Richard Davidson

Femtosecond laser-assisted cataract surgery.

Femtosecond laser-assisted cataract surgery provides surgeons an exciting new option to potentially improve patient outcomes and safety. Over the past 2 years, 4 unique laser platforms have been introduced into the marketplace. The introduction of this new technology has been accompanied by a host of new clinical, logistical, and financial challenges for surgeons. This article describes the evolution of femtosecond laser technology for use in cataract surgery. It reviews the available laser platforms and discusses the necessary modifications in cataract surgery technique and the logistics of incorporating a femtosecond laser into ones practice.

Characterizing the learning curve in phacoemulsification

PURPOSE: To characterize how residents learn phacoemulsification and determine which steps of the procedure are most difficult to master. SETTING: University of Colorado Hospital, Aurora, Colorado, USA. DESIGN: Comparative case series. METHODS: Cataract cases were divided into 3 levels of difficulty for comparison. Residents were given a grade for each step of the procedure by the attending surgeon. Main outcome measures were total case time and a proficiency grade. Independent variables were level of resident experience and degree of difficulty. Case times of attending cases were collected for comparison. RESULTS: Nine residents were evaluated by 4 attending surgeons while performing 324 cases of phacoemulsification. Case times of 319 attending cases were used for comparison. The easiest‐to‐learn steps (highest scores versus level of experience) included intraocular lens insertion, ophthalmic viscosurgical device removal, hydrodissection, and nucleus sculpting. Wound integrity, nucleus disassembly and removal, cortex removal, and capsulorhexis had the lowest scores versus level of experience. Resident case times decreased significantly with experience, approaching average case times for attendings. CONCLUSIONS: For this study, competency was defined as the ability of the resident to perform a case in a reasonable time without intervention or complication. Using this definition, competency was achieved when case experience exceeded 75 cataract surgeries. Financial disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Intraocular pressure-induced interlamellar keratitis after LASIK surgery.

PurposeTo describe a case of interlamellar stromal keratitis induced by increased intraocular pressure (IOP) after LASIK surgery. MethodsCase report and review of the literature. ResultsA 53-year-old white man with a history of treated ocular hypertension underwent uncomplicated LASIK surgery. The postoperative course was complicated by markedly elevated IOP induced by topical corticosteroid drops used to treat what appeared to be diffuse lamellar keratitis. Because IOPs remained uncontrolled despite maximal therapy, topical steroids were discontinued after a total of 9 weeks. The IOP rapidly returned to normal range with complete resolution of the corneal findings. Humphrey visual field analysis, confocal scanning laser imaging of the optic nerve, and stereoscopic disc photographs all demonstrated that significant glaucomatous field loss and optic atrophy developed over this 8-week period. DiscussionThe IOP should be immediately evaluated in patients who present with interlamellar stromal keratitis more than 1 week after LASIK. If the IOP is elevated, corticosteroid drops should be discontinued to prevent permanent visual loss. Furthermore, if a glaucoma specialist examines a patient with a history of LASIK and unexplained visual field loss, the medical record should be reviewed to determine if the postoperative course was complicated by this diffuse lamellar keratitis–like phenomenon.

Dry Eye Syndrome: An Update in Office Management

Dry eye syndrome is a multifactorial disease of the ocular surface and tear film that results in ocular discomfort, visual disturbances, and tear instability, with potential damage to the cornea and conjunctiva. Risk factors for dry eye syndrome include age (>50 years old), female sex, environments with low humidity, systemic medications, and autoimmune disorders. There are several treatment options that range from artificial tears to anti-inflammatory and immunosuppressant agents. Treatment of this highly prevalent condition can drastically improve the quality of life of individuals and prevent damage to the ocular surface.

Incidence of Nd:YAG Capsulotomy After Implantation of AcrySof Multifocal and Monofocal Intraocular Lenses: A Case Controlled Study

