Brian Little

Complications of sulcus placement of single-piece acrylic intraocular lenses Recommendations for backup IOL implantation following posterior capsule rupture

PURPOSE: To describe complications arising from sulcus placement of single‐piece acrylic (SPA) intraocular lenses (IOLs), evaluate IOL options for eyes that lack adequate capsule support, and examine the appropriateness of various IOL designs for sulcus placement. SETTING: University and private anterior segment surgery practices. METHODS: Patients referred for complications of SPA IOLs in the ciliary sulcus from 2006 and 2008 were identified. Demographic information, examination findings, and complications of the initial surgery were recorded. Details of surgical interventions and the most recent corrected distance visual acuity (CDVA) were noted. A thorough review of the literature was undertaken to analyze options for IOL placement. RESULTS: Complications of sulcus SPA IOLs included pigment dispersion, iris transillumination defects, dysphotopsia, elevated intraocular pressure, intraocular hemorrhage, and cystoid macular edema. Two patients in the series of 30 patients experienced 1 complication; 8 experienced 2 complications; 13 experienced 3 complications; 4 experienced 4 complications; and 2 experienced 5 complications. Twenty‐eight eyes (93%) required surgical intervention; IOL exchange was performed in 25 (83%). Postoperatively, the mean CDVA improved, with most eyes attaining 20/20. CONCLUSIONS: Intraocular lenses designed solely for the capsular bag should not be placed in the ciliary sulcus. Backup IOLs in appropriate powers, sizes, and designs should be available for every cataract procedure. The development, investigation, and supply of IOLs specifically designed for placement in eyes that lack adequate capsule support represent clinically important endeavors for ophthalmology and the ophthalmic industry.

Prevention, diagnosis, and management of acute postoperative bacterial endophthalmitis

&NA; This distillation of the peer‐reviewed scientific literature on infection after cataract surgery summarizes background material on epidemiology, etiology, and pathogenesis, describes the roles of surgical technique and antibiotic prophylaxis in prevention, and discusses diagnostic and therapeutic interventions in cases of suspected endophthalmitis. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Multifocal intraocular lenses: relative indications and contraindications for implantation.

UNLABELLED This article presents an extensive overview of best clinical practice pertaining to selection and use of multifocal intraocular lenses (IOLs) currently available in the United States. Relevant preoperative diagnostic evaluations, patient selection criteria, counseling, and managing expectations are reviewed, as well as how to approach patients with underlying ocular intricacies or challenges and best practices for intraoperative challenges during planned implantation of a multifocal IOL. Managing the unhappy multifocal IOL patient if implantation has been performed is also addressed. FINANCIAL DISCLOSURE No author has a financial or proprietary interest in any material or method mentioned.

Same-day versus first-day review of intraocular pressure after uneventful phacoemulsification

Purpose: To compare the incidence and the spectrum of postoperative complications detected when the intraocular pressure (IOP) is reviewed 4 to 6 hours or the day after uneventful phacoemulsification cataract extraction and intraocular lens (IOL) implantation. Setting: Royal Free Hospital, London, United Kingdom. Methods: The study cohort consisted of 141 patients who had uneventful phacoemulsification and IOL implantation under regional (peribulbar/topical) or general anesthesia. Postoperative evaluation of the patients was performed by an ophthalmologist using a standard form at 4 to 6 hours or 24 hours. Results: The mean IOP at 4 to 6 hours and 24 hours was 22.85 mm Hg ± 9.56 (SD) and 19.44 ± 7.04 mm Hg, respectively. The IOP was more likely to be greater than 30 mm Hg when measured on the same day, resulting in a significantly higher intervention rate than on the first day (P = .037). The best corrected visual acuity was significantly better at 24 hours than at the same‐day review (P < .001). There was no significant difference in the extent of anterior chamber activity, patient comfort, or state of the wound between the same‐ or next‐day follow‐up. All patients attended a follow‐up appointment 3 weeks after surgery, had an IOP of 21 mm Hg or less, and were subsequently discharged. Conclusions: The results indicate that moderate IOP spikes (<40 mm Hg) can be left untreated if they are not associated with corneal edema or patient discomfort as they decline spontaneously. Before they are discharged, patients with compromised optic discs or predisposed to retinal or optic nerve pathology should be carefully evaluated the day after surgery to treat IOP elevations.

Anterior segment slitlamp photography using the iPhone.

(17.9%, 7/39) or incision (5.1%, 2/39). Most respondents reported no serious ocular hemorrhagic events from continuing antithrombotic agents (92.3%, 36/39) or serious thrombotic events from discontinuing them (94.4%, 34/36). Most (75.0%, 30/40) reported a greater concern about a perioperative thromboembolic event from discontinuing antithrombotic agents than about a perioperative ocular hemorrhage from continuing them. These results indicate that in most VHA hospitals, oral antithrombotic agents are not discontinued prior to cataract surgery. This finding is similar to the finding in a recent report from the Canadian Society of Cataract and Refractive Surgery 2 that most members (74.4%) did not discontinue antithrombotic therapy before cataract surgery. The rationale for this practice pattern appears to be a greater concern about the systemic risks of discontinuing antithrombotic agents than the risks of perioperative hemorrhagic ocular complications from continuing them. This rationale is supported by reports that ocular hemorrhages in cataract surgery patients on antithrombotic agents generally do not affect visual outcomes. 4,5,6 The weaknesses of a survey-based study have been described 3 and include limitations in generalizability due to distinct setting (most respondents worked in teaching hospitals rather than ambulatory surgery centers) and patient population (U.S. veterans) and potential bias due to a response rate of 45%. This study provides more insight into how cataract surgeons in the VHA currently manage patients on antithrombotic agents. Further research is needed to determine whether differences in management of antithrombotic therapy during cataract surgery are associated with distinct patient outcomes.

Intraocular lens scaffold to facilitate intraocular lens exchange

&NA; We describe a technique of intraocular lens (IOL) exchange in patients with post‐refractive surgery IOL power error or patients who are dissatisfied with the optical performance of the IOL. The technique involves the presence of 2 IOLs in the eye: the offending IOL, which is manipulated out of the capsular bag into the anterior chamber, and the corrective IOL, which is inserted into the bag. The anteriorly elevated IOL is transected with the IOL cutting scissors, while the corrective IOL acts as a scaffold for the posterior capsule. The technique provides continuous distension of the bag with the IOL, which prevents damage to the posterior capsule and acts as a barrier to vitreous prolapse in cases of an open posterior capsule; it also prevents slippage of the optic during transection of the IOL being removed. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

August consultation #6.

7 o’clock positions. This would allow the haptics to span the sulcus in the region with no apparent zonular problems and no history of anterior capsule tears. With an intact capsular bag and good zonular support, I would expect good long-term stability with simple sulcus fixation. If the IOL were indeed clinically stable postoperatively, I would then consider an Nd:YAG laser capsulotomy of the fibrotic capsule scar. If the IOL cannot be released from the capsular bag, if there is significant loss of zonular stability, or if vitreous prolapses, appropriate anterior vitrectomy, secondary haptic fixation, or an IOL exchange may be indicated.