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1.  Glue-assisted intrascleral fixation of posterior chamber intraocular lens 
Indian Journal of Ophthalmology  2013;61(4):163-167.
To analyze the visual outcome of patients undergoing glue-assisted intrascleral fixation of posterior chamber intraocular lens (IOL) in the absence of posterior capsular support.
Materials and Methods:
This retrospective study analyzes 25 eyes which underwent IOL implantation by the glued intrascleral fixation technique. The pre and post-operative uncorrected visual acuity (UCVA), pre and post-operative best corrected visual acuity (BCVA), intraocular pressure (IOP), IOL position, anterior chamber reaction and central macular thickness were assessed and recorded. Immediate and late post-operative complications were also recorded.
A total of 25 eyes of 22 patients were reviewed and analyzed over a period of one year. All eyes had a foldable three-piece IOL implanted. About 84% of the eyes had a gain of one or more lines, 12% had no gain, and 4% had a fall of three lines of BCVA on Snellen's visual chart, which was attributed to cystoid macular edema (CME). Postoperatively, there was a significant improvement in the UCVA (P < 0.05) and in the BCVA (P < 0.05). Postoperative complications included decentration in one case and vitritis with chronic macular edema in another case. Optical coherence tomography (OCT) demonstrated well placed IOL with no tilt.
Although the results of one year follow-up of glued intrascleral fixation are promising, long term studies are recommended.
PMCID: PMC3714953  PMID: 23685487
Fibrin glue; glued intrascleral fixation; glued intraocular lens forceps; three-piece foldable intraocular lens
2.  Pathological assessment of complications with asymmetric or sulcus fixation of square-edged hydrophobic acrylic intraocular lenses 
Ophthalmology  2012;119(5):907-913.
One-piece hydrophobic acrylic intraocular lenses (IOLs) are not indicated for sulcus fixation because of complications, such as uveitis-glaucoma-hyphema syndrome. Similar complications may also be observed with 3-piece lenses having a square optic edge on the anterior surface. The objective of this study was to provide pathological evidence of complications related to out-of-the-bag fixation of 1-piece or 3-piece hydrophobic acrylic IOLs with anterior and posterior square optic edges.
Comparative case series with pathology.
559 pseudophakic cadaver eyes obtained from eye banks within the United States, implanted with different IOLs.
Anterior segment scanning of whole eyes with a high-frequency ultrasound system, or with a high-resolution anterior segment magnetic resonance imaging, followed by gross examination. Selected eyes were processed for complete histopathological analysis; some of them were explanted before histopathology to allow for direct light microscopic evaluation of the lenses.
Main Outcome Measures
Findings from imaging, gross, and histopathological evaluation that could be related to out-of-the-bag fixation of the lenses.
256 eyes were implanted with hydrophobic acrylic IOLs with anterior and posterior square optic edges; 18 of them exhibiting asymmetric or sulcus IOL fixation (six 1-piece, and twelve 3-piece IOLs) underwent complete histopathological evaluation and were compared to the contralateral eyes with symmetric in-the-bag IOL implantation. Pathological findings were composed of IOL decentration and tilt, pigmentary dispersion within the anterior segment and on the IOL surface, iris transillumination defects, iris changes including vacuolization/disruption/loss of the pigmented layer, iris thinning, and iris atrophy, as well as synechiae and loop erosion in the case of 3-piece lenses. Findings were more significant in comparison with the control contralateral eyes, and were particularly evident in relation to the sulcus-fixated haptic in the case of 1-piece lenses. The majority of the eyes with 3-piece lenses showed signs of complicated surgery.
This study provides pathological correlation of complications that were clinically reported in the peer-reviewed literature in relation to sulcus fixation of one-piece hydrophobic acrylic IOLs. The eyes with 3-piece lenses generally exhibited evidences of complicated surgery; therefore all pathological findings in those cases may not be strictly attributed to the out-of-the-bag fixation.
PMCID: PMC3343205  PMID: 22424575
3.  Glued intraocular lens implantation for eyes with defective capsules: A retrospective analysis of anatomical and functional outcome 
Saudi Journal of Ophthalmology  2011;25(3):245-254.
To analyze the anatomical and functional outcome of glued intra ocular lens (IOL) implantation technique and its modifications.
Retrospective observational case series.
This is a retrospective analysis of the patients who underwent glued intra ocular lens implantation from December 2007 to August 2010. Post operative uncorrected vision, best corrected visual acuity (BCVA), intra ocular pressure, IOL position, endothelial cells and anterior chamber reaction at their last follow up are analyzed from their concerned case sheets documentation. Subjective changes are analyzed via individual questionnaire. Immediate and late postoperative complications are also evaluated. Surgical modifications and the difference in the operated eyes are analyzed.
Total 210 glued IOL eyes have been reviewed. Out of this 210, there are 152 (PMMA glued IOL), 21 (three piece foldable IOL), 5 (multifocal foldable IOL), 12 (pediatric glued IOL), 5 (20G sutureless vitrectomy), 2 (glued iris prosthesis) and 3 (transposition of posterior chamber IOL into anterior chamber). In combined surgeries there are, 5 (optical penetrating keratoplasty), 2 (descemet’s stripping endothelial keratoplasty) and 3 (iridoplasty). The modifications in glued IOL are handshake technique, injectable or foldable glued IOL, Multifocal glued IOL and intraoperative 23/25G trocar cannula infusion. Decentration (1.97%), macular edema (1.97%) and optic capture (2.63%) are the post operative complications encountered in rigid glued IOL. Good patient satisfaction is seen in the eyes with IOL repositioning, IOL exchange and multifocal glued IOL. There is significant improvement in BCVA in PMMA IOL (p = 1.35 × 10−5) and foldable IOL (p = 0.000).
Glued IOL seems to be a good alternative in IOL implantation in eyes with deficient capsules. The modifications in the existing technique decrease the learning time and risk for complications.
PMCID: PMC3729651  PMID: 23960932
Glued IOL; Sutureless IOL implantation; Injectable glued IOL; Handshake technique; Foldable glued IOL; Injectable glued IOL; 20G Sutureless vitrectomy with IOL repositioning
4.  Posterior capsulorhexis combined with optic buttonholing: an alternative to standard in-the-bag implantation of sharp-edged intraocular lenses? A critical analysis of 1000 consecutive cases 
Current after-cataract prevention relies on optimizing the natural barrier effect of the optic rim against lens epithelial cell (LEC) migration. However, deficiencies in circumferential capsular bag closure caused by the intraocular lens (IOL) haptic or delayed secondary re-division of the fused capsules by Soemmering´s ring formation lead to primary or secondary barrier failure. Consequently, surprisingly high posterior laser capsulotomy rates have been reported long-term, even with optimal capsular surgery and the most widespread hydrophobic acrylic IOLs, considered to be the most advanced. Intraoperative removal of the central posterior capsule has been shown to be effective in further reducing LEC immigration. However, efficacy has turned out to be limited because of the propensity of LECs to use the posterior optic surface as an alternative scaffold.
Material and methods
Technique: in pediatric cataract surgery, buttoning-in of the optic into an adequately-centered posterior capsulorhexis opening has been described previously. This technique was further elaborated and applied as the standard technique in a large series of adult eyes. In general, the diameter aimed at was 5–6 mm for the anterior, and 4–5 mm for the posterior capsulorhexis. Between September 2004 and June 2007, 1000 consecutive cases have thus been performed and systematically evaluated. One hundred and fifty eyes additionally underwent extensive anterior LEC abrasion. Another sub-series investigated the option of further reducing capsular fibrosis by creating an anterior capsulorhexis larger than the optic.Evaluation: special scrutiny was applied to detect postoperative vitreous entrapment. Regeneratory and fibrotic after-cataract formation were both meticulously followed-up. Postoperative pressure course, anterior segment inflammation, macular thickness and morphology, as well as axial optic stability and optic centration, were evaluated in intraindividual comparison studies.
