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Anand Vinekar,1 Chaitra Jayadev,1 Siddesh Kumar,2 Shwetha Mangalesh,1,3 Mangat Ram Dogra,4 Noel J Bauer,5 Bhujang Shetty6 1Department of Pediatric Retina, Narayana Nethralaya Eye Hospital, Bangalore, 2Raichur Institute of Medical Sciences, Raichur, Karnataka, India; 3Department of Ophthalmology, Duke University, Durham, NC, USA; 4Advanced Eye Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India; 5Department of Ophthalmology, Maastricht University of Health Sciences, Maastricht, the Netherlands; 6Department of Ophthalmology, Narayana Nethralaya Postgraduate Institute of Ophthalmology, Bangalore, India Purpose: To report the reduction in the incidence and severity of retinopathy of prematurity (ROP) in rural India over a 4-year period following the introduction of improved neonatal care practices. Methods: The Karnataka Internet Diagnosis of Retinopathy of Prematurity program (KIDROP), is a tele-medicine network that screens for ROP in different zones of Karnataka state in rural India. North Karnataka is the most underdeveloped and remote zone of this program and did not have any ROP screening programs before the intervention of the KIDROP in 2011. Six government and eleven private neonatal centers in this zone were screened weekly. Specific neonatal guidelines for ROP were developed and introduced in these centers. They included awareness about risk factors, oxygen regulation protocols, use of pulse oxymetry, monitoring postnatal weight gain, nutritional best practices, and management of sepsis. The incidence and severity of ROP were compared before the guidelines were introduced (Jan 2011 to Dec 2012) and after the guidelines were introduced (July 2013 to June 2015). Results: During this 4-year period, 4,167 infants were screened over 11,390 imaging sessions. The number of enrolled infants increased from 1,825 to 2,342 between the two periods (P

Natasha Johan Bauer Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, UK Background: Novel research has revealed that the relative risk of death increased by 10% and 15% for admissions on a Saturday and Sunday, respectively. With an imminent threat of 7-day services in the National Health Service, including weekend operating lists, handover plays a pivotal role in ensuring patient safety is paramount. This audit evaluated the quality, efficiency, and safety of surgical handover of pre- and postoperative cardiothoracic patients in a tertiary center against guidance on Safe Handover published by the Royal College of Surgeons of ­England and the British Medical Association. Methods: A 16-item questionnaire prospectively audited the nature, time and duration of handover, patient details, operative history and current clinical status, interruptions during handover, and difficulties cross-covering specialties over a month. Results: Just over half (52%) of the time, no handover took place. The majority of handovers (64%) occurred over the phone; two-thirds of these were uninterrupted. All handovers were less than 10 minutes in duration. About half of the time, the senior house officer had previously met the registrar involved in the handover, but the overwhelming majority felt it would facilitate the handover process if they had prior contact. Patient details handed over 100% of the time included name, ward, and current clinical diagnosis. A third of the time, the patient’s age, responsible consultant, and recent operations or procedures were not handed over, potentially compromising future management due to delays and lack of relevant information. Perhaps the most revealing result was that the overall safety of handover was perceived to be five out of ten, with ten being very safe with no aspects felt to impact negatively on optimal patient care. Conclusion: These findings were presented to the department, and a handover proforma was implemented. Recommendations included the need for a new face-to-face handover. A reaudit will evaluate the effects of these changes. Keywords: audit, handover pro forma, cardiothoracic surgery

Backgrounds: Bevacizumab (BVZ) is used as a subsequent line of treatment for pediatric optic pathway glioma (OPG) in the case of progression. Data on the treatment effect concerning tumor progression and visual function are scarce and nationwide studies are lacking., Methods: We performed a retrospective, nationwide, multicentre cohort study including all pediatric patients with OPG treated with BVZ in the Netherlands (2009-2021). Progression-free survival, change in visual acuity and visual field, MRI-based radiologic response, and toxicity were evaluated., Results: In total, 33 pediatric patients with OPG were treated with BVZ (median 12 months). Visual acuity improved in 20.5%, remained stable in 74.4%, and decreased in 5.1% of 39 of all analysed eyes. The monocular visual field improved in 73.1%, remained stable in 15.4%, and decreased in 7.7% of 25 analysed eyes. Radiologic response at the end of therapy showed a partial response in 7 patients (21.9%), minor response in 7 (21.9%), stable disease in 15 (46.9%), and progressive disease in 3 (9.3%). Progression-free survival at 18 and 36 months after the start of BVZ reduced from 70.9% to 38.0%. Toxicity (≥grade 3 CTCAE) during treatment was observed in five patients (15.2%)., Conclusion: Treatment of BVZ in pediatric patients with OPG revealed stabilisation in the majority of patients, but was followed by progression at a later time point in more than 60% of patients. This profile seems relatively acceptable given the benefits of visual field improvement in more than 70% of analysed eyes and visual acuity improvement in more than 20% of eyes at the cessation of BVZ.

