Retinal detachment after clear lens extraction for high myopia: seven-year follow-up

Refractive lens exchange: What are the red lines?

Practical advancements in phacoemulsification techniques and intraocular lenses and the wide availability of phacoemulsification machines have led refractive lens exchange (RLE) to increase in popularity. Ethical boundaries in RLE have subsequently been pushed to include patients at higher risk of complications. In this editorial, we consider RLE outcomes and complications per type of refractive error, together with preoperative, intraoperative and postoperative ethical obligations for refractive surgeons. In the conclusions section, we propose an algorithm for ethics-guided indications to RLE.

Retinal detachment after refractive lens exchange: A narrative review

Refractive lens exchange (RLE) allows to correct ametropias and presbyopia by replacing the crystalline lens with an extended depth of focus or multifocal intraocular lens (IOL). Retinal detachment (RD) is one of the most serious adverse events after RLE. This study aimed to review the evidence related to the risk of RD after RLE and clinical outcomes. A search using PubMed and a snowball search approach was conducted to identify articles and case reports. According to the literature, the risks of RD should be considered in patients <60 years old with axial lengths >23 mm. Only nine articles reported visual acuity (VA) after RD in RLE, and only 25% of eyes had a VA > 20/40. Considering that the decrease in VA might be uniform for all types of IOLs after RD, surgeons should focus on selecting the patient to prevent RD rather than on a particular IOL optical design based on the potential risk of DR.

Diagnostic Techniques to Increase the Safety of Phakic Intraocular Lenses

Preoperative and postoperative diagnostics play an important role in ensuring the safety of patients with phakic intraocular lenses (pIOLs). The risk of endothelial cell loss can be addressed by regularly measuring the endothelial cell density using specular microscopy and considering the endothelial cell loss rate and the endothelial reserve in accordance with the patient's age when deciding whether to explant a pIOL. The anterior chamber morphometrics, including the anterior chamber depth and the distance between the pIOL and the endothelium, measured using Scheimpflug tomography and anterior segment optical coherence tomography (AS-OCT), can help to assess the risk of the endothelial cell loss. In patients undergoing posterior chamber pIOL implantation, accurate prediction of the vault and its postoperative measurements using AS-OCT or Scheimpflug tomography are important when assessing the risk of anterior subcapsular cataract and secondary glaucoma. Novel approaches based on ultrasound biomicroscopy and AS-OCT have been proposed to increase the vault prediction accuracy and to identify eyes in which prediction errors are more likely. Careful patient selection and regular postoperative follow-up visits can reduce the complication risk and enable early intervention if a complication occurs.

LEPREL1 -RELATED GIANT RETINAL TEAR DETACHMENTS MIMIC THE PHENOTYPE OF OCULAR STICKLER SYNDROME

PURPOSE

To describe the features of retinal detachments and high myopia in patients with novel pathogenic variants in LEPREL1 and report a possible association with nephropathy.

METHODS

Retrospective study of 10 children with biallelic LEPREL1 pathogenic variants. Data included ophthalmic features, surgical interventions, and genetic and laboratory findings.

RESULTS

10 patients (8 females) from three families with homozygous (2) or compound heterozygous (1) variants in LEPREL1 were included. At presentation, mean age was 9.9 ± 2.6 years. Mean axial length was 28.9 ± 1.9 mm and mean refraction was -13.9 ± 2.8 diopters. Bilateral posterior subcapsular cataracts were present in eight patients (80%), with lens subluxation in five eyes of three patients (30%). Rhegmatogenous retinal detachments (RRD), associated with giant retinal tears (GRT), developed in seven eyes of five patients (50%) at a mean age of 14.14 ± 5.9 years. Six were successfully reattached with mean Snellen best-corrected visual acuity improving from 20/120 preoperatively to 20/60 at last follow-up. Urinalysis in nine patients revealed microhematuria and/or mild proteinuria in six patients (67%).

CONCLUSION

LEPREL1 -related high myopia confers a high risk of early-onset GRT-related RRD. The ocular phenotype may be confused with that of ocular Stickler syndrome if genetic testing is not performed. Further investigations into a potential association with renal dysfunction are warranted.

Long-term efficacy and safety results after iris-fixated foldable phakic intraocular lens for myopia and astigmatism: 6-year follow-up

PURPOSE

To evaluate the long-term efficacy and safety of iris-fixated foldable phakic intraocular lenses (pIOLs) for the management of myopia and astigmatism after 6-year follow-up.

SETTING

Ophthalmology Department, Hospital Braga, Portugal.

DESIGN

Retrospective cohort study.

METHODS

Patients included underwent iris-fixated foldable Artiflex pIOL implantation between January 2010 and December 2013. Follow-up evaluations were performed 6 months postoperatively and every 12 months until 72 months. Preoperative and follow-up data on uncorrected and corrected distance visual acuity (CDVA), manifest refraction, endothelial cell density (ECD), and anterior chamber depth (ACD) were analyzed.

RESULTS

A total of 177 eyes of 98 patients with a mean age of 32.33 ± 7.13 years were analyzed. There was a statistically significant improvement in CDVA from 0.09 ± 0.02 logMAR preoperatively to 0.04 ± 0.02 logMAR (P < .0001) at 6 years postoperatively. The spherical equivalent demonstrated a statistically significant improvement from -9.50 ± 2.93 diopters (D) to -0.41 ± 0.45 D at 6 years. At 72 months, the efficacy and safety indexes were 0.94 and 1.15, respectively. A mean loss of 31.77 cells/mm2 (1.19%) was observed each year until the sixth year. The overall mean ECD loss after correction for the physiological loss was 3.02% after 6 years. No correlations were observed between the mean ECD loss and the preoperative ACD.

CONCLUSIONS

The Artiflex pIOL was a safe, effective, and a stable option to correct myopia. A mean ECD loss of 3.02% was observed over 6 years. No pIOL was explanted due to corneal decompensation.

