Refractive outcomes of small lenticule extraction (SMILE) Pro® with a 2 MHz femtosecond laser

PURPOSE

To evaluate the initial visual outcomes of Small Incision Lenticule Extraction (SMILE) Pro® using a 2 MHz femtosecond laser (VisuMax 800, Carl Zeiss Meditec) and to assess the efficacy, safety, predictability, accuracy, and complication rate.

METHODS

This retrospective analysis included eyes which underwent the SMILE Pro® procedure using VisuMax 800 femtosecond laser to correct myopia. All surgeries were performed by one surgeon (DB). Follow-up was conducted 3 months postoperatively to evaluate visual outcomes after neuroadaptation, corrected visual acuity (CDVA) and intra- and postoperative complications.

RESULTS

One hundred and fifty-two eyes of 82 patients (mean age 31 ± 6 years) results at 3 months are presented. The mean spherical equivalent (SE) was - 4.44 ± 1.86 D preoperatively while -0.24 ± 0.32 D postoperatively. 99% of eyes achieved SE within ± 1.0 D of attempted correction and 91% were within ± 0.5 D. Efficacy index was 0.93 while the safety index was 1. No complications occurred intra- or postoperatively. No eyes lost more than 1 line of their preoperative CDVA. All highly myopic eyes (- 6.25 to - 10.00 D; n = 18) achieved 20/20 at 3 months postoperatively and were within 0.5 D from the attempted SE and no eyes lost more than 1 line of CDVA.

CONCLUSION

The SMILE Pro® is a safe, efficient, and predictable procedure for the treatment of myopia and myopic astigmatism, with comparable results of conventional SMILE surgery. High myopic eyes achieve better results than low and moderate myopia. No complications were recorded in our patients.

Recommendation for Presbyopia-Correcting Intraocular Lenses: A Delphi Consensus Statement by the ESASO Study Group

PURPOSE

To establish consensus among experts in lens and refractive surgery to guide general ophthalmologists on issues related to presbyopia-correcting intraocular lenses (IOLs).

DESIGN

A modified Delphi method to reach a consensus among experts.

METHODS

A steering committee formulated 105 relevant items grouped into four sections (preoperative considerations, IOL selection, intraoperative considerations, and postoperative considerations). The consensus was defined as ≥ 70% of experts agreeing with the evaluation of a statement.

RESULTS

Ten experts participated and completed all rounds of questionnaires (100% response rate). Of 68 items considered in the preoperative considerations, consensus was achieved in 48 (70.6%). There was a lack of consensus over IOL selection, the experts only agreed on the importance of the patient's habits for the optical IOL design selection. Of the 14 considerations related to intraoperative issues, the experts reached a consensus on 10 (71.4%). The postoperative considerations section reached the highest consensus in 10 items of 13 (76.9%).

CONCLUSIONS

Key recommendations for a diffractive multifocal IOL were a potential postoperative visual acuity > 0.5, a keratometry between 40-45 diopters, a pupil >2.8 mm under photopic conditions and <6.0 mm under scotopic conditions, a root mean square of higher order corneal aberrations <0.5 µm for 6-mm pupil size, while monofocal or non-diffractive IOLs should be considered for patients with coexisting eye disorders. A lack of agreement was found in the issues related to the IOL selection.

Evaluation of Nozzle Tip Damage in Intraocular Lens Injectors with V-Shaped Notch

INTRODUCTION

Damage to the nozzle tips of intraocular lens (IOL) injectors has been associated with various adverse events and even IOL surface abnormalities after IOL implantation. In this study, nozzle tip damage of three different injector models with v-notched nozzle tips was systematically evaluated using our self-developed system - the Heidelberg Score for IOL injector damage.

