Search

PURPOSE: To evaluate the outcomes of resident-performed femtosecond laser–assisted in situ keratomileusis (FS-LASIK). METHODS: Records of 138 eyes of 69 patients treated by residents for myopia or myopic astigmatism between March 2018 and June 2020 were reviewed. All preoperative visits, procedures, and postoperative visits were supervised by attending physicians. Follow-up examinations were performed 1 day and 1 month postoperatively. Complications and enhancements were noted. Outcome measures included postoperative uncorrected distance visual acuity (UDVA), refractive accuracy, and complications. RESULTS: Eighteen residents performed FS-LASIK on a median of 8 eyes (interquartile range: 1.75). Fifty-nine patients (118 eyes) returned for a 1-month postoperative examination. UDVA was 20/40 or better in 117 eyes (99%) and 20/20 or better in 108 eyes (92%). The mean preoperative spherical equivalent (SE) refractive error was −4.01 ± 1.82 diopters (D) in 138 eyes, decreasing to −0.12 ± 0.35 D at 1 month after surgery in the 102 eyes that were refracted. The SE was ±1.00 D in 100 eyes (98%) and ±0.50 D in 94 eyes (93%). The CDVA change was within one line in 100% of eyes. Intraoperative complications occurred in 5 eyes (3.62%), enhancements were performed in 3 eyes (2.17%), and postoperative complications developed in 3 eyes (2.17%). CONCLUSIONS: Resident-performed FS-LASIK is relatively safe and effective in comparison to published U.S. Food and Drug Administration premarket approval studies. Early resident experience performing LASIK can improve the training of ophthalmic surgeons while simultaneously increasing patient access to laser vision correction. [ J Refract Surg . 2021;37(8):545–551.]

The proximity of the iris to the instruments and currents of cataract surgery makes iatrogenic damage to the iris a common complication of cataract surgery. This article discusses techniques to prevent or minimize this damage. When damage does occur, the surgeon must decide if, when, and how to repair the damage. Principles governing these decisions and techniques for repair are discussed. Figures and videos, included as online Supplemental Data files, illustrate cases of iatrogenic damage and repair techniques.

Purpose To describe the indications, motivations, and outcomes of artificial iris exchange. Setting Stein Eye Institute. Design Consecutive case series. Methods Review of medical records of patients implanted with an artificial iris device who underwent a subsequent artificial iris exchange. Results Five patients were identified: 4 women and 1 man. Their ages ranged from 19 to 58 years at the time of the exchange. One patient had congenital aniridia; the other 4 had acquired iris defects. Three exchanges were simultaneous; 2 were consecutive. Corneal decompensation was the most common indication for the surgery precipitating the exchange. Explanted iris devices included models from Ophtec, Morcher, BrightOcular, and HumanOptics. Replacement models were from Morcher and HumanOptics. Three of the original irides were passively fixated in the capsular bag or ciliary sulcus. All of the replacement irides were suture-fixated to the sclera, either directly or secondarily by way of an intraocular lens. The motivation for the exchange was improved cosmesis in 4 patients and sustained cosmesis in 1 patient. Final visual acuities were 20/25 for 2 patients, 20/100 for 1 patient, and hand motion for 2 patients. Conclusions No 2 iris exchanges were similar. Clinical indications and outcomes varied considerably from patient to patient. A common thread was each patient's motivation to maintain or improve on the functional and cosmetic benefits of having been previously implanted with an artificial iris device. Final visual acuity results were often poor because of the effects of comorbidities, especially glaucoma and corneal decompensation.

We sought to evaluate the 1- to 9-year safety and efficacy of colored iris reconstruction lens implantation in eyes with visual disturbances caused by partial or complete aniridia.Prospective, interventional case series.Thirty-eight patients were implanted with Ophtec 311 colored iris reconstruction lenses at the University of California, Los Angeles as part of a larger U.S. Food and Drug Administration clinical trial. Patients in group 1 lacked corneal pathology. Patients in group 2 patients had corneal pathology, such as endothelial failure, previous transplants, or scarring. Safety measures included loss of corrected distance visual acuity (CDVA), surgical complications, adverse events, secondary interventions, and corneal endothelial cell loss. Efficacy measures included improvement in uncorrected distance visual acuity (UDVA) and subjective visual disturbances.Groups 1 (n = 8) and 2 (n = 30) showed improvements in CDVA (P = .155 and .038), UDVA (P = .002 and P.001), and subjective visual disturbance scores at year 3. Median CDVA and UDVA declined slightly for both groups after 1-2 years. Group 2 experienced more adverse events, surgical complications, and secondary interventions. Endothelial cell loss was greater for group 2 (19.7%) than group 1 (8.05%), although this difference was not statistically significant (P = .067).Colored iris reconstruction lens implantation improved CDVA, UDVA, and subjective visual disturbances 3 years postoperatively and beyond. Adverse events, complications, and subsequent declines in visual acuity were common, however, in these eyes with complex medical and surgical histories.

Author(s): Bonnet, Clemence; Miller, Kevin M | Abstract: PurposeTo assess the preliminary safety and efficacy of custom silicone artificial iris implantation.SettingStein Eye Institute.DesignProspective consecutive case series.MethodsMedical records of patients implanted with the artificial iris were reviewed and followed for 1 year. Safety measures included corrected distance visual acuity (CDVA), intraocular pressure (IOP), endothelial cell count (ECC), surgical complications, secondary interventions, and adverse events (AEs). Efficacy measures included CDVA with glare, subjective daytime and nighttime glare graded from 0 to 10 (very significant), and subjective cosmetic appearance graded from 0 to 10 (very satisfied).ResultsTwenty eyes (19 patients) were implanted. Safety data were mixed. CDVA improved in 13 eyes and worsened in 6. ECC decreased from 1918 ± 870 to 1405 ± 705 cells/mm (P = .02). Eight eyes experienced postoperative complications. There were 4 IOP elevations, 2 corneal decompensations, 1 case of cystoid macular edema, and 1 device dislocation. Four eyes underwent secondary surgical interventions including 2 AEs (1 glaucoma surgery and 1 device dislocation). Efficacy outcomes were excellent. CDVA with glare improved from 1.5 ± 0.6 to 0.7 ± 0.8 logarithm of the minimum angle of resolution (P l .01). Mean subjective daytime glare decreased from 8.9 ± 1.8 to 2.7 ± 2.6 (P l .01) and nighttime glare decreased from 7.9 ± 1.8 to 2.5 ± 2.7 (P l .01). Mean cosmesis improved from 2.2 ± 1.6 to 8.8 ± 2.1 (P l .01).ConclusionsCustom artificial iris implantation was moderately risky but very effective at reducing light and glare sensitivity and in improving ocular cosmesis.

