2006, Vol.19, Issues 4, Cataract Surgery in The New Millennium

Ophthalmol Clin N Am 19 (2006) ix
Preface
Mark H. Blecher, MD
Guest Editor
We live in times when ideas, research, and experience are shared almost instantly, mostly to the
benet of our patients. And in few areas more than
in cataract surgery, does the state of the art change
more rapidly. It can then be dicult to decide
when a compendium of the current knowledge
base should be committed to hard copy, and probably great hubris to commit it to hard cover.
I think that in 2006, we have come to a reasonable consensus on a number of important clinical
questions in cataract surgery. More importantly,
we have been able to enlist the help of surgeons
considered the nal word in these areas. It is
therefore with some trepidation, but with great
pride, that I oer to you some of the best articles I

have ever read on 10 critically important subjects
that I encounter in my practice very day. I am
deeply indebted to some of the smartest and
busiest ophthalmologists for taking the time to
help with this project and hope that you will nd
it an interesting and useful resource.
0896-1549/06/$ - see front matter 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.ohc.2006.07.010
Mark H. Blecher, MD
Philadelphia Eye Associates
1703 South Broad Street, Suite 207
Philadelphia, PA 19148, USA
E-mail address: mhbmd@earthlink.net
ophthalmology.theclinics.com
Ophthalmol Clin N Am 19 (2006) 415425
The New Epidemiology of Cataract

Alison G. Abraham, MHSa, Nathan G. Condon, MD, MPHb,
Emily West Gower, PhDa,*
a
Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Johns Hopkins School of Medicine,
600 North Wolfe Street, 116 Wilmer Building, Baltimore, MD 21287, USA
b
Helen Keller International, 352 Park Avenue South, 12th Floor, New York, NY 10010, USA
Cataract poses a substantial economic and

public health burden and is the leading cause of
blindness worldwide, accounting for nearly 48%
of all blindness [1]. As such it is also a disease that
has been and will continue to be a target of epidemiologic research. Insights into causative factors
amenable to intervention, genetic factors that
predispose to disease, and avenues for novel
treatment serve to reduce the disease burden.
As a result of decades of research into factors
that may cause age-related cataract, several risk
factors have been well-identied and reviewed in
detail in other manuscripts [26]. More recent
studies, however, have found conicting results
for some risk factors, and have identied other
potential risk factors of interest that need further
study. This article reviews evidence for wellknown risk factors, but focuses primarily on
more recent ndings and factors in which research
is still evolving.
roughly 37 million blind individuals [1]. Of note,

approximately 90% of the contribution of cataract to blindness in this study was seen in
developing countries [1].
The three subtypes of cataract (nuclear, cortical, and posterior subcapsular [PSC]) are seen to
various extents in dierent populations. Prevalence and incidence estimates across populations
are summarized in Table 1. In the United States,
nuclear cataract is seen more commonly in whites,
whereas cortical is seen more commonly in African Americans; however, PSC cataract is prevalent at roughly the same, much lower, rate in
both groups [7]. In studies of populations outside
the United States, various prevalence estimates
for each cataract subtype have been reported
that may reect dierences in either environment
or predisposition (see Table 1) [79].
Impact of disease
The burden of disease
Many surveys have been conducted in various
countries to estimate the prevalence of blindness
and low vision in diverse populations. Data on the
causes of visual impairment yield estimates of the
contribution of cataract to disability. The World
Health Organization estimates that the current
global prevalence of blindness is 0.57% (range:
0.2%1%), with more than 82% of all blindness
occurring in individuals aged 50 and older.
Cataract accounts for 47.8% of the worlds
* Corresponding author.
E-mail address: ewest@jhsph.edu (E. West Gower).
Although 90% of cataract cases are found in

developing countries, the disease has a substantial
impact in developed world countries as well from
social, physical, and nancial perspectives. In the
early 1990s, Steinberg and coworkers [10] estimated that Medicare spent more than $3.4 billion
dollars annually on routine cataract procedures.
Furthermore, approximately 60% of Medicare
spending in the 1990s was devoted to cataract
surgery and associated costs [11]. With the graying
of the United States population, it is expected that
this number will continue to rise dramatically.
The burden of cataract extends beyond the
nancial costs to society. Patients with prevalent
cataract are likely to have signicantly reduced
doi:10.1016/j.ohc.2006.07.008
416
ABRAHAM
et al
Table 1
Prevalence and incidence of cataract, by subtype across populations
Age group studied (y)
Nuclear
Population
American whites (7)
African Americans (7)
Singaporeans (9)
Japanese (9)
Icelandic (9)
65
65
50
50
50
Prevalence (%)
50.7
24.2
33.5
54.2
16.2
16.8
5
46.3
9.5
17.8
Incidence (%)
Population (length of follow-up)

Barbados whites (9 y) (8)
Barbados blacks (9 y) (8)
Beaver Dam, Wisconsin (10 y) (8)
4084
4084
4386
36.5
42
24.6
quality of life resulting from low vision. Cataract

is primarily a disease of older age groups. Often,
decreases in functional abilities are attributed to
other age-related processes and not recognized as
the onset of cataract. In a United Statesbased
study of nursing homes, cataract was the leading
cause of low vision (as dened by visual acuity
worse than 20/40 in the better-seeing eye),
responsible for 37% of low vision among white
subjects and 54% of low vision among African
American subjects [12]. Similarly, in the Netherlands, binocular low vision was present in 31.3%
of nursing home residents, and 78% of this low
vision was caused by cataract [13]. These data
suggest that cataract represents an important contributor to disability in older populations in
developed countries despite treatment availability.
Inequality in access to care in the United States
leads to dierential cataract surgical uptake, resulting in unequal distribution of the disease burden in
these populations. Several investigators have examined factors related to receiving cataract surgery
among individuals who were eligible for surgery
[1417]. Such factors as facility with the English
language, medical insurance, and access to regular
medical care are all predictive of receiving cataract
surgery when surgery is of benet [14].
As with any medical procedure, cataract
surgery has associated risks including a suboptimal outcome. Several studies have demonstrated
that a success rate of good clinical outcomes of
over 90% is attainable in both developed and
developing countries [1821]. Other studies, however, have reported surgical success rates closer
to 50% [22,23]. Zhao and coworkers [23] report
that in Shunyi County, China, 45% of eyes had
vision worse than 6/60 at follow-up. Given the
large number of individuals undergoing cataract
Cortical
14.2
33.8
20
Posterior subcapsular
13
5.5
7.1
6.3
6.8
surgery, surgical failure rates of even 10%

translate to a signicant number of individuals
with poor surgical outcomes and continued visual
disability.
The need for further research into pathways
for prevention and delay of disease is highlighted
by the impact of cataract. Finding alterable
factors that could delay disease by as few as 10
years would have a substantial eect on quality of
life and economic burden, reducing the rate of
cataract development by an estimated 14% and
decreasing the number of cataract surgeries by
nearly 50% [2,24].
Well-established risk factors for cataract
Some risk factors for the development of agerelated cataract, including smoking, diabetes,
and UV light exposure, have been consistently
reported across multiple studies and summarized
in previous reviews [26]. Briey, smoking consistently has been found to be associated with both
nuclear and PSC cataract [6], and several studies
have demonstrated a dose-dependent relationship
between pack-years of use and degree of opacication [2530]. Most recently, a new analysis including 13 years of follow-up from the Physicians
Health Study cohort indicated that smoking
cessation reduced risk primarily by limiting cumulative dose and smoke-related damage, although
there was some indication that there also may be
a reversible component of damage [28].
Research into the link between UVB radiation exposure and cataract dates back several
decades, with most studies showing a signicant
relationship between UVB exposure and cortical
cataract, using various exposure and outcome
assessment strategies [3]. Oxidative damage
NEW EPIDEMIOLOGY OF CATARACT
resulting from UVB exposure is hypothesized to

be the mechanism through which UVB may induce cataract, and the anterior cortical surface
likely receives the most radiant energy, explaining
the predominant ndings of higher cortical cataract risk with less or no eect on rates of nuclear
cataract and PSC [31]. Furthermore, three studies
characterized the distribution of the position of
opacities, and each found increased risk of cortical cataract in the lower nasal quadrant compared
with other areas of the lens [3234]. It has been
hypothesized that the lower nasal quadrant of
the lens is the most eected by solar UV exposure
given the angle of the sun during peak UV hours.
Quantifying the magnitude of the association is
dicult, however, given that methodology for
determining exposure varies widely across studies.
Odds ratios range from 1.10 (95% condence
interval [CI], 1.021.20) per 0.01 Maryland sunyear [35] to 2.48 (95% CI, 1.244.99) for cortical
cataract comparing annual exposures greater
than 564.5 KJ/cm2 with exposures of less than
516.7 KJ/cm2 [36].
Study results are highly dependent on the
method used to quantify the exact UV dosage
received by the lens. Ambient levels are an
imperfect surrogate, because individual behaviors
greatly modify actual lens exposure given constant
ambient UVB. Some studies have attempted to
overcome this problem by asking detailed questionnaires that can be used to quantify lifetime
sun exposure. Such questionnaires are timeconsuming to administer, however, and are limited by the diculty that respondents may have
with accurately reporting behaviors from the
distant past. Personal traits, such as iris color
and nutritional status, also may alter the eect of
UVB radiation that reaches the eye. UVB radiation may act primarily as a synergistic eect,
increasing the rate of an ongoing opacication
process or adding to other oxidative insults to
exceed a threshold for cataract formation.
Research into the association between diabetes
and cataract formation dates back to the 1960s. It
was not until much more recently that prospective
studies were conducted that allowed examination
of the temporal association between diabetes
and incident cataract. Three population-based
prospective studies have reported that diabetes is
a risk factor for both cortical and PSC cataract. In
the Beaver Dam Eye Study, diabetes mellitus was
associated with the 5-year incidence of both
cortical and PSC cataract [37]. The Blue Mountains Eye Study yielded similar results, nding
417
a twofold higher 5-year incidence of cortical cataract in participants with impaired fasting glucose
(odds ratio, 2.2; 95% CI, 1.14.1) and more
frequent PSC incident cataract among diabetics
with newly diagnosed diabetes (odds ratio, 4.5;
95% CI, 1.513) [38]. A history of diabetes was associated with incident cortical cataract (relative
risk 2.4; 95% CI, 1.83.2) and PSC (relative
risk 2.9; 95% CI, 1.94.5) in the Barbados
Eye Study in addition to the nding of a doseresponse relationship between these incident
opacities and increased levels of glycosylated
hemoglobin at baseline [39].
Dierent eect estimates for diabetes on cataract formation have been reported both from age
groups less than approximately 60 years and those
older than approximately 60 years. This nding
has been repeated in a number of studies [4042].
A diminishing eect of diabetes on cataractogenesis in older age groups may indicate either an increasing inuence of other factors thereby
washing out the eect of diabetes or a survivor
bias, such that severe diabetes leads to early
mortality leaving only healthier survivors in the
older age groups. An interaction has also been
noted in some studies with glycated hemoglobin
such that an association between glycated hemoglobin and cataract is seen only in diabetics
[37,43]. Such a result may indicate tight glucose
control can minimize the risk of cataract in those
with diabetes, as has been demonstrated with
other diabetes-associated ocular conditions [44].
Risk factors where current understanding

is evolving or reects conicting results
Myopia
Population studies suggest that the prevalence
of myopia may be increasing over time in some
areas, the implication of which is higher rates of
some of the myopia-associated ocular pathologic
conditions [45]. Recent research provides clinical
evidence for an association between myopia and
nuclear cataract formation. Several cross-sectional studies reported an association between
myopia and prevalent nuclear cataract; however,
prospective studies were needed to conrm the
temporality of the association because nuclear
cataract itself can contribute to increased lens
power and myopia. Indeed, recently published
prospective studies have reported somewhat different results from cross-sectional studies of the
same population. In the prevalence study of the
418
ABRAHAM
Visual Impairment Project conducted in Australia, an association between myopia and all
types of cataract was reported [46]. In the prospective study published in 2006, myopia was only
a risk factor for cortical cataract, reporting
a 2.2-fold increased risk (95% CI, 1.43.4) of incident cortical cataract [47]. This study is the rst to
report an association between myopia and incident cortical cataract. In Beaver Dam, an
association between myopia and prevalent nuclear
cataract was seen; however, no association was
seen between myopia and incident cataract [48].
The Blue Mountains Eye Study reports a 3.3fold increased risk of incident nuclear cataract
among individuals with high myopia (6 diopter
[D]) and a 5.4-fold increased risk of PSC (95%
CI, 2.511.9) cataract formation among individuals with moderate to high myopia (3.5 D). Furthermore, for persons aged 70 years or older,
a myopic shift in refraction was associated with
incident nuclear cataract, cortical cataract, and
PSC [49,50]. In the Barbados Eye Study, myopia,
dened as less than 0.5 D, was associated with
incident nuclear cataract (relative risk 2.8) [51].
Recent ndings reported from the Salisbury Eye
Evaluation demonstrate the importance in the
temporality of this association. Cross-sectional
associations were reported for both nuclear
cataract and PSC. An additional nding was an
association between early spectacle wear and PSC,
a possible indicator of the temporality of the
relationship between myopia and PSC [52]. The
mechanism through which myopia may act to cause
cataract is unknown, although damage-induced
lipid-peroxidation has been hypothesized [45].
Nutrition and supplement usage
Oxidative damage is a putative contributor to
the mechanisms of cataractogenesis for both
nuclear and cortical cataract. Much interest has
been generated by dietary constituents that have
antioxidative properties. Levels of many antioxidants exist naturally in the various structures of
the eye, protecting tissues from the myriad
oxidative insults to which the eye is subject [53].
Many epidemiologic studies have evaluated the
role of vitamins and micronutrients in preventing
cataract, with nutrient measurements varying
from dietary intake to supplement use and plasma
levels of the vitamins in question. The types of
measurement used and the outcome types, ranging from cataract extraction to prevalence of cataract at 5-year follow-up, make comparisons
et al
across studies dicult. Additionally, teasing out

the association of an individual nutritional factor
is dicult because of the colinearity among
various nutritional factors. Individuals who are
nutritionally replete in one factor are likely replete
in most factors of interest.
A 2000 review of the literature of observational
studies conducted by Wu and Leske [54] highlights the conicting data on nutrients in prevention of cataract and demonstrates that even
within the same study population, results may
vary over time. For instance, within their own
studies, the Lens Opacities Case-Control Study
(LOCS) [55] and the Longitudinal Cataract Study
[56], a longitudinal study of the LOCS population,
discrepant results were found. In LOCS, dietary
intake of vitamin C seemed to provide protection
against nuclear cataract [55], whereas in the longitudinal study more recently reported [56], the
association was not found. On the contrary,
when evaluating vitamin E supplementation, no
association was seen in the case control study
[55] but a protective association with nuclear opacication was reported in the longitudinal study
[56]. Similar conicting results have been reported
for the Nurses Health Study and the Physicians
Health Study.
Researchers have hoped that clinical trials
would help to clarify the role of nutrients and
cataract prevention, and would demonstrate protection against cataract development or progression. The Physicians Health Study II evaluating
betacarotene, vitamin A and E, and multivitamins
[57] and the Italian-American Clinical Trial of
Nutritional Supplements and Age-related Cataract evaluating multivitamin use [58] are currently
underway, and follow-up will be completed in the
next few years; however, most recently reported
trial results do not support the hypothesis of
protection from vitamins. The Age-related Eye
Disease Study reported no association between
supplementation with vitamin C, vitamin E, and
betacarotene and 7-year risk of development or
progression of lens opacities [59]; likewise, the
Vitamin E, Cataract and Age-related Maculopathy Trial evaluating vitamin E given for 4 years
reported no overall association between supplementation and incidence or progression of lens
opacities [60]. These ndings are in contrast to
two earlier clinical trials of vitamin supplementation in a population in China with borderline nutritional status, which demonstrated a protective
eect of supplementation on development of nuclear opacities, albeit in only one supplement
combination out of several studied [61]. These

conicting results highlight the importance of
the nutritional status of the population being
studied. Although evidence of a role for nutritional supplementation in retarding the progress
of cataract is currently lacking for nutritionally
replete populations, an ongoing study in southern
India, the Antioxidants and Prevention of Cataract Study, may provide further insight into the
potential role of supplementation in less wellnourished groups, where the bulk of cataract
blindness exists.
Weight status and fat consumption
Many factors relating to health and nutrition
are interrelated, making the individual association
of a specic factor dicult to tease apart. Several
studies have evaluated the relationship between
body mass index and cataract. The Nurses Health
Study cohort, the Physicians Health Study cohort,
the Framingham cohort, and the Beaver Dam Eye
Study cohort have all reported associations
between body mass index and PSC cataract
[37,6265]. The nature of the relationship between
body mass index and cataract has not been fully elucidated; however, some studies suggest a U-shaped
relationship. Numerous other studies have reported associations with cortical and nuclear cataracts and null ndings [63,6669]. The role of
central adiposity is even more unclear [41,62].
Research also has focused on the contribution
of dietary fat and serum lipids to cataract risk
[70,71]. Of particular interest may be the contribution of fatty acids to both cataract development
and protection. One cross-sectional study in the
Nurses Health Study cohort found a higher risk
of nuclear cataract among nurses who consumed
the highest amount of linoleic and linolenic acid
[72]. Lens research has conrmed a cytotoxic
eect of these and other unsaturated, cis-congured fatty acids on lens epithelial cells, an eect
that seems to be moderated by aqueous albumin
concentrations that may rise with age [73]. Such
results could have implications for diseases, such
as diabetes where plasma free fatty acid levels
tend to be elevated. In a second longitudinal study
of the Nurses Health Study cohort eicosapentaenoic and docosahexaenoic acid were found to be
protective against cataract extraction, whereas
linoleic and linolenic acid were not strongly
associated with the outcome [74].
Findings from the various studies of lipid
metabolism, obesity, diabetes, and opacication
419
of the lens may be scratching the surface of

a complex etiologic web. Animal studies may
indicate that these factors interact to promote
cataract development and modication of one
factor may be used to reduce risk from another [75].
Corticosteroids
Numerous studies have reported associations
between oral corticosteroid use and cataract
formation. As early as 1960, studies indicated
a causal role of systemic steroids in PSC development [76]. Many reviews have been written
on the topic summarizing the evidence for an
association between cataract and both oral and inhaled steroids [7781]. Evidence for oral steroid
use as a risk factor for cataract is stronger than
that for inhaled steroids. The use of oral corticosteroids for the treatment of inammatory and
immune disorders, such as asthma, rheumatoid
arthritis, and lupus erythematosus, provided
early evidence of an increased prevalence of PSC
formation in exposed individuals, particularly
children [76,8287]. Controlled trials of steroids
used in combination with other therapy have
strengthened the case for a causative role of oral
steroids in PSC progression. Patients randomized
to receive oral steroids for immunosuppression
showed consistently higher rates of PSC
[80,88,89]. The prevalence of PSC seems to be sensitive to both the dose and duration of steroid administration [76,80,82,83,90].
More recent literature has focused on the role
of inhaled corticosteroids on cataract formation.
A review by Allen and coworkers [81] summarizes
the data through 2003. A cursory review of the
literature might suggest conicting information
because multiple studies report no association
between inhaled corticosteroids and cataract
[9092]. These studies are based on small populations of primarily children and young adults who
are unlikely to develop this typically age-related
condition [91,92], however, or they focus on
a small population in which oral steroids were
used, making it more dicult to isolate the association with inhaled steroids [90]. Three case-control studies examining cataract diagnosis and
extraction without regard to type found
participants taking inhaled steroids to be at higher
risk of prevalent cataract [9396]. Most recently,
a large cross-sectional survey of the Blue Mountains Eye Study cohort found a relative prevalence
of 1.9 (95% CI, 1.32.8) for PSC and 1.5 (95% CI,
1.21.9) for nuclear cataract among subjects using
420
ABRAHAM
inhaled corticosteroids compared with those with

no inhaled corticosteroid use [95]. Cumming and
Mitchell [97] suggest that the evidence for inhaled
steroid on cataract formation is at least as strong
as that for oral steroid use in their cross-sectional
study and that future studies should evaluate
whether direct entry of corticosteroid into the
eye because of poor inhaler technique may play
a role. Prospective studies of inhaled steroid users
may help to conrm the role of their use in
cataract development.
It should be noted that several factors may
complicate the detection of small eects from
inhaled steroids. The particular lesions associated
with steroid use may have a reversible component
and can be dicult to detect because they rarely
aect vision [80,98]. In addition, there may be
a large degree of variability in individual susceptibility, and synergism with other cataractogenic
factors may ultimately determine any individuals
PSC outcome [78,80,99].
Exogenous estrogens
A large body of evidence suggests that across
racial groups, women have higher rates of cataract, even when adjusting for womens greater
longevity [31,39,46,100104]. Postmenopausal estrogen decline has been hypothesized to play
a role. Research into the causal relationship of exogenous hormone use and cataract risk, however,
has provided conicting results. In both the Beaver Dam and Salisbury populations, prevalence
data suggested a relationship between current hormone-replacement therapy use and decreased nuclear cataract. In Salisbury, an association also
was seen with PSC. Recently published prospective evaluations of both of these two populations
reported no association, however, between hormone-replacement therapy and any cataract formation. Additionally, whereas the Blue
Mountains research group concludes that there
is some evidence of a protective association
between estrogen use and incident cataract
formation [105], the recently reported Visual Impairment Project found no association between
female hormonal use and cataract [47]. Clearly,
the role of hormone-replacement therapy in
cataract prevention has not been fully elucidated.
Genetics
The role of genetics in the development of
cataract is a question of increasing interest. Finding
genes that contribute to the mechanism of
et al
cataractogenesis may eventually lead to gene product

targets for intervention. Further, such information
could aid in identifying predisposed individuals who
might be more susceptible to other cataract risk
factors, such as UV exposure [24]. The Framingham
Eye Study examined familial aggregation of lens
opacities and found that the odds of a nuclear cataract or PSC were three times higher among those
with aected siblings compared with those without
an aected sibling [106]. In the Beaver Dam Eye
Study, the contribution of a single gene to the variability in sex- and age-adjusted measures of nuclear
and cortical cataract was estimated to be as high as
35% and 58%, respectively [107,108].
The Twin Eye Study went one step further,
estimating both the contribution of genetic and
environmental factors to various cataract phenotypes. The authors found that the total variability in
nuclear cataract development was partitioned as
follows: heritability accounted for 48% (95% CI,
42%54%); age accounted for 38% (95% CI, 31%
44%); and unique environmental eects accounted
for 14% (95% CI, 12%18%) [109]. A similar investigation of cortical cataract found that dominant
genes were estimated to contribute to 38% (95%
CI, 1%64%); additive genes contributed to
20% (95% CI, 0%57%); age contributed to 16%
(95% CI, 12%21%); and the environment accounted for 26% (95% CI, 22%31%) [110]. Two
studies in the Salisbury cohort estimated the magnitude of heritability to be 35.6% (95% CI, 21%
50.3%) for nuclear cataract and 24% (95% CI,
6%42%) for cortical cataract [111,112].
At least two genes have been reported to be
associated with an increased risk for age-related
cataract itself among Japanese populations;
however, the relationships have not been replicated
in other populations. Sekine and coworkers [113]
found a signicantly higher frequency of deletion
of the gene for glutathione-S-transferase, a key
enzyme involved in free-oxygen radical scavenging,
among Japanese patients with typical age-related
cataract as compared with age-matched controls.
The mean age of cataract patients with the gene
deletion was signicantly younger than for patients
possessing the normal gene. Alberti and coworkers
[114] failed to replicate these results in an Italian
population, and the role of this gene also seems
variable in other populations [115,116].
Another candidate gene currently available for
age-related cataract is galactokinase. A deciency
of this enzyme is the cause of a disorder involving
hypergalactosemia and early cataract formation.
A novel variant of galactokinase, identied during
newborn screening for hypergalactosemia, has

been associated with a twofold increased risk for
age-related nuclear cataract among Japanese
individuals [117]. The original investigators failed
to nd evidence of this particular variant among
blacks and whites in the United States, and other investigators have failed to nd an association
between galactokinase alleles and cataract in an
Italian population [118]. Finally, a locus associated
with cortical cataract on chromosome 6 has been
reported from the Beaver Dam population [119].
Markers of inammation
A very recent interest in markers of inammation and vascular endothelial dysfunction as
predictors of cataract has yielded some results.
Inammation is thought to play a role in the
pathogenesis of at least PSC. A study by Klein
and coworkers [120] using serum samples
obtained between 1988 and 1990 from the Beaver
Dam cohort found that higher levels of tumor
necrosis factor-a, interleukin-6, and serum soluble
intercellular adhesion molecule-1 were associated
with prevalent nuclear cataract. Little previous
evidence exists concerning these and other
markers of inammation and the risk of cataract.
It is hoped that further studies will follow.
Future directions
Recent research supports the theory that the
development of any cataract phenotype is likely
the result of a multifactorial process except in rare
instances of very large occupational exposures.
The future of cataract research will be in more
complex study designs looking at multiple factors
that contribute to a single mechanism of
cataractogenesis.
The need to standardize exposure and outcome
measurements will become more important as
clinicians seek to synthesize data better from
multiple studies. Standardizing exposure assessment entails nding a consensus on the most
biologically meaningful measure of the exposure
of interest. Not only must an appropriate
measurement instrument be considered but also
nding a relevant exposure time window. For
exposures with a hypothesized long lag period
between exposure and a detectable preclinical
phase of disease, such as smoking and environmental UV, quantifying the appropriate
magnitude of exposure can be challenging. Measurements may be subject to recall bias in
421
nonprospective study designs. Further, systemic

or environmental measures of an exposure may
not be linearly related to ocular exposures, such as
in studies of antioxidants and dietary constituents.
Outcome assessment is complicated by the
many systems of cataract severity measurement.
These systems rely on dierent standards for
judging levels of severity. Often these ordinal
scales are reduced to a dichotomous measure of
cataract or no cataract and information regarding
the progression of early disease is lost.
Cataract research is still a fertile eld for
investigation. The high prevalence of the disease
in older age groups makes the elucidation of even
weak modiable risk factors clinically signicant.
Few diseases have as great an impact on public
health worldwide.
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Perioperative and Operative Considerations

in Diabetics
David R. Fintak, MDa, Allen C. Ho, MDb,c,*
a
Department of Ophthalmology, Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107, USA
Department of Ophthalmology, Thomas Jeerson University, 111 South 11th Street, Philadelphia, PA 19107, USA
c
Retina Service, Wills Eye Hospital, 840 Walnut Street, Philadelphia, PA 19107, USA
Diabetes mellitus has become one of the fastest

growing health epidemics in the world. According
to data analyzed from the 2002 National Health
Interview Survey, it is estimated that 18.2 million
Americans are aicted with this disease, with over
1.3 million new cases diagnosed each year in
people over the age of 20. Of those with the
disease, approximately 5.2 million are undiagnosed or underdiagnosed [1]. With the aging of
the United States population, the number of older
persons with diabetes is likely to increase, with an
estimated number of diagnosed persons to reach
29 million by 2050 [2].
Cataracts are an important cause of visual
impairment in diabetics. Poor diabetic control
increases the incidence of cataract and the rate
of cataract progression. Age-adjusted prevalence
for cataracts among those with and without
diabetes is 31.8% and 21.2%, respectively [3].
Consequently, the incidence of cataract surgery
in diabetics is higher; two to ve times higher
than a comparable nondiabetic population [4].
Among persons with diabetes, the prevalence of
cataracts was higher among women than men
(37.3% versus 26.7%); higher among persons
aged R65 years than persons aged 50 to 64
(50.3% versus 16.1%); and higher among nonHispanic whites than those of other racial or
ethnic populations (34.8% versus 24.1%) [3].
The presence of baseline proteinuria was also
* Corresponding author. Retinovitreous Associates,

910 East Willow Grove Avenue, Wyndmoor, PA 19038.
E-mail address: acho@att.net (A.C. Ho).
found to be a signicant risk factor associated

with cataract development [4,5].
Preoperative
The preoperative evaluation should include
a detailed ophthalmic and medical history.
Duration and type of diabetes mellitus; glycemic
control including hemoglobin A1c levels; visual
function of the fellow eye; history of neovascular
glaucoma, retinal surgery or laser, clinically significant macular edema (CSME), or proliferative
diabetic retinopathy; and outcome of cataract surgery in the fellow eye (if applicable) should be
paid particular attention. Other risk factors for
the progression of diabetic retinopathy should
also be documented: cholesterol levels; blood
pressure; and the presence or absence of coronary
heart disease, renal disease, or neuropathy.
As with any cataract evaluation, a comprehensive eye examination should be performed. In
diabetics, specic aspects of the examination must
be given special consideration. Potential visual
outcome using the potential acuity meter or laser
interferometry, evaluation of corneal endothelial
integrity, and pupil size are important. Presence or
absence of iris neovascularization should be documented and assessment of the angle structures using
gonioscopy should be considered. A dilated funduscopic examination determining the degree of
retinopathy and presence or absence of macular
edema is crucial in determining potential visual
outcome, intraoperative and postoperative complications, and potential deferment of cataract extraction for retinal surgery or laser.
doi:10.1016/j.ohc.2006.07.003
428
FINTAK & HO
It is important to dierentiate causal visual

loss between cataract change and diabetic
retinopathy or maculopathy. The type and degree
of cataract should be determined, and correlation
with visual loss calculated. It should be noted that
older patients who are more likely to have
cataracts are also more likely to have retinopathy
or macular edema. This is important in forming
expectation levels and surgical considerations. In
some cases the distinction may be dicult to
make, secondary to poor retinal visualization. It
then may become necessary to perform cataract
surgery, not only to improve vision but also to
allow for assessment and treatment of diabetic
retinopathy.
There has been a recent shift in attitude toward
the timing of cataract surgery in diabetics. Previously, surgeons deferred cataract extraction
until the vision deteriorated to 20/100 to 20/200
because of the perceived threat of rapidly progressive postoperative diabetic retinopathy and
maculopathy [6]. When earlier studies reported
only 9% of diabetic patients achieving postoperative visual acuity better than 20/40 after
extracapsular cataract extraction, a number of
surgeons advocated deferring surgery indenitely
[7]. There is growing evidence, however, in support of a more interventional approach. With
macular edema identied as a major risk factor
for poor postoperative visual acuity, earlier surgical intervention allows for adequate retinal visualization, and identication and treatment of
CSME before lens opacication. This renement
of approach has helped to optimize postoperative
outcomes in modern cataract surgery.
Patients known to have proliferative diabetic
retinopathy with high-risk characteristics or
CSME should be considered for laser treatment
before cataract surgery. Patients not meeting the
Diabetic Retinopathy Studys criteria for laser
panretinal photocoagulation, such as those with
proliferative diabetic retinopathy without highrisk characteristics but with signicant nonperfusion, or those with nonproliferative diabetic
retinopathy with signicant nonperfusion and
high-risk systemic factors, should also be
considered for laser treatment because of their
risk for progression of retinopathy following
cataract extraction. Although regression is often
dicult to assess after completion of laser treatment, an interval of 3 months is typically used
before initiating surgery.
For early or suspected macular edema and
CSME, uorescein angiography should be used to
Fig. 1. Optical coherence tomography demonstrating

clinically signicant macular edema.
determine treatable lesions (Fig. 1). Focal laser

surgery or intravitreal steroids should be used
where appropriate. Treated lesions should be reevaluated in 3 to 4 months, and cataract surgery
reconsidered once macular edema has resolved
or improved (Fig. 2).
Promoting appropriate expectation levels and
discussing any specic risks and complications is
essential in maximizing patient satisfaction.
Diabetic patients may be at increased risk for
a number of complications including intraoperative and postoperative corneal edema,
postoperative inammation, increased intraocular
pressure, intraoperative and postoperative
hyphema from iris neovascularization and vessel
fragility, posterior capsular opacication (PCO),
vitreous hemorrhage from pre-existing neovascularization, progression of retinopathy, macular
edema, epiretinal membrane formation, and
endophthalmitis.
The use and type of preoperative medications
for diabetics undergoing cataract extraction is
highly variable. Although no study has
demonstrated its eectiveness, most surgeons use
preoperative antibiotics as prophylaxis against
endophthalmitis. The benets of this practice
remain controversial. Rationales for using them
include reducing or eliminating the bacterial load
Fig. 2. Optical coherence tomography demonstrating

resolution of macular edema following focal grid laser.
CONSIDERATIONS IN DIABETICS
on the ocular surface, and aqueous penetration to

eradicate bacteria introduced at the time of
surgery. In this regard, an ideal antibiotic would
have a broad spectrum of bactericidal activity,
sucient solubility to reach therapeutic
concentrations, and negligible side eects or
toxicity. The uoroquinolones, namely the
fourth-generation moxioxacin and gatioxacin,
fulll these conditions and are the most commonly prescribed prophylactic antibiotics.
The routine use of nonsteroidal anti-inammatory drugs before surgery is recommended by many
surgeons. Multiple studies have demonstrated the
anti-inammatory eect of these drugs, and with an
already compromised blood aqueous barrier and
increased risk for postoperative inammation,
nonsteroidal anti-inammatory drugs have proved
to decrease the risk of CME. Additionally, these
drugs help to prolong the mydriatic eect of
perioperative dilating drops.
Perioperative and operative
As with any surgery, patients must be
instructed to take nothing by mouth for at least
6 hours before surgery. It is generally recommended that insulin-dependent diabetics take only
half of their NPH insulin and no regular insulin
on the day of surgery. Oral hypoglycemic agents
also should be held. Optimally, scheduling
diabetic patients for surgery early in the morning
facilitates maintenance of ideal glucose levels. If
the ophthalmologist and anesthesiologist are
concerned with preoperative and postoperative
glucose control, the advice of an internist or
endocrinologist should be sought [8].
Pupillary dilation and maintenance in diabetic
patients can be challenging at times. Patients with
long-standing diabetes may dilate poorly secondary to an ischemic and spastic pupil. In addition,
neovascular iris changes may promote brotic
ring development at the pupil margin. To maximize preoperative dilation, the use of tropicamide
1%, phenylephrine 2.5% to 10%, cyclopentolate
0.5% to 1%, and urbiprofen 0.03% or ketorolac
tromethamine 0.5% every 10 minutes for three
doses should be used, starting 1 hour before
surgery.
Patients with diabetes mellitus may already
have compromised corneas, so care must be taken
in deciding wound construction. Aected corneas
may not tolerate a clear cornea incision, leading to
delayed wound healing, corneal edema, wound
leak, and an increased risk of endophthalmitis. In
429
these cases a scleral tunnel-limbal approach may

be considered, especially in patients who may
require immediate postoperative panretinal
photocoagulation that necessitates a clear corneal
view.
Visualization is critical for successful cataract
surgery, requiring adequate pupil dilation to decrease the chance of complications. Liberal use
of high-molecular-weight viscoelastics (Healon,
Healon GV, PROVISC, Coease, or Amvisc Plus)
and mechanical dilation should be used. Pupillary
stretching using two instruments is a popular
and eective technique. Other methods include
pupillary stretching with the Beehler pupil dilator,
and insertion of iris retractor hooks or pupillary
rings. In rare cases, radial iridotomy may be
necessary for adequate visualization. Generally,
a pupil size greater than 6 mm is desired. Avoid
excessive manipulation of the pupil because
this may lead to hyphema and postoperative
inammation.
A large continuous curvilinear capsulorrhexis
is preferable for these cases, to accommodate
a large optic intraocular lens (IOL). With an
increased incidence of anterior capsular contraction in diabetics [9,10], a larger capsulorrhexis and
IOL optic allows for improved postoperative
retinal visualization and facilitates peripheral laser
administration; this is very important for future
monitoring and treatment.
Hydrodissection should be performed carefully,
especially in patients with previous vitreoretinal
surgery. Lack of an intact anterior vitreous to
cushion the posterior capsule increases the risk of
zonular stretching and breaking. In addition, any
patient who has undergone a vitrectomy may
already have weak zonules and a possible posterior
capsular break. For this reason, it is important to
avoid overlling the anterior chamber with viscoelastic. Posterior capsular trampolining is more
common with absent vitreous, so care must be
taken when near the capsule.
Phacoemulsication techniques that minimize
phaco time are preferable to minimize energy
transmitted to the endothelium and subsequent
corneal edema. Phacoemulsication at the papillary plane or in the bag also helps to limit
damage to the corneal endothelium. Thorough
cortical cleanup, including careful polishing of
the posterior capsule and anterior rim, should be
performed after phacoemulsication because of
the higher incidence of PCO in diabetics [11]. A Kuglen hook or similar instrument may be used to
retract the pupil and inspect the capsule for
430
FINTAK & HO
residual cortical material. Meticulous cleanup may

help to decrease the severity and delay presentation
of PCO and anterior capsular opacication.
The material type and size of IOL used for
implantation should be considered carefully. A
large optic IOL should be used to minimize any
contraction of the anterior capsule. In general,
a 6-mm or greater optic is preferable. When
choosing the type of IOL material, silicone is
generally avoided for multiple reasons. These
implants are not a good choice if the patient has
silicone oil in the posterior chamber or is likely to
require silicone oil in the future, secondary to
irreversible silicone oil adhesion to the silicone
IOL. Those patients possibly needing to undergo
a uid-air exchange in the future are also poor
candidates because of an increased risk of
condensation on the silicone lens. Furthermore,
studies have shown that silicone IOLs may
stimulate inammation in diabetic eyes.
To reduce postsurgical inammation, foldable
acrylic IOLs and lenses made from heparin-coated
polymethyl methacrylate are now being used by
many surgeons. Although studies have shown
a reduction in lens-induced postoperative inammation with the heparin-coated polymethyl methacrylate lenses [12], the possibility of increased
inammation caused by the larger surgical wound
necessary to insert this rigid IOL must be considered. A study by Krepler and coworkers [13]
found no statistical dierence in the amount of
postoperative inammation between diabetic
patients receiving a heparin-coated polymethyl
methacrylate lens through a 6-mm sclerocorneal
incision compared with those inserted with a foldable acrylic lens through a 4-mm sclerocorneal
incision. Gatinel and coworkers [14] also found
no statistical dierence when comparing inammation with either an acrylic or heparin-coated
polymethyl methacrylate lens through an
identically sized sclerocorneal incision in patients
with diabetes.
Although modern small-incision cataract
surgery with phacoemulsication has become the
procedure of choice for most cases, extracapsular
cataract extraction should be considered in special
situations. Dense nuclear sclerotic changes, pseudoexfoliation, inadequate pupillary dilation
impeding adequate visualization, and notation of
excessive lens mobility on hydrodissection may all
be indications for conversion to extracapsular
cataract extraction. This is advisable to prevent
possible capsular disruption and loss of nucleus or
lens fragments into the vitreous.
Cataract surgery in those patients with

previous vitrectomy and existing intraocular
silicone oil should be approached dierently. In
these patients, cataract formation has been accelerated and is generally quite soft because of the
short period in which they develop. If possible, oil
removal before cataract extraction is preferable.
If unable, however, care must be taken not to
overll the anterior chamber with viscoelastic,
because this can push silicone oil through the
zonules and into the anterior chamber. For the
same reason, low-ow and lowered infusion
pressure should be used during lens removal.
The use of a silicone IOL in these cases is
absolutely contraindicated, secondary to irreversible silicone oil adhesion to the silicone IOL and
visual obscuration for the patient and retinal
surgeon. Final viscoelastic removal should include
meticulous removal of any silicone oil that has
entered the anterior chamber. Although common
to nd some residual silicone oil droplets in the
anterior chamber on the rst postoperative day,
a large layer of silicone oil (O10% of anterior
chamber volume) should be considered for
removal.
In select cases, cataract extraction with IOL
placement may be combined with concomitant
pars plana vitrectomy. Indications for combined
surgery include proliferative diabetic retinopathy,
diabetic tractional retinal detachment, vitreous
hemorrhage, proliferative vitreoretinopathy, and
others. Although once thought to have an increased risk of complications, the combined procedure has been shown to be a safe and eective
alternative to sequential surgery [15,16]. Advantages include a shorter postoperative recovery
time with faster visual improvement, optimal visualization of the posterior pole during vitrectomy,
avoidance of anesthesia risk from a second
surgery, and signicant cost savings. Postoperative visual outcomes between combined surgery
and sequential surgery patients were not
signicantly dierent as shown in multiple studies
[15,16]. The combined procedure has been associated, however, with a slightly higher risk of postoperative neovascular glaucoma [15,1719].
Postoperative
Studies of cataract surgery in diabetics conrm
preoperative retinopathy severity and macular
edema as the principal determinants of postoperative visual acuity. The Early Treatment Diabetic
Retinopathy Study Report Number 25 (ETDRS
#25) also found poor preoperative visual acuity to

be a statistically signicant risk factor for poor
outcome. Other systemic risk factors, such as age,
sex, race, body mass index, type of diabetes,
duration of diabetes, blood pressure, serum cholesterol levels, urine proteinuria, and glycosylated
hemoglobin concentration, were not associated
with poor visual outcomes [5].
Severity of retinopathy at the time of lens
removal is the most important predictor of poor
visual acuity outcome [5,20,21]. More severe
retinopathy may be associated with an increased
prevalence of macular ischemia, or a reduced
tendency to spontaneous resolution of macular
edema [22]. It should be noted, however, that in
the ETDRS #25 study most patients with more
severe retinopathy improved by at least two lines
of vision (55%), with 25% achieving a nal
visual acuity of 20/40 or better and 42% achieving 20/100 or better [5].
Although many studies have been published on
the inuence of cataract surgery on diabetic
retinopathy, considerable controversy exists over
whether cataract extraction accelerates retinopathy progression. Earlier studies reporting on
retinopathy changes following intracapsular cataract extraction and extracapsular cataract extraction found that patients undergoing surgery did
exhibit disease progression [2327]. With the advent of phacoemulsication, some articles report
a similar progression of diabetic retinopathy
[5,21,2832], whereas others report no signicant
progression postoperatively [3336]. Most noteworthy of these is the ETDRS #25, which found
a borderline statistically signicant risk of accelerated retinopathy progression in operated eyes
compared with fellow unoperated eyes. Greater
weight can be applied to this study because of
its superior methodology in grading retinopathy,
and its use of the fellow unoperated eye as a control [5]. In contrast, Wagner and coworkers [33]
and Kato and coworkers [36] have found that
worsening of diabetic retinopathy reects the natural course of the disease, systemic factors, or
both rather than the inuence of the cataract surgery. Regardless, early and frequent postoperative
evaluation of the level of retinopathy is important
to determine the need for panretinal photocoagulation. In general, dilated funduscopy is recommended at 1 week, 3 to 4 weeks, 6 weeks, and
3 months following cataract extraction.
Multiple studies have also tried to elucidate
specic patient demographic and surgical factors
that may have inuence on the risk of retinopathy
431
progression. Poor blood sugar control, male sex

