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Downloaded from https://journals.lww.com/jcrs by fXqFJ1ayLMsvy188LU3NdeYLP5KjJfnV/WDCkk7h+0aWqBNcEaLxhFyCydnLyzeaCyRXdf9D+4znTEa2pXnIHnX4AMRgzCftALNvfSoP9jYSx4XH0ox+b5dXxNCLJJS4 on 08/30/2020

replacing glue and bandage contact lens (Figure 1, B).
Intravitreal injection of vancomycin, tazobactam, anddexamethasone was administered at the conclusion ofvitrectomy. The patient responded well to treatment. Her
visual acuity improved to 6/60 with accurate projection ofrays, and intraocular pressure was 12 mm Hg; however,corneal edema persisted (Figure 1, B) for which she has
been waitlisted for Descemet-stripping automated endothelial keratoplasty.
A rare category of surgical complications associated withcataract surgery is postoperative endophthalmitis complicated by the presence of sutures.2 Most reported cases haveoccurred 2 to 3 years postoperatively. A retained corneal
suture can be problematic.3 Cataract surgeons should not
be hesitant to place sutures to secure the wound whenrequired nor should they forget the need for timely suture
removal.4 Lifelong follow-up is indispensable for suchcases, which can present after many years. The low yield ofan organism from vitreous biopsy might be attributed tointensive topical antibiotic administration before sample
retreival.1,5 Endophthalmitis calls for vitrectomy, yet accompanying ocular morbidities need to be addressed
simultaneously.
Siddharth Madan, MS, DNB, FICO
Monika Kapoor, MS
Himani Pal, MBBS
Preeti Singh, MBBS, MS
New Delhi, India

inner extension of the microorganism and result in endophthalmitis. In this case, the lack of a posterior capsule orposterior chamber lens led to a more rapid extension into
the posterior chamber. Much of the aggressive nature ofthese cases will depend on the type of microorganism andthe time to diagnosis and management. If time of suture
breakage or loosening to diagnosis and removal and initiation of antimicrobial therapy is rapid, then more severe
sequelae can be avoided. In environments where access to
medical care might be delayed, a more severe sequelae suchas the one seen here can occur. Your case underscores theneed for timely removal of corneal sutures in the early
postoperative period because this severe infection could
have been avoided. Our article regarding postcataract
surgery endophthalmitis related to cases of endophthalmitis
in the acute to subacute postoperative period and not tosuture complications and questioning the necessity of intracameral antibiotics in routine cataract surgery in a developed country.2 The incidence of endophthalmitis without
routine intracameral antibiotics at our tertiary-care hospital
was low in routine cases. —Marjan Farid, MD
REFERENCES
1. Lee BJ, Smith SD, Jeng BH. Suture-related corneal infections after clear
corneal cataract surgery. J Cataract Refract Surg 2009;35:939-942
2. Lu Y, Farid M, Garg S, Wade M. Exploring the 10-year incidence ofendophthalmitis at a tertiary care academic referral practice. J Cataract
Refract Surg 2020;46:641-643

Disclosures: None of the authors has a financial or proprietaryinterest in any material or method mentioned.

REFERENCES
1. Lu Y, Farid M, Garg S, Wade M. Exploring the 10-year incidence ofendophthalmitis at a tertiary care academic referral practice. J Cataract
Refract Surg 2020;46:641–643
2. Al-Mezaine HS, Al-Assiri A, Al-Rajhi AA. Incidence, clinical features, causativeorganisms, and visual outcomes of delayed-onset pseudophakic endophthalmitis. Eur J Ophthalmol 2009;19:804–811
3. Lee BJ, Smith SD, Jeng BH. Suture-related corneal infections after clear
corneal cataract surgery. J Cataract Refract Surg 2009;35:939–942
4. Shirodkar AR, Pathengay A, Flynn HW, Albini TA, Berrocal AM, Davis JL, LalwaniGA, Murray TG, Smiddy WE, Miller D. Delayed- versus acute-onset endophthalmitis after cataract surgery. Am J Ophthalmol 2012;153:391–398.e2
5. Khurshid GS, Fahy GT. Endophthalmitis secondary to corneal sutures: seriesof delayed-onset keratitis requiring intravitreal antibiotics. J Cataract Refract
Surg 2003;29:1370–1372

Disclosures: None of the authors has a financial or proprietaryinterest in any material or method mentioned.
Reply: We appreciate the case report of latedeveloping, suture-related endophthalmitis severalyears after original cataract surgery. This case is unfortunately not unique, and many cases of suture-related
infectious keratitis are witnessed when timely suture
removal is not completed.1 A small fraction of thesesuture-related infectious keratitis cases will lead to an

