Jose L. Rodriguez-Prats

Intracorneal rings for the correction of pellucid marginal degeneration

We report a case of Intacs(R) (KeraVision) implantation for the correction of pellucid marginal degeneration (PMD). Preoperatively, the patients uncorrected visual acuity (UCVA) was 0.05, the best spectacle-corrected visual acuity (BSCVA) was 0.1, and the refraction was -2.00 -7.00 x 90 in the right eye. The flattest meridian (K1) measured 43.8@104 and the steepest meridian (K2), 51.3@14. Ultrasound pachymetry revealed a thin cornea of 420 micrometers. One month postoperatively, the UCVA was 0.2, the BSCVA was 0.5, and the refraction was -8.00 -7.00 x 50. Contact lens best corrected visual acuity was 0.9; 6 months postoperatively, it improved to 1.0. The use of Intacs to treat PMD seems to be viable and improves visual acuity. The residual error can be corrected with contact lenses.

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.

Visual and Optical Performance With Two Different Diffractive Multifocal Intraocular Lenses Compared to a Monofocal Lens

PURPOSE To compare the visual acuity outcomes as well as the ocular optical performance of eyes implanted with either a monofocal or one of two diffractive multifocal intraocular lenses (IOLs). METHODS One hundred two consecutive eyes of 51 bilateral cataract patients (age 49 to 80 years) were divided into three groups: 22 eyes were implanted with a monofocal IOL (monofocal group), 40 eyes with the Acrysof ReSTOR SN6AD3 IOL (ReSTOR group), and 40 eyes with the Acri.Lisa 366D IOL (Acri.Lisa group). Visual acuity and contrast sensitivity were evaluated pre- and postoperatively. Additionally, ocular optical quality and intraocular aberrations were evaluated postoperatively. RESULTS Significant improvement after surgery in uncorrected and corrected distance and near visual acuity was observed in all three groups (P≤.05). Uncorrected near visual acuity was significantly better in eyes from the ReSTOR and Acri.Lisa groups compared to the monofocal group (P≤.01). Photopic contrast sensitivity was significantly better for the spatial frequency of 3 cycles/degree in the monofocal group (P<.01). Significantly higher values of the ocular Strehl ratio and cutoff modulation transfer function spatial frequency were also found in the Acri.Lisa group (P=.01). An acceptable range of vision between near and distance peaks was observed in the defocus curves of the ReSTOR and Acri.Lisa groups. CONCLUSIONS The AcrySof ReSTOR and Acri.Lisa 366D IOLs are able to successfully restore near and intermediate visual function after cataract surgery; however, the Acri.Lisa design seems to provide better optical performance. These results need to be confirmed in a randomized, prospective trial.

Quality of life evaluation after implantation of 2 multifocal intraocular lens models and a monofocal model

PURPOSE: To compare vision‐related quality of life using the National Eye Institute Visual Function Questionnaire (NEI VFQ‐25) in patients with 1 of 3 types of intraocular lenses (IOLs) and to correlate it with postoperative visual outcomes. SETTING: Vissum Corporation–Instituto Oftalmológico de Alicante, Alicante, Spain. DESIGN: Comparative case series. METHODS: This study comprised eyes having cataract surgery with bilateral implantation of a monofocal IOL (Group A), apodized multifocal IOL (Group B), or full diffractive multifocal IOL (Group C). Distance and near visual acuities, contrast sensitivity, and quality of life were evaluated preoperatively and postoperatively. RESULTS: The study enrolled 106 eyes (53 patients; age range 49 to 80 years). All groups had significant improvement in uncorrected and corrected distance visual acuities postoperatively (P≤.05). Near vision outcomes were significantly better in Groups B and C (P≤.01). Groups B and C had significantly less difficulty in some near tasks, such as reading the newspaper (A–B, P=.02; A–C, P=.02) or reading bills (A–B, P=.04; A–C, P=.004). Group C also had significantly less difficulty driving at night than Group B (P<.01). Near visual acuity and contrast sensitivity were significantly correlated with difficulty in near visual tasks in Groups B and C. Night‐driving difficulty correlated significantly with contrast sensitivity in Group B. CONCLUSIONS: Patients with multifocal IOLs could perform several daily tasks at near and intermediate distances, with less night‐driving limitation with the full diffractive IOL than with apodized multifocal and monofocal IOLs. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Human anterior lens capsule as a biologic substrate for the ex vivo expansion of limbal stem cells in ocular surface reconstruction.

