Dimitrios I. Bouzoukis

Treatment of chronic dry eye: focus on cyclosporine

To review the current treatment of chronic dry eye syndrome, focusing on cyclosporine A (CsA), a systematic literature search was performed using PubMed databases in two steps. The first step was oriented to articles published for dry eye. The second step was focused on the use of CsA in dry eye. A manual literature search was also undertaken based on citations in the published articles. The knowledge on the pathogenesis of dry eye syndrome has changed dramatically during the last few years. Inflammation and the interruption of the inflammatory cascade seem to be the main focus of the ophthalmologic community in the treatment of dry eye, giving the anti-inflammatory therapy a new critical role. The infiltration of T-cells in the conjuctiva tissue and the presence of cytokines and proteasis in the tear fluid were the main reason introducing the use of immunomodulator agents such as corticosteroids, cyclosporine, and doxycicline in order to treat dry eye syndrome. CsA emulsion is approved by the FDA for the treatment of dry eye, while clinical trials of this agent have demonstrated efficacy and safety of CsA. CsA seems to be a promising treatment against dry eye disease. New agents focused on the inflammatory pathogenesis of this syndrome in combination with CsA may be the future in the quest of treating dry eye. More studies are needed to determine the efficacy, safety, timing, and relative cost/effect of CsA.

Visual Outcomes and Safety of a Small Diameter Intrastromal Refractive Inlay for the Corneal Compensation of Presbyopia

PURPOSE To investigate the outcomes and safety of an intrastromal refractive inlay (Invue Lens, Biovision AG) for the corneal compensation of presbyopia. METHODS This prospective, noncomparative, interventional clinical study comprised 45 emmetropic presbyopes with a mean age of 52.3 ± 3.3 years (range: 47 to 58 years). The refractive inlay was inserted in the non-dominant eye within a corneal pocket that was created using a mechanical microkeratome. Last follow-up was 12 months in all patients and examinations were scheduled at 1 week and 1, 3, 6, and 12 months after surgery. Visual, wavefront, contrast sensitivity, and topographic outcomes as well as structural corneal alteration were evaluated. RESULTS Twelve months after surgery, uncorrected near visual acuity was 20/32 or better in 98% of operated eyes and binocularly, whereas uncorrected distance visual acuity was 20/40 or better in 93% of operated eyes and 20/25 or better in all patients binocularly. Three patients lost one line of corrected distance visual acuity in the operated eye. Overall, higher order aberrations were increased and contrast sensitivity was decreased in the operated eye. No tissue alterations were found using corneal confocal microscopy. No intra- or postoperative complications occurred. CONCLUSIONS The intracorneal refractive inlay (Invue Lens) seems to be an effective surgical method for the corneal compensation of presbyopia in emmetropes aged between 45 and 60 years.

Femtosecond laser-assisted corneal pocket creation using a mask for inlay implantation.

PURPOSE To describe the technique of femtosecond laser-assisted intracorneal pocket creation, using a mask for the implantation of a corneal inlay in the non-dominant eye of a 56-year-old, emmetropic, presbyopic woman for the correction of presbyopia. METHODS Using the iFlap treatment-type software of the femtosecond laser (IntraLase 150, Abbott Medical Optics), a full lamellar cut was created at 280-μm depth. A keyhole-shaped mask was placed at the internal part of the glass of the applanation cone. A separator was used to separate the stroma, and an inserter was used to implant the inlay at the center of the line of sight. To determine the line of sight, the microscope and centration system of the excimer laser (Allegretto Wave 400 Hz, WaveLight Laser Technologie AG) were used. The Flexivue Microlens inlay (Presbia) was implanted. RESULTS No intra- or postoperative complications occurred during follow-up. Uncorrected near visual acuity improved from 20/50 to 20/20 at the first postoperative week. CONCLUSIONS Femtosecond-assisted intracorneal pocket creation using a mask is a simple, safe, and efficient approach for the implantation of corneal inlays.

Effect of excimer laser repetition rate on outcomes after photorefractive keratectomy

PURPOSE: To compare the refractive outcomes after photorefractive keratectomy (PRK) for low to moderate myopic corrections using 2 excimer lasers with different repetition rates (200 Hz and 400 Hz). SETTING: University refractive surgery center. METHODS: This retrospective study included all consecutive patients who underwent PRK using the 200 Hz or the 400 Hz Allegretto laser platform (WaveLight Laser Technologie AG). Thirty‐five patients (70 eyes) and 29 patients (58 eyes) had PRK with the 200 Hz platform and the 400 Hz platform, respectively, using the same surgical technique. RESULTS: The mean follow‐up was 13.22 months ± 1.16 (SD) (range 11 to 15 months). No intraoperative or early postoperative (eg, late reepithelialization) complications were found in either group. At 1 year, 66 eyes (94.2%) in the 200 Hz group and 56 eyes (96.6%) in the 400 Hz group were within ±1.00 diopter of the attempted correction. At 3 months, 20 eyes (29%) in the 200 Hz group and 27 eyes (46%) in the 400 Hz group had mild or moderate corneal haze (P = .03). These corneas showed progressive clearing over subsequent months without statistically significant differences in haze formation between the 2 groups. Twelve months after PRK, all corneas in both groups were clear. CONCLUSION: Photorefractive keratectomy for the treatment of low to moderate refractive errors using a 200 Hz or 400 Hz excimer laser gave comparable results.

