Rotation stability of a toric intraocular lens with a second capsular tension ring.

An Acrysof toric intraocular lens (IOL) and a capsular tension ring (CTR) were implanted in the highly myopic eye of a 74-year-old white man during cataract surgery. On the first postoperative day, the IOL was found 90 degrees from the required position, with a consequent high amount of astigmatism. A second procedure was performed and because it was not possible to secure the toric IOL in the correct position, an additional in-the-bag CTR was inserted, with an immediate optimal outcome. The IOL remained stable up to the final follow-up examination. Co-implantation of a toric IOL and a single CTR has been reported. In our case, 2 CTRs were required to fixate the toric IOL in the correct position. This procedure is simple and safe and should be considered in cases of postoperatively misaligned toric IOLs.

Preclinical safety and stability study of a next generation telescope prosthesis for end-stage macular degeneration.

BACKGROUND: To assess the surgical procedure, safety and stability of a next generation injectable telescope prosthesis in a rabbit model. METHODS: After removal of the crystalline lenses of eight New Zealand White rabbits, the next generation device was randomly implanted in one eye, and the available telescope prosthesis (Normal device) was implanted in the fellow eye. Operative parameters (incision, capsulorrhexis size and operative time), intraoperative and postoperative complications rates, endothelial cell density changes and the distance between the corneal endothelium and the telescope (central clearance distance) were measured and compared between the groups. RESULTS: Incision size and capsulorrhexis size were smaller, and operative time was shorter in the next generation group in comparison with the Normal group. No difference was found in the intraoperative and postoperative complication rates between the groups. Endothelial cell density loss observed in the next generation group was less than the loss in the Normal group, but the difference was not significant statistically. The central clearance distance was significantly larger in the next generation group in comparison with the Normal group (P = 0.001). CONCLUSIONS: The next generation telescope was implanted through a smaller incision, with a shorter surgical time and a larger central clearance distance in the rabbit eyes, in comparison with the Normal group. The next generation device may allow reduced trauma to the corneal endothelium, better control during surgery and induce less astigmatism while preserving the optical advantages of the Food and Drug Administration-approved telescope prosthesis.

Risk assessment of simple phacoemulsification in patients on combined anticoagulant and antiplatelet therapy.

PURPOSE: To assess the safety of phacoemulsification cataract extraction in patients on combined anticoagulant and antiplatelet treatment. SETTING: Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel. DESIGN: Prospective interventional case series. METHODS: Consecutive patients with simple cataract on combined anticoagulant (warfarin) and antiplatelet (aspirin or clopidogrel) treatment who were unable to discontinue the treatment because of a high risk for thromboembolic events were included. Patients had cataract extraction under topical anesthesia with a clear corneal incision (CCI), phacoemulsification, and implantation of a foldable posterior chamber intraocular lens. Prothrombin time-international normalized ratio and platelet functions were evaluated immediately before surgery. Patients were also examined 1 day and 7 days postoperatively. Intraoperative and postoperative ocular bleeding and other related complications were assessed. RESULTS: Forty patients (51 eyes) with a mean age of 72 years (range 51 to 90 years) had phacoemulsification. Hemorrhagic complications were not observed at surgery or during the 1-week follow-up. Surgical complications included 1 rupture of the capsulorhexis and 1 implantation of a capsular tension ring due to partial zonulysis. No patient had a thromboembolic event. CONCLUSIONS: In patients with uncomplicated cataract at high risk for thromboembolic events, phacoemulsification cataract surgery using a CCI under topical needle-free anesthesia was safely performed without discontinuing systemic anticoagulant and antiplatelet treatment.

Cataract extraction without prophylactic treatment in patients with severe factor XI deficiency.

PURPOSE: To assess the risks of intraoperative and postoperative bleeding associated with cataract extraction without prophylactic treatment in patients with severe factor XI (FXI) deficiency. DESIGN: Prospective interventional case series. SETTING: Single institute. STUDY POPULATION: Consecutive unrelated patients with severe FXI deficiency who underwent cataract extraction under topical anesthesia, with a clear corneal incision, phacoemulsification, and implantation of a foldable posterior chamber intraocular lens (PCIOL) were enrolled. Patients with associated intraocular conditions that could complicate the surgery were excluded. INTERVENTION: Cataract extraction without prophylactic treatment for the FXI deficiency. MAIN OUTCOME MEASURES: Assessment of intraoperative and postoperative ocular bleeding and other related complications. RESULTS: Seven patients ranging in age from 61 to 95 years (median, 79) underwent phacoemulsification and PCIOL implantation in 11 eyes. Five patients (71%) were homozygotes for type II mutation of the FXI gene (activity level of <1 U/dl), 1 patient was a homozygote for type III mutation (activity level of 11 U/dl), and 1 patient was a compound heterozygote for types II and III (activity level of 3 U/dl). Three of the patients (43%), all type II homozygotes, also had an inhibitor antibody to FXI. All 7 patients were followed for at least 1 week after the operation. The surgery was uneventful in all eyes, and neither major nor minor bleeding events were observed in any of the operated eyes during surgery and follow-up. CONCLUSIONS: Cataract extraction by phacoemulsification in uncomplicated eyes can be performed safely without prophylactic treatment in patients with severe FXI deficiency with or without inhibitor antibodies against FXI.

