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Stephen A LoBue,1 Curtis R Martin,1 Krysta K Benson,1 Krystle B Trosclair,2 Christopher L Shelby,1 Wyche T Coleman III1 1Department of Ophthalmology, Willis-Knighton Medical Center, Shreveport, LA, USA; 2Department of Graduate Medical Education, Statistics, Willis-Knighton Medical Center, Shreveport, LA, USACorrespondence: Wyche T Coleman III, Department of Ophthalmology, Willis-Knighton Medical Center, Bert Kouns Industrial Loop, Suite 116, Shreveport, LA, 71118, USA, Tel +1-318-212-5901, Email wychetcoleman@gmail.comPurpose: To determine the effect of early Nd:YAG (neodymium:yttrium-aluminum-garnet) laser capsulotomy on objective and subjective visual quality in symptomatic trifocal intraocular lens (IOL) patients.Methods: A single-center, prospective study examined symptomatic patients after bilateral cataract extraction with trifocal IOL implantation. A ten-question survey was conducted one month after surgery. Study endpoints included the assessment of monocular and binocular uncorrected distance visual acuity (UDVA), uncorrected near visual acuity (UNVA), contrast sensitivity (CS), and subjective visual quality before and after Nd:YAG capsulotomy prior to 4 months after cataract surgery.Results: A total of 38 eyes from 21 patients were included with a TFAT00 (n = 23) or TFAT30-60 (n = 15). Overall satisfaction with the IOL was 8.55 ± 1.77 (range 5– 10). A Nd:YAG capsulotomy was performed at 55 ± 26 days. Monocular UDVA and UNVA > 20/25 before Nd:YAG were 53.0% and 42.0%, which improved post-Nd:YAG to 63.0% and 66.0%, respectively (P = 0.41, P = 0.051). Binocular UDVA and UNVA > 20/25 before Nd:YAG were 82.0% and 63.0%, which increased to 97% and 97%, respectively (P < 0.05, P < 0.001). CS increased in all post-Nd:YAG capsulotomies (P < 0.01). The presence of glare was documented at 74% pre-Nd:YAG, which decreased to 41% post-Nd:YAG (P < 0.01). Glare which limited activities was documented at 24%, which decreased to 5% post-Nd:YAG (P = 0.21).Conclusion: Early treatment of posterior capsule opacities in mild to moderately dissatisfied trifocal IOL patients may be beneficial in improving CS, visual quality, and reducing the presence and severity of dysphotopsias.Keywords: trifocal IOL, posterior capsule opacification, Nd:YAG laser capsulotomy, visual performance, dysphotopsias, symptomatic patients

Stephen A LoBue,1,2 Sofya Gindina,2 Nicholas J Saba,2 Tom Chang,2 Michael J Davis,2 Steven Fish2 1Department of Ophthalmology, Acuity Eye Group, Pasadena, CA, USA; 2Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, NY, USACorrespondence: Tom Chang, Department of Ophthalmology, Acuity Eye Group, 100 E California Blvd, Pasadena, CA, 91105, USA, Email tchang@acuityeyegroup.comPurpose: To study the effects of intravitreal injection (IVI) of anti-VEGF (vascular endothelial growth factor) agents on intraocular pressure (IOP) and find associations with acute pressure spikes.Methods: This was a three-month, prospective study of patients receiving outpatient IVI of anti-VEGF agents for diabetic retinopathy (DR), age-related macular degeneration (AMD), and retinal vein occlusion (RVO) at the Acuity Eye Group Medical Centers. IOP was measured pre- and post-injection at 10-minute intervals up to 50 minutes after injection with a handheld tonometer. Patients with an IOP greater than 35 mmHg at 30 minutes received an anterior chamber paracentesis (ACP), while patients below 35 mmHg were monitored without intervention.Results: A total of 617 patients (51% female, 49% male) received IVI for DR (n = 199), AMD (n = 355), and RVO (n = 63). ACP was performed in 17 patients. Average pre-injection IOP was 16 ± 4 compared to 24 ± 7 mmHg for the non-ACP vs ACP group, respectively (mean ± standard deviation), p < 0.0001. IOP returned to baseline in 98% of patients at 50 minutes. A diagnosis of glaucoma and glaucoma suspect was more prevalent in the ACP group compared to the non-ACP group, 82.3% vs 14.2% and 17.6% vs 9.0%, respectively, p < 0.0001 and p > 0.05. Patients with a pre-injection IOP > 25 mmHg and a history of glaucoma had a 58.3% rate of ACP. A 31-gauge needle had a higher mean increase in IOP from baseline compared to 30-gauge needle, p < 0.0001.Conclusion: IOP spikes are most significant in the first 10 minutes after IVI but typically resolve within the first hour. However, utilizing a smaller 31-gauge IVI in patients with a glaucoma history and pre-injection IOP > 25 mmHg may be associated with significant IOP spikes lasting longer than 30 minutes.Keywords: intravitreal injection, anti-VEGF, glaucoma, acute pressure spikes, anterior chamber paracentesis

