Clinical performance after implantation of an EDOF intraocular lens in the dominant eye and a presbyopia-correcting intraocular lens in the nondominant eye

PURPOSE

To evaluate subjective and objective outcomes after combined implantation of an extended depth-of-focus (EDOF) intraocular lens (IOL) and a combined technology multifocal lens (CT-IOL).

SETTING

2 clinical practices (Carolina Eyecare Physicians, Center For Sight) in the United States.

DESIGN

Prospective, unmasked, multicenter, nonrandomized bilateral eye study.

METHODS

Patients interested in reducing their dependence on spectacles were implanted with an EDOF IOL in the dominant eye and a CT-IOL in the nondominant eye. Refractive and visual acuity (VA) data at various distances (4 m, 66 cm, 40 cm, and 33 cm) were collected 3 months postsurgery, along with the distance-corrected binocular defocus curve and responses to questionnaires related to spectacle independence, visual disturbances, and overall visual function.

RESULTS

Data from 37 participants were analyzed. The distance-corrected binocular defocus curve showed a mean VA better than 0.1 logMAR (20/25) at all vergences from +1.00 to -2.50 diopters (D). 36 participants (97%) had an uncorrected binocular VA of 0.3 logMAR or better, at all test distances. 70% of participants (26/37) reported never wearing spectacles at any distance, and 84% (31/37) were "completely" or "mostly" satisfied with their overall vision after surgery. Halos were the disturbance reported most frequently and reported as most bothersome, with difficulty driving at night the most common visual function issue. Difficulty reading was the next most reported issue. Overall eyesight was rated as "excellent" or "good" by 92% (34/37) of participants.

CONCLUSIONS

This combined EDOF/CT-IOL approach was well-tolerated by participants and provided some potential benefits relative to bilateral implantation of either lens.

Comparing Visual Performance and Subjective Outcomes with an Enhanced Monofocal Intraocular Lens When Targeted for Emmetropia or Monovision

Purpose

To evaluate relative visual performance and subjective outcomes after implantation of the TECNIS Eyhance™ intraocular lens (IOL) targeted for bilateral emmetropia or monovision.

Methods

This was a prospective, single-center randomized, patient-masked trial. Patients were implanted with the enhanced IOL targeted for bilateral emmetropia or slight monovision (-0.75 D in the non-dominant eye). At 3 months the binocular visual acuity (VA) was measured at distance, intermediate and near, along with low contrast VA in photopic and mesopic conditions, and the distance corrected defocus curve. Questionnaires related to spectacle independence, satisfaction, visual symptoms, and functional vision were administered.

Results

Data from 71 subjects (34 Emmetropia, 37 Monovision) were analyzed. There was no difference in the mean uncorrected distance VA (p = 0.11), but uncorrected intermediate and near VAs were one line better in the Monovision group (p = 0.02 and 0.01, respectively). Mesopic and photopic low contrast VA were similar between groups. There was a trend for less difficulty and higher satisfaction with near and intermediate vision in the Monovision group, but no significant differences in any of the subjective questionnaires. Difficulty reading was the most reported concern in both groups, though 93% of all subjects reported "little" or "no" difficulty with daily activities. Overall, 82% of subjects were "completely" or "very" happy with their lens choice.

Conclusion

Using this enhanced IOL with slight monovision in the non-dominant eye increased intermediate and near VA with no apparent effect on low contrast distance VA, subjective visual quality, or satisfaction.

Visual Outcomes, Quality of Vision, Patient Satisfaction and Spectacle Independence After Bilateral Implantation of the Synergy™ Intraocular Lens

Purpose

To evaluate vision, visual quality, patient satisfaction and spectacle independence after bilateral implantation of the TECNIS Synergy™ intraocular lens.

Setting

Two clinical practices in the USA.

Design

Ambispective unmasked non-randomized clinical trial.

Methods

Patients with a history of uneventful bilateral femtosecond laser assisted cataract surgery with the study IOL implanted, targeted for emmetropia, at least 3 months prior to the study visit were enrolled. Monocular and binocular visual acuity (VA) were measured at distance, intermediate and near, along with binocular mesopic VA. Low contrast binocular VA and reading speed in mesopic and photopic conditions were also measured. Patient satisfaction, spectacle independence, visual symptoms, and functional vision questionnaires were completed.

Results

Results from 52 subjects were available for analysis. Mean binocular unaided visual acuity was ~0.1 logMAR (20/20) from distance to 33 cm, with 81% of subjects having 0.2 logMAR (20/25) vision or better at all test distances and 92% reporting never needing glasses at any distance. Average reading speed at 40 cm was only 10 words/minute slower in dim light (p = 0.03). Mesopic and low contrast acuity appeared good. Halos were the most frequent and bothersome visual disturbances, with the greatest effect on driving at night. Eighty-eight percent of subjects reported being "completely" or "mostly" satisfied with their overall unaided vision.

Conclusion

This hybrid technology IOL provided a range of binocular visual acuity from distance to 33 cm and good functional vision, even in dim light. Patients should be advised of the likelihood of visual disturbances, particularly halos.

Visual outcomes, satisfaction, and spectacle independence with a nondiffractive extended vision intraocular lens targeted for slight monovision

PURPOSE

To evaluate vision, satisfaction, and spectacle independence of the AcrySof IQ Vivity intraocular lens when the nondominant eye is targeted for slight myopia.

SETTING

1 clinical practice in the United States.

DESIGN

Prospective unmasked nonrandomized clinical trial.

METHODS

Patients presenting for cataract surgery interested in reducing their dependence on spectacles were enrolled, with the dominant eye targeted for emmetropia and the nondominant eye targeted for slight monovision (-0.50 diopters [D]). Visual disturbances, satisfaction, and spectacle independence were evaluated. Visual acuity (VA) was tested at distance (4 m), intermediate (66 cm), and near (40 cm) at 3 months postoperatively when uncorrected, with both eyes corrected to emmetropia and with 1 eye adjusted for monovision. 2 binocular defocus curves were also collected under the latter 2 conditions.

RESULTS

Data from 31 patients were analyzed. The mean refractive spherical equivalent was 0.45 D more myopic in the nondominant eye, resulting in worse uncorrected VA at distance but better uncorrected VA at near. The binocular defocus curve with monovision showed significantly better VA from -2.0 to -3.0 D, and patients reported less need for spectacles (and better vision) at near than reported with binocular emmetropia. Glare, blurred vision, and starbursts were the most reported visual disturbances. Although not correlated with the difference in refraction, glare and blurred vision were significantly correlated with overall satisfaction.

CONCLUSIONS

Implanting this IOL with a target of slight myopia in the nondominant eye appears to be a viable way to improve near vision, although with an increased potential for visual disturbances.

The Effects of Angle Kappa on Clinical Results and Patient-Reported Outcomes After Implantation of a Trifocal Intraocular Lens

Purpose

To objectively determine if angle kappa materially influenced clinical outcomes or patient-reported satisfaction and visual quality of patients implanted with a trifocal intraocular lens (IOL).

Methods

This was a non-interventional study of clinical outcomes. Subjects were patients choosing to be bilaterally implanted with a trifocal IOL (PanOptix^®) who were then evaluated 3 months postoperative. Angle kappa (AK) was measured before surgery and at the 3-month visit. The 3-month visit included a manifest refraction, and measurement of uncorrected and distance corrected acuity at 4 m, 60 cm and 40 cm. Visual quality and satisfaction questionnaires were also administered.

Results

Data from 56 eyes of 28 subjects were analyzed; 26 eyes had an AK magnitude <0.3 mm, 14 had an AK from 0.3 mm to less than 4 mm and 16 had an AK ≥0.4 mm. Neither visual disturbances (eg, glare, halos, starbursts), satisfaction nor spectacle dependence were correlated to the magnitude of angle kappa. The magnitude of postoperative AK was significantly lower than preoperative (0.24 ± 0.12 mm vs 0.30 ± 0.16 mm, p < 0.01).

