José Ma Ruiz-Moreno

Phakic anterior chamber lenses for the correction of myopia: a 7-year cumulative analysis of complications in 263 cases.

OBJECTIVE To perform a prospective, clinical trial to determine the potential cumulative complications of patients implanted with angle-supported phakic intraocular lenses (PIOLs) for the correction of myopia. DESIGN Nonrandomized, prospective, comparative trial. PARTICIPANTS Two hundred sixty-three eyes of 160 consecutive patients were included. INTERVENTION Angle-supported anterior chamber intraocular lenses were implanted into phakic eyes. MAIN OUTCOME MEASURES Night halos and glare were recorded. Central endothelial cell count, postoperative inflammation, applanation tonometry, cataract development, retinal detachment, and pupil ovalization were recorded by the same physician. RESULTS Night halos and glare were reported as significant by 20.2% at 1 year and 10% at year 7 of follow-up. This complication was significantly lower in the larger optical zone PIOL (ZSAL-4) than in the ZB5M/ZB5MF group (P < 0.05). Acute postoperative iritis was observed in 4.56% of cases. High intraocular pressure that required antiglaucoma medications appeared in 7.2% of cases. Central corneal endothelial cell density was significantly decreased at postoperative month 3 (P < 0.0001). The percentages of cell loss were 3.76% at month 3 and 1.83% at year 1, and then the percentages decreased by 1.37% more at year 2, 0.72% at year 3, 0.3% at year 4, 0.6% at year 5, 0.4% at year 6, and 0.56% at year 7. The total cumulative loss of central endothelial cells after 7 years was 8.37%. Pupil ovalization was present in 5.9% of cases, although smaller degrees of this complication were observed in another 10.3%. Retinal detachment appeared in 3% of cases. The PIOL explantation was decided in 11 cases (4.18%) because of cataract development (9 cases) and extreme pupil ovalization associated with severe glare (2 cases). The Kaplan-Meier cumulative survival analysis study showed an expected period free from complication of 86.5% for IOP elevation, 98.75% for endothelial cell count inferior to 1500 cells/mm2, 86.97% for pupil ovalization, 95.43% for retinal detachment, and 89.02% for explantation. CONCLUSIONS Angle-supported PIOL appeared to be well tolerated by the corneal endothelium with a low rate of other complications. Pupil ovalization seemed to be a specific problem for this type of PIOL.

Retreatment after laser in situ keratomileusis1

Abstract Objective To evaluate the effectiveness, predictability, and safety of laser in situ keratomileusis (LASIK) retreatment for correcting residual myopia. Design Retrospective noncomparative case series. Participants and intervention Fifty-nine consecutive eyes (43 patients) underwent LASIK retreatment at 3 or 6 months after the primary LASIK procedure. Lifting the corneal flap and reablating the stromal bed with a VISX 20/20 excimer laser was the procedure used for LASIK enhancement. Main outcome measures The following parameters were studied before and after retreatment: visual acuity, refraction, videokeratography, applanation tonometry, and corneal thickness. Complications after LASIK enhancement also were evaluated. Follow-up was 12 months. Results Before retreatment, only 3.38% of eyes (2 of 59) had an uncorrected visual acuity of 0.5 (20/40) or better, and after retreatment, this percentage increased to 60% (30 of 50) at 6 months and 61.8% (34 of 55) at 12 months. After reoperation, mean best-corrected visual acuity improved by half a line over the values before retreatment. The preretreatment refraction of −2.92 ± 1.22 diopters (D) (mean ± standard deviation) decreased significantly to −0.44 ± 0.80 D at 6 months and to −0.61 ± 0.82 D at 12 months ( P P Conclusions LASIK retreatment was an effective and predictable procedure for correcting residual myopia. Epithelial ingrowth and flap melting were more frequent after than before LASIK retreatment, whereas decentration and night-vision symptoms improved.