Introduction: Testicular trauma is classified aetiologically as blunt, penetrating or degloving. Blunt testicular trauma, caused by interpersonal violence, sporting injuries and RTAs account for the majority of cases, typically affecting males aged 15-40 [1]. Approximately 98.5% of blunt trauma resulted in unilateral testicular injury; about 12-15% involving cyclists or motorcyclists (Cass and Luxenberg, 1988) [2]., Presentation of Case: A 48-year-old male motorcyclist presented to the accident and emergency department with an acute scrotum following collision with an oncoming vehicle. On arrival, he was fully conscious, tachycardic and hypertensive. Examination of his genitalia revealed ecchymosis of the right hemi-scrotum and perineal bruising. The right hemi-scrotum was grossly swollen but the left testis was normal. Ultrasound revealed gross haematoma and ruptured capsule of the right testicle. Intraoperatively, emergency exploration of the right hemiscrotum revealed evidence of lower pole rupture. Clot evacuation and debridement of necrotic testicular tissue preceded closure of the tunica albuginea., Discussion: The majority of all testicular ruptures are diagnosed secondary to sport-related injuries [3] and motor vehicle or motorbike accidents. However, analysis of the literature has revealed a total of five cases of rupture, which have been linked to testicular tumours, the most recent of which was reported in 2014 (Lunawat et al., 2014) [5]. In two out of these five cases, trivial trauma preceded the diagnosis. It raises the question whether the presence of malignancy decreases the threshold of suffering a blunt testicular injury hence increasing the likelihood of testicular rupture., Conclusion: Emergency assessment and diagnosis as well as scrotal exploration are important components of the management of acute testicular rupture. Analysis of the literature proves that timely surgical intervention is crucial; early intervention results in higher rates of preservation and avoids the need for an orchidectomy., (Copyright © 2016 The Author. Published by Elsevier Ltd.. All rights reserved.)

Purpose: To compare visual outcomes in patients with cataract surgery and bilateral implantation of a trifocal or bifocal intraocular lens (IOL)., Setting: University Eye Clinic Maastricht, the Netherlands., Design: Prospective randomized clinical trial., Methods: Eyes with cataract and less than 1.0 diopter (D) of corneal astigmatism were randomized to receive bilateral implantation of Finevision Micro F trifocal IOLs or Acrysof IQ Restor +3.0 bifocal IOLs. Outcome measures were monocular and binocular uncorrected distance (UDVA), uncorrected intermediate (UIVA), and uncorrected near (UNVA) visual acuities; refractive outcomes; binocular defocus curve; contrast sensitivity; reading speed; patient satisfaction; and spectacle independence., Results: Six months postoperatively, the mean binocular UDVA, UIVA, and UNVA in 56 eyes of 28 patients were 0.01 logMAR ± 0.11 (SD), 0.32 ± 0.15 logMAR, and 0.15 ± 0.13 logMAR in the trifocal group (n = 15) and 0.00 ± 0.09 logMAR, 0.28 ± 0.08 logMAR, and 0.12 ± 0.08 logMAR in the bifocal group (n = 13), respectively. The trifocal group showed a more continuous defocus curve and better results at -1.0 D of defocus (P < .01). The mean mesopic contrast sensitivity was higher in the bifocal group (P = .02). Complete spectacle independence was reported by 80% of trifocal patients and 50% of bifocal patients. There were no significant differences in refractive outcomes, reading speed, or patient satisfaction., Conclusion: This study showed noninferiority of visual outcomes with the trifocal IOL compared with the bifocal IOL, although the defocus curve was better at an intermediate distance with the trifocal IOL., Financial Disclosure: Dr. Bauer received study grants from Alcon Laboratories, Inc., Carl Zeiss Meditec AG, and Physiol S.A. and a lecture fee from Alcon Surgical, Inc. Dr. Nuijts is a consultant to Alcon Surgical, Inc., Théa Pharma GmbH, and ASICO LLC; he has received study grants from Acufocus, Inc., Alcon Surgical, Inc., Carl Zeiss Meditec AG, Ophtec BV, and Physiol S.A. No other author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Importance: Spectacle independence is becoming increasingly important in cataract surgery. Not correcting corneal astigmatism at the time of cataract surgery will fail to achieve spectacle independency in 20% to 30% of patients., Objective: To compare bilateral aspherical toric with bilateral aspherical control intraocular lens (IOL) implantation in patients with cataract and corneal astigmatism., Design, Setting, and Participants: A multicenter, hospital-based, randomized clinical trial was conducted. The participants included 86 individuals with bilateral cataract and bilateral corneal astigmatism of at least 1.25 diopters (D) who were randomized to receive either bilateral toric (n = 41) or bilateral control (n = 45) IOL implantation., Interventions: Bilateral implantation of an aspherical toric IOL or an aspherical control IOL., Main Outcomes and Measures: Spectacle independency for distance vision, uncorrected distance visual acuity, refractive astigmatism, contrast sensitivity, wavefront aberrations, and refractive error-related quality-of-life questionnaire., Results: Preoperatively, mean (SD) corneal astigmatism was 2.02 (0.95) D and 2.00 (0.84) D in the toric and control groups, respectively. Four patients (5%) were lost to follow-up. At 6 months postoperatively, 26 (70%) of the patients in the toric group achieved an uncorrected distance visual acuity of 20/25 or better compared with 14 (31%) in the control group (P < .001; odds ratio, 5.23; 95% CI, 2.03-13.48). Spectacle independency for distance vision was achieved in 31 patients (84%) in the toric group compared with 14 patients (31%) in the control group (P < .001; odds ratio, 11.44; 95% CI, 3.89- 33.63). Mean refractive astigmatism was -0.77 (0.52) D and -1.89 D (1.00) D, respectively. Vector analysis of toric IOLs showed a mean magnitude of error of +0.38 D, indicative of overcorrection. No significant differences were found in contrast sensitivity, higher-order aberrations, or refractive error-related quality of life., Conclusions and Relevance: In patients with cataract and corneal astigmatism, bilateral toric IOL implantation results in a higher spectacle independency for distance vision compared with bilateral control IOL implantation. No significant differences were identified in contrast sensitivity, higher-order aberrations, or refractive error-related quality of life following both treatments., Trial Registration: clinicaltrials.gov Identifier: NCT01075542.

