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To determine whether type 2 diabetes mellitus (T2DM) with and without diabetic retinopathy (DR) is independent risk factor for posterior capsular rupture (PCR) during cataract surgery.A retrospective study was conducted from 2014 to 2019. Patients from the University of Colorado Cataract Outcomes Database who had undergone phacoemulsification cataract surgery were included. Patients with traumatic, congenital or polar cataracts, type 1 diabetes or less than 18 years old were excluded. The primary outcome was incidence of PCR during surgery in patients with T2DM with and without DR, accounting for previous intravitreal anti-VEGF injections (IVI).A total of 6636 patients were included. A PCR occurred in 59 (0.5%) of 10 893 eyes studied: 35 (0.4%) eyes in patients without diabetes, comparatively to 13 (0.7%) eyes with T2DM without DR (p = 0.142) and 11 (1.8%) eyes with DR (p 0.0001). All groups with previous IVI demonstrated a significant increase in PCR compared with eyes without IVI or T2DM. In the absence of IVI, T2DM without DR was not significant (p = 0.520), but T2DM with DR had a significantly increased risk of PCR in univariate analysis (OR 3.55, 95% CI: 1.49,8.50, p = 0.004) and an increased risk of borderline significance in multivariate analysis (AOR 2.33, 95% CI: 0.98, 5.56, p = 0.056).Previous IVI is an independent risk factor for PCR. Diabetic retinopathy without previous IVI is likely a risk factor but was of borderline significance due to small sample size. Consideration of PCR risk should be given during surgical planning for patients with DR and/or previous IVI.

PURPOSE: To assess the accuracy of intraoperative aberrometry, the Barrett True-K No History (Barrett TKNH), Barrett TKNH with posterior corneal measurements (Barrett TKNH with PC), Shammas-PL, and Haigis-L formulas in patients with cataract who had prior myopic refractive surgery. METHODS: This was a retrospective consecutive case series of patients with prior myopic refractive surgery undergoing cataract extraction. Mean absolute error (MAE) and median absolute error (MedAE) of refraction prediction were compared for each formula. Interactions of each biometry measurement were modeled for each formula to evaluate those with the most significant impact on refraction prediction. RESULTS: One hundred sixteen eyes of 79 patients were analyzed. MAE was 0.40 ± 0.33 diopters (D) for intraoperative aberrometry and 0.42 ± 0.31 D for the Barrett TKNH, 0.38 ± 0.30 D for the Barrett TKNH with PC, 0.47 ± 0.38 D for the Shammas-PL, and 0.56 ± 0.39 D for the Haigis-L formulas. Comparisons between formulas were significant for Barrett TKNH versus Barrett TKNH with PC formulas ( P = .046), Barrett TKNH with PC versus Shammas-PL formulas ( P = .023), and for all comparisons with the Haigis-L formula ( P < .001), and not significant for all other comparisons ( P > .05). Eyes were within ±0.50 D of prediction 73%, 72%, 69%, 62%, and 52% of the time for intraoperative aberrometry, the Barrett TKNH with PC, Barrett TKNH, Shammas-PL, and Haigis-L formulas, respectively. Corneal asphericity (Q value) was significantly associated with prediction error for all five methods. Changes in anterior chamber depth had a significant impact on Shammas-PL prediction errors. CONCLUSIONS: Newer technology using information from the posterior cornea modestly improved outcomes when compared to established methods for intraocular lens selection in eyes that had previous laser refractive surgery for myopia. [ J Refract Surg . 2021;37(1):60–68.]

To examine the risk of posterior capsule rupture (PCR) during phacoemulsification cataract surgery in patients who received intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections prior to surgery.A retrospective study was conducted of cataract surgeries at the Sue Anschutz-Rodgers UCHealth Eye Center from January 1, 2014, through December 31, 2018. The primary outcome was the occurrence of PCR during surgery. Other variables of interest included age, race, sex, ocular comorbidities, diabetes, mature cataract, primary surgeon, injection frequency and type, and date of most recent injection. Predictors of PCR were assessed using logistic regression with generalized estimating equations to account for correlation between patient eyes. Additional sub-analysis was performed on eyes with PCR with and without anti-VEGF injection history to compare intraoperative characteristics, post-operative complications, and visual outcomes.In total 10,327 cataract surgeries were included in the analysis, and 308 of these eyes received anti-VEGF injections prior to surgery. Of the 308 eyes that received anti-VEGF injections, eight (2.6%) had a PCR during surgery compared to 45 of 10,019 eyes (0.5%) that did not receive injections (unadjusted OR = 5.9, 95% CI: 2.8-12.7,History of intravitreal anti-VEGF injections was associated with higher odds of PCR during cataract surgery.

