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

Prosthetic iris implantation for congenital, traumatic, or functional iris deficiencies.

PURPOSE: To determine the efficacy and safety of surgical implantation of prosthetic iris devices in patients with anatomic or functional iris deficiencies. SETTING: Cincinnati Eye Institute, Cincinnati, Ohio, USA. METHODS: Twenty-five patients were enrolled in an interventional prospective noncomparative case series. Twenty-eight eyes had prosthetic iris diaphragm implantation for traumatic iris defects, congenital aniridia or iris coloboma, herpetic iris atrophy, surgical iris loss, or ocular albinism. Prosthetic iris implantation was performed with phacoemulsification and intraocular lens (IOL) implantation in 20 eyes, secondary IOL implantation in 6 eyes, and IOL exchange in 1 eye. A single pseudophakic eye with disabling glare secondary to traumatic aniridia had secondary prosthetic iris implantation alone. The surgical ease of insertion, intraoperative and postoperative complications, postoperative anatomic results, visual acuity, and subjective glare reduction were evaluated. RESULTS: Patients were followed postoperatively for a mean of 10.2 months (range 1.4 to 25.7 months). All eyes achieved the desired anatomic result. Visual acuity was improved in 22 of 28 eyes (79%), unchanged in 5 eyes, and worsened by a single line in 1 eye. Patients were surveyed postoperatively to determine the change in glare disability. The severity of glare disability was subjectively improved in 23 of 24 patients (96%) who responded to the survey. Intraoperative complications included 3 fractured implants as well as an incomplete or torn capsulorhexis in 3 eyes. Postoperative complications included transient hypotony in 2 eyes, mild persistent inflammation in 1 eye, and macular edema followed by a retinal detachment in 1 eye with recent severe trauma. CONCLUSIONS: Implantation of prosthetic iris devices improved postoperative outcomes by reducing glare disability and, in selected cases, by correcting aphakia. Although operating on traumatized, congenitally aniridic, or uveitic eyes presents special challenges, implantation of prosthetic iris devices appears to be a safe and effective method for reducing the ubiquitous glare in patients with iris deficiency.

Incidence of ocular misalignment and diplopia after uneventful cataract surgery.

PURPOSE: To evaluate the incidence of ocular misalignment and diplopia after uneventful cataract surgery. SETTING: An outpatient private practice eye institute. METHODS: One hundred thirty-eight patients referred to 1 cataract surgeon were prospectively evaluated. Orthoptic evaluations were performed within 1 month before and then 1 day, 1 week, and 1 month after cataract surgery. Anesthesia was by retrobulbar injection, and cataract extraction was done by phacoemulsification. RESULTS: Cataract surgery was performed in 118 patients. Preoperatively, 16 patients had ocular misalignment; 10 were phoric, 4 were intermittently tropic, and 2 were tropic. Follow-up evaluation was obtained for 101 patients (86%) at 1 day, 91 (77%) at 1 week, and 88 (75%) at 1 month. A change in ocular alignment occurred in 22 of 101 patients (22%) at 1 day, 9 of 91 (10%) at 1 week, and 6 of 88 (7%) at 1 month. Only 1 patient who had a change in alignment at 1 month was symptomatic. CONCLUSIONS: A persistent change in ocular alignment after uneventful cataract surgery occurred in 7% of patients. However, symptomatic diplopia was uncommon (1 in 118; 0.85%) in this relatively small series.

Management of profound zonular dialysis or weakness with a new endocapsular ring designed for scleral fixation.

The endocapsular tension ring has helped in the management of patients with moderate loss of zonular support. However, the eye with profound zonular dialysis or weakness may require scleral fixation of the ring for centration and long-term stabilization. We used a new, modified endocapsular tension ring designed to provide scleral support without violating the integrity of the capsular bag in 4 patients. All patients had extreme loss of zonular support preoperatively or a significant risk of progressive zonular weakness. In each case, the new ring provided excellent support and centration of the capsular bag and intraocular lens intraoperatively and postoperatively.

Re-forming the flat anterior chamber with Healon.

A shallow or flat anterior chamber may occur after complicated cataract surgery, a filtering procedure for glaucoma, or combined surgery. We describe a technique for injecting sodium hyaluronate (Healon) into the anterior chamber through the previous paracentesis tract in the operating room or at the slitlamp microscope. Re-forming the anterior chamber with Healon may pre-empt the anatomical sequelae of prolonged anterior chamber shallowing and prevent the need for more invasive surgery.

Endocapsular ring approach to the subluxed cataractous lens.

