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In the present study, we aimed to demonstrate the objective guiding role of objective scatter index (OSI) in patients with early stage posterior capsule opacification (PCO), especially in patients with multifocal intraocular lens (IOL) implantation. A prospective randomized case analysis was conducted on elderly patients experiencing PCO, exhibiting best-corrected visual acuity (BCVA) below 0.2 LogMAR. Exclusion criteria comprised patients with diabetes, glaucoma, high myopia, trauma, endothelial dystrophy, maculopathy or prior eye surgery affecting visual acuity. The main observational indicators were patient gender, age, post-cataract surgery duration, BCVA (LogMAR), and OSI values. For patients undergoing laser posterior capsulotomy, meticulous documentation of pre-laser OSI values and post-laser OSI values was undertaken. Subjective visual quality was then compared using the Chinese version visual function index-14 (VF-14-CN). The study comprised 65 eyes from 56 patients. PCO developed, on average, 2.06 ± 0.94 years (ranging from 0.5 to 4 years) after the initial surgery, with the OSI consistently exceeding 3.0. Among these cases, only 40 eyes underwent laser posterior capsulotomy using Nd:YAG laser, including 26 eyes implanted with monofocal IOLs and 14 eyes implanted with multifocal IOLs. Following laser posterior capsulotomy for early-stage secondary cataracts, there was a significant decrease in OSI values compared to the presurgery state, coupled with a notable increase in VF-14-CN scores. Among the 14 cases with multifocal IOL implantation, pre-laser VF-14-CN scores were lower compared to those with monofocal IOLs. Post-laser posterior capsulotomy, patients reported a marked improvement in self-perceived symptoms. The OQAS functioned as an objective assessment metric for the laser treatment of early stage PCO. In cases involving multifocal IOL implantation, the visual disturbance caused by PCO was more pronounced, underscoring the significance of OSI as a valuable guide for laser treatment in these patients., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Nowadays, lasers are used in various medical fields. Ophthalmology was the first medical specialty to utilize lasers in patient treatment and still remains the leading medical field that uses laser energy for both therapeutic and diagnostic purposes. The neodymium: yttrium-aluminum-garnet (Nd: YAG) laser is one of the most common lasers used in ophthalmology. It is a solid-state laser with a wavelength of 1064 nm that works on the principle of photodisruption. Since its introduction in ophthalmology over 40 years ago, it has found various applications, mainly for procedures where cutting or disruption of ocular tissue is required. Compared to surgical alternatives, the use of Nd: YAG lasers on ocular tissue is minimally invasive. In this review, we focus on the two most common ophthalmic applications of Nd: YAG laser - laser peripheral iridotomy and posterior capsulotomy. The history of the techniques, current trends, potential complications, and the prognosis for future use is discussed., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Purpose: To investigate toric monofocal intraocular lens (TIOL) rotation and associated changes in cylinder power caused by Nd:YAG laser capsulotomy performed due to posterior capsule opacification (PCO)., Setting: Ekol Eye Hospital, Izmir, Turkey., Design: Prospective case series., Methods: 41 eyes of 20 women and 21 men were included in the study. Before and 1 month after Nd:YAG laser capsulotomy, TIOL tilt and decentration were determined with Scheimpflug camera, and TIOL axial rotation and the change in cylinder power induced by this rotation were measured by ray tracing aberrometry. The time interval between cataract surgery and Nd:YAG laser capsulotomy was noted., Results: Rotational misalignment of the TIOL was measured as 4.65 ± 2.75 degrees (range 0 to 11 degrees) before vs 6.97 ± 2.92 degrees (range 0 to 13 degrees) after capsulotomy, and absolute rotation was 2.75 ± 1.94 degrees (range 0 to 7 degrees, P = .028). Before and after Nd:YAG laser capsulotomy, cylinder power was 0.24 ± 0.70 diopter (D) (range 0.00 to 0.63 D) vs 0.56 ± 0.77 D (range 0.02 to 0.91 D), respectively, with an absolute change in cylinder power of 0.34 ± 0.22 D (range 0.01 to 0.90 D, P = .001). After capsulotomy, there was a significant decrease in IOL tilt in the horizontal and vertical planes and an increase in decentration ( P < .05). Time interval (33.02 ± 12.9 months) and IOL horizontal decentration were independent factors affecting IOL rotation after capsulotomy ( P < .05)., Conclusions: Nd:YAG laser capsulotomy may cause TIOL rotation as well as tilt and decentration, resulting in a change in the TIOL's corrective effect on corneal astigmatism. Although this change was clinically insignificant, it may be beneficial to consider that TIOL rotational misalignment may occur in patients undergoing early capsulotomy., (Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To explore ocular refraction shift after Neodymium: yttrium aluminum garnet (Nd:YAG) posterior capsulotomy in pseudophakic eyes., Methods: A systematic literature search was performed in the PubMed, Embase, and Cochrane Library databases until November 10, 2021. Studies on the evaluation of changes in spherical equivalent (SE), cylindrical error (CE), or anterior chamber depth (ACD) after Nd:YAG laser capsulotomy were included in the meta-analysis. The review was registered in the international platform of registered systematic review and meta-analysis protocols (INPLASY202120059)., Results: A total of 805 eyes from 18 studies were included in the final analysis. The pooled mean differences in SE from baseline to postoperative follow-up points were not significant (1 hour: 0.04 diopters [D], 95% CI: -0.13 to 0.21, P = .644; 1 week: 0.04 D, 95% CI: -0.12 to 0.20, P = .640; 1 month: 0.05 D, 95% CI: -0.06 to 0.16, P = .349). There was no significant difference between baseline CE and any subsequent visit (1 week: 0.14 D, 95% CI: -0.06 to 0.33, P = .172; 1 month: 0.17 D, 95% CI: -0.04 to 0.38, P = .108). No statistical difference in ACD from baseline was observed either (1 hour: 0.01 mm, 95% CI: -0.07 to 0.09, P = .846; 1 week: -0.12 mm, 95% CI: -0.24 to 0.01, P = .079; 1 month: -0.06, 95% CI: -0.14 to 0.01, P = .110)., Conclusions: Neither ocular refraction nor ACD changed within 1 month after laser capsulotomy, suggesting laser capsulotomy did not affect ocular refraction in short-term observation. [ J Refract Surg . 2022;38(7):465-473.] .