Bilateral Toric Phakic Intraocular Lens Implantation for Correction of High Myopic Astigmatism in a Patient with Marfan Syndrome with Lens Coloboma: A Case Report

Marfan syndrome (MFS) is known to cause significant refractive error. Treatment options are limited in this condition for correcting refractive error. Clear lens exchange is done in these cases, but complication rates are high. Loss of accommodation is another concern in these young adults. We report toric phakic intraocular lens (pIOL) implantation in improving the uncorrected visual acuity (UCVA) in a known case of MFS with lens coloboma. A 22-year-old female patient with MFS with inferior lens coloboma underwent bilateral toric pIOL implantation in the same sitting. Pre- and post-operative UCVA and best-corrected visual acuity were assessed. Central and peripheral vaulting of the pIOL in relation to the natural lens was also assessed. UCVA improved from 20/500 to 20/20 in the right and 20/550–20/20 in the left eye. Marked central vaulting with partial peripheral vaulting was achieved. There were no post-operative complications. Phakic IOL implantation surgery could be an effective approach to achieve excellent uncorrected refractive outcome in patients with MFS to treat high myopia.

Clear lens extraction for patients who are unfit for laser-assisted in situ keratomileusis and implantable contact lenses in central Indian population

Purpose:

The purpose of this study is to establish the safety of clear lens extraction (CLE) for the correction of high myopia in patients unfit for implantable contact lenses (ICLs) and laser in situ keratomileusis in the central Indian population.

Methods:

In this retrospective observational study performed at a tertiary care centre, medical records of the patients who had undergone CLE with implantation of intraocular lens (IOL) to treat high myopia were retrieved. Details of the demographic profile, surgical procedure, complications, power, and type of IOLs implanted were recorded.

Results:

The average postoperative follow-up period was 64.1 ± 4.2 months. The average postoperative spherical power was −1.4 ± 0.6 D, which was much lower than the preoperative spectacle power - 15 ± 4.4 D. There was improvement in the postoperative visual acuity (0.4 ± 0.2 logMAR) from the preoperative distant uncorrected visual acuity (0.8 ± 0.2 logMAR). No significant change in intraocular pressure (IOP) was observed. The postoperative average anterior chamber depth (ACD) (2.66 ± 0.1 mm) was significantly deeper than the preoperative ACD (2.61 ± 0.1 mm) P = 0.00. Barrage laser was required for lattice degeneration in one patient before CLE and in two patients during follow-up. Two patients (8.7%) required Nd:YAG capsulotomy for posterior capsular opacification. None of the patients had corneal decompensation, retinal detachment, or endophthalmitis.

Conclusion:

CLE with implantation of IOL is the safe procedure for correcting high myopia in patients who are unfit for ICL. None of the patient had eye loss in the follow-up period of 5 years. The low incidence of complications can be attributable to the closed chamber lens removal and implantation of IOL and prophylactic retinal treatment.

Descemet membrane endothelial keratoplasty for corneal decompensation caused by a phakic anterior chamber intraocular lens implantation

PURPOSE

To describe the clinical outcomes of Descemet membrane endothelial keratoplasty combined with phacoemulsification/posterior chamber intraocular lens implantation (triple procedure) for treatment of corneal decompensation induced by a phakic anterior chamber intraocular lens (AC IOL) implantation.

METHODS

Ten patients (10 eyes) with corneal decompensation due to phakic AC IOL implantation that had undergone the triple procedure were included in this study. Among the 10 eyes, 5 eyes underwent explantation of AC IOL prior to the transplantation, and then underwent the triple procedure. The remaining 5 eyes with a phakic AC IOL in situ underwent the triple procedure with concurrent explantation of AC IOL. Corrected distance visual acuity (CDVA), subjective refraction, endothelial cell density (ECD), and complications were documented.

RESULTS

The triple procedure was performed across all eyes without any adverse events. The average CDVA improved from 1.32 ± 0.24 preoperatively to 0.15 ± 0.05 logarithm of the minimum angle of resolution (logMAR), which represents an improvement in Snellen equivalent from 20/400 (0.05) preoperatively to 20/28 (0.71) at 12 months after surgery. At 12 months, all eyes reached a CDVA of 20/32 (0.63) or better, and 50% of eyes reached a CDVA of 20/25 (0.8) or better. The mean donor ECD±SD was 2868.7 ± 67.9 cells/mm², which decreased to 1724.1 ± 84.6 cells/mm² at 12 months, representing 39.9% of endothelial cell loss. Patients did not experience any severe adverse events.

CONCLUSION

The triple procedure is a safe and effective option for corneal decompensation induced by a phakic AC IOL implantation, helping achieve a satisfactory visual rehabilitation with few complications.

Risk Factors for Onset or Progression of Posterior Vitreous Detachment at the Vitreomacular Interface after Cataract Surgery

PURPOSE

To study the incidence and risk factors for onset or progression of posterior vitreous detachment (PVD) at the vitreomacular interface (VMI) after cataract surgery.

DESIGN

Retrospective case series.

PARTICIPANTS

Patients with a history of phacoemulsification from April 2018 through April 2019 at the Keye Eye Center, Seoul, Korea, and postoperative monitoring for more than 2 months.

METHODS

Cox proportional hazard ratios for the onset or development of PVD after cataract surgery in the presence of selected risk factors and demographic data were calculated. To evaluate the ocular risk factors, various ocular metrics, including spherical equivalent (SE), axial length (AL), anterior chamber depth, lens thickness, central subfield thickness, PVD status at macula and optic nerve head (ONH), peripapillary retinal nerve fiber layer thickness, and ONH parameters from OCT scans, were used for the analysis.

MAIN OUTCOME MEASURES

Onset or development of PVD at the VMI.

RESULTS

Among 988 eyes without PVD at baseline, 174 eyes (17.6%) showed changes in the VMI. Univariate analysis showed that age, SE, AL, PVD status at macula and ONH, and average and vertical cup-to-disc ratios (CDRs) were associated significantly with PVD onset or development (P = 0.046, P = 0.004, P = 0.040, P < 0.001, P < 0.001, P = 0.008, and P = 0.042, respectively). In a multivariate analysis, PVD status at the macula and ONH and smaller CDR were associated with PVD onset or progression after cataract surgery after adjustment for age, SE, and AL (P < 0.001, P < 0.001, and P = 0.005, respectively).

