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To evaluate the visual and refractive outcomes of laser corneal enhancement after trifocal intraocular lens (IOL) implantation in eyes previously treated with myopic/hyperopic laser corneal refractive surgery (LCRS).Clinica Baviera-AIER-Eye Group, Spain.Retrospective comparative case series.Patients were divided by primary LCRS into myopic and hyperopic groups. The outcomes evaluated were uncorrected distance (UDVA), corrected distance (CDVA), uncorrected intermediate (UIVA), and uncorrected near visual acuity (UNVA), and predictability, safety, efficacy, and satisfaction after implantation of 2 trifocal IOL models (Physiol-FineVision and Zeiss-ATLisa 839) and subsequent laser enhancement.186 eyes (89 myopic and 97 hyperopic eyes) from 146 patients were assessed. At the last visit, refractive outcomes were better in myopic than those in hyperopic eyes, with statistically significant differences for sphere ( P.001), cylinder ( P.001), manifest refraction spherical equivalent (MRSE) ( P = .003), CDVA ( P = .005), UDVA ( P = .047), and UNVA ( P = .003) but not for UIVA ( P = .580), binocular UIVA ( P = .660), or binocular UNVA ( P = .836). Predictability differences were nonsignificant between groups for a final MRSE of ±0.5 diopters (D) and ±1.0 D (P = .167 and .502, respectively). Efficacy and safety were similar in both groups ( P = .235 and P = .080). A greater myopic MRSE was present after trifocal implantation in myopic than in hyperopic eyes (MRSE = -0.93 vs -0.69 D, P = .013), and the statistically significant differences were maintained after enhancement between both groups (MRSE -0.00 vs 0.00 D, P = .003). Overall satisfaction was similar in both groups ( P.05 all items).Corneal laser enhancement after implantation of a trifocal IOL in eyes previously treated for myopia or hyperopia with LCRS was safe, effective, predictable, and highly satisfactory.

Purpose To establish if Difluprednate 0.05% nanoemulsion (DIFL) twice a day (BID) is as effective as Prednisolone acetate 1% + Phenylephrine hydrochloride 0.12% suspension (PRED) four times a day (QID) on postsurgical inflammation treatment. Setting 4 private Argentine ophthalmological centers. Design Non-inferiority, prospective, multicenter, double-blind, randomized, parallel-group, comparative trial. Methods A total of 259 patients who underwent phacoemulsification randomly received DIFL or PRED starting the day before surgery and continuing for 28 days. The primary endpoint was central corneal thickness. Non-inferior anti-inflammatory efficacy was considered if the difference of corneal thickness between baseline and Day 4 did not differ beyond 17 µm between treatments. Secondary endpoints were cell & flare, corrected distance visual acuity (CDVA), endothelial cell count, OCT-central macular thickness, and intraocular pressure (IOP). All outcomes were evaluated at baseline, day 1, 4, and 28 after surgery. Results 225 patients finished the study. The difference in corneal thickness at baseline and Day 4 did not differ beyond 17 µm between treatments (IC95% -2.78µm - 14,84 µm), with no statistically significant difference between treatments (p = 0.523). There were not statistically significant differences between groups on total anterior chamber clearance at any study time (p > 0.05). No statistically significant differences were reported between treatments in CDVA (p = 0.455), endothelial cell count (p = 0.811), OCT-central macular thickness (p = 0.869), and in intraocular pressure outcome (p = 0.316). Conclusions Difluprednate administered BID is at least as effective as Prednisolone acetate administered QID on inflammatory treatment following cataract surgery.

PURPOSE Evaluation of intra-operative aphakic axial eye length (AL) measurements using swept source optical coherence tomography. SETTING Hanusch Hospital, Vienna, Austria. DESIGN Prospective single-center study. METHODS Patients scheduled for cataract surgery were measured using swept-source optical coherence tomography (ss-OCT, IOLMaster 700, Carl Zeiss Meditec AG, Jena, Germany) to assess the axial eye length. Intra-operatively, swept source optical coherence tomography (ss-OCT) measurements were performed with a prototype device (IOLMaster 700 connected to an OPMI Lumera 700 microscope, CZM) at the beginning of cataract surgery furthermore of the aphakic eye and 2 months after surgery. RESULTS Of the 59 eyes of 59 patients, the phakic median AL pre-operatively (pre-OP) and intra operatively (intra-OP) were 23.61 mm ± 0.96 (SD) and 23.51 mm ± 0.96 (SD). Absolute median difference was 0.028 ± 0.02 (SD) (p=0.049). Median phakic AL intra-OP versus 2 months post operatively (post-OP) was 23.51 mm ± 0.97 (SD) vs 23.49 mm ± 0.95 (SD). Absolute median difference was 0.049 ± 0.04 (SD) (p=0.000).Median AL intra-OP aphakic versus vs 2 months post-Op pseudophakic were 23.42 mm ± 0.97 (SD) versus 23.42 mm ± 0.97 (SD). Absolute median difference was 0.038 ± 0.04 (SD) (p=0.379). CONCLUSIONS Intra-OP swept source OCT technology of the phakic and aphakic eye shows excellent comparability to pre- and post-operative measurements. This technique allows axial eye length measurements with high precision in cases where pre-op biometric measurements are not possible.

Purpose To examine the long-term efficacy and safety of myopic implantable collamer lens (ICL) implantation in active duty US military personnel. Setting Hospital practice. Design Retrospective longitudinal observational study. Methods 1485 patients (median age: 25, Inter-quartile range: 22, 29) underwent ICL surgery. Patients received a preoperative exam including uncorrected visual acuity (UDVA), intraocular pressure (IOP), manifest refraction measuring best corrected visual acuity (CDVA), corneal topography and tomography, qualitative grading of perceived ectatic risk, ophthalmic biometry, and baseline endothelial cell counts (ECC). Outcome measures included UDVA, IOP, vault size, manifest refraction, CDVA, and ECC. Long-term follow-up data ware drawn from the US Military medical record system. Results A total of 3105 eyes were evaluated. Patients received ICLs either due to abnormal topography 68% (2111 eyes) or due to high myopia 32% (994 eyes). Nearly 80% (94 eyes) of eyes maintained UDVA of 20/25 or better up to 8 years postoperatively. The rate of achieving the desired refractive correction was 97% (503 eyes) at 1 year and 90% (81 eyes) at 8 years. Stability of these outcomes were also shown by minimal change in manifest refraction. Documented mean ECC loss was 22% at post-operative year 5. The overall rate of adverse events was 1.2% (36 eyes) including visually significant cataract formation, glaucoma, retinal detachment, and traumatic incision opening. A removal/replacement rate of 4.5% (135 eyes) was observed. Conclusions ICL implantation was found to be effective and safe. Vault sizes decreased over time suggesting an increased risk of cataract formation after seven years. Further study is necessary to assess long-term clinical significance of ECC decline.

Purpose To evaluate the effectiveness of previously applied successful accelerated cross-linking (CXL) treatment in keratoconus stabilization during and after pregnancy. Setting Ankara Yildirim Beyazit University, Ataturk Training and Research Hospital, Turkey. Design Prospective, clinical study. Methods Patients who became pregnant with stable keratoconus (after having an accelerated CXL procedure) were included. Uncorrected (UDVA) and corrected distance visual acuity (CDVA), manifest astigmatism (MA), keratometry (K)1, K2, K-max, central corneal thickness (CCT), thinnest corneal thickness (TCT), anterior (AE) and posterior elevation (PE) were recorded at baseline (before CXL), before pregnancy (the last visit after CXL), during pregnancy (3rd trimester) and after pregnancy (the last visit after pregnancy). Results Study included 24 eyes of 19 patients. The mean time between CXL and conception was 12.4±5.1 months. The mean post-partum follow-up period was 27.6±13.3 months. The mean UDVA, CDVA, MA, and PE values did not show any significant differences during and after pregnancy compared to the post CXL values (p>0.05). The mean K-max flattened significantly after the CXL procedure (p=0.011), however it increased during pregnancy (p=0.037:after CXL-pregnancy) and then decreased back to the pre-pregnancy level after pregnancy (p=0.035:pregnancy-after pregnancy). The mean K1, K2, AE, CCT, and TCT remained stable during pregnancy and significantly decreased after pregnancy (p Conclusion Keratoconus appears to progress during pregnancy in corneas that have previously received successful accelerated CXL treatment. However, this progress is mostly temporary, and generally regression occurs after delivery.