METHODS

Nozzle tip damage was categorized into 6 grades: no damage (grade 0), slight scratches (1), deep scratches (2), extensions (3), cracks (4), and bursts (5). Each grade was assigned to a score of 0-5. In each IOL injector group, all IOLs were divided into 2 subgroups based on IOL power: +15 to +21D group and +21 to +26D group. The total scores for each group were the sum of scores for all injectors in this group. Further analysis was performed on the nozzle tip configuration and parameters in each injector model.

RESULTS

The median (Q1-Q3) for each injector group in group +15 to +21D was 1.5 (1-2) for Avansee, 4 (3-4) for iSert, and 4 (3-4) for multiSert. A statistically significant difference was found between Avansee and iSert (p < 0.001) as well as between Avansee and multiSert (p < 0.01) in terms of median scores. The median (Q1-Q3) for each injector group in group +21 to +26D was 1.5 (1-2) for Avansee, 4 (4-4) for iSert, and 3 (3-3.75) for multiSert. A statistically significant difference was found between Avansee and iSert in terms of median scores (p < 0.001). The outer cross-sectional diameters were 1.80 and 1.78 mm for Avansee, 1.70 and 1.69 mm for iSert, and 1.69 and 1.68 mm for multiSert. The radii of each notch-based circle were 0.21 mm (Avansee), 0.09 (iSert), and 0.06 (multiSert), respectively. The tip angles for three injector models were 48° (Avansee), 46° (iSert), and 37° (multiSert).

CONCLUSIONS

Avansee showed the least nozzle tip damage of all three groups. Compared with our earlier study using preloaded injectors with intact endpieces, all the injector groups with v-notched nozzle tips had more damage to the nozzle tip. It was found that the closer the notch of the nozzle tip was to the letter "V," the more damaged the nozzle tip was after IOL implantation.

Nozzle tip damage in three generations of intraocular lens injector models: an experimental laboratory study

PURPOSE

To assess the nozzle tip damage of IOL injectors in three generations from the same manufacturer using the self-developed system-the Heidelberg Score for IOL Injector Damage.

SETTING

David J Apple Center for Vision Research, Department of Ophthalmology, University Hospital Heidelberg, Heidelberg, Germany DESIGN: Experimental laboratory study METHODS: The nozzle tip damage of three injector models (Emerald, iTec, and Simplicity) was determined using the Heidelberg score for IOL injector damage. Damage to the nozzle tip was examined under a microscope and graded as follows: no damage (score 0), slight scratches (1), deep scratches (2), extensions (3), cracks (4) and bursts (5). The total scores for each injector system were the sum of scores for all injectors in this model. Total scores of the three injector systems were evaluated and compared. The nozzle tip parameters (diameters, tip angles) were also measured in each group.

RESULTS

The Emerald system achieved the highest total scores, while the other two systems achieved similar total scores. There was no statistically significant difference in the total scores between the study groups (P > 0.05). The outer cross-sectional diameters were 2.10 and 2.10 mm for Emerald, 1.80 and 1.78 mm for iTec, and 1.78 and 1.80 mm for Simplicity. The thickness of the nozzle tips was 0.13 mm (Emerald), 0.17 mm (iTec) and 0.17 mm (Simplicity). The tip angle for three injector models was 35° (Emerald), 45° (iTec), and 45° (Simplicity).

CONCLUSIONS

Although different injector models exhibited varying degrees of damage to the nozzle tip, all injector models generally showed relatively good results. Newer generations of IOL injector models tend to perform better in terms of nozzle tip damage after IOL implantation.

Comparison of Minimally Invasive XEN45 Gel Stent Implantation in Glaucoma Patients Without and With Prior Interventional Therapies

INTRODUCTION

The aim of our analysis was to compare the effectiveness of the XEN45 gel stent implantation in patients without and with prior glaucoma intervention.

METHODS

Retrospective analysis including 148 medical records of consecutive glaucoma eyes without prior glaucoma intervention (group A, n = 45) or with prior glaucoma intervention (group B, n = 103). Follow-up data up to 12 months after XEN45 gel implantation were available for all eyes.