Importance Federal policy in the United States prohibits corneal donation by men who have had sex with another man (MSM) in the preceding 5 years, whereas Canada enforces a 12-month ban. The potential consequences of these policies on corneal donations should be evaluated. Objective To estimate the number of potential corneal donations associated with MSM deferral policies in the United States and Canada. Design, Setting, and Participants A nonvalidated telephone survey study was conducted of all 65 eye banks in the United States and Canada to investigate how many potential corneal donors were disqualified in 2018 because of federal MSM restrictions. Published demographic data were also used to arrive at a separate estimate. Survey data were gathered from May 2019 to February 2020. Main Outcomes and Measures Eye banks were asked if they keep records of referrals disqualified specifically because of the federal MSM restrictions and, if so, how many referrals they disqualified in 2018 owing to MSM status. Results Fifty-four of 65 eye banks (83%) responded to the survey, with 30 eye banks reporting they do not keep specific records of MSM deferrals. The remaining 24 eye banks reported disqualifying 360 referrals in 2018 because of MSM status, equating to 720 corneas. The 24 eye banks accounted for 46.2% of corneal donations in the United States and Canada in 2018, yielding an estimate of approximately 1558 corneas rejected that year because of MSM status. A separate estimate using published MSM demographic data indicates that up to 3217 potential corneal donations may have been disqualified in 2018 because of these federal policies. Conclusions and Relevance Findings suggest that between 1558 and 3217 corneal donations were disqualified in 2018 because of federal regulations prohibiting corneal donation by men who have had sex with another man in the preceding 5 years in the United States or 1 year in Canada. With modern virologic testing that is reliable within days of HIV exposure and given the global shortage of corneal tissue, these policies should be reevaluated using current scientific evidence to increase the availability of vision-restoring surgery worldwide.

Purpose Steroid-induced ocular hypertension (OHTN) after penetrating keratoplasty (PKP) may cause irreversible damage to the optic nerve and graft failure. The purpose of this study is to report the first case of a post PKP patient with poorly controlled IOP, successfully treated with Kahook Dual Blade (KDB) goniotomy in both eyes. Observations The patient was a 62-year old male with prior PKP in both eyes for lattice corneal degeneration. After an uncomplicated phacoemulsification in the left eye, his IOP increased to 32 mmHg on maximum tolerated IOP lowering therapy, including oral acetazolamide. This patient was dependent on scleral contact lenses for his irregular astigmatism post PKP to achieve his best-corrected visual acuity. Thus, we needed to consider a conjunctival sparing procedure and decided to proceed with performing a KDB goniotomy in the left eye. At 29 months follow up the visual acuity (VA) remained at 20/20 and IOP 13 mmHg on dorzolamide/timolol combination drop. A year following, his right eye also required KDB goniotomy combined with cataract surgery to treat his cataract and elevated IOP of 28 mm Hg. At 18 months post KDB goniotomy, the right eye VA was 20/50 and IOP 13 mmHg on dorzolamide/timolol combination drop. Conclusions This case demonstrates KDB goniotomy may be a good surgical alternative for post PKP steroid-induced OHTN or glaucoma, especially in patients requiring scleral contact lens for their visual rehabilitation.

BACKGROUND AND OBJECTIVE: To examine the cost of a posterior capsule rupture (PCR) in patients who underwent planned phacoemulsification. PATIENTS AND METHODS: Retrospective review of 8,113 cataract surgeries performed between January 2014 and December 2017 at one academic institution. The rate of PCR was 0.55%, and 34 patients with PCR who met inclusion criteria were identified. Investigators evaluated the added operating room time required to manage PCR, subsequent surgeon visits beyond the typical average, referrals to other specialties, further imaging, and additional required surgeries. RESULTS: Patients with PCR had an additional 2.76 (standard deviation [SD] ± 3.27) postoperative encounters and 3.06 (SD ± 3.78) visits to another subspecialty. Operating room time was found to average 61.43 minutes (range: 21 to 191 minutes) at an additional cost of $455.48 (SD ± $407.37). Additional visits, imaging, and procedures added $655.59 (SD ± $767.21). The total additional average cost was $1,111.07 (SD ± $1,021.20) per PCR. CONCLUSION: Posterior capsular ruptures impose a substantial cost burden on the health care system. [ Ophthalmic Surg Lasers Imaging Retina. 2020;51:444–447.]

