Keratoplasty in patients with intellectual disability.

PURPOSE: The aim was to report the outcome of keratoplasty in patients with intellectual disability (ID). METHODS: All patients with ID who had undergone keratoplasty at the Eye Department, Red Cross Hospital, Munich, between January 1, 1991, and December 31, 2010, were identified and recalled for examination. In cases of missing data, the information contained in the patient's chart was analyzed and/or his ophthalmologist was contacted. RESULTS: A total of 38 eyes (29 patients) that had undergone 53 keratoplasty procedures were included in the analysis. In 20 patients, the general diagnosis was Down syndrome, 1 patient had ID as a result of brain tumor excision, and 8 patients had ID of an unknown origin. The indication for the primary keratoplasty (n = 35) was keratoconus in 33 patients and corneal opacity because of exposure in facial nerve palsy in 2 patients. In the 3 remaining patients, the first procedure at the study institution was a repeat keratoplasty. The median follow-up was 9 years (minimum 6 months, maximum 20 years). The graft survival rate of the primary graft was 86% (n = 30/35) from 27 months to 11 years. At the last follow-up visit, a clear graft was present in 89% of all the patients (n = 34/38). One eye underwent enucleation, and 3 other eyes remained with a cloudy graft after multiple interventions for rejection/corneal ulceration. CONCLUSIONS: The majority of the patients with ID clearly benefited from keratoplasty, although a few deleterious courses occurred. Keratoplasty in these individuals can be considered whenever patients can no longer comply with the visual demands of their particular individual life.

Intraocular lens calcification after keratoplasty.

PURPOSE: To report calcification of intraocular lenses (IOLs) after various keratoplasty procedures. METHODS: Clinical data of all cases with calcified IOLs after keratoplasty procedures were analyzed. A total of 6 explanted IOLs were analyzed with light microscopy before and after staining with 1% alizarin red and the von Kossa method. RESULTS: A total of 7 cases occurred after Descemet stripping automated endothelial keratoplasty, 1 case after deep anterior lamellar keratoplasty, and 2 cases after penetrating keratoplasty. Median time interval from keratoplasty to first notice of IOL opacification was 6.5 months (minimum 3 months, maximum 51 months). A total of 3 IOLs had been placed at the time of keratoplasty and 7 IOLs before keratoplasty. All affected IOLs were hydrophilic acrylic and comprised IOLs from at least 3 different polymer sources. Common clinical aspects were some amount of inflammation in the anterior chamber during the postoperative period and use of air at the end of surgery in 8 of the 10 cases. Histochemical analysis demonstrated the presence of fine granular deposits located within the very superficial optic material in all cases. The deposits stained positive for calcium with alizarin red and the von Kossa method. CONCLUSIONS: IOL calcification associated with keratoplasty in our series does not seem to be a problem related to a specific IOL model or polymer. The process of calcification may be mediated by inflammation, which also may be related to multiple injections of air into the anterior chamber.

Intraoperative retinal break formation in 23-/25-gauge vitrectomy versus 20-gauge vitrectomy.

BACKGROUND: This study was undertaken to examine the possible effect of microcannula-guided entry sites on the rate of intraoperative retinal break formation. METHODS: In this historical cohort study, all patients having undergone vitrectomy with epiretinal or internal limiting membrane peeling performed by one surgeon between January 2005 and March 2009 were included. All procedures with microcannula-guided entry sites (23- and 25-gauge vitrectomy) were compared to procedures without the use of microcannulas (20-gauge vitrectomy). RESULTS: A total of 221 eyes with a follow-up of at least 30 days were analyzed. The total incidence of intraoperative retinal break formation was 25.2% (n = 28/111) for the 20-gauge group and 12.7% (n = 14/110) for the 23-/25-gauge group, resulting in an odds ratio of 2.313 (95% confidence interval 1.142-4.685) of an increased rate in the 20-gauge group. CONCLUSION: This study demonstrates that intraoperative retinal breaks during vitrectomy are reduced in the microcannula-guided techniques compared to 20-gauge vitrectomy. This effect may be attributed to the protection of the vitreous base during surgery. Further prospective studies are warranted.

Visualization and follow-up of acute macular neuroretinopathy with the Spectralis HRA+OCT device.