A low rate of vitreous complications was found, which can be avoided by appropriate surgery. Vitreous entanglement occurred in six eyes, and vitreous herniation after PPCCC over-sizing in two. In three, anterior vitrectomy was performed. There was only one single case of retinal detachment—supposedly unrelated to the technique itself—and no case of cystoid macular edema. Retro-optical regenerate formation was completely abolished, while fibrosis was drastically reduced by the posterior capsule sandwiched in between the anterior LEC layer on the backside of the anterior capsule and the anterior optic surface, thereby blocking contact-mediated myofibroblastic LEC transdifferentiation. Additional capsular polishing further reduced residual fibrosis emerging from the anterior capsule contacting the optic adjacent to the haptic junction, as well as regeneratory LEC re-proliferation on the posterior capsule overlying the optic. Postoperative pressure course was almost identical to that found after standard in-the-bag implantation of the IOL, as was flare, and macular thickness and morphology. As opposed to bag-fixated IOLs, no axial movement of the optic was detected. IOL optics always perfectly centered even when the capsular opening was not optimally centered. Due to the exquisite stretchability and elasticity of the posterior capsule, the 6-mm IOL optic could safely be buttoned-in in a posterior capsulorhexis of 4 mm and smaller.
Posterior optic buttonholing (POBH) is a safe and effective technique which not only excludes retro-optical opacification, but also withholds capsular fibrosis by obviating direct contact between the anterior capsular leaf and the optic surface. Anterior LEC abrasion significantly reduced both the residual fibrosis and regeneratory LEC proliferation. Apart from pediatric cataract, POBH is currently recommended for eyes with pseudoexfoliation syndrome, high axial myopia, peripheral retinal disease, and multifocal IOL implantation. Toric IOLs and magnet-driven accommodative IOL systems are other potential applications. Generally, POBH holds promise for becoming a routine alternative to standard in-the-bag IOL implantation in the future.
PMCID: PMC2367393  PMID: 18425525
Posterior capsule opacification; Fibrosis; Regeneratory after-cataract; Primary posterior capsulorhexis; Reclosure; Optic buttonholing; Vitreous entrapment; IOP; Flare; Cystoid macular edema; Retinal detachment; Axial optic shift; Optic centration; Toric IOLs
5.  Phakic Intraocular Lenses for the Treatment of Refractive Errors 
Executive Summary
The objective of this analysis is to review the effectiveness, safety, and cost-effectiveness of phakic intraocular lenses (pIOLs) for the treatment of myopia, hyperopia, and astigmatism.
Clinical Need: Condition and Target Population
Refractive Errors
Refractive errors occur when the eye cannot focus light properly. In myopia (near- or short-sightedness), distant objects appear blurry because the axis of the eye is too long or the cornea is too steep, so light becomes focused in front of the retina. Hyperopia (far sightedness) occurs when light is focused behind the retina causing nearby objects to appear blurry. In astigmatism, blurred or distorted vision occurs when light is focused at two points rather than one due to an irregularly shaped cornea or lens.
Refractive errors are common worldwide, but high refractive errors are less common. In the United States, the prevalence of high myopia (≤ −5 D) in people aged 20 to 39, 40 to 59, and 60 years and older is 7.4% (95% confidence interval [CI], 6.5% – 8.3%), 7.8% (95% CI, 6.4% – 8.6%), and 3.1% (95% CI, 2.2% – 3.9%), respectively. The prevalence of high hyperopia (≥ 3 D) is 1.0% (95% CI, .6% – 1.4%), 2.4% (95% CI, 1.7% – 3.0%), and 10.0% (95% CI, 9.1% – 10.9%) for the same age groupings. Finally, the prevalence of astigmatism (≥ 1 D cylinder) is 23.1% (95% CI, 21.6% – 24.5%), 27.6% (95% CI, 25.8% – 29.3%) and 50.1% (48.2% – 52.0%).
Low Vision
According to the Ontario Schedule of Benefits, low visual acuity is defined by a best spectacle corrected visual acuity (BSCVA) of 20/50 (6/15) or less in the better eye and not amenable to further medical and/or surgical treatment. Similarly, the Ontario Assistive Devices Program defines low vision as BSCVA in the better eye in the range of 20/70 or less that cannot be corrected medically, surgically, or with ordinary eyeglasses or contact lenses.
Estimates of the prevalence of low vision vary. Using the criteria of BSCVA ranging from 20/70 to 20/160, one study estimated that 35.6 per 10,000 people in Canada have low vision. The 2001 Participation and Activity Limitation Survey (PALS) found that 594,350 (2.5%) Canadians had “difficulty seeing ordinary newsprint or clearly seeing the face of someone from 4 m,” and the Canadian National Institute for the Blind (CNIB) registry classified 105,000 (.35%) Canadians as visually disabled.
Phakic Intraocular Lenses (pIOL)
A phakic intraocular lens (pIOL) is a supplementary lens that is inserted into the anterior or posterior chamber of the eye to correct refractive errors (myopia, hyperopia, and astigmatism). Unlike in cataract surgery, the eye’s natural crystalline lens is not removed when the pIOL is inserted, so the eye retains its accommodative ability. In Canada and the United States, iris-fixated (anterior chamber lenses that are anchored to the iris with a claw) and posterior chamber lenses are the only types of pIOLs that are licensed by Health Canada and the Food and Drug Administration, respectively.
Evidence-Based Analysis Method
Research Questions & Methodology
What are the effectiveness, cost-effectiveness, and safety of pIOLs for the treatment of myopia, hyperopia, and astigmatism?
Do certain subgroups (e.g. high myopia and low vision) benefit more from pIOLs?
How do pIOLs compare with alternative surgical treatment options (LASIK, PRK, and CLE)?
Using appropriate keywords, a literature search was conducted up to January 2009. Systematic reviews, meta-analyses, randomized controlled trials, and observational studies with more than 20 eyes receiving pIOLs were eligible for inclusion. The primary outcomes of interest were uncorrected visual acuity (UCVA), predictability of manifest refraction spherical equivalent (MRSE), and adverse events. The GRADE approach was used to systematically and explicitly evaluate the quality of evidence.
Summary of Findings
The search identified 1,131 citations published between January 1, 2003, and January 16, 2009. Including a health technology assessment (HTA) identified in the bibliography review, 30 studies met the inclusion criteria: two HTAs; one systematic review; 20 pre-post observational studies; and seven comparative studies (five pIOL vs. LASIK, one pIOL vs. PRK, and one pIOL vs. CLE).
Both HTAs concluded that there was good evidence of the short-term efficacy and safety of pIOLs, however, their conclusions regarding long-term safety differed. The 2006 HTA found convincing evidence of long-term safety, while the 2009 HTA found no long-term evidence about the risks of complications including cataract development, corneal damage, and retinal detachment.
The systematic review of adverse events found that cataract development (incidence rate of 9.6% of eyes) is a substantial risk following posterior chamber pIOL implantation, while chronic endothelial cell loss is a safety concern after iris-fixated pIOL implantation. Adverse event rates varied by lens type, but they were more common in eyes that received posterior chamber pIOLs.
The evidence of pIOL effectiveness is based on pre-post case series. These studies reported a variety of outcomes and different follow-up time points. It was difficult to combine the data into meaningful summary measures as many time points are based on a single study with a very small sample size. Overall, the efficacy evidence is low to very low quality based on the GRADE Working Group Criteria.
