Oscar Gris

Limbal-conjunctival autograft transplantation for the treatment of recurrent pterygium

OBJECTIVE Different investigators have recently emphasized the importance of the limbus and its stem cells in the pathogenesis of the pterygium. In this article we examine the usefulness of limbal-conjunctival autograft transplantation for the treatment of advanced recurrent pterygium. DESIGN Prospective noncomparative case series. PARTICIPANTS Seven patients with advanced recurrent pterygium. All had previously been treated a minimum of two times by simple excision (two of them with intraoperative mitomycin C). INTERVENTION Limbal-conjunctival autograft transplantation after pterygium excision was performed in all cases. MAIN OUTCOME MEASURES Pterygium recurrences and complications with a minimal follow-up period of 14 months. RESULTS There were no recurrences of pterygial growth beyond the limbal edge. In addition, no significant complications were noted. Only one case of limited pseudopterygium in the donor site and one case of graft retraction were recorded. No further surgical interventions were needed in any case. CONCLUSIONS Limbal-conjunctival autograft transplantation is a promising technique for the treatment of advanced recurrent pterygium.

Artisan toric phakic intraocular lens for the correction of high astigmatism

PURPOSE To evaluate efficacy, predictability, and safety of Artisan toric phakic intraocular lens (Ophtec, Groningen, The Netherlands) implantation for the correction of astigmatism higher than 2 diopters. DESIGN Interventional case series. METHODS This prospective study included 27 eyes of 16 patients with a mean preoperative spherical equivalent of -11.78 +/- 6.24 diopters and a mean preoperative astigmatism of -3.43 +/- 0.81. The Artisan phakic intraocular lens was inserted in the anterior chamber through a posterior corneal incision; the technique is similar to the implantation of the classical Artisan lens, but in these cases it is particularly important to secure the lens accurately in the correct axis. The main parameters evaluated in this study were uncorrected visual acuity, best-corrected visual acuity, refraction, and endothelial cell count. RESULTS Twelve months after the implantation of the Artisan toric phakic intraocular lens, 62.90% of the eyes were within +/-0.50 diopters. of emmetropia and 96.20% within +/-1.0 diopters. Seventy percent of the eyes gained 1 or more Snellen lines from their preoperative best-corrected visual acuity, and 11.11% lost 1 Snellen line. Mean endothelial cell count increased 2.9%. Mean of the parallel and orthogonal components of cylinder correction were 1.97 diopters and 0.10 diopters, respectively, of the intended cylinder change. The mean of axis alignment error was 10.53 degrees. No serious complications were observed. CONCLUSION Artisan toric phakic intraocular lens implantation appears to be a safe and predictable method for the correction of high levels of astigmatism.

Secondary Artisan-Verysise aphakic lens implantation

PURPOSE: To evaluate efficacy, predictability and safety of Artisan–Verysise intraocular lens (IOL) secondary implantation for aphakia correction. SETTING: Instituto de Microcirugía Ocular, and Autonoma University of Barcelona, Barcelona, Spain. METHODS: Uncorrected visual acuity, best spectacle‐corrected visual acuity (BSCVA), manifest refraction, endothelial cell count, and clinical complications were evaluated. Sixteen consecutive eyes of 14 patients with aphakia were submitted to surgery. Postoperative examinations were done at 6 weeks, 6 months, 1 year, and every year for at least 3 years. An iris‐supported Artisan–Verysise IOL was implanted for aphakia correction. RESULTS: Thirty‐six months after Artisan–Verysise lens implantation, BSCVA was 20/40 or better in 6 eyes (37.5%). Preoperatively, 5 eyes had the same BSCVA (31.25%). Mean postoperative spherical equivalent (SE) was 0.46 diopter (D). Mean endothelial cell loss was 10.9% 36 months postoperatively. The cell loss occurred predominantly during the first year (7.78%). Cystoid macular edema was observed in 2 cases, 1 of them associated with chronic unresponsive low intraocular pressure. No other serious complications were observed. CONCLUSION: Artisan–Verysise IOL implantation seems a safe, predictable, and effective option for aphakic eyes without capsule support.

