Refractive cataract surgery.

Cataract surgery is the most commonly performed refractive procedure in the world today. Improvements in the calculation of intraocular lens power and design have allowed complete spherical correction of preexisting refractive error with intraocular lens implantation. Advances in incision construction have improved the refractive results of cataract surgery by minimizing surgically induced astigmatism. Astigmatism and pseudophakic presbyopia continue as the primary indications for spectacle correction following cataract surgery. Improvements in the technique of correcting preexisting astigmatism with cataract surgery have improved the uncorrected visual outcome of cataract surgery. The application of these advances in technology over the past year has demonstrated that full refractive correction of the cataract patient is now possible.

Clear corneal cataract surgery and the correction of myopia, hyperopia, and astigmatism.

PURPOSE: Advances in cataract removal using topical anesthesia through a clear corneal microincision have created a new opportunity to fully correct refractive errors at the time of cataract surgery. This study was undertaken to assess the effectiveness of keratolenticuloplasty (KLP), the simultaneous modification of the cornea at cataract removal to create emmetropia with lens implantation. METHODS: Data were analyzed for 690 consecutive cataract procedures performed between March 1993 and March 1995, with follow-up of 12 to 24 months. Each patient underwent cataract removal with topical anesthesia, clear corneal incision fashioned as an arcuate keratotomy to correct pre-existing astigmatism, intercapsular phacoemulsification, and microinjection of a single-piece elastic intraocular lens (IOL) into the capsular bag to correct spherical error. RESULTS: Preoperative best-corrected visual acuity was worse than 20/50 in all patients; 58% were myopic, 32% were hyperopic, and 57% had astigmatism of greater than 1 diopter (D). Postoperatively, spectacle independence was achieved with uncorrected visual acuity of 20/40 or better in 87% of eyes. The sphere was fully corrected in 78%, within 1 D in 17%, and within 2 D in 5%. No patients were overcorrected. The cylinder was fully corrected in 72%, within 1 D in 26%, and within 2 D in 2%. Of those with residual astigmatism, there was no significant postoperative shift in cylinder axis. There were no sight-threatening complications. All patients were able to resume normal unrestricted activities within 24 hours of undergoing the procedure. CONCLUSIONS: The KLP technique can correct spherical and astigmatic refractive errors, helping individuals become free of eyeglasses after clear corneal cataract surgery.

Evaluation of bidirectional radial and astigmatic keratotomy.

PURPOSE: To analyze the outcome of incisional radial and astigmatic keratotomy using a bidirectional keratome. METHODS: We used a bidirectional cutting diamond keratome on 100 consecutive eyes (mean patient age 38 years, range 18 to 67 years) whose mean preoperative cycloplegic refraction was -4.64 (range of sphere -1.50 to -15.25) and +1.25 of cylinder (range of cylinder +0.50 to +5.00). RESULTS: Mean postoperative cycloplegic refraction was -0.31 (range +0.50 to -1.25) and +0.25 cylinder (range 0 to +1.00). At the end of 1 year, 97% of eyes had an uncorrected visual acuity of 20/40 or better. The rate of enhancement of the original keratotomy was 10%; all of these eyes had more than -6.25 diopters (D) of sphere or +2.00 D of cylinder preoperatively. Side effects were minimal, and no sight-threatening complications occurred. CONCLUSION: In this study, bidirectional incisional radial and astigmatic keratotomy was an accurate and predictable technique for myopia and astigmatism; all patients were satisfied with the procedure.

Nonpenetrating trabeculectomy with placement of a collagen drainage device.

Since the advent of trabeculectomy with antimetabolite therapy, there have been few changes in the surgical management of glaucoma. This is the first report of a new technique, nonpenetrating trabeculectomy with placement of a collagen drainage device. The procedure facilitates aqueous drainage without entering the human eye. Meticulous surgical dissection of the trabecular meshwork is required with creation of an external filtration tract and subscleral positioning of a collagen device to facilitate aqueous drainage. With this procedure, the surgeon can avoid common complications of glaucoma surgery such as synechias, overfiltration, hypotony, intraocular infection, uveal prolapse, and failed surgical blebs. The procedure and device have been used extensively in Russia.

