Chronic Recurrent Methicillin Resistant Staphylococcus Hemolyticus Endophthalmitis after Cataract Surgery

PURPOSE: To report a case of recurrent endophthalmitis due to methicillin resistant Staphylococcus hemolyticus after phacoemulsification and posterior chamber intraocular lens (IOL) implantation. CASE SUMMARY: A 76-year-old female visited our outpatient clinic with decreased vision 40 days after uncomplicated cataract surgery in her right eye. At the visit, anterior chamber inflammation and cloudy fluid between the posterior capsule and IOL were observed. Uveitis due to residual cortex of lens or capsular block syndrome was suspected, so YAG laser capsulotomy and subconjunctival injection of dexamethasone were performed. Two days later, hypopyon and vitreous opacity were seen. The patient underwent an emergency vitrectomy and intravitreal antibiotic injection with suspicion of bacterial endophthalmitis. The culture was negative. Twenty days after the vitrectomy, anterior chamber inflammation and vitreous opacity developed. The recurrence of endophthalmitis was suspected due to infection by bacteria in the surrounding tissue of the IOL, so the patient underwent an IOL and lens capsule removal with intravitreal antibiotic injection. At this time, the culture revealed methicillin resistant staphylococcus hemolyticus. Systemic and topical vancomycin was then administered, resulting in decreased inflammation. Twenty days after the IOL removal, decreased vision, anterior chamber inflammation, and vitreous opacity developed. Endophthalmitis was decreased by intravitreal antibiotic injection and topical antibiotic treatment. CONCLUSIONS: Methicillin resistant staphylococcus hemolyticus should be considered in the differential diagnosis of chronic recurrent endophthalmitis after cataract surgery.

Retinal Nerve Fiber Layer Volume Measurements in Normal Children Using Spectral Domain Optical Coherence Tomography

PURPOSE: To measure retinal nerve fiber layer (RNFL) volume in normal children using spectral domain optical coherence tomography (SD-OCT). METHODS: This study included 79 eyes of 54 normal children between 4 and 15 years of age evaluated from February 2012 to November 2012. All participants underwent ocular examination and 3D-disc scanning using SD-OCT. RNFL volume was calculated between 2.5 and 5 mm diameter circles using the length, width, and height of each pixel derived from the RNFL thickness map with Matlab software. The relationship between RNFL volume and thickness was analyzed. RESULTS: The RNFL volumes of the mean total, superior, nasal, inferior, and temporal areas were 1.48 ± 0.09 mm3, 0.45 ± 0.04 mm3, 0.29 ± 0.04 mm3, 0.46 ± 0.03 mm3, and 0.29 ± 0.04 mm3, respectively. Comparing RNFL volume and conventional circumpapillary RNFL thickness measured using built-in software, a strong correlation between mean total, superior, and inferior areas (R = 0.980, 0.953 and 0.932, respectively) and a moderate correlation between the nasal and temporal areas were observed (R = 0.545 and 0.514, respectively). The negative correlations between RNFL thickness and RNFL volumes of the mean total, superior, nasal, inferior, and temporal areas and age were not significant (p > 0.05). CONCLUSIONS: This study reports RNFL volume measured from RNFL thickness map analysis in normal children. These data regarding RNFL volume of normal children may provide useful information for diagnosis and monitoring of pediatric glaucoma.

Astigmatic Correlation between the Automated Refractometry and Dual Scheimpflug Analyzer in Pseudophakic Eyes

PURPOSE: To examine the relationship between the refractive astigmatism by automated refractometry and the corneal astigmatism by a dual Scheimpflug analyzer in pseudophakic eyes. METHODS: Prospectively, 75 patients (100 eyes) were enrolled in the present study. Refractive astigmatism was obtained by automated refraction. Corneal astigmatism was obtained using automated keratometry (ARK-530A®) and dual Scheimpflug scanning analysis (Galilei G4®). All refractive values were converted to the power vector components J0 and J45 for comparison and regression analysis of refractive versus corneal astigmatism. Bland-Altman plots were created to estimate the agreement between measurements. RESULTS: The average astigmatism from each measurement was -1.11 ± 1.44 D (refractive astigmatism from automated refraction), -0.77 ± 1.06 D (corneal astigmatism from automated keratometry), -0.93 ± 1.02 D (simulated K from Galilei G4®), and -1.11 ± 1.48 D (total corneal power from Galilei G4®). Refractive J0 and keratometric J0 were significantly correlated (r = 0.557, p ≤ 0.001), as well as the corresponding J45 values (r = 0.655, p = 0.025). Refractive astigmatism and total corneal power components were also significantly correlated (J0: r = 0.618, p ≤ 0.001; J45: r = 0.608, p = 0.04). In the Bland-Altman plots, keratometric J0 and total corneal power J0 showed the best agreement. CONCLUSIONS: The accuracy of measurements for corneal refraction and astigmatism in pseudophakic eyes is higher using the dual Scheimpflug analyzer, especially for total corneal power. This value of astigmatism can take into account the refractive astigmatism of pseudophakic eyes and can be used in evaluating postoperative corneal astigmatism.

