Endoscopic endonasal retrieval of a nasolacrimal duct stone via the valve of Hasner in the inferior meatus.

A 37 year old man presented with a 6 month history of a right epiphora with associated mucus discharge. Lacrimal irrigation demonstrated right unilateral partial nasolacrimal duct obstruction, confirmed with lacrimal scintigraphy. Nasal endoscopy showed a pale elevation in the right inferior meatus. Endoscopic endonasal examination revealed a yellow-white nasolacrimal duct stone emerging from the valve of Hasner in the inferior meatus. The distal nasolacrimal duct in the lateral wall of the inferior meatus was marsupialised and the stone removed. At 12 months follow-up the patient maintained complete resolution of symptoms.

Fellow-eye comparison of posterior capsule opacification rates after implantation of 1CU accommodating and AcrySof MA30 monofocal intraocular lenses.

PURPOSE: To measure posterior capsule opacification (PCO) and neodymium:YAG (Nd:YAG) capsulotomy rates between the AcrySof MA30 intraocular lens (IOL) (Alcon) and the 1CU IOL (HumanOptics) in a fellow-eye comparison. SETTING: Ophthalmology Department, St. Thomas' Hospital, London, United Kingdom. METHODS: Thirty patients who had bilateral cataract surgery with a 1CU IOL prospectively randomly allocated to 1 eye and an AcrySof MA30 monofocal IOL to the other eye were examined. Best corrected distance visual acuity was recorded using the Early Treatment Diabetic Retinopathy Study logMAR chart. Digital retroillumination images of the posterior capsule were taken with the pupil dilated and analyzed with POCO software. RESULTS: Eyes with the 1CU IOL had significantly higher PCO rates than eyes with the MA30 IOL at all time points. By 2 years after surgery, 50% of eyes with a 1CU IOL had required Nd:YAG capsulotomy compared with no eyes with an MA30 IOL. There was no significant difference in visual acuity at any time point when post Nd:YAG capsulotomy was taken in to account. CONCLUSIONS: The 1CU IOL has 4 broad optic-haptic junctions where the square-edged barrier is breached; this appeared to allow passage of lens epithelial cells, leading to an increase in PCO. However, the increased PCO cannot be attributed to this alone as the 1CU is hydrophilic, a factor known to be associated with higher PCO rates.

Objective measurement of intraocular lens movement and dioptric change with a focus shift accommodating intraocular lens.

PURPOSE: To objectively measure the shift and refractive change of the 1CU accommodating intraocular lens (IOL) (HumanOptics) and compare them to that of a monofocal AcrySof MA30 IOL (Alcon Laboratories) in the fellow eye. SETTING: Ophthalmology Department, St. Thomas' Hospital, London, United Kingdom. METHODS: Thirty patients who had bilateral cataract surgery 18 to 24 months previously with a 1CU IOL prospectively randomly allocated to 1 eye and an AcrySof MA30 monofocal IOL to the other eye were examined. Distance correction, near vision, reading fluency, near point, and defocus to minus spheres were measured. Intraocular lens shift to an accommodative stimulus following instillation of pilocarpine 4% was measured with the ACMaster. Refractive change between distance and near was measured with the Tracey wavefront analyzer. RESULTS: Of the original 30 patients recruited, complete measurements could only be obtained for 20. There was no significant difference in near visual function with either IOL. A small anterior movement of the 1CU was seen with accommodation 0.010 mm +/- 0.028 (SD). After pilocarpine 4% instillation, a forward movement of 0.220 +/- 0.169 mm was seen with the 1CU compared to a backward movement of 0.028 +/- 0.095 with the MA30. There was no significant correlation between distance corrected near visual acuity and IOL movement. No change in spherical equivalent between distance and near was seen on wavefront analysis of either IOL. CONCLUSIONS: Small forward movement of the 1CU IOL was seen with accommodation and increased following pilocarpine, compared to the posterior movement of the MA30 IOL. The amount of the IOL shift was not sufficient to provide useful near vision, but the difference suggests that the engineering concept behind the 1CU IOL is valid.

Hydrophobic acrylic and plate-haptic silicone intraocular lens implantation in diabetic patients: pilot randomized clinical trial.

