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Purpose: To compare visual outcomes and patient satisfaction after bilateral implantation of a nondiffractive extended vision intraocular lens (IOL) when targeting emmetropia vs mini-monovision., Setting: Iladevi Cataract & IOL Research Centre, Ahmedabad, India., Design: Prospective, randomized controlled trial., Methods: Patients undergoing bilateral cataract surgery with an extended vision IOL (Vivity) randomized to group I-IOL implantation with emmetropic target in both eyes or group II-IOL implantation with mini-monovision of -0.5 diopters (D) were included in this study. Outcome measures evaluated 6 months postoperatively were unaided and corrected near visual acuity (UNVA, CNVA) at 40 cm and unaided and corrected distance (UDVA, CDVA) and intermediate (UIVA, CIVA) visual acuity at 66 cm. Mesopic contrast sensitivity, binocular defocus curve, Patient-Reported Spectacle Independence Questionnaire, and satisfaction on the McAlinden questionnaire were also assessed., Results: 70 patients enrolled in this study. 34 and 33 patients in groups I and II, respectively, completed follow-up. Binocular UNVA was significantly better in group II (0.26 ± 0.05 vs 0.22 ± 0.08 logMAR, P = .03). Reading add required in group II was significantly lower. UIVA (0.09 ± 0.06 vs 0.07 ± 0.08 logMAR, P = .15) and UDVA (0.02 ± 0.04 vs 0.02 ± 0.05 logMAR, P = .78) were not significantly different between groups. Mesopic contrast sensitivity was not significantly different between the groups. Binocular defocus curve showed significantly better mean visual acuities between -2.0 D and -3.0 D in group II. Patients in both groups had high levels of spectacle independence, with no patient reporting dysphotopsia., Conclusions: Binocular UNVA was significantly better, with comparable UDVA and mesopic contrast sensitivity when targeting mini-monovision with the nondiffractive extended vision IOL as compared with targeting binocular emmetropia., (Copyright © 2024 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To compare intraoperative performance and early postoperative outcomes following phacoemulsification with two systems using active fluidics and one using gravity-based fluidics., Methods: In this prospective randomized trial, 200 eyes were randomized to the traditional and Active Sentry groups (n = 80 eyes each) where the Centurion Vision System was used with traditional or Active Sentry (Alcon Laboratories, Inc) hand-pieces, respectively, or the Infinit group (n = 40 eyes) where the Infiniti Vision System (Alcon Laboratories, Inc) was used. Within the traditional and Active Sentry groups, there were two subgroups with low (30 mm Hg) or high (55 mm Hg) intraocular pressure (IOP) used. Outcome measures compared were: cumulative dissipated energy (CDE), percentage change in central corneal thickness (CCT) at 1 day, 1 week, and 1 month, anterior chamber cells at 1 day and 1 week, rate of rise and fall of IOP following occlusion break, corneal endothelial cell density (ECD), and macular thickness 6 months postoperatively., Results: CDE was significantly lower in group II compared to the traditional group (2.96 ± 1.4 vs 4.14 ± 2.2, P = .001). With 30 mm Hg IOP, the Active Sentry group had significantly less percentage change in CCT at 1 week postoperatively compared to the traditional handpiece group (0.01% vs 0.02%, P = .008). Incidence of anterior chamber cells less than grade 2 on day 1 was significantly higher in the Active Sentry group (82.9% vs 52%, P = .03). Percentage change in ECD was significantly lower in the Active Sentry group (-0.957 vs -0.98%, P = .005). Significantly faster rise of IOP to baseline following occlusion break was seen in the Active Sentry group., Conclusions: The use of Active Sentry handpiece was associated with lower CDE, less postoperative increase in CCT, fewer anterior chamber cells, and faster rise of IOP following occlusion break. [ J Refract Surg . 2024;40(5):e304-e312.] .

