Ioannis M. Aslanides

Long-term outcome of aqueous shunt surgery in ten patients with iridocorneal endothelial syndrome

PURPOSE To report the long-term outcome of ten patients with iridocorneal endothelial (ICE) syndrome who underwent aqueous shunt surgery for uncontrolled glaucoma. DESIGN Noncomparative, retrospective case series. PARTICIPANTS The authors reviewed charts of ten patients with ICE syndrome-related glaucoma who underwent aqueous shunt surgery at one institution between 1987 and 1996. MAIN OUTCOME MEASURES Intraocular pressure (IOP), number of glaucoma medications, and further surgical interventions were measured. RESULTS With a median follow-up of 55 months, four eyes had adequate IOP control (IOP <21 mm Hg) with one or two medications after the initial aqueous shunt surgery. An additional three eyes achieved adequate IOP control after one or more tube repositionings or revisions of the initial aqueous shunt. In this series, the aqueous shunt surgery most often failed because of blocking of the tube ostium by iris, ICE membrane, or membrane-induced tube migration. CONCLUSION Aqueous shunt surgery appears to be an effective method for IOP lowering in some eyes with ICE syndrome-related glaucoma when medical treatment or conventional filtration surgeries fail, but additional glaucoma procedures and/or aqueous shunt revisions and tube repositionings are not uncommon.

Comparison of single-step reverse transepithelial all-surface laser ablation (ASLA) to alcohol-assisted photorefractive keratectomy.

Purpose To evaluate postoperative pain, corneal epithelial healing, development of corneal haze, refractive outcomes, and corneal aberrations in a novel one-step, modified transepithelial photorefractive keratectomy (PRK), termed All-surface laser ablation (ASLA), compared to conventional, alcohol-assisted PRK. Materials and methods Sixty eyes of 30 myopic patients were prospectively recruited to a randomized fellow eye study. Patients underwent conventional alcohol-assisted PRK in one eye (control group) and ASLA-modified transepithelial PRK in the other (30 eyes in each treatment arm). Primary endpoints were postoperative pain and haze scores at 1 day, 3 days, 1 week, and 1, 3, 6, and 12 months. Secondary endpoints included visual acuity at 1, 3, 6, and 12 months, corneal aberrations at 3, 6, and 12 months, and early and late onset haze. Refractive predictability, safety, and efficacy of the two methods were considered. Results The average age of the cohort was 29 years (standard deviation [SD]: 9; range: 18–46), and the average spherical equivalent refractive error was −4.18 diopters (SD: 1.9). At 3 days after surgery, the average pain score was 64% lower in the ASLA group (P < 0.0005). At this point, 96% of ASLA eyes had no epithelial defect, whereas 43% in the alcohol-assisted group did not achieve complete epithelial healing, and required replacement of bandage contact lens. The haze level was consistently lower in the ASLA group at all time points from 1 to 6 months. Conclusion This study shows that the ASLA technique may have a future role in refractive surgery, due to the fact that it offers faster epithelial healing, lower pain scores, and significantly less haze formation.

Topography-guided treatment of irregular astigmatism with the wavelight excimer laser.

PURPOSE To evaluate the feasibility, safety, and predictability of correcting high irregular astigmatism in symptomatic eyes with the use of topography-guided photoablation. METHODS In a prospective, non-comparative case series, 16 consecutive symptomatic eyes of 11 patients with small hyperopic and myopic excimer laser optical zones, decentered and irregular ablation after corneal graft, and corneal scars were operated. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), manifest and cycloplegic refraction, and corneal topography, with asphericity and regularity, were analyzed. LASIK (n = 10) and photorefractive keratectomy (n = 6) were performed using the ALLEGRETTO WAVE excimer laser and T-CAT software (Topography-guided Customized Ablation Treatment; WaveLight Laser Technologie AG, Erlangen, Germany). RESULTS In the LASIK group, UCVA improved from 0.81 +/- 0.68 IogMAR (20/130) (range: 0.2 to 2.0) to 0.29 +/- 0.21 logMAR (20/39) (range: 0.1 to 0.7) at 6 months. In the PRK group, mean UCVA improved from 0.89 +/- 0.87 IogMAR (20/157) (range: 0.1 to 2.0) to 0.42 +/- 0.35 logMAR (20/53) (range: 0.1 to 1.0) at 6 months. Best spectacle-corrected visual acuity did not change significantly in either group. One PRK patient lost one line of BSCVA. Refractive cylinder for the LASIK group improved from -2.53 +/- 1.71 diopters (D) (range: -0.75 to -5.75 D) to -1.28 +/- 0.99 D (range: 0 to -2.50 D) at 6 months. Refractive cylinder in the PRK group improved from -2.21 +/- 2.11 D (range: -0.25 to -5.50 D) to -1.10 +/- 0.42 D (range: -0.50 to -1.50 D). Index of surface irregularity showed a decrease from 60 +/- 12 (range: 46 to 89) to 50 +/- 9 (range: 32 to 63) at 6 months in the LASIK group whereas no significant change was noted in the PRK group. Subjective symptoms, such as glare, halos, ghost images, starbursts, and monocular diplopia, were not present postoperatively. CONCLUSIONS Topography-guided LASIK and PRK resulted in a significant reduction of refractive cylinder and increase of UCVA, without a significant loss of BSCVA.

