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Objective: To evaluate the clinical results of implantation of the new 1CU accommodative intraocular lens (IOL) in cataract patients and to compare results with those of conventional IOLs., Design: Nonrandomized comparative trial., Participants: Twenty eyes of 20 patients (mean age = 65.8+/-13.3 years) in the 1CU group and 20 eyes of 20 patients (mean age = 67.4+/-11.6 years) in the control group., Methods: All patients underwent phacoemulsification and IOL implantation. The 1CU accommodative lens was used in 20 eyes, and conventional IOLs (polymethyl methacrylate, hydrophilic or hydrophobic acrylate) were used in the control group. Patients were observed prospectively, and 6-month data were analyzed., Main Outcome Measures: Accommodative ranges determined by 3 different methods (near point, defocusing, and retinoscopy). Secondary outcome measures were (1) increase of anterior chamber depth after topical application of 1% cyclopentolate eyedrops and (2) distance-corrected near visual acuity with Birkhäuser reading charts at 35 cm., Results: We observed a higher accommodative range with all 3 methods (mean = 1.83+/-0.49 vs. 1.16+/-0.27 diopters [D] [near point], 1.85+/-0.43 vs. 0.64+/-0.21 D [defocusing], and 0.98+/-0.55 vs. 0.17+/-0.22 D [retinoscopy]), a larger increase of anterior chamber depth after cyclopentolate eyedrops (mean = 0.42+/-0.18 vs. 0.11+/-0.06 mm), and better distance-corrected near visual acuity (median = 0.4 vs. 0.2) in the 1CU group relative to the control group. All differences between the 2 groups were statistically highly significant (P<0.001)., Conclusions: In the present study, the 1CU accommodative IOL showed increased accommodative range and better near visual acuity than a control group with conventional IOLs. Further research is necessary to confirm these results in masked, randomized, prospective studies and to confirm further the accommodative power of this group of new IOLs.

Objective: To assess the impact of graft diameter on corneal curvature before and after removal of a double-running suture after nonmechanical penetrating keratoplasty (PK)., Design: Prospective, nonrandomized, comparative (self-controlled) single-center clinical trial., Patients: Four hundred eighty-nine eyes with "two sutures in" and 308 eyes with "all sutures out" (mean age, 52+/-19 years) were included. The diagnoses were keratoconus (48%), Fuchs' and stromal dystrophies (31%), aphakic or pseudophakic bullous keratopathy (11%), and scars (10%)., Interventions: In all eyes, a central trephination was performed (donor trephination from the epithelial side) using the 193-nm Meditec excimer laser (Carl Zeiss Meditec, Jena, Germany) along metal masks with eight "orientation teeth/notches." Diameters were 8.0 mm, 7.5 mm, and 7.0 mm with a graft oversize of 0.1 mm. In 29% of eyes, additional cataract, intraocular lens surgery, or both were performed simultaneously. In all eyes, a double-running 10-0 nylon suture was applied. Zeiss keratometry and TMS-1 topography analysis were performed before removal of the first suture (14+/-4 months) and at least 6 weeks after removal of the second suture (20+/-4 months), but before any additional surgery, such as cataract extraction or refractive keratotomies., Main Outcome Measures: Topographic central corneal power (CP; keratometric diopters), keratometric astigmatism (KA), surface regularity index (SRI), and surface asymmetry index (SAI). The regularity of keratometry mires was recorded semiquantitatively from 0 = regular to 3 = not measurable (as published earlier)., Results: With both sutures in, median CP in 7.0-mm (42.0 diopters [D]; P = 0.04) and in 7.5-mm grafts (42.3 D; P = 0.007) was significantly lower than in 8.0-mm grafts (43.0 D). Keratometric astigmatism did not differ between groups (3.0 D vs. 3.0 D vs. 2.7 D). The SRI (1.66 vs. 1.43 vs. 1.11) and SAI (1.55 vs. 1.24 vs. 0.85) decreased significantly with increasing diameter. The proportion of regular keratometry mires (13% vs. 17% vs. 29%) increased, and the proportion of not measurable keratometries (45% vs. 18% vs. 9%) decreased with increasing diameter. With all sutures out, CP in 7.0-mm grafts (40.4 D) was significantly smaller than in 7.5-mm (43.6 D; P = 0.04) and 8.0-mm grafts (43.3 D; P = 0.04). Again, KA did not differ between groups (3.0 D vs. 3.2 D vs. 3.0 D). The SRI (1.40 vs. 1.09 vs. 0.84) and SAI (1.24 vs. 0.83 vs. 0.62) decreased significantly with increasing diameter. The proportion of regular keratometry mires (5% vs. 31% vs. 52%) increased, and the proportion of not measurable keratometries (42% vs. 11% vs. 4%) decreased with increasing diameter., Conclusions: After PK, a smaller graft diameter results in a flatter curvature and a higher degree of topographic irregularity, but not in higher net astigmatism. After suture removal, graft topography tends to regularize, whereas the principal differences between diameters do persist.

