Luis J. Haddock

Femtosecond laser-assisted retreatment for residual refractive errors after laser in situ keratomileusis

Purpose To study the utility of creating an additional side cut within the old laser in situ keratomileusis (LASIK) flap using a femtosecond laser to reduce the incidence of epithelial ingrowth in patients having retreatments for residual refractive errors after LASIK. Setting Bascom Palmer Eye Institute, Miller School of Medicine, Miami, Florida, USA. Design Comparative case series. Methods On a chart review of all cases that had retreatment between January 2004 and April 2011, eyes in which an additional side cut with the femtosecond laser within the old LASIK flap margin was created were classified as Group 1. All eyes having retreatment using traditional flap‐relifting techniques between January 2008 and April 2011 were classified as Group 2. Results Twenty‐four eyes of 18 patients had femtosecond laser–assisted retreatment with side cut only (Group 1), while 103 eyes of 80 patients had a flap‐lift LASIK enhancement (Group 2). Twenty‐seven cases of epithelial ingrowth were identified in the 2 groups, 4 cases (17%) in the side‐cut group and 23 cases (22%) in the flap‐lift group. There was a statistically significant difference between the 2 groups in the incidence of epithelial ingrowth in patients in which the microkeratome was used as the initial method of flap creation (P<.05). Conclusion Femtosecond laser–assisted side‐cut LASIK resulted in a statistically significant lower incidence of epithelial ingrowth after stratification because of the higher risk for epithelial ingrowth in patients who had primary LASIK with microkeratome flaps. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Cataracts induced by neodymium–yttrium-aluminium-garnet laser lysis of vitreous floaters

Background Neodymium–yttrium-aluminium-garnet (Nd:YAG) laser vitreolysis has been proposed as a treatment modality for symptomatic vitreous floaters. The purpose of this paper is to report two cases of cataracts associated with posterior capsular compromise, induced by Nd:YAG laser vitreolysis for symptomatic vitreous floaters. Method Case series. Results Two patients who underwent ND:YAG laser vitreolysis for symptomatic floaters, presented with decline in visual acuity in the treated eye after the laser procedure. At the slit-lamp biomicroscope, each patient was found to have a posterior subcapsular cataract in the treated eye, with obvious loss of integrity of the posterior capsule. These two patients underwent cataract extraction by the same surgeon via phacoemulsification. Both eyes were found to have a defect in the posterior capsule intraoperatively. In both cases, a three-piece acrylic intraocular lens implant was placed in the sulcus, achieving optic capture. The best-corrected visual acuity (BCVA) was 20/20 in both patients, at 1 month following the surgery. At 2 months, one patient had a BCVA of 20/15. The second patient maintained a BCVA of 20/20 at 3 months. Conclusions Secondary cataract formation accompanied by loss of integrity of the posterior capsule is a potential complication of Nd:YAG laser vitreolysis for symptomatic floaters.

Histopathological Findings after Descemet's Stripping Automated Endothelial Keratoplasty for the Management of Descemet's Membrane Breaks Secondary to Obstetrical Forceps Injury

Case of a 39 y/o male patient that presented due to decreased vision and pain in the left eye secondary to corneal edema related to vertical Descemets membrane breaks. The patients past medical history was remarkable for a complicated vaginal delivery with the use of obstetrical forceps and presumed obstetrical forceps corneal injury. Herein, we demonstrate for the first time the use of descemets stripping automated endothelial keratoplasty (DSAEK) in the management of this complication and for the first time show histologically the area of prior descemets membrane break in the submitted stripped descemets membrane.

Histopathologic correlation of Aspergillus endophthalmitis following uncomplicated cataract surgery.

A clinicopathologic correlation between two patients with acute-onset Aspergillus endophthalmitis undergoing enucleation is reported. These two patients presented with pain, redness, and decreased vision following uncomplicated cataract surgery. In both patients, vitreous aspiration and intravitreal injections were the initial treatment followed later by pars plana vitrectomy for clinical worsening. Despite repeated surgical and medical interventions, the clinical course of both patients was prolonged, unsuccessful, and resulted in enucleation for a blind painful eye. Histologic examination of the enucleated specimens showed that, in spite of prolonged local and systemic therapy, there was persistent diffuse infiltration of the anterior chamber and ciliary body by a filamentous mold.

Clinical outcomes of 4-point scleral fixated 1-piece hydrophobic acrylic equiconvex intraocular lens using polytetrafluoroethylene suture

