George D. Kymionis

One-Year Results and Anterior Segment Optical Coherence Tomography Findings of Descemet Stripping Automated Endothelial Keratoplasty Combined With Phacoemulsification

OBJECTIVEnTo report 1-year results and anterior segment optical coherence tomography findings of Descemet stripping automated endothelial keratoplasty combined with phacoemulsification in patients with cataract and Fuchs endothelial dystrophy.nnnMETHODSnTwelve eyes of 11 patients with at least 1-year follow-up were retrospectively reviewed. Measured variables included best spectacle-corrected visual acuity, refractive spherical equivalent and predictability, anterior corneal keratometric values, complications, and anterior segment optical coherence tomography findings.nnnRESULTSnThe mean follow-up was 14.33 months (range, 12-18 months). The best spectacle-corrected visual acuity was unchanged (8%) or improved (92%) in all eyes compared with the preoperative levels. A mean (SD) discrepancy between the targeted postoperative refraction and the actual postoperative spherical equivalent refraction (hyperopic shift) of 1.46 (0.76) diopters (D) (range, -0.05 to 3.14 D) was observed. A significant correlation existed between the ratio of central graft thickness to mean peripheral donor corneal lenticule thickness at 3 mm and induced hyperopic shift (R(2) = 0.65, P < .001).nnnCONCLUSIONSnDescemet stripping automated endothelial keratoplasty combined with phacoemulsification and intraocular lens implantation in patients with coexisting Fuchs endothelial dystrophy and cataract improved best spectacle-corrected visual acuity without progressive time-dependent complications. A correlation exists between donor corneal lenticule shape and induced hyperopic shift.

Femtosecond Laser-Assisted Sutureless Anterior Lamellar Keratoplasty

PURPOSEnTo report the technique and small case series results of femtosecond laser-assisted sutureless anterior lamellar keratoplasty (FALK) for anterior corneal pathology.nnnDESIGNnRetrospective, noncomparative, interventional case series.nnnPARTICIPANTSnTwelve consecutive eyes from 12 patients with anterior corneal scarring.nnnINTERVENTIONnFemtosecond laser-assisted sutureless anterior lamellar keratoplasty.nnnMAIN OUTCOME MEASURESnMeasured parameters included femtosecond laser settings, technique, uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), and complications.nnnRESULTSnMean follow-up was 12.7 months (range, 6-24). No intraoperative complications were found. Uncorrected visual acuity (VA) improved in 7 eyes (58.3%) compared with preoperative VA. The mean difference between preoperative and postoperative UCVAs was a gain of 2.5 lines (range, unchanged-7 lines). Best-corrected VA was unchanged or improved in all eyes compared with preoperative levels. The mean difference between preoperative and postoperative BCVAs was a gain of 3.8 lines (range, unchanged-8 lines). In 2 eyes, adjuvant surgical procedures were performed (one treated with phototherapeutic keratectomy and the other with photorefractive keratectomy). Six patients (50%) developed dry eye after FALK, which improved during the follow-up period. No graft rejection, infection, or epithelial ingrowth was found in this series of patients.nnnCONCLUSIONSnFemtosecond laser-assisted sutureless anterior lamellar keratoplasty could improve UCVA and BCVA in patients with anterior corneal pathology.

Management of pellucid marginal corneal degeneration with simultaneous customized photorefractive keratectomy and collagen crosslinking

A 34-year-old woman had simultaneous photorefractive keratectomy and corneal collagen crosslinking with riboflavin-ultraviolet-A irradiation for the treatment of progressive pellucid marginal corneal degeneration in both eyes. No intraoperative or early postoperative complications occurred. Twelve months postoperatively, the uncorrected visual acuity was assessed at 20/40 in both eyes compared with counting fingers preoperatively. The corrected visual acuity also improved from 20/50 and 20/63 to 20/25 and 20/32 in the right eye and left eye, respectively. Corneal topography revealed a significant improvement in both eyes. Despite the encouraging results, longer follow-up is necessary to confirm the stability of the results.

