Incidence of Dislocation of Intraocular Lenses and Pseudophakodonesis 10 Years after Cataract Surgery

Eva I. Mnestam, MD, PhD

Purpose: To estimate the incidence of early and late intraocular lens (IOL) dislocation and the frequency of pseudophakodonesis in a population-based cohort of cataract surgery cases. The patients were followed up from before to 10 years after surgery. Design: Cohort study. Participants: Eight hundred ten cataract surgery patients. Methods: A prospective population-based cohort of 810 cataract surgery patients with presenile or senile cataracts was examined before surgery. Ten years later, 289 (73%) of 395 survivors agreed to participate in an eye examination. In addition to a routine eye examination of the anterior and posterior segment, all eyes were assessed for pseudophakodonesis and signicant dislocation of the IOL. The medical records were studied and information concerning previous postoperative surgical interventions such as IOL exchange or repositioning was noted. This information was also obtained from the records of the deceased patients and those unable or unwilling to participate. The material was analyzed statistically. Main Outcome Measures: Previous IOL exchange or repositioning surgery, signicant IOL dislocation, and degree of pseudophakodonesis. Results: Most patients (n 795/810; 98%) underwent sutureless clear corneal phacoemulsication surgery with a 3.2-mm temporal incision. A foldable IOL was implanted, 95% of which were an Alcon MA60BM AcrySof (Alcon Inc, Fort Worth, TX). Approximately 40% of the patients had pseudoexfoliations (PEX). After a 10-year follow-up, 5 (0.6%) of the 800 patients at risk required surgery for a dislocated IOL. All of these patients were male, and in all cases, the dislocation was late and within the capsular bag. The cumulative incidence over 10 years was 1%. At the examination 10 years after surgery, 2 (0.7%) of 287 patients at risk had pronounced pseudophakodonesis and 4 (1.4%) had moderate pseudophakodonesis. Conclusions: The 10-year cumulative incidence of dislocated IOLs needing surgical attention was low in this population-based cohort with a high frequency of PEX. Early dislocation did not occur in any of the patients. The risk of this complication in an individual patient seems to be low. Because of the large number of people with previous cataract surgery, dislocated IOLs may cause a relatively large public health care burden. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Ophthalmology 2009;116:23152320 2009 by the American Academy of Ophthalmology.

Posterior chamber intraocular lens (IOL) dislocation or decentration is a well-known complication of cataract surgery, but the exact incidence is not known.1 A retrospective survey published in 2005 indicated that approximately 0.3% required subsequent IOL exchange resulting from IOL dislocation.2 Most cases of early IOL dislocation occur in the rst week after cataract surgery.1 In these cases, the major cause is inadequate support for the IOL resulting from zonular or capsular damage, rupture, or both.3,4 Late IOL dislocation is dened as occurring 3 months or more after cataract surgery and has been reported with increasing frequency in recent years.1,5 Both the relatively long time frame for the presentation of this complication and the large number of people who have undergone cataract surgery have led to concerns of an impending epidemic of IOL dislocations.6 8 Late dislocations are associated with trauma9 or silicone plate IOLs passing through capsular defects, or as a result of progressive zonular dehiscence caused by contraction
2009 by the American Academy of Ophthalmology Published by Elsevier Inc.

of the capsular bag6 many years after an uneventful surgery. The risk for capsule contraction syndrome and zonular weakness seems to be greater in elderly patients.10 Other predisposing factors include pseudoexfoliation syndrome (PEX),7,11,12 high myopia, retinitis pigmentosa,11 myotonic dystrophy, certain connective tissue disorders (i.e., Marfans syndrome), homocystinuria, hyperlysinemia, Ehlers-Danlos syndrome, scleroderma, Weill-Marchesanis syndrome, and previous vitreoretinal surgery.11,13,14 A dislocated IOL often requires explantation or repositioning because of potential complications such as retinal tears, rhegmatogenous retinal detachment, and vitreous hemorrhage.1,14 The purpose of this study was to estimate the cumulative incidence of IOL dislocation, the rate of pseudophakodonesis, and signicant IOL decentration in a population-based cohort of cataract surgery cases, of which 95% received implantation of a 3-piece hydrophobic acrylic IOL. The patients were followed up from before to 10 years after surgery.
ISSN 0161-6420/09/$see front matter doi:10.1016/j.ophtha.2009.05.015