Purpose To evaluate patients with Down syndrome for keratoconus and corneal abnormalities using Scheimpflug imaging (Pentacam HR) in a pediatric setting. Methods The Pentacam scans of patients with Down syndrome seen at Children's Hospital Colorado Ophthalmology Department were reviewed retrospectively, and the following data were collected: keratometry values, pachymetry values, components of the Belin ABCD Grading System, the Belin/Ambrosio enhanced ectasia display D value, and topometric indices, including ISV, IVA, and KI. Subjective interpretation was used to classify scans as normal, abnormal, keratoconus suspect, and definite keratoconus. Results A total of 56 eyes of 31 patients aged 4-24 years (mean, 12.4) were included. The average value for K1 was 44.95 ± 1.73 D (range, 40.90-49.3 D); for K2, 46.87 ± 2.16 D (range, 42.50-51.80 D); for Kmax, 48.20 ± 3.11 D (range, 43-61.7 D); and for Kmean, 45.81 ± 1.85 D (range, 41.7-50.35 D). Mean pachymetry at the thinnest point was 509 ± 44.24 μm (range, 410-612 μm) and at the apex was 519 ± 44.24 μm (range, 412-646 μm). The mean D value was 2.08 ± 1.57 (range, 0.08-9.71). There were 10 patients (32%) with either keratoconus suspect or definite keratoconus in at least one eye. Conclusions We found a high frequency of keratoconus and keratoconus suspect in pediatric and young adult patients with Down syndrome. The corneas in this population had steeper K values and thinner pachymetry values compared to previously reported controls.

PURPOSE: To compare visual outcomes of eyes with and without previous laser refractive surgery that received an extended depth of focus intraocular lens during cataract surgery. METHODS: This was a retrospective review of all eyes implanted with an extended depth of focus intraocular lens by two surgeons. Preoperative demographic and eye examination information were collected, as well as postoperative refraction, uncorrected distance visual acuity, and Visual Function Index (VF-14) questionnaire responses. Medical records were reviewed postoperatively to collect the number of patients who required a refractive touch-up or lens exchange. RESULTS: Most patient eyes (187 of 215, 87%) had no prior refractive surgery, and there was no significant difference in preoperative characteristics between this group and the 28 eyes that did have previous laser refractive surgery. Postoperatively, most patients had a refractive error within ±0.50 diopters (D) (79% without vs 77% with previous laser refractive surgery, P = .40). Although more patients in the group without previous laser refractive surgery achieved 20/20 uncorrected distance visual acuity (UDVA) (56.8% versus 28.6%, P = .01), the majority in both groups achieved 20/25 or better UDVA (79.5% versus 85.7% for without versus with previous laser refractive surgery, P = .42). Postoperative subjective visual function score was also similar between the two groups as measured by the VF-14 questionnaire (86.9 vs 79.4, P = .15). Few patients required refractive surgery enhancement in either group (9 of 187 (4.8%) versus 1 of 28 (3.6%) for without versus with previous laser refractive surgery, P = .77). CONCLUSIONS: The data suggest that extended depth of focus lens implantation can have successful results for patients with prior laser refractive surgery. [ J Refract Surg. 2020;36(1):28–33.]

Purpose To describe the use of the femtosecond laser in complex cataract cases. Setting Department of Ophthalmology, University of Colorado, Aurora, Colorado, USA. Design Retrospective case series. Methods This was a single-center retrospective review of consecutive complex cataract surgery cases in which the Lensx femtosecond laser was used between October 2012 and February 2015. Complex cases were defined as white cataracts, dense brunescent cataracts, or cataracts in which zonulopathy was identified preoperatively. Outcome measures included an assessment of the capsulotomy, surgical complications, and postoperative corrected distance visual acuity (CDVA). Results Thirty-four eyes of 34 patients were included in this study; 27 had white cataract, 3 had dense brunescent cataract, and 6 had zonulopathy (2 of these also had white cataract). Three patients had an incomplete capsulotomy, and 3 had small radial tears in the anterior capsule. Four patients (11.7%) developed posterior capsule tears during phacoemulsification; 1 of these subsequently had pars plana vitrectomy for a retained lens fragment. Twenty-eight (97%) of 29 patients had a postoperative CDVA of 20/40 or better. Three patients were identified with comorbidities that limited postoperative CDVA. One patient developed postoperative cystoid macular edema. Conclusion The femtosecond laser was useful in the surgical approach to patients with complex cataracts, especially for the creation of the capsulotomy. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

