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Proceedings of the

American Society of
Cataract and Refractive
Surgery 2008
4th - 9th April 2008, Chicago, IL, USA
Watertight wound closure without stromal hydration paramount for reducing
endophthalmitis risk

Good surgical technique that includes maintenance of a sterile environment, antisepsis of

the lids and ocular surface, thoughtful prophylactic antibiotic use, and most importantly,
assurance of watertight wound closure without stromal hydration should result in a rare
occurrence of endophthalmitis, said James P. McCulley, MD.

"In the interest of saving a few seconds and a few dollars, cataract surgeons will perform
stromal hydration and skip suturing the wound," said Dr. McCulley, chairman,
Department of Ophthalmology, University of Texas Southwestern Medical Center,
Dallas. "However, the effect of stromal hydration lasts only a few minutes, and so it is
critical to make sure that the incision, with or without a suture, is watertight without
stromal hydration.

"If we employ all of these factors, we can approach a better and lesser rate of
endophthalmits after cataract surgery," he said.

As evidence for this premise, Dr. McCulley reported that at his own institution, only a
single case of endophthalmitis occurred in 11,928 cataract procedures performed through
a temporal clear corneal incision. This translates into a rate of 0.08 per 1,000, which is
comparable with the rate associated with intracameral cefuroxime use in the European
Society of Cataract and Refractive Surgeons (ESCRS) study of postcataract surgery
endophthalmitis prophylaxis and is much lower than the rate of 38 per 1,000 cases
reported in the control group of that prospective, randomized trial where no intracameral
cefuroxime or preoperative levofloxacin was used.

"The ESCRS study also found an increased risk of endophthalmitis associated with use of
a clear corneal incision," Dr. McCulley said. "My best guess is that not having a
watertight wound closure at the end of surgery was a major factor for that and the high
rate of endophthalmitis in the ESCRS control group."
DSAEK graft effect on refractive power holds implications for cataract surgery

A study from Duke University Eye Center showing that Descemet's stripping automated
endothelial keratoplasty (DSAEK) grafts add refractive power to the posterior surface of
the cornea has implications for graft patients undergoing cataract surgery.

"Further studies are warranted to understand the mechanism of the refractive change
associated with the DSAEK graft," said Bokkwan Jun, MD, research associate, Duke
University, Durham, NC. "However, we recommend considering adjusting the IOL
power in patients undergoing a DSAEK triple procedure (DSAEK, phacoemulsification,
and IOL implantation) and in DSAEK patients undergoing cataract surgery."

Dr. Jun and colleagues undertook a retrospective review of all cases of DSAEK surgery
performed by three surgeons at the Duke University Eye Center between August 2005
and December 2006, in order to investigate any postoperative refractive change and
correlations with graft thickness and diameter. Data were analyzed for a total of 45 cases
of 44 patients that had at least 3 months follow-up after DSAEK and refractive data
preoperatively and at last follow-up.

The overall refractive change in the 45 eyes was +0.88 D. After subgroup classification,
the mean refractive change was +1.15 D in 17 eyes that underwent DSAEK triple surgery
and +0.71 D in 28 pseudophakic DSAEK eyes. The difference between the two groups
was not statistically significant.

A negative correlation was found between the amount of refractive change and graft
central thickness, although it was not statistically significant. There was a positive
correlation between the refractive change and graft diameter that approached statistical
significance (p = 0.05).
Standardized digital imaging technique aims to increase understanding of
intralenticular glistenings

Researchers developing a method for standardized digital photographic analysis of

intralenticular glistenings believe it represents an important step forward in the scientific
assessment of this IOL complication and its visual significance. William Trattler, MD,
described the work that has been done to develop protocols for capturing images of the
microvacuoles under standardized conditions in order to maximize visibility of the
microvacuoles and enhance the utility of the images obtained.

The studies have involved patients implanted with an acrylic IOL who have clinically
documented intralenticular glistenings, said Dr. Trattler, a private practitioner in Miami,
and volunteer assistant professor, Bascom Palmer Eye Institute, University of Miami.

Parameters considered included angle of illumination, slit lamp magnification, slit size,
area of focus, camera type, and resolution. The investigators also developed a grading
system where the severity of the glistenings are scored using digital image processing
software that takes into account the number and size of the microvacuoles in a central 2-
× 2-mm region.

"We are all familiar with glistenings in IOL material," Dr. Trattler said. "However, their
prevalence, severity, and visual significance with respect to effects on visual acuity,
contrast sensitivity, and/or dysphotopsias remain controversial because no consistent
standard exists for the in vivo evaluation or photographic capture of these microvacuoles.

"We believe glistenings represent an important biomaterial issue that should be

considered in IOL selection," he said. "Through the use of standardized imaging
techniques and grading scales and the undertaking of a full scale study, we hope to be
able to better assess them and understand how they impact vision."
Laser vision correction: good results after multifocal IOL implantation resolve
residual refractive errors

Using an excimer laser to treat patients with residual refractive error after implantation of
a multifocal IOL reduces astigmatism and sphere and increases visual satisfaction. Using
an excimer laser for re-treatment in this patient population may help overcome side
effects of multifocal IOL implantation such as glare and halos, according to David
Hardten, MD.

