Results of the United States Food and Drug Administration Clinical Trial of the CustomFlex Artificial Iris.

PURPOSE: To evaluate safety and efficacy of a custom-manufactured artificial iris device (CustomFlex Artificial Iris; HumanOptics AG) for the treatment of congenital and acquired iris defects. DESIGN: Multicenter, prospective, unmasked, nonrandomized, interventional clinical trial. PARTICIPANTS: Patients with photophobia, sensitivity secondary to partial or complete congenital or acquired iris defects, or both. METHODS: Eyes were implanted from November 26, 2013, to December 1, 2017, with a custom, foldable artificial iris by 1 of 4 different surgical techniques. Patients were evaluated 1 day, 1 week, and 1, 3, 6, and 12 months after surgery. At each examination, slit-lamp findings, intraocular pressure, implant position, subjective visual symptoms, and complications were recorded. Corrected distance visual acuity (CDVA) and endothelial cell density (ECD) were measured at 3, 6, or 12 months as additional safety evaluations. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was used to assess health-related quality of life affected by vision. The Global Aesthetic Improvement Scale was used to assess cosmetic results. MAIN OUTCOME MEASURES: Photosensitivity, glare, visual symptoms, NEI VFQ-25 score, Global Aesthetic Improvement Scale rating, prosthesis-related adverse events, intraocular lens (IOL)-related adverse events, and surgery-related adverse events 12 months after surgery. RESULTS: At the 12-month postoperative examination, a 59.7% reduction in marked to severe daytime light sensitivity (P < 0.0001), a 41.5% reduction in marked to severe nighttime light sensitivity (P < 0.0001), a 53.1% reduction in marked to severe daytime glare (P < 0.0001), and a 48.5% reduction in severe nighttime glare (P < 0.0001) were found. A 15.4-point improvement (P < 0.0001) in the NEI VFQ-25 total score was found, and 93.8% of patients reported an improvement in cosmesis as measured by the Global Aesthetic Improvement Scale 12 months after surgery. No loss of CDVA of > 2 lines related to the device was found. Median ECD loss was 5.3% at 6 months after surgery and 7.2% at 12 months after surgery. CONCLUSIONS: The artificial iris surpassed all key safety end points for adverse events related to the device, IOL, or implant surgery and met all key efficacy end points, including decreased light and glare sensitivity, improved health-related quality of life, and satisfaction with cosmesis. The device is safe and effective for the treatment of symptoms and an unacceptable cosmetic appearance created by congenital or acquired iris defects.

All about capsular tension rings.

PURPOSE OF REVIEW: To discuss capsular tension devices and recent evidence regarding their use. RECENT FINDINGS: The capsular tension ring, modified capsular tension ring, and capsular tension segment are well established tools for use during phacoemulsification when zonular instability is present. Recent research has provided additional evidence of their benefits in decreasing intraoperative and postoperative complications. SUMMARY: Endocapsular support devices allow for cataract surgery success in the setting of zonular instability.

Retrospective analysis of an intraoperative aberrometry database: a study investigating absolute prediction in eyes implanted with low cylinder power toric intraocular lenses.

