PURPOSE To evaluate incision sizes for 6.0 mm optic hydrophobic acrylic intraocular lenses (IOLs) implanted with different injector systems and surgical techniques. SETTING Department of Ophthalmology, Johann Wolfgang Goethe-University, Frankfurt, Germany. METHODS In this prospective randomized trial of 100 cataract patients, hydrophobic acrylic IOLs (SN60WF) were implanted using 2 injector systems with 2 cartridges (Monarch II and Monarch III with C and D cartridges, respectively; Alcon) and 2 surgical techniques (direct implantation and wound-assisted docking implantation). Incision sizes were measured before and after phacoemulsification as well as before and after IOL implantation using a Tsuneoka microincision gauge. The Saphiro-Wilks test was performed to detect nonparametric distribution and the Kruskal-Wallis test, to test for significant differences between groups. RESULTS The mean incision sizes (mm) at the 4 points of treatment with the Monarch III with the D cartridge were 1.98+/-0.07, 2.01+/-0.05, 2.42+/-0.07, and 2.51+/-0.05, respectively, with direct implantation and 1.92+/-0.06, 1.98+/-0.04, 2.02+/-0.11, and 2.09+/-0.11, respectively, with wound-assisted implantation. With the Monarch II with the C cartridge, the mean incision sizes were 2.17+/-0.06, 2.2+/-0.16, 2.77+/-0.11, and 2.86+/-0.11, respectively, with direct implantation and 2.12+/-0.10, 2.17+/-0.19, 2.19+/-0.09, and 2.28+/-0.08, respectively, with wound-assisted implantation. Postoperative incision sizes differed significantly from preoperative incision sizes and from each other (P<.05). CONCLUSION With new injector systems and an appropriate docking implantation technique, foldable hydrophobic acrylic IOLs can be implanted through 2.0 mm tunnel incisions.

PURPOSE To determine incision sizes for 6-mm optic foldable intraocular lenses (IOLs) implanted with injector systems. DESIGN Nonrandomized, prospective clinical study. PARTICIPANTS One hundred fifty eyes of 150 patients with cataract and without other anterior segment pathological features or previous eye surgeries. INTERVENTION We performed implantation of foldable IOLs with sharp optic edges and 6-mm total optic diameter with their recommended injector systems and cartridges:(1) Alcon MA60BM with Monarch II/cartridge A,(2) Alcon SA60AT with Monarch II/cartridge B,(3) Alcon SA60AT with Monarch II/cartridge C,(4) AMO AR40e with Unfolder Sapphire,(5) AMO AR40e with Unfolder Emerald, and (6) AMO Clariflex with Unfolder Silver. With every combination, 25 IOLs were implanted. MAIN OUTCOME MEASURES We measured incision width before and after phacoemulsification as well as before and after IOL implantation using a Kohnen caliper. RESULTS The tunnel width (in millimeters;+/- standard deviation) for each combination before and after IOL implantation, respectively, was (1) 3.61 (+/-0.12) and 3.74 (+/-0.15),(2) 3.31 (+/-0.12) and 3.44 (+/-0.16),(3) 2.88 (+/-0.11) and 2.96 (+/-0.11),(4) 3.37 (+/-0.12) and 3.52 (+/-0.09),(5) 2.99 (+/-0.16) and 3.11 (+/-0.14), and (6) 3.06 (+/-0.12) and 3.15 (+/-0.11). The incision sizes before and after implantation for (3) were significantly smaller than all other combinations. Combinations (2) and (4) were not statistically significantly different, but were statistically significantly smaller in preimplantation and postimplantation incision size compared with combination (1) and were larger compared with combinations (5) and (6). However, the relationship of incision size and effective IOL optical zone differed: AR40e (Unfolder Sapphire)< MA60BM < Clariflex < AR40e (Unfolder Emerald)< SA60AT with both Monarch II B and C cartridge (greater means better relationship). CONCLUSIONS Postimplantation incisions sizes of 2.96 to 3.74 mm were determined with 6-mm total optic foldable IOLs using Monarch and Unfolder injector systems. Because the effective optical zone size is different for some of these IOLs, the incision size alone may not be the only relevant factor for optical outcome.

