Surgical correction of presbyopia

Presbyopia is the most common refractive disorder for people older than 40 years. It is characterized by a gradual and progressive decrease in accommodative amplitude. Many surgical procedures for the correction of presbyopia exist, with additional procedures on the horizon. This review describes the prevalent theories of presbyopia and discusses the available surgical options for correction.

FINANCIAL DISCLOSURE

Proprietary or commercial disclosures are listed after the references.

Cataract surgery and nonsteroidal antiinflammatory drugs

Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. These medications have been found to reduce pain, prevent intraoperative miosis, modulate postoperative inflammation, and reduce the incidence of cystoid macular edema (CME). Whether used alone, synergistically with steroids, or for specific high-risk eyes prone to the development of CME, the effectiveness of these medications is compelling. This review describes the potential preoperative, intraoperative, and postoperative uses of NSAIDs, including the potency, indications and treatment paradigms and adverse effects and contraindications. A thorough understanding of these issues will help surgeons maximize the therapeutic benefits of these agents and improve surgical outcomes.

FINANCIAL DISCLOSURE

Proprietary or commercial disclosures are listed after the references.

Intraoperative complication rates in cataract surgery performed by ophthalmology resident trainees compared to staff surgeons in a Canadian academic center

PURPOSE

To compare the intraoperative complication rates in cataract surgery performed by resident trainees and staff ophthalmologists.

SETTING

Kensington Eye Institute, University of Toronto, Toronto, Canada.

DESIGN

Prospective case series.

METHODS

This study included 8738 consecutive cases of primary phacoemulsification cataract surgery performed by staff surgeons and resident trainees from January to December 2016. There were no exclusion criteria. Data collected included the level of resident training, case complexity, degree of resident involvement, and intraoperative complications. Primary outcome measures included intraoperative complication rates and level of complexity of cataract surgeries performed by resident trainees and staff surgeons.

RESULTS

Resident trainees were involved in 44% of surgeries. Of those, 82% were completed in their entirety by a resident and 18% were performed by both the staff surgeon and resident. Staff surgeons performed 56% of all surgeries without resident involvement. Sixty-seven percent of surgeries were simple and 33% were complex, with small pupil or intraoperative floppy-iris syndrome being the most common reason for complex cases. For simple cases, there was no difference in the overall complication rates (1.7% and 2.0%; P = .52), posterior capsule rupture rates (0.9% and 0.8%; P = .76), or vitreous loss rates (0.4% and 0.2%; P = .08) between staff and residents, respectively.

CONCLUSION

There were no differences in complication rates between the two groups.

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.

Antibiotic prophylaxis of postoperative endophthalmitis after cataract surgery: Results of the 2014 ASCRS member survey

A 2014 online survey of the American Society of Cataract and Refractive Surgery members indicated increasing use of intracameral antibiotic injection prophylaxis compared with a comparable survey from 2007. Forty-seven percent of respondents already used or planned to adopt this measure. One half of all surgeons not using intracameral prophylaxis expressed concern about the risks of noncommercially prepared antibiotic preparations. Overall, the large majority (75%) said they believe it is important to have a commercially available antibiotic approved for intracameral injection. Assuming reasonable cost, the survey indicates that commercial availability of Aprokam (cefuroxime) would increase the overall percentage of surgeons using intracameral antibiotic injection prophylaxis to nearly 84%. Although the majority used topical perioperative antibiotic prophylaxis, and gatifloxacin and moxifloxacin were still the most popular agents, there was a trend toward declining use of fourth-generation fluoroquinolones (60%, down from 81% in 2007) and greater use of topical ofloxacin and ciprofloxacin (21%, up from 9% in 2007).

Documenting the subjective patient experience of first versus second cataract surgery

PURPOSE

To examine the subjective patient experience after cataract surgery.

SETTING

Single multisurgeon cataract facility.

DESIGN

Prospective intraindividual observational study.

METHODS

Patients completed a questionnaire immediately after cataract extraction performed in their second eye. All patients had second-eye surgery within 6 months of first-eye surgery. Cases longer than 30 minutes were excluded.