Clear lens extraction to correct high myopia

Purpose: To assess the refractive outcome and postoperative complications in a single surgeon series of clear lens extraction for high myopia. Setting: Ophthalmology Department, Cornea and Refractive Surgery Unit, Vall d’Hebrón Hospital, Autónoma University of Barcelona, Spain. Methods: Forty‐six clear lens extraction procedures performed in 37 patients from November 1992 to January 1994 by one surgeon were retrospectively analyzed. Capsule tear and vitreous loss, endothelial cell loss, preoperative and postoperative best corrected visual acuity and cycloplegic refraction, and retinal detachment occurrence were looked at. Results: Capsule tear with vitreous loss occurred in one eye (2.17%). Mean endothelial cell loss was 2.6% during the first postoperative year. Best corrected visual acuity was 6/12 or better in 69.4% of eyes preoperatively and in 88.5% postoperatively. Mean cycloplegic refraction was −16.05 diopters (D) preoperatively; the residual cycloplegic refraction was within 1.00 D in 48.4% of eyes and within 2.00 D in 92.5% postoperatively. Conclusion: Because of its high predictability, stability, and low morbidity, we believe clear lens extraction is a reasonable refractive surgery option for middle‐aged patients with myopia.

Combined Surgery to Correct High Myopia: Iris Claw Phakic Intraocular Lens and Laser in situ Keratomileusis

PURPOSE To evaluate the results of combined surgery, implantation of an Artisan phakic iris claw intraocular lens (IOL) followed by laser in situ keratomileusis (LASIK) to correct high myopia. METHODS A prospective study of 6 patients (8 eyes) with high myopia who had Artisan phakic IOL implantation followed by LASIK was undertaken. The IOL was a standard -15.00-D, 6-mm diameter optical zone. Residual refractive error was corrected by LASIK. Mean follow-up was 16 +/- 4 months (range, 12 to 20 mo). RESULTS After the second procedure (LASIK), uncorrected visual acuity ranged from 0.4 to 0.63 (mean, 0.5 +/- 0.07) at 1 month and from 0.6 to 0.7 (mean, 0.62 +/- 0.04) at 12 months. Spectacle-corrected visual acuity improved 2 or more lines in 62.5% (5 eyes) from preoperative values. Mean postoperative spherical equivalent refraction was -0.68 +/- 0.23 at 1 month and -0.35 +/- 0.22 at 12 months after LASIK. All eyes were within +/-1.00 D of emmetropia following the LASIK portion of the two-stage procedure and 5 eyes were within +/-0.50 D. We had no major complications. No significant endothelial damage occurred. CONCLUSIONS The accurate refractive outcome, absence of major complications, stability of results, and most important, improvement in quality of vision (defined as no change in vision when illumination conditions varied, eg, at night) experienced by these highly myopic patients are reasons to continue using and improving this combined technique.

Phacoemulsification of the crystalline lens and implantation of an intraocular lens for the correction of moderate and high myopia: four- year follow-up

Purpose: To assess the safety of lens extraction and intraocular lens (IOL) implantation in patients with high myopia treated for initial lens opacity and/or refractive indications. Setting: Instituto de Microcirugía Ocular de Barcelona, Barcelona, Spain. Methods: This retrospective nonrandomized case series study comprised 44 eyes of 30 consecutive myopic patients who had surgery because of initial lens opacity and/or refractive indications during a 2‐year period. In each case, phacoemulsification was performed using an ultrasonic technique and an IOL was implanted in the capsular bag. The patients were seen preoperatively to evaluate retinal pathology. They also had a complete ophthalmologic evaluation that included detailed indirect ophthalmoscopy. All patients were followed at regular intervals. The main outcome measures were preoperative and postoperative spherical equivalent (SE), the incidence of posterior capsule opacification (PCO) and the need for capsulotomy, and the incidence of retinal complications. Results: In all eyes, the surgery was uneventful. The mean patient age at surgery was 42.83 years; the mean preoperative SE was −15.77 diopters (D) and the mean postoperative SE, −1.05 D. No eye required preoperative peripheral retinal photocoagulation. Twenty‐five eyes (56.8%) had PCO and had a neodymium:YAG laser capsulotomy. One eye had a retinal tear 14 months after surgery and was treated with focal photocoagulation. The mean endothelial cell loss was 2.1% during the first postoperative year. Two eyes had an immediate postoperative intraocular pressure (IOP) rise, 1 with an inflammatory membrane and the other with corneal edema; both resolved with topical treatment. One eye with elevated IOP and a bad response to medical treatment had argon laser trabeculoplasty. No eye had a retinal detachment during the follow‐up. Conclusion: With a thorough preoperative ophthalmologic evaluation and uneventful surgery, patients who have phacoemulsification and IOL implantation for the correction of myopia have a satisfactory chance of obtaining good visual results with few complications.