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Table 1. The Type of Cataract Surgery Performed and Intraocular Lens Implanted at Surgery
Type of Surgery Sutureless clear corneal phacoemulsication with 3.2-mm temporal incision and a foldable IOL As above but with an incision of 5.5 to 6 mm (PMMA IOL) Phacoemulsication surgery converted to ECCE Sclerally sutured IOL because of insufcient capsular support ICCE with no IOL ICCE anterior chamber IOL ECCE anterior chamber IOL Total No. of Patients 790 8 2 4 2 2 2 810 % 97.5 1 0.25 0.5 0.25 0.25 0.25 100

Patients underwent the same eye examination as that performed 10 years previously. In addition, the centration of the IOL was assessed and graded using the pupil as a reference. A decentration of at least 2 mm in any direction was classied as signicant. If there were no obvious signs of pseudophakodonesis, the patients were asked to gaze upward quickly, to wait 5 seconds, and then to gaze downward quickly to induce movements of the IOL. Pseudophakodonesis was assessed by 1 surgeon (EIM) as none, slight or minor (barely discernible), moderate (obvious), or pronounced (looks like it will immediately drop into the vitreous). The records of all 810 patients were checked to determine if any IOL exchange or repositioning surgery had been performed in the 10 years since the surgery.

Statistical Methods
Independent sample t tests were used to compare age-differences between groups. The Fisher exact test was used to analyze the 2-by-2 and 2-by-4 tables regarding the frequency of PEX and need for additional surgery as determined by a surgeon. A chi-square test for trends was used to assess gender-related differences in the degree of pseudophakodonesis. A life table calculation was made to estimate the 10-year cumulative incidence of IOL dislocation requiring surgical attention. Statistical analyses were performed using SPSS software version 17.0 (SPSS, Inc., Chicago, IL).

ECCE extracapsular cataract extraction; ICCE intracapsular cataract extraction; IOL intraocular lens; PMMA polymethyl methacrylate (rigid IOL).

Methods
Patient Cohort 19971998
A total of 898 patients with presenile and senile cataracts who underwent cataract surgery between June 1, 1997, and May 31, 1998, at Norrlands University Hospital in Ume, Sweden, were registered prospectively. Patients who underwent cataract surgery for reasons other than restoring vision or who had surgery combined with other types of ocular surgery were excluded (n 38). Seventeen patients who died before the rst follow-up at approximately 1 month after surgery and 1 patient scheduled before surgery for cataract surgery without IOL implantation also were excluded. Thirty-two patients were lost to follow-up or declined to participate. Therefore, the study included a total of 810 patients. Patients who had undergone surgery in both eyes during the period studied were included as 1 cataract patient, and data from only the rst surgery were included in the analysis. Because of the Swedish Social Security regulations, patients seldom crossed county borders to obtain treatment during the study period. Therefore, the number of residents who underwent surgery in other districts was negligible. All cataract surgeries in the study population were performed at the university clinic, because there are no other public or private eye clinics performing cataract surgery in the area. Four different surgeons performed all the operations. Informed consent was obtained from all patients. The study followed the tenets of the Declaration of Helsinki and was approved by the local ethics committee.

Results
Type of Surgery and Intraocular Lens Implanted
The type of cataract surgery performed is shown in Table 1. Eleven (1.4%) of the 790 patients who had undergone sutureless clear corneal phacoemulsication and had a foldable IOL implanted also had a capsular tension ring (CTR) implanted. The CTR implantation was performed routinely when judged necessary by the surgeon, i.e., for intraoperative zonular weakness or zonular rupture to such a degree that the future stability of the IOL was believed

Table 2. The Distribution of the Intraocular Lenses Implanted

Type of Intraocular Lens Alcon MA60BM (AcrySof)( )* Alcon MA30BA* Alcon LX90BD* Pharmacia 757C Pharmacia 911A Pharmacia 812A Pharmacia 722A Pharmacia 812C Pharmacia 352C (anterior chamber lens) Corneal ACR6D Storz H50M Alcon CZ70BD (sutured) No IOL Missing data Total No. of Patients 771 1 1 6 2 1 1 1 4 5 4 4 2 7 810 % 95.2 0.1 0.1 0.8 0.2 0.1 0.1 0.1 0.5 0.6 0.5 0.5 0.2 1.0 100

Preoperative and Postoperative Examination

A few weeks before surgery, all patients underwent a routine eye examination with dilation. The presence of any ocular comorbidity or past surgery was recorded. Approximately 1 month after surgery, the eye examination was repeated.

