Reza Ghaffari

A combined approach of amniotic membrane and oral mucosa transplantation for fornix reconstruction in severe symblepharon.

Purpose: To evaluate the results of a combined approach of cicatrix lysis, intraoperative mitomycin C (MMC) application, oral mucosal transplantation (OMT), and amniotic membrane transplantation (AMT) for surgery of severe symblepharon. Methods: This prospective study included 32 eyes with severe symblepharon in which after cicatrix lysis the residual conjunctiva was not enough to cover the tarsus (grade III symblepharon) or there was no residual conjunctiva (grade IV symblepharon). After symblepharon lysis and MMC application, OMT was used to cover the tarsus throughout to fornix, and AMT with fibrin glue was performed to cover the exposed sclera. Outcome was defined as complete success (restoration of an anatomically deep fornix), partial success (focal recurrence of scar), or failure (return of symblepharon). Results: Etiology of symblepharon included chemical burn (n = 16), thermal burn (n = 7), Stevens–Johnson syndrome (n = 5), mucous membrane pemphigoid (n = 2), xeroderma pigmentosum (n = 1), and graft-versus-host disease (n = 1). Motility restriction was present in 87.5% preoperatively. After a mean follow-up of 16.4 ± 7.6 months, the anatomical outcome included complete success in 84.4%, partial success in 9.4%, and failure in 6.2%. In grades III and IV symblephara, the outcomes were complete success in 89.5% and 76.9%, partial success in 10.5% and 7.7%, and failure in none and 15.4%, respectively. No motility restriction was noted in any eye postoperatively. Complications included entropion (n = 2), ocular surface keratinization (n = 1), and pyogenic granuloma (n = 4). Conclusions: In severe symblepharon, a combined approach of cicatrix lysis, MMC application, OMT, and sutureless AMT was a safe and effective technique for fornix reconstruction.

Effect of adjunctive viscogonioplasty on drainage angle status in cataract surgery: a randomized clinical trial.

To compare the anatomic effects of phacoemulsification (Phaco) versus combined phacoemulsification and viscogonioplasty (Phaco‐VGP) on drainage angle status in primary angle‐closure glaucoma (PACG) using anterior segment optical coherence tomography (AS‐OCT).

Evaluation of conjunctival graft thickness after pterygium surgery by anterior segment optical coherence tomography.

Background: To evaluate changes in thickness of the conjunctival graft after pterygium surgery by anterior segment optical coherence tomography (AS-OCT). Materials and Methods: Eleven eyes of 11 patients with primary nasal pterygium underwent excision followed by free conjunctival autograft. Imaging with AS-OCT was performed at 1 week, 1 month and 3 months after surgery to measure thickness of the conjunctival graft at 1, 2 and 3 mm posterior to the scleral spur. As the control, thickness of the normal bulbar conjunctival epithelium in the temporal area was also measured at the same locations. Results: Average thickness of the graft decreased from 458 ± 171 µm at 1 week after surgery to 306 ± 64 µm at 1 month (p < 0.0001). Although the graft thickness decreased to 291 ± 124 µm at 3 months postoperatively, the difference between 1-month and 3-month values was not statistically significant (p = 0.94). Average thickness of the normal conjunctival epithelium was 58 ± 13 µm, 60 ± 19 µm and 61 ± 12 µm at 1 week, 1 month and 3 months after surgery, respectively, with no statistically significant difference. Graft thickness was significantly greater than thickness of the normal conjunctival epithelium at various time points (p < 0.05). Conclusion: Evaluation by AS-OCT showed that there was significant thickening of the conjunctival graft at 1 week after pterygium surgery which continued to decrease up to 3 months. Quantitative data by AS-OCT allows accurate evaluation of the conjunctival changes over time.

Posterior lamellar keratoplasty (DSAEK) in Peters anomaly.

