Interlenticular opacification: clinicopathological correlation of a complication of posterior chamber piggyback intraocular lenses

Ultrasound biomicroscopy in the management of complex cataract and intraocular lens: A review

Ultrasound biomicroscopy (UBM) is an invaluable investigation for imaging anterior segment structures. Although it is operator-dependent and time consuming, unlike optical-based imaging techniques, it is able to image structures posterior to the iris, such as the zonules, ciliary body and part of the pars plana. It is especially useful in advanced cataracts, traumatic cataracts, subluxed lenses, posterior polar cataracts, and congenital and developmental anomalies affecting the anterior segment. It provides diagnostic information in eyes with complex cataracts or intraocular lens (IOL)-related pathology, and aids in surgical planning in order to minimise complications. In this review, we describe the UBM features of various lenticular pathologies and demonstrate its application in the diagnosis and surgical management of lens and IOL-related pathologies.

Reversible Multifocality Achieved Through Polypseudophakia

Simultaneous implantation of a monofocal or monofocal toric intraocular lens (IOL) into the capsular bag and a multifocal IOL into the ciliary sulcus, referred to as duet procedure, allows us to create multifocality that is more easily reversible than the implantation of a capsular bag-fixated multifocal IOL. The optical quality and results after the duet procedure are equivalent to those of a capsular bag-fixated multifocal IOL. Patients who cannot tolerate the side effects of multifocal optics or who develop an ocular condition leading to loss of function such as age-related macular degeneration (AMD) or glaucoma in the course of their lives may benefit from the reversibility of the procedure.

Comparison of a Presbyopia-Correcting Supplementary Intraocular Lens Combination and a Capsular-Bag Lens: An In Vitro Study

We evaluated the optical quality of two approaches to trifocality: polypseudophakia versus monopseudophakia. The combination (polypseudophakia) of a monofocal Basis Z B1AWY0 and AddOn Trifocal A4DW0M intraocular lens (IOL) was compared to using one Basis Z Trifocal B1EWYN IOL, all from 1stQ GmbH. In both approaches, we measured modulation transfer function (MTF) and Strehl Ratio (SR) values at 3.0 and 4.5 mm pupil sizes. We determined the through-focus (TF) MTF at 25, 50 and 100 lp/mm for the 3 mm aperture. United States Air Force (USAF) target images were recorded. MTF measurement of the trifocal lens and the combined monofocal and trifocal AddOn IOL showed good performance at the far and near focus for the 3 mm aperture. For the 4.5 mm aperture the MTF improved for the far focus but decreased for the intermediate and near focus. TF MTF showed better contrast at the far focus for the polypseudophakic setup but at the expense of the efficiency at the near focus. However, the USAF chart images revealed only minimal differences between both approaches. The optical quality of the polypseudophakic approach was not affected by the presence of two IOLs instead of one and proved to be comparable with the performance of one capsular-bag-fixated trifocal IOL. Differences between the single vs. two-lens approach seen in the TF MTF analysis could be attributed to the optical design that varied between the trifocal models.

Efficacy of a Secondary Trifocal Sulcus IOL in Providing Near and Intermediate Vision in Patients with Prior Myopic Laser Vision Correction and Cataract Surgery

Purpose

To evaluate the visual function of patients with a history of prior laser vision correction and cataract surgery with implantation of a monofocal primary IOL after subsequent implantation of a secondary sulcus trifocal intraocular lens (IOL).

Setting

One clinical practice in Haugesund, Norway.

Design

Prospective, single arm, non-interventional unmasked study.

Methods

Eligible subjects who had previous laser vision correction and cataract surgery involving implantation of a monofocal IOL in the capsular bag of one or both eyes were subsequently implanted with a secondary IOL in the sulcus. Postoperative uncorrected and best distance-corrected visual acuities (VAs) were measured at distance (4 m), intermediate (60 cm), and near (40 cm), along with low contrast visual acuity and the monocular distance corrected defocus curve.

Results

Twenty-five eyes were evaluated from 7 to 24 months after trifocal implantation. The mean monocular uncorrected VAs were 0.06, 0.21 and 0.10 logMAR at distance, intermediate and near, respectively. Uncorrected near VA was 0.2 logMAR or better in 80% of eyes (20/25). VA of 0.2 logMAR or better at all test distances was achieved in 15/25 eyes (60%) in the uncorrected state and 17/25 eyes (68%) when corrected for distance vision. Binocular uncorrected distance visual acuity was 0.1 logMAR or better in all subjects while binocular uncorrected near visual acuity was 0.1 logMAR or better in all but one subject. The defocus curve showed a range of functional vision from distance to 30 cm. No adverse events were identified.

Conclusion

The trifocal sulcus IOL provided excellent distance and near vision and a good range of functional vision, similar to results obtained when a primary trifocal IOL is implanted. It is a viable option to provide better intermediate and near vision to patients with a prior history of refractive surgery and a monofocal IOL implanted.

Refractive and Visual Outcomes After Implantation of a Secondary Sulcus Intraocular Lens with an Extended Depth of Focus

Purpose

To evaluate the range of vision, visual function, and quality of vision after implantation of a secondary extended depth of focus intraocular lens (EDOF IOL) implanted in the sulcus.

Setting

One clinical practice in Haugesund, Norway.

Design

Prospective single arm non-interventional study.

Methods

Eligible subjects presenting for surgery, or who had previous successful primary cataract or refractive lens exchange surgery in both eyes were subsequently implanted with the AddOn® secondary EDOF IOL in the sulcus. Manifest refraction and visual acuity at distance, intermediate and near were measured 3 months after surgery, along with the monocular defocus curve. Subjects also completed a visual function and a quality of vision questionnaire.

Results

The study included 32 eyes of 16 subjects. At 3 months postoperative, the mean refraction spherical equivalent (MRSE) was −0.16 ± 0.30 D, with a residual cylinder of 0.29 ± 0.27 D. The mean monocular uncorrected VA was 0.1 logMAR (20/25) or better at all test distances. The monocular defocus curves showed a depth of focus of 2.0 D. For every category except reading fine print, all but one subject (94%) had no difficulty or little difficulty with near tasks. Glare and halos were the most common visual disturbances, with no reports of starbursts. There was no evidence of any intralenticular opacification in any of the eyes, and no evidence of iris chafing/depigmentation.

Conclusion

This secondary EDOF IOL provided excellent distance and intermediate vision, and very good near vision to subjects. Subject reported near visual function was also very good and visual disturbances were limited. This lens appears to be a good option for patients who would like to improve their range of vision. Results appear as good or better than those reported for primary EDOF lenses.

