Felicidad Manero

Artisan toric phakic intraocular lens for the correction of high astigmatism

PURPOSE To evaluate efficacy, predictability, and safety of Artisan toric phakic intraocular lens (Ophtec, Groningen, The Netherlands) implantation for the correction of astigmatism higher than 2 diopters. DESIGN Interventional case series. METHODS This prospective study included 27 eyes of 16 patients with a mean preoperative spherical equivalent of -11.78 +/- 6.24 diopters and a mean preoperative astigmatism of -3.43 +/- 0.81. The Artisan phakic intraocular lens was inserted in the anterior chamber through a posterior corneal incision; the technique is similar to the implantation of the classical Artisan lens, but in these cases it is particularly important to secure the lens accurately in the correct axis. The main parameters evaluated in this study were uncorrected visual acuity, best-corrected visual acuity, refraction, and endothelial cell count. RESULTS Twelve months after the implantation of the Artisan toric phakic intraocular lens, 62.90% of the eyes were within +/-0.50 diopters. of emmetropia and 96.20% within +/-1.0 diopters. Seventy percent of the eyes gained 1 or more Snellen lines from their preoperative best-corrected visual acuity, and 11.11% lost 1 Snellen line. Mean endothelial cell count increased 2.9%. Mean of the parallel and orthogonal components of cylinder correction were 1.97 diopters and 0.10 diopters, respectively, of the intended cylinder change. The mean of axis alignment error was 10.53 degrees. No serious complications were observed. CONCLUSION Artisan toric phakic intraocular lens implantation appears to be a safe and predictable method for the correction of high levels of astigmatism.

Secondary Artisan-Verysise aphakic lens implantation

PURPOSE: To evaluate efficacy, predictability and safety of Artisan–Verysise intraocular lens (IOL) secondary implantation for aphakia correction. SETTING: Instituto de Microcirugía Ocular, and Autonoma University of Barcelona, Barcelona, Spain. METHODS: Uncorrected visual acuity, best spectacle‐corrected visual acuity (BSCVA), manifest refraction, endothelial cell count, and clinical complications were evaluated. Sixteen consecutive eyes of 14 patients with aphakia were submitted to surgery. Postoperative examinations were done at 6 weeks, 6 months, 1 year, and every year for at least 3 years. An iris‐supported Artisan–Verysise IOL was implanted for aphakia correction. RESULTS: Thirty‐six months after Artisan–Verysise lens implantation, BSCVA was 20/40 or better in 6 eyes (37.5%). Preoperatively, 5 eyes had the same BSCVA (31.25%). Mean postoperative spherical equivalent (SE) was 0.46 diopter (D). Mean endothelial cell loss was 10.9% 36 months postoperatively. The cell loss occurred predominantly during the first year (7.78%). Cystoid macular edema was observed in 2 cases, 1 of them associated with chronic unresponsive low intraocular pressure. No other serious complications were observed. CONCLUSION: Artisan–Verysise IOL implantation seems a safe, predictable, and effective option for aphakic eyes without capsule support.

Clear lens extraction to correct high myopia

Purpose: To assess the refractive outcome and postoperative complications in a single surgeon series of clear lens extraction for high myopia. Setting: Ophthalmology Department, Cornea and Refractive Surgery Unit, Vall d’Hebrón Hospital, Autónoma University of Barcelona, Spain. Methods: Forty‐six clear lens extraction procedures performed in 37 patients from November 1992 to January 1994 by one surgeon were retrospectively analyzed. Capsule tear and vitreous loss, endothelial cell loss, preoperative and postoperative best corrected visual acuity and cycloplegic refraction, and retinal detachment occurrence were looked at. Results: Capsule tear with vitreous loss occurred in one eye (2.17%). Mean endothelial cell loss was 2.6% during the first postoperative year. Best corrected visual acuity was 6/12 or better in 69.4% of eyes preoperatively and in 88.5% postoperatively. Mean cycloplegic refraction was −16.05 diopters (D) preoperatively; the residual cycloplegic refraction was within 1.00 D in 48.4% of eyes and within 2.00 D in 92.5% postoperatively. Conclusion: Because of its high predictability, stability, and low morbidity, we believe clear lens extraction is a reasonable refractive surgery option for middle‐aged patients with myopia.