Purpose : To study the complication rate of Nd:YAG laser posterior capsulotomy in patients with uveitis. Method : Retrospective case note analysis of pseudophakic uveitis patients having undergone Nd:YAG laser posterior capsulotomy between January 2016 and December 2018. Complications documented included uveitis flare, raised intraocular pressure, intraocular lens damage/displacement, cystoid macular edema, and retinal detachment. Results : There were 39 eyes of 38 patients (20M, 18F; age 27-89 years). Mean interval between cataract surgery and laser was 55 months (range 8-286 months). Mean laser energy was 79 mJ (range 33-207 mJ). At 3 months 62% of eyes achieved a 2-5 Snellen line improvement that was maintained at 12 months. Vision was unchanged in 21% of eyes due to preexisting pathology, with no eyes having worse vision. No post-laser complications were documented. Conclusions : Nd:YAG laser posterior capsulotomy is a safe procedure in uveitis patients, resulting in a good improvement in vision.

Purpose: To determine the effect of metformin on early Nd:YAG laser treatment for posterior capsule opacification (PCO) and to explore a molecular mechanism to explain a possible protective effect of metformin against PCO., Methods: We conducted: 1) a retrospective cohort study of patient eyes undergoing phacoemulsification at our institution; and 2) laboratory investigation of the effect of metformin on the behavior of lens epithelial cells in the context of an animal model for PCO. Population-averaged Cox proportional hazards modeling was used to estimate risk for time to Nd:YAG. For laboratory studies, expression of markers for epithelial-to-mesenchymal transition (EMT) implicated in PCO pathogenesis was measured in tissue culture and following extracapsular lens extraction in a mouse model., Results: The rate of Nd:YAG laser capsulotomy was 13.1% among the 9798 eyes. Both metformin use and diabetes were protective factors for Nd:YAG laser capsulotomy in univariate analysis. However, in multivariable analysis with nondiabetics as the reference group, only metformin use among diabetics was significantly protective of Nd:YAG (hazard ratio: 0.68, 95% CI: 0.54-0.85, P = 0.0008), while eyes of patients with diabetes without metformin use did not significantly differ (P = 0.5026). Treatment of lens epithelial cells with metformin reduced the level of the EMT markers ⍺-SMA and pERK induced by TGF-β2. Similarly, metformin treatment reduced ⍺-SMA expression in lens epithelial cells following extracapsular lens extraction in a mouse model., Conclusions: The protective effect of metformin against early Nd:YAG may relate to its ability to downregulate EMT in residual lens epithelial cells that otherwise trend toward myofibroblast development and PCO.

Background: Obsessive-compulsive disorder (OCD) is a disabling condition characterized by intrusive thoughts and repetitive behaviors. A subset of individuals have severe, treatment-resistant illness and are nonresponsive to medication or behavioral therapies. Without response to conventional therapeutic options, surgical intervention becomes an appropriate consideration., Objective: To report clinical outcomes and the safety profile of bilateral ventral anterior capsulotomy for OCD using magnetic resonance (MR)-guided laser interstitial thermal therapy (LITT) in 10 patients followed for 6 to 24 mo., Methods: A total of 10 patients underwent LITT for severe OCD; 1 patient withdrew prior to follow-up. LITT is a minimally invasive ablative technique performed with precise targeting and use of thermography under MR guidance. Lesions of the ventral anterior limb of the internal capsule by other techniques have been shown to be efficacious in prior studies., Results: A total of 7 of the 9 patients were considered full responders (77.8%; Yale-Brown Obsessive-Compulsive Scale change ≥35%). Adverse effects included transient apathy/amotivation postsurgery (2 patients). One patient had a small tract hemorrhage where the laser fiber traversed the cerebral cortex as well as persistent insomnia postsurgery. One individual died after a drug overdose 7 mo postsurgery, which was judged unrelated to the surgery., Conclusion: LITT ventral capsulotomy was generally well tolerated, with promising evidence of effectiveness in the largest such series to date. Results were comparable to those after gamma knife ventral capsulotomy, as well as ventral anterior limb deep brain stimulation., (© Congress of Neurological Surgeons 2021.)

