Daniel Elies

Collagen crosslinking and toric iris-claw phakic intraocular lens for myopic astigmatism in progressive mild to moderate keratoconus.

PURPOSE: To report the long‐term results of combined collagen crosslinking (CXL) and toric phakic intraocular lens (pIOL) implantation to correct myopic astigmatism in patients with progressive mild to moderate keratoconus. SETTING: Instituto de Microcirugia Ocular, Barcelona, Spain. DESIGN: Case series. METHODS: From November 2006 to July 2009, CXL was performed in eyes with proven progressive keratoconus. Once refraction and topography stabilized, toric Artiflex/Artisan pIOL implantation was performed to correct residual myopic astigmatism. A complete ophthalmologic examination, including manifest refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, biomicroscopy, tonometry, fundoscopy, keratometry, corneal tomography, and central endothelial cell count (ECC), was performed before each procedure and postoperatively at 3 months and at yearly intervals up to 5 years. Main outcome measures were accuracy and stability of the spherical equivalent (SE) and cylinder, keratometry, UDVA (efficacy), CDVA (safety), central ECC, and complications. RESULTS: The median follow‐up in the 9 patients (17 eyes) was 36.9 months ± 15.0 (SD). The median interval between CXL and pIOL implantation was 3.9 ± 0.7 months. Fourteen eyes (82%) were within ±0.50 diopter (D) of the attempted SE correction and 13 eyes (76%) were within ±1.00 D of the attempted cylinder correction. The mean difference in simulated keratometry between preoperatively and the last follow‐up was 0.17 ± 0.45 D (range −0.55 to 1.45 D). The postoperative UDVA was 20/40 or better in 16 eyes (94%). No eye lost lines of CDVA. No significant decrease in central ECC occurred (P>.05). CONCLUSION: Combined CXL and toric iris‐claw pIOL implantation effectively and safely corrected myopic astigmatism in progressive mild to moderate keratoconus. Financial Disclosure: Dr. Güell is a consultant to Ophtec. No other author has a financial or proprietary interest in any material or methods mentioned.

Bimanual technique for insertion and positioning of endothelium-Descemet membrane graft in Descemet membrane endothelial keratoplasty.

Purpose: To describe a new bimanual technique for insertion and positioning of endothelium–Descemet membrane (EDM) grafts in Descemet membrane endothelial keratoplasty (DMEK). Methods: Prospective, noncomparative, consecutive interventional case series, including 15 pseudophakic eyes of 15 patients treated with DMEK at the Instituto de Microcirugia Ocular, Barcelona, Spain. A bimanual infusion technique was used to introduce and position donors EDM. Partial tamponade was achieved with 20% sulfur hexafluoride (SF6). Intraocular manipulation time of EDM grafts, rebubbling rate, and endothelial cell density were evaluated. Results: Six months postoperatively, mean uncorrected visual acuity and best spectacle–corrected visual acuity (BSCVA) improved from 20/100 to 20/50 and from 20/80 to 20/25, respectively (P < 0.001). Six eyes (40%) had ≥20/20 BSCVA, and 13 (86%) eyes had ≥20/30 BSCVA. Mean donor cell density decreased from 2690 ± 302 to 1998 ± 621 cells per square millimeter, representing a mean cell loss of 26% ± 20%. EDM was stripped successfully in all cases. Mean intraocular manipulation time of donors EDM (interval between main incision closure and final EDM positioning) was 4.10 ± 0.5 minutes. Intracameral air reinjection was needed in 1 case (6.6%) with a partial peripheral graft detachment. No episodes of immunologic graft rejection were documented. Conclusions: Insertion and positioning of EDM grafts in DMEK was successfully achieved using this bimanual infusion technique and 20% SF6 partial tamponade, with a low intraocular manipulation time and very low postoperative rebubbling rates, regardless of the preservation method and the donors age. However, prospective comparative studies are required to demonstrate the long-term safety compared with other approaches.

Secondary iris-claw anterior chamber lens implantation in patients with aphakia without capsular support

Background/aims To evaluate the efficacy, predictability, safety and complications of secondary iris-claw intraocular lens (IOL) implantation in aphakic eyes without capsular support. Methods Retrospective, non-comparative, interventional case series of 128 aphakic eyes, which consecutively underwent secondary iris-claw Artisan IOL (Ophtec BV) implantation, were included. Manifest refraction, uncorrected visual acuity, best-spectacle corrected visual acuity, biomicroscopy, tonometry, funduscopy and central endothelial cell count (cECC) were evaluated before surgery, and at yearly intervals up to 5 years. Minimum follow-up time was 1 year. Results One hundred twenty-eight eyes were treated. Mean age was 54.55 years (range, 1–98 years). Mean follow-up was 41.8 months (SD 23.63). Mean preoperative logarithm of the minimum angle of resolution BSCVA and spherical equivalent (SE) were 0.67 ((SD) 0.53) and 9.63 D (SD 5.50), respectively. One year postoperatively, mean logarithm of the minimum angle of resolution best-spectacle corrected visual acuity improved to 0.52 (SD 0.46) (p<0.05), and remained stable up to 5 years. One year postoperatively, mean SE was −0.52 (SD 2.21) (p<0.05). Mean SE progressively decreased during the 1st year, and remained stable thereafter (p<0.05). Mean preoperative cECC was 2237.47 (SD 793.33) cells/mm2. cECC showed a slight, though statistically significant, decrease over the years (p=0.05). Main complications were: 2 pupillary block; 3 transient increase in intraocular pressure; 1 IOL replacement; 2 penetrating keratoplasty and 4 cystoid macular oedema. Conclusions Iris-claw IOL implantation in aphakic eyes is an effective, predictable and safe procedure in the first 5 years of follow-up. However, a longer follow-up is required to demonstrate its long-term safety.

