Systematic Literature Review of Clinical, Economic, and Humanistic Outcomes Following Minimally Invasive Glaucoma Surgery or Selective Laser Trabeculoplasty for the Treatment of Open-Angle Glaucoma with or Without Cataract Extraction.

Introduction: Selective laser trabeculoplasty (SLT) and minimally invasive glaucoma surgery (MIGS) are increasingly used options for mild-to-moderate open-angle glaucoma (OAG) care. While most MIGS devices are indicated for use in combination with cataract surgery only, with phacoemulsification playing a role in lowering IOP, newer technologies can also be used as standalone glaucoma surgery. Methods: This systematic literature review (SLR) aimed to assess the clinical, economic, and humanistic outcomes of MIGS and SLT for the treatment of OAG and was conducted according to PRISMA guidelines. Studies that assessed MIGS or SLT in at least one treatment arm versus any other glaucoma treatment in adults with mild-to-moderate OAG were included. Clinical, humanistic (health-related quality of life [HRQoL] and patient burden), and economic data were extracted, and the methodological quality of included studies was evaluated. Results: A total of 2720 articles were screened, and 81 publications were included. Fifty-eight reported clinical outcomes. The majority assessed iStent or iStent inject (n=41), followed by OMNI (n=9), gonioscopy-assisted transluminal trabeculotomy (GATT) or the Kahook Dual Blade (KDB) (n=7), Hydrus (n=6), SLT (n=5), Xen Gel Stent (n=2), PreserFlo (n=1), and iTrack (n=1). IOP reduction was observed across prospective studies, varying from -31% to -13.7% at month 6 and from -39% to -11.4% at year 1 versus baseline. Most adverse events were transient and non-serious. Limited humanistic and economic data were identified. Conclusion: Given their established efficacy and safety, there is a rationale for wider use of MIGS in mild-to-moderate OAG. Of the MIGS devices, iStent and OMNI have the largest clinical evidence base supporting their sustained effectiveness.

Determination of bleb capsule porosity with an experimental glaucoma drainage device and measurement system.

IMPORTANCE: Control of intraocular pressure after implantation of a glaucoma drainage device (GDD) depends on the porosity of the capsule that forms around the plate of the GDD. OBJECTIVE: To compare capsular porosity after insertion of 2 different GDDs using a novel implant and measurement system. DESIGN, SETTING, AND SUBJECTS: We performed an experimental interventional study at an eye research facility in a tertiary eye care center. Testing was performed on 22 adult New Zealand white rabbits that received the experimental GDD or an existing GDD. INTERVENTIONS: A new experimental GDD, the Center for Eye Research Australia (CERA) implant, was created using computer-aided design and a 3-dimensional printer. The CERA GDDs were implanted in the eyes of rabbits randomized into 1 of the following 3 groups: with no connection to the anterior chamber (n = 7), with connection to the anterior chamber for 1 week (n = 5), and with connection to the anterior chamber for 4 weeks (n = 5). In a control group (n = 5), a pediatric GDD was implanted without connection to the anterior chamber. We measured the capsular porosity using a pressure-gated picoliter pump at a driving pressure of 12 mm Hg. The animals were killed humanely for histologic study. MAIN OUTCOMES AND MEASURES: Porosity of the fibrous capsule around the implant. RESULTS: We found no difference in mean (SEM) capsular porosity between the CERA (3.39 [0.76; 95% CI, 1.43-5.48] µL/min) and pediatric (4.52 [0.52; 95% CI, 3.19-5.95] µL/min) GDDs (P = .28, unpaired t test) at 4 weeks without aqueous exposure. Mean (SEM) capsular porosity of CERA GDDs connected to the anterior chamber at 1 week was 2.46 (0.36; 95% CI, 1.55-3.44) µL/min but decreased to 0.67 (0.07; 95% CI, 0.49-0.86) µL/min at 4 weeks (P = .001, unpaired t test). CONCLUSIONS AND RELEVANCE: Our experimental method permits direct measurement of capsular porosity of an in situ GDD. In a comparison between an experimental (CERA) and an existing GDD, no differences were identified in capsular porosity or histologic reaction between the implants. These results suggest that the CERA GDD model can be used to test key components of glaucoma surgery and implant design.

Wound Healing Modulation in Glaucoma Filtration Surgery- Conventional Practices and New Perspectives: Antivascular Endothelial Growth Factor and Novel Agents (Part II).

