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Experts Tackle Cataract Complications, Part 3
 
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At last November’s Spotlight Session, audience members voted on video case studies highlighting myriad clinical challenges, including IOL exchanges, traumatic cataracts, and surgery in patients with chronic uveitis. Here, the experts weigh in with additional perspectives.

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Case 5: Posterior Capsule Rupture With Descending Nucleus

 

Q  After you initiate chopping and rotation, the entire nucleus appears to partially descend in this elderly woman with pseudoexfoliation. What would you do next?

Cautiously continue to phaco

12.8%

Advance the iris retractors around the capsulorrhexis edge and resume phaco

31.8%

Levitate the nucleus with a posterior assisted levitation (PAL) technique and convert to manual ECCE

35.1%

Levitate the nucleus with a PAL technique and continue phaco

13.5%

Abort the case and refer the patient

6.8%


Lisa Arbisser  The audience chose the two safest options depending on the capsule’s condition. The video view fails to clarify whether the entire bag with intact posterior capsule appears to be descending in this pseudoexfoliation eye due to zonular incompetence or whether the nucleus is sinking outside a torn bag.

If the rhexis and posterior capsule are intact and still contain the nucleus, then advancing the iris hooks onto the rhexis edge will permit a virtually routine phaco, assuming there is no vitreous forward of the bag. Sparingly painting trypan blue over the edge of the rhexis can facilitate this maneuver. Once the lens material is removed, if it is possible to place a Cionni capsular tension ring (CTR) or Ahmed capsular tension segment (CTS), the surgeon will be able to suture the bag to the sclera, maintaining a two-chambered eye with an in-the-bag lens implantation.

If the capsule is broken and the nucleus is sinking, elevating the nucleus into the anterior chamber is required. This can be accomplished, as the audience agrees, either by a PAL technique or, anteriorly, via Arbisser Nuclear Spears (Epsilon EyeCare). The latter is my preference. These two small, precise, sharp spears are deployed through clear corneal paracenteses 180 degrees apart to skewer and elevate the lens. The opposing vector forces minimize downward pressure and can levitate the nucleus without invading the pars plana and vitreous cavity, where we risk traction. Once the nucleus is above the iris, one of the spears is exchanged for a dispersive viscoelastic cannula while the other spear holds the nucleus stable. OVD is irrigated beneath the nucleus to trap it and compartmentalize any prolapsed vitreous backward.

Given the density of the lens in the video, conversion to ECCE is reasonable, especially if the surgeon suspects vitreous around the nucleus. In the absence of prolapsed vitreous, Miochol-E (acetylcholine) for temporary miosis minimizes the chance of losing fragments during slow-motion phacoemulsification. If the chamber is sufficiently deep, the Agarwal IOL scaffold technique can be employed. Appropriate vitrectomy and the surgeon’s favored method of IOL fixation without bag support complete the case.

Amar Agarwal  In this particular case, iris retractors are already placed, and the nucleus in the middle of surgery appears to be descending. The audience response—trying to first elevate the nucleus and then extend the incision—is very good. One can use the Arbisser Nuclear Spears, which can spear the nucleus and levitate it, or use a cannula to bring the nucleus anteriorly above the iris. Alternatively, one can go via the pars plana and levitate the nucleus.

Once the nucleus is above the iris, I would not extend the incision, as the nucleus was neither a hard brown nor a black cataract. I would release the iris retractors, as that would help constrict the pupil, and then inject some viscoelastic to protect the endothelium. Take a three-piece foldable IOL and inject it above the iris but below the nucleus. Both haptics could be placed above the iris or even into the sulcus. Once this is done, the IOL would act like a scaffold or an artificial posterior capsule. Now I would emulsify the nucleus with the phaco handpiece without the fear of the nuclear pieces falling into the vitreous cavity. I would then refit the iris retractors, do the vitrectomy, remove the cortex, and assess if enough anterior capsular support is there for either a sulcus implantation or a glued fixation of the same three-piece IOL. All this I would do with the help of an AC maintainer so that infusion is always on.

When we extend the incision, the eye is open—and once nuclear delivery is done, we have to again suture, then do the vitrectomy, then reopen the sutures and implant the IOL. Creating scleral flaps once again in an open eye is tough if one decides to do a glued IOL. The odds of expulsive hemorrhage and endophthalmitis also increase with the eye open. The IOL scaffold technique solves a lot of issues in this case.

