Capsular Waves: A Warning Indicator for Potentially Malpositioned Intraocular Lenses.

Purpose: To share examination findings of the lens capsule which may act as an indicator for malpositioned intraocular lenses (IOL). Setting: Single large multi-specialty private practice, Houston, Texas, USA. Design: Focused, observational case series. Methods: A review of pre-operative images of malpositioned single-piece IOLs with at least one haptic in the ciliary sulcus was conducted. The review included five cases who were referred to a single large multi-specialty private practice from June 2023 to December 2024 for an evaluation of posterior capsular opacification (PCO) and potential Nd:YAG capsulotomy. Findings: A total of five eyes which previously had undergone cataract surgery and were referred for Nd:YAG capsulotomy for PCO were identified on slit lamp examination to have capsular waves, defined as a centripetal and circumferential striated pattern of PCO that results from a fused anterior and posterior capsule with at least part of the IOL anterior to the capsule. While one eye exhibited transillumination defects and pigment dispersion, the remainder of eyes did not. In some cases, the capsular wave was the only clue to IOL malpositioning due to a small pupil. These eyes had single-piece IOLs with at least one haptic in the sulcus and required subsequent IOL repositioning or exchange. Conclusion: If capsular waves are seen on slit lamp exam, a thorough inspection of IOL placement should be conducted, especially before treatment with Nd:YAG capsulotomy. Capsular waves result from anterior and posterior capsule contact with an anteriorly situated IOL. This finding is a potential indicator of at least part of an IOL positioned anterior to the anterior capsule.

Standalone Interventional Glaucoma: An Evolution from the Combination-Cataract Paradigm.

DESCRIPTIVE ABSTRACT: One of the most impactful recent developments in the glaucoma community has been the concept of interventional glaucoma. In brief, this paradigm shift involves proactive rather than reactive intervention to address glaucoma earlier in the disease process, including in both standalone and combination-cataract settings. By intervening earlier with minimally-invasive surgical, laser, or drug-delivery treatments instead of prolonged topical medications, interventional glaucoma aims to take the burden of medication compliance off the patient. It also allows for standalone surgical interventions rather than letting cataract surgery dictate the glaucoma treatment plan. This interventional mindset has been made possible by the increasing diversity and availability of effective minimally-invasive treatment options. With these options as a springboard, it is time to reevaluate and advance the traditional glaucoma treatment paradigm.

Head-to-Head Comparison of Intermediate Vision of Two Monofocal Intraocular Lenses.

Purpose: To compare intermediate visual outcomes in patients previously implanted with bilateral Clareon monofocal IOLs versus bilateral Eyhance IOLs. Methods: This was a non-interventional, single-center, examiner-masked, comparative study. Participants were cataract patients presenting at least 3 months after uncomplicated, bilateral implantation of either Clareon or Eyhance non-toric and toric IOLs. Outcomes measures included binocular distance-corrected intermediate visual acuity (DCIVA), binocular corrected distance visual acuity (CDVA), binocular best-corrected defocus curve, postoperative mean residual spherical equivalent (MRSE), and residual astigmatism. Results: A total of 620 eyes of 310 subjects (155 subjects per group) were evaluated. The mean difference in DCIVA was 0.05 logMAR between the Eyhance and Clareon IOLs which was significant (p < 0.01), but within the 0.1 logMAR non-inferiority margin. Mean CDVA of the Clareon group was 0.01 ± 0.03 logMAR compared to 0.02 ± 0.03 logMAR of the Eyhance Group (p > 0.05). Defocus curves from +1.0 D to -3.0 D were not clinically nor statistically different between the Clareon and Eyhance groups (p > 0.05). Conclusion: The results of this study show that bilateral implantation of Clareon monofocal IOLs and Eyhance monofocal IOLs lead to similar distance and intermediate visual outcomes.

Biometric Indicators for Maximizing Intermediate Vision with a Monofocal IOL.

