Jaime Javaloy

Microbial keratitis after corneal collagen crosslinking.

Several infiltrates appeared in the upper midperipheral cornea of a 29-year-old woman who had had uneventful corneal collagen crosslinking (CXL) with riboflavin and ultraviolet-A light (UVA) for the treatment of keratoconus in the right eye. Staphylococcus epidermidis keratitis was confirmed by microbiological studies, which guided treatment with topical fortified antibiotic agents. Before CXL, the best spectacle-corrected visual acuity (BSCVA) in the right eye was 20/25, the manifest refraction was -0.25 -0.25 x 125, and the anterior segment was normal under biomicroscopy. Five months after the procedure, the BSCVA was 20/22, the manifest refraction was +1.00 -2.50 x 40, and slitlamp examination revealed a mild residual haze in the upper midperipheral cornea. Collagen crosslinking with riboflavin-UVA is a minimally invasive method but traditionally requires epithelial removal, which could be a predisposing factor to bacterial keratitis.

Comparison of four corneal pachymetry technique;s in corneal refractive surgery.

PURPOSE To assess the effectiveness of optical and ultrasonic pachymetry when examining corneas of patients before and after laser in situ keratomileusis (LASIK). METHODS We conducted a prospective study of 25 patients (50 eyes) who had LASIK for myopia or myopic astigmatism (mean spherical equivalent refraction -4.80 +/- 3.60 D; range -1.75 to -12.00 D). Corneal thickness was measured using 1) conventional ultrasonic pachymetry (20 MHz probe) in the central cornea, 2) ASL confocal microscopy (CMTF analysis), 3) Orbscan II Analyzer, and 4) ultrasound biomicroscopy (UBM) (50 MHz probe) preoperatively and 3 months postoperatively. RESULTS Preoperative pachymetry values measured with the Orbscan II Analyzer (551.3 +/- 27.3 microm) were almost identical to those measured with the 20 MHz ultrasonic probe (553.7 +/- 25.7 microm; t-test P = .652). The mean preoperative pachymetry for UBM was 566.7 +/- 38.8 microm and for CMTF was 553.2 +/- 15.5 microm. The optic and ultrasonic system measurements differed in operated eyes; 20 MHz ultrasonic pachymetry yielded an average 478.7 +/- 23.5 microm and the UBM, 482.4 +/- 40.3 microm. These measurements differed from the Orbscan II (Tukey test; P = .023) measurement of 461.1 +/- 37.5 microm but not from the confocal microscopy measurement of 475.2 +/- 41.8 microm. UBM registered greater values that were more variable than those obtained with ultrasonic pachymetry. CONCLUSIONS In non-operated eyes, corneal thickness was similar using conventional ultrasound, Orbscan II, or confocal techniques, with ultrasound biomicroscopy giving thicker readings.

Comparison of a New Refractive Multifocal Intraocular Lens with an Inferior Segmental Near Add and a Diffractive Multifocal Intraocular Lens

PURPOSE To compare the visual acuity outcomes and ocular optical performance of eyes implanted with a multifocal refractive intraocular lens (IOL) with an inferior segmental near add or a diffractive multifocal IOL. DESIGN Prospective, comparative, nonrandomized, consecutive case series. PARTICIPANTS Eighty-three consecutive eyes of 45 patients (age range, 36-82 years) with cataract were divided into 2 groups: group A, 45 eyes implanted with Lentis Mplus LS-312 (Oculentis GmbH, Berlin, Germany); group B, 38 eyes implanted with diffractive IOL Acri.Lisa 366D (Zeiss, Oberkochen, Germany). METHODS All patients underwent phacoemulsification followed by IOL implantation in the capsular bag. Distance corrected, intermediate, and near with the distance correction visual acuity outcomes and contrast sensitivity, intraocular aberrations, and defocus curve were evaluated postoperatively during a 3-month follow-up. MAIN OUTCOME MEASURES Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), uncorrected near visual acuity (UNVA), corrected distance near and intermediate visual acuity (CDNVA), contrast sensitivity, intraocular aberrations, and defocus curve. RESULTS A significant improvement in UDVA, CDVA, and UNVA was observed in both groups after surgery (P ≤ 0.04). Significantly better values of UNVA (P<0.01) and CDNVA (P<0.04) were found in group B. In the defocus curve, significantly better visual acuities were present in eyes in group A for intermediate vision levels of defocus (P ≤ 0.04). Significantly higher amounts of postoperative intraocular primary coma and spherical aberrations were found in group A (P<0.01). In addition, significantly better values were observed in photopic contrast sensitivity for high spatial frequencies in group A (P ≤ 0.04). CONCLUSIONS The Lentis Mplus LS-312 and Acri.Lisa 366D IOLs are able to successfully restore visual function after cataract surgery. The Lentis Mplus LS-312 provided better intermediate vision and contrast sensitivity outcomes than the Acri.Lisa 366D. However, the Acri.Lisa design provided better distance and near visual outcomes and intraocular optical performance parameters.