Conclusion

The magnitude of preoperative Angle Kappa had no apparent effect on the refractive, visual acuity or subjective (visual disturbances, quality of vision, satisfaction) clinical outcomes with this trifocal IOL. The magnitude of angle kappa was significantly lower after surgery.

Visual Acuity, Defocus Curve, Reading Speed and Patient Satisfaction with a Combined Extended Depth of Focus Intraocular Lens and Multifocal Intraocular Lens Modality

Purpose

To evaluate the vision, defocus curve, reading speed and patient satisfaction after implantation of an extended depth of focus (EDOF) IOL in one eye and a diffractive multifocal in the fellow eye.

Setting

One clinical practice in the USA.

Design

Prospective unmasked non-randomized clinical trial.

Methods

Subjects presenting for routine cataract surgery interested in reducing their dependence on spectacles were enrolled. Study endpoints included uncorrected and distance-corrected binocular distance (4 m), intermediate (66 cm) and near (40 cm) visual acuity at 3 months. Additional endpoints included the residual refraction, spectacle independence, overall satisfaction with vision, visual symptoms, reading speed and defocus curve.

Results

With a best distance correction, 77% (30/39) of subjects had 20/25 or better VA at distance, intermediate and near and nearly all subjects had 20/32 or better VA at all three distances. Defocus curve results showed mean continuous vision of 20/25 or better from plano to −2.50 D. Nearly 80% (31/39) of subjects had 20/25 visual acuity from 0.00 D to −2.50 D. The critical print size was between 0.3 and 0.4 logMAR (20/40 to 20/50 Snellen Equivalent). Spectacle independence was 100% at distance, 95% at intermediate and approximately 70% at near. The percentage of subjects who were “not at all” or “slightly” bothered by visual disturbances ranged from 64% (16/25) for Halos to 88% (22/25) for Starbursts.

Conclusions

EDOF/bifocal IOL blended implantation results in at least 20/25 mean visual acuity from distance to near with good spectacle independence and low reports of severe visual disturbances.

Evaluating Rotational Stability of an Extended Depth of Focus Toric Intraocular Lens Using a Slit Lamp and Image-Based Analysis

Purpose

To evaluate the rotational stability of a toric extended depth of focus (EDOF) intraocular lens (IOL), using either slit lamp evaluation or image-processing software.

Setting

Three clinical practices in the USA.

Design

Prospective unmasked randomized clinical trial.

Methods

Subjects presenting for routine cataract surgery that were interested in improved near vision received toric EDOF lenses (TECNIS Symfony^® Toric) in both eyes. The measures of interest in the current analysis were the change in orientation of the IOL between 1 day, 1 month and 3 months postoperative. Orientation was measured at the microscope on the day of surgery, and with the slit lamp at all other visits. Day 1, 1-month and 3-month images of the lens orientation were captured with a slit lamp camera. Differences in orientation were recorded and analyzed.

Results

A total of 150 eyes had IOL orientation data available. Image analysis showed mean absolute lens orientation changes from 1 day to 1 month and 3 months of less than 2 degrees. The percentage of lenses exhibiting rotation of ≤5 degrees between any measured time points was 97% or higher. Results were similar, but significantly more variable, when IOL orientation was measured at the slit lamp.

Conclusion

The toric EDOF lens evaluated here demonstrated rotational stability that exceeded the prior ANSI standard. The best method to determine IOL orientation changes was through image analysis.  

Five-Year Outcomes Prospective Study of Two First-Generation Trabecular Micro-Bypass Stents (iStent®) in Open-Angle Glaucoma

PURPOSE

To assess 5-year effectiveness and safety of 2 iStent® trabecular micro-bypass stents in eyes with open-angle glaucoma (OAG) not controlled on 1 medication.

MATERIALS AND METHODS

This prospective, interventional, single-arm, multi-surgeon study (NCT #1252862, clinicaltrials.gov) enrolled eyes with OAG, preoperative intraocular pressure (IOP) of 18-30 mmHg on 1 ocular hypotensive medication, and 22-38 mmHg after medication washout. Eyes underwent standalone implantation of 2 iStent devices and were followed through 60 months postoperatively. Efficacy was quantified by mean diurnal IOP and medication usage. Efficacy endpoints included the proportion of eyes with ≥20% IOP reduction versus baseline unmedicated IOP (primary efficacy), and the proportion of eyes with IOP ≤18 mmHg (secondary efficacy) without medication or secondary glaucoma surgery. Safety parameters included visual acuity, cup-to-disc ratio, visual field, and complications and adverse events.

RESULTS

Preoperative mean IOP on 1 medication was 20.6 ± 2.0 mmHg and post-washout unmedicated IOP was 24.1 ± 1.4 mmHg (n = 39). At 5 years postoperative, medication-free mean diurnal IOP reduced to 14.5 ± 2.2 mmHg, constituting a 40% decrease versus preoperative washed-out IOP (p < .0001). In addition, this 5-year medication-free IOP constituted a 30% decrease versus preoperative IOP on 1 medication (p < .0001). At Month 60, 89.7% (26/29) of eyes achieved the primary efficacy endpoint of ≥20% IOP reduction versus baseline unmedicated IOP, and 86.2% (25/29) of eyes achieved the secondary efficacy endpoint of IOP ≤18 mmHg, without medication or secondary glaucoma surgery. Throughout follow-up, 89.7-91.3% of eyes were on no medications. Favorable safety included no secondary glaucoma surgeries, minimal adverse events, and stable visual acuity, cup-to-disc ratio, and visual fields through 5 years postoperative.

CONCLUSIONS

This prospective interventional study demonstrates persistent 5-year reductions in IOP and freedom from medications, together with favorable safety, following implantation of 2 first-generation trabecular micro-bypass stents in eyes with OAG on 1 preoperative medication.

Comparing Combination Drop Therapy to a Standard Drop Regimen After Routine Cataract Surgery

PURPOSE

To evaluate the efficacy of a combined steroid/antibiotic/non-steroidal anti-inflammatory drop relative to a regimen of multiple drops after cataract surgery.

SETTING

Single clinical practice in the USA.

DESIGN

Prospective randomized contralateral eye study.

METHODS

Subjects presenting for bilateral cataract surgery were enrolled with contralateral eyes randomly assigned to one of the two groups. Test eyes received a combination therapy (prednisolone acetate 1%, gatifloxacin 0.5%, and bromfenac sodium 0.075%) while control eyes received the same medications in separate drops (bromfenac sodium was 0.07%). Subjects were examined 1, 15 and 30 days after surgery. Visual acuities were measured, along with the refraction, intraocular pressure, patient pain and satisfaction, macular thickness and corneal pachymetry. The primary measure of interest was the change in macular thickness from baseline to the 15- and 30-day visits. The frequency and severity of reported ocular adverse events were tabulated for each group and compared.

RESULTS

Thirty-three subjects completed the study. Changes in central macular thickness were similar between groups, with only one control eye exhibiting significant macular edema. No differences in visual acuity, corneal edema, cells or flare were observed between groups. There were eight mild adverse events reported for all eyes of all subjects; the difference in the number of eyes experiencing adverse events was not statistically significantly different between groups (p ≥ 0.05 for all comparisons). While subjective symptoms were similar, all subjects indicated that they preferred the combination drop.

CONCLUSION

A combination drop showed similar efficacy to multiple drops and was overwhelmingly preferred by subjects.

Defocus Curve and Patient Satisfaction with a New Extended Depth of Focus Toric Intraocular Lens Targeted for Binocular Emmetropia or Slight Myopia in the Non-Dominant Eye

Purpose

To evaluate the defocus curve and patient satisfaction after implantation of an extended depth of focus (EDOF) toric IOL when both eyes were targeted for emmetropia and when the non-dominant eye was targeted for mini monovision (−0.50D).