Objective: Aqueous melanin granules may be accurately quantified with the laser flare-cell meter and have been demonstrated to be increased in primary pigment dispersion syndrome (PDS). It was the aim of this study to correlate intraocular pressure, glaucomatous damage of the optic nerve head, and visual field defects with the number of aqueous melanin granules in PDS., Design: Cross-sectional study., Participants: Thirty-nine eyes of 21 patients with PDS and either ocular hypertension or pigmentary glaucoma., Main Outcome Measures: A 24-hour intraocular pressure (IOP) profile, automated perimetry (Octopus G1), and analysis of photostereographs and HRT (Heidelberg Retina Tomograph) images of the optic disc were performed. Aqueous melanin granules were quantified using the cell count mode of the laser flare-cell meter (KOWA FC-1000) with undilated and dilated pupils. Granule counts were correlated with maximum and mean IOP, maximum range (amplitude) of IOP, mean defect of automated perimetry (G1-program), and damage to the optic disc was measured with the HRT., Results: The number of aqueous melanin granules showed a strong correlation with maximum IOP in both undilated (r = 0.72, P < 0.001) and dilated eyes (r = 0.5, P = 0.02). A marginal correlation was found with the IOP range (r = 0.43, P = 0.04) and the mean defect of automated perimetry (r = 0.41, P = 0.06) in undilated eyes. The mean IOP and HRT measurements of the optic disc (area, volume of the neuroretinal rim, third moment in contour) showed no statistically significant correlation with the number of aqueous melanin granules (r < 0.4, P > 0.2)., Conclusions: A larger number of aqueous melanin granules is strongly associated with high IOP and also with visual field loss, providing additional evidence of the relation between aqueous melanin dispersion and development of pigmentary glaucoma. Quantification of aqueous melanin granules with the laser flare-cell meter might be useful for evaluation of treatment effects, including laser iridotomy, in patients with PDS.

Objective: To review the authors' results using nonmechanical excimer laser trephination in penetrating keratoplasty for perforated or predescemetal corneal ulcers., Design: Noncomparative, consecutive, interventional case series., Participants: Thirty-two patients with perforated (17) or deep (15) corneal ulcers (9 bacterial, 5 acanthamoebal, 10 herpetic, 3 associated with rheumatoid arthritis, 5 other) necessitating immediate tectonic keratoplasty., Intervention: Penetrating tectonic keratoplasty with excimer laser trephination was performed along metal aperture masks in donor and recipient corneas., Main Outcome Measures: Clinical results including intraoperative and postoperative complications were evaluated., Results: Trephination was possible in all eyes without perforation of predescemetal ulcers or extrusion of intraocular contents. No eyes with bacterial or acanthamoebal ulcers showed persistence or recurrence of infection. One eye showed recurrent epithelial herpetic keratitis. Best-corrected postoperative visual acuity ranged from 20/700 to 20/20 (median, 20/58), with 30 of 32 eyes achieving improvement of best visual acuity during follow-up (mean, 22.4 months) and with 12 of 32 eyes reaching a visual acuity of 20/40 or greater. Eyes with bacterial or acanthamoebal ulcers showed best results. Episodes of graft rejection occurred in nine eyes and resulted in irreversible opacity of the graft in seven cases. None of the eyes lost all vision, developed endophthalmitis, or had to be enucleated., Conclusions: Nonmechanical trephination is a useful technical refinement of tectonic penetrating keratoplasty à chaud for perforated or deep progressive corneal ulcers. This technique greatly facilitates exact trephination under these difficult surgical conditions and might possibly improve the prognosis of this procedure.

