Samuel Masket

A Prospective, Randomized, Double-masked Comparison of a Zonal-Progressive Multifocal Intraocular Lens and a Monofocal Intraocular Lens

INTRODUCTION Multifocal intraocular lenses (IOLs) have been designed to provide improved near visual acuity without spectacles compared with monofocal IOLs. Early studies have reported variables amounts of decreased visual acuity and contrast sensitivity with multifocal IOLs, and some patients have experienced halos and glare. METHODS The authors performed a prospective, double-masked, multicenter evaluation of 62 patients randomized between a new zonal-progressive optic multifocal IOL and a monofocal IOL. RESULTS Mean postoperative spherical equivalent, astigmatism, and uncorrected and best-corrected distance visual acuity were similar between the two groups. Patients with a multifocal IOL achieved significantly better uncorrected near visual acuity than patients with monofocal IOLs (J3+ versus J7; P less than 0.0001). With distance correction only, mean near visual acuity was J2 versus J5- (P = 0.0001). Best-corrected near visual acuity was J1 for both groups, with 1.36 diopters (D) for the multifocal group versus 2.37 D for the monofocal group (P less than 0.0001). Regan contrast sensitivity was lower for the multifocal patients at all contrast levels, and achieved statistical significance at very low contrast (11% contrast; P = 0.0024). Fifty-two percent of patients with a multifocal IOL reported that they did not need spectacles at all or used them only for their fellow eye, compared with 25% of the patients with monofocal IOLs. CONCLUSION Both monofocal and multifocal implant patients were very satisfied with the results of their cataract extraction and IOL implant surgery. A small loss of contrast sensitivity with the multifocal IOL was demonstrated, consistent with theoretical predictions. The functional significance of the loss of contrast sensitivity appears to be small and counterbalanced by the advantage of improved uncorrected near visual acuity.

Postoperative complications of capsulorhexis

ABSTRACT Capsulorhexis has become the preferred method of anterior capsulotomy, and untoward effects have not been frequently noted. Nevertheless, distinct complications of continuous tear anterior capsulotomy are now recognized. These include capsular bag hyperdistention, shrinkage of the anterior capsule opening with visual loss and/or intraocular lens decentration, and lens epithelial cell hyperproliferation on the posterior lens capsule. The latter has not been reported and may be associated with reduction or closure of laser posterior capsulotomies in the form of a “string of pearls” around the capsule opening. Current styles of capsular surgery and intraocular lens implantation in which the anterior capsule edge overlaps the lens may be responsible for these phenomena. Although altering the surgical methods may obscure these complications, eliminating the anterior subcapsular and equatorial lens epithelial cells is necessary to prevent capsule contraction and lens epithelial cell hyperproliferation.

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.

Simple regression formula for intraocular lens power adjustment in eyes requiring cataract surgery after excimer laser photoablation

PURPOSE: To develop a simple and accurate method for determining appropriate intraocular lens (IOL) power in cataract patients who had prior excimer laser photoablation for myopia or hyperopia, because laser vision corrective surgery interferes with traditional keratometry and corneal topography, rendering IOL power calculations inaccurate. SETTING: Private Practice in Century City (Los Angeles), California, and free‐standing outpatient surgery centers with institutional review boards. METHODS: Based on the empiric experience of the senior author, an IOL power correction factor that was proportional to the prior laser photoablation was determined and applied to the IOL power calculated by the IOLMaster (Zeiss). It was necessary to add to the predicted IOL power in eyes with prior myopic laser ablation, whereas eyes having prior hyperopic laser vision correction required a reduction in the IOL power. The correction factor was applied to 30 eyes that required cataract surgery at some time after laser refractive surgery; 23 eyes had prior treatment for myopia, and the remaining 7 eyes had prior hyperopic laser ablation. A regression formula was generated from the IOL power correction factor that was used in the 30 eyes. RESULTS: Using the correction factor for 30 eyes, the mean deviation from the desired postcataract refractive outcome was −0.15 diopter (D) ± 0.29 (SD); 28 of 30 eyes were within ±0.5 D of the intended goal; the remaining 2 eyes were both −0.75 D from the desired optical result of cataract surgery. Fourteen of the 30 eyes were emmetropic. CONCLUSIONS: A simple IOL power corrective adjustment regression formula allowed accurate determination of IOL power after laser refractive photoablation surgery. The weakness of the current method is that knowledge of the amount of prior laser vision correction is necessary.