Methods

A prospective unmasked randomized clinical trial in three clinical practices in the USA. Subjects presenting for routine cataract surgery were assigned to one of two groups, both receiving bilateral toric EDOF lenses. One group had the non-dominant eye targeted for slight myopia (−0.50D). Measures of interest were the postoperative defocus curve and reported patient satisfaction and visual disturbances.

Results

Questionnaire and defocus curve data were available from 37 subjects in the Emmetropia group, while the mini monovision group included questionnaire data from 39 subjects and valid defocus curve data from 14 subjects. Mini monovision subjects had significantly better VA (a half line to a line better, p < 0.05), from a defocus of −1.50 D to −3.00 D. Reported spectacle wear and satisfaction were not significantly different between groups at any distance, but more patients in the mini monovision group reported the ability to function comfortably without glasses at near and overall (near p = 0.02, overall p < 0.01). Halos and starbursts were the two phenomena reported most often for both groups, with reported starbursts slightly more common in the mini monovision group.

Conclusions

A slightly myopic correction in the non-dominant eye improved binocular near vision by 0.5 to 1.0 lines based on defocus curve data. Patients reported better functional vision, but with a slight increase in reported starbursts in the mini monovision group.

Extended depth-of-focus toric intraocular lens targeted for binocular emmetropia or slight myopia in the nondominant eye: Visual and refractive clinical outcomes

PURPOSE

To compare the visual and refractive outcomes with a diffractive toric extended depth-of-focus (EDOF) intraocular lens (IOL) when both eyes are targeted for emmetropia and the nondominant eye is targeted for slight myopia.

SETTING

Three clinical practices, United States.

DESIGN

Prospective case series.

METHODS

Patients having routine cataract surgery with bilateral Tecnis Symfony toric EDOF IOL implantation were assigned to 1 of 2 groups. In 1 group, the nondominant eye was targeted for -0.50 diopter (D) (mini-monovision). Assessments included uncorrected monocular and binocular visual acuities (logarithm of the minimum angle of resolution) at distance (4 m), intermediate (66 cm), and near (40 cm) and the postoperative residual refractive error.

RESULTS

Forty patients were enrolled in each group, with 1 dropout. The mean postoperative residual refractive astigmatism was 0.25 D in both groups, with no statistically significant difference. The mean residual refractive astigmatism was 0.50 D or lower in 92% of eyes (72/78) in the mini-monovision group and 95% of eyes (74/78) in the emmetropia group 3 months postoperatively. The mini-monovision group had slightly worse uncorrected visual acuity at 4 m than the emmetropia group (0.16 versus 0.09; P = .002) but better uncorrected acuity at 40 cm (0.25 versus 0.34; P < .001). Binocular uncorrected acuity was not statistically significantly different between groups at 4 m (-0.03 versus -0.01; P = .33) or 66 cm (0.06 versus 0.04; P = .34) but was statistically significant at 40 cm (0.25 versus 0.19; P = .03).

CONCLUSIONS

The EDOF toric IOL provided functional distance, intermediate, and near vision. A slight monovision approach appears to improve near visual acuity.

Correcting astigmatism at the time of cataract surgery: Toric IOLs and corneal relaxing incisions planned with an image-guidance system and intraoperative aberrometer versus manual planning and surgery

PURPOSE

To compare the outcomes of the combination of an image-guided system and intraoperative aberrometer with the surgeon's standard of care in correcting astigmatism using toric intraocular lenses (IOLs) or corneal incisions.

SETTING

Single site in United States.

DESIGN

Prospective case series.

METHODS

Contralateral eyes of patients having uncomplicated bilateral cataract surgery and astigmatism correction were randomly assigned to Group A or Group B. Group A received the surgeon's preferred standard of care. Group B had preoperative planning using an image-guidance system (VERION), intraoperative aberrometry (ORA System with VerifEye+), and femtosecond laser-assisted cataract surgery. The primary endpoint was the residual refractive astigmatism at 3 months.

RESULTS

Thirty-eight eyes were treated with toric IOLs and 40 eyes with corneal astigmatic incisions. On average, toric IOLs resulted in almost 0.25 diopter (D) less cylinder than corneal astigmatic incisions (P < .01), with no difference between groups (P = .41). There was no statistically significant difference in the mean spherical equivalent refraction by group (P = .51). At 3 months, the IOL in 4 eyes (11%) (2 in Group A and Group B each) was more than 10 degrees of absolute orientation from the intended orientation. The mean keratometry was 0.16 D higher with the image-guided system compared with optical biometry (Lenstar). The vector difference between the 2 measurements was 0.5 D or lower in all eyes.

CONCLUSIONS

The combined use of an image-guided system and intraoperative aberrometer did not significantly improve outcomes compared with the surgeon's standard of care. Based on keratometry, there was good agreement in corneal astigmatism measurements between the image-guided system and the optical biometer.

Clinical study using a new phacoemulsification system with surgical intraocular pressure control

PURPOSE

To compare cumulative dissipated energy (CDE), aspiration fluid used, and aspiration time during phacoemulsification cataract extraction using 2 surgical configurations.

SETTING

Two clinical sites in the United States and 1 in Spain.

DESIGN

Prospective randomized clinical case series.

METHODS

For each patient, the first eye having surgery was randomized to the active-fluidics configuration (Centurion Vision System with Active Fluidics, 0.9 mm 45-degree Intrepid Balanced tip, and 0.9 mm Intrepid Ultra infusion sleeve) or the gravity-fluidics configuration (Infiniti Vision System with gravity fluidics, 0.9 mm 45-degree Mini-Flared Kelman tip, and 0.9 mm Ultra infusion sleeve). Second-eye surgery was completed within 14 days after first-eye surgery using the alternate configuration. The CDE, aspiration fluid used, and aspiration time were compared between configurations, and adverse events were summarized.

RESULTS

Patient demographics and cataract characteristics were similar between configurations (100 per group). The CDE was significantly lower with the active-fluidics configuration than with the gravity-fluidics configuration (mean ± standard error, 4.32 ± 0.28 percent-seconds) (P < .001). The active-fluidics configuration used significantly less aspiration fluid than the gravity-fluidics configuration (mean 46.56 ± 1.39 mL versus 52.68 ± 1.40 mL) (P < .001) and required significantly shorter aspiration time (mean 151.9 ± 4.1 seconds versus 167.6 ± 4.1 seconds) (P < .001). No serious ocular adverse events related to the study devices or device deficiencies were observed.

CONCLUSION

Significantly less CDE, aspiration fluid used, and aspiration time were observed with the active-fluidics configuration than with the gravity-fluidics configuration, showing improved surgical efficiency.

FINANCIAL DISCLOSURES

Drs. Solomon and Cionni are consultants to Alcon Research, Ltd., and received compensation for conduct of the study. Dr. Lorente received compensation for clinical work in the study. Mr. Fanney is an employee of Alcon Research, Ltd.

Efficacy of two trabecular micro-bypass stents combined with topical travoprost in open-angle glaucoma not controlled on two preoperative medications: 3-year follow-up

Purpose

To evaluate the long-term intraocular pressure (IOP)-lowering effect and safety parameters following treatment with two trabecular micro-bypass stents and topical prostaglandin in phakic eyes with open-angle glaucoma (OAG) not controlled on two preoperative medications.

Methods

This prospective, single-arm, unmasked study enrolled 39 qualified phakic eyes with OAG not controlled on 2 medications, preoperative medicated IOP of 18–30 mmHg, and IOP following medication washout of 22–38 mmHg. Two trabecular micro-bypass stents were implanted as a standalone procedure, and travoprost was started on postoperative day 1. Evaluations included IOP, best-corrected visual acuity, medication use, fundus and slit-lamp examinations, visual field, cup:disc ratio, central corneal thickness, and ocular complications. Data through 18 months were summarized previously. Thirty-seven of the original 39 subjects have been followed for 3 years postoperatively; follow-up is continuing for 5 years.

