Bilaterally subluxed diffractive intraocular lenses: big expectations and even bigger comorbidities.

A 78-year-old woman with an ocular history of cataract surgery with a diffractive intraocular lens (IOL) in each eye has developed fluctuating vision, greater in the right eye than the left eye, after 4 years. She has a history of inactive central serous retinopathy and a vision potential of 20/25 + 2 in the right eye and 20/25 in the left eye. She has well-controlled diabetes, hypertension, and hypercholesterolemia. She has enjoyed her spectacle independence for some time and wishes to have her vision restored. On examination, her uncorrected distance visual acuity (UDVA) was 20/50 in the right eye and 20/25 in the left eye and her uncorrected near visual acuity (UNVA) was J3 in the right eye and J1 in the left eye. Intraocular pressures (IOPs) measured 22 mm Hg in the right eye and 18 mm Hg in the left eye. Pupils had limited reactivity with irregularity in the right eye but no obvious relative afferent pupillary defect. Motility and confrontation visual fields were unremarkable in both eyes. Retinal acuity meter was 20/20 in both eyes, and manifest refraction was plano -1.25 × 105 20/40, J3 in the right eye and +0.50 × 20/25, J1 in the left eye. Pertinent findings on slitlamp examination included temporal iris atrophy and transillumination defects greater in the right eye than the left eye, peripupillary pseudoexfoliative changes in both eyes, significant inferior subluxation of a diffractive 3-piece posterior chamber IOL in the capsular bag with lens-pitting peripherally and few central, moderate pseudophacodonesis, and an open posterior capsule in the right eye. In the left eye, she had mild inferior subluxation of a single-piece acrylic diffractive IOL in the capsular bag with moderate pseudophacodonesis and an open posterior capsule (Figure 1JOURNAL/jcrs/04.03/02158034-202403000-00019/figure1/v/2024-02-20T193212Z/r/image-tiff). All other anterior segment findings were unremarkable. On dilated posterior examination, she had a cup-to-disc ratio of 0.50 in the right eye and 0.65 in the left eye without edema hemorrhage or pallor. There were attenuated vessels in both eyes, posterior vitreous detachment in both eyes, and a few small drusen peripherally in both eyes. There was retinal pigment epithelium irregularity and dropout parafoveal in the right eye and subfoveal in the left eye (Figure 2). There was no evidence of macular edema, subretinal fluid, choroidal thickening, or neovascular membranes. The periphery was unremarkable in both eyes.JOURNAL/jcrs/04.03/02158034-202403000-00019/figure2/v/2024-02-20T193212Z/r/image-tiff What testing would you obtain preoperatively to help guide your decision-making? How would you counsel the patient regarding comorbid conditions and expectations?

Radial keratotomy and cataract surgery: A quest for emmetropia.

A 75-year-old man with an ocular history of 8-cut radial keratotomy (RK) in both eyes presented for cataract surgery evaluation. He was previously correctable in spectacles in years prior despite his irregular corneas to 20/25 in the right eye and 20/30 in the left eye. He recently noticed a change in his overall visual function with significant nighttime glare and difficulty reading despite spectacle correction. Of note, he was unable to tolerate contact lenses and was resistant to refitting despite additional encouragement. Cataract surgery was delayed for many years, given he was correctable in spectacles and the concern of uncovering a highly aberrated cornea after removing his cataracts (Figures 1 and 2JOURNAL/jcrs/04.03/02158034-202308000-00021/figure1/v/2023-07-21T030437Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202308000-00021/figure2/v/2023-07-21T030437Z/r/image-tiff). Of note, the patient was interested in returning to the spectacle independence he enjoyed in the past. Ocular examination revealed a corrected distance visual acuity (CDVA) of 20/30 in the right eye and 20/60 in the left eye, with a manifest refraction of +4.50 -0.50 × 177 in the right eye and +5.75 -1.75 × 14 in the left eye. Glare testing was 20/50 in the right eye and 20/100 in the left eye, with retinal acuity meter testing of 20/25 in each eye. Pupils, confrontation visual fields, and intraocular pressures were normal. Pertinent slitlamp examination revealed corneal findings of 8-cut RK with nasal-gaping arcuate incisions in both eyes and lens findings of 2+ nuclear sclerosis with 2+ cortical changes in the right eye and 3+ nuclear sclerosis with 3+ cortical changes in the left eye. Cup-to-disc ratios of the optic nerves measured 0.5 with temporal sloping in the right eye and 0.6 with temporal sloping in the left eye. The dilated fundus examination was unremarkable. What intraocular lens (IOL) options would you offer this patient and how would you counsel regarding realistic expectations? What additional diagnostic testing would be helpful in your assessment? How would you calculate the IOLs?