Glaucoma filtration surgery is regularly performed for the treatment of glaucoma and trabeculectomy is often regarded as the 'gold standard' glaucoma operation. The biggest risk of failure of the operation is bleb scarring. The advent of antifibrotic agents, such as mitomycin C (MMC) and 5-fluorouracil (5FU) has vastly prolonged the longevity of the bleb, but concerns remain regarding the potential increase in postoperative complications. More selective therapeutic targets have therefore been explored. One of these is vascular endothelial growth factor (VEGF) inhibition. VEGF inhibition has a role not only in subconjunctival angiogenesis inhibition but also it has direct anti-fibrotic properties. Newer pharmacological compounds and materials have also been developed in recent years in attempt to modulate the wound healing in different ways after glaucoma surgery. These include physical barriers to scarring and vehicles for sustained release of pharmacological agents, and early promising results have been demonstrated. This two-part review will provide a discussion of the application of anti-fibrotic agents in glaucoma filtration surgery and evaluate the newer agents that have been developed. How to cite this article: Fan Gaskin JC, Nguyen DQ, Ang GS, O'Connor J, Crowston JG. Wound Healing Modulation in Glau coma Filtration Surgery-Conventional Practices and New Pers pectives: Antivascular Endothelial Growth Factor and Novel Agents (Part II). J Curr Glaucoma Pract 2014;8(2):46-53.

Wound Healing Modulation in Glaucoma Filtration Surgery-Conventional Practices and New Perspectives: The Role of Antifibrotic Agents (Part I).

Glaucoma filtration surgery is regularly performed for the treatment of glaucoma and trabeculectomy is often regarded as the 'gold standard' glaucoma operation. The biggest risk of failure of the operation is bleb scarring. The advent of anti-fibrotic agents, such as mitomycin C (MMC) and 5-fluorouracil (5FU) has vastly prolonged the longevity of the bleb, but concerns remain regarding the potential increase in postoperative complications. More selective therapeutic targets have therefore been explored. One of these is vascular endothelial growth factor (VEGF) inhibition. Vascular endothelial growth factor inhi bition has a role not only in sub conjunctival angiogenesis inhi bition but also it has direct anti-fibrotic properties. Newer phar macological compounds and materials have also been developed in recent years in attempt to modulate the wound healing in different ways after glaucoma surgery. These include physical barriers to scarring and vehicles for sustained release of pharmacological agents, and early promising results have been demonstrated. This two-part review will provide a discussion of the application of anti-fibrotic agents in glaucoma filtration surgery and evaluate the newer agents that have been developed. How to cite this article: Fan Gaskin JC, Nguyen DQ, Ang GS, O'Connor J, Crowston JG. Wound Healing Modulation in Glaucoma Filtration Surgery-Conventional Practices and New Pers pectives: The Role of Antifibrotic Agents (Part I). J Curr Glaucoma Pract 2014;8(2):37-45.

Effect of phacoemulsification on trabeculectomy function.

BACKGROUND: To evaluate the effect of phacoemulsification on trabeculectomy function. DESIGN: Retrospective case-control study. PARTICIPANTS: Forty-eight patients who underwent trabeculectomy surgery and had at least 2 years of follow up. METHODS: Patients were classified into two groups: patients who had phacoemulsification subsequent to trabeculectomy (Trab_phaco, n = 18) and patients who were pseudophakic for greater than 6 months preceding their trabeculectomy (Phaco_trab, n = 30). Groups were matched for length of follow up of 2 years from time of trabeculectomy. MAIN OUTCOME MEASURES: The primary outcome measures were target intraocular pressure of criteria A, ≤12 mmHg; B, ≤15 mmHg; C, ≤18 mmHg with or without additional topical treatment. A separate measure for bleb function failure was also used; with failure defined as the need for additional topical antiglaucoma therapy or surgical intervention to achieve control of intraocular pressure. RESULTS: There was no significant difference in achieving each intraocular pressure criterion between groups (12 months, P = 1.0; 24 months, P = 0.330). In the first 12 months, significantly more trabeculectomies in the Trab_phaco group failed, requiring additional intervention to control the IOP (39%) compared with the Phaco_trab (10%) group (P = 0.028). Although this trend continued at 24 months, there were no significant differences in failure rates (P = 0.522). CONCLUSIONS: Phacoemulsification performed after trabeculectomy significantly increased rates of bleb failure in the following 12 months but not at 24 months.