Treatment of Acute Retinal Necrosis with Acute Kidney Injury after Intravenous Antiviral Injection

PURPOSE: In the present study, a case of acute retinal necrosis with acute renal injury due to high-dose intravenous antiviral injection which was treated by intravitreal ganciclovir injection is reported. CASE SUMMARY: A 46-year-old female visited our clinic complaining of red eye and decreased vision in the right eye. At the first visit, her corrected visual acuity was finger count in the right eye, and 20/20 in the left eye. Fundus examination of the right eye revealed multiple peripheral arterial occlusion, papilledema, and whitish necrotic infiltration at the periphery. Clinically diagnosed as acute retinal necrosis, the patient was started on intravenous acyclovir. Two days after injection, her serum creatinine level increased, therefore, intravenous acyclovir was discontinued and she was started on intravitreal ganciclovir. Five days after the intravenous injection was discontinued, the serum creatinine level returned to normal range. Four months after the first visit, visual acuity was 20/100 and no recurrence was observed. CONCLUSIONS: Intravitreal ganciclovir injection can be an effective alternative in patients with acute retinal necrosis and poor kidney function.

Comparison of Ocular Biometry and Postoperative Refraction in Cataract Patients between Galilei-G6(R) and IOL Master(R)

PURPOSE: To compare the axial lengths, anterior chamber depths, and keratometric measurements and to predict postoperative refractions of Dual Scheimpflug analyzer Galilei G6(R) and intra ocular lens (IOL) Master(R). METHODS: A total of 50 eyes in 50 patients who received cataract surgery were included in the present study. The axial length, anterior chamber depth, and keratometry were measured using 2 types of partial coherence interferometries (Galilei G6(R) and IOL Master(R)). The SRK/T formula was used to calculate IOL power and the predictive error which subtracts predictive refraction from postoperative refraction was compared between the ocular biometry devices. RESULTS: Axial lengths were 23.36 +/- 0.80 mm and 23.36 +/- 0.90 mm measured by Galilei G6(R) and IOL Master(R), respectively. Axial length measured by Galilei G6(R) was not statistically significant compared with IOL Master(R) (p = 0.321). The anterior chamber depth and keratometry were 3.22 +/- 0.35 mm and 44.29 +/- 1.40 D measured by Galilei G6(R) and 3.11 +/- 0.46 mm and 44.39 +/- 1.41 D measured by IOL Master(R), respectively. The differences of anterior chamber depth and keratometry between the 2 devices were statistically significant (p < 0.001 and p = 0.028, respectively). The mean absolute prediction errors were 0.45 +/- 0.37 D and 0.49 +/- 0.39 D in Galilei G6(R) and IOL Master(R), respectively and was not statistically significantly different (p = 0.423). CONCLUSIONS: The ocular biometric measurements and prediction of postoperative refraction using Galilei G6(R) were as accurate as with IOL Master(R).

Central Corneal Thickness Measured by Noncontact Specular Microscopy, Dual Rotating Scheimpflug Camera and Ultrasound Pachymetry

PURPOSE: To compare central corneal thickness (CCT) as measured using noncontact specular microscopy (NCSM), dual rotating Scheimpflug camera (Galilei(R)), and ultrasound pachymetry (USP). METHODS: The measurements of CCT using NCSM, dual rotating Scheimpflug camera and USP in 70 eyes of 70 healthy subjects were compared. RESULTS: The average measurements of CCT using NCSM, dual rotating Scheimpflug camera, and USP were 567.70 +/- 31.21 microm, 557.84 +/- 26.29 microm, and 553.31 +/- 29.69 microm, respectively. The CCT measurement using NCSM was statistically significantly thicker than when measured using USP (p 0.900, p < 0.001). CONCLUSIONS: The results of the 3 methods were significantly correlated but the measurement using NCSM was significantly thicker than when using USP. CCT measurements of healthy eyes using dual rotating Scheimpflug camera were more correlated with USP than NCSM. The CCT measurements using dual rotating Scheimpflug camera is a better alternative for USP than NCSM.