Purpose: To report intraoperative performance and postoperative outcomes of femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification (PE) in the hands of junior surgeons., Setting: Iladevi Cataract & IOL Research Centre, Ahmedabad, Gujarat, India., Design: Prospective single-masked randomized controlled trial., Methods: 320 eyes (320 patients) undergoing cataract surgery for uneventful cataracts in the hands of junior surgeons were randomized to Group 1-FLACS or Group 2-PE. Intraoperatively, cumulative dissipated energy (CDE) and fluid used were compared. Postoperatively, the following were compared: central corneal thickness (CCT) on day 1, 1 week, and 1 month; corneal clarity (day 1 and 1 week); anterior chamber inflammation (day 1 and 1 week); change in endothelial cell density (ECD) at 6 months postoperatively; and corrected distance visual acuity (CDVA) at 1 week and 1 month postoperatively., Results: 157 and 158 patients in groups 1 and 2 analysed. Intraoperatively, CDE (5.41 ± 2.73 vs 8.83 ± 4.28 in Groups 1 and 2, P = .0001) and fluid used (79.33 ± 33.46 vs 101.82 ± 32.23 mL in Groups 1 and 2, P < .0001) were significantly lesser in Group 1. CCT was significantly higher in Group 2 on day 1 (550.96 ± 33.64 vs 587.70 ± 55.76 μm in Groups 1 and 2, P < .0001) and at 1 week postoperatively (527.94 ± 30.78 vs 545.11 ± 35.17 μm in Groups 1 and 2, P = .001). 72% of eyes had clear corneas on day 1 in Group 1 compared with 39% in Group 2 ( P = .01). Anterior chamber inflammation and CDVA were comparable. Change in ECD was significantly lower (9.3%) in Group 1 vs 12.7% in Group 2, P < .0001., Conclusions: FLACS showed lower intraoperative CDE, fluid usage, lesser increase in CCT, better early postoperative corneal clarity, and lesser change in ECD at 6 months postoperatively in the hands of junior surgeons during standard cataract surgery., (Copyright © 2022 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Aim: To compare intraocular lens (IOL) calculation methods not requiring refraction data prior to myopic laser-assisted in situ keratomileusis (LASIK) and radial keratotomy (RK)., Methods: In post-LASIK eyes, the methods not requiring prior refraction data were Hagis-L; Shammas; Barrett True-K no-history; Wang-Koch-Maloney; 'average', 'minimum' and 'maximum' IOL power on the American Society of Cataract and Refractive Surgeons (ASCRS) IOL calculator. Double-K method and Barrett True-K no-history, 'average', 'minimum' and 'maximum' IOL power on ASCRS IOL calculator were evaluated in post-RK eyes. The predicted IOL power was calculated with each method using the manifest postoperative refraction. Arithmetic and absolute IOL prediction errors (PE) (implanted-predicted IOL powers), variances in arithmetic IOL PE and percentage of eyes within ±0.50 and ±1.00 D of refractive PE were calculated., Results: Arithmetic or absolute IOL PE were not significantly different between the methods in post-LASIK and post-RK eyes. In post-LASIK eyes, 'average' showed the highest and 'minimum' showed the least variance, whereas 'average' and 'minimum' had highest percentage of eyes within ±0.5 D and 'minimum' had the highest percentage of eyes within ±1.0 D. In the post-RK eyes, 'minimum' had highest variance, and 'average' had the least variance and highest percentage of eyes within ±0.5 D and ±1.0 D., Conclusion: In post-LASIK and post-RK eyes, there are no significant differences in IOL PE between the methods not requiring prior refraction data. 'Minimum' showed least variance in PEs and more chances of eyes to be within ±1.0 D postoperatively in post-LASIK eyes. 'Average' had least variance and more chance of eyes within ±1.0 D in post-RK eyes., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To compare real-time intraocular pressure (IOP) response to occlusion break event in 2 phacoemulsification systems., Setting: Iladevi Cataract and IOL Research Center, India., Design: Randomized, experimental study., Methods: Rabbits were randomized to:Group I (n = 10 eyes), Centurion Vision system with active fluidics, or, Group II (n = 10 eyes), Centurion with Active Sentry. Within each group, parameter set 1 (IOP 30 mm Hg, aspiration flow rate [AFR] 20 mL/min, and vacuum 600 mm Hg) and parameter set 2 (IOP 50 mm Hg, AFR 25 mL/min, and vacuum 600 mm Hg) were tested. Real-time rate of drop and rise of IOP after occlusion break event (mm Hg per second) and percentage reduction of IOP from maximum during nuclear fragment removal were compared., Results: 10 rabbits (20 eyes) were included. Rate of drop of IOP after occlusion break was not significantly different between groups. Rate of rise of IOP was statistically significantly higher in Group II with both parameter sets (199.09 ± 69.28 vs 94.33 ± 45.66 in parameter set 1, P = .006; and 256 ± 45.05 vs 165.25 ± 51.80 in parameter set 2, P = .005), suggesting faster recovery to baseline IOP after occlusion break. The mean percentage reduction of IOP from maximum was significantly higher in Group I (P = .003)., Conclusions: Rise of IOP to baseline after occlusion break event was faster and mean percentage reduction of IOP from maximum during nuclear fragment removal was lower when using the Centurion Vision system with the Active Sentry upgrade compared with the traditional handpiece. The ability to sense IOP at the level of the handpiece with the Active Sentry upgrade allows faster mitigation of surge response., (Copyright © 2021 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To assess the outcome of 2 weeks phacoemulsification training program that is a unique collaboration between premier ophthalmic training institutes of India and Alcon Inc. initiated 10 years ago., Methods: Cataract surgeons eager to adopt phacoemulsification surgery as the primary treatment modality were enrolled in an intensive 2 weeks training program across seven premier ophthalmic institutes in India. These surgeons performed supervised phacoemulsification surgery under the guidance of expert faculty. Simultaneously didactic lectures, postoperative video discussions, and wet laboratory training were conducted. To assess improvement in the surgical skills each surgery was scored using the International Council of Ophthalmology-Ophthalmology Surgical Competency Assessment Rubrics (ICO-OSCAR). Phaco Development Specialist supported these surgeons for minimum duration of 1 year and maximum of 9 years and 2 months. In this multicentric study, surgical data of the participants enrolled between June 2010 to August 2018 was retrospectively analyzed., Results: Nine hundred 89 ophthalmologists across 27 Indian states and 4 Union Territories were trained between June 2010 and August 2018. The mean age of participants was 40.6 (+ 8.2 years) and 64.8% were males. After completing their training they performed 1,022,508 phacoemulsification surgeries in 9 years and 2 months. At follow-up, 92.11% and 88.77% of the surgeons were performing phacoemulsification at the end of 1 year and final follow-up, respectively., Conclusion: This program highlights how partnership model between industry and ophthalmologists can go hand in hand for training and skill development of doctors contributing to much-needed improvement in patient care across societies., Competing Interests: None

