Oliver Schwenn

Objective and subjective evaluation of photic phenomena after monofocal and multifocal intraocular lens implantation.

OBJECTIVEnTo objectively measure and compare halo, flicker, and glare disability in pseudophakic eyes with monofocal (MONO) and multifocal (MULTI) intraocular lenses (IOLs) with respect to the influence of corneal surface quality, astigmatism, and age.nnnDESIGNnProspective case series.nnnPARTICIPANTSnThis clinical trial involved 28 eyes of 28 patients after small-incision cataract surgery with a MONO silicone IOL and 28 eyes of 28 patients with zonal-progressive silicone IOL.nnnINTERVENTIONnA computer program objectively determined halo, glare, and flicker. Corneal surface quality and astigmatism were measured using computerized videokeratography. Ray-tracing analysis was performed based on the videokeratography data to calculate retinal peak distance and distortion index. A questionnaire was sent to all patients to evaluate the incidence of subjective photic phenomena.nnnRESULTSnMean halo size (square degrees +/- standard deviation) valued 6.1 (+/- 1.3) in the MONO group and 7.2 (+/- 2.3) in the MULTI group with no statistically significant difference between MONO and MULTI. Flicker (in % contrast to add) was -0.7 (+/- 2.9) in the MONO group and -1.0 (+/- 4.2) in the MULTI group with no statistical differences. Glare (in % contrast to add) was 5.5 (+/- 16.5) in the MONO group and 6.5 (+/- 18.0) in the MULTI group with no statistical differences. Patients in the MONO group older than 70 years of age had significantly more glare than those younger than 70 years (P = 0.017). In the MULTI group, patients with corneal shape irregularities (peak distance > 6.0 microm) or astigmatism (> 1 diopter) had statistically significant greater halos than did patients with regular corneal shape (peak distance < or = 6.0 microm) or astigmatism (< or = 1 diopter) (P < 0.005). Three of 27 MONO patients and 9 of 28 MULTI patients noticed light sensations (mainly halos) after surgery that were not present before surgery, with the majority not being bothered by these at all.nnnCONCLUSIONnIn monofocal as well as in multifocal eyes, halo and glare disability occurred. Patient age, corneal surface quality, and IOL design played an important role in these photic phenomena. Because these photic phenomena may be more prevalent in night driving conditions, the authors study suggests that night driving ability, especially in the elderly patient with pseudophakia, should be examined carefully.

Toric phakic intraocular lens: European multicenter study.

OBJECTIVEnTo evaluate safety, efficacy, predictability, stability, complications, and patient satisfaction after implantation of Artisan toric phakic intraocular lenses (TPIOLs) for the correction of myopia or hyperopia with astigmatism.nnnDESIGNnProspective, nonrandomized, comparative (self-controlled) multicenter trial.nnnPARTICIPANTSnSeventy eyes of 53 patients (mean, 35 years; range, 22-59 years) with preoperative spherical equivalent between +6.50 and -21.25 diopters (D) and cylinder between 1.50 and 7.25 D.nnnMETHODSnSeventy eyes underwent implantation of a TPIOL with an optical zone of 5.0 mm (Artisan, Ophtec, Groningen, The Netherlands). The dioptric power of the intraocular lens was calculated by considering refraction, keratometry, and anterior chamber depth. The follow-up was 6 months in all cases. Lenses were available in powers ranging from +12.0 D to -23.5 D (spherical equivalent) in 0.5-D increments, with additional cylinder from 1.0 D to 7.0 D, also in 0.5-D increments.nnnMAIN OUTCOME MEASURESnThe main parameters assessed were best spectacle-corrected visual acuity (BSCVA), uncorrected visual acuity (UCVA), refraction, endothelial cell count (ECC), intraocular pressure, slit-lamp biomicroscopy, indirect ophthalmoscopy, subjective complaints, and patient satisfaction.nnnRESULTSnEyes were divided into group A, myopia (n = 48), with an average preoperative spherical equivalent of -8.90 +/- 4.52 D, and group B, hyperopia (n = 22), with an average preoperative spherical equivalent of +3.25 +/- 1.98 D. No eyes in either group experienced a loss in BSCVA, and 46 eyes gained 1 or more lines of their preoperative BSCVA. In 62 eyes (88.6%), UCVA was 20/40 or better. There was a significant reduction in spherical errors and astigmatism in all cases after surgery. All eyes of both groups were within +/-1.00 D of target refraction, and 51 eyes (72.9%) were within +/-0.50 D of target refraction. There was a 4.5% mean total loss of ECC during the first 6 months. No serious complications were observed. Overall patient satisfaction was very high.nnnCONCLUSIONSnSix-month clinical trial results demonstrate that implantation of the Artisan TPIOL safely, predictably, and effectively reduced or eliminated high ametropia and astigmatism with one procedure. The refractive effect was stable at 6 months after surgery.

