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PURPOSE To investigate the effectiveness of a mobile laminar airflow (LAF) device designed to reduce both airborne particles and lint fibers within the sterile field during cataract surgery. SETTING Cincinnati Eye Institute, Cincinnati, Ohio. DESIGN Prospective case series. METHODS The number of airborne particles sized 0.5 μm, 1.0 μm, and 1.5 μm were measured at different locations and times during 116 routine phacoemulsification procedures with and without the use of a mobile LAF device. In a companion study, the presence of lint fibers in 99 eyes undergoing cataract surgery with a mobile LAF device was compared with 50 eyes in the control group. Lint fibers were differentiated as either falling onto the ocular surface or being carried into the sterile field by an instrument. RESULTS A statistically significant reduction (P < .0005) occurred in all 3 particle sizes measurements when the LAF device was used: 79.0% (93.6 ± 16.1 vs 445.3 ± 30.9), 81.7% (11.30 ± 1.98 vs 61.85 ± 5.34), and 90.8% (0.241 ± 0.056 vs 2.624 ± 0.362) in the 0.5 μm, 1.0 μm and 5.0 μm particles, respectively. Lint fibers were identified in 18% (9/50) of eyes in the control group and 16.16% (16/99) of eyes in the LAF group. Although the number of lint fibers carried into the sterile field was similar in each group, the incidence of lint fibers falling onto the sterile field was reduced from 6% (3/50) to 0% (0/99) when the LAF was used (P = .014). CONCLUSIONS The mobile LAF device was highly effective in reducing the number of particulate matter and lint fibers within the sterile surgical field when used during cataract surgery.

Purpose To present visual and functional results following implantation of iris prosthesis combined with cataract surgery in eyes with previous iridocyclectomy for iris melanoma or presumed iris melanoma. Design Retrospective noncomparative case series. Methods Sixteen patients (16 eyes) with iris defects after iridocyclectomy for iris melanoma in 15 cases and iris adenoma in 1 case underwent prosthetic iris device implantation surgery. Prosthetic iris implantation was combined with phacoemulsification and intraocular lens (IOL) implantation. The visual acuity, subjective glare and photophobia reduction, anatomic outcome, and complications were reviewed. Results Best-corrected visual acuity was improved in 13 eyes (81.25%), remained stable in 2 eyes (12.25%), and decreased in 1 eye (6.25%). Photophobia and glare improved in every case except for 1 (93.75%). Notably, after surgery 12 patients (75.00%) reported no photophobia and 10 patients (62.50%) reported no glare. The median postoperative follow-up was 29.5 months, with a minimum of 5 months and a maximum of 189 months. All iris devices were in the correct position, and all eyes achieved the desired anatomic result. The IOL optic edges were covered in all areas by either residual iris or opaque portions of a prosthetic iris device. Conclusions In patients who have undergone previous iridocyclectomy for presumed iris melanoma, combined cataract surgery and iris prosthesis placement, with or without iris reconstruction, can lead to visual improvement as well as reduction of both glare and photophobia.

Background To identify and classify materials in the vitreous observed during phacoemulsification cataract surgery (phaco). Design Prospective, consecutive, observational case series at one ophthalmic day surgery in Sydney, Australia. Participants A total of 767 consecutive phaco cases. Cases were excluded if there was posterior capsule rupture or vitreous loss intraoperatively. Methods For each patient, age, gender, baseline corrected distance visual acuity, presence of pseudoexfoliation, nuclear sclerosis grade and phacoemulsification ultrasound time were recorded. The relationship between these variables and materials in the vitreous was evaluated with regression analysis. Two patients with materials in the vitreous developed an acute intraoperative rock-hard eye syndrome. In these two patients, pars plana needle aspiration of retrolenticular fluid was performed to re-establish normal intraocular pressure. Histology was undertaken to compare this fluid with known lens material retrieved from the Fluid Management System bags in two unrelated cases. Main outcome measurements Presence of materials in the vitreous during phaco. Results Materials in the vitreous were observed in either Berger's space or the anterior vitreous in 386 eyes (50.3% of cases); the majority was putatively lens material (46.5% of all cases). Pigment and ophthalmic viscoelastic device were seen in the anterior vitreous in 9.8% and 1.7% of cases, respectively. Logistic regression analysis demonstrated that higher nuclear sclerosis grade (P = 0.025), male gender (P = 0.003) and greater age (P = 0.016) were predictive of the presence of materials in the vitreous. Histological assessment with light microscopy and birefringence techniques identified the materials in the vitreous as lens material. Conclusion Materials in the vitreous were seen in 50.3% of phaco cases. It has been histologically demonstrated that lens materials can be introduced into the anterior vitreous during phaco.