Purpose: The purpose of this study is to evaluate fluid droplet spray generation during phacoemulsification (PE), pars plana vitrectomy (PPV), and fragmatome lensectomy (FL) and assess factors affecting these., Methods: This is an experimental study. PE through 2.2 and 2.8 mm incisions was performed in six goat eyes and four simulator eyes using both continuous and interrupted ultrasound (U/S). PPV and FL were performed in three goat eyes. Generation of visible fluid droplet spray was analyzed from video recordings through the microscope camera and an external digital camera. Hydroxypropylmethylcellulose (HPMC) was applied over the incision site during PE and FL., Results: When PE was performed through both incision sizes, there was no visible fluid droplet spray if the phaco tip was centered in the incision, without sleeve compression. When there was phaco tip movement with the phaco sleeve sandwiched between the tip and the incision wall, there was visible fluid droplet spray generation. It was more difficult to induce fluid droplet spray with 2.8 mm incision, and spray was lesser with interrupted U/S. During PPV, there was no droplet spray. During FL, fluid droplet spray was only seen when U/S was delivered with the fragmatome tip close to the sclerotomy. HPMC impeded droplet spray., Conclusion: Fluid droplet generation during PE can be minimized to a large extent by keeping the phaco tip centered within the incision, avoiding sleeve compression. Smaller incision and continuous U/S were more prone to droplet generation. FL should be performed away from sclerotomy. HPMC over incision is recommended., Competing Interests: None

Purpose: To investigate agreement between biometric measurements obtained from the Lenstar LS 900 (Haag-Streit AG) based on optical low-coherence reflectometry (OLCR) and the Tomey OA-2000 (Tomey Corporation) based on swept-source optical coherence tomography (SS-OCT) in dense cataracts., Methods: In this prospective observational study, axial length, keratometry, anterior chamber depth (ACD), lens thickness, and central corneal thickness (CCT) were measured in 124 eyes of 76 patients. Intraocular lens prediction errors and absolute prediction errors were assessed based on postoperative manifest refraction. Analyses used were paired t test, Pearson correlation coefficient (r), and Bland-Altman plots., Results: Failure in axial length measurements was noted in 28 eyes (22.58%) with OCLR compared to 2 eyes (1.6%) with SS-OCT. Although not statistically significant, axial length measurements were clinically higher with SS-OCT (23.78 ± 1.76 mm) compared to OCLR (23.72 ± 1.58 mm) (P = .81) (r = 0.23; P = .01). There was a significant trend toward myopic intraocular lens prediction with SS-OCT (-0.09 ± 0.48) compared to OLCR (0.09 ± 0.41, P < .01) (r = 0.25, P = .01). There was good agreement for keratometric and ACD values between the two devices. SS-OCT gave significantly higher values of lens thickness compared to OCLR (4.44 ± 0.44 vs 4.18 ± 0.48 mm, P < .01) (r = 0.39, P < .01). CCT measured with OCLR was significantly higher than SS-OCT (525.64 ± 27.0 vs 513.21 ± 29.24 µm; P < .01) (r = 0.98, P < .01)., Conclusions: One-fifth of the patients with dense cataracts failed axial length measurement on OCLR. SS-OCT gives clinically higher axial length measurements leading to more myopic intraocular lens prediction errors postoperatively. OCLR provides higher pachymetry and lower lens thickness values compared to the SS-OCT device. [J Refract Surg. 2020;36(8):557-564.]., (Copyright 2020, SLACK Incorporated.)

Purpose: To evaluate long-term visual outcomes and complications after toric intraocular lens (IOL) implantation in children with preexisting corneal astigmatism undergoing cataract surgery., Setting: Iladevi Cataract & IOL Research Center, Ahmedabad, India., Design: Prospective, interventional case series., Methods: Children with regular corneal astigmatism of at least 1.5 diopters (D) were included. A standardized surgical technique with in-the-bag implantation of a toric IOL was performed. All children were followed up on postoperative day 1 and periodically thereafter, until 36 months postoperatively. The uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and residual refractive astigmatism were documented 36 months postoperatively. Rotational stability of toric IOL was also evaluated through the follow-up duration. Complications, particularly visual axis obscuration (VAO) and glaucoma, were documented., Results: In total, 76 eyes (51 children) were included in the study. Mean age at surgery was 7.41 ± 2.82 years (SD) and mean preoperative keratometric astigmatism was 1.56 ± 2.13 D. The CDVA (logarithm of the minimum angle of resolution [logMAR]) improved significantly from 0.59 ± 0.43 preoperatively to 0.23 ± 0.27 36 months postoperatively (P = .03). Mean postoperative UDVA was 0.32 ± 0.26 logMAR. Mean refractive astigmatism at final follow-up was -0.55 ± 0.40 D, with 74% patients having a UDVA of at least 20/40; 5% of eyes needed VAO treatment and none developed glaucoma. No eye required repositioning of toric IOL until final follow-up., Conclusions: Toric IOL implantation reduced postoperative refractive astigmatism and gave excellent UDVA at 36 months follow-up in pediatric eyes undergoing nontraumatic cataract surgery.

Purpose: To evaluate the eff ect of different aspiration flow rates (AFR) and bottle heights (BH) on vitreous face (AVF) during phacoemulsifi cation., Methods: Experimental study in 20 porcine eyes. Transzonular viscodissection was performed between the posterior capsule(PC) and AVF to dissect out the Berger's space. Triamcinolone acetonide was injected into this space to aid visualization with ultrasound B-Scan(USG). Realtime USG was performed during phacoemulsifi cation. Eyes were divided randomly into-Group I: Low parameters(AFR = 20 cc/min, BH = 90 cm, vacuum = 400 mmHg),and Group II: High parameters (AFR = 40 cc/min, BH = 110 cm, vacuum=650 mm Hg)., Results: 15 eyes were analysed (8 in Group I; 7 in Group II). In all eyes, forward and backward movement of the PC was seen when going from foot position 0 to 1, or on occlusion break. Amplitude of these movements was much greater in Group II compared to Group I. There was no PC rupture in either group. In 2 of the 7 eyes in Group II, USG showed a sudden, spontaneous dispersion appearance of sono-opaque echoes in the vitreous cavity alongwith disappearance of the well-defi ned, crescentic stained space despite an intact PC. This suggests rupture of the AVF, leading to dispersion of the triamcinolone into the entire vitreous cavity. No AVF rupture was seen in Group I., Conclusion: We report a rarely described entity of AVF rupture with intact PC. The use of high AFR and BH may have clinically invisible detrimental consequences to the anterior vitreous face., Competing Interests: There are no conflicts of interest.