Approach to a spontaneously ruptured posterior polar cataract.

A 61-year-old man presented with gradual blurring of vision and glare in both eyes for a couple of years, with worsening of the vision in his right eye over the past 2 months. He had no medical history of note. On clinical examination, his visual acuities were 20/80 in the right eye and 20/30 in the left eye, uncorrected. The cornea was clear, and the anterior chamber (AC) was deep in both eyes. He had bilateral mild nuclear sclerosis with round central onion-ring-like posterior opacities. The opacities measured approximately 2 mm in diameter and were marginally larger in the right eye than in the left eye (Figure 1JOURNAL/jcrs/04.03/02158034-202305000-00018/figure1/v/2023-04-20T184543Z/r/image-tiff). In addition, there were 2 curvilinear lines across the right posterior capsule (PC), one of which passed across the lens opacity (Figure 2JOURNAL/jcrs/04.03/02158034-202305000-00018/figure2/v/2023-04-20T184543Z/r/image-tiff). Fundus examination was normal in both eyes, and the vitreous was clear. Optical coherence tomography (OCT) of the macular and optic nerve in both eyes was normal. The endothelial cell count in both eyes exceeded 2000 cells/mm2. He had been told by a previous ophthalmologist to have bilateral cataracts and was now keen for surgery starting with the right eye. He works as a manager in a large company and is an avid golf player. He is emmetropic and wears spectacles for near work. Optical biometry using predicated posterior corneal astigmatism did not recommend a toric intraocular lens (IOL). He had done his internet research on IOL options and requested trifocal IOLs. What is your surgical plan for right cataract removal? Explain which IOL you would choose to implant.

Surgical decisions in the setting of zonulopathy.

An 85-year-old man with a history of type 2 diabetes, pseudoexfoliation (PXF) in both eyes, and tamsulosin use was referred for the evaluation of a dense cataract in the right eye and a subluxated intraocular lens (IOL) in the left eye. Unfortunately, his surgery in the left eye was complicated by diffuse zonulopathy. The referring surgeon placed a 3-piece IOL in the sulcus. However, the passively fixated 3-piece IOL moved inferiorly causing monocular diplopia for over a year. Because the patient was pleased with the IOL immediately postoperatively, a refixation procedure was performed in the form of sulcus placement with iris suture fixation in the left eye. Fortunately, the iris-fixated IOL in the left eye has remained well centered and stable without cystoid macular edema (CME) or chronic inflammation for over 8 months. The patient is on no ocular medications and has no family history of glaucoma. He now needs cataract surgery in the right eye and is extremely apprehensive because of his difficult course in the left eye. The corrected distance visual acuity is 20/70 in the right eye and 20/25 in the left eye. Intraocular pressures (IOPs) measure 20 mm Hg in the right eye and 14 mm Hg in the left eye by Goldmann tonometry. Pachymetry is 536 µm in the right eye and 543 µm in the left eye. Pupils are round with minimal reactivity and without a relative afferent pupillary defect. Extraocular motility is normal in both eyes, and confrontation visual fields is full in both eyes. Gonioscopy reveals an angle open to the pigmented trabecular meshwork (PTM) in the right eye and the ciliary body in the left eye with 1+ PTM and without peripheral anterior synechia in both eyes. The retinal nerve fiber layer and macular optical coherence tomography are normal in both eyes. On slitlamp examination, pertinent findings include pseudoexfoliative changes at the pupillary margin with poor dilation of 3.5 mm in both eyes; the anterior chamber (AC) is shallow but adequate in the right eye and deep and quiet with rare pigmented cells in the left eye. There is a 5+ nuclear sclerotic cataract with pseudoexfoliative changes on the anterior capsule and no obvious phacodonesis in the right eye and a 3-piece posterior chamber IOL in the sulcus fixated to the iris with 10-0 polypropylene sutures at 6 and 12 o'clock without pseudophacodonesis in the left eye. Dilated fundus examination reveals a cup-to-disc ratio of 0.4 with healthy neuroretinal rims in both eyes, posterior vitreous detachments in both eyes, and no evidence of diabetic retinopathy in both eyes. All other findings are unremarkable. How would you counsel this patient regarding his risk factors for surgery in the right eye? What surgical maneuvers would you use to remove the cataract safely? How would you stabilize the IOL if the capsule bag becomes compromised due to zonulopathy?

