Subluxated cataract lens surgery using sutured segments or rings and implantation of toric intraocular lenses.

PURPOSE: To evaluate the intraoperative performance and postoperative outcomes of toric intraocular lens (IOL) with suture ring implantation in adult patients with subluxated lenses. SETTING: Department of Ophthalmology, Kaiser Permanente, Santa Clara, California, and the Eye Institute of Utah, Salt Lake City, Utah, USA. DESIGN: Retrospective case review. METHODS: Eyes with subluxated cataractous lenses and preoperative corneal astigmatism having toric IOL implantation with a sutured ring or segment were studied. Preoperative and postoperative analyses included uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and cylindrical power postoperatively and 3, 6, and 12 months postoperatively. RESULTS: Twenty-one eyes of 15 patients were studied. The median follow-up was 14.6 months. The mean CDVA at the final follow-up (0.10 logMAR ± 0.15 [SD]) was significantly improved from the mean preoperative CDVA (0.73 ± 0.40 logMAR). Postoperative cylindrical power was significantly improved in all patients (mean reduction in astigmatism 2.37 ± 1.46 diopters). Patients who required postoperative enhancement had anterior laser capsulotomy for bilateral capsule phimosis (2 eyes), photorefractive keratectomy (1 eye), pupilloplasty (1 eye), and posterior laser capsulotomy (2 eyes). CONCLUSION: Cataract removal and implantation of a toric IOL combined with a sutured ring or segment capsule stabilizing device was a safe and efficacious long-term solution for patients with subluxated cataract lenses and corneal astigmatism.

Iris mattress suture: a technique for sectoral iris defect repair.

Achieving a cosmetic and functional outcome from iris defect repair is a surgical challenge. We describe an adaptation of techniques to address a case of 2.5 clock hours of sectoral iris tissue defect. Our method combines Siepser's modified closed-chamber sliding knot technique with the placement of a double-armed iris mattress suture to approximate iris tissue to the scleral wall and thereby create a pseudo-iris root. This technique reduces glare and achieves a cosmetic outcome for the patient.

Surgical management of pediatric limbal dermoids with sutureless amniotic membrane transplantation and augmentation.

PURPOSE: To further evaluate the efficacy of a new surgical technique for removal of pediatric corneal-limbal dermoids and ocular surface reconstruction using multilayered amniotic membrane. METHODS: Three pediatric patients with corneal-limbal dermoid (grade I) in one practice were identified in a retrospective fashion. All patients underwent deep lamellar excision followed by sutureless multilayered amniotic membrane transplantation by a single surgeon (AP). Preoperative and postoperative visual acuity, anterior segment examination, anterior segment B-scan, and cycloplegic refraction were performed. RESULTS: Three patients with ages ranging from 6 months to 18 years had a postoperative follow-up of 9 to 12 months from the time of surgery. This surgical technique achieved rapid postoperative corneal re-epithelialization, reduced postoperative pain, and diminished postoperative scarring in all three patients. Existing preoperative astigmatism remained unchanged throughout the follow-up period. No intraoperative or postoperative complications were noted. CONCLUSION: This surgical approach offers an alternative surgical technique to a simple excision with or without deep lamellar keratoplasty for removal of pediatric corneal-limbal dermoids (grade I). In the management of pediatric limbal dermoids (grade I), surgical excision combined with sutureless multilayered amniotic membrane transplantation eliminates painful postoperative recovery and corneal neovascularization, and can achieve an improved long-term ocular surface cosmesis.

Simultaneous Interface Candida Keratitis in 2 Hosts Following Descemet Stripping Endothelial Keratoplasty With Tissue Harvested From a Single Contaminated Donor and Review of Clinical Literature.