For all refractive errors (low to high), most eyes experienced a substantial increase in uncorrected visual acuity (UCVA) with more than 75% of eyes achieving UCVA of 20/40 or better at all postoperative time points. The proportion of eyes that achieved postoperative UCVA 20/20 or better varied substantially according type of lens used and the type of refractive error being corrected, ranging from about 30% of eyes that received iris-fixated lenses for myopia to more than 78% of eyes that received posterior chamber toric lenses for myopic astigmatism.
Predictability of manifest refraction spherical equivalent (MRSE) within ± 2.0 D was very high (≥ 90%) for all types of lenses and refractive error. At most time points, more than 50% of eyes achieved a MRSE within ± 0.5 D of emmetropia and at least 85% within ± 1.0 D. Predictability was lower for eyes with more severe preoperative refractive errors. The mean postoperative MRSE was less than 1.0 D in all but two studies.
Safety, defined as a loss of two or more Snellen lines of best spectacle corrected visual acuity (BSCVA), was high for all refractive errors and lens types. Losses of two or more lines of BSCVA were uncommon, occurring in fewer than 2% of eyes that had received posterior chamber pIOLs for myopia, and less than 1% of eyes that received iris-fixated lens implantation for myopia. Most eyes did not experience a clinically significant change in BSCVA (i.e. loss of one line, no change, or gain of one line), but 10% to 20% of eyes gained two or more lines of BSCVA.
The pIOL outcomes for UCVA, predictability, BSCVA, and adverse events were compared with FDA targets and safety values for refractive surgery and found to meet or exceed these targets at most follow-up time points. The results were then stratified to examine the efficacy of pIOLs for high refractive errors. There was limited data for many outcomes and time points, but overall the results were similar to those for all levels of refractive error severity.
The studies that compared pIOLs with LASIK, PRK, and CLE for patients with moderate to high myopia and myopic astigmatism showed that pIOLs performed better than these alternative surgical options for the outcomes of:
predictability and stability of MRSE,
postoperative MRSE,
safety (measured as clinically significant loss of BSCVA), and
gains in BSCVA.
Correction of refractive cylinder (astigmatism) was the only outcome that favoured refractive surgery over pIOLs. This was observed for both toric and non-toric pIOLs (toric pIOLs correct for astigmatism, non-toric pIOLs do not).
Common adverse events in the LASIK groups were diffuse lamellar keratitis and striae in the corneal flap. In the pIOL groups, lens repositioning and lens opacities (both asymptomatic and visually significant cataracts) were the most commonly observed adverse events. These studies were determined to be of low to very low evidence quality based on the GRADE Working Group Criteria.
Eye, myopia, hyperopia, astigmatism, phakic intraocular lens, LASIK, PRK, uncorrected visual acuity, best corrected visual acuity, refractive errors, clear lens extraction
PMCID: PMC3377525  PMID: 23074518
6.  Pathologic comparison of asymmetric or sulcus fixation of 3-piece intraocular lenses with square versus round anterior optic edges 
Ophthalmology  2013;120(8):1580-1587.
To evaluate pathologic findings of 3-piece intraocular lenses (IOLs) with asymmetric or sulcus fixation in pseudophakic cadaver eyes, comparing IOLs with square or round edges on the anterior optic surface.
Comparative case series with pathology.
661 pseudophakic cadaver eyes obtained from eye banks within the United States, implanted with different IOLs
Anterior segment scanning of whole eyes with a high-frequency ultrasound system, or with a high-resolution anterior segment magnetic resonance imaging, followed by gross examination. Selected eyes were processed for complete histopathologic analysis.
Main Outcome Measures
Findings from imaging, gross, and histopathologic evaluation that could be related to out-of-the-bag fixation of the lenses.
Out of 661 pseudophakic cadaver eyes obtained, 13 had 3-piece hydrophobic acrylic IOLs with anterior and posterior square optic edges, and 14 had 3-piece lenses with anterior round edges (13 silicone lenses, and 1 hydrophobic acrylic lens) without symmetric in-the-bag fixation. These 27 selected eyes were processed for complete histopathologic analysis. Gross findings in both groups were composed of IOL decentration and tilt, pigmentary dispersion within the anterior segment and on the IOL surface, and iris transillumination defects. Histopathology of the 14 eyes with 3-piece IOLs with round anterior optic edges showed mild focal disruption of the iris pigmented layer, and loop protrusion/erosion in the ciliary sulcus. Additional changes observed in the 13 eyes with square anterior optic edge IOLs included iris changes such as vacuolization, disruption and loss of the pigmented epithelial layers, iris thinning and atrophy, synechiae, and pigmentary dispersion within the trabecular meshwork. One eye also exhibited initial signs of optic nerve disc cupping.
In this series, pathologic findings were more severe in eyes implanted with 3-piece IOLs with square anterior optic edges, suggesting that IOLs with round anterior edges are more suitable for sulcus fixation.
PMCID: PMC3718860  PMID: 23597794
7.  An analysis of corneal endothelial and graft survival in pseudophakic bullous keratopathy. 
PBK has become an important complication of cataract surgery and a leading indication for keratoplasty. While there are many potential causative factors, erroneous concepts of IOL positioning and design appear to have led to PBK with many iris-supported and anterior chamber lens styles. Underlying host endothelial abnormalities are an important risk factor with posterior chamber lenses. Previous studies of keratoplasty for PBK have shown variable early results in terms of graft clarity and visual rehabilitation. Specular microscopy and life-table survival analysis have been infrequently used to study endothelial and graft survival after keratoplasty. This study combined these techniques to evaluate several approaches to the original IOL at PKP for PBK. Four-hundred sixty-nine patients having PKP for PBK between 1976 and 1986 were studied in five retrospective cohorts on the basis of whether their IOL was retained, removed, or exchanged. Specular microscopy was performed prospectively on 390 patients. Survival analysis showed overall failure in 20% of IOL-removed, 24% of IOL-retained, and 16% of IOL-exchanged grafts, without significant differences. Within the retained group, however, graft failure rate for posterior chamber IOLs (6%) was significantly less than for anterior chamber (34%) and iris-supported (29%) lenses. With lens exchange, the failure rate was 8% for sutured posterior chamber lenses, 5% for one-piece anterior chamber lenses, and 24% for closed-loop anterior chamber lenses. Graft failure rates exceeded rejection rates for retained iris-supported and anterior chamber lenses, and exchanges for closed-loop anterior chamber lenses, suggesting nonimmunologic causes. The survival curve for all groups combined showed cumulative survival of 93% at 1 year, decreasing to 62% by 6 years. Survival was lowest for retained anterior chamber and iris-supported lenses and exchanged closed-loop anterior chamber lenses. Visual acuity results were best for retained posterior chamber IOL eyes and exchange for one-piece anterior chamber IOLs. Exchange for one-piece anterior chamber IOLs gave significantly better visual acuity than exchange for sutured posterior chamber IOLs. There was not a significant relationship between duration of corneal edema prior to PKP and visual outcome, refuting earlier findings. Cystoid macular edema was related to poor vision in 62% of those with visual acuity of less than 20/40 and in 36% of all patients. Specular microscopy findings at 1 year were predictive of longer term survival results. The least cell loss was for retained and exchanged posterior chamber lenses and exchange for one-piece anterior chamber lenses.(ABSTRACT TRUNCATED AT 400 WORDS)
PMCID: PMC1298563  PMID: 2562532
8.  Types of intraocular lenses for cataract surgery in eyes with uveitis 
Cataract formation often occurs in people with uveitis. It is unclear which intraocular lens (IOL) type is optimal for use in cataract surgery for eyes with uveitis.