Anterior segment reconstruction due to cosmetic iris implants placed in the anterior chamber.

A 27-year-old woman had BrightOcular iris implants placed for cosmetic purposes that changed eye color from brown to blue bilaterally. Of note, BrightOcular implants are not approved by the U.S. Food and Drug Administration (FDA) for use in the United States and have been associated with severe ocular complications. In keeping with their design, they were placed in the anterior chamber (AC) in both eyes of this patient; surgery was performed outside the United States. As has been described previously and tragically in other cases, she developed chronic inflammation, intolerable glare, angle-closure glaucoma, corneal edema, and cataracts in both eyes. For medically unmanageable elevated intraocular pressure (IOP), she underwent diode laser cyclophotocoagulation (CPC) in both eyes, and eventually, an Ahmed tube shunt (New World Medical, Inc.) was placed in the right eye. Although she was advised and urged to have the iris implants removed, despite her ocular issues, she refused removal until intolerable glare and reduced vision ensued. Ultimately, both iris implants were extracted 5 years after implantation by a U.S. surgeon; the procedures resulted in corneal decompensation and progressive cataract development. Subsequent penetrating keratoplasty (PKP) was performed for the right eye, but it failed because of contact with the glaucoma tube shunt. She sought additional consultation and presented with the following findings: corrected distance visual acuity was 20/400 in the right eye and 20/40 in the left eye, IOP of 18 mm Hg in the right eye and 16 mm Hg in the left eye, pupils were nonreactive and fixed, and extraocular muscles and central visual field were normal. Pachymetry was 868 µm in the right eye and 653 µm in the left eye. Anterior segment examination in the right eye revealed a failed corneal graft with 3+ edema, peripheral anterior synechiae (PAS) for 360 degrees, shallow AC, Ahmed tube shunt at the 11 o'clock position and remnant iris adherent to the graft-host junction for 270 degrees, 3+ posterior subcapsular cataract, and 2+ cortical cataract (Figure 1JOURNAL/jcrs/04.03/02158034-202208000-00024/figure1/v/2022-08-01T210317Z/r/image-tiff). The sclera revealed multiple circular and circumferential atrophic blue spots consistent with high-energy transscleral CPC (Figure 2JOURNAL/jcrs/04.03/02158034-202208000-00024/figure2/v/2022-08-01T210317Z/r/image-tiff). In the left eye, she had remnant fixed dilated iris for 270 degrees, missing iris superiorly for 3 clock hours, an adequate AC, and 2+ cortical cataract (Figure 3JOURNAL/jcrs/04.03/02158034-202208000-00024/figure3/v/2022-08-01T210317Z/r/image-tiff). Posterior segment examination revealed a 0.5 cup-to-disc ratio in both eyes with normal vessels, macula, vitreous, and retinal periphery, bilaterally. Given this constellation of findings, how would you proceed?

