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Cataract

Source: J Cataract Refract Surg 
Evaluation of the safety of prophylactic intracameral moxifloxacin in cataract surgery


PURPOSE: To evaluate posterior and anterior segment safety of an intracameral injection of moxifloxacin 0.5% ophthalmic solution as prophylaxis for endophthalmitis in patients having cataract surgery.

SETTING: Three private practices, the University of Minnesota School of Medicine, Stillwater, Minnesota, and the University of Cincinnati, Cincinnati, Ohio, USA.

METHODS: In this prospective randomized combined-center open-label trial, 57 eyes of 47 patients were treated with intracameral moxifloxacin (250 mug/0.050 mL) or an equal volume of balanced salt solution at the conclusion of cataract surgery with intraocular lens implantation. Safety parameters, including visual acuity, intraocular pressure, endothelial cell counts, corneal pachymetry, corneal clarity and edema, and anterior chamber cells and flare, were evaluated preoperatively and for 3 months postoperatively.

RESULTS:
Optical coherence tomography results showed no statistically significant differences between the 2 treatment groups preoperatively or at 3 months. There were also no statistically significant differences between the 2 treatment groups in all other parameters preoperatively or at 1 day, 2 to 4 weeks, or 3 months. No study-related adverse events occurred.

CONCLUSION:
There was no increased safety risk associated with a 250 mug/0.050 mL intracameral injection of moxifloxacin, which appears to be safe in the prophylaxis of endophthalmitis after cataract surgery.
 
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Source: J Cataract Refract Surg 
Third- and fourth-generation fluoroquinolones: Retrospective comparison of endophthalmitis after cataract surgery performed over 10 years


PURPOSE: To determine differences in endophthalmitis rates with prophylactic use of third- versus fourth-generation fluoroquinolones in cataract surgery.

SETTING: University hospitals.

METHODS
: This retrospective cross-sectional (prevalence) study looked at patients who had phacoemulsification at a university eye center over a 10-year period. A nosocomial infectious reporting database was used to report endophthalmitis occurrences. The following were performed: a retrospective analysis of prospectively collected data to establish endophthalmitis rates, a prevalence analysis of the postoperative quinolone antibiotic prescribed, and a comparative analysis of endophthalmitis rate versus postoperative quinolone prescribed for all reported endophthalmitis cases. The main outcome measure was occurrence of endophthalmitis after cataract surgery.

RESULTS:
From January 1997 to December 2007, 29276 patients had phacoemulsification cataract surgery. Forty cases of postoperative bacterial endophthalmitis were reported. The endophthalmitis rate from January 1997 to August 2003 associated with use of third-generation fluoroquinolones (ciprofloxacin, ofloxacin) was 0.197% (33/16710). The rate from September 2003 to December 2007 associated with fourth-generation fluoroquinolones (gatifloxacin, moxifloxacin) was 0.056% (7/12566). The difference between third- and fourth-generation drugs was statistically significant (P = .0011). Of fourth-generation fluoroquinolone infections, 0.015% (1/6651) and 0.1% (6/5915) were associated with gatifloxacin and moxifloxacin, respectively. The difference between drugs was statistically significant (P = .040).

CONCLUSIONS: The differences in the pharmacokinetic and pharmacodynamic properties of quinolone antibiotics may affect the endophthalmitis incidence after cataract surgery. The significant difference in endophthalmitis rates between gatifloxacin and moxifloxacin requires further study.
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IOL Options for Patients Undergoing Cataract Surgery :
Achieving Spectacle Independence With Intraocular Lenses in the 21st Century

James E. McDonald, MD; David J. Deitz, MPhil / Medscape Ophthalmology

Background

The aging of the population means a big increase in the number of people who have developed and will develop cataracts -- and a consequent increase in the demands on the ophthalmic surgeon. Moreover, the success of refractive surgery has created an awareness of and expectation for spectacle independence following cataract surgery. No longer simply satisfied with a return to unobstructed vision, cataract patients are increasingly demanding near 20/20 vision, as well as expecting good distance vision -- all without using spectacles or contact lenses.