Femtosecond laser-assisted astigmatic keratotomy in naturally occurring high astigmatism

The technique and a case report of femtosecond laser-assisted astigmatic keratotomy (FS AK) are reported in a patient with naturally occurring high astigmatism. The operation was performed using flap mode software to create two anterior arcuate side cuts in each eye using a femtosecond laser (IntraLase/AMO, Irvine, California; 30 kHz) in a 30-year-old female with a naturally occurring high astigmatism (with-the-rule) of 5.25 D in both eyes. In the right eye, the manifest refraction improved from −3.5+5.25×89 preoperatively, with an uncorrected visual acuity (UCVA) of counting fingers (CF) and a best spectacle-corrected visual acuity (BSCVA) of 20/25, to −1.75+2.75×90 postoperatively, with a UCVA of 20/50 and a BSCVA of 20/20. In the left eye, the manifest refraction improved from −3.5+5.25×83 preoperatively, with a UCVA of 20/200 and a BSCVA of 20/20, to −1.75+2.25×85 postoperatively, with a UCVA of 20/30 and a BSCVA of 20/20.

Tacrolimus ointment 0.03% in the eye for treatment of giant papillary conjunctivitis.

Purpose: To report a case of refractory giant papillary conjunctivitis (GPC) treated by using topical tacrolimus 0.03% ointment. Methods: A 16-year-old white boy with a history of GPC was referred to our department for severe GPC with eye itching, tearing, photophobia, discharge, and blepharospasm. The patient had received previous treatments with antihistamines, mast cell stabilizers, topical corticosteroid ointments, and surgical resection-cryopexy of GPC that were ineffective. Results: Topical tacrolimus 0.03% ointment (Protopic; 0.5 cm) was applied into the lower fornix twice a day. An improvement of the patients symptoms was observed during the first 5 days of therapy, and the GPC was resolved within 15 days. After 1 month of continued topical tacrolimus ointment treatment, there was no evidence of GPC. Topical tacrolimus was tapered during the next 2 months. Six months after treatment, there were no GPC findings, and no side effects were reported. Conclusions: Topical tacrolimus 0.03% ointment for severe GPC, refractory to conventional therapy, appears to be an effective alternative treatment.

Femtosecond-assisted astigmatic keratotomy for post-keratoplasty irregular astigmatism

We describe the technique of femtosecond-assisted astigmatic keratotomy (AK) in a post-keratoplasty patient with irregular, nonorthogonal astigmatism. Using the keratoplasty software, an anterior arcuate side cut (400 mum thick, 6.5 mm diameter) was created using the femtosecond laser in a 68-year-old woman with irregular astigmatism 28 years after penetrating keratoplasty for keratoconus. No intraoperative or postoperative adverse events were seen during the follow-up period. Six months after the procedure, the uncorrected visual acuity improved from 20/60 to 20/50 and the best spectacle-corrected visual acuity, from 20/50 to 20/32. The mean manifest astigmatic correction decreased from 4.00 diopters (D) to 0.50 D; corneal topography showed a significant improvement in irregular astigmatism. The technique of femtosecond-assisted AK is simple and efficient for managing irregular and nonorthogonal astigmatism in post-keratoplasty patients and may overcome the limitations of earlier techniques.

Complications of LASIK flaps made by the IntraLase 15- and 30-kHz femtosecond lasers.

PURPOSEnTo describe complications associated with femtosecond laser-assisted flap creation in LASIK surgery. The management and visual outcomes of femtosecond laser complications related to flap creation in LASIK patients are also described.nnnMETHODSnAll eyes that underwent LASIK with the IntraLase femtosecond laser from September 2003 to June 2006 at a university-based refractive center were included in this retrospective, noncomparative, interventional case series and IntraLase-related LASIK complications are described. All flaps were made with the 15- and 30-kHz IntraLase femtosecond laser.nnnRESULTSnIncluded in the study were 4772 eyes, of which 44 (0.92%) eyes had direct or indirect complications due to flap creation. Thirty-two eyes had indirect complications (diffuse lamellar keratitis [DLK] and transient light sensitivity)--20 (0.42%) eyes developed DLK (stage 1 to 2) and 12 (0.25%) eyes had transient light sensitivity syndrome. Twelve (0.25%) eyes had direct femtosecond laser flap-related complications--8 (0.17%) eyes had premature breakthrough of gas through the epithelium within the flap margins, 3 (0.06%) eyes had incomplete flaps due to suction loss, and 1 (0.02%) eye had irregular flap due to previous corneal scar.nnnCONCLUSIONSnLess than 1% of eyes had direct or indirect complications due to femtosecond laser flap creation. Laser in situ keratomileusis complications specifically related to the IntraLase femtosecond laser did not cause loss of best spectacle-corrected visual acuity in any eyes.