Results of the United States Food and Drug Administration Clinical Trial of the CustomFlex Artificial Iris.

PURPOSE: To evaluate safety and efficacy of a custom-manufactured artificial iris device (CustomFlex Artificial Iris; HumanOptics AG) for the treatment of congenital and acquired iris defects. DESIGN: Multicenter, prospective, unmasked, nonrandomized, interventional clinical trial. PARTICIPANTS: Patients with photophobia, sensitivity secondary to partial or complete congenital or acquired iris defects, or both. METHODS: Eyes were implanted from November 26, 2013, to December 1, 2017, with a custom, foldable artificial iris by 1 of 4 different surgical techniques. Patients were evaluated 1 day, 1 week, and 1, 3, 6, and 12 months after surgery. At each examination, slit-lamp findings, intraocular pressure, implant position, subjective visual symptoms, and complications were recorded. Corrected distance visual acuity (CDVA) and endothelial cell density (ECD) were measured at 3, 6, or 12 months as additional safety evaluations. The 25-item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) was used to assess health-related quality of life affected by vision. The Global Aesthetic Improvement Scale was used to assess cosmetic results. MAIN OUTCOME MEASURES: Photosensitivity, glare, visual symptoms, NEI VFQ-25 score, Global Aesthetic Improvement Scale rating, prosthesis-related adverse events, intraocular lens (IOL)-related adverse events, and surgery-related adverse events 12 months after surgery. RESULTS: At the 12-month postoperative examination, a 59.7% reduction in marked to severe daytime light sensitivity (P < 0.0001), a 41.5% reduction in marked to severe nighttime light sensitivity (P < 0.0001), a 53.1% reduction in marked to severe daytime glare (P < 0.0001), and a 48.5% reduction in severe nighttime glare (P < 0.0001) were found. A 15.4-point improvement (P < 0.0001) in the NEI VFQ-25 total score was found, and 93.8% of patients reported an improvement in cosmesis as measured by the Global Aesthetic Improvement Scale 12 months after surgery. No loss of CDVA of > 2 lines related to the device was found. Median ECD loss was 5.3% at 6 months after surgery and 7.2% at 12 months after surgery. CONCLUSIONS: The artificial iris surpassed all key safety end points for adverse events related to the device, IOL, or implant surgery and met all key efficacy end points, including decreased light and glare sensitivity, improved health-related quality of life, and satisfaction with cosmesis. The device is safe and effective for the treatment of symptoms and an unacceptable cosmetic appearance created by congenital or acquired iris defects.

A mysterious myopic surprise.