Purpose: To report the outcome of Descemet stripping automated endothelial keratoplasty (DSAEK) in 2 patients with Peters anomaly. Methods: Case 1 was a 6-year-old boy who presented with congenital central corneal opacity, cataract, and iridocorneal adhesion in both eyes and keratolenticular touch in the left eye. The second case was an 11-year-old boy with a history of congenital corneal opacity involving the central cornea with iridocorneal adhesion, cataract, and mild microphthalmos in the left eye. Both patients had a more prominent corneal opacity localized posteriorly. DSAEK was performed with lensectomy and posterior chamber intraocular lens implantation in the left eye in both patients (2 months later in a second stage in case 1). During the procedure, stripping of Descemet membrane was performed in the periphery of the opacity with scraping of the posterior part of the opacity. Results: Descemetorhexis in the periphery of the opacity was found to be more difficult in both cases with the absence of Descemet membrane in the center. Both the patients had reduction in the density of corneal opacity and improved vision postoperatively, which was more obvious in case 2. Except for a peripheral graft detachment that necessitated rebubbling in both cases, the operation was uneventful and the patients retained clear grafts up to 1 year after the operation. Conclusions: Posterior lamellar keratoplasty (DSAEK) may be a promising option in properly selected cases of Peters anomaly. Further studies are needed to define the role of DSAEK or other types of posterior lamellar keratoplasty in this condition.

Femtosecond-Assisted LASIK Versus PRK: Comparison of 6-Month Visual Acuity and Quality Outcome for High Myopia.

Objective: To compare the results of femtosecond-assisted laser in situ keratomileusis (femto-LASIK) and photorefractive keratectomy with mitomycin C (PRK-MMC) for the correction of myopia more than 7.0 diopters (D). Methods: In this comparative nonrandomized trial, 60 eyes (30 eyes in each group) were enrolled. Patients were tested for uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction spherical equivalent, ocular and corneal aberrations, and contrast sensitivity (CS) before surgery and at 3 and 6 months postoperatively. Results: Mean preoperative myopia was −8.65±1.51 and −8.04±1.70 D in the femto-LASIK and PRK-MMC groups, respectively (P=0.149). Intergroup differences in baseline indices were not statistically significant. At 6 months after surgery, UDVA showed an improving trend, but it was better in the femto-LASIK group (P=0.026). CDVA in the two groups remained similarly unchanged (P=0.170). For the femto-LASIK and PRK-MMC groups, the safety indices were 1.01±0.05 and 1.01±0.14 (P=0.949), respectively, and the efficacy indices were 0.99±0.07 and 0.93±0.22 (P=0.192), respectively. Comparing CS, only CS18 showed a significantly greater decrease in the femto-LASIK group compared with the PRK-MMC group (P=0.016). Intergroup differences were not statistically significant in other spatial frequencies. Changes in the ocular and corneal higher order aberrations were not statistically different between the two groups except ocular coma, which increased in the femto-LASIK group (P=0.041). Conclusion: Femto-LASIK improves UDVA better than PRK-MMC in high myopia. However, because of increased coma, the quality of vision is reduced. In other words, visual acuity outcome is better with femto-LASIK and visual quality outcome is better with PRK-MMC.

Evaluation of Corneal Biomechanics After Excimer Laser Corneal Refractive Surgery in High Myopic Patients Using Dynamic Scheimpflug Technology.

Objective: To compare the effect of femtosecond-assisted thin flap laser-assisted in situ keratomileusis (FS-LASIK) and photorefractive keratectomy with mitomycin-C (PRK-MMC) in highly myopic patients (>7.0 D [D]) on corneal biomechanical parameters. Methods: In this prospective comparative interventional case series, 60 patients (30 patients in each group) with a manifest refractive spherical equivalent (MRSE) greater than 7.0 D were enrolled. Corvis ST parameters were measured before and at 3 and 6 months postoperatively. Results: Preoperatively, mean MRSE was −8.65±1.51 D in FS-LASIK and −8.04±1.70 D in PRK-MMC groups (P=0.149), and corneal thickness was 570.67±36.79 &mgr;m and 507.12±32.55 &mgr;m, respectively (P<0.001). At 6 months, both groups showed significantly higher applanation (A) 2 time and A2-velocity (P<0.05 in both), whereas intraocular pressure (IOP), corrected IOP, A1 time, A1-velocity, and radius at highest concavity were significantly reduced (P<0.05 in all). In the FS-LASIK group, there was a significant increase in deformation amplitude (DA) (P=0.001), and significant decreases in A2-length (P=0.004). Peak distance increased in the PRK-MMC group (P=0.029). At 6 months, after controlling for fellow eye correlations and preoperative corneal thickness between the two groups, decreases in IOP, A1-time, A2-length and radius, and the increase in DA was greater in FS-LASIK. Conclusion: This study demonstrated significant changes in Corvis ST ocular biomechanical metrics after both PRK-MMC and FS-LASIK in high myopic patients, indicating the significant effect of excimer laser refractive surgery on corneal biomechanical properties. However, changes that occur with FS-LASIK are more significant than with PRK-MMC. Further randomized studies are needed to better characterize the pattern of biomechanical changes associated with each type of surgery.