PURPOSE To report the indications, outcomes, and complications regarding the Bag-in-the-lens (BIL) intraocular lens (IOL) exchanges over a period of 13 years in a tertiary ophthalmologic centre. SETTING Department of Ophthalmology of the University Hospital of Antwerp (UZA). DESIGN Observational retrospective study. PATIENTS AND METHODS Between 2003 and 2020, 12 176 patients were operated using the BIL technique. We included adult patients who underwent an intraocular BIL exchange and recorded the demographics, indications, outcomes, and complications. RESULTS Fifty-nine eyes of 59 patients who underwent a BIL exchange between 2007 and 2020 were included (0.48%). The mean age was 61.15 ±13.53 years. The mean time between primary surgery and IOL exchange was 25.73 ± 41.88 months. The main indication for explantation was refractive surprise mostly related to the patients' risk factors e.g. preoperative corneal and refractive surgery. The mean preoperative uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) were 0.36 ± 0.24 and 0.79 ± 0.24 respectively. The postoperative 1 month-UDVA and CDVA were 0.66 ± 0.28 and 0.86 ± 0.19 respectively. The improvement in UDVA was statistically significant (

To study the effect of decentration on the quality of vision in 2 aspheric intraocular lenses (IOLs): aspheric balance curve (ABC) design Vivinex iSert XY1 (Hoya Surgical Opticals, Inc.) and posterior aspheric design AcrySof IQ SN60WF (Alcon Laboratories, Inc.).Advanced Eye Centre, PGIMER, Chandigarh, India.Randomized prospective trial using a random number table.85 eyes were randomized to group 1 (Vivinex XY1) and group 2 (AcrySof IQ) with 40 and 45 eyes, respectively. The higher-order aberration (HOA) profile, Strehl ratio, decentration of the IOL from the visual axis (decentration from the visual axis [DVA]) and the geometric axis (decentration from the geometric axis [DGA]), angle α, and κ were recorded on the iTrace aberrometer, and contrast sensitivity was measured using the Functional Acuity Contrast Test at 12 weeks postsurgery.A total of 85 eyes in 60 patients were evaluated in this study. The mean values of the Strehl ratio (P = .48) and the HOAs (P = .12) of both IOLs were comparable. The HOAs gradually increased with increasing DVA for both lenses at 3.0 mm, 4.0 mm, and 5.0 mm pupil sizes. On comparing the HOAs with the DGA, a statistically insignificant positive correlation was observed. The Strehl ratio did not deteriorate with an increasing angle α in the Vivinex XY1 group; however, it worsened in the AcrySof IQ group. Contrast sensitivity was comparable in both the IOLs except at 1.5 cycles per degree under photopic conditions where the AcrySof IQ was better.Decentration of the lens was best measured with respect to the visual axis. In eyes with a large α, the ABC design induced lesser HOAs and maintained a better Strehl ratio.

Purpose To create an equation for predicting the trabecular iris angle (TIA) and to verify its accuracy after implantable collamer lens (ICL) implantation. Setting Nagoya Eye Clinic, Nagoya, Japan. Design Retrospective evaluation of a screening approach. Methods The subjects included 174 eyes (174 patients) that underwent ICL implantation. Patients were randomly assigned to the prediction equation group (116 eyes) or verification group (58 eyes). Anterior segment optical coherence tomography (AS-OCT; CASIA2 TOMEY) was performed before and 3 months after ICL surgery. For the prediction group, a prediction equation was created with the preoperative AS-OCT parameters and ICL size as independent variables and the postoperative anterior chamber depth (ACD) as dependent variables. Then, by applying the predicted post-ACD and preoperative AS-OCT parameters as independent variables and TIA after ICL surgery as the dependent variable, a prediction equation was created to predict the postoperative TIA (post-TIA) after ICL surgery. Each prediction equation was created using stepwise multiple regression analysis, and its accuracy was verified by a Bland-Altman plot in the verification group. Results The explanatory variables (standardized partial regression coefficient) selected in the post-TIA prediction equation were post-ACD (0.629), TIA750 (0.563), iris curvature (0.353), pupil diameter (-0.281), iris area (-0.249), and trabecular iris space area 250 (-0.171) (R2 = 0.646). There were no clinically significant systematic errors between measured and predictive post-TIA values in the verification group. The average absolute prediction error was 3.43° ± 2.22°. Conclusions Post-TIA can be accurately predicted from the predicted post-ACD and other preoperative AS-OCT parameters.

PURPOSE: To evaluate the refractive, visual, and morphometric changes after implantation with a foldable iris-fixated phakic intraocular lens (pIOL) to correct myopia or astigmatism.SETTING: University Eye Clinic Maastricht, the Netherlands.DESIGN: Prospective case series.METHODS: We evaluated patients implanted with the Artiflex Myopia (Toric) iris-fixated pIOL as of January 2004. Measurements were performed annually and reported after 1 and 5 years.RESULTS: The study included 481 eyes (277 patients; age 39.8±10.9 years [SD]). Five years postoperatively 91% of eyes were within ±1.0 D of target, and the mean myopisation over a 5 year period was 0.22 diopters (pCONCLUSION: Over 5 years logMAR CDVA and UDVA decreased significantly due to myopisation caused by lenticular changes and AXL elongation.

Purpose To quantify the damage to the corneal endothelium from the flow of balanced salt solution during phacoemulsification. Setting John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. Design Experimental Study. Methods Twelve New Zealand white rabbits received bilateral surgery. Six eyes served as controls with no irrigation (incision only). In 18 eyes, the Intrepid Balanced tip of the Centurion (Alcon) Ozil handpiece was inserted into the anterior chamber for continuous irrigation at 50mL/minute with either 250 mL or 500 mL of balanced salt solution (BSS). After euthanasia and enucleation, the corneas were removed, stained with trypan blue/alizarin red, and photographed in a standardized manner (X400 photographs from 5 specific areas, and 1 overview photograph from each corneal button). The ImageJ program was used to evaluate cell damage and loss in the photographs obtained from each cornea. Results Analysis of the X400 photographs showed no statistical differences between control, 250 mL, and 500 mL groups in the percentage of intact, damaged, or lost cells (P= 0.896, 0.851, and 0.972 respectively). For the overview photos, the differences in areas of intact and damaged cells among the groups were statistically significant, likely due to the peripheral areas of damage related to touches between the phaco tip and the endothelium during irrigation. Conclusion The volume of BSS flow alone does not appear to be a major contributing source of endothelial cell damage and loss, providing further insight on mechanisms of corneal endothelium damage during phacoemulsification.

Purpose To assess a single-piece monofocal hydrophobic acrylic intraocular lens (IOL) with hydroxyethyl methacrylate (HEMA) (Clareon, Alcon Laboratories, Inc.) contained in automated preloaded delivery system (AutonoMe, Alcon Laboratories, Inc.). Setting Eighteen surgical sites in Japan. Design Observational study. Methods In patients undergoing phacoemulsification and IOL implantation of a new hydrophobic acrylic IOL using an automated injector, clinical data were collected preoperatively and at 1 day, 1 week, and 1, 6, and 12 months postoperatively. The degree of glistenings was graded on a four-point scale. The surgeons rated usability and performance of the IOL delivery system on a five-point scale. Results The study enrolled 384 eyes of 384 patients, ranging in age from 41 to 93 (73.8 ± 8.2, mean ± standard deviation) years old. The percentage of eyes with corrected distance visual acuity of 20/25 or better at 1 day, 1week, and 1, 6, and 12 months postoperatively was 82.6%, 91.9%, 92.8%, 96.6%, and 95.2%, respectively. Refractive error was within 1.0 diopter in approximately 90% of cases. No glistenings were found in all cases throughout the study period. The rate of Nd:YAG laser posterior capsulotomy was 0.9 % at 1 year. The IOL delivery system received high ratings on its usability and performance by the surgeons. Conclusions The new hydrophobic acrylic IOL with HEMA showed excellent visual and refractive outcomes without developing glistenings throughout the 1-year study period. The surgeons gave high marks for usability and performance of the automated preloaded delivery system.

