Neodymium:YAG treatment of interlenticular opacification in a secondary piggyback case.

Interlenticular opacification (ILO) developed 7 months after secondary acrylic piggyback lens implantation in which the anterior lens was placed in the bag. This resulted in glare and a hyperopic shift. Treating the ILO with the neodymium:YAG laser successfully reduced the glare and corrected the hyperopic shift.

Pupillary capture of the optic in secondary piggyback implantation.

Two patients who received a minus-power intraocular lens implanted as a secondary piggyback to correct pseudophakic myopia experienced pupillary optic capture following dilation in the early postoperative period. Both cases were successfully managed by pressing the optic back into the ciliary sulcus and constricting the pupil with pilocarpine.

Interlenticular opacification: clinicopathological correlation of a complication of posterior chamber piggyback intraocular lenses.

PURPOSE: To present a clinicopathological correlation of 2 pairs of piggyback posterior chamber intraocular lenses (PC IOLs) explanted because of opacification between the lens optics. SETTING: Gayton Health Center, Eyesight Associates of Middle Georgia, Warner Robins, Georgia, and Center for Research on Ocular Therapeutics and Biodevices, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: Two pairs of piggyback AcrySof lenses were explanted from 2 patients with significant visual loss related to opacification between the optics. They were submitted for pathological analysis. Gross and histopathological examinations were performed, and photomicroscopy was used to document the results. RESULTS: Gross examination showed accumulation of a membrane-like white material between the lenses. Histopathological examination revealed that the tissue consisted of retained/proliferative lens epithelial cells (bladder cells or pearls) mixed with lens cortical material. CONCLUSION: Piggyback PC IOLs were explanted in 2 cases because of a newly described complication, interlenticular opacification. Three surgical means may help prevent this complication: meticulous cortical cleanup, especially in the equatorial region; creation of a relatively large continuous curvilinear capsulorhexis to sequester retained cells peripheral to the IOL optic within the equatorial fornix; insertion of the posterior IOL in the capsular bag and the anterior IOL in the ciliary sulcus to isolate retained cells from the interlenticular space.

Combined cataract and glaucoma surgery: trabeculectomy versus endoscopic laser cycloablation.

PURPOSE: To determine whether combined cataract surgery with endoscopic laser cycloablation produces less inflammation than cataract surgery combined with a filtering procedure. SETTING: Taylor Regional Hospital (surgeries) and EyeSight Associates (examinations), Warner Robins, Georgia, USA. METHODS: A randomized prospective study was conducted of 58 eyes of 58 patients comparing endoscopic laser cycloablation performed through a cataract incision at the time of cataract surgery with combined trabeculectomy and cataract surgery. RESULTS: Mean follow-up was 2 years. At the final available visit, 30% of endoscopic laser patients achieved intraocular pressure control (below 19 mm Hg) without medication and 65% with medication. Forty percent of trabeculectomy patients achieved control without medication and 52% with medication. Four endoscopic laser patients (14%) and 3 trabeculectomy patients (10%) were considered treatment failures (required additional surgical intervention). CONCLUSION: Endoscopic laser cycloablation performed through a cataract incision was a reasonably safe and effective alternative to combined cataract and trabeculectomy surgery, providing an option for cataract patients who have glaucoma requiring surgical intervention.

Piggybacking intraocular implants to correct pseudophakic refractive error.

OBJECTIVE: To determine the safety and efficacy of implanting a second intraocular lens (IOL) to correct pseudophakic refractive error. DESIGN: Noncomparative, prospective, consecutive case series. PARTICIPANTS: Eight eyes of eight normal pseudophakes and seven eyes of seven postpenetrating keratoplasty (PK) pseudophakes were included in the study. INTERVENTION: A second intraocular lens (IOL) was implanted anterior to the first in each eye in the study. MAIN OUTCOME MEASURES: Efficacy was determined based on the achieved refractive correction and Snellen uncorrected visual acuity measurements. Safety was determined based on loss of best-corrected visual acuity and operative and postoperative complications. RESULTS: Before surgery, spherical equivalents ranged from -5.12 diopters (D) to 7.5 D, with a mean absolute deviation from emmetropia of 3.38 D (1.62). After surgery, spherical equivalents ranged from -2.75 D to 0.5 D, with a mean absolute deviation from emmetropia of 1.21 D (0.90). Before surgery, only 7% of patients had 20/40 or better uncorrected vision, whereas after surgery, 50% had that level of vision. CONCLUSIONS: Implanting a second IOL is a viable option for correcting pseudophakic refractive error.

