Helga P. Sandoval

Refractive Surgery Survey 2001.

&NA; To determine the refractive surgery preferences of ophthalmologists worldwide, questionnaires were sent to 8920 members of the American Society of Cataract and Refractive Surgery. A total of 1174 questionnaires was returned by the deadline. The practice distribution included 30.0% cataract surgeons, 47.3% comprehensive ophthalmologists, 14.4% refractive surgery (RS) specialists, 4.5% corneal/external disease specialists, 1.9% glaucoma specialists, and <1% retinal/oculoplastics/pediatrics/neurophthalmologists/researchers/retired. Responses were compared with those in the 2001 and 2002 surveys and demonstrate that RS practice patterns continue to evolve.

Flap thickness accuracy ☆ ☆☆ ★ ★★: Comparison of 6 microkeratome models

Purpose: To determine the flap thickness accuracy of 6 microkeratome models and determine factors that might affect flap thickness. Setting: Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. Methods: This multicenter prospective study involved 18 surgeons. Six microkeratomes were evaluated: AMO Amadeus, Bausch & Lomb Hansatome®, Moria Carriazo‐Barraquer, Moria M2, Nidek MK2000, and Alcon Summit Krumeich‐Barraquer. Eyes of 1061 consecutive patients who had laser in situ keratomileusis were included. Age, sex, surgical order (first or second cut), keratometry (flattest, steepest, and mean), white‐to‐white measurement, laser used, plate thickness, head serial number, blade lot number, and occurrence of epithelial defects were recorded. Intraoperative pachymetry was obtained just before the microkeratome was placed on the eye. Residual bed pachymetry was measured after the microkeratome cut had been created and the flap lifted. The estimated flap thickness was determined by subtraction (ie, mean preoperative pachymetry measurement minus mean residual bed pachymetry). Results: A total of 1634 eyes were reviewed. Sex distribution was 54.3% women and 45.7% men, and the mean age was 39.4 years ± 10.6 (SD). In addition, 54.5% of the procedures were in first eyes and 45.5%, in second eyes. The mean preoperative pachymetry measurement was 547 ± 34 &mgr;m. The mean keratometry was 43.6 ± 1.6 diopters (D) in the flattest axis and 44.6 ±1.5 D in the steepest axis. The mean white‐to‐white measurement was 11.7 ± 0.4 mm. The mean flap thickness created by the devices varied between head designs, and microkeratome heads had significant differences (P<.05). Factors that explained 78.4% of the variability included microkeratome model, plate thickness, mean preoperative pachymetry, Kmin, surgery order, head serial number, blade lot number, and surgeon. Factors such as age, sex, Kmax, Kaverage, white to white, and laser had no significant correlation to flap thickness. Conclusions: The results demonstrated variability between the 6 microkeratome models. Device labeling did not necessarily represent the mean flap thickness obtained, nor was it uniform or consistent. Thinner corneas were associated with thinner flaps and thicker corneas with thicker flaps. In addition, first cuts were generally associated with thicker flaps when compared to second cuts in bilateral procedures.