Transscleral Fixation of Intraocular Lenses Using Modified Injector

PURPOSE: To evaluate the clinical stability and outcomes of 3-piece intraocular lens (IOL) transscleral fixation surgery using a modified injector. METHODS: We have modified and used the Sapphire unfolder injector system (Allergan(R), USA). This involved, cutting a slit longitudinally at the terminal part of the injector so that a thread could pass through it freely. After a conjunctival peritomy created at 2 and 8 o'clock, a long curved needle with double-armed 10-0 polypropylene is passed through the exposed sclera. Two pieces of suture are withdrawn through the 2.8 mm corneal incision and 1 suture (from 8 o'clock) is passed through the opening of the cartridge and then tied to the leading haptic. Next, the IOL was implanted with the cartridge and then inserted through the corneal incision site. The other suture (from 2 o'clock) is tied to the haptic on the opposite side and inserted. RESULTS: The study included 20 eyes of 20 patients with a mean age of 62.8 years at the initial visit. There were no complications, such as vitreous hemorrhage, retinal detachment, glaucoma, corneal edema, or iris injury. While the knot fixed to the leading haptic of IOL passed by the cartridge, there was no change of position. During the follow-up period, IOL dislocation did not occur and the corrected visual acuity and corneal astigmatism improved significantly. CONCLUSIONS: This technique is an effective procedure for minimizing entangled thread and corneal astigmatism.

A Prospective Study of Blepharoptosis after Panretinal Photocoagulation Using Ophthalmoscopic Contact Lens

PURPOSE: To investigate the possibility of blepharoptosis as a complication after panretinal photocoagulation using ophthalmoscopic contact lens. METHODS: We prospectively evaluated patients who were diagnosed with diabetic retinopathy and scheduled to be treated with panretinal photocoagulation. Margin reflex distance 1 (MRD1), levator function, palpebral fissure height and width, and tarsal plate height were measured at the day of photocoagulation and 3 months after treatment. RESULTS: MRD1 was decreased in 8 eyes (25.8%), levator function was decreased in 5 eyes (16.1%), and palpebral fissure height was decreased in 6 eyes (19.4%). The decrement of MRD1 and palpebral fissure height after photocoagulation were significant (p = 0.008, p = 0.031, respectively). There was a significant negative correlation between MRD1 decrement and tarsal plate height (p = 0.045). CONCLUSIONS: We identified blepharoptosis after panretinal photocoagulation using contact ophthalmoscopic lens, which was related with low tarsal plate height.

The Changes of Anterior Chamber Depth, Axial Length, Refractive Errors after Combined Vitrectomy

PURPOSE: To evaluate the changes of anterior chamber depth (ACD), Axial length (AXL) after combined vitrectomy and cataract surgery and to analyze the association with refractive errors. METHODS: In 22 eyes who underwent combined vitrectomy and cataract surgery (PPV-Phaco group), 20 eyes who underwent vitrectomy-only (PPV-only group) and 28 eyes who underwent uncomplicated cataract surgery (Phaco-only group), ACD and AXL were measured with IOL master (Carl Zeiss Jena, Germany) preoperatively and 3 months postoperatively. We compared the preoperative desired refraction and postoperative 3 months refraction. RESULTS: ACD were increased in PPV-Phaco group and Phaco-only group (all, p < 0.001) and this change was more prominent in PPV-Phaco group (p = 0.030). In PPV only group, ACD was decreased (p < 0.001). The AXL after surgery was not significant different from the preoperative AXL in PPV-Phaco and PPV only groups (p = 0.612, p = 0.090). But the AXL was decreased in Phaco-only group (p = 0.022). Hyperopic shifting were noticed in PPV-Phaco and phaco-only groups, but myopic shifting was noticed in PPV-only group. However, these changes were not statistically significant (p = 0.292, p = 0.251, p = 0.068). CONCLUSIONS: ACD was increased after combined vitrectomy and cataract surgery. AXL was not changed. The hyperopic shifting was noticed after combined vitrectomy and cataract surgery, but was not statistically significant.