This chapter dealing with the birth of astigmatic keratotomy with cataract surgery is a reasonable way to begin a book devoted to this surgical correction of astigmatism. Although it has some scientific merit and historical accuracy, the most invaluable lesson that can be gained is to understand human emotional response to change.

Purpose To evaluate the effect on visual acuity of the implantation of a new intraocular pinhole device (Xtrafocus) in cases of irregular corneal astigmatism with significant visual impairment. Setting University of Sao Paulo, Sao Paulo, Brazil. Design Prospective case series. Methods Pseudophakic eyes of patients with irregular corneal astigmatism were treated with the pinhole device. The causes of irregular corneal astigmatism were keratoconus, post radial keratotomy (RK), post-penetrating keratoplasty (PKP), and traumatic corneal laceration. The device was implanted in the ciliary sulcus in a piggyback configuration to minimize the effect of corneal aberrations. Preoperative and postoperative visual parameters were compared. The main outcome variables were manifest refraction, uncorrected and corrected distance and near visual acuities, subjective patient satisfaction, and intraoperative and postoperative adverse events and complications. Results Twenty-one patients (ages 35 to 85 years) were included. There was statistically significant improvement in uncorrected and corrected (CDVA) distance visual acuities. The median CDVA improved from 20/200 (range 20/800 to 20/60) preoperatively to 20/50 (range 20/200 to 20/20) in the first month postoperatively and remained stable over the following months. Manifest refraction remained unchanged, while a subjective visual performance questionnaire revealed perception of improvement in all the tested working distances. No major complication was observed. One case presented with decentration of the device, which required an additional surgical intervention. Conclusions The intraocular pinhole device performed well in patients with irregular astigmatism caused by keratoconus, RK, PKP, and traumatic corneal laceration. There was marked improvement in visual function, with high patient satisfaction.

Purpose To evaluate clinical outcomes when toric intraocular lens (IOL) calculations are based on the keratometric output from the Lenstar LS-900 dual zone automated keratometer (Haag-Streit AG, Koeniz, Switzerland). Methods Eligible subjects presenting for toric IOL implantation at five sites were measured with a dual-zone automated keratometer. The data were used to plan the power and angle of the toric IOL to be implanted. Refractive and visual acuity status were checked at 1 and 3 months postoperatively. Results A total of 102 eyes had relevant data for analysis. More than 76% of eyes had 0.50 diopter or less of refractive astigmatism at 1 and 3 months, with no difference by level of astigmatism corrected. More than half of the eyes had uncorrected distance visual acuity of 20/20 or better and 78% were 20/25 or better. A new measure of effectiveness of toric correction power is described that suggested lens selection was appropriate. Results appeared better than those obtained in previous studies when the IOL cylinder power and alignment were calculated using manual keratometry. Conclusions In this series of eyes from multiple centers, the calculation of toric IOL power using dual-zone automated keratometry measurements produced clinical results that were better than results in the literature where manual keratometry was used.