Purpose To compare the differences in the time of completion of cataract surgery for residents and attending surgeons and to assign a dollar cost. Setting University of Colorado teaching hospital, Aurora, Colorado, USA. Design Comparative case series. Methods Cataract cases were divided into 3 levels of difficulty for comparison. Main outcome measures were total case time (incision to patch) and degree of difficulty. Results Nine residents and 6 attending surgeons participated in the study. Case times were collected for 324 resident cases and 319 attending surgeon cases. The mean attending surgeon case time was 25.75 minutes ± 12.32 (SD) and the mean resident case time, 46.35 ± 16.75 minutes. There was no significant difference in the degree of difficulty between resident cases and attending surgeon cases. Approximately 600 total cases were performed by 4 residents during 3 years of residency training. Taking into account the mean time of case completion for attending surgeons versus residents, the total difference in time if attending surgeons had performed 600 cataracts would be 12 360 minutes. Using a dollar cost of approximately $11.24 per minute at the institution, the cost difference was calculated to be $138 926.40. Conclusion There was a significant time and dollar cost incurred in teaching cataract surgery. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Purpose To evaluate the relationship between 1-day postoperative intraocular pressure (IOP) after phacoemulsification cataract surgery and tamsulosin use. Setting University of Colorado Health Eye Center, Aurora, Colorado, USA. Design Retrospective cohort study. Methods Registry data from men who had cataract surgery were used. Patients taking tamsulosin at the time of surgery were included as cases, while patients with no history of tamsulosin use were used as controls. The primary outcome was a 1-day postoperative IOP spike defined as an IOP increase greater than 10 mm Hg compared with baseline or a 1-day postoperative IOP of 30 mm Hg or higher. General estimating equations were used for analysis. Results The study comprised 584 men (864 eyes). An IOP increase greater than 10 mm Hg or IOP 30 mm Hg or higher after cataract surgery occurred in 12.4% and 9.3%, respectively, of eyes in the tamsulosin group versus 4.4% and 2.1%, respectively, in the control group (all P = .001). After adjusting for significant covariates, patients on tamsulosin were 2.6 times (95% confidence interval [CI], 1.2-5.7; P = .01] and 3.8 (95% CI, 1.3-10.9; P = .01) more likely to have a 1-day postoperative IOP increase greater than 10 mm Hg or a 1-day postoperative IOP of 30 mm Hg or higher. Conclusion Patients on tamsulosin had an increased risk of a 1-day postoperative IOP spike after cataract surgery, showing the importance of identifying patients on tamsulosin preoperatively to better manage and potentially mitigate IOP spikes. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

PURPOSE: To compare size, circularity, and centration outcomes of continuous curvilinear capsulorhexis (CCC) performed with or without assistance from the VERUS ophthalmic caliper (Mile High Ophthalmics, Denver, CO). METHODS: This was a multicenter retrospective consecutive case controlled series review. RESULTS: Data from 40 consecutive cases using the VERUS device for CCC were compared to 40 consecutive cases with standard manual CCC. VERUS-assisted CCC size, circularity, and centration were closer to target compared to that of manual only procedures ( P < .05). The average time from initiation to completion of the capsulotomy was shorter with manual (40 ± 11 seconds) compared to VERUS-assisted (71 ± 13 seconds) cases ( P < .0001). CONCLUSIONS: The VERUS ophthalmic caliper is effective at improving size, circularity, and centration of the CCC in a time-efficient manner when compared to manual procedures performed without VERUS guidance. [ J Refract Surg. 2016;32(10):654–658.]