RESULTS

At 12 months, qualified success (IOP reduction of ≥ 20% and IOP < 18 mmHg without and with medication) was achieved in 76% of eyes in group A and in 72% of eyes in group B; corresponding values for complete success (IOP reduction of ≥ 20% and IOP < 18 mmHg without medication) were 56% and 55%. Mean IOP was significantly reduced by 58% from 36.0 ± 10.7 mmHg preoperatively to 14.2 ± 3.4 mmHg at 12 months in group A (p = 0.000) and by 53% from 31.6 ± 8.9 mmHg to 14.3 ± 4.2 mmHg and in group B (p = 0.000). The mean number of hypotensive medications had significantly decreased from 3.6 ± 0.8 at baseline to 0.3 ± 0.7 medications in group A (p = 0.000) and from 3.0 ± 1.0 to 0.3 ± 0.7 medications in group B (p = 0.000). Needling was required in 29% of eyes in group A and in 35% of group B within 12 months. No statistically significant differences were observed between eyes without and with prior glaucoma intervention.

CONCLUSION

The 1-year results of our retrospective analysis indicate that patients without and with previous glaucoma intervention can benefit from XEN45 gel stent implantation. Both groups achieved significant and similar reductions in IOP and hypotensive medication, with a slight trend towards greater reductions in eyes without prior glaucoma intervention. Further controlled prospective studies with longer follow-ups are required.

FUNDING

Editorial support and article processing charges were funded by Allergan.

[Optical quality of three trifocal intraocular lens models : An optical bench comparison]

BACKGROUND

Knowledge of the optical quality of different trifocal intraocular lenses (IOL) is important in customized patient care.

OBJECTIVE

Different trifocal IOL were compared regarding their optical quality.

MATERIALS AND METHODS

We analyzed the FineVision (PhysIOL, Liège, Belgium), the AT LISA tri 839MP (Zeiss, Oberkochen, Germany), and the AcrySofIQ PanOptix (Alcon, Fort Worth, TX, USA) with a power of +21D for the distance using the OptiSpheric IOL PRO optical bench (Trioptics, Wedel, Germany). The additions for the near and intermediate distances were as follows: +3.5D/+1.75D (FineVision), +3.33D/+1.66D (AT LISA tri), and + 3,25D/+ 2,17D (PanOptix). We evaluated the modulation transfer function (MTF) at a spatial frequency of 50lp/mm and the Strehl ratio using 3‑ (photopic) and 4.5-mm (mesopic) apertures.

RESULTS

The MTF at 50 lp/mm (FineVision/AT Lisa tri/PanOptix) at the far focus was 0.373/0.399/0.400 (3-mm aperture) and 0.512/0.311/0.243 (4.5-mm aperture). At the intermediate focus, the MTF was 0.162/0.147/0.153 (3-mm aperture) and 0.092/0.125/0.137 (4.5-mm aperture). The MTF at the near focus was 0.229/0.192/0.404 (3-mm aperture) and 0.217/0.212/0.169 (4.5-mm aperture). The Strehl ratio was 0.335/0.298/0.370 (3-mm aperture) and 0.243/0.180/0.270 (4.5-mm aperture) at the far focus. At intermediate distances, the Strehl ratio was 0.189/0.185/0.162 (3-mm aperture) and 0.099/0.097/0.114 (4.5-mm aperture). The Strehl ratio was 0.305/0.283/0.464 (3-mm aperture) and 0.177/0.181/0.155 (4.5-mm aperture) at the near focus.

CONCLUSION

Evaluation of the three trifocal IOL models at the optical bench could show distinct peaks at the far, intermediate, and near focus. The results were comparable in terms of optical performance.

