Alan S. Crandall

Visual significance of glistenings seen in the AcrySof intraocular lens.

Purpose: To investigate the visual significance of “glistenings” in acrylic intraocular lenses (IOLs). Setting: John Moran Eye Center, University of Utah, Salt Lake City. Methods: Seventeen patients who had phacoemulsification with implantation of the AcrySof® acrylic IOL were evaluated by slitlamp examination and visual acuity, contrast sensitivity, and glare testing. Ten patients had a silicone posterior chamber IOL in the opposite eye and had testing with similar visual parameters for comparison. Glistenings noted in the acrylic IOLs were graded at the slitlamp. Laboratory analysis of five acrylic IOLs was also done to reproduce the glistenings noted clinically. Results: All 17 patients with the acrylic IOLs had some lenticular glistenings, ranging from trace to 2+. Statistical analysis of visual acuity, contrast sensitivity, and glare testing revealed a statistically significant difference between the acrylic and the silicone IOLs only in contrast sensitivity. Laboratory analysis of the acrylic IOLs showed similar glistenings from 48 to 72 hours after they were placed in balanced salt solution. Conclusions: All patients who received AcrySof IOLs that came in the AcryPak® had some degree of glistenings. There was also a significant decrease in contrast sensitivity compared with that of fellow eyes with silicone IOLs. The glistenings are likely caused by water vacuoles that form within the lens after hydration within the eyes. Further studies are necessary to assess the exact cause of these glistenings.

A Comparison of Topical and Retrobulbar Anesthesia for Cataract Surgery

PURPOSE To evaluate and compare the efficacy of topical and retrobulbar anesthesia for cataract extraction with intraocular lens implantation. METHODS One hundred thirty-eight patients prospectively were assigned to the topical (group 1; n = 69) or retrobulbar (group 2; n = 69) anesthesia groups by permuted block restricted randomization. Group 1 received topical 0.75% bupivacaine and intravenous midazolam and fentanyl for anesthesia. Group 2 received intravenous methohexital followed by retrobulbar block with an equal mixture of 2% lidocaine and 0.75% bupivacaine plus hyaluronidase (150 U). A visual pain analogue scale was used to assess the degree of pain during the administration of anesthesia, during surgery, and post-operatively. The degree to which eye movement, touch, and light caused patient discomfort was assessed. Complications and surgical conditions were recorded. RESULTS There was no difference in the surgical conditions (P = 0.5) or pain during surgery (P = 0.35) between the two groups. There was more discomfort during administration of topical anesthesia (P < 0.0001) and postoperatively (P < 0.05) in the topical group. Chemosis, subconjunctival hemorrhage, and eyelid hemorrhage were seen almost exclusively in the retrobulbar group. One patient in group 2 had a retrobulbar hemorrhage. Although eyeball movement and squeezing of the eyelids were present more frequently in the topical group, neither was a problem to the surgeon. CONCLUSION Topical anesthesia can be used safely for cataract extraction. The degree of patient discomfort is only marginally higher during administration of the anesthesia and postoperatively. However, surgical training and patient preparation are the keys to the safe use of topical anesthesia.

Progressive constriction of the anterior capsular opening following intact capsulorhexis.

ABSTRACT The continuous curvilinear capsulorhexis has rapidly increased in popularity as the procedure of choice when using phacoemulsification for cataract extraction. Only recently, however, have complications of this technique been reported. We review the complications of a continuous curvilinear capsulorhexis and present three cases involving progressive constriction of the postoperative anterior capsular opening. One patient had a history of myotonic muscular dystrophy, another had pars planitis, and the third had high myopia. A review of ocular findings in myotonic dystrophy and pars planitis is also presented, and the possible pathophysiology of this progressive constriction is explored.