Stephen A LoBue,1,2 Prashant Tailor,3 Thomas D LoBue1 1Department of Ophthalmology, LoBue Laser and Eye Medical Center Inc, Murrieta, CA, USA; 2Lincoln Medical Center, Affiliated to Weill Cornell Medical College, Bronx, NY, USA; 3Medical College of Georgia, Augusta, GA, USACorrespondence: Thomas D LoBueLoBue Laser and Eye Medical Center Inc, 40700 California Oaks Road, Ste 106, Murrieta, CA 92562, USATel +1 951-696-1135Email Thomas.lobue@lobueeyecenters.comPurpose: To report a simple, effective technique for surgeons creating a capsulorhexis in patients with pupillary miosis and a dense, mature cataract.Methods: A single center, two-year retrospective chart review examined 1408 phacoemulsification cataract surgeries. The criteria for inclusion involved a dense, mature cataract and a pupil that was unresponsive to pharmacologic dilation preoperatively. A standardized technique was used for all cases consisting of a 1mm corneal paracentesis and 2.4mm temporal clear corneal incision. Synecholysis was performed if present, followed by the insertion of a 6.25mm malyugin ring under cohesive viscoelastic. The cohesive viscoelastic was removed via the irrigation aspiration tip. The paracentesis was sealed with a small amount of viscoelastic and an air bubble was placed in the anterior chamber. The anterior capsule was then painted with trypan blue. The air bubble and trypan blue were then replaced by a dispersive viscoelastic. Curvolinear capsulorrhexis was performed followed by standard phacoemulsion.Results: Nine patients ranging from 76 ± 12 years (mean ± standard deviation) met the criteria with a 4+ NS (n=5), white mature (n=3), or deep brunescent (n=1) cataract and 3mm pupil preoperatively. Pupillary miosis was caused by posterior synechia in 44.5% of the cases followed by pharmacologic interactions from tamsulosin and donepezil in 22.25% of cases respectively. One case involved idiopathic miosis likely from aging. Capsulorhexis formation was successful in all cases with no capsular tear, vitreous loss, or conversion to extracapsular cataract extraction (ECCE). However, one case had cortex retention requiring a second procedure for removal.Conclusion: Dense, mature cataracts and small pupils both compromise the view for the surgeon and may be significant risk factors for training ophthalmologists. Thus, good visualization of the anterior capsule and peripheral nucleus with our simple technique facilitates a reliable capsulorhexis, potentially limiting the risk of complications for ophthalmic surgeons.Keywords: dense cataract, miosis, IFIS, dementia, novice surgeon, pupil ring

Purpose: To investigate the impact of smartphone viewing distance and angle on reaction times., Design: A prospective, self-controlled, single-center study., Methods: Participants engaged in a driving simulation facing a large screen with a simulated brake pedal. They were tasked to stop the simulation once recognizing the deceleration of upcoming traffic. Tests were conducted without distraction and with a standardized distraction simulating texting while driving (TWD). Smartphone positions varied at distances of 30 cm and 60 cm, and at angles parallel to and 30° below the road plane. Reaction times were measured from the onset of simulated closure to detection. Stopping distances were extrapolated using data from the National Highway Traffic Safety Administration., Results: Ninety-four participants were included with a mean age of 24 ± 2.7 years. The control reaction time was 11.5 ± 4.1 s. Reaction times significantly decreased with smartphone placement at a closer distance of 30 cm parallel (17.0 ± 3.3 s) vs 60 cm parallel (15.4 ± 3.8 s), P < 0.001. A 30-degree downward placement at 30 cm (18.6 ± 4.0 s) and 60 cm (17.9 ± 3.6 s), further decreased reaction time compared to parallel phone positioning, P < 0.001. Extrapolating to stopping distances based on real-world data, smartphone distractions placed at 30 cm 30° below the dashboard had the greatest effect, resulting in a 3 times increase of stopping distance compared to the control, 1201 vs 394 ft respectively, P < 0.001., Conclusion: TWD significantly delays reaction time in young participants. Both the distance and viewing angle of a smartphone significantly influences reaction times during driving simulations. The greatest delays are observed when the smartphone is positioned closer to the user and at a 30-degree angle which we hypothesize is due to vision blur from increased accommodation, loss of stereopsis, and fixation with the peripheral retina., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors. Published by Elsevier Ltd.)