In addition to these needs, the evolving technology and work and cultural needs of the 21st century have changed the paradigm of what outcomes are most desired from lens replacement surgery. One change in particular is the new-found importance of "intermediate vision." As computers, personal device assistants (PDAs), and other handheld or arms-length technologies become more prominent for work and social networking, I have increasingly seen patients requesting intermediate vision at the expense of near vision. This preference represents a stark transition from a prioritization of near, low-field vision -- such as that that results from bifocals -- that sufficed when books and printed material dominated our near experience.

Concurrent to changing patient demands is an increased repertoire of tools available to the cataract surgeon. Although a select field of ophthalmologists had been working with the refractive mentality and skill set for 10 years or more, it was the medical industry itself that created new intraocular lens (IOL) designs that created the push toward spectacle-free independent cataract surgery. In addition to clear corneal wounds and the modern fluidics of today's phacoemulsification machines, the patient's surgical experience has metamorphosed from one of a significant disturbance and long recovery to what now is a 15-minute procedure with minimal recovery downtime. Increasingly accurate predictability of needed IOL power has resulted from the refinement of biometrics of eye measurements with the IOLMaster and Immersion A-scan (Carl Zeiss, Jena, Germany). The improvements in viscoelastics, which protect the anterior chamber during IOL surgery, and the processes for measuring corneal topography have also led to safer and more accurate procedures.

However, at the heart of the transition to spectacle independence is the development of a new generation of IOLs. What follows is a discussion of the currently available IOLs, along with some of their benefits and drawbacks, based on the available research and on the author's clinical experience.

Monofocal IOLs
Monofocal IOLs are the oldest version of pseudophakic lens replacement and are still considered the standard. Traditional bilateral lens replacement with monofocal IOLs produces excellent distance vision but a loss in the ability of patients to accommodate for near vision, often resulting in patient dissatisfaction and the necessity of reading glasses.[1,2] More recently, the advent of aspheric IOLs has enhanced the quality of visual outcome for monofocals. Conventional IOLs have been shown to contribute to significantly higher-order aberrations as a result of implantation, especially due to positive spherical aberrations.[3] Although the young human crystalline lens tends to have a negative spherical aberration, conventional IOLs possess positive spherical aberration proportional to IOL strength.[4] The result is an increase in overall spherical aberrations that degrade the final image.[5]

Indeed, positive spherical aberration induces a myopic shift away from the naturally prolate shape of the cornea, causing reduced contrast sensitivity and the presence of glare and halos.[6] In addition, spherical aberration reduces the quality of scotopic vision.[7] An aspheric IOL removes the added gain in spherical aberration, preserving the natural spherical dimensions of the eye and resulting in more predictable outcomes. Studies have demonstrated that aspheric lenses produce better best-corrected visual acuity and contrast sensitivity than conventional IOLs.[8,9]

Monovision and the Return of the Monofocal Approach
According to the annual American Society of Cataract and Refractive Surgery (ASCRS) members' surveys from 2002 and 2003,[10,11] monovision is the most common surgical approach to spectacle independence currently employed in the United States. According to those surveys, 56% and 55% of surgeons, respectively, thought that monovision was the best surgical approach to presbyopia, whereas another 32% and 31% thought that a modified monovision approach (-0.5D to -1.0D in the nondominant eye) was preferred. Although I suspect that these figures have decreased slightly in the past few years with the advent of new-generation IOLs, it is reasonable to assume that monovision is still the preferred approach. (Recent changes to the ASCRS survey have cataloged the data in different ways.)

Monovision, which involves a defocusing of one of the lenses of the eyes, was developed in response to the limitations of standard bilateral lens replacement with monofocal IOLs (a loss in the accommodative ability of patients for near vision).[12,13] In monovision, a slight defocus is applied to one of the 2 eyes, whereas the other is corrected for normal distance during monofocal IOL implantation. Currently, most surgeons correct the patient's dominant focal eye for distance vision and the nondominant eye for near. Although this technique produces only slight losses in distance vision, it greatly improves the patient's ability to see objects at close range.[14,15] "Monovision" is actually a poor term because both eyes are fixated and fusing on the same image. The only difference in the 2 images is the absence of some of the higher spatial frequencies in the not perfectly focused distanced eye.