To summarize the effects of different IOLs on visual acuity, other visual outcomes, and quality of life in people with uveitis.
Search methods
We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2013, Issue 7), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2013), EMBASE (January 1980 to August 2013), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to August 2013), the metaRegister of Controlled Trials (mRCT) (, ( and the WHO International Clinical Trials Registry Platform (ICTRP) ( We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 14 August 2013. We also performed forward and backward searching using the Science Citation Index and the reference lists of the included studies, respectively, in August 2013.
Selection criteria
We included randomized controlled trials (RCTs) comparing hydrophobic or hydrophilic acrylic, silicone, or poly(methyl methacrylate) (PMMA) IOLs with or without heparin-surface modification (HSM), with each other, or with no treatment in adults with uveitis, for any indication, undergoing cataract surgery.
Data collection and analysis
We used standard methodological procedures expected by The Cochrane Collaboration. Two review authors screened the search results and for included studies, assessed the risk of bias and extracted data independently. We contacted study investigators for additional information. We did not perform a meta-analysis due to variability in reporting and follow-up intervals for the primary and secondary outcomes of interest.
Main results
We included four RCTs involving 216 participants (range of 2 to 140 participants with uveitic cataract per trial) and comparing up to four types of IOLs. The largest study was an international study with centers in Brazil, Egypt, Finland, France, Japan, the Netherlands, Slovak Republic, Spain, and the USA; two studies were conducted in Germany and one in Saudi Arabia. There was substantial heterogeneity with respect to the ages of participants and etiologies of uveitis within and across studies. The length of follow-up among the studies ranged from 1 to 24 months after cataract surgery. The studies were at low risk of selection bias, but two of the four studies did not employ masking and only one study included all randomized participants in the final analyses. The funding source was disclosed by investigators of the largest study (professional society) and not reported by the other three. Due to heterogeneity in lens types evaluated and outcomes reported among the trials, we did not combine data in a meta-analysis.
In the largest study (140 participants), the study eye of each participant was randomized to receive one of four types of IOLs: hydrophobic acrylic, silicone, HSM PMMA, or unmodified PMMA. Proportions of participants with one or more Snellen lines of visual improvement were similar among the four treatment groups at one year' follow-up: 45 of 48 (94%) in the hydrophobic acrylic IOL group, 39 of 44 (89%) in the silicone IOL group, 18 of 22 (82%) in the HSM PMMA IOL group, and 22 of 26 (85%) in the unmodified PMMA IOL group. When comparing hydrophobic acrylic IOLs with silicone IOLs, the risk ratio (RR) was 1.06 (95% confidence interval (CI) 0.93 to 1.20). At one year' follow-up, fewer eyes randomized to hydrophobic acrylic IOLs developed posterior synechiae when compared with eyes receiving silicone IOLs (RR 0.18, 95% CI 0.04 to 0.79); the effects between these groups were less certain with respect to developing posterior capsule opacification (PCO) (RR 0.74, 95% CI 0.41 to 1.37), corneal edema (RR 0.49, 95% CI 0.22 to 1.12), cystoid macular edema (RR 0.10, 95% CI 0.01 to 1.84), or mild IOL decentration (RR 0.92, 95% CI 0.06 to 14.22).
Two intra-individual studies also compared HSM PMMA IOLs with unmodified PMMA IOLs at three or six months of follow-up. These studies, including a combined total of 16 participants with uveitis, were insufficiently powered to detect differences in outcomes among eyes of people with uveitis randomized to receive HSM PMMA IOLs when compared with fellow eyes receiving unmodified PMMA IOLs.
In the fourth study (60 participants), the study eye of each participant was randomized to receive a hydrophobic or hydrophilic acrylic IOL. At three months, there were no statistical or clinical differences between hydrophobic and hydrophilic acrylic IOL types in the proportions of participants with two or more Snellen lines of visual improvement (RR 1.03, 95% CI 0.87 to 1.22). There were similar rates in the development of PCO between hydrophobic or hydrophilic acrylic IOLs at six months' follow-up (RR 1.00, 95% CI 0.80 to 1.25). The effect of the lenses on posterior synechiae was uncertain at six months' follow-up (RR 0.50, 95% CI 0.05 to 5.22).
None of the included studies reported quality of life outcomes.
Authors' conclusions
Based on the trials identified in this review, there is uncertainty as to which type of IOL provides the best visual and clinical outcomes in people with uveitis undergoing cataract surgery. The studies were small, not all lens materials were compared in all studies, and not all lens materials were available in all study sites. Evidence of a superior effect of hydrophobic acrylic lenses over silicone lenses, specifically for posterior synechiae outcomes comes from a single study at a high risk of performance and detection bias. However, due to small sample sizes and heterogeneity in outcome reporting, we found insufficient information to assess these and other types of IOL materials for cataract surgery for eyes with uveitis.
PMCID: PMC4261623  PMID: 24590672
9.  Implantation of iris-claw Artisan intraocular lens for aphakia in Fuchs’ heterochromic iridocyclitis 
Indian Journal of Ophthalmology  2014;62(3):373-374.
Implantation of iris-claw Artisan intraocular lens (IOL) is a surgical option for correction of aphakia; however, these IOLs have not been used in eyes with uveitis including Fuchs’ heterochromic iridocyclitis (FHI) due to possible risk of severe postoperative intraocular inflammation. In the case reported here, we secondarily implanted an Artisan IOL in a 28-year-old man with FHI who had aphakia with no capsular support due to a previous complicated cataract surgery. Enclavation was easily performed and no intraoperative complication was noted. Postoperative course was uneventful with no significant anterior chamber inflammation during 12 months of follow-up. Although there were few deposits on the IOL surface, the patient achieved a best-corrected visual acuity of 20/20 without developing glaucoma or other complications. Therefore, Artisan IOL may be considered for correction of aphakia in patients with FHI. However, studies on large number of patients are required to evaluate safety of the procedure.
PMCID: PMC4061690  PMID: 23571252
Aphakia; Fuchs’ heterochromic iridocyclitis; iris-claw Artisan intraocular lens
10.  Spontaneous dislocation of posterior chamber intraocular lenses (PC IOLs) in patients with retinitis pigmentosa – Case series 
Saudi Journal of Ophthalmology  2011;26(1):61-65.
To report the outcomes of intraocular lens (IOL) dislocation management in 6 cases with Retinitis Pigmentosa (RP).
Private practice, Los Angeles, USA.
Retrospective interventional case series.
The medical reports of six eyes of four RP patients with capsule bag fixated posterior chamber IOL dislocation were retrospectively reviewed. Pre-operative data included demographics, systemic or ocular disorders, history of trauma, previous intraocular surgery and pre-operative visual acuity. Outcome measures included the type of surgery, surgical complications, elevation of intraocular pressure (IOP), ocular inflammation, cystoid macular edema (CME) and IOL dislocation at 3 months or greater post-operatively.
The medical records of six eyes of four patients operated on between December 2009 and May 2011 were evaluated. In four cases, dislocated PC IOL implants were sutured to the sclera. In two eyes of one patient anterior chamber IOLs (AC IOLs) were implanted after PC IOLs were explanted. One eye developed CME during the follow-up period. Despite modest tilt in one case and modest decentration in another, stability and centration of the IOLs was excellent during the follow-up period. No eyes had intraocular inflammation requiring long term medical treatment, new onset glaucoma or retinal detachment. Mean follow-up time was 6.9 months (range 3-20).
Cataract surgeons should be aware of the increased risk for decentration and malposition of PC IOLs in patients with RP. Satisfactory results can be achieved by fixation of the PC IOL or AC IOL implantation.