[Explantation of two historical posterior chamber phakic intraocular lenses 31 years after implantation]

This article reports the case of a 56-year-old male patient who had undergone implantation of posterior chamber phakic intraocular lenses in 1987 in Russia. The patient presented to this clinic 31 years after the initial surgery with anterior cortical cataracts and initial stages of corneal decompensation in both eyes. Strategic planning and execution of surgical treatment and the further clinical course are portrayed in this report.

Five-Year, Prospective, Randomized, Multi-Surgeon Trial of Two Trabecular Bypass Stents versus Prostaglandin for Newly Diagnosed Open-Angle Glaucoma

PURPOSE

To evaluate 5-year safety and efficacy of 2 trabecular micro-bypass stents versus prostaglandin as initial stand-alone treatment for newly diagnosed, treatment-naive primary open-angle glaucoma (POAG).

DESIGN

Prospective, randomized, controlled, multi-surgeon clinical trial.

PARTICIPANTS

Enrolled eyes (n = 101) were phakic and had a confirmed POAG diagnosis, normal angle anatomy, mean diurnal intraocular pressure (IOP) 21 to 40 mmHg, and vertical cup-to-disc (C:D) ratio ≤0.9.

METHODS

Eyes were randomized (1:1) to receive either 2 stents (iStent trabecular micro-bypass; Glaukos Corporation, San Clemente, CA) or once-daily topical travoprost.

MAIN OUTCOME MEASURES

The primary and secondary efficacy end points were the change from screening in mean diurnal IOP at months 12 and 24, respectively, without glaucoma surgery or add-on medication (any medication in stent eyes or a second medication in travoprost eyes). Two additional secondary end points were the proportion of eyes achieving treatment success at months 12 and 24, defined as IOP 6 to 18 mmHg without additional medication or glaucoma surgery. This report shows these efficacy measures through 60 months. Safety measures included best-corrected visual acuity, C:D ratio, visual field, pachymetry, complications, and adverse events.

RESULTS

Of 101 enrolled eyes (54 stent eyes, 47 travoprost eyes), 90 eyes (49 stent eyes, 41 travoprost eyes) completed 5-year follow-up. Five-year mean diurnal IOP was 16.5±1.2 mmHg in stent eyes (35.3% reduced vs. 25.5±2.5 mmHg preoperatively; P < 0.0001) and 16.3±1.9 mmHg in travoprost eyes (35.1% reduced vs. 25.1±4.6 mmHg preoperatively; P < 0.0001). During follow-up, add-on medication was initiated in 12 stent eyes (22.2% of the initial 54-eyes) and 18 travoprost eyes (38.3% of the initial 47-eyes). By 5 years, 17% (6/35) of stent eyes and 44% (14/32) of travoprost eyes needed add-on medication to control IOP (P = 0.017). Treatment success was achieved in 77% (27/35) of stent eyes and 53% (17/32) of travoprost eyes (P = 0.04). Both groups exhibited excellent safety.

CONCLUSIONS

This prospective randomized trial demonstrates 5-year effectiveness and safety of 2 trabecular bypass stents in patients with newly diagnosed, treatment-naive POAG, with comparably favorable outcomes as topical prostaglandin.

Prospective Evaluation of Two iStent® Trabecular Stents, One iStent Supra® Suprachoroidal Stent, and Postoperative Prostaglandin in Refractory Glaucoma: 4-year Outcomes

Introduction

This study evaluates long-term outcomes of two trabecular micro-bypass stents, one suprachoroidal stent, and postoperative prostaglandin in eyes with refractory open angle glaucoma (OAG).

Methods

Prospective ongoing 5-year study of 80 eligible subjects (70 with 4-year follow-up) with OAG and IOP ≥ 18 mmHg after prior trabeculectomy and while taking 1–3 glaucoma medications. Subjects received two iStent^® trabecular micro-bypass stents, one iStent Supra^® suprachoroidal stent, and postoperative travoprost. Postoperative IOP was measured with medication and annually following medication washouts. Performance was measured by the proportion of eyes with ≥ 20% IOP reduction on one medication (the protocol-specified prostaglandin) versus preoperative medicated IOP (primary outcome); and the proportion of eyes with postoperative IOP ≤ 15 and ≤ 18 mmHg on one medication (secondary outcome). Additional clinical and safety data included medications, visual field, pachymetry, gonioscopy, adverse events, visual acuity, and slit-lamp and fundus examinations.