Inflammation after sclerocorneal versus clear corneal tunnel phacoemulsification.

OBJECTIVEnTo compare the postoperative inflammation after phacoemulsification followed by intraocular lens (IOL) implantation by means of sclerocorneal versus clear corneal tunnel incision.nnnDESIGNnRandomized controlled clinical trial.nnnPARTICIPANTSnOne hundred eyes of 100 patients were examined at a German University eye hospital.nnnINTERVENTIONnOne hundred eyes with cataract necessitating phacoemulsification with posterior chamber IOL implantation were randomly assigned to receive a temporal sclerocorneal or clear corneal tunnel incision by a single surgeon.nnnMAIN OUTCOME MEASURESnPreoperative and postoperative inflammation was evaluated by measurement of flare using laser flare photometry. Statistical inference was mainly based on nonparametric group comparisons by use of two sample Wilcoxon tests.nnnRESULTSnMean anterior chamber flare in the group with sclerocorneal tunnel increased from 7.5 photon counts/ms preoperatively to 19.6 at 6 hours postoperatively and decreased to 11.1 (day 1), 11.7 (day 2), 11.6 (day 3), and 9.2 (5 months) during the postoperative course. The mean flare in the clear corneal tunnel incision group increased from 7.7 preoperatively to 12.9 at 6 hours postoperatively and then decreased to 9.2 (day 1), 9.8 (day 2), 9.1 (day 3), and 9.2 (5 months). Individual postoperative flare changes were significantly lower in the clear corneal tunnel group at the day of surgery (P<0.0001), as well as at day 1 (P = 0.0011), day 2 (P = 0.0079), and day 3 (P = 0.0020). After 5 months, no statistically significant difference was found.nnnCONCLUSIONSnAfter phacoemulsification and foldable IOL implantation, postoperative alteration in the blood-aqueous barrier was statistically significantly lower with the clear corneal tunnel incision group compared with the sclerocorneal incision group, in the first 3 days postoperatively.

Postoperative astigmatism and rotational stability after artisan toric phakic intraocular lens implantation.

Purpose: To evaluate deviations in the axis (intended versus achieved) and postoperative astigmatism after implantation of an Artisan toric phakic intraocular lens (IOL). Setting: University Eye Hospital, Mainz, Germany. Methods: This prospective study comprised 29 eyes with high ametropia and astigmatism. All eyes had uneventful implantation of a toric phakic IOL through a superior scleral tunnel incision at 12 oclock. After a minimum of 6 months, the uncorrected visual acuity (UCVA), best correct visual acuity, refraction, and astigmatism were analyzed in all eyes. A multivariate analysis of postoperative astigmatism was performed. Results: After a follow‐up of at least 6 months, 95% of eyes were within ±1.00 diopter (D) of emmetropia and 85% of eyes has a UCVA of 20/30 or better. The difference between the mean intended cylinder axis and achieved cylinder axis was 3.9 degrees (median 3 degrees; range to 13 degrees). The difference between the mean intended axis and the achieved axis between miosis and mydriasis was 1.8 degrees (median 1.5 degrees; range 0 to 5 degrees). The mean postoperative astigmatism after 6 months was 0.56 D with an axis of 31 degrees. Doubled‐angle scatterplot analysis showed a tendency toward more flattening in the vertical meridian. Conclusions: During the 6‐month follow‐up, no significant rotation was observed after implantation of Artisan toric phakic IOLs to correct high ametropia. A sutureless sclerocorneal superior approach for phakic IOL insertion resulted in moderate to low astigmatism. Induced astigmatism should be taken into consideration during preoperative planning.