"Implantation of presbyopic IOLs is becoming increasingly common," said Dr. Harden,

adjunct associate professor of ophthalmology, University of Minnesota, Minneapolis.
"These patients have very high expectations about the quality of their vision.
Astigmatism is not managed with these implants, which is very important to the results
achieved for the uncorrected distance visual acuity and near vision. The residual
astigmatism will cause increased glare and halos."

Forty patients were included in this study. The timing of the laser vision correction is
typically 4 to 6 months following IOL implantation.

Dr. Hardten said that the results were very good. He cited the case of a patient implanted
with a multifocal lens (ReZoom, Advanced Medical Optics) who achieved 20/20 at J3. In
this group of patients who went on to laser vision correction, 13 eyes (33%) received an
apodized diffractive IOL (ReSTOR, Alcon Laboratories), 21 eyes (53%) an
accommodating IOL (crystalens, eyeonics/Bausch & Lomb), and six eyes (15%) the

The mean spherical equivalent in this patient group was about 1 D; the mean astigmatism
after implantation of an IOL was about 1.3 D. The mean uncorrected visual acuity was
20/45 after IOL implantation, but the patients were not satisfied with that result.

The vast majority (83%) of patients were treated with standard LASIK, and the remainder
with standard and custom PRK.

"After at least 3 months of follow-up, the mean spherical equivalent at the last follow-up
visit was -0.14 D, and the mean astigmatism 0.4 D from 1.3 D preoperatively. No eyes
lost lines of best-corrected visual acuity," Dr. Hardten said. About 40% of patients had
uncorrected distance visual acuity of 20/20; about 80% had 20/30; 40% had 20/25 at J2.

"The results of laser vision correction after multifocal IOL implantation are promising,"
Dr. Hardten said. "These patients can be enhanced. Astigmatism and sphere are
decreased. The enhancement rates are fairly low in patients with presbyopic IOLs, with
about 10% requiring enhancement. Surface treatments are possible and this improved the
results in our patients with presbyopic IOLs by enhancing the astigmatism and myopia."
Dual-optic accommodating IOL provides stable vision at all distances, researcher

A dual-optic accommodating IOL (Synchrony, Visiogen) can provide good visual acuity
and spectacle independence at all distances without inducing halos or glare, and results
remain stable over time, according to results of a prospective, non-comparative case
series presented by Ricardo Alarcon, MD, of Bogota, Columbia.

Dr. Alarcon presented data on patients in which the dual-optic IOL was implanted
binocularly between 2004 and the present; 42 patients (84 eyes) were seen at 6 months,
39 were seen at 1 year, and 21 were seen at 2 years.

Patients' mean age was 61 years, and all were Hispanic. Patient satisfaction, spectacle
independence, functional vision (reading speed), and quality of vision as assessed via
patient survey, were recorded at the last visit.

The researchers used ETDRS charts to measure uncorrected visual acuity (UCVA) and
distance-corrected visual acuity for far, intermediate, and near distances at 6 months, 1
year, and 2 years. At 1 year, mean UVCA for distance was 0.02 logMAR, for
intermediate was -0.10 logMAR, and for near was 0.10 logMAR.

After 2 years, mean UCVA remains stable, Dr. Alarcon reported, at 0.03 logMAR for
distance, -0.10 logMAR for intermediate, and 0.06 logMAR for near. Distance-corrected
near visual acuity remains stable over time, also, he said; functionality of the lens does
not change.

After 2 years, more than 90% of patients reported that they can read at a 0.3 logMAR
(20/40 Snellen) level, Dr. Alarcon said. Regarding near-vision activities, 95% of patients
said that they could read menus and newspapers without glasses, and about 74% said that
they could read fine print such as labels on bottles of eye drops, he added.
PCO incidence with hydrophobic acrylic IOLs lower than previously shown, study

Information about posterior capsule opacification (PCO) rate can be helpful to surgeons
as they choose IOLs for their patients. Use of the results of a study presented by David J.
Apple, MD, of Charleston, SC, will require a paradigm shift, however, he said; the study
found somewhat lower rates of PCO resistance with a posterior-chamber lens of
hydrophobic acrylic material compared with rates found in previous studies, especially in
the late postoperative period.

The first-of-its-kind study included 5,000 lenses examined from 1981 to 1999 and 500
lenses examined from 2004 to 2008 using the Miyake-Apple posterior technique. The
investigators separated the lens styles by manufacturer and model number.

They evaluated eyes, paying particular attention to PCO and postoperative proliferation
of cells, using criteria that included Soemmering's ring intensity, Soemmering's ring area,
peripheral and central PCO, and rate of posterior capsulotomy. They ranked IOL models
based on the degree of complications affecting each lens. The researchers found low
scores in the early postoperative period with the hydrophobic acrylic designs, but they
saw no differences in the scores with all biomaterials in later stages.

The safety and efficacy of a lens depends on the avoidance of opacification and fibrosis,
Dr. Apple said.

"The matter of avoidance is not inherent in any IOL," he said. "Basically, you're only
delaying it. After 3, 4, 5 years, [all the lenses are] the same as far as I can see. . . . That's
an important point."