Yanny Y.Y. Cheng

Efficacy and safety of femtosecond laser-assisted corneal endothelial keratoplasty: a randomized multicenter clinical trial.

Background. To evaluate the efficacy and safety of femtosecond laser-assisted endothelial keratoplasty (FLEK) versus penetrating keratoplasty (PK) in patients with corneal endothelial disease. Methods. A randomized multicenter clinical trial of 80 eyes of 80 patients with corneal endothelial disease were randomized to FLEK or PK. Clinical outcomes (astigmatism and visual acuity) and incidence of postoperative complications were compared between the two groups. Results. At 12 months, the percentage of eyes with a refractive astigmatism less than or equal to 3 diopters was higher in the FLEK group in comparison with the PK group (86.2% vs. 51.3%, P=0.004). The mean postoperative best corrected visual acuity was 20/70±2 lines in the FLEK group and 20/44±2 lines in the PK group (P<0.001), but the gain in the best corrected visual acuity between the two groups was not significantly different. The endothelial cell loss in the FLEK and PK group was 65±12% and 23±15% (P<0.001). The most common postoperative complication in the FLEK group was graft dislocation (27.8%). Wound healing related problems occurred in six eyes (15%) in the PK group and in none of the FLEK eyes. Conclusions. FLEK effectively reduces postoperative astigmatism and results in an absence of wound healing related problems in patients with endothelial disease. However, visual acuity is lower as compared with conventional PK, and the high level of endothelial cell loss warrants a modification of the insertion technique of the endothelial graft.

Intraocular straylight after implantation of the multifocal AcrySof ReSTOR SA60D3 diffractive intraocular lens.

PURPOSE: To measure intraocular straylight (as a measure of glare) after cataract surgery and implantation of an AcrySof ReSTOR SA60D3 multifocal or AcrySof SA60AT monofocal intraocular lens (IOL) (both Alcon Laboratories). SETTING: University Hospital Maastricht, Maastricht; Isala Clinics, Zwolle; Netherlands Institute for Neurosciences, Amsterdam, The Netherlands. METHODS: In a prospective open observational case series, a newly developed straylight meter was used to objectively measure straylight 6 months postoperatively in 66 eyes with a diffractive AcrySof ReSTOR SA60D3 IOL (multifocal group) and 40 eyes with a monofocal AcrySof SA60AT IOL (monofocal group). A comparison of straylight levels in an age‐matched population without cataract (control group) was performed. RESULTS: The straylight level was 1.20 log units ± 0.16 (SD) in the multifocal group and 1.10 ± 0.19 log units in the monofocal group. When the difference in mean level of straylight was adjusted for age, mean straylight levels were 0.078 log units lower in the monofocal group than in the multifocal group (P = .026). Straylight levels in both pseudophakic groups were lower than in the control group without cataract (P<.0001). CONCLUSIONS: Levels of intraocular straylight log(s) were significantly lower for both types of IOL than in age‐matched subjects from the normal population. The mean level of intraocular straylight 6 months postoperatively was higher in patients with an AcrySof ReSTOR SA60D3 IOL than in patients with a monofocal AcrySof SA60AT IOL. Implantation of the former IOL would therefore result in a smaller gain in contrast sensitivity and a smaller reduction in glare and halos than implantation of the latter IOL.

Preliminary results of femtosecond laser-assisted descemet stripping endothelial keratoplasty

OBJECTIVE To evaluate the preliminary visual results of femtosecond laser-assisted Descemet stripping endothelial keratoplasty (FS-DSEK). METHODS We prospectively analyzed results of 20 consecutive patients with Fuchs endothelial dystrophy or aphakic/pseudophakic bullous keratopathy who underwent FS-DSEK. Best spectacle-corrected visual acuity (BSCVA), refraction, corneal topography, and endothelial cell density were measured preoperatively and 3 and 6 months after FS-DSEK. Corneal thickness was measured using an optical coherence tomography technique. RESULTS The average BSCVA of 11 eyes with normal visual potential significantly improved from 20/110 +/- 4 lines to 20/57 +/- 1 line at 6 months (P < .007). At 6 months, the mean (SD) hyperopic shift was 2.24 (2.3) diopters (D). Preoperative and 6 months postoperative refractive astigmatism were -0.75 (0.9) D and -1.58 (1.1) D (P = .01), but the topographic astigmatism did not change postoperatively (P = .95). Mean (SD) endothelial cell density at 6 months was 1368 (425) cells/mm(2). There was a persistent deswelling of the graft up to 3 months postoperatively. Complications included graft dislocations requiring repositioning (20%), pupillary block glaucoma (5%), epithelial ingrowth (5%), and primary graft failure (5%). CONCLUSIONS Femtosecond laser-assisted Descemet stripping endothelial keratoplasty was effective in treating endothelial failure with minimal induced refractive astigmatism, limited improvement of BSCVA, and induction of a hyperopic shift. Endothelial cell count and dislocation rate were significant, which may be related to the surgical technique.