Results

Preoperatively, mean medicated IOP was 22.0 ± 3.1 mmHg on 1.2 ± 0.4 medications, and mean unmedicated IOP was 26.4 ± 2.4 mmHg. Postoperatively, among eyes without later cataract surgery, mean medicated IOP at all visits through 48 months was ≤ 13.7 mmHg (≥ 37% reduction), and annual unmedicated IOP was ≤ 18.4 mmHg (reductions of ≥ 30% vs. preoperative unmedicated IOP and ≥ 16% vs. preoperative medicated IOP). At all postoperative visits among eyes without additional surgery or medication, ≥ 91% of eyes had ≥ 20% IOP reduction on one medication versus preoperative medicated IOP. At month 48, 97 and 98% of eyes achieved IOP ≤ 15 and ≤ 18 mmHg, respectively, on one medication. Six eyes required additional medication, no eyes required additional glaucoma surgery, and safety measurements were favorable throughout follow-up.

Conclusion

IOP control was achieved safely with two trabecular micro-bypass stents, one suprachoroidal stent, and postoperative prostaglandin. This microinvasive, ab interno approach introduces a possible new treatment option for refractory disease.

Trial Registration

NCT01456390.

Funding

Glaukos Corporation.

Electronic supplementary material

The online version of this article (10.1007/s12325-018-0666-4) contains supplementary material, which is available to authorized users.

Newly Diagnosed Primary Open-Angle Glaucoma Randomized to 2 Trabecular Bypass Stents or Prostaglandin: Outcomes Through 36 Months

Purpose

To examine outcomes through 36 months in phakic eyes with newly diagnosed primary open-angle glaucoma (POAG) naïve to therapy randomized to treatment with two trabecular micro-bypass stents or topical prostaglandin.

Methods

Subjects with POAG naïve to therapy, with intraocular pressure (IOP) ≥21 and ≤40 mmHg, were randomized to implantation of two stents or travoprost. Additional medication was to be prescribed post-treatment for elevated IOP or glaucomatous optic nerve findings. Of 101 randomized subjects, 100 subjects were followed for 24 months and 73 subjects were followed for 36 months. Follow-up on all subjects is ongoing.

Results

In this randomized cohort of 101 POAG subjects, 54 subjects underwent 2-stent surgery and 47 received topical travoprost. Mean pre-treatment IOP was 25.5 ± 2.5 mmHg in stent-treated eyes and 25.1 ± 4.6 mmHg in medication-treated eyes. By 3 years, mean IOP was 14.6 mmHg in stent eyes (with medication added in 6 eyes) and 15.3 mmHg in travoprost eyes (with a second medication added in 11 eyes). In the subset of eyes that did not require additional medical therapy, mean IOP was 14.5 mmHg and 15.7 mmHg in the respective groups. Ninety-one percent of stent eyes had 3-year IOP ≤18 mmHg without additional therapy (62% ≤ 15 mmHg) and 79% of travoprost eyes had 3-year IOP ≤18 mmHg (21% ≤ 15 mmHg). Safety was favorable in both groups.

Conclusions

In this prospective, randomized comparison of subjects with newly diagnosed POAG naïve to therapy, substantial IOP reduction with a favorable low complication rate was shown through 3 years after either 2 trabecular stents implanted as the sole procedure or topical travoprost therapy. These data suggest 2-stent implantation may be a viable initial treatment option comparable to topical prostaglandin in newly diagnosed POAG patients.

Trial registration: ClinicalTrials.gov identifier, NCT01443988.

Funding

Glaukos Corporation, Laguna Hills, CA.

