Intraoperative management of posterior capsule tears in phacoemulsification and intraocular lens implantation.

OBJECTIVE: This paper presents the incidence, causes, and management of posterior capsule (PC) tears and their postoperative outcomes in a large series of eyes that underwent cataract removal and intraocular lens (IOL) implantation, operated on by one surgeon. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Eighteen thousand four hundred seventy consecutive eyes (1992-1999) were reviewed with the assistance of electronic medical records for incidence of PC tears in patients seeking treatment at an outpatient cataract surgery clinic. INTERVENTION: Eyes in this series underwent continuous curvilinear capsulorrhexis (CCC), nucleofractis phacoemulsification, and IOL implantation under topical anesthesia. Different intraoperative surgical strategies such as posterior continuous curvilinear capsulorrhexis (PCCC) were used in the management of PC tears. MAIN OUTCOME MEASURES: Routine preoperative and postoperative visual and refractive outcomes were recorded, including incidence of lens capsule tears, IOL position, and postoperative complications. RESULTS: Posterior capsule tears occurred in 83 of 18,470 eyes, resulting in an overall incidence of 0.45%. Of these 83 eyes with PC tears, 49% received vitrectomy. Fifty-one of 83 PC tears (61.4%) were amenable to be converted to PCCC. Of these 51 procedures, 50 eyes had PC IOL in-the-bag fixation. One eye had PCCC with optic capture. There were no eyes with dropped nuclei or nuclear fragments requiring pars plana vitrectomy. Seventeen eyes (20.5%) had Neuhann anterior capsule rhexis fixation with the haptics placed in the sulcus and IOL securely in the bag. Ten eyes (12.1%) had the IOL placed in the sulcus, and 5 eyes (6.0%) required anterior chamber IOL fixation. None of the 83 PC tears resulted in clinically evident cystoid macular edema, retinal detachment, or endophthalmitis. CONCLUSIONS: With an intact CCC and with conversion of PC tears to PCCC, in-the-bag fixation of IOLs can be achieved in most eyes.

Accuracy of Orbscan pachymetry measurements and DHG ultrasound pachymetry in primary laser in situ keratomileusis and LASIK enhancement procedures.

PURPOSE: To assess the accuracy and variability in pachymetry measurements obtained by Orbscan and by DGH ultrasound in primary laser in situ keratomileusis (LASIK) and LASIK enhancement procedures. SETTING: Gimbel Eye Centre, Calgary, Alberta, Canada. METHODS: A retrospective analysis of 906 consecutive primary LASIK and 183 consecutive LASIK enhancement procedures for which preoperative DGH ultrasound and Orbscan pachymetry measurements were obtained. The theoretical residual corneal thickness was compared to measurements by both instruments in 60 eyes that had primary procedures and enhancements. RESULTS: In primary LASIK eyes, the DGH ultrasound measurements were thicker than the Orbscan measurements by a mean of 18.4 microm +/- 17.4 (SD). The DGH ultrasound measurements were thicker than the Orbscan measurements by a mean of 50.1 +/- 40.7 microm in preenhancement pachymetry measurements. The DGH ultrasound measurements were consistent with theoretical residual corneal thickness, 493.0 +/- 42.0 microm versus 487.0 +/- 31.0 microm (P =.65), while Orbscan measurements were statistically less than the theoretical residual corneal thickness, 431.0 +/- 42.0 microm versus 468.0 +/- 39.0 microm (P =.0001). CONCLUSION: DGH ultrasound was a more accurate measurement of corneal pachymetry than Orbscan. The discrepancies between DGH ultrasound and Orbscan pachymetry measurements were more prominent in eyes that had had LASIK.

Combined cataract surgery, intraocular lens implantation, and viscocanalostomy.

PURPOSE: To describe 2 techniques of combined viscocanalostomy and phacoemulsification and report the results. SETTING: Gimbel Eye Centre, Calgary, Alberta, Canada. METHODS: Combined viscocanalostomy, phacoemulsification, and intraocular lens implantation was performed in 83 eyes. A shared scleral incision was made in 46 eyes and a clear corneal incision separate from the viscocanalostomy site, in 37 eyes. A retrospective review of these cases was performed. RESULTS: Intraocular pressure (IOP) was significantly lower in both groups 2 and 8 weeks and 6 months postoperatively. The decline in IOP postoperatively over time was also comparable. There were no cases of hypotony, choroidal detachment, filtrating bleb, or postoperative cystoid macular edema in either group. Complications included IOP spikes in 2 eyes in the shared-incision group at 1 day (to 43 and 30 mm Hg, respectively). In early shared-incision cases, there was 1 obvious Descement's puncture in 1 eye and a torn scleral flap requiring extra suturing in another eye. CONCLUSION: Combined viscocanalostomy, cataract extraction, and IOL implantation was safe and efficacious in lowering IOP whether a shared scleral incision or a separate clear corneal incision was used for phacoemulsification.

