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Teflon-tipped forceps
CORRESPONDENCE
Conductive keratoplasty for asymmetric corneal astigmatism Navid Ardjomand, MD, Christina Wohlfart, MD, James C. McAlister, FRCOphth, Yosuf El-Shabrawi, MD, Bertram Vidic, MD Various surgical options such as arcuate keratotomies, wedge resection, photorefractive keratectomy, laser in situ keratomileusis, and laser-assisted subepithelial keratectomy have been shown to be successful in treating regular and irregular corneal astigmatism.1 CASE REPORT A 65-year-old white man presented with visual disturbance in the right eye. He had had uneventful phacoemulsification with intraocular lens (IOL) implantation, but because of a postoperative refractive surprise of 1.0 diopter (D), an IOL exchange was done 2 weeks postoperatively. The clinical examination revealed a clear corneal 5.0 mm incision 2.5 mm from the limbus. Three months after IOL exchange, the corneal astigmatism was 4.8 120 (anterior flow, Orbscan, Bausch & Lomb) (Figure 1). The visual acuity was 0.8 with a spectacle refraction of C2.25 4.75 120. Conductive keratoplasty (CK) was performed with 4 spots applied at the flatter site.2 The postoperative treatment included dexamethasone 4 times a day and tobramycin 0.3% 4 times a day. Four weeks after the procedure, the cornea was regular, the topographic corneal astigmatism was 0.4 90, and the uncorrected visual acuity (UCVA) increased to 1.0. At 12 months, the clinical examination showed mild corneal scarring in the CK area (Figure 2), topographic astigmatism was 0.8 90 (Figure 1, C), and UCVA was 0.9, improving to 1.0 with a spectacle refraction of 0.5 90.
DISCUSSION Clinical trials have shown CK to be a safe and predictable procedure to treat hyperopia.2 Hersh et al.3 recently presented 2 cases with high astigmatism that was successfully treated with CK. In contrast to these 2 cases, our patient had asymmetric astigmatism and therefore had asymmetric treatment. However, regression has been seen in a high number of patients.2,3 Conductive keratoplasty seems to be a safe procedure for the treatment of asymmetric astigmatism after corneal surgery, but since there is no nomogram available for this corneal pathology, spots should be applied carefully and controlled by corneal topography intraoperatively or immediately postoperatively. REFERENCES 1. Jain S, Azar DT, Pineda R. Management of astigmatism after corneal trauma. Int Ophthalmol Clin 2002; 42(3):47–55 2. Claramonte PJ, Alio´ JL, Ramzy MI. Conductive keratoplasty to correct residual hyperopia after cataract surgery. J Cataract Refract Surg 2006; 32:1445–1451 3. Hersh PS, Fry KL, Chandrashekhar R, Fikaris DS. Conductive keratoplasty to treat complications of LASIK and photorefractive keratectomy. Ophthalmology 2005; 112:1941– 1947
Teflon-tipped forceps Laura K. Green, MD, Candice Giordano, MD, Walter J. Stark, MD We describe a modification of the angled McPherson forceps used for intraocular lens (IOL) manipulation for the purpose of reducing aberrations on the IOL surface. Since the advent of foldable acrylic IOLs, there have been numerous reports of forceps-induced IOL scratching.1,2 Suggestions for remedying this problem include using injector-folded IOLs and rounded, soft,
Figure 1. A: Corneal topography shows a corneal astigmatism of 4.8 120. The cornea is flat in the superotemporal quadrant. B: Immediately after CK, the corneal topography shows a mild overcorrection at the superotemporal quadrant. C: At 12 months, the corneal topography is regular. All topographies show the anterior flow of the cornea.
874
Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2007.12.044
CORRESPONDENCE
875
Figure 1. Green-colored Teflon-tips added to angled McPherson forceps.
Figure 2. Three months posttreatment, the cornea shows scarring in the area of CK application.
