Oliver Findl

Partial coherence interferometry: a novel approach to biometry in cataract surgery

PURPOSE To compare biometry performed by an enhanced version of dual beam partial coherence interferometry and applanation ultrasound in a prospective study of 85 cataract eyes to improve refractive outcome of cataract surgery due to a more accurate calculation of intraocular lens power. METHODS The SRK II formula using ultrasound biometry data was employed. Three months after surgery, partial coherence interferometry biometry was repeated and refractive outcome was determined. Preoperative partial coherence interferometry biometry data were used to determine the refractive power of the intraocular lenses retrospectively and to calculate the possible refractive outcome. RESULTS Precision of partial coherence interferometry biometry was more than 10 times better than that of ultrasound. Therefore, the possible mean absolute error for postoperative refraction achieved with partial coherence interferometry biometry was 0.49 diopters (compared with 0.67 diopters with ultrasound biometry), resulting in an improvement of 27%. Axial eye length measured with the two techniques differed by a mean of 460 microm. The difference in lens thickness measured with partial coherence interferometry and ultrasound significantly correlated with cataract grade. A mean shortening of 120 microm of axial eye length following cataract surgery was also detected by partial coherence interferometry. CONCLUSIONS The enhanced version of partial coherence interferometry offers biometry with unprecedented precision (<10 microm) and resolution (approximately 12 microm), therefore improving the refractive outcome in cataract surgery. This noninvasive technique provides a high degree of comfort for the patient, with no need for local anesthesia or pupil dilation and minimized risk of corneal infection.

Improved prediction of intraocular lens power using partial coherence interferometry

Purpose: To evaluate the feasibility of using a new optical biometry technique, dual‐beam partial coherence interferometry (PCI), to improve intraocular lens (IOL) power prediction in cataract surgery. Setting: Department of Ophthalmology, Vienna General Hospital, and Institute of Medical Physics, University of Vienna, Vienna, Austria. Methods: Preoperative axial length (AL) data obtained with PCI biometry and applanation ultrasound (US) biometry in 77 eyes of 51 patients was applied to 4 commonly used IOL power formulas. The refractive outcome and the mean absolute error (MAE) were calculated for each formula using both biometry methods. A linear multiple‐regression model based on preoperative PCI biometry data was derived to predict the postoperative anterior chamber depth (ACD). The predictive power of this regression model was assessed by adding the predicted ACD to the SRK/T formula. Predicted residuals were calculated to evaluate the feasibility and stability of this modified IOL power formula. Results: Using PCI instead of US biometry significantly improved the refractive outcome with all 4 IOL power formulas. The Holladay I and SRK/T formulas yielded an MAE of 0.44 diopter (D) using PCI AL data and 0.56 D and 0.57 D, respectively, using US biometry data. The SRK/T formula combined with the PCI regression model for postoperative ACD prediction performed slightly better (MAE 0.42 D) than the conventional SRK/T formula alone. Predicted residuals revealed an MAE of 0.46 D, proving the predictive performance of the new formula. Conclusions: Partial coherence interferometry biometry applied to several widely used IOL power formulas yielded significantly better IOL power prediction and therefore refractive outcome in cataract surgery than US biometry. Further improvement can be achieved by applying PCI to a modified SRK/T formula that predicts the postoperative ACD using PCI biometry data.

Biometric investigation of changes in the anterior eye segment during accommodation

Non-invasive biometry of the anterior structures of the human eye can be performed with unprecedented precision of 8-10 microns and a resolution of approximately 9 microns by partial coherence interferometry, which has the potential to assess the effect of cycloplegia on the ocular components of the anterior eye segment, to further improve the precision to 1-2 microns by the use of these agents and to quantify the amount of residual accommodations in different states of cycloplegia. In addition, the anterior chamber depth, the thickness of the crystalline lens, their changes during accommodation, as well as the movement of the anterior and posterior lens pole during accommodation can be quantified objectively and accurately to investigate the mechanism of accommodation.

Evaluation of the Zeiss retinal vessel analyser.