To compare the safety and efficacy of Active Sentry handpiece with Ozil handpiece for Centurion phacoemulsification system.Tertiary eye center, South India.Prospective observational study.204 eyes of 204 patients with uncomplicated cataract who underwent phacoemulsification cataract surgery with Centurion Vision System were randomized into 2 groups: Ozil handpiece (n = 101) and Active Sentry handpiece (n = 103). Intraoperative factors such as patient pain perception, surgeon comfort level, amount of phacoemulsification energy and aspiration fluid used, and frequency of activation of active surge mitigation (ASM) were analyzed, and postoperatively, corrected distance visual acuity (CDVA) and corneal edema on day 1 were compared.A total of 204 eyes of 204 patients were included among which 101 underwent surgery with ozil hand piece and 103 with Active Sentry handpiece. Patient pain perception was comparable between the groups with no statistically significant differences in patients who had pain-free surgery (66% vs 61.3%) and those who experienced moderate pain (24.3% vs 28.7%). Surgeons were more comfortable using Ozil handpiece during entry into anterior chamber and emulsification of hard nuclei (48.5% vs 28.6%). The mean cumulative dissipated energy for soft and hard cataracts was 5.6 and 4.8 and 9.3 and 9.4 for Ozil and Active Sentry groups, respectively. ASM was activated for 53 eyes (51.5%), of which 42 eyes (79.2%) had soft cataract and 11 eyes (20.7%) hard cataract. Postoperative CDVA and incidence of corneal edema were comparable between the groups.For Centurion Vision System, Active Sentry handpiece was as safe and efficacious as the Ozil handpiece with added benefit of operating at lower intraocular pressure levels.

To evaluate the postoperative behavior of the central corneal stromal thickness after myopic femto-laser-assisted in-situ keratomileusis (LASIK) and small-incision lenticule extraction (SMILE) by using combined anterior segment optical coherence tomography and a Placido disk topographer and to compare the accuracy of both laser machines in predicting the real stromal change.Vissum Miranza, Alicante, Spain.Prospective, observational, comparative study.The VisuMax 500 kHz femtosecond laser (FS) and the Amaris 750 excimer laser were used for the correction of myopia with or without myopic astigmatism. Central and paracentral stromal thicknesses (ST) and 6.0 mm corneal aberrometry were obtained with the MS39 topographer. Laser-predicted stromal consumption was recorded (maximum lenticule thickness for SMILE and central ablation depth for LASIK). Visual and refractive outcomes were also evaluated. Total follow-up was 6 months.77 LASIK eyes were matched with 77 SMILE eyes. Mean preoperative spherical equivalent (SE) was -3.92 ± 1.67 diopters (D) for LASIK and -4.02 ± 1.63 D for SMILE (P = .356). After LASIK, ST parameters showed significant rethickening between months 1 and 3 (+4.38 μm for central ST; P.001), remaining stable thereafter. After SMILE, all ST parameters remained stable from month 1. Stromal ablation prediction was higher for SMILE compared with LASIK for all SE ranges, although postoperatively such differences were significant only for ametropias ≤4 D. At 6 months, mean SMILE laser prediction error was -13.21 ± 7.00 μm, whereas LASIK prediction showed better accuracy (+0.92 ± 8.16 μm; P.001).The accuracy of the Amaris 750 excimer laser in predicting the stromal consumption after LASIK was better than the VisuMax FS laser for SMILE. Although SMILE ST remained stable from month 1, after LASIK, mild stromal rethickening was observed up to the third month.

PURPOSE To determine the 12-month incidence of reoperation to realign two commercially available types of implanted monofocal toric acrylic intraocular lenses (IOLs). SETTING American Academy of Ophthalmology IRIS® (Intelligent Research in Sight) Registry. DESIGN Registry retrospective study. METHODS Eyes that underwent cataract extraction and were implanted with a TECNIS or AcrySof monofocal toric IOL in 2016 and 2017 were identified. The rate of reoperation for IOL realignment (CPT 66825) within 365 days of implantation was determined for each IOL group. Risk factors for repositioning were evaluated using logistic regression modeling. RESULTS A total of 6,482 eyes were implanted with a monofocal toric IOL, including 2,013 (31.06%) with a TECNIS and 4,469 (68.94%) with an AcrySof IOL. During the first postoperative year, 87 (1.3%) eyes underwent surgical IOL repositioning. The incidence of repositioning was significantly higher (p

To evaluate and compare the clinical outcomes after cataract surgery with implantation of 3 types of trifocal diffractive intraocular lenses (IOLs).Hospital da Luz, Lisbon, Portugal.Prospective comparative case series.Patients undergoing phacoemulsification cataract surgery with implantation of 1 of the 3 trifocal IOLs were enrolled: TECNIS Synergy (Synergy group, 30 patients), Acrysof PanOptix (PanOptix group, 30 patients), and POD F (Finevision group, 30 patients). The outcomes of distance, intermediate, and near visual acuity (VA), refraction, defocus curve, photic phenomena, and spectacle independence were evaluated at the 3-month follow-up.180 eyes of 90 patients were enrolled. No statistically significant differences were found between groups in monocular distance-corrected intermediate (Synergy group 0.04 ± 0.11, PanOptix group 0.05 ± 0.09, and Finevision group 0.08 ± 0.10; P = .107) and near VA (0.01 ± 0.08, 0.01 ± 0.06, and 0.04 ± 0.10, respectively; P = .186). Similarly, no statistically significant differences among groups were found in binocular uncorrected distance (P = .572), near (P = .929), and intermediate VA (P = .327). By contrast, statistically significant differences between groups were found in the visual acuity for the vergence demands of -0.50, -1.00, -2.00, -3.50, and -4.00 diopters (P ≤ .045). No statistically significant differences among groups were found in the frequency, severity, and bothersomeness of different disturbing visual symptoms, including glare and halos (P ≥ .129). More than 87 (96%) of patients in all groups did not require the use of spectacles at any distance postoperatively.The 3 trifocal IOLs evaluated provided an effective visual rehabilitation with minimal incidence of photic phenomena. A trend to obtain a wider range of functional focus was observed with the TECNIS Synergy IOL.

PURPOSE: To compare the effectiveness and safety of the TECNIS Symfony® intraocular lens (IOL; ZXR00) with the TECNIS® 1-piece monofocal IOL (ZCB00). SETTING: Fifteen sites in the United States. DESIGN: Prospective, randomized, subject/evaluator-masked clinical trial. METHODS: Randomized participants received either the ZXR00 or ZCB00 IOL bilaterally. Six-month postoperative outcomes included monocular and binocular distance, intermediate, and near visual acuity (VA), spherical equivalent refraction and refractive cylinder, spectacle wear, and visual symptoms. RESULTS: Overall, 299 patients were implanted with a study lens (ZXR00, n = 148; ZCB00 control, n = 151). At 6-month follow-up, mean binocular uncorrected distance VA was comparable between ZXR00 and ZCB00 recipients (P = .1011). The ZXR00 group had significantly better mean binocular uncorrected intermediate VA and uncorrected near VA (both P < .0001) than the ZCB00 group. Mean binocular distance-corrected intermediate VA and distance-corrected near VA were also better in the ZXR00 group (both P < .0001). More ZXR00 recipients reported wearing spectacles "none of the time" or "a little of the time" for overall vision at 6 months compared with the ZCB00 group (85.0% vs 59.9%, P < .0001). In ZXR00-implanted patients, low incidence rates of night glare (mild to moderate, 2.7%), halo (mild to moderate, 13.6%; severe, 2.7%), and starbursts (mild to moderate, 7.5%; severe, 1.4%) were reported. CONCLUSIONS: The TECNIS Symfony® IOL provided comparable distance vision and improved uncorrected and distance-corrected intermediate and near vision, along with decreased spectacle wear and low incidence rates of dysphotopsias, compared with the TECNIS® 1-piece monofocal IOL.

Purpose To compare corneal endothelial damage from longitudinal and torsional ultrasound during phacoemulsification. Setting John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. Design Experimental Study. Methods Nine New Zealand white rabbits underwent bilateral surgery. After incision, the Intrepid Balanced tip of the Centurion (Alcon) Ozil handpiece was inserted into the anterior chamber and the following settings were used: 50 mL/minute flow, 70 mmHg intraocular pressure, 600 mmHg vacuum, and 60% longitudinal (one eye) or torsional (contralateral eye) ultrasound for 30 seconds. Cumulative dissipated energy (CDE) was noted. After euthanasia and enucleation, the corneas were removed, stained with trypan blue/alizarin red, and photographed (X400 photographs from 5 specific areas, and 1 overview photograph from each corneal button). The ImageJ program was used to evaluate cell damage and loss in the photographs obtained from each cornea. Results Cavitation bubbles around the phaco tip was generally observed in the longitudinal group. CDE was 17.4 +/- 0.58 and 6.93 +/- 0.15 in the longitudinal and torsional groups, respectively (P = 0.003). The percentage of intact cells was statistically higher in the torsional group, and the percentage of lost cells was statistically higher in the longitudinal group (P = 0.003). This was observed in the analysis of the X400 photographs, as well as the overview photographs. Conclusion This study suggests that torsional ultrasound was associated with significantly less corneal endothelial cell damage than classical longitudinal tip motion, providing further insight on mechanisms of corneal endothelial damage during phacoemulsification.