Purpose: To investigate the early incidence of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy according to intraocular lens (IOL) type (nontoric vs toric) and surgical techniques (femtosecond laser-assisted cataract surgery vs conventional phacoemulsification) in eyes with refractive multifocal IOLs., Design: Retrospective case-control study., Methods: Nine hundred thirteen eyes from 483 patients implanted with Lentis Mplus LS-313 MF20 (767 eyes) or Lentis Mplus Toric LU-313 MF20T (146 eyes) IOLs (Oculentis GmbH, Berlin, Germany) were enrolled. We compared the incidence of Nd:YAG laser capsulotomy between the nontoric and toric groups. In addition, the incidence of Nd:YAG laser capsulotomy was also evaluated according to the surgical technique used., Results: The overall incidence of Nd:YAG laser capsulotomy was 10.2% (93/913 eyes). The Nd:YAG laser capsulotomy rate was significantly higher in the toric group (24/146; 16.4%) than in the nontoric group (69/767; 9.0%; P = .007). Of the 913 enrolled eyes, 448 eyes (49.1%) underwent femtosecond laser-assisted cataract surgery and 465 eyes (50.9%) underwent conventional phacoemulsification cataract surgery. There was no significant difference in the incidence of Nd:YAG laser capsulotomy between eyes with femtosecond laser-assisted cataract surgery and eyes with conventional phacoemulsification cataract surgery., Conclusion: Patients with refractive multifocal toric IOLs had higher early incidence rates of Nd:YAG laser capsulotomy when compared to those with refractive multifocal nontoric IOLs. Furthermore, femtosecond laser-assisted cataract surgery could not reduce the early incidence of Nd:YAG laser capsulotomy in this study., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: To compare the accuracy of toric intraocular lens (IOL) alignment and visual outcomes using femtosecond laser-assisted capsulotomy marking (CM) versus conventional slit lamp-assisted manual marking (MM)., Design: Prospective cohort study., Methods: A total of 57 patients who required cataract surgery and toric IOL implantation (Acrysof SN6AT3-T8) were assigned to the CM group (26 eyes) or the MM group (31 eyes). Uncorrected distant visual acuity (UCDVA), best-corrected distant visual acuity (BCDVA), residual astigmatism (RA), IOL misalignment, and modulation transfer function (area ratio [AR] value) were measured 1 and 3 months after surgery., Results: Postoperative UCDVA (logarithm of minimal angle of resolution [logMAR]) was significantly lower in the CM group than that in the MM group (P < .05). Postoperative RA and IOL misalignment were significantly lower in the CM group than that in the MM group (both P < .05). No significant difference between the groups was observed for BCDVA or AR value (both P > .05). UCDVA (logMAR) was positively correlated with RA (r = 0.339; P < .05) and IOL misalignment (r = 0.317; P < .05) and negatively correlated with the the AR value (r = -0.272; P < .05); RA was positively correlated with IOL misalignment (r = 0.405; P < .05)., Conclusions: The accuracy of the axis alignment was significantly higher in the CM group, which resulted in lower residual astigmatism and better visual outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: This retrospective study summarized the clinical, radiographic, and arthroscopic manifestation of synovial chondromatosis (SC) of the hip, along with the post-operative effect to discuss the curative effect of arthroscopic management of hip SC., Methods: Twenty-one patients who underwent arthroscopic surgery from the same surgeon for hip SC were followed up for an average of 45 months. T-shaped capsulotomy was routinely performed in each case. Visual analog scale, range of motion, modified Harris Hip Score, and International Hip Outcome Tool score were collected preoperatively and at the time of the latest follow-up. All patients' demographics, radiographs, and arthroscopic images were collected to summarize and conclude the similarities and differences of their manifestation., Results: Large wedged clumps of loose bodies demonstrated distinguishable radiographic, arthroscopic appearance and demanded a different surgical strategy. Postoperative scores were all significantly improved. One case of residual pain and two cases of residual loose bodies with no symptom related were reported at the final follow-up. All but one patient were satisfied with the outcome., Conclusion: Arthroscopy treatment of hip SC with T-shaped capsulotomy has demonstrated a good result in terms of clinical outcome score, recurrence rate, and complication rate. On the basis of this study, we concluded the clinical performance of large wedged clumps of loose bodies of hip SC.

Anterior and posterior capsulotomies were performed in 12 eyes of 12 patients (age range 3 months to 6 years) with congenital cataracts and primary persistent hyperplastic primary vitreous (PHPV) syndrome using a femtosecond laser. The procedure was performed in 8 eyes with PHPV severity level 1 and 4 eyes with severity level 2 (Sudovsky classification). Surgeries were performed at the Kaluga branch of the S. Fyodorov Eye Microsurgery Federal State Institution, Russia. Postoperative follow-up was between 8 months and 36 months. The use of a low-energy femtosecond laser-assisted posterior capsulotomy in this pediatric population provided safe and predictable results with a reduced number of intraocular manipulations, and reduced the risk for complications.

Purpose: To evaluate the safety and efficacy of surgical membranectomy with a vitrector via a limbal approach for posterior capsular opacification (PCO) in children., Methods: In this retrospective analytical interventional study, medical records of children younger than 17 years who underwent surgical membranectomy with anterior vitrectomy via a limbal approach were analyzed. Time lag for PCO formation after cataract surgery was assessed. Any adverse events during surgery, rate of successful completion of membranectomy, postoperative complications, improvement in visual acuity, and intraocular lens (IOL) centration were recorded., Results: A total of 60 eyes of 58 children were included: 26 had traumatic etiology and 34 had developmental cataract. Mean time duration for PCO formation was 27.83 ± 39.83 months for traumatic cases and 53.53 ± 52.20 months for developmental cataract (P = .04). A satisfactory opening in the center of the membrane was achieved in 47 cases (n = 47, 78.3%). The complications encountered were uveitis (5 eyes), corneal edema (3 eyes), pigment deposition over IOL (2 eyes), raised intraocular pressure (1 eye), IOL drop (1 eye), and broken haptic (1 eye). Membranectomy with posterior optic buttonholing of the IOL in 9 aphakic eyes resulted in good IOL centration, no anterior chamber reaction, and no iris optic capture in the postoperative period. Mean visual acuity improved from 1.16 ± 0.52 to 0.73 ± 0.55 logMAR (P < .001)., Conclusions: Surgical membranectomy with a vitrector via a limbal approach is a safe and effective method for managing PCO in the pediatric population. Posterior optic buttonholing of the IOL during membranectomy or secondary IOL implantation results in good IOL centration and fewer complications. [J Pediatr Ophthalmol Strabismus. 2020;57(1):33-38.]., (Copyright 2020, SLACK Incorporated.)

Purpose : The aim of this study is to investigate the ability of ostial irido-zonulo-hyaloido-vitrectomy (ostial IZHV) with primary posterior capsulectomy (PPC) in preventing aqueous misdirection (AM) in combined cataract and filtration surgery in a high-risk group of angle closure disease. Materials and Methods : Comparative case series-data collection of consecutive adult subjects (>18 years) with angle closure, undergoing phaco-trabeculectomy, when per-operatively anterior chamber depth (ACD) remained shallow, putting them at high risk for development of AM post-operatively. Study subjects were compared to controls, who also underwent combined surgery in angle closure, but did not have shallow AC per-operatively, in the study period of January 2012 to December 2016. Ostial-IZHV was done through sclerostomy and iridectomy created routinely as part of the filtration procedure. Main outcome measure- post-operative deep ACD and comparison of biometric (optical) parameters between study subjects and controls. Results : Twelve eyes of 11 primary angle closure glaucoma subjects who underwent ostial-IZHV intra-operatively (study subjects) in the study period were included. None of the subjects developed post-operative AM. The median IOP pre-procedure decreased significantly at average follow-up of 18.25 months (SD 14.1) post-procedure ( p = .003). There was significant decrease in use of anti-glaucoma medications too ( p < .001) post-procedure. When compared to controls, study patients were younger ( p = .006); these eyes demonstrated greater quadrantic synaechial angle closure on gonioscopy ( p < .001), higher pre-operative intraocular pressure ( p = .001) and were also found to be smaller ( p = .011), shallower ( p < .001) with significantly more lens rise ( p = .013). Although lens thickness did not differ ( p = .689), it appeared to be relatively anteriorly placed ( p = .005) in all those eyes that required ostial-IZHV. Conclusions : Ostial IZHV may be considered in eyes in a sub-group of glaucoma patients with high-risk characteristics for prevention of AM in the post-operative period. The anterior segment surgeon can successfully accomplish ostial-IZHV, effectively reducing dependence on a vitreo-retinal surgeon.