Purpose: To determine refractive or biometric variables that might be predictive of increased intermediate vision in patients receiving an Eyhance monofocal intraocular lens (IOL). Methods: This prospective, single-center, bilateral, non-randomized, open-label, observational study included a total of 110 subjects (220 eyes). Subjects had been previously bilaterally implanted with an Eyhance monofocal IOL (Johnson & Johnson Vision Care, Inc.) and were later divided into 2 groups based on their postoperative visual acuity. Subjects that had binocular distance corrected intermediate visual acuity (DCIVA) of 0.2 logMAR or better were classified into the Enhanced Group, and the remaining subjects were classified into the Non-Enhanced Group. Refractive outcomes and biometric measurements were compared between groups. Results: The number of subjects in each group was 61 for the Enhanced Group, and 49 for the Non-Enhanced Group. There were significant differences in pupil size between groups, with pupil sizes in the Enhanced Group significantly smaller than in the Non-Enhanced Group (p < 0.01). Subjects also reported significantly more dysphotopsias in the Non-Enhanced Group compared to the Enhanced Group (p = 0.03). Multiple regression analysis identified pupil size and axial length as significant predictors of increased monocular intermediate vision. Conclusion: The results of this study suggest that pupil size could be a predictor of increased intermediate vision in a patient receiving an Eyhance monofocal IOL.

Impact of presbyopia treatment pilocarpine hydrochloride 1.25% on night-driving performance.

CLINICAL RELEVANCE: Patients prescribed pilocarpine ophthalmic solution are advised to be cautious when driving at night, but studies evaluating the effects of pilocarpine hydrochloride ophthalmic solution 1.25% (pilo), approved to treat presbyopia, on driving at night are lacking. BACKGROUND: This double-masked, crossover, phase 3b study evaluated night-driving performance with pilo or the placebo once daily. METHODS: Forty-three adults (40-55 years) with presbyopia impacting daily activities and mesopic, high-contrast, binocular distance-corrected near vision 6/12-6/30 were randomised to bilateral treatment with pilo followed by placebo or placebo followed by pilo (with a ≥7-day washout between interventions). Night-driving performance was evaluated at twilight at a closed-circuit course. Primary efficacy endpoint: overall composite night-driving performance Z score at the end of the 7-14-day intervention period, 1 hour post-instillation. Pilo was considered non-inferior if the lower limit of the 95% confidence interval (CI) for the least squares mean difference (LSMD, pilo minus placebo) was >-0.25. Other efficacy endpoints: individual components of the night-driving performance test (hazard avoidance rate; road sign recognition rate and distance; pedestrians recognition distance; overall driving and lane-keeping times) and night-driving experience questionnaire. Safety included treatment-emergent adverse events (TEAEs). RESULTS: The mean overall composite Z scores were -0.121 (pilo) and 0.118 (placebo). The LSMD (pilo minus placebo) was -0.224 (95% CI, -0.346, -0.103), with 3 of the 7 individual tasks being significantly better with the placebo. The questionnaire did not reveal significant differences between pilo and the placebo. There were no serious or severe TEAEs and no TEAE-related discontinuations. The most common ocular TEAEs were headache and visual impairment with pilo (both 27.9%), and dry eye (7.0%) with the placebo. CONCLUSION: The overall performance of night driving was inferior with pilo, compared with placebo. The study findings are consistent with the current class labelling and provide evidence to inform regulators and assist clinicians considering prescribing pilo to adults who seek treatment of presbyopia symptoms and drive at night.ClinicalTrials.gov identifier: NCT04837482.

Modified adaptation of the twist-and-out technique for intraocular lens exchange.

Many methods can be used to explant an intraocular lens (IOL) after prior cataract surgery. Here, we describe a modified approach to the twist-and-out technique for IOL removal. The IOL is dissected and brought into the anterior chamber (AC), where 1 haptic is externalized. The adaptation in this technique occurs next; an additional paracentesis is made 180 degrees away from an adjacent side port, and the shaft of a 25-gauge cannula is threaded across the AC to connect these incisions. This maneuver frees both hands to use forceps within the incision, grasp the IOL, and rotate it around the forceps. The use of both hands allows for a smaller, more controlled movement than the original 1-handed pronation. The cannula shaft aids in twisting the IOL tightly around the forceps while protecting the corneal endothelium. The forceps-lens complex is then withdrawn, extracting the IOL whole with 1 efficient movement.

