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    R E P O R T

    Modern cataract surgery allows surgeons to customize and tailor the refractive outcome to the visual needs of individual patients and this has led to increased patient expectation for spectacle independence following cataract surgery.1 Presbyopia-correcting intraocular lenses (IOLs) have been shown to provide good unaided vision at dis- tance, intermediate, and near vision when implanted binocularly.2-4 However, due to issues such as glare, halos, and decreased contrast associated with diffrac- tive optics, other options including presbyopic laser

    in situ keratomileusis and corneal inlays are available for treating presbyopia.5,6 The small-aperture corneal inlay (KAMRA; Acufocus, Inc., Irvine, CA) employs the principle of small-aperture optics and has been shown to improve unaided intermediate and near vi- sion with minimum to no effect on distance vision when implanted monocularly.6 Recently, the same principle of small-aperture optics has been applied at the lenticular plane to develop a new small-aperture IOL. The IC-8 (Acufocus, Inc.) is a single-piece, hydro- phobic acrylic, monofocal, small-aperture IOL with a


    PURPOSE: To evaluate the posterior segment visualization in patients with small-aperture intraocular lens (IOL) implantation.

    METHODS: In this prospective, comparative case series, 15 pa- tients who had unilateral implantation of the small-aperture IOL in their non-dominant eyes were recruited. Their fellow eyes were pseudophakic with a monofocal IOL in 14 patients and phakic in 1 patient. All underwent bilateral posterior seg- ment clinical investigations including fundus photography, threshold perimetry, and optical coherence tomography of the posterior pole including optic nerve head. The results from these investigations were graded by a clinician masked to the laterality and type of IOL. Patient 11 developed postoperative endophthalmitis 4 weeks following cataract surgery with im- plantation of a small-aperture IOL and underwent pars plana

    vitrectomy. The intraoperative view of the posterior segment was subjectively evaluated by the retinal surgeon.

    RESULTS: All 15 patients had successful image captures with all clinical investigative tools with no differences in im- age quality detected between the images obtained from the monofocal pseudophakic and small-aperture IOL eyes. The small-aperture IOL did not subjectively obstruct the intraoper- ative view for the retinal surgeon during pars plana vitrectomy.

    CONCLUSIONS: Standard posterior segment investigations including non-mydriatic fundus photography, optical coher- ence tomography, and automated perimetry can be safely and effectively performed in eyes with small-aperture IOLs. There is no difference in the image quality.

    [J Refract Surg. 2019;35(8):538-542.]

    From the Department of Ophthalmology, University Hospital Ayr, Ayr, Scotland, United Kingdom (SS, LWK, ZK); and the School of Health and Life Sciences, University of West of Scotland, Ayr, Scotland, United Kingdom (SS, LWK).

    Submitted: March 16, 2019; Accepted: July 9, 2019

    Mr. Srinivasan is a member of the medical advisory board of Acufocus, Inc. The remaining authors have no financial or proprietary interest in the materials presented herein.

    © 2019 Srinivasan, Khoo, & Koshy; licensee SLACK Incorporated. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International ( This license allows users to copy and distribute, to remix, transform, and build upon the article, for any purpose, even commercially, provided the author is attributed and is not represented as endors- ing the use made of the work.

    Correspondence: Sathish Srinivasan, FRCSEd, FRCOphth, FACS, Department of Ophthalmology, 3rd Floor, University Hospital Ayr, Dalmellington Road, KA6 6DX, Ayr, Scotland, United Kingdom. E-mail:


    Posterior Segment Visualization in Eyes With Small-Aperture Intraocular Lens Sathish Srinivasan, FRCSEd, FRCOphth, FACS; Lin Wei Khoo, MBChB; Zachariah Koshy, DNB, FRCS(G)

  • • Vol. 35, No. 8, 2019 539

    diameter of 12.5 mm, 6-mm optics, and “C” loop hap- tics (Figure 1). Embedded within the optic is a mask made of polyvinylidene fluoride and nanoparticles of carbon with an overall diameter of 3.23 mm and a cen- tral aperture of 1.36 mm. This IOL is implanted mon- ocularly in the non-dominant eye for the correction of presbyopia and has been shown to provide a continu- ous range of good unaided distance, intermediate, and near vision.7,8

    The purpose of this study was to evaluate posterior segment visualization in eyes that had undergone IC-8 IOL implantation.