Results

At 3 years postoperative, 97% of eyes had achieved an IOP reduction of ≥20% from baseline with a reduction of 1 medication. Eighty-six percent of eyes had IOP of ≤18 mmHg with a reduction of 1 medication. Mean medicated IOP decreased to 14.0±2.6 mmHg on 1 medication versus 22.4±2.3 mmHg on 2 medications preoperatively. The mean unmedicated IOP decreased to 17.7±1.7 mmHg at 37 months from 25.3±1.9 mmHg preoperatively. Long-term postoperative adverse events included cataract surgery in 3 eyes due to cataract progression, and trabeculectomy in 1 eye due to uncontrolled IOP of 23 mmHg. No intraoperative or device-related adverse events occurred.

Conclusion

Significant and sustained reduction in IOP and medications with a favorable safety profile was shown through 3 years after implantation of 2 trabecular micro-bypass stents combined with postoperative travoprost in phakic OAG eyes uncontrolled on 2 preoperative medications. These findings demonstrate the long-term performance and safety of trabecular bypass stents in combination with topical prostaglandin for OAG patients.

A prospective 3-year follow-up trial of implantation of two trabecular microbypass stents in open-angle glaucoma

Purpose

To evaluate 3-year safety and intraocular pressure (IOP) following two trabecular microbypass stents in phakic and pseudophakic subjects with open-angle glaucoma (OAG) not controlled on preoperative medication.

Patients and methods

In this prospective pilot study, phakic or pseudophakic subjects with OAG and IOP between 18 mmHg and 30 mmHg on one preoperative topical ocular hypotensive medication underwent medication washout. Thirty-nine qualified subjects with preoperative unmedicated IOP ≥22 mmHg and ≤38 mmHg received two stents. Postoperative examinations were scheduled at Day 1, Week 1, Months 1, 3, 6, and 12, and semiannually through Month 60. Ocular hypotensive medication was considered if postoperative IOP exceeded 21 mmHg. IOP, medication use, and safety were assessed at each visit. Subject follow-up through Month 36 was completed.

Results

Thirty-six eyes (92.3%; 95% confidence interval [CI] 79.1%, 98.4%) achieved the primary efficacy end point of Month 12 reduction in IOP ≥20% from baseline (unmedicated IOP) without ocular hypotensive medication. Four subjects required medication during the Month 36 follow-up period. Mean IOP at 36 months for subjects not taking medication was 15.2 mmHg. At 36 months, subjects sustained mean IOP decrease of 9.1±2.7 mmHg (95% CI 8.0 mmHg, 10.14 mmHg), or 37% IOP reduction, from unmedicated baseline IOP. Compared to preoperative medicated IOP, subjects had mean reduction at Month 36 of 5.5±2.7 mmHg (95% CI 4.5 mmHg, 6.6 mmHg), or 26% reduction. Both measures of IOP reduction were highly significant (P<0.001). Other than one case of early postoperative hyphema that resolved at 1 week, no postoperative adverse events were attributed to stent implantation.

Conclusion

In a pilot study, two trabecular microbypass stents to treat OAG subjects on one preoperative medication provided statistically significant, sustained, and safe reduction of IOP to ≤15 mmHg without medication through 36 months.

A multicenter randomized controlled fellow eye trial of pulse-dosed difluprednate 0.05% versus prednisolone acetate 1% in cataract surgery

PURPOSE

To compare the effects of 2 corticosteroids on corneal thickness and visual acuity after cataract surgery.

DESIGN

Multicenter, randomized, contralateral-eye, double-masked trial.

METHODS

Fifty-two patients (104 eyes) underwent bilateral phacoemulsification. The first eye randomly received difluprednate 0.05% or prednisolone acetate 1%; the fellow eye received the alternative. Before surgery, 7 doses were administered over 2 hours; 3 additional doses were given after surgery, before discharge. For the remainder of the day, corticosteroids were administered every 2 hours, then 4 times daily during week 1 and twice daily during week 2. Corneal pachymetry, visual acuity, and corneal edema were evaluated before surgery and at days 1, 15, and 30 after surgery. Endothelial cell counts were evaluated before surgery and at 30 days after surgery. Retinal thickness was evaluated before surgery and at 15 and 30 days after surgery.

RESULTS

Corneal thickness at day 1 was 33 μm less in difluprednate-treated eyes (P = .026). More eyes were without corneal edema in the difluprednate group than in the prednisolone group at day 1 (62% vs 38%, respectively; P = .019). Uncorrected and best-corrected visual acuity at day 1 were significantly better with difluprednate than prednisolone by 0.093 logMAR lines (P = .041) and 0.134 logMAR lines (P < .001), respectively. Endothelial cell density was 195.52 cells/mm(2) higher in difluprednate-treated eyes at day 30 (P < .001). Retinal thickness at day 15 was 7.74 μm less in difluprednate-treated eyes (P = .011).

CONCLUSIONS

In this high-dose pulsed-therapy regimen, difluprednate reduced inflammation more effectively than prednisolone acetate, resulting in more rapid return of vision. Difluprednate was superior at protecting the cornea and reducing macular thickening after cataract surgery.

Rabies prophylaxis after an animal attack that caused a ruptured eye and traumatic cataract: a case report

INTRODUCTION

We report on a patient with an animal bite eye injury, his surgical treatment and proper rabies immunoglobulin administration.

CASE PRESENTATION

A 33-year-old Turkey hunter was attacked by a bobcat and his injuries included a ruptured globe with corneal laceration, two iris sphincter tears, and a ruptured anterior capsule with a traumatic cataract. Rabies vaccination was started, primary closure of the corneal laceration, an anterior chamber washout and one week later cataract surgery were performed. Three months postoperatively he achieved an uncorrected visual acuity of 20/50 and a best corrected visual acuity of 20/20.

CONCLUSION

Bobcat attacks on humans are very rare and extremely suspicious for rabies infection of the animal. Ophthalmologists need to be aware of the importance of immediate and appropriate post exposure rabies vaccination. Proper rabies immunoglobulin administration in the setting of globe injuries is challenging and we report on the Center for Disease Control and Prevention recommendations for globe injuries.

Clinical outcomes and functional visual performance: comparison of the ReSTOR apodised diffractive intraocular lens to a monofocal control

AIMS

To compare clinical outcomes of patients bilaterally implanted with SN60D3 intraocular lenses (IOLs) with outcomes of bilateral monofocal controls, and to determine the validity of implanting an apodised diffractive lens in a healthy patient population.

METHODS

Six unmasked US investigators prospectively enrolled 72 patients aged </=70 years with bilateral cataracts in otherwise healthy eyes. Patients underwent routine cataract extraction via phacoemulsification with SN60D3 implantation. Visual outcomes were assessed 1 week, 1 month and 6 months postoperatively. Patients completed two subjective surveys. As controls, 51 patients who were 6 months postoperative to bilateral implantation of AcrySof monofocal IOLs also were assessed.

RESULTS

Corrected and uncorrected distance visual acuity was similar across groups. For uncorrected near and intermediate visual acuity, statistically significant differences were found favouring the SN60D3 group (p<0.0001). Contrast sensitivity was significantly better in monofocal patients at 6 cpd and 18 cpd under various lighting conditions. The Functional Evaluation and the Questionnaire demonstrated that SN60D3 patients achieved significantly higher levels of functional vision and spectacle freedom (p<0.0001).

CONCLUSION

Despite mildly decreased contrast sensitivity when compared with a monofocal IOL, the SN60D3 provided high patient satisfaction, excellent functional vision, and high rates of spectacle freedom.