Data Collected 10 Years after Surgery

Ten years after surgery, 415 (51%) of the 810 patients were deceased. All survivors (n 395) were offered an eye examination and 289 (73%) participated. Forty-one were unable to participate because of dementia (10%), 54 (14%) declined participation, and 11 (3%) could not be located.

IOL intraocular lens. *Alcon, Inc, Fort Worth, TX. Abbott Medical Optics Inc, Santa Ana, CA. Corneal Laboratories Paris, Chroma Pharma GmbH, Korneuburg, Austria. Bausch & Lomb, Storz Ophthalmics Inc, Heidelberg, Germany.

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Dislocation of IOLs 10 Years after Surgery

these dislocations were within the capsular bag. One patient with late dislocation had a CTR implanted during the primary surgery. The cumulative incidence over 10 years was estimated to be 1% (Fig 2). Details of the demographic and clinical patient data for those having surgery for IOL dislocation are shown in Table 3. The mean age of the patients with an in-the-bag dislocation (74.4 years) was not signicantly different from that of the total group of patients (74.7 years; P 0.82). The presence of PEX was more common, but the difference was not signicant (80% vs. 39%; P 0.08). There was no signicant difference between the 4 surgeons in the number of patients needing additional surgery (P 0.77, data not shown). The time lapse from cataract surgery to the date of IOL exchange or repositioning ranged from 36 to 108 months (mean, 76 months). None of the patients had a history of ocular trauma before or after surgery. The IOL was repositioned with scleral xation in 1 eye. In 4 eyes, the IOL had dislocated into the vitreous cavity and was replaced with a sclerally xated posterior chamber IOL. Postoperative best-corrected visual acuity ranged from 20/33 to 20/21. One patient (patient 3) had an in-the-bag IOL dislocation of

to be at risk. Nine (82%) of these 11 patients had PEX, a significantly higher percentage than the 39% of the total group (P 0.005, Fisher exact test). Most of the patients (95%) were implanted with a 3-piece Alcon MA60BM AcrySof IOL (Table 2). The complication rates of posterior capsule rupture and vitreous loss were 4.9% and 2.7%, respectively. Four patients (0.5%) had an anterior chamber lens implanted. The size of the capsular opening was not measured during or after surgery, but none of the patients examined at 10 years had capsular contraction syndrome to such a degree that radial yttriumaluminum garnet laser anterior capsulotomy was indicated (an opening of 4 mm).

Incidence of Intraocular Lens Dislocation

Figure 1 shows a ow chart of the longitudinal 10-year outcome regarding IOL dislocation and pseudophakodonesis. Of the 800 patients at risk, 5 (0.6 %) had a late IOL dislocation that required surgical attention at some point after the initial surgery. All of

Figure 1. Flowchart showing the longitudinal 10-year outcome regarding intraocular lens (IOL) dislocation and pseudophakodonesis. Additional surgery refers to all types of IOL suturing and repositioning. ACL anterior chamber lens; CTR capsular tension ring; ECCE extracapsular cataract extraction; ICCE intracapsular cataract extraction; IOL intraocular lens.

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Discussion
Population-based studies with a 10-year follow-up are comparatively easy to perform in the Swedish health care system. At the time of the study, the risk of cataract patients being operated on outside of county borders was negligible. In studies to estimate the frequency of complications with a low incidence, it is important to obtain low numbers of dropouts to reduce the selection bias and to increase the validity of the results. The incidence of IOL exchange or repositioning as a result of dislocation or decentration 10 years after surgery was low in this population-based cohort with a high frequency of PEX. Most previous estimations of the incidence ranged between 0.2% and 3%, but most studies were published in 1995 or earlier, when a different cataract extraction technique was used.1517 A more recent retrospective study reported 19 cases (0.29%) of IOL exchange caused by decentration or dislocation in a total of 6630 cataract surgeries between 1998 and 2004.2 All patients included had at least a 3-month follow-up, and the time lapse from the initial implantation to IOL exchange was 1 to 180 months (mean, 65 months). The higher rate found in the present study may be explained by the longer follow-up time of 10 years and the addition of cases requiring IOL repositioning, that is, not only IOL exchange. The visual outcome after the second surgical procedure generally was good, which is consistent with previous studies.1,5 Previously, IOL dislocation typically occurred after decentration and migration of the lens through a rupture of the equatorial capsule or posterior capsulotomy.16 The major cause of early IOL dislocation currently is thought to be zonular rupture during surgery.12 None of the patients experienced an early dislocation, which is consistent with the observation that it now seems to be more common for the IOL to dislocate within an intact capsular bag.5,9 This trend

Figure 2. Graph showing the cumulative (Cum) 10-year odds of not needing surgical attention because of dislocation of the intraocular lens.

both eyes. Signicant decentration ( 2 mm) of the IOL was observed in 1% of the patients (4/287). In 283 (99%) of 287 patients, there was no signicant decentration.