Factors Associated with Intraoperative Floppy Iris Syndrome

PURPOSE To identify factors associated with intraoperative floppy iris syndrome (IFIS) in patients undergoing routine phacoemulsification. DESIGN Comparative case series. PARTICIPANTS Analysis of 899 eyes of 660 patients undergoing routine cataract surgery. METHODS All routine cases of cataract extraction with posterior chamber intraocular lens implantation between September 1, 2005, and August 31, 2006, were documented. Pertinent patient information, including age, gender, race, medical history, and current medication use (including tamsulosin [Flomax, Boehringer-Ingelheim, Ingelheim, Germany], other alpha(1)-antagonists, angiotensin antagonists, anticholinergics, cholinergic agonists, muscle relaxants, nitric oxide donors, and saw palmetto), were collected at the time of surgery. A telephone survey was used to determine previous use of tamsulosin, other alpha(1)-antagonists, and saw palmetto. Cases were identified intraoperatively as IFIS or non-IFIS following the triad of criteria developed by Chang and Campbell. MAIN OUTCOME MEASURES Presence of IFIS associated with medication use and medical history. RESULTS Analysis showed IFIS in 27 patients (4.1%) representing 33 eyes (3.7%). Tamsulosin use (P<0.001) and history of alpha(1)-antagonist use other than tamsulosin (P = 0.01) were shown to strongly correlate with IFIS in our study. Hypertension was noted to be a significant variable via multivariable generalized estimating equations analysis (P = 0.04) with a prevalence of 75.8% in patients with IFIS versus 56.4% in patients without IFIS. Saw palmetto showed a slight, but statistically insignificant, trend that current use or history of use may be associated with IFIS. There were no cases of posterior capsular rupture or vitreous loss. CONCLUSIONS Exposure to tamsulosin highly correlates with IFIS. Use of other alpha(1)-antagonists is also associated with IFIS. Several patients in our series were identified to have IFIS with no history of alpha(1)-antagonist use, indicating that other etiologic factors, or a combination of factors, can also elicit this response. Multivariable regression analysis shows no proven relationship between IFIS and individual use of angiotensin antagonists, anticholinergics, cholinergic agonists, muscle relaxants, nitric oxide donors, or saw palmetto, and diabetes or congestive heart failure.

Effect of hinge location on corneal sensation and dry eye after laser in situ keratomileusis for myopia

PURPOSE: To evaluate the effects of a superior or nasal hinge location on corneal sensation and dry eye after laser in situ keratomileusis (LASIK). SETTING: Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: This prospective randomized masked study included 47 patients having bilateral myopic LASIK surgery. The first eye was randomly assigned to have a nasal or superior hinge flap; the fellow eye had the alternate location. Visual acuity, contrast sensitivity, corneal sensation, basic secretion test, tear film breakup time, conjunctival and corneal staining, and a subjective questionnaire were evaluated preoperatively and postoperatively at 1 week and 1, 3, and 6 months. The Wilcoxon signed rank test and paired t test were used for comparison. RESULTS: Dry eye occurred with the same frequency in both groups. However, eyes with the nasal hinge had significantly better nasal sensation than those with the superior hinge (P<.05) at 1 month. CONCLUSION: Better nasal corneal sensation was found at 1 month in the nasal hinge group but there was no difference in any other parameters measured.

Comparison of visual outcomes, photopic contrast sensitivity, wavefront analysis, and patient satisfaction following cataract extraction and IOL implantation: aspheric vs spherical acrylic lenses

PurposeTo determine vision quality when testing two acrylic intraocular lenses (IOLs), AcrysofIQ and AcrysofSingle-Piece, after routine cataract extraction and IOL implantation.SettingStorm Eye Institute and Magill Research Center for Vision Correction, Medical University of South Carolina, Charleston, SC, USA.MethodsProspective, randomized, double-masked study that included 53 eyes of 27 patients who underwent bilateral cataract extraction and IOL implantation. Patients were randomly divided into two groups depending on the type of IOL implanted: AcrysofIQ or AcrysofSingle-Piece. Preoperative, 1- and 3-month postoperative evaluations included ETDRS visual acuity, photopic contrast sensitivity, pupil size, wavefront testing, and a subjective questionnaire. Comparisons between the two groups and comparisons to baseline were made at each visit. P<0.05 was considered statistically significant.ResultsPreoperative, statistically significant differences were evident in response to the subjective questionnaire (near activities, driving dimensions, and overall score) between the two groups. Postoperatively there was a greater increase in contrast sensitivity at 1 and 3 months in the AcrysofIQ group when compared to baseline. Patients with AcrysofIQ IOL had a significant reduction in total high-order aberrations (HOA) and spherical aberration (SA) when compared to those patients with AcrysofSingle-Piece at 1 and 3 months and to baseline. Postoperative patient satisfaction showed no difference among the groups.ConclusionThe use of a new aspheric acrylic IOL may improve the quality of vision as a result of the reduction of total HOA and SA.

Comparison of the incidence and visual significance of posterior capsule opacification between multifocal spherical, monofocal spherical, and monofocal aspheric intraocular lenses.