Outcomes of a Toric Monofocal Piggyback Intraocular Lens for Residual Astigmatic Refractive Error in Pseudophakic Eyes

PURPOSE/AIM

To evaluate the visual outcomes, refractive outcomes and rotational stability of a toric piggyback intraocular lens (1stQ AddOn, GmbH, Mannheim, Germany) for astigmatic refractive error in pseudophakic eyes.

MATERIALS AND METHODS

Visual and refractive outcomes were assessed based on the standard graphs for reporting refractive surgery outcomes. Rotational stability was assessed according to the Intraocular Lens (IOL) standards of the International Organisation for Standards.

RESULTS

Twenty-two eyes of 17 patients (age: 65.1 ± 9.3 years) underwent toric piggyback IOL insertion. After a minimum follow-up of 3 months, 18 eyes (82%) achieved an uncorrected distance visual acuity (UDVA) of 0.00 logMAR (20/20) or better and all eyes achieved 0.1 logMAR (20/25). Mean UDVA improved from 0.27 ± 0.03 to 0.12 ± 0.03 and 0.04 ± 0.04 at one and 3 months (all p < .05). Nineteen eyes (86%) achieved an UDVA at least equal to the pre-operative corrected distance visual acuity (CDVA). No eyes lost more than one line of CDVA. All eyes achieved within 0.5D of target spherical equivalent (SE). In 18 eyes (82%), the residual astigmatism magnitude was 0.5D or less. The mean absolute difference between the target axis and the achieved axis 1 and 3 months postoperatively was 2.5° ± 2.7° and 3.2° ± 3.3°, respectively. The final IOL orientation was within 10 degrees of target axis in 19 of 22 (86.4%) eyes, within 20 degrees in 21 of 22 (95.2%) eyes and within 30 degrees in 22 of 22 (100%) eyes. IOL rotational repositioning was required in two eyes (9.1%).

CONCLUSIONS

In this cohort of patients, the 1stQ AddOn toric monofocal piggyback IOL resulted in very good visual and refractive outcomes and showed reasonable rotational stability. This IOL appears to be an effective treatment option for residual astigmatic refractive error in pseudophakic eyes.

Delayed postoperative opacification of three hydrophobic acrylic intraocular lens: A scanning electron microscopic and energy dispersive spectroscopic study

Purpose:

The aim of this study was to report scanning electron microscopic (SEM) and energy dispersive spectroscopic (EDS) findings of three specimens of opaque hydrophobic acrylic intraocular lens (IOL) explanted in delayed postoperative period for visual indications.

Methods:

Clinical data and photographs from each subject were obtained. Explanted IOLs were examined under gross and light microscopy followed by SEM coupled with EDS.

Results:

All three subjects underwent IOL implantation following senile cataract extraction at an average age of 64.3 ± 0.3 years, and the IOLs were in situ for a duration of 11.3 ± 4.04 years. The IOL explantation and exchange were done due to late postoperative opacification of the IOL and significant visual deterioration. The milky iridescent opacity affected the full thickness of IOL optics in the first two specimens and in the third only two surfaces were involved. SEM detected surface cracks in the first specimen, typical conglumated surface, pores and accumulation of crystals with surface deposit of nano-particles on the second specimen and uneven surface erosion in the third specimen. SEM detected mainly sodium (Na) and chloride (Cl) spikes. All patients recovered normal vision following IOL exchange.

Conclusion:

SEM features of the IOL optics and absence of calcium and phosphate spikes in EDS and other findings were consistent and suggestive of hydrolytic biodegradation of hydrophobic acrylic IOL polymer in ocular media and was responsible for delayed postoperative opacification of the hydrophobic IOLs and visual loss.

Secondary Piggyback Intraocular Lens for Management of Residual Ametropia after Cataract Surgery

Purpose

To investigate the indications, clinical outcomes, and complications of secondary piggyback intraocular lens (IOL) implantation for correcting residual refractive error after cataract surgery.

Methods

In this prospective interventional case series, patients who had residual refractive error after cataract surgery and were candidates for secondary piggyback IOL implantation between June 2015 and September 2018 were included. All eyes underwent secondary IOL implantation with the piggyback technique in the ciliary sulcus. The types of IOLs included Sulcoflex and three-piece foldable acrylic lenses. Patients were followed-up for at least one year.

Results

Eleven patients were included. Seven patients had hyperopic ametropia, and four patients had residual myopia after cataract surgery. The preoperative mean of absolute residual refractive error was 7.20 ± 7.92, which reached 0.42 ± 1.26 postoperatively (P< 0.001). The postoperative spherical equivalent was within ±1 diopter of target refraction in all patients. The average preoperative uncorrected distance visual acuity was 1.13 ± 0.35 LogMAR, which significantly improved to 0.41 ± 0.24 LogMAR postoperatively (P = 0.008). There were no intra- or postoperative complications during the 22.4 ± 9.5 months of follow-up.

Conclusion

Secondary piggyback IOL implantation is an effective and safe technique for the correction of residual ametropia following cataract surgery. Three-piece IOLs can be safely placed as secondary piggyback IOLs in situations where specifically designed IOLs are not available.

Clinical and Surgical Outcome of a Supplementary Multifocal Intraocular Lens Implanted with a Bag-In-the-Lens Intraocular Lens: 5-Year Follow-Up

INTRODUCTION

To assess the postoperative outcome and patient-reported satisfaction, spectacle independence, and dysphotopsia after implantation with the mutifocal Rayner Sulcoflex supplementary intraocular lens (sIOL).

MATERIALS AND METHODS

We analyzed the outcome of all patients implanted with a multifocal sIOL between 2009 and 2011. In all cases, the sIOL was the Rayner Sulcoflex IOL (type 653F) and the primary IOL was a bag-in-the-lens (BIL) IOL. The data were obtained through a retrospective analysis of the patient records and by means of a questionnaire, 5 years after sIOL implantation.

RESULTS

This study included 31 eyes of 20 patients. In 13 eyes, the sIOL needed explantation (n = 13, 41.94%). Dysphotopsia is a frequent complaint (12/15 patients: 80.0%) after sIOL implantation. In 13 out of 31 eyes (41.94%), pigment deposits were found on the sIOL with variable clinical complaints. Five eyes required additional surgery because of clinically significant deposits.

DISCUSSION/CONCLUSION

Patients with a multifocal sIOL in combination with a BIL implantation have a higher incidence of dysphotopsia compared to previously published studies. Dysphotopsia was the main complaint and reason for explantation. We encountered a high incidence of pigmented IOL deposits. The sIOLs can be safely removed even years after implantation.