BACKGROUND: Acute macular neuroretinopathy (AMNR) is a rare disease entity, the diagnosis of which is frequently complicated by the subtlety of biomicroscopic findings. METHODS: Two cases of AMNR are presented, in which the diagnosis and follow-up was enabled using the Spectralis HRA+OCT in the absence of clear biomicroscopic findings. RESULTS: The typical lesions were visualized by hyporeflexion during infrared imaging and faded over time. With spectral domain optical coherence tomography, changes in the outer retina in the affected regions were documented, with no change over time. CONCLUSION: The broader availability of this technology may enhance the diagnosis and follow-up of AMNR.

Static and dynamic rotational eye tracking during LASIK treatment of myopic astigmatism with the Zyoptix laser platform and Advanced Control Eye Tracker.

PURPOSE: To evaluate the amount of cyclotorsion and the effect of static and dynamic rotational eye tracking with the Advanced Control Eye Tracker (Bausch & Lomb) based on iris recognition in the treatment of myopic astigmatism with LASIK. METHODS: All patients with myopic LASIK and attempted cylinder correction >0.75 diopters (D) on the Zyoptix 217z100 excimer laser platform between May 2005 and May 2007 were identified retrospectively through the existing databank. Pre- and postoperative refraction and the amount of cyclotorsion during treatment were extracted and analyzed in 828 eyes with >3-month follow-up. RESULTS: Preoperative mean manifest refraction spherical equivalent (MRSE) was -4.31+/-1.84 D (range: -0.37 to -9.50 D), and mean cylinder was -1.27+/-0.87 D (range: -0.75 to -6.75 D). Mean static rotation was 3.96+/-2.96 degrees (maximum 14.8 degrees ). Median dynamic rotation was 1.32+/-1.85 degrees (maximum 24 degrees). At 3 months postoperatively, MRSE was -0.10+/-0.36 D (range: -2.25 to +1.25 D), and mean cylinder was -0.33+/-0.35 D (range: -2.00 to 0 D). Predictability was 90.2% within +/-0.50 D and 98.2% within +/-1.00 D (MRSE), and 82.5% within +/-0.50 D and 96.9% within +/-1.00 D (cylinder). The efficacy ratio was 0.99. Safety was 99.4% (5 dry eyes), reaching 100% at 12 months. Stability from 3 to 12 months (n=275) was 98.2% for sphere, 95.3% for cylinder, and 96.0% for MRSE. CONCLUSIONS: Our study demonstrates that significant cyclotorsion occurs before and during treatment. By using the dynamic rotational eye tracker presented, the efficacy of cylinder correction can be improved compared to those studies not performing cyclotorsional correction.

Cataract surgery and aniridia.

PURPOSE OF REVIEW: In the past years, several new options have been developed for the surgical management of aniridia in the course of cataract surgery. RECENT FINDINGS: The lens capsule may be altered - thinned - in aniridia, requiring particular attention in order to avoid complications with possible consequences for the surgical plan. Iris prosthetic devices for complete or partial restoration of an iris diaphragm have been developed and their use described. There are options for intracapsular placement as well as for fixation without using a capsular bag and options for improved cosmetic appearance have been created. Corneal tattooing is still an option for selected cases and has been refined technically. Complications attributable with the iris prostheses are relatively infrequent and manageable. SUMMARY: Cataract surgery offers an opportunity to manage associated partial or (sub)total aniridia of all origins with good to excellent functional and esthetic results with a relatively low and manageable complication potential.

Clinicopathological correlation of 3 patterns of calcification in a hydrophilic acrylic intraocular lens.

We present 3 cases of opacification in the Biocomfold 92S intraocular lens (IOL), with a documented increase in the opacification over time in 1 case. Histopathological analysis revealed the opacification was caused by calcification in the IOL's optic material. The pattern of calcium deposition, however, was different in each IOL. The causative mechanisms for this complication are unclear. Further research is warranted.

Virtual reality training improves wet-lab performance of capsulorhexis: results of a randomized, controlled study.