Purpose: To compare intraoperative performance and postoperative outcomes between femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification in eyes with a shallow anterior chamber (AC)., Setting: Iladevi Cataract & IOL Research Centre, India., Design: Prospective randomized masked clinical study., Methods: Patients undergoing cataract surgery with a shallow AC (<2.5 mm) were randomized to have FLACS (Group 1, n = 91) or conventional phacoemulsification (Group 2, n = 91). Patients were followed up at 1 day, 1 week, and at 1, 3, and 6 months. The primary outcome measure was central corneal thickness (CCT). The secondary outcome measures were corneal clarity, AC cells and flare, endothelial cell density (ECD), coefficient of variance, hexagonality, and uncorrected distance visual acuity (UDVA) at 1 week., Results: The study comprised 182 eyes (91 in each group) The cumulative dissipative energy was lower in the FLACS group (P < .05). The mean CCT was significantly lower with FLACS (540.40 μm + 49.40 [SD] vs 556 + 12.5 μm, P = .03) at 1 day and 1 week (535.5 + 44.3 μm vs 551 + 40.8 μm, P = .04), with fewer eyes having higher than grade 2 AC cells and flare with FLACS (85% vs 72%, P = .056) at 1 day and 1 week (15% vs 28%, P = .03). At 1 week, the UDVA was better with FLACS (0.089 ± 0.31 logarithm of the minimum angle of resolution [logMAR] vs 0.178 ± 0.65 logMAR, P = .042). At 6 months, the reduction in ECD was lower in the FLACS group; however, the difference was not statistically significant., Conclusion: In eyes with shallow ACs, compared with conventional phacoemulsification, FLACS maintained clearer corneas, showed less increase in CCT, lower AC inflammation, and better UDVA in the early postoperative period., (Copyright © 2019. Published by Elsevier Inc.)

Purpose: To compare the change in ocular higher-order wavefront aberrations (HOAs), visual acuity, and modulation transfer function (MTF) after lens extraction with intraocular lens (IOL) implantation in patients with subluxated lenses., Setting: Iladevi Cataract & IOL Research Centre, Ahmedabad, India., Design: Prospective case series., Methods: Eyes with subluxated lenses having lens extraction with IOL implantation were included. Capsular bag fixation with in-the-bag IOL implantation or sutured or sutureless scleral fixation of the IOL was performed. Aberrometry was performed preoperatively and 6 months postoperatively. The following were compared: root-mean-square (RMS) value for total ocular HOAs, coma aberration, spherical aberration, MTF, and corrected distance visual acuity (CDVA)., Results: Of the 39 eyes with subluxated lenses, 26 eyes had Cionni ring fixation, 9 had sutured scleral fixation, and 4 had intrascleral fixation of the IOL. The mean preoperative and postoperative values, respectively, were as follows: RMS HOAs, 10.5 μm ± 9.5 (SD) and 4.73 ± 4.6 μm (P < .001); coma aberration, 2.46 ± 2.4 μm and 0.11 ± 0.1 μm (P = .03); and spherical aberration, 0.37 ± 0.9 μm and 0.02 ± 0.06 μm (P = .02). The MTF improved significantly in all eyes (mean 0.05 ± 0.02 preoperatively and 0.32 ± 0.16 postoperatively) (P = .005). The CDVA was statistically significant improved 6 months postoperatively., Conclusion: Lens extraction with IOL fixation in eyes with subluxated lenses significantly reduced ocular HOAs and improved the MTF., (Copyright © 2018 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the impact of varying fluidic parameters on intraoperative intraocular pressure (IOP) fluctuations and postoperative outcomes., Methods: Prospective randomized study of 80 eyes undergoing cataract surgery that were randomly assigned to low (aspiration flow rate: 20 cc/min; bottle height: 90 cm; vacuum: 400 mm Hg) and high (aspiration flow rate: 40 cc/min; bottle height: 110 cm; vacuum: 400 mm Hg) fluidic parameter groups. Real-time dynamic intraoperative IOP was measured during nuclear fragment removal. Mean maximum and minimum IOP and percentage reduction in IOP from maximum were compared between groups. Postoperatively, the rate of change in central corneal thickness and anterior chamber inflammation at days 1 and 7, endothelial cell density at 3 months, and corneal clarity on day 1 were compared., Results: Minimum IOP in the low and high parameters groups was 35 ± 4.0 and 34.5 ± 6.8 mm Hg, respectively. Maximum IOP in the low and high parameters groups was 69 ± 3.0 and 85 ± 1.2 mm Hg, respectively (P < .002). Mean percent reduction from maximum was 59% in the high parameters group compared to 41% in the low parameters group, with the difference being statistically significant (P < .002). Rate of change in central corneal thickness was greater in the high parameters group at postoperative days 1 and 7 (P < .001). Anterior chamber inflammation and corneal clarity on the first postoperative day were significantly better in the low parameters group., Conclusions: Higher aspiration flow rate and bottle heights are associated with high intraoperative IOPs of up to 85 mm Hg. Prolonged elevated IOP during cataract surgery was found to have more anterior segment inflammation and more edematous corneas., (Copyright 2014, SLACK Incorporated.)