Primary posterior laser capsulotomy (PPLC) requires adequate visualization and spacing of the posterior lens capsule (PLC) and anterior hyaloid membrane (AHM). After intraocular lens implantation and watertight incision hydration, the laser is redocked for optical coherence tomography reimaging. If the PLC and AHM are not imaged or interspaced adequately, transzonular capsulo-hyaloidal hydroseparation is attempted by rinsing the zonular fibers with fluid. If the PLC or AHM are still not detected or discernable, an attempt follows to mark the Berger space using diluted triamcinolone acetate. Before hydroseparation, the AHM or PLC are often invisible or variably attached. If structures cannot be defined, triamcinolone-added hydroseparation is often effective in defining the AHM and Berger space. Transzonular capsulo-hyaloidal hydroseparation with an optional triamcinolone acetate addition can initiate or complete AHM detachment and improve visibility and patency of Berger space for augmenting control and feasibility of PPLC., (Copyright © 2019 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Significance: Determining risk factors for posterior capsule opacification will allow for further interventions to reduce the risk of development and thus additional procedures., Purpose: The purpose of this study was to investigate risk factors associated with development of clinically significant posterior capsule opacification requiring yttrium aluminum garnet (YAG) capsulotomy., Methods: Medical records of patients (≥18 years) who underwent cataract surgery between January 1, 2011, and March 31, 2014, at Kresge Eye Institute were reviewed. Three hundred eyes requiring YAG capsulotomy up to 3 years after cataract surgery were included in the YAG capsulotomy group. Three hundred eyes not requiring YAG capsulotomy up to 3 years after cataract surgery were selected via age-matched simple randomization (control group)., Results: The YAG capsulotomy group included patients with younger age (65.8 ± 11.3 vs. 70.1 ± 10.6 years, P < .001), more men (42.67 vs. 34.67%, P = .04), fewer patients with hypertension (73.00 vs. 83.00%, P < .001), and more patients with hydrophilic intraocular lenses (74.67 vs. 47.00%, P < .001). Logistic regression analysis demonstrated a negative association between YAG capsulotomy and age (coefficient, -0.04; 95% confidence interval [CI], 0.95 to 0.98; P < .001) and hydrophobic intraocular lenses (coefficient, -1.50; 95% CI, 0.15 to 0.33; P < .001), and a positive association with presence of glaucoma (coefficient, 0.88; 95% CI, 1.39 to 4.17; P = .002). Elapsed time to YAG capsulotomy was sooner in patients with a history of uveitis (95% CI, 5.10 to 9.70 months; P = .02) and insertion of hydrophilic intraocular lenses (95% CI, 18.67 to 21.57 months; P < .001)., Conclusions: Results of this study suggest that development of visually significant posterior capsule opacification is associated with younger age, glaucoma, and hydrophilic intraocular lenses, and it occurs earlier among those with hydrophilic intraocular lenses and a history of uveitis.

Purpose: The purpose of this study was to objectively assess the optical vision quality of patients before and after Nd:YAG capsulotomy for posterior capsular opacification using a double-pass retinal imaging system., Methods: We retrospectively analyzed the data from 26 pseudophakic eyes with posterior capsular opacification that underwent Nd:YAG capsulotomy. The objective scatter indices, modulation transfer function cutoff frequencies, Strehl ratios, and logMAR corrected distance visual acuities were assessed before and after YAG capsulotomy with a double-pass retinal imaging system (OQAS II, Visiometrics, Spain). We also analyzed data from a subgroup of 10 patients with pre-YAG corrected distance visual acuity of 0.10 logMAR (20/25) or better., Results: Vision quality indices improved in all 26 eyes, resulting in a statistically significant improvement in the corrected distance visual acuity (p=0.007), objective scatter index (p=0.001), modulation transfer function cutoff frequency (p=0.001), and Strehl ratio (p=0.020). The overall mean improvements included 0.12 ± 0.04 logMAR for corrected distance visual acuity, 2.84 ± 0.76 for objective scatter index, 12.29 ± 2.77 for modulation transfer function cutoff frequency, and 0.06 ± 0.03 for Strehl ratio. Our sub-analysis of 10 eyes with 0.10 logMAR (20/25) corrected distance visual acuity or better also showed a statistically significant improvement in the mean objective scatter index (0.76 ± 16; p=0.001), resulting in approximately 35% decrease in intraocular light scatter., Conclusions: The objective vision quality measurements as assessed by the double-pass retinal imaging system showed a significant improvement after YAG capsulotomy. This suggests that the objective scatter index improves after YAG capsulotomy, even in eyes with pre-YAG 0.10 logMAR (Snellen 20/25) corrected distance visual acuity or better.

Objective: To evaluate the efficacy and safety of posterior capsulotomy by analyzing the long-term visual outcomes in patients with rhegmatogenous retinal detachment (RD), who underwent combined phaco-vitrectomy with or without primary posterior capsulotomy., Methods: A retrospective longitudinal cohort analysis was performed by using data of rhegmatogenous RD patients undergoing combined phaco-vitrectomy. Patients were divided into two groups; Group A (68 eyes of 68 patients) with capsulotomy, and Group B (39 eyes of 39 patients) without capsulotomy. We reviewed the best-corrected visual acuity (BCVA), incidence of posterior capsule opacification (PCO), clinical features at the diagnosis of rhegmatogenous RD, and intraoperative or postoperative complications following posterior capsulotomy., Results: The modified BCVA measured by the logarithm of the minimum angle of resolution at initial diagnosis and 3, 6, and 12 months after surgery was 0.67 in Group A versus 0.85 in Group B (p = 0.258), 0.40 in Group A versus 0.50 in Group B (p = 0.309), 0.27 in Group A versus 0.45 in Group B (p = 0.055), and 0.21 in Group A versus 0.47 in Group B (p = 0.014), respectively. In subgroup with macula-on RRD, Group A exhibited better visual outcomes compared to Group B at 6(0.17 versus 0.40 [p = 0.037]) and at 12 months(0.14 versus 0.39 [p = 0.030]). The incidence of PCO in Group B was higher than Group A(28.2% versus 4.4% (p < 0.001)). There were no complications associated with posterior capsulotomy., Conclusions: A primary posterior capsulotomy during combined phaco-vitrectomy using a 23-gauge vitreous cutter was a safe and effective surgical procedure in patients with RRD patients for preventing postoperative intraocular lens-related PCO., Competing Interests: The authors have declared that no competing interests exist.