RESULTS

Of the 292 patients who completed the questionnaire, 12 were excluded based on surgical time. The response rate varied per question. The surgery was rated as taking longer or being more painful in the second eye by 127 patients (45.4%) and in the first eye by 38 patients (13.5%) (P < .05); 115 patients (41.1%) reported no difference. Patients (47.83%) who rated the second eye as the generally more negative experience thought their vision would be better and 3.48% worse (P < .05); 48.70% thought it would be the same. No difference was noted in length of surgery (P = .3) or sedation used (P = .96).

CONCLUSIONS

Of 125 patients who rated second-eye surgery as the generally more unpleasant procedure, 90 (72.0%) were similarly or more relaxed during the second procedure. Second-eye cataract surgery was perceived as being a longer and/or more painful procedure by a significant number of patients (45.4%), and only 3.48% thought that vision in the second eye would be worse. These results can help surgeons when counseling patients regarding expectations for second surgery.

FINANCIAL DISCLOSURE

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

Multifocal intraocular lenses: relative indications and contraindications for implantation

This article presents an extensive overview of best clinical practice pertaining to selection and use of multifocal intraocular lenses (IOLs) currently available in the United States. Relevant preoperative diagnostic evaluations, patient selection criteria, counseling, and managing expectations are reviewed, as well as how to approach patients with underlying ocular intricacies or challenges and best practices for intraoperative challenges during planned implantation of a multifocal IOL. Managing the unhappy multifocal IOL patient if implantation has been performed is also addressed.

FINANCIAL DISCLOSURE

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

The effect of combined topical-intracameral anaesthesia on neuroleptic requirements during cataract surgery

OBJECTIVE

To evaluate whether the addition of intracameral lidocaine to topical anaesthesia during cataract surgery leads to a decrease in the administration of intraoperative midazolam and fentanyl.

DESIGN

Retrospective case-control study.

PARTICIPANTS

The eyes of 124 patients undergoing phacoemulsification were included in the study, with 62 in the intracameral group and 62 in the control group.

METHODS

A single-centre, retrospective chart review of cases between April and October 2007 in which patients had undergone small-incision phacoemulsification with foldable intraocular lens insertion and received preoperatively either topical tetracaine 0.5% with unpreserved intracameral lidocaine 1% (intracameral group) or topical tetracaine 0.5% alone (control group). Intraoperatively, midazolam and fentanyl were administered as needed based on pain and anxiety.

RESULTS

A total of 124 eyes (124 patients) were included. There was no statistically significant difference between the mean intraoperative midazolam doses given for the 2 groups (p = 0.08). The mean intraoperative dose of fentanyl was lower in the intracameral than in the control group (p < 0.0001). A comparison of intraoperative fentanyl requirements between groups using a multivariate regression analysis for age, gender, surgical time, and preoperative fentanyl levels confirmed the lower need for intraoperative fentanyl in the intracameral compared with the control group (p = 0.0037). There were no anaesthetic complications among any of the study patients.

CONCLUSIONS

Patients receiving topical tetracaine 0.5% with unpreserved intracameral lidocaine 1% during cataract surgery demonstrated a reduction in intraoperative fentanyl requirements. Surgeons performing cataract surgery under topical anaesthesia should consider the addition of intracameral lidocaine 1% to decrease fentanyl requirements and improve patient safety and comfort.

Complications of sulcus placement of single-piece acrylic intraocular lenses: recommendations for backup IOL implantation following posterior capsule rupture

PURPOSE

To describe complications arising from sulcus placement of single-piece acrylic (SPA) intraocular lenses (IOLs), evaluate IOL options for eyes that lack adequate capsule support, and examine the appropriateness of various IOL designs for sulcus placement.

SETTING

University and private anterior segment surgery practices.

METHODS

Patients referred for complications of SPA IOLs in the ciliary sulcus from 2006 and 2008 were identified. Demographic information, examination findings, and complications of the initial surgery were recorded. Details of surgical interventions and the most recent corrected distance visual acuity (CDVA) were noted. A thorough review of the literature was undertaken to analyze options for IOL placement.