PURPOSE: To compare the alignment meridian generated by the Zeiss Callisto Eye (Carl Zeiss AG, Dublin, CA) and the Alcon Verion Image Guided System (Alcon Laboratories, Inc., Fort Worth, TX). METHODS: In this retrospective comparative evaluation of technology, intraoperative images were captured at different steps in the same surgery, allowing the comparison of the guidance lines generated by the Verion system to the parallel guidance lines generated by the Callisto Eye system. Measurements of each hemi-meridian were quantified using Adobe Photoshop 2015 CC software (Adobe Systems, San Jose, CA). The numbers of degrees separating these alignment meridians were calculated, entered into a database, and analyzed. RESULTS: The authors found that of 98 captured images of 16 eyes, the two technologies were identical in 0 eyes (θ 1 = θ 2 = 0), similar by 3° in 52 (53%) captured images (θ 1 ≠ θ 2 ≠ 0), and different by at least 3° in 46 (47%) captured images (θ 1 ≠ θ 2 ≠ 0). The target meridians were superimposed, the target lines were minimally separated, and the target lines were dissimilar. It was noted that some intraoperative variation occurred from measurement to measurement. Within the small group of 16 cases of routine toric lens implantation in this study, the absolute average number of degrees of misalignment between the Verion and Callisto Eye systems was 3.355 for θ 1 and 3.838 for θ 2 . On average, the intraoperative variation termed “drift” was noted to be 3.963° for θ 1 , and 4.557° for θ 2 . CONCLUSIONS: The authors found that small deviations were frequent when comparing two sophisticated technologies. Although deviations greater than 3° occurred in less than 47% of captured images from 16 eyes, smaller but significant variations of less than 3° occurred in 53% of captured images from 16 eyes. It was rare to identify a large deviation. However, the authors identified “drift” in the same eye when measurements were taken at different times. The results indicate that the two systems are not currently interchangeable. Superiority of one system over the other was not determined. [ J Refract Surg. 2017;33(7):482–487.]

Purpose To evaluate the visual outcomes and patient satisfaction after unilateral implantation or stepwise bilateral implantation of an apodized diffractive multifocal intraocular lens (IOL). Setting Private practice, Cincinnati, Ohio, USA. Methods Patients requiring cataract surgery in 1 eye were recruited. AcrySof ReSTOR IOLs were implanted in 1 eye of patients with phakic contralateral eyes, patients with contralateral monofocal IOLs, and patients with a contralateral multifocal IOL of the same model. Six months postoperatively, patients were assessed for visual acuity (31.0 cm, 50.0 cm, 4.0 m), contrast sensitivity, and stereopsis. Patients were surveyed for visual disturbances and lifestyle visual quality. Results Of unilateral multifocal IOL patients, 75% were satisfied with their vision (score 7.3 out of 10) and a majority (56% multifocal–phakic, 65% multifocal–monofocal) achieved spectacle independence. These values were slightly lower than values for bilateral multifocal patients (92% satisfied, 77% spectacle independent), but not at a statistically significant level. Mean overall patient satisfaction was statistically significantly different: 8.9 for bilateral patients versus 7.3 for unilateral patients. Objectively, significant differences favored bilateral implantation over unilateral implantation for stereopsis, uncorrected near visual acuity, and best corrected near and intermediate visual acuities. Contrast sensitivity was similar between groups in most cases. The incidence of halos was lower in unilateral patients (57%) than in bilateral patients (77%), although the difference did not reach statistical significance. Conclusion Although unilateral implantation of a multifocal IOL provided patients with high levels of spectacle freedom and good visual acuity without compromising contrast sensitivity, overall clinical results favored bilateral implantation.

Purpose To study the incidence, course, and common factors of patients with negative dysphotopsia and consider the possible role of the corneal incision in cases in which symptoms are transient. Setting Private practice and the University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA. Methods Phacoemulsification with implantation of a single-piece acrylic intraocular lens (IOL) was performed in 250 consecutive routine cataract procedures. Patients were asked whether they noticed a temporal shadow on the day after surgery and were followed by serial evaluations for 3 years. Evaluations included subjective questionnaires and objective testing. Results The incidence of negative dysphotopsia was 15.2% on the first postoperative day, decreasing to 3.2% after 1 year, then 2.4% after 2 and 3 years. Common findings included a shallow orbit, prominent globe, space greater than 0.45 mm between the iris and IOL by ultrasound biomicroscopy, and perimetric comet-shaped light in the area corresponding to the shadow. Slitlamp revealed a transparent peripheral capsule and a shadow sign in which a linear shadow on the iris became curvilinear as the light from the slit beam was projected through the incision toward the pupil. Conclusions Two groups of patients experienced negative dysphotopsia that rapidly resolved or remained unchanged from the first postoperative day. It is hypothesized that the corneal edema associated with a beveled temporal incision contributes to transient negative dysphotopsia.