PURPOSE To compare the frequency of posterior capsulotomies in patients receiving a multifocal or monofocal intraocular lens (IOL) of a similar design following cataract extraction. METHODS Four hundred seventeen eyes underwent cataract extraction and IOL implantation; 275 eyes received the AcrySof SN6OWF (Alcon Laboratories Inc) one-piece monofocal lens (monofocal group) and 142 eyes received the RESTOR multifocal lens (SN60D3 or SA60D3, Alcon Laboratories Inc) (multifocal group). Surgery was performed by two surgeons at one site. Primary outcome measures were incidence, time of onset, and preoperative corrected distance visual acuity (CDVA) for those patients receiving posterior capsulotomies. RESULTS After average 22-month postoperative follow-up (range: 2 to 41 months), 22 (15.49%) eyes in the multifocal group underwent posterior capsulotomies compared with 16 (5.82%) eyes in the monofocal group (P = .0014). The main indication for Nd:YAG laser capsulotomy in the multifocal group was complaint of poor quality of vision rather than decreased CDVA. The multifocal group underwent capsulotomies after a mean of 8.8 months (range: 1.7 to 29.2 months), whereas the monofocal group required capsulotomies after a mean of 10.4 months (range: 0.8 to 28.6 months) (P = .559). Mean logMAR CDVA before capsulotomy was 0.113 (range: 0 to 0.6) for the multifocal group and 0.244 (range: 0 to 0.48) for the monofocal group (P = .073). CONCLUSIONS Use of the RESTOR multifocal IOL in clinical practice may result in more frequent Nd:YAG laser capsulotomies. Reasons for this may include increased visual demands of patients receiving presbyopic-correcting IOLs or complex visual phenomena associated with the interaction of multifocal optics and posterior capsule opacification.

Time and cost of teaching cataract surgery

Purpose To compare the differences in the time of completion of cataract surgery for residents and attending surgeons and to assign a dollar cost. Setting University of Colorado teaching hospital, Aurora, Colorado, USA. Design Comparative case series. Methods Cataract cases were divided into 3 levels of difficulty for comparison. Main outcome measures were total case time (incision to patch) and degree of difficulty. Results Nine residents and 6 attending surgeons participated in the study. Case times were collected for 324 resident cases and 319 attending surgeon cases. The mean attending surgeon case time was 25.75 minutes ± 12.32 (SD) and the mean resident case time, 46.35 ± 16.75 minutes. There was no significant difference in the degree of difficulty between resident cases and attending surgeon cases. Approximately 600 total cases were performed by 4 residents during 3 years of residency training. Taking into account the mean time of case completion for attending surgeons versus residents, the total difference in time if attending surgeons had performed 600 cataracts would be 12 360 minutes. Using a dollar cost of approximately

Current knowledge about and recommendations for ocular methicillin-resistant Staphylococcus aureus.

11.24 per minute at the institution, the cost difference was calculated to be

Iris melanoma arising from sector congenital ocular melanocytosis in a child.

138 926.40. Conclusion There was a significant time and dollar cost incurred in teaching cataract surgery. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Surgical correction of presbyopia

UNLABELLED Staphylococcus aureus is the most important and common pathogen that infects patients following cataract surgery, laser in situ keratomileusis, and photorefractive keratectomy. It is reported to be the second most common pathogen causing bacterial keratitis around the world. Of special concern are increasing reports of postoperative methicillin-resistant S aureus (MRSA) infection. For example, MRSA wound infections have been reported with clear corneal phacoemulsification wounds, penetrating keratoplasty, lamellar keratoplasty, and following ex vivo epithelial transplantation associated with amniotic membrane grafts. These and other data suggest that MRSA has become increasingly prevalent worldwide. In this article, we review the current medical literature and describe the current challenge of ocular MRSA infections. Recommendations are made based on an evidence-based review to identify, treat, and possibly reduce the overall problem of this organism. FINANCIAL DISCLOSURE No author has a financial or proprietary interest in any material or method mentioned.

Descemet-stripping automated endothelial keratoplasty donor tissue preparation using the double-pass microkeratome technique.

Purpose: To report a clinicopathologic correlation of a melanoma arising from iris component of ocular melanocytosis in a child. Methods: A 13-year-old boy developed a progressive iris nodule arising from sector iris pigmentation that was a component of congenital ocular melanocytosis involving the iris, ciliary body and choroid. The tumor was examined clinically and with ultrasound biomicroscopy (UBM), removed by peripheral iridocyclectomy, and studied histopathologically. Results: Clinically, the pigmented nodule was 3 mm in diameter, located within the sector iris pigmentation, and was 2.4 mm in thickness as measured by UBM. Histopathologically, it was composed predominately of spindle B melanoma cells with adjacent spindle and dendritic melanocytes compatible with iris melanocytosis. Conclusion: Although highly unusual, melanoma can arise in the sector iris pigmentation that is often a component of congenital ocular melanocytosis. Even young patients with ocular melanocytosis should be examined periodically for development of melanoma in the ciliary body and choroid.