Objective: To assess the impact of nonmechanical trephination on the outcome after penetrating keratoplasty (PK)., Design: Prospective, randomized, cross-sectional, clinical, single-center study., Patients: A total of 179 eyes of 76 females and 103 males, mean age at the time of surgery 50.6 +/- 18.5 (range, 15-83) years. Inclusion criteria were (1) time interval from October 1992 to December 1997; (2) one surgeon (GOHN); (3) primary central PK; (4) Fuchs dystrophy (diameter, 7.5 mm) or keratoconus (diameter, 8.0 mm); (5) graft oversize, 0.1 mm; (6) no previous intraocular surgery; and (7) 16-bite double-running diagonal suture., Intervention: In a randomized fashion, eyes were assigned either to trephination with the 193-nm Meditec excimer laser (manually guided beam in patients, automated rotation device of artificial anterior chamber in donors) along metal masks with eight orientation teeth/notches (EXCIMER: 53 keratoconus, 35 Fuchs dystrophy; mean follow-up, 37 +/- 16 months) or with a hand-held motor trephine (Microkeratron; Geuder) (, Control: 53 keratoconus, 38 Fuchs dystrophy; mean follow-up, 38 +/- 14 months). Subjective refractometry (trial glasses), standard keratometry (Zeiss), and corneal topography analysis (TMS-1; Tomey) were performed before surgery, before removal of the first suture (15.2 +/- 4.2 months), and after removal of the second suture (21.4 +/- 5.6 months)., Main Outcome Measures: Keratometric and topographic net astigmatism as well as refractive cylinder; keratometric and topographic central power; best-corrected visual acuity (VA); surface regularity index (SRI), surface asymmetry index (SAI), and potential visual acuity (PVA) of the TMS-1., Results: Before suture removal, mean refractive/keratometric/topographic astigmatism did not differ significantly between EXCIMER (2.5 +/- 1.8 diopters [D]/3.4 +/- 2.8 D/4.7 +/- 3.1 D) and CONTROL groups (3.0 +/- 1.8 D/3.7 +/- 2.4 D/4.3 +/- 2.1 D). After suture removal, respective values were significantly lower in the EXCIMER group (2.8 +/- 2.0 D/3.0 +/- 2.1 D/3.8 +/- 2.6 D) than in the CONTROL group (4.2 +/- 2.4 D/6.1 +/- 2.7 D/6.7 +/- 3.1 D) (P < 0.0009). In the EXCIMER versus CONTROL group, mean VA increased from 20/100 versus 20/111 (P > 0.05) before surgery, to 20/31 versus 20/38 before (P = 0.001) and to 20/28 versus 20/39 (P < 0.00001) after suture removal. Mean spherical equivalent was significantly less myopic in the EXCIMER group before (-0.9 +/- 3.6 D vs. -2.6 +/- 3.4 D) (P = 0.01) and after suture removal (-1.4 +/- 3.1 D vs. -2.4 +/- 3.5 D) (P = 0.02). Mean SRI (P = 0.04) and PVA (P = 0.007) were significantly more favorable in the EXCIMER versus CONTROL group after suture removal (0.91 +/- 0.45 and 0.82 +/- 0.15 vs. 1.05 +/- 0.46 and 0.73 +/- 0.18)., Conclusions: Postkeratoplasty results seem to be superior using nonmechanical excimer laser trephination. Thus, this methodology is recommended as the procedure of first choice in avascular corneal pathologies requiring PK.