Purpose: To evaluate the long-term outcome of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser posterior capsulotomy after cataract surgery in children., Design: Retrospective case series., Methods: Electronic medical records of pediatric patients who underwent Nd:YAG laser posterior capsulotomy between January 1, 2008, and October 31, 2012, and followed up for more than 5 years were reviewed., Results: Thirty-one eyes of 25 patients were included. Only compliant patients assessed during slit-lamp examination and anterior segment photography underwent laser treatment. The mean age at the time of initial laser treatment was 9.04 ± 3.51 years (minimum 56 months), and the mean interval between cataract surgery and initial laser treatment was 28.1 ± 22.1 months. Posterior capsular openings were successfully made in 26 (83.9%) eyes with a single attempt and in 3 (9.7%) eyes with a second attempt. Overall success rate was 93.5%. The logMAR best-corrected visual acuity was significantly improved from 0.61 ± 0.36 to 0.19 ± 0.25 at 1 month posttreatment (P < .0001) and well maintained, at least for 5 years of follow-up, without serious complications. The recurrence of posterior capsular opacity was observed in 7 (24.1%) eyes, which was successfully managed by repeated laser procedure or surgical capsulectomy., Conclusions: By selecting compliant patients and repeated attempts, Nd:YAG laser posterior capsulotomy can be successfully performed in a pediatric population without serious complications. Laser treatment is also a good option for managing recurred posterior capsular opacity. Restored visual acuity can be maintained for at least 5 years., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Effective provision of eye care services in government-financed hospitals is essential to balance the discrepancy between growing demand and limited resources. We aimed to improve efficiency of the treatment protocol for Nd:YAG laser posterior capsulotomy. Predetermined quality targets were a patient-oriented and patient-safe approach and the development of a clinical care process with purposeful use of competences., Methods: We utilized a lean process improvement methodology to develop a streamlined Nd:YAG laser posterior capsulotomy treatment protocol. A total of 206 patient visits were evaluated, where the lean-oriented treatment protocol was utilized in 158 of the visits and the conventional (CONV) protocol was followed in 48 of the visits., Results: All baseline variables were comparable between the study groups. Compared to the CONV protocol, implementation of new operational principles shortened the total reception time per patient from 55:36 ± 30:23; 12-136 min to 44:40 ± 4:49; 37-54 min (mean ± SD; range, p = 0.040). The per hour number of patients and eyes treated in the operation room improved from 4.7 ± 1.6; 2.6-8.4 patients and 5.5 ± 2.0; 3.5-11.3 eyes to 16.3 ± 2.3; 14.3-19.4 patients (p < 0.001) and 18.0 ± 1.6; 16.8-20.4 eyes (p < 0.001). The time spent by the operating physician reduced from 8:19 ± 3:06; 3:57-14:30 min to 3:01 ± 1:00; 1:34-6:38 min in unilateral procedure (p < 0.001) and from 8:45 ± 3:55; 5:52-14:10 min to 4:40 ± 2:03; 2:38-10:14 min in bilateral procedure (p < 0.006). Furthermore, the overall patient satisfaction grade improved from 17.3 ± 1.04; 15-18 points to 17.8 ± 0.61; 15-18 points (p = 0.001)., Conclusions: The lean approach improved the treatment protocol for Nd:YAG laser posterior capsulotomy with substantial reductions in lead times without compromising patient satisfaction., (© 2018 Acta Ophthalmologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Purpose: To compare changes in anterior segment parameters after Nd:YAG laser capsulotomy in eyes that underwent either combined phacovitrectomy or cataract surgery., Methods: This retrospective study enrolled 37 eyes of 35 patients with posterior capsular opacification treated with combined phacovitrectomy (group A), and 35 eyes of 32 patients with posterior capsular opacification treated with cataract surgery (group B). Anterior segment parameters, including anterior chamber depth (ACD), anterior chamber angle, and anterior chamber volume, were measured by a Pentacam before Nd:YAG laser capsulotomy and 1 hour, 1 day, 1 week, 1 month, and 3 months after this treatment., Results: In the cataract surgery group, the ACD was significantly lower 1 day (3.75 ± 0.74 mm), 1 week (3.73 ± 0.24 mm), and 3 months (3.74 ± 0.33 mm) after Nd:YAG laser capsulotomy compared with the pretreatment value (4.20 ± 0.62 mm, p = 0.002). By contrast, the ACD did not change significantly over time in the combined phacovitrectomy group. The ACD differed significantly between the two groups at 1 week, 1 month, and 3 months after capsulotomy. There were no significant changes in the anterior chamber volume, anterior chamber angle, central corneal thickness, or pupil size from before to after capsulotomy in either group. A non-significant trend toward myopic shift was observed in group A ( p = 0.072) and B ( p = 0.055)., Conclusions: The results of the present study may help determine the power of the intraocular lens in patients who underwent combined surgery or cataract surgery and who will receive Nd:YAG laser capsulotomy., Competing Interests: No potential conflict of interest relevant to this article was reported., (© 2018 The Korean Ophthalmological Society.)

A 77-year-old man had cataract surgery in the left eye in March 2017. A toric intraocular lens (IOL) was implanted because of astigmatism. The postoperative meridian of the IOL was located nearly exactly in the planned meridian, which was controlled 1 week later with ray-tracing aberrometry (iTrace) and the smartphone application Axis Assistant. The referring ophthalmologist proceeded directly with a neodymium:YAG (Nd:YAG) laser posterior capsulotomy in his own office, after which the meridian of the implanted toric IOL was rotated more than 115 degrees. The rotation of the IOL was likely the result of a very early Nd:YAG treatment. Therefore, when a toric IOL is implanted it is important to wait at least 3 months after cataract surgery before proceeding with Nd:YAG to ensure complete rotational stability of the IOL., (Copyright © 2018. Published by Elsevier Inc.)