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Q  What is your personal experience with PAL?

Have tried and it is my preference

18.5%

Have tried—bad idea/not comfortable

12.0%

Have never tried—would consider trying

41.5%

Have never tried—wouldn’t ever do it

28.0%


Suber Huang  The ability to rescue dislocated lens nuclei using PAL is a useful addition to the cataract surgeon’s skill set. Performed properly, it completes the surgery with minimal loss of efficiency, fewer complications, and no loss of confidence by the patient. Unfortunately, vitreous base traction resulting in retinal tear/detachment is a potentially blinding complication, and the response of the audience may reflect this concern. Being known as the “master of disaster” can be a compliment or an unwelcome statement of fact. Do no harm, involve your retina colleagues, and let good surgical judgment be your guide.

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Q  What is your personal experience with manual large-incision ECCE?

Very experienced

45.5%

Some experience—and comfortable with

23.6%

Some experience—not that comfortable with

17.0%

Very limited (or no) experience

8.4%

Experienced and also comfortable with sutureless manual ECCE

5.5%


Louis D. “Skip” Nichamin  This is an important question, as an ever-growing percentage of ophthalmologists are graduating from training programs with little if any experience in performing manual ECCE. Roughly 70 percent of attendees stated that they are comfortable with performing a manual extraction, and one-quarter are uncomfortable with the technique and/or have little experience with it. 

As the case presented illustrates, conversion to a manual expression may (and eventually will) be required in some complex cases. Residency program directors are faced with the challenge of preparing their trainees to handle this situation in an age in which phacoemulsification has all but replaced manual surgery. Perhaps the growing awareness and proven safety of small-incision, manual, and often sutureless surgery in developing countries will promote the training for and familiarity with this important technique, at least as a backup strategy.

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Q  What is your personal experience with pars plana anterior vitrectomy?

Have tried and it is my preference

36.8%

Have tried—bad idea/not comfortable

4.4%

Have never tried—would consider trying it

43.2%

Have never tried—wouldn’t ever do it

15.6%


Steve Charles  Clearly, the trend is moving from limbal to pars plana vitrectomy. The key advantage is elimination of cellulose sponges and wound sweeping, both of which produce acute vitreoretinal traction, which can result in retinal breaks and detachment. 

In addition, the pars plana approach eliminates iris trauma from cellulose sponges, which is a major cause of postvitrectomy inflammation and CME.

Crucial safety points for the pars plana approach: Use the highest possible cutting rate, never withdraw the cutter while suction is applied, use the lowest effective flow rate or vacuum, and lower the infusion.

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Q  In the absence of any capsular fixation, what IOL and fixation method would you choose?

ACIOL

62.9%

Iris-sutured PCIOL

10.0%

Scleral-sutured PCIOL

13.5%

Glued PCIOL

7.2%

Leave the eye aphakic and refer

6.4%


Roger Steinert  All of these options have merits and drawbacks, and each technique has a place. Consistently, the majority of surgeons choose ACIOL implantation as the procedure of choice. However, this year’s survey shows an increasing number of surgeons who indicate a comfort level with one of the options for PCIOL fixation. And, most interestingly, the scleral tunnel/glue technique recently developed by Amar Agarwal has rapidly gained a foothold. Further experience with this technique may see more widespread adoption.

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Case 6: Traumatic Cataract and Mydriasis

 
 

Q  This 69-year-old patient has a 20/200 cataract, eight months after blunt trauma from a handball. An initial vitreous hemorrhage has cleared. There is a traumatic iris sphincter rupture temporally. Although no vitreous was noted in the anterior chamber preoperatively, vitreous immediately prolapses to the paracentesis through a temporal zonular dialysis as soon as intracameral lidocaine is injected. How would you address this vitreous prolapse?

Perform an anterior vitrectomy via a limbal incision

19.6%

Perform an anterior vitrectomy via a pars plana sclerotomy

15.8%

Proceed with phaco after partitioning off the vitreous with OVD in the AC

53.8%

Convert to a manual ECCE

5.4%

Abort surgery and refer the patient

5.4%


Alan Crandall  The problem of vitreous prolapsing through a zonular dialysis can lead to a number of maneuvers. A stepwise approach to minimize complications is needed. 