Purpose: To determine the relation between patients’ age and degree of myopia on the risk of postoperative retinal detachment following cataract surgery. Setting: University-based cataract referral practice. Patients and methods: This is a retrospective study. The chart of all patients in the practice of 1 surgeon (K.M.M) who had cataract surgery by the Kelman phacoemulsification technique between 1991 and 2010, were reviewed to identify patients (those who had retinal detachment) was associated with 4-control who didn’t detach but had surgery around the same time. Result: Forty-three cases of retinal detachment were identified, the mean age at time of cataract surgery for the RD cases was 57.3 ± 14.7 years (range: 4 to 96 years) and for the control was 69.8 ± 12.9 years (range: 9 to 75 years), p < 0.0001, mean SE refraction error for the RD cases was -4.8 ± 4.7 diopters of myopia and for the control group was -1.6 ± 4.3 diopters of myopia p < 0.0001. Conclusion: The study shows that risk of retinal detachment and the degree of myopia is linear up to 12.00 diopters of myopia then starting to decline, and the risk of retinal detachment is the highest in age group between 50 to 59 years.

Purpose To report complications of cosmetic artificial iris implantation and explantation outcomes. Design Retrospective case series. Methods Medical records of 12 patients (24 eyes) who presented to us after being implanted with cosmetic artificial irises elsewhere were reviewed. Data collected included baseline demographics, presenting symptoms, examination findings, and management outcomes. Results Eight eyes had NewColorIris implants and 16 had BrightOcular implants. The mean interval from cosmetic iris implantation to presentation was 61.7 ± 60.0 months. The mean follow-up after explantation was 35.5 ± 38.1 months. Complications at presentation included iris abnormalities (11 eyes, 45.8%), elevated intraocular pressure (8 eyes, 33.3%), corneal edema (6 eyes, 25%), intraocular inflammation (5 eyes, 20.8%), and cataract (4 eyes, 16.7%). Surgical interventions included cosmetic iris removal (19 eyes, 79.2%), cataract extraction (7 eyes, 29.2%), corneal transplantation (7 eyes, 29.2%), and glaucoma surgery (4 eyes, 16.7%). Complications at the last follow-up examination included native iris defects (11 eyes, 45.8%), persistent glaucoma (7 eyes, 29.2%), cataract (5 eyes, 20.8%), corneal edema (4 eyes, 16.7%), and intraocular inflammation (2 eyes, 8.3%). The mean logarithm of the minimum angle of resolution was 0.56 ± 0.47 at presentation and 0.78 ± 0.88 at the last examination (P = .30). The mean intraocular pressure was 22.7 ± 15.8 mm Hg at presentation and 13.4 ± 6.99 mm Hg at the last examination (P = .02). Conclusion Cosmetic iris implantation was associated with serious complications at the time of presentation, and adverse sequelae persisted for years after explantation.

Author(s): Bonnet, Clemence; Vazirnia, Parsia; Deng, Sophie X; Aldave, Anthony J; Miller, Kevin M | Abstract: PurposeTo assess safety and efficacy outcomes of sutured custom silicone artificial iris and intraocular lens implantation combined with penetrating keratoplasty (triple procedure).MethodsProspective consecutive surgical case series of patients who underwent the triple procedure between 2010 and 2019 at Stein Eye Institute, UCLA, followed up for 1 year minimum. Safety outcomes were changes from preoperative to last follow-up in corrected distance visual acuity (CDVA), endothelial cell count, intraocular pressure (IOP), and postoperative complications. Efficacy outcomes included changes in subjective glare (none to severe), cosmetic appearance (worse to very much improved), and visual function as assessed by the Visual Function Questionnaire-25 at 1-year follow-up.ResultsAmong 82 eyes implanted with an artificial iris, 14 eyes (17.1%) underwent the triple procedure. The median follow-up was 18.1 months (range 12.0-54.9 months). The median CDVA improved from 2.0 log of minimum angle of resolution (logMAR) (range 0.9-2.3 logMAR) to 0.7 logMAR (range 0.2-2.6 logMAR) (P = 0.02). Average endothelial cell count decreased 57.6% (P l 0.01). Six eyes (42.9%) experienced IOP elevations, 13 eyes (92.3%) developed iritis, and 11 eyes (78.6%) underwent secondary surgery. Graft rejection or secondary graft failure occurred in 7 eyes each (50.0%). Cosmesis improved in 12 eyes (85.7%; P l 0.01). The Visual Function Questionnaire-25 score improved from 72 to 77 (P l 0.01). Glare symptoms did not change significantly.ConclusionsThe triple procedure was effective at improving CDVA, cosmesis, and quality of life; however, it was associated with frequent postoperative complications, of which iritis, IOP elevation, and secondary graft failure were the most common.

To assess the safety and efficacy of Morcher 67B black iris diaphragm intraocular lens (IOL) implantation for managing large iris defects and aphakia.Stein Eye Institute, UCLA, Los Angeles, California, USA.Prospective case series.The demographic, preoperative, and postoperative data on patients implanted with a black iris diaphragm IOL and followed to 1 year were reviewed. Safety measures included loss of corrected distance visual acuity (CDVA), perioperative complications, adverse events, and secondary surgical interventions. Efficacy measures included CDVA with glare, daytime and nighttime glare symptom scores, and subjective cosmesis scores.Thirty-one eyes of 31 patients were implanted. There was a 7-line improvement in median Snellen CDVA (P .001). Four eyes worsened more than 1 line. There was 1 minor intraoperative complication. Twenty-one eyes experienced postoperative complications, most of which were related to preexisting ocular comorbidities. Three adverse events included cystoid macular edema, corneal graft dehiscence, and uveitis with ocular hypertension. There were 12 secondary surgical interventions. The CDVA with glare improved 6 Snellen lines (P .0001). The mean subjective glare symptoms improved 4.94 points on a 0 to 10 scale during the day (P .0001) and 3.61 points at night (P .0001). The mean cosmesis score improved 2.23 points (P .0001) on the same scale.Black iris diaphragm IOL implantation in aphakic eyes with large iris defects and significant ocular comorbidity was found to be relatively safe and very effective at improving CDVA and reducing light and glare sensitivity.

Purpose: To discuss problems associated with the implantation of two Morcher iris diaphragm models. Methods: We describe the history, intraoperative complications, and postoperative complications of 5 patients with specific Morcher iris implants. Results: We implanted Morcher 50D devices in 1 patient and Morcher 96S devices in 4 patients. Complications included postoperative rotation, device mis-sizing, difficult intraoperative rotation, zonular dehiscence, and intraoperative hemorrhage. Conclusion: Artificial iris implantation has a steep learning curve. With widespread availability on the horizon in the United States, the sharing of surgical experiences is key to achieving the best outcomes for patients.