PMCID: PMC3729523  PMID: 23960970
Retinitis pigmentosa; IOL dislocation; IOL dislocation management
11.  Comparison of Artisan iris-claw intraocular lens implantation and posterior chamber intraocular lens sulcus fixation for aphakic eyes 
To compare the efficacy and complications of Artisan iris-claw intraocular lens (IOL) implantation and posterior chamber IOL sulcus fixation for the treatment of aphakic eyes without capsular support after vitrectomy.
A prospective study of 45 cases was conducted. Forty-five eyes without sufficient lens capsule support following pars plana vitrectomy (PPV) combined lens extraction were divided into two groups. Group A: 25 eyes received Artisan iris-claw IOL implantation. Group B: 20 eyes received posterior chamber IOL sulcus fixation. The corrected distance visual acuity (CDVA) and intraocular pressure (IOP), corneal endothelial cell loss rate, surgical time and complications were compared between the two groups. Pigment changes of trabecular meshwork and anterior chamber depths were measured at each time point in Artisan group.
The mean surgical time of Artisan group was significantly shorter (P<0.05). No statistically significant difference in endothelial cell loss rate was noted between two groups at any time point (P>0.05). CDVA of Artian group was better than that of the sulcus fixation group 1d after surgery (P<0.05) and there was no statistically significant difference 1 and 3mo after surgery (P>0.05). Mean IOP showed no significant differences between groups before and after surgery. The postoperative complications of Artisan group were anterior uveitis, iris depigmentation, pupillary distortion and spontaneous lens dislocation. The complications of sulcus fixation group include choroidal detachment, intraocular haemorrhage, tilt of IOL optic part and retinal detachment.
Secondary Artisan IOL implantation can be performed less invasively and in a shorter surgical time period with earlier visual recovery after surgery compared to transscleral suturing fixation of an IOL. This technique is an effective and safe procedure. It is a promising option for the treatment of aphakic eyes without capsular support after vitrectomy.
PMCID: PMC4003083  PMID: 24790871
iris-claw intraocular lens; aphakic eye; vitrectomy
12.  Evaluation of Time Domain and Spectral Domain Optical Coherence Tomography in the Measurement of Diabetic Macular Edema 
To evaluate macular thickness and volume measurements and their intrasession repeatability in two optical coherence tomography (OCT) systems: the Stratus OCT, a time domain system, and the Cirrus HD-OCT, a spectral domain system (both by Carl Zeiss Meditec, Inc., Dublin, CA), in the context of diabetic macular edema (DME).
Thirty-three eyes of 33 diabetic patients with clinically significant macular edema (CSME) were scanned in a single session by a single operator on both OCT systems. Macular thickness measurements of nine standard macular subfields and total macular volume were obtained and analyzed. Bland-Altman plots were constructed to assess agreement in macular measurements. Intraclass correlation coefficients (ICCs), coefficients of repeatability (CRW), and coefficients of variation (CVW) were used to assess intrasession repeatability.
Macular thickness in nine retinal subfields and macular volume were significantly higher in the Cirrus HD-OCT system compared with the Stratus OCT system. Subfield thickness and total volume measurements, respectively, were 30 to 55 μm and 3.2 mm3 greater for the Cirrus HD-OCT system compared with the Stratus OCT system. Both Stratus OCT and Cirrus HD-OCT systems demonstrated high intrasession repeatability, with overlapping ranges for CRW, CVW, and ICC. Repeatability measures (CRW and CVW) differed significantly between systems in only one of nine subfields (outer temporal subfield).
Absolute measures of macular thickness and volume in patients with DME differed significantly in magnitude between the Stratus OCT and Cirrus HD-OCT systems. However, both OCT systems demonstrated high intrasessional repeatability. Although the two systems may not be used interchangeably, they appear equally reliable in generating macular measurements for clinical practice and research.
PMCID: PMC2574838  PMID: 18515567
13.  Influence of intraocular lens material and design on postoperative intracapsular cellular reactivity. 
PURPOSE: To evaluate the influence of intraocular lens (IOL) material and design on the outcome of postoperative lens epithelial cell proliferation within the capsular bag after cataract surgery. METHODS: A total of 5,079 human globes containing rigid and foldable posterior chamber IOL styles commonly implanted in the United States (n = 8) were analyzed in this study. Each globe, fixated in 10% formalin, was sectioned at the equator and analyzed using the Miyake-Apple posterior technique. The study consisted of 3 parts: First, to evaluate posterior capsule opacification (PCO); the Nd:YAG laser posterior capsulotomy rate (%) was documented and plotted on a monthly basis, creating a computerized trend line for each IOL style. Second, to evaluate anterior capsule opacification (ACO); 460 globes were processed for histologic examination. Anterior capsule fibrosis was scored from 0 to III, according to the thickness of proliferative tissue/cells on the inner surface of the anterior capsule at the capsulorhexis margin. Third, interlenticular opacification (ILO) was studied by analysis of 3 pairs of acrylic piggyback lenses that had been explanted because of opacification between their optics. Each IOL pair was processed for histologic examination, and scanning electron microscopy was performed on 1 of the lenses. RESULTS: In the first study, relatively higher Nd:YAG laser posterior capsulotomy rates (19.1% to 32.8%) were noted with the 4 oldest IOL designs in this study (2 foldable lenses, 1 3-piece polymethyl methacrylate [PMMA] design, and 1 single-piece all-PMMA design). Four modern lenses, 1 acrylic lens, and 3 silicone foldable IOL designs had Nd:YAG rates ranging from 1.3% to 14.6% (P < .0001). In the second study, mean ACO scores were highest with silicone-plate lenses (1.77 +/- 0.86 and 1.28 +/- 0.77). The lowest mean score was observed with the acrylic lens (0.51 +/- 0.52; P < .0001). In study 3, the analyses of the 3 pairs of explanted acrylic piggyback lenses showed that the opacification between them (ILO) may have different forms. CONCLUSIONS: Control of postoperative intracapsular cellular proliferation is important in avoiding 3 significant clinical complications. Postoperative lens epithelial cell proliferation is involved in the pathogenesis of PCO, ACO, and ILO, the latter being a newly described form of opacification within the capsular bag related to piggyback IOL implantation. IOL material and design are important factors influencing the outcome of these complications.
PMCID: PMC1298231  PMID: 11190028
14.  Late in-the-bag intraocular lens dislocation requiring explantation: risk factors and outcomes 
Eye  2013;27(7):795-802.
To study the predisposing factors for late in-the-bag intraocular lens (IOL) dislocation and to analyze the outcomes after explantation surgery.
In this retrospective multicentre study, 61 eyes were enrolled. The main inclusion criterion was in-the-bag spontaneous IOL dislocation after uneventful phacoemulsification cataract extraction. Only eyes with serious dislocation that required IOL explantation were eligible. Follow-up after explantation surgery of at least 3 months was required. Exclusion criteria were complicated cataract surgery, out-of-the-bag IOL dislocation, and dislocations that occurred in the first year after the cataract surgery. The main outcome measures were predisposing factors for dislocation, interval between cataract surgery and dislocation, surgical treatment at the time of explantation, preoperative and postoperative corrected distance visual acuity (CDVA), and postoperative complications.
High myopia was detected in 12 cases (19.7%) and it was the main predisposing factor. Mean time interval from cataract surgery to dislocation was 7.5 (SD 5.2) years. The dislocated in-the-bag IOL was replaced with a scleral fixated IOL (36.1%), angle-supported anterior chamber IOL (31.1%), sulcus repositioning (18%), or posterior chamber iris sutured IOL (4.9%). Finally, 9.8% of the patients were left aphakic. Mean CDVA improved significantly after surgery (P=0.005). Final CDVA of 20/40 or better was achieved in 29 cases (47.5%).