Outcome of trabeculectomy with mitomycin-C in the iridocorneal endothelial syndrome

PURPOSE Eyes with iridocorneal endothelial (ICE) syndrome have a high risk of failure in glaucoma filtering surgery failing. We investigated the efficacy of trabeculectomy with intraoperative mitomycin-C application in these patients. DESIGN Retrospective nonrandomized comparative trial with historical controls. PARTICIPANTS AND CONTROLS Ten patients with unilateral iridocorneal endothelial (ICE) syndrome were reviewed. Their intraocular pressures could not be controlled medically. In five eyes, this was the primary surgery performed. Five of the patients had undergone prior intraocular pressure-(IOP) lowering surgery that had failed at the time enrolled. Results were compared with previously published case series of similar patients treated with trabeculectomy alone or trabeculectomy and subconjunctival 5-fluorouracil injections. INTERVENTION Intervention consisted of trabeculectomy with a limbus-based conjunctival flap and mitomycin-C application. The dosage of mitomycin-C was 0.4 mg/ml for 1 to 4 minutes (mean, 1.9 min). MAIN OUTCOME MEASURES Adequate control of IOP (without medication lower than 21 mm Hg). RESULTS In eight eyes the IOP remained well controlled (mean IOP, 12.1 mm Hg) over the entire length of available of follow-up (mean, 14.9 months). Two eyes required implantation of an aqueous tube shunt at 4 and 11 months, respectively, after trabeculectomy with mitomycin-C. One eye experienced visual loss of 3 Snellen lines because of hypotony maculopathy. CONCLUSIONS Trabeculectomy with mitomycin-C application offers a reasonable intermediate-term success rate in ICE patients, who are otherwise at high risk for failure of filtering surgery.

LASIK for Myopia and Astigmatism Using the SCHWIND AMARIS Excimer Laser: An International Multicenter Trial

PURPOSE To assess the efficacy, predictability, and safety of LASIK for the surgical correction of low to moderate myopia with astigmatism using the SCHWIND AMARIS excimer laser. METHODS Six international study sites enrolled 358 eyes with a manifest refraction spherical equivalent (MRSE) from -0.50 to -7.38 diopters (D) (mean sphere: -3.13+/-1.58 D) with up to -5.00 D of astigmatism (mean: -0.69+/-0.67 D). All eyes underwent treatment with the nonwavefront-guided aspheric algorithm of the SCHWIND AMARIS excimer laser. All eyes were targeted for emmetropia. Refractive outcomes and corneal higher order aberrations were analyzed pre- and postoperatively. Visual quality was assessed using photopic and mesopic contrast sensitivity. Six-month postoperative outcomes are reported. RESULTS At 6 months postoperative, the MRSE for all eyes was -0.21+/-0.20 D, and 96% (343/358) of eyes had MRSE within +/-0.50 D. Uncorrected visual acuity was 20/20 or better in 98% (351/358) of eyes, and no eyes lost 2 or more lines of best spectacle-corrected visual acuity. The total corneal higher order aberrations root-mean-square increased by 0.09 microm, spherical aberration increased by 0.08 microm, and coma increased by 0.04 microm postoperatively. Photopic and mesopic contrast sensitivity did not change 6 months postoperatively. CONCLUSIONS Treatment of myopia with astigmatism using the SCHWIND AMARIS excimer laser is safe, efficacious, predictable, and maintains visual quality.