Purpose: To compare 25- and 20-gauge pars plana vitrectomy (PPV) for the management of pediatric cataract., Methods: 20 eyes of 15 patients were randomly divided into two groups to undergo pars plana capsulotomy and vitrectomy by either 25-gauge (group A) or 20-gauge (group B) PPV after lens aspiration and IOL implantation. The two groups were compared for total surgical time, time taken in doing pars plana capsulotomy and vitrectomy, and the size of posterior capsulotomy. Post-operative astigmatism was compared at 3 months., Results: The mean total surgical time in group A was 49.2 ± 6.7 min, while mean total surgical time in group B was 62.5 + 5.48 min (p = 0.001). The mean time taken for pars plana capsulotomy and vitrectomy was 4.1 ± 1.19 min in group A and 5.0 ± 0.73 min (p = 0.03) in group B. The mean size of the PCCC in group A was 3.3 ± 0.34 mm, while in group B it was 4.0 ± 0.33 mm (p = 0.001). The mean astigmatism at 3 months in group A was 0.65 ± 0.31 diopters, while in group B it was 1.45 ± 0.92 diopters (p = 0.019)., Conclusions: 25-gauge transconjunctival sutureless PPV can be an attractive alternative to 20-gauge system in the management of pediatric cataracts.

OBJECTIVE Anterior capsulotomy (AC) is sometimes used as a last resort for treatment-refractory obsessive-compulsive disorder (OCD). Previous studies assessing neuropsychological outcomes in patients with OCD have identified several forms of cognitive dysfunction that are associated with the disease, but few have focused on changes in cognitive function in OCD patients who have undergone surgery. In the present study, the authors investigated the effects of AC on the cognitive function of patients with treatment-refractory OCD. METHODS The authors selected 14 patients with treatment-refractory OCD who had undergone bilateral AC between 2007 and 2013, 14 nonsurgically treated OCD patients, and 14 healthy control subjects for this study. The 3 groups were matched for sex, age, and education. Several neuropsychological tests, including Similarities and Block Design, which are subsets of the Wechsler Abbreviated Scale of Intelligence; Immediate and Delayed Logical Memory and Immediate and Delayed Visual Reproduction, which are subsets of the Wechsler Memory Scale-Revised; and Corrects, Categories, Perseverative Errors, Nonperseverative Errors, and Errors, subtests of the Wisconsin Card Sorting Test, were conducted in all 42 subjects at baseline and after AC, after nonsurgical treatment, or at 6-month intervals, as appropriate. The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was used to measure OCD symptoms in all 28 OCD patients. RESULTS The Y-BOCS scores decreased significantly in both OCD groups during the 12-month follow-up period. Surgical patients showed higher levels of improvement in verbal memory, visual memory, visuospatial skills, and executive function than the nonsurgically treated OCD patients. CONCLUSIONS The findings of this study suggest that AC not only reduces OCD symptoms but also attenuates moderate cognitive deficits.

Purpose: To analyze 3 unusual mesenchymal transformations within the eye: adipose or osseous metaplasia of the lens and adipose tissue in the vitreous cavity., Design: Observational case series., Methods: Reevaluation of clinicopathologic diagnoses and histopathologic findings in sections stained with hematoxylin-eosin, periodic acid-Schiff (PAS) reaction, and Masson trichrome method., Results: The 3 cases of mesenchymal transformation occurred in microphthalmic eyes with persistent hyperplastic primary vitreous (more recently termed persistent fetal vasculature). In 1 case there was total lens replacement with lamellar bone; in another, total replacement of the crystalline lens by adipose tissue; and in a third, an anomalous pocket of adipose tissue in the central vitreous. Multifocal remnants of the lens capsule were seen in the osseous case but were absent from the adipocytic cases. The vitreous adipose tissue was surrounded by an elaborate capillary plexus with an empty, collapsed PAS-positive lens capsule in the pupillary region. Anterior pigmented neuroectodermal disorganization, dysgenesis of angle structures, and a hypoplastic or disorganized iris were also observed in the 3 cases., Conclusions: After review of the literature, it appears that lenticular osseous replacement occurs more often than adipocytic. In addition to vascularization of the lens through a capsular dehiscence, other causes are explored, including direct epithelial-mesenchymal transformations of the lens epithelium or, less likely, of the disorganized adjacent neuroectoderm. The focus of vitreous adipose tissue may represent a transformed luxated lens extruded from its capsule, which was left behind in the pupillary zone., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Femtosecond laser-assisted cataract surgery (FLACS) was introduced in 2009 and has increasingly been incorporated into surgical practice. The automation of three key aspects of cataract surgery was expected to deliver a significant improvement in both refractive and safety outcomes. The published literature has not yet shown consistent refractive improvement above conventional techniques. The purpose of this paper is to review current FLACS refractive outcomes and explore factors that may have contributed to the current findings and whether future improvements are possible.