[37], and limited surgical experience (ie, longer
surgery duration) [30] were all found to accelerate
retinopathy in diabetic patients. Longer surgery
duration is associated with increased postoperative inammation [38], and this may result in an
increased breakdown of the blood-retinal barrier
and play a role in the progression of retinopathy.
If this mechanism proves to be critical in the
development of progression, then aggressive
preoperative and postoperative therapy with
anti-inammatory medications and attempts to
shorten the surgical time should prove to be
benecial.
The ETDRS #25 study found no statistically
signicant dierence in the proportions of eyes
with clinically signicant macular edema before or
after lens surgery, and that CSME found after
surgery was not markedly dierent between eyes
that underwent surgery and those that did not [5].
Similar ndings were reported in another concurrent study [22]. At rst, these ndings seem to
contradict earlier studies reporting a signicant
prevalence of macular edema after surgery
[21,23], but on further investigation are entirely
consistent with natural history studies. Although
these studies report a 56% incidence of new clinically detectable macular edema in the rst year
after surgery, spontaneous resolution occurred
without treatment in 50% of aected eyes by 6
months and in 75% by 1 year after surgery [22].
Patients with CSME at the time of surgery
behaved quite dierently, however, with none
resolving spontaneously by 1 year, and most
showing clinical and angiographic deterioration.
With this in mind, it may be possible that previous
case reports of severe macular edema after cataract surgery were described in patients who had
unrecognized or untreated edema before lens
extraction. This also reinforces the need for
aggressive treatment of CSME before surgery.
The incidence of PCO is slightly higher in
diabetics than in nondiabetics [11]. Additional risk
factors include young age [39] and pseudoexfoliation syndrome [40]. A recent study published by
Hayashi [11] found no signicant dierence in
the incidence of PCO for the rst 12 months,
but that at 18 months and later, the PCO value
in the diabetic group increased signicantly and
was signicantly greater than in the control group.
In addition, no signicant correlation was found
between degree of PCO and stage of retinopathy,
type of diabetic treatment, duration of diabetes,
and hemoglobin A1c level.
432
FINTAK & HO
An yttrium-aluminum-garnet laser capsulotomy may become necessary in cases of signicant

PCO to improve vision or improve visualization
of the retina. In these cases, a large capsulotomy is
preferable. Generally, the capsulotomy should be
delayed until absolutely necessary because of the
increased risk of macular edema in diabetics.
Multiple studies have also demonstrated the
increased incidence of anterior capsular contraction
in diabetics, possibly related to the greater degree
of postoperative inammation these patients
exhibit [9,10]. Confounding risk factors include
pseudoexfoliation syndrome [41], pigmentary retinal degeneration [4244], uveitis [41,42], and old
age [45]. No correlation was found between the degree of PCO and anterior capsular contraction [9].
The development of anterior capsular rim
opacication can be unfavorable because proper
visualization of the entire retina is important for
both monitoring and treatment in the postoperative period. Kato and coworkers [10] found that
diabetic patients had a statistically signicantly
smaller anterior capsular opening at 3, 6, and 12
months when compared with nondiabetic controls.
This stresses the need for a large capsulorrhexis
in conjunction with a large optic IOL.
Ocular inammation is a common cause of
reduced vision after cataract surgery. Factors
contributing to the degree of inammation
include duration of surgery, wound size, posterior
capsule rupture, and vitreous loss. In diabetics,
the increased risk of postoperative inammation
arises from a compromised blood-aqueous barrier. This risk is apparent in all diabetics, regardless of the presence of diabetic retinopathy. The
prolonged use of topical steroids and nonsteroidal
anti-inammatory drugs can help prevent serious
complications related to this issue.
Postoperative endophthalmitis is one of the
most serious and potentially devastating complications after cataract surgery. Although most
cases are still infectious (69%), diabetics have an
increased tendency to develop sterile endophthalmitis. The Endophthalmitis Vitrectomy Study
found that diabetics tend to have more virulent
organisms, a higher percentage of gram-negative
isolates, and are less likely to be culture-negative
[46]. Risk factors include inadequate disinfection
of the eyelid and conjunctiva, surgery longer
than 60 minutes, vitreous loss, use of prolene haptics, wound leak or dehiscence, and inadequately
buried sutures [47]. The mainstay of treatment
for patients with hand motion vision or better still
includes vitreous tap and injection of antibiotics.

Vancomycin, 1 mg/0.1 mL, and ceftazidime, 2.25
mg/0.1 mL, or amikacin, 0.4 mg/0.1 mL, were
found by the Endophthalmitis Vitrectomy Study
Group to cover 100% of gram-positive organisms
and 97% to 100% of gram-negative organisms
[48,49]. If no clinical improvement is noted in
the rst 48 to 72 hours, or if the presenting vision
is light perception only, a vitrectomy should be
considered. In all cases, concomitant use of corticosteroids, either topically, intravitreally, or systemically, has been shown to reduce intraocular
inammation and secondary complications associated with infectious endophthalmitis [50,51],
but also has been shown to have no eect on visual outcome [52]. Unfortunately, diabetics tend
to have worse vision after treatment of endophthalmitis, with only 56% of patients achieving
20/100 versus 77% of nondiabetics [53].
Summary
Diabetes mellitus is one of the fastest growing
health epidemics in the world, and with a high
percentage of these patients developing visually
signicant cataracts, the number of cataract
surgeries for diabetics is only expected to increase.
Surgical outcomes have improved in recent years
with the advent of early intervention, and improved preoperative diagnosis and treatment of
retinopathy and macular edema. Although these
patients present unique challenges to the cataract
surgeon, appropriate preoperative and intraoperative considerations lend to good outcomes.
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Enhancing Intraocular Lens Outcome Precision:

An Evaluation of Axial Length Determinations,
Keratometry, and IOL Formulas
Thomas C. Prager, PhD, MPHa,*, David R. Hardten, MDb,c,
Benjamin J. Fogal, ODb
a
Department of Ophthalmology and Visual Science, Hermann Eye Center, University of Texas Health
Science CenterHouston, 6411 Fannin Street, Houston, TX 77030, USA
b
Minnesota Eye Consultants, 710 East 24th Street, Suite 106, Minneapolis, MN 55404, USA
c
University of Minnesota, 710 East 24th Street, Suite 106, Minneapolis, MN 55404, USA
With increased safety of the procedure itself,

cataract surgery now is being performed in
patients who have less visual disability than
several years ago. Todays cataract surgery occurs
at an earlier age, and with implants for monofocal
and multifocal corrections, patients now anticipate excellent uncorrected acuity, not just improved best corrected vision. Because patients
have come to view cataract surgery as both
a rehabilitative and refractive procedure, surgeons, for better or for worse, now are being
judged mainly for their refractive outcomes. This
expectation places increased importance on accurate biometry and intraocular lens (IOL) calculations, the topics covered in this article. Accuracy
of the measurements has a consequence in patient
satisfaction and depends on correct determination
of eye length, IOL position, refractive power of
the cornea, and selection of the proper IOL
formula. Familiarity with these variables will
make it easier to achieve precise results in both
the intact eye and in eyes that have had previous
surgeries, including keratorefractive procedures.
The rst section discusses considerations pertaining to IOL formulas. The other sections
Thomas C. Prager, PhD, MPH has a financial interest in the Prager Shell (ESI, Plymouth, Minnesota).
E-mail address: Thomas.C.Prager@uth.tmc.edu
(T.C. Prager).
address the details of measuring axial length and

corneal curvature accurately. The second section
focuses on the advantages and disadvantages of
various methods of measuring biometry as well as
tips and practical information to reduce biometry
errors. The third section addresses various
methods of determining corneal power. Keratometry after refractive surgery can be dicult, and
several measurement strategies are presented.
Calculation formulas for intraocular lens
The rst estimation of IOL power was made in
1967 by Federov and colleagues [1]. Based on vergence formulas, the basics of the original calculations have not changed much. Only slight
variations in the formula have occurred with the
onset of new technological advances such as ultrasonography. In the 1970s, several investigators
devised a variety of theoretical formulas to
describe the various relationships of the dierent
ocular components [2,3]. With the advent of accurate A scan ultrasound, they were better able to
predict the axial length of the eye and therefore
achieve reliable IOL power predictions.
Slight variations in the formulas accounted for
the dierent values by dierent investigators, but
for the most part, only a few variables were used
in the formula: corneal power, axial length, desired postoperative refraction, eective lens position, power of the IOL, and vertex distance. Some
doi:10.1016/j.ohc.2006.07.009
436
PRAGER
minor dierences in the values for the corneal

index of refraction and the thickness of the retina
existed. Eective lens position is the only variable
that cannot be measured directly preoperatively.
There are two basic groups of formulas:
theoretical formulas that use geometrical optics
and empiric studies based on retrospective case
studies and statistical analysis. The SandersRetzla-Kra (SRK) formula was one such empiric regression formula [4]:
IOL power A constant 2:5 AL 0:9 K;
where AL represents axial length, and K represents
corneal power as measured with keratometry in
Diopters.
Today, the theoretical formulas are considered
more reliable in predicting correct IOL power. In
the rst-generation theoretical formulas, the eective lens position was actually the anterior chamber depth, and it was a constant factor (4 mm)
dependant on the IOL position [2,3]. The secondgeneration formulas related the axial length to
the eective lens position [5]. By 1988, it was
proven that accuracy could be improved further
by using a two-variable predictor of eective lens
position [6]. The third-generation, and more reliable, formulas vary the eective lens position as
a function of the axial length and the corneal
power. Examples of these formulas are the Holladay 1, the SRK/T, and the Hoer Q [68].
Later-generation formulas include the Holladay 2 and Olsen formulas. These formulas calculate the eective lens position using more than two
variables. The Holladay 2, for example, uses seven
dierent variables to describe the eective lens
position accurately: axial length, corneal power,
white-to-white corneal diameter, anterior chamber depth, age, lens thickness, and preoperative
refraction [9].
Measurement of parameters for calculation
IOL formulas depend on accurate measurements of the various components of the formulas
such as axial length, anterior chamber depth, and
corneal power. IOL prediction changes dramatically with keratorefractive procedures because of
errors in measurement of corneal power [1036].
The instrumentation used today in the measurement of corneal curvature and corneal power
make basic assumptions about the refractive properties of the eye that do not hold once the anatomy
is altered with surgery. These breakdowns in the
et al
formulas for IOL calculation may cause increased

inaccuracy in the refractive error after cataract
surgery. Many patients have now undergone refractive surgical correction of ametropia, and
some have developed cataractous changes requiring surgery.
The various theoretical and empiric formulas
rely on accurate measurement of the axial length
as part of the calculations. As discussed, immersion ultrasound and partial coherence interferometry (or optical coherence biometry) show a high
degree of correlation.
Although many formulas work well in many
eyes, certain formulas may be more accurate,
depending on the axial length of the eye. Formulas that may have an advantage in accuracy based
on axial length are
Axial length less than 22 mm: Hoer Q, Holladay II
Axial length 22 to 26 mm: Holladay I, Hoer Q,
SRK/T
Axial length greater than 26 mm: SRK/T, Holladay II
Biometry
Cataract surgery and refractive surprises
Signicant cataract formation is estimated to
occur in 18% of persons aged 65 to 74 years
[37]. Consistent with this high prevalence, cataract
extractions are the single most commonly reimbursed surgery (1.3 million/year) in the Medicare
system [38,39]. With todays multifocal lenses
and patient expectations of perfection in what is
often referred to as the most successful surgery
in medicine, accuracy in preoperative measurements is paramount. An early article by Holladay
and colleagues [40] estimated that refractive surprises, dened as a 2-diopter (D) dierence in
the predicted results, might occur in 5% of the
cataract population. Such results can lead to a diminished quality of life [4143], binocular diplopia, altered depth perception, possible lens
exchange, or loss of patient referrals.
Axial length errors are the most likely source
of refractive surprises and methods of measurement
The greatest source of refractive surprise seems
to be dierences in measuring axial length, which
are estimated to account for 54% of postoperative
refractive error [40]. Great precision is required
for correct eye length measurement, and an
ENHANCING IOL OUTCOME PRECISION
inaccuracy of only 1 mm can result in a 3-D refractive error.

Optical coherence biometry (OCB), such as the
Zeiss IOL Master (Dublin, California), has
emerged as a new modality for biometry [44]. Its
accuracy compares closely with that of immersion
ultrasound biometry [4549] One advantage is
that OCB is not subject to cross-contamination because it is a noncontact procedure, but visual acuity must be equal to or better than 20/200 [45]. In
eyes with silicone in the posterior vitreous, the
OCB technology is clearly superior to ultrasound.
An advantage of the IOL Master is in its ease of
use and speed of testing. Scanning with the IOL
Master takes about 1 minute, whereas immersion
ultrasound takes a few minutes longer. OCB measures the optical axial length, that is, the cornea
fovea vertex distance, rather than the anatomic
length of the eye as measured by ultrasound
[50,51]. This measurement is important in eyes
that are aected by a posterior pole staphyloma,
such as those seen in the higher myopes, in which
the fovea actually may lie along the slope of the
staphyloma wall [50,51]. This dierence would account for potentially erroneous axial measurements (falsely long axial length) with ultrasound.
There are disadvantages associated with OCB,
which does not allow reliable measurements in
the presence of any signicant axial opacity (eg,
corneal scars, keratopathy, severe tear lm
437
problems, dense posterior subcapsular cataracts,

brunescent cataracts or vitreous hemorrhage, neovascular membranes, maculopathy, and retinal
detachment) [45,49,52,53]. OCB cannot be performed when the subject has tremor, respiratory
distress, nystagmus, or lid abnormalities or cannot
xate on a target [45,50]. Consequently, the eyes of
8% to 17% of patients cannot be measured with
OCB [45,50,5254]. In addition, instrumentation
may be prohibitively expensive for a small practice.
Thus, there will always be a role for immersion
biometry in the foreseeable future.
The contact technique or direct applanation on
the eye is used commonly but is fraught with
problems. Even the skilled technician may have
parallax diculties: in centering the probe on the
cornea there is always the potential of indenting
the eye, especially in patients who have lower
intraocular pressure. The immersion technique
eliminates these problems by using a liquid interface between the eye and the ultrasound probe.
Early pioneers include Ossoinig [55,56] and Hoer
[57]. Immersion may be performed with an open
cylinder (eg, the Hansen Shell, Iowa City, Iowa)
lled with Goniosol or with a xed immersion
shell (eg, the Prager Shell, ESI, Inc., Plymouth,
Minnesota). The Prager Shell (Fig. 1) was rst designed in 1982, with several improvements also
improving upon an immersion shell created by
Coleman [58]. In the authors opinion, the use of
Fig. 1. Prager Immersion Shell and special tubing. (Courtesy of Thomas C. Prager, PhD, Houston, TX.)
438
PRAGER
the xed immersion shell, a one-handed procedure, is easier to master; it does not require the
use of Goniosol, which may blur the vision and
prevent additional testing that same day. The immersion technique minimizes technician variables
such as corneal compression, alignment of the ultrasound beam, and probe insertion, leading to
more reproducible results. After practice, immersion biometry using the Prager Shell has been reported to be faster than the contact method [46].
A partial explanation is that historically, with
contact biometry, after obtaining several axial
measurements, the technician or physician must
take considerable time to review the scans and delete those that present corneal compression errors.
In the quest of greater accuracy in surgical
outcome, there have been many comparisons
between applanation and immersion techniques.
In 1984 Shammas [59] was the rst to report that
immersion scans consistently result in longer axial
lengths and less variability than the contact technique. These ndings have been replicated in
numerous studies during the past 20 years
[46,5967]. The Prager Shell and other immersion
approaches have been compared directly with the
noncontact interferometer (Zeiss IOL Master)
determination of axial length; there is no clinical
dierence in precision between the two methodologies, although there is a signicant dierence in
cost [45,46,61]. A study by Packer and colleagues
[46] looked at 50 cataractous eyes and compared
the Axis II (immersion ultrasound unit) with the
IOL Master (OCB). Results showed a high correlation between the two units in axial length calculation (Pearson correlation coecient 0.996). In
a cohort of 253 patients, axial length measurements using the IOL Master were unobtainable
in 17% of the population because of low visual
acuity and dense cataracts [49].
Considerations when using the xed
immersion shell
The balance of this section describes the proper
use of the xed immersion Prager Shell and
a commonsense approach to reduce measurement
error. Simply using an immersion shell does not
guarantee perfect results on every patient. The
biometrist must understand the potential sources
of error and a use mental checklist when performing immersion biometry. An inexperienced technician who does not understand the basic principles
underlying axial length scanning can undermine
the eorts of the most skillful cataract surgeon.
et al
Read the chart before measuring the eye

Most refractive surprises occur in eyes of
unusual length, more frequently in short eyes.
Proportionately, a 1-mm mistake in a 21-mm eye
has a greater postoperative refractive consequence
than the same 1-mm error in a 30-mm eye.
Although staphylomas may make it more dicult
to locate foveal spikes in a long eye, the smaller
dimensions encountered in the short eye require
greater accuracy of measurement to maintain
error tolerance. Thus, before making an ocular
measurement, the biometrist should determine if
the eye is unusual in any way. A previous scleral
buckle can change shape of the eye, producing
a signicant dierence in axial length between the
eyes. In most patients both eyes are approximately
the same length, typically within 0.3 mm of one
another. Replicate measurement ndings several
times; if a dierence of 0.3-mm or more remains,
note in the chart that the measurements exceed
normal physiologic ndings. Determine if either
eye is aphakic, because this condition will require
a change in sound velocity to compensate for the
missing lens. Similarly, a pseudophakic eye will
require a change in tissue velocity. Many instruments have settings for eyes with implanted IOLs,
although an alternative method is to measure
every pseudophakic eye at the aphakic setting
(1550 m/s) and then add 0.4 mm to the anteriorposterior length if the lens is made of polymethylmethacrylate, subtract 0.8 mm if the IOL lens is
silicone, or add 0.2 mm for an acrylic lens.
Measuring eyes that contain silicone oil in the
posterior vitreous poses another diculty in
obtaining accurate axial length measurements.
Silicone oil in the eye, used to replace vitreous in
eyes with retinal detachments, changes the speed
of sound through the eye. To further complicate
matters, the two most common types of silicone
have dierent tissue velocities, 1050 or 980 m/s,
and the clinician must know which velocity to
select to avoid a small mistake in axial length.
Sandra Frazier Byrnes [68] excellent book on axial length measurements details procedures to correct for silicone in the posterior vitreous cavity.
Each ocular component of the eyedanterior
chamber, lens, and posterior vitreous cavityd
must be measured individually. Each component
can be measured at 1532 m/s. Although the anterior chamber does not require a mathematical adjustment, to obtain true values for the lens use
1641/1532 times the measured lens thickness and
980 (most cases)/1532 times the measured vitreous
length. Final IOL power determination is made
more confusing because the index of refraction

diers in the eye with silicone and the normal
eye and requires the addition of more refractive
power. Given these problems, OCB technology
will produce a more accurate axial length measurement than the ultrasound technique in the
eye with silicone.
Search the chart for other information that
potentially can aect the surgical outcome. What
is the IOL power requested? If there is an
anticipated dierence of 2 D or more in the nal
refraction, and the other eye does not require
cataract surgery, patients may not be able to
tolerate the anisometropia. Look at the current
glasses prescription to estimate the anticipated
axial length. The average eye is 23.3 mm; 1 mm
equals 3 D; therefore a 24-mm eye should be
myopic by roughly by 3 D. If the glasses have
a hyperopic optical correction of 3.00 D, and the
axial length measurement is 26 mm, this should
alert the biometrist to a possible mistake.
Practical tips in obtaining immersion

anterior-posterior length measurements
To be in compliance with Centers for Disease
Control and Prevention (CDC) guidelines [69], before the eye is measured the shell and probe
should be soaked in alcohol or hydrogen peroxide
for at least 5 minutes. The immersion shell should
be allowed to dry completely and ushed with
balanced saline solution (BSS). Alcohol can compromise the cornea. To reduce the likelihood of
transmitting pathogens from patient to patient,
it is important to change the connecting tubing
and BSS with each patient. A study conducted
at 34 ophthalmology clinics showed wide variability in probe cleanliness [70]. After a single immersion biometry measurement, 18 of 34 samples
(53%) grew organisms from either the probe/shell
or the tubing. Positive cultures were found in 32%
of the immersion shell/probes (11 of 34) and in
31% of the infusion tubing samples (10 of 32).
The bacterium most commonly cultured from
both probe/shell and tubing was coagulase-negative Staphylococcus. Although Staphylococcus is
associated with conjunctival ora, its presence still
indicates poor hygiene. Fungus potentially puts
patients at risk, especially if the cornea has been
compromised. Penicillium species were the most
commonly cultured fungi (exclusively from the
probe/shell). Overall, fungi (Penicillium and Alternaria species) were cultured in 12% of the probe/
shell samples. Only 14% of the study sites
439
adequately disinfected the probe/shell according

to CDC guidelines [69].
The Prager Shell has a Luer tting to facilitate
changing the tubing. A bottle of BSS can
be attached directly to the tubing, or BSS can
be placed in a syringe. Always replace the BSS
bottle or BSS-lled syringe after every patient
(unless the tubing contains a check valve, if so,
the BSS source can continue to be used). Tubing is
strictly single use. The minimal cost of new sterile
tubing and BSS for each cataract patient represents
less than 3% of the Medicare reimbursement for
biometry and ensures that there is no patient crosscontamination. In terms of cost/benet, rather than
attempting to clean and reuse the tubing, biometrists can more eciently use their time seeing
other patients.
If there is a plastic sheath for applanation, pull
it away from the probe. Insert the biometry probe
into the shell. The software will capture scans only
if the probe (main bang) is at the exact distance
from the cornea specied by each ultrasound
manufacturer. The Prager Shell has an automatic
stop feature that seats the probe at the instrument
manufacturers specied distance from the cornea.
This feature ensures that the corneal gate on the
biometer is positioned on the anterior cornea and
not on the posterior cornea, thus precluding the
introduction of a 0.5-mm error. Note that internal
centering guides hold the probe in place at six locations, so perpendicularity is assured. Observe
that the probe tip is placed at the scored line of
the Prager Shell. Once the probe has been positioned to the score line/auto-stop, gently tighten
the setscrew and seat against the probe. Routine
topical anesthesia is administered to the patients
eyes. Have the patient seated with the head tilted
slightly back against a counter or use an ordinary
chair (Fig. 2).
Both patient and biometrist will benet from
the use of a regular reclining examination chair
with a headrest. A xation light on a exible stem
is crucial. Be sure that it is far enough from the
patients eyes so that the eyes are not stimulated
to converge, thus increasing the diculty of
locating the fovea during biometry (Fig. 3). The
patients attention is normally drawn to a xation
light, which is benecial if language diculties
make communication dicult.
When examining a one-eyed patient, it can be
dicult to ensure proper xation. Have the
patient extend the arm, make a st, and then
stare at the thumb. Even in blind patients the eye
will be able to locate and follow the thumb
440
PRAGER
et al
Fig. 2. Head should be tilted back for examination.

(Courtesy of Thomas C. Prager, PhD, Houston, TX.)
through proprioceptive feedback. Always support

and move the arm to minimize fatigue (Fig. 4).
Examining technique
Place a disposable towel on the patients
shoulder, rest the BSS bottle or syringe on the
towel, and hold the probe/shell in preparation for
the insertion. Direct the patient to look downward, toward the feet; then lift the patients upper
eyelid and insert the ared rim of the shell
underneath the lid (the upper portion of the shell
will make contact with the sclera, and the lower
part of the shell will be held away from the eye).
Ask the patient to look straight ahead with the
uncovered eye, toward the xation light. Pull
the patients lower eyelid down and gently pivot
the lower portion of the shell into the lower
Fig. 3. Fixation light extended beyond area of eye convergence. (Courtesy of Thomas C. Prager, PhD, Houston,
TX.)
Fig. 4. Method of maintaining proper eye xation in the

one-eyed patient. (Courtesy of Thomas C. Prager, PhD,
Houston, TX.)
fornix, making sure by close inspection that it is

in the fornix and not sitting atop a fold in the
conjunctiva. This pivotal motion avoids contact
with the cornea and ensures centration of the
device around the limbus (Fig. 5).
How to hold the shell
The goal is to put minimal pressure on the eye.
In fact, it is quite instructive for the biometrist to
Fig. 5. Correct ocular insertion of the Prager Immersion

Shell. (Courtesy of Thomas C. Prager, PhD, Houston,
TX.)
be the patient (at least once) and learn rst hand

the benets of a light touch.
Note the Luer ller port is facing temporally.
The biometrists left hand/palm is resting on the
patients forehead (assuming the biometry instrument is to the biometrists left) and is used to
reduce shell pressure on the eye. Try to keep the
A-scan instrument in a direct line of site. It is
important to position the biometer screen so that
it can be seen easily during the procedure.
Moreover, the palm acts as the fulcrum or pivot
point for the shell. Sometimes the shell can be
stabilized with the right hand to allow micromovements. With practice most biometrists usually hold the shell using only the hand resting on
the patients forehead. The right hand is free to
make instrument adjustments, if necessary. Although not shown here, a facial tissue can be
placed on the temporal canthus to catch any
excess saline.
To make a measurement, the biometrist should
pick up the BSS bottle or syringe from its place on
the patients shoulder and slowly inject the saline
into the shell. As soon as the liquid lls the shell
suciently to reach the tip of the probe (about
2 cm), the characteristic waveforms of immersion
biometry will be seen on the screen. The user may
wish to review their waveforms by toggling
through the list on the screen and deleting those
that are less than perfect. By keeping the shell in
the patients eye during this review, any measurement that is deleted will be replaced immediately
with a new reading, which in turn may be accepted
or deleted. Optionally one can begin manually
saving acceptable scans.
To remove the shell from the eye, raise the
patients upper eyelid, which releases the top part
of the shell from under the eyelid. Next, pivot
the shell downward, directing the patient to
continue looking straight ahead. Then pull
away from the eye without contacting the
cornea. Upon the initial release, the remaining
contents of the shell (12 ml of liquid) will spill
down the patients cheek. Be prepared with
a towel or facial tissue.
Additional biometry tips
Although the Prager Shell completely eliminates
corneal compression as a complicating factor and
greatly assists in the alignment of the probe with the
macula, it is still necessary to review and analyze
waveforms to ensure a perfect reading.
Be sure to accept only steeply rising retinal
spikes. The corneal, anterior lens, and retinal
441
spikes should be of equal height. Spikes that

demonstrate a downward trend or are stair-stepped
suggest that the scan is o axis. With dense
cataracts, the tendency is to increase the gain,
thereby elevating the spikes. Spikes with attened
tops may indicate that the ampliers are saturated,
resulting in an inaccurate reading (Fig. 6).
With very long eyes, as in patients who have
staphylomas, the macula may be located on the
sloping portion of the staphyloma, and the retinal
spike may not rise to the same height as the
corneal spikes. In normal eyes, however, the
retinal/scleral spikes equal the height of the corneal
spikes. To ensure perpendicularity, be sure there is
no stair-stepping on the retinal spike; it must be
90 to the baseline. Also the scleral spike must be
at least 80% of the height of the retinal spike.
Detection of orbital fat spikes is a requirement. A
normal scan has a series of orbital fat echoes with
descending amplitudes. If they are absent or
markedly attenuated, the probe may be misaligned, and the biometrist may have directed the
sound beam to the optic nerve instead of the fovea.
The learning curve requires only a few patients,
and the immersion technique is easily mastered,
but to gain condence the biometrist should
Fig. 6. Incorrect gain settings produce artifacts and inaccurate measurements. (Courtesy of Thomas C. Prager,
PhD, Houston, TX.)
442
PRAGER
follow the additional suggestions and be familiar

with the sources of error discussed in this article.
Corneal power measurements

In most eyes with normal corneas, corneal
power is measured with keratometry using a standard keratometer. It is important to calibrate the
keratometers frequently to obtain accurate results.
With the advent of keratorefractive surgery,
previous methods for calculating the corneal
power after corneal refractive surgery are inaccurate [1015,1736,71]. The instrumentation used
in the calculation of keratometric power makes
basic assumptions about corneal physiology that
change with refractive surgery. These changes inuence accurate computation of corneal power.
For example, the keratometer assumes that the
central cornea is spherical and prolate, with a posterior radius of curvature that is 1.2 mm less than
the anterior (that is, steeper curvature posteriorly
with respect to the anterior surface). Seitz and colleagues [18] found a mean increase in the posterior
curvature of 0.11 D in 57 eyes after myopic
surgery. Refractive surgery changes the basic
anatomy of the cornea through ablationdthe anterior central cornea becomes oblate and aspherical, and the rate of curvature is changed respect to
the posterior surface [1820]. These basic changes
skew the measurements of corneal power taken
with current instrumentation, and without knowing the true corneal power it is dicult to calculate the necessary IOL power needed.
There are problems with keratometer accuracy
even in patients who have had radial keratometry,
whose corneal radii of curvature are assumed to
remain relatively unchanged [17]. It has been suggested that these problems are caused by a atter
central zone, which falls inside the keratometers
annulus. The keratometer reads the steeper paracentral zone outside the transition zone of the radial keratometry treatment, which erroneously
indicates a higher keratometry (K) value. Even
with corneal topography (CT), incorrect assumptions of corneal anatomy lead to errors: true central readings of corneal power are missed with
keratometry, because the actual readings are paracentral [72,73].
Individuals who have undergone keratorefractive procedures expect accurate results after cataract surgery, because they had accurate results with
their refractive surgery. It therefore is important to
identify the most accurate means of calculating IOL
et al
power. There are many methods and theories as to

the best way to measure the true central corneal
power after refractive surgery. The theoretical
optical formulas (Haigas, Hoer Q, and Holladay
1 and 2) determine the eective lens position
through additional parameters such as horizontal
white-to-white distance, anterior chamber depth,
lens thickness, and (in the Holladay 2 formula)
age of patient, because the eective lens position
cannot be measured preoperatively [9,74].
There are both indirect and direct methods of
calculating keratometric power after refractive
surgery. These methods help the surgeon circumvent the inability to measure the central corneal
power directly after refractive surgery. The indirect methods are so named because they use
measurements other than postrefractive surgery
corneal powers to calculate IOL power. These
methods include the clinical history method, the
contact lens over-refraction (ORx) method, the
vertexed IOL power method, and the intraoperative autorefraction method.
Indirect measurements
Clinical history method
The clinical history method traditionally has
been considered the best indirect method of
deriving postoperative keratometric power. Introduced by Holladay in 1989, this method uses
preoperative K values and manifest refraction
along with stable postoperative manifest refraction values [11,12,1517,21,22,32,36]. The formula
is shown by:
Kpost Kpre difference in SphEq;
where Kpost represents the postoperative K value,
Kpre represents the preoperative K value, and
SphEq represents the spherical equivalent.
This method relies on the ability to obtain
preoperative K values and refraction as well as
a stable postoperative refraction before any inuence from cataract. A review of patients in the
authors practice who had been treated with laser in
situ keratomileusis (LASIK) showed that using the
historical K method would have resulted in a postoperative refractive error of 1.25 1.75 D.
Contact lens over-refraction method
The contact lens over-refraction (ORx) method
was rst described for IOL calculations after
radial keratometry in 1989 and for calculations
after LASIK in 1997 [15,16]. It can be used when
no presurgical data are available. Four dierent

parameters are needed in the calculations:
Base curve of contact lens in Diopters (BC)
Power of contact lens (P)
Manifest refraction (MRx) before ORx
This formula is shown by:
Kpost BC P ORx MRx
The main limitation of this method is the
reliability of the refraction in the patient who
has a cataract [10,14,75]. As well, a stable contact
lens t is often dicult to achieve in eyes with
especially at postsurgical corneas; excessive pooling of tears under the contact lens may aect the
ORx results. A review of patients in the authors
practice who had been treated with LASIK
showed that with use of the contact lens ORx
method a postoperative result of 1.91 2.31 D
would have occurred.
Vertexed intraocular lens method

The vertexed IOL method is based on theoretical studies by Feiz and colleagues [13] and Latkany and colleagues [32] using the SRK/T
formula following LASIK and three methods for
calculating IOL power. They looked at standard
keratometric power after LASIK and the clinical
history method. They then determined the IOL
power for emmetropia based on pre-LASIK corneal powers. The change in spherical equivalent
after LASIK was then used to modify the IOL
power. Using linear regression of the vertexed
IOL power method compared with standard keratometry (K), they developed some nomograms:
Post-myopic LASIK : IOLadj
IOLk 0:231 0:595 SErx
Post-hyper LASIK : IOLadj
443
change at the spectacle plane corresponds to 0.7 D

at the IOL plane.
Intraoperative refraction method
The intraoperative refraction method calculates the IOL power without requiring axial length
measurements or corneal power readings by using
intraoperative refractive determination to calculate the IOL required for emmetropia [76]. A formula to describe the IOL power for a given A
constant is used [76]. This method has not gained
widespread popularity [10,23,77,78].
Direct methods
The direct methods are so named because they
make direct measurements of the postoperative
cornea to calculate eective keratometric diopters
[10]. These methods must correct somehow for inherent inaccuracies in the instruments taking the
measurements (ie, change in the relationship of
anterior and posterior corneal curvature). Experience has shown that the keratometer makes basic
assumptions about the cornea that do not hold
true after keratorefractive surgery. There are techniques that ignore the posterior corneal curvature
change, such as simulated keratometric diopters
(SimK). Modern corneal topographers have sophisticated algorithms to calculate estimated corneal powers that reect anterior corneal power
over a 3-mm annular zone [79]. Eective refractive
power (ERP) is another parameter whereby the
mean refractive power is calculated for the central
3-mm corneal surface (Holladay Diagnostic Summary, EyeSys Vision, Houston, Texas) [74]. None
of these techniques accurately accounts for the
posterior curvature, which is known to be variable
after keratorefractive surgery [80,81]. Topography
units do not measure the true central corneal curvature, because Placido-based units have rings
that are displaced peripherally because of the attening of the central cornea.
IOLk 0:751 0:862 SErx

where IOLadj is the adjusted IOL power to
implant for emmetropia, IOLk is the IOL power
using standard K values of the of post-LASIK
cornea and SRK/T, and Serx is the spherical
equivalent after LASIK (absolute value).
One limitation of this study is the theoretical
nature of the study. There are no published
reports that tested this technique in a prospective
fashion. Essentially this study assumed that 1 D of
Gaussian optics formula and linear regression