Purpose: To compare the frequency of posterior capsulotomies in patients receiving a multifocal or monofocal intraocular lens (IOL) of a similar design following cataract extraction. Methods: Four hundred seventeen eyes underwent cataract extraction and IOL implantation; 275 eyes received the AcrySof SN60WF (Alcon Laboratories Inc) one-piece monofocal lens (monofocal group) and 142 eyes received the RESTOR multifocal lens (SN60D3 or SA60D3, Alcon Laboratories Inc) (multifocal group). Surgery was performed by two surgeons at one site. Primary outcome measures were incidence, time of onset, and preoperative corrected distance visual acuity (CDVA) for those patients receiving posterior capsulotomies. Results: After average 22-month postoperative follow-up (range: 2 to 41 months), 22 (15.49%) eyes in the multifocal group underwent posterior capsulotomies compared with 16 (5.82%) eyes in the monofocal group ( P =.0014). The main indication for Nd:YAG laser capsulotomy in the multifocal group was complaint of poor quality of vision rather than decreased CDVA. The multifocal group underwent capsulotomies after a mean of 8.8 months (range: 1.7 to 29.2 months), whereas the monofocal group required capsulotomies after a mean of 10.4 months (range: 0.8 to 28.6 months) ( P =.559). Mean logMAR CDVA before capsulotomy was 0.113 (range: 0 to 0.6) for the multifocal group and 0.244 (range: 0 to 0.48) for the monofocal group ( P =.073). Conclusions: Use of the RESTOR multifocal IOL in clinical practice may result in more frequent Nd:YAG laser capsulotomies. Reasons for this may include increased visual demands of patients receiving presbyopic-correcting IOLs or complex visual phenomena associated with the interaction of multifocal optics and posterior capsule opacification.

Purpose To evaluate cases of delayed nonarteritic anterior and posterior ischemic optic neuropathy after cataract extraction and to evaluate the need for centralized prospective reporting of nonarteritic ischemic optic neuropathy after cataract extraction. Setting Neuro-ophthalmology Clinics, University of Colorado Health Sciences Center and Denver Veterans Affairs Medical Center, Denver, Colorado, USA. Methods A retrospective review of all patients referred to the Neuro-ophthalmology Divisions, University of Colorado Health Sciences Center and Denver Veterans Affairs Medical Center, from January 2001 to October 2005 was performed. All patients with a diagnosis of nonarteritic anterior or posterior ischemic optic neuropathy were identified. Patients with ischemic optic neuropathy that occurred between 2 months and 12 months after cataract extraction were selected for evaluation. Results Six eyes with nonarteritic ischemic optic neuropathy that occurred 2 to 6 months after cataract extraction in 4 patients (2 bilateral nonarteritic ischemic optic neuropathy) and 1 eye with nonarteritic ischemic optic neuropathy that occurred after 6 months in 1 patient were identified. One patient had nonarteritic ischemic optic neuropathy in 1 eye 3 months after cataract extraction and 4 years later had nonarteritic ischemic optic neuropathy in the fellow eye 5 months after cataract extraction. Follow-up after the last cataract extraction was 1 to 3 years for all patients. Conclusions Although an association between cataract extraction and delayed nonarteritic anterior and posterior ischemic optic neuropathy has been suggested, current data do not support a causal relationship. In addition, the window of postoperative susceptibility for delayed ischemic optic neuropathy after cataract extraction is unclear.

Purpose: To evaluate the incidence of intraoperative flap complications in laser in situ keratomileusis (LASIK) and compare the incidence between eyes and between the Hansatome and Automated Corneal Shaper® (Bausch & Lomb) microkeratomes. Setting: Open-access outpatient excimer laser surgical facility. Methods: A retrospective analysis was done of 84711 primary LASIK cases performed between November 1998 and May 2000 in 28 national open-access laser facilities. The intraoperative flap complications were identified and categorized into type of complication, eye involved, and microkeratome type. All cases used the Automated Corneal Shaper or the Hansatome microkeratome. Results: Two hundred fifty-six complications (0.302%) were identified: 29 failures to achieve intraocular pressure (0.034%), 84 partial flaps (0.099%), 59 buttonholes (0.070%), 74 thin or irregular flaps (0.087%), and 10 free flaps (0.012%). There were 134 right eye complications and 122 left eye complications ( P = .45). No patient developed an intraoperative flap complication in both eyes. A comparison of Hansatome and Automated Corneal Shaper microkeratomes was possible for the cases performed between December 1999 and May 2000: 46 of 28 201 Hansatome procedures (0.16%) had a complication versus 21 of 329 Automated Corneal Shaper procedures (6.38%). This difference was statistically significant ( P Conclusion: The incidence of intraoperative flap complications during LASIK was acceptably small. The overall complication rate was similar in both eyes. The Hansatome was associated with a lower complication rate than the Automated Corneal Shaper.