Purpose: To evaluate the safety and feasibility of a new femtosecond laser-assisted method for posterior capsule opacification (PCO) prevention., Setting: University Eye Hospital Bochum, Bochum, Germany., Design: Prospective randomized intraindividual case series., Methods: Eyes scheduled for bilateral cataract surgery between April 2015 and January 2016 were enrolled in the study. In 1 eye, routine manual cataract surgery with intraocular lens (IOL) implantation was performed with a primary posterior laser capsulotomy as the last step in the procedure. For the laser treatment, the posterior capsule between the anterior hyaloid surface and the posterior optic surface of the IOL was identified with integrated 3-dimensional spectral-domain optical coherence tomography. In the fellow eye, routine manual cataract surgery without posterior capsulotomy was performed. Follow-up examinations were done 1 week, 2 months, and 6 months after surgery. The main outcome measures were feasibility of the procedure and between-group difference in visual acuity, macular thickness, laser flare, intraocular pressure (IOP), and PCO., Results: Fifty-six eyes were included. No differences in cataract density (P = .2), axial length (P = .8), or amount of ultrasound energy used (P = .55) were found between the groups. In all cases, it was possible to identify and target the posterior capsule. In 1 case, a minimal attachment of a half-hour length was seen. No significant between-group differences in visual acuity, macular thickness, laser flare, or IOP were seen., Conclusion: The described off-label use of primary posterior laser capsulotomy was a safe, feasible technique in preventing PCO over a 6-month follow-up., (Copyright © 2017 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Rhegmatogenous retinal detachment associated with choroidal detachment (RRDCD) is a special type of complex retinal detachment, and usually has a poor prognosis. This study aimed to assess the anatomical outcomes of 23-gauge pars plana vitrectomy (23G PPV) combined with phacoemulsification (phaco) and capsulotomy without intraocular lens (IOL) implantation in patients with RRDCD.Seventy-six consecutive patients with RRDCD, who underwent retinal repair surgery from January 2010 to December 2014, were retrospectively analyzed. Forty patients underwent 23G PPV + phaco + IOL implantation, and 36 underwent 23G PPV + phaco + capsulotomy without IOL implantation (i.e., aphakia). All cases were filled with silicone oil. The follow-up time was 6 months after silicone oil was removed. Multivariate logistic regression analysis was the statistical method used.The overall retinal anatomical reattachment rate was 58% (44/76): 40% (16/40) of patients receiving 23G PPV + phaco + IOL implantation; and 78% (28/36) of patients receiving 23G PPV + phaco + capsulotomy + aphakia (P = .007).Surgical repair using 23G PPV + phaco + capsulotomy without IOL implantation can improve anatomical reattachment rates in patients with RRDCD.

We report intraoperative issues, patient outcomes, and lessons learned from inadvertently contacting a Kamra corneal inlay with a neodymium:YAG (Nd:YAG) laser during a routine capsulotomy procedure for posterior capsule opacification. We also present scanning electron microscopic and histopathologic images from a series of 4 inlays implanted in postmortem porcine eyes that were purposely contacted with an Nd:YAG laser. Our capsulotomy patient developed a clinically insignificant and transient corneal opacity accompanied by mild blanching on the inlay. Modeling this scenario in porcine corneas demonstrated the potential for carbon particle liberation into the overlying stroma, damage to the inlay body, and fusion of inlay nutrition holes., (Copyright © 2017 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess pupil diameter before and after femtosecond laser-assisted capsulotomy in patients who were pretreated with a short-term topical nonsteroidal anti-inflammatory drug (NSAID) (ketorolac) versus those without pretreatment., Methods: This prospective, randomized, observational case series included consecutive patients scheduled to undergo cataract extraction using the Catalys femtosecond laser platform (Abbott Medical Optics, Inc., Santa Ana, CA) to perform only capsulotomies. The same protocol for preoperative medical mydriasis was used for all patients, whereas pupil diameter was assessed using a surgical ruler immediately before and 3 minutes after femtosecond laser-assisted capsulotomy. The patients were divided into two groups: one received short-term topical ketorolac preoperatively and the other did not receive NSAID pretreatment (control)., Results: A total of 42 eyes of 42 patients (1 eye per patient) were included in the study. Mean pupillary miosis was 0.79 ± 1.08 and 1.57 ± 1.19 mm for the ketorolac and control groups, respectively. There was a statistically significant decrease in pupil diameter for both groups individually (P < .05). There was also a statistically significant difference between the two groups (P < .05) with the induced miosis in the eyes that did not receive topical NSAIDs prior to cataract extraction being twofold greater when compared with the miosis of the eyes that received ketorolac pretreatment., Conclusions: Short-term topical use of ketorolac prior to femtosecond laser-assisted cataract surgery seems to induce significantly less pupillary miosis in comparison to eyes that did not receive NSAID pretreatment. NSAID use is advised prior to femtosecond laser-assisted cataract surgery to minimize pupil miosis-related surgical difficulties or complications during cataract extraction. [J Refract Surg. 2017;33(4):230-234.]., (Copyright 2017, SLACK Incorporated.)

Introduction: Femtosecond laser is a revolutionary, innovative treatment method used in cataract surgery., Aim: To evaluate free radical quantity in the anterior chamber of the eye, during femtosecond laser assisted capsulotomy, in a porcine eye model., Method: Seventy fresh porcine eyes were collected within 2 hours post mortem, were transported at 4 ºC and treated within 7 hours. Thirty-five eyes were used as control and 35 as femtosecond laser assisted capsulotomy group. A simple luminol-dependent chemiluminescence method was used to measure the total scavenger capacity in the aqueous humour, as an indicator of free radical production. The emitted photons were expressed in relative light unit %., Results: The relative light unit % was lower in the control group (median 1%, interquartile range [0.4-3%]) than in the femtosecond laser assisted capsulotomy group (median 4.4%, interquartile range [1.5%-21%]) (p = 0.01)., Conclusions: Femtosecond laser assisted capsulotomy decreases the antioxidant defense of the anterior chamber, which refers to a significant free radical production during femtosecond laser assisted capsulotomy. Orv. Hetil., 2016, 157(47), 1880-1883.