CONCLUSIONS

The risk of PVD onset or progression was dependent on PVD status and the CDR detected on OCT scans, not on age or AL, in a large patient cohort. Patients who show risk factors on OCT should be monitored carefully during the postoperative period.

Incidence of Intraoperative and Early Postoperative Adverse Events in a Large Cohort of Consecutive Refractive Lens Exchange Procedures

PURPOSE

To evaluate the incidence of adverse events (AEs) in patients who underwent refractive lens exchange.

DESIGN

Retrospective case series.

METHODS

Setting: Private refractive surgery clinics. Patients/Study Population: Patients who underwent refractive lens exchange between July 1, 2014, and June 30, 2016. Intervention/Observation Procedures: All AEs recorded in the electronic medical record were extracted and retrospectively reviewed. The total incidence of AEs and serious AEs was calculated. Loss of 2 or more lines of corrected distance visual acuity (CDVA) was calculated for the entire cohort of patients that attended a minimum of 3 months follow-up.

MAIN OUTCOME MEASURES

AEs.

RESULTS

The total number of patients included was 10,206 (18,689 eyes). A multifocal intraocular lens (IOL) was implanted in 84.3% of eyes; 15.7% of eyes received a monofocal IOL. A total of 1164 AEs were recorded (1112 eyes of 1039 patients, incidence 6.0% of eyes, 1:17 eyes). The most common AE was posterior capsular opacification (PCO; 748 eyes, incidence 4.0%). Of all AEs, 171 events (occurring in 165 eyes of 151 patients, incidence 0.9%, 1:113 eyes) were classified as serious, potentially sight threatening. Loss of 2 or more lines of CDVA was 0.56% when excluding eyes where the loss of CDVA was due to PCO; the majority of these were due to macular causes.

CONCLUSION

The incidence of sight-threatening AEs and significant loss of CDVA in elective refractive lens exchange surgery was low. Other than PCO, postoperative macular issues were the most common cause of vision loss in this cohort.

Contralateral Posterior Chamber Phakic Intraocular Lens Implantation as Rehabilitation of Refractive Lens Exchange with a Monofocal Intraocular Lens in a Young, Nonpresbyopic, Bilateral Highly-Myopic Patient

Background

Refractive errors are widespread in the human population; nowadays, numerous surgical options allow for efficient and safe correction them. One of the main elements to ensure success in this kind of intervention will depend on the careful patient and surgical approach selection. Excimer laser corneal surgery is considered by most for low to moderate ametropias. Another option, which has been suggested may be safer, is to cut a small corneal lenticule with femtosecond laser, and then extracting it through a small incision. Nevertheless, in some specific cases, such as patients with high refractive error or those with some corneal abnormality, laser corneal ablations are considered unsafe from either a biomechanical or refractive standpoint. In this kind of particular cases, Phakic Intraocular Lens (P-IOL) implantation constitutes attractive, highly predictable and safe option.

Objective

The authors want to show the case of a young high-myopic woman, already pseudophakic in one eye, where the P-IOL implantation in the fellow eye yielded excellent short-term visual results, and high patient's satisfaction, is presented.

Materials

The authors present the case of a 32-years-old, highly myopic female patient underwent a Refractive Lens Exchange (RLE) with a monofocal Intraocular Lens (IOL) implantation in her left eye elsewhere, and developed severe visual issues, especially regarding near-work. Symptoms resolved through the implantation of a posterior chamber P-IOL in the contralateral eye.

Results

The postoperative course was unremarkable, inflammation was mild, and visual recovery was quick. There was no need to perform any procedure on her left eye or to use any reading glasses, as unilateral effective near vision through her right eye was enough for all her daily tasks.

Conclusions

RLE in young pre-presbyopic highly myopic patients may not be an advisable alternative in most cases, because of the high risks of retinal complications observed. In addition, eliminating accommodation will cause significant limitations, and multifocal IOLs currently available are far from the quality of vision that a young human crystalline lens yields. On the other hand, implantation of a P-IOL is a good option if eye conditions are optimal, as it preserves natural accommodation. In this case an EyeCryl Phakic Toric® IOL showed excellent short-term refractive predictability and safety.

Current Trends in Modern Visual Intraocular Lens Enhancement Surgery in Stable Keratoconus: A Synopsis of Do's, Don'ts and Pitfalls

Keratoconus is a relatively common ectatic, non-inflammatory corneal disorder that involves gradual visual deterioration through progressive alteration of the shape of the cornea. The corneal thinning, irregular astigmatism and higher order aberrations that occur as the disease progresses pose major challenges in the visual rehabilitation of such patients. This paper summarizes the current literature regarding the results of visual enhancement procedures in patients with stable keratoconus treated with standalone anterior or posterior chamber phakic intraocular lens implantation and monofocal, toric or multifocal toric intraocular lens implantation following phacoemulsification for age-related cataract extraction or refractive lens exchange.

Does Nd:YAG Capsulotomy Increase the Risk of Retinal Detachment?

Laser capsulotomy is accepted as a standard and effective treatment for posterior capsule opacification. It is generally believed that neodymium:YAG (Nd:YAG) capsulotomy is related to an increased risk of retinal detachment (RD). The aim of this study was to evaluate the association between Nd:YAG capsulotomy and risk for developing RD. A PubMed and Medline search was conducted using the terms "retinal detachment" and "Nd:YAG laser capsulotomy." Of the articles retrieved by this method, all publications in English and abstracts of non-English publications were reviewed. The literature analysis presented no convincing evidence supporting the association between Nd:YAG capsulotomy and increased risk for developing RD. The existing discrepancy between some studies might be related to inadequate group sizes, short observation period, and co-existing disorders. We also reviewed the possible risk factors for RD after Nd:YAG capsulotomy and found no association with preceding surgical approach, existing posterior vitreous detachment, and intraocular lens design. Myopic patients should be treated with caution, as it cannot be concluded that Nd:YAG capsulotomy does not increase RD rate in this cohort. Treatment energy should be as low as possible, as high energy levels and anterior hyaloid damage might increase the chance for RD development. Cataract surgery itself is a potential RD risk factor, particularly after intraoperative capsule complications.