Hamed and colleagues [24] looked at 100 eyes
and compared ve dierent methods for determining corneal power after myopic LASIKd
ERP, standard keratometry (K), the Gaussian
optics formula (GauRP), and ERP and K both
modied by linear regression (according to the
amount of LASIK-induced refractive change)d
with the traditional clinical history method. The
Gaussian formula uses the radius of curvature of
444
PRAGER
the anterior and posterior cornea, along with the

index of refraction of air (1.00), anterior K surface
(1.376), and aqueous humor (1.336), and also the
corneal thickness to determine the ERP of the
cornea. The posterior curvature was not measured
directly but was estimated based on ndings
from Olsen and colleagues [82] that stated that
the two curvatures are related by a constant:
R2 K R1 (where K 0.883). Posterior curvature (R2) and anterior curvature (R1) therefore
were estimated based on preoperative ERP.
The Gaussian formula oers an improved estimation of keratometric diopters when compared with
standard keratometry and videokeratometers. This
formula suggested using an adjusted K reading of
Kadj K 0:24 SE change from refractive
surgery 0:15 D
In the authors practice, using this method to
adjust manually or topographically derived simulated K readings still results in a residual mean
hyperopic error of more than 1 D. By using this
adjustment to the attest central K reading on
Placido topography, however, the refractive error
postoperatively is reduced to a slight myopic
correction on average of 0.09 1.36 D.
Aramberri double K method
In 2001 Aramberri [83] reported that the atter
postsurgical K measurements should not be used
in modern formulas to calculate eective lens position. The attening and thinning of the cornea
with keratorefractive surgery does not aect the
biometric measurements of the anterior chamber
structures (the cornea is the same distance from
the lens position and iris). The preoperative K
values are used to predict the eective lens position (essentially the anterior chamber depth),
and the postoperative K values are used in the formula to compute IOL power. Holladay recognized the importance of this concept and
incorporated it in the Holladay IOL Consultant
software. The Holladay 2 calculation formula
uses the K value in a vergence formula to calculate
the power of the eye and in determining the eective lens position [9].
Camellin and Calossi method
Camellin and Calossi [36] reported a formula
that uses either the induced refractive change or
the anterior and posterior curvature of the cornea
to adjust for IOL power in eyes that have undergone prior refractive surgery. In a series of 20
et al
eyes with prior refractive surgery, they reported

a mean postoperative spherical equivalent of
0.26 0.73 D (range, 0.25 to 1.58 D).
Topographic method
When information is not available for a
method calculation, one can take a keratometric
reading and use the attest corneal power within
the central 3 mm of the cornea mapping [32]. The
simulated keratometry from the topography almost always leads to a K reading that is too steep,
but by nding the very attest reading, the power
obtained is usually a atter keratometry reading.
Maloney topographic method
The Maloney topographic method uses the
postoperative SimK reading from the central
cornea from the topography unit [71]. The value
then is used in the formula
K 376=337:5=SimK 5:5
to derive a K reading to be used in the IOL
calculation software. The results of this method
have not been reported in a large series of eyes.
Shammas no history method
The benet of the Shammas no history
method is that it requires only postoperative
average values for manual keratometry [34]. To
calculate the eyes estimated corneal power, the
following formula is used:
K 1:143 average K 6:8
The results of this method have not been
reported in a large series of eyes.
Rosa method
Rosa and colleagues [23,84] suggested yet another method for calculating IOL power after refractive surgery. They used a correcting factor for
corneal radius (R factor) that was derived from
a regression formula (Y 0.0276 0.3635)
and compared it with clinical history and
double-K methods. Nineteen eyes were evaluated
after refractive surgery, and IOL powers were calculated with SRK/T, Hoer Q, and Holladay 1
formulas. A test for correlation was then conducted (Wilcoxon test and Spearman correlation).
They found that the R factor used with both
SRK/T and Holladay 1 formulas gave the best results (84.2% and 89.5% of eyes seeing within 2 D
of emmetropia, respectively). The R factor seemed
superior in this study to both the clinical history

method and the double-K method. The actual formula used in the calculation of IOL power is derived from manual measurements of corneal
power and axial length:
K 0:0276 AL 0:3635 manual K;
where AL represents axial length, and K represents corneal power.
Measurement of anterior and posterior
corneal surfaces
There are two instruments that may be able to
measure corneal power of the anterior and posterior surface of the cornea and provide a more
accurate direct measurement of the corneal power
for use in the IOL calculation formulas. The
Orbscan (Bausch & Lomb, Miami, Florida) has
been in use for several years and is capable of
measuring the front and back surface of the
cornea, although its accuracy has been debated
[8588]. In a series of eyes undergoing cataract
surgery after LASIK in their practice, the authors
retrospectively calculated the actual corneal
power from the refractive results from the cataract surgery. This measurement indicated that
the 3.0-mm mean total axial power calculation
on the Orbscan correlated relatively well with
the power needed for the SRK/T formula for emmetropia. The axial total power at the 3.0-mm
zone had a relatively small SD of 0.87 D in
10 eyes with prior LASIK, with a mean error of
0.16 D and an error range of 1.72 to 1.02 D.
The Pentacam has become available recently
and also is capable of directly measuring the front
and back surfaces of the cornea [8991]. This system allows measurement of the direct center of
the cornea, unlike Placido topographers. The Pentacam can report the true net power of the cornea,
but the IOL calculation formulas contain an adjustment factor for the fact that the K value measured is
actually about 0.75 D more than the actual power
of the normal cornea. The equivalent K reading
of the Pentacam reports what the equivalent K
reading should be for use in the IOL calculation formulas. It is anticipated that the 4-mm equivalent K
reading on the Pentacam may be slightly more accurate than the Orbscan readings. This comparison
has not yet been reported in patients actually undergoing cataract surgery but seems to correlate with
pre- and postoperative refractive information in
patients undergoing LASIK.
445
Summary
Lens-based surgery, in the form of cataract
surgery or refractive lens exchange surgery for
refractive error, is growing each year as the
population ages and as the improved IOL choices
allow younger patients to undergo lens exchange
for surgical refractive correction. Because of increasing patient expectations, the accuracy of
these calculations is important. The accuracy of
the calculations depends on the choice of an
appropriate formula for calculating IOL, accurate
measurement of corneal power and axial length,
lens thickness, anterior chamber depth, and an
accurate estimation of eective lens position.
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Endophthalmitis Prophylaxis
Judy I. Ou, MD1, Christopher N. Ta, MD*
Department of Ophthalmology, Stanford University School of Medicine, 900 Blake Wilbur Drive,
W3036, Stanford, CA 94305, USA
Endophthalmitis is a rare but devastating

complication of intraocular surgery that often
carries a poor prognosis. This article examines
the rising incidence of endophthalmitis and reviews perioperative techniques used to reduce the
rate of endophthalmitis.
Incidence
Rising incidence of endophthalmitis
It has been suggested that there may be a recent
increase in the prevalence of postcataract endophthalmitis [15]. This increase may be associated
with the rising popularity of clear cornea incision.
In a multicenter prospective randomized trial conducted by Nakagi and coworkers [3] between
March 1998 and March 2001, a statistically significant increase in endophthalmitis was observed
with clear cornea incision as compared with sclerocorneal incisions (0.29% versus 0.05%). In a retrospective case-control study conducted between
January 1997 and December 2000 by Cooper
and coworkers [1], a threefold greater risk of endophthalmitis was observed with clear cornea
wounds as compared with scleral tunnel wounds.
In a larger single-center observational retrospective study of acute postoperative endophthalmitis
diagnosed between January 2000 and November
2004 at Bascom Palmer Eye Institute, a trend (although not statistically signicant) toward increased rate of endophthalmitis was seen with
clear cornea incision [2].
E-mail address: cta@stanford.edu (C.N. Ta).
1
Present address: Proctor Foundation, University of
California, San Francisco, Department of Ophthalmology, 95 Kirkham Street, San Francisco, CA 94143.
The true incidence of endophthalmitis is dicult

to determine given its rare occurrence within
a single institution. A review of the literature may
provide a greater number of patients and increase
the power of the study. In a recent systematic review
of the literature by Taban and coworkers [4] of 215
studies of 3,140,650 cataract extractions published
between 1963 and 2003, a higher overall postcataract endophthalmitis rate occurred between 2000
and 2003 (0.265%) as compared with between
1963 and 2000 (0.128%). The rate of endophthalmitis was higher with clear cornea incision
(0.189%) versus scleral incision (0.079%) between
1992 and 2003. In another recent large population-based review of United States Medicare beneciary claims between 1994 and 2001 of 447,627
cataract surgeries, 1026 cases of presumed endophthalmitis was diagnosed and an increased incidence
was associated with the introduction of clear cornea
incision [5]. The incidence of endophthalmitis was
higher from 1998 to 2001 (2.5 per 1000) as compared with between 1994 and 1997 (1.8 per 1000),
possibly reecting the increasing use of clear cornea
incision by ophthalmologists.
These reviews of the literature and Medicare
beneciary claims provide a large amount of data.
There are inherent limitations to any large review of
the literature, however. For example, the reviews by
Taban and coworkers [4] and West and coworkers
[5] are retrospective in nature and included smaller
studies that dier in methodology and denitions.
In addition, decreased preoperative use of povidine-iodine and fewer administrations of subconjunctival injections at the end of surgery may have
occurred as ophthalmologists converted from retrobulbar or peribulbar anesthesia to topical anesthesia during this time period; these changes may
serve as confounding factors that could lead to an
increased rate of endophthalmitis. Therefore, data
doi:10.1016/j.ohc.2006.07.005
450
OU & TA
suggesting an increase in the prevalence of endophthalmitis and the association with clear cornea incision must be interpreted with caution. Nonetheless,
these two reviews provide large amounts of information and support the overall increased rate of endophthalmitis associated with clear cornea
incision.
The increased prevalence of postoperative endophthalmitis is an important observation since
the number of cataract surgeries performed each
year and demand for cataract surgery continue to
rise. In 2002, there were approximately 2.5 million
cataract surgeries performed in the United States
[6]. According to the annual survey of the American Society of Cataract and Refractive Surgeons
the popularity of clear cornea incision is increasing; 47% of ophthalmologists used clear cornea
incision in 1997 compared to 72% in 2003 [7,8].
Prophylaxis to prevent endophthalmitis is critical
given the increased use of clear cornea incision
and associated endophthalmitis.
Endophthalmitis and clear cornea incision
Endophthalmitis rates may be increasing with
clear cornea incision because of decreased wound
integrity associated with clear cornea incision.
Variation in intraocular pressure (as caused by
eyelid squeezing or eye rubbing) can introduce
ocular surface bacteria into the anterior chamber
[9,10]. In a study by Taban and coworkers [10],
entrance of surface uid into the sutureless cornea
of cadaveric eyes (as marked by India ink) occurred with uctuations of intraocular pressure.
In addition, McDonnell and coworkers [9] showed
with optical coherence tomography that at low intraocular pressures, the clear cornea wound of
rabbit and cadaveric eyes tended to gape at the internal aspect of the wound and allowed uid from
outside the eye into the cornea wound and anterior chamber.
Risk factors
The relative risks of developing postoperative
endophthalmitis depend on a number of factors,
including the presence of eyelid or conjunctival
diseases, the patients general health, the use of
immunosuppressant medications, the type of intraocular surgery, and intraoperative complications. Systemic risk factors, such as diabetes, have
been associated with endophthalmitis. In a review
by Phillips and Tasman [11] of 162 consecutive
patients treated for endophthalmitis, 21% had
diabetes. These patients had poorer visual
outcomes and had higher incidences of gramnegative endophthalmitis. One possible explanation
for the association between diabetes and endophthalmitis is that diabetics have delayed wound healing and may eradicate bacteria more slowly. This
association was observed in the Endophthalmitis
Vitrectomy Study, a multicenter randomized prospective clinical trial of 420 patients with acute
postoperative endophthalmitis. Patients with diabetes had a trend toward worse vision at baseline,
higher incidence of positive cultures and need for
additional surgeries during follow-up, and worse
nal visual outcome [12].
Specic eyelid or periorbital diseases also may
predispose these patients to endophthalmitis. In
a case-report study, Scott and coworkers [13]
studied 10 cases of endophthalmitis following secondary intraocular lens implantation and compared this with 34 control patients who had the
same surgery but did not develop endophthalmitis. The study revealed that 5 (50%) out of 10 patients in the study group had preoperative eyelid
abnormalities, such as blepharitis or ectropion,
compared with four (11.8%) patients in the control group (P .018). Further evidence regarding
the relationships between eyelid or conjunctiva
abnormalities is provided by de Kaspar and colleagues [14]. In this prospective study, conjunctival cultures were obtained from patients before
the application of antibiotics and before intraocular surgery. Antibiotic susceptibility tests were
performed on all bacterial isolates. The results
showed that patients with local risk factors, dened as the presence of scurf, eyelid, or conjunctival hyperemia, chemosis, or discharge, were more
likely to harbor multiresistant organisms, dened
as bacteria resistant to ve or more of the 21
antibiotics tested (P .0049). As a result, these
patients may be more likely to develop postoperative endophthalmitis. Furthermore, multiresistant
bacteria have been shown to cause more inammation resulting in worse prognosis compared
with non-multiresistant bacteria in an endophthalmitis rabbit model [15].
A study by Mayer and coworkers [16] suggests
that minimizing contact between the intraocular
lens and the ocular surface may reduce the risk
of endophthalmitis. In this 10-year retrospective
study, the rate of endophthalmitis was 0.28%
for injectable intraocular lens as compared
1.21% for foldable lenses. Injectable intraocular
lenses avoid the ocular surface and may be associated with lower rates endophthalmitis. A Swedish
study of 58 cases of endophthalmitis in 54,666
ENDOPHTHALMITIS PROPHYLAXIS
cataract operations revealed that polymethyl

methacrylate lenses were associated with a higher
rate of endophthalmitis as compared with acrylic
intraocular lens [17].
Perhaps the most signicant risk factor for the
development of endophthalmitis is intraoperative
complications, specically posterior capsular
break or vitreous loss. In the study published by
Norregaard and coworkers [18] involving 19,426
patients who underwent cataract surgery from
1985 to 1987, the odds ratio for endophthalmitis
associated with an anterior vitrectomy was 4.86
(P .03) compared with patients without anterior
vitrectomy. Meniko and coworkers [19] found in
a case-control study involving 54 patients diagnosed with endophthalmitis that the odds ratio
after anterior vitrectomy compared with patients
who did not have an anterior vitrectomy was
13.7 (P ! .001).
Targets for prophylaxis

Given that the endophthalmitis rate has increased since the mid to late 1990s it is important
to evaluate methods to decrease the rate of
endophthalmitis with proper prophylaxis. The
authors examine the role of conjunctival ora,
povidone-iodine, preoperative antibiotics, intraoperative antibiotics, subconjunctival antibiotic
injection, and preoperative patient preparation
as techniques for endophthalmitis prophylaxis.
Role of conjunctiva ora
The conjunctival ora contains bacteria that
cause endophthalmitis. In a study by Speaker and
coworkers [20], in 14 (82%) of 17 cases of endophthalmitis the organisms from the vitreous were the
same as that found on the patients eyelid, conjunctiva, or nose. This study implicated the external conjunctiva, eyelid, and nose as sources of
bacteria that lead to endophthalmitis. In another
prospective study by Mistlberger and coworkers
[21], 76.6% of preoperative conjunctival smear
of 700 consecutive patients who underwent cataract extraction were positive; of these, 75% were
coagulase-negative staphylococci. Furthermore,
14.1% of the anterior chamber aspirates were
positive for bacteria, with coagulase-negative
staphylococci and corynebacterium as the most
common organisms isolated from the aqueous
uid. In the Endophthalmitis Vitrectomy Study,
69.3% of patients had culture-positive endophthalmitis [22]. Of these patients, 70% had
451
gram-positive bacteria, the source presumably being from the external ocular surface. Bannerman
and coworkers [23] further analyzed the data
from the Endophthalmitis Vitrectomy Study and
found that 68% of the 225 patients diagnosed
with endophthalmitis had the identical bacteria
as those found on their eyelids. Because the patients conjunctiva and lid are implicated as the
source of infection, prophylaxis, such as proper
patient preparation, povidone-iodine, and preoperative antibiotics, are aimed toward decreasing
the bacterial load in this area.
Povidone-iodine
Povidone-iodine is the only prophylactic agent
that has been shown to reduce the rate of
endophthalmitis. Povidone-iodine is a complex
polymer of polyvinyl pyrolidine and iodine,
a complex that enhances the bactericidal activity
of iodine. In a study by Speaker and Meniko
[24], a signicant fourfold reduction of culturepositive endophthalmitis was seen in patients
who underwent preparation with povidone-iodine
(0.06%) as compared with silver protein solution
(0.24%). A survey of German ophthalmologists
regarding the rate of endophthalmitis suggests
that the application of povidone-iodine was associated with a lower rate of postoperative endophthalmitis [25]. The ndings are supported by
studies demonstrating that povidone-iodine is effective in killing conjunctival bacteria ora. In
a study by Apt and coworkers [26], application
of povidone-iodine signicantly decreased the colonies of bacteria on the conjunctiva surface of 30
patients from 91% to 50%. Five percent povidone-iodine solution applied at the conclusion of
surgery also signicantly decreased the number
of colony-forming units immediately postoperatively and at 24 hours following surgery, thereby
decreasing bacteria that may enter the surgical
wound postoperatively [27]. This may be of particular importance given the recent evidence regarding the possible compromised wound architecture
of a clear cornea incision [9,10].
The concentration and technique of povidoneiodine application varies widely. In a prospective,
randomized, double-blind study of 105 patients
in the United Kingdom, preoperative conjunctival fornices irrigation with 5% rather than 1%
povidone-iodine resulted in greater decrease in
colony-forming units, especially with heavier initial bacterial load (greater than 100 colony-forming units before irrigation with povidone-iodine)
452
OU & TA
[28]. A statistically signicant drop of 96.7% colony-forming units was seen in the 5% povidoneiodine group as compared with the 40% decrease
in the 1% povidone-iodine group when there was
heavier initial bacterial load. In another prospective, randomized, controlled trial of 200 eyes undergoing anterior segment surgery treated with
topical ooxacin, the study group that underwent
irrigation of the fornices with 10 mL of povidone-iodine had fewer positive conjunctival cultures than the control group that received two
drops of povidone-iodine preoperatively [29]. In
this study, 26% of study eyes had positive conjunctival cultures immediately before surgery compared with 43% of control eyes. At the end of
the surgery, 18% and 32% of eyes had positive
conjunctival culture in the study and control
group, respectively. This suggests that irrigation
of conjunctival sac may be more eective in reducing the conjunctival bacterial load and possibly decrease susceptibility to endophthalmitis.
Antibiotics
The use of topical antibiotics preoperatively to
decrease conjunctival bacterial ora has been
studied extensively. Although no clear study has
shown that the application of antibiotics decreases
the risk of endophthalmitis, it is presumed that
reducing bacterial load may lead to decreased
incidence of endophthalmitis. In a prospective,
randomized controlled trial of 92 eyes of 89
patients undergoing anterior segment surgery,
application of topical ooxacin for 3 days (study
group) compared with 1 hour before surgery
(control group) resulted in greater reduction of
conjunctival bacterial ora [30]. All patients were
treated with topical povidone-iodine. Nineteen
percent of eyes in the study group versus 42% of
the control group had positive conjunctival ora
immediately before surgery. Fourteen percent of
eyes in the study group versus 34% in the control
group had positive conjunctival ora at the conclusion of surgery. This research group also
showed the rate of contamination of intraoperative microsurgical knives to be 5% versus 26%
in eyes that received ooxacin for 3 days versus
1 hour preoperatively [31]. These studies suggest
that 3-day preoperative use of ooxacin results
in greater reduction of conjunctival bacterial load
compared with a 1-hour application and thereby
may decrease the risk for endophthalmitis.
The increasing use of uoroquinolones may
result in a higher prevalence of antibiotic
resistance. In a prospective observational study

of 120 eyes, 15% and 16% cultured coagulasenegative staphylococci isolated from the conjunctiva of patients undergoing intraocular surgery
were resistant to ciprooxacin and ooxacin,
respectively [32]. The nding of increasing bacterial resistance to uoroquinolone in bacterial keratitis is supported by several other studies [33,34].
In a study by Recchia and coworkers [35], review
of records of microbiologic culture of vitreous of
patients with postoperative endophthalmitis and
in vitro antibiotic susceptibility showed an increasing resistance among all bacterial isolates to
ciprooxacin (23%37%).
Recently, new generations of uoroquinolones,
such as moxioxacin and gatioxacin, have been
introduced. These uoroquinolones have enhanced activity toward gram-positive pathogens
while still maintaining broad-spectrum coverage
against gram-negative organisms [36,37]. The
uoroquinolones interfere with bacterial deoxyribonucleic acid gyrase (topoisomerase II) and topoisomerase IV and bacterial resistance seems to be
lower because mutations of both bacterial topoisomerase II and IV are necessary.
Studies have shown that some uoroquinolones can achieve high aqueous humor concentration following topical applications. For example,
in a recent prospective, double-masked, clinical
study of 52 eyes of 52 patients given preoperative
topical gatioxacin 0.3%, moxioxacin 0.5%, or
ciprooxacin 0.3% 1 hour before surgery, both
moxioxacin and gatioxacin resulted in signicantly higher aqueous humor concentration than
ciprooxacin [38]. The use of topical antibiotics
following cataract surgery may be even more important following clear cornea incision. Given
the recent evidence of suboptimal wound architecture and possible inux of tears into the anterior
chamber following clear cornea cataract surgery,
it may be prudent to prescribe topical antibiotics
following cataract surgery at least until the wound
is covered with epithelium [9,10].
Systemic antibiotics
The role of systemic antibiotics for endophthalmitis prophylaxis has historically been uncertain. The Endophthalmitis Vitrectomy Study
showed no benet in using intravenous amikacin
and ceftazidime for postoperative endophthalmitis (because of poor intravitreal antibiotic penetration) [3941]. Recent studies have shown that
oral uoroquinolones, such as levooxacin, have
much improved vitreous penetration and exceeded

the 90% minimum inhibitory concentration for
many organisms that cause endophthalmitis [42],
such as Streptococcus pneumonia and Bacillus cereus [43]; the addition of oral ooxacin to topical
ooxacin increased vitreous penetration sevenfold
in one study [44] and may be eective for the prophylaxis of endophthalmitis.
The use of the more recent oral uoroquinoles,
such as gatioxacin and moxioxacin, for endophthalmitis prophylaxis is also promising. For
example, Hariprasad and coworkers [45] conducted a prospective, nonrandomized study of
24 consecutive patients who underwent pars plana
vitrectomy between September 2001 and May
2002 during which aqueous, vitreous, and serum
samples were obtained after administration of
two 400-mg gatioxacin tablets taken 12 hours
apart. The mean standard deviation gatioxacin concentrations in serum (N 23), vitreous
(N 23), and aqueous (N 11) were 5.14
1.36 mg/mL, 1.34 0.34 mg/mL, and 1.08 0.54
mg/mL, respectively. Mean inhibitory vitreous
and aqueous MIC90 level was achieved against
many pathogens including S pneumoniae and
Staphylococcus epidermidis. The use of oral moxioxacin, two tablets containing 400 mg of moxioxacin 12 hours apart, has also resulted in
MIC90 levels that exceed a wide spectrum of
gram-positive and gram-negative pathogens in
the vitreous [46]. These studies suggest that oral
gatioxacin and moxioxacin maybe useful in endophthalmitis prophylaxis especially in high-risk
cases, such as when the posterior capsule is broken and vitreous loss occurs.
Irrigation and intracameral antibiotics
The use of intracameral antibiotics and antibiotics in irrigation solution is controversial. Gills
[47] suggested the use of vancomycin (20 mg/mL)
in the infusion uid in order to decrease the rate
of endophthalmitis. Beigi and coworkers [48]
showed a statistically signicant decrease in positive anterior chamber aspirate cultures (from
20% to 2.7%) in a group that received balanced
salt solution with vancomycin (20 mg/mL) and
gentamicin (8 mg/mL) compared with control. In
contrast, a paper by Feys and coworkers [49] of
372 patients showed no signicant dierence in
bacteria load in the study group that underwent
surgery with vancomycin irrigating solution compared with control groups. Cultures of the anterior chamber aqueous uid can be quite dicult
453
to obtain, however, and the results unreliable

[50]. Interestingly, there was a case report of coagulase-negative staphylococcus endophthalmitis after cataract surgery despite the use of intraocular
vancomycin (20 mg/mL in 75 mL of balanced saline solution) [51].
Vancomycin may be toxic to the retina in
addition to being ineective. In a prospective,
randomized, double-masked clinical study of 118
patients, postoperative cystoid macular edema
was signicantly higher in the study patients
receiving irrigating balanced salt solution supplemented with vancomycin (10 mg/mL) compared
with control group (angiographic cystoid macular
edema rate of 55% versus 19% at 1 month; clinical macular edema of 23% versus 7% at 1 month)
[52]. Finally, there is increasing bacterial resistance to vancomycin and the Centers for Disease
Control and Prevention has advocated against
the routine use of vancomycin in intraoperative irrigating bottles [53].
Subconjunctival antibiotics
Subconjunctival injection of antibiotics is routinely used, although no study has clearly shown
a decreased rate of endophthalmitis. In a study by
Dallison and coworkers [54], perioperative subconjunctival cephazolin reduced or eliminated lid
and conjunctival microora 48 hours following
surgery. In another small retrospective, case control study none of the nine patients with endophthalmitis received perioperative subconjunctival
cefuroxime, whereas in the control group 47.8%
received perioperative subconjunctival cefuroxime, suggesting that by not using subconjunctival
antibiotic injection, this may be associated with an
increased rate of endophthalmitis [55]. A trend toward decreasing endophthalmitis rate was seen
also with patients who underwent periocular postoperative injection in a cross-sectional German
survey [25]. Although there are no studies that
clearly show an association between subconjunctival antibiotic injection and decreased endophthalmitis, many surgeons perform this technique given
its low risk and toxicity.
Patient preparation
Routine preparation of patients undergoing
intraocular surgery includes draping the eyes and
keeping eyelashes out of the surgical eld. Sterile
drapes and speculum are used to isolate the lashes
from the surgical eld. Buzard and Liapis [56]
demonstrated the use of two Steri-Strips to isolate
454
OU & TA
the upper eyelid and a single Steri-Strip to isolate

the lower eyelid before the application of plastic
drapes. Although in a study by Perry and Skaggs
[57] eorts to decrease bacterial load by trimming
lashes did not alter periocular bacterial ora, most
surgeons routinely keep lashes away from the surgical eld because they are a source of bacterial
contaminant. In addition to the use of povidoneiodine and antibiotics, it is important to maintain
a sterile surgical eld and strict adherence to sterile techniques.
Summary
Recent publications have produced a body of
evidence suggesting an increase in the prevalence
of endophthalmitis caused by poor wound architecture sometimes associated with a clear cornea
incision. Local risk factors, such as blepharitis,
systemic risk factors, such as diabetes, and intraoperative complications, such as vitreous loss,
further increase the risk of endophthalmitis.
Endophthalmitis prophylaxis, such as the use of
povidone-iodine, has been shown to decrease the
rate of endophthalmitis. The use of 5% povidoneiodine and irrigation in the fornices and use of
preoperative antibiotics may decrease conjunctival
bacterial load and in turn lower the rates of
endophthalmitis. In addition, it may be important
to apply povidone-iodine and antibiotics at the
conclusion of a clear cornea cataract surgery.
The role of postoperative subconjunctival antibiotic injection is not clear but has been associated with decreased ocular bacterial ora. Finally,
discretion should be used with intracameral antibiotics, especially vancomycin, because data have
not been clear regarding ecacy and may lead to
cystoid macular edema and increased resistance of
bacteria to vancomycin.
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Phaco Fluidics and Phaco Ultrasound

Power Modulations
Uday Devgan, MD, FACSa,b,c,*
a
Maloney Vision Institute, 10921 Wilshire Boulevard, Suite 900, Los Angeles, CA 90024, USA
b
Olive ViewUCLA Medical Center, 14445 Olive View Drive, Sylmar, CA 91342, USA
c
Jules Stein Eye Institute, UCLA School of Medicine, 100 Stein Plaza, Los Angeles, CA 90095, USA
The most common surgical procedure in the

United States is cataract surgery [1]; more specifically, phacoemulsication. Understanding the
uidics and ultrasonic power fundamentals for
phacoemulsication machines is instrumental for
their safe and ecient use. Although phaco machines have evolved considerably since they were
introduced a few decades ago, the basic concepts
have remained the same.
Phaco machines allow ultrasonic-assisted aspiration of the cataract while maintaining stability
within the eye and minimizing the trauma of
surgery to ocular structures. In this light, the two
primary concepts are the uidics of the lens aspiration and the application of the ultrasound power.
Fluidics
The uidics of phaco machines allows aspiration of the cataract while keeping the eye inated
and stable, and prevents collapse of the anterior
chamber. The basic concepts of phaco uidics are
ow and vacuum.
Flow
The uid used in phaco machines is a balanced
saline solution that mirrors the composition of
aqueous humor. It behaves like a classic Newtonian uid, being a noncompressible solution,
and therefore the simple concepts of laminar ow
* Jules Stein Eye Institute, UCLA School of Medicine, 100 Stein Plaza, Los Angeles, CA 90095.
E-mail address: devgan@ucla.edu
explain its behavior. The ow of the uid is

laminar and the tubing walls are straight, xed,
and inelastic, in contrast with cardiology, which
deals with pulsatile ow, elastic and variable
vessel walls, and viscous suspension uid, blood.
The basics for all uidics in phacoemulsication surgery can be analyzed with Poiseuilles
equation:
DPpr4
8hL
F ow
DP change in pressure/vacuum level
p the mathematical constant pi
r radius of the tubing
h viscosity of uid
L length of tubing
Because the viscosity of the balanced saline
solution (h) is constant, as is the length of phaco
tubing that is used (L) in every case, the only
variables that need to be considered in determining ow rate are the change in pressure or vacuum
level (DP) and the radius of the tubing. Because
the radius is to the fourth power, a slight change
in the radius of the tubing can make a dramatic
dierence in the ow of uid. If the diameter is
used instead of the radius, the formulas denominator is changed by a factor of 16.
r d
thus : r4 d4 4 d4 d4 =16
doi:10.1016/j.ohc.2006.08.001
458
DEVGAN
DPpd4
128hL
F ow
DP change in pressure/vaccum level
p the mathematical constant pi
d diameter of the tubing
h viscosity of uid
L length of tubing
The balanced saline solution ows in and out
of the eye, primarily limited to the anterior and
posterior chamber in routine phacoemulsication
surgery. Therefore ow balance is easy to evaluate
based on the inow versus the outow.
Inow versus outow
The source of the inow uid is from the bottle
of balanced saline solution that hangs on the
phaco machines. The two primary sources of
outow are through the lumen of the phaco needle
during aspiration of the lens material, and
through any leaks from surgical incisions. Keeping the inow of uid greater than the outow is
important in maintaining stability and preventing
collapse of the eye during surgery.
Inow
To keep the inow higher than the outow, the
diameter of the inow infusion tubing is larger
than that of the outow suction tubing. Other
dierences can also be seen when examining
a cross-section of the phaco machine tubing.
The inow infusion tubing has a larger bore
with thinner, more compliant tubing. The outow
suction tubing has a narrower bore and thicker,
more rigid tubing. This dierence is because of the
dierent vacuum level each tube must withstand
during surgery, and is discussed in more detail in
the Vacuum section.
The inow of the infusion uid is increased by
controlling the height of the balanced saline
solution bottle. As the height of the infusion
bottle is increased, gravity increases the pressure
gradient (DP from Poiseuilles equation). Phaco
machines use an indirect measure of the infusion
inow: the bottle height, typically listed in centimeters. The dierence in height between the
infusion bottle and the patients eye determines
the pressure gradient. If the operating room table
is raised without an equal elevation in the bottle
height, then the inow will decrease. This fact is

important for tall surgeons who require more
legroom under the operating room table and in
treating patients who have cardiac, pulmonary, or
spinal problems that prevent them from lying at.
Because the bottle height is limited by the
phaco machine apparatus or perhaps the ceiling
height in the operating room, surgeons can increase inow by using a second inow line, such as
an anterior chamber maintainer. An additional
incision into the anterior chamber is made and the
additional infusion line is inserted, thereby doubling the eective inow rate.
Current phaco machine platforms use gravity
alone to achieve the pressure gradient required for
inow. Similar to residential water towers, the
height of the water column in the tubing will
determine the infusion inow pressure gradient.
Retinal surgeons use vitrectomy machines that
have a forced infusion through a pump, therefore
achieving higher pressure gradients than simple
gravity can provide. Future phaco machines may
also incorporate this technology.
Outow
The primary source of uid outow during
phacoemulsication is the phaco needle during
aspiration, and the secondary source is leakage
from the incisions. The total outow of uid from
the eye must be less than the inow to prevent
instability and collapse of the eye. Therefore, the
radius of the outow suction tubing must be kept
smaller than that of the inow tubing. The outow
rate through the phaco needle, often measured in
milliliters per minute, can be directly adjusted on
machines with peristaltic pumps, and indirectly adjusted on machines with venturi pumps.
The most restrictive part of the outow tubing
is typically the phaco needle, and therefore phaco
needle selection is important when choosing
uidic parameters. As the phaco needle size
decreases, the ow drops exponentially because
Poiseuilles equation has this factor raised to the
fourth power. To achieve the same inow while
decreasing the needle size, a very substantial
increase in the pressure gradient (DP from Poiseuilles equation) is required.
According to Poiseuilles equation, ow is
proportional to the radius of the tube to the
fourth power, meaning that a small change in the
size of the phaco needle can result in a very large
change in the ow. When two common-sized
phaco needles (0.9 mm versus 1.1 mm) are
PHACO FLUIDICS & ULTRASOUND POWER
compared, with all other factors equal, the ow

through the larger 1.1-mm needle is more than
twice that of the 0.9-mm needle (Fig. 1).
Because the change in ow is exponential,
a lower limit to size exists where the lumen is so
small that ow approaches zero (Fig. 2). For surgeries to be ecient, ultrasmall bores will unlikely
be used in traditional phacoemulsication. The
eciency of surgery, which is better with larger
bores, must be balanced with the benets of
smaller incisions, which better accommodate
smaller bores.
A simple analogy for understanding Poiseuilles equation is drinking a milkshake through
a straw: if one drinks the milkshake with a smallcaliber cocktail straw, then a much higher pressure gradient will be needed in the mouth and only
a low ow rate will be achieved. However, if
a larger-bore straw is used, then the required
pressure gradient is much less and a higher ow
rate can be achieved, resulting in more ecient
aspiration of the shake (Fig. 3).
Confounding factors
Matters are further complicated if a phaco
needle with an additional hole in its side-wall is
used, such as those that are intended to maintain
low ow during complete occlusion. Although
Poiseuilles equation and the milkshake analogy
still apply, in this instance the straw has a small
hole in its side. During states of higher ow and
lower vacuum, the ow through the additional
bypass hole is limited. However, when the end of
the needle is occluded, the vacuum increases
dramatically, the ow through the end of the
needle drops, and the ow through the bypass
459
Fig. 2. As the size of the phaco needle decreases linearly,

the relative ow through the needle decreases
exponentially.
hole increases. Compared with a traditional phaco

needle, higher phaco-machine vacuum levels are
required to achieve the same holding power at the
phaco tip (Fig. 4).
Outow restrictors are available for phaco
machines that create a bottleneck distal to the
phaco needle in the outow suction tubing. These
ow restrictors further decrease the outow to
ensure that the inow is never outstripped, thereby
increasing stability within the eye, although at the
cost of reduced ow (Fig. 5).
For split-infusion cataract surgery, often
termed bimanual small incision cataract surgery,
the infusion line is split from the aspiration line.
The advantage of this technique is the ability to use
the infusion separately from the aspiration line,
compared with traditional coaxial phaco where
both irrigation infusion and aspiration are on the
same handpiece. The limitation of split-infusion
cataract surgery is that the irrigating infusion
instruments are typically of a smaller bore than
the coaxial infusion line, resulting in a signicant
decrease in inow. Surgeons can attempt to
compensate for this decrease in ow by increasing
the pressure gradient (DP) by way of raising the
infusion bottle to its maximum height or even
further using an anterior chamber maintainer or
forced infusion. If this technique is not sucient,
the outow from the eye must be decreased using
the phaco machine settings (Fig. 6).
Vacuum
Fig. 1. Comparing tubing tips with a seemingly small

dierence in diameter can result in a dramatic dierence
in ow because of the exponential nature of tubing
radius in Poiseuilles equation.
Vacuum within the phaco machine must be

created to provide the driving force for the outow of uid during cataract extraction. The
vacuum level is dynamic and changes during the
various parts of surgery. The machines allow
selection of a maximum vacuum level, typically
expressed in mm Hg, and surgeons can have
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DEVGAN
Fig. 3. A simplication of Poiseuilles equation at work. (A) When a small caliber cocktail straw is used to drink a milkshake, very high vacuum is required in the mouth to create relatively little ow through the straw. (B) A larger-bore
straw is used and low vacuum in the mouth can be used to achieve high ow in the straw. (C) The vacuum generator
of choice for aspiration of milkshakes. (Courtesy of Uday Devgan, MD, FACS, Los Angeles, CA.)
relative control of the vacuum level up to this limit

through foot pedal positioning, depending on the
type of vacuum pump.
Two primary vacuum pumps are used in
phacoemulsication platforms: peristaltic and
Venturi. Although they work in dierent ways,
each has its advantages.
The peristaltic pump uses rollers to compress
the phaco outow tubing in a peristaltic manner,
thereby creating ow. Although the phaco
machine can directly control this ow level, the

preset vacuum level is only achieved when the
outow line is occluded, typically from cataract
material at the phaco needle tip. As the occlusion
occurs, the vacuum builds, the rollers slow down,
and the outow level decreases. On complete
occlusion, the rollers stop, the outow approaches
zero, and the vacuum is at its highest level (Fig. 7).
The Venturi pump uses the Venturi eect to
create a vacuum. The Venturi eect creates
Fig. 4. By allowing a small constant ow of uid even

when the phaco tip is occluded, the phaco needles with
additional bypass holes can help maintain ow; however, a higher vacuum level would likely be required to
achieve the same holding power at the tip.
Fig. 5. Restrictive outow tubing decreases the size of

the outow tubing, thereby limiting the ow. This mechanism helps ensure that the inow of uid into the eye is
always greater than the outow from the eye, which is
crucial to prevent surge. The purpose of the lter is to
prevent the cataract pieces from clogging the tubing.
Fig. 6. In split-infusion bimanual cataract surgery, the

infusion of uid is through the instrument in the left
hand, here an irrigating chopper. Because of the small
tubing size of this instrument, the inow of uid is limited; therefore the peristaltic machine has been set to
a lower ow rate to keep the inow greater than the
outow.
a vacuum from the ow of a uid, typically air,

over an opening. Some phaco machines require
nitrogen tanks or a self-contained air compressor.
The advantage of the Venturi pump is that it can
create the preset vacuum level without requiring
occlusion of the phaco needle tip. When the surgeon depresses the foot pedal, the preset vacuum
level is immediately created. The outow rate is
variable, determined by the vacuum level created;
it cannot be set directly by the surgeon (Fig. 8).
Because of these dierences, surgery performed
with these two vacuum pumps diers somewhat.
To create the preset maximum vacuum level with
Fig. 7. A peristaltic uid pump functions by compressing and milking the phaco tubing to create ow. This
system is therefore ow-based.
461
Fig. 8. A Venturi uid pump works by creating a vacuum. With this device, the ow of compressed air
through a constriction creates a vacuum inside a rigid
cassette. The ow of uid is proportional to the vacuum
level, but cannot be independently set or controlled. This
system is vacuum-based.
a peristaltic pump, the phaco needle must be

completely occluded with cataract material. To
create the preset vacuum level with a Venturi
pump, the surgeon must simply depress the foot
pedal. For surgeons performing split-infusion bimanual cataract surgery, the peristaltic pump
allows a maximum ow rate to be set so that the
limited inow from the smaller-bore infusion
instruments is not outstripped. The most commonly used vacuum pumps in the United States
are of the peristaltic design (Fig. 9).
Surge
When the phaco needle tip is occluded with
cataract material, a high vacuum state is created
Fig. 9. Comparison of the peristaltic pump to the Venturi pump.
462
DEVGAN
within the outow tubing. This high vacuum level

would collapse the walls of elastic tubing and, once
the occlusion breaks, the walls would rebound back
into shape, thereby rapidly sucking uid from the
eye and creating surge. Because the volume of the
anterior and posterior chamber is so small, a slight
collapse in the length of the long outow tubing
would create a signicant surge and increase the
risk for collapse of the eye and aspiration of the
posterior capsule during surgery (Fig. 10).
To combat this problem of surge, phaco
machines use outow aspiration tubing that is of
low compliance. This tubing is very rigid, with
thick walls that are resistant to collapse. Compared with the inow tubing, the outow tubing
has a smaller diameter; thicker, more rigid walls;
and low compliance (Figs. 11 and 12).
Surge can also be addressed with a quickreacting pump that drops the vacuum level as the
occlusion breaks. However, no machine can
adequately compensate for high compliance elastic tubing and improperly selected uidic settings.
Choosing uidic settings

The basic uidic variables that can be set for
peristaltic phaco machines include bottle height
(cm) to determine the inow infusion, outow rate
(mL/min) through the phaco handpiece, maximum vacuum level limit (mm Hg), and phaco
needle diameter. The choice of phaco needle is
Fig. 10. The use of compliant tubing allows collapse of

the tubing and storage of energy in the walls. Once the
occlusion breaks, the tubing rebounds as the energy is
released, creating a sharp rise in the outow from the
eye and potentially causing a surge with resultant collapse of the eye and rupture of the posterior capsule.
Therefore, sti, rigid, noncompliant outow tubing
should be used.
Fig. 11. The outow tubing, shown in red, has thick

walls and therefore low compliance. The inow tubing,
shown in blue, has thinner walls and is more compliant.
important to determine appropriate machinebased settings.