A Randomized Trial of a Schlemm's Canal Microstent with Phacoemulsification for Reducing Intraocular Pressure in Open-Angle Glaucoma

PURPOSEnTo assess the safety and effectiveness of the Hydrus Microstent (Ivantis, Inc, Irvine, CA) with concurrent cataract surgery (CS) for reducing intraocular pressure (IOP) in open-angle glaucoma (OAG).nnnDESIGNnProspective, multicenter, randomized, single-masked, controlled clinical trial.nnnPARTICIPANTSnOne hundred eyes from 100 patients 21 to 80 years of age with OAG and cataract with IOP of 24 mmHg or less with 4 or fewer hypotensive medications and a washed-out diurnal IOP (DIOP) of 21 to 36 mmHg.nnnMETHODSnOn the day of surgery, patients were randomized 1:1 to undergo CS with the microstent or CS alone. Postoperative follow-up was at 1 day, 1 week, and 1, 3, 6, 12, 18, and 24 months. Washout of hypotensive medications was repeated at 12 and 24 months.nnnMAIN OUTCOME MEASURESnResponse to treatment was defined as a 20% or more decrease in washed out DIOP at 12 and 24 months of follow-up compared with baseline. Mean DIOP at 12 and 24 months, the proportion of subjects requiring medications at follow-up, and the mean number of medications were analyzed. Safety measures included change in visual acuity, slit-lamp observations, and adverse events.nnnRESULTSnThe proportion of patients with a 20% reduction in washed out DIOP was significantly higher in the Hydrus plus CS group at 24 months compared with the CS group (80% vs. 46%; P = 0.0008). Washed out mean DIOP in the Hydrus plus CS group was significantly lower at 24 months compared with the CS group (16.9±3.3 mmHg vs. 19.2±4.7 mmHg; P = 0.0093), and the proportion of patients using no hypotensive medications was significantly higher at 24 months in the Hydrus plus CS group (73% vs. 38%; P = 0.0008). There were no differences in follow-up visual acuity between groups. The only notable device-related adverse event was focal peripheral anterior synechiae (1-2 mm in length). Otherwise, adverse event frequency was similar in the 2 groups.nnnCONCLUSIONSnIntraocular pressure was clinically and statistically significantly lower at 2 years in the Hydrus plus CS group compared with the CS alone group, with no differences in safety.

Healon5 versus Viscoat during cataract surgery: intraocular pressure, laser flare and corneal changes

Abstractu2002Background: The use of a viscoelastic substance facilitates cataract surgery. Healon 5 is a new viscoelastic product with special rheological properties. We evaluated the postoperative effect of Viscoat and Healon5 on intraocular pressure (IOP), central corneal thickness (CCT), endothelial cell counts and laser flare. Methods: Forty-eight eyes of 48 patients undergoing routine phacoemulsification followed by foldable IOL implantation were enrolled. Either Healon5 or Viscoat was used according to a block- randomization scheme. The aspiration technique was standardized. IOP, CCT, endothelial cell counts and laser flare were compared pre- and postoperatively. Statistical analysis was performed using the two-sample Wilcoxon test. Data description was based on median and quartiles, while graphic description was performed by non-parametric box plots. Results: Viscoat demonstrated a statistically significant higher IOP than Healon5 at 4 and 8 h postoperatively (P<0.01 and <0.05, respectively). Further, the laser flare values were statistically significantly higher for the Viscoat than for the Healon5 group 8 h postoperatively (P<0.05). Endothelial cell loss did not differ significantly between the two groups (relative change in endothelial cell density after 3 months: –4.3% for the Healon5 group and –6.2% for Viscoat group). Conclusion: There was neither a statistically nor a clinically significant difference in endothelial cell loss after the use of Healon5 or Viscoat in routine cataract surgery. However, the IOP in the early postoperative period was higher in the Viscoat group than in the Healon5 group.

