Richard Stutzman

Alcohol versus brush PRK: Visual outcomes and adverse effects†‡§¶‖

A smooth corneal surface prior to laser ablation is important in order to achieve a favorable refractive outcome. In this study, we compare PRK outcomes following two commonly used methods of epithelial debridement: Amoils epithelial scrubber (brush) versus 20% ethanol (alcohol).

Sutureless cryopreserved amniotic membrane graft and wound healing after photorefractive keratectomy.

Purpose To evaluate the effect of sutureless cryopreserved amniotic membrane (Prokera) on corneal wound healing after photorefractive keratectomy (PRK). Setting Center for Refractive Surgery, Walter Reed Army Medical Center, Washington, DC, USA. Design Prospective nonrandomized control trial. Methods Patients had PRK for myopia with or without astigmatism. A 20% ethanol solution was used to create a standard 9.0 mm epithelial defect followed by photoablation with the Allegretto Wave Eye‐Q 400 Hz laser. After surgery, a high‐oxygen‐transmissible bandage contact lens (Acuvue Oasys) was applied on the dominant eye and cryopreserved amniotic membrane on the nondominant eye. The postoperative regimen was otherwise identical for both eyes. Postoperatively, patients were evaluated daily until complete corneal reepithelialization occurred in both eyes and then at 2 weeks and 1, 3, 6, and 12 months. Reepithelialization was assessed daily with slitlamp examination, fluorescein staining, and photography. Secondary outcome measures included adverse effects, ocular comfort, visual outcomes, and corneal haze. Results Forty patients were enrolled. The amniotic membrane graft sped corneal reepithelialization 1 day after PRK but was not better than the bandage contact lens in hastening complete reepithelialization of the cornea. Visual outcomes, corneal clarity, and optical quality of the cornea were comparable between the amniotic membrane graft eyes and bandage contact lens eyes. Conclusion Although the amniotic membrane graft was reasonably well tolerated with few significant adverse effects, the role of amniotic membrane in modulating wound healing after PRK remains speculative. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

Residency training in refractive surgery.

PURPOSE: To evaluate resident refractive surgery caseload and surgical outcomes in an academic medical center. SETTING: Walter Reed Army Medical Center, Washington, DC, USA. DESIGN: Comparative case study. METHODS: Keratorefractive procedures performed by residents at the Walter Reed Center for Refractive Surgery between 2002 and 2010 were reviewed. Outcomes of surgeries performed by the graduating classes of 2008 to 2010 were compared with those of cases performed by staff. The uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent, corrected distance visual acuity (CDVA), and complications were analyzed. RESULTS: Between 2002 and June 2010, residents performed 1566 procedures (1414 photorefractive keratectomy [PRK], 152 laser in situ keratomileusis), for a mean of 20.2 procedures from 2002 to 2004, 51.6 from 2005 to 2007, and 99.9 from 2008 to 2010. Outcomes analysis was performed on 333 resident eyes and 977 staff eyes treated between 2008 and June 2010. Six months postoperatively, 96.1% of resident‐treated eyes and 94.6% of staff‐treated eyes had a UDVA 20/20 or better (P=.312) and 61.3% and 64.3%, respectively, had a UDVA 20/15 or better (P=.324). The percentage of eyes within ±0.50 diopter of emmetropia at 6 months was 94.0% for residents and 91.1% for staff (P=.105). The postoperative CDVA was within 2 lines of preoperative baseline in all resident cases and 99.8% of staff cases (P=.999). CONCLUSIONS: Resident experience grew steadily over the period studied. Overall safety and efficacy of resident‐performed surgery, albeit mainly PRK based, matched that of fellowship‐trained refractive surgeons. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Goblet cell response after photorefractive keratectomy and laser in situ keratomileusis.