PURPOSE: To compare the capsular and uveal reaction after implantation of a plate-haptic silicone intraocular lens (IOL) (C11UB, Chiron) and a hydrophobic acrylic (AcrySof MA60, Alcon) IOL in diabetic patients. SETTING: Moorfields Eye Hospital and St. Thomas' Hospital, London, United Kingdom. METHODS: Thirty-five diabetic patients were recruited consecutively and randomly assigned to have implantation of either of the 2 IOLs. The percentage area of posterior capsule opacification (PCO), anterior capsule contraction (ACC), and postoperative inflammatory indices (flare and cells) were assessed objectively at 2 to 3 weeks, 6 months, and 1 year. Between-group and within-group analyses were conducted using the Student t test or Mann-Whitney test and Friedmann test, respectively. RESULTS: Between-group analysis showed the percentage area of PCO was significantly greater in patients with plate-haptic silicone IOLs at 6 and 12 months (P = .002). At 6 months, ACC was significantly greater in the plate-haptic group (P = .04), but the difference was not significant at 12 months. There was higher flare in the hydrophobic acrylic IOL group than in the plate-haptic silicone IOL group at 2 to 3 weeks (P = .08). Within-group analysis showed that over the follow-up period, the plate-haptic silicone group, but not the hydrophobic acrylic group, had a progressive increase in PCO (P = .003). In the hydrophobic acrylic group, but not the plate-haptic silicone group, there was a significant reduction in the mean anterior chamber flare value (P = .01). There was no significant difference in visual acuity or contrast sensitivity at any postoperative visit. CONCLUSION: In diabetic patients, hydrophobic acrylic IOLs can lead to an increased flare in the early postoperative period but they seem to be more favorable than plate-haptic silicone IOLs because the latter lead to more PCO.

Spontaneous suprachoroidal hemorrhage secondary to thrombolysis for the treatment of myocardial infarction.

Suprachoroidal haemorrhage occurs most commonly as an intraoperative or a postoperative complication of ocular surgery. Spontaneous suprachoroidal haemorrhage is rare. Herein a case is described of spontaneous suprachoroidal haemorrhage in a patient who received recombinant tissue plasminogen activator for the treatment of a myocardial infarction. Systemic thrombolysis may induce spontaneous suprachoroidal haemorrhage. Prompt diagnosis and treatment can improve the likelihood of a favourable visual outcome. To the authors' knowledge, there have been only three previous reports in the literature of spontaneous suprachoroidal haemorrhage secondary to thrombolysis.

Fellow eye comparison between the 1CU accommodative intraocular lens and the Acrysof MA30 monofocal intraocular lens.

PURPOSE: To examine the near visual clinical performance of an accommodative intraocular lens (IOL) when compared with a standard monofocal IOL in a fellow eye comparison. DESIGN: Prospective, randomized fellow eye comparison. METHODS: Thirty patients (60 eyes) with bilateral cataracts but otherwise normal eyes were recruited from a single university hospital cataract waiting list. Patients were randomized to receive either the 1CU accommodative IOL in their first eye or the Acrysof MA30 monofocal IOL. The alternative lens was then implanted in the second eye 4 to 6 weeks later. At all follow-up visits, a full assessment was made of distance, near and reading visual performance, and accommodative amplitude. RESULTS: Data are available for all patients at 6 months and 20 patients at 1 year. At 6 months, no difference was found in distance-corrected visual acuity between the two IOLs. Of the 1CU eyes, nine patients (30%) could read J6 or better at a reading speed of 80 words/min or better. In these nine patients, the mean difference in the amplitude of accommodation between the two eyes was 0.71 diopters. CONCLUSIONS: No measurable variable distinguished eyes that developed functional reading vision from those that did not. The accommodative IOL appears to produce improved near vision in some eyes, but it does not work in all eyes, and in eyes where there is apparent accommodation, there is a discrepancy between subjective reading performance and the modest measured increase of accommodative amplitude.

Comparison of posterior capsule opacification rates between hydrophilic and hydrophobic single-piece acrylic intraocular lenses.

PURPOSE: To determine the effect of intraocular lens (IOL) material on the development of posterior capsule opacification (PCO) at 1 year. SETTING: Department of Ophthalmology, St. Thomas' Hospital, London, United Kingdom. METHODS: One hundred six eyes of 53 patients with bilateral cataract and no other ocular comorbidity were prospectively randomized to receive a hydrophobic acrylic or hydrophilic acrylic single-piece IOL in the first eye to have surgery. The alternate IOL was implanted in the fellow eye 4 to 6 weeks later. All surgery was performed by a single surgeon. Postoperative follow-up was 1 day, 1 and 6 months, and 1 year. At each visit, the best corrected high- and low-contrast visual acuities were assessed and a high-intensity digital retroillumination photograph was taken. Posterior capsule opacification was assessed from the digital images by a single operator using a dedicated software program and calculated as the percentage area of opacified capsule. RESULTS: One year postoperatively, the median percentage area of PCO was 50.3% in the hydrophilic IOL group and 4.9% in the hydrophobic IOL group (P<.001). The difference in PCO was not accounted for by loss of contact between the capsulorhexis and IOL surface. Further analysis showed that lens epithelial cells tended to invade the posterior capsule at the haptic-optic junction. This was more marked in the hydrophilic IOL group. CONCLUSIONS: The rate of PCO was significantly higher with the hydrophilic IOL. However, the results cannot be attributed to the IOL material alone as they show the importance of both IOL material and design.

Correlation between the measurement of posterior capsule opacification severity and visual function testing.