Intraocular pressure lowering is associated with an increase in the photopic negative response (PhNR) amplitude in glaucoma and ocular hypertensive eyes.

PURPOSE: The aim of our study was to determine whether IOP lowering in glaucomatous and ocular hypertensive (OHT) eyes leads to an improvement in the full-field photopic negative response (PhNR) of the electroretinogram. METHODS: A prospective nonrandomized interventional cohort study was conducted. Patients with OHT or glaucomatous optic neuropathy were recruited, and photopic full-field electroretinograms (ERG) were performed at baseline and then repeated 1 to 2 months later. The change in PhNR amplitude was compared between those eyes that had a significant lowering in IOP (defined as >25% decrease from baseline or to a predetermined target IOP) during follow-up and those that did not. RESULTS: From a cohort of 30 eyes, 18 eyes had a significant reduction in IOP during follow-up (n = 18) and 12 eyes had no significant change in IOP (<25% reduction in IOP, n = 12). A significant increase in PhNR amplitude and the PhNR/b-wave amplitude ratios was observed in the reduced IOP group, but not in the IOP stable group for the two flash intensities used (2.25 and 3.00 cd.s/m(2)). CONCLUSIONS: The full-field PhNR amplitude provides a potentially reversible measure of inner retinal function that improves after IOP lowering. Further study now is required to assess its use as a measure of optic nerve health in glaucoma patients.

Sociodemographic factors and utilization of eye care services: is there an association with patients presenting to a tertiary referral hospital in acute angle-closure?

BACKGROUND: The aim of this study is to examine the relationship between sociodemographic factors and utilization of eye care services in patients presenting in acute angle-closure (AAC). DESIGN: A hospital-based retrospective, case-control study. PARTICIPANTS: Fifty-five patients consecutively presenting to the emergency department of the Royal Victorian Eye and Ear Hospital with AAC (cases), and 43 patients consecutively referred to the outpatient department for prophylactic laser peripheral iridotomy (controls) over a 3-year period. METHODS: Standardized telephone questionnaires. MAIN OUTCOME MEASURES: Comparisons were made for sociodemographic factors, utilization of eye care services and provision of information on glaucoma and premonitory symptoms of AAC. RESULTS: No significant differences across a range of socioeconomic and demographic factors were found. Fewer cases reported having attended an eye care professional ever (P = 0.02), or in the 12 months preceding their acute hospital attendance (P = 0.002), and had less awareness of angle closure glaucoma (P = 0.001). Logistic regression modelling demonstrated premonitory symptoms of AAC (odds ratio 3.96, [95% confidence interval 1.52-10.32], P < 0.001) and a period of greater than 12 months since the last eye examination (odds ratio 3.89, [95% confidence interval 1.64-9.21]) were significantly associated with the risk of AAC. CONCLUSIONS: No significant differences in socioeconomic or demographic parameters between cases and controls were identified. Control subjects had a history of more frequent and recent access to eye care services than cases. The finding that more than one-third of patients presenting with AAC had consulted an eye care provider in the preceding year suggests that a significant proportion of individuals at risk of AAC remain undetected.

A model to measure fluid outflow in rabbit capsules post glaucoma implant surgery.

PURPOSE: Prior models of glaucoma filtration surgery assess bleb morphology, which does not always reflect function. Our aim is to establish a model that directly measures tissue hydraulic conductivity of postsurgical outflow in rabbit bleb capsules following experimental glaucoma filtration surgery. METHODS: Nine rabbits underwent insertion of a single-plate pediatric Molteno implant into the anterior chamber of their left eye. Right eyes were used as controls. The rabbits were then allocated to one of two groups. Group one had outflow measurements performed at 1 week after surgery (n = 5), and group two had measurements performed at 4 weeks (n = 4). Measurements were performed by cannulating the drainage tube ostium in situ with a needle attached to a pressure transducer and a fluid column at 15 mm Hg. The drop in the fluid column was measured every minute for 5 minutes. For the control eyes (n = 6), the anterior chamber of the unoperated fellow eye was cannulated. Animals were euthanized with the implant and its surrounding capsule dissected and fixed in 4% paraformaldehyde, and embedded in paraffin before 6-µm sections were cut for histologic staining. RESULTS: By 7 days after surgery, tube outflow was 0.117 ± 0.036 µL/min/mm Hg at 15 mm Hg (mean ± SEM), whereas at 28 days, it was 0.009 ± 0.003 µL/min/mm Hg. Control eyes had an outflow of 0.136 ± 0.007 µL/min/mm Hg (P = 0.004, one-way ANOVA). Hematoxylin and eosin staining demonstrated a thinner and looser arrangement of collagenous tissue in the capsules at 1 week compared with that at 4 weeks, which had thicker and more densely arranged collagen. CONCLUSIONS: We describe a new model to directly measure hydraulic conductivity in a rabbit glaucoma surgery implant model. The principal physiologic endpoint of glaucoma surgery can be reliably quantified and consistently measured with this model. At 28 days post glaucoma filtration surgery, a rabbit bleb capsule has significantly reduced tissue hydraulic conductivity, in line with loss of implant outflow facility, and increased thickness and density of fibrous encapsulation.