PURPOSE: To evaluate the spherical equivalent outcomes of intraoperative aberrometry (IA) power calculations compared with the surgeons' preoperative power calculations in eyes implanted with AcrySof® IQ T3 intraocular lenses (IOLs). PATIENTS AND METHODS: We assessed data collected by an IA system from multiple centers in the United States. Data was from patients who had undergone cataract extraction by phacoemulsification with the use of the Optiwave Refractive Analysis System and whose eyes had been implanted with model SN6AT3 (1.5 diopter [D] at IOL plane) aspheric lenses. The analysis was performed in 2 stages: hypothesis generation and confirmatory testing. Confirmatory endpoints were a comparison of absolute prediction errors for IA for the implanted IOL versus preoperative formula power calculations. DESIGN: Retrospective analysis of preoperative, intraoperative, and postoperative data concerning eyes implanted with model SN6AT3 (1.5 D) aspheric lenses from the AnalyzOR™ database. RESULTS: Mean absolute IA prediction error was significantly lower than preoperative prediction error (paired difference: -0.06 D; p<0.0001); this was mirrored by the median paired difference of -0.04 D (p<0.0001). For eyes where the power of the implanted IOL differed from the power of the preoperatively planned lens, mean and median paired differences in prediction errors were greater: -0.13 D (p<0.0001) and -0.15 D (p<0.0001), respectively. The percentage of eyes with prediction error ≤0.50 D was significantly higher with IA (83.4%, n=5388/6460) than with the preoperative formula (76.5%, n=4942/6460, p<0.0001). When the powers of the implanted IOL and the preoperatively planned lens were different, the percentage of eyes with prediction error ≤0.50 D was 83.3% (2155/2587) for IA and 68.8% (1781/2587, p<0.0001) for the preoperative formula. CONCLUSION: IA produces more accurate spherical equivalent outcomes for eyes implanted with a low toric IOL than the preoperative formulas.

A large retrospective database analysis comparing outcomes of intraoperative aberrometry with conventional preoperative planning.

PURPOSE: To evaluate differences between the absolute prediction error using an intraoperative aberrometry (IA) device for intraocular lens (IOL) power determination versus the error that would have resulted if the surgeon's preoperative plan had been followed. SETTING: Multiple centers in the United States. DESIGN: Retrospective analysis of data collected using an IA device. METHODS: The database information was limited according to predetermined inclusion/exclusion criteria. Primary endpoints included the difference between mean and median absolute prediction error with IA use versus preoperative calculation, and the percentage of cases were compared when the prediction error was 0.5 diopters (D) or less. RESULTS: A total of 32 189 eyes were analyzed. The IA mean absolute prediction error was lower than the preoperative calculation, 0.30 D ± 0.26 (SD) versus 0.36 ± 0.32 D (P < .0001). The aberrometry absolute median prediction error was lower than the preoperative calculation, 0.24 D versus 0.29 D (P < .0001). There was a significantly greater percentage of eyes with an aberrometry absolute prediction error of 0.5 D or less than eyes with a preoperative absolute prediction error of 0.5 D or less (26 357 [81.9%] of 32 189 vs. 24 437 [75.9%] of 32 189, P < .0001). In addition, in those cases in which power of the IOL implanted was different than the preoperatively planned IOL power, significantly more eyes had an aberrometry absolute prediction error of 0.5 D or less (10 385 [81.3%] of 12 779 vs. 8794 [68.8%] of 12 779, P < .0001). CONCLUSIONS: In a database of more than 30 000 eyes, calculations incorporating IA outperformed preoperative calculations. The difference was more pronounced in those cases in which the preoperatively planned IOL power was different than the power of the IOL implanted.

[Evaluation of the modified capsular tension ring in cases of traumatic lens subluxation]. / Avaliação do uso do anel endocapsular modificado em casos de subluxação traumática do cristalino.

PURPOSE: To evaluate the behavior of the modified capsular tension ring (MCTR) in traumatic subluxated cataracts analyzing the visual acuity, centration of the capsular bag, pseudophacodonesis, postoperative follow-up and intra- and postoperative complications. SETTING: Cincinnati Eye Institute, Cincinnati, Ohio, USA. METHODS: Twenty-two eyes of 22 patients with traumatic loss of zonular support had phacoemulsification using PCIOL and MCTR implantation. The preoperative examination included best correct visual acuity (BCVA) and the presence or absence of phacodonesis, lens decentration and vitreous prolapse. The postoperative evaluation included BCVA, the presence of pseudophacodonesis, PCIOL centration, necessity of vitrectomy and other complications. RESULTS: 21 eyes (95.45%) had an improvement in BCVA. The preoperative examination disclosed phacodonesis in 11 eyes (50%) and no eye presented pseudophacodonesis in the postoperative period. Preoperatively, symptomatic decentration was presented by 10 eyes (45.45%) and 22 eyes (100%) had no decentration after surgery. The preoperative examination revealed vitreous prolapse in the anterior chamber in 9 eyes (40.90%). Vitrectomy was required in 11 eyes (50%). CONCLUSIONS: The use of the MCTR resulted in a good centration of the capsular bag and the PC IOL in 22 eyes with traumatic cataract and loss of zonular support.