RESULTS

Complications of sulcus SPA IOLs included pigment dispersion, iris transillumination defects, dysphotopsia, elevated intraocular pressure, intraocular hemorrhage, and cystoid macular edema. Two patients in the series of 30 patients experienced 1 complication; 8 experienced 2 complications; 13 experienced 3 complications; 4 experienced 4 complications; and 2 experienced 5 complications. Twenty-eight eyes (93%) required surgical intervention; IOL exchange was performed in 25 (83%). Postoperatively, the mean CDVA improved, with most eyes attaining 20/20.

CONCLUSIONS

Intraocular lenses designed solely for the capsular bag should not be placed in the ciliary sulcus. Backup IOLs in appropriate powers, sizes, and designs should be available for every cataract procedure. The development, investigation, and supply of IOLs specifically designed for placement in eyes that lack adequate capsule support represent clinically important endeavors for ophthalmology and the ophthalmic industry.

Second instrument tip breaks during phacoemulsification

BACKGROUND

Second instrument tip breaks during phacoemulsification are complications that are anecdotally recalled, yet little information exists on why and how often they occur, whether they are consistently tracked, and how they are managed. They may be an underreported, but potentially serious, complication of phacoemulsification.

METHODS

We surveyed 114 cataract surgeons in Ontario to determine reported rates of second instrument tip breaks, their management, and presumed etiology. We reviewed 4 Toronto cataract centres for incident reports, instrument sterilization processes, and purchase histories. Using scanning electron microscopy (SEM), we compared the characteristics of a broken Sweeney tip to new and used second instruments.

RESULTS

Of the 35 surgeons responding to the survey, 34% had experienced a second instrument tip break during their careers. Approximately 73% (16 cases) of the 22 cases reported were managed successfully during the procedure by the primary surgeon, 14% (3 cases) required imaging by computerized tomography or x-ray, and another 14% (3 cases) required pars plana vitrectomy for tip retrieval. Purchase histories revealed that 1 Sweeney hook was exchanged monthly, equivalent to 100 to 150 surgeries. SEM of new and used second instruments revealed signs of metal fatigue on both new and used second instruments.

INTERPRETATION

Although both physicians and hospitals lack a method for ensuring quality control of second instruments, approximately one third of cataract surgeons encounter second instrument tip breaks during the course of their careers. Although most cases are managed intraoperatively, consistent hospital tracking records and standardized instrument inspection by institutions and surgeons are needed to determine how these complications occur and to establish protocols for complication reporting and management.

Should ophthalmologists receive communication skills training in breaking bad news?

BACKGROUND

Effective communication is essential in the delivery of health care. The purpose of the present study was to determine whether formal communication skills training in breaking bad news should be incorporated into the training of ophthalmologists.

METHODS

An online survey was offered to every member of the Canadian Ophthalmological Society (COS) with a registered email address. Survey questions focused on 2 specific scenarios: (S1) disclosing permanent vision loss to a patient and (S2) revoking a patient's driver's licence. Main outcome measures were the respondents' opinions on the need for and benefit of including communication skills in the training of ophthalmologists and, if considered necessary, its optimal format and point in their training.

RESULTS

The response rate was 28% (225/800). The vast majority of respondents believed that it is important for ophthalmologists to be able to communicate effectively when breaking bad news (S1: 99%, mean Likert score 4.81; S2: 97%, 4.73); that communication skills training would be beneficial in breaking bad news for both future ophthalmologists (S1: 88%, 4.28; S2: 87%, 4.24) and patients (S1: 92%, 4.26; S2: 87%, 4.24); and that it should be included in the training of ophthalmologists (S1: 87%, 4.27; S2: 83%, 4.15). Residency was the preferred point in training (95% for both scenarios), but there was no consensus on what type of training format(s) to use.

INTERPRETATION

Survey respondents strongly support the inclusion during ophthalmology residency of formal communication skills training in breaking bad news. This would be a logical choice of content for ophthalmology residency programs striving to meet the mandated "interpersonal and communication skills" core competency requirements.