Performing an anterior vitrectomy may seem logical—and, sometimes, it must be done, particularly if there is a tremendous amount of vitreous. Usually, however, more vitreous will follow, and it may increase the dialysis. If I can, I will partition off the vitreous with either Healon 5 or DiscoVisc. If the lens is stable, then I would use low-flow, slow-motion phaco. One can also use a CTR, which will expand the bag and may keep vitreous back. If the bag is not completely stable, I may add capsular support with either the MST or Mackool hooks.

I prefer to wait for the vitrectomy, which I do through the pars plana. The advantage of the posterior approach is to bring vitreous backward instead of forward. If possible, I also prefer to wait until the lens is stable, because removing the vitreous can lead to the lens becoming more mobile with less support. With these steps, it is usually possible to complete the case with minimal trauma.

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Q  If you encounter a significant zonular dialysis intraoperatively, what should you do next?

Continue to cautiously phaco

11.5%

Implant a CTR before resuming phaco

36.3%

Insert capsular retractors before resuming phaco

17.6%

Combine options two and three

28.6%

Convert to a manual ECCE

3.8%

Abort surgery and refer the patient

2.2%


Boris Malyugin  A CTR and capsular retractors are the first tools to consider when the surgeon faces zonular dialysis at the time of the surgery. The decision whether to use one or both of them depends on the extent of the area of missed zonules and the condition of the remaining intact zonular fibers. If the defect does not exceed three clock-hours and the remaining zonules are in good condition, it is possible to place a conventional CTR and proceed with the surgery. 

A conventional CTR restores the shape of the capsular bag equator and evenly distributes the centripetal forces caused by the remaining zonules. The only downside of the CTR is that it makes lens cortex aspiration more complex. This is because the cortical material is entrapped at the equator of the capsular bag. The problem can be overcome by using bimanual I&A and stripping the cortex in the tangential direction.

When the defect is larger and/or it is associated with significant zonular weakness, then capsular hooks will help to temporarily support the lens and sustain the pupil in the dilated state. The latter is very important, in that zonular weakness is commonly associated with compromised iris sphincter function, as seen with glaucoma and pseudoexfoliation syndrome.

Obviously, implanting capsular retractors is a temporary measure, and they should be removed at the completion of the surgical procedure. To stabilize the capsular bag in the presence of extensive zonular defects, it is necessary to create permanent synthetic zonular support by suturing the capsular bag to the sclera, utilizing some specially designed devices. Several are available, including the Cionni CTR and Ahmed CTS. My personal preference is the Malyugin ring (Morcher), which is the Cionni CTR modification based on the fixation element placement at the very end of the ring. This design improvement allows the whole ring to be inserted into the injector tube. As a result, the surgeon’s control during implantation is significantly improved. The curved tip of the ring slides easily along the capsular bag equator without any risk of damaging the capsule. In addition, this ring can be used through a 2.2-mm microincision. In my experience, the Malyugin ring provides favorable functional and anatomic results in patients with acquired and congenital zonular pathology.

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Q  How would you fixate a posterior chamber IOL with a significant zonular dialysis?

Place in the bag without a CTR (but direct haptic toward dialysis)

10.4%

Place in the bag with a CTR

59.0%

Place in the bag with a Cionni CTR or CTS

8.5%

Place in the sulcus without suturing

14.6%

Place in the sulcus with suture fixation of haptic(s)

4.2%

Implant an ACIOL

3.3%


Ike Ahmed  In a well-supported intact capsular bag, there’s little doubt that the best location for an IOL is in the bag. In this case, it is important to support the zonular weakness with appropriate capsular tension devices. In mild zonular insufficiency, a CTR alone is usually enough. In cases of more profound zonular dialysis, a CTS or Cionni CTR is required for suture fixation (with either a 9-0 polypropylene or a 7-0 Gore-Tex suture) to the sclera. Placing an IOL in the sulcus in the presence of zonular dialysis increases the risk of dislocation, as zonules are typically required for sulcus support. In addition, if one is already suturing, it’s best to suture a device that would be used to support the capsular bag to enable endocapsular IOL fixation.

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Q  In this case of vitreous prolapsing through a zonular dialysis, through what incision would you perform the anterior vitrectomy?

Phaco incision (coaxial infusion)

7.6%

Phaco incision (split infusion)

29.7%

New corneal incision (split infusion)

39.2%

Pars plana sclerotomy (split infusion)

23.4%


Bill Fishkind  The audience response is surprising! Not in the divide between the anterior approach and the pars plana approach, but in the number who would use the phaco incision. This has been shown to be unsatisfactory, as the larger incision does not satisfactorily restore a closed system. Therefore, vitreous is both washed out and pushed out through the large incision, thus increasing the volume of the vitrectomy and often resulting in vitreous strands to the wound. 

