Criteria for premium intraocular lens patient selection.

PURPOSE OF REVIEW: To discuss available premium intraocular lenses (IOLs), patient selection, and important considerations for each premium IOL. RECENT FINDINGS: We review important topics and considerations for premium IOL selection: specifically, toric, extended depth of focus (EDOF), multifocal/trifocal, light adjustable lenses (LALs), and small aperture IOLs. Toric lenses are an excellent option for patients with astigmatism. However, to achieve optimal patient satisfaction, it is critical to account for the ATR astigmatism contribution from the posterior cornea and high angle alphas. Additionally, examining the ocular surface prior to placement of EDOF/multifocal IOLs is important, yet the significance of HOAs on outcomes after implantation still must be elucidated more. Finally, recent studies reveal that the small aperture lens is a good alternative for those with corneal irregularities, and second generation LALs are a great option to achieve target refractions in those with less predictable refractive outcomes, such as in Fuchs' dystrophy or in eyes with previous refractive surgery.

Femtosecond Laser-Assisted Cataract Surgery: A Report by the American Academy of Ophthalmology.

PURPOSE: To evaluate refractive outcomes, safety, and cost-effectiveness of femtosecond laser-assisted cataract surgery (FLACS) compared with phacoemulsification cataract surgery (PCS). METHODS: A PubMed search of FLACS was conducted in August 2020. A total of 727 abstracts were reviewed and 33 were selected for full-text review. Twelve articles met inclusion criteria and were included in this assessment. The panel methodologist assigned a level of evidence rating of I to all 12 studies. RESULTS: No significant differences were found in mean uncorrected distance visual acuity, best-corrected distance visual acuity, or the percentage of eyes within ± 0.5 and ± 1 diopter of intended refractive target between FLACS and PCS. Intraoperative and postoperative complication rates were similar between the 2 groups, and most studies showed no difference in endothelial cell loss between FLACS and PCS at various time points between 1 and 6 months. In large randomized controlled studies in the United Kingdom and France, FLACS was less cost-effective than PCS. CONCLUSIONS: Both FLACS and PCS have similar excellent safety and refractive outcomes. At this time, one technique is not superior to the other, but economic analyses performed in some populations have shown that FLACS is less cost-effective.

Multifocal and Accommodating Intraocular Lenses for the Treatment of Presbyopia: A Report by the American Academy of Ophthalmology.

PURPOSE: To review the published literature assessing the efficacy and safety of presbyopia-correcting intraocular lenses (IOLs) for the treatment of presbyopia after cataract removal. METHODS: Literature searches were undertaken in January 2018 and September 2020 in the PubMed, Medline, and Cochrane Library databases. This yielded 761 articles, of which 34 met the criteria for inclusion in this assessment and were assigned a level of evidence rating by the panel methodologist. Thirteen studies were rated level I and 21 studies were rated level II. RESULTS: Presbyopia-correcting lenses were effective at improving distance and near visual acuity after cataract surgery. Near acuity at different focal lengths was related directly to the effective add power of multifocal and extended depth-of-focus (EDOF) IOLs. Most multifocal and EDOF lenses that were compared with a control monofocal lens demonstrated that patient-reported spectacle independence was superior to the monofocal lens. All patients who had multifocal and EDOF lenses implanted showed decreased contrast sensitivity and reported more visual phenomena as compared with control participants who received monofocal lenses. CONCLUSIONS: Presbyopia-correcting lenses improve uncorrected near and distance visual acuity and decrease spectacle dependence after cataract surgery. Mesopic contrast sensitivity is decreased compared with monofocal lenses, and patient-reported visual phenomena are more likely in patients receiving multifocal or EDOF lenses.

Refractive outcomes after multifocal intraocular lens exchange.

PURPOSE: To evaluate the refractive outcomes after multifocal intraocular lens (IOL) exchange. SETTING: Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA. DESIGN: Retrospective case series. METHODS: Patients had multifocal IOL explantation followed by IOL implantation. Outcome measures included type of IOL, surgical indication, corrected distance visual acuity (CDVA), and refractive prediction error. RESULTS: The study comprised 29 patients (35 eyes). The types of IOLs implanted after multifocal IOL explantation included in-the-bag IOLs (74%), iris-sutured IOLs (6%), sulcus-fixated IOLs with optic capture (9%), sulcus-fixated IOLs without optic capture (9%), and anterior chamber IOLs (3%). The surgical indication for exchange included blurred vision (60%), photic phenomena (57%), photophobia (9%), loss of contrast sensitivity (3%), and multiple complaints (29%). The CDVA was 20/40 or better in 94% of eyes before the exchange and 100% of eyes after the exchange (P = .12). The mean refractive prediction error significantly decreased from 0.22 ± 0.81 diopter (D) before the exchange to -0.09 ± 0.53 D after the exchange (P < .05). The median absolute refractive prediction error significantly decreased from 0.43 D before the exchange to 0.23 D after the exchange (P < .05). CONCLUSIONS: Multifocal IOL exchange can be performed safely with good visual outcomes using different types of IOLs. A lower refractive prediction error and a higher likelihood of 20/40 or better vision can be achieved with the implantation of the second IOL compared with the original multifocal IOL, regardless of the final IOL position.

Evaluation of Femtosecond Laser Intrastromal Incision Location Using Optical Coherence Tomography.