A 60-year-old male patient was referred to the vascular clinic with a 2-week history of a 1.5 cm pulsatile tender swelling in the left hypothenar eminence. He worked as a gas fitter and sustained this swelling following an injury at work. Interestingly, unlike many cases reported, his left, non-dominant hand was only used passively while his dominant right hand was using the hammer. Duplex ultrasonography confirmed the presence of a true aneurysm of the left ulnar artery, measuring 11 mm in diameter, as it approached the palmar arch. The ulnar nerve was revealed to be ectatic and tortuous and was found to cork-screw in the palm. The aneurysm was removed surgically and histological specimens revealed an intraluminal organizing thrombus. The literature reveals that, in a true aneurysm, it is rare to present with symptoms of this syndrome in the non-dominant, passive hand., (Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2014.)

Purpose: To evaluate clinical outcomes and optical performance of the AT Lisa 909M diffractive multifocal toric intraocular lens (IOL)., Setting: Multicenter study., Design: Cohort study., Methods: The measured outcomes included refractive error; distance, near (40 cm), and intermediate (60 cm and 80 cm) visual acuities; defocus curve; rotational stability; and monocular and binocular photopic and mesopic contrast sensitivity. Astigmatism was evaluated by Alpins vector analysis., Results: The multifocal toric IOL was implanted in 284 eyes of 142 patients. At 6 months, 89.4% of eyes were within ±1.00 diopter (D) of emmetropia. The mean refractive cylinder decreased from -2.39 D ± 1.48 (SD) to -0.49 ± 0.53 D; it was lower than 1.00 D in 80.9% of eyes. The mean visual acuities (logMAR) were monocular uncorrected distance 0.16 ± 0.22, monocular corrected distance 0.04 ± 0.15, binocular corrected distance -0.00 ± 0.09; monocular uncorrected near 0.21 ± 0.22, monocular corrected near 0.08 ± 0.16, binocular distance-corrected near 0.07 ± 0.14; intermediate at 60 cm (80 cm): monocular uncorrected 0.16 ± 0.21 (0.09 ± 0.21), monocular distance corrected 0.13 ± 0.19 (0.07 ± 0.20), and binocular distance corrected 0.07 ± 0.17 (0.00 ± 0.18). At 3 months and 6 months, 95.8% of IOLs showed no rotation over 5 degrees., Conclusions: This is the largest study yet on the first commercially available diffractive multifocal toric IOL. Results confirm its efficacy, predictability, and safety in restoring distance, near, and intermediate vision and allowing patients with significant levels of corneal astigmatism to achieve spectacle independence., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