Punch and rescue technique for scleral fixation of dislocated single-piece intraocular lenses.

In-the-bag intraocular lens (IOL) dislocation is a well-known complication after cataract surgery. As the number of cataract surgeries performed annually continues to increase, so will the incidence of IOL dislocations requiring surgical correction. Described is a new technique for rescue and refixation of a single-piece acrylic IOL. In this method, a new instrument called the IOL punch is used to create a hole at the optic-haptic junction or along the border of the optic, which acts as an anchor point for centration and subsequent scleral fixation of a dislocated IOL. The IOL punch allows for precise intraocular manipulation of the IOL and is less invasive compared with popular scleral fixation methods. This innovative technique may decrease the risk for postoperative complications and allows patients to maintain or recover previous uncorrected visual acuity by circumventing the need for IOL explantation or exchange.

Motor Vehicle-Associated Traumatic Ocular Injuries Secondary to External Rear-Facing Sideview Mirrors: A Report of 3 Patients.

IMPORTANCE: Rear-facing sideview mirrors are a potentially reducible source of ocular morbidity following motor vehicle crashes. OBJECTIVE: To report cases highlighting shattered glass from sideview mirrors as a potential cause of ocular trauma in motor vehicle crashes. DESIGN, SETTING, AND PARTICIPANTS: Case series of 3 patients who presented to Grady Memorial Hospital, a level 1 trauma center and tertiary hospital, between May 5, 2017, and July 10, 2017, with ocular trauma as a result of shattered glass from sideview mirrors during motor vehicle crashes. A review of the literature was also conducted. Data were analyzed between July 2017 and August 2017. INTERVENTIONS OR EXPOSURES: Operation for exploration and repair of open globe in all 3 cases. MAIN OUTCOMES AND MEASURES: Visual prognosis and ocular morbidity postoperatively. RESULTS: All patients were white men in the age range of 26 to 43 years. This was a retrospective review of 3 of 208 patients who presented to Grady Memorial Hospital after motor vehicle crashes from May 5, 2017, to July 10, 2017. From the time of presentation of the 3 reported patients from Grady Memorial Hospital, all 3 had 2 surgeries inclusive of the initial open globe repair. Patients with this mechanism of injury experienced ocular morbidity, with all 3 cases resulting in uveal prolapse and 2 of 3 resulting in retinal detachments. Among the 3 patients, visual acuities after the second surgery within the first year were hand motion, 20/100, and 20/150. CONCLUSIONS AND RELEVANCE: Sideview mirrors can be a cause of serious ocular injuries in motor vehicle crashes. These 3 reported cases, combined with cases previously reported, suggest that this mechanism of ocular injury does occur. Further studies seem warranted to investigate the frequency of these findings and whether any design modifications may help reduce the frequency.

Current and Next Generation Portable Screening Devices for Diabetic Retinopathy.

Diabetic retinopathy (DR) is the leading cause of legal blindness in the United States, and with the growing epidemic of diabetes, a global increase in the incidence of DR is inevitable, so it is of utmost importance to identify the most cost-effective tools for DR screening. Emerging technology may provide advancements to offset the burden of care, simplify the process, and provide financially responsible methods to safely and effectively optimize care for patients with diabetes mellitus (DM). We review here currently available technology, both in production and under development, for DR screening. Preliminary results of smartphone-based devices, "all-in-one" devices, and alternative technologies are encouraging, but are largely pending verification of utility when used by nonophthalmic personnel. Further research comparing these devices to current nonportable telemedicine strategies and clinical fundus examination is necessary to validate these techniques and to potentially overcome the poor compliance around the globe of current strategies for DR screening.