Purpose To expand understanding of presentation, diagnosis, and outcomes of hemorrhagic occlusive retinal vasculitis (HORV). Design Retrospective case series. Participants Thirty-six eyes of 23 patients. Methods The American Society of Cataract and Refractive Surgery (ASCRS) and the American Society of Retina Specialists (ASRS) formed a joint task force to define clinical characteristics of HORV and to study its prevalence, cause, treatment, and outcomes. An online registry was established on both societies' web sites. Surveys were e-mailed to members of both societies soliciting cases of suspected HORV. A literature search was performed to uncover additional cases. Main Outcome Measures Historical data including intraoperative characteristics, images, treatment regimens, and visual and anatomic outcomes. Results Characteristic findings of HORV included unremarkable postoperative day 1 undilated examination, delayed-onset painless vision loss, mild anterior chamber and vitreous inflammation, sectoral retinal hemorrhages in areas of ischemia, and predilection for venules and peripheral involvement. Based on predetermined diagnostic criteria, 36 eyes of 23 patients were diagnosed with HORV. All eyes received intraocular vancomycin via intracameral bolus (33/36), via intravitreal injection (1/36), or through the irrigation bottle (2/36). Patients sought treatment with HORV 1 to 21 days after surgery or intravitreal injection. Visual results usually were poor: 22 of 36 eyes (61%) had 20/200 or worse visual acuity and 8 of 36 eyes (22%) had no light perception (NLP). Neovascular glaucoma developed in 20 of 36 eyes (56%). Seven eyes received additional intravitreal vancomycin after surgery; 5 of these 7 eyes had NLP visual acuity at the most recent examination. Three eyes received intravitreal corticosteroids and had final visual acuities of 20/40, 20/70, and hand movements. Conclusions Hemorrhagic occlusive retinal vasculitis is a rare, potentially devastating condition that can develop after cataract surgery or intraocular injection. All cases in this series were associated with intraocular vancomycin. Disease course and findings suggest that HORV is caused by a delayed hypersensitivity reaction to vancomycin. Early treatment with corticosteroids likely is beneficial. Subsequently, anti–vascular endothelial growth factor injections and panretinal photocoagulation are important to prevent neovascular glaucoma, a common complication. Avoidance of additional intravitreal vancomycin is recommended if HORV is suspected.

Purpose: To determine the effect of anterior capsule polishing (APC) on the rate of posterior capsule opacification (PCO) as assessed by the need for laser posterior capsulotomy. Setting: University-based clinical practice, Jules Stein Eye Institute, Los Angles, California, USA. Methods: This study involved a retrospective review of eyes that underwent phacoemulsification and intraocular lens implantation between September 1991 and June 1999. Lens epithelial cells in the 763 study eyes were mechanically debrided or polished from the inside surface of the anterior capsules using a pair of Shepherd-Rentsch (Morning STAAR Inc.) capsule polishers. The 484 control eyes that had surgery earlier in the series were not polished. The rate of laser capsulotomy in the ACP and the non-ACP groups was compared using a Kaplan-Meier survival analysis. Multivariate regression was performed to determine if variables other than ACP influenced the need for laser posterior capsulotomy. Results: We identified 763 eyes that had ACP and 484 that did not. At the 24-month follow-up interval, 26.6% of the eyes in the ACP group had received a capsulotomy versus 19.50% in the non-APC. Next, a separate study was done using only one eye per patient, taking the patient as the unit of analysis. Again the capsulotomy rate was higher in the ACP group compared to the non-ACP (1.02 per 100 person-months of follow-up vs. 0.74 per 100 person-months of follow-up). Finally, a third Kaplan-Meier analysis was done on 52 patients that had one eye treated with the ACP procedure and the other eye with the non-ACP procedure. Although the log-rank test showed the statistical significant of this analysis to be borderline, the results again favored the non-ACP group with a lower capsulotomy rate. Multivariate analysis showed very similar results to the above univariate studies. The mean time to capsulotomy was 46 months for the polished group and 70 months for the unpolished group. The severity of cataract (p = 0.46) and the type of haptics (p = 0.86) did not influence the rate of capsulotomy. Plate haptic IOLS had a higher rate of capsulotomy than loop haptic IOLS (p = 0.001). Conclusions: Polishing of the anterior capsule with Shepherd-Rentsch polishers may unexpectedly increase the rate of posterior capsule opacification in eyes with round-edge silicone lenses.

Despite the modified Brostrom Procedure (MBP) being the gold standard for surgical treatment of chronic ankle instability (CAI), there is little data regarding factors that impact rehabilitation time. This retrospective analysis includes 67 consecutive Modified Brostrom Procedures (MBPs). Records were reviewed to define patient factors associated with increased time to return to activity (RTA). Of the 67 cases reviewed, 23 patients underwent reconstruction of the calcaneofibular (CFL) with a semimembranosus allograft in addition to repair of the anterior talofibular ligament (ATFL) with a suture tape. There were no significant demographic or clinical differences between these two groups. All patients had a minimum follow-up of 12 months. The mean age and body mass index (BMI) of the cohort was 44.7 years and 33.7 kg*m2, respectively, with a ratio of females to males of 2.35:1. Males began weight bearing as tolerated (WBAT) in a walking boot 1.08 weeks earlier than females (p = 0.053). Those with a BMI ≥ 35 kg/m2 RTA in normal shoe gear 0.50 weeks later (p = 0.443). Workers’ compensation cases were correlated with RTA (+0.431, p

The Marangoni effect describes fluid flow near an interface in response to a surface tension gradient. Here, we demonstrate that the Marangoni effect is the underlying mechanism for flow driven feature formation in an azobenzene-containing polymer film; features formed in azobenzene-containing polymers are often referred to as surface relief gratings or SRGs. An amorphous poly(4-(acryloyloxyhexyloxy)-4′-pentylazobenzene) was synthesized and studied as a model polymer. To isolate the surface tension driven flow from the surface tension pattern inscription step, the surface tension gradient was preprogrammed via photoisomerization of azobenzene in a glassy polymer film without forming topographical features. Subsequently, the latent image was developed in the absence of light by annealing above the glass transition temperature where the polymer is a liquid. The polymer flow direction was controlled with precision by inducing different surface tension changes in the exposed regions, in accordance with expect...

To evaluate the safety and efficacy of Morcher 96F iris diaphragm implantation to manage small defects of the human iris.Jules Stein Eye Institute, UCLA, Los Angeles, California, USA.Prospective nonrandomized interventional case series.Demographic, preoperative, and postoperative data of patients who had implantation of the modified capsular tension ring (CTR) and followed to 1 year were reviewed. Safety measures included loss of corrected distance visual acuity (CDVA), perioperative complications, adverse events, and secondary surgical interventions. Efficacy measures included CDVA with glare, daytime and nighttime glare symptom scores, and subjective cosmesis scores.Sixteen patients had CTR implantation. There was a statistically significant improvement in the median CDVA of 2.5 Snellen lines (P.01), with 4 patients having minor decreases in CDVA for reasons unrelated to the device. There were no intraoperative complications. Three adverse events were reported: 1 ocular hypertension, 1 postoperative retinal detachment, and 1 25-degree rotation of the CTR. There were 4 secondary surgical interventions. There was a statistically significant improvement in the median CDVA with glare of 8 Snellen lines (P.01), but 2 patients had a decrease in CDVA with glare for reasons unrelated to the device. There were statistically significant improvements in the median daytime and nighttime glare symptom scores of 5 points and 4 points, respectively (both P.01). There was no change in cosmesis for most patients.Iris diaphragm CTR implantation was relatively safe and effective at reducing light and glare sensitivity in eyes with small iris defects.No author has a financial or proprietary interest in any material or method mentioned.