To evaluate the safety and efficacy of transepithelial accelerated corneal crosslinking (CXL) for advanced keratoconus eyes with maximum keratometry (Kmax) values58 diopters (D).Department of Ophthalmology, Eye and ENT Hospital, Fudan University, Shanghai, China.Prospective parallel control study.41 keratoconus eyes from 41 patients (mean age, 21.93 ± 5.48 years) who underwent transepithelial accelerated CXL were included prospectively. The enrolled eyes were divided into 2 groups according to their Kmax values (Group A, Kmax ≥58.0 D; Group B, Kmax58.0 D). The examinations including assessment of uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), corneal topography, and corneal endothelial cell density count were conducted preoperatively, at 1 day, 1 month, 3 months, 6 months, and 1 year postoperatively.All 41 eyes finished 1 year follow-up. No statistical difference was noted between the mean UDVA and CDVA in both groups throughout the follow-up duration. At 1-year postoperative follow-up, the CDVA increased by ≥2 lines in 45% (9/20) and 28.6% (6/21) eyes in Groups A and B, respectively. The mean preoperative Kmax in Groups A and B were 62.51 ± 3.34 D and 49.98 ± 4.32 D, respectively, and that at postoperative 1-year follow-up were 61.94 ± 4.11 D and 50.24 ± 4.72 D, respectively. The Kmax values of 30% (6/20) eyes in Group A and 4.8% (1/21) eyes in Group B decreased by more than 1 D. Deduction of flat K, steep K, mean K, and Kmax showed no significant difference between the 2 groups at 1-year postoperative follow-up. Moreover, 20% (4/20) and 23.8% (5/21) of eyes in Groups A and B, respectively, showed progress at postoperative 1-year follow-up.Transepithelial accelerated CXL can safely treat advanced keratoconus eyes with Kmax values ≥58.0 D with some extent of efficacy and has similar progressive rate as Kmax values58.0 D.

PURPOSE To compare outcomes of contact lens assisted corneal cross linking (CACXL) and transepithelial corneal cross linking (TECXL) with standard 'epithelium off'' ('epi -off') cross linking (CXL) for progressive keratoconus. SETTING Advanced Eye Centre, Post Graduate Institute of Medical Education and Research, Chandigarh , India. DESIGN Retrospective, comparative study. METHODS Patients with progressive keratoconus undergoing CXL with a minimum follow up of 24 months were included. CACXL and TECXL was performed in patients with 'epithelium on' minimal pachymetry between 350 µm to 450 µm. Main outcome measures included change in maximum keratometry (Kmax), corrected distance visual acuity (CDVA), and efficacy in halting progression (increase in Kmax ≥ 1 diopter [D]). RESULTS Standard 'epi -off' CXL, CACXL and TECXL was performed in 34,14 and 10 eyes respectively. Baseline Kmax and CDVA were comparable for all groupsKmax reduced significantly by -2.83 ± 3.35 D, -3.18 ± 2.74D and -2.02 ± 1.66 D in standard 'epi-off' CXL (p

Purpose A "dead bag syndrome" has been recently described, in which the capsular bag appears to be clear many years after surgery, becoming diaphanous and floppy, and unable to support the intraocular lens (IOL) within it. The aim of this study was to describe findings of this syndrome. Setting John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. Design Case series with clinicopathological correlation. Methods Out of 10 cases suspected to be from dead bag syndrome, 8 IOLs/7 capsular bags were removed due to subluxation/dislocation. The seven capsular bags available for analysis were fixed in formalin and submitted to histopathological examination (hematoxylin/eosin and Masson's trichrome stains). The associated explanted IOLs in 5 cases were also examined microscopically. Results Histopathologic examination of the seven capsular bags showed capsular thinning and/or splitting. Lens epithelial cells (LECs) were completely absent on two specimens while the other five specimens had rare LECs on the inner surface of the capsule. Explanted IOLs were three-piece silicone lenses or single-piece hydrophobic acrylic lenses. One IOL optic showed a small amount of granular pigment deposition, but the optics of the other four lenses were unremarkable. Conclusions In this syndrome, there appears to be an absence of secondary proliferation of LECs, as well as fibrotic changes. The capsule shows some signs of degradation, such as thinning and/or splitting. Weakness of zonular attachments appears to be an associated finding, with subsequent in-the-bag IOL dislocation. Further studies are necessary to ascertain the etiology of this condition.

Intraocular transmission of exogenous pathogens in cataract surgery can lead to endophthalmitis. This review evaluates the features of endophthalmitis clusters secondary to pathogen transmission in cataract surgery. Articles reporting on pathogen transmission in cataract surgery were identified via searches of Ovid MEDLINE, EMBASE, and Cochrane CENTRAL, and a total of 268 eyes from 24 studies were included. The most common source of infectious transmission was attributed to a contaminated intraocular solution (ie, irrigation solution, viscoelastic, or diluted antibiotic; n = 10). Visual acuity at presentation with infectious features was 1.89 logMAR (range: 1.35 to 2.58; ∼counting fingers) and 1.33 logMAR (range: 0.04 to 3.00; Snellen: ∼20/430) at last follow-up. Patients with diabetes had worse outcomes compared with patients without diabetes. The most frequently isolated pathogen from the infectious sources was Pseudomonas sp. (50.0%). This review highlights the various routes of pathogen transmission during cataract surgery and summarizes recommendations for the detection, prevention, and management of endophthalmitis clusters.

A new sutureless technique used for repositioning and scleral fixation of the capsular bag-intraocular lens (IOL) complex in the surgical treatment of subluxated lenses is described. Iris retractors were used not only to induce a tent effect on the capsule but also to permanently fix the capsular bag to the sclera in this method, without the need to prepare scleral or conjunctival flaps. Surgery with the use of a capsular tension ring (CTR) and iris retractors, the ends of which were brought out through the sclera and cauterized, was performed in 7 eyes of 7 patients with moderate or severe subluxation of the crystalline lens. In all cases, simultaneous use of a CTR and iris retractors ensured good centration of the capsular bag-IOL complex. The method was safe and effective in fixing the capsule to the sclera in the case of significant damage to the ligamentous apparatus of the lens.

Purpose To analyze precision and safety of femtosecond laser-assisted descemetorhexis as well as postoperative corneal wound healing in human ex vivo specimens. Setting Department of Ophthalmology, University Hospital, LMU Munich, Munich, Germany. Design Experimental ex vivo study. Methods Four donor corneas underwent femtosecond laser-assisted descemetorhexis. The descemetorhexis was performed using the LDV Z8 femtosecond laser followed by live/dead staining, phase contrast microscopy and scanning electron microscopy. The descemetorhexis parameters were set using a modified optical coherence tomography image capturing of 8 segments within a focus of 100 μm at the posterior corneal stroma (reversed capsulotomy program). Results Live/dead sample staining analysis demonstrated that the femtosecond laser had minimal impact on the vitality of surrounding endothelial cells. Phase contrast microscopy and scanning electron microscopy evaluation showed that the laser produced precise, clear-cut edges leaving no stromal tissue bridges. Conclusions Femtosecond laser-assisted descemetorhexis could serve as a safe and precise technique with only minimal endothelial cell damage. To minimize stromal damage, further laser energy profile adjustments are necessary to optimize corneal treatment within different stages of corneal tissue swelling.