PURPOSE: To develop software to measure the severity of posterior capsule opacification (PCO) using analysis of retroillumination images and to correlate the results with clinical evaluation of PCO severity and visual function. SETTING: Department of Physics, King's College, and Department of Ophthalmology, St. Thomas' Hospital, London, United Kingdom. METHODS: A technique for calculating PCO severity was developed based on calculating the variance of intensity by transforming retroillumination images to a similar mean intensity. The computer-derived severity was compared to grading of clinical severity by 3 independent observers using a library of 100 retroillumination images ranging from clear posterior capsules to very severe PCO. The computer results were also compared with the following other current methods of measuring PCO: Evaluation of Posterior Capsule Opacification (EPCO), POCOman, and Automated Quantification of After-Cataract. A further 35 images were used to compare the results of computer-derived severity with the results of visual function analysis (high-contrast acuity, 100%; low-contrast acuity, 9%) using the Early Treatment Diabetic Retinopathy Study chart, contrast sensitivity testing using the Pelli-Robson chart, and glare assessment using the van den Berg straylight meter. RESULTS: The severity scores showed a good correlation with clinical severity scores for the library of images (r=0.86) and with severity scores using POCOman and EPCO (r=0.85 and r=0.81, respectively). The correlations with visual function tests were also good, with low-contrast visual acuity (9%) showing the best correlation (r=0.87). CONCLUSION: Variance in intensity of PCO was successfully used to calculate the severity of PCO.

Factors that influence the development of posterior capsule opacification with a polyacrylic intraocular lens.

PURPOSE: To identify factors that contribute to posterior capsule opacification (PCO) after implantation of a 5.5 mm polyacrylic (IOL). DESIGN: A retrospective analysis of a cohort of sequential images taken from the PCO database at St. Thomas' Hospital, London, to include all patients with an AcrySof MA30 lens and a 1-year retroillumination image. METHODS: Records of age, gender, axial length, and PCO measurements using the POCO software system were available. Images were divided into those with greater or less than 10% PCO. The degree of rhexis-IOL contact was recorded in clock hours. RESULTS: Images of 60 eyes were analyzed. Twenty-one eyes had more than 10% PCO. No correlation was found between PCO and age, gender, or axial length. Forty-eight eyes (80%) had some loss of rhexis-IOL contact. These eyes had increased PCO (P < .001) compared with eyes with complete IOL-rhexis contact. More PCO developed when the rhexis was partly on and partly off the IOL. CONCLUSIONS: PCO is reduced when the rhexis is in complete contact with the anterior IOL surface. The failure to achieve this accounts for the majority of increased PCO seen in patients implanted with this IOL model. PCO formation is related to surgical technique as well as IOL design, and comparisons cannot be made between IOLs without taking this into consideration. These results support the trend to the use of larger optic IOLs to prevent PCO and also support the "capsule compression" theory of PCO prevention.

POCOman: new system for quantifying posterior capsule opacification.

PURPOSE: To describe a new method of measuring posterior capsule opacification (PCO) and intraocular lens (IOL) rotation and report the validation of the method. SETTING: Ophthalmology Department, St. Thomas' Hospital, and Medical Imaging, Department of Physics, King's College, London, United Kingdom. METHOD: A new interactive software program, POCOman, was developed for the semiobjective assessment of PCO. Digital images of the posterior capsule, which can be acquired by any technique, are analyzed by the observer to determine the percentage area of PCO and assign a severity score. The system was validated by comparing it to clinical slitlamp evaluation of PCO and automated POCO system analysis using a library of 100 images taken from archives. The software also measures sequential IOL rotation for the evaluation of toric IOLs. RESULTS: An image could be analyzed in approximately 2 minutes. The results of the POCOman system correlated well with the results of the automated POCO system and clinical evaluation. CONCLUSIONS: The POCOman is an effective, user-friendly system for quantifying PCO. It can be obtained for free and has advantages over other methods.

Effect of pupil dilation on the accuracy of the IOLMaster.

PURPOSE: To evaluate the effect of pupil dilation on the accuracy of the IOLMaster (Zeiss) in performing biometry and to assess test-retest variability without pupil dilation. SETTING: Ophthalmic outpatient department of a district general hospital. METHODS: This prospective study comprised consecutive patients presenting to a cataract clinic (study group) who had biometry performed with the IOLMaster before and after pupil dilation. A control group was recruited from consecutive patients attending a cataract preassessment clinic who had 2 sets of biometric measurements with the IOLMaster but without pupil dilation. The SRK/T formula was used to calculate intraocular lens (IOL) power. RESULTS: The IOLMaster showed excellent reproducibility in the control group with no significant test-retest variability between the 2 sets of readings. The study group showed a statistically significant change in K2 and average keratometry values (P <.05) but no significant change in axial length or IOL power between undilated and dilated pupil biometry readings. No systematic errors were revealed. CONCLUSIONS: Dilating the pupil did not adversely affect the clinical accuracy of the IOLMaster.