The surgical management of the cataract associated with extensive zonular dialysis presents a challenge for the anterior segment surgeon. In 1993, a poly(methyl methacrylate) endocapsular ring was introduced to stabilize the capsular bag. We describe the use of this endocapsular ring in phacoemulsification and intraocular lens (IOL) implantation in the capsular bag in four patients with extensive traumatic or congenital zonular dialysis. The endocapsular ring allows expansion and stabilization of the capsular bag to facilitate cortical aspiration and uncomplicated IOL implantation. With follow-up of 4 to 10 months, all IOLs have remained well centered and the patients have had excellent vision free of complications.

Treatment of anterior chamber fibrin following cataract surgery with tissue plasminogen activator.

Three patients who developed anterior chamber fibrinous exudates after cataract surgery were treated with tissue plasminogen activator injected into the anterior chamber. There was prompt dissolution of the fibrinous exudates and no observed complications. When fibrinous exudates occur in high-risk patients after cataract surgery, tissue plasminogen activator provides an excellent means of clearing the fibrin.

Retrobulbar hemorrhage.

Retrobulbar hemorrhage associated with retrobulbar anesthesia has been construed as a contraindication to cataract surgery. Cancellation of the surgery results in disappointment for both the patient and surgeon. A retrospective study of 60 eyes was undertaken to evaluate the safety of proceeding with small-incision phacoemulsification surgery after retrobulbar hemorrhage when specific criteria are met. If digital massage achieved a soft globe that was easily retropulsed and the eyelids were loose and easily mobilized, the surgery was performed as scheduled. If the globe remained firm within a tense orbit and proptosis with tight lids was present, surgery was cancelled. Fifty-seven cases with retrobulbar hemorrhage met these criteria and underwent phacoemulsification with implantation of a posterior chamber intraocular lens. The lack of intraoperative and postoperative complications suggests that small-incision cataract surgery can be safely performed when preceded by a limited retrobulbar hemorrhage.

The torn posterior capsule: its intraoperative behavior, surgical management, and long-term consequences.

A retrospective study of cataract surgery performed between January 1983 and December 31, 1989, disclosed 48 eyes in which the posterior capsule was torn. The overall incidence of this complication was approximately 1% but was further reduced when the technique of capsulorhexis was mastered. Our review of the video tapes of these surgical procedures revealed that the tear occurred most frequently during nucleus removal (41%) and posterior capsular vacuuming (28%). The anatomy of each tear was classified and related to the event responsible for the torn capsule, as well as to the likelihood of vitreous involvement. Vitreous presented through the tear in 32% of the 48 cases, entered the wound in 6%, and remained posterior to the torn capsule in 62%. Intraocular lenses were implanted in every case; only posterior chamber lenses were used during the last four years of the study. Vitreous-related complications included vitreous prolapse, peaked pupils, and vitreous-induced pupillary block. Acute postoperative intraocular pressure elevation was a frequent finding and was managed by conservative therapy. Transient cystoid macular edema developed in one case which had a rotating anterior chamber intraocular lens. No retinal detachments occurred in this series. Final visual acuity of 20/40 or better was achieved in 89% of the 48 cases. When properly managed, a torn posterior capsule is compatible with an excellent visual outcome.

Collagen metabolism following corneal laceration in rabbits.

We investigated the synthesis and degradation of collagen in lacerated rabbit corneas. The rate of collagen synthesis was measured by the incorporation and hydroxylation of [14C]proline up to 5 weeks after a penetrating laceration. Our results indicate that protein and collagen synthesis is initially reduced during the 24 h period after laceration and then increases in two phases. A moderate increase in protein and collagen synthesis occurs up to day 5 after laceration. Synthesis then decreases to a low level through the 10th day after injury. A second wave of increase in protein and collagen synthesis takes place reaching a new peak of approximately twice the activity as found in control corneas after 5 weeks of healing. Afterwards, the rate of protein and collagen synthesis declines and reaches the basal level after 7 weeks of healing. In a separate set of experiments, rabbit corneas were lacerated and allowed to heal for one or three weeks at which point 100 microCi of [14C]proline was injected into each anterior chamber. The corneas were excised 1 to 17 days later and subjected to collagen analysis. Our data indicates that the degradation of collagen synthesized by the cornea 1 week after laceration followed biphasic kinetics. In the first phase, the half-life of newly-synthesized collagen is 20 days, whereas it is approximately 4 days in the second phase. It is of particular interest that the accelerated degradation of the newly-synthesized [14C]collagen is concomitant with the increased rate of collagen synthesis during the wound healing process. The degradation of collagen synthesized 3 weeks after injury was slower and followed monophasic kinetics having a half-life of 14 days. The degradation of non-collagenous 14C-proteins follow a monophasic kinetics having a half-life of 6-7 days. Polyacrylamide gel electrophoresis of newly-synthesized collagen indicated that the collagen(I) and collagen(V) were the main collagenous components synthesized by the lacerated corneas.