Bilateral Implantation of the Acri.LISA Bifocal Intraocular Lens in Myopic Eyes

Purpose

To asses visual quality after bilateral implantation of the Acri.LISA 366D intraocular lens (IOL) (Carl Zeiss Meditec) in patients with high and low–moderate myopia.

Methods

A total of 304 eyes of 152 patients had bilateral implantation of the Acri.LISA 366D IOL. The patients were divided into 2 groups: low–moderate myopia (IOL power from 15 to 20.5 D) and high myopia (IOL power from 0 to 14.5 D). Monocular and binocular best-corrected distance visual acuity (BCVA) and best distance-corrected near visual acuity (BCNVA), binocular best distance-corrected intermediate visual acuity (BCIVA), and distance contrast sensitivity (OS) under photopic (85 cd/m2) and mesopic (5 cd/m2) conditions were determined.

Results

At the 6-month postoperative visit, there were no statistically significant differences in monocular and binocular BCVA (p=0.13 and p=0.22, respectively). Monocular and binocular BCNVA was comparable between the groups (p=0.26 and p=0.09, respectively). The mean binocular BCIVA changed significantly as a function of the distance of the test (p<0.01) in both groups, and there were no statistically significant differences between groups at any distance. Monocular and binocular CS under photopic and mesopic conditions was similar between both groups (p>0.01).

Conclusions

Bilateral implantation of the Acri.LISA 366D in high myopic eyes provides a satisfactory full range of vision comparable to that obtained in low–moderate myopic eyes.

Refractive lens exchange in younger and older presbyopes: comparison of complication rates, 3 months clinical and patient-reported outcomes

Purpose

To compare refractive and visual outcomes, patient satisfaction, and complication rates among different age categories of patients who underwent refractive lens exchange (RLE).

Methods

A stratified, simple random sample of patients matched on preoperative sphere and cylinder was selected for four age categories: 45–49 years (group A), 50–54 years (group B), 55–59 years (group C), and 60–65 years (group D). Each group contained 320 patients. All patients underwent RLE with a multifocal intraocular lens at least in one eye. Three months postoperative refractive/visual and patient-reported outcomes are presented.

Results

The percentage of patients that achieved binocular uncorrected distance visual acuity 20/20 or better was 91.6% (group A), 93.8% (group B), 91.6% (group C), 88.8% (group D), P=0.16. Binocularly, 80.0% of patients in group A, 84.7% in group B, 78.9% in group C, and 77.8% in group D achieved 20/30 or better uncorrected near visual acuity (P=0.13). The proportion of eyes within 0.50 D of emmetropia was 84.4% in group A, 86.8% in group B, 85.7% in group C, and 85.8% in group D (P=0.67). There was no statistically significant difference in postoperative satisfaction, visual phenomena, dry eye symptoms, distance or near vision activities. Apart from higher rate of iritis in the age group 50–55 years, there was no statistically significant difference in postoperative complication rates.

Conclusion

RLE can be safely performed in younger as well as older presbyopes. No significant difference was found in clinical or patient-reported outcomes.

Implantation of Implantable Collamer Lenses After Radial Keratotomy

PURPOSE

To assess the predictability, efficacy, and safety of posterior chamber phakic implantable collamer lens (ICL) implantation after radial keratotomy.

METHODS

In a retrospective non-comparative interventional case series, outcomes in 6 consecutive eyes of 4 patients with residual refraction after radial keratotomy were analyzed after the implantation of ICLs. All of the lenses were implanted to correct the residual refractive error, ranging from -12.00 to +3.50 diopters (D) for sphere and from -0.75 to -3.75 D for cylinder.

RESULTS

The mean uncorrected distance visual acuity after ICL implantation was 0.31 ± 0.36 logMAR and the corrected distance visual acuity was 0.12 ± 0.10 logMAR. The mean efficacy index was 0.86. No eyes lost lines of visual acuity, two eyes did not change after surgery, two eyes gained one line, and two eyes gained two lines. The mean safety index was 1.17. No intraoperative complications were found and ICL explantation or repositioning was not required during the follow-up. No cases of cataract, pigment dispersion glaucoma, pupillary block, or other vision-threatening complications were found.

CONCLUSIONS

ICL implantation may be considered a reasonable surgical procedure for correcting residual refractive errors after radial keratotomy. [J Refract Surg. 2017;33(6):395-398.].

Iris-fixated phakic intraocular lens implantation in an adult with retinopathy of prematurity: 1-year follow-up

PURPOSE

To report a case of iris-fixated phakic intraocular lens (pIOL) implantation in a patient with an extremely steep cornea, shallow anterior chamber, and small corneal diameter caused by retinopathy of prematurity (ROP) and scleral encircling.

METHODS

Case report.

RESULTS

Iris-fixated pIOLs were implanted in a 19-year-old patient with refraction of -18.5 -0.75 × 180 in the right eye and -15.5 -1.25 × 180 in the left eye. The keratometric values were 53.50 and 51.25 diopters (D) in the right eye and 54.75 and 51.75 D in the left eye. The white-to-white diameter and anterior chamber depth were 10.6 and 3.37 mm, respectively, in the right eye and 10.5 and 3.33 mm, respectively, in the left eye.

CONCLUSION

A small pIOL was used to guarantee a safety distance and resulted in a one-line gain in uncorrected distant visual acuity and stable endothelial cell density 1 year after surgery. An iris-fixated pIOL Vis therefore an effective option for myopic patients with ROP.