Keratolenticuloplasty: arcuate keratotomy for cataract surgery and astigmatism.

Cataract surgery has evolved into a procedure in which pre-existing refractive errors can be corrected simultaneously to improve uncorrected visual acuity following surgery. This paper describes keratolenticuloplasty, a new technique of clear corneal arcuate keratotomy for cataract surgery that corrects pre-existing astigmatic errors at the time of cataract extraction. This technique uses topical anesthesia, a single pair of arcuate corneal incisions placed on the steepest axis of astigmatism, one-step capsulorhexis, hydrodissection, intercapsular phacoemulsification, and injection of an elastic intraocular lens within the capsular bag. The technique has been used in over 1,000 patients with follow-up of 24 months. Uncorrected visual acuity of 20/40 or better with no associated complications was achieved in 96% of patients.

Simple method of transscleral fixation of a posterior chamber intraocular lens in the absence of the lens capsule.

BACKGROUND: There are several advantages to implanting a posterior chamber intraocular lens (IOL) in the ciliary sulcus when the lens capsule is absent. I have developed a simple method of fixating an IOL into the ciliary sulcus which does not require different needles, multiple needle passes, scleral dissection, or awkward surgical maneuvers. METHODS: Thirty eyes were enrolled in this study. All eyes were either aphakic, requiring a secondary lens implantation, or required IOL exchange. The patients were followed for 30 months. Using a single 10-0 double-armed, polypropylene suture, a through-and-through infraciliary scleral pass secured each haptic without tying. The lens was then positioned into the ciliary sulcus and the knots tied outside the eye under direct visualization. RESULTS: This procedure has been used in 30 eyes without erosion of sutures, dislocation or tilting of the IOL, or induced astigmatism. Twenty-one eyes (70%) had spectacle-corrected visual acuity of 20/40 or better. CONCLUSION: The results of this study demonstrate that posterior chamber transscleral fixated IOLs give improved postoperative visual results.

Topical anesthesia for small incision self-sealing cataract surgery. A prospective evaluation of the first 100 patients.

Small incision self-sealing cataract surgery has created the opportunity to use less invasive anesthesia. One hundred patients were evaluated in a prospective study using a new technique of topical anesthesia to allow small incision construction, intercapsular phacoemulsification, and small incision intraocular lens implantation without a peribulbar or retrobulbar injection. This study demonstrated that topical anesthesia avoids the risk of globe perforation, retrobulbar hemorrhage, and prolonged postoperative akinesia of the eye and is effective for intraoperative anesthesia for cataract surgery.

Sutureless one-handed intercapsular phacoemulsification. The keyhole technique.

Advances in the phacoemulsification technique have made small incision cataract surgery with lens implantation and sutureless incision closure a reality. This paper describes a step-by-step technique of small incision construction (the key), capsulorhexis (the keyhole), hydrodissection, intercapsular phacoemulsification (the doorway), and small incision lens implantation without the need for suture closure. A review of 200 cases with follow-up at one year is described. Evaluation of a postmortem eye at eight weeks following this sutureless technique indicates that these incisions are self-sealing, do not leak, do not induce astigmatic change, and allow rapid visual recovery.

One-step forceps for capsulorhexis.

There are several popular methods for creating a continuous-tear capsulotomy, or capsulorhexis, which usually involve several instruments and steps. This report describes a new forceps for capsulorhexis that can be used to open the capsule and complete the circular tear in one step. Its unique features are its small size, shortened length, thin, rounded blades with cystotome-type tips for opening the capsule, and round handles for manipulation ease.

Systemic side effects associated with the ophthalmic administration of timolol.

Since the introduction of ophthalmic timolol solution in 1978 there have been numerous reports of systemic toxicity associated with its use. The majority of the systemic side effects reported are the same as those associated with oral timolol. Several cases of respiratory distress have been described generally in patients with underlying restrictive airway disease. Cardiovascular effects range from effects on resting pulse rate to the development of overt bradycardia and heart failure. Central nervous system effects reported include fatigue, confusion, depression, and hallucinations. A variety of other systemic effects have also been described. Caution should be used when ophthalmic timolol is administered to elderly patients or those patients with contraindications to systemic beta-blockers.