Technique
Dierent techniques, even dierent parts of the
same technique, can benet from tailored uidic
settings. For sculpting or grooving a nucleus, low
vacuum and low aspiration rates can be used
because the primary purpose of the uidics is to
remove small amount of nucleus that has been
emulsied (Fig. 13).
For a chopping technique, the uidics must
allow the phaco needle to rmly hold a nuclear
piece so that it may be mechanically disassembled.
In this case, a higher vacuum level is required to
create holding power, and the phaco needle must
be occluded to achieve this higher preset vacuum.
A range of aspiration rates may be eectively used
with chopping.
Fig. 12. Comparison of the inow versus outow tubing, shown in cross-section.
Fig. 13. While creating a groove in the nucleus, the tip is

nonoccluded and the vacuum level is low, whereas the
ow is high. Once occlusion occurs, the vacuum level
rises to the higher preset maximum level as the ow
drops.
For quadrant or nuclear segment removal,

a more moderate vacuum level but a higher
aspiration rate is needed for eciency. For removing the epinuclear shell, the vacuum level and
aspiration rates can be decreased to prevent
inadvertent touching of the posterior capsule as
the last bits of cataract are removed.
Patient variables
A dense cataract behaves like a solid, whereas
a soft cataract often exhibits uid motions.
Therefore, the grade of cataract inuences the
uidic settings used for its removal. Because a soft
cataract tends to deform and collapse when
vacuum is applied through the phaco needle,
lower levels should be used.
Eyes with shallow anterior chambers would
benet from a higher bottle height because this
would increase the infusion pressure and push the
lensiris diaphragm posterior. Eyes with low
scleral rigidity, such as high myopes, tend to
have an overdeepening of the anterior chamber
and may benet from a lower bottle height.
Phaco power
Ultrasound energy can be used to emulsify and
aspirate the cataract. The high frequency produces a piston-like movement of the phaco needle
at a constant frequency, typically between 28.5
and 40 kHz, depending on the machine. Although
this frequency cannot be adjusted, the surgeon can
control the stroke length of each piston-like
463
movement. The surgeon can set the maximum

power level, and then the phaco foot pedal can be
used to deliver varying amounts of energy up to
this maximum. The units of power provided by
the manufacturers of the current phaco machines
are percent of maximum, rather than a true
measure of power, such as milliwatts, and therefore comparison of relative power levels from one
phaco platform to another is inexact.
The ultrasonic power has four components: the
mechanical impact, the uid/particle wave, the
cavitation eect, and the acoustical wave. These
four components together allow emulsication of
the cataract.
The mechanical impact is the actual force of
the phaco needle hitting the cataract nucleus,
much like a jackhammer. Standard Newtonian
forces apply, with the force of the impact determined by the product of the mass and acceleration (F MA). The force of the impact is
applied at the phaco needle tip, and therefore
a sharper needle will have less surface area and
will provide more force per unit area. If a dull
phaco needle is used, a higher phaco power level is
required to achieve the same cutting eciency.
This scenario is similar to a sharp knife creating
a higher force per unit area at the blade edge and
thus cutting better given the same overall force
versus a dull knife. A dull knife requires more
application of force to achieve the same cut as
a sharp knife.
The uid/particle wave is like a re hose as it
shoots the saline irrigation solution and tiny
phaco fragments out of the phaco tip on application of ultrasound energy. This uid/particle wave
has some ability to break down the nuclear
cataract material at the phaco tip.
Cavitation is the eect of shooting the uid
wave from the phaco tip and creating an area of
low pressure immediately in front of the phaco
needle. This lower pressure area causes implosion
of nuclear cataract pieces that are in the vicinity.
Finally, the acoustical wave is the soundwave
created by the phaco needles vibrations. This
wave travels at the speed of sound and provides
the auditory feedback that the surgeon hears
during phacoemulsication. The acoustical wave
plays a small role in the break down of the
cataract.
The ultrasonic energy delivered into the eye is
great for emulsication of cataracts, but can also
damage other ocular structures, particularly the
delicate corneal endothelium. In early phacoemulsication surgery, the level of corneal endothelial
464
DEVGAN
cell loss was high and many patients developed

corneal failure. With the development of better
ways to protect the cornea through viscoelastics,
and methods to modulate and decrease the phaco
energy, the rate of pseudophakic bullous keratopathy has decreased dramatically.
Phaco power modulations are methods to
program the way ultrasonic energy is delivered.
By delivering smaller pulses or bursts of energy in
variable patterns, the phaco eciency can be
maximized while decreasing the total amount of
phaco energy, phaco time, and phacogenerated
heat placed into the eye.
Measuring phaco energy
Phacoemulsication machines can measure the
average phaco power and the phaco time (the
total amount of time spent on the foot pedal at
position 3). However, no standard method exists
to quantify and measure the units of energy
delivered to the eye. What can be measured is
the absolute amount of phaco energy delivered
into the eye at 100% power, known as absolute
phaco time (APT). More specically, APT can be
considered the product of phaco time multiplied
by the average phaco power. For example, 15
seconds 100% power level 15 seconds of
APT; 30 seconds 50% power level 15 seconds
of APT; and 60 seconds 25% power level 15
seconds of APT.
Therefore, a decrease in APT signies a decrease in phaco time and average phaco power. A
surgeon can attain an ultralow time or 0-second
phaco, for example, by having a phaco time of
17 seconds 4% power 0.68 seconds, or less
than 1 second of APT (Fig. 14). An ultralow APT
results in clearer corneas and sharper vision on the
rst postoperative day, thus achieving a high patient satisfaction rate.
Decreasing phaco time and energy
To reduce total phaco time and energy placed
into the eye, a mechanical method of breaking the
nucleus, such as chopping, must be used.
Mechanical nuclear disassembly using the chopping technique allows the surgeon to mechanically
break the nucleus into small fragments. Additionally, switching from a four-quadrant to a stop-andchop technique allows for less grooving. During the
procedure, the surgeon must also switch from the
four-quadrant divide-and-conquer technique to
a stop-and-chop approach and avoid using singlehanded phacoemulsication.
Fig. 14. An eye immediately after phacoemulsication

in which phaco power modulations have been used to
truly minimize the amount of ultrasound energy delivered into the eye.
The surgeon may lessen time on the foot pedal

by phacoemulsifying only on the forward strokes
during grooving or divide-and-conquer. Additionally, phacoemulsication should only be performed when the phaco tip is occluded with
nuclear material, because otherwise aspiration is
compromised.
Basic versus advanced power modulations
The basic power settings are continuous, pulse,
and burst. The continuous power setting delivers
energy continuously, with variable power, depending on how long the foot pedal is depressed.
The maximum power setting can be preset, thus
allowing surgeons to control the maximum
amount of phaco power delivered. In other words,
the longer the foot pedal is depressed, the greater
the phaco power (Fig. 15).
In pulse mode, the pulses of energy dispensed
have variable power, depending on how long the
foot pedal is depressed. The longer it is depressed,
the greater the power of each sequential pulse of
energy. The dening feature of pulse mode is that
after each pulse of energy is delivered, a period
occurs during which no energy is supplied between increasing pulses of energy, which is the
o period. Alternating between the on and
o periods reduces heat and dispenses half the
energy into the eye (Fig. 16).
Finally, in burst mode, each burst of energy
has the same amount of power, but the interval
between each burst increases as the foot pedal is
depressed. The longer the foot pedal is depressed,
Fig. 15. Continuous phaco mode delivers more energy

as the foot pedal is depressed, delivered in a linear, continuous manner.
the shorter the o period will be between each

burst. As a result, at maximum depression of the
foot pedal, the delivery of energy will be continuous (Fig. 17).
Although, the basic power modulations are
eective at decreasing phaco energy, they are
limited in their degree of programmability. Thus,
with the advanced, or hyper, settings, an additional set of options can be programmed for the
pulse and burst modes. For example, in hyperpulse mode, the rate can be as high as 120 pulses
per second, compared with 20 pulses per second in
basic pulse mode. The hyperpulse mode provides
surgeons the feeling of continuously delivering
energy, or even of using a nely serrated knife
during grooving if performing the divide-and-conquer technique (Fig. 18). This setting also allows
each burst to be set as low as 4 ms, whereas in
the basic power setting, each burst is set at 80
ms. An additional feature is that both pulse and
Fig. 16. In pulse mode, the phaco power is delivered in

a linear manner, but instead of continuous energy, the
energy is delivered in pulses.
465
Fig. 17. In burst mode, every burst is identical. As the

foot pedal is depressed in position 3, the interval between each burst becomes shorter and the bursts get
closer and closer together, until the energy delivered becomes continuous on maximum depression.
burst hyper settings have an option of using a variable duty cycle and variable rise time for each
packet of energy delivered.
Duty cycle and variable rise time
In pulse mode, the default duty cycle is 50%.
For instance, the pulse is in the on position for
250 ms and o for 250 ms. The benet of the
new power-modulation software is that the duty
cycle can be changed; for example, to 20% (10 ms
on, 400 ms o), giving a ratio of 20:80. The benet
Fig. 18. Continuous phaco energy gives the cutting feel

of a sharp, nonserrated knife. Using a low pulse rate,
such as 16 pulses per second, gives an eect of a coarsely
serrated knife that does not cut smoothly. With a very
high pulse rate of 120 pulses per second, the cutting effect of the energy is similar to continuous energy, the
way that a nely serrated knife cuts like a sharp
straight-blade.
466
DEVGAN
of a lower duty cycle is a longer cooling time for the

phaco needle, which decreases the amount of
phaco energy delivered into the eye. In addition,
during the on time, ultrasound energy is dispensed with a jackhammer repulsion eect. During
the o time, no energy is delivered, and nuclear
fragments may be aspirated (Figs. 19 and 20).
With the variable rise-time option, during each
preset pulse of 250 ms, a 100-ms ramp of increasing energy can be set to lead up to the
remaining 150-ms pulse of phaco energy delivered, with cooling periods in between. Again, the
benets of this option are less energy going into
the eye and a reduction in the repulsive eect of
phacoemulsication that pushes nuclear pieces
away from the phaco tip. Immediately afterward,
the surgeon may use higher phaco power to
aspirate the nuclear fragments.
The authors personal settings in pulse and burst
modes
The author routinely works with three dierent
phaco machines, one from each of the major
manufacturers. The following settings are applicable to all machines and illustrate the uid and
ultrasound principles discussed earlier.
To decrease APT and, consequently, endothelial damage to the cornea, the author uses the
following settings, which lower the phaco power
by approximately 10% to 20% during each
routine case and 20% to 30% during cases of
dense cataracts. In pulse mode, the author sets the
Fig. 20. Comparison of the on time versus o time

for dierent duty cycles.
power at 10%, with 50 pulses per second and

a 25% duty cycle. Decreasing the duty cycle by up
to 40% is not noticeable to the surgeon but can
dramatically decrease APT. For the vacuum response, the author keeps the settings at level 1
with a maximum vacuum of 200 and yaw at 250
mm Hg using a large-bore 1.1-mm needle. Finally,
the author sets the ow rate at 50 mL/min and the
bottle height at 95 cm.
Similarly, in hyperburst mode, the author uses
a power of 5% to 10% and a burst width of 15 to
25 ms with an end point of 50% duty cycle. The
vacuum response is level 1, with a maximum
vacuum of 200 and yaw of 250 with a ow rate
of 50 mL/min and a bottle height of 95 cm.
Suggested settings for surgeons
Fig. 19. Decreasing the duty cycle is a way to deliver less

phaco energy and allow for more cooling while keeping
the pulse rate the same (here two pulses per second for
simplicity).
First, surgeons should remember to keep the

phaco needle and all vacuum and ow levels the
same as usual; no change in surgical technique is
needed. Only the delivery of the phaco power will
change.
If surgeons are accustomed to working in
continuous phaco mode, they will likely have an
easy time starting with a hyperpulse mode at 60 to
120 pulses per second, initially at a 50% duty
cycle, and using their same maximum phaco
power. This one simple change will likely cut the
total phaco time and energy in half with no eect
on technique.
If surgeons are accustomed to a pulsed phaco
mode, they will have an easy time staying within
the same number of pulses per second and keeping
the maximum phaco power the same while decreasing the duty cycle to 25% to 45%. They can
then implement a variable rise time to further
decrease the total phaco time and energy and

enhance purchasing power and followability.
To program a pulse mode, surgeons can enter
the data in two manners: setting the rates or direct
pulse programming. For example, setting the rates
of 10 pulses per second with a 40% duty cycle will
produce individual pulses, each having an on
time of 40 ms and an o time of 60 ms. The
pulse mode could also be directly programmed to
have an on time of 40 ms and an o time of
60 ms to achieve the same result (Fig. 21).
Phaco chop surgeons will have an easier time
adapting to hyperburst mode. Because the surgeon will be controlling the interval between
identical bursts through the third position, they
should keep the maximum phaco power level low.
Because the percentage power level cannot be
varied using the foot pedal, setting a maximum
level of 10% to 30% is advisable. The burst width
should be kept short, between 10 and 30 ms, and
an end point duty cycle of 50% should be used.
Depending on the machine, this may need to be
entered as a minimum-burst interval, which
should be set equal to the burst width in milliseconds to achieve the eective end point duty cycle
of 50% (Fig. 22).
Further tailoring the settings
To get a customized t that is appropriate to
the surgical technique, the settings can be netuned to maximize particular characteristics of the
phaco probe.
To increase grooving or cutting power in
hyperpulse mode and facilitate nuclear sculpting
467
Fig. 22. Elements of the pulse mode can be combined

with the burst mode by preventing continuous delivery
of ultrasound energy, even with maximum foot pedal depression, through using an end point duty cycle.
in the divide-and-conquer technique, the duty

cycle should be increased to 50% to 75%. This
change alone should be sucient to help nuclear
cutting. If an even bigger boost is desired, the
variable rise times should be removed to return to
square wave forms, and then the maximum phaco
power level increased.
To decrease chatter at the phaco tip and enhance
the removal of nuclear segments, one should keep
in mind that the phaco energy is a repulsive force
and therefore the on time of the ultrasound
energy should be decreased. In hyperpulse mode,
this entails increasing the pulse rate, implementing
a variable rise time, decreasing the duty cycle to
50% or less, and perhaps decreasing maximum
phaco power. In hyperburst mode, on time can
be decreased by lessening the burst width and
keeping the end point duty cycle at 50%.
The following options should be considered for
customized tailoring:
Pulse mode

Pulse rate (pulses per second)

Duty cycle (ratio of on:o for each pulse)
Rise time: square waves versus sloped waves
Phaco power (percent of maximum)
Burst mode
Fig. 21. The pulse rate and duty cycle can be programmed through programming the rates or by directly
programming each specic pulse and rest period. The net
result is the same.
Burst width (milliseconds duration of each

burst)
End point duty cycle (ratio of on:o at the
end of foot position 3)
Rise time: square waves versus sloped waves
Phaco power (percent of maximum)
468
DEVGAN
Further shaping of the pulses

As software for modulating phaco power
evolves, new methods for further shaping the
phaco power pulse are being designed, such as
the concept of a micro-punch.
Creating a microvoid between the occluded
phaco tip and the nuclear material can help better
harness the cavitational eects of phacoemulsication. By using a very brief higher-powered
micro-punch of phaco power to repel the
nucleus, a microvoid is created that allows fresh
balanced saline solution to ow between the
phaco needle and the nuclear piece. The cavitation
eects are accelerated and therefore the eciency
of the ultrasound power is increased.
The major equipment manufacturers are currently developing more innovations in the delivery
of phaco power, which will allow safer, more

ecient surgery.
The large range of programming options available with the new power-modulation software
provides a personalized t for every surgeon and
every technique during cataract surgery. Not only
will surgeons enjoy the exibility of all the options
but also patients will benet from signicantly less
phaco energy in the eye. Postoperatively, the
results will be clearer corneas, minimal endothelial
damage, and a high degree of patient satisfaction
with each procedure.
Reference
[1] Javitt JC, et al. Geographic variation in utilization of
cataract surgery. Med Care 1995;33(1):90105.
New Technology IOL Optics

Liliana Werner, MD, PhD*, Randall J. Olson, MD,
Nick Mamalis, MD
John A. Moran Eye Center, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA
Modern cataract surgery is now in the realm of

refractive surgery and patients expect almost
perfect results. The development and manufacture
of intraocular lenses (IOLs) is evolving rapidly.
The most energy and funding is probably being
spent on the development of new and complex
IOLs that not only restore the refractive power of
the eye after cataract surgery, but also provide
special features, including multifocality, toric
corrections, pseudoaccommodation, and so forth
[1,2]. This article describes some of the new technology regarding materials and designs currently
available or under development for the manufacture of modern IOLs.
Multifocal intraocular lenses
Before choosing multifocal IOLs, astigmatism
control and precise biometry are required, and
careful patient selection. This is especially important because of concerns related to the possibility
of a higher incidence of decreased contrast sensitivity and glare with these lenses. Success with
multifocal lenses (and other complex IOLs) is also
dependent on surgical technique: in-the-bag
implantation and appropriate capsulorrhexis are
necessary to ensure good centration, avoid
Supported in part by a grant from Research to
Prevent Blindness, Inc., New York, NY, to the
Department of Ophthalmology and Visual Sciences,
University of Utah. Drs Werner and Mamalis are
members of the scientific advisory board of Visiogen
(Irvine, CA). Dr. Olson is consultant for Advanced
Medical Optics (Santa Ana, CA).
E-mail address: liliana.werner@hsc.utah.edu
(L. Werner).
myopic shift, and reduce posterior capsule opacication (PCO).

The Array lens (Advanced Medical Optics,
Santa Ana, California) is a three-piece multifocal
IOL manufactured from a silicone material having a refractive index of 1.46 (Fig. 1). It has angulated C haptics made of extruded polymethyl
methacrylate. It is the rst multifocal IOL approved by the Food and Drug Administration
(FDA). The optical design of this lens is a
zonal-progressive multifocal optic with ve concentric zones. This lens design is a distance-dominant, zonal progressive optic. The center of the
lens is primarily for distance. All of the other
zones have distance and near in dierent proportions (50% of the available light is devoted to distance vision, 13% to intermediate vision, and 37%
to near vision). No available light is lost in the lens
because the optic is refractive and not diractive.
The addition for near is 3.5 diopters (D). The
IOL is available from 6 to 30 D in 0.5-D steps.
Javitt and coworkers [3] compared bilateral
implantation of the Array lens with a monofocal
lens with respect to visual function, patient satisfaction, and quality of life. They found that those
patients who had bilateral implantation of the
Array obtained better uncorrected and distancecorrected near visual acuities and reported better
overall vision, less limitation in visual function,
and less spectacle dependency than patients with
bilateral monofocal lenses. In the study by
Schmitz and coworkers [4] reduced contrast sensitivity was found in the multifocal group (also implanted with the Array) only at the lowest spatial
frequency without halogen glare. The monofocal
and multifocal groups of patients studied by
them had no statistically signicant dierences in
contrast sensitivity with moderate and strong
doi:10.1016/j.ohc.2006.07.007
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et al
Fig. 1. Gross photograph showing an Array multifocal lens, which is a three-piece silicone optic polymethyl methacrylate haptic design (right). The schematic drawings (left) show the distribution of refractive power in the Array lens according to the dierent zones. (Courtesy of Advanced Medical Optics, Santa Ana, CA; with permission.)
glare. Their results suggest no dierence in glare

disability induced by halogen light similar to oncoming vehicle headlights for patients implanted
with monofocal and multifocal IOLs.
More recently, Advanced Medical Optics
(Santa Ana, California) launched the ReZoom
lens (Fig. 2). This is a second-generation, refractive, multifocal IOL, manufactured from a hydrophobic acrylic material with a refractive index of
1.47. It has angulated (5 degrees) modied C
haptics made of 60% blue core polymethyl methacrylate monolament. The overall diameter of
the lens is 13 mm, with an optic diameter of 6
mm. The optical design of this lens features the
Balanced View Optics Technology, with ve concentric zones modied from the Array design.
Zones 1, 3, and 5 are distance dominant, whereas
zones 2 and 4 are near dominant. The latter provide 3.5 D near add power at the IOL plane.
There is an aspheric transition between the dierent zones. The area of zone 4 was decreased by
55%, zone 3 was increased by 80%, and zone 2
was increased by 2% in relation to the Array.
The IOL is also available from 6 to 30 D in

0.5-D steps. It incorporates the new OptiEdge design, which combines three elements: (1) a rounded
anterior edge, (2) a sloping side edge, and (3)
a sharp vertical posterior edge (Fig. 3). The
rounded anterior edge was designed to minimize
glare. It spreads out rays that pass through its surface and disperses light rays reected from the
edge. This is especially important with IOLs manufactured from hydrophobic acrylic materials,
which have a higher refractive index than silicone
materials. The sloping side edge is designed to reduce the area of the surface that can cause internal
reections and to scatter internal reections away
from the retina. The squared posterior optic rim
design has proved to be eective in the prevention
of PCO.
Another currently available multifocal IOL is
the ReSTOR lens (Alcon Laboratories, Fort Worth,
Texas). This is an apodized, diractive IOL, using
the platform of the single-piece AcrySof lens
(Fig. 4A). The lens is designed so that the diractive grating is present only in the central 3.6 mm
NEW TECHNOLOGY IOL OPTICS
471
Fig. 2. Gross photograph showing a ReZoom multifocal lens, which is a three-piece hydrophobic acrylic optic polymethyl methacrylate haptic design (right). The schematic drawings (left) show the distribution of refractive power in
the ReZoom lens according to the dierent zones. (Courtesy of Advanced Medical Optics, Santa Ana, CA; with
permission.)
of the optic. Apodization is the gradual tapering

of the diractive steps from the center to the periphery. The largest diractive step is at the lens
center and sends most of the light to a near focus.
As the steps move away from the center, they
gradually decrease in size, blending into the
periphery, and sending a decreasing proportion

of light to a near focus. As a result of this design,
when the pupil is small, such as during reading
tasks, the lens provides appropriate near and distance vision. In large pupil situations, however,
such as at night, the ReSTOR lens becomes
Fig. 3. Scanning electron microscopy showing the characteristics of the OptiEdge design, incorporated in the ReZoom
lens. (Courtesy of Advanced Medical Optics, Santa Ana, CA; with permission.)
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WERNER
et al
Fig. 4. Gross photographs showing diractive multifocal IOLs. (A) ReSTOR lens, manufactured using the platform of
the single-piece AcrySof. (Courtesy of Alcon Laboratories, Fort Worth, Texas; with permission.) (B) Tecnis multifocal
lens, manufactured using the platform of the CeeOn Edge. (Courtesy of Advanced Medical Optics, Santa Ana, CA; with
permission.)
a distant-dominant lens, providing appropriate

distance vision while reducing unwanted visual
phenomena, because the defocused near image
has less signal strength.
The Tecnis lens with the Z-Sharp Optic Technology (Advanced Medical Optics, Santa Ana,
California) has an anterior aspheric surface that
compensates for the positive aberration of the
cornea (see section on aspheric IOLs). The manufacturer is also working on a multifocal lens,
which incorporates a diractive posterior surface
to the Tecnis design (model ZM001; Fig. 4B). In
theory, the Tecnis multifocal lens would compensate for the decrease in contrast sensitivity that
may be associated with multifocal lenses by an
increase in contrast sensitivity because of the
aspheric characteristics of the lens.
Peer-reviewed articles on the ReZoom and the
Tecnis multifocal IOLs are not yet available in the
literature. In a recent study, Rocha and coworkers
[5] compared the visual acuity, total and high-order wavefront aberrations (coma, spherical aberrations, and other high-order aberrations), and
contrast sensitivity in 105 eyes implanted with
four dierent lenses: (1) the ReSTOR, (2) threepiece monofocal AcrySof lens, (3) single-piece
monofocal AcrySof lenses, and (4) a single-piece
hydrophilic acrylic monofocal lens. They observed
that the ReSTOR induced signicantly less spherical aberration compared with the monofocal
lenses, but the contrast sensitivity was better

with the monofocal AcrySof lenses. Dierent clinical studies on the three previously mentioned
multifocal designs have been presented at the
twenty third Congress of the European Society
of Cataract and Refractive Surgeons (Lisbon,
Portugal, September 1014, 2005). The three designs
were generally associated with appropriate near, intermediate, and distance vision, and spectacle independence. To date, superiority of one design over
the other is yet to be determined.
Toric intraocular lenses

For IOLs to reduce pre-existing astigmatism in
cataract patients, it is very important to use
a design that provides appropriate centration,
xation, and stability without rotational movements. Any signicant deviation of the IOL from
the intended alignment reduces the eectiveness of
the toric correction by varying degrees.
The Staar Surgical (Monrovia, California)
silicone posterior chamber IOLs with toric optic
(models AA-4203TF and AA-4203TL) are
designed to reduce pre-existing astigmatism in
cataract patients (Fig. 5A). The toric IOLs are single-piece, plate haptic, injectable lenses with biconvex optics designed to be implanted within
the capsular bag. They incorporate a cylindrical
473
Fig. 5. Toric IOLs. (A) Gross photograph showing the Staar toric lens, which is a single-piece silicone plate design, with
large xation holes. (B) Gross photograph showing the AcrySof toric. (Courtesy of Alcon Laboratories, Fort Worth,
TX; with permission.)
correction with a spherical optic to create a toric

lens. The toric IOL has an overall diameter of
10.8 mm in the TF version and of 11.2 mm in
the TL version to t in dierent size capsular
bags. Large fenestration holes are created to allow
brous tissue to grow through them and lock the
lens to the equator of the capsular bag for additional stability. These IOLs are available in
powers from 4 to 35 D, in 0.5-D increments.
The cylindrical powers of the IOLs are of 2 and
3.5 D in the long axis of the lens. The cylindrical
power of the toric IOLs at the corneal plane for
a 2-D lens is about 1.4 D, and about 2.3 D for
the 3.5-D IOL.
Patel and coworkers [6] compared the postoperative rotation of plate- and loop-haptic implants
of spherical power to ascertain the optimal design
appropriate for toric lenses. Severe early rotation
(up to 2 weeks after surgery) was observed in
24% of plate-haptic lenses, compared with 9%
for loop-haptic lenses. Rotation observed between
2 weeks and 6 months after implantation was less
common, however, with plate-haptic lenses.
Chang [7] demonstrated that adequate overall
length is a critical factor in the rotational stability
of plate-haptic lenses, and early rotational stability is enhanced by use of longer IOLs.
Another toric lens recently approved and
available is Alcons model SA60TT, using the
platform of the single-piece AcrySof IOL (Alcon
Laboratories, Fort Worth, Texas; Fig. 5B). This
design has been chosen because of its reported
great stability within the capsular bag, and without signicant postoperative rotation. The
SA60TT is available in three models: (1) 1.50 D
(SA60T3); (2) 2.25 D (SA60T4); or (3) 3 D
(SA60T5) of cylindrical correction at the IOL
plane. The IOLs feature three alignment marks
on each side of the lens to assist with axis orientation. The toric component is present on the posterior optic surface of the lens. Implantation is also
performed by injection with the Monarch II system. Horn [8] has recently presented the results
of a multicenter, randomized study comparing
the SA60TT with the AcrySof single-piece platform. Eligibility criteria for the study included
adults aged 21 years or older, age-related cataracts
in one or both eyes, minimum astigmatism criteria
per protocol, potential postoperative visual acuity
of 0.3 logMAR or better, and preoperative visual
acuity worse than 0.2 logMAR with or without
glare. Clinical outcomes indicated a signicant reduction in the postoperative residual refractive
cylinder in subjects implanted with the investigational AcrySof toric versus the spherical control.
Blue blocking intraocular lenses

The natural human crystalline lens yellows
with age, which is attributable to oxidation
products of tryptophan and to glycosylation of
lens proteins. This change results in a progressive
increase in absorbance within the blue range of
the visible spectrum [9]. Studies suggest that bluelight absorbing IOLs, by replicating the transmission characteristics of the aging crystalline lens,
protect lipofuscin-containing retinal pigment epithelial cells from blue-light damage. There is indirect evidence showing that this may result in
a reduction of the risk for macular degeneration,
or its progression [10].
The AcrySof Natural (SN60AT) provides incremental light protection above and beyond
traditional UV protection. This technology is
incorporated into the platform of the single-piece
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WERNER
AcrySof. It contains a proprietary, integrated

polymer dye (blue lightltering chromophore,
ImprUV) designed to lter both invisible UV rays
and visible blue rays of light. The addition of
a covalently bonded yellow dye results in an IOL
UV-visible light transmittance curve that mimics
the protection provided by the natural, precataractous adult human crystalline lens [11]. Although
the traditional UV-absorbing lenses provide light
ltration from 200 to 400 nm, the AcrySof Natural lens provides variable ltration properties
from 200 to 550 nm.
Possible limitations associated with implantation of these yellow IOLs include the potential
impact on color and night vision. Although
dierent studies did not demonstrate any eect
of yellow-tinted IOLs on color vision [12], the issue of night vision remains controversial [13].
Blue light is more important for scotopic (nighttime) than photopic (daytime) vision. With age,
scotopic sensitivity declines twice as fast as does
photopic sensitivity. Night vision is a major problem for older adults. Cataract surgery with implantation of standard UV absorbing (clear)
IOLs has the potential to improve night vision
for these patients.
Scotopic and photopic luminous eciencies
peak at 507 nm (blue-green) and 555 nm (greenyellow), respectively. In addition to blocking
harmful 330- to 400-nm UV radiation, a 20-D
AcrySof Natural also blocks 50% of blue light at
450 nm and 25% at 480 nm. According to
Mainster [13], this is enough to decrease rod-mediated visual sensitivity, although the clinical signicance of this fact remains to be demonstrated
in clinical studies.
A dierent approach to the possible association
between blue light and macular degeneration is
being investigated by Medennium (Irvine, California), with the development of a new IOL with
photochromic properties [14]. According to the
manufacturer, the lens has a UVnear blue absorption curve similar to the AcrySof Natural lens when
exposed to UV light, whereas it behaves as a standard UV-absorbing IOL in an indoor or night environment. The lens optic changes from colorless
to yellow when exposed to UV light, and back to
colorless in indoor environments. The SmartYellow IOL is manufactured with a proprietary hydrophobic acrylic material (photochromic matrix).
The preliminary design is a three-piece lens with
blue-colored polyvinylidene uoride haptics. The
overall diameter of the lens is 12.5 mm, with a
6-mm optic. The lens has a 5-degree posterior
et al
optic-haptic angulation, and square optic edges.

The authors have recently investigated this lens in
the laboratory, in vitro and in vivo. They found
the photochromic change to be reversible, reproducible, and stable over time, and the lens biocompatible in rabbits after a 6-month follow-up period.
This approach would put an end to the controversy
regarding the impact of yellow lenses on night
vision.
Accommodative intraocular lenses

IOLs proposed to restore accommodation
have initially been designed to do so by enabling
a forward movement of the optic component
during an accommodation eort. The Eyeonics
(Aliso Viejo, California) CrystaLens (model AT45) is a modied plate haptic lens manufactured
from a third-generation silicone material (Biosil)
with a refractive index of 1.43 [15]. The design of
the lens was developed by Dr. J. Stuart Cumming
(Fig. 6). It is hinged adjacent to the optic and has
small looped polyimide haptics, which have been
shown to xate rmly in the capsular bag. The
grooves across the plates adjacent to the optic
make the junction of the optic with the plate haptic the most exible part of the optic-haptic design. The overall length of the lens is 11.5 mm
(loop tip to loop tip measurement), whereas the
overall length as measured from the ends of the
plate haptics is 10.5 mm. The optic is biconvex
and is 4.5 mm in diameter; the recommended
A constant is 119.24, and the lens is designed for
placement in the capsular bag. The theoretical
mechanism of ecacy of this lens is based on
the concept that with accommodative eort, redistribution of the ciliary body mass results in increased vitreous pressure, which moves the optic
forward anteriorly within the visual axis, creating
a more plus-powered lens. One drop of atropine
administered at the time of the surgery and one
drop on the rst day after surgery allows the
lens to remain in the maximal posterior position
within the capsular bag and not move forward
during the period of brosis around the lens haptics. This should result in a greater potential for
forward movement of the lens on ciliary body
constriction. The hinge was incorporated to facilitate the forward movement of the optic by minimizing the resistance to the possible pressure
exerted on the lens by the forward movement of
the vitreous body on contraction of the ciliary
muscle.
Fig. 6. Photographs of the CrystaLens (Eyeonics, Aliso

Viejo, California). (A) Gross photograph. (B) Clinical
picture (retroillumination) of a patient implanted with
the CrystaLens. (Courtesy of John F. Doane, MD,
Kansas City, MO.)
The Crystalens received FDA approval in

November 2003 for the claim of adding approximately 1 D of accommodation over monofocal
lenses. Dierent studies, however, could not demonstrate a correlation between the objective measurement of the anterior shift of the Crystalens and
the reported near vision of the patients [16,17]. In
some cases, a backward shift of the lens was observed. It is likely that pseudoaccommodation, because of such factors as an increased depth of focus,
may play a signicant role in the reading performance of patients implanted with this lens design.
Theoretical studies using model eyes demonstrated that dual-optic IOL systems may represent
an advantage over mono-optic systems in terms of
amplitude of accommodation obtained with optic
movement during eorts for accommodation
[18,19]. This seems to be particularly valid if there
is anterior translation of the anterior optic with an
unchanged position of the posterior optic. The
Synchrony IOL (Visiogen, Irvine, California) is
a one-piece lens manufactured from silicone [20].
475
The lens has two major optic components (anterior and posterior) connected by a bridge through
the haptics, which act like a spring. The posterior
aspect of the device is designed with a signicantly
larger surface area than the anterior, to maintain
stability within the capsular bag during the accommodation-relaxation process. The anterior
optic has two expansions oriented parallel to the
haptic component that lift the capsulorrhexis
edge, preventing complete contact of the anterior
capsule with the anterior surface of the lens. In
this dual optic lens system the anterior lens has
a high plus power beyond that required to produce emmetropia, whereas the posterior lens has
a minus power to return the eye to emmetropia.
The lens is designed to work in concert with the
capsular bag, according to the traditional Helmholtzs theory of accommodation. The distance
between the two optics is stated to be minimum
in the unaccommodated state and maximum in
the accommodated state, with anterior displacement of the anterior optic (Fig. 7).
Studies performed in the authors laboratory
using rabbits demonstrated that signicantly less
anterior capsule opacication and PCO were
observed in rabbit eyes after implantation of the
Synchrony lens in comparison with plate haptic
silicone lenses [21]. The presence of two IOL optics in the capsular bag raises concerns related to
the possibility of ingrowth of regenerative-proliferative crystalline lens material between them,
with formation of interlenticular opacication.
This issue was also addressed in the authors laboratory, by using a rabbit model. They demonstrated that interlenticular opacication was
signicantly associated with pairs of hydrophobic
acrylic lenses implanted in the bag, but not with
the Synchrony [22]. This same study seemed to
conrm clinical observations that implantation
of two silicone plate lenses in the bag is not associated with interlenticular opacication. The Synchrony is currently under clinical trials overseas.
Since the last quarter of 2005, it is being implanted
through a 3.6- to 3.8-mm incision, by using a preloaded injector that only requires balanced salt solution for IOL lubrication. In a recently reported
series of 24 patients implanted with this lens,
100% of them had a distance-corrected near vision of 20/40 or better. Defocus curve analysis
showed a mean accommodative range of 2.83
0.16 D [23].
Another dual-optical accommodating IOL system was invented by Dr. Faezeh M. Sarfarazi, and
it is now being developed by Bausch and Lomb
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WERNER
et al
Fig. 7. Photographs of the Synchrony lens (Visiogen, Irvine, California). (A) Gross photograph of the lens, and the injector, which was designed to be preloaded with the lens. (B) Slit lamp photograph of a patient implanted with the Synchrony lens, taken 12 months postoperatively (retroillumination). (Courtesy of Ivan Ossma, MD, Cali, Colombia.)
(Rochester, New York). This is a single-piece

molded silicone lens with two optics connected
by three haptic components. Preliminary experimental results with the latest version of the
original design are not yet available.
Aspheric intraocular lenses
A recent technology named the Z-Sharp Optic
Technology has been implemented on the CeeOn
Edge IOL, model 911 platform (Tecnis Z 9000
IOL, Advanced Medical Optics, Santa Ana,
California). The principle of this technology,
which had FDA approval in 2004, is based on
the fact that spherical aberrations of the human
eye vary with age. The cornea has positive
spherical aberration, which means peripheral
rays are focused in front of the retina. This
positive spherical aberration of the cornea remains throughout life. In young people, the
crystalline lens corrects this defect. It exhibits
many aberrations, but it is dominated by negative
spherical aberration. The crystalline lens undergoes changes with age, which cause a shift of
spherical aberration toward the positive. The
negative spherical aberration of the young lens
gradually approaches zero at about age 40 and
then continues to become increasingly positive as
aging continues. This adds to the positive spherical aberration of the cornea, with possible increased sensitivity to glare and also reduced
contrast acuity especially under mesopic and
scotopic conditions. Between the ages of 20 and
70 years, total aberrations of the eye increase
more than 300%.
Currently available IOLs also have positive

spherical aberration. When they are tested by laser
scanning, these lenses turn out to be almost perfect
spherical lenses with positive spherical aberration,
the other aberrations being close to zero. In
pseudophakic patients the spherical aberration of
the eye is increased in relation to young and old
phakic eyes. Application of the Z-Sharp Optic
Technology modies the surface of IOLs to produce a negative spherical aberration that compensates for the positive aberration of the cornea.
The Tecnis lens has an aspheric surface, more
specically a modied prolate prole. This means
that the lens has less refractive power at the
periphery (contrary to spherical lenses, which
have more refractive power at the periphery); all
the rays are coming to the same point, leading to
a higher contrast sensitivity. The Z-Sharp Optic
Technology could actually be applied to any lens
biomaterial, because it is based on the modied
prolate prole of the lens optic. Advanced Medical Optics chose the design and material used for
the manufacture of the CeeOn Edge lens for the
incorporation of the Z-Sharp Optic Technology,
creating the Tecnis. The CeeOn Edge lens, model
911, is a foldable three-piece IOL; the diameter of
the biconvex optic is 6 mm and the overall
diameter of the lens is 12 mm. It is also available
in a 13-mm diameter. The optic component is
manufactured from a third-generation silicone
material, polydimethyl diphenyl siloxane developed and manufactured with a high refractive
index (1.46). The optic rim has square truncated
edges for PCO prevention. The haptics are manufactured from polyvinylidene uoride. The
haptic design is a cap C with a 90-degree exit and

an angulation of 6 degrees. As is standard with
modern IOLs, the Tecnis has an incorporated UV
absorber (benzotriazole) to protect the retina
from radiation in the 300- to 400-nm range. An
acrylic platform based on the Advanced Medical
Optics AR40e (Sensar) is also available.
The haptic design is intended to maintain the
shape of the capsular bag oering more clock
hours of contact between the haptics and the
capsule. These characteristics help in the prevention of lens decentration and tilt in cases of
capsular bag contraction. This is very important
because, qualitatively, any aberration correction is
sensitive to decentration and tilt. Patients benet
from the advanced technology of Tecnis within
the normal clinical limits of lens decentration less
than 0.4 mm and lens tilt less than 7 degrees.
The Tecnis is typical of IOLs developed with
the help of wavefront technology. Corneal anterior surface shapes of dierent patients were
measured and used to determine the wavefront
aberration of each cornea. These were then used
to design a model cornea to reproduce the average
spherical aberration found in the patients evaluated. An IOL having negative spherical aberration
was designed to compensate for the average
positive spherical aberration of the model cornea.
In recently published studies comparing Tecnis
with a standard three-piece hydrophobic acrylic
lens with posterior square optic edge (AR40e,
Advanced Medical Optics, Santa Ana, California), Packer and coworkers [24,25] demonstrated
that the modied prolate IOL surface has the potential to improve contrast sensitivity under both
mesopic and photopic conditions. Mester and coworkers [26] evaluated 45 patients with bilateral
cataract implanted with the Tecnis lens in one
eye, and a three-piece silicone lens (SI40, Advanced Medical Optics, Santa Ana, California)
in the other. Their clinical results conrmed the
theoretical preclinical calculations that the spherical aberration of the eye after cataract surgery
can be eliminated by modifying the anterior surface of the IOL. Kershner [27] demonstrated
that Tecnis provided a signicant improvement
in retinal image contrast and visual performance
measured by visual acuity and functional acuity
contrast testing in 221 eyes of 156 patients. This
improvement was greatest in night vision and
night vision with glare compared with the performance of conventional spherical silicone
(AA4207VF, Staar Surgical) and hydrophobic
acrylic (SA60AT, Alcon) lenses. Finally, in a study
477
comparing patients implanted with the Tecnis or

the single-piece AcrySof (SA60AT), Bellucci and
coworkers [28] demonstrated signicantly better
distance contrast sensitivity with the aspheric lens.
The AcrySof aspheric (model SN60WF), manufactured by using the platform of the single-piece
AcrySof, is also a negative spherical aberration
lens. As with the Tecnis, the goal of the SN60WF
lens is to counteract the mean spherical aberration
in the cataract patient population, so that the
resulting total spherical aberration of the eye is
zero. Although the Tecnis lens accomplishes this
with a modied anterior prolate surface, the
SN60WF has an aspheric posterior surface.
The SofPort Advanced Optics (AO) (model
LI61AO), manufactured by Bausch and Lomb
(Rochester, New York), is a three-piece silicone
lens. The optic material has a refractive index of
1.43, and the modied C loops are made of
polymethyl methacrylate. The lens has an overall
diameter of 13 mm, with an optic diameter of
6 mm, and a 5-degree posterior optic-haptic
angulation. The SofPort AO also incorporated
square optic edges, for PCO prevention. Both
anterior and posterior optic surfaces of this lens
are aspheric, with uniform power from the center
to the edge. In contrast to the previous two
aspheric designs, the SofPort AO does not add
negative spheric aberration to the eye, but it is
aberration free. In theory, this means that the
SofPort AO may improve vision over standard
IOLs for all patients, including the estimated 5%
to 7% who do not have any or minimal positive
corneal spherical aberration. Also, in case of
decentration, the lens would not induce other
aberrations as negative-aberration and spherical
IOLs may do. This last fact was veried in a recent
in vitro study [29]. A ray-tracing program was
used to evaluate the eect of IOL decentration
on the optical performance of three silicone
IOLs: (1) the LI61U (Bausch and Lomb); (2) the
Tecnis; and (3) the SofPort AO. The optical performance of the model eye was not aected by decentration of the SofPort AO lens. With
decentration, the performance of this new IOL
was better than with the conventional spherical
LI61U and the Tecnis.
Intraocular lenses for very small incisions