A 73-year-old man with an ocular history of inactive age-related macular degeneration and chronic angle-closure glaucoma (CACG) in both eyes recently underwent femtosecond laser-assisted cataract surgery/phacoemulsification and intraocular lens (IOL) implantation with simultaneous Hydrus microstent (Ivantis, Inc.) implantation in the left eye. Although there was some reported subincisional iris prolapse due to intraoperative floppy iris, the case was otherwise uneventful according to the referring surgeon. Two months postoperatively, he was referred to our office for a myopic surprise of approximately 2.0 diopters (D) in the left eye (Figure 1JOURNAL/jcrs/04.03/02158034-202202000-00022/figure1/v/2022-01-26T192641Z/r/image-tiff). Of note, he has a distant history of acute ACG and complicated cataract surgery in the right eye with a failed trabeculectomy. He subsequently had laser peripheral iridoplasty to pull the iris away from the angle in the right eye (Figure 2JOURNAL/jcrs/04.03/02158034-202202000-00022/figure2/v/2022-01-26T192641Z/r/image-tiff). His topical intraocular pressure (IOP)-lowering medications at presentation included dorzolamide-timolol 1 drop twice daily in the left eye and 1 drop of timolol in the right eye once daily. His past medical history is significant for hypertension and benign prostatic hyperplasia, and his oral medications include Tamsulosin (Flomax), Irbasartan (Avapro), and Atenolol. On examination, he had an UCDVA of 20/20 in the right eye and 20/80 in the left eye, and a BCDVA of 20/20 in the right eye and 20/25 in the left eye. His manifest refraction was plano in the right eye and 1.50 -0.75 × 90 in the left eye. IOP measured 19 mm Hg in the right eye and 26 mm Hg in the left eye. Pupil examination revealed a nonreactive pupil in the right eye and a round sluggish pupil in the left eye without an obvious relative afferent pupillary defect. Extraocular motility and confrontational visual fields were full in both eyes. On slitlamp examination, pertinent findings included the following: 1+ corneal guttata without edema in both eyes; anterior chambers were shallow but adequate in both eyes with scattered peripheral anterior synechiae in the right eye and a uniformly shallow but adequate chamber in the left eye; there was no cell or flare in either eye. Iris findings included a surgical pupil with a fibrotic pupillary membrane, laser iridoplasty scars with scattered temporal transillumination defects (TIDs) in the right eye, and 2.5 clock hours of TIDs and a patent peripheral iridotomy at 1 o'clock in the left eye; lens examination revealed centered posterior chamber IOLs with open posterior capsules in both eyes and lens pitting in the left eye. Pertinent findings on dilated fundus examination included a cup-to-disc ratio of 0.3 in both eyes with good neuroretinal rims and macular examination revealed medium-sized drusen with pigment clumping in both eyes and no active choroidal neovascular membranes. The remainder of the examination was unremarkable. What is the etiology of this myopic surprise? What diagnostic testing will help confirm the diagnosis and what are the best management options for this patient?

Diffractive optic intraocular lens exchange: indications and outcomes.

PURPOSE: To assess indications and outcomes of surgical exchange of diffractive optic multifocal and extended depth-of-focus intraocular lenses (IOLs) in favor of monofocal IOLs. SETTING: Private practice, Los Angeles, California. DESIGN: Retrospective chart review. METHODS: All cases of diffractive optic IOL exchange between June 2007 and October 2020 for diffractive optic dysphotopsia (DOD) (ie, light-induced concentric circles and spider web patterns), poor visual quality, or night vision symptoms were evaluated retrospectively regarding surgical indications, comorbidities, surgical methods, surgical complications, and visual outcomes. Ocular surface disease and ametropia were managed prior to consideration of IOL exchange. RESULTS: The charts of 64 eyes of 46 patients were included. 53/64 (83%) had DOD, 50/64 (78%) experienced reduced quality of vision, and 12/64 (19%) complained of night vision difficulties. 27/64 (42%) of eyes had no ocular comorbidities; 15/64 (23%) of eyes had more than 1 comorbid condition, and 12/64 (19%) were post-laser refractive surgery. Laser posterior capsulotomy had been performed in 15/64 (23%) of eyes. There were a variety of inciting diffractive optic IOLs and various monofocal exchange lenses and fixation techniques were used based on symptoms, comorbidities, and status of the posterior capsule. After IOL exchange, all eyes were relieved of DOD, and all eyes had improved or unchanged corrected distance visual acuity. CONCLUSIONS: Diffractive optic IOLs may induce unsatisfactory visual outcomes. However, in this large series of IOL exchanges, DOD and reduced visual function can be overcome with exchange for a monofocal IOL, despite comorbidities or an open posterior capsule.

Persistent negative dysphotopsia and small eyes August consultation #1.