This study shows that optical biometers based on different technologies provide repeatable measurements for different ocular parameters and, when compared, statistically significant differences between them were found when measuring most parameters., Purpose: To evaluate repeatability and agreement between various biometric parameters using 6 biometers based on different optical technologies. Setting: University of Valencia, Spain. Design: Prospective, comparative case series. Methods: 150 eyes were measured using the Aladdin, AL-Scan, Argos, IOLMaster700, Lenstar LS900, and OA-2000 biometers. Keratometry (K1 and K2), J0 and J45, central corneal thickness (CCT), anterior chamber depth (ACD), lens thickness (LT), axial length (AL), white to white (WTW), and pupil size (PS) were measured 5 times with each device. Intrasubject SD, coefficient of variability (CoV), coefficient of repeatability, intraclass correlation coefficient, and Bland -Altman graphs were analyzed. Results: CoV values were 0.50 diopter. A similar pattern was found for J0/J45. For CCT, many comparisons showed LoA width values of >25 μm. The LoA width for ACD ranged from 0.366 mm to 0.175 mm and for LT was about 0.2 mm. AL showed a highest LoA width of 0.225 mm. The LoA width for WTW was, in most cases, about ≥0.50 mm. The LoA width for PS ranged from 1.578 mm to 3.541 mm. Conclusions: The 6 biometers provided repeatable measurements for the different parameters analyzed. The LoA obtained for each comparison should be analyzed carefully to consider the interchangeability of these devices.

To use optical modeling to compare a 6.0 mm and 7.0 mm intraocular lens (IOL) optic diameters on peripheral retinal illumination with implications for negative dysphotopsia.Mayo Clinic, Rochester, Minnesota, and Simpson Optics LLC, Arlington, Texas.Model eye.Ray-tracing software was used to simulate retinal illumination from an extended light source for a pseudophakic eye with in-the-bag biconvex IOLs (refractive index [n] = 1.46 and 1.55) and a 2.5 mm pupil. Ray-tracing diagrams and simulated retina illumination profiles were compared using the 6.0 mm and 7.0 mm optic diameter IOLs. Retinal locations were scaled to relative visual angles from 70 to 110 degrees horizontally.A 7.0 mm optic (n = 1.46) expands the image field by 2.8 degrees compared with a 6.0 mm optic. High-angle input light misses a 7.0 mm optic at a larger visual angle than a 6.0 mm optic, shifting illumination of the peripheral retina by this light anteriorly by 5.6 degrees. Consequently, a region of nonilluminated peripheral nasal retina is enlarged and shifted peripherally using a 7.0 mm optic (visual angle, 86.3 to 96.3 degrees) compared with a 6.0 mm optic (visual angle, 83.5 to 90.7 degrees). Similar illumination changes were seen modeling a 1.55 n IOL.A narrow dark region in the nasal retina when using a 6.0 mm optic is changed to a broader, more peripheral dark region when using a 7.0 mm optic. An extended, more peripheral dark nasal region may make a temporal shadow less bothersome and explain lower negative dysphotopsia rates using a 7.0 mm optic.

Purpose To determine the impact of IOL with 7.0 mm optic and plate haptic design on incidence of dysphotopsiae and visual functions after cataract surgery. Setting Day-care clinic. Design A prospective monocentric randomized patient-blinded comparative clinical study. Methods Following preoperative measurements, patients underwent cataract surgery with implantation of two IOL designs - with 7.0 mm optic and plate haptics (group 1) or with 6.0 mm optic and C-loop haptics (group 2). In month 1, 3 and 12 follow-ups patients were examined, answered a questionnaire regarding satisfaction, spectacle dependence, frequency and extent of positive and negative dysphotopsiae, and underwent contrast sensitivity, mesopic vision and glare sensitivity testing. The data were analyzed as nominal, ordinal and metric with Chi-Square, Mann-Whitney-U, Wilcoxon and t-tests. Results Group 1 comprised 57 eyes (43 patients) and group 2 comprised 63 eyes (43 patients). Corrected distance visual acuity was the same between groups throughout the study. Group 1 showed significantly lower incidence of positive and negative dysphotopsiae in month 1 follow-up (p=0.021 and 0.015, respectively) and a higher satisfaction rate in month 3 follow-up (p=0.006). Mean contrast sensitivity and mesopic vision with and without glare were the same in both groups. Positive dysphotopsiae cases in month 12 follow-up revealed lower photopic contrast sensitivity (p=0.005, 0.036 and 0.047, respectively), longer AL and greater preoperative pupil dynamics (p=0.04 and 0.06). Conclusions The IOL design with 7.0 mm optic diameter and plate haptics reduces dysphotopsiae, provides good visual acuity, contrast sensitivity, mesopic vision with and without glare and high patient satisfaction.

To assess the impact on visual development of multifocal vs monofocal intraocular lenses (IOLs) implantation in children after congenital cataract surgery.Ophthalmology Department, Bambino Gesù Children's Hospital, Rome, Italy.Retrospective interventional consecutive case series.Records of 56 eyes of 43 pediatric patients who underwent congenital cataract surgery with phacoaspiration and simultaneous implantation of the IOL younger than 1 year were reviewed. Corrected distance visual acuity (CDVA), refractive error, and ocular motility disorders were evaluated at follow-up of greater than 4 years.32 multifocal (18 unilateral, Group A and 14 bilateral, Group B) and 24 monofocal (12 unilateral, Group C and 12 bilateral, Group D) IOLs were implanted. Mean follow-up was 6.67 years. Mean CDVA of the eyes with multifocal IOLs was 0.75 ± 0.46 logMAR in unilateral cataract surgery and 0.34 ± 0.25 logMAR in bilateral ones; with monofocal IOLs was 0.71 ± 0.52 logMAR in unilateral and 0.53 ± 0.43 logMAR in bilateral ones. No statistically significant difference in the CDVA between Groups A and B and Groups C and D were recorded. Final mean spherical equivalent was -3.88 ± 4.73 diopters (D); in Group A, it was -2.74 ± 4.22 D, in Group C was -1.08 ± 1.45 D, in Group B was -4.82 ± 4.64 D, and in Group D was -6.81 ± 4.61 D. The difference was statistically significant between Groups B and D (P = .01), but not between Groups A and C (P = .14). 26 patients (60.4%) showed postoperative strabismus. Surgical correction occurred more in patients with multifocal IOLs implanted (P = .038).Multifocal IOLs did not show significant advantages in visual development in children after congenital cataract extraction younger than 1 year when compared with monofocal IOLs.

Iris defects and distorted pupils are commonly managed with iris suturing techniques that aim to close the defect and/or reform the physiological pupil. The re-creation of an optimally sized and centered pupil is often challenging because of missing iris, asymmetrical iris damage, or variable tension around the pupil. Current options include removing or cutting iris tissue using microscissors or the vitreous cutter, instrument stretching, or postoperative laser photocoagulation. Iris microendodiathermy is a simple technique that is minimally traumatic, titratable, and controlled, avoids excessive tissue manipulation, and is able to create a round cosmetically pleasing pupil. A bipolar endodiathermy cautery is applied to the iris stroma to induce tissue contraction and to gently pull the pupil in the meridian to which probe is applied. Endothermal pupilloplasty (EDP) may be used to recenter or enlarge a small pupil, thereby avoiding additional trauma inflicted by a vitrector or microscissors that physically cuts the iris.

Intraocular lens (IOL) exchange in patients with anterior capsule contraction resulting from phimosis can complicate IOL exchange as the fibrotic anterior capsule must be cut to gain access to the IOL. Maintaining curvilinear capsulotomy is particularly important when the desired outcome is bag-to-bag IOL exchange. Similarly, when the posterior capsule is open, properly sized curvilinear anterior capsulotomy will allow for optic capture and further stability of the exchanged IOL. Secondary capsulotomy size ranged from 4.9 to 5.0 mm, and the energy was set at 4 to 10 μJ depending on diffusiveness of the anterior capsule. The femtosecond laser was adapted to create a secondary anterior capsulotomy to facilitate IOL exchange.

We describe a simplified intra-sclera fixation technique involving implantation of the Carlevale IOL in the posterior chamber that lodges the T-shaped IOL haptics in the scleral wall, not requiring scleral flaps. This surgical modification reduces operative time, limits iatrogenic damage to the sclera and avoids friction between haptics and conjunctiva, which may cause conjunctival erosion and infection in the long term. Thirteen patients with crystalline lens or IOL dislocation/subluxation underwent surgery involving implantation of the Carlevale IOL in the posterior chamber. Mean best-corrected visual acuity (BCVA) before surgery was 0.75 ± 0.5 logMAR (range: 0.2 - 1.5 logMAR) and improved to 0.28 ± 0.3 logMAR (range: 0 - 1.0 logMAR) after surgery. Complications rarely occurred and were not sight threatening. The sutureless scleral fixation of the Carlevale IOL utilizing the modified surgical technique may represent a safe and effective procedure to restore visual function in patients with damaged zonular-capsular support.