Color perception with AcrySof natural and AcrySof single-piece intraocular lenses under photopic and mesopic conditions.

PURPOSE: To examine color perception in patients receiving bilateral implantation of an ultraviolet (UV) and blue-light filtering intraocular lens (IOL) (AcrySof Natural SN60AT, Alcon Laboratories Inc.) or a UV-only filtering IOL (AcrySof SA60AT) and to compare the results with those in a phakic group. SETTING: Cincinnati, Ohio, USA. METHODS: In this prospective study, age-matched subjects who passed the Ishihara test and had visual acuities of 20/25 or better were recruited. There were 2 pseudophakic groups (bilateral SN60AT or SA60AT IOLs) and 1 phakic group. The Farnsworth-Munsell (FM) 100-hue test was administered to each subject twice under different conditions. The phakic and AcrySof Natural SN60AT groups were tested under photopic and mesopic conditions. The SA60AT subjects were further divided into subgroups (with and without yellow clip-on lenses) and tested under photopic and mesopic conditions. RESULTS: A 1-way analysis of variance (ANOVA) of the square-root-transformed total error score showed no statistical differences (P = .637) between the treatment groups. Similarly, a 1-way ANOVA of the red-green error score (P = .729) and blue-yellow error score (P = .484) indicated no statistically significant differences between the treatment groups. The ANOVA results of the FM 100-hue test under mesopic conditions showed that the total error score in the AcrySof Natural IOL group was significantly lower (P = .046) than in the phakic group. There were no between-group differences in error scores under mesopic conditions. CONCLUSION: The FM 100-hue testing showed no difference in color perception between subjects with AcrySof Natural IOLs and those in an age-matched phakic control group or in those with a UV-only filtering AcrySof IOL with or without yellow clip-on lenses.

Surgical technique for congenital iris coloboma repair.

We describe a surgical technique for managing congenital iris coloboma. After phacoemulsification with placement of an intraocular lens in the capsular bag, coloboma repair is begun by bisecting the iris sphincter on both sides of its attachment near the chamber angle. The iris leaflets central to the sphincterectomies are approximated using a 10-0 polypropylene suture (Prolene, Ethicon, Inc.) and a modified Siepser pupilloplasty technique. The remaining peripheral iris defect is closed in a similar fashion. In patients with congenital iris coloboma, phacoemulsification with in-the-bag IOL implantation followed by this pupilloplasty technique was effective in providing functional and cosmetic repair of a congenital iris coloboma.

Subluxated cataract lens surgery using sutured segments or rings and implantation of toric intraocular lenses.

PURPOSE: To evaluate the intraoperative performance and postoperative outcomes of toric intraocular lens (IOL) with suture ring implantation in adult patients with subluxated lenses. SETTING: Department of Ophthalmology, Kaiser Permanente, Santa Clara, California, and the Eye Institute of Utah, Salt Lake City, Utah, USA. DESIGN: Retrospective case review. METHODS: Eyes with subluxated cataractous lenses and preoperative corneal astigmatism having toric IOL implantation with a sutured ring or segment were studied. Preoperative and postoperative analyses included uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and cylindrical power postoperatively and 3, 6, and 12 months postoperatively. RESULTS: Twenty-one eyes of 15 patients were studied. The median follow-up was 14.6 months. The mean CDVA at the final follow-up (0.10 logMAR ± 0.15 [SD]) was significantly improved from the mean preoperative CDVA (0.73 ± 0.40 logMAR). Postoperative cylindrical power was significantly improved in all patients (mean reduction in astigmatism 2.37 ± 1.46 diopters). Patients who required postoperative enhancement had anterior laser capsulotomy for bilateral capsule phimosis (2 eyes), photorefractive keratectomy (1 eye), pupilloplasty (1 eye), and posterior laser capsulotomy (2 eyes). CONCLUSION: Cataract removal and implantation of a toric IOL combined with a sutured ring or segment capsule stabilizing device was a safe and efficacious long-term solution for patients with subluxated cataract lenses and corneal astigmatism.