PURPOSE: To determine and compare the incidence of posterior capsule opacification (PCO) and neodymium:YAG (Nd:YAG) laser capsulotomy after implantation of 3 intraocular lens types (IOLs). SETTING: Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: This retrospective chart review comprised eyes having uneventful phacoemulsification and implantation of 1 of 3 AcrySof IOLs: ReSTOR SN60D3 (multifocal spherical group), Natural SN60AT (monofocal spherical group), or IQ SN60WF (monofocal aspheric group). Eyes were matched by age, sex, and follow‐up. The PCO rate, Nd:YAG capsulotomy rate, time from surgery to PCO diagnosis, and time from surgery to Nd:YAG capsulotomy were assessed. RESULTS: Charts of 225 eyes (75 in each group) with a mean follow‐up of 15.9 months ± 6.5 (SD) were evaluated. The PCO rate was 42.7% in the multifocal spherical group, 28.0% in the monofocal spherical group, and 14.7% in the monofocal aspheric group. The Nd:YAG capsulotomy rate was 25.3%, 17.3%, and 4.0%, respectively. The difference in the Nd:YAG rate was statistically significantly higher in the multifocal and monofocal spherical groups than in the monofocal aspheric group (P<.001 and P<.008, respectively) but was not significantly different between the 2 spherical IOL groups (P = .232). The time from surgery to PCO documentation was not significantly different between the 3 groups. CONCLUSIONS: Intraocular lens configuration may have contributed to the difference in the PCO rate between the 2 spherical IOLs and the aspheric IOL. Based on the Nd:YAG rate as an indicator for visual significance, PCO may be less visually significant in eyes with the aspheric IOL than in eyes with 1 of the spherical IOLs.

Safety and efficacy of ketorolac tromethamine 0.4% ophthalmic solution in post-photorefractive keratectomy patients

Purpose: To evaluate the safety and analgesic efficacy of ketorolac tromethamine 0.4% ophthalmic solution in postoperative photorefractive keratectomy (PRK) patients. Setting: Fifteen clinical sites in the eastern and southern United States. Methods: This pooled analysis of 2 multicenter, randomized, double‐masked, vehicle‐controlled, parallel‐group studies comprised 313 patients having unilateral PRK. After surgery, patients were treated with 1 drop of ketorolac tromethamine 0.4% ophthalmic solution (Acular® LS) (n = 156) or vehicle (n = 157) 4 times daily for up to 4 days. Pain intensity, pain relief, use of escape medication, and severity of ocular symptoms were assessed. Adverse events, epithelial healing, and visual acuity were recorded. Results: There was significantly less pain intensity experienced by patients in the ketorolac group (P<.001). During the first 12 hours post PRK, 50% fewer patients in the ketorolac group than in the vehicle group had severe to intolerable pain (41.6% [64/154] and 84.5% [131/155], respectively). The median time to no pain was 30 hours in the ketorolac group and 54 hours in the vehicle group (P<.001, survival analysis). Ketorolac patients reported significantly greater pain relief than vehicle patients throughout the study (P<.001). Ketorolac patients used significantly less escape medication than vehicle patients for 48 hours post PRK (P≤.008). Treatment‐related adverse events occurred in 2.6% (4/156) of ketorolac patients and 6.4% (10/157) of vehicle patients. Conclusion: Ketorolac 0.4% ophthalmic solution is safe and effective in reducing ocular pain when used 4 times daily for up to 4 days post PRK.

Diffuse lamellar keratitis: evaluation of etiology, histopathologic findings, and clinical implications in an experimental animal model☆