PURPOSE To investigate complications and outcomes of clear corneal incision cataract surgery in patients with thrombocytopenia. SETTING 1 veterans hospital and 2 academic medical centers. DESIGN Multicenter retrospective chart review. METHODS All eyes of thrombocytopenic patients that underwent clear corneal incision cataract surgery with a platelet count of 100 × 103/μL or less measured within 30 days prior to surgery were included. Subject demographics, intraoperative complications, use of pupillary expansion devices, use of local anesthetic injections, and change in corrected distance visual acuity were recorded. RESULTS 3 sites recorded 40 113 clear corneal incision cataract surgeries, of which 196 eyes (0.49%) of 150 thrombocytopenic patients were recorded. The mean platelet count in the study subjects was 73.0 ± 20.5 × 103/μL. Two cases of intraoperative iris hemorrhage that were readily and controlled occurred in conjunction with pupillary expansion. There were no bleeding complications associated with retrobulbar, peribulbar, or sub-Tenon anesthetic injections. There was a statistically significant improvement (P < .0001) in visual acuity post-operatively. CONCLUSIONS Clear corneal incision cataract surgery with pupillary expansion devices and local anesthetic injections can be safely performed in patients with thrombocytopenia.

PURPOSE: To compare calculated corneal surgically induced astigmatism (SIA) by means of anterior-based keratometry (K) and total keratometry (TK) measurements made by 2 biometric devices. SETTING: Ophthalmology Department, Shaare Zedek Medical Center, Jerusalem, Israel. DESIGN: Retrospective, consecutive case series. METHODS: The medical records of patients who had undergone cataract surgery through a 2.4 mm temporal clear corneal incision by a single surgeon between March 2018 and November 2020 were retrospectively reviewed. Patients for whom there were preoperative and postoperative K measurements assessed by 2 biometric devices, optical low-coherence reflectometry (OLCR) (Lenstar LS900, Haag-Streit, software v. eye suite i/9.1.0.0) and swept-source optical coherence tomography (SS-OCT) (IOLMaster700, Carl Zeiss Meditec AG, software v. 1.80.6.60340), were identified. Corneal SIA (mean vector value) was calculated by vector analysis for 3 groups: SS-OCT(K), SS-OCT(TK), and OLCR(K). Bivariate analyses were applied for comparisons. RESULTS: 147 eyes of 123 patients (73 right eyes and 74 left eyes) were enrolled in the study. The right eye corneal SIA values were 0.09 diopters (D) @ 136 degrees, 0.09 D @ 141 degrees, and 0.07 D @ 123 degrees for the SS-OCT(K), SS-OCT(TK), and OLCR, respectively. The corresponding left eye corneal SIA values were 0.13 D @ 120 degrees, 0.11 D @ 123 degrees, and 0.08 D @ 120 degrees. There were no statistically significant differences between the mean vector value and variance of the corneal SIA for the right (P = .78 and P = .65) and the left (P = .75 and P = .37) eyes of the 3 groups. CONCLUSIONS: Corneal SIA values were low (0.07 to 0.13 D) and similar for the SS-OCT and the OLCR biometric devices with standard K measurements. TK measurements yielded similar corneal SIA values compared with anterior corneal-based measurements.

Implantation of intraocular lens after combined procedure of vitrectomy and cataract surgery is usually required to reduce the postoperative refraction errors. However, because of the severe fibrosis of the anterior capsule and the adhesion between the anterior and posterior capsules, it is difficult to reopen the capsular bag to complete the secondary IOL implantation. We describe here a surgical approach for reopening the severe adhesion between capsules and removing the significant fibro-proliferative membranous material by injecting viscoelastic agent into the periphery of the capsular bag to separate the anterior and posterior capsules. The IOL was implanted into the capsular bag without any zonular rupture or posterior capsule tear. The position of the intraocular lens was stable during postoperative follow-ups up to 3 months. Our procedure to open a severely fibrosis capsule is safe and effective, and may be used as a preferred method.

PURPOSE To report the intraoperative changes in corneal pachymetry, as well as the efficacy and safety of accelerated corneal crosslinking (A-CXL) treatment using only hypo-osmolar riboflavin (HO-RF) solution in progressive keratoconus patients with thin corneas. SETTING University of Health Sciences, Prof. Dr. Cemil Tascioglu Education and Research Hospital, Istanbul, Turkey. DESIGN Retrospective study. METHODS Thin keratoconic corneas (

PURPOSE To assess early visual outcomes and military task performance after small-incision lenticule extraction (SMILE) among U.S. military service members. SETTING Warfighter Refractive Eye Surgery Program and Research Center and Night Vision and Electronic Sensors Directorate, Fort Belvoir, Virginia. DESIGN Single-center, prospective, observational study. METHODS The study was composed of active duty service members (n = 37) electing to undergo SMILE for myopia or myopic astigmatism. Testing performed preoperatively and at 1 month and 3 months postoperatively included uncorrected (UDVA) and corrected (CDVA) distance visual acuities, wavefront aberrometry, low-contrast visual acuity (LCVA), contrast sensitivity, and vision-related questionnaire. 14 participants underwent rifle marksmanship with spectacle correction before and without correction at 6 to 8 weeks postoperatively. RESULTS At 3 months postoperatively, the efficacy index was 0.96 and the safety index was 1.03. UDVA was ≥20/20 in 69 (96%) of eyes. LCVA change from baseline was significant under night vision condition. Eye problems contributed to 10% work and 20% activity impairments, both of which decreased to 0% (P = .001). The overall satisfaction rating for SMILE was high at 90.9 (95% CI, 85.3 to 96.5), and 95% of participants would be willing to undergo the procedure again. The median scores between preoperative and 6 to 8 weeks postoperative firing performance were comparable (34 vs 35, with and without correction, respectively; P = .247). CONCLUSIONS After the early recovery period, SMILE seems to preserve quality of vision, which appears to facilitate the accomplishment of tasks related to their work as military service members as well as performing activities outside of work.

Intraoperative optical coherence tomography (OCT) was so far only available as a microscope-integrated or handheld device. Recently, this technology has been integrated into a femtosecond (FS) laser. This pilot study analyzed the potential of intraoperative imaging using OCT during FS-assisted procedures of the anterior eye segment. Therefore, intraoperatively acquired videos using FS-integrated intraoperative OCT (laser-integrated [LI] OCT) in 14 patients (Victus, Bausch & Lomb) were analyzed in different surgical procedures. The results showed that all surgical steps could be successfully visualized by LI-OCT. LI-OCT added important information regarding the depth and location of the incisions and dissection planes. Moreover, dynamic processes could be observed in real-time. LI-OCT represents a new imaging technology that makes it possible to visualize intraoperative steps during FS-assisted surgery. In the future, automatic image analysis based on artificial intelligence could be helpful to detect complications at an early stage and to automatically stop the laser process in relevant constellations.

Current scleral suture fixation techniques pose challenges for highly complex eyes. A scleral suture fixation technique using a snare that is fashioned out of a 27 gauge needle and 8-0 nylon suture is described. This technique is well-suited for scleral suture fixation in complex eyes because it reduces risk factors for intraoperative and post-operative complications, simplifies intraocular maneuvers, minimizes surgical trauma, and does not require specialized microinstrumentation.

PURPOSE To define and compare the centration of the ablation effect in laser in situ keratomileusis (LASIK) with the corresponding effect in small-incision lenticule extraction (SMILE), in myopic laser vision correction to possibly explain the refractive performance differences noted between the two procedures in a contralateral eye study. SETTING Private ambulatory eye surgery unit. DESIGN Prospective randomized contralateral eye study. METHODS In 22 consecutive patients (44 eyes), 1 eye was prospectively randomized to undergo myopic topography-guided LASIK treatment and the contralateral eye to undergo SMILE; digital image analysis of the achieved centration to the aimed corneal vertex was assessed for both procedures on perioperative Scheimpflug tangential curvature maps, using a proprietary digitized methodology. RESULTS The radial displacement measured in micrometers in the above treated 44 eyes, between the attempted centration point on the corneal vertex vs the center of the measured effective anterior corneal curvature flattening was on average 130 ± 62 mm in the 22 eyes of LASIK group and 313 ± 144 mm in the 22 contralateral eyes of the SMILE group (P < .001). CONCLUSIONS In this contralateral eye study, topography-guided myopic LASIK was found to achieve significantly better effective centration compared with myopic SMILE, in regard to digitally measured decentration of the effective refractive change achieved in the anterior corneal curvature from the corneal vertex. This may explain the previously reported superior visual outcomes in the LASIK group eyes when compared with the contralateral SMILE group eyes.