Radial keratotomy enhancements for residual myopia.

BACKGROUND: A systematic method of performing radial keratotomy enhancements in undercorrected eyes may increase accuracy and predictability and decrease the number of procedures required. A consecutive series of 372 radial keratotomy procedures, including 110 eyes that received enhancements under a systematic protocol, was evaluated. METHODS: Radial keratotomy was performed using the Reliable Keratotomy software, which uses the Thornton nomogram for primary radial keratotomy and provides a systematic method of performing enhancements. RESULTS: Ninety eyes (24%) received one enhancement, 16 eyes (4%) received two enhancements, and four eyes (1%) received three enhancements. Mean final spherical equivalent refraction was -0.44 D (-4.00 to +1.875 D, SD 0.86) for eyes that did not receive enhancements and -0.44 D (-2.50 to +1.00 D, SD 0.61) for eyes that had enhancements. Mean final residual myopia for the entire cohort was -0.44 D (-4.00 to +1.875 D, SD 0.79). At final examination, 242 (65%) eyes had a refraction within +/- 0.5 D and 298 (80%) within +/- 1.00. Among eyes that received enhancements, 75 (68%) had a refraction within +/- 0.50 D, and 89 (81%) within +/- 1.00 D; 40 eyes (36%) had uncorrected visual acuity of 20/20 or better, 99 eyes (90%) 20/40 or better, and all but one eye (99%) 20/80 or better at the final postoperative examination. Among the entire cohort, 130 eyes (35%) had uncorrected visual acuity of 20/20 or better, 312 (84%) had 20/40 or better, and 350 (94%) had 20/80 or better. No eye lost more than one line of spectacle-corrected visual acuity. CONCLUSION: A systematic approach to enhancement of undercorrected eyes after radial keratotomy, combined with accurate surgery, may reduce the need for multiple enhancements as well as the overcorrection rate, and provide improved uncorrected visual acuity.

Combined cataract and glaucoma procedures using temporal cataract surgery.

PURPOSE: To evaluate whether separating the procedures in a combined procedure by performing a temporal cataract incision and superior trabeculectomy induces the lower astigmatism of a temporal cataract incision without sacrificing intraocular pressure (IOP) control. SETTING: EyeSight Associates, Warner Robins, Georgia. METHODS: This study evaluated 50 consecutive eyes receiving a superior cataract incision with a superonasal trabeculectomy and 65 eyes receiving a temporal cataract incision with a superonasal trabeculectomy. RESULTS: After 3 months, a substantially greater proportion of temporal incision cases had controlled IOP without medication. A substantially higher proportion in the superior incision group had uncontrolled IOP at each time period. Mean surgically induced cylinder was higher in the superior incision group at every time period. The superior group had early with-the-rule mean induced cylinder that decayed to against-the-rule, with a mean induced cylinder with keratometry at the final available visit (more than 3 months) of -1.01 diopter (D). The temporal group started with a negligible induced cylinder (-0.13 D) that drifted slightly with the rule to a final mean induced cylinder of +0.49 D. At the last visit, 31% in the superior incision group and 57% in the temporal incision group had an uncorrected visual acuity of 20/40 or better, and 72% and 94%, respectively, had a best corrected acuity of 20/40 or better. CONCLUSION: Separating the cataract and glaucoma procedures frees the surgeon to use newer astigmatically neutral techniques for the cataract incision.

Excimer laser phototherapeutic keratectomy for treatment of recurrent corneal erosion.

Two patients with a history of frequent recurrent corneal erosion for whom standard medical therapy was determined ineffective had phototherapeutic keratectomy (PTK) with an excimer laser. Before treatment, one patient had four episodes in a six-month period; the other had ten to 20 recurrences with four serious episodes in a seven-month period. After PTK, neither patient had a recurrence after 18 months follow-up. Subjectively, both patients felt the treated area healed faster than previous abrasions. Vision, refraction, keratometry, and corneal thickness measurements appeared unaffected by the treatment.