Intraocular pressure elevation within the first 24 hours after cataract surgery in patients with glaucoma or exfoliation syndrome.

OBJECTIVE: To investigate whether eyes with glaucoma or exfoliation syndrome without glaucoma are prone to exhibit intraocular pressure (IOP) elevation shortly after cataract surgery and, if so, whether timolol maleate 0.5% reduces these spikes. DESIGN: Prospective randomized double-masked clinical trial. PARTICIPANTS: One hundred twenty-two patients with normal eyes, medically well-controlled glaucoma, or exfoliation syndrome who underwent uneventful phacoemulsification cataract extraction. METHODS: Patients were randomly assigned to an immediately postoperative drop of either timolol maleate 0.5% or no treatment. Intraocular pressure was measured preoperatively and 4, 8, and 24 hours and 1 week later. MAIN OUTCOME MEASURES: Intraocular pressure measurements. RESULTS: The changes in postoperative IOP over time differed significantly between glaucoma, exfoliation syndrome, and normal (P = 0.005). Intraocular pressure was significantly lower in the normal group (n = 25) than in both the glaucoma (n = 18) and exfoliation syndrome (n = 19) groups (P<0.001). With 1 drop of prophylactic timolol maleate 0.5% at completion of surgery, the normal group (n = 25) again had IOP significantly lower than those of the glaucoma (n = 15) and exfoliation syndrome (n = 20) groups (P<0.001). Treatment with timolol maleate 0.5% significantly changed postoperative IOP over time in the glaucomatous eyes (P = 0.003), but it made no difference in the exfoliation syndrome (P = 0.4) or normal (P = 0.5) eyes. Intraocular pressure > 25 mmHg did not occur among normal eyes. Intraocular pressure > 25 mmHg and > 30 mmHg occurred in 10 (55%) and 5 (28%) glaucoma patients, respectively, and 5 (27%) and 2 (11%) exfoliation syndrome patients, respectively. Timolol maleate 0.5% eliminated IOP spikes > 30 mmHg and reduced the frequency of IOP > 25 mmHg in both groups to 14% in the glaucoma group and 5% in the exfoliation syndrome group. Most IOP elevation occurred at 4 hours postoperatively. The mean IOP was <20 mmHg in all groups 1 day postoperatively. CONCLUSIONS: Medically well-controlled glaucoma patients and patients with exfoliation syndrome may experience IOP elevation shortly after cataract surgery. Instillation of timolol maleate 0.5% at the end of the procedure in this series eliminated IOP > 30 mmHg, but IOP elevation below that level can still occur.

Phacoemulsification of cataract in patients receiving Coumadin therapy: ocular and hematologic risk assessment.

PURPOSE: To assess the risks of intra- and postoperative bleeding tendency associated with uncomplicated cataract surgery by phacoemulsification in patients receiving Coumadin treatment. DESIGN: Prospective, nonrandomized, interventional, consecutive case series. METHODS: Sixty-three consecutive patients underwent cataract extraction with lens implantation in 75 eyes. All patients were receiving Coumadin therapy at the time of surgery, and nine patients (14.3%) were also taking antiaggregants. The operations were performed by phacoemulsification technique under topical anesthesia. All patients underwent a hemostatic work-up before intervention. Structured questionnaires were completed by the surgeon immediately after the operation. In 18 (24%) eyes, the surgery was videotaped, and the tapes were reviewed subsequently for any bleedings by an independent observer. RESULTS: Twelve patients (19%) underwent surgery in both eyes, not simultaneously. The mean prothrombin time international normalized ratio (INR) was 2.03 at the time of the surgery. No significant intraoperative bleeding occurred. Four (6.3%) patients had minor postoperative ocular bleeding. A microscopic hyphema and a dot retinal hemorrhage were each seen in one eye on the first postoperative day, and small iris hemorrhages were identified in two additional eyes at the one-week visit. All bleedings disappeared within one week without affecting the visual acuity. The mean INR of the four patients with minor bleedings was 2.1. CONCLUSIONS: Cataract surgery by phacoemulsification in uncomplicated eyes can be performed safely in patients receiving Coumadin treatment. However, a large clinical trial is required to assess the safety of continuous Coumadin treatment associated with phacoemulsification in eyes with complicated cataract.

Primary intraocular lens implantation in pediatric uveitis: a comparison of 2 populations.

