Daniel Waren

Causes and correction of dissatisfaction after implantation of presbyopia-correcting intraocular lenses

Purpose The purpose of this study was to assess the causes and possible solutions for patient dissatisfaction after the implantation of presbyopia-correcting intraocular lenses (IOLs). Methods This study was a retrospective review of clinical records. All patients who were seen between January 2009 and December 2013 whose primary reason for consultation was dissatisfaction with visual performance after presbyopia-correcting IOL implantation were included in the study. A single treating physician, who determined the most probable cause of dissatisfaction, decided which interventions to pursue following the initial consultation. Results Data from 74 eyes of 49 patients were analyzed. The most common cause for complaint was blurry or foggy vision both for distance and near (68%). Complaints were most frequently attributed to residual refractive error (57%) and dry eye (35%). The most common interventions pursued were treatment of refractive error with glasses or contact lenses (46%) and treatment for dry eye (24%). Corneal laser vision correction was done in 8% of eyes; 7% required an IOL exchange. After the interventions, 45% of patients had completed resolution of symptoms, 23% of patients were partially satisfied with the results, and 32% remained completely dissatisfied with the final results. Conclusion The most identifiable causes of dissatisfaction after presbyopia-correcting IOL implantation are residual refractive error and dry eye. Most patients can be managed with conservative treatment, though a significant number of patients remained unsatisfied despite multiple measures.

Anterior capsulotomy outcomes: A comparison between two femtosecond laser cataract surgery platforms

PURPOSE To compare capsulotomy outcomes between two femtosecond laser platforms for cataract surgery. METHODS This retrospective case series included 205 eyes of 162 consecutive patients (75 male and 87 female) aged 68.32 ± 10.27 years (range: 38 to 92 years) who underwent femtosecond laser-assisted cataract surgery (FLACS) using either the LenSx (Alcon Laboratories, Inc., Fort Worth, TX) or the Catalys (Abbott Medical Optics, Abbott Park, IL) laser platform. Intraoperative assessment of the capsulotomy was performed and graded as one of the following four types: complete treatment pattern (type 1), microadhesions (type 2), incomplete treatment pattern (type 3), and complete pattern but not continuous (type 4). RESULTS Ninety-seven eyes underwent FLACS using the LenSx platform and 108 eyes using the Catalys platform. Ninety-four capsulotomies in the LenSx group were graded as type 1 (96.91%), and three were graded as type 2 (3.09%); all capsulotomies in the Catalys group were graded as type 1 (100%). There was no statistically significant difference between the LenSx and Catalys groups (P > .05). No intraoperative complications (specifically, no posterior capsular extension or vitreous loss) were noticed in any of the eyes included in the study. CONCLUSIONS The LenSx and Catalys laser platforms demonstrate similar capsulotomy outcomes. The microadhesions that were demonstrated in three cases in the LenSx group did not lead to intraoperative or postoperative complications.

Effects of Short-term Preoperative Topical Ketorolac on Pupil Diameter in Eyes Undergoing Femtosecond Laser–Assisted Capsulotomy

PURPOSE To assess pupil diameter before and after femtosecond laser-assisted capsulotomy in patients who were pretreated with a short-term topical nonsteroidal anti-inflammatory drug (NSAID) (ketorolac) versus those without pretreatment. METHODS This prospective, randomized, observational case series included consecutive patients scheduled to undergo cataract extraction using the Catalys femtosecond laser platform (Abbott Medical Optics, Inc., Santa Ana, CA) to perform only capsulotomies. The same protocol for preoperative medical mydriasis was used for all patients, whereas pupil diameter was assessed using a surgical ruler immediately before and 3 minutes after femtosecond laser-assisted capsulotomy. The patients were divided into two groups: one received short-term topical ketorolac preoperatively and the other did not receive NSAID pretreatment (control). RESULTS A total of 42 eyes of 42 patients (1 eye per patient) were included in the study. Mean pupillary miosis was 0.79 ± 1.08 and 1.57 ± 1.19 mm for the ketorolac and control groups, respectively. There was a statistically significant decrease in pupil diameter for both groups individually (P < .05). There was also a statistically significant difference between the two groups (P < .05) with the induced miosis in the eyes that did not receive topical NSAIDs prior to cataract extraction being twofold greater when compared with the miosis of the eyes that received ketorolac pretreatment. CONCLUSIONS Short-term topical use of ketorolac prior to femtosecond laser-assisted cataract surgery seems to induce significantly less pupillary miosis in comparison to eyes that did not receive NSAID pretreatment. NSAID use is advised prior to femtosecond laser-assisted cataract surgery to minimize pupil miosis-related surgical difficulties or complications during cataract extraction. [J Refract Surg. 2017;33(4):230-234.].