Bleb vascularity following post-trabeculectomy subconjunctival bevacizumab: a pilot study.

BACKGROUND: To determine whether postoperative subconjunctival bevacizumab significantly alters bleb vascularity. DESIGN: A randomized, prospective interventional study. PARTICIPANTS: Forty-three eyes from 39 patients were recruited, with 21 eyes randomized to subconjunctival injections of 5-fluorouracil, and 22 eyes to combined 5-fluorouracil/bevacizumab. METHODS: All patients who underwent uncomplicated primary antimetabolite augmented trabeculectomy who subsequently required postoperative subconjunctival 5-fluorouracil injection within 4 weeks of surgery were eligible. Patients were randomized to receive subconjunctival 5-fluorouracil only (7.5 mg/0.15 mL) or 5-fluorouracil plus bevacizumab (1.25 mg/0.05 mL). MAIN OUTCOME MEASURES: Primary outcome was bleb vascularity with secondary endpoints including visual acuity, intraocular pressure, bleb morphology, complications and total numbers of 5-fluorouracil injections were recorded at baseline, week 12 and 18 months. RESULTS: At week 12, there was no significant difference between groups for visual acuity, intraocular pressure, bleb vascularity and morphology, or total number of 5-fluorouracil injections. By 18 months, 47.4% of the 5-fluorouracil/bevacizumab group exhibited central bleb avascularity compared with 21.1% of the 5-fluorouracil group (Fisher's exact test, P = 0.17). Two bleb complications (one blebitis; one suture abscess) recorded in the 5-fluorouracil/bevacizumab group. CONCLUSIONS: After a single combined injection, a trend for increased central bleb avascularity was observed, although this effect was not sufficient to reach statistical significance. This, in addition to the occurrence of two bleb-related complications in the bevacizumab group, suggests the need for a larger clinical trial to further evaluate the safety and efficacy of bevacizumab as a modulating agent in glaucoma filtration surgery.

Clinical phenotype of posterior polymorphous corneal dystrophy in a family with a novel ZEB1 mutation.

PURPOSE: To describe the clinical phenotype in a family with posterior polymorphous corneal dystrophy (PPCD) and a novel mutation in the ZEB1 gene. METHODS: Clinical examination, anterior segment photography, specular microscopy and electrophysiological investigations were performed and quantified. Genomic DNA extracted from peripheral blood was sequenced for ZEB1 exons. Cosegregation of identified mutation with the disease status in the family was confirmed using polymerase chain reaction and restriction fragment length polymorphism. RESULTS: Ocular examination was performed on five family members from two generations. Three had anomalies of the corneal endothelium that were consistent with PPCD. Endothelial cell counts ranged from 2306 to 2987 mm(2) (ref. 2000-4000 cells/mm(2) ). No evidence of glaucoma or retinal abnormalities was observed. Extraocular abnormalities such as inguinal herniation, hydrocoele and possible bony or connective tissue anomalies were part of the disease spectrum in this family. Mutation analysis revealed a novel change in exon 5 of ZEB1 (c.672delA) that cosegregated with the affected disease status. CONCLUSION: The detailed clinical features of PPCD associated with a novel ZEB1 mutation are supportive of the previously proposed range of phenotype parameters. Further phenotype-genotype correlations may provide insights into the clinical variability and pathological processes affecting the corneal endothelium, Descemet's membrane, retinal photoreceptor function and extraocular tissues of some patients.

Long-term topical steroid treatment after penetrating keratoplasty in patients with pseudophakic bullous keratopathy.