Pseudophakodonesis Observed 10 Years after Surgery

Most (248/287; 86%) of the patients had no sign of pseudophakodonesis at the examination 10 years after surgery (Fig 1). Minor pseudophakodonesis was observed in 12% (33/287; 11 men and 22 women). Of 287 patients at risk, 4 (1.3%; 2 men and 2 women) had moderate and 2 (0.7%; both were women) had pronounced pseudophakodonesis. There was no signicant difference in degree of pseudophakodonesis or dislocation between men and women (P 0.28, chi-square for trend) if the analysis included those with no, minor, moderate, or pronounced pseudophakodonesis and the 2 patients examined who underwent additional surgery (Fig 1).

Table 3. Demographic and Clinical Data of the Patients with In-the-Bag Intraocular Lens Dislocation
Case No. 1 2 3 Age (yrs)* 80 75 72 Time from Surgery to Gender Dislocation M M M 9 yrs 2 mos 3 yrs 9 mos 4 yrs Predisposing Conditions (Diagnosis/Associated presentation) Myopia gravis (axial length, 28.63 mm) PEX PEX PEX asteroid hyalosis dislocated with CTR; bilateral case None known PEX Neodymium: Yttrium AluminumGarnet Posterior Capsulotomy No Yes No Intraocular Lens Type/Capsular Tension Ring? 1-piece PMMA Pharmacia 812A 3-piece Alcon MA60BM 3-piece Alcon MA60BM CTR Model x14 Morcher 3-piece Alcon MA60BM 3-piece Alcon MA60BM Final Visual Acuity 20/32 20/28 20/21

Surgical Intervention IOL exchange to sclerally sutured IOL IOL exchange to sclerally sutured IOL IOL exchange to sclerally sutured IOL vitrectomy IOL exchange to sclerally sutured IOL Reposition and suture of the original IOL

4 5

73 72

M M

6 yrs 3 mos 8 yrs 6 mos

No No

20/33 20/24

CTR capsular tension ring; F female; IOL intraocular lens; M male; PEX pseudoexfoliation; PMMA polymethyl methacrylate. All patients except case 1 underwent small-incision phacoemulsication (3.2 mm) with implantation of a foldable IOL. Case 1 had his incision enlarged to 5.5 mm because he needed a lens power of 8, which at the clinic at that time only was available in PMMA IOLs. *At the time of cataract surgery. Morcher GmbH, Stuttgart, Germany.

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currently no method available to detect past ocular trauma if the patient has entirely forgotten about it, nothing is found in the records, and there are no signs of ocular trauma noted at the eye examination. Pseudophakodonesis is observed only in eyes in which the IOL is located within the capsular bag. The presence of pseudophakodonesis is an obvious sign of marked zonular degeneration or trauma that precedes IOL dislocation.32 The number of patients with moderate to severe pseudophakodonesis was low, and there was no signicant difference between men and women regarding the degree of pseudophakodonesis. Little is known about the differences between moderate pseudophakodonesis and severe phacodonesis with respect to the time course for the progression to obvious dislocation requiring surgical attention. Further research in this eld clearly is warranted. A limitation of the study is that the size of the capsular opening was not recorded during or after surgery. A small capsular opening is believed to be a signicant factor in the presentation of capsular contraction syndrome, which in some cases precedes late IOL dislocation.1,11 When this study began in 1997, the knowledge of the mechanisms and the interest in late IOL dislocation were not as developed as they are now. This cohort of patients mostly received hydrophobic 3-piece acrylic IOLs; however, none who were examined 10 years after surgery had a capsular opening of less than 4 mm requiring yttriumaluminum garnet laser radial anterior capsulotomy. In conclusion, in-the-bag IOL dislocation or decentration is a late complication of cataract surgery that is more likely to happen in certain predisposed eyes. Prognosis after treatment generally is good. The cumulative incidence of IOL exchange or repositioning was low in this population with a high incidence of PEX and the use of mainly 3-piece hydrophobic acrylic IOLs, with a follow-up time of 10 years. The potential burden to society caused by dislocated IOLs is relatively large, however, because of the large number of people undergoing cataract surgery.