We report a patient who presented with anterior megalophthalmos: corneal diameter of nearly 17.0 mm, anterior chamber depth of 7.0 mm, mild lens subluxation, and nuclear sclerotic cataract. Surgical management consisted of a scleral tunnel incision, capsule staining, a predetermined capsulorhexis size, microcoaxial phacoemulsification with torsional ultrasound, and implantation of a custom IOL to ensure endocapsular fixation. Special consideration must be given to the patient with a very large anterior segment.

Purpose To determine whether microcoaxial phacoemulsification can be reliably and safely performed in a clinical setting and whether a full-sized single-piece acrylic intraocular lens (IOL) can be implanted through a 2.2 mm incision. Setting Private practice, Cincinnati, Ohio, USA. Method One hundred consecutive patients had cataract surgery by microcoaxial phacoemulsification with the MicroSmooth Ultrasleeve (Alcon Surgical) through a 2.2 mm incision. Anterior chamber stability, incision competency, safety of IOL implantation, intraoperative complications, efficiency, and the learning curve were evaluated. Uncorrected visual acuity (UCVA) on the first postoperative day, corneal appearance, intraocular pressure, and postoperative complications were also analyzed. Results Anterior chamber stability and incision competency were consistently excellent. The incision enlarged from 2.2 mm to 2.3 mm in 80% of the patients, to 2.4 mm in 12%, and to 2.5 mm in 8%. A high-power IOL and/or IOL insertion difficulty may account for 7 of the latter 8 cases. Efficiency and safety were equivalent to those in traditional phacoemulsification. The learning curve with the Ultrasleeve was minimal, although IOL implantation was initially more difficult. The UCVA on the first postoperative day was 20/40 or better in 91% of patients, a result consistent with mild corneal edema. There were no postoperative complications. Conclusions The clinical results in a prospective series of 100 patients confirmed the efficacy and safety of microcoaxial phacoemulsification. Fluidic advantages, competent incisions, and the new countertraction implantation technique provide another approach to achieving less-invasive, high-quality cataract surgery.

To report the outcomes of combined cataract surgery with toric intraocular lens (IOL) implantation when performed in conjunction with transconjunctival sutureless pars plana vitrectomy.Retrospective interventional case series.Consecutive series of 55 eyes of 51 patients from April 2007 to December of 2010.All eyes underwent combined simultaneous small incision cataract surgery, toric IOL implantation, and transconjunctival sutureless vitrectomy surgery.Postoperative visual acuity, postoperative astigmatism, and rotational stability of the IOL.Preoperative best-corrected visual acuity was 0.32 ± 0.15 logMar (Snellen 20/43) and improved to 0.16 ± 0.10 (Snellen 20/29) postoperatively uncorrected (P0.01) and to 0.08 ± 0.11 best-corrected (Snellen 20/24) (P0.01). Preoperative astigmatism was 1.75 ± 1.0 diopters (D) (range, 0-4.75 D) and improved to 0.5 ± 0.50 D (range, 0-2.5 D) postoperatively (P0.01). Final measured postoperative IOL axis deviation from target axis was 4 ± 6° (range, 0-32). Final IOL axis was within 5° of target in 47 (85%) eyes, within 10 degrees of target in 51 (93%) eyes, and was within 15° of target in 52 (95%) eyes.Toric lens position and axis remained stable after implantation during combined cataract surgery and transconjunctival sutureless vitrectomy.

To determine if the mean horizontal white-to-white (WTW) corneal diameter, measured intraoperatively with calipers, of a population of cataract surgery patients differs from the currently accepted normal WTW range of greater than 11.0 and less than 13.0 mm. In addition, we compared manual caliper measurements with those with IOLMaster.

