Merce Morral

Phakic intraocular lenses Part 2: Results and complications

&NA; The second part of a review of phakic intraocular lenses (pIOLs) addresses results and complications with current pIOL models. Phakic IOLs demonstrate reversibility, high optical quality, potential gain in visual acuity in myopic patients due to retinal magnification; correction is not limited by corneal thickness or topography. With proper anatomical conditions, pIOLs also show good results in hyperopic patients. Toric pIOL designs enable spherocylindrical correction. Complications are rare and primarily related to pIOL position and type. The main complications of angle‐supported anterior chamber pIOLs are glare and halos, pupil ovalization, and corneal endothelial cell loss; of iris‐fixated anterior chamber pIOLs, chronic subclinical inflammation, corneal endothelial cell loss, and dislocation or pupillary block glaucoma; and of posterior chamber pIOLs, anterior subcapsular cataract formation, pigment dispersion, and luxation or pupillary block glaucoma. No causative relationship between pIOL implantation (of any pIOL type) and retinal detachment has been established. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Phakic intraocular lenses

&NA; In this 2‐part overview, the current status of phakic intraocular lens (pIOL) surgery to correct refractive errors is reviewed. Three types of pIOLs, categorized by their intraocular position, are included: angle‐supported anterior chamber, iris‐fixated anterior chamber, and posterior chamber (usually fixated in the ciliary sulcus). Part 1 reviews the main models of each pIOL type, the selection criteria, and the surgical techniques, with emphasis on currently available pIOLs. Bioptics, adjustable refractive surgery, and enhancements are addressed, and applications of the new anterior segment imaging techniques are reviewed. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Collagen crosslinking and toric iris-claw phakic intraocular lens for myopic astigmatism in progressive mild to moderate keratoconus.

PURPOSE: To report the long‐term results of combined collagen crosslinking (CXL) and toric phakic intraocular lens (pIOL) implantation to correct myopic astigmatism in patients with progressive mild to moderate keratoconus. SETTING: Instituto de Microcirugia Ocular, Barcelona, Spain. DESIGN: Case series. METHODS: From November 2006 to July 2009, CXL was performed in eyes with proven progressive keratoconus. Once refraction and topography stabilized, toric Artiflex/Artisan pIOL implantation was performed to correct residual myopic astigmatism. A complete ophthalmologic examination, including manifest refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, biomicroscopy, tonometry, fundoscopy, keratometry, corneal tomography, and central endothelial cell count (ECC), was performed before each procedure and postoperatively at 3 months and at yearly intervals up to 5 years. Main outcome measures were accuracy and stability of the spherical equivalent (SE) and cylinder, keratometry, UDVA (efficacy), CDVA (safety), central ECC, and complications. RESULTS: The median follow‐up in the 9 patients (17 eyes) was 36.9 months ± 15.0 (SD). The median interval between CXL and pIOL implantation was 3.9 ± 0.7 months. Fourteen eyes (82%) were within ±0.50 diopter (D) of the attempted SE correction and 13 eyes (76%) were within ±1.00 D of the attempted cylinder correction. The mean difference in simulated keratometry between preoperatively and the last follow‐up was 0.17 ± 0.45 D (range −0.55 to 1.45 D). The postoperative UDVA was 20/40 or better in 16 eyes (94%). No eye lost lines of CDVA. No significant decrease in central ECC occurred (P>.05). CONCLUSION: Combined CXL and toric iris‐claw pIOL implantation effectively and safely corrected myopic astigmatism in progressive mild to moderate keratoconus. Financial Disclosure: Dr. Güell is a consultant to Ophtec. No other author has a financial or proprietary interest in any material or methods mentioned.

Bimanual technique for insertion and positioning of endothelium-Descemet membrane graft in Descemet membrane endothelial keratoplasty.

Purpose: To describe a new bimanual technique for insertion and positioning of endothelium–Descemet membrane (EDM) grafts in Descemet membrane endothelial keratoplasty (DMEK). Methods: Prospective, noncomparative, consecutive interventional case series, including 15 pseudophakic eyes of 15 patients treated with DMEK at the Instituto de Microcirugia Ocular, Barcelona, Spain. A bimanual infusion technique was used to introduce and position donors EDM. Partial tamponade was achieved with 20% sulfur hexafluoride (SF6). Intraocular manipulation time of EDM grafts, rebubbling rate, and endothelial cell density were evaluated. Results: Six months postoperatively, mean uncorrected visual acuity and best spectacle–corrected visual acuity (BSCVA) improved from 20/100 to 20/50 and from 20/80 to 20/25, respectively (P < 0.001). Six eyes (40%) had ≥20/20 BSCVA, and 13 (86%) eyes had ≥20/30 BSCVA. Mean donor cell density decreased from 2690 ± 302 to 1998 ± 621 cells per square millimeter, representing a mean cell loss of 26% ± 20%. EDM was stripped successfully in all cases. Mean intraocular manipulation time of donors EDM (interval between main incision closure and final EDM positioning) was 4.10 ± 0.5 minutes. Intracameral air reinjection was needed in 1 case (6.6%) with a partial peripheral graft detachment. No episodes of immunologic graft rejection were documented. Conclusions: Insertion and positioning of EDM grafts in DMEK was successfully achieved using this bimanual infusion technique and 20% SF6 partial tamponade, with a low intraocular manipulation time and very low postoperative rebubbling rates, regardless of the preservation method and the donors age. However, prospective comparative studies are required to demonstrate the long-term safety compared with other approaches.