A 56-year-old man with an ocular history of strabismus surgery at age 3 years, anatomically narrow angles, and patent laser peripheral iridotomies in both eyes underwent refractive lens exchange in which a SA60AT (Alcon Laboratories, Inc.) 38 diopter (D) intraocular lens (IOL) was implanted in the right eye and a SA60AT 36 D IOL was implanted in the left eye. He presented with symptoms consistent with negative dysphotopsia (ND) in both eyes immediately after surgery, describing temporal dark arcs that were constantly present and did not improve over the past 2 years. Of note, the patient was most symptomatic in the left eye. On examination, the manifest refractions and corrected distance visual acuities were -0.50 +1.50 × 20 and 20/20 in the right eye and +0.75 -1.25 × 158 and 20/20 in the left eye; visual fields, extraocular motility, and pupils were normal. Intraocular pressures were normal as measured by applanation tonometry at 10 mm Hg in both eyes. Slitlamp examination revealed trace meibomian gland disease in both eyes, normal tear lake and cornea, and patent peripheral laser iridotomies at the 11 o'clock position in the right eye and the 1 o'clock position in the left eye. The anterior chamber was slightly shallow temporally but deep centrally and quiet in both eyes. The lens examination revealed 4.0 mm anterior fibrotic capsule openings with well-positioned SA60AT posterior chamber IOLs in the bag with haptics at 1 and 7 o'clock in both eyes (Figure 1JOURNAL/jcrs/04.03/02158034-202108000-00021/figure1/v/2021-07-22T111213Z/r/image-tiff). The posterior capsule was intact with trace posterior capsule opacification in both eyes and striae in the posterior capsules. Dilated fundus examination was unremarkable with a cup-to-disc ratio of 0.4 in the right eye and 0.3 in the left eye and normal pink neuroretinal rims. What strategies would you offer this patient to treat the ND and what specific testing and counseling do you provide for patients with this condition?

Femtosecond laser-assisted intraocular lens exchange.

Intraocular lens (IOL) exchange in patients with anterior capsule contraction resulting from phimosis can complicate IOL exchange as the fibrotic anterior capsule must be cut to gain access to the IOL. Maintaining curvilinear capsulotomy is particularly important when the desired outcome is bag-to-bag IOL exchange. Similarly, when the posterior capsule is open, properly sized curvilinear anterior capsulotomy will allow for optic capture and further stability of the exchanged IOL. Secondary capsulotomy size ranged from 4.9 to 5.0 mm, and the energy was set at 4 to 10 µJ depending on diffusiveness of the anterior capsule. The femtosecond laser was adapted to create a secondary anterior capsulotomy to facilitate IOL exchange.

A cataract, 'a million cut' radial keratotomy, and Marfan syndrome February consultation #1.

A 56-year-old man with an ocular history of 20+ cut radial keratotomy (RK) in both eyes and Marfan syndrome presented with blurred vision in both eyes 2 years previously. He was intolerant of contact lenses and was correctable with spectacles for the past 10 years. His presenting photographs and corneal topographies are shown in Figures 1 and 2JOURNAL/jcrs/04.03/02158034-202102000-00022/figure1/v/2021-04-12T204757Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202102000-00022/figure2/v/2021-04-12T204757Z/r/image-tiff, respectively. His left eye had greater than 270 degrees of zonulopathy and a visually significant cataract. He underwent a planned pars plana lensectomy/vitrectomy and implantation of a scleral-fixated CZ70BD (Alcon Laboratories, Inc.) intraocular lens (IOL). He has enjoyed adequate vision in the left eye and now has a worsening cataract in his right eye. He is a practicing dentist and requested the fastest visual rehabilitation possible. His corrected distance visual acuity was 20/50 with a manifest refraction of +5.00-4.00 × 90 in the right eye and 20/25 with a manifest refraction of +1.75-2.50 × 180 in the left eye. Intraocular pressure (IOP) was measured at 16 mm Hg in both eyes, and extraocular motility, confrontational visual fields, and pupils were normal in both eyes. On slitlamp examination, he had mild ptosis in both eyes, the corneas had 20+ RK with multiple arcuate incisions at the 3- and 9-o'clock positions in both eyes, the anterior chamber (AC) was deep and quiet in both eyes, both irides had mild iridodonesis, the right lens had a 2 to 3+ nuclear sclerotic cataract with 6 clock hours of superotemporal zonulopathy that was only evident with dilation (Figure 3JOURNAL/jcrs/04.03/02158034-202102000-00022/figure3/v/2021-04-12T204757Z/r/image-tiff) and no phacodonesis. The left lens had a well-positioned CZ70BD IOL fixated at 6 and 12 o'clock without extrusion or exposure of the Gore-Tex suture. The posterior segment examination was unremarkable. What counseling would you provide for this patient in preparation for surgery? How would you plan the IOL calculations? What intraoperative techniques would you use to achieve the safest outcomes given his comorbidities?

