Laser cataract surgery : A prospective clinical evaluation of 1000 consecutive laser cataract procedures using the Dodick photolysis Nd:YAG system.

BACKGROUND: To evaluate the safety and efficacy associated with the clinical use of a Q-switched neodymium:yttrium-aluminum-garnet (ND:YAG) laser for cataract removal. DESIGN: Multicenter, prospective, noncomparative case series. PARTICIPANTS/INTERVENTION: A total of 1000 consecutive eyes underwent cataract extraction with the photolysis Q-switched ND:YAG laser at 12 international clinical sites. MAIN OUTCOME MEASURES: Visual acuity improvement; total energy used; mean operative time for cataract removal; complications, both intraoperative and postoperative; with a minimum follow-up of 3 months. RESULTS: The mean values were visual acuity improvement from 20/70.2 to 20/24.4. Mean intraocular energy used was 5.65 J per case. Mean operative photolysis time among the surgeons was for up to +1 nuclear sclerosis, 2.15 minutes; up to +2 nuclear sclerosis, 4.8 minutes; and for up to +3 nuclear sclerosis, 9.8 minutes. Three cases were completed by intraocular lens implantation through the original sub-2-mm incision, using a prefolded, by dehydration, acrylic intraocular lens. Minor complications were encountered in 18 cases. CONCLUSIONS: These data suggest this photolysis laser technology may be a safe and effective alternative for cataract extraction in human eyes. By use of small clear cornea incisions, the ability to perform cataract extraction and intraocular lens implantation with incisions less than 2 mm has been shown for the first time.

Dodick photolysis for cataract surgery: early experience with the Q-switched neodymium: YAG laser in 100 consecutive patients.

OBJECTIVE: To evaluate the safety and efficacy of a Q-switched neodymium:YAG (Nd:YAG) laser for removal of the human cataract. DESIGN: A multicenter, prospective, noncomparative study. PARTICIPANTS: A total of 100 consecutive eyes undergoing cataract extraction with the Dodick Photolysis, Q-switched Nd:YAG laser. MAIN OUTCOME MEASURE: Corneal endothelial cell loss, visual acuity improvement, intraocular pressure change, total intraocular energy used, and intraoperative and postoperative complications. RESULTS: The mean values were postoperative visual acuity improvement from 20/46.5 (0.43) to 20/26.6 (0.75), decrease in endothelial cell count of 177 cells/mm2 (7.55%), and intraocular energy used of 6.7 J. Minor complications were encountered in three cases. CONCLUSIONS: These data suggest that Dodick Photolysis may be a safe and effective new technology for cataract removal in human eyes. It appears to offer low intraocular energy and heat release, a clear-cornea incision less than 1.5 mm in size, and safe operation within the capsular bag.

Subconjunctival mitomycin C for the treatment of ocular cicatricial pemphigoid.

PURPOSE: The authors performed a prospective evaluation of the efficacy of treating ocular cicatricial pemphigoid (OCP) with subconjunctival mitomycin C. DESIGN: Unmasked, prospective, internally controlled case series. METHODS: Patients were eligible for treatment with subconjunctival mitomycin C under three criteria: (1) significant complications of systemic immunosuppressant therapy; (2) markedly asymmetric conjunctival disease; and (3) end-stage OCP. All patients received monocular subconjunctival injections of 0.25 ml of 0.2 mg/ml mitomycin C to both the superior and inferior bulbar conjunctivae in the eye with the more severe disease. RESULTS: Nine eyes of nine patients (mean age, 74 years) were treated with subconjunctival mitomycin C to the more-involved eye and were followed for a mean of 23.5 months (range, 12-40 months). Eight of nine patients showed quiescence of their OCP in the treated eye based on serial evaluation of conjunctival cicatrization and grading of conjunctival erythema. Five of the nine untreated eyes showed progression of the conjunctival disease. One patient required concomitant systemic immunosuppressive therapy after subconjunctival mitomycin C. Two patients underwent successful visual rehabilitative surgery in the mitomycin C-treated eye. CONCLUSION: The use of subconjunctival mitomycin C may be effective in preventing progression of conjunctival cicatrization and erythema in patients with OCP. No complications of mitomycin C treatment were noted. Long-term follow-up and further investigation into the efficacy of subconjunctival mitomycin C in the management of OCP is warranted.

Topical Cyclosporine A in the management of postkeratoplasty glaucoma and corticosteroid-induced ocular hypertension (CIOH) and the penetration of topical 0.5% cyclosporine A into the cornea and anterior chamber.