Simultaneous bilateral laser in situ keratomileusis: safety and efficacy.

OBJECTIVE: To compare the safety and efficacy of simultaneous bilateral to sequential bilateral laser in situ keratomileusis (LASIK) surgery for the correction of myopia. DESIGN: Retrospective, nonrandomized, comparative trial. PARTICIPANTS: A total of 2142 consecutive simultaneous and sequential bilateral myopic LASIK surgery eyes operated from March 1996 through June 1998 for the correction of myopia were reviewed. INTERVENTION: Two surgeons (HVG and JAV) performed myopic LASIK using the Nidek EC-5000 excimer laser and either the Chiron Automated Corneal Shaper or the Bausch & Lomb Hansatome microkeratome. MAIN OUTCOME MEASURES: The incidence of intra- or perioperative complications for sequential and simultaneous bilateral LASIK for myopia was recorded. Refractive and visual outcomes at 3 to 6 months postoperative were analyzed. Deviations from targeted spherical equivalent (SE), uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), and retreatment rates are reported. RESULTS: Laser in situ keratomileusis was performed on the first eye of 1853 patients scheduled for simultaneous bilateral myopic LASIK. Of these, 28 (1.5%) first eyes had intraoperative or perioperative complications. The second eye surgery was cancelled in 11 cases, and 1842 second eyes completed simultaneous surgery; 13 (0.7%) intraoperative or perioperative complications occurred. Of these 41 complications in simultaneous cases, 1 eye lost 1 line of BCVA at 6 months follow-up. Two hundred eighty-nine patients were scheduled for sequential bilateral myopic LASIK. Five (1.8%) first eyes of the sequential cases had intraoperative complications compared with four (1.4%) sequential second eyes. There was no loss of BCVA in any sequential bilateral case with complications at a minimum at 6 months follow-up. There was no statistically significant difference between intra- and perioperative complication rates comparing simultaneous to sequential bilateral LASIK. Three to 6 months postoperative visual and refractive data were reviewed; except when comparing simultaneous first eye postoperative SE to sequential first eye, there was no statistically significant difference in refractive or visual outcomes, including deviation from targeted SE, UCVA, BCVA, and retreatment rates. CONCLUSION: Simultaneous bilateral LASIK is as safe and effective as sequential surgery. Simultaneous bilateral LASIK may offer several benefits to the patient.

Incidence and management of intraoperative and early postoperative complications in 1000 consecutive laser in situ keratomileusis cases.

OBJECTIVE: To identify intraoperative and early postoperative complications of laser in situ keratomileusis (LASIK) surgery learning curve and to offer recommendations on prevention and management. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: The first 1000 consecutive myopic LASIK eyes (April 1995-February 1997) operated on by one surgeon (HVG) were examined. INTERVENTION: Myopic LASIK surgery was performed with the Chiron Corneal Shaper and NIDEK EC-5000 excimer laser. MAIN OUTCOME MEASURES: The preoperative and 6-month postoperative spherical equivalent, best-corrected visual acuity, and corneal status were recorded, as was the incidence of intraoperative and early postoperative complications. The rate of retreatments was also recorded. RESULTS: There were 32 (3.2%) intraoperative complications and surgical events recorded, including 19 (1.9%) microkeratome-related flap complications and 13 (1.3%) nonmicrokeratome-related surgical events such as inability to obtain sufficient suction. There were 18 (1.8%) postoperative complications requiring repositioning of microwrinkled or shifted flaps. Six-month spherical equivalent was -0.52 diopter [D] +/- 1.19 D for eyes with microkeratome complications, -0.56 D +/- 1.07 D for the group with nonmicrokeratome-related intraoperative events, and -0.78 D +/- 0.92 for eyes requiring postoperative flap repositioning. None of the 32 eyes with intraoperative complications and surgical events lost 2 or more lines of vision. One eye in the postoperative complications group lost two lines of vision. The rate of microkeratome complications related to surgical technique and the overall surgery times decreased over the course of the first 1000 myopic LASIK cases. CONCLUSION: The complications encountered during the early learning curve of LASIK surgery have not in this series resulted in a significant loss of best-corrected visual acuity. With increasing surgical experience, the incidence of complications, along with surgical times, has decreased.