Electronic supplementary material

The online version of this article (doi:10.1007/s40123-016-0065-3) contains supplementary material, which is available to authorized users.

[Avulsion of the Globe after Bicycle Accident--Clinical and Histopathological Evaluation]

BACKGROUND

Potential pathological mechanisms and complications of traumatic avulsio bulbi will be discussed based on the history, clinical, and histopathological findings of two patients.

HISTORY AND SIGNS

Both patients were heavily affected by alcohol and had a bicycle accident with subsequent perforation of the upper eyelid by the handlebar-mounted hand brake levers. The accident resulted in disruption of the optic nerve and anterior displacement of the globe.

THERAPY AND OUTCOME

In one patient, it was possible to reposition the globe into the orbit; however, the second patient's eye had to be enucleated. Functional testing demonstrated permanent loss of vision of the primary involved eyes, visual field defects, and visual impairment of one fellow eye.

CONCLUSION

Avulsio bulbi describes a severe trauma to the eye often induced by sport and traffic accidents. Special attention should be addressed to the primary non-affected fellow eye with regard to potential functional defects.

Safety and accuracy of a new long-term subconjunctival glucose sensor

BACKGROUND

A new biosensor has been developed by EyeSense (Großostheim, Germany) that is placed into the conjunctiva of one eye to measure the glucose concentration of the surrounding tissue in a non-invasive manner. In the present study we investigated the correlation between glucose concentrations measured by the EyeSense implant and those determined by finger prick testing, as well as the tolerability and safety of the implant over a 16-week period.

METHODS

The study was performed in 28 diabetic patients. The biosensor was inserted under local anesthesia and sterile conditions. Correlations between capillary glucose measured by laboratory methods and interstitial glucose determined by the biosensor were investigated by inducing increases and decreases in glucose values between 60 and 300 mg/dL.

RESULTS

Most patients experienced a mild subconjunctival hemorrhage postoperatively. Except for the minor sensation of the presence of foreign body, the implants were well tolerated. Three patients lost the ocular mini insert spontaneously, whereas there was a function failure of the insert in four patients. Error grid analysis showed that the percentage of data pairs in the acceptable ranges (zone A and B) was very high (>96%). However, there was a shift from zone A to zone B during observation. This was due primarily to an increase in the lag time between capillary and interstitial measured glucose.

CONCLUSION

he present study demonstrates good tolerability and measurement performance of the biosensor. The reasons for an increase in the lag time are still unknown; local reactions may be involved.

Undetected development of glaucoma after radial keratotomy

PURPOSE

To report a case of advanced glaucomatous optic atrophy years after bilateral radial keratotomy.

METHODS

Multiple intraocular pressure (IOP) measurements of both eyes in a 40-year-old woman who underwent previous bilateral radial keratotomy were obtained using Goldmann applanation tonometry as well as air-puff and Schiotz tonometry. In addition to regular eye examinations, corneal thickness, surface, and shape were examined using Orbscan and C-Scan.

RESULTS

The cornea of both eyes did not show signs of corneal thinning, but flattening of the corneal surface was observed. The decreased corneal curvatures precipitated a misjudgment of IOP readings measured by central applanantion tonometry (12 to 18 mmHg), whereas impression and non-contact tonometry revealed elevated IOP values (21 to 27 mmHg).

CONCLUSIONS

Changes of the corneal shape without corneal thinning can lead to falsely low IOP values. Therefore, in eyes that have undergone corneal refractive surgery, non-Goldmann measurement of IOP and continued examination of the optic nerve and possibly visual fields are recommended.

Transpalpebral measurement of intraocular pressure using the TGDc-01 tonometer versus standard Goldmann applanation tonometry

BACKGROUND

A recently developed digital tonometer for transpalpebral intraocular pressure (IOP) measurement, distributed by Corneal, Inc., allows the noninvasive measurement of IOP for screening purposes.