A comparison of patient comfort during cataract surgery with topical anesthesia versus topical anesthesia and intracameral lidocaine

OBJECTIVE To determine whether intraocular lidocaine increases patient comfort during cataract surgery while under topical anesthesia. DESIGN Prospective, randomized, double-masked, placebo-controlled clinical trial. PARTICIPANTS Both men and women between 45 and 85 years of age who were scheduled for elective cataract surgery while under topical anesthesia participated. Sixty-eight patients were randomized to each group. INTERVENTION Patients were randomized to receive either topical anesthesia plus intracameral 1% preservative-free lidocaine or intracameral balanced salt solution. MAIN OUTCOME MEASURES Patient assessment of pain during delivery of the anesthesia, surgery, and after surgery using a visual analog pain scale was measured. Patients also recorded the degree to which they were bothered by tissue manipulation and the microscope light. Surgeon assessments of operative conditions, patient cooperation, and intraoperative complications were recorded. The attending anesthesiologist recorded any required supplemental intravenous sedation and any increase in pulse or increase in blood pressure. RESULTS There was no significant difference in patient-reported pain scores for delivery of anesthesia (P = 0.902), surgery (P = 0.170), or after surgery (P = 0.680). Patients in the lidocaine group reported being less bothered by tissue manipulation (P = 0.021). The surgeon assessment showed more patient cooperation in the lidocaine group (P = 0.043). CONCLUSIONS Both topical anesthesia alone and topical anesthesia plus intracameral lidocaine provide good operative conditions for the surgeon and comfortable surgical circumstances for the patient. Injection of intraocular lidocaine increases patient cooperation and decreases the degree to which patients are bothered by tissue manipulation, two outcomes that justify its use.

Late In-the-Bag Spontaneous Intraocular Lens Dislocation: Evaluation of 86 Consecutive Cases

OBJECTIVE As techniques for cataract surgery have evolved, spontaneous intraocular lens (IOL) dislocation has decreased overall. However, since 2006 the Intermountain Ocular Research Center has received an increased number of explanted IOLs within the capsular bag forwarded for pathologic evaluation. Late, spontaneous dislocation of IOLs results from zonular insufficiency and zonulysis that has been associated with pseudoexfoliation, trauma, and other risk factors. The findings of 86 consecutive cases of this complication, analyzed in the laboratory, are described. DESIGN Retrospective case series. PARTICIPANTS Eighty-six IOLs explanted within the capsular bag, submitted in formalin. METHODS Standard light microscopy of specimens, as well as questionnaire sent to explanting surgeons and patient chart review, when available. MAIN OUTCOME MEASURES Lens design, material, and abnormalities; capsular bag anomalies; patient demographic data; surgical dates; and presence or absence of known risk factors. RESULTS This series included polymethyl methacrylate, silicone, and hydrophobic acrylic lenses, manufactured with both 1-piece and 3-piece designs. The mean time from surgery to spontaneous IOL dislocation was 8.5 years. The main conditions associated with the cases of IOL dislocation were as follows: pseudoexfoliation, 50%; prior vitreoretinal surgery, 19%; history of trauma, 6%; uveitis, 2%; and none or unknown, 23%. CONCLUSIONS Patients with any type of IOL are at risk for late in-the-bag dislocation. Pseudoexfoliation and vitreoretinal surgery were the most common associated conditions in this series. Regardless of the presence of known risk factors, IOLs dislocated on average 8.5 years after phacoemulsification and IOL implantation.

Pseudoexfoliation and the cataract surgeon: Preoperative, intraoperative, and postoperative issues related to intraocular pressure, cataract, and intraocular lenses

This review provides a comprehensive assessment of intraocular pressure (IOP), phacoemulsification techniques, and intraocular lenses (IOLs) in pseudoexfoliation (PXF) eyes having cataract surgery. Pseudoexfoliation is ubiquitous and the most common cause for open-angle glaucoma worldwide. Cataracts occur with increased frequency in PXF eyes, and surgery is potentially complicated by the presence of small pupils and zonule laxity and significantly affects IOP in these eyes. Preoperative evaluation and the options for intraoperative management of cataract are presented with recommendations for the use of adjunctive pupil and zonule support devices. Postoperative complications such as capsule contraction and IOL instability are discussed and laser and surgical options to manage these special problems presented.

Anterior chamber lenses. Part II: A laboratory study

ABSTRACT An analysis of 606 surgically removed anterior chamber intraocular lens (IOL) specimens revealed that 351 or 58% of these were smalldiameter, round loop, closed‐loop styles. Because of the extremely high percentage of IOLs with this design received in our laboratory and the correlation of clinical histories with our histopathologic findings, we have concluded that such IOLs do not provide the safety and efficacy achieved by other anterior chamber lens designs. The finely polished, one‐piece, all‐PMMA styles fared well in our study. Although these one‐piece styles comprise well over 50% of the American market share of anterior chamber IOLs, they comprise only 14% of all anterior chamber IOLs accessioned in our laboratory, compared to 58% for closed‐loop designs. We believe that implantation of anterior chamber lenses with small‐diameter, round, closed loops is no longer warranted. Patients in whom these IOLs have already been implanted should be carefully followed. It is our opinion that the FDA should recall or closely monitor all IOLs of this design and that implantation of closed‐loop lenses should be discontinued in the United States. Furthermore, we believe that an IOL deemed to be not medically sound or worthy of implantation in the United States should not be marketed or donated outside of this country.