Purpose: To compare incision integrity and clinical outcomes of 2 microcoaxial phacoemulsification systems., Setting: Iladevi Cataract & IOL Research Centre, Ahmedabad, India., Design: Prospective randomized clinical trial., Methods: Eyes were randomized to have phacoemulsification using a 1.8 mm clear corneal incision (CCI) system (Group 1, Stellaris system) or a 2.2 mm CCI system (Group 2, Intrepid Infiniti system). Incision enlargement at end of surgery was measured. At the conclusion of surgery, trypan blue was applied over the conjunctival surface, anterior chamber aspirate withdrawn, and ingress into anterior chamber measured. Postoperative observations included evaluation of the CCI using anterior segment optical coherence tomography (AS-OCT), change in central corneal thickness (CCT), and anterior segment inflammation at 1 day, 1 week, and 1 month and endothelial cell loss and surgically induced astigmatism (SIA) at 3 months., Results: Incision enlargement (P<.001) and trypan blue ingress in the anterior chamber (mean 1.7 log units ± 0.6 [SD] versus 3.8 ± 0.6 log units, P<.001) was significantly greater in Group 1 (n = 50) than in Group 2 (n = 50). On AS-OCT, endothelial misalignment and gaping were more frequent in Group 1 at 1 day (P=.001) and 1 week (P=.018). There were no significant differences in SIA, change in CCT, endothelial cell loss, or anterior segment inflammation (P>.05)., Conclusion: At the end of surgery, it is not the initial incision size alone but also the distortion of the incision during subsequent stages of surgery that determine the integrity of the CCI., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

We describe the use of high-speed imaging during phacoemulsification in a clinical scenario. Images captured during surgery at high frame rates are converted into a slow-motion film to view and analyze various surgical steps. This technique highlights events that are not captured in a normal-speed video recording. It has obvious applications for understanding surgical techniques and technology., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare incision integrity after clear corneal microcoaxial phacoemulsification using longitudinal and torsional ultrasound (US)., Setting: Iladevi Cataract & IOL Research Centre, Ahmedabad, India., Design: Prospective randomized experimental clinical trial., Methods: Part 1 comprised an experimental study of rabbit eyes. Group 1 received longitudinal US. Group 2 received torsional US. The right eye of each rabbit served as a control. Samples were processed for histomorphology and collagen I denaturation by immunofluorescence. Part 2 comprised a clinical trial of patients. Group 1 received torsional US. Group 2 received longitudinal US. At the end of surgery, trypan blue 0.0125% was instilled. After 2 minutes, 0.1 mL of aqueous was aspirated and its optical density measured., Results: In part 1, incision histomorphology was comparable in both modalities. Collagen denaturation tests (immunofluorescence, dot blot analysis) showed no irregularity in collagen arrangement in either group. In Group 2, Descemet membrane was detached and endothelial cells were minimal at the roof of the incision. In part 2, trypan blue ingress into the anterior chamber was significantly greater in Group 1 than in Group 2 (mean 3.40 + 0.6 log units versus and 3.77 + 0.82 log units) (P<.007)., Conclusions: Incision histomorphology in the torsional group showed minimal Descemet membrane detachment and minimal endothelial cell loss at the roof of the incision. Minimal ingress of trypan blue into the anterior chamber was observed with torsional US, indicating better wound integrity than with longitudinal US., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2012 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare posterior capsule opacification (PCO) 3 years postoperatively in contralateral eyes with a single-piece hydrophobic acrylic and 1 of 2 single-piece hydrophilic acrylic intraocular lenses (IOLs) with different configurations., Setting: Iladevi Cataract and IOL Research Institute, Ahmedabad, India., Design: Prospective randomized clinical trial., Methods: A hydrophobic Acrysof (hydrophobic group) or a hydrophilic C-flex (hydrophilic group C) or Akreos Adapt IOL (hydrophilic group A) was randomized for implantation in the fellow eye or vice versa of each patient. The Evaluation of Posterior Capsule Opacification (EPCO) area, EPCO score, and neodymium:YAG (Nd:YAG) capsulotomy rates were compared using digital photographs., Results: The study enrolled 68 patients. Although there was no significant difference at 1 month, the median EPCO score was statistically significantly lower in the hydrophobic group than in hydrophilic group C (P = .00) and hydrophilic group A (P = .000) at 3 years. There were no significant differences in the median EPCO area at 1 month; however, the area was statistically significantly less in the hydrophobic group than in hydrophilic group C and hydrophilic group A at 3 years (both P = .000). Four (12.9%) of 31 eyes in hydrophilic group C and 5 (16%) of 31 eyes in hydrophilic group A required an Nd:YAG capsulotomy; no eye in the hydrophobic group required a capsulotomy (P = .04 and P = .02, respectively)., Conclusion: Posterior capsule opacification was significantly less with the Acrysof hydrophobic acrylic IOL at 3 years., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate whether intracameral triamcinolone has an effect on anterior segment inflammation and visual axis obscuration after pediatric cataract surgery with intraocular (IOL) implantation., Setting: Iladevi Cataract and IOL Research Institute, Ahmedabad, India., Methods: This retrospective age-matched case-control study comprised consecutive eyes of children having phacoaspiration, posterior capsulectomy, vitrectomy, and IOL implantation. In the study group, eyes received a standardized application of an intracameral preservative-free triamcinolone acetonide suspension intraoperatively. In the control group, age-matched consecutive eyes had surgery with a similar technique but without intracameral preservative-free triamcinolone acetonide. Cell deposits, posterior synechias, visual axis obscuration, and intraocular pressure (IOP) were evaluated 1 month and 12 months postoperatively., Results: The mean patient age at surgery was 9.15 months +/- 5.04 (SD) in the study group (41 eyes) and 9.34 +/- 5.10 months in the control group (83 eyes) (P = .91). The visual axis was not obscured in any eye in the study group, while 9 eyes (10.8%) in the control group had an obscured axis; the difference between groups was statistically significant (P<.029). Six eyes (7.2%) in the control group required secondary membranectomy with pars plana vitrectomy. There was a statistically significant difference between the 2 groups in posterior synechias and cell deposits (both P<.033) and no significant difference in preoperative or postoperative IOP (P = .29 and P = .50, respectively)., Conclusion: Pediatric eyes receiving intracameral triamcinolone intraoperatively had significantly less anterior segment inflammation and no visual axis obscuration after cataract surgery with IOL implantation., (Copyright (c) 2010 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the anatomic location of the haptic and optic of single-piece sulcus-fixated intraocular lenses (IOLs) and their proximity to the iris and ciliary body using ultrasound biomicroscopy (UBM)., Setting: Iladevi Cataract & IOL Research Center, Ahmedabad, India., Methods: This retrospective study comprised eyes that had primary sulcus implantation of a single-piece IOL. Eyes had an intact anterior capsulorhexis that could provide uniform IOL support and a preoperative anterior chamber depth (ACD) greater than 2.7 mm. The fixation site of the haptics, distance between the optic edge and iris, optic tilt, anterior chamber angle (ACA), central ACD, and ciliary body edema were evaluated by UBM., Results: The time from surgery to UBM examination was 7 to 85 months. Both haptics were in the sulcus in 7 of the 10 eyes, 1 haptic was abutting the iris and the other was in the sulcus in 2 eyes, and both haptics were embedded in ciliary body in 1 eye. The mean distance between the optic edge and iris was 0.16 mm +/- 0.07 (SD), 0.15 +/- 0.03 mm, and 0.38 mm, respectively. The mean ACA was 40.2 +/- 4.5 degrees (range 30.9 to 45.2 degrees), 34.1 +/- 4.5 degrees, and 44.1 degrees, respectively. The mean ACD was 3.47 +/- 0.24 mm, 3.50 +/- 0.23 mm, and 3.57 mm, respectively. No eye had optic tilt or ciliary body edema., Conclusions: Implantation of both haptics in the sulcus was not achieved in all eyes. The haptics and optics remained in close proximity to the posterior iris surface., ((c) 2010 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare the effects of fluidic parameters on the central corneal thickness (CCT), corneal endothelium, and anterior segment inflammation after phacoemulsification with longitudinal ultrasound., Setting: Iladevi Cataract & IOL Research Center, Ahmedabad, India., Methods: In this prospective randomized patient- and examiner-masked study, consecutive patients with age-related cataract were randomly assigned to Group 1 (low fluidic parameters: aspiration flow rate 25 cc/min; bottle height 70 cm and 90 cm; vacuum

