Kevin M. Miller

Prophylaxis of postoperative endophthalmitis after cataract surgery Results of the 2007 ASCRS member survey

&NA; An online survey of members of the American Society of Cataract and Refractive Surgery indicated a strong preference for preoperative and postoperative topical antibiotic prophylaxis, with most surgeons favoring latest generation topical fluoroquinolones. A significant percentage of surgeons reported being concerned about the risks of homemade intracameral antibiotic preparations, and there was a strong desire to have a commercially available antibiotic approved for intracameral injection. This is reflected in the fact that 77% of respondents were still not injecting intracameral antibiotics, but 82% would likely do so if a reasonably priced commercial preparation were available.

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.

Intraocular pressure change after sutureless phacoemulsification and foldable posterior chamber lens implantation

Purpose: To investigate the effect on intraocular pressure (IOP) of sutureless scleral and corneal tunnel Kelman phacoemulsification (KPE) with foldable posterior chamber intraocular lens (IOL) implantation. Setting: Jules Stein Eye Institute, Los Angeles, California, USA. Methods: Preoperative and postoperative (: and 6 weeks and 6 to 8 months) IOP measurements of 385 consecutive eyes having uneventful phacoemulsification and foldable posterior chamber IOL implantation were reviewed retrospectively. A subset of 193 eyes for which no IOP measurements were missing at any follow‐up were analyzed separately. Results: Mean preoperative IOP was 1,5.8 mm Hg ± 0.2 (±SE). It dropped postoperatively by 1,3 ± 0.2 mm Hg at 1 week (P < .001), 2.5 ± 0.2 mm Hg at 6 weeks (P < .001), and 2.2 ± 0.2 mm Hg at 6 to 8 months (P < .001). Mean preoperative IOP for the subset without missing data was 16.0 ± 0.3 mm Hg. It decreased by 1.1 ± 0.3 mm Hg at 1 week (P < .001), 2.3 ± 0.2 mm Hg at 6 weeks (P < .001), and 2.2 ± 0.2 mm Hg at 6 to 8 months (P<.001). Wound construction (scleral versus corneal tunnel), anesthesia type (topical versus posterior orbital injection), the eye operated on, and patient age and sex did not significantly influence the postoperative pressure change. Patients with a preoperative diagnosis of glaucoma had significantly higher 1 week postoperative IOPs; however, the differences were statistically insignificant at 6 weeks and 6 to 8 months. Conclusion: Sutureless KPE with foldable posterior chamber IOL implantation lowered IOP by 1.1 to 2.5 mm Hg for the 6 months immediately following surgery. Glaucoma patients had a statistically significant initial rise in IOP at 1 week.

ASCRS White Paper: Clinical review of intraoperative floppy-iris syndrome

Intraoperative floppy-iris syndrome (IFIS) is associated with the use of systemic alpha(1)-antagonists, and tamsulosin in particular. The incidence and severity of IFIS are variable; however, the syndrome is associated with a higher rate of cataract surgical complications, especially when the condition is not recognized or anticipated. Questioning cataract patients preoperatively about current or previous use of alpha(1)-antagonists is therefore important. Intraoperative floppy-iris syndrome surgical management strategies include pharmacologic measures, the use of high-viscosity ophthalmic viscosurgical devices, and mechanical dilating devices. However, sphincterotomies and pupil stretching are ineffective. Whether used alone or in combination, these small-pupil techniques improve the surgical success rate in these cases. Stopping the alpha(1)-antagonist preoperatively is of questionable value.

Clinical experience with intraoperative floppy-iris syndrome Results of the 2008 ASCRS member survey

&NA; According to an online survey, most members of the American Society of Cataract and Refractive Surgery believe that tamsulosin makes cataract surgery more difficult (95%) and increases the risks of surgery (77%). Commonly reported complications of intraoperative floppy‐iris syndrome (IFIS) were significant iris trauma and posterior capsule rupture, with 52% and 23% of respondents, respectively, reporting these complications at a higher rate than in non‐IFIS eyes. There was no single preferred surgical method for managing IFIS; 33% of respondents routinely used multiple strategies. Of respondents with sufficient experience, 90% believe that IFIS is more likely with tamsulosin than with nonspecific α1‐antagonists. Ninety‐one percent believe that physicians prescribing α1‐antagonists should become better educated about IFIS, and 59% would recommend a pretreatment ophthalmic evaluation for patients with cataracts or decreased vision. If they themselves had mildly symptomatic cataracts, 64% of respondents would avoid taking tamsulosin or would have their cataract removed first.