Comparison of corneal endothelial cell loss between two femtosecond laser platforms and standard phacoemulsification

PURPOSE To analyze and compare the changes in endothelial cell density (ECD) and cumulative dissipated energy (CDE) in patients having cataract surgery with two different femtosecond laser platforms and standard phacoemulsification. METHODS This prospective non-randomized comparative study included patients scheduled to undergo cataract extraction using femtosecond laser-assisted cataract surgery (FLACS) (60 eyes) or standard phacoemulsification (60 eyes) between September 2013 and March 2016. The main outcome measures were CDE and percentage of endothelial cell loss. Comparative analysis of CDE and percentage of endothelial cell loss between the two phacoemulsification platforms with respect to conventional and FLACS techniques was performed. RESULTS The CDE and the 1-month mean percentage of endothelial cell loss was 6.11 ± 3.52 and 9.06% ± 8.77% in the standard phacoemulsification group and 4.65 ± 3.61 and 6.00% ± 8.02% in the FLACS group, respectively (P = .039). In the subgroup analysis based on cataract grading, the CDE was significantly less in the FLACS group compared to the standard phacoemulsification group in both the early and advanced cataract group (P = .002). The percent decrease in endothelial cell loss was statistically lower in the FLACS group when compared to the standard phacoemulsification group in the advanced cataract subgroup (P = .02). CONCLUSIONS FLACS pretreatment resulted in a decrease in CDE and less endothelial cell loss when compared to standard phacoemulsification. The decrease in endothelial cell loss was more prominent in the denser cataract group; thus, FLACS may be most beneficial in those cases. There was no significant difference in results between the two laser platforms. [J Refract Surg. 2017;33(10):708-712.].

Endothelial Cell Loss in Diabetic and Nondiabetic Eyes After Cataract Surgery

Purpose: To assess and compare the changes in endothelial cell density in diabetic and nondiabetic patients after routine phacoemulsification cataract surgery. Setting: Bascom Palmer Eye Institute, Miller School of Medicine, Miami, FL, USA. Design: Retrospective nonrandomized cohort study. Methods: This retrospective study included diabetic and nondiabetic patients who underwent phacoemulsification by a single surgeon (K.D.) between September 2013 and March 2016. The main outcome measures were cumulative dissipated energy (CDE) and percentage of endothelial cell loss (ECL). Comparative analysis of CDE and percentage of ECL between the 2 patient groups was performed and then repeated based on the degree of diabetic control (hemoglobin A1c). Results: The study included 66 eyes of 55 diabetic and 67 eyes of 65 nondiabetic patients. Mean CDE was 7.8 ± 7.1 joules, and the 1-month mean percentage of ECL was 15% ± 14% in the diabetic group. Mean CDE was 6.6 ± 3.8 joules, and the 1-month mean percentage of ECL was 11% ± 11% in the nondiabetic group. The CDE was not significantly different between both groups. The percent decrease in ECL was statistically higher in the diabetic group than in the nondiabetic group (P = 0.03). The degree of diabetic control, based on hemoglobin A1c greater or less than 7, did not yield a significant difference in CDE or percentage ECL. Conclusions: Diabetic patients demonstrated increased ECL when compared with nondiabetic patients after cataract surgery. However, the role of diabetic control in reducing ECL remains unclear.

The Effect of LASIK on Timing of Cataract Surgery.

PURPOSE To compare the age at the time of cataract surgery in patients who have undergone microkeratome-assisted LASIK versus individuals matched for axial length, cataract grade, and visual acuity with no history of refractive surgery. METHODS Retrospective chart review of patients who underwent cataract extraction between September 2013 and March 2015 at the Bascom Palmer Eye Institute. Patients had a history of either microkeratome-assisted LASIK or no prior ocular surgery. Corrected distance visual acuity (CDVA) before and after cataract extraction, uncorrected distance visual acuity (UDVA) before cataract extraction, gender, axial length, and cataract grade were assessed, along with age at the time of LASIK, age at the time of cataract extraction, and the time lapse between LASIK and cataract extraction. RESULTS Fifty eyes of 38 patients were included in the LASIK group and 155 eyes of 136 patients were included in the control group. There was no significant difference between these groups with respect to gender (P = .87), CDVA before cataract extraction (P = .11), UDVA before cataract extraction (P = .09), axial length (P = .67), and cataract grade (P = .46). Mean age at the time of cataract extraction for patients in the LASIK group and control group were 64 ± 7 and 73 ± 8 years, respectively (P < .005). Negative correlations were found between age at time of cataract extraction and axial length in the LASIK and control groups (r = -0.18, P = .20 vs r = -0.36, P =. 01, respectively). CONCLUSIONS Microkeratome-assisted LASIK seems to be correlated with earlier cataract extraction. Patients with a history of microkeratome-assisted LASIK under-went cataract surgery a decade sooner than patients with similar demographic and ocular characteristics. [J Refract Surg. 2016;32(5):306-310.].