Refractive Lens Exchange Combined with Primary Posterior Vitrectorhexis in Highly Myopic Patients

Purpose. To evaluate efficacy and safety of primary vitrectorhexis for posterior capsulotomy in highly myopic patients undergoing refractive lens exchange. Methods. The study is a prospective nonrandomized interventional study. The study comprised 60 eyes of 60 myopic patients. All patients underwent refractive lens exchange (RLE) and foldable IOL implantation combined with primary posterior capsulotomy. We used a 23-gauge vitrectomy probe for the creation of the posterior capsule opening. We followed the patients for one year. Results. During surgery, the IOLs remained well centered in the capsular bag after creation of the capsulotomy. Postoperatively, we did not report any complications related to lens centration or changes in the posterior capsulotomy size. No eye required YAG laser posterior capsulotomy and no cases of retinal detachment (RD) occurred during the follow-up period. Conclusion. Primary posterior vitrectorhexis during RLE is an efficient method in preventing the occurrence of posterior capsular opacification (PCO) and the need for YAG laser posterior capsulotomy with its possible complications.

Modern Phacoemulsification and Intraocular Lens Implantation (Refractive Lens Exchange) Is Safe and Effective in Treating High Myopia

Improved efficacy, predictability, and safety of modern phacoemulsification have resulted in cataract surgery being considered as a refractive procedure. Refractive lens exchange by definition is a surgery aimed at replacing the cataractous or clear crystalline lens with an intraocular lens (IOL) in cases of high ametropia. The excellent intraocular optics of this procedure provide a better visual outcome as compared with laser refractive surgery in high myopia. With advances in technology and IOL formulas, the predictability of refractive outcome after cataract surgery in high myopes has improved. The option of addressing presbyopia using multifocal/accommodating IOLs or monovision results in patients achieving reasonable spectacle independence. The most important concern with respect to phacoemulsification in high myopia is the risk of pseudophakic retinal detachment. High myopia is an independent risk factor for retinal detachment, and recent publications have reported a much lesser risk of retinal detachment specifically attributable to phacoemulsification in high myopes, especially if a thorough posterior segment evaluation is done and patients are followed up until development of complete posterior vitreous detachment. Refractive lens exchange is an effective and safe option to correct high myopia and can significantly improve quality of life in select patients.

Incidence, Risk Factors, and Impact of Age on Retinal Detachment after Cataract Surgery in France: A National Population Study

PURPOSE

To assess the incidence, risk factors, and impact of age on retinal detachment (RD) after cataract surgery.

DESIGN

Cohort study.

PARTICIPANTS

All patients older than 40 years of age who underwent a primary cataract surgery in France between January 2009 and December 2012.

METHODS

A Cox proportional-hazard regression model was used to analyze risk factors of RD after cataract surgery.

MAIN OUTCOME MEASURES

Risk factors of RD after cataract surgery.

RESULTS

Over 4 years, 2680167 eyes in 1787021 patients (59.4% women; mean age, 73.9±9.5 years) underwent cataract surgery. A total of 11 424 patients experienced RD after cataract surgery, with an estimated risk of 0.99% at 4 years after surgery. The odds ratio associated with increased risk of RD was 3.87 (95% confidence interval [CI], 3.79-3.95) for cataract surgery itself. The multiadjusted hazard ratio (HR) associated with increased risk of RD was 5.22 (95% CI, 5.05-5.39) for patients 40 to 54 years of age, 3.69 (95% CI, 3.60-3.79) for those 55 to 64 years of age, and 1.98 (95% CI, 1.93-2.03) for those 65 to 74 years of age as compared with those 75 years of age or older. Retinal detachment was associated with high myopia (HR, 6.12; 95% CI, 5.84-6.41), vitrectomy for perioperative capsular rupture (HR, 4.36; 95% CI, 4.07-4.68), history of eye trauma (HR, 3.98; 95% CI, 3.69-4.30), extracapsular extraction (HR, 3.11; 95% CI, 2.94-3.30), male gender (HR, 2.39; 95% CI, 2.35-2.44), and history of diabetes (HR, 1.18; 95% CI, 1.15-1.21). In myopic patients, the multiadjusted HR associated with increased risk of RD was 25.02 (95% CI, 24.76-25.18) for patients 40 to 54 years of age, 20.37 (95% CI, 20.21-20.53) for those 55 to 64 years of age, and 17.05 (95% CI, 16.85-17.25) for those 65 to 74 years of age as compared with nonmyopic patients 75 years of age or older.

CONCLUSIONS

We provide a hierarchy of risk factors for RD onset: high myopia, young age, capsular rupture, history of eye trauma, extracapsular extraction technique, male gender, and diabetes. Young age was an additional risk factor in myopic patients.

Refractive lens exchange in modern practice: when and when not to do it?

Cataract surgery due to advances in small incision surgery evolved from a procedure concerned with the primary focus on the safe removal of cataractous lens to a procedure focused on the best possible postoperative refractive result. As the outcomes of cataract surgery became better, the use of lens surgery as a refractive modality in patients without cataracts has increased in interest and in popularity. Removal of the crystalline lens for refractive purposes or refractive lens exchange (RLE) presents several advantages over corneal refractive surgery. Patients with high degrees of myopia, hyperopia and astigmatism are still not good candidates for laser surgery. Moreover, presbyopia can currently only be corrected with monovision or reading spectacles.

RLE supplemented with multifocal or accommodating intraocular lenses (IOLs) in combination with corneal astigmatic procedures might address all refractive errors including presbyopia, and eliminate the future need for cataract surgery.

Evaluation of early results of quick-chop phacoemulsification in the patients with high myopic cataract

AIM

To assess the early surgical outcomes of quick-chop phacoemulsification technique in patients with high myopia.

METHODS

The data of patients with high myopia who underwent quick-chop phacoemulsification were reviewed retrospectively. There were 42 eyes of 31 patients. The axial length was more than 26 mm in all eyes. All eyes underwent quick-chop phacoemulsification surgery with the placement of an intraocular lens (IOL) in the capsular bag. Postoperative visits were performed at 1, 3d; 2wk, 1mo. Early postoperative best corrected visual acuity (BCVA), preoperative and postoperative corneal endothelial cell density (ECD), central corneal thickness (CCT) and postoperative complications were assessed. Paired sample t-test or Wilcoxon tests were used to compare data between preoperative and postoperative data.

RESULTS

There was no statistically significant difference between preoperative and postoperative ECD and CCT. Retinal detachment was developed in one eye at postoperative first day. There was an iris prolapsus from side port insicion.