PURPOSE To examine the efficacy of using the Unfolder Sapphire series system (Allergan) for implanting acrylic intraocular lenses (IOLs) with a 6.0 mm optic (Sensar AR40, Allergan). SETTING Ambulatory day-surgery center. METHODS Phacoemulsification was performed using topical anesthesia. The Unfolder injection system was used to insert a Sensar AR40 acrylic IOL. Data on complications and the success of implantation were collected retrospectively. RESULTS Two hundred two consecutive patients having implantation of the Sensar IOL with the Unfolder system were examined. Three problems related to the Unfolder injector were identified. Another patient required an anterior vitrectomy, sulcus IOL implantation with the Unfolder, and optic capture; the complication was not related to the Unfolder system. Sulcus implantation was relatively easy with the Unfolder. CONCLUSION Implantation of the Sensar AR40 IOL with the Unfolder system was easy to perform, and no serious complications occurred.

Both cataract and many vitreoretinal diseases occur more frequently and often at the same time in the elderly population. Therefore, one has to consider whether to combine cataract surgery and vitrectomy or to plan a sequential approach. The aim of the present survey - based on a thorough review of the current literature - is to point out the advantages and disadvantages of a combined versus a sequential approach. Furthermore, practically oriented guidelines have been compiled for finding the right indication for a combined procedure with regard to the underlying vitreoretinal disease.

Centration and positional stability of intraocular lenses (IOLs) are crucial factors for optical quality and predictability of the result after IOL implantation. Continuous improvements of IOL design and materials, surgical techniques and measurement methods have contributed to an optimised correction of the presudophakic eye and to a better unterstanding of the effects of IOL positioning. With modern IOLs implanted into the capsular bag, positioning and stability comparable to the natural crystalline lens can be achieved.

HASH(0x10cc5520)

Incision size in micro-incisional cataract surgery (MICS) is dependent on the minimal size of the folded or rolled intraocular lens (IOL) during implantation and thus the outer diameter of the injector system used. At present implantations through incisions <2.0 mm are possible. MICS IOLs have to be optimized for this small dimension in terms of material and lens body design. Compared to standard procedures, MICS induces little astigmatism and higher order aberrations. Thus MICS procedures provide better predictability in terms of postoperative refractive results. This is of special interest when implanting advanced optic designs, such as aspheric, toric or multifocal IOLs.

Microincision cataract surgery (MICS) represents a new level in the development of cataract surgery. Phacoemulsification with intraocular lens (IOL) implantation via incisions of </=2 mm may be performed by the coaxial approach, such as conventional phacoemulsification but with a smaller diameter of the phaco tip (C-MICS), or by the biaxial approach, with separation of the phaco tip and irrigation (B-MICS). Compared with standard small-incision cataract surgery, the advantages of MICS are less corneal astigmatism and fewer corneal surface irregularities, with favorable implications for visual quality and early rehabilitation. In the effort toward smaller incisions, special interest should be given to wound integrity, especially regarding the risk of endophthalmitis. With limited corneal elastic capacity, irreversible expansion of the incision with tissue laceration may occur. Smaller incisions are superior only if they cause less trauma. This requires an optimized relationship between incision size and manipulation during IOL implantation as well as attention to safety issues. MICS offers a platform for new benchmarks in phacoemulsification.

OBJECTIVE: For technical reasons, the rotating knives (microkeratomes) commonly used for flap creation in LASIK may induce cut complications such as buttonholes or incomplete flaps. Femtosecond (femto) lasers should reduce these risks because, compared with microceratomes, femtolasers work more precisely and individually, so the flap can be individualized according to the patient's eye condition. Therefore, surgery should be less of a strain to patients, vision should recover faster, and optical quality should be optimized. METHODS: In this study, 308 consecutive femtolaser cuts for myopic LASIK performed with the IntraLase FS60 between August 2006 and March 2008 were evaluated and compared with the approved key literature. RESULTS: For all cuts, just three complications (incomplete ring cuts of about 20 degrees ) occurred. All were completed with a diamond knife without any further problems. No other complications - including the typical microceratome-induced cut complications - were observed. CONCLUSIONS: In this small series of 308 operations, femto-LASIK induced no major cut complications.