We present an overview of currently available toric intraocular lenses (IOLs) and multifocal toric IOLs. Relevant patient selection criteria, IOL calculation issues, and surgical techniques for IOL implantation are discussed. Clinical outcomes including uncorrected visual acuity, residual refractive astigmatism, and spectacle independency, which have been reported for both toric IOLs and multifocal toric IOLs, are reviewed. The incidence of misalignment, the most important complication of toric IOLs, is determined. Finally, future developments in the field of toric IOLs are discussed., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To present two patients with residual astigmatism following toric intraocular lens (IOL) implantation., Methods: Case reports., Results: A 58-year-old woman underwent toric IOL implantation (spherical power 29.50 diopters [D], cylinder power 3.00 D; SN60T5, Alcon Laboratories Inc) to correct 2.33 D @ 80° of corneal astigmatism. Postoperatively, uncorrected distance visual acuity (UDVA) was 20/30 and corrected distance visual acuity (CDVA) was 20/22 (0 -1.75 × 95), indicating an overcorrection of astigmatism. Slit-lamp examination demonstrated no IOL misalignment. Wavefront aberrometry showed a large pupil diameter (>6 mm) and a lower corneal astigmatism in a 6-mm zone (-1.40 D @ 174°) compared to a 4-mm zone (-2.21 D @ 171°). The second patient, a 60-year-old man, underwent multifocal toric IOL implantation (spherical power 22.50 D, cylinder power 2.25 D; SND1T4, Alcon Laboratories Inc) to correct 1.51 D @ 173° of corneal astigmatism. Postoperatively, UDVA was 20/50 and CDVA was 20/20 (+0.25 -1.00 × 102), indicating an undercorrection of astigmatism. Slit-lamp examination showed no misalignment., Conclusions: Both cases indicate that unexplained residual astigmatism following toric IOL implantation may be the result of multiple factors: the effect of the spherical power and anterior chamber depth on toric IOL calculations, the effect of posterior corneal astigmatism, and the effect of a large pupil size. The first two issues may be compensated for by improving toric IOL calculations. The latter indicates that pupillometry is indicated in relatively young patients who undergo toric IOL implantation., (Copyright 2012, SLACK Incorporated.)

Purpose: To determine the efficacy of the astigmatism correction following toric intraocular lens (IOL) and toric phakic IOL (pIOL) implantation in eyes with no previous ocular surgery and in postkeratoplasty (PKP) eyes. In addition, changes in corneal astigmatism were determined., Methods: Astigmatism was analyzed in 35 eyes with an AcrySof toric IOL, 35 eyes with an Artiflex toric pIOL, 50 eyes with an Artisan toric pIOL, and 40 PKP eyes with an Artisan toric pIOL. Refractive astigmatism was analyzed by using Alpins method. Surgically induced corneal astigmatism (SICA) was determined following a superior 2.2-mm, 3.4-mm, or 5.4-mm incision. Follow-up was 12 months., Results: Following toric IOL implantation, the index of success was 0.14 and overall residual astigmatism, 0.37 diopter (D). Following toric pIOL implantation, the index of success was 0.32 (Artiflex) and 0.18 (Artisan), and overall residual astigmatism was approximately 0.60 D. In PKP eyes, Artisan pIOLs resulted in an index of success of 0.28 and overall residual astigmatism of 1.56 D. The SICA, following 2.2-mm, 3.4-mm, 5.4-mm (normal eyes), and 5.4-mm (PKP eyes) incisions, was -0.25 ± 0.42 D (P = 0.108), -0.31 ± 0.43 D (P < 0.001), -0.48 ± 0.55 D (P < 0.001), and -0.49 ± 1.48 D (P = 0.035), respectively., Conclusions: Toric IOLs and pIOLs provide an effective astigmatism correction. Incorporating the SICA into the toric IOL power calculation may further increase their effectiveness. Therefore, incorporation of 0 D, -0.30 D, or -0.50 D of SICA for a 2.2-, 3.4-, or 5.4-mm superior incision, respectively, is recommended.