Idiopathic recurrence of diffuse lamellar keratitis after LASIK.

PURPOSE To report a case of late recurrence of bilateral diffuse lamellar keratitis (DLK) after LASIK. METHODS A 39-year-old woman presented in the early postoperative period with bilateral DLK after hyperopic LASIK and was treated with topical steroids. One year after and with no obvious cause (idiopathic), recurrence of the same stage (stage III) of disease was observed. RESULTS Slit-lamp examination revealed diffuse, multifocal, and granular haze in the interface. The microbiology culture was negative. Confocal microscopy demonstrated multiple activated keratocytes, debris, and inflammatory cells adjacent to the flap interface. After intense treatment with topical corticosteroids, DLK resolved and corneal transparency was achieved with complete restoration of visual acuity. CONCLUSIONS Diffuse lamellar keratitis may recur in LASIK patients with previous episodes without an obvious cause (idiopathic). Early diagnosis and treatment with topical corticosteroids can achieve complete resolution without visual loss--even in advanced stages of DLK.

Single intrastromal corneal ring segment implantation using the femtosecond laser after radial keratotomy in a keratoconic patient

A 33-year-old woman with irregular astigmatism 6 years after radial keratotomy (RK) for keratoconus was treated with implantation of a single intrastromal corneal ring segment (Keraring) using the femtosecond laser. The segment (0.150 mm thick with a 160-degree arc) was inserted in the steepest area (inferior) with no intraoperative or postoperative complications. Six months postoperatively, the uncorrected visual acuity had improved from 20/40 to 20/25 and the best spectacle-corrected visual acuity, from 20/32 to 20/20. The mean manifest astigmatic correction decreased from -2.50 diopters (D) to -0.75 D, and corneal topography showed improved inferior steepening and less irregular astigmatism. Although the results are encouraging, the long-term effect of this approach in post-RK patients is not known.

Fifteen-year Follow-up After LASIK: Case Report

PURPOSE To present 15-year follow-up of one of the first LASIK-treated patients. METHODS A 40-year-old woman underwent LASIK in the left eye for myopia in July 1991. RESULTS Fifteen years after LASIK, spherical equivalent error was statistically significantly reduced from preoperative -8.75 -3.75 x 025 degrees to postoperative -4.25 -2.75 x 010 degrees. Six months postoperatively, refractive and topographic stability was obtained and remained stable during follow-up with no significant changes between interval mean time (-3.75 -3.00 x 020 degrees 6 months postoperatively to -4.25 -2.75 x 010 degrees 15 years postoperatively). No early or late postoperative complications were observed, and confocal microscopy revealed a regenerated nerve plexus and normal cornea. However, increased scattering and presence of debris were observed at the flap interface even after 15 years. Despite moderate predictability (residual refractive error) and small optical zone, the patient was satisfied with final outcome. CONCLUSIONS One of the first LASIK-treated patients was presented 15 years after surgery. LASIK in this patient had low predictability, although refractive and topographic stability occurred after the sixth postoperative month. No long-term, sight-threatening complications were identified during follow-up.

Photorefractive Keratectomy in a Patient with Epithelial Basement Membrane Dystrophy

Purpose: To report a case of excimer laser photorefractive keratectomy (PRK) in a patient with epithelial basement membrane dystrophy (EBMD). Methods: Interventional case report. Results: A 36-year-old male with clinical manifestations of EBMD underwent bilateral, simultaneous PRK for low myopia correction. A delay (up to 17 days) in the epithelial healing process with unstable epithelium was observed. During the first three postoperative months a visually significant subepithelial haze was developed in both eyes. One year postoperative, an improvement in haze formation and visual acuity in both eyes was found. Conclusions: PRK in patients with EBMD could result in favorable refractive and clinical outcome.

Descement’s Membrane Detachment Diagnosis Using a Very High Frequency Ultrasound Scanning System

A 74-year-old woman was referred to our institute due to persistent corneal edema after cataract surgery. Slit-lamp examination revealed severe total corneal edema (obscuring anterior chamber and iris). Using a very high frequency (VHF) ultrasound scanning system (Artemis 2, Ultralink LLC) descements membrane detachment (DMD) was diagnosed. VHF ultrasound scanning system could be a useful instrument in detecting post-cataract surgery DMD especially in patients in which diagnosis is difficult due to significant corneal clouding.

Intrastromal corneal ring segments for the treatment of irregular astigmatism

Intrastromal corneal ring (ICR; INTACS; Addition Technology, Inc., IL, USA) segments were first designed to provide a refractive adjustment by flattening the central corneal curvature while maintaining a prolate aspheric shape in the central optical zone. In contrast to excimer laser refractive techniques, ICR preserves corneal tissue and does not involve the central optical zone. Owing to these tissue-conserving properties, ICR has been proposed as an interesting surgical alternative in patients with corneal ectatic disorders. The treatment options for patients with corneal ectatic diseases and abnormal astigmatism depend on the severity of the disease. In patients with spectacle correction, ICR does not improve visual acuity and rigid contact lenses are not well tolerated; ICR seems to be an interesting, minimally invasive prekeratoplastic surgical technique. There are several publications in the literature supporting the safety and efficacy of this technique in patients with corneal ectatic diseases and abnormal astigmatism. ICR is considered to be a safe, reversible and minimally invasive procedure.