Reproducibility and validity of laser flare/cell meter measurements of intraocular inflammation.

Preoperative and postoperative anterior chamber reactions in a series of cataract surgery patients were measured with a Kowa FC-1000 laser flare/cell meter by two different technicians, and clinical assessments of inflammation were recorded. The average cell and flare readings by the two technicians were nearly identical at every time point, showing the laser flare/cell measurements to be highly reproducible. The correlations between laser flare/cell measurements and clinical assessments at postoperative time points were highly positive (P < .01), demonstrating the validity of the laser flare/cell measurements.

Reproducibility and validity of laser flare/cell meter measurements as an objective method of assessing intraocular inflammation.

Preoperative and postoperative anterior chamber reactions in a series of patients who had undergone cataract surgery were measured with a laser flare/cell meter (Kowa FC-1000, Kowa Instrument Corp, Japan) by two different technicians (A.M. and T.M.M.), and clinical assessments of inflammation were recorded. The average cell and flare readings of the two technicians were nearly identical at every time point, showing the laser flare/cell measurements to be highly reproducible. The correlations between laser flare/cell measurements and clinical assessments at postoperative time points were all highly positive (P less than .01), demonstrating the validity of the laser flare/cell measurements.

Multifocal versus monofocal intraocular lenses. Visual and refractive comparisons.

In a unilateral prospective clinical trial, 77 cases were randomized to receive a 3M multifocal IOL or a conventional monofocal implant. Multifocal cases had better uncorrected near vision than monofocal cases at the two to four month visit. Thirty percent of the multifocal cases had near acuity J1, while only 4% of the monofocal cases had that acuity. Eighty-seven percent of multifocal cases and 71% of monofocal cases had near acuities of J1 to J3. With distance correction in place, 54% of multifocal cases had near acuities of J1 to J2, while only 28% of monofocal cases had comparable acuities (P = .04). There have been no serious postoperative complications in either group.

Effect of small incision intraocular lens surgery on postoperative inflammation and astigmatism. A study of the AMO SI-18NB small incision lens.

A single center, single surgeon, randomized, prospective clinical trial was performed comparing the effectiveness of small (3.5 mm to 4.0 mm) incision intraocular lens surgery and a larger (6.0 mm) incision in improving uncorrected visual acuity and reducing post-operative inflammation and surgically induced astigmatism. One hundred twelve eligible unilateral cases were randomized to receive a 3.5 mm to 4.0 mm incision with implantation of an Allergan Medical Optics three-piece SI-18NB silicone lens (56 cases) or a 6.0 mm incision with implantation of a three-piece biconvex poly(methyl methacrylate) lens (56 cases). At one day after surgery, significantly (P less than .01) more patients with 3.5 mm incisions had 20/40 or better uncorrected visual acuity than patients with 6.0 mm incisions (45% vs 20%). Forty percent of patients with 6.0 mm incisions vs 14% of patients with 3.5 mm incisions had visual acuities of 20/100 or worse. At one day after surgery, the larger incision group had significantly higher (P less than .01) mean keratometric cylinder (2.28 diopters vs 1.28 diopters in the small incision group). The two groups were comparable by three months. Laser flare/cell meter measurements were taken for each group but showed no significant differences in mean flare or cell measurements between the groups.

Effect of thermokeratoplasty on corneal curvature.

A cadaver eye model was used to evaluate and quantify the use of thermokeratoplasty for steepening the central cornea to correct hyperopia. Four groups of eye-bank eyes were treated with four separate surgical plans. Each plan involved the placement of controlled thermal burns (in the depths of the corneal stroma, using a cautery probe) applied in a radial pattern up to a premarked optical zone. The plans differed in the sequence of surgical steps. All plans progressively added radials and applications (to decrease optical zone) in various sequences. Corneal curvature was measured at baseline and at each surgical step. As more surgery was done within each plan, the corneas became progressively steeper. Total mean changes in corneal curvature ranged from 16.26 diopters to 19.76 diopters, depending on the plan. At each optical zone, as the number of radials increased, the effect increased. With progressively smaller optical zone size, the effect also increased.