Purpose: To evaluate visual outcomes and patient satisfaction after toric multifocal intraocular lens (IOL) implantation in patients with cataract and corneal astigmatism., Setting: University Eye Clinic Maastricht, The Netherlands., Design: Cohort study., Methods: Patients with cataract, corneal astigmatism, and a motivation for spectacle independency had cataract surgery with implantation of a toric diffractive multifocal IOL (AT Lisa). Three months postoperatively, the uncorrected distance (UDVA), intermediate (UIVA), and near (UNVA) visual acuities; corrected distance, intermediate, and near visual acuities; residual refractive astigmatism; defocus curve; contrast sensitivity; and patient satisfaction were evaluated., Results: Forty-five eyes of 25 patients were enrolled. Postoperatively, the mean UDVA was 0.04 logMAR ± 0.15 (SD) and 98% of eyes achieved a UDVA of 20/40 or better. The mean UNVA was 0.20 ± 0.16 logMAR and the mean UIVA (at 60 cm), 0.40 ± 0.16 logMAR. Residual refractive astigmatism of -1.00 diopter or less was achieved in approximately 90% of eyes. Contrast sensitivity levels were high. Approximately 50% of patients reported moderate glare, halos, and starburst symptoms. Spectacle independency for distance and near vision was achieved by 95% of patients and 79% of patients, respectively., Conclusions: Toric IOL implantation in patients with cataract and corneal astigmatism provided good distance and near visual outcomes and acceptable intermediate visual outcomes, allowing patients with considerable amounts of corneal astigmatism to achieve spectacle independence at distance and near., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine the accuracy of a commonly used 3-step procedure for toric pseudophakic and phakic intraocular lens (IOL) implantation., Setting: University Eye Clinic, Maastricht University Medical Centre, Maastricht, The Netherlands., Design: Cohort study., Method: In this analysis of toric IOL implantation, 6 preoperative images of the eye per patient and the surgery video were obtained using a digital imaging system. All 3 steps for toric IOL implantation were analyzed as follows: reference axis marking, alignment axis marking, and IOL alignment. In addition, vector analysis was used to calculate the errors in toric IOL alignment., Results: Forty eyes (26 pseudophakic, 14 phakic) were analyzed. The mean errors in reference axis marking, alignment axis marking, and toric IOL alignment were 2.4 degrees ± 0.8 (SD), 3.3 ± 2.0 degrees, and 2.6 ± 2.6 degrees, respectively. Together, these 3 errors led to a mean total error in toric IOL alignment of 4.9 ± 2.1 degrees. Subgroup analysis showed no significant difference in mean error between pseudophakic IOL and phakic toric IOL alignment (P=.501). Vector analysis showed a mean angle or error of -2 ± 8 degrees (pseudophakic IOLs) and 6 ± 14 degrees (phakic IOLs)., Conclusions: A commonly used 3-step ink-marker procedure to implant toric IOLs led to a mean error in IOL placement of approximately 5 degrees. The error was especially relevant in cases in which higher cylinder power IOLs were implanted. Orienting the toric IOL with great accuracy is necessary in all patients to achieve the best cylinder correction., (Copyright © 2011. Published by Elsevier Inc.)

Purpose: To evaluate the visual and refractive outcomes after toric intraocular lens (IOL) implantation in patients with high amounts of corneal astigmatism., Setting: University Eye Clinic, Maastricht, The Netherlands; Oftalvist Centro Integral Ocular and Fundación Oftalmológica del Mediterráneo, Valencia, Spain., Design: Cohort study., Methods: This study comprised eyes with cataract and more than 2.25 diopters (D) of corneal astigmatism who had toric Acrysof SN60T6, SN60T7, SN60T8, or SN60T9 IOL implantation. The uncorrected (UDVA) and corrected (CDVA) distance visual acuities, visual potential index (ratio of postoperative UDVA to postoperative CDVA), residual refractive cylinder, IOL misalignment, and surgically induced astigmatism (SIA) were evaluated., Results: The mean follow-up in this study of 67 eyes (45 patients) was 6.3 months. Postoperatively, the mean UDVA was 0.61 ± 0.26 (SD) and the mean CDVA, 0.81 ± 0.21. The UDVA of 20/40 was better in 83% of eyes and 20/30 or better in 50% of eyes. The mean visual potential index was 0.78. The residual refractive cylinder was less than 0.75 D in 62% of eyes and less than 1.00 D in 81% of eyes. The mean IOL misalignment was 3.2 ± 2.8 degrees. The mean SIA was -0.40 ± 0.60 D with a superior incision and -0.19 ± 0.78 D with a temporal incision (P=.034)., Conclusion: Implantation of the toric IOL during cataract surgery was effective and safe in correcting high amounts of corneal astigmatism., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: We report 2 cases in which cataract extraction with a foldable acrylic toric intraocular lens (IOL) implantation was used to correct (irregular) corneal astigmatism in patients with keratoconus and cataract., Methods: Case 1 was a 78-year-old man with cataract and keratoconus in the left eye. He underwent phacoemulsification with a toric IOL [Acrysof SN60T9; cylinder power: 6.0 diopters (D)] implantation. Case 2 was a 64-year-old woman with bilateral cataract and keratoconus. She underwent phacoemulsification with toric IOL implantation in the right (Acrysof SN60T9; cylinder power: 6.0 D) and left eyes (Acrysof SN60T5; cylinder power: 3.0 D). Postoperative follow-up in both cases was 6 months., Results: In case 1, the uncorrected visual acuity increased from 20/400 to 20/50. The refractive cylinder decreased from -6.0 to -1.5 D, which is a reduction of 75%. In case 2, the uncorrected visual acuity increased from 20/400 to 20/130 in the right eye and from 20/400 to 20/30 in the left eye. Refractive astigmatism decreased by 70% in both eyes. No IOL misalignment or other complications occurred., Conclusions: Cataract extraction with toric IOL implantation can be used to correct (irregular) astigmatism and to improve visual functioning in patients with mild to moderate amounts of stable keratoconus and cataract.