Cortical aspiration - The "POPS" technique

In the present study, we describe a step-by-step technique for cortex aspiration during cataract surgery- POPS (positioning, occlusion, posterior displacement, and swiping). Firstly, the aspiration probe is positioned under the bulk of cortical fibers beyond the capsulorhexis margin. Subsequently, the aspiration port is occluded with minimal vacuum, and the occluded port is displaced posteriorly to detach the cortical fibers off the anterior capsule. Now, tangential, arc-like swiping movements are performed while gradually increasing vacuum at the same time. The fibers are brought to the center and finally aspirated. This allows complete removal of the equatorial fibers and lens epithelial cells (LEC) with the least stress to the capsulozonular complex. Unlike the conventional technique, which involves the radial pull of cortical fibers, in this technique, there is swiping and posterior displacement of the cortical fibers before pulling towards the center and aspirating. We believe this technique will ensure safer, more effective cortical and LEC removal, reducing zonular stress.

Reversibility of the duet procedure: Bilateral exchange of a supplementary trifocal sulcus-fixated intraocular lens for correction of a postoperative refractive error

Purpose

We present the case of a 49-year old female who underwent bilateral exchange of a supplementary trifocal sulcus-fixated intraocular lens (IOL) to correct a residual refractive error. Six months beforehand, she had been treated for hyperopia, astigmatism and presbyopia with a duet procedure to create reversible trifocality.

Observations

Refractive lens exchange with combined implantation of a monofocal toric IOL into the capsular bag and a trifocal supplementary IOL into the ciliary sulcus (duet procedure) had been performed in both eyes. Decreased uncorrected distance visual acuity due to the refractive outcome of −0.75 diopter sphere (DS)/-0.25 diopter cylinder (DC)x10° for the right eye and −1.0DS for the left eye as well as the perception of photic phenomena were inacceptable for the patient. In the second operations, we exchanged the supplementary IOLs to correct the residual refractive error and achieve the target refraction of emmetropia. UDVA increased from 0.50 logMAR in both eyes prior to the IOL exchange to −0.22 logMAR in the right eye and −0.20 logMAR in the left eye. Binocular uncorrected near and intermediate visual acuity were −0.10 logMAR and 0.00 logMAR respectively after exchanging the sulcus-fixated supplementary IOLs, allowing for complete spectacle independence.

Conclusions

This case demonstrates one of the most important benefits of the duet procedure: the possibility, if necessary, to easily remove or exchange the supplementary IOL from the ciliary sulcus. The duet procedure offers a safe treatment option in the event of postoperative complications like residual refractive error or intolerance to a multifocal optic.

Safety of piggyback intraocular lenses (polypseudophakia) in children: long-term outcomes of a 15-year, single-surgeon study

PURPOSE

To report the outcomes of piggyback (PB) intraocular lens (IOL) implantation, or temporary polypseudophakia, in children who have undergone cataract surgery and to assess their safety in pediatric patients.

METHODS

The medical records of consecutive patients who underwent PB IOL implantation at a single institution over a period of 15 years were reviewed retrospectively. Outcome measures were reoperation rate, complications, and outcome of planned explantation.

RESULTS

A total of 48 eyes of 38 children received PB IOL implantation: 40 eyes at the time of cataract surgery and 8 eyes as a later secondary procedure. Of these, 38 eyes of 31 patients with primary PB IOL implantation had follow-up of >3 years and were included in the present analysis. Median age at cataract surgery with PB IOL implantation was 6.5 months (0.5 months to 2.4 years). Median follow-up was 12.5 years (range, 3.0-20.7). Four eyes required reoperation for adverse events related to PB IOL implantation (1 each for IOL tilt, pupillary capture, pupillary block glaucoma, and pupillary membrane). All 4 of these eyes were operated for cataract before 3 months of age. The sulcus-fixated PB IOL underwent a planned explantation in 33/38 eyes. Eight eyes needed intraocular pressure-lowering topical medications. Planned PB IOL explantation was uncomplicated in our series.

CONCLUSIONS

Early complications occurred in 4 eyes, but late complications were not noted, and glaucoma developed at predictable rates for this population. Piggyback IOL placement in our cohort of young children appears to have an acceptable safety profile.

Intraocular Lens Complications: Decentration, Uveitis-Glaucoma-Hyphema Syndrome, Opacification, and Refractive Surprises

As cataract surgery has evolved, intraocular lens (IOL) complications are rare. The purpose of this review was to report the incidence, diagnosis, and management of IOL decentrations, uveitis-glaucoma-hyphema (UGH) syndrome, IOL opacifications, and refractive surprises. Literature review was performed by searching PubMed, MEDLINE, EMBASE, and the Cochrane Controlled Trial Database and the reference lists of original studies as well as reviews. Intraocular lens decentrations and dislocations can appear at any time, particularly in patients with predisposing factors such as pseudoexfoliation, prior vitreoretinal surgery, or trauma. Recognizing when they require surgical intervention for UGH or to improve visual function is critical in limiting long-term sequela. Intraocular lens opacifications such as glistenings rarely require intervention, but others, such as subsurface nanoglistenings, calcifications, or discolorations, may require IOL exchange. Finally, despite our best efforts to enhance measurements and IOL calculations, refractive surprises still occur. Intraocular lens complications are uncommon with modern cataract surgery. A number of these complications require proper identification and care to optimize patient outcomes.

Refractive and Visual Outcomes After Implantation of a Secondary Toric Sulcus Intraocular Lenses

Purpose

To evaluate the rotational stability, visual acuity and refractive error after sulcus implantation of a secondary toric IOL.

Setting

One clinical practice in Haugesund, Norway.

Design

Non-interventional single-arm diagnostic study.

Methods

Eligible subjects who had previous successful primary cataract or refractive lens exchange surgery in one or both eyes and the AddOn^® secondary toric IOL implanted in the sulcus were evaluated at a single postoperative diagnostic visit to measure visual outcomes. Subjects with surgical complications (either primary or secondary) or pathology that would affect best-corrected visual acuity (eg, amblyopia) were excluded. Clinical evaluations at the diagnostic visit included measurement of visual acuity, manifest refraction and IOL orientation.

Results

Eighteen eyes were evaluated. After secondary IOL implantation, mean residual refractive astigmatism was significantly reduced (1.66 ± 0.92 to 0.32 ± 0.25 D). There was no appreciable change in the spherical equivalent refraction. Sixteen of 18 eyes (89%) had residual refractive astigmatism ≤0.50D, and no eye had more than 0.75D after secondary IOL implantation. Mean UCVA was 0.00 ± 0.03 logMAR, with no eyes worse than 0.10. Mean BCVA was −0.05 ± 0.03 logMAR (20/20+2), with all eyes having BCVA of 0.00 logMAR. The mean change in orientation was near zero, with a mean absolute change of 4.9 ± 3.7 degrees. Sixteen of 18 eyes (89%) had a lens orientation ≤10 degrees from intended, with no eye oriented more than 13 degrees from intended.