Ocular Adverse Events of Systemic Inhibitors of the Epidermal Growth Factor Receptor: Report of 5 Cases

PURPOSE To describe the ocular effects associated with the administration of the systemic epidermal growth factor receptor (EGFR) inhibitors panitumumab and erlotinib. DESIGN Retrospective, noncomparative interventional case series. PARTICIPANTS Ten eyes of 5 patients in treatment with systemic EGFR inhibitors, 4 patients with erlotinib for end-stage lung carcinoma, and 1 patient with panitumumab for end-stage colorectal cancer. METHODS Data collected from charts included gender, age at presentation, systemic disease, and clinical presentation in each eye. MAIN OUTCOME MEASURES Demographics on presentation and clinical findings. RESULTS Multiple epithelial defects were observed in all 10 eyes, corneal melting and thinning were observed in 3 eyes of 2 patients, 2 eyes of 1 patient presented with lower lid ectropion, and 2 eyes of 2 patients presented with corneal perforation, both requiring a penetrating keratoplasty. CONCLUSIONS Severe ocular side effects, including corneal perforation, may be associated with the use of the EGFR inhibitors panitumumab and erlotinib.

Secondary iris-claw anterior chamber lens implantation in patients with aphakia without capsular support

Background/aims To evaluate the efficacy, predictability, safety and complications of secondary iris-claw intraocular lens (IOL) implantation in aphakic eyes without capsular support. Methods Retrospective, non-comparative, interventional case series of 128 aphakic eyes, which consecutively underwent secondary iris-claw Artisan IOL (Ophtec BV) implantation, were included. Manifest refraction, uncorrected visual acuity, best-spectacle corrected visual acuity, biomicroscopy, tonometry, funduscopy and central endothelial cell count (cECC) were evaluated before surgery, and at yearly intervals up to 5 years. Minimum follow-up time was 1 year. Results One hundred twenty-eight eyes were treated. Mean age was 54.55 years (range, 1–98 years). Mean follow-up was 41.8 months (SD 23.63). Mean preoperative logarithm of the minimum angle of resolution BSCVA and spherical equivalent (SE) were 0.67 ((SD) 0.53) and 9.63 D (SD 5.50), respectively. One year postoperatively, mean logarithm of the minimum angle of resolution best-spectacle corrected visual acuity improved to 0.52 (SD 0.46) (p<0.05), and remained stable up to 5 years. One year postoperatively, mean SE was −0.52 (SD 2.21) (p<0.05). Mean SE progressively decreased during the 1st year, and remained stable thereafter (p<0.05). Mean preoperative cECC was 2237.47 (SD 793.33) cells/mm2. cECC showed a slight, though statistically significant, decrease over the years (p=0.05). Main complications were: 2 pupillary block; 3 transient increase in intraocular pressure; 1 IOL replacement; 2 penetrating keratoplasty and 4 cystoid macular oedema. Conclusions Iris-claw IOL implantation in aphakic eyes is an effective, predictable and safe procedure in the first 5 years of follow-up. However, a longer follow-up is required to demonstrate its long-term safety.

SMILE Procedures With Four Different Cap Thicknesses for the Correction of Myopia and Myopic Astigmatism

PURPOSE To study the feasibility of performing myopic femtosecond small incision lenticule extraction (SMILE) with four different cap thicknesses (130, 140, 150, and 160 μm). METHODS In this retrospective, comparative, non-randomized clinical trial, a refractive lenticule of intrastromal corneal tissue was cut with the VisuMax femtosecond laser system (Carl Zeiss Meditec AG, Jena, Germany) using different depths of the non-refractive lenticule cut. Manifest refraction, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and Objective Scattering Index (OSI) were evaluated. Minimum follow-up time was 1 year. RESULTS Ninety-four eyes of 47 patients with myopia with (14 patients) and without (33 patients) astigmatism were treated. One year after the surgery, mean log-MAR UDVA, logMAR CDVA, SE, and OSI were 0.07 ± 0.12, 0.01 ± 0.37, 0.07 ± 0.57, and 0.88 ± 0.17, respectively (P < .05). There were no significant statistical differences in logMAR UDVA, logMAR CDVA, SE, or OSI (P > .05) variables when the different groups were compared for the same periods of time. CONCLUSIONS No differences in visual acuity, refractive outcomes in optical visual quality, or complications were observed when using SMILE at four different depths.