Femtosecond laser-assisted enhancements after laser in situ keratomileusis

UNLABELLED We describe a technique of femtosecond laser-assisted enhancement after primary LASIK with a mechanical microkeratome-created flap. The vertical side-cut incision by the femtosecond laser creates a wound configuration that decreases mechanical trauma to the epithelium and prevents epithelial cell migration. These factors may decrease the risk for post-LASIK enhancement epithelial ingrowth. FINANCIAL DISCLOSURE No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Intrastromal corneal ring segments to correct low myopia in eyes with irregular or abnormal topography including forme fruste keratoconus: 4-year follow-up

PURPOSE: To report the 4‐year outcomes after Intacs intrastromal corneal ring segment (ICRS) implantation to correct low myopia in patients with abnormal topography. SETTING: Instituto de Microcirugia Ocular, Barcelona, Spain. METHODS: This retrospective consecutive interventional case series included eyes with myopia lower than −4.50 diopters (D) and abnormal topography that excluded excimer laser surgery. Evaluation was performed preoperatively and at yearly intervals up to 4 years postoperatively. The 4‐year outcomes measures were uncorrected (UDVA) and corrected (CDVA) distance visual acuities, predictability and stability of refractive correction, the efficacy and safety indices, and complications. RESULTS: After ICRS implantation, 82.05% of 39 eyes (21 patients) were within ±1.00 diopter (D) of emmetropia and 46.15% were within ±0.50 D. Refractive correction improved during the first 6 months and remained stable up to 4 years. The UDVA was 20/40 or better in all eyes and 20/20 or better in 38.46% of eyes. Seven eyes (17.95%) lost 1 line of CDVA, and no eye lost 2 or more lines. No intraoperative complications occurred. The ICRS were exchanged for thicker ICRS in 7 eyes (17.9%) because of undercorrection. One patient requested ICRS removal due to unsatisfactory refractive results. CONCLUSIONS: The 4‐year results indicate that ICRS implantation is effective and safe in the correction of low myopia in patients for whom excimer laser surgery is contraindicated because of abnormal topography, including forme fruste keratoconus. The achieved refractive correction remained stable throughout the follow‐up. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Silicone posterior chamber phakic intraocular lens dislocated into the vitreous cavity.

PURPOSE To report two highly myopic patients with silicone posterior chamber phakic intraocular lenses (Phakic Refractive Lens; CIBA Vision, Duluth, Ga) that luxated into the vitreous cavity without history of ocular trauma. METHODS Two patients with posterior chamber phakic intraocular lenses (PIOLs) that luxated into the vitreous cavity of the right eye were examined. Each eye underwent pars plana vitrectomy and removal of the posterior chamber PIOL under retrobulbar anesthesia. RESULTS Both patients were treated successfully. In the first patient, the posterior chamber PIOL luxated into the anterior vitreous cavity whereas in the second patient, the posterior chamber PIOL lay on the posterior pole. No ocular complications developed postoperatively. CONCLUSION Luxation into the vitreous cavity is a rare, but potentially severe complication of posterior chamber PIOL refractive surgery in highly myopic eyes. Successful management includes pars plana vitrectomy and removal of the posterior chamber PIOL.

Comparative Study of Ablation Profiles of Six Different Excimer Lasers

PURPOSE To compare the morphological features of photorefractive ablations produced by six different excimer lasers. METHODS A spherocylindrical photoablation (-2.00 -2.00 x 90 degrees; 6-mm optical zone) was performed on regular fluence plates with six excimer lasers: Bausch & Lomb Technolas 217C, Schwind Esiris, Kera Technology Isobeam D200, Ladarvision 4000, Zeiss Meditec MEL 70 G-Scan, and Visx Star S3. Morphometric analysis of the fluence plates provided superficial measurements of the ablated areas. RESULTS Two areas were identified visually: a central area with a complete ablation of the metallic surface layer and a surrounding area with a partial ablation. The dimensions of the ablated areas were highly variable in the lasers tested. The major differences appeared in the total ablated area (ranging from 38.55 mm2 [Schwind] to 81.94 mm2 [Bausch & Lomb] and in the peripheral to total area ratio (ranging from 36.95% [Schwind] to 59.51% [Ladarvision]). CONCLUSION Large differences appeared in the superficial dimensions and contours of the ablations produced by different excimer lasers for the treatment tested in this study. It remains unknown how these different ablation patterns induce the same optical correction, but we assume that the depth of the ablation compensates for the differences in the surface extension of the ablated areas.