and smooth grasp-surface forceps,2 as well as meticulously cleaning the folding instruments.3 However, even with these methods, a 2003 survey of members of the American Society of Cataract and Refractive Surgeons4 found that glare and optical aberrations were one of the most common reasons for IOL removal or exchange. In a study by Milazzo et al.,5 3 of 4 implanted IOLs had small marks corresponding to the area compressed by the forceps and 32 of 50 IOLs folded under a surgical microscope had some degree of alteration. In our clinical experience, scratching of acrylic IOLs most commonly occurs during the routine handling and manipulation with the forceps required to fold the lens or insert it into a cartridge. We believe these scratches create a linear glare that is experienced by the patient as being perpendicular to the axis of the scratch in a Maddox rod–like effect. These surface alterations have been shown to be a preferential site for bacterial and possibly inflammatory cell adhesion, which may facilitate posterior capsule opacification.6 To prevent these small but often clinically significant forceps-induced aberrations, we modified the commonly used angled McPherson forceps by adding a Teflon coating to the tips (manufacturer Millennium Surgical Corp.) (Figure 1). Using the Teflon-tipped forceps for manipulating and inserting the IOLs has
reduced the incidence of observable scratches seen intraoperatively and at the slitlamp postoperatively. We have reduced the incidence of IOL scratches from approximately 5% to zero. Consequently, we have had no patient complaints of linear glare corresponding to these marks. The Teflon-tipped forceps can be processed and sterilized in the usual fashion without special handling. The coating usually lasts for at least 1 year and can be reapplied. We found this to be a reasonable and inexpensive modification that improved patient satisfaction.
REFERENCES 1. Vrabec MP, Syverud JC, Burgess CJ. Forceps-induced scratching of a foldable acrylic intraocular lens [letter]. Arch Ophthalmol 1996; 114:777 2. Faschinger C, Haller EM, Reich M. Oberflachenbeschadigung der MemoryLens bei der Implantation. [Superficial damage to the MemoryLens in implantation]. Klin Monatsbl Augenheilkd 1996; 209:37–39 3. Kohnen T, Magdowski G, Koch DD. Scanning electron microscopic analysis of foldable acrylic and hydrogel intraocular lenses. J Cataract Refract Surg 1996; 22:1342–1350 4. Mamalis N, Davis B, Nilson CD, et al. Complications of foldable intraocular lenses requiring explantation or secondary interventiond2003 survey update. J Cataract Refract Surg 2004; 30:2209–2218 5. Milazzo S, Turut P, Blin H. Alterations to the AcrySof intraocular lens during folding. J Cataract Refract Surg 1996; 22:1351–1354 6. Mencucci R, Dei R, Danielli D, et al. Folding procedure for acrylic intraocular lenses; effect on optic surface and bacterial adhesion. J Cataract Refract Surg 2004; 30:457–463
J CATARACT REFRACT SURG - VOL 34, MAY 2008
Conductive keratoplasty for asymmetric corneal astigmatism Navid Ardjomand, MD, Christina Wohlfart, MD, James C. McAlister, FRCOphth, Yosuf El-Shabrawi, MD, Bertram Vidic, MD Various surgical options such as arcuate keratotomies, wedge resection, photorefractive keratectomy, laser in situ keratomileusis, and laser-assisted subepithelial keratectomy have been shown to be successful in treating regular and irregular corneal astigmatism.1 CASE REPORT A 65-year-old white man presented with visual disturbance in the right eye. He had had uneventful phacoemulsification with intraocular lens (IOL) implantation, but because of a postoperative refractive surprise of 1.0 diopter (D), an IOL exchange was done 2 weeks postoperatively. The clinical examination revealed a clear corneal 5.0 mm incision 2.5 mm from the limbus. Three months after IOL exchange, the corneal astigmatism was 4.8 120 (anterior flow, Orbscan, Bausch & Lomb) (Figure 1). The visual acuity was 0.8 with a spectacle refraction of C2.25 4.75 120. Conductive keratoplasty (CK) was performed with 4 spots applied at the flatter site.2 The postoperative treatment included dexamethasone 4 times a day and tobramycin 0.3% 4 times a day. Four weeks after the procedure, the cornea was regular, the topographic corneal astigmatism was 0.4 90, and the uncorrected visual acuity (UCVA) increased to 1.0. At 12 months, the clinical examination showed mild corneal scarring in the CK area (Figure 2), topographic astigmatism was 0.8 90 (Figure 1, C), and UCVA was 0.9, improving to 1.0 with a spectacle refraction of 0.5 90.