Combined Surgery to Correct High Myopia: Iris Claw Phakic Intraocular Lens and Laser in situ Keratomileusis

PURPOSE To evaluate the results of combined surgery, implantation of an Artisan phakic iris claw intraocular lens (IOL) followed by laser in situ keratomileusis (LASIK) to correct high myopia. METHODS A prospective study of 6 patients (8 eyes) with high myopia who had Artisan phakic IOL implantation followed by LASIK was undertaken. The IOL was a standard -15.00-D, 6-mm diameter optical zone. Residual refractive error was corrected by LASIK. Mean follow-up was 16 +/- 4 months (range, 12 to 20 mo). RESULTS After the second procedure (LASIK), uncorrected visual acuity ranged from 0.4 to 0.63 (mean, 0.5 +/- 0.07) at 1 month and from 0.6 to 0.7 (mean, 0.62 +/- 0.04) at 12 months. Spectacle-corrected visual acuity improved 2 or more lines in 62.5% (5 eyes) from preoperative values. Mean postoperative spherical equivalent refraction was -0.68 +/- 0.23 at 1 month and -0.35 +/- 0.22 at 12 months after LASIK. All eyes were within +/-1.00 D of emmetropia following the LASIK portion of the two-stage procedure and 5 eyes were within +/-0.50 D. We had no major complications. No significant endothelial damage occurred. CONCLUSIONS The accurate refractive outcome, absence of major complications, stability of results, and most important, improvement in quality of vision (defined as no change in vision when illumination conditions varied, eg, at night) experienced by these highly myopic patients are reasons to continue using and improving this combined technique.

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.

Historical Review and Update of Surgical Treatment for Corneal Endothelial Diseases.

The cornea remains in a state of deturgescence, maintained by endothelial cell Na+/K+ ATPase and by tight junctions between endothelial cells that limit entrance of fluid into the stroma. Fuchs’ endothelial corneal dystrophy (FECD) was initially described by Fuchs in 1910 as a combination of epithelial and stromal edema in older patients. It manifests as bilateral, albeit asymmetric, central corneal guttae, corneal edema, and reduced vision. When edema is severe, the corneal epithelium can detach from its basement membrane, creating painful bullae on the anterior surface of the cornea. The course of this dystrophy can be further accelerated after intraocular surgery, specifically cataract extraction. Pseudophakic bullous keratopathy (PBK) is endothelial cell loss caused by surgery in the anterior chamber. If the corneal endothelium is damaged during surgery, the same spectrum of symptoms as found in FECD can develop. In the nineteenth century, penetrating keratoplasty was the only surgical procedure available for isolated endothelial disease. In the 1960s, Dr. José Barraquer described a method of endothelial keratoplasty using an anterior approach via laser-assisted in situ keratomileusis (LASIK) flap. In 1999, Melles and colleague described their technique of posterior lamellar keratoplasty. Later, Melles et al. started to change host dissection using simple “descemetorhexis” in a procedure known as Descemet’s stripping endothelial keratoplasty. Following the widespread adoption of Descemet’s stripping automated endothelial keratoplasty, the Melles group revisited selective Descemet’s membrane transplantation and reported the results of a new procedure, Descemet’s membrane endothelial keratoplasty (DMEK). Recently, some eye banks have experimented with the preparation of DMEK/Descemet’s membrane automated endothelial keratoplasty donor tissue that may help the surgeon avoid the risk of tissue loss during the stromal separation step. Recently, the authors described a new bimanual technique for insertion and positioning of endothelium–Descemet membrane grafts in DMEK.

Transverse keratotomy to correct high corneal astigmatism after cataract surgery

Purpose: To assess the outcome of transverse keratotomy to correct high corneal astigmatism after cataract surgery. Setting: Vall d’Hebron Hospital, Department of Ophthalmology, Cornea and Refractive Surgery Unit, Barcelona Autónoma University, Spain. Methods: Thirty‐two eyes with regular corneal astigmatism between 2.50 and 5.00 diopters (D) after previous cataract surgery had two transverse incisions with an optical zone of 5.0 or 7.0 mm, a depth of 80 or 90%, and a length of 3.0 or 4.0 mm, depending on the amount of astigmatism and based on a personal nomogram we developed. Results: From 80 to 100% of the desired correction was achieved in 38.7% of eyes and from 60 to 80% in 38.9%. At 6 months, only 9.1% had a keratometric change of more than 0.50 D. Best corrected visual acuity was the same or better in 85.2% of patients; no patient lost more than one Snellen line. Conclusion: This easy, safe technique had low anatomical and refractive morbidity and high efficacy, making it an excellent option for eyes with high astigmatism after cataract surgery. More research is required in view of the considerable unpredictability of our results and the disparity in methods and results of other published studies.

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.