Conclusion

The AddOn^® toric sulcus IOL significantly reduced postoperative refractive astigmatism in patients with high astigmatism after their primary cataract or RLE surgery, providing very good uncorrected distance vision.

Phakic intraocular lenses: Recent advances and innovations

Phakic intraocular lenses (pIOL) are recommended when counselling refractive surgery candidates presenting with high ametropia or ocular surface and/or corneal conditions that contraindicate corneal refractive surgery. This review aims to present the state-of-the-art regarding pIOL models currently available in Europe, addressing their newer indications and recent design innovations. These include, in the case of posterior chamber pIOLs, the addition of a central hole to improve aqueous humour circulation, the availability of larger optical zones, and multifocal optics for the compensation of presbyopia. The review also highlights their good safety and efficacy results, as well as the role of patient education to ensure adequate outcomes in the medium-long term. The indications of pIOLs in special situations, as well as bi-lensectomy, a procedure that most pIOL patients may eventually require as they age and develop cataracts, are also addressed.

Clinical and material degradations of intraocular lenses: A review

PURPOSE

To review the published scientific literature concerning clinical and material degradations of intraocular lenses after implantation in cataract surgery.

METHODS

A search was undertaken using the following databases: CENTRAL (including Cochrane Eyes and Vision Trials Register; The Cochrane Library: Issue 2 of 12 February 2019), Ovid MEDLINE (R) without Revisions (1996 to February week 2, 2019), Ovid MEDLINE (R) (1946 to February week 2, 2019), Ovid MEDLINE (R) Daily Update 19 February 2019, MEDLINE and MEDLINE non-indexed items, Embase (1980-2019, week 7), Embase (1974-2019, 19 February), Ovid MEDLINE (R) and Epub Ahead of Print, in-Process & Other Non-Indexed Citations and Daily (1946 to 19 February 2019), Web of Science (all years), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrial.gov) and the WHO International Clinical Trials Registry Platform (www.who.int/ictrp/search/en). Only published articles in English were selected. Search terms/keywords included 'IOL' or 'intraocular lens', combined with 'opacification', degradation, glistenings, nanoglistenings, whitening, transmittance, light scatter, discolouration/discoloration, performance, quality, material, biocompatibility, calcification, explantation and ultraviolet/UV radiation. Relevant in-article references not returned in our searches were also considered.

RESULTS

After review of the available articles, the authors included 122 publications in this review, based on the quality of their methodology and their originality. The studies included in this review were randomized controlled trials, cohort studies, case-controlled studies, case series, case reports, laboratory studies and review papers. Differing material degradations of intraocular lenses have been described and their associated pathophysiology studied. Reported anomalies include photochemical alterations, water vacuoles, internal and surface calcific deposits, surface coatings and discolouration. The nature of such changes has been shown to depend on the type of intraocular lenses material used and/or manufacturing processes and storage conditions employed. Changes in the intraocular lens can also be influenced by surgical technique, coexisting ocular pathologies and topical and systemic medications. The clinical significance of these degradations is variable, with some resulting in significant visual disturbance and the need for intraocular lens explantation and others producing only minimal visual impairments. Failure to recognize the precise nature of the problem may lead to unnecessary laser capsulotomy procedures.

CONCLUSION

Clinical degradations of intraocular lenses are uncommon but have been reported following the implantation of intraocular lenses made of differing biomaterials. Their correct identification and thorough investigation to determine the underlying cause is necessary for optimal patient management and the prevention of such problems. Choosing a lens made of a particular material may be important in patients with certain ocular conditions.

Late postoperative opacification of a hydrophobic acrylic intraocular lens AcryNovaTMPC 610Y

PURPOSE

To report late postoperative opacification of a hydrophobic acrylic intraocular lens (IOL) AcryNovaTMPC 610Y as well as the clinical consequences in patients 10 years after uncomplicated cataract surgery.

MATERIALS AND METHODS

Medical records were reviewed of 23 patients (26 eyes) with AcryNovaTMPC 610Y implantated between years 2005 and 2007. Next clinical examination was performed 10 years after surgery. We assessed best corrected distance visual acuity (BCDVA), contrast sensitivity (CSV-1000E) and relative opacity of IOL material, (OCULUS Pentacam HR). Results of BCDVA and Pentacam were analysed statistically. One explanted IOL was analysed using anterior segment OCT in vitro and spectroscopic method EDX (Energy-dispersive X-ray spectroscopy).

RESULTS

Opacification led to a statistically significant reduction in the best corrected distance visual acuity (BCDVA) = (0,95 ± 0,10) versus (0,87 ± 0,20) and to increase of IOL opacity only in some lenses but statistically significant in the average (6,37 ± 2,16)% versus value of (14,22 ± 5,87)%. In the explanted IOL we have documented structural changes of primarily hydrophobic raw material leading to property of hydrophilic one.

CONCLUSION

Some batches of AcryNovaTMPC 610Y were produced from raw material of poor quality which is the cause of its structural changes and its progressive opacification.

Outcomes of toric supplementary intraocular lenses for residual astigmatic refractive error in pseudophakic eyes

PURPOSE

To evaluate rotational stability and visual and refractive outcomes of supplementary toric IOLs (Sulcoflex Toric 653T, Rayner Intraocular Lenses Ltd) for residual astigmatic refractive error in pseudophakic eyes.

METHODS

A retrospective interventional case series was conducted in a single surgeon practice. Charts of patients who had Sulcoflex Toric supplementary IOLs inserted between June 2009 and September 2015 were reviewed. Outcomes were compared between eyes with and without prior corneal transplant. Patients with at least 3-months follow-up were included.

RESULTS

In 51 eyes, mean UDVA improved from 20/86 to 20/43 (p = 0.002), though UDVA was better in eyes without corneal grafts (20/31) than eyes with (20/62). The proportion of eyes achieving 20/20 UDVA was 43%, 61% and 17% overall, in eyes with prior graft and in eyes with no prior graft, respectively. Sixty-four percentage achieved a spherical equivalent of within 0.5D of target (84% no graft, 34% prior graft). Fifty-three percentage of eyes achieved a cylinder of within 0.5D of target (no graft: 73%, prior graft: 0%). Mean lens rotation was 8.23° on day 1, and mean maximal rotation during follow-up was 17.63°. Sixty-two percentage of IOLs required repositioning. Of those that required repositioning, this was conducted a mean of 2.3 times. The mean final IOL rotation (following repositioning if required) was 6.17°.

CONCLUSION

Sulcoflex Toric supplementary IOLs result in good visual and refractive outcomes in eyes with no prior corneal graft. However, outcomes are sub-optimal in eyes with prior corneal transplantation, and the majority of lenses require repositioning.