Purpose To evaluate visual and surgical outcomes of cataract surgery in eyes with a history of iodine-125 (I125) brachytherapy for ocular melanoma. Setting Department of Ophthalmology, David Geffen School of Medicine at UCLA and the Stein Eye Institute, Los Angeles, California, USA. Design Retrospective case series. Methods Patients with ocular melanoma treated by I125 brachytherapy who subsequently had cataract surgery were evaluated. The recorded data included tumor size, location, preoperative ocular comorbidities, corrected distance visual acuity (CDVA), operative complications, and brachytherapy-related maculopathy before and after surgery. Results Thirty-two eyes of 32 patients were included. The mean age at the time of cataract surgery was 66.1 years. The median follow-up was 53.5 months. There were no intraoperative complications. Eighteen eyes (56.3%) had a history of preoperative radiation retinopathy, 10 involving the macula. Between 2 weeks and 4 weeks postoperatively, 22 eyes (68.8%) had an improvement in CDVA (≥2 lines). Seven of 10 eyes that failed to improve had radiation maculopathy. By the last follow-up examination, 13 eyes (40.6%) had improved CDVA, 9 eyes (28.1%) were worse (≥2 lines), and 10 eyes (31.3%) were unchanged (within ±1 line). Of 15 eyes that lost CDVA gains achieved between 2 weeks and 4 weeks postoperatively, 9 eyes had new-onset or worsening maculopathy. Cataract surgery had no effect on local tumor control or distant metastasis. Conclusions Cataract surgery after I125 brachytherapy for ocular melanoma improved CDVA in most eyes during the immediate postoperative period. Gains were often lost with further follow-up. Progression of radiation maculopathy was primarily responsible for subsequent visual decline.

Letters the same authors. Telephone consultation with the Western Institutional Review Board (WIRB), Puyallup, Washington, de- termined this research to be exempt and institutional review board review was waived. RESEARCH LETTER The Role of Subtractive Color Mixing in the Perception of Blue Nevi and Veins—Beyond the Tyndall Effect The original study 1 that proposed the “Tyndall effect” as the explanation behind the coloration of blue nevi drew from spec- trophotometric data on cadaveric skin and not the direct study of blue nevi. Since then, the moniker of the Tyndall effect has been applied to a variety of blue phenomena in the skin de- spite a lack of confirmatory data. We hypothesized that other light-skin optical characteristics may provide a better expla- nation for the visual phenomenon associated with why blue nevi appear blue. To briefly review the optics of the skin, perceived color is produced by light that strikes the skin and is remitted (a com- bination of light reflected and scattered back to the eye). The epidermis plays a minimal role in scattering, responsible pri- marily for the baseline reflectance of 5% to 7% of light from the skin surface. 2 The Tyndall effect originally described the preferential scattering of shorter wavelength blue light through particulate matter in air and fluids, and its application to solid tissue optics is based on extrapolative hypotheses. Accord- ingly, such scattering would occur in a homogenous manner diffusely throughout the skin, not only in blue nevi, which led us to believe that the Tyndall effect does not fully account for the optics associated with blue nevi and veins. Methods | We used a spectrophotometer (Konica-Minolta CM 2600d) to measure reflectance from (1) a normal and blue ne- vus and (2) a vein and comparable normal skin—each pair from Results | Both types of nevi showed reflectance spectra similar to known melanin curves—with high absorption of blue light and decreased absorption of red light (Figure 1). 2 The shorter wavelengths (approximately 400-500 nm) demonstrated the expected baseline reflectance off of the surface of the skin (8%), illustrating that the role of blue light scattering is minimal, and the amount of red-spectrum light is the main determinant of color. The spectral curves between vein skin and normal skin demonstrated similar decrease in red in the skin overlying a vein. Discussion | The decrease in red light that yields the blue ap- pearance of nevi and veins is accounted for through a con- cept termed “subtractive color mixing,” analogous to remov- ing red out of purple paint. 3 While the distinction between preferential blue scattering (Tyndall effect) or less red reflec- tance initially appears semantic, it recognizes that there are ad- ditional reasons beyond light scatter that can lead to de- creased red reflectance, including differences in vasculature, hemoglobin levels, or characteristics of melanin (small struc- tural differences can lead to changes in color, as seen in oxy- hemoglobin vs deoxyhemoglobin). In veins, the decrease in red color prompts a change in color perception. 4,5 In this situation, the eye uses a type of chro- matic induction called “simultaneous contrast” to enhance the contrast between 2 colors, leading the brain to perceive and Figure 1. Reflectance Spectra of Normal Skin, Skin Overlying a Vein, a Normal Nevus, and a Blue Nevus Normal Vein Reflectance, % Nevus Blue nevus Wavelength, mm jamadermatology.com This graph shows the reflectance of a blue nevus, nevus, normal skin, and a vein across a spectrum of visible light ranging from 400 nm to 700 nm. The blue nevus shows a decreased red light reflectance compared with a normal nevus, and the vein shows a decreased red light reflectance compared with normal skin. Through the concept of subtractive color mixing, this decrease in red light contributes to a perceived blue hue. (Reprinted) JAMA Dermatology Published online July 13, 2016 Copyright 2016 American Medical Association. All rights reserved. Downloaded From: http://archderm.jamanetwork.com/ by University of California - Los Angeles, Melissa Shive on 08/18/2016 E1