Objective: To assess the validity of corneal power measurement and standard intraocular lens power (IOLP) calculation after photorefractive keratectomy (PRK)., Design: Nonrandomized, prospective, cross-sectional, clinical study., Participants: A total of 31 eyes of 21 females and 10 males with a mean age at the time of surgery of 32.3 +/- 6.6 years (range, 24.4-49.5 years)., Intervention: Subjective refractometry, standard keratometry, TMS-1 corneal topography analysis, and pachymetry were performed before and 15.8 +/- 10.4 months after PRK for myopia (n = 24, -1 .5 to -8.0 diopters [D], mean -5.4 +/- 1.9 D) or myopic astigmatism (n = 7, sphere -2.0 to -7.5 D, mean -4.4 +/- 1.9 D; cylinder -1.0 to -3.0 D, mean -1.9 +/- 0.7 D). The IOLP calculations were done using two different formulas (SRK/T and HAIGIS)., Main Outcome Measures: Keratometric power (K) and topographic simulated keratometric power (TOPO) as measured (Kmeas, TOPOmeas) and as calculated according to the change of power of the anterior corneal surface or according to the spherical equivalent change after PRK (Kcalc, TOPOcalc), IOLP for emmetropia, and postoperative ametropia for calculated corneal powers were assessed in a model., Results: After PRK, mean Kmeas and TOPOmeas were significantly greater (0.4-1.4 D, maximum 3.3 D) than mean KRcalc and TOPOcalc (P < 0.0001). On average, the relative flattening of the cornea after PRK was underestimated by 14% to 30% (maximum, 83%) depending on the method of calculation. The mean theoretical IOLP after PRK ranged from + 17.4 D (SRK/T, TOPOmeas) to +20.9 D (HAIGIS, Kcalc) depending on the calculation method for corneal power and IOLP calculation formula used. For both formulas, IOLP values using keratometric readings were significantly higher (>1 D) than IOLP values using topographic readings (P < 0.0001). The theoretically induced mean refractive error after cataract surgery ranged from +0.4 to +1.4 (maximum, +3.1) D. Corneal power overestimation and IOLP underestimation correlated significantly with the spherical equivalent change after PRK (P = 0.001) and the intended ablation depth during PRK (P = 0.004)., Conclusions: To avoid underestimation of IOLP and hyperopia after cataract surgery following PRK, measured corneal power values must be corrected. The calculation method using spherical equivalent change of refraction at the corneal plane seems to be the most appropriate method. In comparison with this method, direct power measurements underestimate corneal flattening after PRK by 24% on average. Use of conventional topography analysis seems to increase the risk of error. However, because this study is retrospective and theoretical, there is still a need for a large prospective investigation to validate the authors' findings.

Background: Renewed interest in pseudoexfoliation syndrome (PEX) may be attributed to an increased awareness of many clinical risks not only for open-angle glaucoma and its recent recognition as a generalized disorder. This review summarizes the range of intraocular and extraocular manifestations. Involvement of all tissues of the anterior segment of the eye results in a spectrum of intraocular complications that have management implication for all practicing ophthalmologists., Design: The study design was a review., Methods: Clinical diagnosis depends on biomicroscopy, biocytology, and laser-tyndallometry. Laboratory research methods range from light and electron microscopy, to immunohistochemical and molecular biologic approaches., Observations: Clinical-histopathologic correlations focus on the involvement of lens (PEX-phacopathy), zonular apparatus (zonulopathy), ciliary body (cyclopathy), iris (iridopathy), trabecular meshwork (trabeculopathy), and cornea (corneal endotheliopathy) leading to the following complications: (1) open-angle glaucoma as well as angle-closure glaucoma due to pupillary and ciliary block; (2) phacodonesis, lens dislocation, and increased incidence of vitreous loss in extracapsular cataract surgery caused by alterations of the zonular apparatus and its insertion into the ciliary body and lens; (3) blood-aqueous barrier breakdown (pseudouveitis), anterior chamber hypoxia, iris stromal hemorrhage, pigment epithelial melanin dispersion, poor or asymmetric pupillary dilatation, and formation of posterior synechiae due to involvement of all cell populations of the iris; and (4) early diffuse corneal endothelial decompensation explained by a damaged and numerically reduced endothelium., Conclusions: In view of the multitude of clinical complications, PEX is of relevance to comprehensive ophthalmologists, including specialists in glaucoma, cataract, cornea, neuro-ophthalmology, and retina. Special attention to the risks associated with PEX is advised before, during, and after surgery.

