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Cover Focus | Nov/Dec '17

The Peer-Review Archives

September 1975 | Journal of Cataract & Refractive Surgery

The Cataract Surgeon and Intraocular Lenses: A Basic Approach

Francis C. Hertzog Jr, MD

In September 1975, Dr. Hertzog shared “important information” he learned in 200 IOL implantations. He stated that the basic Binkhorst formula was valid in successful implantation and absolutely required: (1) an adequately skilled surgeon, (2) an appropriate patient candidate, and (3) a lens of adequate design and construction, such as Morcher’s four-loop Binkhorst iris clip lens, Morcher’s two-loop Binkhorst iridocapsular lens, Medical Workshop’s Medallion lens, or Medical Workshop’s one-loop transiridectomy lens.

Dr. Hertzog wrote that, for elderly individuals (aged 65 to 80 years) with transportation or other follow-up visit problems, intracapsular extraction and use of a regular Medallion lens sutured to the iris with a 9–0 nylon suture worked very well, with minimal reaction and uninterrupted ambulation and minimization of postoperative visits. The one-loop Medallion transiridectomy lens worked in much the same manner and was technically easier to use, Dr. Hertzog concluded. He also reported that a sutured four-loop Binkhorst lens worked well in these cases.

For individuals aged less than 65 to 70 years with a good transportation and follow-up visit situation, Dr. Hertzog’s preference was simplified extracapsular extraction using the Kelman type anterior capsulotomy in a 3-mm incision: enlargement of the incision, removal of nucleus by easiest method available, and irrigation of the cortex, per Binkhorst. In Dr. Hertzog’s opinion, the two-loop Binkhorst lens with optional capsular fixation “is the ultimate” in modern cataract operations when a good result is obtained. “We have found that very few posterior capsulotomies are needed—contrary to our expectations,” he noted.

1. Hertzog Jr FC. The cataract surgeon and intraocular lenses: a basic approach. J Cataract Refract Surg. 1975;1(2):41.

September 1975 | Journal of Cataract & Refractive Surgery

Intracapsular or Extracapsular?

Robert M. Thomas Jr, MD

In September 1975, Dr. Thomas weighed intracapsular versus extracapsular cataract extraction. He noted that the combination of a perfect intracapsular extraction with uncomplicated insertion of an IOL would seem to offer the best possible visual rehabilitation to the cataract patient, as the clearing of the optical media was often so rapid that useful vision resulted immediately. “But all too often, the perfect intracapsular result notes a sudden drop in vision, and we are faced with another case of cystoid macular edema, or the dislocation of an iris-fixated lens,” he wrote. “This, coupled with the fact that lens implantation in the face of vitreous loss often results in further problems, has led many to learn the technique of extracapsular extraction and implantation of an iridocapsular lens.”

Dr. Thomas argued that “careful analysis of the vast number of implant statistics” should make surgeons realize Binkhorst was correct in switching to capsular fixation as the operation of choice in the majority of cases. Despite the fact that most cataract surgeons at that time were never taught extracapsular extraction, Dr. Thomas concluded, “Binkhorst has taught us that extracapsular is the method of choice for lens implants, and Kelman has taught us how to do a near-perfect extracapsular extraction. At this stage of IOL technology, the combination of phacoemulsification and capsular lens fixation seems to offer the most physiologic approach to cataract surgery.”

1. Thomas Jr RM. Intracapsular or extracapsular? J Cataract Refract Surg. 1975;1(2):45.

January 1977 | Journal of Cataract & Refractive Surgery

Results and Complications of Our First 500 Implantations

N.L. Snider, MD, and Wm. U. McReynolds, MD

In January 1977, Drs. Snider and McReynolds shared observations from their initial experience with 500 consecutive IOL implantations, with 6-month postoperative analysis. Of their patients, 68% were 70 years of age or older and 90% were 60 years of age or older. Eighty-three percent of all patients treated regardless of preexisting retinal or corneal disease had 20/40 or better vision; 89% had 20/50 or better. Excluding 32 cases of preoperative retinal or corneal disease, 88% of patients achieved 20/40 or better, and 96% achieved 20/50 or better. “A number of the patients in the 20/50 to 20/60 bracket originally had better visual acuity but suffered loss due to cystoid macular edema,” the authors wrote.