To evaluate the efficacy and complications of cataract surgery in high myopia, a comprehensive search query was conducted from January 2000 to August 2020. A total of 19 586 highly myopic eyes from 28 studies were included. Modern cataract surgery turns out efficacious in highly myopic eyes with significant improvement of visual acuity. However, phacoemulsification-related complications such as posterior capsular rupture (3.91%, 95% CI, 1.98%-6.37%), retinal detachment (1.74%, 95% CI, 1.36%-2.15%), progressed myopic traction maculopathy (5.07%, 95% CI, 1.80%-9.37%), capsular contraction syndrome (2.1%), intraocular lens dislocation (0.58%), and transient intraocular pressure elevation (28.15%, 95% CI, 20.29%-36.70%) occurred more frequently in the highly myopic population. Separate analyses were also conducted based on follow-up period. In conclusion, modern cataract surgery was effective for highly myopic cataract patients, whereas careful precautions and sufficient follow-ups were of great value because of higher incidences of intraoperative and postoperative complications.

The management of malignant glaucoma involves either anterior vitrectomy with zonulectomy and iridectomy or 3-port core pars plana vitrectomy (PPV) by retinal surgeons. The proposed modification can be performed with reasonable success rates. In this technique, synechiolysis and anterior chamber irrigation were performed through a limbal incision, and a single-port 23- or 25-gauge vitrector was introduced through PPV superotemporally to perform anterior vitrectomy and central posterior capsulotomy in pseudophakic eyes. The same procedure can be performed after cataract surgery in phakic eyes. Vitrectomy is continued until anterior chamber deepens, ensuring a conduit between anterior and posterior chambers through the posterior capsulotomy alone, bypassing the need for a posterior iridectomy/zonulectomy. In a series on 9 eyes, all achieved optimization of anterior chamber depth with intraocular pressure normalization in 8 of 9 eyes, without showing any signs of recurrence at a mean follow-up of 8.6 months.

An application of the XpandNT iris speculum in eyes with small pupils during secondary intraocular lens (IOL) implantation in congenital cataract patients is described. The iris speculum was first positioned in the eye to expand the pupil. A 30-gauge needle was used to separate the adhesion of the iris tissue and the capsular rim. Vitrectomy was used to clean Soemmerring ring near the capsular rim. The iris expander was retracted with the Williamson XpanNT Manipulator. The IOL was then implanted. Fourteen aphakic eyes from 10 consecutive patients were studied retrospectively; pupil expansion was achieved in all 14 eyes intraoperatively without serious intraoperative or postoperative complications. The XpandNT iris speculum was a safe and excellent tool for removing Soemmerring ring and solving small pupil problems during secondary IOL implantation in pediatric cataract surgery patients.

An incomplete dislocated intraocular lens (IOL) is often treated with IOL exchange because the IOL subluxates posteriorly during surgery and makes it difficult to fixate the IOL in situ. A trocar blade used for 23-gauge vitrectomy was used to lift and stabilize the IOL-capsular complex. The IOL can then be fixated using a suture loop fixation technique, which was originally limited to patients with decentered IOL. The advantage of this technique is that it allows the remaining zonular fibers and IOL to be preserved. The modified technique using a trocar blade to assist scleral fixation allows the incomplete dislocated IOL to be retrieved and fixated with a simplified surgical procedure.

PURPOSE To determine the incidence of retinal detachment after lens surgery in children and young adults with nontraumatic ectopia lentis. SETTING Population-based claims data. DESIGN Population-based retrospective cohort study. METHODS Patients with nontraumatic ectopia lentis aged 30 years or younger who had undergone lens surgery with or without intraocular lens (IOL) implantation and had 1 year or greater continuous enrollment after lens surgery were included in the Optum deidentified Clinformatics Data Mart Database (2003 to 2019) and IBM MarketScan Databases (2007 to 2016). Both databases were assessed for sex, age, etiology of ectopia lentis, IOL implantation, and postoperative retinal detachment separately. Univariate and multivariate analyses were conducted to identify the risk factors for postoperative retinal detachment. RESULTS Among a total of 298 eyes (210 patients), IOL implantation was coupled with lens surgery in 151 eyes (49.8%) that underwent lens surgery for nontraumatic ectopia lentis. The median follow-up was 32 months in aphakic eyes and 29 months in pseudophakic eyes. Patients undergoing IOL implantation were older at the time of lens surgery (median age: no IOL, 6 years; IOL, 16 years; P < .001). Retinal detachment developed in 13 patients (14 eyes [4.7%]) 14 eyes (4.7%). Older age was the baseline characteristic that correlated most closely with the risk for retinal detachment (P = .05). CONCLUSIONS The rate of retinal detachment was similar with or without IOL implantation after lens surgery for nontraumatic ectopia lentis in children and young adults.

PURPOSE To evaluate clinical outcomes delivered by a new hybrid presbyopia-correcting intraocular lens (IOL): TECNIS Synergy ZFR00V IOL model (Johnson & Johnson Vision). SETTING Hospital da Luz Lisboa, Lisbon, Portugal. DESIGN Prospective observational study. METHODS Patients undergoing bilateral IOL implantation were included. Visual acuity (VA) was measured for far distance, intermediate (66 cm), and near (40 cm) vision under both photopic and mesopic conditions. In addition, at the 3-month follow-up visit, the defocus curve was obtained for binocular vision, and questionnaires were administered to measure spectacle independence and level of satisfaction ( quality of vision and Catquest-SF9) with the surgical outcomes. RESULTS 54 eyes of 27 patients were included. At the 3-month follow-up, under photopic conditions, VA values were as follows: corrected distance VA (CDVA) = -0.02 ± 0.07, distance-corrected intermediate VA = 0.03 ± 0.11, and distance-corrected near VA (DCNVA) = 0.00 ± 0.08, whereas under mesopic conditions, VA values were as follows: CDVA = -0.01 ± 0.05 and DCNVA = 0.07 ± 0.09. The binocular defocus curve revealed that mean VA was better than 0.30 logMAR within the +1.00 to -4.00 diopters (D) interval, and better than 0.10 logMAR between +0.50 and -3.00 D. All patients achieved distance vision spectacle freedom, whereas 3.7% of them said they used them in certain intermediate or near vision situations. As much as 88% of the patients reported being fairly satisfied or very satisfied. CONCLUSIONS The TECNIS Synergy ZFR00V IOL model used for cataract surgery is capable of restoring visual function while providing very good intermediate and near vision, under both photopic and mesopic conditions, resulting in a high level of patient satisfaction.

Purpose To analyze the difference in anterior chamber depth (ACD) after uneventful cataract surgery between 2 hydrophobic acrylic 1-piece intraocular lenses (IOLs) with different material properties. Setting Hanusch Hospital, Vienna, Austria. Design Single-center, bilateral randomized paired-eye controlled study. Methods Patients scheduled for bilateral cataract surgery were randomized to receive the Clareon IOL in 1 eye and the AcrySof IQ IOL (both Alcon Laboratories, Inc.) in the contralateral eye. Preoperatively, a slitlamp examination, optical biometry (IOLMaster 700, Carl Zeiss Meditec AG), refraction, and visual acuity measurements were performed. ACD was assessed 1 hour and 1 week postoperatively and with additional measurement of uncorrected (UDVA) and corrected distance visual acuity (CDVA) 6 months postoperatively. Results 80 eyes of 40 patients were analyzed in this study. ACD at the 6-month follow-up was 3.94 ± 0.30 mm for the Clareon IOL and 3.91 ± 0.32 mm for the AcrySof IQ IOL (P = .08). Statistically significant differences in the ACD shift between both IOLs were detected between 1 week and 6 months (P = .04) and 1 hour and 6 months (P = .04). There were no statistically significant differences between both IOLs in UDVA (P = .78), CDVA (P = .59), and spherical equivalent (SE, P = .39) at the 6-month visit. The mean absolute error between the measured and the aimed SE was not significant (P = .97). Conclusions There was no clinically relevant difference in ACD between the Clareon IOL and the AcrySof IQ IOL in patients after uneventful cataract surgery. Both IOLs yielded good refraction and visual acuity outcomes.