The advent of microincision surgical techniques rendered cataract removal through clear
corneal incisions as small as 1 mm possible. The
478
WERNER
natural consequence of this advance is the development of IOLs that can be inserted through
such small incisions. One of the recently developed lenses that can be inserted through a sub
2-mm incision (1.45-mm) is the UltraChoice 1.0
Rollable ThinLens (ThinOptX, Abingdon, Virginia) IOL (Fig. 8). It is manufactured from a hydrophilic acrylic material with 18% water content.
The refractive index of the material is 1.47. The dioptric power of this lens ranges from 25 to 25 D.
The optical thickness is 300 to 400 mm, with a biconvex optical conguration having a meniscus shape.
The overall diameter of the lens is 11.2 mm, and the
optical diameter is 5.5 mm [30].
The ultrathin properties of the lens are attributable to its optical design. The optic features
three to ve concentric optical zones with steps of
50 mm. Each Fresnel-like ring or segment of the
lens has a small change in the radius to correct for
spherical aberration. The dierence in radius is
Fig. 8. Photographs of the UltraChoice lens. (A) Gross

photograph showing its optic steps. (B) Clinical picture
obtained through an operating microscope, showing injection of the lens through a 1.45-mm incision, using the
new roller-injector system. The lens unrolls in 20 seconds
once injected into the eye. (Courtesy of ThinOptX,
Abingdon, VA; with permission.)
et al
stated to ensure that each ring of the lens focuses

light at nearly the same point as the prime
meridian. According to the manufacturer, by
making the lens thinner, other aberrations, such
as coma, and the potential for distortion and glare
are reduced. The four tips of the haptic component have a thickness of 50 mm. They are stated to
roll once in the capsular bag, absorbing capsular
contraction forces, an issue that still needs to be
addressed in long-term clinical studies. The edge
of the lens is also 50-mm thick, which is stated to
reduce the potential for halos and glare. The
teardrop-shaped holes in the haptic component
should point in a clockwise direction. A specially
designed roller-injector system with an autoclavable, reusable cartridge made of Teon is now
available for this lens.
In the rst clinical studies involving this lens
design, many of the patients presented with better
than expected near vision. It has been hypothesized that the thin nature of this design provides
increased amplitude of pseudoaccommodation,
which will be further investigated. One explanation could be that the thin lens is associated with
increased depth of eld. Another possibility is that
the lens moves with the capsular bag during
eorts for accommodation, because it is thin and
light, and exerts little force against the equator. In
a recently published, prospective, clinical study,
16 eyes of eight patients implanted with the
UltraChoice were compared with 20 eyes of 10
patients implanted with a three-piece AcrySof
(MA60BM) lens [31]. The UltraChoice lens provided better best-corrected near and distance
visual acuities, and signicantly higher contrast
acuities than the control lens. Alio and coworkers
[32] evaluated the modulation-transfer function in
eyes implanted with a conventional IOL (AcrySof
MA60BM) and the UltraChoice. This latter
showed excellent modulation-transfer function
performance when implanted after cataract surgery, equal to the conventional lens. At this time
it is uncertain whether the company has the nancial resources to continue development of this
lens.
A new concept of very-small-incision IOLs is
being developed at Medennium and is called the
SmartIOL (Fig. 9). This lens uses a thermodynamic hydrophobic acrylic material that is packaged as a solid rod approximately 30 mm long
and 2 mm wide. The refractive index of the material is 1.47, and the softening temperature is 20 C
to 30 C. When implanted through a small incision, body temperature transforms the solid rod
479
Fig. 9. (AD) Gross photographs of a human eye obtained postmortem (posterior view) implanted with a prototype of
the single-piece SmartIOL. The rod gradually transformed into a full size lens, after instillation of balanced salt solution
at body temperature.
into a soft gel-like material, which has the shape

of a full-sized biconvex lens that completely lls
the capsule. The entire transformation takes about
30 seconds and results in a lens about 9.5 mm
wide and from 2 to 4 mm thick (but averaging about
3.5 mm) at the center, depending on dioptric power.
The lens is highly exible, more closely resembling
a gel, and it recovers its full shape when not compressed. Before being formed into a rod, the precise
dioptric power and dimensions that the transformed material takes on thermal activation in
the eye can potentially be imprinted.
Besides being implanted through a very small
incision, another potential advantage is to restore
accommodation. By combining a full-sized optic
with a very exible material, Medennium scientists hope to be able to mimic the accommodative
action of the young, natural lens and achieve
a larger potential accommodation than other
optical-mechanical designs, according to the classical Helmholtz theory. Also, complete lling of
the capsular bag eliminates space for cell growth.
The hydrophobic acrylic material of this lens
exhibits high tackiness, which might promote its

attachment to the capsular bag, further enhancing
PCO prevention. A new design of this lens is being
developed, which is a three-piece lens with polyvinylidene uoride haptics. This will probably
eliminate potential problems related to the dierent diameters of the capsular bags in dierent
eyes.
Light adjustable lens

Calhoun Vision (Pasadena, California) is developing a three-piece silicone lens with photosensitive silicone subunits, which move within the
lens on ne tuning with a low-intensity beam of
near-UV light (light adjustable lens [LAL]). The
refractive power of the lens can be adjusted
noninvasively after implantation to give the
patient a denitive refraction [3335]. The LAL
is a foldable three-piece lens; the diameter of the
biconvex optic is 6 mm and the overall diameter
of the lens is 13 mm. The optic component is
480
WERNER
manufactured from a silicone material, polydimethyl siloxane) with a refractive index of 1.43.
The optic rim of this lens has square truncated
edges. The haptics are manufactured from polymethyl methacrylate. The haptic design is a modied C, with an angulation of 10 degrees. As with
standard IOLs, the LAL optic lens material has an
incorporated UV absorber to protect the retina
from radiation in the 300 to 400 nm range.
When the eye is healed, 2 to 4 weeks after
implantation, the refraction is measured and
a low-intensity beam of appropriate wavelength
of light is used to correct any residual error. The
mechanism for dioptric change is akin to holography and is pictorially displayed in Fig. 10. The
application of the appropriate wavelength of light
onto the central optical portion of the LAL polymerizes the macromer in the exposed region,
thereby producing a dierence in the chemical
concentration between the irradiated and nonirradiated regions. To re-establish equilibrium, unreacted macromer and photoinitiator diuses
into the irradiated region. As a consequence of
the diusion process and the material properties
of the host silicone matrix, the LAL swells producing a concomitant decrease in the radius of
curvature of the lens (hyperopic change). This
process may be repeated if further refractive
change in the LAL is desired or an irradiation
of the entire lens may be applied consuming the
et al
remaining, undiused, unreacted macromer and

photoinitiator. This action has the eect of locking in the refractive power of the LAL. It is possible to induce a myopic change by irradiating the
edges of the LAL eectively to drive macromer
and photoinitiator out of the central region of
the lens, thereby increasing the radius of curvature
of the lens and decreasing its power. Astigmatism
is treated by using a band-shaped pattern of irradiation across the center of the lens, orienting the
light beam along the astigmatic axis. After verication of the new refraction, the surgeon locks
in the power by irradiating the entire lens optic,
a procedure that does not aect the nal lens
power obtained. This step is very important because some remaining photosensitive unpolymerized macromers may polymerize in bright
sunlight. Indeed, during the interval between
lens implantation and light adjustment, patients
need to wear sunglasses with UV absorbers while
performing outside activities. This is necessary to
avoid unwanted, noncontrolled polymerization
of the silicone macromers with unpredictable results regarding change in the IOL power. At least
1 hour of exposure to bright sunlight is necessary,
however, for any signicant polymerization to occur. A new digital delivery system for light application has recently been developed in conjunction
with Carl Zeiss Meditec (Jena, Germany). Correction of higher-order aberrations, such as the
Fig. 10. (AD) Schematic illustration of the proposed mechanism of swelling and addition of power to the light adjustable lens. (Courtesy of Calhoun Vision, Pasadena, CA; with permission.)
tetrafoil pattern, and inducing asphericity besides

hyperopic, myopic, and astigmatic corrections is
now possible. Preliminary in vitro and in vivo
studies with the rabbit model have demonstrated
appropriate accuracy and reproducibility of the
corrections obtained with the new digital system.
The biocompatibility of the lens material has
also been assessed in rabbit eyes, with no adverse
eect observed in dierent ocular tissues.
This foldable lens will be available in dierent
dioptric powers and can be implanted through
a small incision like a standard three-piece silicone
IOL. The initial clinical application will be a pseudophakic lens for use after cataract surgery, but
the technology can potentially be applied to any
type of IOL, including accommodative or phakic
lenses. Use in conjunction with wavefront sensing
allows full customization of the lens. Initial
human clinical studies of the LAL have been
performed by Dr. Arturo Chayet in Tijuana,
Mexico. The predictability in actual human patients using the LAL with the slit lamp delivery
system was found to be excellent. It is anticipated
that trials will begin this year in Europe with
eventual trials and submission for FDA approval
in the United States to follow.
Implantable miniature telescope

The implantable miniature telescope, manufactured by VisionCare Ophthalmic Technologies
(Saratoga, California), and invented by company
founders Dr. Isaac Lipshitz and Yossi Gross, is
a unique visual prosthetic device designed specifically to improve vision of patients suering from
481
late-stage age-related macular degeneration [36

38]. The second-generation telescope is a wideangle version of the device that allows for a larger
view of the central visual eld than previous
models. This device is an optical apparatus comprised of two main components: a pure glass optical cylinder and a carrying device constructed
from standard biocompatible materials suitable
for implantation in the eye (Fig. 11A). The optical
portion contains ultraprecise, wide-angle microlenses that provide retinal image enlargement of
the central visual eld. Two models are available,
allowing for a magnication of 2.2 or 3, with
an enlarged retinal image produced over approximately 52 to 60 degrees of the central retina. The
carrying device is comprised of a clear carrier and
a blue light restrictor. The carrier has two modied C-loops that hold the prosthetic device in
the capsular bag. Once secured inside the bag,
the anterior window of the optic extends marginally through the pupil (Fig. 11B). It is designed to
allow a clearance of approximately 2 to 3 mm
from the corneal endothelium.
The wide-angle model is currently in late-stage
clinical trials in the United States. Enrolled
patients are at least 55 years of age; have stable
bilateral macular degeneration (disciform scar or
geographic atrophy); and visual acuity between
20/80 and 20/800. The device is implanted in one
eye to improve central vision, whereas the other
eye remains as is to continue to provide peripheral
vision. No other IOL is used in conjunction with
the implantable telescope. Promising results from
the prospective, multicenter phase II-III trial have
recently been reported by Packer and coworkers
[39] at the twenty-third Congress of the European
Fig. 11. (A) Gross photograph showing the current version of the telescope (anterior view). (Courtesy of VisionCare,
Saratoga, California; with permission.) (B) Clinical slit lamp photograph of an eye implanted with the device by an
11-mm superior limbal incision. (Courtesy of Doyle Stulting, MD, Atlanta, GA; James P. Gilman, CRA, Atlanta,
GA.) (C) Gross photograph of a human eye obtained postmortem (posterior view) implanted with a prototype of the
pseudophakic wide angle implantable miniature telescope. The prosthetic device has been experimentally xated in
the ciliary sulcus by Mark Packer, MD (Eugene, OR).
482
WERNER
Society of Cataract and Refractive Surgeons (Lisbon, Portugal, September 2005). At 6 months,
mean distance and near best-corrected visual acuity improved 3.3 and 3 Snellen lines, respectively.
According to the manufacturer, the device has an
optimal focusing distance of 250 cm in front of the
eye. This is designed to improve activities of daily
living, and reading may be accomplished with
standard spectacles to bring the enlarged retinal
image into focus. A patient with an implantable
miniature telescope should be able to scan the
eld of view for reading and distance visual activities through natural eye movements, because the
device is placed entirely in the eye. In addition,
the implantable miniature telescope allows for
a natural cosmetic appearance. Another model
of the telescope is being specially modied for
patients who are pseudophakic (Fig. 11C).
Summary
There has been a rapid evolution in the eld of
IOL technology, much of it inuenced by the
development of surgical techniques, such as very
small incisions, and wavefront aberrometry. With
better evidence that blue light is an important
variable in age-related macular degeneration, the
use of IOLs with blue-light blockers, or eventually
photochromic lenses, could rapidly become the
standard in IOL manufacture. The development
of improved multifocal and accommodative lenses
is a consequence of the increasing popularity of
the refractive lens exchange procedure. Which
optic technology will provide the best patient
satisfaction is unclear at this time.
References
[1] Werner L, Apple DJ, Schmidbauer JM. Ideal IOL
(PMMA and foldable) for Year 2002. In:
Buratto L, Werner L, Zanini M, et al, editors. Phacoemulsication: principles and techniques. Thorofare (NJ): Slack; 2003. p. 43551.
[2] Olson RJ, Werner L, Mamalis N, et al. New IOL
technology. Am J Ophthalmol 2005;140:70916.
[3] Javitt J, Brauweiler HP, Jacobi KW, et al. Cataract
extraction with multifocal intraocular lens implantation: clinical, functional, and quality-of-life outcomes. Multicenter clinical trial in Germany and
Austria. J Cataract Refract Surg 2000;26:135666.
[4] Schmitz S, Dick HB, Krummenauer F, et al. Contrast sensitivity and glare disability by halogen light
after monofocal and multifocal lens implantation.
Br J Ophthalmol 2000;84:110912.
et al
[5] Rocha KM, Chalita MR, Souza CE, et al. Postoperative wavefront analysis and contrast sensitivity of
a multifocal apodized diractive IOL (ReSTOR)
and three monofocal IOLs. J Refract Surg 2005;21:
S80812.
[6] Patel CK, Ormonde S, Rosen PH, et al. Postoperative intraocular lens rotation: a randomized
comparison of plate and loop haptic implants. Ophthalmology 1999;106:21905.
[7] Chang DF. Early rotational stability of the longer
Staar toric intraocular lens: fty consecutive cases.
[8] Horn J. Analysis of residual refractive cylinder with
the investigational AcrySof toric IOL. Presented at
the XXIII Congress of the European Society of Cataract and Refractive Surgeons. Lisbon, Portugal,
September 12, 2005.
[9] Gaillard ER, Zheng L, Merriam JC, et al. Age-related changes in the absorption characteristics of
the primate lens. Invest Ophthalmol Vis Sci 2000;
41:14549.
[10] Sparrow JR, Miller AS, Zhou J. Blue light-absorbing intraocular lens and retinal pigment epithelium
protection in vitro. J Cataract Refract Surg 2004;
30:8738.
[11] Ernest PH. Light-transmission-spectrum comparison of foldable intraocular lenses. J Cataract Refract
Surg 2004;30:17558.
[12] Rodriguez-Galietero A, Montes-Mico R, Munoz G,
et al. Comparison of contrast sensitivity and color
discrimination after clear and yellow intraocular
lens implantation. J Cataract Refract Surg 2005;31:
173640.
[13] Mainster MA. Intraocular lenses should block UV
radiation and violet but not blue light. Arch Ophthalmol 2005;123:5505.
[14] Werner L, Mamalis N, Romaniv N, et al. New photochromic foldable intraocular lens: preliminary
study on feasibility and biocompatibility. J Cataract
Refract Surg 2006;32(7):121421.
[15] Alio JL, Tavolato M, de la Hoz F, et al. Near vision
restoration with refractive lens exchange and pseudoaccommodating and multifocal refractive and diffractive intraocular lenses: comparative clinical
study. J Cataract Refract Surg 2004;30:2494503.
[16] Koeppl C, Findl O, Menapace R, et al. Pilocarpineinduced shift of an accommodating intraocular lens:
AT-45 Crystalens. J Cataract Refract Surg 2005;31:
12907.
[17] Cazal J, Lavin-Dapena C, Marin J, et al. Accommodative intraocular lens tilting. Am J Ophthalmol
2005;140:3414.
[18] Rana A, Miller D, Magnante P. Understanding the
accommodating intraocular lens. J Cataract Refract
Surg 2003;29:22847.
[19] Langenbucher A, Reese S, Jakob C, et al. Pseudophakic accommodation with translation lenses - dual
optic vs mono optic. Ophthalmic Physiol Opt 2004;
24:4507.
[20] McLeod SD, Portney V, Ting A. A dual optic accommodating foldable intraocular lens. Br J Ophthalmol 2003;87:10835.
[21] Werner L, Pandey SK, Izak AM, et al. Capsular bag
opacication after experimental implantation of
a new accommodating intraocular lens in rabbit
eyes. J Cataract Refract Surg 2004;30:111423.
[22] Werner L, Mamalis N, Stevens S, et al. Interlenticular opacication: dual-optic versus piggyback intraocular lenses. J Cataract Refract Surg 2006;32(4):
65561.
[23] Ossma-Gomez I. Long-term follow up of the Synchrony accommodating IOL: two-year data. Presented at the International Society of Refractive
Surgery of the American Academy of Ophthalmology Meeting. Chicago, October 15, 2005.
[24] Packer M, Fine IH, Homan RS, et al. Prospective
randomized trial of an anterior surface modied prolate intraocular lens. J Refract Surg 2002;18:6926.
[25] Packer M, Fine IH, Hofman RS, et al. Improved
functional vision with a modied prolate intraocular
lens. J Cataract Refract Surg 2004;30:98692.
[26] Mester U, Dillinger P, Anterist N. Impact of a modied optic design on visual function: clinical comparative study. J Cataract Refract Surg 2003;29:6278.
[27] Kershner RM. Retinal image contrast and functional visual performance with aspheric, silicone,
and acrylic intraocular lenses: prospective evaluation. J Cataract Refract Surg 2003;29:168494.
[28] Bellucci R, Scialdone A, Buratto L, et al. Visual acuity and contrast sensitivity comparison between Tecnis and AcrySof SA60AT intraocular lenses:
a multicenter randomized study. J Cataract Refract
Surg 2005;31:7127.
[29] Altmann GE, Nichamin LD, Lane SS, et al. Optical
performance of 3 intraocular lens designs in the presence of decentration. J Cataract Refract Surg 2005;
31:57485.
483
[30] Pandey SK, Werner L, Agarwal A, et al. Phakonit

cataract removal through a sub-1.0 mm incision
and implantation of the ThinOptX rollable intraocular lens. J Cataract Refract Surg 2002;28:17103.
[31] Dogru M, Honda R, Omoto M, et al. Early visual results with the rollable ThinOptX intraocular lens.
[32] Alio JL, Schimchak P, Montes-Mico R, et al. Retinal image quality after microincision intraocular
lens implantation. J Cataract Refract Surg 2005;31:
155760.
[33] Schwartz DM. Light-adjustable lens. Trans Am
Ophthalmol Soc 2003;101:41736.
[34] Werner L, Mamalis N, Apple DJ. Biomaterials for
wavefront customization. In: Krueger RR,
Applegate RA, MacRae SM, editors. Wavefront
customized visual correction. Thorofare (NJ): Slack;
2004. p. 2718.
[35] Werner L, Mamalis N. Wavefront corrections of intraocular lenses. Ophthalmol Clin North Am 2004;
17:23345.
[36] Werner L, Kaskaloglu M, Apple DJ, et al. Aqueous
inltration into an implantable miniaturized telescope. Ophthalmic Surg Lasers 2002;33:3438.
[37] Lane SS, Kuppermann BD, Fine IH, et al. A prospective multicenter clinical trial to evaluate the
safety and eectiveness of the implantable miniature telescope. Am J Ophthalmol 2004;137:
9931001.
[38] Chun DW, Heier JS, Raizman MB. Visual prosthetic device for bilateral end-stage macular degeneration. Expert Rev Med Devices 2005;2:65765.
[39] Packer M, Fine IH, Homan R, et al. Phase II/III
study of a visual prosthetic device for the treatment
of vision loss due to advanced macular degeneration.
Presented at the 23rd Congress of the European Society of Cataract and Refractive Surgeons, Lisbon,
Portugal, September 10, 2005.
Astigmatism Control
Louis D. Nichamin, MD
The Laurel Eye Clinic, 50 Waterford Pike, Brookville, PA 15825, USA
Over the past several years the concept of

refractive cataract surgery has received increased
attention from surgeons, and the need for its
adoption has recently been made more urgent by
the approval and availability of new presbyopiacorrecting intraocular lenses (IOL). Indeed, the
need to manage pre-existing astigmatism has become a requisite aspect of modern phacosurgery.
Experience with keratorefractive surgery has
proved that astigmatism of as little as 0.75 diopters
(D) may leave a patient symptomatic with visual
blur, ghosting, and halos. To embrace this notion
of refractive cataract surgery fully, the dedicated
surgeon must aspire to a level of accuracy that
equates with corneal-based refractive surgery. Fortunately, techniques have emerged that aord the
refractive lens surgeon the ability to eectively,
safely, and reproducibly reduce cylinder error to
acceptable levels of 0.50 D or less, either at the time
of cataract surgery, or through a subsequent enhancement procedure.
of the patient, and the status of the fellow eye.

Given that most patients drift against-the-rule over
their lifetime (eg, toward plus cylinder at 180
degrees) many surgeons advocate a slightly less
aggressive approach to the reduction of withthe-rule cylinder. Furthermore, some authors have
suggested that residual with-the-rule astigmatism
may favor better uncorrected distance acuity given
that most visual stimuli are of a vertical nature [2].
Similarly, it has been contended that residual
against-the-rule cylinder may improve uncorrected
near vision [3]. The long-standing tenet that residual (myopic) with-the-rule astigmatism is a desirable goal to lengthen the conoid of Sturm and
optimize depth perception has recently, however,
been called into question [4]. In addressing todays
cataract patient, given recent renements in surgical technique and increased use of presbyopiacorrecting implants, the goal of a spherical outcome
seems to be optimal.
Options to reduce astigmatism
Patient selection and considerations

Estimates of the incidence of signicant, naturally occurring astigmatism vary widely from
7.5% to 75% [1]. In my experience with the general cataract population, approximately 10% of
patients come to surgery with greater than 2 D
of cylinder, 20% have between 1 and 2 D, and
70% have less than 1 D. One can therefore expect
to treat pre-existing astigmatism in greater than
one out of every three patients. Again, the goal
is to leave the patient with a refractive outcome
for both sphere and cylinder of 0.50 D or less.
When planning astigmatism correction, one
must consider the location of the cylinder, the age
E-mail address: nichamin@laureleye.com
The rst decision one is faced with is whether

to address pre-existing astigmatism at the time of
cataract surgery, or to defer and treat the cylinder
separately. Historically, it has been argued that
greater accuracy might be achieved if sucient
time were allotted for adequate wound healing,
and a stable refraction documented before taking
on astigmatic correction. Today, with the use of
foldable IOLs and incision sizes now well under
3.5 mm, essentially neutral astigmatic outcomes
may be consistently achieved [5]. As such, most
surgeons opt to treat pre-existing cylinder concurrently with the implant procedure. This obviates
the time and energy required for a second surgical
sitting, and is the approach most widely taken
when dealing with cataract patients, most often
through the use of limbal relaxing incisions
doi:10.1016/j.ohc.2006.07.004
486
NICHAMIN
(LRIs) as described later. Given the exacting need

for near-perfect refractive results today, however,
particularly when using presbyopia-correcting
IOLs, along with an increasing acceptance and
use of bioptics (using excimer laser technology),
some cataract surgeons are beginning to prefer
a staged procedure should the patient possess
any signicant level of preoperative astigmatism.
The second fundamental decision is whether to
treat the astigmatism through a lenticular approach
(ie, to use a toric IOL) or to use a keratorefractive
technique. From a theoretical perspective a toric
IOL has the advantage of avoiding corneal manipulation and, as such, the possibility of inducing
irregular astigmatism, and also potentially provides for reversibility. Their eectiveness has been
widely reported [6,7]. Until recently, however, the
availability of lens choices, at least within the
United States, has been limited. In addition, postoperative rotation of the rst Food and Drug
Administrationapproved device, the STAAR
Toric (STAAR Surgical Co., Monrovia, California) single-piece plate-haptic IOL, has been a
well-documented issue [6,8]. Fortunately, newer devices are reaching the marketplace and are proving
to be more eective with better rotational stability,
as seen with the Alcon (Alcon Laboratories, Inc.,
Fort Worth, Texas) single-piece acrylic lens [9,10].
As with any form of astigmatic correction, the
key to obtaining propitious outcomes hinges on
proper centration with the axis of astigmatism, in
that relatively small degrees of misalignment may
lead to a profound loss of eect, as discussed in
more detail later [1].
Treatment options
The notion of reducing astigmatism at the time
of IOL surgery, specically by way of astigmatic
keratotomy, dates back to the mid-1980s [1113].
Throughout the 1990s a number of authors began
to recognize the advantages of moving cornealrelaxing incisions out toward the limbus [1416].
These so-called LRIs have become the most popular way to manage astigmatism at the time of
cataract surgery and are discussed in detail later.
Another viable and relatively simple way to
decrease astigmatism is to manipulate the cataract
incision to impact favorably pre-existing astigmatism. This is accomplished by rst centering the
incision on the steep corneal meridian, and then
by varying its size and design, aect a desired
amount of wound attening, and hence a decrease
in cylinder [17]. This approach, however, presents
logistical challenges including movement around

the surgical table, often producing awkward
hand positions. In addition, varying instrumentation may be needed from case to case, along with
a dynamic rather than consistent mindset and repertoire. For these reasons, this technique has
largely been supplanted by the use of a consistent
and astigmatically neutral phacoincision (typically
placed temporally for stability) and then adding
supplemental relaxing incisions (LRIs). A recent
study by Kaufmann and coworkers [18] concluded
that LRIs in combination with a temporal clear
corneal incision provided superior astigmatic outcomes to that of on-axis surgery.
Several other options deserve mention. Lever
and Dahan [19] have suggested a novel technique of
using opposing clear corneal incisions to address
pre-existing astigmatism. In this technique, a second opposite penetrating clear corneal incision is
placed over the steep meridian 180 degrees away
from the main incision. This approach is technically simple and requires no additional instrumentation; however, a second substantial penetrating
incision is now present, possibly increasing the
risk of wound leak or even infection. In addition,
single-plane beveled incisions are known to be
less eective, for a given arc length, at attening
the cornea as compared with traditional perpendicular relaxing incisions [20,21].
Yet another important and increasingly popular alternative is that of bioptics, a technique
originally described to address residual refractive
error following implantation of myopic phakic
IOLs, but one that is just as useful in the setting
of pseudophakic lens surgery [2224]. In this
approach, one exploits the advanced technology
and exquisite accuracy of the excimer laser. In
a staged manner, one may treat both residual
spherical and astigmatic error following implant
surgery. In Zaldivars original description, a laser-assisted in situ keratomileusis ap was created
before the implant procedure, and then as necessary, the ap was lifted and residual refractive error was corrected with the laser. Today, most
surgeons prefer to perform both the ap and laser
ablation concurrently following cataract surgery,
as needed, reducing the number of unnecessary
aps that would otherwise be created. It has
been my experience that laser-assisted in situ keratomileusis may be performed safely following
IOL surgery at 6 weeks, perhaps earlier. Wound
stability and healing must be conrmed, along
with a stable refractive error. It might be further
argued that custom wavefront-guided ablation is
ASTIGMATISM CONTROL
particularly well suited in the pseudophakic eye

because the dynamic lens component no longer
exists [25]. For most refractive cataract surgeons,
bioptics has become an integral part of the preoperative discussion with the patient, and in my experience its use is required in approximately 10%
of cases, depending on the patients preoperative
refractive error. Finally, conductive keratoplasty
used in an o-label fashion has also recently
been described as a means by which residual hyperopia and hyperopic astigmatism may be eectively reduced following cataract surgery [26].
487
intralimbal incisions must be longer in total arc

length than more centrally placed corneal astigmatic incisions; however, unlike longer radial
keratotomy incisions, they seem to be stable with
regard to refractive eect, and show little sign of
inducing problems, such as dry eye syndrome or
other pejorative eects from corneal denervation
[16]. Their stability may well be caused by the proximity of well-vascularized limbal tissue. There are,
of course, potential complications with any surgical
technique and these are addressed later.
The plan
Limbal-relaxing incisions
The rst description of the astigmatic eect of
nonpenetrating incisions placed near the limbus
dates back to 1898 and is credited to the Dutch
ophthalmologist L.J. Lans [27]. As noted, LRIs
have become the most popular technique used today to reduce pre-existing astigmatism at the time
of cataract surgery. Although my preference is to
use a temporal single-plane clear corneal phaco
incision, one may use LRIs with any type of
phaco incision as long as the astigmatic eect is
known and factored into the surgical plan. LRIs
oer several advantages over astigmatic incisions
placed within the cornea, at smaller optical zones.
These include less chance of causing a shift in the
resultant cylinder axis. This presumably is caused
by a diminished need for precise centration on the
steep meridian. More importantly, there is less of
a tendency to cause irregular corneal attening,
and hence less chance of inducing irregular astigmatism. Technically, LRIs are easier to perform
and more forgiving than shorter and more central
corneal astigmatic incisions, and patients generally report less discomfort. Another important advantage gained by moving out to the limbus
involves the coupling ratio, which describes
the amount of attening that occurs in the incised
meridian relative to the amount of steepening that
results 90 degrees away; paired LRIs (when kept
at or under 90 degrees of arc length) exhibit
a very consistent 1:1 ratio, and elicit little change
in spheroequivalent, obviating the need to make
any change in implant power.
Admittedly, these more peripheral incisions are
less powerful, but are still capable of correcting up
to 3.5 D of astigmatism in the cataract-aged
population. One must keep in mind that the goal
is to reduce the patients cylinder, without overcorrecting or shifting the resultant axis. To achieve
a given amount of correction, these peripheral
Perhaps the most challenging aspect of astigmatism surgery involves the determination of the
quantity and exact location of the cylinder that is to
be corrected, and thereby formulating a surgical
plan. Unfortunately, preoperative measurements
(keratometry, refraction, and corneal topography)
do not always correlate. Lenticular astigmatism
may account for some of this disparity, particularly
in cases where there is a wide variance between
refraction and corneal measurements; however,
some discrepancies are likely caused by the inherent
shortcomings of traditional measurements of astigmatism. Standard keratometry, for example, measures only two points in each meridian at a single
optical zone of approximately 3 mm.
When confounding measurements do arise, one
may compromise and average the disparate readings. For example, if refraction shows 2 D of
astigmatism and keratometry reveals only 1 D, it
is reasonable to correct for 1.5 D. Alternatively, if
preoperative calculations vary widely, one may
defer placing the relaxing incisions until a stable
refraction postimplantation is obtained, and then
correct the astigmatism; LRIs may be safely
performed in the oce in an appropriate treatment-room setting. Corneal topography can be
very helpful when refraction and keratometry do
not agree, and it is increasingly becoming the
overall guiding measurement on which the surgical plan is based. Topography is also helpful in
detecting subtle corneal pathology, such as keratoconus fruste, which likely negates the use of LRIs,
or subtle irregular astigmatism, such as that caused
by epithelial basement membrane dystrophy.
Nomograms
Once the amount of astigmatism to be corrected has been determined, a nomogram must be
consulted to determine the appropriate arc length
488
NICHAMIN
of the incisions. A number of popular nomograms

are currently available [28]. My nomogram of
choice originated from the work of Dr. Stephen
Hollis and incorporates concepts taught by
Thornton [21], particularly his age modiers. As
seen in Table 1, astigmatism is considered to be
with-the-rule if the steep axis (plus cylinder) is between 45 and 135 degrees. Against-the-rule astigmatism is considered to fall between 0 and 44,
and 136 and 180 degrees. One aligns the patients
age with the amount of preoperative cylinder to be
corrected and nds the suggested arc length that
the incisions should subtend.
Paired incisions are preferred to optimize
symmetric corneal attening and they are expressed in degrees of arc rather than chord length.
This is done to diminish overcorrections and
undercorrections for unusually small or large
corneas, because corneal diameter may signicantly impact the relative length of the arcuate
incision and its resultant eect (Fig. 1). An empiric blade depth setting is commonly used when
performing LRIs, typically at 600 mm. This seems
to be a reasonable practice when treating cataract
patients; however, in the setting of refractive lens
exchange surgery or when using presbyopia-correcting IOLs (where ultimate precision is required)
it is my preference to perform pachymetry and use

adjusted blade depth settings and a slightly more
aggressive nomogram (Table 2). Pachymetry
may be performed either preoperatively or at the
time of surgery. Readings are taken over the entire
arc length of the intended incision, and an adjustable micrometer diamond blade is then set to
approximately 90% of the thinnest reading obtained. Renements to the blade depth setting
and nomogram adjustments are often necessary
depending on individual surgeon technique; the
instruments used; and, in particular, the style of
the blade. As a nal note, in eyes that have previously undergone radial keratotomy, the length of
the incisions should be reduced by approximately
50%, and in eyes that have undergone signicant
prior keratotomy surgery, it may be best to avoid
additional incisional surgery and use a toric IOL
or laser technology instead.
Surgical technique
In most cases, the relaxing incisions are placed
at the outset of surgery to minimize epithelial
disruption. The one exception to this rule occurs
when the phaco incision intersects or is
Table 1
Intralimbal relaxing incision nomogram for modern phaco surgery: empiric blade-depth setting of 600 mm
Spherical (up to 0.75 90 or 0.50 180)
Incision design: Neutral temporal clear corneal incision (ie, 3.5 mm or less, single plane, just anterior to vascular
arcade)
Against-the-rule, (Steep axis 044 /136180 )
Paired incisions in degrees of arc
Preoperative cylinder
3040 y
4150 y
5160 y
Nasal limbal arc only
6170 y
7180 y
8190 y
91y
35
55
50
45
40
35
70
65
60
55
45
40
90
80
70
60
50
45
90
85
90
70
60
50
o.z 5 mm o.z 9 mm
Incision design: The temporal incision, if greater than 40 of arc, is made by rst creating a two-plane, grooved
incision (600 m depth), which is then extended to the appropriate arc length at the conclusion of surgery.
0.75
1.50
2.25
3.00
1.25
2.00
2.75
3.75
35
40
45
phaco
With-the-rule, (Steep axis 45 135 )

1.00 1.50
50
45
40
1.75 2.25
60
55
50
2.50 3.00
70
65
60
3.25 3.75
80
75
70
Incision design: Neutral temporal clear corneal along with the
35
30
45
40
35
55
50
45
65
60
55
following peripheral arcuate incisions.
30
40
45
When placing intralimbal relaxing incisions following or concomitant with radial relaxing incisions, total arc length is
decreased by 50%.
489
ASTIGMATISM CONTROL
incision is rst made by creating a shortened LRI

whose arc length corresponds to the width of the
phacoincision and IOL incision. This amounts to
a two-plane grooved phacoincision whose depth is
either 600 mm or has been determined by pachymetry, as described previously. Following IOL
implantation and before viscoelastic removal,
while the globe is still rm, the relaxing incision
is extended to its full arc length as dictated by the
nomogram. When an LRI is superimposed on the
phacotunnel, the keratome entry is accomplished
by pressing the bottom surface of the keratome
blade downward on the outer or posterior edge of
the LRI. The keratome is then advanced into the
LRI at an iris-parallel plane. This angulation
promotes a dissection that takes place at midstromal depth, which helps ensure adequate tunnel length and a self-sealing closure.
Proper centration of the incisions over the steep
corneal meridian is of utmost importance. According to Eulers theorem, an axis deviation of 5, 10, or
15 degrees results in 17%, 33%, and 50% reduction, respectively, in eect [1]. This reduction
in eect holds true for both relaxing incisions and
Fig. 1. Nomogram design. Note relative disparity in incision length between a large and small corneal diameter
if measured in millimeters. Degrees of arc lend consistency irrespective of corneal size.
encompassed within a long LRI. For example, in

the case of high against-the-rule astigmatism
wherein the nomogram calls for a temporal arcuate incision of greater than 40 degrees of arc, the
temporal LRI is superimposed on the (temporal)
phaco incision and if it is extended to its full arc
length at the start of surgery, signicant gaping
and edema may result secondary to intraoperative
wound manipulation. In this setting, the temporal
Table 2
Intralimbal arcuate astigmatic nomogram
With-the-rule (Steep axis 45 135 )
Paired incisions in degrees of arc
Preoperative
cylinder (Diopters)
2030 yo
3140 yo
4150 yo
5160 yo
6170 yo
7180 yo
0.75
1.00
1.25
1.50
1.75
2.00
2.25
2.50
2.75
3.00
40
45
55
60
65
70
75
80
85
90
35
40
50
55
60
65
70
75
80
90
35
40
45
50
55
60
65
70
75
85
30
35
40
45
50
55
60
65
70
80
30
35
35
40
45
50
55
60
65
70
30
35
40
45
45
50
55
60
65
40
45
50
55
60
65
70
75
80
85
35
40
45
50
55
60
65
70
75
80
35
40
40
45
50
55
60
65
70
75
30
35
35
40
45
50
55
60
65
70
Against-the-rule (Steep axis 044 /136180 )

0.75
1.00
1.25
1.50
1.75
2.00
2.25
2.50
2.75
3.00
45
50
55
60
65
70
75
80
85
90
40
45
55
60
65
70
75
80
85
90
Blade depth setting is at 90% of the thinnest pachymetry.
490
NICHAMIN
toric IOLs. Also, increasing evidence supports the

notion that signicant cyclotorsion may occur
when assuming a supine position [29]. For this reason, most surgeons advocate placing an orientation
mark at the 12-oclock or 6-oclock limbus while
the patient is in an upright position. This is particularly important when using injection anesthesia
wherein unpredictable ocular rotation may occur.
An additional measure that may be used to help
center the relaxing incisions is to identify the steep
meridian (plus cylinder axis) intraoperatively using
some form of keratoscopy. The steep meridian over
which the incisions are to be placed corresponds to
the shorter axis of the reected corneal mire. A simple hand-held device, such as the Maloney (Storz,
St. Louis, Missouri; Katena, Denville, New Jersey)
or Nichamin (Mastel Precision, Rapid City, South
Dakota) keratoscope, works well or a more robust
and well-dened mire may be obtained through an
elaborate microscope-mounted instrument, such as
the Mastel Ring of Light (Mastel Precision). Another common way in which the steep meridian is
marked uses a Mendez Ring or similar degree
gauge, which is aligned with the previously placed
limbal orientation mark, and then locating the cylinder axis on the 360-degree gauge.
The LRI should be placed at the most peripheral extent of clear corneal tissue, just inside of the
true surgical limbus. This holds true irrespective
of the presence of pannus. If bleeding does occur,
it may be ignored and will cease spontaneously.
One must avoid placing the incisions further out
at the true surgical limbus in that a signicant
reduction of eect will likely occur because of
both increased tissue thickness and a variation in
tissue composition; these incisions are really intralimbal in nature. In creating the incision, it is
important to hold the knife perpendicular to the
corneal surface to achieve consistent depth and
eect, and help to avoid gaping of the incision.
Good hand and wrist support is important, and
the blade ought to be held as if one were throwing
a dart such that the instrument may be rotated
between thumb and index nger as it is being
advanced, leading to smooth arcuate incisions.
Typically, the right hand is used to create incisions
on the right side of the globe, and the left hand for
incisions on the left side. In most cases it is more
ecient to pull the blade toward oneself, as
opposed to pushing it away.
The extent of arc to be incised may be demarcated in several dierent ways. My preferred
method makes use of a modied Fine-Thornton
xation ring (the Nichamin Fixation Ring and
Gauge, available from Mastel Precision, Storz,

Rhein Medical, Tampa, Florida). This instrument
serves to xate and position the globe to optimize
incision placement, and to delineate the extent of
arc to be incised. One visually extrapolates from
the limbus to marks on the surface of the ring.
Each incremental mark is 10 degrees apart, and
bold hash marks (180 degrees) opposite to each
other serve to align and center the incision over
the steep meridian. This approach obviates the
need to ink and physically mark the cornea. If
one desires, particularly when rst gaining experience with LRIs, a two-cut radial keratotomy (RK)
marker may be used to place ink marks upon the
cornea to show the exact extent of arc that is to be
incised, in conjunction with the xation ringgauge (Fig. 2). Alternatively, various press-on
markers are available, such as the Dell-Nichamin
Marker or Nichamin-Kershner Marker manufactured by Rhein Medical. ASICO and many other
instrument companies also oer a full line of dedicated markers, rings, and blades for performing
LRIs.
Various knives have been designed specically
for this application, ranging from disposable steel
blades to exquisite gemstone diamond knives.
Synthetic (and less expensive) diamond materials
are also available and are intended for limited
reuse. My preference is for diamond blade technology, which incorporates a single small and
arced footplate for enhanced visualization at the
limbus (Mastel Precision, Storz). Two models are
available, one with a preset depth of 600 mm, and
the other with an adjustable micrometer handle,
Fig. 2. The Nichamin Fixation Ring and Gauge serves

both to xate the globe and delineate the extent of arc
to be incised; a two-cut radial marker may be used to
mark the extent of arc to be incised, and the Mastel Nichamin Force AK Diamond Blade with preset depth of
600 mm. (Courtesy of Mastel Precision, Rapid City, SD;
with permission.)
ASTIGMATISM CONTROL
which is preferred for refractive lens exchange