Purpose: To analyze the symptoms, etiology, and treatment of patient dissatisfaction after multifocal intraocular lens (IOL) implantation., Setting: Department of Ophthalmology, Maastricht University Medical Center, The Netherlands., Design: Case series., Methods: In this retrospective chart review, the main outcome measures were type of complaints, uncorrected and corrected distance visual acuities, uncorrected and distance-corrected near visual acuities, refractive state, pupil diameter and wavefront aberrometry measurements, and type of treatment., Results: Seventy-six eyes of 49 patients were included. Blurred vision (with or without photic phenomenon) was reported in 72 eyes (94.7%) and photic phenomena (with or without blurred vision) in 29 eyes (38.2%). Both symptoms were present in 25 eyes (32.9%). Residual ametropia and astigmatism, posterior capsule opacification, and a large pupil were the 3 most significant etiologies. Sixty-four eyes (84.2%) were amenable to therapy, with refractive surgery, spectacles, and laser capsulotomy the most frequent treatment modalities. Intraocular lens exchange was performed in 3 cases (4.0%)., Conclusion: The cause of dissatisfaction after implantation of a multifocal IOL can be identified and effective treatment measures taken in most cases., (Copyright © 2011 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Hyperostosis cranialis interna is a hereditary bone disorder that is characterized by endosteal hyperostosis and osteosclerosis of the calvaria and the skull base (OMIM 144755). The progressive bone overgrowth causes entrapment and dysfunction of cranial nerves I, II, V, VII, and VIII, its first symptoms often presenting during the second decade. This study analyzes the clinical course of 13 affected individuals of three related families (32 individuals). The disorder appears to have an autosomal-dominant transmission pattern. Facial and vestibulocochlear nerve dysfunction are most frequently reported. Surgical decompression of the accessible impaired cranial nerves is advised in the early symptomatic period or even in the presymptomatic period in high-risk individuals., ((c) 2010 Wiley-Liss, Inc.)

Purpose: To present clinical data from a single-center prospective clinical trial of the AcrySof toric intraocular lens (IOL)., Setting: Academic Hospital Maastricht, Maastricht, The Netherlands., Methods: Fifty-three eyes (43 patients) had implantation of an AcrySof toric IOL. Three toric models were evaluated in cylinder powers of 1.50 diopters (D) (SN60T3; T3 group, n = 16), 2.25 D (SN60T4; T4 group, n = 14), and 3.00 D (SN60T5; T5 group, n = 23) at the IOL plane. The T5 group was subdivided into eyes that could be fully corrected (T5a, n = 13) and eyes that could be partially corrected (T5b, n = 10)., Results: Four months postoperatively, the mean uncorrected visual acuity (UCVA) was 0.77 +/- 0.23 in the T3 group, 0.93 +/- 0.23 in the T4 group, 0.82 +/- 0.15 in the T5a group, and 0.47 +/- 0.13 in the T5b group. More than 90% of the combined eyes in the T3, T4, and T5a groups achieved a UCVA of 20/40 or better, and almost 80% achieved a UCVA of 20/25 or better. Residual refractive astigmatism of less than 0.75 D was achieved in 74% of eyes and of less than 1.00 D in 91%. The mean IOL misalignment was 2.5 +/- 2.1 degrees in the T3 group, 3.5 +/- 2.3 degrees in the T4 group, and 4.1 +/- 3.5 degrees in the T5 group., Conclusion: Implantation of the AcrySof toric IOL proved to be an effective, safe, and predictable method of managing corneal astigmatism in cataract patients.

Objective: We describe a patient who developed a vertical gaze paralysis after deep brain stimulation performed for intractable Tourette syndrome due to a small deep bleeding in the upper mesencephalon., Clinical Presentation: A 39-year-old man underwent thalamic deep brain stimulation for intractable Tourette syndrome. Immediately postoperatively, he had diplopia and dizziness. The neurological examination revealed vertical gaze palsy with preserved vertical oculocephalic movements. A postoperative computed tomography scan revealed a discrete high-density lesion across the midline at the distal end of the left electrode. This area corresponds with the pretectal area, including the rostral interstitial nucleus of the medial longitudinal fasciculus, with sparing of the oculomotor and rubral nuclei., Intervention: Six months postoperatively, maximal upward and downward smooth pursuit eye movements were achieved. Upward saccadic velocities were still reduced by 20 to 25 degrees., Conclusion: This case report describes a complication that might demand special attention during the planning of thalamic deep brain stimulation for the treatment of Tourette syndrome. Examination of both horizontal and vertical eye movements during deep brain stimulation surgery is recommended.