PURPOSE: To use optical coherence tomography (OCT) to evaluate the femtosecond laser intrastromal incisions made during cataract surgery to reduce corneal astigmatism. DESIGN: Retrospective case series. PARTICIPANTS: Seventy-seven eyes of 77 patients. METHODS: Paired intrastromal incisions were created using the Catalys femtosecond laser (Abbott Medical Optics, Inc., Santa Ana, CA). The planned intrastromal incision parameters were 20% uncut anterior, 20% uncut posterior, midpoint depth of 50%, and 90° side cut angle. Optical coherence tomography scans were obtained 3 weeks or more after surgery to assess these 4 parameters, and actual values were compared with intended values. MAIN OUTCOME MEASURES: Percentages of uncut anterior and posterior tissue, midpoint depth, and degrees of side cut angle. RESULTS: The mean values were 17.2±5.8% (range, 7.2%-36.9%) for uncut anterior, 32.5±8.8% (range, 6.0%-57.9%) for uncut posterior, and 42.3±6.6% (range, 25.5%-65.4%) for midpoint depth, which all were significantly different from the planned parameters (all P < 0.05). The mean side cut angle was 88.5°±5.6° (range, 71°-114°) and was significantly different from the planned side cut angle of 90° (P < 0.05). In 50 eyes that had paired intrastromal incisions scanned by the OCT, there was no correlation between the paired incisions for midpoint depth and side cut angle (correlation coefficient, r = -0.063 and -0.067, respectively; P > 0.05). CONCLUSIONS: The intrastromal incision midpoint depth was significantly more anterior than the planned depth of 50%. The locations of paired intrastromal incisions in each eye were not correlated. Further improvements are needed to ensure the precise location of the intrastromal incisions made with this device.

Evolving risk factors and antibiotic sensitivity patterns for microbial keratitis at a large county hospital.

Purpose: To identify the risk factors, causative organisms, antimicrobial susceptibility and outcomes of microbial keratitis in a large county hospital in Houston, Texas.Design: Case series. METHODS: Setting: A large county hospital in Houston, Texas. STUDY POPULATION: Patients with known diagnosis of microbial keratitis from January 2011 to May 2015. OBSERVATION PROCEDURE: Retrospective chart review. MAIN OUTCOMES: Epidemiology, risk factors, outcomes and antibiotic susceptibility of microbial keratitis. RESULTS: The most commonly identified risk factors were contact lens use (34.4%), ocular trauma (26.3%), diabetes mellitus (16.7%), ocular surgery (13.5%), ocular surface diseases (11.5%), previous keratitis (10.4%), glaucoma (6.3%), cocaine use (5.2%) and HIV-positive status (4.2%). Eyes with positive cultures (61.5%) were associated with worse visual outcomes (p=0.019) and a higher number of follow-up visits (p=0.007) than eyes with negative cultures (38.5%). Corneal perforation was the most common complication (11.5%). Gram-negative organisms (21.9%) were all susceptible to ceftazidime, tobramycin and fluoroquinolones. Gram-positive organisms (33.3%) had worse outcomes than Gram-negative organisms (21.9%) and exhibited a wide spectrum of antibiotic resistance, but all were susceptible to vancomycin. Twenty-seven per cent of the coagulase-negative Staphylococci were resistant to fluoroquinolones. CONCLUSION: This study identified a recent shift in risk factors and antibiotic resistance patterns in microbial keratitis at a County Hospital in Houston, Texas. In our patient population, fluoroquinolone monotherapy is not recommended for severe corneal ulcers. On the basis of these results, vancomycin and tobramycin should be used for empirical therapy until microbial identity and sensitivity results are available.

Repositioning a decentered intraocular lens with 4 haptics.

We describe a technique to reposition a decentered 4-haptic intraocular lens (IOL). Using an ophthalmic viscosurgical device, the haptic with the worst distortion is dissected from the capsular bag and pulled outside the bag. The opposite haptic (180 degrees away) is also dissected and placed in front of the anterior capsule. The remaining 2 haptics are left in the capsular bag. With this repositioning, the 2 haptics in the bag limit the IOL movement, the 2 haptics outside the bag are no longer distorted, and the IOL is centered. We present 2 cases in which this technique was used to reposition decentered 4-haptic IOLs.

Repeatability and comparability of corneal thickness measurements obtained from Dual Scheimpflug Analyzer and from ultrasonic pachymetry.

BACKGROUND: To assess the repeatability and comparability of central corneal thickness (CCT) measurements obtained from the Galilei Dual Scheimpflug Analyzer (Galilei-DSA) and from ultrasonic pachymetry (USP) in normal eyes and in eyes following laser refractive surgery. METHODS: In this prospective observational study, 77 eyes of 39 patients with normal corneas and 39 eyes of 20 patients with prior laser refractive surgery were enrolled. All 116 eyes had three repeated measurements of central CCT with the Galilei-DSA first and then with USP by the same examiner. Reliability of both devices was assessed statistically, and CCT measurements by each were compared. RESULTS: The mean CCT measurement of normal eyes was 549.2 ± 30.5 µm and 548.5 ± 33.1 µm by the Galilei-DSA and USP respectively; the difference between the two modalities was -0.7  ± 7.1 µm (P = 0.365). In post-refractive surgery eyes, the mean CCT measured by the Galilei-DSA and USP was 500.4 ± 44.8 and 494.3 ± 50.3 respectively; the difference between the two devices was -6.2 ± 9.9 µm (P < 0.001). For the three repeated measurements, the mean standard deviation was 2 µm with the Galilei-DSA and 1.8 µm with USP in normal eyes, and 2.4 µm with the Galilei-DSA and 1.9 µm with USP in post-refractive surgery eyes. CONCLUSION: The Galilei-DSA has high repeatability and excellent to moderate agreement with ultrasonic pachymetry when measuring CCT in normal and post-refractive surgery eyes.