Loose zonules in cataract surgery.

PURPOSE OF REVIEW: This review will focus on identifying causes of zonulopathy during cataract surgery and discuss various modalities for treatment. RECENT FINDINGS: There are multiple different options for capsular bag support in the setting of zonulopathy, including capsular or iris hooks, capsular tension rings as well as capsular tension segments (CTS). Surgical techniques on how to insert these devices are many and can be customized based upon the surgeon's preference and the patient's eye anatomy. SUMMARY: Recognizing zonular weakness is critical to achieve stable postoperative vision and avoid future complications. Depending on the degree of zonulopathy, various treatment options can be pursued, ranging from capsular tension hooks or iris hooks, capsular tension rings or sutured or scleral fixated CTS.

Rotational stability of toric intraocular lenses with a newly modified capsular tension ring.

PURPOSE: To determine whether a newly modified capsular tension ring (CTR) is effective at preventing toric intraocular lens (TIOL) rotation and misalignment. SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. DESIGN: Experimental study. METHODS: Ten human cadaver eyes were used to test the ease or difficulty of TIOL rotation in the capsular bag under 3 experimental conditions: a TIOL alone, a TIOL with a standard CTR, or a TIOL with a newly modified CTR with indentations in a sinusoidal pattern. Scores for the ease of IOL rotation were compared by using the nonparametric Friedman analysis of variance test. In addition, both anterior and posterior Miyake-Apple views were filmed to observe the rotational stability of TIOLs in the capsular bag under the 3 test conditions. RESULTS: In the ten eyes of five patients, the rotational stability improved with a standard CTR, but further improvement was statistically observed (P < .05) with the newly modified CTR under all test conditions. This was true for both IOLs used (AcrySof and TECNIS toric IOLs), with or without ophthalmic viscosurgical device, and for either clockwise or counterclockwise rotations. CONCLUSIONS: A newly designed CTR prototype represents a new technology for improving the rotational stability of a TIOL in the capsular bag. Under all test conditions, the prototype performed significantly better than a standard CTR. The results support the use of this new CTR design to improve the accuracy and refractive success of TIOLs.

The Complexities of Negative Dysphotopsia.

The appearance of a dark shadow in the temporal periphery, otherwise known as negative dysphotopsia, continues to be a problem for some patients after routine uncomplicated cataract surgery. Etiologies include type and design of intraocular lens (IOL), anatomical features and dimensions of the eye, pupil size, angle kappa, relationship of the optic to the anterior capsule, and the position of the optic/haptic junction of the IOL. Although the primary etiology remains controversial, it is clear that the cause is multifactorial. All of the factors should be considered when attempting to prevent or treat this phenomenon.

New preventative approach for negative dysphotopsia.

PURPOSE: To evaluate whether positioning the intraocular lens (IOL) to decrease the entry of inferotemporal light would decrease the incidence of negative dysphotopsia. SETTING: Private practices, Boston and Chelmsford, Massachusetts, USA. DESIGN: Prospective randomized case study. METHODS: Patients had cataract surgery with implantation of either a silicone IOL inferotemporally or vertically (randomly assigned) or a 1-piece acrylic IOL with the optic-haptic junction inferotemporally or vertically (randomly assigned). Other patients received acrylic IOLs bilaterally and inferotemporally without randomization. Patients were asked about negative dysphotopsia symptoms postoperatively. Data were analyzed using the z test and a chi-square test for comparing the incidence of negative dysphotopsia between the 3 groups. RESULTS: The study comprised 305 patients (418 eyes). A silicone IOL was implanted inferotemporally in 39 eyes and vertically in 60 eyes. An acrylic IOL was implanted with the optic-haptic junction inferotemporally in 163 eyes and with the junction vertical in 114 eyes. Forty-two eyes had bilateral inferotemporal implantation of an acrylic IOL. For the acrylic IOL on the first postoperative day, the incidence of negative dysphotopsia was smaller for the inferotemporal IOL orientation (6%) than in the control group (14%) (P = .026). The rate of persistent negative dysphotopsia decreased in both groups over time, and the difference 1 month after surgery was no longer statistically significant. The negative dysphotopsia rate for the silicone IOL was 0%. CONCLUSIONS: Positioning the optic-haptic junction of an acrylic IOL inferotemporally resulted in a 2.3-fold decrease in the incidence of negative dysphotopsia after cataract surgery. When implanted in the vertical position, Acrylic IOLs seemed to lead to a higher incidence of negative dysphotopsia than silicone IOLs. FINANCIAL DISCLOSURE: Dr. Henderson is a consultant to Abbott Medical Optics, Inc., Alcon Laboratories, Inc., and Bausch & Lomb, Inc. None of the other authors has a financial or proprietary interest in any material or method mentioned.