High myopia was the main risk factor for late in-the-bag IOL dislocation. Surgical treatment significantly improved the CDVA in our sample and was associated with a low complication rate.
PMCID: PMC3709407  PMID: 23764989
IOL dislocation; pseudoexfoliation; high myopia; cataract surgery and explantation
15.  Intermediate term follow-up after a single-piece-acrylic intraocular lens implantation in the ciliary sulcus- a cross-sectional study 
BMC Ophthalmology  2013;13:76.
Implantation of a single-piece-acrylic intraocular lens (SPA-IOL) in the ciliary sulcus during phacoemulsification complicated with posterior capsule tear (PCT) may be associated with severe complications. The purpose of this study was to report the efficacy and safety of sulcus implantation of a SPA-IOL, designed for both in-the-bag and sulcus positioning.
A prospective cross-sectional study including 12 patients, who underwent phacoemulsification with PCT and sulcus implantation of SPA-IOL designed for both in-the-bag and sulcus positioning (Seelens AF, Hanita, Israel) between January 2009 and March 2012 (follow-up 12–37 months). Preoperatively corrected distance visual acuity (CDVA), subjective refraction and intraocular pressure (IOP) were recorded. Postoperative evaluation included anamnesis for IOL edge symptoms and transient visual obscurations (TVO) along with CDVA, subjective refraction IOP, anterior segment biomicroscopy, gonioscopy, assessment of IOL centration, fundus biomicroscopy and spectral-domain optical coherence tomography of the macula.
Preoperatively, mean CDVA was 0.84 ± 0.60 LogMAR (Counting Finger-20/33) improving to 0.18 ± 0.13 LogMAR (20/40-20/20) at last examination (p = 0.004), as all the patients gained better CDVA. Mean preoperative spherical equivalent was −0.2 ± 2.5 Diopter (D) (−4.0D to +5.4D) reaching −1.9 ± 0.9 (−4.0D to −0.6D) at last examination (p = 0.12). Mean preoperative refractive astigmatism magnitude was 1.0 ± 0.6D (0.3D to 2.3D) changing to 1.1 ± 1.0D (0.0D to 3.0D) at last examination (p = 0.88). Mean preoperative IOP was 14.7 ± 3.2 mmHg (11–23 mmHg) without medications reaching 15.9 ± 3.3 mmHg (10–21 mmHg) at last follow up (p = 0.21). Postoperatively one patient required two medications for IOP control in his study and contralateral eyes. None of the patients had symptoms of IOL edge or TVO. There were no intraocular hemorrhages, inflammatory reactions, or pigment dispersion and the IOLs were well centered in all cases. Central foveal thickness was 280 ± 33 μm (193–310 μm).
Appropriately designed SPA-IOL may be implanted in the ciliary sulcus during phacoemulsification with PCT rather than switching to another backup IOL demanding wound enlargement.
PMCID: PMC4098571  PMID: 24321599
Cataract; Intraocular lens; Posterior capsule tear
16.  Sutureless Intrascleral Pocket Technique of Transscleral Fixation of Intraocular Lens in Previous Vitrectomized Eyes 
In this case series, we assessed a new technique, the intrascleral pocket procedure of transscleral fixation (TF) of the intraocular lens (IOL) in post-vitrectomized eyes. We performed the transscleral fixation of IOL in four aphakic patients who underwent pars plana vitrectomy. Two points 180° apart were marked at the limbus. A 2-mm-sized intrascleral pocket was created by lamellar dissection using a crescent blade without conjunctival dissection. A 2.8-mm clear corneal incision (CCI) was made using a keratome. Prolene sutures were exteriorized through the CCI pocket and a three-piece foldable acrylic IOL was injected via CCI and the ends of the haptics were exteriorized through the CCI. The prolene sutures for each haptic in the intrascleral pocket bed were then tied and knots were buried under scleral flaps. No patient had complaints such as conjunctival irritation, and visual acuity was almost identical to preoperative best-corrected visual acuity at day 1 postoperatively. IOLs were well placed without tilting or subluxation. They had no wound dehiscence or endophthalmitis postoperatively. The intrascleral pocket procedure of TF without the need for conjunctival dissection is a successful method for sulcus fixation in post-vitrectomized eyes predisposed to developing glaucoma.
PMCID: PMC3958636  PMID: 24688263
Aphakia; Intraocular lens implantation; Intrascleral pocket; Transscleral fixation
17.  Intraocular Lenses for the Treatment of Age-Related Cataracts 
Executive Summary
The objective of the report is to examine the comparative effectiveness and cost-effectiveness of various intraocular lenses (IOLs) for the treatment of age-related cataracts.
Clinical Need: Target Population and Condition
A cataract is a hardening and clouding of the normally transparent crystalline lens that may result in a progressive loss of vision depending on its size, location and density. The condition is typically bilateral, seriously compromises visual acuity and contrast sensitivity and increases glare. Cataracts can also affect people at any age, however, they usually occur as a part of the natural aging process. The occurrence of cataracts increases with age from about 12% at age 50 years, to 60% at age 70. In general, approximately 50% of people 65 year of age or older have cataracts. Mild cataracts can be treated with a change in prescription glasses, while more serious symptoms are treated by surgical removal of the cataract and implantation of an IOL.
In Ontario, the estimated prevalence of cataracts increased from 697,000 in 1992 to 947,000 in 2004 (35.9% increase, 2.4% annual increase). The number of cataract surgeries per 1,000 individuals at risk of cataract increased from 64.6 in 1992 to 140.4 in 1997 (61.9% increase, 10.1% annual increase) and continued to steadily increase to 115.7 in 2004 (10.7% increase, 5.2% increase per year).
Description of Technology/Therapy
IOLs are classified either as monofocal, multifocal, or accommodative. Traditionally, monofocal (i.e.. fixed focusing power) IOLs are available as replacement lenses but their implantation can cause a loss of the eye’s accommodative capability (which allows variable focusing). Patients thus usually require eyeglasses after surgery for reading and near vision tasks. Multifocal IOLs aim to improve near and distant vision and obviate the need for glasses. Potential disadvantages include reduced contrast sensitivity, halos around lights and glare. Accommodating IOLs are designed to move with ciliary body contraction during accommodation and, therefore, offer a continuous range of vision (i.e. near, intermediate and distant vision) without the need for glasses. Purported advantages over multifocal IOLs include the avoidance of haloes and no reduction in contrast sensitivity.
Polymethyl methacrylate (PMMA) was the first material used in the fabrication of IOLs and has inherent ultraviolet blocking abilities. PMMA IOLs are inflexible, however, and require a larger incision for implantation compared with newer foldable silicone (hydrophobic) and acrylic (hydrophobic or hydrophilic) lenses. IOLs can be further sub-classified as being either aspheric or spheric, blue/violet filtered or non-filtered or 1- or 3-piece.
Methods of Evidence-Based Analysis
A literature search was conducted from January 2003 to January 2009 that included OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), The Cochrane Library, and the International Agency for Health Technology Assessment/Centre for Review and Dissemination.
adult patients with age-related cataracts
systematic reviews, randomized controlled trials (RCTs)
primary outcomes: distance visual acuity (best corrected distance visual acuity), near visual acuity (best distance corrected near visual acuity)
secondary outcomes: contrast sensitivity, depth of field, glare, quality of life, visual function, spectacle dependence, posterior capsule opacification.
studies with fewer than 20 eyes
IOLs for non-age related cataracts
IOLs for presbyopia
studies with a mean follow-up <6months
studies reporting insufficient data for analysis
Comparisons of Interest
The primary comparison of interest was accommodative vs. multifocal vs. monofocal lenses.