Purpose To evaluate the safety and efficacy of Morcher 50F iris diaphragm implantation to manage moderate to large defects of the human iris. Setting Stein Eye Institute, UCLA, Los Angeles, California, USA. Design Prospective nonrandomized interventional case series. Methods The demographic, preoperative, and postoperative data of patients who had implantation of modified capsular tension rings and followed to 1 year were reviewed. Safety measures included loss of corrected distance visual acuity (CDVA), surgical complications, adverse events, and secondary surgical interventions. Efficacy measures included CDVA with glare, daytime and nighttime glare symptom scores, and subjective cosmesis scores. Results The study comprised 12 patients. The median CDVA was 20/70 before surgery and 20/20 after surgery. There were no lost lines of CDVA and no intraoperative complications. The most common postoperative complication was posterior capsule opacification. Two adverse events were unrelated to the device. Four patients had secondary surgical interventions, the most common of which was laser capsulotomy. The median CDVA with glare improved from less than 20/400 before surgery to 20/50 after surgery. One patient worsened. The median subjective daytime glare symptom score improved from 9 to 3 on a 10-point scale ( P = .001). The median nighttime subjective glare symptom score improved from 8 to 2 ( P = .001). The subjective cosmetic appearance of the eye stayed the same or improved for all patients ( P = .031). Conclusion Iris diaphragm implantation was relatively safe and effective for reducing light and glare sensitivity in eyes with iris defects when combined with cataract extraction and intraocular lens implantation. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Purpose of review Femtosecond lasers for use during cataract surgery carry significant purchase and use costs. The aim of this article is to help surgeons and surgery centers anticipate financial issues related to implementing femtosecond laser-Assisted cataract surgery (FLACS). Such scenarios hopefully can help to inform decision making around the purchase and use of these lasers. Recent findings FLACS has several potential advantages over traditional phacoemulsification. However, although studies have demonstrated noninferiority of FLACS, there continues to be few data to support significantly improved visual outcomes. The literature does show a significantly higher cost for FLACS. As this cost can be passed on to patients under Medicare rules, there is the potential for increased physician revenue, which can be a motivator for adoption of this new technology. The magnitude of this increase is heavily influenced by the financial details of the implementation, like the cost of the laser, the volume of surgery performed, and the incremental increase in revenue. Summary A financial analysis should be performed prior to purchasing a femtosecond laser. This analysis can help predict if FLACS is going to be a financial windfall or a money loser.

Patients expect their vision to improve after cataract surgery and, increasingly, they expect to be free of the encumbrance of glasses and contact lenses. These expectations are driven by technological advancements throughout the ophthalmic industry and the experiences of family and friends. To meet or exceed patient expectations, cataract surgeons must pay increasing attention to the management of pre-existing corneal astigmatism at the time of cataract surgery. Pre-existing corneal astigmatism is a significant component of preoperative ametropia. To achieve satisfactory postoperative refractive results, it is important to correct pre-existing spherical errors by accurate biometry and intraocular lens (IOL) power calculation, and to manage preoperative corneal cylinder errors by a suitable method. Guided by preoperative corneal topography, patients with varying degrees of corneal astigmatism can be placed into a variety of dioptric categories. These categories dictate a systematic ‘stepladder’ approach t...

Purpose To describe a case of suprachoroidal hemorrhage that occurred during femtosecond laser assisted cataract surgery (FLACS). Observations A 67-year-old woman with high myopia underwent FLACS. Following two unsuccessful attempts at docking due to interface air bubbles, the third attempt was successful. Laser treatment and cataract surgery proceeded uneventfully until intraocular lens (IOL) implantation. While positioning the IOL within the capsular bag, the anterior chamber began to shallow, intraocular pressure became high by palpation, and the optic of the IOL prolapsed partially out of the bag. A segmental suprachoroidal hemorrhage was identified in the superior peripheral retina by intraoperative indirect ophthalmoscopy. Following an hour of waiting in the recovery room, the anterior chamber deepened and the intraocular pressure was low enough to position the IOL centrally within the bag. Her subsequent postoperative course was uneventful. Conclusions and Importance To our knowledge, this is the first report of suprachoroidal hemorrhage during FLACS. We speculate that repeated sudden drops in intraocular pressure associated with multiple undockings triggered the suprachoroidal hemorrhage in this case.

Purpose To compare the AcrySof Toric intraocular lens (IOL) and an AcrySof spherical control IOL and to investigate rotational stability of the AcrySof Toric IOL (Alcon Laboratories, Inc., Fort Worth, TX) in subjects with cataracts and preexisting corneal astigmatism. Design Randomized, subject-masked, parallel-group, multicenter, 1-year study. Participants We included 517 subjects (Toric IOL, n=256; control IOL, n=261). Methods Unilateral implantation of an AcrySof Toric or AcrySof spherical control IOL (spherical powers, 12.00–25.00 diopters [D]; cylinder powers 1.50, 2.25, or 3.00 D for corneal astigmatism correction of 0.75 to Main Outcome Measures Visual acuity outcomes, IOL position, patient-reported spectacle use, and safety. Results One year postoperatively, best spectacle-corrected distance visual acuity of ≥20/20 was 77.7% (Toric IOL) versus 69.2% (control IOL). Uncorrected distance visual acuity of 20/20 or better was 40.7% (Toric IOL) versus 19.4% (control IOL; P P P Conclusions Favorable efficacy, rotational stability, distance vision spectacle freedom, and safety results support the use of the AcrySof Toric IOL for patients with cataracts and corneal astigmatism. Financial Disclosure(s) Proprietary or commercial disclosure may be found after the references.

Purpose To compare the heat production of longitudinal versus torsional phacoemulsification under strict laboratory test conditions. Setting Department of Ophthalmology, David Geffen School of Medicine at UCLA, and Jules Stein Eye Institute, Los Angeles, California, USA. Methods Two Infiniti phacoemulsification handpieces were inserted into silicone test chambers filled with a balanced salt solution and imaged serially using a thermal camera. Incision compression was simulated by suspending 25.3 g weights from the silicone chambers. To simulate occlusion of the phacoemulsification tip, the aspiration line was clamped. Peak temperatures were measured 0, 10, 30, 60, and 120 seconds after the commencement of continuous ultrasound power. The 2 handpieces, operating exclusively in longitudinal or torsional modes, were compared 3 ways: (1) using the same power displayed on the instrument console, (2) using identical stroke lengths, and (3) using the same applied energy, a product of stroke length and frequency. Results For all 3 comparisons, torsional phacoemulsification resulted in lower temperatures at each time point. At the same displayed power setting, the scenario most familiar to cataract surgeons, longitudinal phacoemulsification elevated temperatures up to 41.5°C more than torsional phacoemulsification. Conclusions Torsional phacoemulsification generated less heat than longitudinal phacoemulsification in all 3 comparison tests. Lower operating temperatures indicate lower heat generation within the same volume of fluid, and this may provide additional thermal protection during cataract surgery.

Purpose To measure the visual outcomes after cataract surgery in patients with 20/20 or better preoperative visual acuity. Setting University-based cataract referral practice. Methods In this retrospective case review, 2 groups of patients with a corrected distance visual acuity (CDVA) of 20/20 or better in both eyes before cataract surgery were identified. Patients in the first group had a cataract in 1 eye and an intraocular lens (IOL) in the other eye. Patients in the second group had cataracts in both eyes. Each patient completed a Visual Function 14 (VF-14) questionnaire before and after cataract surgery. Changes in VF-14 scores were analyzed. Results The VF-14 scores improved significantly after cataract surgery in both groups. Patients with cataract in 1 eye and an IOL in the other eye before surgery (n = 28) had a mean improvement of 12.2 in the VF-14 score ( P = .029). Patients with cataract in both eyes (n = 31) had a mean improvement of 14.5 in the VF-14 score ( P Conclusions The functional vision of patients with 20/20 or better preoperative CDVA improved significantly after cataract surgery. This finding shows that arbitrary CDVA thresholds of worse than 20/20 cannot always be used to determine who will benefit from cataract surgery.

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.