The Effect of NSAID Pretreatment on Aqueous Humor Prostaglandin E2 Concentration in Eyes Undergoing Femtosecond Laser-Assisted Capsulotomy

Purpose To assess aqueous humor concentration of prostaglandin E2 (PGE2) after capsulotomy creation using a femtosecond laser (FLAC) in patients pretreated with short-term topical ketorolac versus patients without pretreatment. Methods This prospective study comprised consecutive patients scheduled to undergo cataract surgery using a femtosecond laser platform to perform only capsulotomies. An identical protocol for preoperative mydriasis was used for all the eyes included in the study, while aqueous humor was extracted from the anterior chamber of all patients immediately after the initial side port incision. ELISA was performed to quantify aqueous humor PGE2. The patients were divided into 2 groups; in group 1, the patients received short-term topical ketorolac preoperatively, while the patients in group 2 did not receive NSAID pretreatment. Results Twenty eyes of 20 patients were included in the study (10 eyes in each group). Mean concentration of aqueous humor PGE2 after FLAC was 392.16 ± 162.00 pg/ml and 622.63 ± 331.84 pg/ml for groups 1 and 2, respectively. A statistically significant difference in aqueous humor PGE2 concentration between the two groups (p < 0.05) was demonstrated, with the eyes that received ketorolac pretreatment demonstrating a lower concentration of PGE2. Conclusion Short-term topical use of ketorolac prior to FLAC seems to prevent excessive release of PGE2 in the anterior chamber of the eyes that received NSAID pretreatment when compared to the eyes that did not receive NSAIDs preoperatively.

Comparison of phacoemulsification parameters between manual and femtosecond laser-assisted cataract surgery

OBJECTIVE To compare the nucleus removal time (NRT) and cumulative dissipated energy (CDE) outcomes of traditional phacoemulsification and femtosecond laser-assisted cataract surgery (FLACS) performed by cornea attendings and fellows. DESIGN Prospective nonrandomized comparative study. PARTICIPANTS A total of 410 eyes of 410 patients. METHODS Nucleus removal time and CDE were recorded from patients who underwent cataract surgery using either FLACS (Catalys, LenSx, or Victus) or traditional phacoemulsification technique performed by 3 cornea attendings and 4 cornea fellows. One-way analysis of variance with Bonferroni post hoc tests and unpaired t tests were used to determine the differences between groups. RESULTS There was no statistically significant difference in cataract grade between groups. NRT was significantly lower only when using the Catalys system compared with the LenSx and Victus platforms and the traditional surgery, in both the attending group (p = 0.006, p = 0.002, p < 0.000, respectively) and the fellow group (p = 0.049, p = 0.038, p = 0.011, respectively). With respect to CDE, there was no significant difference when using the laser systems compared with the traditional surgery in both attending and fellow groups (p > 0.05). NRT and CDE were significantly higher in the fellow group (NRT = 269.10 ± 117.67, CDE = 7.30 ± 4.83) compared with the attending group (NRT = 218.87 ± 109.67, CDE = 5.76 ± 3.66) in traditional cases; however, in FLACS cases, there was no significant difference in NRT and CDE between the fellow group and the attending group. CONCLUSIONS Inexperienced surgeons seem to require more time and use more ultrasound energy during traditional phacoemulsification when compared with experienced surgeons. The use of FLACS seems to significantly improve the NRT of experienced and inexperienced surgeons.

Ocular Surface Parameters Predicting Patient Satisfaction After a Single Vectored Thermal Pulsation Procedure for Management of Symptomatic Meibomian Gland Dysfunction

Purpose: To evaluate the ocular surface parameters that could predict patient satisfaction after single application of vectored thermal pulsation (VTP). Methods: This is a retrospective interventional case series; it included consecutive patients who underwent bilateral VTP for management of symptomatic meibomian gland dysfunction (MGD). Patients received a full ocular surface evaluation. The outcome was patient subjective improvement during the first 3–4 months after 3 follow-up visits. For analysis, patients were divided into responders and nonresponders. Results: Forty-nine patients received bilateral treatment, with 32 patients (65.3%) reporting subjective improvement after treatment. Responders had lower tear production (6.9 ± 5.9 mm vs. 13.6 ± 6.8 mm; t test P = 0.002), a higher corneal staining score (4.4 ± 5.0 vs. 0.43 ± 1.1; t test P = 0.003), and a higher conjunctival staining score (3.1 ± 2.4 vs. 1.5 ± 1.8; t test P = 0.023) and presented with a higher tear osmolarity (319.7 ± 23.22 mOsm/L vs. 306.9 ± 9.0 mOsm/L; t test P = 0.029) than the nonresponder group. We found no association between patient age, tear breakup time, Ocular Surface Disease Index score, tear lipid layer thickness, or MGD grading score, as measured before intervention, with patient-perceived success of treatment. No complications to treatment were noted, and no patient reported worsening of preexisting symptoms on follow-up. Conclusions: VTP can be effective in treating dry eye symptoms of patients with MGD. Our data show that objective findings of dry eye, as evidenced by lower tear production, higher corneal and conjunctival staining scores, and higher osmolarity, tend to be markers present in the group of patients responding positively to VTP.