Purpose: To study the potential use of human anterior lens capsule as a scaffold for stem cell transplantation in treatment of limbal cell deficiency. Methods: Limbal biopsies and anterior lens capsules were obtained (same eye) from 30 patients during cataract surgery. Biopsies were suspended in Dulbecco modified Eagle medium under sterile conditions and stored at 4°C. Capsules were treated in distilled water under strict asepsis for 2 hours to eliminate the crystalline epithelium and stored at 4°C. After initial processing, the limbal biopsy was plated epithelial-side down (48 hours) on the capsular specimen in a 35-mm culture dish. Samples were sorted into 4 groups. Group 1 was made up of 10 samples in which limbal biopsies were allowed to grow on corresponding capsules from the same eye (autologous). Group 2 was 10 limbal biopsies that were allowed to grow on capsules of different eye (allogeneic). The remaining specimens were randomized into 2 groups. Group 3 included 10 capsules on which an ex vivo expanded cell line was allowed to grow. Group 4 harbored 10 limbal biopsies that were allowed to grow on polystyrene culture plates. All specimens were incubated for 2 weeks at 37°C and 5% CO2. Cell density, viability, morphology, and adherence of the cell-capsule complex were evaluated at 1, 3, 7, and 14 days. Results: Rate of cell growth and density in groups 1 and 2 were comparable to the control groups. Cell viability was 95% or superior in all groups, and desmosomes developed between growing cells. Conclusions: Human anterior lens capsule is a potential scaffold for ex vivo expansion of limbal epithelial cells, possibly providing a substrate for ocular surface reconstruction.

Interface Corneal Edema Secondary to Steroid-induced Elevation of Intraocular Pressure Simulating Diffuse Lamellar Keratitis

PURPOSE To describe interface corneal edema secondary to steroid-induced elevation of intraocular pressure (IOP) following LASIK. METHODS Retrospective observational case series. Diffuse interface edema secondary to steroid-induced elevation of IOP was observed after LASIK simulating diffuse lamellar keratitis (DLK) in 13 eyes. Mean patient age was 31.4 +/- 5.3 years. Patients were divided into two groups according to provisional misdiagnosis: DLK group (group 1) comprised 11 eyes and infection group (group 2) comprised 2 eyes (microbial keratitis). Mean follow-up was 8.1 +/- 0.5 weeks. RESULTS In the DLK group, typical diffuse haze was confined to the interface and extended to the visual axis, impairing vision in all eyes. Provisional diagnosis was late-onset DLK and topical steroids were started. Repeat examination showed elevated IOP as measured at the corneal center and periphery using applanation tonometry (mean 19.1 mmHg and 39.5 mmHg, respectively), causing interface edema with evident interface fluid pockets. Steroids were stopped and topical anti-glaucoma therapy was started. The interface edema decreased and at the end of follow-up the corneal transparency was restored and IOP dropped to normal values. The infection group demonstrated a microbial keratitis-like reaction and underwent flap lifting and interface wound debridement and biopsy with administration of fortified antibiotics and steroids. After elevated IOP was detected, steroids and antibiotics were stopped and topical anti-glaucoma therapy was started, resulting in the resolution of the interface edema. CONCLUSIONS Interface fluid syndrome secondary to steroid-induced elevation of IOP might develop in steroid responders after LASIK with a misleading clinical picture simulating DLK or infectious keratitis. Management includes stopping topical steroids and starting topical antiglaucoma therapy.

Postoperative bilateral reading performance with 4 intraocular lens models: Six-month results

PURPOSE: To compare bilateral reading performance within the first 6 months after implantation of 4 intraocular lens (IOL) models. SETTING: Vissum‐Instituto de Oftalmológico de Alicante, Alicante, Spain, and University Eye Clinic, Paracelsus Medical University, Salzburg, Austria. DESIGN: Comparative case series. METHODS: Patients had bilateral phacoemulsification and implantation of Acri.Smart 48S monofocal, Acrysof Restor SN6AD3 apodized multifocal, Acri.LISA 366D diffractive multifocal, or Rezoom refractive multifocal IOLs. Bilateral reading performance with and without near correction was evaluated preoperatively and postoperatively using the Salzburg Reading Desk. RESULTS: The study comprised 304 eyes of 152 patients 51 to 90 years old. All groups had a significant improvement in uncorrected and corrected distance visual acuities postoperatively (P≤.01). The apodized multifocal and diffractive multifocal groups had significantly better uncorrected reading acuity than the monofocal and refractive multifocal groups 1 month and 6 months postoperatively (P<.01). Uncorrected reading speed was significantly worse in the refractive multifocal group than in the monofocal group at 1 month (P<.01). The monofocal group had the greatest uncorrected reading distance at 1 month and 6 months (P<.01). CONCLUSION: Multifocal IOLs with a diffractive component provided a comparable reading performance that was significantly better than the one obtained with refractive multifocal and monofocal IOLs. Financial Disclosure: Drs. Alió, Plaza‐Puche, Rasp, Piñero, Seyeddain, Rodríguez‐Prats, Ayala, Moreu, Hohensinn, and Riha have no financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