may be a result of the modern standard technique for cataract surgery with continuous curvilinear capsulorrhexis and in-the-bag placement of the IOL. The type of posterior chamber IOL may affect the risk for in-the-bag IOL dislocation. A 1-piece polymethyl methacrylate IOL with rigid haptics provides better centration in the bag compared with the 3-piece IOLs with exible haptics.11,12,18 One-piece polymethyl methacrylate IOLs also are believed to have greater resistance against the development of postoperative bag shrinkage and subsequent decentration.19 Among the various types of foldable IOLs, the acrylic hydrophobic IOL induces less capsule contraction, offers more resistance to contraction of the bag, or both compared with 1-piece acrylic IOLs.1,19,20 Most patients in the present study had a 3-piece hydrophobic acrylic IOL implanted (Alcon MA60BM; AcrySof), which may explain the comparatively low number of dislocations. Trauma and PEX are the most frequent predisposing conditions associated with IOL dislocation.1 Of the 5 cases that needed IOL exchange or repositioning in the present study, 4 had PEX, a long axis, or both. The percentage of cataract cases with PEX is high in many parts of the world. In our population from northern Sweden, 39% to 42% of cataract surgery cases have PEX.21 In PEX cases, it is important to be aware of the possibility of progressive loss of zonular integrity after surgery.7 Several reports recommend placing a CTR in the bag together with the IOL, in cases with zonular weakness.2224 In the present study, 11 (1.4%) of 800 patients had a CTR implanted during surgery, which is a low number considering the high frequency of PEX in the population. A CTR probably reduces, but does not prevent or eliminate, the degree of capsule contraction and spontaneous late IOL dislocation within the capsular bag.25,26 The CTR maintains the circular contour of the capsular bag and distributes forces circumferentially, which improves capsule xation and avoids focal stress on compromised zonulae.9,27 In the absence of signicant zonular dehiscence, routine CTR implantation in cases at risk is believed to reduce the incidence of postoperative IOL dislocation.1 Some surgeons have recommended implanting a CTR in all eyes with PEX,28,29 but the use of CTRs increases the cost of surgery. It is important to identify those patients with a preoperative risk for compromised zonulae who, in the absence of obvious intraoperative complications, should have routine planned insertion of a CTR at surgery. However, currently, it is unknown whether the cost of implanting a CTR in all at-risk eyes is justied by the potential decrease in incidence of dislocations. Consistent with previous studies, a male preponderance in cases needing IOL exchange or repositioning was found.5,12 This is difcult to explain especially because more women than men undergo cataract surgery30 and more women than men have PEX.31 Thus, there may be a genderrelated difference that results in weaker zonulae in men with PEX. Another cause may be that males are more prone to ocular trauma that might have happened decades earlier and has been forgotten by the time of cataract surgery. There is