Incidence of Retinal Disease Following Refractive Surgery in 9,239 Eyes

PURPOSE To analyze the appearance, incidence, and characteristics of retinal diseases in myopic patients after refractive surgery. METHODS We studied retinal disease observed in 9,239 consecutive eyes (5,099 patients) after refractive surgery. Photorefractive keratectomy (PRK) was used to correct myopia in 5,936 eyes (3,184 patients, mean age 30.5 +/- 8.9 years); mean spherical equivalent refraction was -4.71 +/- 2.80 D. Laser in situ keratomileusis (LASIK) was used to correct myopia in 3,009 eyes (1,734 patients, mean age 32.0 +/- 7.8 years); mean spherical equivalent refraction was -13.5 +/- 3.30 D. An anterior chamber phakic intraocular lens (PIOL) was implanted to correct myopia in 294 eyes (181 patients, mean age 32.6 +/- 7.3 yr) with a mean spherical equivalent refraction of -18.5 +/- 5.00 D. RESULTS Retinal detachment occurred at a mean 53.6 +/- 41.4 months after PRK in 9 eyes (0.15%), 24.6 +/- 20.4 months after LASIK in 11 eyes (0.36%), and 20.5 +/- 17.4 months after anterior chamber PIOL implantation in 12 eyes (4.08%). Choroidal neovascularization occurred a mean 26 months after PRK in 1 eye (0.01%), mean 30.2 +/- 19.3 months after LASIK in 10 eyes (0.33%), and mean 49.0 +/- 33.5 months after PACL implantation in 7 eyes (2.38%). One patient developed a macular hole 12 months after LASIK and another patient developed a macular hemorrhage immediately after LASIK. Epiretinal membrane appeared in one patient 19 months after anterior chamber PIOL implantation. CONCLUSION There was no relationship between PRK for myopia and retinal disease. LASIK for correction of myopia was followed by a low incidence of retinal disease; additional study is necessary to assess the true impact of the suction ring in the myopic eye. Implantation of an anterior chamber PIOL to correct high myopia was followed by a low incidence of choroidal neovascularization, a high incidence of retinal detachment, similar to other intraocular interventions in highly myopic patients.

Retinal detachment as a potential hazard in surgical correction of severe myopia with phakic anterior chamber lenses

Phakic anterior chamber lenses have been proposed as an effective refractive surgical procedure for the correction of severe myopias. We managed three cases of retinal detachment that complicated this operation. Two patients had retinal detachment in the immediate postoperative period at the fourth and sixth weeks, respectively. Both patients had preoperative equatorial lattice degeneration, which was prophylactically managed with argon laser in one case. The third patient developed retinal detachment at the eighth postoperative month and was associated with a severe fibrinoid uveitis and a combined exudative and rhegmatogenous retinal detachment. This third patient did not have any previous retinal degenerative lesion. Scleral buckling was successful in two of the patients, whereas the patient with preoperative inflammation required vitreous surgery because of proliferative vitreoretinopathy. The retinas were reattached in all three patients without explanting the phakic anterior chamber lens, but severe loss of visual acuity occurred in one patient. Retinal detachment should be regarded as a potentially important hazard in this type of refractive surgery.

Combined Non-Steroidal Therapy in Experimental Corneal Injury

PURPOSE The effects of anti-inflammatory non-steroidal therapy combined with free-radical scavengers were studied and compared to corticosteroid use in the treatment of experimental corneal injury. METHOD Eighty New Zealand albino rabbits were used in this study. A corneal alkali burn was induced by applying 1-N NaOH filter paper on the central axis of the right cornea for 30 s. Animals were distributed into five treatment groups: group 1 (control group) was only given gentamicin; group 2 was treated with 0.5% dimethylthiourea (DMU); group 3 received 1% dexamethasone; group 4 was given combined 0.5% DMU and 1% indomethacin; group 5 was treated with 0.5% DMU and 0.1% diclofenac sodium. One 50-microliter drop of gentamicin was instilled every 12 h, whereas the other drugs were instilled every 6 h (50 microliters). All groups received the same antibiotic treatment as the control group. The animals were killed on the 5th day. Inflammatory index, area and perimeter of the wounded corneal zone, and corneal transparency were evaluated. RESULTS No significant differences in the inflammatory index were found between the treatment groups and the control group after 72 h. Significant differences (p < 0.001) were observed at 24 h in groups 3-5 when compared with the control group. Planimetry showed significant differences in group 4 when compared with the other groups (p < 0.05). Corneal transparency study showed statistically significantly better values in groups 4 and 5, when compared with the other groups, including group 3 (p < 0.05). CONCLUSIONS The use of 0.5% DMU combined with 1% indomethacin can be considered an alternative to corticosteroid treatment in our experimental chemical corneal injury.

Endophthalmitis after phakic intraocular lens implantation to correct high myopia

A 36-year-old woman had uneventful implantation of an angle-supported anterior chamber phakic intraocular lens (IOL) to correct high myopia. On the first postoperative day, she developed infectious endophthalmitis likely associated with intraoperative contamination. Group B beta-hemolytic Streptococcus endophthalmitis was confirmed by microbiologic studies. To our knowledge, this is the first documented case of infectious endophthalmitis after anterior chamber phakic IOL implantation to correct high myopia.

Retinal detachment in myopic eyes after phakic intraocular lens implantation.