Pseudophakic Dysphotopsia: Review of Incidence, Cause, and Treatment of Positive and Negative Dysphotopsia.

We reviewed the literature concerning positive dysphotopsia (PD) and negative dysphotopsia (ND) regarding cause, incidence, and clinical and surgical management. In addition, we summarized our surgical experience in managing dysphotopsia. A PubMed review, limited to English language articles, yielded 149 citations; multifocal (diffractive optic) and phakic intraocular lens (IOL) dysphotopsia were excluded. Overall, 39 articles were determined to be relevant for the objectives of this investigation. Regarding PD, 7 articles corroborated that the cause of PD is related primarily to internal reflection of oblique light rays that strike the square (truncated) edge of the IOL and are reflected onto the retinal surface. No round-edged foldable IOLs are available in the United States at this time, although IOLs modified with a round anterior edge and square posterior edge show a trend toward decreased incidence of PD. High index of refraction (I/R), surface reflectivity, and IOL optic design are additional causative factors for PD. Regarding the authors' surgical experience, changing the optic material to have a lower I/R improved PD symptoms in the large majority of patients. The cause of ND seems to be multifactorial and less well understood, with some disparity between clinical and laboratory findings. Four articles that explore using ray-tracing optical modeling suggest an "illumination gap," in which some temporally incident light rays to the nasal retina pass anterior to the IOL and some are refracted posteriorly by the IOL, resulting in a gap and resultant temporal shadow. However clinically, ND is associated invariably with well-centered in-the-bag IOLs. Other implicating factors include nasal anterior capsule override, haptic orientation, large-angle κ value, and high hyperopia. Persistent ND has been treated successfully or reduced with reverse (anterior) optic capture, sulcus IOL placement, piggyback IOLs, and neodymium:yttrium-aluminum-garnet nasal capsulectomy. Two articles reference a new optic edge designed to capture the anterior capsulotomy, mimicking reverse optic capture. Persistent dysphotopsia after cataract surgery is a significant cause for patient dissatisfaction. The cause and management of both ND and PD are of significance, and new IOL designs and alternative surgical strategies may help to mitigate these unintended side effects of IOL implantation.

Surgical management of positive dysphotopsia: U.S. perspective.

PURPOSE: To evaluate clinical outcomes of intraocular lens (IOL) exchange for intolerable positive dysphotopsia (PD). SETTING: Private practice, Advanced Vision Care, Los Angeles, California, USA. DESIGN: Retrospective review, case series. METHODS: Fifty-six eyes of 46 pseudophakic patients requiring surgical management of PD between 2013 and 2019 were reviewed. Thirty-seven eyes had PD alone and 19 had combined negative dysphotopsia and PD. INCLUSION CRITERIA: corrected distance visual acuity of 20/30 or better without significant corneal, retinal, or optic nerve pathology. EXCLUSION CRITERIA: corneal, macular, or optic nerve disease and multifocal dysphotopsia alone (defined patterns of concentric multiple halos or spider web patterns when looking at a point source of light). Primary outcome measure was improvement or resolution of self-reported PD symptoms by 3 months postoperatively. Secondary outcome measures included analysis of intraocular lenses (IOLs) that induced PD for IOL material, index of refraction, and edge design. RESULTS: IOL materials successful in the alleviation of PD symptoms were as follows: 20 (87.8%) of 33 silicone, 15 (76.2%) of 21 copolymer, and 2 poly(methyl methacrylate) (100%). However, when considering IOL exchange for an acrylic to silicone optic or acrylic to collamer optic, the percentages of improvement are indistinguishable at 87% and 88%, respectively. CONCLUSIONS: PD symptoms might be improved by changing the IOL material and, therefore, index of refraction. Although edge design plays an important role in etiology, changing the IOL material to a lower index of refraction may prove to be an effective surgical strategy to improve intolerable PD.