PURPOSE: To evaluate the effect on intraocular pressure (IOP) of substituting topical Cyclosporine A 0.5% for topical corticosteroids in patients with postkeratoplasty glaucoma and corticosteroid-induced ocular hypertension (CIOH). We also sought to determine the penetration of topical 0.5% Cyclosporine A into the cornea and anterior chamber. METHODS: Topical Cyclosporine A 0.5% was prospectively substituted for topical corticosteroids in 47 patients (52 eyes) with postkeratoplasty glaucoma and CIOH in order to eliminate the IOP-elevating effect of topical corticosteroids, while maintaining protection against allograft rejection. Ten patients received 0.5% topical Cyclosporine before keratoplasty. Their corneal tissue and aqueous samples were evaluated by high pressure liquid chromatography for Cyclosporine levels. RESULTS: Forty-eight of 52 eyes (92.3%) demonstrated a reduction of IOP at first followup (mean: -7.9 mmHg; range: -19 to +2). Mean followup was 10.3 months, ranging from 1 to 37 months. At last follow-up, mean IOP was -8.2 mm Hg. There were six allograft rejections, five of which were reversed with the reintroduction of topical corticosteroids. Graft clarity was maintained in 46 of 52 eyes (88%). The mean cornea Cyclosporine concentration was 3679 ng/gm (range: 1980 to 5520 ng/ gm) and aqueous humor mean concentration was 6.05 ng/mL (range: 0.4 to 15.5 ng/mL). CONCLUSIONS: Topical Cyclosporine A 0.5% may be substituted for topical corticosteroids to aid in the management of postkeratoplasty glaucoma and CIOH. However, the use of Cyclosporine in place of corticosteroids may be associated with an increased risk of immune rejections. The corneal penetration of topical Cyclosporine is excellent while the penetration into the anterior chamber is poor.

Nitrate therapy may retard glaucomatous optic neuropathy, perhaps through modulation of glutamate receptors.

Nitrates have been a major part of the internist's pharmacopoeia for more than 100 years, predominantly for the relief of anginal symptoms. The effects of nitroglycerin on the eye and specifically on intraocular pressure has been investigated with diverse results. However, nitroglycerin may also serve to protect retinal ganglion cells against glutamate mediated toxicity--a form of cell death that may be critical in glaucomatous blindness. Consequently, we therefore sought to evaluate whether nitroglycerin preparations, taken for non-ophthalmic reasons, had an effect on glaucomatous damage.

Conjunctival flaps.

PURPOSE: The authors reviewed their experience with total conjunctival flaps (TCF) and partial conjunctival flaps (PCF) for the past 5 years in 61 patients. METHODS: Forty-eight patients had TCF and 13 had PCF. Diagnoses for surgery included severe bullous keratopathy for chronic graft failure (not candidates for keratoplasty) (19), herpes zoster ophthalmicus (7), chronic ulcerative keratitis (14), neurotrophic keratitis (2), and herpes simplex keratitis (9). RESULTS: There were seven complications. Four flap retractions occurred in the TCF group, requiring resuturing in two. Three complications occurred in the PCF group. One patient had two flap retractions and recurrent ulceration, requiring tarsorrhaphy. One patient with PCF suffered a perforation after flap retraction, necessitating penetrating keratoplasty. CONCLUSION: The authors believe conjunctival flaps are underused and should be considered seriously for bullous keratopathy, neurotrophic keratitis, recalcitrant keratitis, and persistent nonhealing epithelial defects.

Timolol gel versus acetazolamide in the prophylaxis of ocular hypertension after phacoemulsification.

PURPOSE: To compare postoperative intraocular pressure (IOP) after administration of acetazolamide and timolol following phacoemulsification and intraocular lens implantation. SETTING: Ophthalmic Consultants of Long Island, Rockville Centre, New York, USA. METHODS: Sixty patients were included in a prospective, randomized, masked trial. The patients received either two doses of oral, sustained-release acetazolamide (Diamox Sequels) or a single dose of topical timolol 0.5% gel (Timoptic XE). Intraocular pressure was measured by Goldmann applanation tonometry preoperatively and 1 day postoperatively. RESULTS: Mean preoperative IOP was 16.4 mm Hg. One day postoperatively, it was 19.5 mm Hg in the oral acetazolamide group and 15.9 mm Hg in the timolol gel group. One patient in the acetazolamide group developed significant adverse reactions. CONCLUSION: Prophylactic use of topical timolol 0.5% gel for viscoelastic-induced ocular hypertension after cataract extraction appears to offer better IOP control than oral acetazolamide and has potentially fewer adverse systemic effects.

Topical cyclosporin A in the management of postkeratoplasty glaucoma.

PURPOSE: To evaluate the effect of substituting topical cyclosporin A 0.5% for topical corticosteroids in patients with postkeratoplasty glaucoma. METHODS: Topical cyclosporin A 0.5% was prospectively substituted for topical corticosteroids to treat 25 patients with postkeratoplasty glaucoma. RESULTS: Twenty-one (84%) of 25 patients showed a reduction in intraocular pressure (IOP) (range, 1-22 mm Hg; mean, 8.7 mm Hg). Follow-up ranged from 3 to 12 months (mean, 5.8). Graft clarity was maintained in all patients, with one allograft rejection episode. Thirteen patients were able to discontinue one or more glaucoma medication(s). CONCLUSION: Topical cyclosporin A 0.5% may be substituted for topical corticosteroids to aid in the management of postkeratoplasty patients with glaucoma. However, the resultant decrease in IOP may be associated with an increased risk for immune rejections.