METHOD

We measured the IOP of 218 eyes in 109 patients of the Interdisciplinary Uveitis Center of the University of Heidelberg with intact corneal epithelium. IOPs were measured first with the TGDc-01 tonometer, and then by means of Goldmann tonometry. IOPs were recorded by two independent examiners. The mean of three measurements obtained with the TGDc-01 was taken, whereas only one measurement was performed with the Goldmann tonometer.

RESULTS

The mean difference between the TGDc-01 and Goldmann measurements was 3.7 mmHg. The standard deviation of the differences was +/-4.06 mmHg. Thus measurements acquired with the TGDc-01 may range 4.4 mmHg above or 11.8 mmHg below the values given by Goldmann tonometry.

CONCLUSION

The IOP values obtained with the TGDc-01 were in poor agreement with Goldmann tonometry. We found a higher variation as well as a bias towards lower IOP values with the TGDc-01. It is a question of clinical judgement as to how far these deviating measurements can be accepted for screening purposes. Because the IOPs obtained with the TGDc-01 are generally lower and less accurate than those obtained with the Goldmann tonometer we believe that the TGDc-01 is not a reliable tool for IOP measurement in clinical routine.

Intraocular pressure more reduced during anesthesia with propofol than with sevoflurane: both combined with remifentanil

BACKGROUND

Short-acting anesthetic agents are suitable and commonly used in ocular surgery. Propofol and remifentanil are known to reduce intraocular pressure (IOP), but no information is available regarding the effects of sevoflurane combined with remifentanil on IOP.

METHODS

Therefore, a prospective, randomized study was conducted to compare the effects on IOP of two different anesthetic techniques: one based on a total intravenous anesthesia with propofol (Group P, bolus 1.5-2.0 mg/kg, maintenance 3.0-7.0 mg/kg/h); and the other based on sevoflurane (Group S, inhalational induction, end-tidal concentration 0.7-1.2 vol.%). An infusion of remifentanil (10 microg/kg/h) was used with both techniques. In ASA I-III patients with normal IOP undergoing elective cataract surgery, using an applanation tonometer, IOP was measured contralateral to the operated eye at nine predefined time points before, during and after anesthesia.

RESULTS

The two groups (n=20 each) were comparable with regard to demographic data and hemodynamic variables. Baseline IOP was 14.2+/-2.8 mmHg (Group P) and 14.1+/-2.4 mmHg (Group S; NS). During and following the induction of anesthesia, IOP was reduced in both groups. Intraocular pressure was significantly lower in Group P (6.0+/-3.2 mmHg) than in Group S (8.9+/-3.4 mmHg) during the induction of anesthesia.

CONCLUSION

In patients undergoing cataract surgery under general anesthesia with tracheal intubation, anesthetic regimens with propofol as well as with sevoflurane, both combined with remifentanil, decrease IOP significantly. The decrease in IOP was significantly more pronounced in the propofol group than in the sevoflurane group.

Pediatric cataract surgery and intraocular lens implantation techniques: a laboratory study

The use of primary posterior capsulectomy and anterior vitrectomy during pediatric intraocular lens (IOL) implantation has been advocated as a means of preventing the development of posterior capsule opacification. In this study, we used pediatric eyes obtained postmortem to compare two different sequences in the surgical procedure: (1) anterior capsulectomy, lens substance removal, primary posterior capsulectomy with anterior vitrectomy, and IOL implantation in the capsular bag; (2) anterior capsulectomy, lens removal, IOL implantation in the capsular bag, and primary posterior capsulectomy with anterior vitrectomy. Both sequences could be safely performed in the laboratory setting while maintaining stable capsular fixation of the IOL. Placing the IOL in the capsular bag was easier when the posterior capsule was intact (sequence 2). However, both techniques appear feasible for clinical use. Surgeons not familiar with mechanized primary posterior capsulectomy can gain clinically relevant experience by operating on pediatric autopsy eyes in a laboratory setting.

