Luis E. Fernández de Castro

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 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.

Cryptococcus albidus keratitis after corneal transplantation.

Purpose: To report suspected donor-to-host transmission of Cryptococcus albidus after penetrating keratoplasty. Methods: Review of the literature and a case report of a 69-year-old woman who underwent penetrating keratoplasty for Fuchs corneal dystrophy and developed persistent corneal infiltrates 7 months postoperatively are presented. Results: Cryptococcus albidus was cultured from the original donor tissue at the time of the repeat keratoplasty. Conclusion: This case demonstrates an unusual case of cryptococcal keratitis after keratoplasty suspected to be a donor-to-host transmission.

Bead-flow pattern: Quantitation of fluid movement during torsional and longitudinal phacoemulsification

PURPOSE: To develop a bead‐flow pattern for visualizing and comparatively quantifying fluid movement using a torsional or longitudinal ultrasound (US) phaco handpiece. SETTING: Magill Laser Center, Medical University of South Carolina, Charleston, South Carolina, USA. METHODS: Visualization and quantification of intraocular fluid dynamics were evaluated by injecting neutrally buoyant, collagen‐coated polystyrene beads (diameter, 125 to 212 μm) into the phacoemulsification irrigation flow. Using the anterior chamber of a cadaver or porcine eye or a laboratory test chamber, the bead‐flow pattern was video recorded. Qualitative comparisons between longitudinal and torsional phacoemulsification were made using video‐processing software to track the beads frame by frame. The time (quantitative) required to aspirate a bolus of beads from the anterior chamber (clearance time) was measured and compared between the 2 modalities. Aspiration efficiency was calculated to compare operating conditions in a test chamber using high‐speed videography; conditions included irrigation/aspiration (I/A) only (0% power) and clinically relevant fluidic parameters and power modulations with torsional, longitudinal, or a combination of powers applied. RESULTS: Qualitative and quantitative analyses of the fluidic patterns of bead flow in the peripheral anterior chamber and near the aspirating tip opening indicated that torsional fluidics behave closer to the I/A‐only configuration than longitudinal phacoemulsification, with the latter repelling more bead material in front of the aspiration tip. Bead clearance time was approximately 50% faster with torsional than with longitudinal US, regardless of the power setting. CONCLUSION: Bead flow‐pattern evaluation is a feasible approach to future studies of fluid movement in the anterior chamber. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Ocular manifestations after primary varicella infection.

Purpose: To report a case of ocular manifestations after a primary varicella infection. Methods: Review of the literature and a case report of a 10-year-old male patient with history of blurry vision and an enlarged pupil 2 months after a varicella infection. Examination revealed uveitis, interstitial keratitis, and internal ophthalmoplegia. Results: The uveitis resolved with topical steroids; the interstitial keratitis resolved with a faint scar, and the internal ophthalmoplegia persisted. Conclusion: This case report describes a patient with uncommon ocular manifestations after primary varicella.

Randomized, double-masked clinical trial evaluating corneal endothelial cell loss after cataract extraction and intraocular lens implantation: Fluid-based system versus ultrasound phacoemulsification.

Purpose: To assess the endothelial cell loss after cataract extraction using a fluid-based system and compare it with conventional ultrasound. Methods: A total of 46 eyes of 23 patients with up to 3+ bilateral cataract were included. The first eye was randomized to either fluid-based system or conventional ultrasound, and the fellow eye received the alternate system. Visual acuity and ultrasound pachymetry were measured preoperatively and at 1 day, 1 week, and 1 and 3 months postoperatively. Specular microscopy was performed preoperatively and 3 months after the surgery. Data was analyzed using the paired t test and Wilcoxon signed rank test. A P value less than 0.05 was considered statistically significant. Results: Postoperatively, no significant differences were found among the groups. However, there was a significant difference (P < 0.01, analysis of variance with Tukey as posttest) in corneal pachymetry at day 1 after the surgery compared with baseline in both groups. There was a 6.3% and 7.9% loss of endothelial cells in the fluid-based system and ultrasound group, respectively. Conclusion: Visual acuity, pachymetry, and endothelial cell loss after cataract extraction and intraocular lens implantation using a fluid-based system is similar to conventional ultrasound.

Herpes zoster ophthalmicus: presenting as giant-cell arteritis.

A 74‐year‐old woman was referred to the authors’ clinic with a 1‐week suspicion of giant‐cell arteritis. Uncomplicated, bilateral temporal artery biopsies were performed 3 days after admission for therapy. Four hours after the procedure she developed vesicular lesions of the face compatible with herpes zoster ophthalmicus. The temporal artery biopsy revealed perineural lymphocytic aggregation. Both giant‐cell arteritis and herpes zoster ophthalmicus form part of the differential diagnosis in elderly patients with headache. In such cases, clues from a temporal artery biopsy may aid in diagnosis of herpes zoster. In addition, the patient in this case developed the rash 10 days after onset of symptoms, which is rare as the average time from onset of symptoms to rash in zoster is 3–5 days.

Relationship between cycloplegic and wavefront-derived refraction.

PURPOSE To compare cycloplegic refractions to preoperative wavefront-derived refractions from three Hartmann-Shack-based wavefront devices. METHODS Ninety-nine eyes of 55 subjects were evaluated preoperatively using the LADARWave, WaveScan, and Zywave aberrometers. With cycloplegic refraction as the standard, the spherical equivalent refraction, sphere, and cylinder were compared to the wavefront-derived refractions using the three wavefront devices. RESULTS The LADARWave unit showed the highest correlation between wavefront-derived sphere and mean spherical equivalent refraction values relative to cycloplegic refraction, followed by Zywave and WaveScan. The WaveScan unit exhibited higher variability than the LADARWave or Zywave. Although Alcon Laboratories (LADARWave) and Bausch & Lomb Surgical (Zywave) recommend dilation, VISX specifically recommends against dilation in their WaveScan unit. All devices showed high cylinder error vectors when the cycloplegic cylinder was greater than 1.00 D. CONCLUSION Although wavefront-derived refractions appeared to correlate well to cycloplegic refractions, further research is required to reduce variability and improve the calculation of cylinder terms.

Comparison of the Infiniti Vision and the Series 20,000 Legacy Systems

Purpose: To compare the efficiency of the Infiniti vision system and the Series 20,000 Legacy system phacoemulsification units during routine cataract extraction. Methods: Thirty-nine eyes of 39 patients were randomized to have their cataract removed using either the Infiniti or the Legacy system, both using the Neosonix handpiece. System settings were standardized. Ultrasound time, amount of balanced salt solution (BSS) used intraoperatively, and postoperative visual acuity at postoperative days 1, 7 and 30 were evaluated. Results: Preoperatively, best corrected visual acuity was significantly worse in the Infiniti group compared to the Legacy group (0.38 ± 0.23 and 0.21 ± 0.16, respectively; p = 0.012). The mean phacoemulsification time was 39.6 ± 22.9 s (range 6.0–102.0) for the Legacy group and 18.3 ±19.1 s (range 1.0–80.0) for the Infiniti group (p = 0.001). The mean amounts of intraoperative BSS used were 117 ± 37.7 ml (range 70–195) in the Legacy group and 85.3 ± 38.9 ml (range 40–200) in the Infiniti group (p = 0.005). No differences in postoperative visual acuity were found. Conclusion: The ability to use higher flow rates and vacuum settings with the Infiniti vision system allowed for cataract removal with less phacoemulsification time than when using the Legacy system.