Objective To evaluate the relationship between predicted flap thickness and actual flap thickness and between predicted tissue ablation and actual tissue ablation. Design Prospective, nonrandomized comparative (self-controlled) trial. Participants A total of 60 patients (102 eyes) who underwent laser in situ keratomileusis (LASIK). Main outcome measures Subtraction pachymetry was used to determine actual corneal flap thickness and corneal tissue ablation depth. Other measurements included flap diameter and keratometry readings. Results Actual flap thickness was significantly different ( P P Conclusions Actual corneal flap thickness was consistently less than predicted regardless of the depth plate used; actual tissue ablation was consistently greater than predicted tissue ablation for the laser used in this study.

Background: Persons with ectodermal dysplasias classically have defects in hair, teeth, nails, and sweat glands. Other tissues derived from ectoderm may also be involved. Ocular involvement in ectodermal dysplasias primarily occurs in anhidrotic forms. Methods: We describe a father and son with hidrotic ectodermal dysplasia. Results: Both patients had recurrent corneal epithelial defects from birth, corneal neovascularization, and strabismus. The father had cataracts with crystalline and amorphous inclusions at an early age. Both patients also had alopecia and skin abnormalities. Conclusions: A father and son with a previously unreported hidrotic ectodermal dysplasia and unusual corneal findings are described. (J AAPOS 1999;3:372-5)

To determine the ocular penetration of ofloxacin into the anterior chamber of the human eye when delivered by a presoaked collagen shield.University of Colorado School of Medicine, Denver, Colorado.This prospective randomized clinical study comprised 31 patients having cataract surgery. Patients were divided into 2 groups: the first received 3 preoperative drops of commercially available topical ofloxacin 0.3% given 10 minutes apart; the second had a collagen shield soaked in the same medication applied to the eye before surgery. Aqueous humor was extracted immediately before surgery for analysis.Mean aqueous concentration was 287 ng/mL +/- 69 (SEM) (range 40 to 1141 ng/mL) in the drops group and 957 +/- 189 ng/mL (range 214 to 2437 ng/mL) in the shield group. The difference was statistically significant (P.005). The minimum inhibitory concentration (MIC) for selected ocular pathogens is between 500 and 4000 ng/mL.A collagen shield presoaked in commercially available topical ofloxacin and applied before surgery appears safe. The MICs for many common ocular pathogens were reached or exceeded. Further study is recommended to determine whether this method of infection prophylaxis is an acceptable substitute for subconjunctival injections of antibiotics.

PURPOSE To describe the use of a tarsoconjunctival pedicle flap for the repair of a large scleral melt in a patient with rheumatoid arthritis. METHODS Case report and literature review. RESULTS A 36-year-old woman with a history of rheumatoid arthritis presented to the Rocky Mountain Lions Eye Institute with a large scleral melt in the right eye. Ophthalmic examination revealed a visual acuity of 20/400 and a superior scleral melt measuring 15 x 30 mm. After instituting systemic immunosuppression, a tarsoconjunctival pedicle was used to provide tectonic support to the globe. At her 3-month postoperative visit, her vision improved to 20/30, and the scleral melt was completely epithelialized. CONCLUSIONS A tarsoconjunctival pedicle flap provides an excellent alternative to help restore scleral integrity in patients with severe autoimmune necrotizing scleritis.

Purpose: The purpose of the study is to describe an unusual case of infectious posterior scleritis after excision of a pterygium. Methods: The case history of a patient in whom anterior and posterior scleritis developed after excision of a pterygium is reviewed. Histopathologic findings are presented. Results: Pathologic examination results of a scleral biopsy site and the eye showed extensive involvement of the posterior sclera with fungi that on culture grew Pseudallescheria boydii. The development of posterior scleral thickening and intrascleral abscesses gave the clinical impression of autoimmune posterior scleritis or possible tumor. Ultrasonography and computed tomography scan of the eye and orbit proved particularly helpful in following progression of scleral involvement. Conclusions: Pseudallescheria boydii is capable of causing an infectious posterior scleritis, which can mimic autoimmune posterior scleritis. The use of systemic immunosuppressive agents contributed to this unusual clinical presentation. Progression of posterior scleritis in the face of apparent adequate immunosuppressive therapy always should suggest the possibility of tumor or infection.