    PATIENTS AND METHODS In this prospective fellow eye comparative study,

    15 eyes of 15 patients were included. All had bilateral cataracts except for one (patient 10) who had a unilat- eral cataract. All except one underwent clear corneal phacoemulsification with implantation of the small- aperture IOL in the non-dominant eye and a colorless monofocal IOL (409 MP; Carl Zeiss Meditec AG, Jena, Germany) in the fellow eye. The patient with unilateral cataract underwent phacoemulsification with implan- tation of the small-aperture IOL. There was no other ocular morbidity in the study group. Two months fol- lowing cataract surgery, a trained ophthalmic staff nurse performed the following standard posterior seg- ment examinations bilaterally in all patients: fundus photography with a non-mydriatic fundus camera (Canon CR-2 Plus; Canon, Tokyo, Japan), 24-2 thresh- old automated perimetry (Humphrey Field Analyzer 3, automated visual field analyzer; Carl Zeiss Meditec AG), and optical coherence tomography (OCT) of the

    posterior pole and optic nerve head with two com- mercially available devices (Cirrus 5000; Carl Zeiss Meditec AG, and Spectralis; Heidelberg Engineering, Heidelberg, Germany). All investigations were per- formed in scotopic conditions without topical myd- riatic agents. An independent ophthalmologist (ZK) who was masked to the laterality and type of IOL used then evaluated and scored the digital images of the above-mentioned investigations based on a scoring scale (Table 1).

    Surgical Technique Cataract surgery was performed by a single surgeon

    (SS) under topical and intracameral anesthesia. Fol- lowing 1.8-mm clear corneal phacoemulsification, a colorless, single-piece, preloaded, hydrophilic plate

    Figure 1. High-magnification photograph of the IC-8 small-aperture intraocular lens (Acufocus, Inc., Irvine, CA) with the central mask.

    TABLE 1 Grading Scale Used by the Masked Observer to Grade the Quality of the Images

    Grade Non-mydriatic Fundus

    Photography 24-2 Automated Perimetry OCT of the Macula OCT of the ONH 4 Very clear of the posterior

    pole Very clear view of the entire visual field, with no field defects

    Very clear view, all layers of retina and foveal pit visible

    Very clear view, all margins of the ONH and all four quad- rants of the NFL visible

    3 Mild peripheral shadowing with glare

    Mild, peripheral artifacts, causing ring scotomas

    Mild obstruction and shad- owing but retinal layers and foveal pit visible

    Mild, peripheral artifacts, ONH visible but NFL view obstructed

    2 Moderate shadowing, obscur- ing the details of the retinal vessel

    Moderate paracentral ring scotomas

    Moderate obstruction and shadowing, retinal layers not visible but foveal pit visible

    Moderate obstruction and shadowing, no NFL visibility but ONH visible

    1 Severe shadowing, obscuring view of the macula and optic disc

    Severe ring scotomas with no view of the physiological blind spot

    Severe paracentral defects, with no clear view of the reti- nal layers or foveal pit

    Severe obstruction, ONH just visible

    0 No clear view, unable to make out any details

    Central “black out” with no normal field plot

    No clear view, unable to make out any details

    No clear view, unable to make out any details

    OCT = optical coherence tomography; ONH = optic nerve head; NFL = nerve fiber layer

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    haptic IOL (409 MP; Carl Zeiss Meditec AG) was in- jected into the capsular bag through a 1.8-mm clear corneal wound in the dominant eye of the patient. For the non-dominant eye, following 1.8-mm clear corne- al phacoemulsification, the wound was enlarged to 3 mm to facilitate insertion of the small-aperture IC-8 IOL in the capsular bag. A digital caliper (CALLISTO Eye; Carl Zeiss Meditec AG) set at 5.5 mm and cen- tered on the patient-fixated coaxially sighted corneal light reflex from the operating microscope (Lumera 700; Carl Zeiss Meditec AG) was used to center the capsulorhexis. The IC-8 IOL was centered in the cap- sular bag over this reflex with a slight nasal bias. There were no intraoperative complications. At the end of the procedure, all eyes received intracameral admin- istration of 0.1 mL of preservative-free cefuroxime (Aprokam; Thea Pharmaceuticals, Clermont-Ferrand, France) and postoperatively all were treated with topi- cal corticosteroid (Pred forte 1%; Allergan, Irvine, CA) for 4 weeks.

    RESULTS The trained ophthalmic nurse was able to perform

    non-mydriatic fundus photography (Figure 2), 24-2 automated threshold perimetry (Figure 3), and OCT scan of the macula and the optic nerve head using two

    commercially available OCT machines. There were no cases of image capture failure in the small-aperture IOL