PURPOSE: To assess the use of long-term topical corticosteroid treatment in patients with pseudophakic bullous keratopathy (PBK) after penetrating keratoplasty (PK). DESIGN: Retrospective cohort study. PARTICIPANTS: This study considered patients with PBK undergoing an initial PK procedure for visual reasons in the United Kingdom between April 1999 and March 2004. There were 1274 initial PK procedures for PBK reported to United Kingdom Transplant in this period, of which 1184 (91%) were grafted for visual reasons. Of these 1184 grafts, follow-up was reported in 1033 instances (87%). METHODS: A Cox regression model was used to investigate the combined effects of all preoperative factors (recipient age, human leukocyte antigen [HLA] matching, trephine size, deep stromal vascularization, surgeon activity) on graft failure. The model was fitted using all preoperative factors first, and subsequently, factors associated with corticosteroid and other medications were included. MAIN OUTCOME MEASURES: Graft survival. RESULTS: Three-year survival of grafts for PBK was 65% (95% confidence interval [CI], 59%-70%). Topical corticosteroids were still being used beyond 18 months after surgery in 378 (37%) of the 1033 corneal grafts included in this study. The grafts of patients not currently receiving steroids were 1.5 times as likely to fail (hazard ratio [HR], 1.5; 95% CI, 1.0-2.2; P<0.03). Lack of HLA matching (P = 0.006), trephine size or=8.00 mm (P = 0.03), recipient age younger than 65 years (P = 0.003), and corneal vascularization (P = 0.04) all increased the risk of graft failure. CONCLUSIONS: The use of long-term postoperative corticosteroids improved graft survival after PK for PBK. Barring patient contraindications for long-term topical corticosteroid use, clinicians should consider maintaining patients with PBK on long-term postoperative corticosteroid maintenance.

Conjunctival-corneal melt in association with carotid artery stenosis.

PURPOSE: To report a case of severe conjunctival-corneal melt in association with carotid artery stenosis. METHODS: Observational case report. RESULTS: A 76-year-old man with a history of bilateral severe carotid artery occlusion and nonarteritic ischemic optic neuropathy developed a spontaneous bulbar conjunctival defect. Despite intensive lubrication, and attempts at surgical closure including an amniotic membrane patch graft, it progressed with subsequent adjacent corneal perforation. Thorough investigations revealed no underlying disease, except markedly delayed episcleral vessel filling on anterior segment fluorescein angiography. CONCLUSIONS: Neovascularisation is a known factor in the inhibition of ulceration. In light of the findings in this report, ocular ischemia should be considered as a cause or contributing factor in the differential diagnosis of conjunctival-corneal melt.

Keratectasia as a presentation of surgically induced necrotizing sclerokeratitis (SINS).

PURPOSE: A case of keratectasia is reported as a severe presentation of surgically induced necrotizing sclerokeratitis (SINS). METHODS: A 72-year-old white woman had a painful, raised lesion on the superior cornea of her right eye 3 years after uncomplicated extracapsular cataract extraction with intraocular lens implantation. Examination showed a large ectatic area of the superior cornea with inflamed sclera adjacent to the surgical wound, which was diagnosed as SINS. RESULTS: No underlying systemic autoimmune condition or vasculitis was identified on investigation. Progressive painful keratectasia necessitated enucleation, which confirmed on histopathologic examination features of chronic nodular episcleritis and nongranulomatous scleritis with evidence of keratitis and fibrovascular scarring. CONCLUSION: The predominant inflammatory response in the cornea represents surgically induced necrotizing keratoscleritis (SINK) as a new variant presentation of SINS. Oral corticosteroids and immunosuppressive agents should not be delayed to prevent progressive tissue destruction and poor outcome.

Thimerosal-induced limbal stem cell failure: report of a case and review of the literature.

PURPOSE: To report a case of unilateral total limbal stem cell (LSC) failure and corneal opacification secondary to thimerosal- and contact lens-induced ocular surface toxicity. METHODS: Interventional case report and review of the literature on thimerosal-induced ocular surface changes. RESULTS: A 49-year-old woman with a 2-year history of long-term soft contact lens wear developed unilateral total LSC failure and corneal opacification secondary to presumed thimerosal-induced toxicity and contact lens wear. At presentation, best-corrected visual acuities were 20/120 in the right eye and 20/15 in the left eye. The patient underwent a keratolimbal allograft and amniotic membrane graft followed by a penetrating keratoplasty. At the last follow-up, the right eye showed a clear corneal graft with a best-corrected visual acuity of 20/30. CONCLUSIONS: Thimerosal toxicity can lead to total LSC failure with secondary corneal vascularization and opacification. Keratolimbal allograft followed by penetrating keratoplasty can be successful in reconstructing the ocular surface in such cases.