OBJECTIVE: To evaluate the visual outcome and postoperative complications of cataract surgery with posterior chamber intraocular lens implantation in children with uveitis. DESIGN: A multicenter, retrospective, interventional case series. The setting included 3 medical centers in Israel. The interventions were cataract surgery and intraocular lens implantation. Aggressive preoperative and postoperative systemic and topical anti-inflammatory treatment was instituted. The main outcome measures included postoperative inflammation, complications, and visual outcome. RESULTS: Children with juvenile rheumatoid arthritis (JRA)-associated uveitis were seen and underwent cataract surgery at an earlier age, and had a lower preoperative visual acuity and more severe uveitic complications when first seen, than those with non-JRA-associated uveitis. Visual acuity improved by 2 or more lines in all patients, and in 13 eyes the final visual acuity was 20/40 or better. Postoperative complications included elevated intraocular pressure, posterior and anterior capsular opacities, and macular dysfunction. CONCLUSIONS: Compared with those with non-JRA-associated uveitis, children with JRA-associated uveitis tend to have more severe manifestations of disease when first seen and after surgery, but there is no significant difference in postoperative course or complications. Intraocular lens implantation, including small-incision, foldable, intraocular lenses, is well tolerated, when combined with aggressive medical treatment, for controlling inflammation. We believe that intraocular lens implantation is not contraindicated in those with pediatric uveitis, including uveitis associated with JRA.

Strabismus in senile cataract patients.

PURPOSE: We sought to determine the prevalence of strabismus among patients with senile cataract. METHODS: Forty-seven consecutive patients who were scheduled for cataract surgery underwent complete eye examinations, including ocular alignment evaluation. Twenty-four normal adults of the same age range underwent also complete eye examinations and were used as a control group. All patients of the cataract group underwent unilateral cataract surgery. The angle of strabismus was measured by the prism and cover test or prism and corneal reflex test. RESULTS: Mean preoperative deviation of the study group was 17.8 +/- 9.7 prism diopters (PD) of exophoria/tropia. In this group, 70.2% had exophoria and 27.7% had exotropia. In the control group exophoria was found in 75% of the persons whereas none of them had any heterotropia. Mean deviation in the control group was 4.7 +/- 5.1 PD of exophoria. Postoperatively, the angle of exophoria/tropia improved to 12.8 +/- 8.5 PD, which was different from the preoperative measurements (P < 0.01). In this group 78.8% had exophoria and 19.1% had exotropia. CONCLUSIONS: Patients with cataract have greater tendency to develop exotropia or exophoria than noncataract persons of the same age. Cataract surgery improves the heterophoric status of these patients.

Refractive results with secondary piggyback implantation to correct pseudophakic refractive errors.

PURPOSE: To assess the efficacy and safety of implanting a second intraocular lens (IOL) to correct pseudophakic refractive errors. SETTING: Goldschleger Eye Institute, Sheba Medical Center, Tel Hashomer, Israel. METHODS: This prospective noncomparative case series included 10 pseudophakic eyes, 5 with a myopic residual refractive error and 5 with a hyperopic residual refractive error. All eyes had secondary piggyback IOL implantation with the IOL placed in the ciliary sulcus. Five types of IOLs were used to correct the residual refractive error. RESULTS: The mean preoperative myopia was -6.6 diopters +/- 3.3 (SD), and the refractive outcome was within 0.5 +/- 0.7 D of the desired refraction (range -1.5 [undercorrected] and +1.0 D [overcorrected]). The mean preoperative hyperopia was +3.8 +/- 0.8 D, and the refractive outcome was within 0.46 +/- 0.4 D of the desired refraction (range 0 and 1.0 D overcorrected). All patients showed visual acuity improvement. Best spectacle-corrected visual acuity improved from 20/44 to 20/30 (P<.05). CONCLUSION: An IOL type that is appropriate for implantation in the ciliary sulcus is a viable option for correcting pseudophakic refractive error using the piggyback technique.

Feasibility and safety of laser treatments in eyes with an intraocular implantable miniature telescope.

PURPOSE: To evaluate the feasibility and safety of laser treatments in rabbit eyes fitted with an implantable miniature telescope (IMT). SETTING: The Goldschleger Eye Research Institute, Tel-Aviv University, Sheba Medical Center, Tel-Hashomer, Israel. METHODS: In this study, IMTs were implanted in the capsular bag in 19 eyes of 19 pigmented rabbits. After the rabbits recovered from surgery, neodymium:YAG (Nd:YAG) laser iridectomy (4 eyes), Nd:YAG laser capsulotomy (8 eyes), or argon laser photocoagulation of the retina (6 eyes) was performed. One day after the laser treatment, the rabbits were killed. An observer blinded to the treatment received by individual rabbits examined the enucleated eyes histopathologically to evaluate the laser lesions and their effect on ocular tissues. RESULTS: Laser iridectomy and laser posterior capsulotomy were carried out without difficulty. Laser photocoagulation of the posterior pole and the retinal periphery could be accomplished only when the laser beam was aimed around the optic of the IMT. It was not possible to carry out effective laser treatment of the retina through the IMT's optic. Treatment was difficult when adhesions between the pupil margin and the IMT optic were encountered. CONCLUSIONS: Standard laser treatments in eyes with an IMT in the capsular bag were feasible in pigmented rabbits, whose eyes are a good model for the eyes of human patients. Laser treatment of the retina was difficult to perform when adhesions between the pupil margin and the IMT were present.