Inhibition of Corneal Neovascularization by Topical Bevacizumab (Anti-VEGF) and Sunitinib (Anti-VEGF and Anti-PDGF) in an Animal Model

PURPOSE To evaluate the effects of topically applied bevacizumab and sunitinib on experimentally induced corneal neovascularization. DESIGN Experimental animal study. METHODS Thirty-six New Zealand rabbits were involved. One eye per rabbit was used. Corneal neovascularization was induced by placing 5 silk sutures in the upper cornea. Rabbits were randomized to 1 of 3 groups (12 rabbits each): Group 1 received saline 0.9%, Group 2 bevacizumab 5 mg/mL, and Group 3 sunitinib 0.5 mg/mL. All treatments were administered 3 times daily for 14 days. Photographs were taken on a slit lamp on days 7 and 14, and angiographic photographs were taken on day 14. The area of neovascularization was measured in mm(2), percentage of the total corneal area, and percentage of the corneal surface covered by sutures. RESULTS On day 14, corneal neovascularization area in Group 1 (25.92 ± 5.08 mm(2), 18.78% ± 3.5% of corneal surface, 105.59% ± 18.9% of corneal surface with sutures) was larger than in Groups 2 (18.52 ± 7.94 mm(2), 13.67% ± 5.8%, 76.35% ± 33.2%) (1-way analysis of variance, P = .041) and 3 (4.57 ± 2.32 mm(2), 3.40% ± 1.7%, 18.94% ± 9.2%)(P < .001). Neovascularization in Group 2 was larger than in Group 3 (P < .001). Compared to saline, corneal neovascularization was inhibited 28.5% by bevacizumab and 82.3% by sunitinib. Sunitinib settled on the iris. CONCLUSIONS Topical administration of both bevacizumab and sunitinib inhibits corneal neovascularization in rabbits. But vascular endothelial growth factor (VEGF) pathway blockade by bevacizumab was not sufficient for a profound inhibition. Blocking both VEGF and platelet-derived growth factor pathways using sunitinib was 3-fold more effective.

Optical analysis, reading performance, and quality-of-life evaluation after implantation of a diffractive multifocal intraocular lens.