PURPOSE: To investigate, whether capsulorhexis training on the EYESi surgical simulator improves wet-lab operating performance of surgical novices. METHODS: Randomized, masked experimental study. Thirty-one medical students and 32 ophthalmological residents were randomized to either virtual reality (VR) training, or control. Initially and after 3 weeks each participant performed three capsulorhexis tasks in a porcine wet-lab. In between, participants from the VR training groups completed two training trials on the EYESi surgical simulator (VRmagic, Mannheim, Germany). VR training consisted of basic skill tasks and capsulorhexis tasks of increasing difficulty, and preset performance goals had to be reached for each task. All wet-lab procedures (n = 372) were recorded on DVD, and assessed by a masked observer. Each wet-lab capsulorhexis was evaluated with regard to five criteria (circularity, size, centering, time, tissue protection) using a predefined scoring system with a maximum overall score of 10 points (2 per criterion). The primary outcome measure was the intra-individual difference in the average overall performance score between the first and second wet-lab capsulorhexis procedures. Ten operation videos were additionally assessed by three further investigators to determine interobserver agreement. RESULTS: Inter-observer agreement regarding the overall performance score was high (ICC = 0.91). Compared to control groups, VR-trained students and residents showed significant improvement in their median wet-lab capsulorhexis overall performance score compared to controls (+3.67 vs +0.33 points, P = 0.001 and +3.33 vs +/-0.00 points, P < 0.0001). The capsulorhexis performance of VR-trained students and residents was also more consistent with a lower standard deviation of scores compared to controls (SD 1.3 vs 2.1 and 1.2 vs 1.7 points respectively). CONCLUSIONS: Structured capsulorhexis training on the EYESi to reach specific target criteria significantly improved wet-lab capsulorhexis performance.

Retinal detachment after phacoemulsification in high myopia: analysis of 2356 cases.

PURPOSE: To determine the incidence of and risk factors for rhegmatogenous retinal detachment (RD) in highly myopic eyes after cataract surgery. SETTING: Two ophthalmology centers in Munich and Ahaus, Germany. METHODS: This retrospective medical chart review comprised 1519 consecutive patients (2356 eyes) with an axial length (AL) greater than 27.0 mm who had planned phacoemulsification and intraocular lens implantation in the capsular bag. In addition, all patients and/or the referring ophthalmologist were contacted regarding the occurrence of RD and laser capsulotomy and the date of occurrence. RESULTS: Follow-up was longer than 24 months in 84% of eyes. Because some cases of RD were questionably related to the preceding cataract surgery, the absolute incidence of postoperative RD was determined as highest (2.2%) and lowest (1.5%). Sex, history of laser capsulotomy, and increasing AL had no statistically significant effect on the rate of RD. The risk for postoperative RD was significantly higher in eyes of younger patients and eyes with preoperative prophylactic treatment for retinal degeneration. CONCLUSIONS: The risk for postoperative RD in this study (1.5% to 2.2%) corresponds to the incidence of pseudophakic RD and idiopathic RD in myopia described in the literature. The risk profile for postoperative RD in this series cannot be distinguished from the risk profile for idiopathic RD in myopia of this extent. The true effect of prophylactic treatment of degenerative lesions remains to be elucidated.

Online optical coherence pachymetry as a safety measure for laser in situ keratomileusis treatment in 1859 cases.

PURPOSE: To evaluate the reliability and applicability of online optical coherence pachymetry (OCP) (OCPonline, Heidelberg Engineering GmbH) integrated into the Zyoptix 217z100 excimer laser platform (Bausch & Lomb) under routine clinical conditions. SETTING: Private laser clinic, Munich, Germany. METHODS: Between July 2004 and June 2006, 1859 consecutive eyes having laser in situ keratomileusis (LASIK) using the Zyoptix 217z100 excimer laser platform had preoperative pachymetry with the Orbscan II (Bausch & Lomb) and DGH II (Pachette 2, DGH Technology, Inc.) and continuous intraoperative online OCP with the OCPonline. Preoperative pachymetry values and actual flap thicknesses with the Hansatome and Zyoptix XP microkeratomes (both Bausch & Lomb) and the IntraLase FS30 femtosecond laser keratome (IntraLase Corp.) were evaluated. RESULTS: Preoperative pachymetry values showed a high correlation between the OCPonline device and the Orbscan II (R(2) = 0.78, difference = 0.37%) and DGH II (R(2) = 0.77, difference = 0.69%). The OCPonline measurements resulted in a mean flap thickness of 121.4 microm +/- 19.1 (SD) with the Hansatome (160 microm head), 126.5 +/- 15.5 microm with the Zyoptix XP (120 microm head), and 121.7 +/- 14.7 microm with the IntraLase FS30 (110 microm flap thickness). A correlation between the calculated laser ablation depth and the measured stromal thinning was established. CONCLUSION: OCPonline technology provided reliable intraoperative noncontact pachymetry measurements integrated into a clinical flow, indicating the technology has the potential to improve the safety of corneal ablation procedures.

A new classification of calcification of intraocular lenses.