Secondary comparisons of interest included:
tinted vs. non-tinted lenses
aspheric vs. spheric lenses
multipiece vs. single piece lenses
biomaterial A (e.g. acrylic) vs. biomaterial B (e.g. silicone) lenses
sharp vs. round edged lenses
The quality of the studies was examined according to the GRADE Working Group criteria for grading quality of evidence for interventional procedures.
Summary of Findings
The conclusions of the systematic review of IOLs for age-related cataracts are summarized in Executive Summary Table 1.
Considerations for the Ontario Health System
Procedures for crystalline lens removal and IOL insertion are insured and listed in the Ontario Schedule of Benefits.
If a particular lens is determined to be medically necessary for a patient, the cost of the lens is covered by the hospital budget. If the patient chooses a lens that has enhanced features, then the hospital may choose to charge an additional amount above the cost of the usual lens offered.
An IOL manufacturer stated that monofocal lenses comprise approximately 95% of IOL sales in Ontario and premium lenses (e.g., multifocal/accomodative) consist of about 5% of IOL sales.
A medical consultant stated that all types of lenses are currently being used in Ontario (e.g., multifocal, monofocal, accommodative, tinted, nontinted, spheric, and aspheric). Nonfoldable lenses, rarely used in routine cases, are primarily used for complicated cataract implantation situations.
Conclusions for the Systematic Review of IOLs for Age-Related Cataracts
BCDVA refers to best corrected distance visual acuity; BDCUNVA, best distance corrected unaided near visual acuity; HRQL, health related quality of life; PCO, posterior capsule opacification; VA, visual acuity.
PMCID: PMC3377510  PMID: 23074519
18.  Traumatic Partial Aniridia and Cataract after Iris-Fixated Foldable Phakic Intraocular Lens Implantation 
Case Reports in Ophthalmology  2013;4(3):210-215.
We present the first case of partial aniridia, traumatic cataract, and peripapillary subretinal hemorrhage after blunt trauma to an eye containing a foldable iris-fixated phakic intraocular lens (pIOL). Although the patient experienced visual loss because of considerable corneal astigmatism and a traumatic cataract, vision was recovered by a 2-stage primary corneal repair and cataract surgery with a toric intraocular lens. This case exhibits clinical manifestations that differ from previously reported trauma of a non-foldable iris-fixated pIOL. A relatively small corneal incision and a large optic diameter of Artiflex pIOLs may prevent posttraumatic total expulsion of intraocular tissues and present different clinical features from the case of non-foldable pIOLs (Artisan). Although the extent of the damage is different, the possibility of aniridia and traumatic cataract exists in eyes with both foldable and non-foldable iris-fixated pIOLs.
PMCID: PMC3843930  PMID: 24348404
Artiflex phakic intraocular lens; Artisan phakic intraocular lens; Phakic intraocular lens; Traumatic aniridia
19.  Sensitivity and specificity of time-domain versus spectral-domain optical coherence tomography in diabetic macular edema 
Indian Journal of Ophthalmology  2013;61(5):208-212.
The purpose was to evaluate the sensitivity and specificity of measurements of central macular thickness (CMT) in diabetic macular edema using stratus time-domain and cirrus spectral-domain optical coherence tomography (OCT; Carl Zeiss Meditec, Dublin, CA).
Materials and Methods:
A total of 36 eyes from 19 patients with clinically significant diabetic macular edema (DME) were included. All participants underwent automated scanning patterns using cirrus HD-OCT and stratus OCT examinations on the same day. The sensitivity/specificity of retinal thickness measurements was calculated from published normative data. Agreement was calculated using Bland--Altman method. The receiver operating characteristic curves (ROC) and areas under the ROC were plotted.
The mean difference between the cirrus HD-OCT and stratus OCT in the central foveal zone was 49.89 μm. Bland--Altman analysis confirmed that the retinal thickness measurements had poor agreement in patients with DME. The areas under the ROC for retinal thickness measurements were 0.88 using cirrus HD-OCT and 0.94 with stratus.
In patients with DME, the cirrus HD-OCT gives a higher reading than stratus OCT with poor agreement between the devices in most regions within the nine subfield zones. The sensitivity and specificity of the stratus OCT was comparable to the cirrus.
PMCID: PMC3730503  PMID: 23571234
Diabetic macular edema; optical coherence tomography; sensitivity; specificity
20.  Evaluation of Sterile Uveitis after Iris-fixated Phakic Intraocular Lens Implantation 
To evaluate the clinical features, and visual outcomes of sterile uveitis after iris-fixated phakic intraocular lens implantation (pIOLs) (Artisan-Artiflex® and Verisyse-Veriflex®).
Material and Methods:
In this retrospective non-comparative case series, the medical records of 117 eyes implanted with Artisan-Artiflex® (Ophtec BV, Groningen, Netherlands) and Verisyse-Veriflex® (AMO, Santa Ana, CA) iris claw phakic IOLs were analyzed for postimplantation sterile uveitis. The mean age of the 87 patients included in the study was 27.2±7.4 years. Of these patients, 56 (64.3%) were men and 31 (35.6%) were women. Patient age, gender, IOL brand type, refractive error, optic diameter, unilateral vs bilateral implantation, and anterior chamber depth were analyzed. Features of uveitis, uncorrected and best corrected visual acuity (VA) at presentation and at follow-up visits were examined. The mean follow-up time was 14.6 months (range: 6-37 months).
Clinically significant uveitis was observed in 12 of 117 eyes (10.3%) in a total of ten patients. Of these ten patients, four (40%) were women and six (60%) were men, and the mean age was 25.1±5.3 years (range: 18-36 years). Among those with bilateral implantation, 6.9% of patients developed bilateral uveitis, while 13.8% (4 of the 29 implanted bilaterally) developed unilateral uveitis. Foldable pIOL implantation was the only variable associated with the development of uveitis (P=.03).
Although the prognosis is usually benign, sterile uveitis occurred in 10.3% of patients after iris-fixated pIOL implantation. The implantation of a foldable pIOL was the only variable associated with sterile uveitis. Appropriate medical management can be effective treatment, without the need for pIOL replacement.
PMCID: PMC3353668  PMID: 22623859
Artiflex®; Artisan®; Complications; Phakic Intraocular Lens; Uveitis; Veriflex®; Verisyse®
21.  Mapping of Macular Substructures with Optical Coherence Tomography for Glaucoma Diagnosis 
Ophthalmology  2007;115(6):949-956.
To use optical coherence tomography (OCT) to identify the specific retinal layers and macular regions damaged in glaucoma.
Observational cross-sectional study.
One hundred forty-nine participants in the Advanced Imaging for Glaucoma Study, divided into 3 groups: normal (N) perimetric glaucoma (PG), and glaucoma suspect and preperimetric glaucoma (GSPPG) with 44, 73, and 29 persons, respectively.
The Zeiss Stratus OCT system (Carl Zeiss Meditec, Inc., Dublin, CA) was used to map the macula over a 6-mm diameter and to scan the circumpapillary nerve fiber layer (cpNFL). The macular OCT images were exported for automatic segmentation using software developed by the authors. The thickness of the macular nerve fiber layer (mNFL), ganglion cell layer (mGCL), inner plexiform layer (mIPL), inner nuclear layer (mINL), outer retinal layer (mORL), and total retinal thickness were measured. Thickness measurements of GSPPG and PG eyes were compared with those of N eyes. The ability to differentiate between GSPPG and PG eyes against N eyes was assessed by fractional loss, standardized deviation, and the area under the receiver operating characteristic curve.