Orbscan II anterior elevation changes following corneal collagen cross-linking treatment for keratoconus.

PURPOSE To analyze anterior corneal elevation changes on Orbscan II following corneal collagen cross-linking (CXL) with riboflavin. METHODS This retrospective study included 8 patients (14 eyes) with keratoconus who underwent CXL, with a mean follow-up of 7 months (range: 5 to 10 months). Pre- and postoperative (at last clinic attendance) anterior elevation difference maps were examined for overall patterns of change. On preoperative maps, distances from maximum anterior elevation to pupil center and to topographic geometric center were compared between the two patterns identified. Pre- and postoperative topography, best spectacle-corrected visual acuity (BSCVA), and refraction were also compared between the two patterns. RESULTS Two patterns of anterior elevation change were visually identified: (1) paracentral steepening, no change, or flattening centrally; and (2) central steepening. The preoperative maps of eyes that manifested pattern 1 had shorter mean distances for maximum anterior elevation to pupil center (1.70 vs. 2.27 mm) and maximum anterior elevation to geometric center (1.45 vs. 1.99 mm) than those that resulted in pattern 2. Mean maximum topographic simulated keratometry decreased (P = .004) and mean irregularity indices at 3 mm (P =.03) and 5 mm (P =.04) were reduced postoperatively in pattern 1 eyes; all increased in pattern 2 eyes. Mean BSCVA improved postoperatively for both patterns. Mean preoperative myopia decreased in pattern 1 eyes by 0.44 diopters (D), whereas it increased for pattern 2 eyes by 1.83 D. CONCLUSIONS Corneal shape change influenced by anisotropy of collagen distribution is a factor in the outcome of CXL treatment for keratoconus.

LASIK Flap Characteristics Using the Moria M2 Microkeratome With the 90-µm Single Use Head

PURPOSE To evaluate the accuracy and consistency of corneal flap thickness, horizontal diameter, and hinge size with the Moria M2 90-microm single use head. METHODS Fifty-two myopic patients (104 eyes), mean age 32.6 years, underwent bilateral LASIK with a superior hinged flap using the Moria M2 microkeratome (90-microm single use head). Prospective evaluation included flap thickness (subtraction method), diameter, hinge size, interface particles, intraoperative complications, and visual recovery. RESULTS The mean preoperative spherical equivalent refraction was -5.72 +/- 2.59 diopters (D) (range: -2.88 to -10.75 D) and -5.84 +/- 2.73 D (range: -3.13 to -9.38 D) for right and left eyes, respectively. The mean preoperative central corneal thickness was 548 +/- 24 microm and 547 +/- 25 microm for right and left eyes, respectively. The mean preoperative steepest K was 44.12 +/- 1.28 D and 44.41 +/- 1.27 D for right and left eyes, respectively. Corneal diameter (white-to-white) was 12 +/- 0.4 mm and 11.9 +/- 0.4 mm for right and left eyes, respectively. The mean postoperative flap thickness was 109 +/- 18 microm (range: 67 to 152 microm) and 103 +/- 15 microm (range: 65 to 151 microm) for right and left eyes, respectively. The mean postoperative flap diameter was 9.4 +/- 0.3 mm (expected mean according to the nomogram given by the company was 9.5 mm). The mean postoperative hinge chord was 4.4 +/- 0.4 mm (expected mean 4.2 mm). No interface particles were detected on slit-lamp examination. CONCLUSIONS The Moria M2 90-microm single use head is safe with reasonable predictability for LASIK flap creation.

Adjuvant corneal crosslinking to prevent hyperopic LASIK regression

Purpose To report the long term outcomes, safety, stability, and efficacy in a pilot series of simultaneous hyperopic laser assisted in situ keratomileusis (LASIK) and corneal crosslinking (CXL). Method A small cohort series of five eyes, with clinically suboptimal topography and/or thickness, underwent LASIK surgery with immediate riboflavin application under the flap, followed by UV light irradiation. Postoperative assessment was performed at 1, 3, 6, and 12 months, with late follow up at 4 years, and results were compared with a matched cohort that received LASIK only. Results The average age of the LASIK-CXL group was 39 years (26–46), and the average spherical equivalent hyperopic refractive error was +3.45 diopters (standard deviation 0.76; range 2.5 to 4.5). All eyes maintained refractive stability over the 4 years. There were no complications related to CXL, and topographic and clinical outcomes were as expected for standard LASIK. Conclusion This limited series suggests that simultaneous LASIK and CXL for hyperopia is safe. Outcomes of the small cohort suggest that this technique may be promising for ameliorating hyperopic regression, presumed to be biomechanical in origin, and may also address ectasia risk.