Comparison of the Infiniti vision and the series 20,000 Legacy systems

PURPOSE

To compare the efficiency of the Infiniti vision system and the Series 20,000 Legacy system phacoemulsification units during routine cataract extraction.

METHODS

Thirty-nine eyes of 39 patients were randomized to have their cataract removed using either the Infiniti or the Legacy system, both using the Neosonix handpiece. System settings were standardized. Ultrasound time, amount of balanced salt solution (BSS) used intraoperatively, and postoperative visual acuity at postoperative days 1, 7 and 30 were evaluated.

RESULTS

Preoperatively, best corrected visual acuity was significantly worse in the Infiniti group compared to the Legacy group (0.38 +/- 0.23 and 0.21 +/- 0.16, respectively; p = 0.012). The mean phacoemulsification time was 39.6 +/- 22.9 s (range 6.0-102.0) for the Legacy group and 18.3 +/-19.1 s (range 1.0-80.0) for the Infiniti group (p = 0.001). The mean amounts of intraoperative BSS used were 117 +/- 37.7 ml (range 70-195) in the Legacy group and 85.3 +/- 38.9 ml (range 40-200) in the Infiniti group (p = 0.005). No differences in postoperative visual acuity were found.

CONCLUSION

The ability to use higher flow rates and vacuum settings with the Infiniti vision system allowed for cataract removal with less phacoemulsification time than when using the Legacy system.

A review of the use of ketorolac tromethamine 0.4% in the treatment of post-surgical inflammation following cataract and refractive surgery

The non-steroidal anti-inflammatory drug (NSAID) ketorolac tromethamine 0.4% ophthalmic solution, a recent reformulation containing 20% less active ingredient that the original formulation, is indicated for the reduction of ocular pain and burning/stinging following corneal refractive surgery. Clinical studies have shown ketorolac tromethamine 0.4% to be as effective as ketorolac tromethamine 0.5% to control inflammation after cataract surgery including prevention of cystoid macular edema (CME). Its efficacy to inhibit miosis during cataract surgery as well as its role in the treatment of dry eye has been reported. The purpose of this paper is to review the use of ketorolac tromethamine 0.4% in the treatment of post-surgical inflammation following cataract and refractive surgery.

Comparison of visual outcomes, photopic contrast sensitivity, wavefront analysis, and patient satisfaction following cataract extraction and IOL implantation: aspheric vs spherical acrylic lenses

PURPOSE

To determine vision quality when testing two acrylic intraocular lenses (IOLs), AcrysofIQ and AcrysofSingle-Piece, after routine cataract extraction and IOL implantation.SettingStorm Eye Institute and Magill Research Center for Vision Correction, Medical University of South Carolina, Charleston, SC, USA.

METHODS

Prospective, randomized, double-masked study that included 53 eyes of 27 patients who underwent bilateral cataract extraction and IOL implantation. Patients were randomly divided into two groups depending on the type of IOL implanted: AcrysofIQ or AcrysofSingle-Piece. Preoperative, 1- and 3-month postoperative evaluations included ETDRS visual acuity, photopic contrast sensitivity, pupil size, wavefront testing, and a subjective questionnaire. Comparisons between the two groups and comparisons to baseline were made at each visit. P<0.05 was considered statistically significant.

RESULTS

Preoperative, statistically significant differences were evident in response to the subjective questionnaire (near activities, driving dimensions, and overall score) between the two groups. Postoperatively there was a greater increase in contrast sensitivity at 1 and 3 months in the AcrysofIQ group when compared to baseline. Patients with AcrysofIQ IOL had a significant reduction in total high-order aberrations (HOA) and spherical aberration (SA) when compared to those patients with AcrysofSingle-Piece at 1 and 3 months and to baseline. Postoperative patient satisfaction showed no difference among the groups.

CONCLUSION

The use of a new aspheric acrylic IOL may improve the quality of vision as a result of the reduction of total HOA and SA.

Methicillin-resistant Staphylococcus aureus infectious keratitis following refractive surgery

PURPOSE

To elucidate risk factors, clinical course, visual outcomes, and treatment of culture-proven methicillin-resistant Staphylococcus aureus (MRSA) infectious keratitis following refractive surgery.

DESIGN

Interventional case series.

METHODS

Multicenter chart review of 13 cases of MRSA keratitis following refractive surgery and literature review.

RESULTS

Thirteen eyes of 12 patients, nine of whom were either healthcare workers or exposed to a hospital surgical setting, developed MRSA keratitis following refractive surgery. All patients presented with a decrease in visual acuity and complaints of pain or irritation in the affected eye. Common signs on slit-lamp biomicroscopy were corneal epithelial defects, focal infiltrates with surrounding edema, conjunctival injection, purulent discharge, and hypopyon. All patients were diagnosed with infectious keratitis on presentation and treated with two antibiotics. All eyes were culture-positive for MRSA.

CONCLUSIONS

According to a computerized MEDLINE literature search, this is the first case series of MRSA infectious keratitis following refractive surgery, the first reports of MRSA keratitis after refractive surgery in patients with no known exposure to a healthcare facility, the first report of MRSA keratitis after a laser in situ keratomileusis (LASIK) enhancement, and the first reports of MRSA keratitis after prophylaxis with fourth-generation fluoroquinolones. MRSA keratitis is a serious and increasing complication following refractive surgery. Patients with exposure to a healthcare environment should be considered at additional risk for developing MRSA keratitis. However, in addition, surgeons should now be vigilant for community-acquired MRSA. Prompt identification with culturing and appropriate treatment of MRSA keratitis after refractive surgery is important to improve visual rehabilitation.

High-order aberrations and preoperative associated factors

PURPOSE

The purpose of this study was to determine which preoperative factors are associated with the presence of high-order aberrations.

METHODS

A total of 93 eyes of 52 subjects were evaluated preoperatively between 1 January and 31 March 2003, using a Hartmann-Shack-based aberrometer. Age, gender, cycloplegic refraction, pupil size, keratometry readings, anterior chamber depth, white-to-white tests, intraocular pressure and basic secretion tests were evaluated.

RESULTS

Factors associated with high-order aberrations included age > or = 40 years (mean 4.39 +/- 2.95 microm; p = 0.03, Mann-Whitney test), higher keratometry values (44.96 +/- 1.57 D) (r = 0.447, p < 0.001, Spearman's correlation coefficient), higher degrees of myopia (> or = - 6.1 D) (p < 0.001, Kruskall-Wallis test) and increasing pupil size (p < 0.001, anova). Other factors including anterior chamber depth, white-to-white results, intraocular pressure and basic secretion test results did not correlate with the presence of high-order aberrations preoperatively.

CONCLUSIONS

Ocular wavefront aberrations varied greatly from subject to subject. Treatment should be customized for each laser based on patient characteristics in order to ensure the optimal treatment profile for the aberration.

Evaluation of 0.4% ketorolac tromethamine ophthalmic solution versus 0.5% ketorolac tromethamine ophthalmic solution after phacoemulsification and intraocular lens implantation

PURPOSE

The aim of this study was to compare the effectiveness and patient tolerance of 0.4% ketorolac tromethamine ophthalmic solution and 0.5% ketorolac tromethamine ophthalmic solution after routine phacoemulsification and lens implantation.

SETTING

The setting for this study was the Storm Eye Institute and Magill Research Center for Vision Correction, Medical University of South Carolina (Charleston, SC).

METHODS

This work was a prospective, double-masked study that included 40 eyes of 40 patients randomly assigned to receive topical treatment with 0.4% ketorolac or 0.5% ketorolac, starting 15 min prior to routine phacoemulsification and foldable posterior chamber intraocular lens implantation. Following the procedure, patients were instructed to use the assigned treatment agent 4 times a day after surgery for 1 week and twice a day for 3 weeks, when drops were discontinued. Slit-lamp examination, intraocular pressure (IOP), laser cell and flare measurements, and subjective patient tolerance were evaluated postoperatively at 1, 7, and 30 d. Comparisons between the 2 groups were made at each visit, as well as comparisons to baseline. A P=value less than .05 was considered statistically significant.