Purpose: To compare maximum tensile strength between commonly used 3-piece intraocular lens (IOL) for flanged intrascleral haptic fixation (FISHF)., Setting: Willis-Knight Eye Institute, Shreveport, Louisiana., Design: Laboratory investigation., Methods: Haptic tensile strength was compared with MA60AC, CT Lucia 602, AR40E, and the light-adjustable lens (LAL). Haptic strength with a 24-diopter (D) IOL was compared across all lenses, as well as across a range of 10 to 30 D with the MA60AC. A custom device was created to hold the IOL in correct haptic orientation. The maximum tension (mean ± SD) was recorded in Newtons (N) when the haptic lost tension or broke., Results: CT Lucia was the strongest at 1.53 ± 0.11 N vs 1.00 ± 0.15 (MA60AC), 0.87 ± 0.19 (AR40E), and 0.83 ± 0.14 N (LAL) ( P < .001). The LAL and AR40E were similar to a 9-0 polypropylene suture while being significantly stronger than 10-0 polypropylene suture ( P < .001). No difference in haptic tension for the MA60AC from 10 to 30 D ( P > .05). High magnification revealed the highest haptic fractures for MA60AC at 40% compared with LAL, AR40E, and CT Lucia at 0%. CT Lucia and AR40E had 100% of haptics disinserted from the IOL without any damage compared with 60% LAL and 60% MA60AC. CT Lucia, AR40E, and LAL have a flatter haptic angulation at 5 degrees., Conclusions: Haptic strength, durability, and angulation of the LAL may support the possibility of FISHF in the hands of experienced surgeons. However, further testing is strongly recommended to verify whether physiologic conditions or light treatments may compromise long-term haptic stability., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of ASCRS and ESCRS.)

The Argentinian flag sign (AFS) is a feared complication during cataract extraction. Intralenticular pressures, especially excessive posterior pressure, have been identified as potential mechanisms for capsular stress and tearing associated with AFS. Capsular tension is created by positive intralenticular pressures, which cause the irido-lens diaphragm to move anteriorly once the manual capsulorhexis has been initiated. This tension can cause inadvertent tears that self-propagate to the lens equator, causing an AFS, among other intraoperative complications. Thus, this review highlights the importance of identifying intumescent cataracts as well as a combination of techniques to relieve intracapsular pressures needed to prevent AFS. However, some instances of anterior capsular tears are unavoidable. Therefore, focus will also be placed on techniques during cataract extraction used to manage anterior capsular tears, mitigating extension to the posterior capsule., (Copyright © 2024 Copyright: © 2024 Indian Journal of Ophthalmology.)