Morphologic and Functional Evaluation before and after Vitrectomy in Idiopathic Epiretinal Membrane Patients Using Microperimetry

PURPOSE: To investigate the relationship between photoreceptor inner/outer segment (IS/OS) integrity and macular sensitivity after epiretinal membrane (ERM) surgery using spectral-domain optical coherence tomography combined with microperimetry. METHODS: 20 eyes of 20 patients with idiopathic ERM who underwent pars plana vitrectomy for ERM removal were prospectively reviewed. The IS/OS defect diameter, BCVA, macular sensitivity, and fixation stability were measured using spectral-domain optical coherence tomography combined with microperimetry. The correlation of these factors was analyzed. RESULTS: The macular sensitivity improved after successful ERM surgery (p < 0.001), but the IS/OS defect diameter has not improved. The preoperative and postoperative macular sensitivity were negatively correlated with preoperative IS/OS defect diameter (p = 0.035, p = 0.006). The fixation stability was not correlated with preoperative IS/OS defect diameter. CONCLUSIONS: Macular sensitivity showed significant correlation with IS/OS defect diameter. Macular sensitivity is vital functional parameter allows subjective quantification of the retinal function and reflects morphologic changes.

The Effectiveness of Selective Laser Trabeculoplasty in Steroid-Induced Ocular Hypertension

PURPOSE: To report the effectiveness of selective laser trabeculoplasty (SLT) in patients with intraocular hypertension refractory to maximum tolerated medical therapy after intravitreal triamcinolone acetonide (IVTA). CASE SUMMARY: The records of 3 patients with steroid-induced intraocular hypertension that did not respond to maximum tolerated medical therapy were retrospectively reviewed. The patients received SLT instead of filtering surgery or Argon laser trabeculoplasty. The mean intraocular pressure (IOP) of 13.7 mm Hg increased to 30.7 mm Hg within 13 days of IVTA. IOP was uncontrolled despite maximum tolerated medical therapy. Patients underwent SLT 15.3 weeks after IVTA. Mean IOP decreased to 16 +/- 3.0 mm Hg after 1 day, 19.7 +/- 8.0 mm Hg after 1 week, 17 +/- 8.0 mm Hg after 1 month, 12.3 +/- 2.9 mm Hg after 3 months and 12.3 +/- 0.6 mm Hg after 4 to 6 months. The number of IOP lowering drugs were decreased to 1 from 4.3 after 6 months of SLT. CONCLUSIONS: SLT may be effective and safe for the treatment of steroid-induced intraocular hypertension refractory to maximum tolerated medical therapy.

The Relationship Between Parameters Measured by Optical Coherence Tomography and Visual Field Indices

PURPOSE: To evaluate the diagnostic ability of optic disc topographic parameters and the retinal nerve fiber layer (RNFL) thickness parameter measured by optical coherence tomography (OCT) and to determine the association of these structural parameters with visual field indices. METHODS: Fifty-six glaucomatous eyes and 65 healthy control eyes were enrolled in this retrospective cross-sectional study. Each subject had a 24-2 full threshold test on a Humphrey visual field analyzer and an optical coherence tomographic evaluation. The parameters from the fast RNFL thickness algorithm and the fast optic disc algorithm were analyzed by an ROC curve, and we sought to determine the association of these parameters with visual field indices by linear and logarithmic regression. RESULTS: The area under the receiver operating characteristic curve (AUROC) value of the fast optic disc algorithm parameters ranged from 0.78 to 0.79 and that of the fast RNFL thickness algorithm parameters ranged from 0.74 to 0.81. The associations between the parameters from the fast optic disc algorithm and from the fast RNFL thickness algorithm with visual field indices were statistically significant (P<0.001). CONCLUSIONS: The fast optic disc algorithm and the fast RNFL algorithm revealed comparable diagnostic ability in discriminating glaucoma and significant associations with visual field indices.