Purpose: To induce diffuse lamellar keratitis (DLK) and investigate the potential causative agents in an animal model. Setting: Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. Methods: In 70 eyes of 35 Dutch Belted rabbits, a corneal flap was cut and the interface randomly exposed to 1 of 7 substances: Pseudomonas aeruginosa endotoxin, 1 of 2 Staphylococcus aureus exotoxins, meibomian gland secretion, povidone−iodine 10%, Palmolive® Ultra soap, and Klenzyme® soap. Slitlamp examinations were performed 1, 3, 5, and 7 days postoperatively. The DLK was staged from 1 to 4. On day 7, the rabbits were killed and the eyes enucleated and processed for histopathologic examination. Results: At the end of the study, 54 eyes (46 exposed, 8 control) were available for evaluation. The 8 eyes studied concurrently in the control group remained clear and did not show interface inflammation. Thirty‐one of 46 eyes (67%) treated with the various test substances developed DLK. The highest DLK rates were found with the cleaning soap Palmolive Ultra (100%; P = .022) and P aeruginosa lipopolysaccharide endotoxin (90%; P = .026). Conclusions: Interface inflammation was consistently induced in the animal model. All 7 agents caused DLK in at least some eyes. The histopathologic evaluation showed the morphologic profile of the marked inflammatory cellular reaction that occurred in almost all the specimens.

Endothelial cell integrity after phacoemulsification with 2 different handpieces

Purpose: To investigate corneal endothelial cell loss in fresh phakic human autopsy cadaver eyes after phacoemulsification (PE) with a conventional handpiece or a new oscillatory handpiece. Setting: Department of Ophthalmology, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. Methods: Twenty fresh phakic human autopsy globes were randomized to PE with a conventional handpiece (n = 10) or an oscillatory handpiece (n = 10). The main parameters evaluated were age, nucleus density, amount of ophthalmic viscosurgical device (OVD) used, and mean PE time and ultrasound (US) power. After surgery, the corneas were excised and the endothelia were vitally stained with trypan blue and alizarin red. Light microscopy was used to assess the endothelial cell loss. Results: The mean age, density of the nucleus, OVD used, and US power were similar between the groups. The mean PE time was less with the NeoSoniX handpiece (0.71 minutes ± 0.39 [SD]) than with the conventional handpiece (1.05 ± 0.53 minutes). The mean number of dead endothelial cells was significantly lower in the oscillatory handpiece group (31.3 ± 24.2 cells/mm2) than in the conventional handpiece group (60.4 ± 46.8 cells/mm2) (P<.001, Mann‐Whitney rank sum test). Conclusions: Less corneal endothelial cell loss occurred after PE with an oscillatory handpiece than with a conventional handpiece. Further randomized clinical trials are recommended to validate this study.

Comparison of ketorolac tromethamine 0.5% and loteprednol etabonate 0.5% for inflammation after phacoemulsification Prospective randomized double-masked study

Purpose: To compare the efficacy of a topical nonsteroidal antiinflammatory agent (ketorolac tromethamine ophthalmic solution 0.5%) and a topical steroid (loteprednol etabonate ophthalmic suspension 0.5%) in controlling inflammation after cataract surgery. Setting: Magill Research Center for Vision Correction, Storm Eye Institute, Medical University of South Carolina, Charleston, South Carolina, USA. Methods: Sixty patients were prospectively and randomly assigned to receive topical treatment with ketorolac tromethamine ophthalmic solution 0.5% or loteprednol etabonate ophthalmic suspension 0.5% starting the day after routine phacoemulsification for cataract extraction. Both patient and investigator were masked to treatment. All patients had uneventful small‐incision phacoemulsification with placement of a foldable posterior chamber intraocular lens (IOL). Patients used 1 of the 2 antiinflammatory agents 4 times a day starting 24 hours after surgery. Signs and symptoms of inflammation as documented by external slitlamp examination, intraocular pressure (IOP), and Kowa cell and flare measurements were evaluated on postoperative days 1, 4, 7, and 30. Results: There was no statistically significant difference in any measurement of postoperative inflammation between the 2 groups. There was no difference in objective or subjective cell and flare measurements or in IOP between groups. No patient in either group was removed from the study for lack of treatment efficiency. Conclusions: Ketorolac tromethamine ophthalmic solution 0.5% was as effective as loteprednol etabonate ophthalmic suspension 0.5% in reducing inflammation after routine phacoemulsification and IOL implantation. These results suggest that ketorolac tromethamine 0.5% is a safe and effective antiinflammatory alternative to steroids after cataract extraction.