Background and Objective: To compare intraoperative performance and postoperative outcome of three phacoemulsification technologies in patients undergoing microcoaxial phacoemulsification through 2.2-mm corneal incisions., Patients and Methods: The prospective, randomized, single-masked study included 360 eyes randomly assigned to torsional (Infiniti Vision System; Alcon Laboratories, Fort Worth, TX), microburst with longitudinal (Infiniti), or microburst with longitudinal (Legacy Everest, Alcon Laboratories) ultrasound. Assessments included surgical clock time, fluid volume, and intraoperative complications, central corneal thickness on day 1 and months 1 and 3 postoperatively, and endothelial cell density at 3 months postoperatively. Comparisons among groups were conducted., Results: Torsional ultrasound required significantly less surgical clock time and fluid volume than the other groups. There were no intraoperative complications. Change in central corneal thickness and endothelial cell loss was significantly lower in the torsional ultrasound group at all postoperative visits (P < .001, Kruskal-Wallis test) compared to microburst longitudinal ultrasound modalities., Conclusion: Torsional ultrasound demonstrated quantitatively superior intraoperative performance and showed less increase in corneal thickness and less endothelial cell loss compared to microburst longitudinal ultrasound., (Copyright 2010, SLACK Incorporated.)

Aim: To compare the effects of balanced salt solution (BSS) and Ringer's lactate (RL) on corneal thickness, endothelial morphology, and postoperative anterior chamber inflammation in eyes undergoing phacoemulsification., Setting: Iladevi cataract and IOL research center, Ahmedabad, India., Materials and Methods: This prospective randomized study comprised 90 consecutive patients with age-related cataract who were randomly assigned to either Group 1 (n = 45) with BSS or Group 2 (n = 45) with RL. Observations made included measurement of central corneal thickness (CCT), presence of anterior chamber flare and cells, endothelial cell loss, and change in coefficient of variation (CV). Data was analyzed using Mann Whitney test and test of proportion., Results: Mean increase in CCT on postoperative Day 1 was 58microm and 97microm in Groups 1 and 2 respectively ( P = 0.01). Increase in CCT at one month was 10microm and 11microm in Groups 1 and 2 respectively ( P = 0.99); increase in CCT at three months was 3microm and 6microm in Groups 1 and 2 respectively ( P = 0.86). Number of eyes with flare grades in a range of 0 to 3 was statistically higher in Group 2 on postoperative Day 1 ( P = 0.004, 0.016, < 0.001, 0.047 for Grade 0, 1, 2 and 3 respectively). Number of eyes with cells of Grade 3 on first postoperative day was significantly higher in Group 2 as compared to Group 1 ( P = 0.004). Three months postoperatively, endothelial cell loss was 5.5% and 7.8% in Groups 1 and 2 ( P = 0.21) and change in CV was 3 and 5.4 in Groups 1 and 2 ( P = 0.20) respectively., Conclusion: BSS offers a significant advantage over RL in terms of increase in corneal thickness and postoperative inflammation on the first postoperative day in patients undergoing phacoemulsification.