Evaluation of corneal stromal demarcation line depth following standard and a modified-accelerated collagen cross-linking protocol.

PURPOSEnTo compare the corneal stromal demarcation line depth using anterior segment optical coherence tomography (AS-OCT) after corneal collagen cross-linking (CXL) using 2 different treatment protocols: the standard Dresden protocol (30 minutes with 3 mW/cm(2)) and a modified-accelerated protocol (14 minutes with 9 mW/cm(2)).nnnDESIGNnProspective, comparative study.nnnMETHODSnForty-three keratoconic patients (52 eyes) were enrolled. All patients underwent CXL using the same high-intensity ultraviolet-A (UV-A) irradiation device. Twenty-six eyes were treated for 30 minutes with 3 mW/cm(2) according to the standard Dresden protocol (Group 1), while 26 eyes were treated with a novel modified-accelerated CXL protocol for 14 minutes with 9 mW/cm(2) of UV-A irradiation intensity (Group 2). One month postoperatively, corneal stromal demarcation line depth was measured by 2 independent observers using AS-OCT.nnnRESULTSnCorneal stromal demarcation line depth was assessed with no significant difference between observer measurements for both groups (P = .676 for Group 1 and P = .566 for Group 2). Mean corneal stromal demarcation line depth was 337.00 ± 46.46 μm for Group 1 and 322.91 ± 48.28 μm for Group 2. There was no statistically significant difference (P = .243) in the corneal stromal demarcation line depth between the 2 groups.nnnCONCLUSIONSnCorneal stromal demarcation line depth using UV-A with 3 mW/cm(2) for 30 minutes and 9 mW/cm(2) for 14 minutes was similar. A modified-accelerated protocol of 14 minutes of CXL provided the same treatment depth as the classic Dresden protocol.

Customized pachymetric guided epithelial debridement for corneal collagen cross linking

BackroundWe describe a modified method for deepitheliazation prior to corneal cross linking (CXL). The technique may overcome the current corneal pachymetric limitation parameter (over 400 microns) that is necessary for the safety of the procedure without affecting the overall benefits.MethodsIn a series of two patients, with inferior topographic steepening and regional thinning (less than 400 microns corresponding to the area of corneal steepening), CXL after customized epithelial removal was performed.ResultsThere were no intra- or postoperative adverse events seen by the nine month follow up examination. Stabilization of the corneal ectasia was observed up to nine months post-costumized pachymetric-guided epithelial removal.ConclusionThe technique of customized pachymetric-guided epithelial removal is easy to perform and may overcome the limitations of the preoperative corneal pachymetry expanding the application of the procedure in patients with regional corneal thinning.

Descemet-stripping automated endothelial keratoplasty (DSAEK): Effect of nontoxic gentian violet marking pen on DSAEK donor tissue viability by using vital dye assay

Purpose: To qualitatively assess the endothelial damage on Descemet-stripping automated endothelial keratoplasty (DSAEK) donor tissue resulting from a gentian violet marking pen. Methods: An in vitro model was used, by using corneoscleral rims, DSAEK quality corneal donor tissue, and a gentian violet marking pen. After making a mark on the stromal side of a microkeratome-prepared DSAEK corneal button to confirm appropriate orientation of the donor tissue after insertion into the anterior chamber, the corneal tissue was returned to Optisol GS solution for 1 hour. A vital dye assay was used to identify devitalized and necrotic endothelial cells with alizarin red S and trypan blue. Results: Corneal donor tissue evaluated with the gentian violet marking pen showed positive trypan blue staining, limited to the area marked with the gentian violet ink. Conclusions: Marking the DSAEK donor stromal surface with a gentian violet marker damages the endothelium. Surgeons should limit the size of the mark or use an insertion technique that avoids confusion about orientation of the donor cornea.