There are several options for correcting astigmatism at the time of cataract surgery. They include incision placement on the steep axis of corneal astigmatism, single or paired peripheral corneal relaxing incisions, and toric intraocular lens implantation. The aim of this review is to update readers on advances reported during the last year.Phacoemulsification incision placement on the steep corneal axis corrects small amounts of astigmatism and is sufficient for most eyes. Peripheral corneal relaxing incisions correct greater amounts of astigmatism. They may be necessary when implanting multifocal intraocular lenses in eyes with more than 1 diopter of astigmatism. Toric intraocular lenses are also safe and effective for treating more than 1 diopter of astigmatism, and they now have excellent rotational stability.Good uncorrected postoperative distance visual acuity can be obtained for a high percentage of cataract patients with preexisting corneal astigmatism. Postoperative keratorefractive surgery is available to enhance the condition of patients who achieve less-than-optimal astigmatic results.

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.

Purpose To determine the functional and cosmetic outcomes of combined iris reconstruction lens (Ophtec) implantation and penetrating keratoplasty (PK) in eyes with acquired partial or complete aniridia. Setting Jules Stein Eye Institute and the Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA. Methods In a prospective nonrandomized single-center interventional case series, efficacy measures included improvement in cosmesis and reduction in glare, star bursts, and photophobia. Safety measures included changes in best corrected visual acuity (BCVA), reports of adverse events, and surgical complications. Results The 9 eyes in the study had a history of penetrating or blunt trauma and were aphakic or in need of cataract surgery. Corneal pathologies necessitating transplantation included scarring, decompensation, or failure of a previous graft. Postoperatively, all patients were pleased with the cosmetic improvement of the study eye and all reported a reduction in visual disturbances. By the final follow-up examination, the BCVA improved in 4 patients but worsened in 5. Three adverse events were reported. There were no intraoperative surgical complications. The most serious postoperative complications were a pressure spike leading to loss of light perception, corneal graft rejection, and graft failure. The most common postoperative problem was surgically induced irregular corneal astigmatism. Conclusions Ophtec iris reconstruction lens implantation and simultaneous PK reduced visual disturbances and improved the aesthetic appearance of the eyes. The long-term safety of the procedure, judged by BCVA and postoperative complications, was mixed, with both good and bad outcomes.

Purpose: To evaluate the visual and refractive outcomes, lens power calculation accuracy, and safety of nega- tive power intraocular lenses (IOLs) implanted in highly myopic eyes at the time of cataract surgery. Design: Interventional case series. Methods: Sixteen consecutive highly myopic eyes implanted with IOLs from -1 D to -6 D were identified. IOL power; preoperative and postoperative best-corrected visual acuity (BCVA); postoperative uncorrected visual acuity (UCVA); preoperative, intended, and achieved spherical equivalent (SE) refractive errors; and operative complications were re- corded. Results: Median UCVA improved from finger counting to 20/50-2. Median BCVA improved from 20/125-1 to 20/30+1. Mean axial length was 32.65 mm. The mean SE refractive error was -22.19 ± 5.4 D before surgery and -0.28 ± 1.4 D after surgery. The difference between the mean intended and mean achieved SE refractive errors was +1.16 D for the SRK/T, +1.2 D for the Holladay 1, and +1.60 D for the Hoffer Q formulas. Only 5 (33.3%) of 15 eyes in which postoperative measurements were possible were within 1 D of the intended SE postoperative refraction. Postoperative complications in- cluded a mildly hyperopic postoperative refractive error (+1.75 D) in one eye necessitating an IOL exchange and posterior capsule opacification in most eyes. There were no retinal detachments. Conclusions: The SRK/T formula had the greatest accuracy and predictability when immersion A-scan ultrasonography was used to measure axial length. The mean achieved postoperative refractive error was +1.16 D more hyperopic than predicted by this formula. We recommend targeting highly myopic eyes for -1.5 D using the SRK/T formula if a negative power IOL is calculated and emmetropia or mild residual myopia is the desired postoperative result.

Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. These medications have been found to reduce pain, prevent intraoperative miosis, modulate postoperative inflammation, and reduce the incidence of cystoid macular edema (CME). Whether used alone, synergistically with steroids, or for specific high-risk eyes prone to the development of CME, the effectiveness of these medications is compelling. This review describes the potential preoperative, intraoperative, and postoperative uses of NSAIDs, including the potency, indications and treatment paradigms and adverse effects and contraindications. A thorough understanding of these issues will help surgeons maximize the therapeutic benefits of these agents and improve surgical outcomes. Financial Disclosure Proprietary or commercial disclosures are listed after the references.

To evaluate the safety and efficacy of the Ophtec capsular tension ring (CTR) in providing capsular support during and/or after cataract extraction in cases of a weak or partially broken ciliary zonule.Phase III multicenter, nonrandomized, investigational device study.Twelve investigators at 9 sites enrolled 224 subjects and placed 255 CTRs.Capsular tension rings were placed in patients who were found to have a weakened or partially broken ciliary zonule comprising34% of the circumference of the lens capsule. Two CTR models were evaluated, with noncompressed diameters of 12 mm and 13 mm. Patients were examined preoperatively, intraoperatively, and postoperatively at day 1 and months 1, 3, 6, and 12.Rate of successful stabilization of the capsular bag and intraocular lens (IOL) centration, complications, and adverse events.Interim results from this ongoing study indicate that immediately after surgery 98.8% of IOLs were centered and 1.2% of the IOLs implanted (3/251) were not centered. Subsequently, the prevalence of decentered IOLs was 1.7% (4/236) 3 months after surgery, 3.8% (8/211) 6 months after surgery, and 2.3% (4/172) 12 months after surgery. The primary complication was posterior capsular opacification, which is unlikely to be a complication of CTR insertion. Neodymium:yttrium-aluminum-garnet laser capsulotomies have been performed in 12.8% of eyes by 12 months (22/172).Ophtec CTR models 275 and 276 safely provided capsular support during and after cataract surgery in cases where the zonule was weak or partially broken.

Purpose: To determine the safety and efficacy of the Ophtec model 311 iris reconstruction lens for treatment of visual disturbances, such as glare or photophobia, related to partial or total absence of the human iris. Design: Phase I multicenter, nonrandomized, investigational device study. Participants: Ten iris reconstruction lenses were placed in 10 subjects at 6 sites. Methods: Iris reconstruction lenses were placed in 9 patients who had lost all or part of their iris from trauma and in 1 patient who lacked iris pigmentation due to congenital albinism. Patients were examined preoperatively, intraoperatively, and postoperatively at day 1; week 1; and months 1, 3, 6, and 12. Main Outcome Measures: Efficacy measures were uncorrected visual acuity (UCVA), glare, starbursts, and photophobia. Safety measures were best-corrected visual acuity (VA), surgical complications, and adverse events. Results: Uncorrected VA improved in all eyes after implantation of the iris reconstruction lens. Bestcorrected VA did not change significantly (P 0.24). Postoperative photophobia was reduced in all 9 eyes that experienced moderate to severe preoperative photophobia. Likewise, postoperative glare was reduced in all 6 eyes with moderate to severe preoperative glare. There were no surgical complications. Adverse events included 2 cases of iritis and 1 case of macular edema. Conclusions: Preliminary results suggest that the Ophtec model 311 iris reconstruction lens can improve UCVA and reduce glare and photophobia in patients with partial or total absence of the iris or iris pigmentation. Ophthalmology 2004;111:1847–1852 © 2004 by the American Academy of Ophthalmology.