CONCLUSION

Quick-chop phacoemulsification technique is a safe surgical technique. However we can encounter some complications in high myopic eyes due to histopathological differences. Both side port and clear corneal tunnel insicion size is crucial for preventing postoperative complications. If any persistent leakage is noticed, suture should be placed.

Nd: YAG laser posterior capsulotomy rates in myopic eyes after implantation of capsular tension ring

Background

The aim f this study was to evaluate the effect of capsular tension ring implantation during cataract surgery on the incidence of neodymium: YAG (Nd: YAG) laser posterior capsulotomy in myopic (axial length [AL] ≥25.00 mm) eyes.

Material/Methods

In this retrospective study, the records of the cases of 117 myopic patients who underwent cataract surgery between January 2004 and January 2011 were reviewed. A total of 153 eyes with an axial length of 25 mm or higher were included in the study with consideration of exclusion criteria mentioned below. Eyes were grouped by presence or lack of capsular tension ring (CTR+ and CTR−, respectively).

Results

The study included 153 eyes from 107 myopic patients. Hydrophilic acrylic IOL and capsular tension ring (CTR) were implanted in 78 eyes (CTR+ group), and 75 eyes received only the hydrophilic acrylic IOL (CTR− group). Six eyes (7.6%) in CTR+ and 16 eyes (21.3%) in CTR− required Nd: YAG laser capsulotomy within 7 years. The difference between the 2 groups was statistically significant (p=0.021).

Conclusions

Because CTRs significantly decrease subsequent need for Nd: YAG laser posterior capsulotomy in myopic patients, are very inexpensive, and provide other benefits, our data suggest that the use of CTRs in myopic eyes undergoing cataract surgery with an hydrophilic acrylic IOL implantation is advantageous and should be standard practice.

Risk of pseudophakic retinal detachment in 202,226 patients using the fellow nonoperated eye as reference

PURPOSE

To study the risk of pseudophakic retinal detachment (PRD) after first-eye phacoemulsification cataract surgery in Denmark relative to the risk of retinal detachment (RD) in the patients' fellow nonoperated eyes.

DESIGN

Register-based cohort study.

PARTICIPANTS

Danish patients (n = 202 226).

METHODS

All patients underwent uncomplicated first-eye phacoemulsification cataract surgery from 2000 through 2010. Surgeries were identified via the National Patient Registry in Denmark and the Civil Registration Number. The fellow nonoperated eye was used as a reference.

MAIN OUTCOME MEASURES

Rhegmatogenous RD.

RESULTS

We identified 110 RDs in the fellow nonoperated reference eyes. In these eyes, male sex and younger age were associated significantly with greater risk of RD. We identified 465 PRDs on the cataract-operated eyes. The relative risk of PRD was 4.23. This effect of cataract surgery on the relative risk of RD (the PRD risk ratio) was not statistically significantly modified by sex and age. The PRD risk ratio was not significantly higher in men compared with women (hazard ratio, 1.26); was highest for the 40-year-old cohort and lowest for the 80-year-old cohort; and was highly increased during the first 6 months after surgery and leveled off but remained significantly elevated up to 10 years after cataract surgery.

CONCLUSIONS

Using the fellow nonoperated eye as a reference, this comprehensive matched-design cohort study clearly separates the epidemiologic factors of occurrence of RD from the relative risk of PRD. The epidemiologic factors of RD in the fellow eyes was predicted strongly by age and sex. The 4-fold increase in risk associated with cataract surgery, the PRD risk ratio, was not statistically significantly modified by gender and age. The long follow-up demonstrated a persistently significantly elevated relative risk of PRD up to 10 years after cataract surgery. Because the fellow eye was used as reference, the PRD risk ratio can be considered a true etiologic effect of cataract surgery.

Vincenz Fukala (1847-1911) and the early history of clear-lens operations in high myopia

Vincenz (Wincenty) Fukala, was born in 1847 in Zolkiew at Galicia in Poland, studied medicine and ophthalmology in Vienna in 1871. He was a pioneer in systematically extracting the clear crystalline lens in young patients with high myopia. He demonstrated the benefit to this group of increased visual acuity which enabled them to work and ophthalmologists gradually began to carry out surgery in high myopes worldwide. He persisted in operating despite the vigorous opposition of several authorities but, through sheer determination he convinced skeptics of the efficacy of his surgical method of lens dissection. He performed the first lens discission in 1887 and in 1894, he had successfully treated 44 patients. The late complication of retinal detachment, which was not understood until years later, eventually led surgeons to abandon the procedure until the recent improvements in both lenticular and retinal surgery techniques that led to better prognosis.

Outcome of posterior chamber phakic intraocular lens procedure to correct myopia

PURPOSE

To assess the safety and efficacy of the implantable contact lens (ICL™) to treat myopia.

DESIGN

Clinical, retrospective, single center, non-randomized case series.

PARTICIPANTS

Sixty-nine eyes of 46 patients with myopia ranging from -3.00 to 25.00 D were included in this study.

INTERVENTION

Implantation of the ICL™.

MAIN OUTCOME MEASURES

Uncorrected Visual Acuity (UCVA), refraction, best spectacle corrected visual acuity (BSCVA), adverse events, operative and postoperative complications, subjective assessment and symptoms.

RESULTS

The mean follow-up was 12.35 ± 6.13 (SD) months (range, 6 months-32 months). At the last visit, 49.20% of eyes had 20/20 or better UCVA compared to preoperative 20/20 or better BSCVA of 31.9% of eyes; 69.23% of eyes had postoperative UCVA better than or equal to preoperative BSCVA. The mean manifest refractive cylinder was 1.93 ± 1.21 D at baseline and 1.00 ± 0.92 D postoperatively. The mean manifest refraction spherical equivalent (MRSE) was -11.70 ± 4.24 D preoperatively and -0.69 ± 1.13 D postoperatively. A total of 69.8% of eyes were within ±0.5 D of the predicted MRSE; 84.1% were within ±1.0 D, and 88.90% were within ±2.0 D. BSCVA of 20/20 or better was achieved in 64.6% of eyes postoperatively, compared to 31.9% preoperatively. Mean improvement in BSCVA was 1line. One eye (1.5%) lost ⩾2 lines of BSCVA at the last visit, whereas 20% of eyes improved by ⩾2 lines. A total of 56.92% of cases gained ⩾1 line of BSCVA and 4.62% of cases lost ⩾1 line. Four ICL lenses were removed without significant loss of BSCVA, and 2 eyes with clinically significant lens opacities were observed. Four eyes (5.8%) developed a pupillary block the first day postoperatively. One eye (1.4%) developed a hypotony and AC shallowing.