The emergence of the aspheric lens offers an improved tool for giving patients monovision with lower amounts of defocus. I prefer using aspheric lenses for my monovision patients because not only is the modulation transfer function better in the regarding eye, but there is minimal falloff of the modulation transfer function within the first diopter of defocus.[16] As a result, high-quality binocular vision is maintained throughout the range of vision. In a recent study of our patients with bilateral lens replacement using an aspheric IOL with monovision, 100% had 20/30 or better bilateral distance vision and 73% were 20/20 or better. Concerning near vision, 88% had J2 or better bilateral visual acuity, whereas 48% had J1 or better.[17] Additionally, none of our patients used spectacles for intermediate vision.

Accommodative IOLs
Accommodative IOLs, a new option for lens exchange, are the fastest growing approach to presbyopic IOL use. Although lenses with different mechanisms are in development, the Crystalens IOL (eyeonics, Aliso Viejo, California) is the only currently available accommodative IOL in the United States.[18] In some studies, it has demonstrated an ability to contribute on average 2 diopters of the lens' natural accommodative power.[19] Indeed, accommodative lenses are designed to mimic the natural lens' ability to move between distance, near, and intermediate vision, and both eyes can be corrected for full distance vision, yet retain the ability to achieve adequate near vision. Some studies of the Crystalens IOL have demonstrated the anterior displacement of the lens in vivo accompanied by rotation of the ciliary body, indicating true accommodation.[20] As with monofocal lenses, light rays are not split and all of the advantages of monofocality are preserved. This benefit is one that is shared with monovision, but with accommodative effect, more total spatial frequencies can be achieved at all distances of effect.

Although, as mentioned above, some studies suggest that 2 diopters of accommodation may be achieved with accommodative lenses, I have found a more realistic result in practice to be somewhere between 0.75 and 1.25 diopters of accommodative effect. The just approved Crystalens HD (high definition), introduced in July 2008, has shown a greater increase of J1 while preserving high-quality distance vision. It certainly will improve our outcomes, and I predict an even faster growth in this arena.

My patients seem to have a variation in their accommodative response to the Crystalens, with some achieving good accommodation but others not. Because the Crystalens IOL has movement, its exact position in the capsular bag is slightly less predictable. The practical result of such movement is a less predictable power outcome, meaning that patients can easily be slightly over- or undercorrected. To overcome this situation, I as well as many others suggest using the Crystalens in a modified "mini-monovision" fashion. By separating the powers of the 2 IOLs by 0.75-1.00 diopter and targeting the minus side of correction, my patients are rewarded with a more comprehensive range of near vision, with excellent distance and near vision while maintaining near full fusion and stereopsis throughout their range of vision. In a recent, unpublished study of my patients using this mini-monovision approach with bilateral Crystalens IOLs, 84% had 20/20 or better bilateral distance vision (97% 20/30 or better), whereas 65% had J2 or better bilateral near vision (90% J3 or better). The new HD should markedly improve these good results while retaining the excellent quality of vision that I expect because of its non-multifocal optics.

If a patient ends up with more near acuity at the expense of their ability to see at a distance, slightly reducing the minus can be easily achieved with a minimal refractive procedure to achieve a spot on bilateral distance and near acuities. I currently use a minimal radial keratotomy or corneal relaxing incision approach as my final enhancement, although laser vision can also be employed.

Multifocal IOLs

Multifocal IOLs are another type of IOL option. They employ various optical techniques to divide the lens into different zones that provide simultaneous distance, intermediate, and near vision to each
Eye.[21] Multifocal IOLs have demonstrated improved results over standard implantation of monofocal IOLs for near and distance vision, as well as spectacle independence.[22-26] This result is positively received by patients because the range of possible vision simulates prepresbyopic vision.[27] However, because of the uniocular multi-image, some ultimate loss of contrast sensitivity as well as glares and halos can lower the perceived and real quality of vision. This result may lead to disappointment in outcome for some patients. Fortunately, most patients adapt, but for some, the only solution to the disturbance is explantation.