Purpose: To compare the corticocapsular separation created by viscodissection and by hydrodissection using Miyake-Apple video-photographic analysis., Setting: University-based center., Methods: Fourteen cadaver eyes were randomized to hydrodissection (Group 1, n=7) or viscodissection (Group 2, n=7). Twelve eyes were prepared for Miyake-Apple viewing. One eye in each group was prepared to simulate a closed chamber. On Miyake-Apple viewing, corticocapsular separation was graded from 0 to 3 after hydrodissection/viscodissection and at the sculpting, nuclear division, and early and late fragment removal stages. The surgeon's subjective impression of the mechanical cushion effect was noted. Histopathology of the capsular bag was performed in 4 eyes in each group to determine the amount of residual lens epithelial cells (LECs)., Results: More space was created and maintained between the capsule and cortex in Group 2 than in Group 1. The mean scores in Groups 1 and 2 were endpoint of hydrodissection/viscodissection 1.92+/-0.38 and 2.58+/-0.38, respectively (P=.05); sculpting, 1.6+/-0.42 and 2.3+/-0.45, respectively (P=.05); nuclear division, 0.9+/-0.42 and 1.5+/-0.35, respectively (P=.13); early fragment removal, 0.6+/-0.22 and 1.0+/-0, respectively (P=.04); and late fragment removal, 0.1+/-0.22 and 0.4+/-0.22, respectively (P=.17). Although only early fragment removal achieved statistical significance, the surgeon's impression confirmed greater cushion effect with viscodissection. Residual LECs in the 2 groups were comparable., Conclusion: Viscodissection as an adjunct to hydrodissection created and maintained greater corticocapsular separation than hydrodissection alone during phacoemulsification.

Purpose: To compare ocular surface fluid ingress into the anterior chamber at the end of microcoaxial, standard coaxial, and bimanual phacoemulsification using trypan blue as the quantifying tracer., Setting: Iladevi Cataract and IOL Research Centre, Ahmedabad, India., Methods: This prospective randomized observational study comprised 180 consecutive patients who had microcoaxial, standard coaxial, or bimanual phacoemulsification. Trypan blue was applied over the conjunctival surface, and the amount of ingress was assessed after cortex removal (time point 1) and at the end of the surgery after intraocular lens insertion and stromal hydration (time point 2). Logs of dilution were used for statistical analysis., Results: At time point 1, a statistically significant difference was observed in the ingress of trypan blue in the aqueous aspirate. The bimanual group had the highest ingress and the microcoaxial group, the lowest. The amount of ingress in the standard coaxial group fell between the other 2 groups (P< .001). At time point 2, there was no statistically significant difference between the microcoaxial group and the standard coaxial group (P = 1.00); however, in the bimanual group, trypan blue ingress was statistically significantly higher than in the other 2 groups (P< .001)., Conclusion: At both time points, trypan blue ingress was statistically significantly higher in the bimanual group than in the standard coaxial and microcoaxial groups. At time point 2, there was no statistically significant difference between the standard coaxial and microcoaxial groups.

Background: Corticocapsular adhesions (CCA) are frequently seen between lens capsule and adjacent cortical layer. During cataract surgery, in the presence of CCA, excessive efforts to rotate the nucleus can result in zonular damage. To reduce morbidity, identification of associations with CCA can be helpful in appropriately modifying the surgical procedure., Aim: To investigate probable associations with CCA in patients undergoing cataract surgery., Setting and Design: Iladevi Cataract and IOL research center. Case-control study., Materials and Methods: A single eye of 600 patients, 200 patients with CCA (cases) and 400 patients without CCA (controls) were considered. A CCA diagnosis was based on: (i) preoperative presence of CCA on slit-lamp examination with visualization of furry surface of cortex during surgery; (ii) preoperative absence of CCA on slit-lamp examination but intraoperative visualization of furry surface of cortex. Variables such as age, gender, type of cataract, grade of cataract, high myopia, diabetes mellitus and hypertension were studied., Statistical Analysis: Multivariate logistic regression was done. Results were presented as odds ratio (OR) with 95% CI., Results: Mean age was 64.71 +/- 9.10 years in cases and 59.27 +/- 8.79 years in controls. Presence of CCA increased with age from 22% (n = 59) in 45 to 49 years to 70% (n = 110) in 70 to 79 years. An increase in age was associated with CCA by 3.3% (OR = 3.3%, P = 0.028). The odds of CCA for females were 83% higher ( P = 0.027). Presence of anterior cortical cataract increased odds of CCA by 9.5 times ( P = 0.001), while posterior cortical cataract increased odds by 3.3 times ( P = 0.001)., Conclusion: Corticocapsular adhesions were strongly associated with cortical cataracts, increased age and female gender.

Purpose: To compare the amount of bacterial ingress from the ocular surface into the anterior chamber at the end of bimanual and microcoaxial phacoemulsification in rabbits., Setting: Iladevi Cataract & IOL Research Centre, Raghudeep Eye Clinic, Memnagar, Ahmedabad, India., Methods: This randomized study comprised 40 eyes of 20 rabbits. Rabbits had microcoaxial phacoemulsification through a 2.2 mm single-plane clear corneal incision or bimanual phacoemulsification through a clear corneal 1.2 mm incision for phaco tip access accompanied by an additional 1.4 mm incision for irrigating chopper access. At the end of lens removal, 0.5 mL of culture suspension of Staphylococcus epidermidis (105 colony-forming units [CFU]/mL) was instilled on the ocular surface and kept for 2 minutes. Next, 0.1 mL of aqueous fluid was collected from the anterior chamber and subjected to a microbial viable count., Results: The microcoaxial group had statistically significantly lower ingress of bacteria than the bimanual group (250.0 CFU/mL and 1538.1 CFU/mL, respectively) (P<.002) irrespective of the presence or absence of wound distortion., Conclusion: Bacterial ingress occurred in both groups, although it was statistically significantly higher in the bimanual group.