RESULTS

At day 1, a higher percentage of patients (70% vs. 40%) reported symptoms (mainly foreign body sensation and stinging/burning) in the 0.5% ketorolac group, compared to the 0.4% ketorolac group. No significant differences were found between the 2 groups over time regarding best-corrected visual acuity (BCVA), IOP, slit-lamp assessment of cells, and cell and flare measured using the laser cell/flare meter.

CONCLUSIONS

Treatment with 0.4% ketorolac tromethamine ophthalmic solution is as effective as 0.5% ketorolac tromethamine ophthalmic solution in reducing inflammation after routine cataract surgery. Patients reported less discomfort using 0.4% ketorolac.

Randomized, Double-Masked Clinical Trial Evaluating Corneal Endothelial Cell Loss After Cataract Extraction and Intraocular Lens Implantation

PURPOSE

To assess the endothelial cell loss after cataract extraction using a fluid-based system and compare it with conventional ultrasound.

METHODS

A total of 46 eyes of 23 patients with up to 3+ bilateral cataract were included. The first eye was randomized to either fluid-based system or conventional ultrasound, and the fellow eye received the alternate system. Visual acuity and ultrasound pachymetry were measured preoperatively and at 1 day, 1 week, and 1 and 3 months postoperatively. Specular microscopy was performed preoperatively and 3 months after the surgery. Data was analyzed using the paired t test and Wilcoxon signed rank test. A P value less than 0.05 was considered statistically significant.

RESULTS

Postoperatively, no significant differences were found among the groups. However, there was a significant difference (P < 0.01, analysis of variance with Tukey as posttest) in corneal pachymetry at day 1 after the surgery compared with baseline in both groups. There was a 6.3% and 7.9% loss of endothelial cells in the fluid-based system and ultrasound group, respectively.

CONCLUSION

Visual acuity, pachymetry, and endothelial cell loss after cataract extraction and intraocular lens implantation using a fluid-based system is similar to conventional ultrasound.

Ocular Manifestations After Primary Varicella Infection

PURPOSE

To report a case of ocular manifestations after a primary varicella infection.

METHODS

Review of the literature and a case report of a 10-year-old male patient with history of blurry vision and an enlarged pupil 2 months after a varicella infection. Examination revealed uveitis, interstitial keratitis, and internal ophthalmoplegia.

RESULTS

The uveitis resolved with topical steroids; the interstitial keratitis resolved with a faint scar, and the internal ophthalmoplegia persisted.

CONCLUSION

This case report describes a patient with uncommon ocular manifestations after primary varicella.

Bronchogenic Squamous Cell Carcinoma Presenting as Cicatrizing Conjunctivitis

PURPOSE

To report a case of cicatrizing conjunctivitis as the initial manifestation of a bronchogenic squamous cell carcinoma.

METHODS

Case report of a 57-year-old patient with bilateral history of ocular pain, redness, and discharge, with no apparent predisposing factors. Examination revealed chemosis, pseudomembrane, and symblepharon formation, and multiple ulcerated pustular and vesicular periocular and perioral lesions literature review.

RESULTS

Skin biopsy was compatible with bullous pemphigoid. Two months later he developed respiratory symptoms, and a squamous cell carcinoma was diagnosed.

CONCLUSIONS

This case demonstrates cicatrizing conjunctivitis as a possible paraneoplastic syndrome associated with squamous cell lung carcinoma.

Prevention of Staphylococcus aureus Endophthalmitis with Topical Gatifloxacin in a Rabbit Prophylaxis Model

PURPOSE

The aim of this study was to investigate the prophylactic use of 0.3% gatifloxacin drops to prevent endophthalmitis in a rabbit model.

METHODS

Forty (40) New Zealand white rabbits were randomly placed into group A (20 rabbits) where they received 1 drop of 0.3% gatifloxacin in their right eye every 15 min (0, 15, 30, and 45 min), or group B (20 rabbits) where they received 1 drop of balanced salt solution (BSS) in their right eye every 15 min (0, 15, 30, and 45 min). Following this treatment regimen, the anterior chamber of each rabbit was injected with 0.025 mL of saline containing 5 x 10(5) colonyforming units of a clinical isolate of Staphylococcus aureus (vancomycin-sensitive). After the inoculum injection, the treatment regimen continued: group A (1 drop of 0.3% gatifloxacin) or group B (1 drop of BSS) immediately postinjection, 6, 12, 18, and 24 h, at which time the animals were examined in a masked fashion, photographed, anesthetized, euthanized, and the aqueous and vitreous humors collected to determine the number of viable bacteria.

RESULTS

The median clinical scores for the gatifloxacin group were significantly lower than the control group (P < 0.05). Bacterial recovery of S. aureus was significantly higher in the control group in both the aqueous and vitreous humor (P < 0.05).

CONCLUSIONS

Gatifloxacin-treated eyes demonstrated significantly less inflammation, infection, and culture-positive endophthalmitis (P < 0.05), compared to the control animals. It is important to further investigate the clinical implications from this prophylatic study.

Herpes zoster ophthalmicus: presenting as giant-cell arteritis

A 74-year-old woman was referred to the authors' clinic with a 1-week suspicion of giant-cell arteritis. Uncomplicated, bilateral temporal artery biopsies were performed 3 days after admission for therapy. Four hours after the procedure she developed vesicular lesions of the face compatible with herpes zoster ophthalmicus. The temporal artery biopsy revealed perineural lymphocytic aggregation. Both giant-cell arteritis and herpes zoster ophthalmicus form part of the differential diagnosis in elderly patients with headache. In such cases, clues from a temporal artery biopsy may aid in diagnosis of herpes zoster. In addition, the patient in this case developed the rash 10 days after onset of symptoms, which is rare as the average time from onset of symptoms to rash in zoster is 3-5 days.

Effect of hinge location on corneal sensation and dry eye after laser in situ keratomileusis for myopia

PURPOSE

To evaluate the effects of a superior or nasal hinge location on corneal sensation and dry eye after laser in situ keratomileusis (LASIK).

SETTING

Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.

METHODS

This prospective randomized masked study included 47 patients having bilateral myopic LASIK surgery. The first eye was randomly assigned to have a nasal or superior hinge flap; the fellow eye had the alternate location. Visual acuity, contrast sensitivity, corneal sensation, basic secretion test, tear film breakup time, conjunctival and corneal staining, and a subjective questionnaire were evaluated preoperatively and postoperatively at 1 week and 1, 3, and 6 months. The Wilcoxon signed rank test and paired t test were used for comparison.

RESULTS

Dry eye occurred with the same frequency in both groups. However, eyes with the nasal hinge had significantly better nasal sensation than those with the superior hinge (P<.05) at 1 month.

CONCLUSION

Better nasal corneal sensation was found at 1 month in the nasal hinge group but there was no difference in any other parameters measured.

Cryptococcus albidus keratitis after corneal transplantation

PURPOSE

To report suspected donor-to-host transmission of Cryptococcus albidus after penetrating keratoplasty.

METHODS

Review of the literature and a case report of a 69-year-old woman who underwent penetrating keratoplasty for Fuchs corneal dystrophy and developed persistent corneal infiltrates 7 months postoperatively are presented.

RESULTS

Cryptococcus albidus was cultured from the original donor tissue at the time of the repeat keratoplasty.

CONCLUSION

This case demonstrates an unusual case of cryptococcal keratitis after keratoplasty suspected to be a donor-to-host transmission.