Depending on surgeon expertise and confidence, a split I&A system, with irrigation supplied anteriorly, and vitrectomy through a separate new, small vitrectomy incision—or through the pars plana—is correct.

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Q  There is a torn iris sphincter on the temporal side. How would you address this partial traumatic mydriasis?

Use topical miotic and sunglasses

27.1%

Prescribe a painted soft contact lens

4.2%

Perform iris cerclage suturing

50.8%

Implant an artificial iris prosthesis

5.9%

Refer the patient

11.9%


Ken Rosenthal  In my experience, miotics and sunglasses have helped only a minority of patients with significant iris defects, particularly when the defect is located temporally. In fact, miotics can decenter the pupil because the tonic part of the damaged sphincter muscle will not react to pharmacological stimulation. And while sunglasses reduce the light entering the eye, they do not address the increase in higher-order aberrations caused by the projection of light entering the peripheral cornea and lens onto the retina.

A contact lens can provide temporary relief from the visual symptoms. However, they are expensive, and the majority of patients find them uncomfortable or impractical.

Iris cerclage will be helpful because it will bring the pupil to a more normal diameter; however, the pupil will no longer dilate. Also, because the suture is under constant tension, there is a significant likelihood of sequential cheese-wiring through the fragile iris border. Because the majority of the iris is intact, I would favor a sector closure of the affected iris using a modified McCannel suture technique, which would preserve the ability of the pupil to dilate. Several radially spaced sutures may be needed for satisfactory closure, so the use of a Siepser knot would be advantageous.

Ideally, one would like to consider using a sector iris prosthetic implant, but these are not FDA approved and would therefore require a second intervention or referral to a center where FDA clinical trials are being conducted. Nonetheless, this method of reconstruction would most likely result in a more permanent and stable repair that retains full function of the remaining iris structure.

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Case 7: Severe IFIS

 
 

Q  What is your favored initial strategy for patients showing signs of intraoperative floppy iris syndrome (IFIS)?

Retentive OVD plus lowered fluidics

16.8%

Intracameral epinephrine or phenylephrine

36.1%

Iris retractors

25.7%

Pupil expansion ring

20.9%

Other

0.5%

Refer them

0.0%


Peter Barry  My first priority is to create meticulous incisions, ensuring they do not exceed the size of the instruments and thus avoiding any tendency to leakage and floppy iris incarceration. Secondly, I favor the use of intracameral phenylephrine 2.5 percent, which is readily available in Europe. Next, I would use a retentive OVD and, during I&A, ensure infusion is in front of the iris to minimize prolapse. I would use iris hooks or a pupil expansion ring as a last resort lest the iris disintegrate. 

Nick Mamalis  IFIS occurs secondary to use of α1a adrenergic receptor antagonists, which affect the iris dilator muscle as well as iris tone. IFIS is characterized by a poor dilation with progressive pupillary miosis, iris billowing and undulation, and iris prolapse to the wound. Chronic α1a antagonist use can cause loss of iris dilator thickness as well as iris smooth-muscle atrophy. This is believed to represent a possible disuse atrophy of the iris dilator muscle. These findings lead to potential increased risk of surgical complications in patients with IFIS, including posterior capsule rupture, vitreous loss, and iris prolapse or damage.

Several strategies can be used in patients with IFIS. The survey results show that 16.8 percent of respondents favor a retentive OVD with lowered fluidics. In addition, 36.1 percent used either intracameral epinephrine or phenylephrine. Unfortunately, preservative-free, bisulfate-free epinephrine is no longer being manufactured in the United States, and it is critical to properly dilute epinephrine that contains bisulfate prior to intracameral use in these patients.

Intracameral phenylephrine 1.5 percent has shown promising results in Europe for the prophylaxis of IFIS. However, this is not commercially available in the United States and requires a compounding pharmacy or custom mixing. The use of iris retractors or pupil expansion rings was favored by almost 47 percent of respondents. These devices help prevent the progressive miosis of the pupil as well as the tendency of the floppy iris to prolapse into the wound and into any stab incisions.