Clinical study using a new phacoemulsification system with surgical intraocular pressure control.

PURPOSE: To compare cumulative dissipated energy (CDE), aspiration fluid used, and aspiration time during phacoemulsification cataract extraction using 2 surgical configurations. SETTING: Two clinical sites in the United States and 1 in Spain. DESIGN: Prospective randomized clinical case series. METHODS: For each patient, the first eye having surgery was randomized to the active-fluidics configuration (Centurion Vision System with Active Fluidics, 0.9 mm 45-degree Intrepid Balanced tip, and 0.9 mm Intrepid Ultra infusion sleeve) or the gravity-fluidics configuration (Infiniti Vision System with gravity fluidics, 0.9 mm 45-degree Mini-Flared Kelman tip, and 0.9 mm Ultra infusion sleeve). Second-eye surgery was completed within 14 days after first-eye surgery using the alternate configuration. The CDE, aspiration fluid used, and aspiration time were compared between configurations, and adverse events were summarized. RESULTS: Patient demographics and cataract characteristics were similar between configurations (100 per group). The CDE was significantly lower with the active-fluidics configuration than with the gravity-fluidics configuration (mean ± standard error, 4.32 ± 0.28 percent-seconds) (P < .001). The active-fluidics configuration used significantly less aspiration fluid than the gravity-fluidics configuration (mean 46.56 ± 1.39 mL versus 52.68 ± 1.40 mL) (P < .001) and required significantly shorter aspiration time (mean 151.9 ± 4.1 seconds versus 167.6 ± 4.1 seconds) (P < .001). No serious ocular adverse events related to the study devices or device deficiencies were observed. CONCLUSION: Significantly less CDE, aspiration fluid used, and aspiration time were observed with the active-fluidics configuration than with the gravity-fluidics configuration, showing improved surgical efficiency. FINANCIAL DISCLOSURES: Drs. Solomon and Cionni are consultants to Alcon Research, Ltd., and received compensation for conduct of the study. Dr. Lorente received compensation for clinical work in the study. Mr. Fanney is an employee of Alcon Research, Ltd.

Intraoperative aberrometry versus standard preoperative biometry and a toric IOL calculator for bilateral toric IOL implantation with a femtosecond laser: One-month results.

PURPOSE: To compare astigmatic outcomes in patients with bilateral cataracts having toric intraocular lens (IOL) implantation with intraoperative aberrometry measurements in 1 eye and standard power calculation and a toric IOL calculator with inked axis marking in the contralateral eye. SETTING: Twelve sites in the United States. DESIGN: Prospective cohort study. METHODS: The eye with the more visually significant cataract was randomized to intraoperative aberrometry measurements (Ocular Response Analyzer with Verifeye) or standard preoperative biometry and use of a toric calculator with the contralateral eye automatically assigned to the other group. The primary effectiveness outcome was the proportion of eyes with a postoperative refractive astigmatism of 0.50 diopter (D) or less at 1 month. RESULTS: Of the 130 patients (260 eyes) enrolled, 124 (248 eyes) were randomized; 121 (242 eyes) completed the trial. The percentage of eyes with astigmatism of 0.50 D or less at 1 month was higher in the intraoperative aberrometry group than in the standard group (89.2% versus 76.6%) (P = .006). The mean postoperative refractive astigmatism was lower in the intraoperative aberrometry group (0.29 D ± 0.28 [SD] versus 0.36 ± 0.35 D) (P = .041). Secondary effectiveness endpoints, including manifest refraction spherical equivalent prediction error, uncorrected distance visual acuity, and corrected distance visual acuity, were similar. CONCLUSIONS: Compared with standard methods, the use of the intraoperative aberrometry system increased the proportion of eyes with postoperative refractive astigmatism of 0.50 D or less and reduced the mean postoperative refractive astigmatism at 1 month. Other efficacy outcomes were similar. FINANCIAL DISCLOSURES: Drs. Woodcock, Lehmann, and Cionni are consultants to Alcon Laboratories, Inc. Dr. Breen is an employee of Alcon Laboratories, Inc. Dr. Scott has no financial or proprietary interest in any material or method mentioned.