(RLE) surgery and when using presbyopiacorrecting IOLs with cataract patients (Fig. 3).
Another less common method of creating
peripheral relaxing incisions is to use a device
such as the Terry/Schanzlin Astigmatome (Oasis
Medical, Glendora, California), which circumvents the need to create a free-hand incision.
This trephine-like device has been designed to
produce consistent and symmetric peripheral arcuate corneal-relaxing incisions. It uses a vacuum
speculum that mates with various reusable templates that are selected based on the amount of astigmatic correction that is desired. The incision is
created by simply turning a disposable steel blade
unit that ts inside of the template.
Complications
LRIs are proving to be a safer and more
forgiving approach to managing astigmatism as
compared with more central corneal incisions.
Nonetheless, as with any surgical technique,
potential complications exist, and several are
listed in Box 1. Of these, the most likely to be encountered is the placement of incisions on the
wrong axis. When this occurs, it typically takes
the form of a 90-degree error with positioning
on the opposite, at meridian. This results in an
increase and likely doubling of the patients preexisting cylinder. Compulsive attention is required
in this regard. The surgeon ought to consider
using safety checks to prevent this frustrating
complication from occurring, such as having
a written plan that is brought into the operating
room and is kept visible and properly oriented. Incisions are always placed on the plus () cylinder
axis, and opposite to the minus () cylinder axis.
Although very rare, corneal perforation is
possible. This may be caused by improper setting
Fig. 3. Mastel Prole Blade. (Courtesy of Mastel Precision, Rapid City, SD; with permission.)
491
Box 1. Potential problems

Infection
Weakening of the globe
Perforation
Decreased corneal sensation
Induced irregular astigmatism
Misalignment or axis shift
Wound gape and discomfort
Operating on the wrong (opposite)
axis
of the blade depth, or as a result of a defect in the

micrometer mechanism. This latter problem may
arise after repeated autoclaving and many sterilization runs. Periodic inspection and calibration is
warranted, even with preset single-depth knives.
When encountered, unlike radial microperforations, these circumferential perforations rarely
self-seal and likely require placement of temporary
sutures.
Enhancement techniques
LRIs lend themselves well to in-oce touchups. Although some surgeons place or extend
incisions at the slit-lamp, it is my preference to use
a small operating microscope and to perform the
procedure within a dedicated treatment room. It
has been my experience that this provides far
better surgical control and patient comfort. In the
case of residual astigmatism without prior incisional correction, one uses the same technique and
nomogram as described previously.
In the case of an undercorrection following
previous LRIs, one should inspect the length and
positioning of the incisions. Placement of the
incisions too far out into the true surgical limbus
and beyond clear cornea often leads to undercorrection. If this is the case, new incisions may be
placed inside of the original LRIs, but with a modest
reduction in arc length from that which is dictated
by the nomogram. If the incision placement seems
to be appropriate then one can simply extend the
original LRIs. When faced with an overcorrection,
one should resist the temptation to place additional
incisions in the opposite meridian. This can lead to
an unstable cornea with unpredictable refractive
results, or worse, induce irregular astigmatism.
Rather, one should consider nonincisional modalities, such as photorefractive keratectomy or laserassisted in situ keratomileusis.
492
NICHAMIN
To correct unusually high levels of astigmatism, LRIs may be used in conjunction with a toric
IOL or excimer laser surgery (bioptics). In several
rare cases I have combined all three modalities
and safely corrected up to 9 D of pre-existing
astigmatism.
Summary
Renement of the refractive outcome may
arguably be the single most pressing and important
challenge faced by todays cataract surgeon. Along
with spherical error, pre-existing astigmatism may
now be safely and eectively reduced at the time of
cataract surgery. Astigmatic relaxing incisions are
the most common method used to accomplish this
goal. By moving these incisions out to an intralimbal location, the complications and diculties
associated with astigmatic keratotomy have been
greatly reduced. Toric IOLs represent another
viable mode by which the surgeon may decrease
or eliminate cylinder. Enhancement techniques are
also important to help reduce residual astigmatism.
LRIs may be used in a similar fashion, postoperatively, to accomplish this, or bioptics may be used
with excimer laser technology. The future will
undoubtedly yield further breakthroughs, such as
wavefront-guided customized IOLs or perhaps
laser-adjustable implants, all leading to better
refractive outcomes and improved quality of vision
for pseudophakic patients.
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
References
[1] Abrams D. Ophthalmic optics and refraction. In:
Duke-Elder SS, editor. System of ophthalmology.
St. Louis: Mosby; 1970. p. 6714.
[2] Novis C. Astigmatism and toric intraocular lenses.
Curr Opin Ophthalmol 2000;11:4750.
[3] Trindade F, Oliveira A, Frasso M. Benet of
against-the-rule astigmatism to uncorrected near
acuity. J Cataract Refract Surg 1997;23:825.
[4] Savage H, Rothstein M, Davuluri G, et al. Myopic
astigmatism and presbyopia trial. Am J Ophthalmol
2003;135:62832.
[5] Masket S, Tennen DG. Astigmatic stabilization of
3.0 mm temporal clear corneal cataract incisions.
[6] Sun XY, Vicary D, Montgomery P, et al. Toric intraocular lenses for correcting astigmatism in 130 eyes.
[7] Till JS, Yoder PR, Wilcox TK, et al. Toric intraocular lens implantation: 100 consecutive cases. J Cataract Refract Surg 2002;28:295301.
[8] Ruhswurm I, Scholz U, Zehetmayer M, et al. Astigmatism correction with a foldable toric intraocular
[19]
[20]
[21]
[22]
[23]
[24]
[25]
lens in cataract patients. J Cataract Refract Surg

2000;26:10227.
FDA approves AcrySof toric IOL for cataract
patients. Fort Worth (TX): Alcon Laboratories,
Inc. Ophthalmology Times November 1, 2005.
Food and Drug Administration. Available at: http://
www.fda.gov/cdrh/pdf/p930014s015.html. Accessed
February 27, 2006.
Osher RH. Combining phacoemulsication with
corneal relaxing incisions for reduction of preexisting astigmatism. Presented at the annual meeting
of the American Intraocular Implant Society. Los
Angeles, 1984.
Maloney WF. Refractive cataract replacement:
a comprehensive approach to maximize refractive
benets of cataract extraction. Presented at the annual meeting of the American Society of Cataract
and Refractive Surgery. Los Angeles, 1986.
Osher RH. Transverse astigmatic keratotomy combined with cataract surgery. Ophthalmol Clin North
Am 1992;5:71725.
Budak K, Friedman NF, Koch DD. Limbal relaxing
incisions with cataract surgery. J Cataract Refract
Surg 1998;24:5038.
Muller-Jensen K, Fischer P, Siepe U. Limbal relaxing incisions to correct astigmatism in clear corneal
cataract surgery. J Refract Surg 1999;15:5869.
Nichamin LD. Changing approach to astigmatism
management during phacoemulsication: peripheral
arcuate astigmatic relaxing incisions. Presented at
the annual meeting of the American Society of Cataract and Refractive Surgery. Boston, May 20, 2000.
Koch MJ, Kohnen T. Refractive cataract surgery.
Curr Opin Ophthalmol 1999;10:105.
Kaufmann C, Peter J, Ooi K, et al. Limbal relaxing
incisions versus on-axis incisions to reduce corneal
astigmatism at the time of cataract surgery. J Cataract Refract Surg 2005;31:22615.
Lever J, Dahan E. Opposite clear corneal incisions
to correct preexisting astigmatism in cataract surgery. J Cataract Refract Surg 2000;26:8035.
Nichamin LD. Opposite clear corneal incisions.
Thornton SP. Radial and astigmatic keratotomy:
the American system of precise, predictable refractive surgery. Thorofare (NJ): Slack; 1994.
Zaldivar R, Davidorf JM, Oscerow S, et al. Combined posterior chamber phakic intraocular lens
and laser in situ keratomileusis: bioptics for extreme
myopia. J Refract Surg 1999;15:299308.
Nichamin LD. Bioptics: expanding its role to pseudophakia. Presented at the annual meeting of the
American Society of Cataract and Refractive Surgery. Philadelphia, June 1, 2002.
Nichamin LD. Expanding the role of bioptics to the
pseudophakic patient. J Cataract Refract Surg 2001;
27:13434.
Nichamin LD. Bioptics for the pseudophakic patient. In: Gills JP, editor. A complete guide to
ASTIGMATISM CONTROL
astigmatism management. Thorofare (NJ): Slack;

2003. p. 379.
[26] Nichamin LD. Results of CK after cataract surgery.
Presented at Annual Meeting of the American Society of Cataract and Refractive Surgery. San Diego,
May 2, 2004.
[27] Schimmelpfenning BH, Waring GO. Development
of radial keratotomy in the nineteenth century. In:
493
Waring GO, editor. Refractive keratotomy for myopia and astigmatism. St Louis: Mosby-Year Book;
1992. p. 1745.
[28] Gills JP. A complete guide to astigmatism management. Thorofare (NJ): Slack; 2003.
[29] Swami AU, Steinert RF, Osborne WE, et al. Rotational malposition during laser in situ keratomileusis. Am J Ophthalmol 2002;133:5612.
Management of Vitreous Loss and Dropped

Nucleus During Cataract Surgery
Lisa Brothers Arbisser, MDa,b,*, Steve Charles, MDc,d,
Michael Howcroft, MDa, Liliana Werner, MD, PhDb
a
Eye Surgeons Associates P.C., Iowa and Illinois Quad Cities, 777 Tanglefoot Lane, Bettendorf, IA 52722, USA
b
Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah,
50 North Medical Drive, Salt Lake City, UT 84132, USA
c
Department of Ophthalmology, University of Tennessee, 6401 Poplar Avenue, Suite 190, Memphis, TN 38119, USA
d
Department of Ophthalmology, Columbia College of Physicians and Surgeons, 630 West 168th Street,
Room 218, New York, NY 10032, USA
Vitreous loss is inevitable. Given the variety of

pathology presented by the human eye, even the
best surgeons have some complications. Despite
the application of vigilant maneuvers, broken
capsules still occur at a rate between 0.45% for
very experienced surgeons [1] and up to 14.7% for
residents in training [2]. The frequency of retained
lens fragments is estimated at 0.3% to 1.1% [3,4].
The challenge of cataract surgery is to minimize
the risk of complications and to manage optimally
complications that do occur.
Intraoperative complications can be placed
into three categories: (1) broken capsule or loss
of zonular integrity with an intact anterior hyaloid; (2) vitreous prolapse (dened as vitreous
within the connes of the anterior chamber); and
(3) vitreous loss through the incision. Retained
lens material adds to the complicated picture. The
likelihood of postoperative sequelae increases
signicantly with each of these categories, and
motivates the surgeon to recognize and limit
damage at the earliest stage.
This article provides a review and update of
techniques for handling complications when they
occur. The management of vitreous loss and
retained lens fragments is the biggest determining
factor inuencing the likelihood of an excellent
visual outcome [5].
E-mail address: drlisa@arbisser.com (L.B. Arbisser).
Sequelae
Complications of vitreous loss at cataract
surgery are as follows:
Cystoid macular edema
Retinal detachment
Persistent increase in intraocular pressure
Intraocular lens dislocation or subluxation
Choroidal detachment
Endophthalmitis
Suprachoroidal hemorrhage
Corneal edema
Retinal detachment may occur at the rate of 1%
after uncomplicated cataract surgery and increases
to between 6.8% and 8.6% following intraoperative vitreous loss [6]. This jump in incidence is
related to vitreoretinal traction at the time of the
primary surgery or later secondary to biochemical
and structural changes in the vitreous accelerating
the development of a postoperative acute posterior
vitreous detachment. The incidence of retinal detachment increases to 14.5% when lens fragments
are retained. This statistic includes eyes with giant
retinal tears [7]. Eyes with giant retinal tears have
a particularly bad prognosis for successful reattachment and visual recovery [8]. It is not the dropped nucleus or vitreous loss that directly causes
most vision threatening complications but their inappropriate management risks retinal detachment.
By far the most common sequela of complicated surgery is an increased risk of cystoid
doi:10.1016/j.ohc.2006.07.002
496
ARBISSER
macular edema. Cystoid macular edema seems

related to the increased levels of inammatory
mediators released by iris and ciliary body uveal
tissues, which are increased when the anterior
hyaloid face is ruptured and when there are
retained lens fragments. Comorbidities leading
to poor visual outcome include acute and chronic
glaucoma and corneal edema. The incidence of
these sequelae can be minimized by appropriate
management of complicated cataract surgery both
intraoperatively and postoperatively.
In the heat of the battle one is least likely to be
logical and analytical. It behooves all to prepare
a mental ow chart of maneuvers and a sequence
of decisions before entering a patients eye. The
well-prepared surgeon anticipates potential problem cases, as listed below, and keeps the required
instrumentation on stand-by. This article provides
a framework to maximize chances of an optimal
result.
Pseudoexfoliation syndrome
Traumatic cataract
Fellow eye of complicated cataract surgery
Eyes with transillumination defects in iris
Previously vitrectomized eyes
Eyes with phacodonesis
Dense brunescent cataracts
Hypermature cataracts
Very aged patient
Intraoperative oppy iris syndrome
High ammetropia
Prevention
An ounce of prevention is worth a pound of
cure. One heard it from their mother as a youngster, and the adage remains valuable today in
every endeavor. Each step of cataract surgery is
built on the solid foundation of the prior maneuver. If one has misjudged the patients ability to
tolerate the choice of anesthesia (or the lack
thereof), or ones own ability to communicate
and work on a moving target, the stage has been
set for disaster. Clinicians advocate always having
a plan B (ie, standby intravenous anesthesia or
sub-Tenons injection intraoperatively).
Wound construction is central to the maintenance of the chamber. Minimal leak through the
main incision and the paracentesis results in
a deep chamber and minimization of surge and
turbulence. An understanding of the uidics and
dynamics of the phacoemulsication machine
used is critical for the clinician to respond to
et al
untoward occurrences and to optimize the intraocular environment.

Anticipate poor zonular integrity preoperatively in pseudoexfoliation syndrome, traumatized
eyes, vitrectomized eyes, and the very elderly and
intraoperatively by the ease with which the anterior
capsule can be perforated and the response to
applied vectors of force during the continuous
circular capsulotomy (CCC). Be prepared with
techniques to minimize zonular stress, such as
phaco chop or supracapsular phaco. Keep capsular
tension rings available. Extra dispersive viscoelastic (ophthalmic viscosurgical device [OVD]) and
compartmentalization of the area over zonulolysis
with viscoadaptives can save the day and prevent
egress of vitreous around defects. Capsular suspension hooks may be rarely needed. Maintain a at
lens dome during capsulorrhexis. The choice of
a more viscous OVD in the settings of capsule
elasticity as in the pediatric cataract or with
spherical lens morphology as in the high hyperope
is helpful. Regrasp the CCC edge frequently so the
vector force is always in the right direction in case of
sudden patient movement during creation of the
CCC under topical anesthesia. Improve visualization of the lens capsule in hypermature cataracts by
using capsular dye. In myopes and vitrectomized
eyes prevent or relieve reverse pupillary block to
avoid an overdeep anterior chamber. Hydrodissection and delineation are risky in the face of a very
shallow anterior chamber. Be careful to avoid
posterior capsular rupture secondary to bag overination. Risk is reduced by burping the bag as
the uid wave progresses thereby preventing tamponade of the CCC edge by the nucleus. Adequate
mobility of lens material inside the bag must be
established before initiating phaco to avoid stress
on the zonules and a complicated disassembly
phase. Beware of capsular-cortical adhesions visible as discreet broad opacities. These may contribute to capsule rupture on rotation if not gently lysed
by hydrodissection or viscodissection.
During phacoemulsication keep the phaco tip
in the safe zone within the center of the pupil as
much as possible. Only use ultrasound to gain
purchase on fragments in the periphery and limit
emulsication only to the safe zone. Always place
the nondominant hand instrument under the phaco
tip to avoid contact with the posterior capsule in
case of surge when emulsifying the last fragments.
Silicone sleeves for irrigation and aspiration
provide a good seal and a controlled chamber
while removing cortex. An open bag fornix cannot
be achieved with a metal sleeve because the rigid
VITREOUS LOSS, DROPPED NUCLEUS, CATARACT SURGERY
tube permits leakage around it. Remove the

subincisional cortex rst while the bag is held
open by the remaining more easily accessed
cortical material. During insertion of the intraocular lens (IOL) be certain the capsular bag is
suciently concave to avoid snagging the posterior capsule and disinserting proximal zonules.
Try to maintain positive pressure in the anterior segment at all times. This habit becomes
especially valuable when patients Valsalva, as
with unpredicted coughing. Do not withdraw the
phaco tip. Instead, have the assistant hold the
forehead rmly down against the headrest, ax
the hands to the patients face, and stay in foot
position one. In this way positive pressure is
maintained and the risk of complications reduced.
Early recognition
The index of suspicion must be high to
appreciate the early signs of complication and
allow optimum corrective action. Something as
subtle as a bounce of the iris diaphragm, change in
anterior chamber depth, or a change in pupil size
may be caused by the sudden redistribution of
uid associated with a break in the posterior
capsule.
Assuming that one has checked the phaco
parameters and eliminated the possibility of
a clogged tip, loss of followability of lens material
and phaco eciency during phaco or irrigation
and aspiration is a reliable sign that vitreous is
present. It is vital that aspiration be discontinued
because vitreous cannot be phacoed and continued traction is transmitted to the retina.
Phacoemulsication energy may give the surgeon
the impression that it can be used for vitrectomy
but it only liquees the hyaluronate gel while
leaving the collagen bers intact. It is very unsafe
to place a phacoemulsier in the vitreous to
remove the nucleus or lens fragments. Even low
ow or suction levels result in unsafe vitreoretinal
traction when the tip engages vitreous collagen
bers.
Tilting of the lens equator, loss of the ability to
rotate the nucleus, or a deepening of the anterior
segment during emulsication are ominous signs
of impending loss of lens material into the
posterior segment. These signs deserve immediate
attention.
Anything between the lips of the incision
prevents an internal seal from forming. In
a well-constructed wound that fails to prove
497
watertight, after irrigating the tunnel to eliminate

debris, suspect an occult strand of vitreous insinuating itself invisibly and take steps to identify
it. A peaked pupil or movements of the pupil edge
with remote touch are classic signs not to be
ignored.
Early response
When one touches a hot stove the innate response is withdrawal. One must control that
natural response to pull out of the eye when
recognizing a complication. The phaco tip between
the lips of the wound controls the intraocular
environment. On recognition of a problem go
to foot position zero to maintain the anterior
chamber but do not move the phaco tip.
Remove the nondominant hand instrument
from the paracentesis, which does not result in
chamber instability. After removing the second
instrument, prepare to inject OVD through the
paracentesis incision. Once the cannula is past
the internal Descemets membrane while in foot
position zero and instill OVD (dispersive ideally)
through the paracentesis between the posterior
capsule and any remaining lens fragments until
the anterior chamber is normal depth. Only then
can the phaco tip be withdrawn from the eye
without anterior chamber collapse. If the chamber is permitted to collapse in the presence of
a tear in the capsule, vitreous pressure extends
the tear and the stage of complication may
progress from capsular rupture to vitreous prolapse or from prolapse to vitreous loss. Vitreous
always follows the path of lowest pressure.
With the incision eectively closed and the
condition static, it is time to assess the situation,
inspect, relax, and think. Announce the delay to
the operating room sta to avoid having the next
patient, who may be on the cart in the next room,
prepared and draped prematurely. Remember,
too, to relax yourself and your voice. Many times
family is watching and patients are awake, alert,
and aware of what is going on and they need to
know that you are in calm control of the situation.
Once the complication is identied the sta should
be able to spring into action with a prepared and
well-rehearsed plan. The vitrector should be
seamlessly assembled with predetermined cutting
and aspirating parameters. The surgeon should be
familiar with the operation of the foot pedal in
vitrectomy mode, which is always cutting before
vacuum. Additional instruments and medications
498
ARBISSER
should be included in a vitrectomy kit with the

items needed to respond to the situation assembled as follow:
Vitrector set
Microvitreoretinal blade
Chamber maintainer
Washed Kenalog (instructions)
Lidocaine for subconjunctival injection
Cautery
8-0 Vicryl suture (unless sutureless technique is
used with 23 gauge)
Kansas forceps
Caliper
Vectus
Miochol E
Conjunctival scissor
Postoperative medicines (subconjunctival injection or oral)
Alternate implant
Ocular hypotensives
Antibiotic prophylaxis of choice
Anesthesia
In potentially dicult cases or for patients who
cannot follow directions during an indirect retinal
examination, the surgeon may wish to consider
peribulbar anesthesia preoperatively. For patients
who cannot be relied on to remain still during the
procedure (pediatric, retarded, or severely claustrophobic patients) the surgeon may consider
general anesthesia. Topical anesthesia is not,
however, incompatible with managing complications. Without pain receptors, the vitreous cannot
hurt. Topical or intracameral anesthesia may
not require supplementation except when the pars
plana incision is used, or the wound needs to be
signicantly enlarged. A bleb of subconjunctival
lidocaine 2% over the intended scleral incision
before incising a fornix ap for pars incision is
appropriate. A cellulose sponge soaked in anesthetic as a pledget held directly in contact with the
sclera for 30 seconds may also suce.
Avoid reintroduction of intracameral unpreserved 1% Xylocaine. Although there is evidence
that there is no permanent damage to the neuroretina [9], there is a transient amaurosis as a result
of contact of the anesthetic with the posterior segment through broken zonules or a capsule rupture. This can be disconcerting or even
frightening to both patient and surgeon.
The availability of intravenous sedation is
desirable to help the patient cooperate or to
et al
make the time pass more quickly during a prolonged case. Using a calm voice (vocal local) and
having an operating room team that can seamlessly prepare for a vitrectomy is extremely helpful
in minimizing patient anxiety without sedation.
If these measures fail and the patient looses the
ability to cooperate akinesia may be required.
First be sure the incisions are closed to avoid loss
of the anterior chamber. A snip down to bare
sclera and use of a Greenbaum or Masket cannula
to perform sub-Tenons or parabulbar block
resulting in akinesia without sharp injection is
optimal. This reduces the risk of retrobulbar
hemorrhage, particularly untimely in this setting.
Damage control
After the existing complication is recognized,
one next controls the damage by compartmentalization with a dispersive OVD. If the rent in the
posterior capsule is central or paracentral, this
must be converted to a circular capsulorrhexis if
at all possible. Even when the posterior tear
appears round, it still lacks resistance to extension
unless it is converted. Insinuating a small amount
of OVD through the tear to push back the intact
vitreous face is helpful. While zooming the microscope to high magnication, the edge of the
tear may be grasped with forceps and the proper
centripetal vector (directed centrally) should be
applied to minimize the size of the opening. If
there is no edge it may be necessary to start o
with a tiny cut made with a microscissor. Accomplishing this challenging maneuver results in
a stable tear and permits the use of an in-thebag implantation after clean up.
When the complication is recognized, posterior
chamber nuclear fragments must be raised above
the iris plane into the anterior chamber. In the
presence of miosis, pupil stretch or microsphincterotomies are helpful. It is imperative to make
the best eort to maintain the integrity of the
CCC for implantation of the IOL. If it restricts
a large fragment from forward movement the
CCC can be enlarged. Under OVD control,
a tangential cut is made and forceps used to
enlarge the continuous tear to the minimum
eective size. Alternatively, radial relaxing incisions are the default to prevent a tear extending
around the equator to the posterior capsule. Next,
maneuvers to dial, lift, cantilever, or oat the
nucleus or nuclear fragment with OVD can be
used making them accessible for removal.
If the lens fragment is below the posterior

capsule and has descended into the posterior
segment, at the time of this writing there is
controversy among anterior segment surgeons as
to its management. No controversy exists among
vitreoretinal surgeons or this articles authors: the
fragments should be left in place for later removal
with a full three-port pars plana vitrectomy and
fragmenter as needed.
Dropped nucleus during cataract surgery

Contrary to the belief of some surgeons, lens
material cannot damage the retina. Jagged pieces
of very hard nucleus can oat around the vitreous
cavity and even rest on the retinal surface never
causing retinal damage unless manipulated by
a surgeon. Lens material is only slightly denser
than vitreous and the modulus of water is such
that movement of the lens material during a saccade does not result in retinal damage.
Posterior-assisted levitation was recommended
by Kelman [10] to raise a dropped nucleus into the
anterior chamber for removal. Inserting a spatula
through the pars plana creates positive pressure,
which pushes the vitreous anteriorly creating unsafe vitreoretinal traction. Anterior displacement
of lens material with a spatula also creates excessive vitreoretinal traction. Passing a spatula
through the pars plana and the choroid in a soft
eye may result in suprachoroidal hemorrhage
with potentially catastrophic results. Injecting viscoelastic through the pars plana to support lens
material after capsular rupture as suggested by
Chang and Packard [11] also may risk suprachoroidal hemorrhage and invariably induces anterior
displacement of the vitreous. In a laboratory with
human eye bank eyes both with a whole eye and
a Miyake analysis [12] performed by two of the
authors (LBA, LW) posterior assisted levitation
was tested.
The Miyake view was not ideal for allowing
vitreous prolapse; however, it aorded a wonderful view of the mechanics of viscolevitation. When
placing the Viscoat cannula through the pars
plana incision, it was very dicult, if not impossible, to place it reliably between vitreous and
dropped nucleus. It was even challenging to place
the cannula under rather than into the dropped
nucleus. Also observed were fragments being
directed laterally under the iris, undetectable
from the usual surgeons view. Based on these
ndings, the impression was conrmed that the
499
risk of retinal damage through vitreous traction or

leaving residual material regardless of the use of
this maneuver outweighed the benet. The authors advocate against this technique.
If a capsular defect is observed and the nucleus
has not dropped, Viscoat injected through the
limbus should be used to create a barrier over the
capsular defect. These authors do not recommend
viscolevitation from the pars plana.
Some surgeons have recommended using irrigation to mobilize the nucleus anteriorly after it
has fallen in the vitreous cavity. This too is a very
unsafe method. Remember that Machemer and
Norton [13] and previously Foulds [14] used jets
of balanced salt solution to create retinal breaks
in their experimental retinal detachment model.
A lens loop has also been recommended as
a tool to retrieve a dropped nucleus from the
vitreous cavity. This method can also result in
retinal breaks because vitreous engaged in the
loop while attempting to lift the nucleus results in
unsafe vitreoretinal traction.
There are literally scores of papers in the
literature documenting the dangers of shing
for lens fragments [1518]. If the nucleus drops,
the surgeon must focus on safe management of
the vitreous, lens implantation, and the wound.
It is far better practice to have a vitreoretinal specialist perform vitrectomy followed by removal of
lens material with the fragmenter as needed. Minimal requirements include a relatively clear cornea, a widely dilated pupil, a trained surgeon
and sta, endoillumination, a cutter that operates
at 1500 cuts per minute or greater, a fast Venturi
suction system, and a fundus contact lens or wide
angle visualization system. It is highly unlikely
that a cataract surgery setting can rapidly and
eciently meet these requirements.
The timing of the secondary vitrectomy and
fragmenter removal of the dropped nucleus is
determined on an individual case basis. Although
the eye sometimes tolerates small amounts of lens
material, the chances of chronic inammation or
ocular hypertension are high. A vitreoretinal
surgeons availability to team with the anterior
segment surgeon at the same surgery or on the
same day may prove ideal both emotionally for
the patient and structurally for the eye [1921].
Early vitrectomy (fewer than 3 weeks postoperatively) was associated with better visual results,
whereas late vitrectomy resulted in limited visual
acuity in a higher percentage of patients and increased the risk for glaucoma and retinal detachment [22]. This may be caused in part by
500
ARBISSER
selection bias. Some cases may require delay to

permit clearing of corneal edema for surgical visualization. In cases with markedly elevated intraocular pressure refractory to medical management,
urgent surgical intervention may be indicated. In
general, surgery within 2 weeks is probably prudent [5,15].
The anterior segment surgeon may be held to
the standard of care of the vitreous surgeon when
crossing the line into the posterior segment. It is
never pleasant to need two surgeries to achieve the
goal that one was to accomplish, but the preponderance of evidence shows that this course
provides the best long-term outcomes. Patients
should be counseled accordingly during preoperative informed consent.
The cataract surgeons job is to nish the case
with a clean anterior segment, a well-placed IOL,
and a secure closure paving the way for the
vitreoretinal surgeon if needed. Careful followup, honest communication with the patient, and
appropriate referral almost always lead to a happy
result. Now that the eye has been stabilized and
the damage controlled a plan must be formulated
to complete the case for the optimal outcome.
et al
environment, care must be taken to establish

adequate ow just before activating ultrasound
energy to avoid wound burn.
If a stable capsular tear and compartmentalized vitreous are not the prevailing conditions,
conversion to extracapsular extraction technique
should be pursued. Choose the incision based on
the size of the remaining fragments. If the
fragment is judged to t through an opening of
4 mm or less, the clear corneal incision can be
used. Any longer incision requires at least one
suture, which increases postoperative astigmatism
and prolongs healing time. For this reason it is
advisable to ensure that the clear corneal incision
is watertight and abandon it as though it were
merely a super paracentesis. Move superiorly and
perform an adequate limbal or scleral tunnel
incision appropriate to the fragment size. Do not
express with external pressure as used in primary
extracapsular surgery. That technique depends on
an intact vitreous body and, in this case, would
express vitreous along with the nucleus. Instead,
remove the fragment with a cystotome used as
a pick, forceps, such as a Kansas forceps, or
a vectus, something to glide it out, preferably
under an OVD sandwich always mindful of
endothelial integrity.
To phaco or convert to extracapsular extraction

Strict conditions exist for safely completing the
removal of nuclear fragments with ultrasound in
the setting of vitreous prolapse. It is essential there
be no admixture of vitreous and lens material.
Vitreous is preferentially attracted to the phaco
port displacing nucleus and preventing aspiration
of lens material. More important than the resulting ineciency is the danger of placing traction on
the vitreous, with a high likelihood of retinal tear
and detachment. Unless vitreous can be isolated
and compartmentalized away from lens fragments, the phaco handpiece should not be used
to complete the removal of the nucleus.
The second condition required is the presence
of a controlled capsule tear. This must be adequately covered by OVD, a lens glide, or the iris to
minimize the risk of forcing nuclear fragments
posteriorly or displacing vitreous. Acetylcholine
(Miochol E) can be used to bring the pupil down
behind the fragment.
When the decision is made to phaco, a slow
motion technique should be used with low-ow,
moderate vacuum and appropriate pulses of
energy to promote followability and to minimize
chatter. Because this takes place in an OVD-lled
Vitreous management
Because vitreous is virtually invisible, preservative-free triamcinolone acetate (Kenalog) particulate marking of the vitreous should be used to
identify its presence and to delineate the extent of
prolapse. This huge advance in the management
of complications cannot be overestimated. The
technique was rst suggested by Peyman but
published by Burk and coworkers [23] in the anterior segment literature. Most surgeons recommend washing the Kenalog to remove
preservatives that may be toxic to the endothelium. When the suspension is irrigated into the anterior chamber it sticks to the vitreous matrix but
washes out of OVD or balanced salt solution and
it has the eect of throwing a sheet over a ghost
guiding vitreous removal and providing a secure
end point for its removal (Fig. 1). Care should
be taken to remove as much triamcinolone as possible by the conclusion of the case because some
patients may show a steroid response of ocular
hypertension. Even when no obvious suspension
remains there is a desirable anti-inammatory
501
Low suction levels and low ow rates are safer

because they produce less vitreoretinal traction
because of uncut collagen bers traveling through
the cutter. The suction or ow rate should be
slowly increased until vitreous starts being removed, while always using the highest cutting rate
available. The cutter should be held stationary or
advanced into the vitreous while suction is applied
to reduce traction; it is unsafe to pull back on the
probe while the foot pedal is in position three with
vacuum engaged. The cutter tip should always be
in view.
Fig. 1. Kenalog identication of vitreous.
Laboratory ndings
therapeutic eect along with the diagnostic
advantage.
Cellulose sponges are still used by many
surgeons for anterior vitrectomy and for testing
for vitreous in the anterior chamber, in the
wound, or on the iris. This was rst introduced
in 1968 [24]. Leading vitreoretinal surgeons have
universally recommended against cellulose sponge
vitrectomy for three decades because it inherently
causes marked instantaneous vitreoretinal traction. Traction on the anterior vitreous is particularly dangerous because of proximity to the
strong, permanent vitreoretinal adherence at the
vitreous base and the fact that peripheral retina
has approximately 1/100 the tensile strength of
posterior retina. The sponge produces traction
both by wicking and by lifting to cut the vitreous
strand.
The wound should not be swept with a spatula.
This produces vitreoretinal traction with one end
of the collagen bers entrapped in the wound and
the other end adherent to thin peripheral retina at
the vitreous base. The vitreous cutter should be
used to amputate any posterior connection to
wound-entrapped vitreous. In some instances
OVD can be used to reposit vitreous.
Unlike scissors, which cause traction, vitreous
cutters section vitreous collagen bers by shearing
as the inner needle moves past a port in the outer
needle. Fast cutting (800 cuts per minute and
greater) reduces vitreoretinal traction as collagen
bers ow through the port. The smaller the
average cut ber length, the less vitreoretinal
traction that is produced. Fast cutting also limits
ow because the port is temporarily obstructed as it
cycles open and closed increasing uidic stability.
This is analogous to the anterior chamber stability
produced by high-vacuum, low-ow phaco.
The authors tested various methods to remove

prolapsed and lost vitreous in cadaver eyes. The
anterior segment vitrector of the Inniti phacoemulsication machine (Alcon, Irvine, California)
cuts at 800 cuts per minute and the air pump
from the Accurus posterior vitrectomy machine
(Alcon) were used.
With both Miyake preparations and with
whole eyes the authors performed vitrectomy for
prolapsed and lost vitreous with two techniques:
anterior clear cornea vitrectomy under air and
pars plana partial vitrectomy with anterior balanced salt solution irrigation. Kenalog tattooed
the vitreous to facilitate visualization [25].
One of the goals was to assess whether one
could be thorough and ecient with air in the
anterior chamber. The motivation was to nd
a way to keep tenuous anterior segment surgeons
from having to learn a pars plana approach
without sacricing its benets. The authors are
totally convinced that the pars plana approach
with balanced salt solution is superior to the
standard limbal approach most commonly used
both by viewing vitreous removal when Kenalogstained by the surgeons view and by the Miyake
view [26,27]. The authors used the Accurus to
pump air at several intraocular pressures through
a chamber maintainer anteriorly and the Inniti
vitrector handpiece with a chamber maintainer
for inow through a clear corneal paracentesis.
A tight-tting incision through the clear cornea
was fashioned with the 20-gauge microvitreoretinal blade.
Although the authors removed vitreous eciently under the air bubble, visualization was
compromised. The air-vitreous interface could
only be seen once the Viscoat in the anterior
chamber (which is normally used to stabilize the
502
ARBISSER
chamber when the complication is recognized)

was nally suciently removed to allow for
a complete bubble. Loculation of the bubble was
a signicant factor aecting eciency. Also, the
bubble could leak out of a slightly too large
incision. This impedes chamber maintenance and
pressure control. It also was dicult to control the
bubble, which sometimes loculates into the vitreous cavity leaving air out of sight (except in the
Miyake view). This may be a potential mechanism
for vitreous displacement and traction on the
retina or vitreous base. Lastly, vitreous trapped
in the incision was attened by the air and dicult
to remove. The authors feared nipping the iris or
capsule edge during attempts to amputate this
escaped vitreous. To remove residual cortex or to
place an implant (the next steps in vivo), the
bubble had to be removed because the leaves of
the iris and anterior and posterior capsule aps
are all smashed together by the surface tension of
the bubble precluding access to appropriate
planes of tissue.
Although the authors use a soft shell of
Viscoat against the corneal endothelium to prevent corneal contact with the air there remains
some concern about endothelial toxicity especially
if the bubble is left in place long term. Several
articles from the literature support some degree of
toxicity [28,29]. An additional disadvantage is that
the patient cannot see until the air bubble
disappears.
Most importantly, it was impossible to keep
the pressure from becoming lower in the anterior
segment relative to the posterior segment. Vitreous always ows to the path of lower pressure
along a gradient. This had the eect of allowing
vitreous to ow forward again (after apparent
adequate vitrectomy) around the bubble during
attempted closure of the incisions or during any
manipulation to complete the case.
Every time the authors nished a specimen
they then completed the vitrectomy with a pars
plana incision. They now had a reliable removal
without recurrent prolapse or presentation to the
incision despite manipulation of the anterior
chamber or the eye after incision closure. It is
believed that this is caused by better removal of
vitreous behind the iris and by leaving a pressure
gradient, causing the vitreous to stay at home.
The authors also conrmed that sweeping and
wecking the incision resulted in traction. With the
pars plana approach entrapped vitreous could be
amputated below the iris edge severing attachments to vitreous between the lips of the incision.
et al
The remaining anterior vitreous was simply

wecked away by touching the exterior of the limbus only and without any traction at all. It was
worthwhile retattooing the vitreous with Kenalog
to conrm its complete removal and eliminating
the need to sweep the incision.
With multiple attempts to remove prolapsed
vitreous completely (with Kenalog identication)
the authors found that the biaxial pars plana
approach with the vitrector posteriorly and irrigation anteriorly was vastly superior in all respects to the bubble vitrectomy or standard
anterior limbal approach.
Biaxial pars plana vitrectomy
Any phaco incision, clear corneal or scleral, is
too large to secure a closed system with the
vitrector handpiece without a coaxial sleeve.
Two-handed vitrectomy has become standard of
care because of the reduced tendency to displace
vitreous and promote further prolapse. The original clear corneal paracentesis becomes the port
for irrigation through a chamber maintainer,
buttery needle, or other cannula of 20 or 23
gauge. Thought then needs to be given to the
creation of the vitrectomy port incision. Just as
one would never use a leaky incision safely for the
rest of the procedure so does the incision need
snuggly to t the vitrectomy handpiece. A 20gauge microvitreoretinal blade or a keratome
capable of creating this size opening can be
used. The goal is to remove all vitreous from the
anterior segment and back behind the plane of the
posterior capsule. The authors do not recommend
a paracentesis-like clear corneal incision but
rather a pars plana approach, which is far more
ecacious because the vitreous is drawn in the
proper direction rather than being encouraged to
come forward. Particularly in the setting of
zonular dehiscence it can be safer to draw vitreous
back down, lowering the risk of further unzipping
the zonular apparatus. The only way to remove
vitreous behind the iris and leave a lower pressure
posteriorly relative to the anterior segment is by
the pars plana. This approach results in the best
amputation of the forward vitreous, severing any
attachments to vitreous in the anterior segment.
The pars plana incision is made by creating
a small fornix-based ap away from the four
cardinal positions to avoid ciliary nerves and
vessels. Apply minimal cautery as needed to any
vessels that bleed and measure with a caliper for
the sclerotomy 3.5 mm posterior to the limbus
(Fig. 2). The eye is prermed through the side port

and a microvitreoretinal blade is aimed at the optic nerve as it is advanced until visualized in the
pupil (Fig. 3). A slight wiggle of the blade on withdrawal facilitates smooth entry of the vitrectomy
tip into the vitreous cavity.
The cut rate should always be at its highest
setting, between 400 and 800 for current anterior
vitreous cutters. The bottle is usually best placed
signicantly higher than the default of the machines factory setting and should be judged based
on the maintenance of the anterior chamber
during active vitreous removal. Position the assistant to raise the bottle to avoid the eye becoming
soft or collapsing. The vacuum should be high
enough to prevent clogging and often needs to be
raised from factory settings especially when dispersive OVD is present in the chamber. Keep in
mind that foot position one is irrigation, two is
cutting, and three initiates vacuum. The foot must
be to the oor to aspirate vitreous. In foot
position two there is no vitreous removed. This
sequence is always required to remove vitreous
safely without causing traction. Many machines
have a manual setting that switches the function
of foot position two and three so that vacuum can
be applied without cutting to facilitate followability. This should only be used when vitreous is no
longer present as in the removal of residual cortex.
Vigilance for an unexpected strand of vitreous can
initiate immediate activation of foot position
three to avoid traction.
When removing vitreous, the vitrector should
be held as still as possible in direct view and the
port turned appropriately to remove prolapsed
vitreous and relieve any adherent material until
the goal is achieved.
Residual cortex should be cleanly removed
either with a dry technique meaning aspirated
with a syringe under OVD without irrigation, or
Fig. 2. Drawing of pars plana incision.
503
Fig. 3. Endoscopic view of instrument through pars plana

incision.
with the vitrector handpiece set to vacuum before

cutting to avoid damage to the capsule edge, to
promote followability, and to minimize risk of
vitreous traction. The irrigation and aspiration
handpiece should not be used unless no possibility
of further vitreous presentation exists.
On completion of the vitrectomy, the incision
should be free of vitreous incarceration. The
incision can be temporarily plugged (if a plug is
available), or it may be closed with a two-bite
mattress 8-0 Vicryl suture that is temporarily tied
with a bow knot until it is certain that vitrectomy
is complete. The conjunctiva is then coapted with
cautery or sutured closed with the Vicryl to cover
this incision securely. Closure of this type is
necessary when working with conventional
20-gauge instruments.
At the time of this writing there is increasing
experience with 25-gauge sutureless vitrectors,
which use a trocar for entry. These tend to be
too exible and require a very rm eye for safe
entry, which is not always reliable in this clinical
situation. Additionally, there is a signicant
chance of postoperative hypotony caused by
inadequate sealing of the pars plana wound. The
round incision made by the trocar may seal
primarily by vitreous incarceration, which is undesirable. Alternatively, a 23-gauge vitrector
(Dutch Ophthalmic Medical Company, Zuidland,
The Netherlands) using a scleral tunnel sutureless
entry is available. The incision is as sharp and
atraumatic as the conventional entry, but is truly
self-sealing once the technique is mastered. No
peritomy is needed because conjunctiva is displaced resulting in supercial and deep punctures,
504
ARBISSER
which are not coincident. The entry is made with

a special microvitreoretinal blade followed by a
trocar, which is immediately placed gaining a
port for the insertion of the cutter. Real-time
endoscopy reveals a clean entry with no traction
with this method and a virtually undetectable incision on removal of instruments. Some form of sutureless vitrectomy incision may ultimately prove
to be the most ecient technique for the anterior
segment surgeons purposes.
The goal is vigilantly to avoid vitreous traction
while thoroughly removing any vitreous anterior
to the posterior capsule. A pars plana approach
most eectively accomplishes this goal.
Inspection and intraocular lens choice