Femtosecond laser-assisted cataract incisions: Architectural stability and reproducibility

There is considerable interest in the potential relationship between postoperative endophthalmitis and clear corneal tunnel incisions for cataract surgery. Earlier work from Ernest et al. clearly demonstrated that incisions that are square in surface architecture are significantly more resistant to deformation and leakage than those that are rectangular. The purpose of this preliminary investigation was to determine whether corneal tunnel incisions could be constructed with femtosecond laser technology and in a manner that would preclude deformation and leakage at any intraocular pressure (IOP).

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.

Pseudophakic posterior iris chafing syndrome.

ABSTRACT Posterior iris chafing by the loop or the optic portion of sulcusfixated posterior chamber lens implants may cause a spectrum of disorders that include iris‐pigment epithelial “window defects,” pigment dispersion with or without elevation of intraocular pressure, intermittent microhyphemas with transient visual obscurations, and the UGH syndrome. It appears that secondary pigmentary glaucoma is more likely with planar loop design than with angulated loops. Optic and loop materials may play a role in the development of the disorder. Implantation of both supporting loops of the implant within the capsular bag is suggested to prevent posterior iris chafing.

Evaluation of the safety of prophylactic intracameral moxifloxacin in cataract surgery

PURPOSE: To evaluate posterior and anterior segment safety of an intracameral injection of moxifloxacin 0.5% ophthalmic solution as prophylaxis for endophthalmitis in patients having cataract surgery. SETTING: Three private practices, the University of Minnesota School of Medicine, Stillwater, Minnesota, and the University of Cincinnati, Cincinnati, Ohio, USA. METHODS: In this prospective randomized combined‐center open‐label trial, 57 eyes of 47 patients were treated with intracameral moxifloxacin (250 μg/0.050 mL) or an equal volume of balanced salt solution at the conclusion of cataract surgery with intraocular lens implantation. Safety parameters, including visual acuity, intraocular pressure, endothelial cell counts, corneal pachymetry, corneal clarity and edema, and anterior chamber cells and flare, were evaluated preoperatively and for 3 months postoperatively. RESULTS: Optical coherence tomography results showed no statistically significant differences between the 2 treatment groups preoperatively or at 3 months. There were also no statistically significant differences between the 2 treatment groups in all other parameters preoperatively or at 1 day, 2 to 4 weeks, or 3 months. No study‐related adverse events occurred. CONCLUSION: There was no increased safety risk associated with a 250 μg/0.050 mL intracameral injection of moxifloxacin, which appears to be safe in the prophylaxis of endophthalmitis after cataract surgery.

Astigmatic stabilization of 3.0 mm temporal clear corneal cataract incisions

Purpose: To determine the time needed for corneal shape changes to stabilize after a laterally oriented, 3.0 mm, unsutured, single‐hinge clear corneal tunnel cataract incision combined with implantation of a foldable acrylic 5.5 mm intraocular lens. Setting: Advanced Vision Care, West Hills, California. Methods: The study comprised 45 patients who had a similar phacoemulsification technique and lens implantation through an unenlarged 3.0 × 2.5 mm self‐sealing temporal clear corneal tunnel incision. Changes in corneal curvature were determined by computerized videokeratography (corneal topography) prior to surgery and at 1, 2, and 6 weeks after surgery. Simulated keratometry was ascertained from topography and analyzed with the Lens‐Stat software program. Results: Preoperative corneal cylinder, cylinder axis, and central corneal curvature did not change markedly after surgery. By vector analysis, approximately 0.50 diopter (D) of induced cylinder was noted, whereas less than 0.25 D of cylinder change was observed in the surgical meridian. Although statistically similar, there were slight differences between the data at 1 and 2 weeks postoperatively. However, the 2 and 6 week data were indistinguishable, indicating that the incision method used in the study was fully stable within 2 weeks of surgery. Conclusions: The surgical method resulted in stable corneal curvature by 2 weeks after surgery at which time the patient is ready for final spectacle prescription and can be discharged from acute postoperative ophthalmologic care in the absence of complicating factors. The shortened recovery time is beneficial for the patient and has significant potential effects on the global costs of cataract rehabilitation and the reimbursement schemes for postoperative management.

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.