Real-time dynamic intraocular pressure fluctuations during microcoaxial phacoemulsification using different aspiration flow rates and their impact on early postoperative outcomes: a randomized clinical trial.

PURPOSE: To compare the impact of varying fluidic parameters on intraoperative intraocular pressure (IOP) fluctuations and postoperative outcomes. METHODS: Prospective randomized study of 80 eyes undergoing cataract surgery that were randomly assigned to low (aspiration flow rate: 20 cc/min; bottle height: 90 cm; vacuum: 400 mm Hg) and high (aspiration flow rate: 40 cc/min; bottle height: 110 cm; vacuum: 400 mm Hg) fluidic parameter groups. Real-time dynamic intraoperative IOP was measured during nuclear fragment removal. Mean maximum and minimum IOP and percentage reduction in IOP from maximum were compared between groups. Postoperatively, the rate of change in central corneal thickness and anterior chamber inflammation at days 1 and 7, endothelial cell density at 3 months, and corneal clarity on day 1 were compared. RESULTS: Minimum IOP in the low and high parameters groups was 35 ± 4.0 and 34.5 ± 6.8 mm Hg, respectively. Maximum IOP in the low and high parameters groups was 69 ± 3.0 and 85 ± 1.2 mm Hg, respectively (P < .002). Mean percent reduction from maximum was 59% in the high parameters group compared to 41% in the low parameters group, with the difference being statistically significant (P < .002). Rate of change in central corneal thickness was greater in the high parameters group at postoperative days 1 and 7 (P < .001). Anterior chamber inflammation and corneal clarity on the first postoperative day were significantly better in the low parameters group. CONCLUSIONS: Higher aspiration flow rate and bottle heights are associated with high intraoperative IOPs of up to 85 mm Hg. Prolonged elevated IOP during cataract surgery was found to have more anterior segment inflammation and more edematous corneas.

Thin-flap laser in situ keratomileusis with femtosecond-laser technology.

PURPOSE: To evaluate the results of thin-flap laser in situ keratomileusis (LASIK) using a femtosecond-laser platform for flap creation. SETTING: Institute of Vision and Optics, Faculty of Medicine, University of Crete, Heraklion, Greece. DESIGN: Prospective interventional case series. METHODS: Patients had LASIK with the FS200 femtosecond laser for flap creation and the Allegretto Wave Eye-Q excimer laser. Flap thickness was set at 105 µm. All eyes were examined 1 month postoperatively. Flap thickness was assessed with anterior segment optical coherence tomography using the manual flap tool at 5 locations on a horizontal B scan. RESULTS: This study comprised 50 eyes of 25 patients (mean age 28 years ±5.72 [SD]); 42 eyes completed 6 months of follow-up. Preoperatively, the mean sphere was -3.61 ± 1.87 diopters (D) and the mean cylinder, -1.08 ± 1.23 D. Six months postoperatively, no eye lost lines of corrected distance visual acuity (CDVA), 29% gained 1 line, and 7% gained 2 lines. The mean spherical equivalent was -0.03 ± 0.42 D (range -0.88 to +0.88 D); 86% had an uncorrected distance visual acuity of 20/20 or better. The mean central flap thickness at 1 month was 102.98 ± 6.33 µm (range 91 to 114 µm). There were no intraoperative or postoperative complications. CONCLUSIONS: No significant complications occurred after treatment with this new femtosecond-laser platform in thin-flap LASIK. Clinical (visual and refractive) results were satisfactory in terms of safety, predictability, and stability.

Intraocular lens explantation technique for one-piece acrylic lenses.

