Gianluca Carifi

Cataract surgery in small adult eyes

Aim To evaluate the clinical outcomes of phacoemulsification cataract surgery in microphthalmos. Methods Retrospective consecutive case series of eyes with axial length <20.9 mm, and requiring a high intraocular lens (IOL) power (≥30 or ≥35 dioptres for anterior or posterior chamber fixation, respectively), with no history of previous ocular surgery, and undergoing planned phacoemulsification cataract surgery with IOL implantation at Moorfields Eye Hospital was investigated to observe the incidence of intraoperative and postoperative complications. Results During a 5-year study period, 47 of 22 093 eyes were treated in two locations (0.21%). Thirty-nine eyes met the study inclusion criteria. No serious intraoperative adverse events were recorded. Severe postoperative complications (retinal detachment and chronic postoperative uveitis) occurred in two cases. The postoperative corrected distance visual acuity (CDVA) was logMAR 0.30 or better in 24 eyes (62%), and only three eyes obtained worse vision. The overall ocular comorbitidy rate was 53%; 10 microphthalmic eyes (26%) presented with associated congenital or hereditary pathology, and had worse visual outcomes (p<0.0001). Conclusions Microphthalmic eyes requiring high IOL power are rare, and their presence is often associated with other ocular congenital or acquired disorders. Overall, the clinical outcomes were satisfactory and the surgical procedure affected by a low complication rate.

Intravitreal bevacizumab for pseudophakic cystoid macular edema.

Fard et al (1) evaluated a homogeneous group of patients with moderate to severe diabetic retinopathy and absent past or present maculopathy. Their study confirmed that there is pseudophakic macular thickening on optical coherence tomography (OCT) examination associated with mild visual impairment in some of the eyes with diabetic retinopathy due to cystoid macular edema (CME). Unfortunately, they did not produce data regarding the incidence of pseudophakic CME in their 2 groups. The previously reported incidence ranges between 31% and 22% in a more recent series (2, 3). Such information is important, and it remains to be demonstrated whether the bevacizumab treatment retains its statistical superiority in the short term compared to the simple observation when the number of affected eyes, rather than the mean macular thickness, is used as a parameter. There is also lack of information regarding the postsurgical domiciliary topical treatment. Given that the authors concluded by pointing out how the bevacizumab treatment reduces the incidence of pseudophakic CME, it has to be highlighted that they only found a mean difference of 2 lines in corrected distance visual acuity (CDVA) between the groups in the short term, gradually fading. Relevant considerations are that a difference of 3 lines or more is clinically evident, as it corresponds to a doubling of the minimal angle of resolution; the authors confirmed that none of the eyes developed a clinically significant macular edema; a recent study found that changes on OCT or fundus fluorescein angiography (FFA) are often seen without any obvious effect on CDVA (4). Given that the proposed adjuvant prophylactic intravitreal bevacizumab treatment is an invasive off-label therapy, with no effect on the long-term visual prognosis, and only able to prevent a nonclinically significant pseudophakic CME in the immediate postoperative period, I would not employ it in my practice. Instead, I would like to point out that the authors’ findings could be of help in counseling diabetic paCORRESPONDENCE

Bilateral intracavernous carotid artery aneurysms presenting as diplopia in a young patient.

Introduction. Bilateral intracavernous carotid artery aneurysms (ICAAs) are extremely rare and difficult to treat. Case Report. A 26-year-old female presented in our clinic with acute diplopia due to oculomotor nerve palsy on the left side. Magnetic resonance imaging of the brain showed two heterogeneously enhanced masses indicating bilateral ICAA. An endovascular coil embolization was performed on the left side successfully, resulting in resolution of her symptoms. Conclusion. Thorough systemic evaluation in young patients with diplopia can reveal life-threatening underlying pathology and prevent major complications.

Cataract surgery in eyes with nanophthalmos and relative anterior microphthalmos.

n 4. Bayramlar H, Totan Y, Borazan M. Heparin in the intraocular irrigating solution in pediatric cataract surgery. J Cataract Refract Surg 2004;30(10):2163–2169. 5. Infant Aphakia Treatment Study Group, Lambert SR, Buckley EG, Drews-Botsch C, et al. A randomized clinical trial comparing contact lens with intraocular lens correction of monocular aphakia during infancy: grating acuity and adverse events at age 1 year. Arch Ophthalmol 2010;128(7):810–818. 6. Vasavada A, Shastri L, Raj S, Ashutosh S. Cell response to AcrySof intraocular lenses in an Indian population. J Cataract Refract Surg 2002;28(7):1173–1181.

Phacoemulsification using 8 flexible iris hooks in a patient with a short eye, small pupil, and phacodonesis

UNLABELLED We describe a technique that uses flexible iris hooks to dilate and stabilize the capsular bag in a patient with a very deep set and small eye, narrow palpebral fissure, shallow anterior chamber, and very small pupil, who was scheduled for routine phacoemulsification for a white cataract. At the time of iris hook placement, the capsular bag was noted to be markedly unstable. The patient was managed successfully with phacoemulsification of the lens using 4 iris hooks to dilate the pupil and 4 iris hooks to stabilize the capsular bag during surgery. A foldable posterior chamber 3-piece intraocular lens was fixated in the ciliary sulcus. FINANCIAL DISCLOSURE Neither author has a financial or proprietary interest in any material or method mentioned.

Alpha-1 Adrenergic Agonists for the Prevention of Floppy Iris Syndrome

Laboratory Medicine and Pathobiology, Faculty of Medicine, University of Toronto, Ontario, Canada; Ophthalmic Pathology Laboratory, University of Toronto, St. Michael’s Hospital, Toronto, Ontario, Canada; Keenan Research Centre at the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada; Glaucoma Unit, St. Michael’s Hospital, Toronto, Ontario, Canada; Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Ontario, Canada

Capsulorhexis optic intraocular lens capture technique.