BACKGROUND: Collagen cross-linking with administration of riboflavin and UV radiation may delay or halt the progression of keratoconus. This study examines the effects of the treatment on the corneal wavefront error. MATERIALS AND METHODS: Twenty eyes of 20 patients with keratoconus received collagen cross-linking with riboflavin administration and 30 min of UV radiation at a wavelength of 365 nm. Preoperatively as well as 1 and 6 months postoperatively, the corneal wavefront error was computed from axial keratometric topography data by Zernike decomposition over a pupil diameter of 6 mm. RESULTS: Preoperative mean keratometric astigmatism was 5.37 +/- 2.36 D. Six months postoperatively it was 5.29 +/- 2.73 D (p = 0.35). Total higher order aberrations were preoperatively 3.35 +/- 1.65 microm and after 6 months 3.31 +/- 1.79 microm (p = 0.116). Coma's root mean square was 2.94 +/- 1.47 microm preoperatively and 2.75 +/- 1.38 microm after 6 months (p = 0.047). CONCLUSION: Within the first 6 postoperative months, collagen cross-linking with riboflavin administration and UVA irradiation does not significantly increase or decrease corneal wavefront aberrations.

PURPOSE To assess the impact on incision size of IOL implantation using a new motorized intraocular lens (IOL) injector versus a standard manual injector. SETTING Cataract Treatment Centre, Sunderland Eye Infirmary, Sunderland, United Kingdom. DESIGN Comparative case series. METHODS All patients received an Acrysof SN60WF IOL implanted using a D cartridge and an Autosert motorized injector at fast speed, an Autosert motorized injector at slow speed, or a manual Monarch injector. Each group had a range of preimplantation incision sizes (1.9 mm, 2.0 mm, 2.1 mm, 2.2 mm, 2.3 mm). Incision gauges were used to measure the incision width before and immediately after IOL implantation. RESULTS The study recruited 256 patients. All incisions that were 1.8 mm at the commencement of surgery increased in size by the end of irrigation/aspiration. The motorized injector used with a fast speed (4.4 mm/sec) caused significantly less incision enlargement than the manual injector for all preimplantation incision sizes tested (P<.02). For 4 of the 5 preimplantation incision size subgroups, the motorized injector used at slow speed (1.5 mm/sec) produced less incision stretch than the manual injector, although the difference did not reach statistical significance. CONCLUSION The motorized injector was easy to use, and its use with an injection speed of 4.4 mm/sec caused significantly less incision enlargement than the manual injector during IOL implantation.

Scleral fixation of a foldable intraocular lens (IOL) was performed in 17 eyes of 17 patients using a new small incision technique with injector implantation. All eyes were implanted with a hydrophobic acrylic three-piece IOL, either with phacoemulsification surgery or secondarily. No cases of intraoperative or postoperative complications were observed. The operation time required for scleral fixation only was less than 30 minutes in all cases. Scleral fixation of foldable IOLs using a self-sealing tunnel incision and injector technique minimizes intraoperative hypotony and related complications such as suprachoroidal hemorrhage. Furthermore, this technique saves surgery time and the sutureless technique used for most patients can reduce postoperative astigmatism.

PURPOSE To evaluate incision sizes during different stages of phacoemulsification and after implantation of a foldable acrylic intraocular lens (IOL). SETTING Private eye center, Manila, Philippines. METHODS In this prospective observational case series, incision widths were measured before and after microcoaxial phacoemulsification (2.2 mm), after cortical removal, and after implantation of a 6.0 mm optic, foldable, single-piece aspheric hydrophobic acrylic IOL using a D cartridge and a Monarch III injector. RESULTS The incision width increased in 101 (93.5%) of the 108 eyes; the enlargement was 0.1 mm in 78 eyes (77.2%) and 0.2 mm in 23 eyes (22.8%). The final incision width was 2.3 mm in 78 eyes (72.2%), 2.2 mm in 27 eyes (25.0%), 2.1 mm in 2 eyes, and 2.4 mm in 1 eye. Enlargement occurred during phacoemulsification in 39 eyes, during cortical removal in 33 eyes, and during IOL implantation in 52 eyes; 23 eyes had more than 1 enlargement. Before IOL implantation, the incision was smaller than 2.2 mm in 76 eyes (70.4%); after IOL implantation, the incision increased to 2.3 mm in 47 eyes (61.8%). Thirty-two eyes (29.6%) had a 2.3 mm incision before IOL implantation; the incision increased further (by 0.1 mm) after IOL implantation in 1 eye. CONCLUSIONS Incision enlargement occurred at different stages of phacoemulsification, mostly during IOL implantation. More than 72% of eyes had a final incision of 2.3 mm. Beginning with a 2.3 mm incision may prevent wound tears and surface irregularities.