Refractive Surgery Survey 2004

To determine the refractive surgery (RS) preferences of ophthalmologists worldwide, questionnaires were sent to 8897 members of the American Society of Cataract and Refractive Surgery. A total of 1053 questionnaires were returned by the deadline. The practice distribution included 29.5% cataract surgeons, 48.8% comprehensive ophthalmologists, 11.6% RS specialists, 5.1% cornea and external disease specialists, 1.9% glaucoma specialists, 1.1% retina specialists, and <1.0% oculoplastics/pediatrics/researchers/retired. Results were compared with those in the 2003 survey and demonstrate that refractive surgery continues to develop and change.

Corneal endothelial cell damage after lens extraction using the fluid-based system compared to ultrasound phacoemulsification in human cadaver eyes

PURPOSE

To compare the endothelial cell damage after lens removal using a fluid-based system to conventional ultrasound.

METHODS

Twenty human cadaver eyes were randomized to undergo phacoemulsification using either a fluid-based system or conventional ultrasound. After surgery, each corneoscleral button was removed, stained and damaged endothelial cells per square millimeter were assessed using light microscopy.

RESULTS

Fluid-based system mean damaged endothelial cells/mm was 60.2 +/- 24.1 compared with 60.4 +/- 42.6 when using conventional ultrasound (P = 0.248).

CONCLUSION

The fluid-based system is as safe for the corneal endothelium as conventional ultrasound during cataract removal in human cadaver eyes.

Safety and efficacy of ketorolac tromethamine 0.4% ophthalmic solution in post-photorefractive keratectomy patients

PURPOSE

To evaluate the safety and analgesic efficacy of ketorolac tromethamine 0.4% ophthalmic solution in postoperative photorefractive keratectomy (PRK) patients.

SETTING

Fifteen clinical sites in the eastern and southern United States.

METHODS

This pooled analysis of 2 multicenter, randomized, double-masked, vehicle-controlled, parallel-group studies comprised 313 patients having unilateral PRK. After surgery, patients were treated with 1 drop of ketorolac tromethamine 0.4% ophthalmic solution (Acular(R) LS) (n = 156) or vehicle (n = 157) 4 times daily for up to 4 days. Pain intensity, pain relief, use of escape medication, and severity of ocular symptoms were assessed. Adverse events, epithelial healing, and visual acuity were recorded.

RESULTS

There was significantly less pain intensity experienced by patients in the ketorolac group (P<.001). During the first 12 hours post PRK, 50% fewer patients in the ketorolac group than in the vehicle group had severe to intolerable pain (41.6% [64/154] and 84.5% [131/155], respectively). The median time to no pain was 30 hours in the ketorolac group and 54 hours in the vehicle group (P<.001, survival analysis). Ketorolac patients reported significantly greater pain relief than vehicle patients throughout the study (P<.001). Ketorolac patients used significantly less escape medication than vehicle patients for 48 hours post PRK (P< or =.008). Treatment-related adverse events occurred in 2.6% (4/156) of ketorolac patients and 6.4% (10/157) of vehicle patients.

CONCLUSION

Ketorolac 0.4% ophthalmic solution is safe and effective in reducing ocular pain when used 4 times daily for up to 4 days post PRK.

Refractive Surgery Survey 2003

To determine the refractive surgery preferences of ophthalmologists worldwide, questionnaires were sent to 8920 members of the American Society of Cataract and Refractive Surgery. A total of 1174 questionnaires was returned by the deadline. The practice distribution included 30.0% cataract surgeons, 47.3% comprehensive ophthalmologists, 14.4% refractive surgery (RS) specialists, 4.5% corneal/external disease specialists, 1.9% glaucoma specialists, and < 1% retinal/oculoplastics/pediatrics/neurophthalmologists/researchers/retired. Responses were compared with those in the 2001 and 2002 surveys and demonstrate that RS practice patterns continue to evolve.

Comparison of wavefront sensing devices

Wavefront measurement is an emerging technology that can evaluate low-order and high-order aberrations. This review compiles the different wavefront sensing devices and compares the most popular Hartmann-Shack aberrometers.

Flap thickness accuracy

PURPOSE

To determine the flap thickness accuracy of 6 microkeratome models and determine factors that might affect flap thickness.

SETTING

Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.

METHODS

This multicenter prospective study involved 18 surgeons. Six microkeratomes were evaluated: AMO Amadeus, Bausch & Lomb Hansatome, Moria Carriazo-Barraquer, Moria M2, Nidek MK2000, and Alcon Summit Krumeich-Barraquer. Eyes of 1061 consecutive patients who had laser in situ keratomileusis were included. Age, sex, surgical order (first or second cut), keratometry (flattest, steepest, and mean), white-to-white measurement, laser used, plate thickness, head serial number, blade lot number, and occurrence of epithelial defects were recorded. Intraoperative pachymetry was obtained just before the microkeratome was placed on the eye. Residual bed pachymetry was measured after the microkeratome cut had been created and the flap lifted. The estimated flap thickness was determined by subtraction (ie, mean preoperative pachymetry measurement minus mean residual bed pachymetry).

RESULTS

A total of 1634 eyes were reviewed. Sex distribution was 54.3% women and 45.7% men, and the mean age was 39.4 years +/- 10.6 (SD). In addition, 54.5% of the procedures were in first eyes and 45.5%, in second eyes. The mean preoperative pachymetry measurement was 547 +/- 34 microm. The mean keratometry was 43.6 +/- 1.6 diopters (D) in the flattest axis and 44.6 +/-1.5 D in the steepest axis. The mean white-to-white measurement was 11.7 +/- 0.4 mm. The mean flap thickness created by the devices varied between head designs, and microkeratome heads had significant differences (P<.05). Factors that explained 78.4% of the variability included microkeratome model, plate thickness, mean preoperative pachymetry, Kmin, surgery order, head serial number, blade lot number, and surgeon. Factors such as age, sex, Kmax, Kaverage, white to white, and laser had no significant correlation to flap thickness.

CONCLUSIONS

The results demonstrated variability between the 6 microkeratome models. Device labeling did not necessarily represent the mean flap thickness obtained, nor was it uniform or consistent. Thinner corneas were associated with thinner flaps and thicker corneas with thicker flaps. In addition, first cuts were generally associated with thicker flaps when compared to second cuts in bilateral procedures.

Endothelial cell integrity after phacoemulsification with 2 different handpieces

PURPOSE

To investigate corneal endothelial cell loss in fresh phakic human autopsy cadaver eyes after phacoemulsification (PE) with a conventional handpiece or a new oscillatory handpiece.

SETTING

Department of Ophthalmology, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.

METHODS

Twenty fresh phakic human autopsy globes were randomized to PE with a conventional handpiece (n = 10) or an oscillatory handpiece (n = 10). The main parameters evaluated were age, nucleus density, amount of ophthalmic viscosurgical device (OVD) used, and mean PE time and ultrasound (US) power. After surgery, the corneas were excised and the endothelia were vitally stained with trypan blue and alizarin red. Light microscopy was used to assess the endothelial cell loss.

RESULTS

The mean age, density of the nucleus, OVD used, and US power were similar between the groups. The mean PE time was less with the NeoSoniX handpiece (0.71 minutes +/- 0.39 [SD]) than with the conventional handpiece (1.05 +/- 0.53 minutes). The mean number of dead endothelial cells was significantly lower in the oscillatory handpiece group (31.3 +/- 24.2 cells/mm(2)) than in the conventional handpiece group (60.4 +/- 46.8 cells/mm(2)) (P<.001, Mann-Whitney rank sum test).

CONCLUSIONS

Less corneal endothelial cell loss occurred after PE with an oscillatory handpiece than with a conventional handpiece. Further randomized clinical trials are recommended to validate this study.