Comparison of energy required for phaco-chop and divide and conquer phacoemulsification

Purpose: To evaluate the safety and usefulness of phaco‐chop cataract extraction. Setting: A university‐associated, multispecialty ophthalmology practice. Methods: Fifty‐three patients in a university‐associated ophthalmology practice had cataract extraction, 32 by the phaco‐chop technique and 21 by four‐quadrant divide and conquer phacoemulsification. Phacoemulsification energy and complication rates were compared. Results: Mean phacoemulsification energy was significantly lower in the phaco‐chop group (mean 782 J ± 446 [SD]) than in the divide and conquer group (mean 3264 ± 1218 J) (P < .00001). No complications occurred in either group. Conclusion: The phaco‐chop technique provided safe, effective cataract extraction with significantly less energy than that required for divide and conquer phacoemulsification.

Prospective evaluation of topical versus retrobulbar anesthesia: A converting surgeon's experience

Purpose: To evaluate and compare the efficacy of topical versus retrobulbar anesthesia for cataract surgery performed by a surgeon newly converting to the topical technique. Setting: Department of Ophthalmology, Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. Methods: Ninety patients were prospectively assigned by permuted block restricted randomization to receive topical (Group 1; n = 45) or retrobulbar (Group 2; n = 45) anesthesia. Group 1 received topical bupivacaine 0.75% and intravenous midazolam and fentanyl for anesthesia. Group 2 received intravenous methohexital followed by retrobulbar block with an equal mixture of lidocaine 2% and bupivacaine 0.75% plus hyaluronidase 150 units. A visual pain analog scale was used to assess the degree of pain during anesthesia administration and surgery and postoperatively. The degree to which eye movement, touch, and light caused patient discomfort was assessed. Intraoperative conditions and complications were recorded. Results: Intraoperative operating conditions were significantly better in Group 2 (P < .05). There was a small but statistically significant difference in the degree of discomfort during anesthesia administration and surgery (P < .05). There was no difference in postoperative discomfort. Chemosis, subconjunctival hemorrhage, and eyelid hemorrhage occurred only in Group 2, in which there was one retrobulbar hemorrhage. Although eyelid squeezing and ocular motility were present more frequently in Group 1, neither was a problem to the surgeon. Conclusion: Cataract surgery was safely performed by a surgeon converting to topical anesthesia. After a distinct learning curve, the procedure was performed with minimal patient discomfort. Surgical training and patient preparation are the key to safe use of topical anesthesia.

Cataract surgery complications in 1 year at an academic institution

PURPOSE To delineate all complication rates of cataract surgery and define normative rates, trends, and outliers as part of continuous quality management. SETTING John A. Moran Eye Center, University of Utah Health Sciences Center, Salt Lake City, Utah, USA. METHODS All cataract surgeries done at the John A. Moran Eye Center from July 1, 1996, to June 30, 1997 (1 complete academic year) were reviewed for intraoperative complications using operative reports. Cases with documented preoperative zonular dehiscence, traumatic capsule breakage, previous vitreous in the anterior chamber, or an accompanying major secondary procedure (e.g., trabeculectomy, corneal transplantation) were eliminated from the study. Over this year, 1729 cataract surgeries were performed by 12 attending physicians, 3 fellows, and 4 residents. Cases of cataract removal with intraocular lens implantation ranged from 18 to 510 per surgeon. RESULTS There were 44 cases (2.54%) of posterior capsule rupture, with 29 (1.68%) requiring vitrectomy. Most capsule breakages occurred during phacoemulsification. The Student t test showed no statistically significant difference in the incidence of capsule breakage among surgeons (incidence from 0% to 6.25%). All cases were started as phacoemulsification, with 6 conversions (0.35%) to planned extracapsular cataract extraction. CONCLUSIONS In evaluating continuous quality management, no outliers were found within our center. Phacoemulsification was the part of cataract surgery most likely to cause posterior capsule rupture.