Clinical experience with intraoperative floppy-iris syndrome. Results of the 2008 ASCRS member survey

According to an online survey, most members of the American Society of Cataract and Refractive Surgery believe that tamsulosin makes cataract surgery more difficult (95%) and increases the risks of surgery (77%). Commonly reported complications of intraoperative floppy-iris syndrome (IFIS) were significant iris trauma and posterior capsule rupture, with 52% and 23% of respondents, respectively, reporting these complications at a higher rate than in non-IFIS eyes. There was no single preferred surgical method for managing IFIS; 33% of respondents routinely used multiple strategies. Of respondents with sufficient experience, 90% believe that IFIS is more likely with tamsulosin than with nonspecific alpha1-antagonists. Ninety-one percent believe that physicians prescribing alpha1-antagonists should become better educated about IFIS, and 59% would recommend a pretreatment ophthalmic evaluation for patients with cataracts or decreased vision. If they themselves had mildly symptomatic cataracts, 64% of respondents would avoid taking tamsulosin or would have their cataract removed first.

Prophylaxis of postoperative endophthalmitis after cataract surgery

An online survey of members of the American Society of Cataract and Refractive Surgery indicated a strong preference for preoperative and postoperative topical antibiotic prophylaxis, with most surgeons favoring latest generation topical fluoroquinolones. A significant percentage of surgeons reported being concerned about the risks of homemade intracameral antibiotic preparations, and there was a strong desire to have a commercially available antibiotic approved for intracameral injection. This is reflected in the fact that 77% of respondents were still not injecting intracameral antibiotics, but 82% would likely do so if a reasonably priced commercial preparation were available.

Primary piggyback implantation of 3 intraocular lenses in nanophthalmos

We present a patient with bilateral nanophthalmos who had uneventful cataract extraction in the right eye with primary implantation of 3 intraocular lenses (IOLs) of 2 different materials: a 30 diopter (D) acrylic IOL and a 9 D silicone IOL in the capsular bag and a 30 D silicone IOL in the ciliary sulcus. Subsequently, cataract extraction was done in the left eye with bag-sulcus implantation of two 30 D silicone IOLs. The use of 3 IOLs in 1 eye was necessary because the highest available power of acrylic and silicone IOLs at our institution was 30 D. The only short-term complications were temporary corneal edema and partial displacement of the sulcus IOL anterior to the iris in the right eye and bilateral posterior capsule opacification. The late complication of interlenticular opacification was not present 1 year after piggyback IOL implantation.

Phacoemulsification in anterior megalophthalmos

This case outlines the phacoemulsification technique used to overcome the challenge of the hyperdeep anterior chamber, weak zonules, abnormal anterior capsule, and large capsular bag. Key steps included trypan blue staining of the anterior capsule, a large capsulorhexis, prolapse of the nucleus into the anterior chamber with phacoemulsification anterior to the capsulorhexis, and a posterior chamber-placed iris-clip intraocular lens. Successful visual rehabilitation is achievable in these anatomically challenging eyes.

Thermal effect of microburst and hyperpulse settings during sleeveless bimanual phacoemulsification with advanced power modulations

PURPOSE

To assess wound temperature during bimanual sleeveless phacoemulsification using customizable power modulations such as hyperpulse and microburst technology.

SETTING

In vitro laboratory.

METHODS

The Millennium Microsurgical System (Bausch & Lomb) with custom control software (CCS) was used to perform phacoemulsification in 5 porcine eyes with MicroFlow needles (Bausch & Lomb) and with power varied from 20% to 80% in 10% increments. Pulse modes were set for fixed microburst (4 ms on, 4 ms off; and 6 ms on, 12 or 24 ms off) and for hyperpulse (30% duty cycle with 8 or 75 pulses per second [pps]), with and without aspiration-line occlusion. Wound temperatures were measured 3 times per second.

RESULTS

Using 80% total power, the wound temperature during 3 minutes of occlusion did not exceed 39.0 degrees C. The maximum temperature with fixed microbursts of 4 ms on, 4 ms off was 29.0 degrees C without occlusion and 37.8 degrees C with occlusion (duration 3 minutes). At 6 ms on, 12 ms off, the maximum temperatures were 28.1 degrees C and 38.7 degrees C, respectively. At 6 ms on, 24 ms off, peak temperatures were 24 degrees C and 23.6 degrees C, respectively. The hyperpulse mode of 30% duty cycle and 8 pps produced maximum temperatures of 25.5 degrees C nonoccluded and 33.4 degrees C occluded. With 30% duty cycle, 75 pps, temperatures were 28 degrees C and 38.0 degrees C, respectively. For all power below 80%, temperatures were lower.