The ReZoom IOL (AMO, Santa Ana, California) uses a concentric series of lenses to achieve a multilayered refractive effect. Focal distances dependent on pupil size are superimposed, giving rise to expansion of its range. At its central 2.3-mm zone, the patient sees only distance in bright light, thus producing excellent vision for outdoor distance, with an okay reading and good intermediate vision in dim illumination.[28] A detracting issue with this lens is that it is very pupil-dependent on function; if the patient has a relatively small, poorly reactive pupil, the multifocal potential is lost.[29,30] The other disadvantage is that nighttime halos can be an issue for some patients.[31-34]

The ReSTOR IOL (Alcon, Fort Worth, Texas) is a multifocal diffractive lens that promotes good near vision, with a center +4.50 diffractive zone that allows for good near acuities in normal-to-bright light. However, the intermediate vision distances suffer.[35] In my opinion, most of today's active patients enjoy the intermediate computer and PDA distances and may complain of this shortfall.[36] In addition, the bright outdoor scenario sometimes presents an issue with "waxylike vision." I believe that this phenomenon results from the almost even split of near-far focus at a 2.3-3.0 pupil size. Consequently, the blurred, near-image, lower spatial frequencies tend to "blur the sharpness" of the overall perceived image; the splitting of the light as well results in a lower contrast sensitivity.[37-41]

As a result of the drawbacks of each approach, the mixing or matching of these multifocal strategies has become popular. In preliminary studies, using the more distant-dominant ReZoom multifocal in the dominant eye and the more near-dominant ReSTOR in the near eye produces better intermediate vision than bilateral implementation of either, and near vision statistically equivalent to bilateral ReSTOR implementation.[42,43]

Astigmatism
I must stress that a significant tool in the presbyopic tool belt is the control of pre- and postoperative astigmatism. I prefer to handle this condition with corneal relaxing incisions. Because I grew up in the world of incisional surgery, this tool is an automatic one for me. To accommodate for astigmatism, I keep my calculations slanted to the myopic side of outcome. All incisional surgery works by relaxation of the corneal collagen. Relaxation causes flattening, so if the patient is always left on the minus side of cylinder or sphere, he/she is optionally positioned for incisional tune-ups of the refraction without making the patient hyperopic. For most patients, using astigmatic arcs, whether at the limbus as suggested by many or somewhat more centrally in the 8-mm zone, results in small amounts of myopic coupling. When more minus is needed, I occasionally use a 2- or 4-incision mini-radial keratotomy as my final refractive remedy.

Laser surgery can be used for these refractive tweaks and tune-ups, but they are, I find, financially and time-consuming burdens for the patient as well as the surgeon. Further, many of our patients in the cataract age group have accompanying dry eyes. This fact sways me toward the use of incisional corrections over that of a laser. Future laser algorithms may make the post-IOL tune-ups more effective and desirable.

Conclusion
All of the above strategies, when coupled with surgical skills and knowledge of how to handle each individual patient, make for a very satisfying practice. The delivery of this spectacle-independent "menu" requires that not only the surgeon but the entire staff understand the total picture of how each surgeon prefers to reach the endpoint of spectacle independence, and how to prepare and comfort the patient toward that end without confusing the patient with too many choices.

The good news is that spectacle independence is reachable. Like any destination I would like to stress that there are several avenues to get there. Some surgeons and their staff prefer the journey to go through the multifocal channel. Some surgeons prefer to travel the avenue of monofocal. A growing number of surgeons prefer the accommodative Crystalens highway. In my opinion, the just released Crystalens HD will continue to attract more patients and surgeons to this modality. What we must appreciate is that they can all be successful but all demand a high level of skill, commitment, and understanding of the modern refractive cataract patient.