Purpose To determine the incidence of anterior capsule tears, at what stage of surgery they occurred, and their intraoperative behavior. Setting Ambulatory surgery center, Cincinnati Eye Institute, Cincinnati, Ohio, USA. Methods This 5-year retrospective study was of patients having phacoemulsification with posterior chamber intraocular lens (IOL) implantation complicated by unplanned peripheral extension of the capsulorhexis tear or a radial anterior capsule tear. The operative notes and a videotape of the surgery were reviewed. The stage at which the tear was initially observed and when it extended were identified, as was whether the tear extended to the posterior capsule. Anterior vitrectomy and the design and location of the IOL implanted were also analyzed. Results A discontinuous anterior capsulorhexis or a break in the anterior capsule rim was observed in 21 eyes of 2646 cases, for an overall incidence of 0.79%. Anterior capsule tears were identified during ophthalmic viscosurgical device injection in 1 eye, capsulorhexis in 13 eyes, hydrodissection in 2 eyes, phacoemulsification in 3 eyes, irrigation/aspiration (I/A) in 1 eye, and implantation of a prosthetic iris device in 1 eye. Seven of the 13 tears identified during the capsulorhexis were managed by redirecting the second edge of the "safety" capsulorhexis to incorporate the tear. In 14 eyes, the tear in the anterior capsule extended into the zonules; 4 of these tears were limited. Ten tears extended around the equator and through the posterior capsule, occurring during the hydrodissection in 1 eye, phacoemulsification in 2 eyes, I/A in 1 eye, and IOL implantation in 6 eyes. An anterior vitrectomy was required in 4 eyes that had posterior capsule involvement. Endocapsular fixation of a 1-piece acrylic IOL was achieved in 18 eyes. Three eyes required implantation of a 3-piece acrylic IOL in the ciliary sulcus. Conclusions Extension of an anterior capsule tear can complicate cataract surgery at any stage. Extension of the tear through the posterior capsule occurred in almost half the eyes with an anterior capsule tear, often requiring an anterior vitrectomy. Managing an anterior capsule tear can be challenging yet compatible with implantation of a posterior chamber IOL.

Purpose: To describe 5 subtle signs of zonular damage. Setting: Cincinnati Eye Institute, Cincinnati, Ohio, USA. Methods: Three patients with a history of ocular trauma and 1 patient with Marfan's syndrome are described. During the preoperative examination, subtle signs of zonular damage were detected. As a result of the early recognition, critical modifications in cataract surgery technique and technology were made. Results: The signs of zonular damage identified in the patients were visibility of the lens equator during eccentric gaze, decentered nucleus in primary position, iridolenticular gap, changes in the contour of the lens periphery, and focal iridodonesis. Conclusion: Identification of subtle but important signs of zonular damage will better prepare the surgeon for a challenging surgical procedure.

A 3-step technique for staining the anterior lens capsule was developed to optimize the use of a capsule dye (trypan blue or indocyanine green) during capsulorhexis. After the injection of a viscoadaptive ophthalmic viscosurgical device (OVD) (sodium hyaluronate 2.3% [Healon®5]), which fills the anterior chamber, balanced salt solution (BSS®) is gently injected onto the anterior capsule, creating a wafer-thin, fluid-filled space beneath the OVD. The dye is slowly injected through a 27-gauge cannula (Duckworth & Kent), selectively mixing with the BSS and allowing relatively accurate painting of the anterior capsule, approximating the size and shape of the intended capsulorhexis. This 3-step technique avoids the use of air as well as the uncontrolled dispersion and excessive accumulation of dye within the OVD.

We developed and evaluated a method of visualizing vitreous gel in the anterior segment. In this study, 0.2 mL of injectable triamcinolone (Kenalog) 40 mg/mL was captured in a 5 microm filter and rinsed with 2 mL of balanced salt solution (BSS). It was then resuspended in 5 mL of BSS and recaptured to thoroughly remove the preservative. The Kenalog particles were ultimately resuspended in 2 mL of BSS and injected into the anterior chamber through a 27-gauge cannula. Kenalog particles were trapped on and within the vitreous gel, making it clearly visible. The visualization provided direct observation of vitreous behavior in various experimental settings and assisted surgeons intraoperatively in the identification and removal of vitreous in the anterior segment.

Accurate alignment of a toric intraocular lens (IOL) is a requisite to achieving the intended reduction in astigmatism at the time of cataract surgery. However, it requires a reasonably clear view of the limbal vascular anatomy, which is sometimes altered by chemosis from a subconjunctival anesthetic injection or a hemorrhage. We describe a technique that can quickly restore vascular anatomy and facilitate toric IOL alignment.