Purpose: The aim of this research was to determine the molecular factors of influence on the clinical expression of Leber hereditary optic neuropathy (LHON), which might aid in counseling LHON patients and families. The prevalence of LHON in the Dutch population was determined., Design: Observational, retrospective population cohort study., Methods: The clinical characteristics of LHON patients of 25 families, previously described in 1963, were reevaluated. The mutation and haplotype were determined in the DNA of one affected LHON patient per family. The genotype of their relatives could be deducted, enabling us to evaluate retrospectively the genotype-phenotype correlation. The prevalence of LHON was determined on the basis of anamnestic evaluation of patients in 1963 and by using population registers of that period., Results: The LHON mutation does not influence disease penetrance (50% in male subjects; 10% to 20% in female subjects). More than half of the patients with the 14484 mutation exhibit a partial recovery of vision, regardless of the acuteness of disease onset (P = .001), whereas only 22% of the 11778 carriers and 15.4% of the 3460 carriers recovered. The recovery did not take place within the first year after onset and was uncommon after four years. The onset of LHON is in general very acute but might be more gradual in 11778 carriers and in children. The calculated prevalence of LHON in the Dutch population (1/39,000) is very likely an underestimation caused by a selection bias of familial cases in the original study., Conclusions: The LHON genotype influences the recovery of vision and disease onset but is unrelated to age, acuteness of onset, or gender. The genotype does not influence disease penetrance. Children might exhibit a slower onset of disease.

We demonstrated the feasibility of Raman spectroscopy for remote temperature monitoring within the aqueous humor of the rabbit eye in vivo. Using a confocal Raman spectroscopy system, Raman spectra from 2580 to 3800 cm(-1) were recorded in HPLC-grade water and in the aqueous humor of the rabbit eye under in vivo and ex vivo conditions within a temperature range of 14-34 degrees C. The ratio between the integrated Raman intensities of two temperature dependent OH-vibrational regions (OH2/OH1) in the spectra of water showed high linear dependence on temperature both in pure water [0.0049(+/-1.2%)T+0.4522(+/-0.5%), R2=0.99, n=50, p<0.05], as well as in the rabbit aqueous humor [0.0036(+/-2.8%)T+0.4966(+/-0.6%), R2=0.98, n=162, p<0.05] with a high degree of reproducibility and sensitivity ( approximately 0.2-0.7 degrees C). Raman spectroscopy can be used for high resolution and remote monitoring of temperature in the aqueous humor under in vivo conditions., (2005 Society of Photo-Optical Instrumentation Engineers.)

Purpose: To investigate the feasibility of a confocal Raman spectroscopic technique for the noncontact assessment of corneal hydration in vivo in two legally blind subjects., Methods: A laser beam (632.8 nm; 15 mJ) was maintained on the cornea using a microscope objective lens (25x magnification, NA=0.5, f=10 mm) both for focusing the incident light as well as collecting the Raman backscattered light, in a 180 degrees backscatter configuration. An optical fiber, acting as the confocal pinhole for elimination of light from out-of-focus places, was coupled to a spectrometer that dispersed the collected light onto a sensitive array-detector for rapid spectral data acquisition over a range from 2,890 to 3,590 cm(-1). Raman spectra were recorded from the anterior 100 to 150 microm of the cornea over a period of time before and after topical application of a mild dehydrating solution. The ratio between the amplitudes of the signals at 3,400 cm(-1) (OH-vibrational mode of water) and 2,940 cm(-1) (CH-vibrational mode of proteins) was used as a measure of corneal hydration., Results: High signal-to-noise ratio (SNR 25) Raman spectra were obtained from the human corneas using 15 mJ of laser light energy. Qualitative changes in the hydration of the anterior-most part of the corneas could be observed as a result of the dehydrating agent., Conclusion: Confocal Raman spectroscopy could potentially be applied clinically as a noncontact tool for the assessment of corneal hydration in vivo.

Purpose: To investigate the feasibility of a confocal Raman spectroscopic technique for the noninvasive assessment of corneal hydration in vivo in two legally blind subjects., Methods: A laser beam (632.8 nm; 15 mJ) was maintained on the cornea by using a microscope objective lens (x25 magnification, NA = 0.5, f = 10 mm) both for focusing the incident light as well as collecting the Raman backscattered light, in a 180 degrees backscatter configuration. An optical fiber, acting as the confocal pinhole for elimination of light from out-of-focus places, was coupled to a spectrometer that dispersed the collected light onto a sensitive array detector for rapid spectral data acquisition over a range from 2,890 to 3,590/cm(-1). Raman spectra were recorded from the anterior 100-150 microm of the cornea over a period before and after topical application of a mild dehydrating solution. The ratio between the amplitudes of the signals at 3,400/cm(-1) (OH-vibrational mode of water) and 2,940/cm(-1) (CH-vibrational mode of proteins) was used as a measure for corneal hydration., Results: High signal-to-noise ratio (SNR = 25) Raman spectra were obtained from the human corneas by using 15 mJ of laser light energy. Qualitative changes in the hydration of the anteriormost part of the corneas could be observed as a result of the dehydrating agent., Conclusion: With adequate improvements in system safety, confocal Raman spectroscopy could potentially be applied clinically as a noninvasive tool for the assessment of corneal hydration in vivo.