Purpose: To describe cases in which netarsudil ophthalmic solution 0.02% precipitated reversible, reticular cystic epithelial edema., Methods: A retrospective case review at the Brooklyn Veteran's Association Hospital of patients with corneal stromal edema that were treated with netarsudil and subsequently developed cystic epithelial edema., Results: Four male patients with a mean age of 72 ± 8.0 years developed a reticular, honeycomb-like pattern of epithelial edema located in the interpalpebral and inferior cornea. In 3 of 4 patients, epithelial edema arose within 1 month compared with 2 months in 1 patient. New epithelial cysts did not correlate with worsening central corneal thickness and best spectacle-corrected visual acuity in every patient, which was likely due to the location of the cysts. Two of 4 patients developed increased central corneal thickness with worsening best spectacle-corrected visual acuity. In comparison, 1 patient had improvement in both parameters, whereas 1 patient had no significant change. In all cases, there was resolution of the epithelial cysts after discontinuation of netarsudil., Conclusions: Although rho-kinase inhibitors have been suggested to improve endothelial function, we have documented worsening epithelial cysts in a subset of patients with pre-existing corneal edema. These effects of netarsudil were transient and resolved after discontinuing treatment within 2 weeks in most patients. We hypothesize that the incidence of this adverse finding is more common than previously believed. Nevertheless, large-scale studies are needed to accurately report on the incidence and clinical significance of this novel finding., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To investigate posterior vitreous detachment (PVD) and pars plana vitrectomy (PPV) effects on contrast sensitivity function (CSF) in patients with a multifocal intraocular lens (MfIOL)., Methods: This single-center prospective case-control study analyzed 27 patients with 43 consecutive eyes. Twenty patients with 36 consecutive eyes received MfIOL implantation with either ZLB00 or ZMB00. CSF was measured as the area under the log contrast sensitivity function (AULCSF) in the presence and absence of PVD (PVD+ group and PVD- group, respectively). Seven eyes associated with a symptomatic PVD and severe visual dissatisfaction after MfIOL implantation underwent PPV (symptomatic PVD+ group). CSF was measured prior to and after PPV., Results: The mean AULCSF was significantly lower in the PVD+ group (1.5 ± 0.1) versus the PVD- group (1.7 ± 0.1, p < 0.0001). Major complaints in the symptomatic PVD+ group included floaters (n = 2) and blurry vision (n = 5). The preoperative AULCSF (1.4 ± 0.1) was significantly lower in the symptomatic PVD+ group versus the PVD- group (p < 0.0001) and PVD+ group (p = 0.02). The preoperative AULCSF in the symptomatic PVD+ group was significantly improved after PPV (1.4 vs. 1.7, respectively, p = 0.002)., Conclusions: PVD significantly decreased CSF in patients with MfIOL. Patients with symptomatic PVD exhibited the greatest decrease in CSF, which was significantly improved after PPV. Measurement of CSF and careful assessment of PVD may be useful in determining the appropriateness of surgical intervention for improving visual performance and satisfaction in MfIOL patients with symptomatic PVD.

Retinal pigment epithelium (RPE) transplantation for the treatment of macular degeneration has been studied for over 30 years. Human clinical trials have demonstrated that RPE monolayers exhibit improved cellular engraftment and survival compared to single cell suspensions. The use of a scaffold facilitates implantation of a flat, wrinkle-free, precisely placed monolayer. Scaffolds currently being investigated in human clinical trials are non-degradable which results in the introduction of a chronic foreign body. To improve RPE transplant technology, a degradable scaffold would be desirable. Using human fibrin, we have generated scaffolds that support the growth of an RPE monolayer in vitro. To determine whether these scaffolds are degraded in vivo, we developed a surgical approach that delivers a fibrin hydrogel implant to the sub-retinal space of the pig eye and determined whether and how fast they degraded. Using standard ophthalmic imaging techniques, the fibrin scaffolds were completely degraded by postoperative week 8 in 5 of 6 animals. Postmortem histologic analysis confirmed the absence of the scaffold from the subretinal space at 8 weeks, and demonstrated the reattachment of the neurosensory retina and a normal RPE-photoreceptor interface. When mechanical debridement of a region of native RPE was performed during implantation surgery degradation was accelerated and scaffolds were undetectable by 4 weeks. These data represent the first in situ demonstration of a fully biodegradable scaffold for use in the implantation of RPE and other cell types for treatment of macular degeneration and other retinal degenerative diseases., Competing Interests: JSP and ADM have ownership interests in LAgen Laboratories LLC. ADM serves as CEO of LAgen Laboratories LLC. TWO has ownership of iMacular Regeneration LLC, none of the technology used in this study is relevant. However, none of the disclosures pertain directly to this paper and none of the companies provided financial support for this paper.