Angle-Closure Glaucoma after Piggyback Intraocular Lens Implantation

Purpose

To report a case of angle closure glaucoma after piggyback intraocular lens implantation and its treatment.

Methods

The authors present the case of a 75-year-old woman who was seen in the emergency department with angle closure glaucoma. Two years before she had undergone piggyback intraocular lens (IOL) implantation in order to correct a refractive error after cataract surgery. Ultrasound biomicroscopy revealed a closed angle with synechiae in 360° as well as the presence of two IOLs: one in the capsular bag and the other in the ciliary sulcus. Extraction of the anterior IOL was precluded due to the poor endothelial count. Peripheral iridotomy and trabeculectomy were ineffective to lower the intraocular pressure (IOP); the authors decided to implant with an Ahmed valve and to place the valve's tube between the two IOLs to protect the endothelium.

Results

After Ahmed valve implantation, IOP maintains stable around 10–12 mmHg without medical treatment.

Conclusions

Ahmed valve implantation is a good option in angle closure glaucoma due to piggyback. The placement of the valve's tube between the two IOLs is a good option to protect corneal endothelium.

Scanning Electron Microscopy and Energy Dispersive Spectroscopy Findings in Explanted Pmma and Hydrophilic Acrylic Intraocular Lenses

Purpose

To investigate the presence of calcium (Ca) aggregates influencing biocompatibility and the factors that affect calcium accumulation in explanted intraocular lenses (IOL) and to analyze the Ca distribution in an opacified hydrophilic acrylic lens.

Methods

Surface irregularities and aggregates of 13 IOLs were studied with scanning electron microscopy, and their relative concentrations with energy dispersive spectroscopy (EDS). Relationships of distribution between Ca and silicone (Si) and nitrogen (N) and between N and Si and Na, and the influence of Si on Ca accumulation and the effect of differences in lens material on the distribution of N, and the effect of endophthalmitis on the distribution of Ca were evaluated statistically. EDS analyses were performed on the surface and cross-section of the opacified lens.

Results

The statistically significant relationships between the distribution of Ca and N, and between the distribution of N and Na, the significant effect of Si on the Ca accumulation, significant relationship between endophthalmitis and the Ca accumulation in the aggregates were shown. The EDS analysis of the opacified IOL, Ca and P peaks were shown from the whole surface, Ca, O peaks were determined from cross-sections over a 70–80 μm distance.

Conclusions

In the aggregates influencing IOL biocompatibility, presence of proteins was determined to be more important than the presence of Si regarding the distribution of Ca, while the presence of Si affected the accumulation of Ca. Opacification, caused by the Ca accumulation within the lens, was found to result from Ca penetrating from lens pores.

Supplementary IOLs: Monofocal and Multifocal, Their Applications and Limitations

Supplemental intraocular lenses (IOLs) have been developed to replace IOLs designed for in-the-bag placement being used as "piggy-back" IOLs in the sulcus due to unacceptable complications. The new IOLs have unique platform designs to avoid these complications. As a result, a new nomenclature is needed to describe the 4 scenarios when supplemental IOL use is now indicated.

Reversible opacification of hydrophobic acrylic intraocular lens- two cases report

Background

The opacification of the intraocular lens (IOL) can cause significant visual deterioration. It is known that opacity of hydrophobic acrylic IOLs is rare. We report 2 cases of reversible optic opacification of hydrophobic acrylic intraocular lenses (Tecnis ZCB00, Abbott), observed within 2 months after uneventful cataract surgery.

Case presentation

Case 1: Uneventful cataract surgery was performed on the left eye of an 86-year-old diabetic man with chronic open-angle glaucoma. A hydrophobic acrylic intraocular lens (IOL; Tecnis ZCB00, Abbott, Lake Bluff, IL) was implanted in the bag. Eye drops containing 0.5% levofloxacin and 1.0% prednisolone were used after surgery along with topical anti-glaucoma medications. At 7 weeks postoperative, cloudy, concentric IOL opacification developed, accompanied by decreased visual acuity and increased intraocular pressure. However, the opacification completely disappeared after 9 weeks.

Case 2: Uneventful cataract surgery was performed on the left eye of a 72-year-old woman. A hydrophobic acrylic IOL (Tecnis ZCB00) was implanted in the bag. At 2 weeks postoperative, cloudy, concentric IOL opacification developed, accompanied by ocular discomfort. After 4 weeks, opacification and discomfort completely disappeared.

Conclusions

We observed two cases of completely reversible opacification of hydrophobic acrylic IOLs. The exact nature of the transient opacity remains unclear, but an inflammatory origin cannot be completely ruled out.

Assessment of a new hydrophilic acrylic supplementary IOL for sulcus fixation in pseudophakic cadaver eyes

PurposeManagement of refractive errors after cataract surgery includes spectacles or contact lens, secondary laser vision correction, intraocular lens (IOL) exchange, or piggyback lens implantation. We evaluated for the first time a single-piece hydrophilic acrylic IOL designed for supplementary sulcus fixation in postmortem pseudophakic human eyes.MethodsPseudophakic human cadaver eyes were imaged by anterior segment optical coherence tomography (AS-OCT) to assess position of the primary IOL. Eyes were prepared as per the Miyake-Apple technique. The supplementary IOL (Medicontur A4 Addon IOL family) was then inserted into the ciliary sulcus. AS-OCT and photographs from anterior and posterior views were used to assess IOL centration, tilt, and interlenticular distance from the primary IOL.ResultsData were obtained from 12 eyes having primary IOLs of varying materials and designs in the bag and representing different sizes of eyes and severity of Soemmering's ring formation. The A4 Addon IOL was successfully inserted into the ciliary sulcus and was well centered in all cases. Four cases of tilt were observed on AS-OCT: three with mild tilt due to pre-existing zonular dehiscence, and one due to a localized area of Soemmering's ring formation. Interlenticular distance ranged from 0.34 to 1.24 mm and was not dependent on severity of Soemmering's ring or type of primary IOL.ConclusionsThe A4 Addon IOL was designed for sulcus fixation as a supplementary lens, with a large diameter, a square-shaped optic, four smooth loop haptics, and a convex-concave optical surface. It exhibited appropriate centration and interlenticular distance with different primary in-the-bag IOLs.