A Laser Scanning Confocal Raman Spectroscopy (LSCRS) system was applied for the non-invasive quantification of the transport of a drug through the rabbit cornea in vivo. Employing LSCRS, the changes in the amplitude of a drug-specific Raman signal were assessed over time in the tearfilm and corneal epithelium of the living rabbit eye (n = 6), after topical application of 25 microL Trusopt 2%. This allowed for quantification of pharmacokinetic variables. The effect of the drug on corneal hydration was also monitored. LSCRS demonstrated adequate sensitivity and reproducibility, for continuous real-time monitoring of the Trusopt concentration. Each concentration-time curve had a bi-phasic trend; the rapid initial phase (t<8 min.) corresponds to the nonproductive losses of Trusopt from the tears (k10 = 0.24+/-0.04 min(-1), and the slower later phase (t>20 min.) is the result of transfer of the drug from the corneal epithelium to the stroma (k23 = 0.0047+/-0.0004 min(-1). Drug absorption into the corneal epithelium occurred at a rate of k12 = 0.034+/-0.006 min(-1). Trusopt caused an acute dehydrating effect, with a maximum decrease in corneal hydration of approximately 15% at approximately 60 min. following application of the drug. LSCRS has the specificity, sensitivity, reproducibility and spatial resolution for employment as a potentially valuable tool for the study of ocular pharmacokinetics.

Purpose: The feasibility of Raman spectroscopy for the noninvasive assessment of axial corneal hydration was investigated., Methods: A scanning confocal Raman spectroscopy system, with an axial resolution of 50 microns, was used to assess noninvasively the water (OH-bond) to protein (CH-bond) ratio as a measure of the hydration in collagen-based phantom media and rabbit corneas., Results: Raman spectra with high signal-to-noise ratios were obtained under in vitro and in vivo conditions within a range of corneal hydration (H = 0.0-8.3 mg water/mg dry wt). The Raman intensity ratio OH/CH showed a strong correlation with the hydration of the phantom medium (R2 > 0.99) and the rabbit corneas (R2 > 0.95). A degree of reproducibility was seen in measurements performed at a specific depth within the cornea (SD = 1.2%-2.7%). Quantitatively, the spatially resolved corneal water content, as assessed with our method, showed an increasing gradient from the anterior to the posterior region, with a difference of approximately 0.9. Significant qualitative differences in the axial hydration gradient were observed between the in vitro and in vivo situation, caused by the presence of an intact tear-film in vivo. Characterization of the axial corneal hydration using Raman spectroscopy provided a reliable estimation of total corneal hydration compared with conventional measurements using pachymetry and lyophilization., Conclusions: The proposed noninvasive confocal Raman spectroscopic technique has the potential to assess the axial corneal water gradient with a degree of sensitivity and reproducibility.

S-Adenosyl-L-methionine:macrocin O-methyltransferase catalyzes conversion of macrocin to tylosin, the terminal and main rate-limiting step of tylosin biosynthesis in Streptomyces fradiae. The O-methyltransferase was stabilized in vitro and purified to electrophoretic homogeneity. The purified enzyme had a molecular weight of 65,000 and consisted of two identical subunits of 32,000 with an isoelectric point of 4.5. The enzyme required Mg2+, Mn2+, or Co2+ for maximal activity and was catalytically optimal at pH 7.5-8.0 and 31 degrees C. The O-methyltransferase catalyzed the conversion of macrocin to tylosin at a stoichiometric ratio of 1:1. The enzyme also mediated conversion of lactenocin----desmycosin. The corresponding Vmax/Km ratios for the two analogous conversions were similar, and both enzymic conversions were susceptible to extensive competitive and noncompetitive inhibitions by macrolide metabolites. Steady-state kinetic studies for initial velocity, substrate analogue, and product inhibitions have allowed formulation of Ordered Bi Bi as the reaction mechanism for macrocin O-methyltransferase.

A high-performance liquid chromatographic (HPLC) procedure was developed to assay S-adenosyl-L-methionine: macrocin O-methyltransferase. This enzyme catalyzes the rate-limiting terminal reaction of tylosin biosynthesis in Streptomyces fradiae. HPLC analysis was improved by resin treatment of cell-free extracts to remove endogenous tylosin and related compounds. Relomycin was selected as an internal standard and the enzymatic reaction conditions were optimized. The reaction mixture was extracted with ethyl acetate to recover the substrate, product and the internal standard. Efficient separation of the macrolide antibiotics was provided by ion-pair reversed-phase HPLC. An average relomycin recovery was 90%. The O-methyltransferase activity could be routinely and reproducibly determined by monitoring tylosin formation at 285 nm.