Danny G.P. Mathysen

Clinical outcomes of cataract surgery after bag-in-the-lens intraocular lens implantation following ISO standard 11979-7:2006

PURPOSE: To assess the clinical outcomes of bag‐in‐the‐lens intraocular lens (BIL IOL) implantation following the International Organization for Standardization (ISO) 11979‐7:2006 in pediatric eyes and eyes with ocular comorbidities. SETTING: Antwerp University Hospital, Department of Ophthalmology, Antwerp, Belgium. DESIGN: Cohort study. METHODS: This cohort included the first series of patients having IOL implantation using the bag‐in‐the‐lens technique. Surgeries were performed between December 1999 and September 2006. In addition to IOL implantation, the technique comprised creation of a primary posterior continuous curvilinear capsulorhexis (PCCC) equal in size to the anterior capsulorhexis. RESULTS: The study enrolled 807 eyes of 547 patients; 326 of the eyes (40.40%) had ocular comorbidity. In the 481 eyes without ocular comorbidity, the mean decimal corrected distance visual acuity was 0.52 ± 0.24 (SD) (0.276 ± 0.206 logMAR) preoperatively and 0.94 ± 0.18 (−0.012 ± 0.053 logMAR) postoperatively. The mean postoperative achieved spherical equivalent was 0.48 ± 0.83 diopter (D) and the mean targeted refraction, −0.24 ± 0.71 D. The A‐constant was modified from 118.4 to 118.04. Posterior capsule opacification (PCO) did not occur in any adult eye during the follow‐up. Retinal detachment after IOL implantation occurred in 10 eyes (1.24%). In 19 eyes, the iris was captured by the IOL haptics postoperatively. Hypopyon occurred in 3 patients and toxic anterior segment syndrome in 1 patient. CONCLUSION: The BIL IOL met the ISO criteria; that is, primary PCCC was safe in healthy eyes and in eyes with ocular comorbidities and no eye developed PCO over a mean follow‐up of 26.1 ± 21.3 months. Financial Disclosure: Drs. Gobin, Mathysen, Van Looveren, and De Groot have no financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes.

Influence of contact lens wear on the results of ultraviolet A/riboflavin cross-linking for progressive keratoconus

Aims To report on the influence of rigid gas permeable contact lens (CL) wear on the results of ultraviolet A/riboflavin cross-linking (CXL) for stabilisation of progressive keratoconus. Methods Prospective non-comparative study of 15 eyes without CL and 12 eyes fitted with CL from 1 to 10 weeks post-CXL. None of the patients had been wearing CL before CXL. The effect of the CXL treatment was measured by the change from the baseline of best spectacle corrected visual acuity (BSCVA), refractive sphere and cylinder, maximal keratometry value (K max), simulated keratometry steep, flat, astigmatism, refractive power (RP) steep, flat and astigmatism, I-S value on EyeSys (EyeSys Vision Inc, Houston, Texas, USA) and K max on Pentacam (Oculus Optikgeräte, Wetzlar, Germany). The results of these measurements are reported pre-CXL and at 6-month intervals up to 18 months post-CXL. Results In the eyes without CL, none of the study parameters showed a significant change from baseline. Only in the group of eyes fitted with CL post-CXL, several parameters showed a significant improvement: I-S value and K max on EyeSys (all time points), RP steep and simulated astigmatism (6 and 12 months) and RP flat (12 months). Conclusion CL can be a confounding factor in interpreting the results of CXL: lens wear itself leads to improved topographic parameters.

Clinical results after spherotoric intraocular lens implantation using the bag-in-the-lens technique