Comparison of stability between a modular intraocular lens system and a single-piece hydrophobic acrylic intraocular lens.

PURPOSE: To compare the movement of a modular intraocular lens (IOL) with that of a standard single-piece hydrophobic acrylic IOL in a human cadaver eye perfusion model. SETTING: Department of Ophthalmology, University of Colorado, Aurora, Colorado, USA. DESIGN: Experimental study. METHODS: Eight phakic human donor eyes of 4 patients had standard phacoemulsification with lens removal. One of 2 IOLs was then implanted in the capsular bag: a modular IOL (Harmoni) or a standard single-piece IOL (Acrysof SN60). Each globe was connected to a programmable perfusion pump with an in-line pressure transducer. Ultrasound biomicroscopy (UBM) was used to evaluate the anterior chamber depth (ACD) in each eye, measuring from the posterior cornea to the anterior surface of the optic at an intraocular pressure (IOP) of 5 mm Hg, 10 mm Hg, 20 mm Hg, and 30 mm Hg. Five consecutive measurements were recorded for all eyes at each pressure, and the results were averaged. RESULTS: There was significantly less movement in eyes with the modular IOL than in eyes with the single-piece IOL. The mean position of the modular IOL varied from a minimum of 0.03 mm to a maximum of 0.07 mm, and the mean position of the single-piece IOL varied from a minimum of 0.26 mm to a maximum of 0.87 mm (P = .002). CONCLUSIONS: The modular IOL showed less movement with changes in IOP than a standard single-piece IOL. Improved IOL stability might allow more accuracy in determining the effective lens position and hence improve the predictability of the refractive target. FINANCIAL DISCLOSURE: Proprietary or commercial disclosures are listed after the references.

Continuous Curvilinear Capsulorhexis Performed With the VERUS Ophthalmic Caliper.

PURPOSE: To compare size, circularity, and centration outcomes of continuous curvilinear capsulorhexis (CCC) performed with or without assistance from the VERUS ophthalmic caliper (Mile High Ophthalmics, Denver, CO). METHODS: This was a multicenter retrospective consecutive case controlled series review. RESULTS: Data from 40 consecutive cases using the VERUS device for CCC were compared to 40 consecutive cases with standard manual CCC. VERUS-assisted CCC size, circularity, and centration were closer to target compared to that of manual only procedures (P < .05). The average time from initiation to completion of the capsulotomy was shorter with manual (40 ± 11 seconds) compared to VERUS-assisted (71 ± 13 seconds) cases (P < .0001). CONCLUSIONS: The VERUS ophthalmic caliper is effective at improving size, circularity, and centration of the CCC in a time-efficient manner when compared to manual procedures performed without VERUS guidance. [J Refract Surg. 2016;32(10):654-658.].

Modification of the Siepser slip-knot technique.

A new modification of the Siepser sliding knot technique allows the surgeon to create a locking knot when performing iris reconstruction or intraocular lens fixation to the iris.