The Clinical Results of Silicone Oil Tamponade in Pars Plana Vitrectomy for Various Vitreoretinal Diseases

PURPOSE: This study aimed to report anatomic and visual acuity outcomes after 5000-centistoke silicone oil was used as a retinal tamponade for the treatment of various causes of vitreoretinal diseases. METHODS: Two hundred ten eyes of 196 patients who had undergone vitrectomy with silicone oil between 1995 and 2004 were reviewed retrospectively. According to etiology, the eyes were divided into five groups : (1) Group 1 included 60 eyes associated with proliferative diabetic retinopathy, (2) Group 2 included 90 eyes associated with proliferative vitreoretinopathy, (3) Grouop 3 included 30 eyes associated with trauma, (4) Group 4 included 13 eyes associated with infection or other inflammatory disease, (5) Group 5 included 17 eyes associated with submacular hemorrhage or etc. Anatomic outcomes included complete retinal attachment and macular attachment. Visual acuity outcomes included ambulatory vision (> or =4/200) and preservation of preoperative visual acuity. RESULTS: At the last examination, the retina was completely attached in 98.1% of cases in Group 1, 98.9% Group 2, 82.6% Group 3, 83.3% Group 4 and 100% Group 5. The macula was attached in 98.1%, 98.9%, 87.0%, 100%, and 100% eyes, respectively. Ambulatory vision was achieved in 28 eyes (46.7%) in Group 1, 50 eyes (55.6%) in Group 2, 9 eyes (30.5%) in Group 3, 8 eyes (61.5%) in Group 4, and 6 eyes (35.3%) in Group 5. CONCLUSIONS: Vitrectomy with 5000-centistoke silicone oil tamponade is an effective method in the management of vitreoretinal diseases with multiple etiologies.

Scanning Laser Polarimetry Using Variable Corneal Compensation in Detection of Localized Visual Field Defects

PURPOSE: To evaluate the ability of scanning laser polarimetry parameters and a novel deviation-map algorithm to discriminate between healthy and early glaucomatous eyes with localized visual field defects confined in one hemifield. METHODS: In this prospective case-controlled study, 61 glaucomatous eyes with localized visual field defects and 66 normal controls were enrolled. Humphrey field analyzer 24-2 glaucoma hemifield test and scanning laser polarimetry (GDx-VCC ) were used. RESULTS: There were significant differences in the mean parametric values of TSNIT average, superior average, inferior average, and TSNIT SD (P<0.05) between the glaucoma group and normal subjects. The sensitivity of each GDx-VCC variable was as follows: TSNIT average, 47.5%; superior average, 31.1%; inferior average, 47.5%; and TSNIT SD, 24.6% (when abnormal was defined as P<0.05). The overall sensitivities combining each probability scale and severity score at 80%, 90%, and 95% specificity were 90.2%, 72.1%, and 59%, respectively. There was a statistically significant correlation between the GDx-VCC severity score and the visual field severity score (P<0.05). CONCLUSIONS: GDx-VCC parameters may not be sufficiently sensitive to detect glaucomatous patients with localized visual field damage. Our algorithm using the GDx-VCC deviation map may enhance the understanding of GDx-VCC in terms of the locality, deviation size, and severity of localized RNFL defects in eyes with localized visual field loss.

Chemical Burns of the Cornea Due to Soda Lime Used for Line Marking on the Playground

PURPOSE: The hydrated form of lime used for marking lines on the ground is a corrosive alkali. The harmful effects of lime are well known, and chemical burns of human tissue due to lime have been reported. We report a case of chemical injury of the cornea caused by exposure to lime at a playground. METHODS: A 3-year-old male patient presented with decreased visual acuity after slipping on the playground. His best corrected visual acuity (BCVA) was 20/40 in the right eye (OD), and hand motion in the left eye (OS). On biomicroscopic examination, bilateral corneal opacity and corneal erosion were observed. In the OS, the corneal opacity involved the visual axis and resulted in vision impairment. He was treated with eye drops. RESULTS: After treatment for 3 months, his corrected visual acuity was 20/30 in the OD, and 20/125 in the OS. The corneal opacity was not improved and corneal thinning was observed in the OS. After 1 year, BCVA was 20/25 in the OD, and 20/100 in the OS. CONCLUSIONS: The lime used for marking white lines on the ground can cause opacity and thinning of the cornea. Other, safer methods for line marking should be considered.