Prevention of postoperative capsular bag opacification using intraocular lenses and endocapsular devices maintaining an open or expanded capsular bag

Postoperative capsule opacification is a multifactorial physiological consequence of cataract surgery that remains the most common complication of this procedure. A literature review that included several intraocular lenses (IOLs) and endocapsular devices studied in our laboratory found that devices maintaining the capsular bag in an open or expanded state were associated with improved bag clarity. This observed effect likely occurs secondary to the complex interactions of myriad mechanisms, which include formation of a barrier to lens epithelial cell (LEC) migration, mechanical compression of residual LECs, mechanical stretch at the level of the capsule equator, maintenance of overall bag contour, and enhanced endocapsular circulation of aqueous humor. We review the designs of endocapsular devices and IOLs that minimize the degree of postoperative capsule opacification by preventing capsular bag collapse and discuss the underlying mechanisms that contribute to this phenomenon.

FINANCIAL DISCLOSURE

None of the authors has a financial or proprietary interest in any material or method mentioned.

Refractive outcomes in nanophthalmic eyes after phacoemulsification and implantation of a high-refractive-power foldable intraocular lens

PURPOSE

To evaluate the refractive and postoperative outcomes of a high-power foldable intraocular lens (IOL) in nanophthalmic eyes.

SETTING

Six ophthalmic surgical centers in Canada.

DESIGN

Retrospective case series.

METHODS

Consecutive charts of nanophthalmic patients having cataract extraction and insertion of the CT Xtreme D IOL were reviewed. Demographic and clinical data were collected, including age, sex, axial length (AL), minimum keratometry (K) value and maximum K value, corneal white-to-white (WTW), anterior chamber depth, lens thickness (LT), and complications. The following preoperative and operative data were collected: uncorrected distant visual acuity (UDVA), corrected distant visual acuity (CDVA), sphere, cylinder, and spherical equivalence (SE). The primary outcome measure was change in SE. The secondary outcome measures were changes in UDVA and CDVA.

RESULTS

A total of 21 eyes from 13 patients with a mean follow-up time of 9.6 ± 8.5 months were studied. Mean preoperative data were: age (51.4 ± 15.2 years), AL (16.63 ± 0.68 mm), minimum K value (46.20 ± 2.26 D), maximum K value (47.55 ± 2.34 D), anterior chamber depth (2.60 ± 0.49 mm), WTW (11.08 ± 1.38 mm), LT (4.70 ± 0.97 mm), and IOL power implanted (+49.9 ± 3.3 diopters [D]). SE improved from +16.11 ± 3.26 D preoperatively to +2.00 ± 2.37 D postoperatively (P < .0001). UDVA improved from 1.47 ± 0.30 logMAR preoperatively to 0.74 ± 0.43 logMAR postoperatively (P = .016). CDVA did not change significantly. Five eyes (23.8%) had serious postoperative complications. Of these eyes, 2 had malignant glaucoma, 2 had vitreous hemorrhages, and 1 eye had a vitreous hemorrhage with retinal detachment resulting in visual acuity of no light perception.

CONCLUSION

Implanting foldable high-power IOLs in a series of nanophthalmic eyes yielded significant improvement in UDVA and SE. Cataract surgery in these eyes carries increased risk.

FINANCIAL DISCLOSURE

Iqbal Ike K. Ahmed is a consultant to Carl Zeiss Meditec AG. No other author has a financial or proprietary interest in any material or method mentioned.

Cataract surgery in the small eye

The surgical management of cataract in the small eye presents the ophthalmic surgeon with numerous challenges. An understanding of the anatomic classification in addition to a thorough preoperative assessment will help individualize each case and enable the surgeon to better prepare for the obstacles that might be encountered during surgery. Small eyes are especially challenging in terms of intraocular lens (IOL) calculations and possible current limitations of available IOL powers, which could necessitate alternative means of achieving emmetropia. Surgical strategies for minimizing complications and maximizing good outcomes can be developed from knowledge of the anatomic differences between various small-eye conditions and the pathologies that may be associated with each. A thorough understanding of the challenges inherent in these cases and the management of intraoperative and postoperative complications will ensure that surgeons approaching the correction of these eyes will achieve the best possible surgical results.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Refractive Results: Safety and Efficacy of Secondary Piggyback Sensar™ AR40 Intraocular Lens Implantation to Correct Pseudophakic Refractive Error

In this study we evaluate the visual outcomes, safety, efficacy, and stability of implanting of second sulcus intraocular lens (IOL) to correct unsatisfied ametropic patients after phacoemulsification. Methods. Retrospective study of 15 eyes (15 patients) underwent secondary intraocular lens implanted into the ciliary sulcus. The IOL used was a Sensar IOL three-piece foldable hydrophobic acrylic IOL. The first IOL in all patients was acrylic intrabagal IOL implanted in uncomplicated phacoemulsification surgery. Results. Fifteen eyes (15 patients) were involved in this study. Preoperatively, mean log⁡MAR UDVA and CDVA were 0.88 ± 0.22 and 0.19 ± 0.13, respectively, with a mean follow-up of 28 months (range: 24 to 36 months). At the end of the follow-up, all eyes achieved log⁡MAR UDVA of 0.20 ± 0.12 with postoperative refraction ranging from 0.00 to −0.50 D of attempted emmetropia. Conclusions. Implantation of the second sulcus SensarAR40 IOL was found to be safe, easy, and simple technique for management of ametropia following uncomplicated phacoemulsification.

Analysis of the Optical Quality of Spherical and Aspheric Intraocular Lenses in Simulated Nanophthalmic Eyes

PURPOSE

To analyze the optical performance of different implant strategies in simulated nanophthalmic eyes.

METHODS

An optical design software was used. Analysis included eye models that required 30.00, 45.00, and 60.00 diopters (D) intraocular lenses (IOLs) to achieve emmetropia. Spherical and aspheric IOLs were designed. They were tested either with a single implant setting S or by splitting the power into two lenses. Setting P1 had an even split of the power between the lenses and setting P2 had an uneven power split with one-third of the power in the anterior lens and two-thirds in the posterior IOL. The area under the modulation transfer function (MTF) curve was calculated and spherical aberration was recorded in each setting.

RESULTS

Setting S had the worst optical performance in the spherical group and the best performance in the aspheric group. A statistically significant difference was found between setting S and the piggyback options (settings P1 and P2) in all analyzed variables for the spherical and aspheric groups for the 45.00 and 60.00 D IOL requirement. No statistically significant difference was found between the piggyback settings.

CONCLUSIONS

Single aspheric IOLs had better optical performance than piggybacking lower-power aspheric IOLs. In the spherical lenses group, the results were the opposite, with the piggyback options having higher optical quality than the single IOL. MTF shows that single aspheric lenses provide the highest contrast sensitivity among all of the analyzed settings.

[Clinical results of a multifocal pseudophakic additional lens]

BACKGROUND

In order to meet the patients wish for compensation of presbyopia in a flexible way, even in cases of an already pseudophacic eye, sulcus-fixated additional intraocular lenses (IOL) have been developed as an alternative to multifocal IOLs (MIOL) in the capsular bag. This allows subsequent application of multifocal optics. Furthermore, these additional lenses offer a relatively simple opportunity for postoperative refractive fine tuning or, in cases of incompatibility, a minimally invasive explantation of the multifocal part of the optical system.