CONCLUSIONS

Customizable power modulation with microburst and hyperpulse technology further reduced wound temperatures during bimanual sleeveless phacoemulsification. This enhances the safety and effectiveness of phacoemulsification through a sleeveless needle and a small stab incision.

Hydro-chop technique for soft lenses

Chopping techniques were initially developed to expend the least amount of phacoemulsification power inside the eye to remove a lens and to improve efficiency. Soft nuclei are not generally conducive to traditional chopping techniques and have required alternate, energy-consuming techniques, such as sculpting, to be removed. We describe a modified chopping technique that can be used to mechanically cleave soft nuclei into distinct fragments before phaco power is required, reducing total power and energy expended in the eye.

Bimanual microincisional phacoemulsification: the future of cataract surgery?

PURPOSE OF REVIEW

Bimanual microincisional cataract surgery has recently become a procedure of interest among cataract surgeons, and a number of trials have shown its potential as a minimally invasive cataract surgery. The purpose of this review is to examine the studies that have been published to date and to evaluate the potential of bimanual phacoemulsification as a method of cataract extraction.

RECENT FINDINGS

Recent studies have reinforced the safety of bimanual phacoemulsification. In particular, recently published studies have focused on evaluating various phacoemulsification technologies and their safety when used in bimanual phacoemulsification. Newly developed rollable hydrophilic acrylic ThinOptX lenses have been shown to be implantable in 2.2-mm incisions safely with good visual outcomes.

SUMMARY

Bimanual phacoemulsification has been a potential technique for a number of years, but only recently have the technology, software, and technique advanced sufficiently to make bimanual phacoemulsification a feasible method of cataract extraction. Although the main disadvantage to bimanual phacoemulsification remains the lack of intraocular lenses that can fit through microincisions, necessitating the enlargement of corneal wounds for intraocular lens implantation, bimanual phacoemulsification has a number of advantages over traditional small-incision phacoemulsification. Theses advantages have been a source of interest for cataract surgeons and surgical companies who are now developing technologies that will permit the performance of truly microincisional cataract surgery.

Monitored anesthesia care provided by registered respiratory care practitioners during cataract surgery

OBJECTIVE

To evaluate the safety and feasibility of having monitored anesthesia care during cataract surgery provided by registered respiratory care practitioners (RRCPs).

DESIGN

Retrospective case series.

PARTICIPANTS

One thousand nine hundred fifty-seven consecutive patients undergoing cataract surgery at one surgical center between November 2001 and October 2003.

METHODS

Phacoemulsification cataract surgery with intraocular lens insertion was performed using topical anesthesia, with or without IV sedatives. An RRCP, trained to function as an anesthesia assistant, provided monitored anesthesia care during all stages of surgery, with an anesthesiologist immediately available for consultation or assistance as required.

MAIN OUTCOME MEASURES

The number of serious medical complications resulting from the anesthesia or surgery was measured. The rate of anesthesiologist intervention required at each stage of surgery--preoperative, intraoperative, and postoperative--was determined, along with the reasons for the interventions. Age, American Society of Anesthesiologists (ASA) risk class (a rating of preoperative physical status), and number of IV sedative agents given were analyzed as potential predictors of the need for anesthesiologist intervention.

RESULTS

Among the 1957 cataract surgeries, there were no adverse medical events that resulted in death, hospitalization, or tracheal intubation. Two cases were aborted intraoperatively for medical reasons. A total of 78 cases (4.0%) required anesthesiologist intervention, with 34 (1.7%) requiring preoperative intervention, 43 (2.2%) requiring intraoperative intervention, and 3 (0.2%) requiring postoperative intervention; 4 cases required 2 separate interventions. The mean age of the intervention group (73.9 years) was statistically greater than that of the nonintervention group (71.0) (P = 0.02). A higher ASA rating (>2) correlated with an increased need for anesthesiologist intervention in terms of the total intervention rate (P<0.0001) and the intraoperative rate alone (P<0.0001). The use of more IV sedative agents (2 or 3 vs. 0 or 1) was marginally associated with a higher total intervention rate (P = 0.053) but not with a higher intraoperative intervention rate (P = 0.68).