Accuracy of refractive outcomes in myopic and hyperopic laser in situ keratomileusis: Manifest versus aberrometric refraction

PURPOSE: To compare the achieved refractive accuracy of laser in situ keratomileusis (LASIK) performed based on manifest refraction with the predicted accuracy that would have been achieved using WASCA aberrometric refraction with and without Seidel correction factor for sphere. SETTING: London Vision Clinic, London, United Kingdom. DESIGN: Comparative case series. METHODS: Myopic eyes and hyperopic eyes had LASIK based on manifest refraction. Two aberrometric refractions were obtained preoperatively: Seidel, which includes spherical aberration in the sphere calculation, and non‐Seidel. Bland‐Altman plots were used to show the agreement between aberrometric and manifest refractions. Predicted LASIK outcomes had aberrometric refraction been used were modeled by shifting the postoperative manifest refraction by the vector difference between the preoperative manifest and aberrometric refractions. RESULTS: This study included 869 myopic eyes and 413 hyperopic eyes. The mean differences (manifest minus aberrometric) in spherical equivalent were +0.03 diopters (D) ± 0.48 (SD) (Seidel aberrometric) and +0.45 ± 0.42 D (non‐Seidel aberrometric) for myopia and −0.20 ± 0.39 D and +0.39 ± 0.34 D, respectively, for hyperopia. The mean differences in cylinder magnitude were −0.10 ± 0.27 D and 0.00 ± 0.25 D, respectively. The percentage of eyes within ±0.50 D of the attempted correction was 81% (manifest), 70% (Seidel), and 67% (non‐Seidel) for myopia and 71% (manifest), 61% (Seidel), and 64% (non‐Seidel) for hyperopia. CONCLUSIONS: The achieved refractive accuracy by manifest refraction was better than the predicted accuracy had Seidel or non‐Seidel aberrometric refractions been used for surgical planning. Using the Seidel method improved the accuracy in myopic eyes but not in hyperopic eyes. Financial Disclosure: Dr. Reinstein is a consultant to Carl Zeiss Meditec AG and has a proprietary interest in the Artemis technology (Arcscan Inc., Morrison, Colorado, USA) through patents administered by the Cornell Center for Technology Enterprise and Commercialization, Ithaca, New York. No other author has a financial or proprietary interest in any material or method mentioned.

Epithelial ingrowth after LASIK: visual and refractive results after cleaning the interface and suturing the lenticule.

Purpose: The aim was to study the visual and refractive results in patients with epithelization in the corneal interface after laser in situ keratomileusis (LASIK) who were treated by cleaning the corneal interface (epithelial cyst extraction) and suturing the corneal flap. Methods: This is a retrospective, noncomparative interventional case series. The main outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refractive cylinder (CYL), spherical equivalent (SE), recurrence of epithelial ingrowth, and complications. Results: From a total of 7520 LASIK refractive eyes, 13 eyes with epithelial ingrowth were treated. The mean age was 46.9 years. The mean preoperative logMAR UDVA was 0.34 (SD, 0.19). At 2 months, the mean postoperative logMAR UDVA was 0.18 (SD, 0.17) and at 1 year was 0.12 (SD, 0.18) (P = 0.01). The mean logMAR CDVA before surgery was 0.16 (SD, 0.16). Two months and 1 year postoperatively, the mean logMAR CDVA was 0.05 (SD, 0.08) and 0.03 (SD, 0.06), respectively (P = 0.03). The mean SE before surgery was 0.30 D (SD, 1.09). The mean SE 2 months and 1 year after surgery was −0.07 (SD, 0.53) and −0.004 (SD, 0.18), respectively (P = 0.04). The mean CYL before surgery was −0.92 D (SD, 1.09); and the mean CYL 2 months and 1 year after surgery was −0.60 (SD, 0.84) and −0.18 (SD, 0.75), respectively (P = 0.26). No epithelial ingrowth recurrence was observed up to 1 year after epithelial removal. Conclusions: Cleaning the corneal interface and suturing the corneal flap was effective and appeared safe in treating epithelial ingrowth after LASIK, with an extremely low rate of regrowth. However, further prospective controlled studies with a longer follow-up are needed.

Treatment of symptomatic bullous keratopathy with poor visual prognosis using a modified Gundersen conjunctival flap and amniotic membrane.

A modified Gundersen conjunctival flap combined with amniotic membrane to treat symptomatic bullous keratopathy and poor visual prognosis is described. A 360° conjunctival peritomy was performed 2 mm from the limbus. After complete epithelial removal of the corneo-conjunctival surface, an amniotic membrane graft was sutured at the peripheral cornea with a running 10-0 nylon suture. Single 9-0 polyglactin sutures attached the edges of the amniotic membrane with the peritomized conjunctiva, which lay over the amniotic membrane. Five eyes were treated. Epithelialization, resolution of the pain, presence of ocular surface inflammation, and reinterventions were assessed. All eyes showed immediate resolution of the pain and minimal inflammation. In 1 eye, the amniotic membrane was reabsorbed before complete epithelialization. No reinterventions were required. All eyes were asymptomatic for at least 16 months. This technique provided sustained relief of symptomatic bullous keratopathy while significantly reducing the conjunctival manipulation and the anatomical distortion associated with classic sliding conjunctival flaps.