One must stop and inspect. Verify a clean bag
and the absence of residual vitreous prolapse. Use
an instrument gently to retract the pupil edge, and
consider a slit beam or external illumination. A
last small injection of Kenalog may be indicated
to verify the absence of vitreous. Be sure the pupil
is round without a peak, which is pathognomonic
of a residual vitreous strand adherent usually to
the incision. The pupil should be constricted
before the end of the case to verify symmetry.
Be certain all incisions are sealable. Evaluate the
intactness of the CCC and the extent of the
posterior capsule tear and residual sulcus support.
A foldable IOL should be placed in the bag
only if the posterior tear has been converted to
a CCC or there are less than 3 hours of zonulolysis without a capsular tension ring. The haptic
should be placed to support the area of zonulolysis. Lacking a posterior capsule if the anterior
CCC is intact the foldable lens should have sulcus
haptic placement with the optic captured through
the CCC into the bag. In the absence of an intact
CCC, a sulcus-style IOL may be placed entirely in
the sulcus if there is adequate posterior capsule
support 180 degrees apart. Avoid plate haptic and
one-piece acrylic lenses. They are not intended for
the sulcus and can only appropriately be placed
into an intact capsular bag. The sulcus lens haptic
diameter should be at least 13 mm from end to
end. All of the foldable lenses can be placed
through any style incision.
A single piece polymethyl methacrylate lens
should only be used through a scleral or limbal
wound because a larger than 4-mm incision is
required. In the absence of capsular support one
could use a sutured posterior chamber lens either
et al
iris or scleral xated or an anterior chamber open

loop lens according to surgeon preference. Consider reducing operative time and trauma after
a dicult case by the choice of the anterior
chamber lens. A patent peripheral iridectomy is
then needed best accomplished with the vitrector
in an OVD dry environment. When appropriately sized for an eye, the modern-style lenses have
not been associated with an increased risk of
corneal decompensation or glaucoma.
If the surgeon has been unable to clean the
anterior chamber or there is signicant edema and
reduced view by the end of the case, and particularly if posterior loss of lens material is conrmed or suspected, leaving the eye temporarily
aphakic may be the wisest option. A poorly placed
lens or an unstable one can create increased
inammation and hamper a subsequent vitreoretinal procedure.
Postoperative care
Because of the increased surgical time and
tissue manipulation associated with these complications, the surgeon should anticipate increased
postoperative inammation. This requires intensive topical steroids and nonsteroidal anti-inammatory medications. The surgeon may also wish
to consider peribulbar steroids at the conclusion
of the surgery.
Remember that there is a signicantly increased risk of endophthalmitis with vitreous
loss compared with lens extraction with an intact
capsule. Consideration should be given to more
elaborate antibiotic prophylaxis, such as subconjunctival injection of antibiotics or oral dosing of
fourth-generation uoroquinolone if there is no
systemic contraindication. At the time of this
writing, intracameral antibiotics are being explored for their safety and ecacy.
Intraocular pressure elevation, often severe, is
common. A variety of antihypertensive medications and carbonic anhydrase inhibitors are usually required. High intraocular pressure within the
rst 24 hours is often caused by retained OVD,
whereas the high pressure from the inammation
secondary to retained lens fragments takes several
days to develop.
If there are retained lens fragments, a timely
referral to a retinal surgeon is well advised. Similarly, a careful peripheral indented retinal examination should be performed in all patients with
vitreous loss within 2 to 4 weeks of the surgery [30].
The surgeon must have a frank and complete

discussion of the surgical complication with the
patient not only to explain all the steps taken and
planned to minimize the risk of problems but also
to enlist the patients vigilance for symptoms of
complications in the future [31].
It is important to remember that although
vitreous loss, with or without retained lens fragments, is a serious cataract surgery complication,
most patients achieve good visual recovery [32].
Careful preoperative, intraoperative, and postoperative care can help reduce the risk of visual loss.
Summary
Cellulose sponges, sweeping the wound, pulling back on the cutter, using scissors to cut the
vitreous, a high ow rate or vacuum setting
coupled with low cutting rates, and bubble removal all cause anterior movement and traction
on the vitreous, which may result in retinal tears
and detachment. One should never sh for dropped lens fragments. Management of dropped
nucleus and pars plana biaxial anterior vitrectomy
using the concepts described can reduce retinal
detachment and other complications. Eectively
dealing with crisis is, more often than not, a matter
of having prepared for crisis. It is hoped that this
article helps one achieve the excellent visual
results that are still obtainable in these challenging
cases.
References
[1] Gimbel HV. Posterior capsule tears using phacoemulsication causes, prevention and management.
Eur J Implant Refract Surg 1990;2:639.
[2] Allinson RW, Metrikin DC, Fante RG. Incidence
of vitreous loss among third year residents performing phacoemulsication. Ophthalmology 1992;99:
72630.
ASCRS members1994 survey. J Cataract Refract
Surg 1995;21:37885.
[4] Pande N, Dabbs TR. Incidence of lens matter dislocation during phacoemulsication. J Cataract
[5] Scott IU, Flynn HW Jr, Smiddy WE, et al. Clinical
features and outcomes of pars plana vitrectomy in
patients with retained lens fragments. Ophthalmology 2003;110:156772.
[6] Aaberg TM Jr. Retinal detachment in eyes undergoing pars plana vitrectomy for removal of retained
lens fragments discussion. Ophthalmology 2003;
110:713.
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[7] Aaberg TM Jr, Rubsamen PE, Flynn HW, et al.

Giant retinal tear as a complication of attempted
removal of intravitreal lens fragments during cataract surgery. Am J Ophthalmol 1997;124:2226.
[8] Blodi BA, Flynn HW Jr, Blodi CF, et al. Retained
nuclei after cataract surgery. Ophthalmology 1992;
99:414.
[9] Linco H, Zweifach P, Brodie S, et al. Intraocular
injection of lidocaine. Ophthalmology 1985;92(11):
158791.
[10] Kelman CD. Posterior capsule rupture: PAL technique. Video J Cataract Refract Surg 1996;12:2.
[11] Chang DF, Packard RB. Posterior assisted levitation for nucleus retrieval using Viscoat after posterior capsule rupture. J Cataract Refract Surg 2003;
29:18605.
[12] Eller AW, Barad RF. Miyake analysis of anterior
vitrectomy techniques. J Cataract Refract Surg
1996;22:2137.
[13] Machemer R, Norton EW. Experimental retinal
detachment and reattachment: I. Methods, clinical
picture and histology. Bibl Ophthalmol 1969;79:
8090.
[14] Foulds WS. Experimental detachment of the retina
and its eect on the intraocular uid dynamics.
Bibl Ophthalmol 1969;79:5163.
[15] Moore JK, Scott IU, Flynn HW, et al. Retinal detachment in eyes undergoing pars plana vitrectomy
for removal of retained lens fragments. Ophthalmology 2003;110:70914.
[16] Scott IU, Flynn HW Jr. Retained lens fragments
after cataract surgery. Ophthalmol Clin North Am
2001;14:6759.
[17] Kapusta MA, Chen J, Lam W. Outcomes of dropped nucleus during phacoemulsication. Ophthalmology 1996;103:11847.
[18] Lambrou FH, Stewart MW. Management of dislocated lens fragments during phacoemulsication.
[19] Kim JE, Han DP. Managing retained lens fragments. J Cataract Refract Surg Today 2005;8:
636.
[20] Kageyama T, Ayaki M, Ogasawara M, et al. Results
of vitrectomy performed at the time of phacoemulsication complicated by intravitreal lens fragments.
Br J Ophthalmol 2001;85:103840.
[21] Kim J, Flynn HW, Smiddy WE, et al. Retained lens
fragments after phacoemulsication. Ophthalmology 1994;101:182732.
[22] Stefaniotou M, Aspiotis M, Pappa C, et al. Timing
of dislocated nuclear fragment management after
cataract surgery. J Cataract Refract Surg 2003;29:
19858.
[23] Burk SE, Da Mata AP, Snyder ME, et al. Visualizing
vitreous using Kenalog suspension. J Cataract
[24] Kasner D. Vitrectomy: a new approach to the management of vitreous. Highlights Ophthalmol 1968;
11:30429.
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[25] Apple DJ, Lim ES, Morgan RC, et al. Preparation

and study of human eyes obtained postmortem
with the Miyake posterior photographic technique.
[26] Burk S. Identifying the vile humor. First place video
ESCRS September 610, 2003, Munich, Germany.
[27] Eller AW, Barad RF. Miyake analysis of anterior
vitrectomy techniques. J Cataract Refract Surg
1996;22:2137.
[28] Wilson LDA, Yoshizumi MO, Hall M. The ocular effects of gases when infected into the anterior chamber
of rabbit eyes. Arch Ophthalmol 1991;109:5715.
et al
[29] Green K, Cheeks L, Stewart DA, et al. Intraocular
gas eects on corneal endothelial permeability.
Lens Eye Toxic Res 1992;9:8591.
[30] Borne MJ, Tasman W, Regillo C, et al. Outcomes of
vitrectomy for retained lens fragments. Ophthalmology 1996;103:9716.
[31] Monshizadeh R, Samiy N, Haimovici R. Management of retained intravitreal lens fragments after cataract surgery. Surv Ophthalmol 1999;43:397404.
[32] Tan JHY, Karwatowski WSS. Phacoemulsication cataract surgery and unplanned anterior vitrectomydis it bad news? Eye 2002;16:11720.
Capsular Tension Rings: Update on Endocapsular

Support Devices
Khalid Hasanee, MD, FRCSCa, Iqbal Ike K. Ahmed, MD, FRCSCa,b,*
a
University of Toronto, Toronto, Ontario, Canada
University of Utah, 201 South Presidents Circle, Room 201, Salt Lake City, UT 84112, USA
Small-incision phacoemulsication with endocapsular posterior chamber intraocular lens

(PCIOL) xation has become the standard of
care in cataract management because of numerous
intraoperative and postoperative advantages.
When associated with zonular weakness, cataract
surgery is associated with increased risk of vitreous prolapse, capsular rupture, retained lens
material, and postoperative IOL dislocation. In
cases of profound zonular dialysis, alternative
approaches have included intracapsular cataract
extraction or pars plana vitrectomy and lensectomy. The capsular tension ring (CTR) and its
derivatives have enabled surgeons to approach
zonular weakness with improved safety, and
spawned novel surgical techniques. Successful
phacoemulsication approaches in these cases
requires stabilization of the capsulozonular apparatus during surgery, enabling the surgeon safely
to remove the crystalline lens, retain the capsular
bag, and place a PCIOL securely. This requires an
understanding of capsule and zonular anatomy,
development of a grading system for zonular weakness, technique modications, and an understanding of available capsular tension devices and their
selection criteria.
Approach to weak zonules
It is often helpful to categorize the approach to
compromised zonules into methods of cataract
extraction and IOL xation. Cataract extraction

options include phacoemulsication and extracapsular or intracapsular approaches. In severe cases,
a posterior approach with pars plana lensectomy
and vitrectomy may also be considered. Phacoemulsication, by maintaining the advantages of
small-incision surgery, is the preferred option,
assuming this can be safely performed.
IOL implantation options include a sulcus
PCIOL, an anterior chamber IOL, iris-xated
IOL, or in-the-bag PCIOL with CTR. Capsular
bag xation is the ideal location of an IOL,
providing optimal biocompatibility, centration,
and optics, assuming it can remain in a stable
position in the long-term. The CTR and its
modications permit small-incision phacoemulsication and endocapsular PCIOL xation in mild,
moderate, and severe cases of zonular loss.
Dening zonular weakness: clock hours versus
severity
Zonular weakness can be categorized according
to the number of clock hours (degree of zonular
dialysis) and the severity of generalized zonular
instability [14]. This division is key because specic zonular cases each have their own underlying
etiologies or a combination thereof. The choice of
cataract extraction and endocapsular support device relies greatly on this distinction.
How the capsular tension ring works
* Corresponding author. Credit Valley EyeCare,

3200 Erin Mills Parkway, Unit 1, Mississauga, Ontario
L5L 1W8, Canada.
E-mail address: ike.ahmed@utoronto.ca
(I.I.K. Ahmed).
The CTR serves two functions: an intraoperative support tool during cataract surgery or
a long-term implant device for postoperative
IOL xation. Because the diameter of the CTR
doi:10.1016/j.ohc.2006.07.001
508
HASANEE & AHMED
is larger than that of the capsule bag, the

centrifugal forces inherent within the ring expand
the capsular equator and buttress areas of poor
zonular support, providing equal distribution of
support from remaining zonules [5]. The CTR
re-expands the capsular bag, provides countertraction, and tautens the posterior capsule intraoperatively. Postoperatively, it oers the advantage
of preventing capsule shriveling and allows for
postphaco yttrium aluminum garnet capsulotomy
[6]. Because the capsular bags circular contour is
maintained, enhanced zonular support is produced [7]. The CTR also recruits tension from existing zonules and redistributes the forces to the
remaining weaker zonules thereby stabilizing the
entire zonular apparatus. This added support
of the CTR may also help to recenter a mildly
subluxed capsular bag to avoid decentration and
dislocation (Box 1) [1]. Additional advantages of
the CTR include enhanced safety during phacoemulsication and decreased prevalence of posterior capsule opacication [8], and possibly
reduced incidence of capsular contraction syndrome. Standard CTRs fail to recenter severely
subluxed capsular bags, however, and do not prevent progressive zonular loss. In these situations,
scleral-xated devices like the modied
CTR ([M-CTR] Morcher GmbH, Stuttgart, Germany) or the capsular tension segment ([CTS]
Morcher GmbH, Stuttgart, Germany) are more
appropriate.
Capsular tension ring indications
and contraindications
Common indications for CTR implantation
include pseudoexfoliation, traumatic zonulysis,
iatrogenic zonular damage, Marfan syndrome [9],
homocystinuria, hypermature cataracts, and postvitrectomy and ltration patients [6]. Other less
frequent situations include aniridia, retinitis
pigmentosa [10], intraocular neoplasms, WeilMarchesani syndrome, and microspherophakia
[6]. CTR implantation has also been successfully
performed in cases of congenital lens colobomas
[11].
A standard CTR is indicated (authors preferences) in cases demonstrating evidence of mild
zonular instability based on either localization of
zonulysis (!4 clock hours) or mild degree of
generalized zonular weakness. Clinical signs indicative of mild generalized weakness include mild
phacodonesis, slight lens movement on capsulorrhexis formation, and mild rhexis ovalization, but
Box 1. Mechanics of the CTR

Expansion of capsular equator
Buttress areas of weak zonules
Recruit and redistribute tension
from existing zonules
Recenter a mildly subluxed capsular
bag
without bag collapse or overt decentration [14].

Pseudoexfoliation characterized with a mild oppy
capsular bag may be considered in this group. If
these criteria are not met, however, the degree of
zonulopathy is likely moderate (Fig. 1) to advanced,
and a standard CTR is considered insucient.
CTR implantation is contraindicated in cases
where an anterior radial or posterior tear is
present [12,13]. In cases of noncontinuous capsulorrhexis, implanting this ring device can be dangerous because the centrifugal forces generated
by the CTR may provoke further extension of
the capsular tear toward the posterior direction
with increased risk of the CTR dislocating posteriorly [1214].
History of endocapsular support devices
The rst ever endocapsular device was designed in Japan in the late 1980s with the original
purpose of compressing the equator of the capsule
bag to prevent lens epithelial migration and
posterior capsule opacication. It was not until
1991 when Hara and coworkers [15] described the
insertion of a ring structure into the capsular bag
fornix for the purpose of maintaining the circular
bag. The device used was a silicone-closed ring
Fig. 1. Moderate zonular dialysis.
CAPSULAR TENSION RINGS
called the equator ring. Although the equator

ring maintained the circular contour of the capsule, its closed-ring structure limited its use
because it was not designed for capsular bags
of varying sizes. Also in 1991, Nagamoto and
Bissen-Miyajuma [16] presented a video at the
lm festival of the American Society of Cataract
and Refractive Surgery describing an open polymethyl methacrylate (PMMA) ring. Known as
the capsular bag supporting ring, this device
was further described in an experiment involving
human cadaver eyes published in 1994.
Leger and Witschel [5] introduced the CTR at
the American Society of Cataract and Refractive
Surgery meeting in May 1993. The CTR was the
rst open PMMA ring to be implanted during cataract surgery, and had the advantage of having
eyelets on either free end. The rounded eyelets
served to lower the risk of spearing the capsular
fornix on insertion and enhancing intracapsular
manipulation of the ring.
After the introduction of the CTR, a variety of
devices have been designed to expand further on
the CTRs initial surgical application. The capsular edge ring addressed the issue that gave birth to
the CTR idea in the rst place, namely posterior
capsular opacication. It was devised with a
square-edge intended to repel the advancement
of epithelial cells on the posterior capsule that
leads to opacication [17].
In 1998, Cionni and coworkers [18] reported
the use of an open endocapsular ring with the
modication of a xation hook positioned anterior to the main ring lament. The hook has an
eyelet on the tip that acts as an anchor for suturing without damaging the capsular bag. Known as
the modied CTR (M-CTR), this ring is of particular importance in cases of profound and progressive zonular weakness.
The CTS, introduced by Ahmed in 2002 [19],
was developed to deal with cases of profound
zonular weakness. The CTS is a 90-degree partial
PMMA ring segment that also has a central xation eyelet. The eyelet oers both intraoperative
support through iris hooks or long-term postoperative xation with scleral sutures. Because of
its smaller size, it can safely be implanted in
cases of anteroposterior capsule tears or incomplete rhexis. Multiple (two to three) segments
may be inserted as depending on the amount
of zonular support needed. This device may
also be combined with other endocapsular support devices as needed to address dierent zonular concerns.
509
Current endocapsular devices

Standard capsular tension ring
In 1991, Hara and coworkers [15] and
Nagamoto and Bissen-Miyajuna [16] introduced
the rst endocapsular devices. This was later popularized and further developed by Legler and coworkers [5] in 1993. The standard CTR (Fig. 2)
is an open-ring structure made of PMMA. This
compressible circular ring has an oval-shaped
cross-section with two smooth-edged end terminals. The ski ramp design of the end terminals
aids to avoid entrapment of the capsular equator
on insertion and also allows for placement of secondary instrumentation.
Both Morcher GmbH (Stuttgart, Germany)
and Ophtec (Groningen, The Netherlands) manufacture US Food and Drug Administration
approved CTRs. The Morcher ring (also labeled
the reform ring) is available in three dierent
sizes based on an uncompressed diameter: type 14,
12.3 mm (compresses to 10 mm); type 14C, 13 mm
(compresses to 11 mm); and type 14A, 14.5 mm
(compresses to 12 mm). The Ophtec ring (Advanced Medical Optics, Irvine, California; labeled
as StabilEyes in the United States) is available
in a 13-mm ring that compresses to 11 mm, and
a 12-mm ring that compresses to 10 mm. Implantation of the CTR may be performed manually or
with an injector (authors preference). Both Ophtec and Geuder (Heidelberg, Germany) manufacture CTR injectors.
In a prospective study of 21 eyes, Jacob and
coworkers [1] evaluated the safety and ecacy of
the CTR in patients with less than 150 degrees of
zonular dialysis (mean follow-up of 242.33 days).
Fig. 2. Standard capsular tension ring.
510
HASANEE & AHMED
They found that phacoemulsication with in-thebag PCIOL and CTR implantation had a 90.47%
success rate. Capsular collapse did not occur in
any eye, but two eyes developed intraoperative extension of dialysis. Fifteen eyes (71.42%) had a nal
visual acuity of 20/40 or better. All patients with
successful implantation remained well centered at
6 months.
There have been few published studies examining the safety and ecacy of the CTR in
cataract surgery. Bayraktar and coworkers [2]
examined the eect of the CTR in preventing zonular complications during phacoemulsication in
pseudoexfoliation patients. This prospective randomized study of 78 eyes with pseudoexfoliation
cataracts was randomly divided into two groups.
CTRs were implanted in 39 eyes and 39 served
as controls without CTR implantation. Five eyes
(12.8%) in the control group and no eyes in the
CTR group developed intraoperative zonular separation. The posterior capsule rupture rate was
7.7% in the control and 5.2% in the CTR groups.
Capsular IOL xation was 94.9% and 74.3% in
the CTR and control groups, respectively.
In their retrospective series of 14 cases with
loose or broken zonules managed with CTR,
Gimbel and coworkers [3] concluded that CTRs
help to avoid capsular bag collapse and vitreous
presentation during surgery. No observable IOL
decentration occurred in their group.
Lee and coworkers [20] examined the issue of
IOL tilt and decentration in their report on 40
eyes of 20 patients who were followed for
2 months. Each patient had an IOL in one eye
and a CTR with an IOL in the fellow eye. The
IOL-CTR group had a statistically less rate of
IOL decentration versus the IOL-only group.
The mean decentration in the IOL-CTR group
was 0.42 0.17 mm, whereas the IOL-only
group was 0.57 0.16 mm. The amount of IOL
tilt at 60 days was also signicantly less in the
IOL-CTR group (IOL-CTR: 2.47 0.40 degrees;
IOL-only: 3.06 0.56 degrees).
Price and coworkers [21] reported their results
of a phase III multicenter, nonrandomized investigational study evaluating the safety and ecacy of
the Ophtec CTR in cases of weak zonules during
cataract extraction. A total of 255 CTRs was
placed in patients who were found to have weakened or broken zonules comprising !34% of the
circumference of the lens capsule. Two CTR
models were evaluated, with noncompressed
diameters of 12 and 13 mm. It was concluded
that both Ophtec CTR models safely provided
capsular support during and after cataract surgery

in cases of weak zonules. Patients were examined,
intraoperatively and postoperatively, at Day 1
and Months 1, 3, 6, and 12. Interim results demonstrated that immediately after surgery 98.8%
of IOLs were centered. Subsequently, the prevalence of IOL decentration was 1.7% at 3 months,
3.8% at 6 months, and 2.3% at 12 months. The
primary complication was posterior capsule opacication. Neodymium:yttrium-aluminum-garnet
capsulotomies were performed in 12.8% of eyes
by 12 months postoperatively. They concluded,
however, that the posterior capsule opacication
was not caused by CTR insertion.
Choosing appropriate capsular tension ring size

The selection of CTR size is based on capsular
bag dimensions. Typically, a larger capsular bag
requires a larger ring with the reverse holding
true. Many surgeons prefer to choose a slightly
larger implant, with 13 mm being most common.
Overlap of the end terminals is needed to provide
for complete circumferential support. Vass and
coworkers [22] have shown that the size of the
capsular bag positively correlates with the globes
axial length. Stepwise multiple regression resulted
in the following regression formula: predicted capsular bag diameter (3.44 to 0.056 P) (0.713
AL) (0.0135 AL 2).
The corneal diameter is also an indicator of
capsular bag size [22]. Based on this information,
white-to-white corneal measurement and axial
measurements can be used as a guide to CTR sizing, although many surgeons advocate routinely
using larger sizes (authors preference) to ensure
adequate overlap of end terminals. Furthermore,
it is appropriate to use a larger CTR in cataract
surgery involving highly myopic eyes [22].
Modied capsular tension ring
Before the introduction of the M-CTR,
profound lens subluxation was managed with
more invasive and complicated surgery. This was
necessary because the standard CTR is unable
adequately to provide intraoperative support and
center the capsule bag in situations of severe
zonulysis. Previous approaches included suturing
the standard CTR through the capsule bag with
or without a peripheral capsulorrhexis and then
lassoing the CTR along with the peripheral
capsule [23]. To address the issue of increased
risks of creating capsular tears with this
technique, Cionni developed the M-CTR in 1998

(Food and Drug Administration approved in
October, 2005) (Fig. 3, Box 2). This device addresses extensive or progressive zonular damage
by allowing the surgeon to anchor the capsule
bag to the eye wall. The open-ring design with
one (model 1-L or 1-R) or two (model 2-L) xation eyelets attached to the central ring permits
scleral-suture xation. The eyelets protrude
0.25 mm forward from the body of the CTR
thereby sitting in front of the anterior capsule preserving the capsular bags integrity on suturing [6].
It is important to perform an adequately sized
capsulorrhexis (ie, 5.5 mm) when working with
the M-CTR. With a smaller capsulorrhexis margin, the hook may drag on the capsulorrhexis edge
and result in iris chang and related pigment
dispersion and chronic uveitis.
Cionni and coworkers [18] studied the eect of
the M-CTR in 90 eyes with congenital loss of
zonular support. In 94% of cases, the M-CTR
provided good centration of the capsular bag
and PCIOL. In 80% of eyes, the best-corrected
visual acuity was 20/40 or better. The suture
breakage incidence was 10%. Recommendations
were made to use 9-0 rather than 10-0 sutures to
address this concern.
511
Box 2. Key points about the standard

CTR and M-CTR
When to use a CTR or M-CTR
Mild zonular weakness (<4 clock
hours)
All pseudoexfoliation patients
(debated); does improve centration
and tilt
Scleral fixation required (M-CTR)
When not to use a CTR or M-CTR
Anterior capsule tear
Posterior capsule rent
Incomplete rhexis
Recenter severely subluxed capsular
bag
In a series of 68 consecutive patients, Ahmed

and coworkers [24] reported their ndings on the
M-CTR implantation in cases of profound
zonulopathy caused by a variety of causes. The
double eyelet M-CTR was implanted in 10 cases
with the remainder receiving the single eyelet
M-CTR. Varying etiologies for zonular weakness
included Marfan syndrome (22 cases); trauma (19
cases); ectopia lentis (10 cases); pseudoexfoliation
(6 cases); and other (12 cases). The average follow-up was 12.4 months with all cases achieving
adequate centration. Complications included elevated IOP (six cases); mild posterior capsule opacication tilt (ve cases); pigment dispersion (two
cases); mild iritis (ve cases); and cystoid macular
edema (four cases). These results demonstrated
the wide range of clinical situations where the
M-CTR may be used. One of the major ndings
of these studies is that the need for vitrectomy,
which would have been routinely required with
many of these cases, is often obviated with the
use of capsular tension devices.
In their case series of seven eyes (ve patients),
Moreno-Montanes and coworkers [25] demonstrated that M-CTR implantation was an
acceptable procedure to correct limited lens
subluxation, with preservation of the capsular
bag and relatively few complications.
Capsular tension segment
Fig. 3. Cionni-modied capsular tension ring for suture

scleral xation. (A) Single eyelet. (B) Double eyelet.
In 2002, Ahmed designed the CTS (Fig. 4AD).

Also intended for patients with profound zonular
insuciency, this device is designed for cases requiring optimal intraoperative support (see
512
HASANEE & AHMED
Fig. 4. (A) Capsular tension segment (CTS). (B) CTS with iris retractor through eyelet for intraoperative stabilization.
(C) Phacoemulsication with CTS and iris retractor in place. (D) CTS in place postoperatively with well-centered
intraocular lens.
Fig. 4B,C) or for patients in need of long-term postoperative centration of an IOL within the capsular
bag. This partial PMMA ring segment (Fig. 5) is
120 degrees with a radius of 5 mm. Like the
M-CTR, the CTS also possesses an anteriorly positioned xation eyelet.
It may be challenging to place a CTR into an
eye with a dense cataract or signicant zonular
weakness before phacoemulsication with increased risk of creating further zonular damage
[26]. This is especially true with the higher tensile
M-CTR. The CTS can be implanted with fewer
traumas, however, because a dialing technique is
not necessary. Much less force is transmitted to
the zonular apparatus before lens extraction,
and this has a distinct advantage over the CTR
and M-CTR in these situations. The CTS is
designed to slide atraumatically into the capsule
bag with minimal eort. This device may be
used in cases of a discontinuous capsulorrhexis,
anterior capsule tear, or a posterior capsule rent.
It is inserted into the capsule bag after capsulorrhexis and placed over the area of zonular
weakness. The main body of the device sits inside

the capsule bag supporting and extending the capsule equator with the central eyelet remaining
anterior to the capsule. When used for
intraoperative support, an inverted iris retractor
(by a paracentesis) is placed through the eyelet
acting as a coat hanger to support the capsular
bag in the area of zonular weakness (see
Fig. 4B,C). Multiple CTS devices may be used in
a similar fashion for cases of global weakness
(Fig. 6) [27]. Unlike other endocapsular devices,
the CTS may be used only as an intraoperative device and can be easily removed once lens extraction is complete or, as most surgeons choose to
do, it can be permanently suture-xated to the
sclera, much like the M-CTR, for long-term capsular bag support and centration. It should be
noted that the CTS provides support in the transverse plane when sutured to the scleral wall. To
address circumferential support, a CTR may be
implanted in conjunction with an already positioned CTS (authors preference). The CTS is
available in three dierent sizes: (1) 4.75 mm
513
Fig. 5. Dimensions of capsular tension segment.
(model 6D); (2) 5 mm (model 6E); and (3) 5.5 mm

(model 6C). Model 6D is the more commonly
used device.
In a consecutive series of 35 patients in which
a CTS was implanted with or without another
support device, IOL centration was achieved in all

cases with no signicant IOL tilt [19]. Several
combinations of devices were used including one
CTS (nine patients); two CTSs (eight patients);
CTS plus CTR (nine patients); CTS plus
M-CTR (four patients); CTS plus iris coloboma
ring (one patient); and CTS plus iris diaphragm
rings (four patients). Two patients had an intraoperative anterior capsule tear and one patient developed a posterior capsule rent but the CTS was
still successfully implanted in these cases. Three
patients developed posterior capsule opacication. Initial outcomes have demonstrated the
versatility of the CTS both as an intraoperative
tool and implant support device.
Closed foldable capsular ring
Fig. 6. Postoperative photographs of dual CTS. Closeup view (top left).
The closed foldable capsular ring was recently

introduced by Dick [28], which is a foldable capsular
tension and bending ring system designed with
a sharp edge. The closed foldable capsular ring has
eight hydrophobic and eight hydrophilic ring segments. The minimum overall diameter is 9.2 mm.
This implant device can be inserted either manually
with forceps and a two-folded technique or through
514
HASANEE & AHMED
an injector cartridge system. In the series of 104 eyes,

this implant was inserted through a small incision
(1.63.2 mm) with no signicant complications
over 6-months follow-up. Posterior capsule opacication was minimal or absent in all cases.
Capsular bending ring
This modication of the CTR theme is an
open-ring design with a 0.7 0.2 mm crosssection at a 90-degree angle with an unpolished
surface [17]. Designed by Nishi, the capsular
bending ring (CBR) is made of PMMA and is engineered further to inhibit lens epithelial cell migration because of the sharp-edge design. The
0.7-mm lateral height maintains distance between
the anterior and posterior capsules thereby minimizing the risk of capsule sheet adhesion, which
may lead to capsular brosis or posterior capsule
opacication. It also maintains capsular bag contour, reduces capsular contraction, increases intraoperative safety, and avoids IOL dislocation
in cases of zonulysis. The CBR is implanted with
an injector (Geuder, type G 32,965). Morcher
GmbH also manufactures this device and it comes
in a 13-mm diameter, which compresses to 11 mm.
Like CTR insertion, it is important to ll the capsule bag with ophthalmic viscosurgical device so
that the leading edge does not become entrapped.
The insertion of the CBR may be slightly more
challenging because of its height and rigidity. It
is recommended to gain experience with CTR implantation rst.
Aniridia and coloboma rings
The aniridia ring is designed as a CTR with
seven black-dyed PMMA sector shields with a diameter of 10.75 mm (Morcher type 50C for 6-mm
pupil, type 50D for 4-mm pupil, type 50E for
3.5-mm pupil). Combining two aniridia rings

allows for a full 360-degree shield that acts as an
iris substitute.
For patients with isolated regions of iris
deciency, Morcher manufactures coloboma rings
with a centrally protruding shield of either 60 or 90
degrees. The single sector shield, incorporated over
60 or 90 degrees (Rasch 96L and 96F, Morcher),
consists of black-dyed PMMA. The ring diameter is
12.6 mm and has a segment width of 2.5 mm. The
end of the ring with the sector shield is brought into
the capsule bag rst. After implantation, the ring is
rotated into the appropriate position with forceps
and positioning hooks.
Capsular tension ring current issues
Selection of endocapsular device
Some surgeons feel that the choice of
endocapsular support devices depends mainly on
the nature of zonular weakness (nonprogressive
versus progressive) [27]. It is also useful to take
into consideration the degree of zonular loss or
extent of generalized zonular instability (Table 1).
Standard CTRs are appropriate for nonprogressive zonulopathy cases like traumatic,
iatrogenic zonular dialysis, or zonular colobomas.
The remaining zonular bers in these cases are
usually quite strong, and with redistribution of
these forces with the CTR, can support the
capsular bag [27]. In progressive cases, however,
such as advanced pseudoexfoliation syndrome or
Marfan syndrome with profound zonular dialysis,
a scleral-sutured M-CTR or CTS may be of optimal value because it can be permanently secured.
Further support can be achieved as necessary by
combining devices depending on the amount of
scleral-xation needed. Additionally, conventional
CTR implantation does not eliminate the
Table 1
Comparison of CTR, M-CTR, and CTS
Requires continuous curvilinear capsulorrhexis

May be placed before lens removal
Use with anterior capsule tear
Use with posterior capsule rent
Use with large zonular dialysis (O4 clock hours)
Use in progressive zonulysis
Allows for suture xation to sclera
May be easily removed from eye if needed
Cortical removal diculty
CTR
M-CTR
CTS
Yes
With diculty
No
No
No
No
No
No
Yes
Yes
With diculty
No
No
Yes
Yes
Yes
No
Yes
No
Yes
Yes
Yes
Yes (/ multiple segments)
Yes
Yes
Yes
No
Abbreviations: CTR, capsular tension ring; CTS, capsular tension segment; M-CTR, modied capsular tension ring.
underlying cause of zonular weakness and in severe cases of progressive dialysis it may be unavoidable to prevent pseudophakodonesis,
further luxation, or dislocation of the capsular
bag complex into the vitreous [4].
CTRs are indicated in cases of mild, generalized zonular weakness or small, localized zonular
dialysis (!34 clock hours). In cases of profound
zonular weakness, a standard CTR may not
supply enough intraoperative and postoperative
support to maintain the desired orientation of the
capsular bag.
In more advanced or progressive cases of
zonular instability, the M-CTR or the CTS is
indicated. A 9.0 polypropylene suture with
double-armed CTC-6 needles (Ethicon, Somerville, New Jersey) is passed through the eyelet of
the xation hook of the CTS or M-CTR before or
after implantation [29]. An ab-externo approach
through a scleral groove to suture the CTS or
M-CTR has been proposed, which can be
performed under topical anesthesia [30].
Appropriate timing of capsular tension ring
placement
There has been debate as to the optimal timing
of CTR insertion because it can be inserted into
the capsule bag at any time following capsulorrhexis and hydrodissection (Box 3). CTR implantation before nucleus extraction (early
implantation) has been purported to be a safe alternative in cases of pseudoexfoliation. By using
this early implantation technique, reduced
Box 3. Timing of CTR insertiona

Before phaco
Offers better nuclear stability for
phacoemulsification
More difficult with dense lens (higher
risk of iatrogenic zonular damage)
Difficult to remove cortex
After phaco or cortical removal
Use iris hooks during phaco or cortical
irrigation and aspiration
Risk of iris hook dislodgement
(subsequent tears)
a
CTS may be inserted at any time because
of atraumatic entry.
515
intraoperative complications caused by zonular

separation have been reported [2]. During phacoemulsication and cortical aspiration, the distended capsular orientation decreases the risk
of it being aspirated by the phaco or irrigationaspiration tips [3,31].
Drawbacks to early CTR implantation include
entrapment of cortical material by the CTR in the
capsular bag fornix thereby hindering removal
[12]. To solve this problem, however, one could
place the CTS as an intraoperative device during
phaco and cortex because it is much easier to strip
cortex around the partial segment as opposed to
the full ring structure.
CTR implantation before cataract removal
may result in further iatrogenic zonular damage.
Ahmed and coworkers [26] have demonstrated using Miyake-Apple video analysis that early CTR
implantation in cases with a dense cataract and
moderate zonulysis results in signicant zonular
elongation and capsular displacement of up to
4 mm compared with later CTR implantation.
Furthermore, if a capsular tear occurs there is
risk of CTR subluxation into the vitreous body
[12,14]. It is the authors recommendation that
the optimal timing of CTR or M-CTR insertion
into the capsular bag be as late as safely possible
(CTS may be implanted early because of its atraumatic insertion). For cases of serious zonular
weakness, the CTS may be used in conjunction
with an iris retractor for intraoperative support
as described previously. Alternatively, iris retractors or modied capsule retractors (Mackool
Cataract Support System, Duckworth and
Kent, Hertfordshire, England) placed on the capsulorrhexis (Fig. 7) may provide support; however, this risks capsular tear or dislodgement,
which is less likely with the CTS. Performing
phaco in profound zonular instability without
the support of CTS or iris-capsular retractors
risks capsule bag dislocation and lens subluxation,
even if a CTR has been implanted.
Pseudoexfoliation and capsular tension devices
Because pseudoexfoliation is associated with
zonular weakness, these patients are potential
candidates for CTR implantation [2]. There is
debate, however, as to whether all pseudoexfoliation patients should receive CTRs. These patients
are at an increased risk for intraoperative complications and postoperative IOL dislocation
especially from superior zonular dialysis [32,33].
Postoperative capsular phimosis is also at
516
HASANEE & AHMED
Fig. 7. Iris retractors placed at capsulorrhexis edge to

stabilize loose capsular-zonular complex. They run the
risk of inadvertent dislodgement or anterior capsular
tear.
increased risk in pseudoexfoliation syndrome.