Purpose To compare human donor corneal lenticule thickness, endothelial cell viability, area of cell damage, and cell counts between corneal tissue prepared with a double-pass microkeratome cut versus the standard single-pass microkeratome cut. Setting University of Colorado Teaching Hospital, Aurora, Colorado, USA. Design Experimental study. Methods Eleven matched pairs of human donor corneas unfit for transplantation were used for analysis. Tissue was prepared using a Moria CB microkeratome and artificial anterior chamber. One cornea was prepared using the standard single-pass cut; the second cornea was prepared with a double-pass technique. Visante optical coherence tomography images were obtained from each cornea, and central and peripheral thickness measurements were made. The tissue was also stained with trypan blue and alizarin red to assess tissue damage from preparation. Results The mean central thickness measurement was 92 μm ± 20 (SD) for the double-pass technique and 126 ± 34 μm for the single-pass technique. The area of cell damage after preparation was not significantly different between the 2 methods; however, there was a statistically significant increase in the ratio of nonviable to viable cells for the double-pass technique. Conclusion The double-pass microkeratome technique for donor preparation resulted in a thinner lenticule than a single-pass technique and an increase in endothelial cell damage. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Purpose To characterize how residents learn phacoemulsification and determine which steps of the procedure are most difficult to master. Setting University of Colorado Hospital, Aurora, Colorado, USA. Design Comparative case series. Methods Cataract cases were divided into 3 levels of difficulty for comparison. Residents were given a grade for each step of the procedure by the attending surgeon. Main outcome measures were total case time and a proficiency grade. Independent variables were level of resident experience and degree of difficulty. Case times of attending cases were collected for comparison. Results Nine residents were evaluated by 4 attending surgeons while performing 324 cases of phacoemulsification. Case times of 319 attending cases were used for comparison. The easiest-to-learn steps (highest scores versus level of experience) included intraocular lens insertion, ophthalmic viscosurgical device removal, hydrodissection, and nucleus sculpting. Wound integrity, nucleus disassembly and removal, cortex removal, and capsulorhexis had the lowest scores versus level of experience. Resident case times decreased significantly with experience, approaching average case times for attendings. Conclusions For this study, competency was defined as the ability of the resident to perform a case in a reasonable time without intervention or complication. Using this definition, competency was achieved when case experience exceeded 75 cataract surgeries. Financial disclosure No author has a financial or proprietary interest in any material or method mentioned.

Certain forms of glaucoma are associated with displacement of the iris from its normal contour. We present here a mathematical model of the coupled aqueous humor–iris system that accounts for the contribution of aqueous humor flow and passive iris deformability to the iris contour. The aqueous humor is modeled as a Newtonian fluid, and the iris is modeled as a linear elastic solid. The resulting coupled equation set is solved by the finite element method with mesh motion in response to iris displacement accomplished by tracking a pseudo-solid overlying the aqueous humor. The model is used to predict the iris contour in healthy and diseased eyes. The results compare favorably with clinical observations, supporting the hypothesis that passive iris deformation can produce the iris contours observed using ultrasound biomicroscopy.

Purpose To determine whether respirable-size particles are present in the excimer laser plume following ablation of the corneal stroma. Setting Outpatient laser vision correction facility. Methods In this experimental study, an excimer laser was used to ablate 2 eye-bank corneas. Material from the plume was collected with filter paper that was coupled to a smoke evacuator. The filter paper was examined and photographed with an electron microscope. The particle size was measured with a computer program using digitized images of the photographs. As a control, room air was sampled using a smoke evacuator connected to a holder containing filter paper prior to the tissue ablation. Results Ninety-eight particles were measured. The mean diameter was 0.22 μm ± 0.056 (SD). No particles were seen on the control filter paper. Conclusions The plume created during excimer laser ablation of the cornea contained respirable-size particles. It is not known whether inhalation of these particles poses a significant health hazard. However, we recommend that a mask be worn by the surgeon and technical personnel assisting in excimer laser surgery. The plume should also be evacuated.