LASIK for the Correction of Residual Refractive Errors From Previous Surgical Procedures

BACKGROUND AND OBJECTIVE To evaluate laser assisted in situ keratomileusis (LASIK) efficacy in correcting residual refractive errors after corneal or intraocular surgery (penetrating keratoplasty, radial keratotomy, photorefractive keratectomy, phacoemulsification with intraocular lens (IOL) implantation, penetrating ocular trauma and phakic IOL implantation). MATERIAL AND METHODS We performed LASIK in 87 eyes of 62 patients previously operated by means of other surgical techniques to completely correct the residual refractive error. We report the mean refractive error (in terms of spherical equivalent refraction), uncorrected visual acuity (UCVA) and spectacle corrected visual acuity (SCVA) before and after the surgical procedure. We also analyze safety and stability, in these results with a minimum of 12 months follow-up. RESULTS Mean preoperative spherical equivalent was -5.25 +/- 2.1 diopters (D). Postoperatively, mean spherical equivalent was -0.70 +/- 0.65 D, 76% of eyes were between plano and -1.00 D and 99% were between plano and -2.25 D. At 12 months follow-up the change in the refractive result was equal or less than 0.5 D in 94% of eyes. Preoperatively SCVA was 1.0 or better in 24.13% of cases, and 0.5 or better in 89.65%. Postoperative SCVA was 1.0 or better in 26.43% and 0.5 or better in 95%. Preoperative UCVA was 0.1 in 2 eyes, 0.05 in 4 eyes and count fingers in the rest of the cases. Postoperative UCVA was 1.0 or better in 1.1% and 0.5 or better in 70.1%. We had an extremely low complication rate in this particular group of patients. CONCLUSIONS LASIK can be successfully used to correct residual refractive errors after other surgical procedures.

Histologic findings after amniotic membrane graft in the human cornea

OBJECTIVE To describe the histopathologic findings in the human cornea several months after a stromal amniotic membrane graft. To show the clinicopathologic correlation after the graft in two cases with different follow-up times. DESIGN Two interventional case reports with clinicopathologic correlation. PARTICIPANTS Two patients with neurotrophic corneal ulcer unresponsive to medical treatment (one with stromal vascularization and the other without stromal vascularization). INTERVENTION Amniotic membrane graft was performed in both patients to treat the neurotrophic ulcer. Three and 7 months after amniotic membrane grafting, a penetrating keratoplasty was needed, and the removed corneas were analyzed. MAIN OUTCOME MEASURES Clinical and histopathologic examinations, including routine histopathologic and immunohistochemical studies. RESULTS Complete epithelialization was observed on histologic examination over the basement membrane of the amniotic membrane graft. The amniotic membrane was slowly reabsorbed in the cornea without stromal vascularization with no inflammatory reaction produced. In the cornea that had stromal vascularization the amniotic membrane was rapidly reabsorbed because of the presence of abundant inflammatory cells. Once reabsorbed, the amniotic membrane was replaced by new fibrotic stroma, that was different from that found in the rest of the cornea but that helped to maintain corneal thickness. CONCLUSIONS The amniotic membrane graft allows for correct epithelialization in cases of neurotrophic corneal ulcer. Once the amniotic membrane is reabsorbed, it is replaced by a new fibrotic stroma, which can reduce corneal transparency. In corneas that have no stromal vascularization, the graft may remain in the stroma for many months, compromising corneal transparency during this period.

Amniotic membrane implantation as a therapeutic contact lens for the treatment of epithelial disorders.

Purpose. To evaluate the efficacy and safety of amniotic membrane implantation as a therapeutic contact lens in the treatment of different epithelial defects without stromal ulceration. Methods. We used amniotic membrane implantation as a therapeutic contact lens in 20 consecutive patients with epithelial defects. Group 1 included 10 patients with persistent epithelial defects that did not respond to medical treatment. Group 2 included 10 patients with surgically induced epithelial defects. Results. No intra-or postoperative complications were observed. The amniotic membrane implant remained in place for a mean of 12.5 days (range, 3–34). In 11 of the 20 patients, the amniotic membrane implant became detached within the first 8 days. When the corneal implant was postoperatively covered with a soft contact lens, this time increased. In group 1, complete epithelialization was achieved in three of the four cases in which the amniotic membrane remained in place for 2 or more weeks. There were no cases of complete epithelialization in which the implant remained in place for less than 1 week. In group 2, epithelialization was achieved in all cases, regardless of the time that the implant remained in place. Conclusion. Amniotic membrane implanted as a therapeutic contact lens can be an effective and safe option for the treatment of different epithelial defects. In patients with persistent epithelial defects, the number of cases with complete postoperative epithelialization was higher when the amniotic membrane remained in place longer. The early detachment of the amniotic membrane implant remains a major problem, even with the use of multiple fixation sutures.

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.