Drs. Snider and McReynolds noted that, in nearly 1,000 cases to date, no eyes had been lost. “There has not been an enucleation nor an indication for an enucleation. Likewise there has not been an IOL removed nor indication for such,” they concluded. Of their series, five retinal detachments (1% of total cases) occurred. Three cases had phacoemulsification with capsulectomy, one had phacoemulsification without capsulectomy, and one was treated with intracapsular cataract extraction.

1. Snider NL, McReynolds WU. Results and complications of our first 500 implantations. J Cataract Refract Surg. 1977;3(1):10-13.

1979 | Ophthalmology

Phacoemulsification in the Anterior Chamber

Charles D. Kelman, MD

In 1979, Dr. Kelman wrote about why he believed emulsification of the lens in the anterior chamber was “the method of choice.” He noted that the lens could be emulsified, liquefied, or fragmented either in its capsule from an anterior route (through the limbus) or through a posterior route (pars plana). The latter approach, however, added “numerous complications, such as mixing of lens material with vitreous” to the procedure, he noted.

Dr. Kelman maintained that, with the nucleus in the anterior chamber, it was possible for the surgeon to emulsify the lens with no concern about the pupil constricting “as it often does during emulsification.” Emulsification behind the iris could be dangerous, he warned. If the pupil constricted during emulsification, visualization of the lens and the tip would be greatly reduced.

He noted that the possible disadvantage to emulsification in the anterior chamber “lies with the corneal endothelium.” He stated it was imperative that the surgeon avoid rubbing the emulsifier or the lens against the endothelium. “By refraining from sudden and rapid motions of the emulsifier within the eye, the surgeon need not compromise the corneal endothelium,” he wrote.

1. Kelman CD. Phacoemulsification in the anterior chamber. Ophthalmology. 1979;86(11):1980-1982.

September 1980 | Ophthalmology

Management of Anterior Segment Complications of Intraocular Lenses

Frank M. Polack, MD

In the September 1980 issue of Ophthalmology, Dr. Polack reported on the management of anterior segment complications of IOLs. He noted that corneal edema was found in 24 of 43 eyes with anterior segment complications of IOLs. Keratoplasty was performed in 20 eyes. Three eyes required other surgical therapy for edema, and medical treatment of edema was performed in one case. “Thirty-two lenses were removed because of pain, inflammation, bleeding, or glaucoma,” Dr. Polack wrote. Nineteen of those were removed at the time of keratoplasty. Further, “three eyes were enucleated because of absolute glaucoma, retinal detachment, and endophthalmitis.”

1. Polack FM. Management of anterior segment complications of intraocular lenses. Ophthalmology. 1980;87(9):881-886.

January/February 1997 | Journal of Cataract & Refractive Surgery

Laser In Situ Keratomileusis to Treat Myopia: Early Experience

Ioannis G. Pallikaris, MD, and Dimitrios S. Siganos, MD

In 1997, Drs. Pallikaris and Siganos presented their early experience with and results of LASIK for the treatment of moderate and high myopia. Their study included 43 moderately to highly myopic eyes that underwent LASIK. Follow-up was between 12 and 24 months.

According to the authors, the Draeger’s rotor microkeratome was used to create a 8.5 x 9.5 mm corneal flap with a thickness of 150 μm, and the stromal bed was ablated for the myopic correction using the Munnerlynn photorefractive keratectomy algorithm. Preoperative spherical equivalent ranged from -8.50 D to -25.87 D. Attempted correction ranged from 8.00 D to 16.00 D. Four eyes developed complications (ie, anterior chamber perforation and keratoconus, intrastromal epithelial cells, macular lacquer cracks, and transient epithelial decompensation) and were excluded from the study. The remaining 39 eyes were retrospectively divided into two groups according to the preoperative spherical equivalent (higher or lower than -14.00 D).

Drs. Pallikaris and Siganos observed that refractive and corneal topography stabilized between 4 and 12 weeks postoperatively. Best spectacle-corrected visual acuity was within 1 Snellen line in all eyes. At 24 months, 19 eyes (79.2%) were within 2.00 D of intended correction. Attempted correction was “very close to mean achieved correction” at 12 and 24 months. Mean postoperative astigmatism at 24 months was close to the mean preoperative value. An average 2.43% endothelial cell loss was observed at 24 months.

“With limitations, LASIK could be considered as a treatment for moderate and high myopia,” the authors concluded.

1. Pallikaris IG, Siganos DS. Laser in situ keratomileusis to treat myopia: early experience. J Cataract Refract Surg. 1997;23(1):39-49.