OBJECTIVE: To define and classify the major types of intraocular lens (IOL) calcification. DESIGN: Retrospective observational case series with clinicopathologic correlation. PARTICIPANTS: More than 400 IOLs explanted because of opacification. METHODS: The authors reviewed the clinical information and histologic findings of all IOLs that had been explanted because of opacification or calcification of the IOLs accessioned in their laboratory between January 1999 and December 2004. MAIN OUTCOME MEASURE: The proposed mechanism that led to calcification of each IOL design. RESULTS: Three major types of calcification were identified: (1) primary calcification, (2) secondary calcification, and (3) false-positive calcification or pseudocalcification. The primary form refers to calcification that is inherent in the IOL, that is, is based on possible inadequate formulation of the polymer, fabrication of the IOL, or issues with its packaging process. The calcification presumably occurs in otherwise normal eyes and generally is not associated with preexisting diseases. The secondary form refers to deposition of calcium onto the surface of the IOL most likely the result of environmental circumstances (e.g., changes in the aqueous milieu surrounding the implanted IOL associated with preexisting or concurrent diseases or indeed any condition that has disrupted the blood-aqueous barrier). By definition, it is not related to any problem with the IOL itself. The false-positive or pseudocalcification refers to those cases in which other pathology is mistaken for calcification or false-positive staining for calcium occurs. CONCLUSIONS: When evaluating the pathogenesis and nature of IOL calcification in or on any given design, one should categorize it according to these types. Primary calcification is IOL related and the IOL should be withdrawn or modified to correct the problem. After the cause is identified and the lens is implanted again, patients should be followed up for up to 2 years to be sure the problem is alleviated. Secondary calcification is by definition not IOL related; it may occur with virtually all IOL designs implanted under various adverse circumstances. No IOL, hydrophilic or hydrophobic, is immune to secondary calcification. The false-positive form is recognized readily in the laboratory and this erroneous diagnosis is avoided.

Postoperative surface deposits on intraocular lenses in children.

PURPOSE: To report the clinicopathologic features of 4 intraocular lenses (IOLs) composed of 3 different hydrophilic biomaterials explanted from children who had postoperative opacification of the IOL optic. SETTING: David J Apple, MD, Laboratories for Ophthalmic Devices Research, John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, Utah, USA. METHODS: The IOLs were explanted 20, 11, 22, and 25 months postoperatively from children aged 10, 3, 36, and 20 months old, respectively, at IOL implantation. Clinical data were obtained to correlate the findings with possible associated risk factors. The explanted IOLs were examined by gross and light microscopy. They were further analyzed with a stain for calcium, alizarin red 1%. Scanning electron microscopy and energy dispersive X-ray spectroscopy (EDS) were also performed. RESULTS: The primary reason for cataract surgery in Case 1 and Case 2 was persistent hyperplastic primary vitreous (PHPV); 1 patient received a B-Lens IOL (Hanita) and the other a Centerflex IOL (Rayner). The primary reason in Case 3 was familial bilateral congenital cataract and in Case 4, rubella cataract; both patients received a Hydroview IOL (Bausch & Lomb). All 4 IOLs had surface deposits on the optic, but the morphology of the deposits on the B-Lens and Centerflex IOLs was different than that in previously reported cases. The deposits in all four cases stained positive with alizarin red and consisted of calcium and phosphorus when imaged with EDS. CONCLUSIONS: Calcified deposits on 2 Hydroview IOLs explanted from children were similar to those seen in adults with the same IOL. The deposits on the B-Lens and Centerflex IOLs were probably secondary to a breakdown of the blood-aqueous barrier caused by preexisting PHPV.

Long-term capsular bag survival without functional lens epithelial cells.

PURPOSE: To evaluate the survival of the capsular bag without the support of functional lens epithelial cells (LECs). SETTING: David J. Apple, MD, Laboratories for Ophthalmic Devices Research, John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, Utah, USA. METHODS: One hundred slides of cadaver pseudophakic eyes (from 1991 to 2000) stained with hematoxylin and eosin were analyzed to determine the presence of Soemmering's ring, integrity of the capsular bag, fixation configuration of the haptics, and presence and functionality of the LECs. RESULTS: A Soemmering's ring was present in 69% of cases. The capsular bags were intact in 100% of cases. In-the-bag fixation was seen in 44% of cases. In 89% of cases, either no cells or nonfunctional LECs were found. CONCLUSION: Results suggest the capsular bag can survive anatomically without the support of functioning LECs.