PURPOSE: To evaluate the reading performance, changes in quality of life, and optical performance after cataract surgery with multifocal diffractive intraocular lens (IOL) implantation. SETTING: Vissum Corporation, Alicante, Spain. DESIGN: Prospective case series. METHODS: Patients with bilateral cataract had implantation of Acri.LISA 366D multifocal IOLs. Visual acuity and contrast sensitivity outcomes were evaluated during a 6‐month follow‐up. Other parameters evaluated included reading performance (Salzburg Reading Desk), a 25‐item quality‐of‐life questionnaire (National Eye Institute Visual Functioning Questionnaire‐25 [NEI VFQ‐25] and appendix NEI VFQ‐39), and ocular optical performance (ocular aberrometry and modulation transfer function). RESULTS: The study included 48 eyes (24 patients) ranging in age from 47 to 77 years. The mean uncorrected distance visual acuity (logMAR) improved significantly 1 month postoperatively (P<.01), with no significant changes afterward (6 months, P≥.06). The mean reading acuity without correction improved significantly from 0.68 logRAD ± 0.20 (SD) to 0.16 ± 0.08 logRAD 1 month after surgery (P < .01). However, it was worse by the end of the follow‐up (6 months, P = .04). During the follow‐up, no significant changes were found in the mean reading speed without near correction (6 months, P = .50). Contrast sensitivity improved significantly at all spatial frequencies under photopic and scotopic conditions after surgery (6 months, P≤.02). The quality‐of‐life index related to reading ability also improved significantly (3 months, P = .03). CONCLUSION: Implantation of the multifocal diffractive IOL significantly improved reading performance, which had a positive effect on the patient’s quality of life postoperatively. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Transient light-sensitivity syndrome after laser in situ keratomileusis with the femtosecond laser Incidence and prevention

PURPOSE: To describe the incidence of transient light‐sensitivity syndrome (TLSS) after laser in situ keratomileusis (LASIK) with the femtosecond laser and to identify preventive strategies. SETTING: Hospital NISA Virgen del Consuelo, Valencia, Spain. METHODS: The first 765 eyes operated on with the 15 KHz femtosecond laser were prospectively analyzed for subjective complaints and clinical findings compatible with TLSS. Intraoperative settings, postoperative treatment, and development of complications were analyzed. RESULTS: Overall, TLSS developed in 10 eyes (incidence 1.3%). However, the incidence decreased from 2.8% to 0.4% when aggressive topical steroids were used during the first 3 postoperative days. Postoperative interface inflammation and postoperative use of a low‐dose topical steroid regimen were associated with a higher incidence of TLSS. CONCLUSIONS: Transient light‐sensitivity syndrome is a relatively uncommon complication related to the use of the femtosecond laser. Postoperative interface inflammation may increase the probability of developing TLSS, whereas an aggressive postoperative steroid regimen seemed to provide protection against it.

Confocal microscopy comparison of intralase femtosecond laser and Moria M2 microkeratome in LASIK.

PURPOSE To analyze the quality of LASIK flaps created using a femtosecond laser or a mechanical microkeratome. METHODS A prospective study of consecutive bilateral LASIK flaps (100 patients) created with a 15 kHz femtosecond laser (IntraLase) or with a mechanical microkeratome (Moria M2) was performed. Outcome measures included visual and refractive outcomes, flap dimensions, and intraoperative complications. The first consecutive ten patients (20 eyes) were examined using confocal microscopy 1 and 3 months following surgery. RESULTS No significant differences were noted in the visual outcomes between groups (t test, P > .05 for all comparisons). Analysis of superficial measurements revealed more round flaps and greater predictability in surface dimensions for the femtosecond laser group (t test, P = .016). Mean deviation of flap thickness from target was the same for both instruments, 10 microm, with greater variability for the mechanical microkeratome. The incidence of diffuse lamellar keratitis was significantly greater in the femtosecond laser group (17%) than in the mechanical group (0%) (chi-square test, P < .001). Confocal microscopy revealed a higher wound healing opacity index in the femtosecond laser group. CONCLUSIONS Although the clinical results are similar, the femtosecond laser produces LASIK flaps with more accurate dimensions compared to the mechanical microkeratome.

Laser in situ keratomileusis to correct post-keratoplasty astigmatism: 1-step versus 2-step procedure☆☆☆