PURPOSE: The objective of this study was to report 2 cases of interface fungal keratitis in 2 separate patients following Descemet stripping automated endothelial keratoplasty (DSAEK) with tissue harvested from the same donor. DESIGN: This was a retrospective simultaneous interinstitutional hosptial-based case reports. METHODS: Two patients with corneal infections following DSAEK were identified from 2 individual practices. Both patients had undergone DSAEK from the same donor. Preoperative and postoperative eye examination included visual acuity, anterior and posterior segment evaluations, and clinical follow-up course from the time of surgery. Methods of medical therapy and surgical intervention are additionally discussed. RESULTS: The 2 patients presented in our series present with interface fungal keratitis postoperatively in the face of the original source coming from a single donor (patient 1: 7 days postoperatively and patient 2: 7 weeks postoperatively). As medical treatment failed in both cases, surgery was undertaken in both cases (therapeutic penetrating keratoplasty). With prompt recognition as well as medical and surgical treatment, patient 1 achieved best corrected visual acuity of 20/30 at 6 months postoperatively, and patient 2 had best corrected visual acuity of 20/80 at 10 months postoperatively. CONCLUSIONS: Fungal keratitis following DSAEK occurs in a sequestered space and therefore represents a treatment challenge with potentially devastating outcome. We recommend an aggressive surgical approach with early removal of the donor button and irrigation with intracameral antifungal agents.

Bilateral total Descemet's membrane detachments after strangulation.

The eyes of a 25-year-old male were collected by the Utah Lions Eye Bank after his suicide by hanging. Following dissection of the corneoscleral buttons from intact globes, bilateral detached Descemet's membranes with subsequent scrolling in the periphery were observed. We believe these findings were caused by a large increase in intraocular pressure secondary to the hanging. Lens and anterior capsule fractures after hanging have been reported, but corneal damage has never been discussed. We invite transplant surgeons and eye bank recovery specialists to share their experience of similar corneal changes in donated eyes following strangulation or hanging.

Management of corneal endothelial decompensation caused by iris-fixated phakic intraocular lenses with descemet stripping automated endothelial keratoplasty.

PURPOSE: To describe 2 cases of corneal decompensation after iris-fixated phakic intraocular lens (pIOL) implantation requiring Descemet stripping automated endothelial keratoplasty (DSAEK). MATERIALS AND METHODS: Case reports and literature review. RESULTS: Two cases of corneal decompensation after pIOL implantation are reported. The average age at presentation was 52 years (range: 37 to 67 years) in 2 women. The mean presentation time of corneal decompensation after pIOL implantation was 29 months (range: 22 to 36 months). Both the affected eyes required pIOL explantation and DSAEK to treat corneal decompensation. One patient (1 eye) had concurrent cataract surgery to maximize visual rehabilitation. The mean follow-up after DSAEK surgery was 14 months (range: 12 to 16 months). The best-corrected visual acuity was 20/50 (range: 20/40 to 20/60) at the last follow-up. CONCLUSIONS: Despite a good safety profile for iris-fixated pIOLs, some patients may still develop corneal decompensation after implantation. We report a pair of cases with corneal decompensation severe enough to warrant endothelial transplantation and pIOL explantation, with and without concomitant cataract surgery.

Complications of NewColorIris implantation in phakic eyes: a review.

PURPOSE: To provide a literature review of implant related complications from bilateral NewColorIris implantation (Kahn Medical Devices, Panama City, Panama). METHODS: A PubMed search of peer-reviewed ophthalmology journals for complications related to NewColorIris implants was performed. RESULTS: Including a recent case published by the authors, a total of nine patients (18 eyes) with management of complications such as endothelial cell loss, elevated intraocular pressure (IOP), corneal edema, anterior chamber inflammation, decreased visual acuity, and cataract formation were reviewed. CONCLUSIONS: Sight-threatening complications including corneal decompensation, IOP elevation, uveitis, and hyphema have been described after NewColorIris implantation.

Fibrin-glue assisted multilayered amniotic membrane transplantation in surgical management of pediatric corneal limbal dermoid: a novel approach.

PURPOSE: To report a new surgical technique for excising pediatric corneal limbal dermoid and the post-resection ocular surface reconstruction. METHODS: We describe a method of deep lamellar excision followed by sutureless multilayered amniotic membrane transplantation in surgical management of corneal limbal dermoid. RESULT: This technique achieves a rapid corneal re-epithelization, reduces post-operative pain, and will diminish post-operative scarring. Preoperative corneal astigmatism will persist. CONCLUSION: This method offers an alternative surgical approach in comparison to simple excision in removal of simple pediatric corneal limbal dermoids.

Bilateral diffuse lamellar keratitis following consecutive selective laser trabeculoplasty in LASIK patient.