Comparison of corneal sensation following photorefractive keratectomy and laser in situ keratomileusis.

PURPOSE: To evaluate the effect of photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) on corneal sensation. SETTING: Eye Institute, Medical School of the University of Crete, Heraklion, Greece, and Orasis, Hellenic Eye Center of Athens, Greece. METHODS: In a masked study, corneal sensation was measured with the Cochet-Bonnet aesthesiometer in 40 consecutive patients 6 to 12 months following PRK and LASIK (60 mm constitutes normal reading and < 40 mm, abnormal). RESULTS: After 6 to 12 months, the mean corneal sensation following PRK was 39.2 mm (range 30 to 55 mm) (mean 9.5 months) and after LASIK, 53.6 mm (range 40 to 60 mm) (mean 9.3 months). The mean correction attempted for PRK was 7.05 diopters (D) (range 2.5 to 12.0 D) and for LASIK, 11.71 D (range 6.0 to 20.0 D). CONCLUSION: In this group of patients, with correction of primarily severe myopia, corneal sensation was significantly greater after LASIK than after PRK.

Comparison of topical timolol gel to oral acetazolamide in the prophylaxis of viscoelastic-induced ocular hypertension after penetrating keratoplasty.

PURPOSE: Viscoelastic-induced ocular hypertension following penetrating keratoplasty (PK) may result in endothelial cell loss and optic nerve damage. METHODS: In a prospective, randomized, masked trial, two doses of oral sustained-release acetazolamide were compared to a single dose of topical 0.5% timolol gel after 40 PKs. RESULTS: The mean preoperative intraocular pressure (IOP) was 17.4 mm Hg for the oral acetazolamide group and 16.7 mm Hg for the timolol gel group. The mean IOP on the first postoperative day was 17.9 mm Hg with oral acetazolamide and 12.9 mm Hg with timolol gel. One patient developed significant adverse reactions with oral acetazolamide; there were no adverse reactions with timolol gel. CONCLUSION: Prophylactic use of timolol gel for viscoelastic-induced ocular hypertension after PK appears to offer better IOP control than oral acetazolamide, with potentially fewer adverse systemic effects.

Visually debilitating pterygium: surgical and contact lens treatment.

PURPOSE: We present the management of a patient with large pterygia complicated by irregular astigmatism and corneal opacities. Visual rehabilitation required both surgical excision and contact lens fitting. METHODS: We examined a 30-year-old man with hand motion vision from a large pterygium overgrowing his right cornea. Histopathology was consistent with pterygium. During the first few postoperative weeks, his uncorrected visual acuity improved to 20/60, and manifest refraction yielded no further improvement. In the subsequent months, there were increasing anterior stromal corneal opacities, and the refraction became hyperopic to a variable degree. RESULTS: Best corrected visual acuity was 20/70-20/100. Axial length was 22.64 +/- 0.07 mm. Computerized corneal topography 6 months postoperative was similar to the preoperative topography and revealed irregular and asymmetric astigmatism, with marked variation of the central corneal dioptric power. Slit lamp biomicroscopy suggested that the corneal opacities were responsible for the patient's decreased acuity; however, contact lens fitting provided 20/30 vision with a rigid gas permeable contact lens. CONCLUSIONS: The improved vision with contact lens therapy strongly suggested that the irregular and asymmetric astigmatism were more visually significant than the corneal opacities.

Decreased corneal sensation as an initial feature of Acanthamoeba keratitis.

BACKGROUND: Herpes simplex keratitis is the most common misdiagnosis in patients with Acanthamoeba keratitis, which is increasing in frequency and is associated with daily wear soft contact lenses. Both entities usually present as unilateral keratitis. The manifestations of superficial Acanthamoeba keratitis (i.e., unilaterality, dendriform appearance, positive response to antivirals, and decreased corneal sensation) increase the opportunity for misdiagnosis as herpes simplex keratitis. The authors have encountered six patients with Acanthamoeba keratitis in whom the correct diagnosis was delayed from 2 weeks to 3 months. METHODS: All six patients underwent testing with the Cochet-Bonnet esthesiometer and extensive pharmacologic treatment for herpes simplex keratitis. Corneal scrapings were taken between 2 and 6 weeks after the initial examination. RESULTS: In all six patients, corneal sensation was decreased significantly. Drug therapy was ineffective. Cultures were positive for Acanthamoeba. Five of six patients underwent penetrating keratoplasty. CONCLUSIONS: Decreased corneal sensation has contributed to the misdiagnosis of Acanthamoeba as herpes simplex keratitis. Misdiagnosis results in delayed treatment and worse outcome. The authors found that significantly decreased corneal sensation is a frequent finding in early Acanthamoeba keratitis. Therefore, physicians should consider Acanthamoeba keratitis as an alternative diagnosis in patients with presumed herpes simplex keratitis with decreased corneal sensation.