Factors influencing corneal biomechanical changes after microincision cataract surgery and standard coaxial phacoemulsification

PURPOSE: To determine the factors affecting corneal biomechanics using biomechanical waveform analysis after microincision cataract surgery (MICS) and standard coaxial phacoemulsification with different incision sizes. SETTING: Vissum‐Instituto Oftalmologico de Alicante, Alicante, Spain. METHODS: This prospective nonrandomized study comprised eyes with significant cataract that had MICS (sub‐1.8 mm incision) or coaxial phacoemulsification (2.75 mm incision). Corneal hysteresis (CH) and the corneal resistance factor (CRF) were measured by biomechanical waveform analysis (Ocular Response Analyzer) preoperatively, immediately postoperatively, and at 1 month. Results were analyzed and compared between groups. RESULTS: In the MICS group (n = 30), there was a significant increase in Goldmann‐correlated intraocular pressure (IOP) and corneal‐compensated IOP, although CH decreased in the immediate postoperative period (P<.05). At 1 month, all parameters in the MICS group returned to normal. The coaxial group (n = 30) had an increase in Goldmann‐correlated IOP and corneal‐compensated IOP, both of which were higher than normal at 1 month. Backward multiple regression analysis showed significant correlations between CH and preoperative Goldmann‐correlated IOP and preoperative CRF (r2 = 0.631, P<.05); between age, axial length (AL), and preoperative CRF (r2 = 0.418, P<.05); and between the change in CH and AL, total incision length, and preoperative CH (r2 = 0.429, P<.05). CONCLUSIONS: Cataract surgery with MICS and coaxial phacoemulsification significantly altered corneal biomechanics. Corneal hysteresis was inversely correlated with Goldmann‐correlated IOP; CRF was inversely correlated with age and AL. The MICS technique provided more stable corneal biomechanical properties than standard coaxial phacoemulsification 1 month postoperatively. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Visual and accommodative outcomes 1 year after implantation of an accommodating intraocular lens based on a new concept

PURPOSE: To evaluate visual outcomes and accommodative gains 1 year after implantation of the NuLens accommodating intraocular lens (IOL). SETTING: Department of Refractive Surgery, Vissum Corp., Alicante, Spain. METHODS: This study comprised patients with cataract and atrophic macular degeneration. In each patient, the accommodating IOL was implanted in the eye with the worse visual acuity. At the 12‐month follow‐up visit, visual acuity and accommodation were measured to determine the efficacy of the IOL. Ultrasound biomicroscopy was used to measure accommodative amplitude. RESULTS: Ten eyes of 10 patients were evaluated. The mean number of lines patients could read increased from 1.0 preoperatively to 3.8 lines 6 months postoperatively, indicating improvement in uncorrected near visual acuity after IOL implantation. The mean change in cross‐section measurements of the IOL was 0.06 mm at 1 month; the value peaked at 3 months (0.21 mm), after which it decreased steadily, becoming stable at 9 months (0.09 mm, which is equivalent to 10.00 diopters [D] of accommodation). Corrected near visual acuity improved slightly (0.7 Jaeger lines) at 12 months, with the best reading distance at 10 cm. These results suggest that the near and distance visual acuities were approximately equal and, therefore, the IOL can produce accommodation of 10.00 D. CONCLUSIONS: The accommodation mechanism of the IOL can produce an ocular power variation of 10.00 D. Near visual acuity improved without compromising distance visual acuity.

The influence of age on the refractive index of the human corneal stroma resected using a mechanical microkeratome.

Purpose: To measure the refractive index (RI) of the human corneal stroma in vivo using an objective Abbé refractometer (VCH-1) and to determine if RI of the stroma is related to age. Methods: The VCH-1 was calibrated against a standard subjective Abbé refractometer using 7 randomly selected turbid semiliquid media. VCH-1 was used to measure RI at the central midstroma immediately after lifting the flap in neophyte patients preselected for laser-assisted in situ keratomileusis. Surgical procedures continued as preplanned after measuring the RI; in binocular cases, measurements were taken from the right eye only. Flaps were created using a mechanical microkeratome. Results: The VCH-1 was capable of measuring the RIs of all 7 turbid semiliquid media. The average RMS difference between RI estimates according to the VCH-1 and standard subjective Abbé refractometer was 0.003. The mean RI (±SD) of the stroma was 1.369 (±0.008; range, 1.356–1.390), and the mean age (±SD) of the subjects was 33.7 years (±8.86; range, 18–56 years). A significant linear correlation was found between age and RI. Least squares regression lines equating RI with age (x, years) was of the form: RI = 1.35711 + 0.00034x (r = +0.383, n = 36, P = 0.011). Conclusions: RI of the stroma in vivo has a tendency to be increased in older patients when the stroma is resected using a mechanical microkeratome.