Visual complaints associated with the AcrySof acrylic intraocular lens

Purpose: To describe the visual complaints of a series of patients implanted with the AcrySof® (Alcon Surgical) acrylic intraocular lens (IOL) that resolved with IOL exchange. Setting: Jules Stein Eye Institute, Los Angeles, California, and John A. Moran Eye Center, Salt Lake City, Utah, USA. Methods: This was a retrospective review of patients who had AcrySof IOL exchange from January 1997 to December 1998. Results: Eight patients (9 eyes) with bothersome visual symptoms following AcrySof IOL implantation were identified. Problems included glare, halos around point light sources, and peripheral arcs of light, often worse at night. In each case, the IOL was well‐centered in the capsular bag and there was no significant posterior capsule opacification. Six patients (7 eyes) had the MA30BA model with a 5.5 mm optic, and 2 patients (2 eyes) had the MA60BM model with a 6.0 mm optic. No extralenticular reasons for the patients complaints could be identified. Exchanging the AcrySof IOLs with silicone or poly(methyl methacrylate) IOLs alleviated most symptoms. In 5 of 8 patients, dysphotopsias resolved completely. Conclusions: A small number of patients implanted with AcrySof IOLs have specific complaints of glare, halos, and peripheral arcs of light. Optical considerations that may help explain these symptoms include the high refractive index of the IOL material and the truncated design of the optic. Patients who are highly observant and those with large pupils may be particularly symptomatic. Intraocular lens exchange may be necessary in some cases.

Phacoemulsification and lens implantation in patients treated with aspirin or warfarin

Purpose: To determine the incidence and nature of hemorrhagic complications in patients having phacoemulsification and foldable intraocular lens (IOL) implantation while taking aspirin or warfarin. Setting: The Jules Stein Eye Institute, University of California at Los Angeles School of Medicine, Los Angeles, California, USA. Methods: This retrospective study reviewed the charts from the practice of 1 ophthalmic surgeon. The type of medication, dosage, indication for anticoagulant therapy, type of incision, type of anesthesia, and intraoperative and postoperative hemorrhagic complications were recorded. Results: Sixty‐two patients (82 eyes) taking aspirin and 25 patients (31 eyes) taking warfarin were identified. Seven eyes in the aspirin group (8.5%) and 3 in the warfarin group (9.7%) experienced subconjunctival hemorrhages. Eight of the 10 subconjunctival hemorrhages occurred in eyes with scleral incisions. The remaining 2 occurred in eyes with corneal incisions. No eye developed lid ecchymosis, retrobulbar hemorrhage, hyphema, or suprachoroidal hemorrhage. Conclusion: Phacoemulsification with foldable IOL implantation was performed safely in patients taking aspirin or warfarin. Subconjunctival hemorrhage was the most common hemorrhagic complication.

Accuracy of Scheimpflug Holladay equivalent keratometry readings after corneal refractive surgery.

PURPOSE: To determine the accuracy of Pentacam Scheimpflug system Holladay equivalent keratometry (K) readings (EKRs) in calculating intraocular lens (IOL) power after corneal refractive surgery, including laser in situ keratomileusis (LASIK), photorefractive keratectomy (PRK), and radial keratotomy (RK). SETTING: Jules Stein Eye Institute, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, USA. METHODS: In this combined retrospective and prospective clinical study, patients who had cataract surgery after corneal refractive surgery were recalled to have Scheimpflug imaging of the operated cornea and Holladay EKR determination. The Holladay EKR was compared with a gold‐standard K value, which was the back‐calculated value using the original Hoffer formula based on the actual surgical outcomes. Eyes without a history of refractive surgery served as controls. RESULTS: Twenty‐seven patients (41 eyes) were evaluated; 26 eyes had previous LASIK or PRK and 15, previous RK. Forty‐one eyes served as controls. The mean error of the Holladay EKR in eyes with previous LASIK or PRK was +1.84 diopters (D) (range +0.66 to +4.94 D). The mean error in eyes with previous RK was +2.17 D (range +0.48 to +3.09 D). In the control eyes, the mean EKR error was +1.38 D (range −0.17 to +2.54 D). CONCLUSIONS: The Holladay EKR calculated using version 1.16r04 of the Scheimpflug system software was inaccurate in virgin corneas and in those with a history of LASIK, PRK, or RK using current IOL power calculation formulas. The Scheimpflug power measurements were consistently steeper than the true corneal power.

Phacoemulsification in the standing position with loupe magnification and headlamp illumination

Abstract A patient who could not recline from the seated position because of myotonic dystrophy and advanced interstitial lung disease presented to the UCLA Department of Ophthalmology Inpatient Consultation Service complaining of poor vision in both eyes as a result of corticosteroid‐induced cataracts. We performed phacoemulsification and posterior chamber intraocular lens implantation in the standing position using magnifying loupes and fiber optic headlamp illumination. The excellent red reflex provided by the coaxial headlamp and the surgical control provided by bracing the operating hand against the cheek made this approach a viable option for this severely compromised patient. We discuss the surgical technique and its limitations.

Posterior dislocation of a plate-haptic silicone intraocular lens with large fixation holes

We present a patient who had uneventful phacoemulsification with in-the- bag implantation of a silicone plate-haptic posterior chamber intraocula r lens (IOL) with 1.15 mm fixation holes. Six months after a neodymium: YAG laser capsulotomy, the IOL spontaneously dislocated posteriorly. A pars plana vitrectomy was performed, the IOL was explanted, and a 3-piece loop-haptic IOL was implanted in the ciliary sulcus. Eight weeks after surgery, best corrected visual acuity was 20/20.