The Malyugin ring is particularly helpful in the prevention of surgical complications in patients with IFIS. The use of this pupil expansion ring has proved invaluable in the prevention of IFIS-related complications in patients undergoing surgery by ophthalmology residents or trainees.

A combination of all of these strategies is often necessary when performing cataract surgery in patients with IFIS.

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Q  The referring surgeon aborted cataract surgery on this 83-year-old male Flomax patient yesterday because of severe iris prolapse prior to initiating the capsulotomy. What would be your initial surgical approach?

Intracameral epinephrine or phenylephrine only

27.1%

Iris retractors

34.3%

Malyugin or other pupil expansion ring

38.1%

Refer the patient elsewhere

0.6%


Sam Masket  Although there is a history of the use of Flomax (tamsulosin), iris prolapse is uncommon at the very outset of surgery in cases of IFIS. More typically, iris floppiness is noted with infusion of BSS, particularly if the fluid is directed behind the iris. So in this case, one must also be concerned about a crowded anterior segment, as iris prolapse was noted before any BSS was infused.

If the prolapsed iris tissue remains exposed to the environment via the paracentesis, surgery must be expedited, and the exposed iris tissue should be excised. Absent iris prolapse, surgery is not emergent.

Given that IFIS and crowded anterior segment syndrome share certain clinical characteristics, it would be prudent to prepare for both. I prefer to use atropine in the dilating regimen, although it requires two to three days for maximum action. Unless it is contraindicated, I would administer intravenous mannitol preoperatively to reduce vitreous volume and soften the eye. If, despite this, the chamber was very shallow, I would also consider a small single-port pars plana vitrectomy to further reduce vitreous volume and allow the OVD to deepen the chamber. The OVD should be supercohesive in rheology. Incisions should be constructed to have long tracts to help guard against iris prolapse and, without hesitation, pupil mechanical dilating tools should be used. I prefer the Malyugin ring, although similar devices and iris hooks are very usable.

During nuclear emulsification it is best to have the BSS infusion directed in front of rather than behind the iris to prevent iris billowing and prolapse. I prefer to chop the nucleus into pieces and then elevate them to the iris plane before emulsification and aspiration. Additional OVD may be instilled during emulsification and cortical aspiration, should the iris behavior mandate.

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Q  After IOL implantation, how would you manage this patient’s mangled iris caused by the iris prolapse and incarceration?

Would not treat it

36.2%

Prescribe topical miotic

19.7%

Iris suture cerclage

37.8%

Artificial iris implant

3.2%

Refer the patient

3.2%

 

 
 

Tom Oetting  I agree with the audience that suturing the iris is probably the best option, but there is no hurry. You can easily reposition the iris and see if the patient is symptomatic, as another large group of audience members suggested.

If the patient is symptomatic, sutures would likely help to re-form the pupil and block light. I really like to use one or two interrupted sliding sutures (video, above) rather than a cerclage suture. The cerclage suture, in my hands, is a tricky technique, and it is more difficult—for me, at least—to control the ultimate size of the pupil. Usually, patients with iatrogenic trauma from iris prolapse will have a section of iris atrophy just under the wound. Often, a single suture in this area will bring the pupil back to a reasonable size. I usually use 10-0 Prolene with a long curved needle (CTC-6L). Often I will use microforceps, such as the Duet (MST), to position the iris for the suture passes. The suture is retrieved through a paracentesis as described by McCannel1 and tied with a sliding knot as described by Siepser.2

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1 McCannel MA. Ophthalmic Surg. 1976;7(2):98-103.

2 Siepser SB. Ann Ophthalmol. 1994;26(3):71-72.

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Q  For patients listing drug brand names on their medication list, which of these is least likely to cause severe IFIS?

Flomax

19.0%

Uroxatral

20.3%

Jalyn

50.6%

Rapaflo

10.1%


David Chang  Interestingly, 80 percent of the respondents got this question wrong. A number of published retrospective and prospective studies show that the incidence and severity of IFIS is greater with the α1a-selective antagonist tamsulosin (Flomax) than it is with alfuzosin (Uroxatral). The latter is a nonselective α blocker. 

The newest α antagonist to be approved for benign prostatic hyperplasia (BPH) in the United States is silodosin (Rapaflo). Like tamsulosin, it is selective for the α1a subtype and is associated with severe IFIS.