Visian toric implantable collamer lens for correction of compound myopic astigmatism.

PURPOSE To assess the safety, efficacy, predictability, and stability of a toric posterior chamber phakic intraocular lens for the correction of myopia with astigmatism. METHODS A non-randomized, retrospective analysis of 63 eyes of 36 patients with a minimum follow-up of 6 months was performed. The STAAR Toric Implantable Collamer Lens (TICL) was implanted under topical anesthesia through a 3-mm temporal clear corneal incision. Mean preoperative spherical equivalent refraction was -10.71+/-3.55 diopters (D). Median preoperative best spectacle-corrected visual acuity (BSCVA) was 20/25, with a mean sphere of -8.78 D (range: -2.50 to -16.50 D) and mean cylinder of 3.60 D (range: 1.25 to 7.00 D). Postoperative parameters were analyzed at different time points, and vector analysis was performed to calculate surgically induced astigmatism. RESULTS Fifty-nine (93.6%) eyes had a spherical equivalent refraction within +/-1.00 D and 52 (82.5%) eyes were within +/-0.50 D of emmetropia. Median postoperative uncorrected visual acuity was 20/25 and BSCVA was 20/20. Preoperative keratometric astigmatism was 1.99@178.2 vs 1.82@178.6 postoperative keratometric astigmatism, most likely due to the surgical incision. Preoperative refractive astigmatism was 2.17@93 whereas postoperatively it reduced to 0.38@99.6. No eye lost 2 or more lines of Snellen BSCVA. Twenty-two (34.9%) eyes gained 2 or more Snellen lines of vision. Preoperatively, 45 (71.4%) eyes had a BSCVA of 20/30 or better, whereas 60 (95.2%) eyes were within this range of BSCVA after surgery. The TICL demonstrated good rotational stability in this study. CONCLUSIONS Implantation of the STAAR TICL was an effective, predictable, and safe method for correction of high myopia and myopic astigmatism as shown in this retrospective observational series.

SMILE Procedures With Four Different Cap Thicknesses for the Correction of Myopia and Myopic Astigmatism

PURPOSE To study the feasibility of performing myopic femtosecond small incision lenticule extraction (SMILE) with four different cap thicknesses (130, 140, 150, and 160 μm). METHODS In this retrospective, comparative, non-randomized clinical trial, a refractive lenticule of intrastromal corneal tissue was cut with the VisuMax femtosecond laser system (Carl Zeiss Meditec AG, Jena, Germany) using different depths of the non-refractive lenticule cut. Manifest refraction, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and Objective Scattering Index (OSI) were evaluated. Minimum follow-up time was 1 year. RESULTS Ninety-four eyes of 47 patients with myopia with (14 patients) and without (33 patients) astigmatism were treated. One year after the surgery, mean log-MAR UDVA, logMAR CDVA, SE, and OSI were 0.07 ± 0.12, 0.01 ± 0.37, 0.07 ± 0.57, and 0.88 ± 0.17, respectively (P < .05). There were no significant statistical differences in logMAR UDVA, logMAR CDVA, SE, or OSI (P > .05) variables when the different groups were compared for the same periods of time. CONCLUSIONS No differences in visual acuity, refractive outcomes in optical visual quality, or complications were observed when using SMILE at four different depths.

Conjunctival resection with and without amniotic membrane graft for the treatment of superior limbic keratoconjunctivitis.

Purpose: To compare the efficacy of conjunctival resection versus conjunctival resection with amniotic membrane graft (AMG) in patients with superior limbic keratoconjunctivitis not responsive to medical therapies. Methods: In a retrospective and comparative study, 16 eyes of 9 patients with long-lasting superior limbic keratoconjunctivitis who were refractory to medical treatment were included. Conjunctival resection was performed in 8 cases, and conjunctival resection with AMG was performed in 8 cases. Subjective symptoms, biomicroscopic signs, and impression cytology were evaluated both pre- and postoperatively. Results: The mean follow-up period was 46 months, ranging from 1.5 to 6 years. After surgery, all cases undergoing conjunctival resection and 7 of 8 cases undergoing conjunctival resection with AMG remained asymptomatic. One case undergoing conjunctival resection with AMG experienced recurrence, requiring reoperation 2 years later (conjunctival resection without AMG). In this patient, complete disappearance of symptoms and signs was achieved during a 4-year period of follow-up after the second surgery. No intra- or postoperative complications were observed in either group. Preoperative impression cytology disclosed severe squamous metaplasia, and goblet cells were markedly decreased in all patients. Postoperative impression cytology 3 months after surgery did not show any significant improvement in squamous metaplasia in either of the groups. Conclusions: Conjunctival resection and conjunctival resection with AMG are effective and safe surgical procedures. Despite the potential benefits of the AMG, this procedure did not provide additional advantages in our study.