Purpose To determine whether patients without dry eye preoperatively have an altered conjunctival goblet cell density and mucin secretion postoperatively and to explore what factors affect changes in goblet cell density and mucin secretion. Setting The former Walter Reed Army Medical Center, Washington, DC, USA. Design Prospective nonrandomized clinical study. Methods Impression cytology was used to determine conjunctival goblet cell density before and 1 week, 1 month, and 3 months after photorefractive keratectomy (PRK) or laser in situ keratomileusis (LASIK). The McMonnies questionnaire, Schirmer test, tear breakup time, corneal sensitivity, rose bengal staining, and computerized videokeratoscopy were also performed to assess tear‐film and ocular‐surface health. Results The ratio of goblet cell to total cells changed postoperatively from baseline in both groups (P < .001). The most significant change was a median 29% decrease 1 month postoperatively. However, there were no significant differences between groups over time (P = .772). The ratio of filled goblet cell to total goblet cell did not change significantly over the same time period (P = .128), and there were no significant differences between the PRK group and the LASIK group over time (P = .282). Conclusions Patients without apparent dry eye had an altered conjunctival goblet cell population after PRK or LASIK. The conjunctival goblet cell population tended to decrease in the early postoperative period after either surgery and was most affected by preoperative goblet cell density. The changes in the tear film and ocular surface did not seem to affect goblet cell mucin secretion after either procedure. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

Traumatic cataracts secondary to combat ocular trauma

Purpose To describe the characteristics, visual outcomes, and predictive value of the Ocular Trauma Score (OTS) in eyes with traumatic cataract from combat ocular trauma. Setting Walter Reed Army Medical Center, Washington, DC, USA. Design Retrospective case series. Methods Records of service members with traumatic cataract from combat ocular trauma over a 7‐year period were reviewed. Visual acuity at initial presentation and visual acuity at the final follow‐up were compared in addition to outcomes in closed versus open globes, by final lens status, and in eyes receiving primary versus secondary intraocular lenses (IOLs). Visual outcomes were predicted using the OTS and compared to the achieved corrected distance visual acuity (CDVA). Results A total of 181 eyes of 167 patients were included in the final analysis. Twenty‐six percent of all eye injuries sustained traumatic cataract. The mean final visual outcome was 0.86 logMAR ± 1.01 (SD) with 44 no light perception (NLP) eyes and 26 light perception (LP) eyes compared with an initial visual acuity of 2.41 ± 0.88 logMAR with 27 no NLP eyes and 64 LP eyes (P ≤ .001, 2‐tailed Student t test). Final CDVAs in eyes receiving primary IOLs were 0.72 ± 0.84 logMAR with 1 NLP and 1 LP eye versus 0.51 ± 0.78 logMAR with 2 LP eyes in eyes receiving a secondary IOL (P = .37, Student t test). Conclusion Traumatic cataracts are frequently associated with ocular trauma. The OTS is a reliable means of predicting visual outcome. There was no difference in eyes receiving primary IOLs versus secondary IOLs. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Wavefront-Guided Versus Wavefront-Optimized Photorefractive Keratectomy: Visual and Military Task Performance

PURPOSE To compare visual performance, marksmanship performance, and threshold target identification following wavefront-guided (WFG) versus wavefront-optimized (WFO) photorefractive keratectomy (PRK). METHODS In this prospective, randomized clinical trial, active duty U.S. military Soldiers, age 21 or over, electing to undergo PRK were randomized to undergo WFG (n = 27) or WFO (n = 27) PRK for myopia or myopic astigmatism. Binocular visual performance was assessed preoperatively and 1, 3, and 6 months postoperatively: Super Vision Test high contrast, Super Vision Test contrast sensitivity (CS), and 25% contrast acuity with night vision goggle filter. CS function was generated testing at five spatial frequencies. Marksmanship performance in low light conditions was evaluated in a firing tunnel. Target detection and identification performance was tested for probability of identification of varying target sets and probability of detection of humans in cluttered environments. RESULTS Visual performance, CS function, marksmanship, and threshold target identification demonstrated no statistically significant differences over time between the two treatments. Exploratory regression analysis of firing range tasks at 6 months showed no significant differences or correlations between procedures. Regression analysis of vehicle and handheld probability of identification showed a significant association with pretreatment performance. CONCLUSIONS Both WFG and WFO PRK results translate to excellent and comparable visual and military performance.