PURPOSE: To present a simple technique to remove a one-piece, acrylic AcrySof (Alcon Laboratories Inc) intraocular lens (IOL) via the original incision. METHODS: The AcrySof IOL is removed via the original (2.75-mm) incision, without cutting or folding the IOL or widening the incision. After the IOL is viscodissected from the capsular bag and brought into the anterior chamber, toothed forceps hold the optic through the incision while the manipulator enters the side-port incision and hooks onto the optic 180° away. RESULTS: With the forceps pulling and the lens manipulator pushing the IOL toward the incision, the IOL will fold and be delivered. CONCLUSIONS: A one-piece, acrylic (Acrysof) IOL can be removed without cutting or folding the lens and without widening the original 2.75-mm incision.

Safety and efficacy of bromfenac ophthalmic solution (Bromday) dosed once daily for postoperative ocular inflammation and pain.

PURPOSE: To evaluate the efficacy and ocular safety of bromfenac ophthalmic solution (bromfenac) 0.09% dosed once daily for the treatment of ocular inflammation and pain after cataract surgery with posterior chamber intraocular lens implantation. DESIGN: Randomized, double-masked, vehicle-controlled or active-controlled, multicenter, clinical trials. PARTICIPANTS AND CONTROLS: A total of 872 subjects (872 study eyes: bromfenac in 584, placebo in 288). METHODS: Four randomized, double-masked, vehicle or active-controlled, clinical trials were conducted at 134 ophthalmology clinics in the United States. Subjects aged ≥ 18 years were randomized to receive either bromfenac 0.09% or placebo dosed once daily beginning 1 day before cataract surgery (day -1), continuing on the day of surgery (day 0), and continuing for an additional postoperative 14 days. Subjects were evaluated for efficacy and safety on days 1, 3, 8, 15, and 22. The primary efficacy end point was cleared ocular inflammation, measured by the summed ocular inflammation score (SOIS; anterior chamber cells and flare) by day 15. The secondary efficacy end point was the number of subjects who were pain-free at day 1. The data from the 4 trials were pooled for analyses. MAIN OUTCOME MEASURES: The SOIS and ocular pain. RESULTS: The proportion of subjects who had cleared ocular inflammation by day 15 was significantly higher in the bromfenac 0.09% group than in the placebo group (P < 0.0001). The mean SOIS in the bromfenac 0.09% group was significantly lower than in the placebo group at days 3, 8, 15, and 22 (P < 0.0001). The proportion of subjects who were pain-free at days 1, 3, 8, and 15 was significantly higher in the bromfenac 0.09% group than in the placebo group (P < 0.0001). The incidence of adverse events reported in the bromfenac 0.09% group was significantly lower than in the placebo group (P < 0.0001). On day 15, 84.0% of the bromfenac subjects had ≥ 1-line improvement in visual acuity compared with 66.1% of placebo subjects (P < 0.0001). CONCLUSIONS: Bromfenac 0.09% dosed once daily was clinically safe and effective for reducing and treating ocular inflammation and pain associated with cataract surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Optimizing resident education in cataract surgery.

PURPOSE OF REVIEW: Evaluate recent literature focusing on improving or assessing resident education in cataract surgery. RECENT FINDINGS: Recently published studies outline methods of evaluating residents' performance, educational progress, and evaluating a surgical curriculum. Authors found that the rate of complications in resident-performed cataract surgery falls by 50% after the first 40 cases and stays the same for the next 20 cases. Preoperative risk factors for complications include mature cataract and abnormal zonular function. Left-handed residents had fewer complications compared with right-handed residents. Authors evaluated adherence by residents to the American Academy of Ophthalmology's Preferred Practice Patterns, and found that residents were lacking in eliciting patient's symptoms or function. A guide to establishing and maintaining a wet laboratory was published. Several studies evaluating the use of a physical-surgical simulator reported improvement in performance. The simulator was accepted and appreciated by residents. A cognitive simulation program was also found to be beneficial in improving fund of knowledge regarding cataract surgery. SUMMARY: Teaching cataract surgery remains a difficult task. Educators continue to focus on curriculum, assessment, and complications. Resources for education are improving with establishment of wet laboratories and development of surgical simulators.

Clinical pseudophakic cystoid macular edema. Risk factors for development and duration after treatment.