Capsulorhexis optic intraocular lens capture technique Lee et al. recently described a surgical technique for implanting an intraocular lens (IOL). The concept of IOL anterior capsule fixation has been known for some time and was subsequently developed by Jacob et al. and Gimbel and DeBroff into the technique we know as capsulorhexis optic IOL capture or optic IOL buttonholing. I would like to offer some comments and ask the authors’ opinion about details that would make this surgical technique appealing to readers. The authors did not explain what type of posterior chamber IOL they implanted. I imagine it was a 3-piece IOL. I wonder whether Lee et al. made any adjustment for the IOL power. In fact, when sulcus fixation is adopted, IOL power adjustment has been recommended. In contrast, my experience is that hyperopic postoperative refractive results are obtained when the optic IOL capture technique is used and the IOL power adjusted. This suggests that any adjustment should be avoided when implanting IOLs using this technique. A possible explanation is that the effective lens position is similar to the one achieved while implanting IOLs in the capsular bag. I would encourage the authors to provide information about the refractive results they achieved. I agree with Lee et al. that optic IOL capture produces a tight seal of the IOL–capsule diaphragm and the obtained compartmentalization is of great benefit in case of inadvertent posterior capsule rupture to reduce chances of vitreous loss, as described by Gimbel and DeBroff. I also agree with the authors about the need for good centration and appropriate size of the continuous curvilinear capsulorhexis. Finally, I am skeptical about Lee et al.’s thesis regarding the theoretically reduced migration of growth factors from the vitreous cavity to the anterior chamber with this technique of IOL implantation.

Rapid exaggeration of a pre-existing epiretinal membrane following uneventful cataract surgery.

Idiopathic epiretinal membrane (ERM) is a preretinal membrane, developing and proliferating at the vitreomacular interface. The aetiopathogenesis of epiretinal membrane remains not fully understood. In a recent large epidemiological study, the prevalence of epiretinal membrane in patients of 65 years of age or older was greater than 22 per cent, with significant inter-racial differences. Epiretinal membranes are associated with visual dysfunction that ranges from asymptomatic to severe. It normally requires surgical intervention when there is metamorphopsia or significant visual deterioration. A large number of ocular conditions can promote or have been associated with epiretinal membranes that are consequently termed as secondary and are normally characterised by focal retinal adhesions, as opposed to the broader adhesions observed in idiopathic epiretinal membranes. Cataract surgery is thought to be one cause of secondary epiretinal membranes. It has been linked to an increase in the prevalence of epiretinal membrane, although patients are generally asymptomatic. A recent controlled study found that the progression of idiopathic epiretinal membrane was not accelerated in patients who have undergone phacoemulsification cataract surgery and that the visual acuity was not markedly impaired in the first year following surgery. On the basis of these results, the authors of the above study concluded that surgeons need not hesitate to perform phacoemulsification in eyes with idiopathic epiretinal membrane. We report an unusual case of rapid visual deterioration and development of vitreomacular traction following uneventful phacoemulsification and intraocular lens implantation in a patient affected with agerelated cataract and idiopathic epiretinal membrane.

Retained Lens Fragments After Cataract Surgery: Outcomes Of Same-Day vs Later Pars Plana Vitrectomy

WE READ WITH GREAT INTEREST THE RECENT ARTICLE BY Modi and associates about the important and still controversial topic concerning the timing of pars plana vitrectomy for the management of nucleus drop. The authors reported on a large case series of patients surgically treated at their institution for retained lens fragments, analyzing the visual outcomes and the rates of adverse events. We noticed that the authors used the corrected distance visual acuity at final follow-up for the analysis; given that there were some patients who were left aphakic, did the authors consider the visual acuity following the intraocular lens implantation performed in a further surgery, or were those cases excluded from the analysis? We also observed that the authors pointed out how the correct timing of pars plana vitrectomy in these cases had remained controversial prior to their study. Respectfully, we highlight that their report unfortunately still does not provide definitive evidence, although they performed an analysis on a large sample. In fact, the authors might want to clarify the inclusion criteria adopted: did they operate on patients with dropped nucleus fragments smaller than a quarter of lens size or with epinucleus material retained in the vitreous cavity? If that was the case, were these patients with small fragments equally distributed among the 3 study groups? And can the authors analyze whether outcomes and complications were different in relation to the sizes and densities of the dropped lens material? For the delayed intervention, did the authors also base the indication for surgery on clinical conditions, such as excessive intraocular inflammation, elevated intraocular pressure, occurrence of cystoid macular edema, or decreased visual acuity? In addition, it is not clear whether the patients in the groups with delayed pars plana vitrectomy had received specific medical treatments prior to surgery. Finally, it might be of interest to analyze whether there was any difference in the lengths of follow-up needed in cases undergoing immediate vs delayed vitreoretinal intervention.

Hydroimplantation of intraocular lenses

using the Camellin formula when the patient clinical history is unknown. With the Camellin formula, it is possible to calculate the radius of curvature of the posterior corneal surface based on the measurement of the curvature radius of the anterior corneal surface, corneal pachymetry, and a series of pachymetry measurements performed in a 3.0 mm circular zone. It then is possible to obtain the relative keratometric refractive index without knowing the surgically induced refractive change. Therefore, unless we have misunderstood this, the Camellin–Calossi formula does not always require preoperative data.d Megumi Saiki, PhD, Kazuno Negishi, MD, Naoko Kato, MD, Rika Ogino, Hiroyuki Arai, MD, Ikuko Toda, MD, Murat Dogru, MD, Kazuo Tsubota, MD