Evaluation of preoperative and postoperative prophylactic regimens for prevention and treatment of diffuse lamellar keratitis

PURPOSE

To investigate preoperative and postoperative prophylactic treatment with different pharmacological agents before flap cutting and exposure to a diffuse lamellar keratitis (DLK) causative agent.

SETTING

Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.

METHODS

The study comprised 48 eyes of 24 Dutch-belted rabbits. Three days before a corneal flap was cut and the corneal interface was exposed to Pseudomonas aeruginosa lipopolysaccharide endotoxin, a DLK causative agent, the eyes were randomly assigned to treatment with a mast-cell stabilizer, a nonsteroidal antiinflammatory drug (NSAID), or a corticosteroid or left without treatment as controls. The treatment was maintained throughout the 1-week follow-up. Slitlamp examinations and photographs were performed at 1, 3, 5, and 7 days; DLK was graded by a masked observer from 0 (no DLK) to IV. Corneal interface scrapings were performed in selected eyes on day 7.

RESULTS

At the end of the follow-up, 36 eyes were available for evaluation. At 1 week, 100% of the control eyes and the eyes treated with the mast-cell stabilizer developed DLK; in the NSAID-treated and corticosteroid-treated eyes, the DLK rate was 86% and 70%, respectively. At 1 day, the severity of DLK was significantly lower in eyes treated with the mast-cell stabilizer (0.44) and at 7 days, it was significantly lower in corticosteroid-treated eyes (0.3) than in the control group (1.5 and 1.4, respectively) (P<.05, Wilcoxon test). Corneal interface scraping from an eye with grade III DLK showed numerous inflammatory cells.

CONCLUSIONS

Preoperative and postoperative treatment with corticosteroids significantly reduced the severity of DLK compared to the untreated control eyes in this animal model. Treatment with a mast-cell stabilizer and an NSAID had less effect on the postoperative course of DLK.

Relationship Between Cycloplegic and Wavefront-derived Refraction

PURPOSE

To compare cycloplegic refractions to preoperative wavefront-derived refractions from three Hartmann-Shack-based wavefront devices.

METHODS

Ninety-nine eyes of 55 subjects were evaluated preoperatively using the LADARWave, WaveScan, and Zywave aberrometers. With cycloplegic refraction as the standard, the spherical equivalent refraction, sphere, and cylinder were compared to the wavefront-derived refractions using the three wavefront devices.

RESULTS

The LADARWave unit showed the highest correlation between wavefront-derived sphere and mean spherical equivalent refraction values relative to cycloplegic refraction, followed by Zywave and WaveScan. The WaveScan unit exhibited higher variability than the LADARWave or Zywave. Although Alcon Laboratories (LADARWave) and Bausch & Lomb Surgical (Zywave) recommend dilation, VISX specifically recommends against dilation in their WaveScan unit. All devices showed high cylinder error vectors when the cycloplegic cylinder was greater than 1.00 D.

CONCLUSION

Although wavefront-derived refractions appeared to correlate well to cycloplegic refractions, further research is required to reduce variability and improve the calculation of cylinder terms.

Residual cleaner after normal cleaning of laser in situ keratomileusis instruments

PURPOSE

To determine whether residual cleaner could be detected in the rinse solution of surgical instruments after a standard cleaning protocol.

SETTING

Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA.

METHODS

The wavelength for maximum absorbance of 5 cleaners (Endozime) [The Ruhof Corp.], Enzol/Cidezyme [Advanced Sterilization Products], and Klenzyme [Steris Co.] enzymatic detergents; Palmolive Ultra dishwashing liquid [Colgate-Palmolive Co.]; and Universal concentrated surgical instrument cleaner and lubricant [B. Graczyk, Inc.]) was determined. Identically designed stainless-steel and titanium instruments were cleaned using a standardized protocol. Water temperatures of 25 degrees C (room temperature) or 40 degrees C (warm temperature) were used to rinse the instruments. The amount of residual cleaner in each rinse solution and remaining on each instrument at the completion of the cleaning procedure as a percentage of the total cleaner was determined.

RESULTS

Residues of all cleaners were detected using a standard protocol involving rinse solutions at 25 degrees C. Increasing the temperature of the rinse solutions significantly reduced the cleaner residues (P<.05, Friedman repeated-measures analysis of variance on ranks test and Student-Newman-Keuls test) regardless of the instrument material. No significant difference was detected in the residual cleaners on stainless-steel and titanium instruments.

CONCLUSIONS

Lower levels of cleaner residue were found on surgical instruments after a standard cleaning protocol using warm rinse water. Because cleaner residue has been reported to cause inflammation (eg, diffuse lamellar keratitis) after laser in situ keratomileusis (LASIK), it is advisable to use cleaners and cleaning protocols that result in acceptable cleaning without detectable levels of cleaner residue to avoid potentially harmful effects to the cornea after LASIK.

[Diagnosis and treatment of mycobacterial keratitis following LASIK. Case report and review of the literature]

BACKGROUND

Mycobacterial keratitis is a rare complication following LASIK but can lead to an extremely unfavourable outcome. The diagnosis and treatment is often delayed due to confusion with other entities including diffuse lamellar keratitis and poor clinical outcomes with flap amputation and/or keratoplasty are often the case.

PATIENT AND METHODS

We report the results of LASIK in a 51-year-old woman with subsequent early-diagnosed mycobacterial keratitis and compared this case to treatments and outcomes reported in the literature.

RESULTS

The patient presented 10 days following LASIK with a white focal infiltrate in the stromal interface. The flap was lifted and cultures from the stromal bed and the reverse of the flap were obtained and the interface irrigated. The patient was treated with topical antibiotics (ciprofloxacin 0.3%, amikacin 2.5%, clarithromycin 40 mg/ml and tobramycin 15 mg/ml) for 8 weeks and at the most recent follow-up she had a visual acuity of 1.25.

CONCLUSION

In a large number of published cases in the literature the flap had to be amputated and/or corneal transplants were necessary. Early diagnosis and treatment however, are essential to successfully treat post-LASIK keratitis. Therefore the patients should be followed up carefully in the early postoperative period.

Photodynamic therapy with verteporfin in a rabbit model of corneal neovascularization

PURPOSE

To determine the efficacy of photodynamic therapy (PDT) with verteporfin (Visudyne; Novartis AG, Basel, Switzerland) for treatment of corneal neovascularization in a rabbit eye model.

METHODS

Corneal neovascularization was induced in Dutch belted rabbits by placing an intrastromal silk suture near the limbus. Verteporfin was administered by intravenous injection at a dose of 1.5 mg/kg, and the pharmacokinetics of verteporfin distribution in the anterior segment or PDT-induced (laser energy levels 17, 50, and 150 J/cm(2)) regression of corneal blood vessels were then determined. To assess PDT-induced toxicity of the anterior segment, corneal and iris/ciliary body histology, and IOP were evaluated after PDT.

RESULTS

Verteporfin accumulation in vascularized regions of the cornea and the iris/ciliary body tissue were time dependent and maximum levels achieved at 60 minutes after injection. In rabbits, PDT of corneal vessels using laser energy of 17 or 50 J/cm(2) resulted in 30% to 50% regression of corneal neovascularization; however, in these animals, a rapid regrowth of new blood vessels occurred between 3 and 5 days. In the rabbits receiving PDT using laser energies of 150 J/cm(2), the mean vessel regression was 56%. During the nine days of the laser therapy follow-up period, no vessel regrowth was observed in these rabbits. Histologic examination of the anterior segment after PDT (150 J/cm(2)) showed localized degeneration of the corneal blood vessels without observable change in other anterior segment structures.

CONCLUSIONS

These results provide evidence that PDT can produce significant regression of neovascular corneal vessels with no observable toxicity to the anterior segments. However, the optimal laser energy necessary to induce long-term regression (150 J/cm(2)) was three times that used to treat choroidal neovascularization.