Many patients require surgery for cataract after retinal surgery. When evaluating patients preoperatively, the surgeon should pay careful attention to the assessment of visual function and potential acuity, and to the slit lamp examination of the lens, posterior capsule, anterior cortical vitreous, and zonules. The surgeon's technique must account for increased nuclear sclerosis, intraoperative miosis, a characteristically longer axial length, and fluctuations in anterior chamber depth from movement of the iris-lens diaphragm. Posterior capsule plaques are not unusual. Posterior capsule opacification is the most frequent late complication. Visual outcomes are usually good except when limited by pre-existing macular pathology. Vision-threatening complications of cataract surgery are unusual.

A 76-year-old man with a severe neck deformity resulting in a facedown posture presented with a visually significant cataract in his right eye. The patient had been scheduled for cataract surgery elsewhere, but the surgery was cancelled in the operating room when he could not be positioned beneath the operating microscope. The patient's surgery was safely and effectively performed by placing 25 to 30 pillows under his buttocks and legs and one pillow and a towel beneath his head and neck. The patient and pillows were taped to the operating table so that they would not move.

Purpose To describe the visual complaints of a series of patients implanted with the AcrySof® (Alcon Surgical) acrylic intraocular lens (IOL) that resolved with IOL exchange. Setting Jules Stein Eye Institute, Los Angeles, California, and John A. Moran Eye Center, Salt Lake City, Utah, USA. Methods This was a retrospective review of patients who had AcrySof IOL exchange from January 1997 to December 1998. Results Eight patients (9 eyes) with bothersome visual symptoms following AcrySof IOL implantation were identified. Problems included glare, halos around point light sources, and peripheral arcs of light, often worse at night. In each case, the IOL was well-centered in the capsular bag and there was no significant posterior capsule opacification. Six patients (7 eyes) had the MA30BA model with a 5.5 mm optic, and 2 patients (2 eyes) had the MA60BM model with a 6.0 mm optic. No extralenticular reasons for the patients’ complaints could be identified. Exchanging the AcrySof IOLs with silicone or poly(methyl methacrylate) IOLs alleviated most symptoms. In 5 of 8 patients, dysphotopsias resolved completely. Conclusions A small number of patients implanted with AcrySof IOLs have specific complaints of glare, halos, and peripheral arcs of light. Optical considerations that may help explain these symptoms include the high refractive index of the IOL material and the truncated design of the optic. Patients who are highly observant and those with large pupils may be particularly symptomatic. Intraocular lens exchange may be necessary in some cases.

We describe a technique for performing laser vitreolysis in patients lying upside down on a gurney.

PURPOSE Traumatic aniridia is often associated with severe anterior segment disruption, resulting in aphakia and corneal irregularity. Previous treatments included corneal tattooing and prosthetic contact lens correction. In the last 15 years, artificial iris implants have been demonstrated as safe and efficacious for reducing glare. Corneal scarring and irregularity from trauma still need to be addressed after artificial iris implantation. METHOD This case report describes a patient who was rehabilitated with a custom rigid gas permeable contact lens after Morcher iris reconstruction lens implantation. RESULTS The patient experienced a significant decrease in photophobia glare sensitivity and achieved mechanical, physiologic and optical success, but only limited tolerance with the contact lens. CONCLUSIONS Iris reconstruction lens implantation followed by rigid contact lens fitting is an option for correcting the aperture and optical defects of traumatic aniridia.

Purpose: To investigate the effect on intraocular pressure (IOP) of sutureless scleral and corneal tunnel Kelman phacoemulsification (KPE) with foldable posterior chamber intraocular lens (IOL) implantation. Setting: Jules Stein Eye Institute, Los Angeles, California, USA. Methods: Preoperative and postoperative (: and 6 weeks and 6 to 8 months) IOP measurements of 385 consecutive eyes. having uneventful phacoemulsification and foldable posterior chamber IOL implantation were reviewed retrospectively. A subset of 193 eyes for which no IOP measurements were missing at any follow-up were analyzed separately. Results: Mean preoperative IOP was 1,5.8 mm Hg ± 0.2 (±SE). It dropped postoperatively by 1,3 ± 0.2 mm Hg at 1 week ( P P P P P Conclusion: Sutureless KPE with foldable posterior chamber IOL implantation lowered IOP by 1.1 to 2.5 mm Hg for the 6 months immediately following surgery. Glaucoma patients had a statistically significant initial rise in IOP at 1 week.

Objective: This study aimed to describe the intraoperative and postoperative complications and visual acuity outcomes of patients undergoing Kelman phacoemulsification (KPE) and intraocular lens (IOL) implantation after pars plana vitrectomy (PPV). Design: The study design was a retrospective review of a consecutive surgical series. Participants: Forty-four eyes of 43 patients who underwent surgery at the Jules Stein Eye Institute, Los Angeles, California, or Advanced Vision Care, West Hills, California, were studied. Intervention: Office records, referring retina specialists' records, and operative reports were reviewed for demographic information, indications for PPV, preoperative cataract severity, unplanned intraoperative events and complications, early and late postoperative complications, and postoperative visual acuities. Main Outcome Measures: Complications and postoperative visual acuities were measured. Results: The mean interval from PPV to KPE was 20 months. The mean interval from KPE to final examination was 19 months. Primary indications for PPV included development of a macular epiretinal membrane, macular hole, proliferative diabetic retinopathy, retinal detachment, vitreous abscess, and vitreous hemorrhage. The degree of nuclear sclerosis in postvitrectomy eyes was greater than that in typical cataract eyes ( P = 0.00002). The most common intraoperative problem was the discovery of a posterior capsule plaque. In a few cases, surgery was made difficult by unusual fluctuations in anterior chamber depth and lens zonule instability. The most common early postoperative complication was corneal edema; the most common late complication was the need for neodymium:YAG (Nd:YAG) laser posterior capsulotomy. An IOL was implanted in every eye. There were no retinal detachments. Median visual acuity improved from 20/125 before cataract surgery to 20/40 6 weeks after surgery to 20/30 on final examination. Visual acuity of 20/40 or better was achieved by 63.6% of eyes at 6 weeks and by 72.7% of eyes by final examination. Conclusions: Kelman phacoemulsification and IOL implantation can be performed safely after PPV. Intraoperative and postoperative complications are uncommon. Pre-existing posterior segment pathology limits the ultimate improvement in visual acuity, but substantial gains in visual acuity are realized by most patients.