Purpose: To evaluate the intraoperative performance and postoperative outcomes after microcoaxial phacoemulsification., Setting: Iladevi Cataract & IOL Research Centre, Ahmedabad, India., Methods: A prospective observational case series comprised 84 eyes with age-related uncomplicated cataract having microcoaxial phacoemulsification through a 2.2 mm clear corneal incision by a standard surgical technique. Phacoemulsification parameters (Infiniti Vision System, Alcon) were microburst width, 30 ms; preset power, 50%; vacuum, 650 mm Hg; aspiration flow rate, 25 cc/minute. A single-piece Alcon AcrySof intraocular lens was implanted with the C cartridge (Alcon) cartridge. The incision was measured at the end of surgery. Observations included surgical time (from commencement of sculpting to end of epinucleus removal), cumulative dissipated energy (CDE), wound burns, intraoperative complications, postoperative increase in mean central corneal thickness (CCT) at 1 day and 1 month, mean % decrease in endothelial cell density (ECD), absolute mean change in coefficient of variation (cv) 3 months, and uncorrected visual acuity (UCVA) at 1 day. Data were analyzed using a 1-sample t test with 95% confidence intervals (CIs)., Results: The mean follow up was 3 months +/- 0.3 (SD). The mean incision size at the end of surgery was 2.3 +/- .09 mm; mean surgical time, 4.5 +/- 1.5 minutes; and mean CDE, 2.3 +/- 2.2 seconds. No wound burns or other intraoperative complications occurred. The postoperative CCT increased by a mean of 16 microm at 1 day (95% CI, 8-25; P = .66;) and by a mean of 3.14 microm at 1 month (95% CI, 2.26-4.05; P = .92). The ECD decreased by a mean of 5.8% (95% CI, 6.8-3.5; P = .82) and the mean coefficient of variation, by 3.3 (95% CI, 4.5-2.0; P = .65). At 1 day, the UCVA was 20/20 in 29% of cases, 20/20 to 20/40 in 58%, and 20/40 to 20/50 in 12%., Conclusion: Microcoaxial phacoemulsification was safely and effectively performed, achieving consistent and satisfactory postoperative outcomes.

Purpose: To use trypan blue as a quantifiable ingress tracer to determine whether stromal hydration reduces ocular surface fluid ingress at the end of phacoemulsification., Setting: Iladevi Cataract and IOL Research Centre, Memnagar, Ahmedabad, India., Methods: A prospective randomized study included 80 eyes having phacoemulsification through 2.2 mm incisions. These eyes were divided into 2 equal groups: 1 had stromal hydration (surgery completed by injecting fortified balanced salt solution [BSS Plus] to hydrate the lateral walls and internal entry of incision) and the other had no stromal hydration. One half milliliter of 0.0125% sterile trypan blue was instilled on the ocular surface and allowed to remain for 2 minutes. One-tenth milliliter of aqueous fluid was aspirated from the anterior chamber, and its optical density was measured using ultraviolet spectrophotometry. Logs of dilution of trypan blue were used for statistical analysis using the nonparametric Mann-Whitney U test., Results: There was a statistically significant decrease and difference between groups in mean dilution of trypan blue in the aqueous aspirate (P<.001). The mean was 1:11,337 in the stromal hydration group and 1:220 in the no stromal hydration group. Logs of mean dilution of trypan blue had statistically significant lower values in the stromal hydration group than in the no stromal hydration group (3.21 and 2.14, respectively) (P<.001)., Conclusions: Stromal hydration of clear corneal incisions reduced ingress into the anterior chamber of the trypan blue instilled on the ocular surface. Clinically, these findings may have a beneficial effect in reducing the risk for postoperative endophthalmitis.

A 61-year-old man presented with gradual blurring of vision and glare in both eyes for a couple of years, with worsening of the vision in his right eye over the past 2 months. He had no medical history of note. On clinical examination, his visual acuities were 20/80 in the right eye and 20/30 in the left eye, uncorrected. The cornea was clear, and the anterior chamber (AC) was deep in both eyes. He had bilateral mild nuclear sclerosis with round central onion-ring–like posterior opacities. The opacities measured approximately 2 mm in diameter and were marginally larger in the right eye than in the left eye (Figure 1 Figure 1. Right eye with mild nuclear sclerosis and central onion-ring–like posterior opacity. ). In addition, there were 2 curvilinear lines across the right posterior capsule (PC), one of which passed across the lens opacity (Figure 2 Figure 2. Retroillumination view of the right cataract showing 2 curvilinear lines in the area of the posterior lens opacity. ). Fundus examination was normal in both eyes, and the vitreous was clear. Optical coherence tomography (OCT) of the macular and optic nerve in both eyes was normal. The endothelial cell count in both eyes exceeded 2000 cells/mm2. He had been told by a previous ophthalmologist to have bilateral cataracts and was now keen for surgery starting with the right eye. He works as a manager in a large company and is an avid golf player. He is emmetropic and wears spectacles for near work. Optical biometry using predicated posterior corneal astigmatism did not recommend a toric intraocular lens (IOL). He had done his internet research on IOL options and requested trifocal IOLs. What is your surgical plan for right cataract removal? Explain which IOL you would choose to implant. [ABSTRACT FROM AUTHOR]

We describe the subtle signs of the anterior vitreous face as a bulging structure, a homogenous staining pattern of 3 buttonholes, and a lamellar or fibrillar pattern intact. This should help surgeons correctly recognize the intact anterior vitreous face. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. [ABSTRACT FROM AUTHOR]