PURPOSE Study on cell growth on the posterior capsule after implantation of hydrophobic acrylic (Acrysof SA 60 AT) and hydrophilic acrylic (Akreos Disc) intraocular lenses (IOL) in a rabbit model and comparison of posterior capsule opacification (PCO). METHODS Phacoemulsification was performed in 22 rabbit eyes, and two different IOL types (Acrysof SA60 AT and Akreos Disc) were implanted. These IOLs had the same optic geometry (square edged) but different material and design. Central PCO (CPCO), peripheral PCO (PPCO), Sommering's ring (SR) formation, type of growth, extension of PCO, cell type, inhibition, and fibrosis were evaluated three weeks after surgery. Histological sections of each globe were prepared to document the evaluation of PCO. RESULTS No statistically significant difference was observed between a hydrophobic acrylic IOL and a hydrophilic acrylic IOL in relation to the CPCO, PPCO, type of growth, extension, cell type, inhibition, and fibrosis. Statistically significant difference was observed in relation to the formation of SR with Acrysof SA 60 AT group presenting more SR than Akreos Disc group. CONCLUSION PCO was not influenced by the material of the IOL or the design of the haptics of the IOLs we studied.

OBJECTIVE To evaluate and compare the impact of two sharp-edge optic foldable intraocular lenses (IOLs) of similar design made from different material (hydrophilic acrylic or hydrophobic acrylic) on visual function, anterior and posterior capsule opacification at one-year follow-up after cataract phacoemulsification. MATERIAL AND METHODS Seventy-two eyes of 72 patients scheduled for cataract surgery were included in a prospective clinical study. Two foldable sharp-edge optic posterior chamber acrylic IOLs of similar design were used. Thirty-nine eyes of 39 patients received a single-piece hydrophilic acrylic (PC 511, Ophtec) IOL and 33 eyes of 33 patients - single-piece hydrophobic acrylic (AcrySof, SA60AT, Alcon) IOL. Visual acuity, anterior capsule opacification (ACO), capsulorrhexis/optic overlapping, and posterior capsule opacification (PCO) were evaluated. The intensity of ACO was assessed subjectively. PCO values in the entire IOL optic area and in the central 3-mm optic zone were assessed using a photographic image analysis system (EPCO 2000). The patients were examined at one year postoperatively. RESULTS There were no significant differences in best-corrected visual acuity and capsulorrhexis/optic overlapping between IOL types at 1-year follow-up after surgery. In the single-piece hydrophilic acrylic IOL group, the grade of ACO density was significantly higher in capsulorrhexis rim area (1.56+/-0.71 and 1.00+/-0.75) and in the capsule/optic area (1.62+/-0.67 and 1.00+/-0.75)(P<0.05). PCO values of the entire IOL optic area (0.12+/-0.13 and 0.024+/-0.02) as well as in the central 3-mm optic zone (0.06+/-0.11 and 0.001+/-0.003) was significantly higher in the single-piece hydrophilic acrylic IOL group one year postoperatively (P<0.05). In 33.3% of cases of the single-piece hydrophilic acrylic IOL group, contraction of haptics to IOL optics was present one year postoperatively, which was not present in any case of the single-piece hydrophobic acrylic IOL group. CONCLUSIONS One-year follow-up after cataract surgery has shown a significant difference in ACO and PCO development comparing single-piece hydrophilic acrylic and single-piece hydrophobic acrylic intraocular lenses. The effect of hydrophobic acrylic foldable lenses on preventing anterior and posterior capsule opacification is mainly a result of the acrylic hydrophobic biomaterial.