CONCLUSION

With the inherent safety of cataract surgery and the relatively low need for anesthesiologist intervention, we believe it is justified to allow RRCPs, trained as anesthesia assistants, to provide monitored anesthesia care during cataract surgery so long as anesthesiologist support is directly available when required. Potential benefits include cost savings in health care and decreased demand for anesthesiology services. To validate formally the preservation of patient safety from such a change in practice, however, a larger sample size would be required due to the inherently low rate of cataract surgery complications.

Feasibility of sleeveless bimanual phacoemulsification with the Millennium microsurgical system

PURPOSE

To assess the feasibility of sleeveless bimanual phacoemulsification using the Millennium Microsurgical System (Bausch and Lomb Surgical) by measuring wound temperature during phacoemulsification.

SETTING

In vitro laboratory.

METHODS

The Millennium system was used in 6 eye-bank eyes using pulse mode and 80-milllisecond and 160-millisecond phaco burst mode width intervals. Wound temperatures were measured, and the wounds were observed for thermal injury.

RESULTS

In pulse mode and the nonoccluded state at 100% power, the maximum temperature was 43.8 degrees C. In the occluded state at 30% power, the maximum temperature was 51.7 degrees C after 70 seconds of occlusion. In phaco burst mode with a 160-millisecond burst-width interval, the maximum temperature was 41.4 degrees C (nonoccluded at 100% power). At 80% power, the maximum temperature was 53.2 degrees C within 60 seconds of full aspiration occlusion with the footpedal fully depressed. With an 80-millisecond burst-width interval in the nonoccluded and occluded states (100% power, footpedal fully depressed for 3 minutes), there was no significant temperature rise. The maximum temperature was 33.6 degrees C in the nonoccluded state and 41.8 degrees C in the occluded state. In all instances, the corneal wound remained clear. No wound burn or contracture was noted.

CONCLUSIONS

The demonstrated temperature rises were under clinically unusual parameters. Phacoemulsification with a sleeveless needle through a small stab incision can be safely performed with the Millennium system using conventional phaco burst mode settings within certain parameters.

Using medical lubricating jelly in human cadaver eyes to teach ophthalmic surgery

Attempting to learn phacomemulsification through the severely edematous cornea of a human cadaver eye is often difficult. We propose a method of improving the view of the anterior chamber structures. Medical lubricating jelly is injected into the anterior chamber of a cadaver eye. After 10 minutes, excellent corneal clarity is achieved. There was no change in the corneal edema with the injection of sodium hyaluronate 1.4% (Healon GV as a control. Using medical lubricating jelly in place of viscoelastic material is an inexpensive, effective adjunct in ophthalmic surgical teaching.

Foldable silicone versus poly(methyl methacrylate) intraocular lenses in combined phacoemulsification and trabeculectomy

PURPOSE

To compare the outcome of phacotrabeculectomy with implantation of poly(methyl methacrylate) (PMMA) or foldable silicone intraocular lenses (IOLs).

METHODS

Thirty patients were randomized to receive a 5.5 mm PMMA IOL through a 5.0 mm incision or a foldable silicone IOL (Allergan SI-30) through a 3.2 mm incision. Visual acuity, intraocular pressure (IOP), bleb survival, inflammation, endothelial cell changes, and complications were examined at intervals up to 6 months.

RESULTS

There was no difference between the 2 groups in final visual outcome, final IOP control, bleb survival, and endothelial cell changes. Two months after surgery, there was significantly more inflammation in the silicone IOL group than in the PMMA group (P <. 05). The silicone group had a significantly higher combined complication rate including iris capture, choroidal effusion, and epiretinal membrane formation (P <.05).

CONCLUSIONS

Foldable silicone IOLs were comparable to conventional PMMA lenses in visual outcome, IOP control, bleb formation, and endothelial changes. However, some silicone lenses are associated with an increased risk of recurrence of inflammation and a higher final complication rate in combined cataract and filtration surgery.