PURPOSE: To evaluate the clinical results after implantation of a spherotoric intraocular lens (IOL) using the bag‐in‐the‐lens (BIL) technique. SETTING: Antwerp University Hospital, Department of Ophthalmology, Antwerp, Belgium. DESIGN: Evidence‐based manuscript. METHODS: Consecutive eyes with cataract and corneal astigmatism had implantation of a spherotoric BIL intraocular lens (IOL). The IOL was centered based on the patient’s pupillary entrance using Purkinje reflexes of the surgical microscope light. RESULTS: The study enrolled 52 eyes of 35 patients (23 women) with corneal astigmatism ranging from 0.90 to 6.19 diopters (D). The toric power was between 1.00 D and 8.00 D. One‐third of eyes had an additional ocular comorbidity (including amblyopia) that could influence the clinical outcomes; 5.2% had an irregular astigmatism up to 15 degrees. Twelve eyes had high myopia (axial length [AL] >26 mm) and 5 eyes, high hyperopia (AL <21 mm). The mean preoperative corrected distance visual acuity was 0.58 ± 0.25 (SD). Postoperatively, the uncorrected distance visual acuity (UDVA) was 0.5 or better in 92% of eyes, the mean UDVA was 0.85 ± 0.21 D, the mean magnitude of error was 0.05 ± 0.49 D, and the mean angle of error was 0.29 ± 0.89 degree. Astigmatism correction was successful in 82% of eyes. CONCLUSION: Spherotoric BIL IOL implantation yielded outcomes similar to those with other spherotoric IOLs, even in eyes with ocular comorbidity or irregular astigmatism up to 15 degrees. Financial Disclosure: Drs. Gobin and Van Looveren and Mr. Mathysen have no financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes.

Evaluation of UVA Cytotoxicity for Human Endothelium in an Ex Vivo Corneal Cross-linking Experimental Setting

PURPOSE To evaluate endothelial cytotoxicity after exposure of human corneas to ultraviolet-A (UVA) (λ = 365 nm; 5.4 J/cm(2)) in an experimental ex vivo corneal cross-linking setting. METHODS Sixteen pairs of human donor corneas were cut into two pieces. One piece of each cornea was treated with 0.025% riboflavin solution prior to UVA irradiation (5 minutes; 18 mW/cm(2)), whereas the other piece was not irradiated but treated with riboflavin (right eye) or preservation medium (left eye). By irradiating from the endothelial side, the UVA dosage applied to endothelial cells exceeded at least eight times the cytotoxic threshold established in animal models (0.65 J/cm(2)). Endothelial cell counts were performed by two independent investigators after storage (4 to 5 days at 31 °C) and staining (trypan blue, alizarin red). Normality (Q-Q plot; Shapiro-Wilk test) and equivalence (mixed-effects modeling with a 10% equivalence threshold) of the endothelial cell counts of the different groups were evaluated. RESULTS Equivalence of mean endothelial cell density between both groups was observed: 2,237 ± 208 cells/mm(2) in UVA-irradiated pieces and 2,290 ± 281 cells/mm(2) in control pieces (mean difference of 53 ± 240 cells/mm(2) between both groups). CONCLUSIONS Despite direct irradiation of human donor endothelium using the clinical dosage for cross-linking, equivalence in endothelial cell counts was observed between irradiated tissues and controls. Ex vivo human corneal endothelial cells seem to be far more resistant to riboflavin-enhanced UVA irradiation than previously estimated by animal experiments.

Incidence of rhegmatogenous retinal detachment after bag-in-the-lens intraocular lens implantation.

Purpose To determine the incidence of rhegmatogenous retinal detachment (RRD) and associated risk factors after phacoemulsification and bag‐in‐the‐lens intraocular lens (IOL) implantation. Setting Antwerp University Hospital, Department of Ophthalmology, Antwerp, Belgium. Design Prospective cohort study. Methods All consecutive bag‐in‐the‐lens IOL implantations performed between January 2001 and December 2007 were included, with the exception of combined procedures and IOL exchanges. The retinal detachment (RD) incidence was studied in the total cohort, in a subgroup of patients with 1 to 5 years of follow‐up, and finally in the group remaining after exclusion of all risk factors except gender. Results RD after bag‐in‐the‐lens IOL implantation in 1323 eyes with an average follow‐up of 44.75 months (range 0 to 152 months) was found in 19 eyes (1.44%). The 1‐year RD incidence was 0.49% (5 RD cases in 1024 eyes) (0.00% in patients without risk factors). The 2‐year cumulative RD incidence was 0.84% (9 RD cases in 931 eyes; 0.15% without risk factors). Four clinically significant risk factors were confirmed: male gender, young age at time of surgery (<60 years), axial myopia (axial length ≥25 mm), and history of contralateral RD in the total cohort. Conclusion The RRD incidence following bag‐in‐the‐lens IOL implantation was comparable to that seen after lens‐in‐the‐bag (LIB) implantation. The wide variation in study design in the literature precludes direct comparison, so there is a need for standardization in evaluating RRD incidence after cataract surgery. Future prospective studies should consider patients with and without risk factors (except gender) separately. Financial Disclosure Prof. dr. M.J. Tassignon has intellectual property rights to the bag‐in‐the‐lens intraocular lens (U.S. patent 6 027 531; EU patent 009406794; PCT/120268), which is licensed to Morcher GmbH, Stuttgart, Germany.