A series of 130 eyes with ocular melanomas, 19 normal eyes, and 18 eyes affected with other disorders leading to blood-ocular barrier (BOB) breakdown were immunohistochemically stained for albumin to localize sites of BOB failure within the retina, ciliary body, and iris. Thirty-nine of the eyes containing melanomas and all of the other eyes were also immunohistochemically stained for vascular endothelial growth factor (VEGF), to investigate its potential role as a mediator for BOB failure. Eyes with melanomas showed widespread leakage through the retinal pigment epithelium, and 58% demonstrated leakage from retinal vessels in the proximity of the tumor. BOB failure remote from the tumor also occurred in retina (50%), optic nerve head (77%), ciliary body (51%), and iris (51%), suggesting that a soluble mediator may be involved. VEGF was demonstrated intraretinally in the proximity of (46%) and remote from (24%) melanomas and in eyes affected by other disease processes, particularly those involving neoplasia or retinal detachments, usually within particular cell populations (ie, retinal vessel walls, ganglion cells, inner or outer nuclear layers, retinal pigment epithelium). VEGF localization in retina, ciliary body, and iris often coincided with sites of extravasated albumin. Preincubation of albumin or VEGF antibodies with normal serum or VEGF peptide, respectively, eliminated or markedly reduced all immunoreactivity. Only 1 of 14 normal postmortem eyes and 0 of 5 normal surgically removed eyes showed VEGF positivity in the retina, 5 of 19 normal eyes had weak positivity in the ciliary body, and VEGF was not demonstrated in the iris of normal eyes. VEGF cannot account for all of the BOB failure associated with ocular melanomas, but appears likely to play a contributing role in many cases.

Background: Traumatic or postoperative cyclodialysis frequently is associated with persisting ocular hypotony, causing morphologic changes and visual loss., Methods: The authors retrospectively analyzed the data of 29 eyes of 29 patients who underwent consecutive direct surgical cyclopexy for hypotonus cyclodialysis between 1980 and 1993 at the authors' institution. Cyclopexy was performed by directly suturing the ciliary body to the scleral spur under a scleral flap., Results: The cyclodialysis clefts were posttraumatic (26 eyes) or postsurgical (3 eyes), extended for 3.6 +/- 1.7 clock hours (range, 1.5-9.5 clock hours), and were most frequently located superiorly. In eight eyes, argon laser photocoagulation of the cyclodialysis cleft (1-11 sessions) was performed before surgical cyclopexy but failed to permanently close the clefts. Preoperatively, all eyes showed persisting ocular hypotony with intraocular pressure of 3.1 +/- 2.3 mmHg (range, 0-8 mm Hg), macular edema, and disc swelling. Postoperatively, intraocular pressure was 14.0 +/- 3.7 mmHg (range, 6-20 mmHg), and visual acuity improved in 25 eyes (86%) and remained unchanged in 4 (14%) because of posttraumatic posterior segment problems. In 14 eyes, painful reversible pressure spikes of up to 58 mmHg developed during the first postoperative days, but no persisting secondary glaucoma was observed during further follow-up of 37.7 +/- 35.9 months (range, 2-134 months). All ten phakic eyes that were refracted preoperatively and postoperatively showed hyperopic shifts of more than 1 diopter after cyclopexy., Conclusions: Direct surgical cyclopexy is a successful treatment for large hypotonus cyclodialysis clefts that are unresponsive to or too large for laser photocoagulation. Painful early postoperative pressure spikes are frequent, but the development of glaucoma seems to be very uncommon. Postoperative visual acuity may be compromised due to posterior segment sequelae of preceding ocular trauma.