References
1- Nijkamp MD, Dolders MGT, de Brabander J, et al. Effectiveness of multifocal intraocular lenses to correct presbyopia after cataract surgery: a randomized controlled trial. Ophthalmology. 2004;111:1832-1839. Abstract
2- Leyland MD, Langan L, Goolfee F, et al. Prospective randomised double-masked trial of bilateral multifocal, bifocal or monofocal intraocular lenses. Eye. 2002;16:481-490. Abstract
3- Padmanabhan P, Yoon G, Porter J. Wavefront aberrations in eyes with Acrysof monofocal intraocular lenses. J Refract Surg. 2006;22:237-242. Abstract
4- Barbero S, Marcos S, Jimenez-Alfaro I. Optical aberrations of intraocular lenses measured in vivo and in vitro. J Opt Soc Am A Opt Image Sci Vis. 2003;20:1841-1851. Abstract
5- Iseli HP, Jankov M, Bueeler M, et al. Corneal and total wavefront aberrations in phakic and pseudophakic eyes after implantation of monofocal foldable intraocular lenses. J Cataract Refract Surg. 2006;32:762-771. Abstract
6- Dick HB, Krummenauer F, Schwenn O, et al. Objective and subjective evaluation of photic phenomena after monofocal and multifocal intraocular lens implementation. Ophthalmology. 1999;106:1878-1886. Abstract
7- Tahzib NG, Bootsma SJ, Eggink FA, et al. Functional outcome and patient satisfaction after Artisan phakic intraocular lens implantation of the correction of myopia. Am J Ophthalmol. 2006;142:31-39. Abstract
8- Belucci R, Scialdone A, Buratto L. Visual acuity and contrast sensitivity comparison between Tecnis and AcrySof SA60AT intraocular lenses: a multicenter randomized study. J Cataract Refract Surg. 2005;31:712-717. Abstract
9- Marcos S, Barbero S, Jimenez-Alfaro I. Optical quality and depth-of-field of eyes implanted with spherical and aspheric intraocular lenses. J Refract Surg. 2005;21:223-235. Abstract
10- Leaming D. Practice styles and preferences of ASCRS members-2003 survey. J Cataract Refract Surg. 2004;30:892-900. Abstract
11- Leaming D. Practice styles and preferences of ASCRS members-2002 survey. J Cataract Refract Surg. 2003;29:1412-1420. Abstract
12- Nijkamp MD, Dolders MGT, de Brabander J, et al. Effectiveness of multifocal intraocular lenses to correct presbyopia after cataract surgery: a randomized controlled trial. Ophthalmology. 2004;111:1832-1839. Abstract
13- Leyland MD, Langan L, Goolfee F, et al. Prospective randomised double-masked trial of bilateral multifocal, bifocal or monofocal intraocular lenses. Eye. 2002;16:481-490. Abstract
14- Boerner CF, Thrasher BH. Results of monovision correction in bilateral pseudophakes. J Am Intraocul Implant Soc. 1984;10:49-50. Abstract
15- Greenbaum S. Monovision pseudophakia. J Cataract Refract Surg. 2002;28:1439-1443. Abstract
16- Holladay JT, Piers PA, Koranyi G, van der Mooren M, Norrby NE. A new intraocular lens design to reduce spherical aberration of pseudophakic eyes. J Refract Surg. 2002;18:683-691. Abstract
17- McDonald JE, Deitz DJ. Monovision with aspheric IOLs. In: Chang D, Ed. Mastering Refractive IOLs: The Art and the Science. Thorofare, NJ: SLACK; 2008.
18- Dick HB. Accomodative intraocular lenses: current status. Curr Opin Ophthalmol. 2005;16:8-26. Abstract
19- Macsai MS, Padnick-Silver L, Fontes BM. Visual outcomes after accommodating intraocular lens implantation. J Cataract Refract Surg. 2006;32:628-633. Abstract
20- Marchini G, Pedrotti E, Sartori P. Ultrasound biomicroscopic changes during accommodation in eyes with accommodating intraocular lenses: pilot study and hypothesis for the mechanism of accommodation. J Cataract Refract Surg. 2004;30:2476-2482. Abstract
21- Bellucci R. Multifocal intraocular lenses. Curr Opin Ophthalmol. 2005;16:33-37. Abstract
22- Nijkamp MD, Dolders MGT, de Brabander J, et al. Effectiveness of multifocal intraocular lenses to correct presbyopia after cataract surgery: a randomized controlled trial. Ophthalmology. 2004;111:1832-1839. Abstract
23- Leyland MD, Langan L, Goolfee F, et al. Prospective randomised double-masked trial of bilateral multifocal, bifocal or monofocal intraocular lenses. Eye. 2002;16:481-490. Abstract
24- Javitt JC, Wang F, Tretacost DJ, et al. Outcomes of cataract extraction with multifocal intraocular lens implantation: functional status and quality of life. Ophthalmology. 1997;104:589-599. Abstract