To evaluate the safety and efficacy of hyperopic laser in situ keratomileusis (LASIK) in treating hyperopia caused by overcorrected myopic LASIK and to evaluate a new technique to place the hyperopic treatment after lifting the initial myopic flap.Open-access outpatient excimer laser surgical facility.A retrospective analysis was performed of 54 eyes in 47 patients who had spherical hyperopic LASIK by 21 surgeons for the treatment of significant hyperopia after overcorrected LASIK for myopia. In 42 eyes, the initial LASIK flaps were lifted and in 12 eyes, new flaps were cut. The mean age of the 25 men (53%) and 22 women (47%) was 48.2 years +/- 8.4 (SD). Outcome measures included refractive error, uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), and complications. The mean follow-up was 2.97 months.In eyes in which postoperative emmetropia was attempted (n = 45), the mean spherical equivalent improved from +1.21 +/- 0.49 diopters (D) preoperatively to -0.38 +/- 0.50 D postoperatively (P.001). The mean UCVA improved from 20/38.6 +/- 16.3 to 20/27.4 +/- 9.4 (P.001). At the last follow-up, 69% of eyes were within +/-0.5 D and 96% were within +/-1.0 D of emmetropia; 42% had a UCVA of 20/20 and 96% had a UCVA of 20/40 or better. No eyes lost 2 or more lines of BSCVA. No vision-threatening complications occurred. Results in patients who had initial flaps lifted and those who had new flaps cut were statistically indistinguishable. On average, achieved hyperopic corrections were 18% greater than intended.Hyperopic LASIK was safe, predictable, and effective in the treatment of hyperopia caused by overcorrected myopic LASIK. Results were similar whether the original flap was lifted or a new one was cut.

Objectives To determine whether live virus can withstand excimer laser ablation and pose a possible health hazard to medical personnel. Design Experimental study. Methods Fibroblasts infected with oral polio vaccine virus were ablated with an excimer laser. The plume was collected using a smoke evacuator and bubbled through viral culture media. Main outcome measures The inlet tube from the smoke evacuator was swabbed and cultured for virus. Liquid from the bubble trap was also cultured. Results Live virus was shown in the material trapped from the laser plume. Conclusions Oral polio vaccine virus can survive excimer laser ablation. Whether other more clinically relevant viruses, such as human immunodeficiency virus, can withstand ablation and remain infectious remains to be determined.

Purpose We studied six patients with human immunodeficiency virus (HIV) who had cytomegalovirus retinitis and abnormal endothelial deposits in at least one eye, to characterize their corneal endothelial deposits. Methods The corneas of the six patients were examined by slit-lamp biomicroscopy and specular microscopy with morphometric analysis. The eyes of one patient with endothelial changes were obtained post mortem for histopathologic and ultrastructural examination. Results There were multiple diffuse, fine, retractile, stellate-shaped deposits on the corneal endothelium in all affected eyes. The deposits were best seen with retroillumination. Two of six patients examined with specular microscopy showed severe abnormalities, which included marked areas of polymegathism and decreased endothelial cell counts. Examination of one eye obtained post mortem disclosed chains of dendritic macrophages and fibrin adherent to the apical surface of the corneal endothelium. There was no evidence of direct infection of the corneal endothelium by cytomegalovirus. Conclusions Deposits on the corneal endothelium in patients with cytomegalovirus retinitis most likely result from an anterior uveitis. A preponderance of macrophages observed by histopathologic examination may be related to the inability of the immunodeficient patient to mount a normal T-cell response.

Objective: To report a possible adverse effect of topical steroid-phosphate preparations and to identify factors that may contribute to the development of this effect. Design: The medical records of five patients who developed calcium deposition in the cornea were reviewed and analyzed for possible contributing factors. Patients: Five cases of calcium deposition in the cornea associated with the use of topical steroid-phosphate preparations are described. Scrapings from the cornea and/or specimens obtained at keratoplasty were available in all cases. These cases had the following characteristics in common: use of steroidphosphate preparations (n=5); multiple topical drops (n=5); penetrating keratoplasty (n=3); presence of epithelial defects (n=4); history of herpetic stromal keratitis (n=4); and history of iritis (n=3). A hypothesis explaining calcium deposition in association with steroid-phosphate preparations is presented. Conclusions: We recommend withdrawal of steroidphosphate preparations in patients who develop band keratopathy.

Objective: To determine if intact and potentially infectious viral particles can withstand excimer laser ablation and possibly pose a health hazard to medical personnel. Methods: Excimer laser ablation of fibroblasts infected with attenuated varicella-zoster virus was performed. The laser plume was collected for polymerase chain reaction analysis and viral culture. Results: While viral DNA was detected in the material trapped from the laser plume, live virus could not be demonstrated to have survived ablation. Conclusions: Attenuated varicella-zoster virus does not seem to survive excimer laser ablation. However, we recommend the use of safety precautions such as wearing a mask during the procedure. Further research is necessary to determine if other viruses could possibly remain infectious despite exposure to excimer laser radiation.