A 49-year-old woman developed bilateral pupillary block after implantation of a phakic posterior chamber intraocular lens despite patent-appearing but nonfunctional peripheral iridotomies. This case serves as a basis to identify clinical signs that distinguish this diagnosis from other causes of elevated intraocular pressure and types of pupillary block.

PURPOSE: To increase precision in toric intraocular lens selection by reducing the frequency of outliers that arise from technology-dependent variability during the preoperative assessment for routine cataract surgery. METHODS: Mean preoperative values for absolute sphere, amount of astigmatism, and steepest cylindrical axis were obtained for 87 eyes (54 patients) each with a manual keratometer and four automated keratometers. The mean sphere, amount of astigmatism, and steepest cylindrical axis across five technologies for each eye were defined as the meld sphere, meld astigmatism, and meld axis, respectively. Each technology was evaluated against the meld by Bland–Altman analysis, Student’s paired t test, and correlation coefficients. Further comparison between individual technologies and the meld quantified the number of outlier measurements each technology produced. RESULTS: The number of outliers between individual keratometers and the meld differed with specific measurement of sphere, axis, or amount of astigmatism. Although statistical analysis using Bland–Altman plots, correlation coefficients, and paired t tests suggested insignificant difference from meld measurements for each parameter, precision-guided analysis presented more clinically significant outliers. The number of outliers can be reduced for sphere (range: 2%–46% to 1%–6%), astigmatism (range: 6%–23% to 0%–2%), and axis outliers (range: 15%–27% to 3%–6%) by averaging measurements from automated and manual keratometers. CONCLUSIONS: Although multiple keratometry technologies produced similar, average measurements, the authors found a disturbing number of outliers that may be overlooked when employing a single technology. Measurement errors can be dramatically reduced by averaging measurements from manual keratometry with any automated technology to make toric lens selection more precise. [ J Refract Surg. 2014;30(1):67–72.]

We describe the case of a 78-year-old highly myopic woman who had bilateral phacoemulsification with posterior chamber intraocular lens implantation. During surgery, the anterior chamber was extremely deep and the pupil was excessively dilated, consistent with lens-iris diaphragm retropulsion syndrome (LIDRS). Subsequent biomicroscopy revealed multifocal iris sphincter ruptures, a new finding associated with LIDRS.

We describe 6 patients who presented with cataract or aphakia and absent or nonfunctional irides. The etiologies included congenital aniridia, traumatic iris loss, and chronic mydriasis secondary to recurrent herpetic uveitis. In 5 eyes, a prosthetic iris was successfully implanted in combination with small incision cataract surgery. In 2 eyes, a single-piece iris diaphragm and optical lens was implanted. Artificial irides offer a safe alternative for patients who previously had no viable options for iris reconstruction.

Two patients developed a hyperopic shift following uneventful phacoemulsification with implantation of a Collamer plate-haptic intraocular lens (Staar Surgical) in the capsular bag. Posterior bowing of the IOL was corrected by IOL exchange, achieving near emmetropia.

The endocapsular tension ring has helped in the management of patients with moderate loss of zonular support. However, the eye with profound zonular dialysis or weakness may require scleral fixation of the ring for centration and long-term stabilization. We used a new, modified endocapsular tension ring designed to provide scleral support without violating the integrity of the capsular bag in 4 patients. All patients had extreme loss of zonular support preoperatively or a significant risk of progressive zonular weakness. In each case, the new ring provided excellent support and centration of the capsular bag and intraocular lens intraoperatively and postoperatively.

Crisscross lensotomy is a new technique for removing a silicone plate intraocular lens (IOL) through a small incision. A case is described in which strategic incisions in the IOL allowed the lens to be explanted in pieces through a 3.0 mm incision. Less invasive surgery may enhance safety in complicated cases.

Purpose of review This paper reviews the recent literature regarding anterior capsular staining. Recent findings Safety and efficacy of dyes used in facilitating visualization of the anterior capsule during phacoemulsification are compared. Advantages of using different techniques for injection of the dyes are discussed. Summary Trypan Blue and Indocyanine Green appear to be most effective in staining the anterior capsule with the highest safety profile. Injection strategies should be aimed at reducing uncontrolled dispersion especially into the vitreous.