Results of bilateral cataract extraction with posterior chamber intraocular lens implantation in children.

OBJECTIVE: A retrospective study was undertaken to evaluate long-term anatomic and visual outcomes in eyes of children who underwent bilateral intraocular lens implantation. DESIGN: The study design was a review of medical records of 24 children operated on for bilateral cataracts and posterior chamber-intraocular lenses. PARTICIPANTS: Twenty-four children operated on for bilateral cataracts by 1 surgeon between February 1980 and February 1995 were studied. INTERVENTION: Cataract extraction with bilateral posterior chamber-intraocular lens implantation was performed. MAIN OUTCOME MEASURES: Best-corrected visual acuity, visual acuity without correction, intraocular pressure, manifest refraction, and any intraoperative or postoperative complications were measured. RESULTS: At last follow-up (mean follow-up, 50.8 months; range, 10-149 months), the intraocular lens was in good position and the intraocular pressure was normal without medication in all eyes. Four years after surgery, 79.2% (19 of 24) of first eyes achieved a best-corrected visual acuity of 20/40 or better compared to 66.7% (16 of 24) of second eyes. No eye had any loss in best-corrected visual acuity. In first eyes of 3- to 8-year olds at the time of surgery, 73.3% (11 of 15) achieved a spherical equivalent within 2 diopters of the intended at 4 years after surgery compared to 80% of second eyes. In the 9- to 18-year-old group, 88.9% (8 of 9) of first eyes and 100% of second eyes achieved a spherical equivalent within 2 diopters of the intended at 4 years after surgery. Intraoperative and postoperative complications were minimal. CONCLUSIONS: Long-term anatomic and visual results have been gratifying in this series of patients with bilateral implants.

Experience during the learning curve of laser in situ keratomileusis.

PURPOSE: To identify pitfalls and offer hints on achieving a successful outcome during the early laser in situ keratomileusis (LASIK) learning process. SETTING: Gimbel Eye Centre, Calgary, Alberta, Canada. METHODS: This was a retrospective review of the preoperative planning, surgical procedure, intraoperative and postoperative problems, and early postoperative anatomic and refractive results in the first 73 eyes that had LASIK. RESULTS: Intraoperative complications included failure of the keratome to make a cut, excessively thin cap, repositioning difficulty, and inadequate intraocular pressure elevation. Early postoperative complications included excessive central and peripheral wrinkling of the cap, peripheral lipid deposits, and central edema of the cap. One month postoperatively, mean spherical equivalent refraction was -0.90 diopters (D) (range +1.75 to -6.00 D), and 45 eyes had a best corrected visual acuity between 20/15 and 20/40. CONCLUSION: Our retrospective review of the problems experienced during the early LASIK learning process should help novice lamellar refractive surgeons avoid such problems and shorten the learning curve.

Effect of pharmacological dilation and constriction of pupil on corneal topography.

A prospective study was undertaken to investigate the effect of pharmacological pupillary dilation and constriction on corneal topography. Corneal topography was performed using the EyeSys system on 28 normal subjects before and after pupil dilation, constriction, and then with the pupil intact (no medication). Our results show that both flattening and steepening of the corneal curvature were found in all three examination periods. The numbers of corneas with flattening and steepening in each examination period were compared and found not to be statistically different. Mean change of corneal flattening was compared with mean change of corneal steepening in each examination period and again no significant difference was found. These results indicate that the slight changes in corneal power and radius following pharmacological pupillary dilation or constriction may be due to either the inability to repeat by the subjects, or error by observers or instrument.

Intraocular pressure response to combined phacoemulsification and trabeculotomy ab externo versus phacoemulsification alone in primary open-angle glaucoma.