Optimal timing of capsular tension ring implantation: Miyake-Apple video analysis.

PURPOSE: To evaluate the appropriate timing for capsular tension ring implantation in cases of zonular weakness either prior to or after lens extraction using Miyake-Apple video analysis. SETTING: John Moran Eye Center, Salt Lake City, Utah, USA. METHODS: Four cadaver eyes were prepared using a standard Miyake-Apple protocol with image capture using digital video recording. After continuous curvilinear capsulorhexis and hydrodissection/viscodissection were performed, 2 eyes had early capsular tension ring implantation (CTR) and 2 eyes had CTR implantation after lens extraction. The 12.3 mm CTR was implanted in all eyes. Capsular bag torque and displacement, zonular elongation and stress, and ease of CTR placement were evaluated in each eye. RESULTS: Early CTR implantation resulted in significantly increased capsular torque and displacement of up to 4.0 mm compared to insertion in an empty capsular bag. There was significant zonular elongation and tension during early placement. CONCLUSION: In terms of minimizing further zonular stress and damage and capsular destabilization, the ideal timing for CTR placement is after lens extraction and decompression of the capsular bag.

Clinical results of the blue-light filtering AcrySof Natural foldable acrylic intraocular lens.

PURPOSE: To verify the safety and effectiveness of the new AcrySof Natural (Alcon Laboratories, Inc.) blue-light filtering intraocular lens (IOL), which was designed to achieve a light-transmission spectrum similar to that of the natural human crystalline lens. SETTING: Multicenter U.S. clinical trial. METHODS: In a prospective randomized patient-masked multicenter study, 150 patients received the AcrySof Natural IOL and 147 patients received the AcrySof single-piece IOL as a control. Patients with bilateral age-related cataracts who were willing and able to wait at least 30 days between cataract procedures and had verified normal preoperative color vision were eligible for the study. Standardized surgery included a 4.0 to 5.0 mm capsulorhexis and phacoemulsification. All lenses were inserted in the capsular bag, with verification of in-the-bag placement of both haptics. In all bilateral implantation cases, the same model IOL was used in each eye. Postoperatively, contrast sensitivity and color perception were measured up to 180 days and up to 1 year (for visual acuity) after implantation. RESULTS: No statistically significant differences were discovered between the 2 patient groups in visual acuity, contrast sensitivity evaluated under mesopic and photopic conditions, or the number of patients who passed the Farnsworth D-15 color perception test. There were no lens-related adverse events in either group. CONCLUSIONS: The blue-light filtering AcrySof Natural IOL was equivalent to the conventional AcrySof lens in terms of postoperative visual performance. Additional long-term clinical studies should show whether the IOL actually provides the theoretical benefits to retinal health.

Simultaneous surgeon and side-view video analysis comparing in situ fracture and stop-and-chop phacoemulsification.

A simultaneous surgeon and side-view camera video analysis demonstrated that in situ fracture requires more ultrasonic power behind the iris than the stop-and-chop technique, which requires a longer period of manipulation of larger fragments in the anterior chamber.

Evaluating Red Reflex and Surgeon Preference Between Nearly-Collimated and Focused Beam Microscope Illumination Systems.

PURPOSE: To evaluate the intensity and stability of the red reflex produced by ophthalmic surgical microscopes with nearly-collimated versus focused illumination systems and to assess surgeon preference in a simulated surgical setting. METHODS: This two-part evaluation consisted of postproduction surgical video analysis of red reflex intensity and a microscope use and preference survey completed by 13 experienced cataract surgeons. Survey responses were based on bench testing and experience in a simulated surgical setting. A microscope with nearly-collimated beam illumination and two focused beam microscopes were assessed. RESULTS: Red reflex intensity and stability were greater with the nearly-collimated microscope illumination system. In the bench testing survey, surgeons reported that the red reflex was maintained over significantly greater distances away from pupillary center, and depth of focus was numerically greater with nearly-collimated illumination relative to focused illumination. Most participating surgeons (≥64%) reported a preference for the microscope with nearly-collimated illumination with regard to red reflex stability, depth of focus, visualization, surgical working distance, and perceived patient comfort. CONCLUSIONS: The microscope with nearly-collimated illumination produced a more intense and significantly more stable red reflex and was preferred overall by more surgeons. TRANSLATIONAL RELEVANCE: This is the first report of an attempt to quantify red reflex intensity and stability and to evaluate surgically-relevant parameters between microscope systems. The data and methods presented here may provide a basis for future studies attempting to quantify differences between surgical microscopes that may affect surgeon preference and microscope use in ophthalmic surgery.