Jalyn was approved in 2010, and it is the brand name for a combination of tamsulosin and dutasteride. Dutasteride (Avodart) is a 5α-reductase inhibitor and does not cause IFIS. However, the combination of these two agents was shown in a large prospective 2010 clinical trial to be more effective at reducing the progression of BPH compared with either drug alone, and ophthalmologists will therefore be seeing increasing numbers of patients on this drug.

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Q  There is a torn iris sphincter on the temporal side. How would you address this partial traumatic mydriasis?

Use topical miotic and sunglasses

27.1%

Prescribe a painted soft contact lens

4.2%

Perform iris cerclage suturing

50.8%

Implant an artificial iris prosthesis

5.9%

Refer the patient

11.9%


Ken Rosenthal  In my experience, miotics and sunglasses have helped only a minority of patients with significant iris defects, particularly when the defect is located temporally. In fact, miotics can decenter the pupil because the tonic part of the damaged sphincter muscle will not react to pharmacological stimulation. And while sunglasses reduce the light entering the eye, they do not address the increase in higher-order aberrations caused by the projection of light entering the peripheral cornea and lens onto the retina.

A contact lens can provide temporary relief from the visual symptoms. However, they are expensive, and the majority of patients find them uncomfortable or impractical.

Iris cerclage will be helpful because it will bring the pupil to a more normal diameter; however, the pupil will no longer dilate. Also, because the suture is under constant tension, there is a significant likelihood of sequential cheese-wiring through the fragile iris border. Because the majority of the iris is intact, I would favor a sector closure of the affected iris using a modified McCannel suture technique, which would preserve the ability of the pupil to dilate. Several radially spaced sutures may be needed for satisfactory closure, so the use of a Siepser knot would be advantageous.

Ideally, one would like to consider using a sector iris prosthetic implant, but these are not FDA approved and would therefore require a second intervention or referral to a center where FDA clinical trials are being conducted. Nonetheless, this method of reconstruction would most likely result in a more permanent and stable repair that retains full function of the remaining iris structure.