PURPOSE: To analyze the risk of retinal detachment in highly myopic patients who underwent implantation of phakic intraocular lenses (PIOLs). METHODS: In a retrospective, non-comparative, interventional case series, the occurrence of retinal detachment was analyzed in 522 consecutive highly myopic eyes (323 patients) that underwent PIOL implantation. Treatment and results were reviewed. Parameters evaluated were best corrected visual acuity before and after retinal detachment surgery and time between refractive surgery and retinal detachment. RESULTS: Fifteen (2.87%) eyes presented with retinal detachment after PIOL implantation, with a mean time between surgery and detachment of 24.4 +/- 24.4 months (range: 1 to 92 months). The risk of retinal detachment in patients with high myopia corrected by PIOL implantation was 0.57% at 3 months, 1.64% at 12 months, 2.73% at 36 months, and 4.06% at 92 to 145 months (Kaplan-Meier analysis). A comparative study between the group of patients with retinal detachment and the remaining patients without retinal detachment was performed. Differences were found in axial length (30.65 +/- 1.97 vs 29.51 +/- 2.02; P=.028, one factor-analysis of variance test). CONCLUSIONS: The risk of retinal detachment in eyes implanted with phakic lenses for the correction of high myopia is higher in eyes with axial length >30.24 mm.

Photodynamic therapy to treat choroidal neovascularisation in highly myopic patients: 4 years’ outcome

Aims: To report the visual outcome in a series of eyes with myopic choroidal neovascularisation treated by photodynamic therapy (PDT) followed during 48 months. Methods: Prospective, consecutive, non-randomised interventional case series. Thirty-nine eyes from 36 highly myopic patients treated by PDT were evaluated. Best corrected visual acuity (BCVA) and fluorescein angiography were performed every 3 months. Multiple regression analysis was used to analyse changes in BCVA in relationship with initial BCVA, spherical equivalent, age, diameter of CNV and chorioretinal atrophy. Results: Mean initial BCVA was 9.0 Early Treatment Diabetic Retinopathy Study lines (SD 4.3). BCVA was 10.4 lines (3.6) at month 12, 9.7 lines (SD 3.9) at month 24, 9.6 lines (SD 3.8) at month 36 and 9.6 lines (SD 4.2) at month 48. BCVA improvement was associated with initial BCVA (p<0.002), lesion diameter (p<0.04) and age (p<0.04) (multiple regression analysis). Conclusions: Our results suggest a better visual outcome for those eyes with better initial BCVA and larger lesions in younger patients treated by PDT. The poorer results for elderly patients with lower initial BCVA might lead us to consider other therapeutic approaches.

Choroidal neovascularization in myopic eyes after laser-assisted in situ keratomileusis.

Purpose To analyze the appearance and characteristics of choroidal neovascularization (CNV) in patients with high myopia corrected by laser-assisted in situ keratomileusis (LASIK). Patients and Methods The authors studied CNV in 2955 consecutive eyes (1632 patients) that underwent LASIK for the correction of myopia (from −6 to −27.5 diopters). Follow-up was 34.2 ± 11.3 months. Results Choroidal neovascularization occurred in three eyes (0.10%) and in one eye previous CNV was reactivated (three women, one man). The time interval between refractive surgery and CNV was 13 ± 9.5 months (range, 4–26 months). Mean best-corrected visual acuity (BCVA) after LASIK and before CNV development was 20/57 (range, 20/100–20/29). After the appearance of CNV, mean BCVA was 20/606 (range, 20/2000–20/80). Differences between BCVA before and after CNV were statistically significant (P = 0.04, paired Student’s t-test). The CNV was treated in two cases by argon laser photocoagulation and in two cases by surgical excision of CNV by vitrectomy. The final mean BCVA was 20/277 (range, 20/800–20/50). Differences between BCVA after LASIK and after CNV treatment were statistically significant (P = 0.04, paired Student’s t-test). Conclusions Laser-assisted in situ keratomileusis as a correcting procedure for myopia was followed by low appearance of CNV. The appearance and treatment of CNV was followed by a significant decrease of BCVA.

Intravitreal bevacizumab for adult-onset vitelliform dystrophy: a case report.

Purpose Adult-onset foveomacular vitelliform dystrophy (AFVD) is often misdiagnosed as occult choroidal neovascularization (CNV) secondary to age-related macular degeneration (AMD). The authors report the anatomic and functional outcome of intravitreal bevacizumab in a case of AFVD associated with a suspected occult CNV. Methods Prospective, interventional, single case report. One female patient with decreased visual acuity (VA) and metamorphopsia secondary to AFVD received one single intravitreal injection of bevacizumab 1.25 mg. Results The patient reported unchanged VA and decreased metamorphopsia 6 weeks after the injection. Fluorescein angiography (FA) and optical coherence tomography (OCT) showed progressive decrease of subretinal fluid until complete disappearance. VA, OCT, and FA remained unchanged during 10 months follow-up. Conclusions Intravitreal bevacizumab showed a morphologic improvement and stable VA in a patient with AFVD. Further case series are required to confirm this observation.