A 48-year-old man with a history of myopic laser in situ keratomileusis (LASIK) had selective laser trabeculoplasty (SLT) for the treatment of glaucoma in the right eye. He subsequently developed grade 2 diffuse lamellar keratitis (DLK). He then elected to have SLT in the left eye and developed grade 1 DLK. To our knowledge, this is the first report of bilateral consecutive late postoperative DLK following SLT after LASIK.

Acquired infantile Horner syndrome and spontaneous internal carotid artery dissection: a case report and review of literature.

Horner syndrome, a triad of ptosis, anisocoria, and anhidrosis, results from interruption in the oculosympathetic pathway. It is classically described as either congenital or acquired to depict its underlying pathophysiology and requisite work-up. We report a case of a 10-month-old infant presenting with an acute onset of left Horner syndrome secondary to a spontaneous extracranial internal carotid artery dissection. To the best of our knowledge, this is the first case report in the literature of acute onset of acquired infantile Horner syndrome in association with spontaneous carotid artery dissection confirmed with magnetic resonance angiogram.

Corneal profile analysis after Descemet stripping endothelial keratoplasty and its relationship to postoperative hyperopic shift.

PURPOSE: To evaluate changes in the corneal profile after Descemet stripping endothelial keratoplasty (DSEK) using anterior segment optical coherence tomography (AS-OCT) analysis and to describe its relationship to a dynamic postoperative hyperopic shift. SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, USA. METHODS: In this retrospective observational study, 9 eyes had DSEK and were followed with manifest refractions and AS-OCT analysis. To assess changes in the thickness of the cornea, measurements for each AS-OCT image were taken at the vertex of the cornea, at 1.5 mm on each side of the vertex, and at the distal edges of the graft. RESULTS: Patients were followed for a mean of 134 days (range 46 to 228 days). Monthly Graft thinning rates were 5.2 microm per month at the vertex, 7.9 microm per month 1.5 mm from the vertex, and 26 microm per month at the edges, with the edges thinning significantly faster than the cornea vertex (P = .0024) and the points on either side of the 3.0 mm visual axis (P = .0018). The mean spherical equivalent (SE) showed an initial hyperopic shift that decreased over the ensuing 100 to 200 days postoperatively. The mean monthly postoperative SE change was -0.25 diopter (D) with a mean preoperative to postoperative SE change of +1.26 D. CONCLUSIONS: The donor graft underwent changes after DSEK, which may account for the induced hyperopia and its diminishment over time via changes in the posterior corneal curvature. Results suggest that intraocular lenses be targeted to -1.00 to -1.25 D of myopia for combined DSEK and cataract procedures.

Prospective randomized trial of wavefront-guided laser in situ keratomileusis with the CustomCornea and CustomVue laser systems.

PURPOSE: To compare visual function, safety, and higher-order aberrations (HOAs) after wavefront-guided laser in situ keratomileusis (LASIK) with the LadarVision CustomCornea (Alcon Laboratories, Inc.) and Star S4 CustomVue (Visx) laser systems. SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. METHODS: Seventy-eight eyes of 39 patients with myopia with or without astigmatism were randomized for LASIK treatment in 1 eye with the CustomCornea laser; the other eye was treated with the CustomVue laser. Patients were followed for 6 months after surgery. The primary outcome measures were uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), manifest refraction, and changes in HOAs. RESULTS: At 6 months, the mean logarithm of the minimum angle of resolution (logMAR) UCVA was -0.0135 +/- 0.07 (SD) in the CustomVue group and 0.0417 +/- 0.12 in the CustomCornea group (P = .023). Eighty-eight percent of eyes in the CustomVue group had 20/20 or better UCVA compared with 67% in the CustomCornea group (P<.02). At 6 months, 91% of eyes in the CustomVue group and 79% in the CustomCornea group were within +/-0.50 diopter (D) of emmetropia (P<.1); 88% and 50%, respectively, were within +/-0.25 D (P<.001). Both platforms led to a small increase in total HOAs. The CustomVue system reduced trefoil and induced less of an increase in total HOAs, whereas the CustomCornea platform increased trefoil but induced less of an increase in spherical aberrations and coma. CONCLUSIONS: Both laser systems were effective, safe, and predictable. Wavefront-guided LASIK with the CustomVue system resulted in better visual acuity, with more eyes having 20/20 acuity than in the CustomCornea group.