We investigated trabeculotomy ab externo as a means of optimizing intraocular pressure (IOP) control in glaucoma patients having phacoemulsification and implantation of an intraocular lens (IOL). A prospective, randomized, controlled study was performed to evaluate the effect on IOP and the incidence of complications associated with combined phacoemulsification and trabeculotomy ab externo. The study group had the combined procedure, while the control group had only phacoemulsification with IOL implantation. A total of 106 patients were randomized, and the IOP for each group was compared at 3, 6, 12, and 24 months. At two years, the mean IOP reduction was 6.1 mm Hg in the study group and 3.8 mm Hg in the control group (P = .001). There were no complications in the control group. Two complications (2/53 or 3.8%) occurred in the study group: a small tear in Descemet's membrane and a postoperative microhyphema. There was no increase in medication in either the study or control group. Combined phacoemulsification and trabeculotomy ab externo represents an option to lower IOP and potentially reduce the need for pressure-lowering medications in patients with primary open-angle glaucoma and visually significant cataracts.

Comparison of laser and manual removal of corneal epithelium for photorefractive keratectomy.

BACKGROUND: Photorefractive keratectomy relies on precise ablation of cornea stromal tissue to achieve a desired change in refraction. The routine technique for photorefractive keratectomy has been manual debridement of the epithelium prior to performing excimer laser ablation. We investigated whether laser ablation versus manual debridement of the corneal epithelium influences the refractive result. METHODS: A retrospective matched controlled study analyzing the refractive outcome of 46 eyes after excimer laser photorefractive keratectomy was performed. Half of the eyes had the corneal epithelium ablated with the excimer laser, while the other half had mechanical removal. Topical postoperative corticosteroid dosing was different in the two groups. All photorefractive keratectomies were performed by the same surgeon (H.V.G.). The two groups were analyzed for statistical differences in refractive outcomes and corneal haze after 6 months. RESULTS: The mean preoperative spherical equivalent refraction in the laser removal group was -5.11 diopters (D), and -5.09 D in the manual group. At 6 months postoperatively, the mean spherical equivalent refraction in the laser group was +0.03 D and -0.40 D for the manual group (p = .21). At no point postoperatively was there any significant difference in the mean refractive outcome or variance of the refractive results between the two groups, although there was a trend toward greater correction with laser ablation of epithelium. There was no statistical difference in the amount of stromal haze by slit-lamp microscopy in the two different debridement groups. There was no significant difference in final uncorrected visual acuity, rate of reepithelialization, or reported incidence of halos or glare between the two groups. CONCLUSION: There was a tendency toward greater refractive correction at 6 months using the laser for corneal epithelial removal than manual debridement, although the difference was not statistically significant. The trend toward slightly higher correction emphasizes the need for care when removing epithelium with the laser to prevent concomitant stromal ablation.

Implantation in children.

With the development of posterior chamber lenses and continuous curvilinear capsulorhexis, and with the availability of viscoelastic agents, the use of intraocular lenses (IOLs) in children is becoming more popular. Since 1982, we have implanted posterior chamber IOLs (PC-IOLs) in the capsular bags of 61 cataractous eyes of 46 children and adolescents. The goal was in-the-bag placement facilitated by the use of a small capsulectomy, and, since 1984, by the use of the continuous curvilinear capsulorhexis. Forty-four cataracts were congenital, 13 were traumatic, and 4 were developmental. Cataract extraction with IOL implantation was performed in 16 (26%) preschool cases (ages 2 through 5), in 31 (51%) child cases (ages 6 through 12), and 14 (23%) adolescent cases (ages 13 through 18). Surgical and postoperative complications were minimal. Visual results were good. Fifty-six percent of preschoolers, 87% of children, and 86% of adolescents achieved 20/40 or better best corrected vision, with 79% of the total cohort achieving 20/40 or better. Overall, 35% achieved an uncorrected visual acuity of 20/40 or better. All but two cases had improvement in best corrected vision; if 20/20 was not attained, the cause was mainly due to deprivation amblyopia. Forty-eight percent of patients were within a diopter of emmetropia.

Visual, refractive, and patient satisfaction results following bilateral photorefractive keratectomy for myopia.

Reports of the visual, refractive, and patient satisfaction results after photorefractive keratectomy (PRK) are now becoming available. The visual, refractive, and patient satisfaction results of 52 patients after bilateral excimer laser photorefractive keratectomy for myopia were studied. Patient satisfaction was measured using a five-part questionnaire. Initial patients obtained an overcorrection which necessitated adjusting the programmed correction to 75% of targeted correction.