References
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7. Masket S, Osher RH. Late complications with intraocular lens dislocation after capsulorrhexis in pseudoexfoliation syndrome. J Cataract Refract Surg 2002;28:1481 4. 8. Shigeeda T, Nagahara M, Kato S, et al. Spontaneous posterior dislocation of intraocular lenses xated in the capsular bag. J Cataract Refract Surg 2002;28:1689 93. 9. Kim SS, Smiddy WE, Feuer W, Shi W. Management of dislocated intraocular lenses. Ophthalmology 2008;115:1699 704. 10. Assia EI, Apple DJ, Morgan RC, et al. The relationship between the stretching capability of the anterior capsule and zonules. Invest Ophthalmol Vis Sci 1991;32:283539. 11. Hayashi H, Hayashi K, Nakao F, Hayashi F. Anterior capsule contraction and intraocular lens dislocation in eyes with pseudoexfoliation syndrome. Br J Ophthalmol 1998;82:1429 32. 12. Gross JG, Kokame GT, Weinberg DV. Dislocated In-the-Bag Intraocular Lens Study Group. In-the-bag intraocular lens dislocation. Am J Ophthalmol 2004;137:630 5. 13. Cionni RJ. Surgical management of the congenitally subluxed crystalline lens using the modied capsular tension ring. In: Steinert RF, ed. Cataract Surgery: Technique, Complications, and Management. 2nd ed. Philadelphia: Saunders; 2004:30513. 14. Sarrazadeh R, Ruby AJ, Hassan TS, et al. A comparison of visual results and complications in eyes with posterior chamber intraocular lens dislocation treated with pars plana vitrectomy and lens repositioning or lens exchange. Ophthalmology 2001; 108:829. 15. Smiddy WE, Ibanez GV, Alfonso E, Flynn HW Jr. Surgical management of dislocated intraocular lenses. J Cataract Refract Surg 1995;21:64 9. 16. Smith SG, Lindstrom RL. Malpositioned posterior chamber lenses: etiology, prevention, and management. J Am Intraocul Implant Soc 1985;11:584 91. 17. Pallin SL, Walman GB. Posterior chamber intraocular lens implant centration: in or out of the bag. J Am Intraocular Implant Soc 1982;8:254 7. 18. Hayashi K, Hayashi H, Nakao F, Hayashi F. Comparison of decentration and tilt between one piece and three piece polymethyl methacrylate intraocular lenses. Br J Ophthalmol 1998;82:419 22. 19. Werner L, Pandey SK, Escobar-Gomez M, et al. Anterior capsule opacication: a histopathological study comparing different IOL styles. Ophthalmology 2000;107:46371. 20. Werner L, Pandey SK, Apple DJ, et al. Anterior capsule opacication correlation of pathological ndings with clinical sequelae. Ophthalmology 2001;108:1675 81. 21. Mnestam E, Kuusik M, Wachtmeister L. Topical anesthesia for cataract surgery: a population-based perspective. J Cataract Refract Surg 2001;27:44551. 22. Cionni RJ, Osher RH. Endocapsular ring approach to the subluxed cataractous lens. J Cataract Refract Surg 1995;21:2459. 23. Mackool RJ, Sirota MA. Intracapsular foldable posterior chamber lens implantation in eyes with posterior capsule tears or zonular ber instability. J Cataract Refract Surg 1998;24: 739 40. 24. Menapace R, Findl O, Georgopoulos M, et al. The capsular tension ring: designs, applications, and techniques. J Cataract Refract Surg 2000;26:898 912. 25. Rosenthal KJ. Improving surgical outcomes with capsular tension rings. Rev Ophthalmol 2001;8:4755. 26. Moreno-Montas J, Rodriguez-Conde R. Capsular tension ring in eyes with pseudoexfoliation [letter]. J Cataract Refract Surg 2002;28:22412. 27. Lee DH, Lee H-Y, Lee KH, et al. Effect of a capsular tension ring on the shape of the capsular bag and opening and the intraocular lens. J Cataract Refract Surg 2001;27:452 6. 28. Kuchle M, Amberg A, Martus P, et al. Pseudoexfoliation syndrome and secondary cataract. Br J Ophthalmol 1997;81: 862 6. 29. Hara T, Hara T, Sakanishi K, Yamada Y. Efcacy of equator rings in an experimental rabbit study. Arch Ophthalmol 1995; 113:1060 5. 30. Klein BE, Klein R, Moss SE. Incident cataract surgery: the Beaver Dam Eye Study. Ophthalmology 1997;104:57 80. 31. Astrom S, Linden C. Incidence and prevalence of pseudoexfoliation and open-angle glaucoma in northern Sweden: I. Baseline report. Acta Ophthalmol Scand 2007;85:828 31. 32. Futa R, Furuyoshi N. Phakodonesis in capsular glaucoma: a clinical and electron microscopy study. Jpn J Ophthalmol 1989;33:3117.

Footnotes and Financial Disclosures

Originally received: December 18, 2008. Final revision: May 11, 2009. Accepted: May 12, 2009. Available online: October 7, 2009. The author(s) have no proprietary or commercial interest in any materials discussed in this article. Manuscript no. 2008-1517. Supported by the Crown Princess Margaretas Committee for the Blind, Stockholm, Sweden; and by the Vsterbottens County Council Research Fund, Ume, Sweden. Neither the sponsor nor funding organizations had a role in the design or conduct of this research. Correspondence: Eva Mnestam, MD, PhD, Department of Clinical Sciences/Ophthalmology, Ume University, S-901 85 Ume, Sweden. E-mail: eva.monestam@vll.se.

Department of Clinical Sciences/Ophthalmology, Norrlands University Hospital, Ume, Sweden. Presented in part at: European Society of Cataract and Refractive Surgeons (ESCRS) Annual Meeting, September 2008, Berlin, Germany. Financial Disclosure(s):

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