Single-step transepithelial ASLA (SCHWIND) with mitomycin-C for the correction of high myopia: long term follow-up

Purpose We wanted to compare the outcomes of single-step modified transepithelial photorefractive keratectomy (tPRK) termed a SCHWIND all surface laser ablation (ASLA) versus conventional alcohol-assisted photorefractive keratectomy (PRK) and laser-assisted in situ keratomileusis (LASIK) for the correction of higher myopia of 6.00 diopters (D) or more, in an area with high risk of haze due to high intensity of sunlight. Methods We used a prospective interventional cohort with matched retrospective control groups. Patients with >6 D myopia and <3.5 D of astigmatism were included. All treatments were performed with the SCHWIND Amaris system using aspheric ablation profiles. Mitomycin C was used in all PRK and ASLA cases. Outcomes were postoperative refraction, visual acuity, stability, and complications. The follow-up period was up to 12 months. Results In total, 101 eyes were included after exclusions. Mean preoperative spherical equivalent refraction was -7.9 D, -8.2 D, and -7.4 D in the ASLA (n=41), PRK (n=29), and LASIK (n=31) groups. Mean postoperative spherical equivalent at 12 months postoperatively was −0.1 (standard deviation [SD]: 0.34), −0.2 (SD: 0.59), and −0.08 (SD: 0.36) in the ASLA, PRK, and LASIK groups, with 91.4%, 85.7%, and 83.9% within 0.5 D of target, respectively. Refractive outcomes and regression at 12 months did not vary among groups (P>0.05). Mean logMAR (logarithm of the minimum angle of resolution) uncorrected distance visual acuity at 12 months was 0.00 (SD: 0.05), 0.06 (SD: 0.1), and 0.05 (SD: 0.09) in the ASLA, PRK, and LASIK groups, with significantly better vision in the tPRK group versus LASIK (P=0.01) and PRK (P=0.01) groups. Conclusion ASLA (SCHWIND) tPRK with mitomycin C for high myopia demonstrates comparable refractive outcomes to LASIK and PRK, with relatively favorable visual acuity outcomes. There was no increased incidence of haze in the ASLA group.

A pharmacological modification of pain and epithelial healing in contemporary transepithelial all-surface laser ablation (ASLA)

Purpose We report our experience with the use of the matrix regenerating agent (RGTA) Cacicol® after reverse transepithelial all-surface laser ablation (ASLA)-SCHWIND to assess the safety, efficacy, pain, and epithelial healing. Methods Forty eyes of 20 myopic patients were prospectively recruited to a randomized fellow eye study. Patients underwent transepithelial ASLA in both eyes, with one of the eyes randomly assigned to the use of the RGTA Cacicol. Postoperative pain and vision were subjectively assessed with the use of a questionnaire on the operative day, at 24 hours, 48 hours and 72 hours. Epithelial defect area size was measured at 24 hours, 48 hours, and 72 hours. Uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) were assessed at 1 month. Results Mean UDVA at 1 month was LogMAR 0.028. The epithelial defect area was 10.91 mm2 and 13.28 mm2 at 24 hours and 1.39 mm2 and 1.24 mm2 at 48 hours for treated and nontreated eyes, respectively. Overall, 50% and 65% of treated and nontreated eyes healed by 48 hours. There was no statistically significant difference in the subjective vision between the groups, although vision of patients in the RGTA group was reported to be better. Pain scores were better at 24 hours and 48 hours in the RGTA group but with no statistically significant difference. Conclusion The use of RGTA Cacicol shows faster epithelial recovery after transepithelial ASLA for myopia. Subjectively reported scores of pain and subjective vision were better in the RGTA group, although the difference was not statistically significant. There seems to be a consensual acceleration of epithelial healing even in eyes that did not receive treatment. There were no adverse events and no incidents of inflammation, delayed healing, or haze.