AIM To investigate the reproducibility and sensitivity of the Zeiss retinal vessel analyser, a new method for the online determination of retinal vessel diameters in healthy subjects. METHODS Two model drugs were administered, a peripheral vasoconstrictor (the α receptor agonist phenylephrine) and a peripheral vasodilator (the nitric oxide donor sodium nitroprusside) in stepwise increasing doses. Nine healthy young subjects were studied in a placebo controlled double masked three way crossover design. Subjects received intravenous infusions of either placebo or stepwise increasing doses of phenylephrine (0.5, 1, or 2 μg/kg/min) or sodium nitroprusside (0.5, 1, or 2 μg/kg/min). Retinal vessel diameters were measured with the new Zeiss retinal vessel analyser. Retinal leucocyte velocity, flow, and density were measured with the blue field entoptic technique. The reproducibility of measurements was assessed with coefficients of variation and intraclass correlation coefficients. RESULTS Placebo and phenylephrine did not influence retinal haemodynamics, although the α receptor antagonist significantly increased blood pressure. Sodium nitroprusside induced a significant increase in retinal venous and arterial diameters (p<0.001 each), leucocyte density (p=0.001), and leucocyte flow (p=0.024) despite lowering blood pressure to a significant degree. For venous and arterial vessel size measurements short term coefficients of variation were 1.3% and 2.6% and intraclass correlation coefficients were 0.98 and 0.96, respectively. The sensitivity was between 3% and 5% for retinal veins and 5% and 7% for retinal arteries. CONCLUSIONS These data indicate that the Zeiss retinal vessel analyser is an accurate system for the assessment of retinal diameters in healthy subjects. In addition, nitric oxide appears to have a strong influence on retinal vascular tone.

Imaging of polarization properties of human retina in vivo with phase resolved transversal PS-OCT

Recently, we developed a phase resolved polarization sensitive OCT system based on transversal scanning. This system was now improved and adapted for retinal imaging in vivo. We accelerated the image acquisition speed by a factor of 10 and adapted the system for light sources emitting at 820nm. The improved instrument records 1000 transversal lines per second. Two different scanning modes enable either the acquisition of high resolution B-scan images containing 1600x500 pixels in 500ms or the recording of 3D data sets by C-scan mode imaging. This allows acquiring a 3D-data set containing 1000x100x100 pixels in 10 seconds. We present polarization sensitive B-scan images and to the best of our knowledge, the first 3D-data sets of retardation and fast axis orientation of fovea and optic nerve head region in vivo. The polarizing and birefringence properties of different retinal layers: retinal pigment epithelium, Henles fiber layer, and retinal nerve fiber layer are studied.

The capsular tension ring: designs, applications, and techniques

&NA; Originally, the open poly(methyl methacrylate) (PMMA) capsular tension ring (CTR) was designed to compensate for zonular defects or to stretch the posterior capsule in highly myopic eyes not receiving an intraocular lens (IOL). We address the variety of subsequent designs, applications, and techniques that have evolved. With pre‐existing or intraoperative zonular defects, a standard CTR may be inserted before or at any time during cataract removal to maintain or re‐establish an extended capsular diaphragm. For profound zonular dialysis or weakness, a CTR was designed for scleral fixation. Capsular tension rings with integrated tinted sector shields have been developed to compensate for sector iris colobomas or aniridia. The CTR has also been used as a measuring gauge for in vivo quantification of capsule dimensions and postoperative capsular shrinkage. The CTR has improved control during primary posterior capsulorhexis and prevented oval distortion along the lens axis postoperatively. During combined cataract and vitreous surgery, a CTR prevents capsule damage and provides undisturbed peripheral visualization before IOL implantation. Capsular tension rings may also influence capsule opacification formation. A special band‐shaped CTR with sharp edges was developed to inhibit lens epithelial cell migration and avoid capsulorhexis–optic contact.

Comparison of 4 methods for quantifying posterior capsule opacification.