Management of lens-iris diaphragm retropulsion syndrome during phacoemulsification.

Lens-iris diaphragm retropulsion syndrome (LIDRS) occurs more often than recognized during small-incision phacoemulsification. This syndrome requires an infusion of fluid into the anterior chamber and is characterized by posterior displacement of the lens-iris diaphragm, marked deepening of the anterior chamber, posterior iris bowing, pupil dilation, and often significant patient discomfort. Using microendoscopy, we have observed that LIDRS is essentially a reverse pupillary block. We describe a surgical technique to mechanically break the iridocapsular block to restore normal chamber depth, relieve patient discomfort, and allow the surgeon to proceed safely with phacoemulsification.

Empty-bag technique for acrylic intraocular lens implantation using Healon5.

PURPOSE: To determine how often the empty-bag technique (EBT) for injecting an acrylic foldable intraocular lens (IOL) into the capsular bag using Healon5 (sodium hyaluronate 2.3%) will require a 2-compartment technique to remove the ophthalmic viscosurgical device (OVD) and compare this with that of a standard injection method using Healon5. SETTING: Cincinnati Eye Institute and Ambulatory Surgical Center, Cincinnati, Ohio, USA. METHODS: Forty-one eyes of 40 patients were randomly assigned to 1 of 2 groups. In Group A, standard capsular bag expansion was performed with Healon5 before implantation of an acrylic posterior chamber (PC) IOL. In Group B, Healon5 was placed in the anterior chamber followed by balanced salt solution expansion of the capsular bag before acrylic PC IOL implantation. In all patients, complete OVD removal was attempted with the automated aspiration tip anterior to the optic (rock 'n roll technique). The number of patients in each group who required placement of the aspiration tip posterior to the optic for complete removal was compared. Early postoperative intraocular pressure (IOP) was also compared. RESULTS: In Group A, 15 (75%) of 20 eyes required placement of the aspiration tip posterior to the optic for complete OVD removal and in Group B, 1 (0.05%) of 20 eyes. The postoperative IOP was similar in both groups. CONCLUSIONS: The EBT decreased the likelihood that a 2-compartment OVD removal method would be necessary when using Healon5 for acrylic PC IOL implantation. The limitations of this new technique must be fully understood before it is used.

Focal multistriae: postoperative finding in posterior lenticonus patients.

A brother and sister presented with a history of difficulty reading fine print and an intolerance to glare. Family history was positive for bilateral posterior lenticonus in the mother. Biomicroscopy confirmed that each sibling had bilateral posterior lenticonus that was more easily diagnosed in the brother. Uneventful phacoemulsification was performed in each eye with a foldable acrylic posterior chamber intraocular lens (IOL) placed vertically within the capsular bag in 3 eyes and horizontally in 1 eye. On the day after surgery, biomicroscopy revealed vertical wrinkles limited to the central 2.0 mm of the posterior capsule corresponding to the cone in the eyes in which the IOLs had been vertically placed. We hypothesize that these striae occurred within the cone as a result of redistributing the usual mechanical forces associated with capsule stretch between the most distal contact points of the haptics. We believe that the appearance of these multiple striae limited to the central posterior capsule represents an unreported postoperative finding associated with posterior lenticonus.