Tacrolimus Eye Drops as Adjunct Therapy in Severe Corneal Endothelial Rejection Refractory to Corticosteroids

Purpose: To evaluate the safety and efficacy of tacrolimus eye drops as adjunctive therapy in the treatment of severe corneal endothelial rejection after penetrating keratoplasty refractory to corticosteroids. Methods: In this prospective interventional case series, 11 eyes of 11 patients assessed for severe corneal endothelial rejection, with an inadequate response to topical, local, and systemic corticosteroids, were treated with either 0.01% or 0.05% tacrolimus eye drops 4 times daily. Improvement in signs of rejection, visual function, and development of complications were monitored. Results: The duration of steroid treatment before intervention was 8.1 ± 1.4 days (range = 7–11). Patients were subsequently administered topical tacrolimus 0.01% or 0.05% qid. The time to clinical improvement was 10.3 ± 3.4 days (range = 3–17). The time to rejection reversal was 27.8 ± 16.3 days (range = 7–52). After 3 months, 10 patients (90.8%) demonstrated clinical improvement, and complete restoration of graft clarity was achieved in 5 patients (45.4%). In responsive cases, steroid therapy was successfully tapered off after 60.2 ± 19.7 days (range = 36–93). The best spectacle-corrected visual acuity improved from 1.7 ± 0.9 to 0.8 ± 0.5 logMAR (P = 0.0016). Reported side effects included stinging on drop instillation and punctate epithelial keratopathy. Conclusions: Tacrolimus eye drops may be able to play an adjunctive therapeutic role in patients with severe corneal endothelial rejection refractory to conventional steroid treatment. Controlled studies are needed to further investigate the role of tacrolimus in this setting.

Corneal Biomechanics After Accelerated Cross-linking: Comparison Between 18 and 9 mW/cm2 Protocols

PURPOSE To determine 1-year corneal biomechanical changes after accelerated corneal cross-linking in patients with progressive keratoconus and compare them between 5-minute (18 mW/cm2) and 10-minute (9 mW/cm2) protocols. METHODS In this non-randomized clinical trial, cases in both groups were examined with the Corneal Visualization Scheimpflug Technology (Corvis ST; Oculus Optikgeräte GmbH, Wetzlar, Germany) at baseline and at 6 and 12 months after treatment. Extracted indices included intraocular pressure (IOP), central corneal thickness (CCT), first and second applanation times, lengths, and velocities (T1, T2, L1, L2, V1, and V2), highest concavity time (HCT), deformation amplitude (DA), peak distance between bending points, and radius of curvature. RESULTS Mean patient age, baseline maximum keratometry, CCT, and IOP were similar between groups. After adjusting for CCT and baseline values with repeated measures analysis of covariance, at 1 year after the procedure, IOP (13.14 ± 1.41 vs 12.12 ± 1.49 mm Hg, P = .034) and T1 (6.84 ± 0.20 vs 6.67 ± 0.23 ms, P = .036) were higher in the 5-minute group, but T2 (21.31 ± 0.27 vs 21.58 ± 0.28 ms, P = .007), HCT (16.06 ± 0.51 vs 16.31 ± 0.48 ms, P = .017), and DA (1.03 ± 0.09 vs 1.10 ± 0.08 mm, P = .028) were lower. Other inter-group differences were not statistically significant (all P > .050). All 1-year changes were independent of cone position (all P > .050). CONCLUSIONS At 1 year after cross-linking in cases of mild and moderate keratoconus, corneal biomechanics appeared stable or stronger than baseline with both 5- and 10-minute protocols. However, mild cases who had the 5-minute protocol showed better improvement based on Corvis ST indices. [J Refract Surg. 2017;33(8):558-562.].