PURPOSE

The objective of our work was the examination of a diffractive multifocal additional IOL and its functional characteristics.

MATERIAL AND METHODS

In a prospective, monocentric trial 32 eyes of 21 patients had cataract surgery with implantation of a monofocal IOL into the capsular bag and simultaneous implantation of a multifocal additional IOL into the sulcus. The visual acuity was tested at different distances 6 weeks and 3 months postoperatively. At the 3 month follow-up contrast sensitivity and defocus curves were additionally assessed. Patients with bilateral implantation filled in a questionnaire to assess their subjective satisfaction of postoperative visual quality.

RESULTS

All eyes had an uneventful postoperative course. At both follow-ups an uncorrected distance and near visual acuity (VA) of 0.2 LogMAR or better was achieved. In intermediate vision 29 out of 32 eyes after 6 weeks and 31 out of 32 eyes after 3 months reached an uncorrected VA of 0.2 LogMAR or better. The defocus curves showed a typical two-peaked shape. At intermediate distance (-1.5 D of defocus) the median VA was 0.35 LogMAR. Contrast sensitivity testing showed results in the upper region of the standard range of age-matched, healthy patients.

DISCUSSION

The examined type of diffractive additional IOL achieved good to very good functional results, which are comparable to corresponding IOLs in the capsular bag. Multifocal additional IOLs can be considered as a useful extension of refractive surgical alternatives for the compensation of presbyopia. The possibility to implant the multifocal optic part independently of the primary surgery, the minimal invasivity of the procedure and the likewise time-independent reversibility can be pointed out as special qualities of these IOL.

Clinical results with a supplementary toric intraocular lens for the correction of astigmatism in pseudophakic patients

PURPOSE

To evaluate the visual outcomes of pseudophakic patients who underwent supplementary toric intraocular lens (IOL) implantation to correct astigmatic refractive errors.

METHODS

Pseudophakic patients referred for the implantation of a supplementary toric IOL (Sulcoflex Toric 653T) were evaluated. Uncorrected and corrected distance visual acuities (UDVA and CDVA, respectively), spherical equivalent (SE) refraction, rotational stability, higher order aberrations (HOA), and photopic glare and no-glare contrast sensitivity (CSV-1000, VectorVision) were evaluated.

RESULTS

A total of 10 eyes of 10 patients were included. The mean age was 56.42 ± 5.9 years (range 45-65 years). Mean follow-up was 6.99 ± 5.1 months (6-18 months). Postoperatively, UDVA improved to 0.10 ± 0.12 (0.3 to -0.1) (p = 0.004) and CDVA to 0.07 ± 0.12 (0.3 to -0.1) (p = 0.021). Mean SE was -0.30 ± 0.56 D (-1.00 to +0.75) (p = 0.001). Mean toric IOL axis rotation at 6-month follow-up was 3.0° ± 2.45° (0-6). Ocular aberrometry values decreased after surgery (for average HOA root mean square, p = 0.008). Photopic contrast sensitivity (for all spatial frequencies) showed a trend for improvement after surgery; however, this was not borne out from the analysis (p&gt;0.05).

CONCLUSIONS

The implantation of the Sulcoflex Toric IOL to correct astigmatism in pseudophakic patients provided excellent visual outcomes, predictability of refractive results, rotational stability, and optical performance. The implantation of this IOL is a safe and effective technique to correct pseudophakic cylindrical refractive errors and reduce spectacle dependence in these patients.

Long-term results of clear lens extraction combined with piggyback intraocular lens implantation to correct high hyperopia

AIM

To assess the refractive outcome of clear lensectomy combined with piggyback intraocular lens implantation in highly hyperopic patients.

METHODS

This case review included 19 eyes of 10 patients with high hyperopia and axial length less than 21mm. Intraocular lens power was calculated for emmetropia using the Holladay II formula in 17 eyes, and SRK/T formula in 2 eyes following clear lens extraction and piggyback intraocular lens implantation. Patients were examined periodically over 24 months for visual acuity and spherical equivalent (SE).

RESULTS

The mean postoperative SE at 24 months was 0.20±1.39D (range, -3.00 to 2.50D), better than preoperative 9.81±2.62D (range, +6.00 to +14.50D) (P<0.001). Five eyes had SE within ±0.5D of emmetropia and 11 eyes within ±1.00D at postoperative 24 months. The mean postoperative uncorrected visual acuity (UCVA) at 24 months was 0.60±0.36, significantly improved compared to preoperative 1.39±0.33 (P<0.001). The mean best-corrected visual acuity (BCVA) at 24 months was 0.49±0.35, not statistically different compared to preoperative 0.38±0.30 (P=0.34). Twelve eyes maintained and 1 gained 1 or more Snellen line of BCVA, 4 eyes lost 1 line, and 2 eyes lost 2 lines at 24 postoperative months. Twelve eyes best-corrected near visual acuity (BCNVA) achieved J1 at postoperative 24 months compared to preoperative 7 eyes and the other 7 eyes better than J3.

CONCLUSION

Clear lens extraction combined piggyback intraocular lens implantation appears to be an effective procedure to correct high hyperopia but mild overcorrection and intralenticular opacification may require secondary procedure.

Combining primary and piggyback intraocular lenses to treat extreme myopic astigmatism in stable keratoconus following cataract surgery

The majority of those with keratoconus can maximise visual acuity with spectacle or contact lens correction as they age; however, as subjects enter their sixties, cataracts may supervene and contact lens tolerance diminishes with consequent reduction in visual acuity. Following cataract extraction, the complex refractive error associated with keratoconus may not be readily corrected by an intraocular lens alone. This report highlights the planned implantation of a primary posterior chamber toric intraocular lens with a secondary piggyback, sulcus-based, intraocular lens in advanced but stable keratoconus with extreme myopic astigmatism and cataract.

Sulcus anatomy and diameter in pseudophakic eyes and correlation with biometric data: evaluation with a 50 MHz ultrasound biomicroscope

PURPOSE

To evaluate the sulcus anatomy and possible correlations between sulcus diameter and white-to-white (WTW) diameter in pseudophakic eyes, data that may be important in the stability of add-on intraocular lenses (IOLs).

SETTING

University Eye Hospital, Tuebingen, Germany.

DESIGN

Case series.

