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Femtosecond laser-assisted cataract surgery (FLACS) was introduced with the hope of making cataract surgery safer and making the refractive result more predictable. It is only in the last four years that level 1 prospective randomised controlled trials (RCT) using current technology have been published. These, along with a meta-analysis of recent studies have shown that there seems to be little long-term visual benefit when using FLACS with monofocal lenses. The promised decrease in ultrasound energy required to remove a cataract has not been consistently demonstrated. There is level one evidence that the rate of posterior capsular rupture is less with FLACS using modern software. The round capsulotomy may be of increasing importance with the uptake of toric, multifocal and extended depth of focus lenses where a predictable capsulotomy size and precise placement of the lens becomes more important., Video abstract Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/nCS4ub-OBUc

Mariska Ackerman,1 Michael Lawless,2,3 Lewis Levitz,4 Uday Bhatt,4 Joseph A Reich,4 Gerard Sutton,2,3 Timothy V Roberts,2,3 Abi Tenen,4 Amanpreet Kaur,4 Chris Hodge2,3,5,6 1Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; 2Vision Eye Institute, Sydney, New South Wales, Australia; 3Save Sight Institute, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; 4Vision Eye Institute, Melbourne, Victoria, Australia; 5Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia; 6Macquarie University, Sydney, AustraliaCorrespondence: Michael Lawless, Vision Eye Institute, Level 3 270 Victoria Avenue, Chatswood, Sydney, NSW, 2067, Australia, Tel +61 2 9424 9999, Fax +61 2 9410 3000, Email michael.lawless@vei.com.auPurpose: Trifocal Intraocular Lenses (IOLs) were developed to provide patients with effective near, intermediate and distance vision, thus minimizing spectacle dependency. Residual astigmatism has previously been shown to impact unaided visual acuity across all distances; therefore, to optimise the expected outcomes, consideration of preoperative corneal astigmatism is essential. The purpose of this study was to provide a real-world, multi-site review of visual and refractive outcomes in eyes undergoing implantation with the Panoptix Trifocal toric IOL platform.Patients and Methods: This study represents a two-fold approach. Patients who had previously undergone routine cataract removal and IOL insertion with the Panoptix Toric IOL were retrospectively analysed for routine efficacy and safety endpoints (“Retrospective Cohort”). Data was retrieved from the preoperative, surgical and postoperative visits (range 2– 6 weeks). A further subset of patients undergoing lens removal and bilateral Panoptix Toric IOL insertion were identified at surgery (“Qualitative Cohort”). These patients underwent additional testing inclusive of quality of vision questionnaire and bilateral defocus curve.Results: A total of 466 eyes of 254 patients were included in the retrospective cohort. Between 91% and 98% of eyes, respectively, were within 0.50D and 1.00D of target. Mean absolute difference from Spherical Equivalent (SE) target was 0.22 ± 0.24Ds. Following surgery, 94% of eyes demonstrated a refractive astigmatism of 0.50D or less. Further, 61% eyes achieved uncorrected distance visual acuity (UDVA) of 20/20 or better, increasing to 94% achieving 20/32 or better. Seventy percent of eyes unilaterally achieved N5 unaided and 66.0% achieved N8 or better at intermediate. In the qualitative cohort, no patient described any symptom as significant or requested explant.Conclusion: In a real-world setting, the PanOptix toric trifocal IOL continues to demonstrate refractive accuracy and good visual performance at all focal distances. This IOL also exhibited good quality of vision, with minimally bothersome visual disturbances or photic phenomena.Keywords: cataract surgery, IOL, trifocal, lens extraction, visual acuity

Lewis Levitz,1 Joseph Reich,1 Chris Hodge1,2 1Vision Eye Institute Camberwell, Hawthorn East, VIC, Australia; 2Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia Purpose: The aim of the study was to determine whether femtosecond-assisted laser cataract surgery (FLACS) reduces the posterior capsular complication (PCC) rate compared to manual cataract surgery when performed by an experienced surgeon. Patients and methods: We reviewed 2,021 consecutive FLACS procedures between 1 June 2012 and 30 August 2017. All cases of posterior capsular rupture (PCR) with or without vitreous prolapse or zonular dialysis (ZD) that prevented an in-the-bag placement of the intraocular lens were included. Risk factors were noted and outcomes documented. Results: Six eyes of 2,021 (0.3%) who underwent FLACS had either a PCR or ZD. One eye (0.25%) of 403 eyes that had manual cataract surgery had a PCR. There was no significant difference in outcomes. Risk factors included advanced age, dense nuclei, pseudoexfoliation and small pupil. Only a single case in the FLACS series may have been directly attributed to the FLACS procedure. Conclusion: This study provides evidence that there is no significant difference in the PCC rate between FLACS and manual cataract surgery in the hand of an experienced surgeon who performs >350 cases annually. This low rate of complications may be achieved by less experienced surgeons adopting FLACS. Keywords: cataract surgery, phacoemulsification complications, femtosecond laser-assisted cataract surgery, safety, posterior capsule rupture, zonular dehiscence