OBJECTIVE To study the changes in anterior chamber configuration after phacoemulsification and foldable intraocular lenses (IOL) implantation with panoramic ultrasound biomicroscopy (UBM). METHODS A novel panoramic UBM was developed for anterior segment scanning. Small-incision phacoemulsification and foldable IOL implantation were performed in 102 eyes of 81 patients with age-related cataract. The anterior chamber diameter in horizontal meridian and vertical meridian and the anterior chamber depth (ACD) were measured by computer calipers before and two months after the surgery. The changes of the anterior chamber angle were measured in 36 eyes. RESULTS Diameter of anterior chamber in vertical meridian was greater than that in horizontal meridian in most cases. In all patients, horizontal anterior chamber diameter was widened significantly two months after surgery (t = 7.10, P < 0.01), a significantly negative correlation existed between preoperative and postoperative data(r = 0.801, P < 0.01). The ACD was deepened ( t = 39.97, P < 0.01). In 36 eyes, the anterior chamber angle was widened. CONCLUSIONS Diameter of the anterior chamber in vertical meridian is greater than that in horizontal meridian in most cases. After phacoemulsification and foldable IOL implantation, UBM revealed that the anterior chamber diameter is increased and postoperative chamber diameter can be estimated by preoperative one. After the operation, the iris diaphragm shifts backward, the anterior chamber is deepened and anterior chamber angle is widened.

PURPOSE To evaluate incision sizes for 6.0 mm optic hydrophobic acrylic intraocular lenses (IOLs) implanted with different injector systems and surgical techniques. SETTING Department of Ophthalmology, Johann Wolfgang Goethe-University, Frankfurt, Germany. METHODS In this prospective randomized trial of 100 cataract patients, hydrophobic acrylic IOLs (SN60WF) were implanted using 2 injector systems with 2 cartridges (Monarch II and Monarch III with C and D cartridges, respectively; Alcon) and 2 surgical techniques (direct implantation and wound-assisted docking implantation). Incision sizes were measured before and after phacoemulsification as well as before and after IOL implantation using a Tsuneoka microincision gauge. The Saphiro-Wilks test was performed to detect nonparametric distribution and the Kruskal-Wallis test, to test for significant differences between groups. RESULTS The mean incision sizes (mm) at the 4 points of treatment with the Monarch III with the D cartridge were 1.98+/-0.07, 2.01+/-0.05, 2.42+/-0.07, and 2.51+/-0.05, respectively, with direct implantation and 1.92+/-0.06, 1.98+/-0.04, 2.02+/-0.11, and 2.09+/-0.11, respectively, with wound-assisted implantation. With the Monarch II with the C cartridge, the mean incision sizes were 2.17+/-0.06, 2.2+/-0.16, 2.77+/-0.11, and 2.86+/-0.11, respectively, with direct implantation and 2.12+/-0.10, 2.17+/-0.19, 2.19+/-0.09, and 2.28+/-0.08, respectively, with wound-assisted implantation. Postoperative incision sizes differed significantly from preoperative incision sizes and from each other (P<.05). CONCLUSION With new injector systems and an appropriate docking implantation technique, foldable hydrophobic acrylic IOLs can be implanted through 2.0 mm tunnel incisions.

The tenth annual survey of complications associated with foldable intraocular lenses (IOLs) requiring explantation or secondary intervention was sent to members of the American Society of Cataract and Refractive Surgery and the European Society of Cataract and Refractive Surgeons. Preoperative data about visual acuity, patient signs and symptoms, and complications requiring IOL removal were evaluated. Complications were then tabulated for each of the following major foldable IOL groups: 1-piece (plate) silicone, 1-piece hydrophobic acrylic with haptics, 3-piece silicone, 3-piece hydrophobic acrylic, 3-piece hydrophilic acrylic (hydrogel), 3-piece unknown, multifocal acrylic, and multifocal silicone. One hundred forty-two surveys were returned for evaluation. Dislocation/decentration, incorrect IOL power, glare/optical aberrations, and IOL calcification were the most common reasons for removing foldable IOLs. Good surgical technique, accurate IOL power measurements, and high manufacturing standards for foldable IOL materials and designs are the most important factors in preventing complications.