[Pseudo-accommodation of diffractive multifocal lenses and monofocal lenses]

35 patients were examined for their pseudoaccommodation 6 to 18 months after cataract extraction and implantation of a diffractive multifocal intraocular lens (MIOL). While in 15 patients a MIOL had been implanted in both eyes 20 patients had a MIOL in one eye only. 45 type 3M 815 LE and 5 3M 825 XE lenses were implanted. The mean age was 58.2 years +/- 9.6 years (33 to 76). Only patients without any pathology except cataract and preoperative refractive errors < +/- 5 diopters of spherical and +/- 1 diopter of astigmatic refraction were eligible for implantation of MIOLs. After estimation of the objective and subjective refraction the patients' pseudoaccommodation was measured by testing their visual acuity, adding lenses of +/- 1, 2, 3, 4, 5 diopters to their best distance correction. All patients with MIOLs reached a visual acuity of 0.4 or better with a maximum peak at 0 and -3 diopters. The visual acuity of the MIOL patients was significantly better in the range of -1 to -4 diopters compared to the results of a control group of patients with monofocal IOLs. This suggests a wider range of pseudoaccommodation in patients with MIOLs.

Cycloplegic refraction in children: single-dose-atropinization versus three-day-atropinization

A new scheme for refractive measurements under atropine cycloplegia was tested in 90 strabismic children aged two to several years. Refraction was determined by an autorefractor (CANON R 10) 90 minutes after application of two drops of atropine (0.5% atropine children < 2 1/2 years; 1.0% atropine children > 2 1/2 years) and compared with the results after 3 days of receiving 1 atropine eyedrop 3 times daily. In 86.5% the spherical equivalents differ not more than 1.0 diopter (p = 0.05); the correlation was 0.99. Astigmatic corrections were in agreement in 95.5%, the axis of cylinders in 93.0% (p = 0.05); the correlations were 0.95 and 0.97. The residual accommodation 90 minutes after 2 drops of atropine was not more than 1 diopter in all children. The additional cycloplegic effect of the three-day-atropinization was only 0.5 diopters. This new type of application allows a more rapid and less toxic assessment of refraction than the usual three-day-atropinization.

[Refraction by atrophine cycloplegia]

A new method for refractive measurements with atropine cycloplegia was tested in 90 children with squint. Measurements were taken by an autorefractor (Canon R 10) 90 min after application of 2 atropine eye drops and after 3 days of receiving 1 atropine eye drop 3 times daily, i.e. 9 drops per eye. Results were also compared to conventional "objective" refractometry by means of a hand refractometer (Rodenstock PR 50). According to this method, the total refraction, spherical and cylindric power and the cylinder axis are in agreement with refractive data in 80-90% of the children after 3-day atropinization. The additional cycloplegic effect of atropine given for 3 days is only 0.5 dptr compared to the application of 2 drops on the first day. So for practical purposes the refractive data evaluated after 90-min atropinization can be used as a basis for the prescription of glasses.

[Clinical use of the Canon R10 autorefractometer for determining refraction in children with strabismus]

Using a Canon R 10 Autofractor, refraction was measured in 131 children with squint. Measurements before and after cycloplegia were compared to a reference measurement (taken with the Rodenstock PR 50 hand-held refractometer after cycloplegia). In 80% of the cases the power and axis of the cylinder equalled the reference measurements. Due to accommodation, 40% of the values for spherical equivalents before cycloplegia were false. After cycloplegia 80% of the spherical equivalents were also in agreement with the reference measurement. The short examination time and the interesting fixation target facilitate multiple measurements in children. As a result, refraction can be measured more reliably with the R 10 Autorefractor than with the hand-held refractometer in children from age 2 1/2 or 3. Retinoscopy is only indispensable in cases where it is difficult or impossible to use an autorefractor, i.e., on children aged under 2 1/2 and those with extreme head tilt.