PURPOSE: To characterize the incidence, duration, and risk factors for and outcome of cystoid macular edema (CME) after cataract surgery and investigate the effects of treatment regimens on visual outcome and duration. SETTING: University-based comprehensive ophthalmology practice. METHODS: This study included 1659 consecutive cataract surgeries performed by residents between 2001 and 2006. Cases were classified according to the presence of CME. Subset analysis excluded patients with diabetes mellitus (DM). The CME groups were analyzed according to type of treatment to compare duration of CME and final best corrected visual acuity. RESULTS: The incidence of postoperative CME was 2.35% (39/1659), and history of retinal vein occlusion (RVO) was predictive of postoperative CME (odds ratio [OR], 47.12; P<.001). When patients with DM were excluded, the incidence of CME was 2.14% (29/1357) and history of RVO (OR, 31.75; P<.001), epiretinal membrane (ERM) (OR, 4.93; P<.03), and preoperative prostaglandin use (OR, 12.45; P<.04) were predictive of postoperative CME. Patients with DM and/or intraoperative complications did not have an increased risk for CME when treated with prophylactic postoperative nonsteroidal antiinflammatory drugs (NSAIDs) for 3 months. Groups treated with NSAIDs plus a steroid had significantly shorter resolution times than the untreated group (P = .004). CONCLUSIONS: A history of RVO, ERM, and preoperative prostaglandin use were associated with an increased risk for pseudophakic CME. Treatment with NSAIDs plus steroids was associated with faster resolution of CME than no treatment. Treating high-risk patients with NSAIDs after cataract surgery decreases the incidence of postoperative CME to that of patients who are not at high risk.

Incidence and causes of ocular surgery cancellations in an ambulatory surgical center.

PURPOSE: To report the incidence and analyze potentially preventable causes of ocular surgery cancellations. SETTING: Ambulatory Care Surgical Center of the Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA. METHODS: A retrospective review of the ambulatory surgical center cancellation records and patient medical records from December 2001 to December 2003 was conducted. The primary statistical analysis was conditional logistic regression. RESULTS: Three hundred seventy-nine of 7153 (5.3%) ambulatory ophthalmic surgeries were cancelled within 24 hours of the scheduled start time. Cancellation rates varied by patient age, with the rate among children being highest (8.7%) and that among older patients (age 60+) lowest (4.9%; P = .08). Surgeons who performed at least 4 surgeries per month on average had the lowest cancellation rate (P = .08). Cancellations occurred less frequently in warmer months (June, 3.3%; August, 4.2%) than during the rest of the seasons (P<.001). The highest incidence of cancellations occurred in February (7.8%) and the lowest in June (3.3%). Of the total causes, 41% were considered "preventable," 45% "unpreventable," and 14% "no reason given." Cancellations deemed preventable were lower in general anesthesia cases (1.0%) than in local anesthesia cases (2.0%; P = .02). Preventable cancellation rates also varied by procedure and were statistically significant. CONCLUSIONS: Among ambulatory ophthalmic surgeries, there was a higher incidence of late cancellations in pediatric cases. Late cancellation rates were highest in cases scheduled in the winter, especially in February. Of the reasons documented for cancellations, 41% were considered "preventable" with proper preoperative counseling and instructions. The costs of late cancellations to the particular institution are estimated to be at least $100 000 per year, or nearly 1 month of scheduled surgeries in a 2-year period.

Intraocular choristoma.

Choristomas have been reported in the orbit, cornea, conjunctiva, uvea, retina, and optic nerve. Many reports have described the choristoma mainly in the epibulbar area, but little is known of the choristoma that occurs intraocularly. We reviewed the literature and summarized the reports that described the choristoma inside the eyes. Iris, ciliary body, choroid, and optic nerve head are the commonly affected tissues. In the anterior uveal tissue, an ectopic lacrimal gland is common and appears as a pinkish, nodular, fleshy mass. Its clinical course largely depends on the enlargement of the accompanying cyst. Osseous choristoma is mainly found in the choroid in young female patients. Although it is regarded as a benign tumor, it grows progressively and can decrease visual function. Treatment consists of close observation and possibly surgical intervention. Fortunately, most of the intraocular choristomas do not need aggressive treatment.