Purpose: To assess changes in anterior-chamber depth (ACD) and angle width after neodymium:yttrium aluminum garnet (Nd:YAG) laser capsulotomy pseudophakia in eyes with pseudoexfoliation (PEX)., Methods: This prospective and interventional case series study included 25 pseudophakic eyes of 25 patients with PEX and 26 pseudophakic eyes of 26 patients without PEX scheduled for Nd:YAG laser capsulotomy in a single institution. Anterior-chamber depth and angle width were measured with anterior segment optical coherence tomography before and three days after Nd:YAG laser capsulotomy. Preoperative and postoperative measurements of ACD and angle width included the angle opening distance (AOD), measured as the perpendicular distance from the trabecular meshwork at 500 and 750 mm anterior to the scleral spur to the anterior iris surface (AOD500 and AOD750, respectively) and anterior-chamber angle (ACA) in the nasal and temporal quadrants. Main outcome measures were the changes in ACD and angle width parameters., Results: The mean ACD, AOD500, AOD750, and ACA (nasal and temporal) measurements were 3.67±0.12 mm, 0.63±0.05 mm and 0.65±0.05 mm, 0.67±0.06 mm and 0.77±0.04 mm, 35.25±1.69° and 35.37±1.68° in eyes with PEX and 3.73±0.11 mm, 0.6±0.05 mm and 0.63±0.05 mm, 0.66±0.06 mm and 0.74±0.06 mm, 34.24±1.6° and 34.6±1.47° in control eyes, respectively (P>0.05 for all). After Nd:YAG laser capsulotomy, mean ACD, AOD500, AOD750, and ACA (nasal and temporal) measurements were 3.76±0.09 mm, 0.73±0.05 mm and 0.76±0.05 mm, 0.75±0.06 mm and 0.87±0.04 mm, 36.82±1.46° and 35.06±1.52° in eyes with PEX and 3.77±0.1 mm, 0.68±0.06 mm and 0.72±0.06 mm, 0.72±0.05 mm and 0.84±0.06 mm, 34.95±1.4° and 35.79±1.36° in control eyes, respectively (P=0.811, P=0.019, P=0.021, P=0.109, P=0.126, P=0.001, and P=0.01, respectively)., Conclusions: The depth and width of the anterior chamber in eyes with PEX and in control eyes increased significantly after Nd:YAG laser capsulotomy. The change in the width of the anterior chamber in eyes PEX was statistically significant comparing control eyes.

Blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) is a rare autosomal dominant genetic disease. It is clinically characterized by four major features; blepharophimosis, ptosis, epicanthus inversus, and telecanthus. We report a case of a 1-year-old female with BPES with unilateral anterior persistent fetal vasculature (PFV). On examination, she was found to have all the clinical features of BPES, along with calcified and partially absorbed cataract with elongated ciliary processes in her left eye. B-scan of left eye showed attached retina with no evidence of posterior PFV. Systemic examination was normal. She underwent cataract surgery with primary posterior capsulotomy with intraocular lens implantation under general anesthesia. Literature search did not reveal any previous reports of unilateral anterior PFV and BPES. The clinical features, other associations, and the difficulties in the surgical management of this condition are discussed.

Purpose: To evaluate the effect of neodymium:YAG (Nd:YAG) laser capsulotomy on the visual function in patients with posterior capsule opacification (PCO) and good visual acuity., Setting: Keio University Hospital, Tokyo, Japan., Design: Observational case series., Methods: Eyes were evaluated that had previous cataract surgery with a clinical diagnosis of PCO requiring Nd:YAG laser capsulotomy regardless of a good corrected distance visual acuity (CDVA) (at least 20/20). The CDVA, 10% low contrast visual acuity (LCVA), wavefront aberrations from the 3rd to 6th order, and retinal straylight were measured before and after Nd:YAG laser capsulotomy., Results: The study included 16 eyes of 16 patients (10 men, 6 women; mean age 69.5 years ± 9.3 [SD]). The mean CDVA, LCVA, and straylight after Nd:YAG laser capsulotomy improved significantly (P < .05). The root mean square (RMS) of the 3rd Zernike coefficients (S3) and the RMS of the total higher-order aberrations (HOAs) from the 3rd to 6th order decreased significantly after capsulotomy (P < .05). The straylight correlated significantly with the total HOAs (r = 0.727, P = .002) and S3 (r = 0.748, P = .001) before capsulotomy. Subjective symptoms resolved after capsulotomy in all cases., Conclusions: Neodymium:YAG laser capsulotomy enabled a significant improvement in visual function even in patients with PCO with good visual acuity. Straylight measurements might be useful to determine the indications for Nd:YAG laser capsulotomy when patients report visual disturbances without decreased visual acuity., (Copyright © 2016 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: Optic coherence tomography (OCT) evaluation of the choroid, retina, and retinal nerve fiber layer after uncomplicated yttrium-aluminum-garnet (YAG) laser capsulotomy., Methods: OCT analysis of retinal and choroidal structures was performed in 28 eyes of 28 patients following routine examinations before and 24 h, 72 h, 2 weeks, 4 weeks, and 12 weeks after YAG laser capsulotomy. Data were analyzed using the SPSS software., Results: Data collected before YAG capsulotomy and at the above mentioned follow-up visits are summarized as follows. Mean central subfoveal choroidal thickness before YAG capsulotomy was 275.85 ± 74.78 µm; it was 278.46 ± 83.46 µm, 283.39 ± 82.84 µm, 280.00 ± 77.16 µm, 278.37 ± 76.95 µm, and 278.67 ± 76.20 µm after YAG capsulotomy, respectively. Central macular thickness was 272.14 ± 25.76 µm before YAG capsulotomy; it was 266.53 ± 26.47 µm, 269.14 ± 27.20 µm, 272.17 ± 26.97 µm, 270.91 ± 26.79 µm, and 273 ± 26.63 µm after YAG capsulotomy, respectively. Mean retinal nerve fiber layer thickness before YAG was 99.89 ± 7.61 µm; it was 98.50 ± 8.62 µm, 98.14 ± 8.69 µm, 99.60 ± 8.39 µm, 99.60 ± 8.39 µm, and 99.60 ± 8.35 µm after YAG capsulotomy, respectively. No observed change was statistically significant. No significant changes were observed with regard to mean intraocular pressure., Conclusions: After YAG laser capsulotomy, no statistically significant changes were found in choroidal, retinal, and optical nerve fiber layer thicknesses, although slight thickness changes in these structures were observed, particularly during the first days.

Femtosecond laser-assisted cataract surgery is becoming more widely available as an option for patients considering cataract surgery. Controversies exist around determining the best platform for LCS, the potential global role and cost to the health care system of LCS, as well as the future of LCS in resident surgical training.

Unlabelled: We describe 2 cases in which a spontaneously rotated toric intraocular lens (IOL) was fixated and stabilized using the femtosecond laser to create a primary posterior capsulotomy for posterior optic capture. We also review the literature on previous techniques that have been used to prevent or stabilize recurrent toric IOL rotation. The design of toric IOLs must be evaluated further to determine the risk for rotation in myopic eyes., Financial Disclosure: Dr. Scott is a consultant to Abbott Medical Optics, Inc. Neither author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)