Purpose: To compare the results of posterior capsule opacification (PCO) quantification and the repeatability of a fully automated analysis system (Automated Quantification of After‐Cataract [AQUA]) with that of 2 other quantification methods and subjective grading of PCO. A test set of digital retroillumination images of 100 eyes with PCO of varying degrees was used. Setting: Department of Ophthalmology, University of Vienna, Vienna, Austria. Methods: One hundred digital retroillumination images of eyes (100 patients) with PCO were selected to attain an even distribution from mild to severe cases. The images were evaluated by 4 methods: subjective grading by 4 experienced and 4 inexperienced examiners, the subjective Evaluation of Posterior Capsular Opacification (EPCO) system, posterior capsule opacification (POCO) software, and the AQUA system. Ten images were presented twice to assess the reproducibility of the analysis systems. Results: Subjective grading correlated best with the subjective EPCO system and the objective AQUA system (r = 0.94 and r = 0.93, respectively). The POCO system showed very early saturation and therefore a much weaker correlation (r = 0.73). The POCO scores reached the maximum of 100% in several minimal to mild PCO cases. The reproducibility of the AQUA software was perfect and that of the other analysis systems, comparably satisfactory. Conclusion: The objective AQUA score correlated well with subjective methods including the EPCO system. The POCO system, which assesses PCO area, did not adequately describe PCO intensity and includes a subjective step in the analysis process. The AQUA system could become an important tool for randomized masked trials of PCO inhibition.

Effect of a silicone intraocular lens with a sharp posterior optic edge on posterior capsule opacification

Purpose: To compare the inhibiting effect on posterior capsule opacification (PCO) of a silicone intraocular lens (IOL) with a sharp posterior optic edge (ClariFlex OptiEdge®, Advanced Medical Optics) and a silicone IOL with a round optic edge (PhacoFlex SI‐40, Advanced Medical Optics). Setting: Department of Ophthalmology, University of Vienna, Vienna, Austria. Methods: This prospective randomized patient‐ and examiner‐masked study comprised 104 eyes of 52 patients with bilateral age‐related cataract. All patients had cataract surgery in both eyes and received a sharp‐edged IOL in 1 eye and a round‐edged IOL in the other eye. Postoperative examinations were at 1 week, 1 and 6 months, and 1 year. Digital slitlamp and retroillumination images were taken of each eye. The amount of PCO was assessed subjectively at the slitlamp and objectively using Automated Quantification of After‐Cataract (AQUA) automated‐image analysis software. Results: The sharp‐edged IOL group had significantly less regeneratory and fibrotic PCO 1 month, 6 months, and 1 year after surgery. The mean AQUA PCO score (scale 0 to 10) was 0.71 in the sharp‐edged IOL group and 1.40 in the round‐edged IOL group (P<.001). The sharp‐edged IOL group had less peripheral fibrotic PCO. There was no significant difference between the 2 IOL groups in patient reports of edge glare. Conclusion: The sharp‐edged design of the ClariFlex OptiEdge silicone IOL led to significantly less PCO than the round‐edged PhacoFlex SI‐40 IOL 1 year postoperatively.

High precision biometry of pseudophakic eyes using partial coherence interferometry

Purpose: To investigate the applicability of the scanning version of dual‐beam partial coherence interferometry (PCI) for measuring the anterior segment and axial length of pseudophakic eyes in a clinical setting and to determine the achievable precision with this biometry technique. Setting: Department of Ophthalmology, Vienna General Hospital, and Institute of Medical Physics, University of Vienna, Austria. Methods: Partial coherence interferometry was performed in 39 pseudophakic eyes of 39 patients after implantation of a foldable acrylic intraocular lens (IOL). Results: Effective lens position (ELP), IOL thickness, and lens‐capsule distance (LCD) were determined with a precision of 2 to 3 &mgr;m; corneal thickness and axial eye length, with a precision of 0.8 and 5.0 &mgr;m, respectively. The mean ELP of the IOL was 4.093 mm ± 0.290 (SD). In 7 eyes (18%), a positive LCD of 68 ± 40 &mgr;m was detected with PCI. Mean corneal thickness was 526.4 ± 31.5 &mgr;m; mean IOL thickness, 791.5 &agr; 40.2 &mgr;m; and mean axial length, 23.388 ± 0.824 mm. Conclusion: The scanning version of PCI enables high precision (≤5 &mgr;m) and high resolution (∼12 Fun) biometry of pseudophakic eyes that is better than conventional ultrasound by a factor of more than 20. For the first time, positive LCD, a possible risk factor for posterior capsule opacification, could be detected and quantified. Furthermore, this technique offers a high degree of comfort for the patient since it is a noncontact method with no need for local anesthesia or pupil dilation and has a reduced risk of corneal infection.