25- Javitt J, Brauweiler HP, Jacobi KW, et al. Cataract extraction with multifocal intraocular lens implantation: clinical, functional, and quality-of-life outcomes. Multicenter clinical trial in Germany and Austria. J Cataract Refract Surg. 2000;26:1356-1366. Abstract
26- Elgohary MA, Beckingsale AB. Effect of illumination of visual function after monofocal and intraocular lens implantation. Eye. 2006;20:144-149. Abstract
27- Walkow T, Klemen UM. Patient satisfaction after implantation of diffractive designed multifocal intraocular lenses in dependence on objective parameters. Graefes Arch Clin Exp Ophthalmol. 2001;239:683-687. Abstract
28- Chiam PJ, Chan JH, Haider SI, Karia N, Kasaby H, Aggarwal RK. Functional vision with bilateral ReZoom and ReSTOR intraocular lenses 6 months after cataract surgery. J Cataract Refract Surg. 2007;33:2057-2061. Abstract
29- Hayashi K, Hayashi H, Nakao F, Hayashi F. Correlation between pupillary size and intraocular lens decentration and visual acuity of a zonal-progressive multifocal lens and a monofocal lens. Ophthalmology. 2001;108:2011-2017. Abstract
30- Artigas JM, Menezo JL, Peris C, Felipe A, Diaz-Llopis M. Image quality with multifocal intraocular lenses and the effect of pupil size: comparison of refractive and hybrid refractive-diffractive designs. J Cataract Refract Surg. 2007;33:2111-2117. Abstract
31- Choi J, Schweigerling J. Optical performance measurement and night driving simulation of ReSTOR, ReZoom, and Tecnis multifocal intraocular lenses in a model eye. J Refract Surg. 2008;24:218-222. Abstract
32- Pepose JS, Qazi MA, Davies J, et al. Visual performance of patients with bilateral vs combination Crystalens, ReZoom, and ReSTOR intraocular lens implants. Am J Ophthalmol. 2007;144:347-357. Abstract
33- Chang D. Prospective functional and clinical comparison of bilateral ReZoom and ReSTOR intraocular lenses in patients 70 years or younger. J Cataract Refract Surg. 2008;34:934-941. Abstract
34- Hayashi K, Hayashi H, Nakao F, Hayashi F. Correlation between pupillary size and intraocular lens decentration and visual acuity of a zonal-progressive multifocal lens and a monofocal lens. Ophthalmology. 2001;108:2011-2017. Abstract
35- Pepose JS, Qazi MA, Davies J, et al. Visual performance of patients with bilateral vs combination Crystalens, ReZoom, and ReSTOR intraocular lens implants. Am J Ophthalmol. 2007;144:347-357. Abstract
36- Blaylock JF, Si Z, Vickers C. Visual and refractive status at different focal distances after implantation of the ReSTOR multifocal intraocular lens. J Cataract Refract Surg. 2006;32:1464-1473. Abstract
37- Chiam PJ, Chan JH, Aggarwal RK, et al. ReSTOR intraocular lens implantation in cataract surgery: quality of vision. J Cataract Refract Surg. 2006;32:1459-1463. Abstract
38- Souza CE, Muccioli C, Soriano ES, et al. Visual performance of AcrySof ReSTOR apodized diffractive IOL: a prospective comparative trial. Am J Ophthalmol. 2006;141:827-832. Abstract
39- Rocha KM, Chalita MR, Souza CE, et al. Postoperative wavefront analysis and contrast sensitivity of a multifocal apodized diffractive IOL (ReSTOR) and three monofocal IOLs. J Refract Surg. 2005;21:S808-812. Abstract
40- Javitt JC, Steinert RF. Cataract extraction with multifocal intraocular lens implantation: a multinational clinical trial evaluation clinical, functional, and quality-of-life outcomes. Ophthalmology. 2000;107:2040-2048. Abstract
41- Pepose JS, Qazi MA, Davies J, et al. Visual performance of patients with bilateral vs combination Crystalens, ReZoom, and ReSTOR intraocular lens implants. Am J Ophthalmol. 2007;144:347-357. Abstract
42- Evans RE, Bucci FA Jr. Bilateral multifocal cataract and lensectomy patients receiving ReZoom/ReSTOR vs. ReSTOR/ReSTOR -- long term follow-up. Program and abstracts of the Association for Research in Vision and Ophthalmology 2007 Annual Meeting; May 6-10, 2007; Fort Lauderdale, Florida. Abstract 3121.
43- Akaishi L, Fabri PP. PC IOLs mix and match technologies: Brazilian experience. Program and abstracts of the 2006 World Ophthalmology Congress; February 19-24, 2006; Sao Paulo, Brazil.
 
 
 

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