Purpose This study aimed to describe the efficacy of toric intraocular lenses (IOLs) in patients with low degrees of corneal astigmatism. Design Retrospective case series was undertaken. Methods Patients with low amounts of corneal astigmatism who were treated with either a toric monofocal lens (SN6AT2 Toric, n = 76) or a toric multifocal lens (SND1T2 +3.00, n = 44) were reviewed. Eyes were evaluated preoperatively and 3 months postoperatively. Refraction and visual outcomes were monitored. Results Patients (69.7%) in the monofocal toric group obtained refractive cylinder less than 0.25 diopters (D) compared with 70.5% of the multifocal toric group. Both toric groups showed a statistically significant reduction in refractive cylinder after surgery (P = 0.001). Monofocal (66.7%) and multifocal (68.2%) toric patients achieved uncorrected distance visual acuity of 20/20 or better. Conclusions This represents the first article to investigate the use of low-power toric IOLs in patients with less than 1.25 D of corneal cylinder. Before the development of low-power toric IOLs, patients with low to moderate amounts of astigmatism required concurrent intraoperative adjustments or additional forms of treatment to benefit from cataract and IOL surgery. Evidence suggests that the toric T2 IOL now removes this barrier, providing consistent, accurate refractive and astigmatic results, and enables these patients to achieve excellent outcomes with a single treatment across IOL platforms. Larger studies will help to consolidate our results.

Response to: RE: Long-term outcomes and risk factors for failure with the EX-press glaucoma drainage device

Top of pageAbstract Purpose To report on the long-term outcomes and risk factors for failure with the EX-PRESS shunt implanted under a scleral flap. Settings Eye Department, University of Ancona, Ancona, Italy and the Oxford Eye Center, University of Witwatersrand, Johannesburg, South Africa. Methods The medical records of glaucoma patients who underwent consecutive EX-PRESS implantations under a scleral flap between 2000 and 2009 were reviewed. The operations were performed by two experienced surgeons using an identical surgical technique. The potential risk factors for failure that were analysed included age, sex, race, glaucoma type, previous antiglaucoma medications, previous glaucoma surgeries, diabetes, and smoking. Complete success was defined as postoperative intraocular pressure (IOP) 5 mm Hg>IOP IOP

Surgical intervention in traumatic hyphaemas becomes necessary when high intraocular pressure (IOP) is intractable and there is persistent corneal staining. Anterior chamber (AC) washout and elimination of blood clots have been described previously using one paracentesis. We describe the value of creating two paracenteses. The first one is made in the lower temporal quadrant and accommodates a 20-gauge anterior chamber maintainer (ACM) that is connected to a bottle of Balanced Salt Solution. The second paracentesis is made in an upper quadrant and serves to evacuate liquefied blood and blood clots. With an ACM in place, the fluctuations of intraoperative IOP are minimized and the AC depth is stabilized throughout the operation. The risk of renewed bleeding is reduced because of the continuous positive intraoperative IOP. The ACM is an important tool in the surgical management of traumatic hyphaemas because it facilitates AC washout and reduces iatrogenic damage to the iris and corneal endothelium.

Radiation retinopathy can present many years after the application of either brachytherapy or teletherapy to the head or neck. If severe, it drastically reduces visual acuity due to macular ischemia or edema. This is the first article, to the author's knowledge, to document the use of optical coherence tomography in the assessment of radiation-induced maculopathy. [Ophthalmic Surg Lasers Imaging 2005;36:410-411.]

Background Independence from all optical aids, and freedom from unwanted symptoms, following cataract and lens surgery remains the ultimate goal of both patient and surgeon. The development of trifocal IOL technology provides an ever-increasing range of options. The purpose of our study is to understand the predictability, safety and efficacy of a new trifocal intraocular lens (IOL) following cataract or refractive lens exchange (RLE) surgery. Methods This was a retrospective consecutive case series of patients undergoing cataract extraction or RLE followed by implantation of the Alcon IQ Panoptix IOL. Pre and postoperative refractive and visual parameters were recorded and evaluated. As the cohort followed a normal distribution, standard parametric tests were used. Paired t-test was used to compare the difference between target and postoperative refractive errors. The incidence of intraoperative and postoperative complications was also reported. Results The IOL was implanted in 66 eyes of 33 patients. Mean postoperative spherical equivalent (SE) refraction was -0.08 ± 0.25 dioptres (D). This was not significantly different from the target refraction (p = 0.841). Sixty-five percent of patients were within ± 0.25 D of the target SE refraction with 100% within ± 0.50 D of intended correction. Mean postoperative uncorrected distance visual acuity (UDVA) was 0.01 ± 0.10 LogMAR. All patients achieved an unaided distance acuity of 20/40 or better postoperatively. Binocularly, 100% saw 0.20 LogMAR or better at near without correction and 88.9% achieved this level for uncorrected intermediate visual acuity. No intraoperative complications were noted. Five patients complained of moderate haloes in the early postoperative period. Conclusion The AcrySof IQ Panoptix IOL provides functional uncorrected visual acuity at distance, intermediate and near positions. Our results remain equivalent with existing trifocal IOL outcomes and provide surgeons with a further IOL alternative for the patient motivated to obtain true spectacle independence. Surgeons should consider individual reading and working requirements when counselling patients preoperatively to optimise postoperative patient satisfaction. Electronic supplementary material The online version of this article (doi:10.1186/s40662-017-0076-8) contains supplementary material, which is available to authorized users.