same surgeon using the same machine (Sovereign WhiteStar, American Medical Optics). In all cases, the incision was made superiorly in clear cornea and a hydrophobic acrylic flexible intraocular lens (Acri. Smart 48 S, Acri.Tec) was implanted. Intraoperative parameters were mean phacoemulsification time, total phacoemulsification percentage, effective phacoemulsification time (EPT), total volume of balanced salt solution (BSS) used, total surgical time, and final size of the corneal incision. Postoperative parameters were visual acuity, astigmatism changes by vector analysis, corneal thickness, endothelial cell count, and presence of flare and cells in the anterior chamber. RESULTS: The only statistically significant difference between the 2 groups was the total volume of the BSS used (P = .004) and total surgical time (P = .045). CONCLUSIONS: Both techniques were safe and effective for cataract surgery. With bimanual microphacoemulsification, significantly less BSS was used and the total surgical time was significantly shorter than with the coaxial method.

Orbital actinomycosis associated with painful ophthalmoplegia. Actinomycosis of the orbit.

PURPOSE: To evaluate a case of orbital actinomycosis presenting as Tolosa-Hunt syndrome in a patient with a history of carcinomas of the kidney and breast. METHODS: A woman with ingravescent painful ophthalmoplegia was brought to our observation. Brain and orbital and total body CT scans showed the presence of two orbital neoformations and a miliary pattern of dissemination in the lung. The initial diagnosis, which pointed to secondary localisations of the previous kidney and breast tumours, was changed to orbital and pulmonary actinomycosis following microbiological analysis of lung biopsy samples. RESULTS: Prolonged antibiotic therapy with synthetic penicillin completely resolved the case. CONCLUSIONS: Actinomycosis is a very rare infection that may also affect the orbit and its association with a pulmonary dissemination is highly unusual. It is important to consider this type of infection among the causes of painful ophthalmoplegia.

Lidocaine versus ropivacaine for topical anesthesia in cataract surgery(1).

PURPOSE: To assess the anesthetic efficacy and safety of topical ropivacaine versus topical lidocaine in cataract surgery. SETTING: Institute of Ophthalmology, University of Modena and Reggio Emilia, Modena, Italy. METHODS: This prospective controlled randomized double-blind study comprised 64 patients scheduled for planned routine cataract extraction. Patients were randomized into 2 groups; 1 received topical ropivacaine 1% and the other, topical lidocaine 4%. The duration of surgery, intraoperative and early postoperative complications, and the need for supplemental intracameral anesthesia were recorded. Intraoperative and postoperative subjective pain was quantified by patients using a scale from 1 to 10. An endothelial cell count was performed preoperatively and 2 months after surgery. RESULTS: The mean endothelial cell density decreased from 2334 cells/mm(2) +/- 496 (SD) to 2016 +/- 674 cells/mm(2) in the ropivacaine group and from 2519 +/- 404 cells/mm(2) to 1847 +/- 607 cells/mm(2) in the lidocaine group. The difference in cell density between groups was not significant before (P =.154) or after surgery (P =.329); however, the difference in mean cell loss between groups was statistically significant (P =.031). The duration of surgery and intraoperative complications were the same in both groups. Four patients in the ropivacaine group and 5 in the lidocaine group required supplemental anesthesia (P >.05). The mean subjective analog pain score was slightly higher in the lidocaine group (P >.05). The day after surgery, 12 eyes in the ropivacaine group and 6 in the lidocaine group had transient corneal edema (P =.150). CONCLUSIONS: Topical ropivacaine performed at least as well as topical lidocaine in efficacy and safety in cataract surgery. It provided sufficient and long-lasting analgesia without the need for supplemental intracameral anesthesia in most cases.