The Potential Role of the Light Adjustable Lens in Flanged Intrascleral Haptic Fixation.

PURPOSE: To compare maximum tensile strength between commonly used 3-piece intraocular lens (IOL) for flanged intrascleral haptic fixation (FISHF). SETTING: Willis-Knight Eye Institute. DESIGN: Laboratory investigation. METHODS: Haptic tensile strength was compared with MA60AC, CT Lucia 602, AR40E, and the light-adjustable lens (LAL). Haptic strength with a 24D (diopter) IOL was compared across all lenses, as well as a range of 10-30D with the MA60AC. A custom device was created to hold the IOL in correct haptic orientation. The max tension (mean +/- standard deviation) was recorded in newtons (N) when the haptic lost tension or broke. RESULTS: CT Lucia was the strongest at 1.53 +/- 0.11 N vs 1.00 +/- 0.15 (MA60AC), 0.87 +/- 0.19 (AR40E), and 0.83 +/- 0.14 N (LAL), P<0.001. The LAL and AR40E were similar to a 9-0 polypropylene suture while being significantly stronger than 10-0 polypropylene suture, P<0.001. No difference in haptic tension for the MA60AC from 10-30D, P>0.05. High magnification revealed the highest haptic fractures for MA60AC at 40% compared to LAL, AR40E, and CT Lucia at 0%. CT Lucia and AR40E had 100% of haptics disinserted from the IOL without any damage compared to 60% LAL and 60% MA60AC. CT Lucia, AR40E, and LAL have a flatter haptic angulation at 5 degrees. CONCLUSION: Haptic strength, durability, and angulation of the LAL may support the possibility of FISHF in the hands of experienced surgeons. However, further testing is strongly recommended to verify if physiologic conditions or light treatments may compromise long-term haptic stability.

Preventing the Argentinian flag sign and managing anterior capsular tears: A review.

The Argentinian flag sign (AFS) is a feared complication during cataract extraction. Intralenticular pressures, especially excessive posterior pressure, have been identified as potential mechanisms for capsular stress and tearing associated with AFS. Capsular tension is created by positive intralenticular pressures, which cause the irido-lens diaphragm to move anteriorly once the manual capsulorhexis has been initiated. This tension can cause inadvertent tears that self-propagate to the lens equator, causing an AFS, among other intraoperative complications. Thus, this review highlights the importance of identifying intumescent cataracts as well as a combination of techniques to relieve intracapsular pressures needed to prevent AFS. However, some instances of anterior capsular tears are unavoidable. Therefore, focus will also be placed on techniques during cataract extraction used to manage anterior capsular tears, mitigating extension to the posterior capsule.

Interface Fluid Syndrome Masquerading as Diffuse Lamellar Keratitis After Small Incision Lenticule Extraction.

A 34-year-old male with no past medical or ocular history underwent bilateral uncomplicated small incision lenticule extraction (SMILE). On day 1, uncorrected distance visual acuity (UDVA) was 20/25 in the right eye (OD) and 20/20 in the left eye (OS). The intraocular pressure (IOP) was 12 mmHg in both eyes (OU). On day 17, UDVA was 20/70 OD and 20/30+2 OS. Slit-lamp examination (SLE) revealed diffuse 2+ haze at the interface suspicious for diffuse lamellar keratitis (DLK). Topical difluprednate was added twice a day (BID). Vision decreased by day 20 with a significant myopic shift and 3+ interface haze OU. A washout of the interface was performed. Topical steroids were increased with oral prednisone. One day after the washout, vision and interface haze improved. On day 3 status post washout, UDVA decreased to 20/70 OD and 20/50 OS. IOP was 42 mmHg OU. A diagnosis of interface fluid syndrome (IFS) was confirmed. All steroids were stopped while adding ocular hypotensive medication. One month later, visual acuity was 20/20 OU with a complete resolution of interface haze. Only a handful of IFS has been documented in SMILE, an incidence that may increase as SMILE becomes more common. Among all SMILE cases, IFS was most commonly associated with steroid-induced ocular hypertension and a myopic shift around 21 days postoperatively. A fluid cleft at the interface may not always be visible with SLE, masquerading as DLK. Scheimpflug densitometry and anterior segment optical coherence tomography (AS-OCT) may aid in quantifying interface edema needed to confirm a diagnosis when IOP is unclear. A corneal washout can immediately improve corneal edema, but the preferred treatment is discontinuing all steroid medication and starting glaucoma drops.

The Role of Multifocal Intraocular Lens Implantation in Extreme Axial Myopia: A Case Report and Literature Review.

The prevalence of high myopia is rising globally. In addition to an increased risk of retinal detachment, high myopia is associated with earlier cataract formation. Patients with myopia are also often more motivated to become spectacle-independent after a lens procedure. However, the use of multifocal intraocular lens (MfIOL) remains controversial for patients with extreme myopia, which is classified as patients with an axial length >28 mm. Here, we present the case of a 64-year-old patient with visually significant cataract and extreme axial myopia >31 mm in both eyes who desired to be spectacle-independent. A preoperative workup revealed a normal macula with peripheral lattice degeneration. On optical coherence tomography, the macula had a normal fovea contour without the presence of a staphyloma. A thorough peripheral examination was performed by a retina specialist which required no prophylactic treatment. Pentacam analysis demonstrated a low spherical aberration and minimal ectasia risk. Cataract surgery was uneventful with a 5 mm laser capsulotomy centered over the visual axis with the placement of a trifocal intraocular lens. Two months after the cataract surgery, the remaining refractive error was corrected with a laser-assisted in situ keratomileusis enhancement. The patient achieved an uncorrected distance visual acuity of 20/15- and uncorrected near visual acuity of J1+ in both eyes. Overall, this case report and review aims to highlight important preoperative, intraoperative, and postoperative techniques to improve patient outcomes with MfIOL in patients with extreme myopia.

Activation of Ocular Syphilis After Small-Incision Lenticule Extraction.

A 41-year-old female presented to the Willis-Knighton Eye Institute to undergo evaluation for refractive surgery. The patient had a best-corrected visual acuity for a distance of 20/15-1 of the right eye (OD) and 20/15-1 of the left eye (OS) with a manifest refraction of -2.75 OD and -1.75 OS. Near visual acuity was J1+ in both eyes (OU). A trial of a monovision contact lens was successful with the dominant eye selected for distance. The patient was then planned for small-incision lenticule extraction (SMILE) OD only with a plano target. SMILE was performed and was uncomplicated with uncorrected visual acuity of 20/15- on postoperative day one. Two weeks after the initial SMILE procedure, the anterior segment was notable for 1-2+ cells OD. Topical prednisone was changed to difluprednate 0.05% TID OD with improvement in symptoms. However, the anterior chamber cell was never fully resolved by month three. A systemic workup revealed a positive rapid plasma reagin with 1:64 titer and a positive fluorescent treponemal antibody absorption in a patient never treated for syphilis. The patient was diagnosed with ocular syphilis and received a two-week course of intravenous penicillin G. A slow topical prednisone tapper was performed with the resolution of inflammation by one year. Anterior uveitis after refractive surgery is uncommon. The incidence of anterior uveitis after SMILE is even rarer with no previously documented incidence in the literature. As a result, persistent cell seen in refractive procedures, especially SMILE, is a concerning finding, warranting further workup to rule out underlying systemic diseases including syphilis.