Moreno-Montanes and Rodriguez-Conde [34]
have recommended that CTR placement should
be mandatory when operating on all patients
with pseudoexfoliation. There is currently no evidence, however, demonstrating that pseudoexfoliation patients without any zonulopathy require
prophylactic CTR insertion. Furthermore, even
with CTR implantation, certain progressive cases
may still dislocate years later [4].
Capsule phimosis
Capsule phimosis may occur in cases of
zonulopathy because weak zonules result in
decreased centrifugal forces. The contractile
forces of an anterior brosing capsule may be
overwhelming leading to capsular phimosis. Capsular contraction forces may be symmetric or
asymmetric. Asymmetric forces cause the IOL to
shift to one side (usually the stronger side),
whereas symmetric contraction is less likely to
result in lens decentration.
Tehrani and coworkers [35] demonstrated a positive correlation between capsular bag shrinkage
and axial length in their study with the capsule measuring ring (HumanOptics, Erlangen, Germany).
Using preoperative biometric data, a regression
formula of moderate validity was determined to
predict the amount of capsular bag shrinkage.
Although it was initially believed that anterior
capsule contraction following cataract surgery
with CTR placement may be prevented [3,36],
more recent reports have indicated that capsular
phimosis is still a postoperative concern despite
CTR implantation [31]. Capsular contraction to
the point of complete capsulorrhexis opening

occlusion has also been reported despite CTR usage [36,37]. Capsular contraction has occurred
following CTR implantation with IOLs made
from silicone, PMMA, and acrylic materials [36].
CTRs are still benecial in these situations, however, because the capsular contraction is typically
symmetric as opposed to asymmetric without the
use of a CTR.
To reduce the risk of capsule contraction
syndrome further, one may create a capsulorrhexis
opening of 5.5 to 6 mm, use an acrylic IOL [33,38
40], and aspirate lens epithelial cells on the undersurface of the anterior capsule to reduce lens
epithelial cells proliferation and metaplasia [41].
Lens epithelial cells metaplasia and brosis may
also be reduced by the presence of an endocapsular ring by decreasing contact between the optic
and anterior capsule [17]. To prevent decentration, anterior capsule relaxing incisions either
intraoperatively with microscissors or postoperatively with a neodymium:yttrium-aluminumgarnet laser anterior capsulotomy is invaluable
(Fig. 8).
The spring constant of a CTR has been shown
by Kurz and Dick [42] to be a suitable mechanical
characteristic to facilitate the choice of CTR
model. CTRs with lower spring constants were
more advantageous for the management of zonular dialysis, where higher spring constant CTRs
were more ideal for the prevention of capsular
bag shrinkage.
Kurz and coworkers [43] examined the eect of
the CTR and CBR on capsular bag shrinkage. In
a series of 92 eyes, a capsular measuring ring was
implanted after phacoemulsication to measure
Fig. 8. CTS with neodymium:yttrium-aluminum-garnet

laser radial cuts to anterior capsule for capsule
contracture. Intraocular lens is well centered.
capsular bag size in vivo. Patients were randomized into three groups: (1) capsular measuring
ring and CBR, (2) capsular measuring ring and
CTR, and (3) capsular measuring ring alone.
Measurements were performed preoperatively,
intraoperatively, and postoperatively at 3 days,
1 month, and 3 months. Clinical end points
included capsular bag size and capsulorrhexis
diameter. Eyes implanted with the CBR showed
shrinkage of the capsular bag from 10.6 to
10.4 mm after a median of 3 months (sign test;
P .023); eyes with a CTR showed a comparable
median capsular bag shrinkage from 10.5 to
10.2 mm (P ! .001), whereas eyes without
a CTR showed a median shrinkage from 10.5 to
10 mm (P ! .001). This study concluded that capsular bag shrinkage can be inhibited by a CBR
and to a lesser extent with a CTR. This gain in
shrinkage prevention is limited, however, when
compared with a capsular measuring ring. This reduction of capsule bag shrinkage after CTR implantation may reduce IOL dislocation and tilt.
Management of capsular tension ring dislocation
Subluxation or dislocation of the CTR postoperatively is a risk for patients with severe or
progressive zonulysis. In a retrospective interventional case series of 11 patients, Ahmed and
coworkers [4] demonstrated that CTR decentrations, including into posterior vitreous, may be
eectively managed with scleral-suture xation
of the CTR through the brotic capsular bag, or
with the placement of a CTS under the anterior
capsule to reposition the displaced apparatus.
Moreno-Montanes and coworkers [44] have also
reported their technique of late IOL and CTR
dislocation using two 10-0 polypropylene sutures
placed transsclerally 180 degrees apart through
both the anterior and posterior capsules capturing
the CTR complex.
Several techniques of CTR retrieval have been
reported in cases where it has displaced into the
vitreous cavity. Lang and coworkers [14] have reported the successful removal of an intact ring
through a sclerotomy site. Another possible
approach is to cut the fallen ring into two halves
and remove each half by using two forceps and
a bimanual technique [45]. A third technique proposed by Ma and coworkers [46] seems to be the
most viable and safest option. This approach encompasses the use of a CTR injector to withdraw
the ring in one piece through the initial phaco
incision.
517
Posterior capsule opacication

Posterior capsule opacication has still been
reported postoperatively [27], although the incidence of posterior capsule opacication is
reduced with the use of CTRs [8]. To minimize
this risk, Nishis CBR may be used, with the
added feature of a square-edge design [17]. This
model has been shown signicantly to reduce the
risk of posterior capsule epithelial growth [17].
Additionally, Dick and coworkers [47] report
that combining a viscoadaptive viscoelastic agent
and a CBR not only enhances the safety of
primary and secondary PCIOL implantation and
IOL exchange in pediatric cases, but also reduces
posterior capsule opacication. A square-edged
IOL design used in conjunction with a CTR
may also decrease the incidence of posterior
capsule opacication [40].
Posterior capsule opacication was reported to
be of particular concern when using the Cionni
M-CTR [25]. With the xation hook protruding
anterior to the capsulorrhexis margin, it has
been suggested that the anterior capsule may be
slightly lifted away from the optic and this may
facilitate lens epithelial cells migration in this
zone [25].
Summary
In cases of zonular weakness, capsular tension
devices oer numerous advantages including decreased risk of posterior capsule opacication,
decreased capsular bag collapse and risk of
aspiration, re-establishment of the capsular bag
contour, limited late IOL decentration caused by
asymmetric capsule contraction, decreased irrigation uid passing behind the capsule, decreased
risk of vitreous herniation, decreased IOL decentration, reduced closure of the capsule, and decreased extension of zonular dialysis [46,48,49].
There have been dramatic advances in the
management of zonular weakness over the past
10 years. The evolution of capsular tension devices, from the CTR to the more recent CTS, has
served to play a specic role in the management of
weak zonules in cataract surgery.
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Contrast Sensitivity and Measuring

Cataract Outcomes
Mark Packer, MD*, I. Howard Fine, MD,
Richard S. Homan, MD
Department of Ophthalmology, Oregon Health and Sciences University, 1550 Oak Street,
Suite 5, Eugene, OR 97401, USA
Functional vision means the ability of the visual

system to receive, transmit, and report information. The optical system of the eye allows reception,
whereas the neurosensory retina and the neural
pathways to the visual cortex govern transmission.
Cortical elements in turn report information.
Images form the elements of visual data. The
formation of the image on the retina depends on
the optical elements of the eye, including all of the
ocular media: the tear lm, cornea, aqueous
humor, lens, and vitreous body. The principal
elements in this system, the cornea and the lens, lie
within the province of the anterior segment
surgeon or ophthalmologist who performs cataract and refractive surgery.
The evaluation of functional vision in the clinic
or laboratory may take a variety of approaches.
Wavefront aberrometry, ray tracing, corneal topography, and double-pass devices enable one
objectively to measure retinal image quality.
Contrast-sensitivity testing, reading speed, and
driving simulations represent subjective tests that
measure the neural and the optical performance of
the visual system. Both approaches add to the
knowledge of functional vision.
As the understanding of the visual system has
advanced, the evaluation of surgical techniques
and devices has also evolved. Clinical studies have
measured the outcomes of both corneal refractive
Drs. Packer and Fine are consultants for Advanced

Medical Optics and Bausch and Lomb.
E-mail address: mpacker@nemd.com (M. Packer).
surgery and lenticular surgery with the full armamentarium of functional vision testing. The results of ongoing research help to guide further
developments in these elds.
Patients heightened expectations provide
a challenge for the increasing sophistication of
anterior segment surgeons. The methods used in
clinical research today will likely become standards of clinical practice tomorrow. These
methods highlight the limitations of currently
entrenched techniques, such as measurement of
Snellen acuity. Now the American National
Standards Institute has adopted sine wave grating
contrast sensitivity at ve spatial frequencies and
the Early Treatment of Diabetic Retinopathy
Study logarithmic letter chart. Cataract and refractive surgeons should take notice of developments in visual science that will strongly aect
their practices in the very near future.
Although the achievement of 20/20 uncorrected
visual acuity remains a laudable target for any
cataract or refractive surgeon, the goal of highquality vision increasingly reects the understanding of the visual system as a whole. In fact, Snellen
acuity represents only a small portion of functional
vision. A comparison of vision and hearing highlights the limitations of standard visual acuity tests:
the auditory equivalent of a standard high-contrast
Snellen eye chart is a hearing test with only one
high level of loudness for all sound frequencies.
Today, contrast-sensitivity testing is emerging as
a more comprehensive measure of vision that will
probably replace Snellen letter acuity testing, just
as audiometric testing replaced the click and
spoken-word tests used before World War II [1].
doi:10.1016/j.ohc.2006.07.006
522
PACKER
Engineers understand that Fourier analysis

allows the representation of any visual object as
a composite of sine waves of various frequencies,
amplitudes, and orientations. In fact, visual processing in the human nervous system works like
Fourier analysis in reverse, with functionally
independent neural channels ltering images to
create what is seen [2]. Sine wave gratings are the
building blocks of vision, just as pure tones are the
building blocks of audition.
Ophthalmologists realize that patients may
complain about haziness, glare, and poor night
vision despite 20/20 Snellen acuity. This anomaly
can be understood when one realizes that the
Snellen acuity letter recognition test uses very high
contrast. The jet black letters on the bright white
background have a great deal of reserve contrast,
so that even a patient with severely reduced
contrast sensitivity can still read the chart. That
patient perceives the letters as gray on white
rather than black on white, but still is able to
recognize them. The examiner has no way of
knowing just how gray the letters look to any
particular patient. Snellen acuity is a relatively
insensitive test of visual function.
Contrast-sensitivity testing has the ability to
detect dierences in functional vision when
Snellen visual acuity measurements cannot [3].
For example, a patient with loss of low-frequency
contrast sensitivity may be able to read 20/20 but
be unable to see a truck in the fog. Although blur
caused by refractive error alone aects only the
higher spatial frequencies, scatter of light caused
by corneal or lenticular opacities causes loss at
all frequencies. Glaucoma and other optic neuropathies generally produce loss in the middle and
low frequencies. Contrast sensitivity testing oers
critical information to help elucidate patients
diagnoses.
Numerous studies have demonstrated the relationship of contrast sensitivity and visual performance. From driving diculty [4] and crash
involvement [5], to falls [6] and postural stability
in the elderly [7], to activities of daily living and
visual impairment [8], to the performance of pilots
in aircraft simulators [9], contrast sensitivity has
consistently been found to provide a high degree
of correlation with visual performance.
Contrast sensitivity declines because
of increasing aberrations
Unfortunately, contrast sensitivity declines
with age even in the absence of ocular pathology,
et al
such as cataract, glaucoma, or macular degeneration (Fig. 1). The pathogenesis of this decline in
vision likely involves changes in the spherical aberration of the crystalline lens.
Spherical aberration is a property of spherical
lenses. A spherical lens does not refract all parallel
rays of incoming light to a single focal point. The lens
bends peripheral rays more strongly so that these rays
cross the optical axis in front of the paraxial rays. As
the aperture of the lens increases the average focal
point moves toward the lens, so that a larger pupil
produces greater spherical aberration.
Spherical aberration of the cornea changes
little with age. Total wavefront aberration of the
eye increases more than threefold, however, between 20 and 70 years of age [10]. Wavefront aberration measurements combined with data from
corneal topography demonstrate that the optical
characteristics of the youthful crystalline lens
compensate for aberrations in the cornea, reducing total aberration in younger people. Unfortunately, the aging lens loses its balance with the
cornea, because both the magnitude and the sign
of its spherical aberration change signicantly
[11]. A loss of balance between corneal and lenticular spherical aberration causes the degradation
of optical quality in the aging eye.
The sine wave grating contrast sensitivity of
a pseudophakic patient with a spherical intraocular lens (IOL) implanted is no better than that of
Fig. 1. Contrast sensitivity in ve age groups 3 cd/m2.

The decline in contrast sensitivity with age was demonstrated in a multicenter study of healthy normal subjects.
(From Packer M. Contrast sensitivity in healthy subjects
20 to 69 years old. Presented at the Symposium on Cataract, IOL and Refractive Surgery, American Society of
Cataract and Refractive Surgery. San Francisco, April
12, 2003; with permission.)
CONTRAST SENSITIVITY, MEASURING CATARACT OUTCOMES
a phakic patient of a similar age who has no

cataract [12]. When a 65-year-old patient with cataracts has the cataracts removed and is implanted
with spherical IOLs the resulting visual outcome
is no better than the visual quality of a 65-yearold without cataracts (Fig. 2). The fact that the visual quality of the IOL patients is no better than
that of their same-age counterparts may seem surprising because an IOL is optically superior to the
natural crystalline lens. This paradox is explained,
however, when one realizes that the intraocular
implant has positive spherical aberration like
the aging lens. It is not the optical quality of the
IOL in isolation that creates the image, but the
optical quality of the IOL in conjunction with
the optical quality of the cornea.
The spherical aberration of a manufactured
spherical IOL is in no better balance with the
cornea than the spherical aberration of the aging
crystalline lens. Aberrations cause incoming light
that is otherwise focused to a point to be blurred,
which in turn causes a reduction in visual quality.
This reduction in quality is more severe under low
luminance conditions because ocular aberrations
increase when the pupil size gets larger.
Pseudophakic correction of spherical aberration
The youthful, emmetropic, minimally (or perhaps optimally) aberrated eye [13] has become the
standard by which the results of cataract and refractive surgery are evaluated. The erosion of accommodation and the decline in functional
vision that occurs with age [14] have both been
linked to changes in the human lens [15,16].
Lens replacement surgery oers a natural avenue
for the correction of presbyopia, and for the
523
reversal of increasing lenticular spherical aberration. Because the optical wavefront of the cornea
remains essentially stable throughout life [17], refractive lens exchange seems to represent a permanent solution to the challenges of restoring
accommodation and achieving youthful quality
of vision. For these reasons the lens has started
to come into its own as the primary locus for refractive surgery.
Recent advances in aspheric monofocal lens
design also lend themselves to improvements in
multifocal and accommodative IOLs. Because the
positive spherical aberration of a spherical pseudophakic IOL tends to increase total optical
aberrations, attention has turned to the development of aspheric IOLs [18]. These designs are intended to reduce or eliminate the spherical
aberration of the eye, improve modulation transfer function as compared with a spherical pseudophakic implant, and enhance functional vision.
A variety of aspheric IOL designs are currently
marketed in the United States: the Tecnis Z9000
IOL (Advanced Medical Optics, Santa Ana, California); the AcrySof IQ IOL (Alcon, Ft. Worth,
Texas); and the SofPort AO IOL (Bausch and
Lomb, San Dimas, California).
The Tecnis IOL was designed with a modied
prolate anterior surface to compensate for the
average corneal spherical aberration found in the
adult eye. It shares basic design features with
the CeeOn 911A IOL, including a 6-mm biconvex
square edge optic and angulated capsular C
polyvinylidene uoride haptics. The Tecnis Z9000
is a multipiece lens. It is available in both secondgeneration silicone and acrylic. The silicone IOL
has a refractive index of 1.46, and the acrylic lens
has a refractive index of 1.47. It introduces 0.27 m
Fig. 2. Contrast-sensitivity function with 4-mm pupil. The contrast sensitivity of pseudophakic patients with spherical
IOLs is no better than the contrast sensitivity of age-matched control subjects without cataract. (From Nio YK, Jansonius NM, Fidler V, et al. Spherical and irregular aberrations are important for the optimal performance of the human
eye. Ophthalmic Physiol Opt 2002;22:10312; with permission.)
524
PACKER
of spherical aberration to the eye. The clinical

investigation of the Tecnis IOL submitted to the
US Food and Drug Administration (FDA) demonstrated elimination of mean spherical aberration
and signicant improvement in functional vision
when compared with a standard spherical IOL [19].
The US Centers for Medicare and Medicaid Services announced New Technology IOL Status for
the Tecnis IOL on January 26, 2006 [20]:
Todays announcement of coverage with additional payment for an innovative type of intraocular lens reects Medicares attention to
improved clinical benets, said CMS Administrator, Mark McClellan, MD, PhD. For these
lenses, there is clear evidence of improved functional vision and contrast acuity.
The AcrySof IQ shares the UV and blue light

ltering chromophores found in the single-piece
acrylic AcrySof Natural IOL. The special feature
of this IOL is the posterior aspheric surface
designed to compensate for spherical aberration
by addressing the eects of overrefraction at the
periphery. The AcrySof IQ is a single-piece lens
made of hydrophobic acrylic, and it has a refractive index of 1.55. It adds 0.20 m of spherical
aberration to the eye.
The SofPort Advanced Optics (LI61AO) IOL
is an aspheric IOL that has been specically
designed with zero spherical aberration so that it
does not contribute to any pre-existing higherorder aberrations. It is a foldable silicone IOL
with polymethyl methacrylate haptics and square
edges, and it was specically designed for use with
the Bausch and Lomb SofPort System, an integrated, single-use, single-handed planar delivery
IOL insertion system. The SofPort lens is a multipiece lens made of second-generation silicone. It
has a refractive index of 1.43, and it introduces no
spherical aberration to the eye.
Peer-reviewed, prospective, randomized scientic publications have demonstrated reduction of
spherical aberration and excellent contrast sensitivity and contrast acuity with the Tecnis modied prolate IOL when compared with a variety
of spherical IOLs (as of this writing there are no
peer-reviewed publications evaluating clinical results with either of the other two aspheric IOLs
available in the United States) [2128].
Mester [29] compared the quality of vision obtained with the Tecnis IOL and a spherical silicone IOL (SI 40, Advanced Medical Optics,
Santa Ana, California). A total of 45 patients
were enrolled and randomized to receive the
et al
Tecnis IOL in one eye and the SI 40 in the fellow

eye. The average photopic contrast-sensitivity
values demonstrated a statistically signicant advantage for the Tecnis IOL at all spatial frequencies (Fig. 3). The contrast-sensitivity curves show
an even greater dierence under mesopic conditions (Fig. 4), an expected result caused by the
larger pupil size and consequent greater contribution from spherical aberration in dim light.
A comparison of corneal and total ocular aberrations demonstrates the improved wavefront of the
eye with the Tecnis Z9000 IOL (Fig. 5). This improvement in total aberrations demonstrates the
critical compensatory relationship of cornea and
lens in reducing spherical aberration.
Packer and coworkers [30] compared peak
contrast sensitivity in healthy, normal eyes, stratied by age of patient, with eyes implanted with
either the Tecnis IOL or an acrylic spherical
IOL (AR40e, Advanced Medical Optics, Santa
Ana, California). They reported that mesopic contrast sensitivity declined with age. Among 69 eyes
of 36 patients, ranging in age from 21 to 61, they
found mean peak mesopic contrast sensitivity at
three cycles per degree of 72.4 units for the 20 to
30 year olds, whereas subjects aged 30 to 50 years
demonstrated mean peak mesopic contrast sensitivity of 51.9 units. Ten eyes implanted with the
Tecnis IOL in patients of average age 69.5 years
achieved mean peak mesopic contrast sensitivity
at three cycles per degree of 83.8, better than the
20 to 30 year old group. Meanwhile, 11 eyes implanted with the control IOL in patients of average age 69.4 years demonstrated mean peak
mesopic contrast sensitivity at three cycles per
Fig. 3. Photopic contrast sensitivity of subjects implanted with the Tecnis Z9000 and SI40 IOLs. (From
Mester U. Improved optical and visual quality with
aspheric IOL. Presented at the American Society of Cataract and Refractive Surgery Symposium. Philadelphia,
June 2, 2002; with permission.)
Fig. 4. Mesopic contrast sensitivity of subjects implanted with the Tecnis Z9000 and SI40 IOLs. (From
aspheric IOL. Presented at the American Society of Cataract and Refractive Surgery Symposium. Philadelphia,
June 2, 2002; with permission.)
degree of 47.1, worse than the 30 to 50 year old

age group (Fig. 6).
The results of peer-reviewed publications on
the Tecnis IOL are summarized in Table 1. The
weight of evidence demonstrating superior functional vision and contrast sensitivity with the
modied prolate IOL has continued to grow.
That the pseudophakic elimination of spherical
aberration reverses the age-related decline in contrast sensitivity conrms the hypothesis that decreased functional vision results primarily from
aging changes in the human lens.
The eect of tilt and decentration on

wavefront-corrected intraocular lenses
Optical laboratory studies have cast doubt on
the ecacy of aspheric IOLs with negative
525
Fig. 6. Peak mesopic contrast sensitivity of subjects implanted with the Tecnis IOL is higher than that of
healthy, normal subjects in their twenties. (From Packer
M, Fine IH, Homan RS. Quality of vision with a modied anterior prolate aspheric intraocular lens. Presented
at the European Society of Cataract and Refractive Surgery Symposium. Nice, France, September 11, 2002;
with permission.)
spherical aberration, such as the Tecnis and

AcrySof IQ, because of the range of tilt and
decentration of pseudophakic lenses in general
[31,32]. The eye model used to design the Tecnis
IOL assumed a rotationally symmetric cornea reecting the mean spherical aberration in a population of patients presenting for cataract surgery
[18]. This model assumed monochromatic light
and a symmetric cornea. Criticism of the model
suggested, however, that it oversimplied the actual eects of the wavefront-corrected IOL by ignoring the contributions of polychromatic light
and the implications of asymmetric corneal aberrations, such as coma [33].
Fig. 5. Photopic and mesopic contrast sensitivity of subjects implanted with the Tecnis Z9000 and SI40 IOLs. (From
Mester U. Improved optical and visual quality with aspheric IOL. Presented at the American Society of Cataract and
Refractive Surgery Symposium. Philadelphia, June 2, 2002; with permission.)
526
Table 1
Results of peer-reviewed publications on Tecnis IOL
Date
Comparator IOLs: study design
Results
Mester
J Cataract Refract Surg
2003
SI40; intraindividual study; 37

patients
Spherical aberration in Tecnis eyes not

signicantly dierent from zero.
Signicantly better low-contrast visual acuity at
all chart contrast levels after 3 months
postoperatively.
Signicantly better contrast sensitivity
under photopic conditions at all spatial
frequencies at 3 months postoperatively.
Signicantly better contrast sensitivity under
mesopic conditions at all frequencies
at 3 months postoperatively.
Packer
2004
AR40e; interindividual study;

30 patients
After monocular comparison: at 3 months

postoperatively, signicantly better
contrast sensitivity under photopic
conditions at 6 cpd and under mesopic
conditions at 1.5 and 3 cpd.
After bilateral comparison: signicantly better
contrast sensitivity under photopic conditions
at 3 and 6 cpd and under mesopic conditions
at 1.5, 3, and 6 cpd.
Kershner
2003
Silicone plate-haptic and

single-piece acrylic; 221 eyes
of 156 patients
Compared with other lens, signicantly

greater improvement in postoperative
contrast sensitivity over preoperative
values under photopic conditions without
glare at 1.5, 6, and 12 cpd.
Enhanced retinal image contrast.
Bellucci
J Refract Surg
2004
911A; SA60AT; MA60BM;

AR40e; interindividual
study; 25 eyes of 25 patients
Lower total ocular spherical aberration

at 4-mm and 6-mm optical zones
compared with other IOLs in study.
Lower myopic refractive shift with mydriasis.
Ricci
Arch Ophthalmol Scand
2004
911A; intraindividual study; 12

patients
Signicantly better low-contrast photopic

visual acuity for all contrast levels tested
except 100%, with mydriasis
et al
Journal
PACKER
Author
Bull Soc Belge Ophthalmol
2004
AR40e; SN60AT;
interindividual study; 98 eyes
of 71 patients randomly
received one of the three
lenses
Compared with the AR40e, signicantly better

contrast sensitivity at 3 and 12 cpd under
photopic conditions without glare; at
3, 12, and 18 cpd under photopic conditions
with glare; at 1.5, 12, and 18 cpd under
mesopic conditions without glare; and at
12 and 18 cpd under mesopic conditions
with glare.
Compared with the SN60AT, signicantly
better contrast sensitivity at 19 of 20 spatial
frequencies tested (photopic and mesopic
conditions with and without glare).
Bellucci
2005
Casprini
Acta Ophthalmol Scand
2005
SA60AT; interindividual
study; 60 eyes of 60 patients
randomly received one
type of lens
MA30BA; AR40; SA30AL;
AR40e; interindividual
study; 175 patients randomly
received one type of lens
Signicantly better contrast sensitivity for

spatial frequencies higher than 1.5 cpd
under both photopic and mesopic
conditions.
Statistically signicant dierence in mean spherical aberration coecient (Z4.0) of the whole
eye for a 5-mm pupil between the SA30AL,
AR40e, and Tecnis groups, and the MA30BA
group.
Compared with the other IOLs, a lower
percentage of patients experienced photic
phenomena while driving at night at
2 months postoperatively.
MartinezPalmer
Arch Soc Esp Oftalmol
2005
SA60AT; Inter-individual;
bilateral implantation of
same lens in 58 patients
Signicantly better monocular and binocular

visual acuity 3 months postoperatively.
Better monocular and binocular mesopic
contrast sensitivity at 3 months
postoperatively.
Kennis
Abbreviation: cpd, cycles per degree.
527
528
PACKER
In fact, the eye model using monochromatic,

symmetric optics does suggest tight tolerances for
tilt and decentration of IOL correcting spherical
aberration. For example, the model eye used in the
Tecnis IOL design study demonstrates a tolerance
of 0.4 mm decentration and 7-degree tilt for the
modied prolate IOL with Z (4,0) 0.27 m [18].
At this degree of decentration or tilt the 15 cycle
per degree contrast ratio of the wavefront-corrected
IOL with negative spherical aberration becomes
equivalent to that of a standard spherical IOL.
The reason that decentration reduces the
optical eciency of an aspheric lens may be
explained by the induction of higher-order aberration, such as coma [34]. As an example, consider
an aspheric IOL decentered 0.5 mm along the 180degree meridian for a 6-mm pupil. Given a coecient of fourth-order spherical aberration in the
IOL of 0.29 mm, then the coecient of induced
third-order horizontal coma is 0.30 mm.
A meta-analysis of the peer-reviewed literature
on the subject of IOL tilt and decentration has
been performed to determine the approximate
percentage of pseudophakic eyes that may be
expected to reside within the tolerances set by
the reported Tecnis design eye model [35]. The selected studies required a complete, continuous
curvilinear capsulorrhexis and in-the-bag IOL xation. Postoperative measurement of IOL position
was measured using Scheimpug photography,
which measures along the visual axis. When asymmetric aberrations and polychromatic light are
taken into account, however, a newly developed
model has suggested relatively relaxed tilt and decentration tolerances for wavefront-corrected
et al
IOLs. This model was developed using corneal

wavefront data from patients presenting for cataract surgery, including both symmetric and asymmetric aberrations, and was subsequently veried
with these patients clinical postoperative data
[33]. In the verication study, three surgeons randomly assigned a wavefront-corrected IOL to one
eye and a standard spherical IOL to the fellow eye
of 79 patients. The Zernike terms predicted by the
model for both the wavefront-corrected IOL and
the control IOL closely approximated the clinical
results. In particular, this model very closely
predicted the Z (4,0) term for both the wavefrontcorrected and the control IOL. This validated eye
model was then used to evaluate the eects of decentration and tilt on the modulation transfer
function of the wavefront-corrected IOL. Assuming polychromatic illumination and incorporating
the eects of the clinically validated asymmetric
aberrations, the degradation of modulation transfer function with decentration to the level of a control standard spherical IOL occurred at 0.8 mm
instead of 0.4 mm as in the simplied, symmetric
eye model. The degradation of modulation transfer
function with tilt to this level occurs at 10 degrees
instead of 7 degrees (Figs. 7 and 8).
By analyzing the peer-reviewed literature on
decentration in terms of a tolerance of 0.8 mm, as
demonstrated by the clinically veried eye model,
a signicant reduction in the percentage of cases
outside of tolerance emerges. For example, the
percentage of eyes with a three-piece silicone IOL
with polymethyl methacrylate haptics decentered
greater than 0.8 mm is expected to be 0.0001%
(Table 2). The number of IOLs expected to tilt
Fig. 7. Average radial modulation transfer function (MTF) versus decentration. Assuming polychromatic illumination
and incorporating the eects of the clinically validated asymmetric aberrations, the degradation of MTF with decentration
to the level of a standard spherical IOL occurs at 0.8 mm instead of 0.4 mm as in the simplied, symmetric eye model.
(From Packer M. Tilt and decentration: toward a new denition of tolerance. EyeWorld 2005;10:656; with permission.)
529
Fig. 8. Average radial modulation transfer function (MTF) versus tilt. Assuming polychromatic illumination and incorporating the eects of the clinically validated asymmetric aberrations, the degradation of MTF with tilt occurs at 10
degrees instead of 7 degrees as in the simplied, symmetric eye model. (From Packer M. Tilt and decentration: toward
a new denition of tolerance. EyeWorld 2005;10:656; with permission.)
Table 2
Percentage of eyes with a decentration O0.8 mma
Overall
Optic-haptic materials
Silicone-PMMA
PMMA-PVDF
Silicone-prolene
PMMA 1 piece
Acrylic-PMMA
Hydrogel-PMMA
0.06
0.0001
4.27
0.33
0.07
0.06
0.0002
Abbreviations: PMMA, polymethyl methacrylate; PVDF, polyvlnylidene uoride.

a
In this analysis of the available peer-reviewed literature on decentration and tilt the means and standard deviations
for each IOL design were used to calculate the percentage of IOLs expected to decenter more than 0.8 mm, the point at
which the MTF of the modied prolate Tecnis IOL is equivalent to that of a standard spherical IOL. The analysis included the following reports:
Akkin C, Ozler SA, Mentes J. Tilt and decentration of bag-xated intraocular lenses: a comparative study between
capsulorhexis and envelope techniques. Doc Ophthalmol 1994;87:199209.
Hayashi K, Harada M, Hayashi H, et al. Decentration and tilt of polymethyl methacrylate, silicone, and acrylic soft
intraocular lenses. Ophthalmology 1997;104:7938.
Kim JS, Shyn KH. Biometry of 3 types of intraocular lenses using Scheimpug photography. J Cataract Refract Surg
2001;27:5336.
Hayashi K, Hayashi H, Nakao F, et al. Comparison of decentration and tilt between one piece and three piece polymethyl methacrylate intraocular lenses. Br J Ophthalmol 1998;82:41922.
Mutlu FM, Bilge AH, Altinsoy HI, et al. The role of capsulotomy and intraocular lens type on tilt and decentration
of polymethylmethacrylate and foldable acrylic lenses. Ophthalmologica 1998;212:35963.
Hayashi K, Hayashi H, Nakao F, et al. Intraocular lens tilt and decentration after implantation in eyes with glaucoma. J Cataract Refract Surg 1999;25:151520.
Wang MC, Woung LC, Hu CY, et al. Position of polymethyl methacrylate and silicone intraocular lenses after phacoemulsication. J Cataract Refract Surg 1998;24:16527.
Hayashi K, Hayashi H, Nakao F, et al. Anterior capsule contraction and intraocular lens decentration and tilt after
hydrogel lens implantation. Br J Ophthalmol 2001;85:12947.
Taketani F, Matuura T, Yukawa E, et al. Inuence of intraocular lens tilt and decentration on wavefront aberrations. J Cataract Refract Surg 2004;30:215862.
Dick HB, Schwenn O, Krummenauer F, et al. Refraction, anterior chamber depth, decentration and tilt after implantation of monofocal and multifocal silicone lenses. Ophthalmologe 2001;98:3806.
530
PACKER
10 degrees or more is vanishingly small and

insignicant.
If common levels of tilt and decentration
signicantly aected the functioning of wavefront-corrected IOLs, it would be dicult to
explain the evidence of elimination of spherical
aberration and improved functional vision found
in multiple investigations of the Tecnis IOL. The
new clinically validated eye model described by
Piers and coworkers [33] helps relieve this potential paradox. Areas for future research include
verication of the decentration and tilt of the
wavefront-corrected IOL itself.
Customizing the correction of spherical aberration

Another important consideration for the general applicability of aspheric IOLs involves the
range of spherical aberration in the human
cornea. In the design study of the Tecnis IOL, it
was determined that approximately 90% of the
patient population would demonstrate a benet
from implantation of the IOL [18]. The distribution of corneal spherical aberration found in the
study population clustered around the mean
such that 10% of subjects would demonstrate
greater absolute spherical aberration after implantation of the modied prolate IOL than they
would have demonstrated after implantation of
a spherical IOL. Additional data collection suggests that the proportion may in fact be closer
to 4% of the population (Fig. 9). Regardless of
the precise proportion of outliers, it is clear that
Fig. 9. Distribution of corneal spherical aberration

values (N 202 patients). The Tecnis IOL was designed
to correct the population mean corneal spherical aberration. A certain percentage of individuals to the left of the
mean are not expected to show a demonstrable benet
from implantation of an IOL with negative spherical
aberration.
et al
further customization of the spherical aberration

of IOLs could potentially create a wider benet.
One approach to customization entails selection
of patients based on their preoperative corneal
spherical aberration. A limitation, however, of the
selection process remains corneal aberrations induced by surgery with IOL implantation, particularly astigmatism and trefoil terms [36].
Nevertheless, selection has been shown capable of
producing enhanced results, as demonstrated by
sine wave grating contrast sensitivity with targeted
postoperative total ocular spherical aberration
[37]. In his study, Beiko [37] used the Easygraph
corneal topographer (Oculus, Lynnwood, Washington) to select patients with corneal spherical aberration of 0.37 m, targeting a postoperative total
ocular spherical aberration of 0.10 m (the Easygraph includes an optional software package that
provides Zernike analysis). The selected patient
group demonstrated signicantly better contrast
sensitivity than an unselected group of control patients under both mesopic and photopic conditions.
The development and popularization of wavefront-corrected and aspheric IOLs represents a signicant trend in current cataract and refractive lens
surgery. With preoperative corneal topography
and wavefront analysis, surgeons can achieve
enhanced results through patient selection. One
method of proceeding with this approach might
involve the following protocol:
1. Preoperative testing to include corneal topography and axial length determination, anterior chamber depth, phakic lens thickness,
and corneal white-to-white diameter.
2. Application of a software package, such as
VOL-CT (Sarver and Associates, Carbondale, Illinois) to transform the topography elevation data into preoperative corneal
Zernike coecients, with special attention
to Z (4,0), fourth-order spherical aberration.
3. Application of an IOL calculation formula,
such as the Holladay 2 (available as part of
the Holladay IOL Consultant and Surgical
Outcomes Assessment Program, Jack T. Holladay, Houston, Texas) to determine correct
IOL power for desired postoperative spherical equivalent.
4. Determination of desired postoperative total
ocular spherical aberration and selection of
IOL type.
For example, if the desired postoperative total
ocular spherical aberration is zero and the
preoperative corneal spherical aberration measures about 0.27 m, the Tecnis with 0.27 m is
selected. If the preoperative corneal spherical
aberration is negative, a spherical IOL might
represent the best choice because it adds to the
total. This might be the case in a patient who had
undergone previous hyperopic laser in situ keratomileusis or conductive keratoplasty.
One challenge of customization, however, is
determining the desired postoperative state. Cataract and refractive surgeons have already faced
this dilemma in terms of lower-order aberrations
when they decide to target emmetropia, or achieve
slight residual with-the-rule astigmatism. It seems
that there exists a trade-o between spherical
aberration and depth of focus: Although best
corrected optical quality is signicantly better
with aspheric IOLs, tolerance to defocus tended
to be lower [36]. The evidence of the clinical investigation of the Tecnis IOL, and in particular
the results of the wavefront aberrometry and night
driving simulation, oer a compelling argument
for setting the postoperative spherical aberration
to zero. The data show that the mean spherical
aberration in the eyes implanted with the Tecnis
IOL was, in the words approved by the FDA,
not dierent from zero, whereas the subjects
performed functionally better in 20 of 24 driving
conditions (and statistically better in 10 conditions) when using best-spectacle correction with
the eye implanted with the Tecnis IOL, as compared with best-spectacle correction with the eye
implanted with the AcrySof spherical IOL [19].
These ndings represent the basis for the FDA labeling indication for improved functional vision,
which may improve patient safety for other life
situations under low-visibility conditions.
The ability to achieve superior functional
vision with best spectacle correction reects both
the strength and weakness of wavefront-corrected
IOLs. Given the state of the art of biometry and
IOL power calculation, it is not possible to
achieve precise emmetropia in all eyes. Many
pseudophakic patients nd that their uncorrected
vision is adequate for most tasks of daily living
and do not wear spectacles. The amount of
defocus and astigmatism they accept may negate
the pseudophakic correction of their spherical
aberration. Nio and coworkers [12] noted in
2002, Both spherical and irregular aberrations
increase the depth of focus, but decrease the modulation transfer at high spatial frequencies at optimum focus. These aberrations, therefore, play an
important role in the balance between acuity
531
and depth of focus. For some patients with adequate uncorrected distance acuity, the advantages
of a bit more depth of focus may be worth a little
loss of contrast. The ultimate expression of this
trend is embodied in the multifocal IOL, which
by its design reduces optical quality to enhance
spectacle independence. The Tecnis multifocal
IOL, currently under study in the United States
through an FDA Investigational Device Exemption, represents a conscious compromise between
optical eciency and functional vision, and quality of life.
Practical implementation of contrast-sensitivity

testing
The implementation of contrast-sensitivity
testing in practice requires investment in both
technology and training. When shopping for new
equipment it behooves the physician to compare
testing systems with respect to validation, functionality, and ease of use. Critical parameters
include control of luminance, consistency of
viewing distance, and correction of refractive
error. Standardization of testing methods in the
oce ensures comparability of results. Technicians should become procient at practicing the
established protocols for test administration with
each specic system. In the United States, practitioners should note the systems accepted by the
FDA in clinical investigations of cataract and
refractive surgery. Frequently cited products include the CSV-1000 (VectorVision, Greenville,
Ohio) and the Optec 6500 (Stereo Optical, Chicago, Illinois). A newly introduced product is the
Holladay Automated Contrast Sensitivity Testing
System (M & S Technologies, Skokie, Illinois).
As advances in technology allow cataract and
refractive surgeons to address higher-order optical
aberrations, the measurement of functional vision
becomes increasingly critical as a gauge of progress.
Contrast-sensitivity testing is assuming a prominent place in the evaluation of surgical modalities because it reects functional vision, correlates
with visual performance, and provides a key to
understanding optical and visual processing of
images.
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2006, Vol.19, Issues 4, Cataract Surgery in The New Millennium

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2006, Vol.19, Issues 4, Cataract Surgery in The New Millennium

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Ophthalmol Clin N Am 19 (2006) ix

pride, that I oer to you some of the best articles I

Ophthalmol Clin N Am 19 (2006) 415425

The New Epidemiology of Cataract

Cataract poses a substantial economic and

roughly 37 million blind individuals [1]. Of note,

Although 90% of cataract cases are found in

Population (length of follow-up)

quality of life resulting from low vision. Cataract

surgery, surgical failure rates of even 10%

NEW EPIDEMIOLOGY OF CATARACT

resulting from UVB exposure is hypothesized to

Risk factors where current understanding

across studies dicult. Additionally, teasing out

NEW EPIDEMIOLOGY OF CATARACT

combination out of several studied [61]. These

of the lens may be scratching the surface of

inhaled corticosteroids compared with those with

cataractogenesis may eventually lead to gene product

NEW EPIDEMIOLOGY OF CATARACT

newborn screening for hypergalactosemia, has

nonprospective study designs. Further, systemic

[12] Friedman DS, West SK, Munoz B, et al. Racial

NEW EPIDEMIOLOGY OF CATARACT

[59] A randomized placebo-controlled, clinical trial of

[75] Tsutsumi K, Inoue Y, Yoshida C. Acceleration of

patients treated with inhaled glucocorticoids. Lancet 1993;342:7768.

NEW EPIDEMIOLOGY OF CATARACT

[108] Heiba IM, Elston RC, Klein BE, et al. Genetic

Ophthalmol Clin N Am 19 (2006) 427434

Perioperative and Operative Considerations

Diabetes mellitus has become one of the fastest

* Corresponding author. Retinovitreous Associates,

found to be a signicant risk factor associated

It is important to dierentiate causal visual

Fig. 1. Optical coherence tomography demonstrating

determine treatable lesions (Fig. 1). Focal laser

Fig. 2. Optical coherence tomography demonstrating

on the ocular surface, and aqueous penetration to

these cases a scleral tunnel-limbal approach may

residual cortical material. Meticulous cleanup may

Cataract surgery in those patients with

#25) also found poor preoperative visual acuity to

progression. Poor blood sugar control, male sex

An yttrium-aluminum-garnet laser capsulotomy may become necessary in cases of signicant

includes vitreous tap and injection of antibiotics.

[5] Chew EY, Benson WE, Remaley NA, et al. Results

patients with type 2 diabetes. Br J Ophthalmol 2002;

[44] Nishi O, Nishi K. Intraocular lens encapsulation by

Ophthalmol Clin N Am 19 (2006) 435448

Enhancing Intraocular Lens Outcome Precision:

With increased safety of the procedure itself,

address the details of measuring axial length and

minor dierences in the values for the corneal

formulas for IOL calculation may cause increased

ENHANCING IOL OUTCOME PRECISION

inaccuracy of only 1 mm can result in a 3-D refractive error.

problems, dense posterior subcapsular cataracts,

Read the chart before measuring the eye

ENHANCING IOL OUTCOME PRECISION

more confusing because the index of refraction

Practical tips in obtaining immersion

adequately disinfected the probe/shell according