PURPOSE Intraocular lens (IOL) power calculation in eyes with keratoconus typically results in hyperopic postoperative refractive error. The purpose of this study was to investigate the visual and refractive outcomes in patients with keratoconus having cataract surgery with a toric IOL and compare IOL power calculation accuracy of conventional formulas and keratoconus-specific formulas. SETTING Ein-Tal Eye Center, Tel-Aviv, Israel. DESIGN Retrospective case-series study. METHODS Postoperative visual acuity and manifest refraction were examined. The error in predicted refraction and IOL power calculation accuracy within a range of 0.50 to 2.00 diopters (D) were compared between different IOL calculating formulas. RESULTS 32 eyes with keratoconus were included. Visual acuity improved in all cases, and subjective astigmatism decreased from -2.95 ± 2.10 D to -0.95 ± 0.80 D (P < .001). The mean absolute errors were as follows: Barrett True-K formula for keratoconus with measured or predicted posterior corneal power, 0.34 D; Barrett Universal II formula, 0.64 D; Kane formula, 0.69 D; Kane formula for keratoconus, 0.49 D; SRK/T formula, 0.56 D; Haigis formula, 0.72 D; Holladay 1 formula, 0.71 D, and Hoffer Q formula, 0.87 D. Barrett True-K formula with measured posterior corneal power, SRK/T formula, and Kane formula for keratoconus resulted in a prediction error within ±0.50 D of 87.5%, 59.4%, and 53.1%, respectively. CONCLUSIONS Cataract removal with a toric IOL significantly improves visual acuity and decreases astigmatism in keratoconic eyes with a topographic central relatively regular astigmatic component. Keratoconus-specific formulas resulted in lower mean error in predicted refraction compared with conventional calculating formulas. Using the posterior corneal power within the Barrett True-K formula for keratoconus improved IOL power prediction accuracy.

PURPOSE To evaluate quality and duration of implantation of 2 preloaded intraocular lens (IOL) injectors and assess postimplantation damage. SETTING The David J. Apple Center for Vision Research, Department of Ophthalmology, University of Heidelberg, Heidelberg, Germany. DESIGN Prospective, randomized, comparative study with laboratory investigation. METHODS Implantation videos and postuse injectors from 60 paired eyes of 30 bilateral cataract patients were included. Patient eyes were randomly assigned for implantation with 2 different preloaded injectors: the AutonoMe with a Clareon IOL (Alcon Laboratories, Inc.) and the iSert with a Vivinex IOL (Hoya Corp.). Videos were reviewed for events during the implantation procedure, and the duration of each step of implantation. Injector nozzles were examined under light and scanning electron microscopy. Damage was graded and correlated with the IOL power. Three months postoperatively IOLs were assessed for material changes. RESULTS IOL delivery was without any critical events in 60 of the 60 eyes. The implantation took 56 seconds with the AutonoMe and 44 seconds with the iSert (P < .05). Most AutonoMe injectors (29; 97%) showed no damage or slight deformation. In most of the iSert injectors (25; 80%), short or extended cracks were present, and damage lengths correlated with the IOL power. All IOLs were free of material changes, including glistenings, 3 months postoperatively. CONCLUSIONS Both preloaded IOL injectors allowed a safe and convenient IOL delivery. Implantation of the Clareon IOL took, on average, slightly longer than that of the Vivinex IOL, mostly due to a slower IOL unfolding. The AutonoMe showed less nozzle tip damage than that of the iSert.

PURPOSE To report the 5-year visual, refractive, and patient-reported outcomes following implantation of a trifocal intraocular lens (IOL) during cataract surgery. SETTING Csolnoky Ferenc University Hospital, Veszprem, Hungary. DESIGN Prospective, longitudinal, single-center, interventional study. METHODS 100 eyes of 50 patients underwent bilateral implantation of a trifocal IOL during cataract surgery. Preoperative corrected distance (CDVA) and postoperative uncorrected distance visual acuity (UDVA), CDVA, uncorrected (UIVA) and corrected (CIVA) intermediate and uncorrected (UNVA) and corrected (CNVA) near visual acuity were collected. All subjects were seen at day 1, 1 month, 3 months, 6 months, 12 months, and 24 months, and at year 5. Contrast sensitivity, slitlamp photography, and quality of vision questionnaire were performed at months 3, 6, 12, and 24 and at year 5. Of these 50 patients, 41 completed their 5-year follow-up. RESULTS At year 5, 74 eyes of 37 patients were analyzed. The mean postoperative UDVA was 0.02 ± 0.10 (logMAR). The mean CDVA was -0.04 ± 0.07. The mean UIVA was 0.04 ± 0.09. The mean CIVA was 0.00 ± 0.08. The mean UNVA was 0.09 ± 0.09. The mean CNVA was 0.05 ± 0.07. Mesopic and photopic contrast sensitivity values were in the upper third range of the age-matched normal values. CONCLUSIONS 5-year prospective study data showed that bilateral implantation of a diffractive-refractive trifocal IOL with centralized diffractive rings provided good functional vision at all distances. There was high level of spectacle independence and patient satisfaction with minimal levels of dysphotopsia.

Purpose To evaluate the efficacy of using intraoperative optical coherence tomography (iOCT) to adjust the tilting of an intraocular lens (IOL) during implantation with intrascleral fixation. Setting Kyorin University Hospital, Tokyo, Japan. Design Retrospective, case-control, single-center study. Methods Thirty-seven eyes of 37 patients who had undergone pars plana vitrectomy with intrascleral fixation of an IOL by a single surgeon were retrospectively studied. The length of the externalized haptics was determined when the anterior surface of the IOL was parallel to the plane of the iris as observed by iOCT. The maximal IOL tilt relative to the visual axis and to the iris plane was measured by anterior segment OCT (CASIA2; Tomey Corp.). Results Intraoperative crosssectional OCT (RESCAN 700: Carl Zeiss Meditec AG) scans were used to adjust the degree of IOL tilt in 23 eyes (iOCT group) and not used in 14 eyes (control group). The maximal angle of IOL tilt relative to the visual axis was significantly smaller in the iOCT group than that in the control group (5.45 ± 2.63 degrees vs 10.38 ± 10.48 degrees, P = .034). The maximal angle of the IOL tilt to the iris plane was also significantly smaller in the iOCT group than that in the control group (4.58 ± 1.86 degrees vs 9.60 ± 10.82 degrees; P = .040). The distance of decentration was greater in the iOCT group (0.56 ± 0.29 mm) than that of the control group (0.41 ± 0.41 mm, P = .005). Conclusions Intraoperative OCT can be used to adjust the degree of IOL tilt to reduce the lenticular astigmatism during intrascleral fixation surgery.

Purpose To evaluate visual performance and optical quality of an extended depth-of-focus intraocular lens (EDoF IOL) compared with a monofocal aspheric IOL. Setting Department of Ophthalmology, Charite-Medical University Berlin, Germany. Design Prospective case series. Methods After phacoemulsification, a total of 28 patients (56 eyes) underwent bilateral implantation of either the Mini Well (EDoF IOL) or the Mini 4 (monofocal IOL). Assessments including refraction, distance, intermediate and near visual acuity, defocus curves, contrast sensitivity, glare disability, higher-order aberrations (HOAs), and patient satisfaction were performed at 1 month and 3 months postoperatively. Results Both study groups comprised 14 patients (28 eyes) each. At 3-month follow-up, the EDoF IOL showed better results in monocular uncorrected intermediate visual acuity (-0.04 vs 0.10 logMAR, P = .000) and in uncorrected near visual acuity (0.13 vs 0.36 logMAR, P = .000), whereas no statistically significant difference was found between groups in monocular uncorrected distance visual acuity (0.04 vs 0.00 logMAR, P = .110). The monocular depth of focus was 0.8 D greater in the Mini Well IOL group. Measurements of internal HOAs revealed a greater negative primary spherical aberration in the EDoF group at pupil sizes of 2.0 to 5.0 mm. At 5.0 mm, total internal HOAs did not differ statistically significantly (0.376 vs 0.340 μm root mean square, P = .068). Conclusions The Mini Well IOL provided greater depth of focus with superior outcomes at intermediate and near distances and comparable outcomes at far distance. Although inducing higher amounts of spherical aberration, it showed good results under low lighting conditions with little subjective dysphotopsia.