Trabeculotomy in congenital glaucoma

Abstractu2002Background: Congenital glaucoma is a potentially blinding disease that requires surgical therapy. This paper describes the outcome of trabeculotomy in primary congenital glaucoma.u2002Methods: Thirty-nine eyes of 22 children with congenital glaucoma who underwent trabeculotomy with or without a simultaneous trabeculectomy between 1992 and 1997 were retrospectively analyzed.u2002Results: Mean follow-up was 24.7±17.9 months. A mean of 1.3 operations per eye were performed. The mean IOP at the end of follow-up (n=39) was 17.7±6.0 mmHg; in 8 eyes (20.5%) the IOP was >21 mmHg, in 31 eyes (79.5%) it was ≤21 mmHg. The mean difference between pretreatment IOP and IOP at the end of follow-up (n=39) was –10.5±9.4 mmHg (–37.2%). Success rates were calculated: IOP was ≤21 mmHg in 36/39 eyes (92.3%) after 1/2 year of follow-up, in 25/27 eyes (92.6%) after 1 year, in 15/18 eyes (83.3%) after 2 years, in 8/12 (66.7%) eyes after 3 years, in 4/8 eyes (50%) after 4 years and in 4/4 (100%) eyes after 5 years of follow-up. Complications included hypotony (three eyes), subchoroidal bleeding (one eye ), detachment of Descemet’s membrane (one eye) and macular pucker (one eye in which later mitomycin C was used). Visual acuity (VA) was tested with various methods in 35 eyes. VA was within the normal nomogram range in 12 eyes and below the normal range in 23 eyes at the end of follow-up. Axial length measurements showed normalization according to the age nomogram in 22 of 35 eyes.u2002Conclusion: This study shows that trabeculotomy is an effective surgical procedure in congenital glaucoma with satisfactory success rates up to 5 years of follow-up.

Correlation of postoperative axial length growth and intraocular pressure in congenital glaucoma – a retrospective study in trabeculotomy and goniotomy

Abstract.Background: This paper investigates the correlation of postoperative intraocular pressure (IOP) with axial length growth in children who underwent either trabeculotomy (TO) or goniotomy (GO) as primary surgery for congenital glaucoma. Methods: Thirty-seven eyes of 21 children with congenital glaucoma who underwent one or two TOs from 1992 to 1997 and 26 eyes of 16 children with congenital glaucoma who underwent one or more GOs from 1974 to 1993 were retrospectively analyzed. None of the eyes had undergone other surgery previously. Thirteen of the TOs were combined with a small trabeculectomy. IOP was measured by handheld applanation tonometry (Perkins). Axial length was measured by ultrasound. The data were analyzed for correlation of postoperative IOP reduction with postoperative axial length growth. Results: Mean duration of follow-up was 27.3 months in the TO eyes and 37.1 months in the GO eyes. Mean pretreatment IOP before surgery was 28.4±6.9xa0mmHg in the TO eyes and 30.8±8.5xa0mmHg in the GO eyes. Mean IOP at the end of follow-up was 17.5±5.8xa0mmHg in the TO eyes and 17.4±10.2xa0mmHg in the GO eyes. Axial length growth was normalized (proportional or slowed down compared with the nomogram of axial length growth) in 31 of the 37 TO eyes and in 20 of the 26 GO eyes, and was increased in 6 of the TO eyes and 6 of the GO eyes at the end of follow-up. Regarding axial length growth, 6 of 37 TO eyes had increased axial length growth at the end of follow-up. Three of these eyes also did not fulfill the IOP success criterion; 2 of the 3 eyes with normalized IOP had only borderline increased axial length growth. Six of 26 GO eyes had increased axial length growth at the end of follow-up. Five of these eyes did not fulfill the IOP success criterion; 1 eye with normalized IOP had only borderline increased axial length growth. Conclusion: The data show remarkably good correlation of postoperative IOP with postoperative axial length growth. Axial length measurements can therefore help to ascertain halting or progression of congenital glaucoma and thus are considered an important parameter for congenital glaucoma follow-up.