Main Outcome Measures
Area-weighted average thicknesses of retinal sublayers in the macula.
The mNFL, mGCL, mIPL, and mINL were significantly (P<0.001) thinner in both the GSPPG and PG eyes than in the N eyes. In PG eyes, mNFL, mGCL, and mIPL thinning was most severe (approximately 20%), mINL thinning was intermediate (7%), and mORL thinning was minimal (3%). The repeatability (coefficient of variation and intraclass correlation) of thickness measurements was improved by combining the mNFL, mGCL, and mIPL measurements as the inner retinal layer (mIRL). The mIRL was the best macular parameter for glaucoma diagnosis and had discriminant power comparable with that of the cpNFL. The fractional loss of mIRL thickness was most severe in the inferior perifoveal region for both the PG and GSPPG groups.
Glaucoma leads to thinning of the mNFL, mGCL, mIPL, and mINL, even before detectable visual field changes occur. A combination of the 3 innermost layers seems to provide optimal glaucoma detection. Increasing the sampling of peripheral macula with a new OCT scan pattern may improve glaucoma diagnosis further.
PMCID: PMC2692598  PMID: 17981334
22.  Multiple methods of surgical treatment combined with primary IOL implantation on traumatic lens subluxation/dislocation in patients with secondary glaucoma 
To describe clinical findings and complications from cases of traumatic lens subluxation/dislocation in patients with secondary glaucoma, and discuss the multiple treating methods of operation combined with primary intraocular lens (IOL) implantation.
Non-comparative retrospective observational case series. Participants: 30 cases (30 eyes) of lens subluxation/dislocation in patients with secondary glaucoma were investigated which accepted the surgical treatment by author in the Ophthalmology of Xi'an No.4 Hospital from 2007 to 2011. According to the different situations of lens subluxation/dislocation, various surgical procedures were performed such as crystalline lens phacoemulsification, crystalline lens phacoemulsification combined anterior vitrectomy, intracapsular cataract extraction combined anterior vitrectomy, lensectomy combined anterior vitrectomy though peripheral transparent cornea incision, pars plana lensectomy combined pars plana vitrectomy, and intravitreal cavity crystalline lens phacofragmentation combined pars plana vitrectomy. And whether to implement trabeculectomy depended on the different situations of secondary glaucoma. The posterior chamber intraocular lenses (PC-IOLs) were implanted in the capsular-bag or trassclerally sutured in the sulus decided by whether the capsular were present. Main outcome measures: visual acuity, intraocular pressure, the situation of intraocular lens and complications after the operations.
The follow-up time was 11-36mo (21.4±7.13). Postoperative visual acuity of all eyes were improved; 28 cases maintained IOP below 21 mm Hg; 2 cases had slightly IOL subluxation, 4 cases had slightly tilted lens optical area; 1 case had postoperative choroidal detachment; 4 cases had postoperative corneal edema more than 1wk, but eventually recovered transparent; 2 cases had mild postoperative vitreous hemorrhage, and absorbed 4wk later. There was no postoperative retinal detachment, IOL dislocation, and endophthalmitis.
To take early treatment of traumatic lens subluxation/dislocation in patients with secondary glaucoma by individual surgical plan based on the different eye conditions would be safe and effective, which can effectively control the intraocular pressure and restore some vision.
PMCID: PMC4003080  PMID: 24790868
crystalline lens; subluxation; dislocation; secondary glaucoma; surgical treatment
23.  Bilateral Implantation of Scleral-Fixated Cionni Endocapsular Rings and Toric Intraocular Lenses in a Pediatric Patient with Marfan's Syndrome 
Case Reports in Ophthalmology  2012;3(1):16-23.
The management of ectopia lentis in Marfan's syndrome is challenging. Multiple disease-associated factors conspire to deprive these patients of adequate vision. While optical correction with glasses and contact lenses is usually advocated early on, the irregular astigmatism and even partial aphakia that accompanies advanced cases generally warrant surgical intervention. Several surgical strategies have been devised to manage these challenging cases, including the combination of endocapsular or pars plana lensectomy and iris or scleral fixation of the intraocular lens (IOL) or IOL-bag complex. All of the reported cases have been implanted with IOLs that correct for myopia only. With toric lenses, it is now possible to correct for corneal astigmatism in these patients as well, provided that the capsular bag is maintained and can be properly centered. We report the combination of scleral-fixated Cionni endocapsular rings and toric IOLs in a pediatric patient with bilateral ectopia lentis secondary to Marfan's syndrome.
PMCID: PMC3357140  PMID: 22615696
Ectopia lentis; Marfan's syndrome; Toric intraocular lens; Cionni endocapsular ring
24.  Research on Calculation of the IOL Tilt and Decentration Based on Surface Fitting 
The tilt and decentration of intraocular lens (IOL) result in defocussing, astigmatism, and wavefront aberration after operation. The objective is to give a method to estimate the tilt and decentration of IOL more accurately. Based on AS-OCT images of twelve eyes from eight cases with subluxation lens after operation, we fitted spherical equation to the data obtained from the images of the anterior and posterior surfaces of the IOL. By the established relationship between IOL tilt (decentration) and the scanned angle, at which a piece of AS-OCT image was taken by the instrument, the IOL tilt and decentration were calculated. IOL tilt angle and decentration of each subject were given. Moreover, the horizontal and vertical tilt was also obtained. Accordingly, the possible errors of IOL tilt and decentration existed in the method employed by AS-OCT instrument. Based on 6–12 pieces of AS-OCT images at different directions, the tilt angle and decentration values were shown, respectively. The method of the surface fitting to the IOL surface can accurately analyze the IOL's location, and six pieces of AS-OCT images at three pairs symmetrical directions are enough to get tilt angle and decentration value of IOL more precisely.
PMCID: PMC3725812  PMID: 23935701
25.  Results of intraocular lens implantation with capsular tension ring in subluxated crystalline or cataractous lenses in children 
Indian Journal of Ophthalmology  2009;57(6):431-436.
To evaluate the outcome of intraocular lens (IOL) implantation using capsular tension ring (CTR) in subluxated crystalline or cataractous lenses in children.
Tertiary care setting
Materials and Methods:
We prospectively studied 18 eyes of 15 children with subluxation of crystalline or cataractous lenses between 90° up to 210° after phacoemulsification, CTR and IOL implantation. Each child was examined for IOL centration, zonular dehiscence and posterior capsular opacification (PCO).
Age of the patient ranged between five to 15 years. Out of 18 eyes, seven had traumatic and 11 had spontaneous subluxation of crystalline or cataractous lens. Phacoemulsification was successfully performed with CTR implantation in the capsular bag. Intraoperative zonular dialysis occurred in two eyes. Anterior vitrectomy was performed in six eyes to manage vitreous prolapse. IOL implanted was polymethyl methacrylate (PMMA) in eight eyes, hydrophobic acrylic in seven and hydrophilic acrylic in three. Follow-up ranged from 24 months to 72 months. Sixteen eyes had a best corrected visual acuity of 20/40 or better. Nine eyes developed significant PCO and were managed with Neodymium Yttrium Aluminum Garnet (Nd:YAG) laser posterior capsulotomy. One eye with acrylic IOL in the capsular bag had IOL dislocation after two years which was managed with vitrectomy and secondary trans-scleral fixation of IOL.
Phacoaspiration with CTR implantation makes capsular bag IOL fixation possible in most of the eyes with subluxated crystalline or cataractous lenses. PCO still remains a challenge in children with successful phacoaspiration with CTR implantation
PMCID: PMC2812761  PMID: 19861744
Capsular tension ring; posterior capsular opacification; subluxated lens; traumatic cataract

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