Reproducibility of Ocular Surface Staining in the Assessment of Sjögren Syndrome-Related Keratoconjunctivitis Sicca: Implications on Disease Classification.

OBJECTIVE: The objective of this study was to assess the performance and reproducibility of the two currently used ocular surface staining scores in the assessment of keratoconjunctivitis sicca in Sjögren syndrome (SS) research classification. METHODS: In a multidisciplinary clinic for the evaluation of sicca, we performed all tests for the American European Consensus Group (AECG) and the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria, including the van Bijsterveld score (vBS) and the Ocular Staining Score (OSS), in 994 participants with SS or with non-SS sicca. We analyzed the concordance between the scores, the diagnostic accuracy and correlation with clinical variables, and interrater and intrasubject reproducibility. RESULTS: A total of 308 (31.1%) participants had a discordant vBS and OSS that was due to extra corneal staining points in the OSS. The presence of one or more of the additional points was highly predictive of SS classification (odds ratio = 3.66; P = 1.65 × 10e-20) and was associated with abnormal results of all measures of autoimmunity and glandular dysfunction. Receiver operating characteristic curves showed optimal cutoff values of four for the vBS (sensitivity = 0.62; specificity = 0.71; Youden's J = 0.33) and five for the OSS (sensitivity = 0.56; specificity = 0.75; Youden's J = 0.31). Notably, there was very poor consistency in interobserver mean scores and distributions (P < 0.0001) and in intrasubject scores after a median of 5.5 years (35% changed status of the ocular criterion). CONCLUSION: Ocular surface staining scores are useful for SS research classification; however, they are subject to significant interrater and intrasubject variability, which could result in changes in classification in 5%-10% of all subjects. These results highlight the need for objective and reproducible markers of disease that have thus far remained elusive for SS.

Surgical management of negative dysphotopsia.

PURPOSE: To evaluate curative and preventative surgical strategies for negative dysphotopsia. SETTING: Private practice, Los Angeles, California, USA. DESIGN: Retrospective case series. METHODS: Patients with self-reported chronic negative dysphotopsia had corrective surgery as the therapeutic group. Second eye surgery, in cases with negative dysphotopsia in the previously operated eye, comprised the preventative group. Chronologically, several surgical strategies were used, including bag-to-bag intraocular lens (IOL) exchange, reducing posterior chamber depth, piggyback secondary IOL placement, bag-to-sulcus IOL exchange, and reverse optic capture. The primary outcome measure was improvement of negative dysphotopsia by 3 months postoperatively. RESULTS: The therapeutic group comprised 40 eyes of 37 patients; 76.6% of causative IOLs were acrylic and 23.4% were silicone and all were bag-fixated. There were 21 eyes in the preventative group of which 11 were second eyes from the therapeutic group; the remaining 10 did not require surgery for the symptomatic eye. Successful outcomes for each surgical strategy were as follows: bag-to-bag IOL exchange (0/5), a reduction in posterior chamber depth with iris suture fixation of the bag-haptic complex (0/1), piggyback secondary IOL (8/11), secondary reverse optic capture (21/22), ciliary sulcus posterior chamber IOL exchange (7/8), and primary reverse optic capture (21/21). CONCLUSIONS: Negative dysphotopsia was associated with acrylic or silicone IOLs of either square- or round-edge design. Negative dysphotopsia was reduced, eliminated, or prevented when the IOL optic overlaid the anterior capsulotomy rather than when the capsule edge overlaid the optic. Bag-to-sulcus IOL exchange and reverse optic capture were highly successful in managing or preventing negative dysphotopsia.