CONCLUSION

Implantation of ICL for the correction of myopia was a safe procedure with good visual and refractive results from the early postoperative period to 1 year. Long-term follow-up is required to confirm the long-term safety of this implant.

Clear lens phacoemulsification combined with vitrectomy to correct high myopia: four years of follow-up

PURPOSE

To evaluate the outcome, intraoperative and postoperative complications of refractive lens exchange (RLE) by phacoemulsification with posterior chamber intraocular lens (IOL) implantation combined with simultaneous pars plana vitrectomy (PPV) in the management of high myopia.

METHODS

This prospective study consisted of 45 eyes of 26 patients with preoperative myopia greater than -12.5 dpt. Clear lens phacoemulsification with IOL implantation surgery was combined with PPV. Main outcome measures were best-corrected visual acuity (BCVA), stability of the spherical equivalent (SE) and complications at follow-up.

RESULTS

The combined procedure of clear lens phacoemulsification combined with PPV has a favorable outcome with acceptable SE predictability and improvement in BCVA. The postoperative BCVA was 0.67 ± 0.21 compared to 0.15 ± 0.10 preoperatively (p < 0.001). The mean postoperative SE was -1.6 ± 0.9 dpt, showing a significant difference when compared with a mean value of -20.0 ± 5.2 dpt before the operation (p < 0.001). During the follow-up, all IOLs were placed stably in the bag with no capsular tear occurring and only 1 case (2.2%) developed retinal detachment.

CONCLUSION

RLE and implantation of an IOL combined with simultaneous PPV is a reasonable refractive surgery option for middle-aged patients with high myopia.

Five-year follow-up after anterior iris-fixated intraocular lens implantation in phakic eyes to correct high myopia

PURPOSE

To evaluate the 5-year follow-up of safety, efficacy, predictability, stability, and complications of anterior iris-fixated phakic intraocular lens (pIOL) implantation to correct high myopia, and patients' satisfaction after implantation.

DESIGN

Prospective, nonrandomized, and comparative (self-controlled) trial.

METHODS

A prospective clinical trial of 84 eyes of 43 patients with high myopia was conducted. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), refraction, endothelial cell count, intraocular pressure (IOP), anterior chamber depth, slit lamp biomicroscopy, and indirect ophthalmoscope were measured preoperatively and postoperatively.

RESULTS

At the 5-year follow-up, UCVA was significantly improved, with 85.7% of eyes reaching 20/25 or better. No eyes experienced a loss in BSCVA, and 71.4% gained one or more lines of their preoperative BSCVA. There was a significant reduction in spherical errors in all patients after operation. Loss of endothelial cells was observed 3 years after operation and no more loss was observed 4 years after operation in statistical analysis. No increase in IOP was observed 5 years after operation in statistical analysis. No intraoperative complications were observed in this study. However, pigment precipitates of varying intensities on the lens optic were noted in all patients 1 day after operation, and only five eyes were observed to have the pigment residual five years after operation.

CONCLUSION

At the 5-year follow-up, the implantation of the anterior iris-fixated pIOL was proved to be effective, predictable and capable of reversibility to correct high myopia in phakic eyes. It was a safety addition to the laser refractive surgery. However, longer follow-up with larger numbers of patients is still necessary to evaluate long-term complications.

Phakic intraocular lenses outcomes and complications: Artisan vs Visian ICL

PURPOSE

To evaluate the safety and visual outcomes of two phakic intraocular lenses (IOLs) for correction of high myopia: Artisan and Visian ICL (ICL).

PATIENTS AND METHODS

In this retrospective study, a phakic IOL was implanted in 68 highly myopic eyes of 34 patients; 42 eyes received an Artisan IOL, and 26 eyes received ICL IOL.

RESULTS

All patients completed a 1-year follow-up. The mean preoperative spherical equivalent (SEQ) was -12.89 ± 3.78, and -12.44 ± 4.15 diopters (D) for Artisan and ICL (P=0.078), respectively. The mean postoperative (1-year) uncorrected distance visual acuity was 0.39 ± 0.13 and 0.41 ± 0.15 logMAR for Artisan and ICL, respectively (P=0.268). The mean postoperative (1-year) corrected distance visual acuity was 0.36 ± 0.12 and 0.31 ± 0.12 logMAR for Artisan and ICL, respectively (P=0.128). The mean postoperative SEQ was -0.86 ± 0.5 and -0.63 ± 0.38 D for Artisan and ICL, respectively (P=0.67). Intraocular pressure change at 1 year was 0.64 ± 2.7 and 1.88 ± 0.6 mm Hg for Artisan and ICL, respectively (P=0.77).

CONCLUSION

Artisan and ICL showed equal and comparable safety, predictability, and efficacy.

Pseudophakic rhegmatogenous retinal detachment in a large Asian tertiary eye centre: a cohort study

BACKGROUND

To determine the incidence and identify risk factors for the development of rhegmatogenous retinal detachment in patients who had cataract surgery at the Singapore National Eye Centre between 2001 and 2003.

DESIGN

Retrospective case-control study.

PARTICIPANTS

All patients who had cataract surgery between 2001 and 2003 and subsequently retinal detachment surgery in the same eye, between 2001 and June 2008, at Singapore National Eye Centre.

METHODS

Review of case records.

MAIN OUTCOME MEASURES

Incidence of posterior capsular rupture and retinal detachment.