Purpose To report the visual outcomes and complications of scleral fixated intraocular lenses (IOLs) using Gore-Tex suture. Methods The current study is a retrospective noncomparative case series including patients who underwent scleral fixation of IOL (Akreos AO60) using Gore-Tex suture from August 2015 to March 2017 at a university teaching center. Primary outcome measures were visual acuity and complications at last follow-up. Results The current study included 49 eyes of 48 patients. Mean follow-up duration postsurgery was 6.9 months (range: 0.9–29.4 months). The indications for secondary IOL surgery were dislocated IOL in 16/49 (33%), subluxed IOL in 9/49 (18%), dislocated or subluxed crystalline lens in 9/49 (18%), traumatic cataract in 8/49 (16%), and complicated cataract surgery in 7/49 (14%). Mean best-corrected logMAR visual acuity improved from 1±0.7 (20/200 Snellen equivalent) preoperatively to 0.5±0.5 (20/63 Snellen equivalent) at last follow-up. There were no intraoperative complications noted. Early postoperative complications included significant persistent corneal edema (longer than 1 week) in 4/49 (8.2%), ocular hypertension (intraocular pressure ≥25 mmHg) in 8/49 (16.3%), hypotony (intraocular pressure ≤5 mmHg) in 6/49 (12.2%), cystoid macular edema 3/21 (6.1%), IOL tilt 2/49 (4.1%), hyphema in 2/49 (4.1%), and vitreous hemorrhage in 5/49 (4.8%). There was one case of recurrent retinal detachment. One patient presented with an erosion of the Gore-Tex suture through the conjunctiva resulting in a purulent scleritis 6 months after the initial surgery, and was managed with removal of the IOL, debridement, and cryotherapy. Forty-one of 49 patients completed 3-month follow-up, among which visual acuity improved, deteriorated, or remained same compared to baseline in 27/49 (55.1%), 8/49 (16.3%), and 6/49 (12.2%) eyes, respectively. Conclusion In the current study, visual acuity outcomes were generally favorable. The complications were largely transient. Significant complications included a suture-related infection, which required removal of the IOL, and a recurrence of a retinal detachment.

Long-term outcomes of the aphakic snap-on Boston type I keratoprosthesis at the bascom palmer eye institute

Purpose To determine the indications, long-term clinical and visual outcomes, and complications of the aphakic snap-on type I Boston keratoprosthesis (KPro). Design Retrospective, non-comparative case series. Methods Forty-five eyes of 43 patients with type I aphakic snap-on KPros with at least 1 year of follow-up were included. The past medical histories, preoperative indications, best-corrected visual acuities (BCVAs), postoperative complications, and retention rates were analyzed. Results The most common indication for KPro implantation was a failed corneal graft (89%). The mean preoperative BCVA was count fingers–hand motion (2.14±0.45 logarithm of minimum angle of resolution [logMAR]), which initially improved to 20/200 (1.04±0.85 logMAR; P<0.0001). At the last examination, 24 eyes (53%) maintained some visual gain, 22% retained their preoperative visual acuity, and 24% lost vision due to postoperative events and underlying ocular comorbidities. Postoperative complications included retroprosthetic membranes (8/45, 18%), corneal melts (5/45, 11%), glaucoma progression (6/45, 13%), and endophthalmitis or sterile vitritis (6/45, 13%). The KPro retention rate was 89%, with a mean follow-up of 51 months. The mean BCVA at the last visit was 20/1,400 (1.82±0.92 logMAR). Conclusion Most patients experienced improved visual acuity after the implantation of the aphakic, snap-on type I KPro; however, the visual gains were not sustained over time, correlating with the onset of postoperative complications.

Central retinal artery occlusion on postoperative day one after vitreoretinal surgery

Purpose To report two cases of central retinal artery occlusion (CRAO) associated with vitreoretinal surgery. Observations Two patients underwent vitreoretinal surgery and were diagnosed with CRAO on postoperative day one. Both had received retrobulbar anesthetic blocks, followed by pars plana vitrectomy in one patient and scleral buckling in the other patient. Best-corrected visual acuity at last follow-up was 20/40 and 20/400. Conclusions/Importance CRAO is a rare but serious adverse event after vitreoretinal surgery. The causative mechanism is not known in these patients.

Extrascleral Vitreous Prolapse Following Intravitreal Injection

An 82-year-old man presented with right eye discomfort 3 days after an intravitreal aflibercept injection using a 32-gauge needle for treatment of neovascular age-related macular degeneration. His visual acuity was stable however slit lamp examination of the right eye showed prolapsed vitreous extending to the lower eyelid arising from the inferotemporal pars plana scleral injection site. There was no evidence of intraocular inflammation and his fundus examination was stable. The scleroconjunctival defect and prolapsed vitreous were repaired in the operating room. Postoperatively his vision remained stable with no signs of endophthalmitis or retinal detachment.

Endophthalmitis after intravitreal injections

Endophthalmitis after intravitreal injections is a rare but devastating complication of this common eye procedure. Patients typically present within 5 days of their injection with decreased vision, pain, and redness. However, the absence of any one of these in the presence of other symptoms should not exclude the diagnosis of endophthalmitis. Treatment consists of obtaining a vitreous sample and administering intravitreal antibiotics. Vitrectomy may be indicated in some cases. Preventive measures include the use of a lid speculum and topical povidone-iodine during the procedure, and clinicians may consider the use of masks or having all participants refrain from speaking.

Vitrectomy in the Management of Diabetic Macular Edema

The vitreous has been shown to be a contributing factor in the pathogenesis of tractional and non-tractional diabetic macular edema (DME). Modern techniques in pars plana vitrectomy (PPV) allow the safe removal of the vitreous with the posterior hyaloid which relieves vitreomacular traction and removes inflammatory factors believed to play a role in DME. Additional techniques such as endolaser, peeling of epiretinal membranes and the internal limiting membrane can also be performed at the time of PPV. Satisfactory visual and anatomic outcomes have been achieved in DME cases refractory to non-surgical therapies. The purpose of this article is to review the relevant literature related to the use of vitrectomy in the treatment of DME and provide an update of current practices.