Long-term results of cataract surgery combined with trabeculotomy.

Abstract.Background: There are different surgical approaches for cataract and concomitant primary open-angle glaucoma (POAG). In a retrospective study we examined the long-term results of cataract extraction combined with trabeculotomy. Patients and methods: Between1990 and 1997, 194 eyes with cataract and POAG were operated on in a combined manner. Eighty-eight eyes received a trabeculotomy (TT), in 82 eyes a trabeculectomy was added to the trabeculotomy (TT+TE) and in 24 eyes, in which probing of Schlemms canal was impossible, standard trabeculectomy (TE) was performed. Pre- and postoperative intraocular pressure (IOP), glaucoma medication, and the intra- and postoperative complications of all patients were analyzed. Results: Hyphema was the most common complication in the TT group (20.5%). Fibrin reaction occurred in 27.8% of all cases. There was no statistically significant difference in postoperative IOP between the TT group and the TT+TE group. A statistically significant decrease in IOP compared to preoperatively lasted 60 months in the TT group. In eyes with a preoperative IOP ≤20xa0mmHg, none of the three procedures reduced IOP significantly (<20% of the preoperative IOP). In the first 2 years after operation 50% of the patients had no need for antiglaucomatous medication. Conclusions: Cataract surgery combined with TT resulted in few complications. In low-tension glaucoma the combination with TT is not sufficient to decrease the IOP. In patients with higher preoperative IOP, however, cataract surgery combined with TT could be – on the basis of a postoperative observation time of 72 months – a suitable method for lowering the IOP sufficiently. Furthermore, the use of antiglaucomatous substances was reduced by this combined procedure.

Intraocular pressure after small incision cataract surgery: temporal sclerocorneal versus clear corneal incision

Purpose: To compare intraocular pressure (IOP) after phacoemulsification and foldable intraocular lens (IOL) implantation using a temporal sclerocorneal or clear corneal incision. Setting: Department of Ophthalmology, Johannes Gutenberg‐University, Mainz, Germany. Methods: One hundred patients (100 eyes) with cataract having phacoemulsification with posterior chamber IOL implantation were randomly assigned to receive a temporal sclerocorneal or clear corneal tunnel incision. Intraocular pressure was measured preoperatively and 6 hours, 1, 2, and 3 days, and 5 months postoperatively. Statistical significance was determined by nonparametric group comparisons using 2‐sample random Wilcoxon tests. Results: Six hours postoperatively, the median IOP increase was significantly higher in the sclerocorneal tunnel group (57%) than in the clear corneal incision group (18%) (P < .001). No significant between‐group difference in IOP was found at 1, 2, or 3 days or 5 months. At 5 months, IOP was 0.6 mm Hg lower than preoperatively in the sclerocorneal tunnel group and 1.5 mm Hg lower in the clear corneal group. Conclusions: After phacoemulsification and foldable IOL implantation, the immediate postoperative IOP increase was higher in eyes having a sclerocorneal incision than in those having a clear corneal tunnel incision. These results could be important in eyes with decreased outflow facility or preexisting optic nerve damage.