Two-year follow-up of the Artisan/Verisyse iris-supported phakic intraocular lens for the correction of high myopia.

PURPOSE: To evaluate the implantation of Artisan/Verisyse phakic intraocular lenses (pIOLs) (Advanced Medical Optics) as an effective and safe method for the correction of high myopia. SETTING: Department of Ophthalmology, John A. Moran Eye Center, University of Utah Medical Center, Salt Lake City, Utah, USA. METHODS: This retrospective outcomes trial examined the implantation of Artisan/Verisyse pIOLs in 85 highly myopic eyes (mean spherical equivalent -12.2 diopters). Patients were followed for 2 years and examined postoperatively at 1,6,12, and 24 months. Data collected included best spectacle-corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), corneal endothelial cell density, and adverse events. RESULTS: Six months postoperatively, 5 (7%) eyes lost 1 line of the BSCVA; no eye lost 2 or more lines. The UCVA was better than 20/40 in 83% of eyes and better than 20/25 in 32%. Endothelial cell density decreased by 3.3% and 6.5% over the 1-year and 2-year intervals, respectively. Glare and halos, the most common complications of surgery, were reported by 6% of patients at 1 month and by 3% at 2 years. CONCLUSION: Implantation of the Verisyse/Artisan pIOL yielded accurate refractive results with acceptable safety in highly myopic eyes.

Infectious and noninfectious keratitis after laser in situ keratomileusis Occurrence, management, and visual outcomes.

PURPOSE: To retrospectively review the occurrence, treatment, and visual outcomes associated with various etiologies of keratitis as a postoperative complication of laser in situ keratomileusis (LASIK) at an academic surgical center. SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. METHODS: The charts of 5618 post-LASIK patients (10 477 eyes) were reviewed for the development of keratitis. Occurrence rates, management regimens, and final best spectacle-corrected visual acuity (BSCVA) were reported for infectious and noninfectious keratitis etiologies. RESULTS: Post-LASIK keratitis was diagnosed in 279 eyes. The keratitis was diagnosed as infectious in 33 eyes (12%) and as noninfectious in 246 eyes (88%). Infectious cases included 5 eyes (15%) with herpes simplex keratitis (HSV), 18 (55%) with adenoviral keratitis, and 10 (30%) with nonviral (including bacterial, fungal, and parasitic) keratitis. Of noninfectious cases, 193 (78%) were classified as diffuse lamellar keratitis (DLK), 36 (15%) as staphylococcal marginal hypersensitivity, and 17 (15%) as localized debris-related keratitis. CONCLUSIONS: The occurrence of post-LASIK keratitis was 2.66%, with DLK being the most common diagnosis overall. The occurrence of noninfectious keratitis (2.34%) was 7.5 times greater than the occurrence of infectious keratitis (0.31%). Adenoviral keratitis had the best visual outcomes overall, with all 18 patients achieving 20/20 BSCVA. In contrast, all 5 eyes with HSV keratitis lost 1 or 2 lines of BSCVA. Excluding adenoviral keratitis, infectious etiologies had significantly worse visual outcomes than noninfectious etiologies at the 20/40 and 20/20 levels (P = .0013 and P<.001, respectively).

Glaucoma lasers: a review of the newer techniques.

PURPOSE OF REVIEW: This paper serves to review the safety and efficacy of new laser techniques for the treatment of glaucoma with emphasis on those studies published within the past year. RECENT FINDINGS: Recently published studies have reinforced the strong safety profile, and efficacy of selective laser trabeculoplasty (SLT). Endoscopic photocoagulation, while more technically challenging and more invasive, offers several advantages over transcleral cyclophotocoagulation including direct observation of treatment and therefore, fewer complications. Laser goniopuncture is a fledgling technology with, thus far, a good safety profile, and benefits that include conjunctival sparing and good treatment response. Many unanswered questions remain including long-term success rates and ideal treatment parameters. SUMMARY: The benefits of laser in the treatment of glaucoma have been well established, and while some techniques will add to the ophthalmologists' armamentarium, others will fall into disuse as the efficacy and safety profiles of these procedures become recognized. Novel laser modalities, as well as the more traditional ones, require continued evaluation to further refine treatment parameters and to determine their long-term benefits.