DISCUSSION Clinical trials have shown CK to be a safe and predictable procedure to treat hyperopia.2 Hersh et al.3 recently presented 2 cases with high astigmatism that was successfully treated with CK. In contrast to these 2 cases, our patient had asymmetric astigmatism and therefore had asymmetric treatment. However, regression has been seen in a high number of patients.2,3 Conductive keratoplasty seems to be a safe procedure for the treatment of asymmetric astigmatism after corneal surgery, but since there is no nomogram available for this corneal pathology, spots should be applied carefully and controlled by corneal topography intraoperatively or immediately postoperatively. REFERENCES 1. Jain S, Azar DT, Pineda R. Management of astigmatism after corneal trauma. Int Ophthalmol Clin 2002; 42(3):47–55 2. Claramonte PJ, Alio´ JL, Ramzy MI. Conductive keratoplasty to correct residual hyperopia after cataract surgery. J Cataract Refract Surg 2006; 32:1445–1451 3. Hersh PS, Fry KL, Chandrashekhar R, Fikaris DS. Conductive keratoplasty to treat complications of LASIK and photorefractive keratectomy. Ophthalmology 2005; 112:1941– 1947
Teflon-tipped forceps Laura K. Green, MD, Candice Giordano, MD, Walter J. Stark, MD We describe a modification of the angled McPherson forceps used for intraocular lens (IOL) manipulation for the purpose of reducing aberrations on the IOL surface. Since the advent of foldable acrylic IOLs, there have been numerous reports of forceps-induced IOL scratching.1,2 Suggestions for remedying this problem include using injector-folded IOLs and rounded, soft,
Figure 1. A: Corneal topography shows a corneal astigmatism of 4.8 120. The cornea is flat in the superotemporal quadrant. B: Immediately after CK, the corneal topography shows a mild overcorrection at the superotemporal quadrant. C: At 12 months, the corneal topography is regular. All topographies show the anterior flow of the cornea.
874
Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2007.12.044
CORRESPONDENCE
875
Figure 1. Green-colored Teflon-tips added to angled McPherson forceps.
Figure 2. Three months posttreatment, the cornea shows scarring in the area of CK application.
and smooth grasp-surface forceps,2 as well as meticulously cleaning the folding instruments.3 However, even with these methods, a 2003 survey of members of the American Society of Cataract and Refractive Surgeons4 found that glare and optical aberrations were one of the most common reasons for IOL removal or exchange. In a study by Milazzo et al.,5 3 of 4 implanted IOLs had small marks corresponding to the area compressed by the forceps and 32 of 50 IOLs folded under a surgical microscope had some degree of alteration. In our clinical experience, scratching of acrylic IOLs most commonly occurs during the routine handling and manipulation with the forceps required to fold the lens or insert it into a cartridge. We believe these scratches create a linear glare that is experienced by the patient as being perpendicular to the axis of the scratch in a Maddox rod–like effect. These surface alterations have been shown to be a preferential site for bacterial and possibly inflammatory cell adhesion, which may facilitate posterior capsule opacification.6 To prevent these small but often clinically significant forceps-induced aberrations, we modified the commonly used angled McPherson forceps by adding a Teflon coating to the tips (manufacturer Millennium Surgical Corp.) (Figure 1). Using the Teflon-tipped forceps for manipulating and inserting the IOLs has
reduced the incidence of observable scratches seen intraoperatively and at the slitlamp postoperatively. We have reduced the incidence of IOL scratches from approximately 5% to zero. Consequently, we have had no patient complaints of linear glare corresponding to these marks. The Teflon-tipped forceps can be processed and sterilized in the usual fashion without special handling. The coating usually lasts for at least 1 year and can be reapplied. We found this to be a reasonable and inexpensive modification that improved patient satisfaction.
REFERENCES 1. Vrabec MP, Syverud JC, Burgess CJ. Forceps-induced scratching of a foldable acrylic intraocular lens [letter]. Arch Ophthalmol 1996; 114:777 2. Faschinger C, Haller EM, Reich M. Oberflachenbeschadigung der MemoryLens bei der Implantation. [Superficial damage to the MemoryLens in implantation]. Klin Monatsbl Augenheilkd 1996; 209:37–39 3. Kohnen T, Magdowski G, Koch DD. Scanning electron microscopic analysis of foldable acrylic and hydrogel intraocular lenses. J Cataract Refract Surg 1996; 22:1342–1350 4. Mamalis N, Davis B, Nilson CD, et al. Complications of foldable intraocular lenses requiring explantation or secondary interventiond2003 survey update. J Cataract Refract Surg 2004; 30:2209–2218 5. Milazzo S, Turut P, Blin H. Alterations to the AcrySof intraocular lens during folding. J Cataract Refract Surg 1996; 22:1351–1354 6. Mencucci R, Dei R, Danielli D, et al. Folding procedure for acrylic intraocular lenses; effect on optic surface and bacterial adhesion. J Cataract Refract Surg 2004; 30:457–463
J CATARACT REFRACT SURG - VOL 34, MAY 2008