RESULTS

Thirty-nine eyes, out of 24 846 cataract operations performed between 2001 and 2003, developed rhegmatogenous retinal detachment in the follow-up period from 2001 to 2008 (cumulative incidence 0.16%, 95% confidence interval 0.11-0.21%). Of the 508 eyes with posterior capsular rupture during cataract surgery, nine developed retinal detachment (cumulative incidence 1.77%, 95% confidence interval 0.87-3.23%). Men were more likely to develop retinal detachment (P < 0.001). On Kaplan-Meier survival analysis, younger patients had a higher probability of retinal detachment in comparison with older subjects (P < 0.001). Similarly, eyes with posterior capsular rupture during surgery had shorter interval duration to retinal detachment, compared with eyes that did not (P = 0.002). When compared with patients more than 70 years of age, younger patients had significantly higher hazard ratios of retinal detachment (hazard ratio 19.7, 95% confidence interval 3.6-107.3, P < 0.05).

CONCLUSION

The incidence of pseudophakic retinal detachment in our institution is low. Posterior capsular rupture during surgery, men and younger age at time of surgery increases the risk of developing retinal detachment, and careful observation for the occurrence of retinal detachment may be warranted in these groups of patients.

Clinical characteristics and outcomes of cataract surgery in highly myopic Koreans

Purpose

To evaluate the clinical characteristics and outcomes of cataract surgery in highly myopic Korean subjects.

Methods

We retrospectively reviewed the medical records of 694 eyes of 694 patients who underwent cataract surgery. The case group included 347 eyes of 347 patients whose axial lengths (AXL) were ≥26.00 mm, and the control group included 347 eyes of 347 patients with AXL between 22.00 and 25.99 mm. Cataract density was determined preoperatively using the Pentacam Scheimpflug imaging system. We compared age at operation, cataract type, coexisting disease, visual prognosis, and complications.

Results

The mean age at the time of the operation was 59.60 ± 12.28 years in the case group and 67.47 ± 11.36 years in the control group. The case group had a larger proportion of nuclear cataracts and posterior subcapsular cataracts (PSC), 40.63% and 26.22%, respectively, versus 25.07% and 11.82%, respectively, in the control group. Postoperative corrected visual acuity showed a negative correlation with AXL (R² = 0.172), and severe funduscopic findings were related to poor visual prognosis (p = 0.05). The incidence of retinal detachment in the case group after cataract surgery was 1.72%, compared with 0.28% in the control group.

Conclusions

Highly myopic eyes tend to develop cataracts earlier than normal eyes and to have a higher prevalence of coexisting disease and complications, such as retinal detachment. Nuclear cataracts and PSC were more common in the highly myopic group. Poor visual prognosis was associated with longer axial length and retinal myopic degeneration.

Comparison of clear lens extraction and collamer lens implantation in high myopia

Aim:

To compare the outcomes of clear lens extraction and collamer lens implantation in high myopia.

Patients and methods:

Myopic patients younger than 40 years old with more than 12 diopters of myopia or who were not fit for laser-assisted in situ keratomileusis were included. Group 1 comprised patients undergoing clear lens extraction and Group 2 patients received the Visian implantable collamer lens. Outcome and complications were evaluated.

Results:

Postoperative best corrected visual acuity was −0.61 ± 0.18 in Group 1 and 0.79 ± 0.16 in Group 2. In Group 1, 71.4% achieved a postoperative uncorrected visual acuity better than the preoperative best corrected visual acuity, while only 51.8% patients achieved this in Group 2. Intraocular pressure decreased by 12.55% in Group 1, and increased by 15.11% in Group 2. Corneal endothelial cell density decreased by 4.47% in Group 1 and decreased by 5.67% in Group 2. Posterior capsule opacification occurred in Group 1. In Group 2, lens opacification occurred in 11.11%, significant pigment dispersion in 3.7%, and pupillary block glaucoma in 3.7%.

Conclusion:

Clear lens extraction presents less of a financial load up front, and less likelihood of the need for a secondary intervention in the future. Clear lens extraction is a more viable solution in developing countries with limited financial resources.

Assessment of phacoaspiration techniques in clear lens extraction for correction of high myopia

Purpose:

To evaluate various phacoaspiration techniques in clear lens extraction for the incidence of intraoperative difficulties and complications.

Patients and methods:

This was a prospective study in which bilateral clear lens extraction was performed on 40 eyes of 20 patients, to correct high myopia. The patients were divided into 2 groups: group A underwent supracapsular phacoaspiration; group B were the contralateral eyes of the same patient. These patients were operated on with endocapsular phacoaspiration with the divide and conquer (D and C) technique. Preoperative ocular examination data were recorded and tested for significance. Intraoperative difficulties and complications such as nucleus cracking, capsule rupture and vitreous loss, and repeated chamber collapse were recorded. Postoperative examination data were recorded.

Results:

Mean age was 35.65 ± 5.85 years. Mean follow-up time was 17.1 ± 8.56 months. In group A mean myopia was −17.3 ± 5.07 diopters; in group B myopia was −17.9 ± 4.20 diopters. Mean preoperative uncorrected visual acuity (UCVA) was 0.04 ± 0.0167, while the mean postoperative UCVA was 0.435 ± 0.1442. There was a significant difference in pre- and postoperative BCVA within both groups, but not between the two groups. In both groups endothelial cell count (ECC) showed a significant difference between pre- and postoperative data; however, there was no statistically significant difference between both groups in postoperative ECC. The effective phacoaspiration time for group A was 4.6 ± 1.6 seconds, and for group B 9.90 ± 2.27 seconds (P < 0.005). No cases of capsule rupture occurred in group A, but 3 cases occurred in group B (15 %) (not significant, P = 0.231). Nucleus cracking did not occur in group A, but in group B 13 cases occurred (65%). Chamber collapse occurred in 4 cases (20%) in group A and 5 cases (25%) in group B (not significant, P = 1.000). Three cases of moderate postoperative iritis were recorded in group B in (15%), in which posterior capsular rupture also occurred. No cases of iritis were recorded in group A (not significant, P = 0.231). Two cases of cystoid macular edema were recorded in group B (10%) and none in group A (not significant, P = 0.487).

Conclusions:

Supracapsular phacoaspiration for clear lens extraction in correction of high myopia seems to present no risk for the posterior capsule, although there is a marginal risk to the ECC.