Microbial keratitis in keratoglobus-associated vernal keratoconjunctivitis and atopic dermatitis.

PURPOSE: The authors describe a patient with keratoglobus and a history of vernal keratoconjunctivitis and atopic dermatitis who acutely developed corneal hydrops and severe microbial keratitis. The infectious keratitis responded poorly to medical management and resulted in enucleation of the eye. METHODS: A 25-year-old man presented with an acutely painful, red left eye. He had an ocular history of keratoglobus in association with vernal keratoconjunctivitis and atopic dermatitis. His visual acuity was light perception in the left eye and 20/40 in the right eye. Ocular examination showed a grossly edematous cornea with breaks in Descemet's membrane, a central infiltrative ulcer, and hypopyon. RESULTS: Corneal scrapings showed gram-positive beta-hemolytic streptococci, for which topical treatment of ceftazidime and benzylpenicillin every 30 minutes by day and night was commenced with an oral course of ciprofloxacin 750 mg twice a day. Despite aggressive therapy, the microbial keratitis progressed, and the hypopyon increased in size. The patient subsequently underwent enucleation of his left eye. CONCLUSIONS: This is the first reported case of microbial keratitis with corneal hydrops in a patient with keratoglobus, vernal keratoconjunctivitis, and atopic dermatitis. His ocular and dermatologic comorbidity may have impaired corneal integrity and allowed penetration of organisms, resulting in a severe case of keratitis that responded poorly to medical management.

Releasable conjunctival suture for adjustable suture surgery.

BACKGROUND: Adjustable sutures are widely used in adult strabismus surgery, with a second procedure performed to close the conjunctiva irrespective of whether adjustment is required. We describe a technique where the conjunctiva is closed using a buried releasable suture, eliminating the second procedure if adjustment is deemed unnecessary. METHOD: The conjunctiva is closed using a 6/0 absorbable polyglactin 910 releasable suture. It is tied in a bow, like the muscle sutures, and tucked under the conjunctiva. If adjustment is not required, the eye does not need to be touched because the conjunctiva is secured by the suture. If adjustment is required, it is easy to untie the conjunctival suture, allowing good exposure to the underlying muscle sutures. RESULTS: In our prospective series of 30 patients, we found our technique effective and patient friendly. Patients had at least 3 months of follow-up with no significant complications. CONCLUSIONS: This technique is acceptable, accessible, and time saving for both surgeons and patients. It is especially useful for anxious patients and adolescents, for whom postoperative manipulation can be difficult, and for cases where the probability of adjustment is low.

Irregularities on the surface of single-piece AcrySof SA60AT intraocular lenses.

PURPOSE: To report a case series of what initially appeared to be macroscopic biomaterial deposits and irregularities on the surface of AcrySof SA60AT intraocular lenses (IOLs) (Alcon Inc.) SETTING: Department of Ophthalmology and Somerset Hospital, Taunton, United Kingdom; Department of Ophthalmology and Visual Sciences, John A Moran Eye Center, University of Utah, Salt Lake City, Utah, USA; and Intraocular Implant Unit, Sydney Eye Hospital, University of Sydney, Sydney, Australia. METHODS: Twelve AcrySof SA60AT IOLs were initially thought to have irregularities on their surfaces when examined under the operating microscope before implantation in the capsular bag during cataract surgery. The IOLs were sent for further analysis, including gross examination and light and scanning electron microscopy, to John A. Moran Eye Center, Salt Lake City, Utah, USA, and to Alcon Laboratories, Hemel Hempstead, United Kingdom. RESULTS: Light microscopy revealed the presence of irregular fine lesions on the IOLs' optics and haptics. The lesions consisted of elevations and depressions of the IOL surface that were present on both the anterior and the posterior surfaces of the IOLs. Scanning electron microscopy confirmed the presence of physical/mechanical damage to the IOLs, which was thought to originate from the packaging. The manufacturer believed this to have resulted from compression of the IOL between the container and its cover. CONCLUSIONS: Implantation of an imperfect IOL remains a potentially serious occurrence. Faults still occur in modern IOLs, and some defects can be detected by examining the IOL under the operating microscope before implantation into the eye.