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P = PATENTS/ROYALTY

S = GRANT SUPPORT

DR. AGARWAL: Abbott Medical Optics, Bausch + Lomb, Staar Surgical, C; Dr. Agarwal’s Pharma, O; Slack, Thieme Medical Publishers, P. DR. AHMED: Iridex, Endo Optiks, Transcend Medical, C; Alcon, Allergan, Carl Zeiss Meditec, Ivantis, Merck, Pfizer, C L S; AqueSys, Clarity, Glaukos, C S; Abbott Medical Optics, NeoMedix, New World Medical, L. DR. ARBISSER: None. DR. ARSHINOFF: Abbott Medical Optics, Alcon, ArcticDx, Bausch + Lomb, C. DR. BARRY: None. DR. CHANG: Abbott Medical Optics, C; Clarity, LensAR, Transcend Medical, C O; Allergan, Carl Zeiss Meditec, L; Calhoun Vision, Icon Bioscience, One Focus Ventures, PowerVision, Revital Vision, O; Eyemaginations, Slack, P; Glaukos, S. DR. CHARLES: Alcon, Topcon Medical Systems, C P. DR. CIONNI: WaveTec, C; Alcon, C L; Morcher, P. DR. CRANDALL: AqueSys, Asico, eSinomed, Glaucoma Today, Glaukos, iScience, Ivantis, Journal Cataract Refractive Surgery, Mastel Surgical, Omeros, Transcend Medical, Vimetrics, C; Alcon, C L; Allergan, Ocular Surgery News, L. DR. DONNENFELD: AcuFocus, AqueSys, Cataract and Refractive Surgery Today, Glaukos, LenSx, Odyssey, Pfizer, QLT Phototherapeutics, WaveTec, C; Abbott Medical Optics, Alcon, Allergan, Bausch + Lomb, C L S; TrueVision, C O; Inspire Pharmaceuticals, C P; TLC Laser Eye Centers, L O. DR. DUNN: None. DR. FISHKIND: Abbott Medical Optics, LensAR, C; Thieme Medical Publishers, P. DR. GÜELL: Alcon, Carl Zeiss Meditec, Ophtec, C; Calhoun Vision, O. DR. HENDERSON: Alcon, Bausch + Lomb, Ista Pharmaceuticals, C; Massachusetts Eye and Ear Infirmary, P. DR. HILL: Bausch + Lomb, Elenza, Haag-Streit, LensAR, Oculus, Santen, C; Alcon, Carl Zeiss Meditec, C L. DR. HUANG: Bausch + Lomb, Notal Vision, Second Sight, Sequenom, C; Retinal Diseases Image Analysis Reading Center, C L; Alcon, L; I2i Innovative Ideas, O. DR. KIM: Ocular Systems, SARcode Bioscience, C; Alcon, Bausch + Lomb, Ista Pharmaceuticals, C L; Ocular Therapeutix, PowerVision, C O. DR. KOCH: Abbott Medical Optics, Alcon, C; OptiMedica, O; Ziemer, S. DR. KOHNEN: Alcon, Rayner Intraocular Lenses, Schwind Eye Tech Solutions, C L S; Bausch + Lomb, Hoya, L S; Neoptics, S. DR. LANE: Abbott Medical Optics, Inspire Pharmaceuticals, Ista Pharmaceuticals, Ocular Therapeutics, PowerVision, SARcode Bioscience, SMI, SRxA, TearScience, VisionCare, WaveTec, C; Alcon, C L; Bausch + Lomb, C L S. DR. LINDSTROM: Abbott Medical Optics, Alcon, Clarity Ophthalmics, Curveright, Hoya, Ista Pharmaceuticals, LenSx, Lumineyes, Ocular Surgery News, Ocular Therapeutix, Omeros, SRxA, C; 3D Vision Systems, AcuFocus, Biosyntrx, Calhoun Vision, Clear Sight, CoDa Therapeutics, EBV Partners, EGG Basket Ventures, Encore, Evision, Eyemaginations, Foresight Venture Fund, Fziomed, Glaukos, High Performance Optics, Improve Your Vision, LensAR, Life Guard Health, Minnesota Eye Consultants, NuLens, Ocular Optics, Omega Eye Health, Pixel Optics, Refractec, C O; Qwest, C O P; Bausch + Lomb, C P; Confluence Acquisition Partners, Healthcare Transaction Services, Heaven Fund, ReVision Optics, O. DR. MALYUGIN: Bausch + Lomb, C; Morcher, Microsurgical Technologies, P. DR. MAMALIS: OptiMedica, C; Abbott Medical Optics, ANew, C S; Alcon, Allergan, Bausch + Lomb, Calhoun Vision, Medennium, Nuview, PowerVision, S. DR. MASKET: PowerVision, C; Alcon, C L; Ocular Theraputix, C O; Haag-Streit, C P; Bausch + Lomb, Zeiss, L; Accutome, S. DR. MILLER: Alcon, L S; Calhoun Vision, Hoya, Physical Optics, S. DR. NICHAMIN: Abbott Medical Optics, Allergan, Bausch + Lomb, Foresight Biotherapeutics, Glaukos, C; 3D Vision Systems, Eyeonics, iScience, LensAR, PowerVision, Revital Vision, WaveTec, C O; Harvest Precision Components, O. DR. OETTING: None. DR. OLSON: None. DR. OSHER: Abbott Medical Optics, Alcon, Bausch + Lomb, Beaver-Visitec International, Carl Zeiss Meditec, Clarity, Haag-Streit, SMI, C; Video Journal of Cataract & Refractive Surgery, O. DR. PACKER: Abbott Medical Optics, Advanced Vision Science, Allergan, Auris Surgical Robotics, Bausch + Lomb, GE Healthcare, Ista Pharmaceuticals, Ivantis, Rayner Intraocular Lenses, VisionCare, C; Corinthian Ophthalmic, LensAR, mTuitive, NewSee, SurgiView, Transcend Medical, TrueVision, WaveTec, C O. DR. RAVINDRAN: None. DR. ROSENTHAL: Bausch + Lomb, Inspire Pharmaceuticals, Ista Pharmaceuticals, Johnson & Johnson, Microsurgical Technologies, C; Alcon, C L; Abbott Medical Optics, Ophtec, C L S. DR. SOLOMON: Bausch + Lomb, C L; Abbott Medical Optics, Advanced Vision Research, Alcon, Allergan, C L S; Glaukos, C O; QLT Phototherapeutics, C O S; Nidek, S. DR. STARK: VueCare Media, O. DR. STEINERT: OptiMedica, ReVision Optics, C; Abbott Medical Optics, C S; Rhein Medical, P. DR. TIPPERMAN: Alcon, Marco, Piezo Resonance Innovations, C; Carl Zeiss Meditec, L.

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