OBJECTIVE: To compare the difference in posterior capsular opacification (PCO) between highly refractive silicone and hydrophobic acrylic foldable intraocular lenses (IOLs) with sharp and round edge designs 3 years after in-the-bag IOL implantation in subjects undergoing bilateral cataract surgery. DESIGN: Open-label, prospective, randomized, multicenter clinical trial. PARTICIPANTS: Two hundred and eighty-eight patients with bilateral surgery for senile cataract operated in German university clinics, eye hospitals, and private ophthalmic surgical centers (Aachen, Ahaus, Bad Hersfeld, Frankfurt/Main, Jena, Rosenheim, and Sulzbach/Saar). INTERVENTIONS: At each center, a highly refractive index silicone IOL with a sharp optic edge (CeeOn) was intraindividually compared either with a high-refractive index silicone IOL with a round optic edge (PhacoFlex) in 108 patients or with an acrylic IOL with a sharp optic edge (AcrySof) in 139 patients. All patients received standard phacoemulsification with IOL implantation in the bag in both eyes from the same surgeon. A morphological evaluation of PCO was performed by the Evaluation of the Posterior Capsule Opacification (EPCO) system 1 to 2 weeks and 11 to 14 and 35 to 37 months after surgery. The blinded digital pictures were evaluated by an independent investigator. Posterior capsular opacification was statistically evaluated by paired comparisons of 3-year cumulative incidences of neodymium:yttrium-aluminum-garnet (Nd:YAG) laser treatment and EPCO scores. MAIN OUTCOME MEASURES: Posterior capsular opacification. RESULTS: The 3-year cumulative incidences of Nd:YAG laser capsulotomy were 2.1%(CeeOn), compared with 2.1%(AcrySof)(risk difference, 0%; 90% confidence interval,-3.4% to 3.4%), and 5.7%(CeeOn), compared with 17.0%(PhacoFlex)(risk difference,-11.4%; 90% confidence interval,-18.1% to -4.7%). In patients without Nd:YAG laser treatment, medians of the total area EPCO score were 0.0005 (CeeOn) versus 0.0440 (AcrySof) and 0 (CeeOn) versus 0.0700 (PhacoFlex) at 3 years. Functional results, safety, and handling did not significantly differ for the 3 lenses. CONCLUSIONS: Our results suggest that modern foldable IOLs have a low incidence of PCO after 3 years. There is less PCO for sharp optic edge designs independent of IOL material.

AIM: To assess the risk of dysphotopsia after phacoemulsification, with the use of four different intraocular lens (IOL) models. METHODS: In this prospective randomized study, 600 patients underwent phacoemulsification surgery. Four study groups were formed, according to the type of the IOL implanted: Meridian HP60M [Bausch & Lomb, hydrogel, 6 mm, three piece (3P), square edge, refraction index (RI): 1.470], Acrysof MA60BM (Alcon, acrylic, 6 mm, 3P, square edge, RI: 1.550), Acrysof MA30BA (Alcon, acrylic, 5.5 mm, 3P, square edge, RI: 1.550) and Clariflex (AMO, silicone, 6 mm, 3P, anterior round and posterior square edge, RI: 1.460). Patients were examined for dysphotopsia symptoms after 1 week, 1, 3 and 6 months. RESULTS: During the first follow-up visit, 117 patients (19.5%) reported dysphotopsia. During the next visits, the actual number of patients still reporting phenomena declined. Optic phenomena occurred less frequently in patients with AMO Clariflex lens, especially when compared to Acrysof (5.5 and 6 mm); IOL odds ratios ranged from 2.27 to 6.7, depending on follow-up time (p value < 0.05). IOL optic diameter was negatively but significantly associated with the risk of dysphotopsia. CONCLUSIONS: The design of the optic edge and the optic diameter of the IOL play an important role in the occurrence of dysphotopsia. AMO Clariflex, with round anterior and square posterior edge, overcomes the problem of dysphotopsia to a considerable extent.