To Study and Determine the Role of Anterior Segment Optical Coherence Tomography and Ultrasound Biomicroscopy in Corneal and Conjunctival Tumors

Purpose. To analyze and describe corneal and conjunctival tumor thickness and internal characteristics and extension in depth and size and shape measured by two noninvasive techniques, anterior segment optical coherence tomography (AS-OCT) and ultrasound biomicroscopy (UBM). Design. Systematic review. Methods. This systematic review is based on a comprehensive search of 4 databases (Medline, Embase, Web of Science, and Cochrane Library). Articles published between January 1, 1999, and December 31, 2015, were included. We searched for articles using the following search terms in various combinations: “optical coherence tomography”, “ultrasound biomicroscopy”, “corneal neoplasm”, “conjunctival neoplasm”, “eye”, “tumor” and “anterior segment tumors”. Inclusion criteria were as follows: UBM and/or AS-OCT was used; the study included corneal or conjunctival tumors; and the article was published in English, French, Dutch, or German. Results. There were 14 sources selected. Discussion. Several studies on the quality of AS-OCT and UBM show that these imaging techniques provide useful information about the internal features, extension, size, and shape of tumors. Yet there is no enough evidence on the advantages and disadvantages of UBM and AS-OCT in certain tumor types. Conclusion. More comparative studies are needed to investigate which imaging technique is most suitable for a certain tumor type.

Procedural aspects of the organization of the comprehensive European Board of Ophthalmology Diploma examination.

The comprehensive European Board of Ophthalmology Diploma (EBOD) examination is one of 38 European medical specialty examinations. This review aims at disclosing the specific procedures and content of the EBOD examination. It is a descriptive study summarizing the present organization of the EBOD examination. It is the 3rd largest European postgraduate medical assessment after anaesthesiology and cardiology. The master language is English for the Part 1 written test (knowledge test with 52 modified type X multiple-choice questions) (in the past the written test was also available in French and German). Ophthalmology training of minimum 4 years in a full or associated European Union of Medical Specialists (UEMS) member state is a prerequisite. Problem-solving skills are tested in the Part 2 oral assessment, which is a viva of 4 subjects conducted in English with support for native language whenever feasible. The comprehensive EBOD examination is one of the leading examinations organized by UEMS European Boards or Specialist Sections from the point of number of examinees, item banking, and item contents.

Influence of the vitreolenticular interface in pediatric cataract surgery

PURPOSE To report the status of Berger space in pediatric cataract cases and the influence of anterior vitreolenticular interface dysgenesis during primary posterior continuous curvilinear capsulorhexis (PCCC). SETTING Department of Ophthalmology, Antwerp University Hospital, Edegem, Belgium. DESIGN Prospective case series. METHODS The study comprised consecutive pediatric cataract cases planned for bag-in-the-lens intraocular lens (BIL IOL) implantation. A video-based analysis of the surgical interventions included the type of crystalline lens opacification, presence of a posterior capsule plaque (PCP), presence of anterior vitreolenticular interface dysgenesis, complications during primary PCCC, integrity of the anterior hyaloid membrane, need for anterior vitrectomy, and feasibility of BIL IOL implantation. RESULTS Abnormalities in Berger space were observed in 35 of the 64 pediatric cataract cases. Anterior vitreolenticular interface dysgenesis was most often found in cases with persistent fetal vasculature (PFV) and those with posterior cataract. Anterior vitreolenticular interface dysgenesis was diagnosed significantly more often in eyes with unilateral cataract and those with PCP. In pediatric cataract cases presenting with PCP and anterior vitreolenticular interface dysgenesis, the primary PCCC procedure was surgically more demanding, often resulting in detectable breaks in the anterior hyaloid membrane (58.6%) and sometimes necessitating an unplanned anterior vitrectomy (13.8%). Bag-in-the-lens IOL implantation was feasible in all except 1 eye with PFV, which was left aphakic. CONCLUSIONS Primary vitreolenticular interface abnormalities are often encountered during pediatric cataract surgeries, especially when confronted with PCP in a unilateral cataract. The presence of anterior vitreolenticular interface dysgenesis may complicate a primary PCCC procedure, resulting in an unplanned anterior vitrectomy in some cases.