Three-year follow-up of Clinical Results after SI-30NB Intraocular Lens Implantation Through Temporal Clear Corneal Incision

We examined the clinical results of silicone IOL[SI-30NB]for 3 years or more. A total of 50 eyes underwent phacoemulsification and foldable silicone posterior chamber lens implantation through 3.2 millimeter temporal clear corneal incision. Preoperative and post-operative intraocular pressure, visual acuity, corneal astigmatism and complications were evaluated. More than 94%of all cases showed best corrected visual acuity better than 20/40 and intraocular pressure was decreased for 2 months. At 1 day after operation, mean surgically induced astigmatism was minimal[0.64 +/-1.42]and recovered fast. Posterior capsular opacity was found in 26%;however, Nd-YAG laser capsulotomy was performed in 18%. In conclusion, foldable silicone lens implantation through 3.2 millimetertemporal clear corneal incision revealed a low incidence of complication, minimally induced astigmatism, and rapid visual rehabilitation.

Assessment of Idiopathic Macular Hole Surgery by Heidelberg Retina Tomograph

For the evaluation of preoperative and postoperative factors effecting the results of vitrectomy as a treatment of full thickness macular hole, we estimated the three dimensional morphology of macular hole using the HRT [Heidelberg retina tomography]and investigated every patient's history and operation method. Pars plana vitrectomy, epiretinal and internal limiting membrane removal, and C3F8 injection were performed in 19 patients[19 eyes]with full thickness macular holes. Anatomic success was seen in 12 eyes[63.2%]and was statistically related with preoperative hole area, volume and depth. Functional success was seen in 6 eyes[31.6%]and was significantly related with preoperative hole volume and depth, marginal detachment area and volume, hole diameter and hole area. In addition, anatomic success was statistically related with internal limiting membrane removal[p<0.01], stage and preoperative visual acuity [p<0.05]. Functional success was significantly related with preoperative visual acuity, internal limiting membrane removal[p<0.01], stage and duration of the disease[p<0.05]. We conclude that preoperative HRT is a useful method in deciding the operative indications and also in predicting the outcomes.

Analysis of HRT Heidelberg Retina Tomograph in High Myopic Patient

In high myopic patients with optic disc tilting, reference height is underestimated and many parameters depending on reference height will be changed with previous Heidelberg Retina Tomograph[HRT, under version 1.01].Therefore, care must be taken to classify the patients with tilted optic disc because underestimation of the amount of their cup area and volume may cause faulty decision to normal disc. However, by using "tilted analysis method" in recent HRT program[ver.2.01], we can expect to overcome such problems so, in this study we try to find out how much the HRT results are different between tilted and untilted analysis methods.We evaluated 26 high myopic patients under -6 diopters with tilted optic disc and glaucomatous visual field defects from March 1998 to July 1998. We compared their HRT parameters measured by untilted and then tilted method to each other.The mean reference height was changed from 0.2735 to 0.2892, the cup volume from 0.1961 to 0.1790 and the neural rim volume from 0.3060 to 0.3358 but glaucoma classification, the final conclusion of test, was not changed significantly due to neural rim volume and height variation contour increase with constant cup shape measure. Therefore, although refrence height is lowered and cup volume decreased with HRT[ver.1.01]in high myopic patients, if considering other many parameters, we can interpretate results rightly.

Comparison of Clinical Results of Lens Extraction and LASIK for Correction of High Myopia

We compared the clinical results of lens extraction with or without intraocular lens (IOL) for 41 eyes of 24 high myopic patients (axial length: >26mm, diopter: <-10) to those of laser in situ keratomileusis (LASIK) for 54 eyes of 29 patients. After operation,uncorrected visual acuity and best corrected visual acuity were improved in both patient groups. They gained visual improvement of 2 or more lines in 73% and 11%, respectively. Predictability was significantly higher in lens extraction group than LASIK group, while postoperative near vision was vise versa. The postoperative intraocular pressure was measured significantly low in LASIK group, while the number of corneal endothelium was significantly decreased in lens extraction group. In the point of postoperative complications, the incidence of posterior capsular opacity was 9.8% in lens extraction group and that of corneal ectasia was 5.3%in LASIK group. Conclusively, for precision and quality of vision, lens extraction with or without IOL implantation would be superior to LASIK for correction of high myopia. However, corneal endothelial cell loss, near vision impair-ment, and developememt of after-cataract might be problems in the procedure of lens extraction.