Background To compare the heat production of 3 different phacoemulsification machines under strict laboratory test conditions. More specifically, the thermal behavior was analyzed between the torsional modality of the Infiniti system and longitudinal modalities of the Abbot WhiteStar Signature Phacoemulsification system and Bausch and Lomb Stellaris system. Methods Experiments were performed under in-vitro conditions in this study. Three phacoemulsification handpieces (Infiniti, Signature, and Stellaris) were inserted into balanced salt solution-filled silicone test chambers and were imaged side-by-side by using a thermal camera. Incision compression was simulated by suspending 30.66-gram weights from the silicone chambers. The irrigation flow rate was set at 0, 1, 2, 3, 4, and 5 cc/min and the phacoemulsification power on the instrument consoles was set at 40, 60, 80, and 100%. The highest temperatures generated from each handpiece around the point of compression were measured at 0, 10, 30, and 60 seconds. Results Under the same displayed phacoemulsification power settings, the peak temperatures measured when using the Infiniti were lower than when using the other two machines, and the Signature was cooler than the Stellaris. At 10 seconds, torsional phacoemulsification with Infiniti at 100% power showed data comparable to that of the Signature at 80% and the Stellaris at 60%. At 30 seconds, the temperature from the Infiniti at 100% power was lower than the Signature at 60% and the Stellaris at 40%. Conclusions Torsional phacoemulsification with the Infiniti generates less heat than longitudinal phacoemulsification with the Signature and the Stellaris. Lower operating temperatures indicate lower heat generation within the same fluid volume, which may provide additional thermal protection during cataract surgery.

Purpose We compared the changes in corneal astigmatism after phacoemulsification and intraocular lens implantation in 93 consecutive eyes with unsutured 4-mm superior scleral tunnel incisions to those through 105 consecutive eyes with unsutured 3.2- to 3.5-mm temporal corneal tunnel incisions. Methods Keratometry measurements were obtained preoperatively and at postoperative day 1, week 1, and week 6. Group differences in scalar and vector astigmatism were compared by using analysis of variance methods. Results Mean scalar astigmatism in the scleral incision group changed from preoperative astigmatism by 0.65 diopter at postoperative day 1, 0.37 diopter at postoperative week 1, and 0.13 diopter at postoperative week 6. Mean scalar astigmatism in the corneal incision group changed from preoperative astigmatism by 0.39 diopter at postoperative day 1, 0.21 diopter at postoperative week 1, and 0.13 diopter at postoperative week 6. Mean vector astigmatism in the scleral incision group changed 1.26 diopters at 80 degrees at postoperative day 1, 1.05 diopters at 83 degrees at postoperative week 1, and 0.42 diopter at 103 degrees at postoperative week 6. Mean vector astigmatism in the corneal incision group changed 0.77 diopter at 90 degrees at postoperative day 1, 0.75 diopter at 88 degrees at postoperative week 1, and 0.61 diopter at 89 degrees at postoperative week 6. The differences were statistically significant (P = .003) only by vector analysis at the postoperative day 1 examination. Conclusions We found significantly greater with-the-rule change in astigmatism in the scleral incision group than in the corneal incision group on the first postoperative day. The effect disappeared by the sixth postoperative week.

We describe a hand-held gyroscope deviometer that an examiner can use to measure strabismic deviations without prisms. The deviometer is ideally suited for use with small children who will not allow prisms to be held near their eyes, and adults with poor fixation in one eye. The device consists of a fixation light attached to a gimbal-mounted single-axis gyroscope. The gyroscope provides the necessary reference for horizontal deviations. Gravity provides the reference for vertical deviations. As the patient observes his or her reflection with the fixing eye in a plane mirror at the end of the room, the examiner positions the corneal light reflex in the pupil of the deviating eye and presses a rocker switch to the "reset" position, zeroing the deviometer. The examiner then aims the deviometer fixation light at a reflection of itself in a plane mirror located on the wall behind the subject and presses the rocker switch to the "read" position. Horizontal and vertical deviations are displayed to the nearest degree. The accuracy of the device is dependent upon the examiner's ability to position the corneal light reflex correctly in the pupil of the deviating eye.

PURPOSE To describe the variations in intraoperative technique, postoperative complications, and visual outcomes associated with Descemet stripping endothelial keratoplasty (DSEK) after Ophtec iris reconstruction lens implantation. DESIGN Retrospective, interventional, consecutive case series. PARTICIPANTS Patients who underwent DSEK after Ophtec 311 iris reconstruction lens implantation at the Jules Stein Eye Institute, University of California, Los Angeles. METHODS Medical records were reviewed for demographic information, ophthalmic history, DSEK surgical technique, and postoperative clinical course. MAIN OUTCOME MEASURES Intraoperative and postoperative complications and visual outcomes. RESULTS Four patients were identified (1 man and 3 women, age: 43-78). Three of the eyes had undergone prior penetrating keratoplasty (PKP), and each of the eyes had a history of glaucoma, with previous glaucoma surgery having been performed in 2 of the eyes. No intraoperative complications were encountered during the procedures, although an unplanned anterior vitrectomy was required in a previously vitrectomized eye. In each case, a complete air fill of the globe was obtained to ensure adherence of the donor button, and in 3 of the 4 cases, the donor button was sutured to the recipient cornea to prevent potential posterior dislocation. None of the cases developed donor button dislocation or primary graft failure. Corrected distance visual acuities improved to 20/40-20/160, corresponding to a mean improvement of 0.25 (range, 0.12-0.40), limited by irregular corneal astigmatism and advanced glaucomatous optic neuropathy. During a mean follow-up period of 15.6 months (range, 4.9-24.8 months), graft rejection developed in 2 of the 3 eyes with a history of endothelial rejection after PKP (0.42 episode per eye-year). Both of these eyes developed secondary graft failure, which also developed 14 months after DSEK in the other eye with a history of PKP failure before DSEK. CONCLUSIONS DSEK can be successfully performed in eyes with partial or complete aniridia, such as those after Ophtec iris reconstruction lens implantation. Modifications to the standard DSEK technique increase the probability of successful donor adherence and decrease the risk of posterior dislocation of the donor corneal button. However, endothelial rejection may occur at an increased frequency, resulting in secondary graft failure.

A 50-year-old black man enters with a chief complaint of monocular diplopia and blurred vision (20/100) of the right eye that was noted when he got up this morning. He denies prior injury, disease or surgery of the eye; denies working with chemicals; and denies the use of ocular or systemic medication. Examination reveals normal eye examination OD, except a 2.25-diopter hyperopic shift and corneal topography that shows a small flattened area of the central cornea. Refraction improves vision to 20/25 blurred, but does not eliminate the diplopia. With a piano hard contact lens over the eye, and the eye refracted again, vision of 20/15 is obtained and monocular diplopia is eliminated. What is your diagnosis? What do you believe the etiology is? What further tests would you consider? What treatment would you advise?.