Clinical presentation of intraocular lens schisis.

PURPOSE: To analyze the clinical presentation and implications of cavity or schisis formation in the MemoryLens (CIBA Vision) intraocular lens (IOL) optic. SETTING: Eye Department, Red Cross Hospital, Munich, Germany. METHODS: This study was a retrospective chart review and slitlamp photography analysis of IOL schisis. RESULTS: Four patients with IOL schisis were identified and their charts analyzed. Clinically, the schisis presented as a sharply demarcated round structure. The aspect was clear on coaxial illumination, but on tangential illumination the schisis area was opaque. Patients experienced glare, foggy vision, and deteriorated visual function or had no symptoms. One patient lost visual acuity, and the IOL was explanted. CONCLUSIONS: Clinically, IOL schisis was easily differentiated from cases of IOL opacification due to calcification. The clinical implication was not uniform, ranging from no symptoms to great visual disturbance leading to explantation of the IOL. The cause of this complication remains unclear. A possible explanation is the impact of solvent-induced tensile stress on the IOL optic material during the manufacturing process.

Two opacification patterns of the same hydrophilic acrylic polymer: case reports and clinicopathological correlation.

We report 2 intraocular lenses (IOLs) manufactured from the same hydrophilic acrylic polymer by Ioltech that developed optic opacification. In both cases, the postoperative course after implantation of the IOLs was complicated by significant inflammatory reaction with fibrin formation in the anterior chamber. Pathologic analyses of the explanted IOLs were consistent with dystrophic calcification leading to optic opacification, but the pattern was different between the 2 IOL designs. Patient-related factors might have been responsible for this complication.

"Special" intraocular lens designs: why do they sometimes fail?

A variety of new "special" intraocular lens models to optimize the visual performance after cataract surgery have been introduced. The majority of these new intraocular lens designs require a good centration within the capsular bag and/or capsular elasticity. Today, the main post-operative complications after cataract surgery still arise from retained lens epithelial cells within the capsular bag, resulting mainly in anterior and posterior capsule opacification. Some special intraocular lenses are not designed to be effective against proliferating lens epithelial cells. Although lens epithelial cells can never be completely removed from the capsular bag, surgical quality is a major factor for success or failure of these intraocular lens designs.

Postoperative opacification of the peripheral optic region and haptics of a hydrophilic acrylic intraocular lens: case report and clinicopathologic correlation.

We report the first case of opacification of the BioComFold 92S (Morcher GmbH) intraocular lens. The opacification pattern is unique, presenting mainly in the periphery of the optic and the haptics of the lens, leaving the central portion of the optic clear. The clinical course of this opacification pattern is not observed typically with other hydrophilic acrylic lens designs and requires further study.

Intraocular concentrations of gatifloxacin and moxifloxacin in the anterior chamber via diffusion through the cornea using collagen shields.

PURPOSE: To evaluate the penetration of gatifloxacin and moxifloxacin into the anterior chamber, and any adverse reaction to the cornea, using collagen shields presoaked in oversaturated solutions of the antibiotics. METHODS: Collagen shields, presoaked for 10 minutes in an oversaturated solution of gatifloxacin or moxifloxacin, were placed on the surface of each of the corneas of 15 rabbits for a total of 30 eyes (15 in each group). The antibiotics were prepared by dissolving the powder form of the antibiotics in a solution until no further particulate could be further dissolved. Aqueous humor samples were taken 3.5 and 6 hours later. RESULTS: The initial concentrations of gatifloxacin and moxifloxacin were 5.43 +/- 0.16 mg/mL and 3.14 +/- 0.22 mg/mL, respectively. The average concentration of gatifloxacin in the anterior chamber was higher than that of moxifloxacin at the 3.5-hour sample (6.32 +/- 2.67 microg/mL versus 3.55 +/- 3.5 microg/mL, P = 0.0034). The concentrations of both antibiotics, although decreased, remained relatively high at the 6-hour sample (1.39 +/- 1.13 microg/mL versus 0.816 +/- 0.6 microg/mL at 6 hours, respectively, P = 0.22). No obvious clinical or histologic signs of toxicity were noticed in either group. CONCLUSION: Gatifloxacin and moxifloxacin showed good penetration into the anterior chamber with no obvious adverse reaction to the cornea. The concentrations in the anterior chamber exceeded the minimal inhibitory concentration (MIC) 90 of most organisms responsible for postoperative endophthalmitis (POE).