Purpose: We measure and compare surgical devices using an ex vivo, temperature-controlled, choroidal incision model during thermal energy transfer with a high-resolution infrared camera., Methods: Ex vivo porcine choroidal tissue specimens ( n = 516) were isolated and placed on a temperature-regulated (37°C) perfusion platform. We tested the pulsed electron avalanche knife (PEAK), micropulse laser (MpL), continuous laser (CL), and bipolar cautery (BpC) at three energy settings (11 [low], 45 [medium], and 134 [high] mJ/mm). Each device was clamped to a stationary mechanical arm. Movement of tissue specimens beneath the surgical device was achieved using a stepping motor-driven x-y table. An infrared video camera measured orthogonal temperature variation in the surrounding tissue., Results: Increased power resulted in greater lateral thermal spread using all modalities ( P < 0.001). Mean (standard deviation) lateral thermal spread at low energy was smallest for the MpL at 0.0 (0.01) mm ( P < 0.001), whereas BpC had the least collateral tissue damage at medium and high energies (0.02 [0.08] and 0.34 [0.22] mm, respectively; P < 0.001). Fluidics of the ex vivo system may limit thermal spread. The PEAK had the greatest thermal spread across all energy groups ( P < 0.001), with clinically relevant variation between disposable blades., Conclusions: Our ex vivo model enabled direct comparison of threshold thermal tissue injury across four devices. MpL and BpC showed the least thermal damage. PEAK had a higher variation in energy delivery, but also has the advantage of more effective tissue cutting., Translational Relevance: Our ex vivo surgical device analysis provides thermal tissue injury predictions for choroidal surgery.

Background: To report a 68-year-old female with an autosomal-dominant vitreoretinochoroidopathy (ADVIRC) phenotype associated with a subretinal hemorrhage (SRH) and novel BEST1 pathogenic variation p.Met571Thr., Materials and Methods: The patient was assessed by fundus photography, fluorescence and indocyanine green angiography, spectral-domain optical coherence tomography, photopic and scotopic electroretinogram (ERG), and electrooculogram (EOG). Whole-exome and Sanger sequencing of the patient's and selected family members' DNA was performed. Ophthalmoscopic examinations were also performed on six patient's relatives., Results: The patient presented moderate vitreous and SRH in the left eye. A distinct, annular hyperpigmented band was present in both eyes. Vitrectomy improved visual acuity, and the SRH gradually regressed without recurrence. Preserved macular function was shown by optical coherence tomography (OCT). Genetic analysis identified a novel heterozygous mutation, resulting in p.Met571Thr in BEST1. No mutations were observed in a panel of other eye disease genes, suggesting that this pathogenic variation in BEST1 is associated with an ADVIRC phenotype. No other evaluated family member had the variant or the fundus findings., Conclusions: We present a patient with a novel p.Met571Thr pathogenic variation associated with an ADVIRC phenotype. SRH is a unique finding in ADVIRC patients and may correspond to peripheral exudative hemorrhagic chorioretinopathy. The BEST1 pathogenic variation p.Met571Thr might be the likely cause of ADVIRC in this patient. However, further study is necessary to determine whether this mutation is causative.

Purpose: We hypothesized that the elastic nature of the choroid leads to tissue contraction following a full-thickness, sharp incision. Furthermore, we sought to quantify, measure, and compare tissue contraction in ex vivo porcine globes and human globes of various ages using predetermined variables., Method: A full-thickness, ex vivo choroidal incision was performed in either pig ( n = 97) or human ( n = 30) specimens. Variables included trephine diameter (1.5, 2.0, or 2.5 mm) versus a straight surgical blade, and temperature (1.7 °-4.4° vs. 36.6°F). Central centripetal and surround centrifugal tissue contractions were measured. Mean percentage tissue contraction was assessed as a ratio of trephine diameter to final tissue contraction measured immediately following each incision using a standardized device., Results: For trephination in pig specimens, centripetal contraction ranged from 38% to 50% with a mean of 44%. Centrifugal contraction was approximately 15%. Human choroidal contraction was 39% and 15%, respectively, with a statistically significant inverse relationship to age ( R 2 = 0.35, P ≤ 0.01). Asymmetric contraction was noted when incisions were closer to choroidal attachment sites to the sclera, such as near vortex ampullae. Linear incisions resulted in contraction that correlated with incision length ( R 2 = 0.35, P ≤ 0.001)., Conclusions: A full-thickness choroidal incision results in significant tissue contraction. For circular incisions, the centripetal contraction approaches 50% of the original incision size. For linear incisions, the contraction corresponds directly with incision length. In human specimens, there is less contraction with advancing age., Translational Relevance: Our findings have clinical relevance for choroidal biopsy, traumatic injury, and choroidal translocation surgery.