Role of NO in the O2 and CO2 responsiveness of cerebral and ocular circulation in humans

It is well known that changes in PCO2 or PO2 strongly influence cerebral and ocular blood flow. However, the mediators of these changes have not yet been completely identified. There is evidence from animal studies that NO may play a role in hypercapnia-induced vasodilation and that NO synthase inhibition modulates the response to hyperoxia in the choroid. Hence we have studied the effect of NO synthase inhibition by NG-monomethyl-L-arginine (L-NMMA, 3 mg/kg over 5 min as a bolus followed by a continuous infusion of 30 micrograms.kg-1.min-1) on the changes of cerebral and ocular hemodynamic parameters elicited by hypercapnia and hyperoxia in healthy young subjects. Mean flow velocities in the middle cerebral artery and the ophthalmic artery were measured with Doppler ultrasound, and ocular fundus pulsation amplitude, which estimates pulsatile choroidal blood flow, was measured with laser interferometry Administration of L-NMMA reduced ocular fundus pulsation. (-19%, P < 0.005) but only slightly reduced mean flow velocities in the larger arteries. Hypercapnia (PCO2 = 48 mmHg) significantly increased mean flow velocities in the middle cerebral artery (+26%, P < 0.01) and fundus pulsation amplitude (+16%, P < 0.005) but did not change mean flow velocity in the ophthalmic artery. The response to hypercapnia in the middle cerebral artery (P < 0.05) and in the choroid (P < 0.05) was significantly blunted by L-NMMA. On the contrary, L-NMMA did not affect hyperoxia-induced (PO2 = 530 mmHg) hemodynamic changes. The hemodynamic effects of L-NMMA (at baseline and during hypercapnia) were reversed by coadministration of L-arginine. The present study supports the concept that NO has a role in hypercapnia induced vasodilation in humans.It is well known that changes in [Formula: see text] or[Formula: see text] strongly influence cerebral and ocular blood flow. However, the mediators of these changes have not yet been completely identified. There is evidence from animal studies that NO may play a role in hypercapnia-induced vasodilation and that NO synthase inhibition modulates the response to hyperoxia in the choroid. Hence we have studied the effect of NO synthase inhibition by N G-monomethyl-l-arginine (l-NMMA, 3 mg/kg over 5 min as a bolus followed by a continuous infusion of 30 μg ⋅ kg-1 ⋅ min-1) on the changes of cerebral and ocular hemodynamic parameters elicited by hypercapnia and hyperoxia in healthy young subjects. Mean flow velocities in the middle cerebral artery and the ophthalmic artery were measured with Doppler ultrasound, and ocular fundus pulsation amplitude, which estimates pulsatile choroidal blood flow, was measured with laser interferometry. Administration ofl-NMMA reduced ocular fundus pulsations (-19%, P < 0.005) but only slightly reduced mean flow velocities in the larger arteries. Hypercapnia ([Formula: see text] = 48 mmHg) significantly increased mean flow velocities in the middle cerebral artery (+26%, P < 0.01) and fundus pulsation amplitude (+16%, P < 0.005) but did not change mean flow velocity in the ophthalmic artery. The response to hypercapnia in the middle cerebral artery ( P < 0.05) and in the choroid ( P < 0.05) was significantly blunted by l-NMMA. On the contrary,l-NMMA did not affect hyperoxia-induced ([Formula: see text] = 530 mmHg) hemodynamic changes. The hemodynamic effects ofl-NMMA (at baseline and during hypercapnia) were reversed by coadministration ofl-arginine. The present study supports the concept that NO has a role in hypercapnia-induced vasodilation in humans.