Purpose: To investigate the correction of post‐penetrating keratoplasty (PKP) astigmatism using laser in situ keratomileusis (LASIK). Visual and refractive outcomes were evaluated after LASIK was performed in 1 step (lamellar cut and ablation in 1 procedure) or 2 steps (lamellar cut then ablation in 2 successive procedures). Setting: Department of Cornea and Refractive Surgery, Vissum–Instituto Oftalmológico de Alicante, University of Miguel Hernández, Alicante, Spain. Methods: In this prospective observational study, 22 consecutive eyes were divided into 2 groups depending on the LASIK procedure performed to correct post‐PKP astigmatism. Group 1 (1‐step LASIK) included 11 eyes and Group 2 (2‐step LASIK), 11 eyes. The patients were followed for 6 months. Results: A statistically significant improvement was obtained in Group 2 with a mean vector analysis result of the cylinder of –4.37 diopters (D) ± 1.79 (SD) (P = .018). In Group 1, the mean astigmatism correction was 2.38 ± 1.71 D. The number of reoperations and residual refractive defects were significantly better in Group 2. Conclusion: The 2‐step technique improved the accuracy of excimer laser correction of post‐PKP astigmatism.

Outcomes of ZB5M Angle-supported Anterior Chamber Phakic Intraocular Lenses at 12 Years

PURPOSE To evaluate the visual and refractive stability and the potential long-term risks associated with ZB5M phakic intraocular lens (PIOL) implantation. METHODS A retrospective, non-randomized, cumulative clinical study was performed over 12 years in a consecutive group of 225 eyes implanted with the ZB5M PIOL. The main analyzed variables were visual and refractive outcomes (best spectacle-corrected visual acuity [BSCVA], uncorrected visual acuity [UCVA], and spherical equivalent), endothelial cell density, and postoperative complications. RESULTS Mean preoperative spherical equivalent refraction was -17.23 +/- 7.69 diopters (D) and 12 years postoperatively it was -1.80 +/- 0.80 D. Mean BSCVA at 1- and 12-year follow-up was 0.38 +/- 0.19 and 0.57 +/- 0.18, respectively (Wilcoxon test, P < .001). At 12 years postoperatively, 3.5% of eyes lost > or = 2 lines of BSCVA. An initial 10.6% reduction in endothelial cell density was noted in the first year, followed by a mean annual rate of decrease of 1.78%. The cumulative incidence of pupil ovalization was 34.7% (78 eyes), and there was no statistical correlation with endothelial cell impairment. Bilateral hypertensive uveitis was diagnosed in 3 (1.33%) eyes. CONCLUSIONS The ZB5M PIOL offers good refractive outcomes and stability in the long-term; however, endothelial cell loss increases over 12 years, requiring annual endothelial cell counts.

Comparison of the visual and intraocular optical performance of a refractive multifocal IOL with rotational asymmetry and an apodized diffractive multifocal IOL.

PURPOSE To compare the visual outcomes and intraocular optical quality observed postoperatively in patients implanted with a rotationally asymmetric multifocal intraocular lens (IOL) and an apodized diffractive multifocal IOL. METHODS Seventy-four consecutive eyes of 40 cataract patients (age range: 36 to 79 years) were divided into two groups: zonal refractive group, 39 eyes implanted with a rotationally asymmetric multifocal IOL (Lentis Mplus LS-312 IOL, Oculentis GmbH); and diffractive group, 35 eyes implanted with an apodized diffractive multifocal IOL (ReSTOR SN6AD3, Alcon Laboratories Inc). Distance and near visual acuity outcomes, contrast sensitivity, intraocular optical quality, and defocus curves were evaluated during 3-month follow-up. Calculation of the intraocular aberrations was performed by subtracting corneal aberrations from total ocular aberrations. RESULTS Uncorrected near visual acuity and distance-corrected near visual acuity were better in the diffractive group than in the zonal refractive group (P=.01), whereas intermediate visual acuity (defocus +1.00 and +1.50 diopters) was better in the zonal refractive group. Photopic contrast sensitivity was significantly better in the zonal refractive group (P=.04). Wavefront aberrations (total, higher order, tilt, primary coma) were significantly higher in the zonal refractive group than in the diffractive group (P=.02). CONCLUSIONS Both multifocal IOLs are able to successfully restore visual function after cataract surgery. The zonal refractive multifocal IOL provides better results in contrast sensitivity and intermediate vision, whereas the diffractive multifocal IOL provides better near vision at a closer distance.