Another use forcapsulorhexis-fixatedintraocular lenses
I read with interest the report of the results and outcomes ofcapsulorhexis-fixated extended depth-of-focus intraocularlenses (IOLs) by Darian-Smith and Versace.1 Their findings
gave support to the concept that IOL capsulorhexis fixation eliminated negative dysphotopsia. They further suggested that capsulorhexis-fixated IOLs might improve
postoperative refractive predictability because the effective
lens position and the alignment of the optic with the visual
axis would be improved and that posterior capsule opacification, described by Tassingon et al., and negative dysphotopsia, described by Masket et al., might be prevented.2,3
Capsulorhexis fixation of an IOL has yet an additional
indication when performed together with small-incisioncataract surgery and refilling of the lens capsule to restore
accommodation, described some 30 years ago.4 In that report, 2 IOL designs were used, 1 with and 1 without a haptic(Figure 1). The groove at the IOL optic edge was enclaved tothe capsulorhexis margin in both pig and rabbit eyes using

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Figure 1. Capsulorhexis-supported intraocular lens made of poly(methyl methacrylate).

a similar technique to that of Darian-Smith and Versace. The
needle of a syringe containing a silicone mix was injected(Figure 2). The needle was withdrawn on complete refillingof the capsular bag with the silicone mix.
As a consequence, an immediate firm enclavement of theoptic edge groove to the capsulorhexis margin without
silicone leakage was achieved. Within 2 hours, the silicone
mix polymerized in the capsular bag, creating such a firm
fixation that the IOL remained in its position despite extensive pressure exerted on the refilled capsular bag by thesoft, malleable, silicone compound. Similar techniques
using capsulorhexis-fixated IOLs might well have potential
in the evolution of future cataract surgery methodology.

Figure 2. Schematic representation of the silicone refilling of thelens (From Ref. 4 with the permission of Graefes Arch Clin ExpOphthalmol).

Okihiro Nishi, MD, PhD
Osaka, Japan
REFERENCES
1. Darian-Smith E, Versace P. Visual performance and positional stability ofa capsulorhexis-fixated extended depth-of-focus intraocular lens. J Cataract
Refract Surg 2020;46:179–187

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2. Tassingon MJ, Veva de Groot, Vrensen GF. Bag-in-the-lens implantation of intraocular lenses. J Caract Refract Surg 2002;28:1182–1188
3. Masket S, Fram NR, Cho A, et alet al. Surgical management of negative
dysphotopsia. J Cataract Refract Surg 2018;44:6–16
4. Nishi O, Sakka Y. Anterior capsule-supported intraocular lens. A new lens forsmall-incision surgery and for sealing the capsular opening. Graefes Arch ClinExp Ophthalmol 1990;228:582–588

Disclosures: None of the authors has a financial or proprietaryinterest in any material or method mentioned.
Reply: We thank the correspondent for taking
the time to remind us of capsular bag refilling as
an aspirational technique for creation of an accommodating pseudophakic IOL. Capsular bag refilling withsilicone polymers is an attractive option for restoring
accommodation. An optical element could be used bothto seal the capsular bag by closing the capsulorhexis
opening and as a lens that moves in an anterior–posterior
axis with the polymer lens shape change giving a powershift for near focusing. Various techniques have been
described for capsular bag refilling, but all have been
limited by their inability to give a predictable refractive
outcome and the loss of accommodative effect with capsularfibrosis.
The Femtis capsule-fixated extended depth-of-focus IOL(Oculentis) uses static optical principles to give the IOL extended range of focus. This avoids the vagaries of the changing
anatomy of the eye postoperatively with the inevitable capsular fibrotic stiffening and allows predictable refractive
outcomes. Attachment of the Femtis IOL to the anterior
capsulorhexis is designed not to seal the capsular bag but tominimize the chance of capsular bag syndrome, and thisprinciple of enclavation would not be appropriate for capsularbag refilling techniques. Lens development remains one of themost exciting areas of prosthesis research in medicine, andeach design adds to our ability to optimize outcome andpredictability of quality vision for our patients.—Erica
Darian-Smith, MBBS MMed, Patrick Versace, FRANZCO

Ophthalmic Photographers’ Society Exhibit, May 2019
Category: Slitlamp Photography—Honorable Mention

INTRALENTICULAR METALLIC BODYThe OPS annual exhibit, presented during the ASCRS • ASOA
Annual Meeting, is sponsored by the ASCRS. Publishedwith the permission of the photographer.

Nicole Mantel
Inselspital, BernBern, Switzerland

Volume 46 Issue 7 July 2020
Copyright © 2020 Published by Wolters Kluwer on behalf of ASCRS and ESCRS. Unauthorized reproduction of this article is prohibited.