METHODS

In pseudophakic eyes, the axial length (AL) and horizontal WTW were measured by the IOLMaster device. Cross-sectional images were obtained with a 50 MHz ultrasound biomicroscope on the 4 meridians: vertical, horizontal (180 degrees), temporal oblique, and nasal oblique. Sulcus-to-sulcus (STS), angle-to-angle (ATA), and sclera-to-sclera (ScTSc) diameters were measured. The IOL optic diameter (6.0 mm) served as a control. To test reliability, optic measurements were repeated 5 times in a subset of eyes.

RESULTS

The vertical ATA and STS diameters were statistically significantly larger than the horizontal diameter (P=.0328 and P=.0216, respectively). There was no statistically significant difference in ScTSc diameters. A weak correlation was found between WTW and horizontal ATA (r = 0.5766, P<.0001) and between WTW and horizontal STS (r = 0.5040, P=.0002). No correlation was found between WTW and horizontal ScTSc (r = 0.2217, P=.1217).

CONCLUSIONS

The sulcus anatomy had a vertical oval shape with the vertical meridian being the largest, but it also had variation in the direction of the largest meridian. The WTW measurements showed a weak correlation with STS. In pseudophakic eyes, Soemmerring ring or a bulky haptic may affect the ciliary sulcus anatomy.

The use of a supplemental sulcus fixated IOL (HumanOptics Add-On IOL) to correct pseudophakic refractive errors

Purpose.

To evaluate the safety and efficacy of piggybacking with the HumanOptics Add-On intraocular lens (IOL) to correct pseudophakic refractive errors.

Materials and Methods.

Ten eyes of 10 patients with pseudophakic refractive errors were included in this study. All patients were targeted for a range of refraction −0.50 to +0.50 D. Uncorrected and corrected distance visual acuities (UDVA and CDVA, respectively), endothelial cell count (ECC), anterior chamber depth (ACD), the distance between intraocular lenses, and contrast sensitivity measurements under mesopic, scotopic, and scotopic with glare conditions were evaluated preoperatively and postoperatively.

Results.

The mean age of the patients was 54±27 years (range 4-78). Mean follow-up time was 10.5±1.36 months (range 6-15 months). Mean diopters of implanted Add-On IOLs were −1.4±6.9 (range −12 to +9 D). Mean preoperative and postoperative UDVA was 0.133±0.12 and 0.73±0.27, respectively (p=0.0001); mean preoperative and postoperative CDVA were 0.77±0.26 and 0.79±0.27, respectively (p=0.066). Mean preoperative and postoperative ACD were 3.87±0.91 mm vs 3.58±1.05 mm, respectively (p=0.343); mean inter-IOL distance was 0.53±0.08 mm. Mean preoperative and postoperative ECC were 2455±302 and 2426±294, respectively (p=0.55). All patients were within the targeted refractive range of −0.50 D to +0.50 D. No complications were observed during the operations or postoperative follow-up period.

Conclusions

Piggybacking with the Add-On IOL is a safe, efficient, and reliable technique to correct pseudophakic refractive errors.

Endoscopic cyclophotocoagulation (ECP) in the management of uncontrolled glaucoma with prior aqueous tube shunt

PURPOSE

To evaluate the efficacy and safety of endoscopic cyclophotocoagulation (ECP) in the treatment of uncontrolled glaucoma with a prior aqueous tube shunt.

METHODS

A prospective, nonrandomized, interventional clinical trial with up to 2 years of follow up included 25 eyes of 25 consecutive glaucoma patients with a previous tube shunt and uncontrolled intraocular pressure (IOP) despite medical therapy. Patients had IOP greater than 21 mm Hg on maximal medications or IOP ≤21 mm Hg but intolerant to medications or using an oral carbonic anhydrase inhibitor. Application of ECP over 360 degrees was performed and subjects were followed for 6 months minimum. Main outcome measures were mean reduction in IOP and medications at 12 months. Success was defined as reduction in IOP of 3 mm Hg and discontinuation of nontolerated glaucoma medications. A failure was defined as continued uncontrolled IOP, vision loss to no light perception, or additional medications or glaucoma surgery required.

RESULTS

At 12 months, the mean IOP dropped from 24.02 to 15.36 mm Hg. The mean of the differences was -7.77 mm Hg (-30.8%). The mean number of medications was 3.2 before laser and 1.5 at 12 months (P<0.001). The success rate at 12 months (n=18) was 88% and remained at that level until the end of the follow-up period of 2 years (n=11, P<0.00005). There were no serious complications.

CONCLUSIONS

ECP seems to be a safe and effective treatment in patients with uncontrolled IOP with a prior aqueous tube shunt, and is a reasonable option in this group of refractory glaucoma patients.

Modern cataract surgery: unfinished business and unanswered questions

We summarize information, based on clinicopathologic studies over the past decade, on various cataract intraocular lens (IOL) procedures and modern "specialized" IOLs, that will help surgeons continuously improve long-term results for cataract patients. Although most operations do initially provide excellent refractive correction and visual rehabilitation, late complications occur. These sometimes are missed because they are outside of the routine period of follow-up care. We have tried to determine if the various techniques and IOLs truly deliver the long-term results that we desire. Most safety and efficacy information is derived from the manufacturer and is passed through the U.S. Food and Drug Administration (FDA). This is often based on limited, relatively short-term observations made by the manufacturer. After a lens receives FDA approval, there are few means to assess the outcome of each procedure and lens years later. We rarely hear of a 10- or 20-year follow-up study. We have found that one of the best means to assess long-term results is pathologic analyses. We discuss recently studied aspects of pathologic reactions, such as posterior capsule opacification, intracapsular fibrosis, glistenings, intralenticular opacification, and other issues with the various IOL platforms; we then present a clinicopathological overview of tissues and IOLs from our database. These include hydrophobic and hydrophilic acrylic designs, plate lenses, and a dual optic lens.

Correction of extreme hyperopia: artisan iris-fixated intraocular lens implantation for pseudophakia after clear lens extraction

A 22-year-old patient suffering from both-side extreme hyperopia with amblyopia was corrected with an Artisan iris-fixated intraocular lens (IOL) implantation followed to clear lens extraction (CLE) with posterior chamber (PC)-IOL implantation. The preoperative refraction values were +17.75DS -1.50DC × 168° for the right eye and +17.25DS -0.75DC × 8° for the left eye. The uncorrected visual acuity (UCVA) was 20/200 bilaterally and the spectacle-corrected visual acuity (BSCVA) was 20/50 bilaterally. One year after Artisan iris-fixated IOL implantation, bilateral BSCVA was 20/50 with a refraction of +1.25DS -0.75DC × 13° for the right eye and +1.50DS -1.00DC × 55° for the left eye. The outcomes of an Artisan iris-fixated IOL implantation followed to CLE with PC-IOL implantation were encouraging for the correction of extreme hyperopia. Long term follow-up examinations were necessary for further determination of the efficacy and safety of this combinational procedure.