Visual outcome and patient satisfaction after multifocal intraocular lens implantation: aspheric versus spherical design.

PURPOSE: To evaluate visual outcomes and patient satisfaction after implantation of an aspheric apodized diffractive intraocular lens (IOL) or a spherical apodized diffractive IOL in cataract surgery. SETTING: Maastricht University Medical Center, The Netherlands. DESIGN: Nonrandomized clinical trial. METHODS: This prospective nonrandomized study with a 6‐month follow‐up compared the results of cataract surgery with implantation of an aspheric AcrySof ReSTOR SN6AD3 IOL and a spherical AcrySof ReSTOR SN60D3 IOL. Main outcome measures were uncorrected (UDVA) and corrected (CDVA) distance visual acuities, uncorrected (UNVA) and distance‐corrected (DCNVA) near visual acuities, straylight levels, incidence of glare and halos, and contrast sensitivity levels. RESULTS: The mean UDVA was 0.14 ± 0.15 logMAR in the aspheric group (47 eyes) and 0.14 logMAR ± 0.17 (SD) in the spherical group (45 eyes) and the mean CDVA, −0.01 ± 0.06 logMAR and 0.02 ± 0.10 logMAR, respectively. The mean UNVA was Jaeger (J) 1 in 83.0% of patients in the aspheric group and 55.5% of patients in the spherical IOL group (P = .003). The DCNVA was J1 in 95.7% and 71.1%, respectively (P = .001). There were no significant differences between the 2 groups in contrast sensitivity levels, intraocular straylight levels, incidence of night‐vision symptoms, or subjective rating of vision. CONCLUSIONS: Patients with the aspheric multifocal IOL had significantly better near vision than patients with the multifocal spherical IOL. The UDVA, CDVA, intraocular straylight, night‐vision symptoms, and contrast sensitivity were similar between the 2 groups. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

Histologic evaluation of human posterior lamellar discs for femtosecond laser Descemet's stripping endothelial keratoplasty.

Purpose: To evaluate the histologic changes in corneal structure after femtosecond laser preparation of posterior lamellar discs, more specifically, the smoothness of the stromal bed and the accuracy of the predicted depth of the horizontal lamellar cut. Materials and methods: Nineteen human donor eyes unsuitable for transplantation were used. Femtosecond laser was used to prepare a horizontal lamellar cut in donor corneas at a depth of 400 μm. Transmission electron microscopy images were used to evaluate the changes in the corneal structure and to measure the damage zone. Scanning electron microscopy images were used to determine the relative depth of the horizontal lamellar cut, and the stromal bed was examined to determine the smoothness of the surface. Results: Transmission electron microscopy images showed a mean damage zone of 6.8 ± 3.1 μm, which consisted of irregularly oriented collagen fibrils and electron-dense granular material. The collagen lamellae, both anteriorly and posteriorly of the damaged zone, showed a regular parallel configuration. The relative depth of the horizontal lamellar cut as percentage of the total corneal thickness in the center and periphery was 70.4% ± 4.5% and 55.6% ± 5.9%. Scanning electron microscopy images of the stromal bed showed a relatively smooth surface. Conclusion: The femtosecond laser is effective to prepare a deep horizontal lamellar cut in a standardized method. The stromal bed is smooth and without extensive adjacent tissue damage. The is thinner in the center and thicker at the edges, which may produce a mild hyperopic shift after femtosecond laser-assisted Descemets stripping endothelial keratoplasty.

Effects of Graft Thickness and Asymmetry on Visual Gain and Aberrations After Descemet Stripping Automated Endothelial Keratoplasty

IMPORTANCE Understanding the contribution of graft thickness and asymmetry to visual gain and posterior corneal (PC) higher-order aberrations (HOAs) may assist optimizing visual outcomes after Descemet stripping automated endothelial keratoplasty (DSAEK). OBJECTIVE To investigate the effects of graft thickness and asymmetry on visual gain and aberrations after DSAEK. DESIGN Retrospective analysis of an interventional case series of eyes undergoing DSAEK. Visual gain was defined as the difference between preoperative and 6-month postoperative best-corrected visual acuity in logMAR equivalents. Graft thickness was measured by anterior-segment optical coherence tomography. Corneal topography and HOAs were measured by Scheimpflug imaging. Raw posterior corneal (PC) elevation data were exported and fitted against a best-fitted sphere, providing a measure of donor lenticule asymmetry. Correlation analysis was performed among visual gain, graft thickness, graft asymmetry, and PC HOAs. SETTING University Eye Clinic Maastricht. PARTICIPANTS Seventy-nine eyes with corneal endothelial dysfunction. EXPOSURE All patients underwent DSAEK [corrected]. MAIN OUTCOMES AND MEASURES Visual gain, graft thickness, graft asymmetry, and PC HOAs. RESULTS Mean best-corrected visual acuity improved from 0.63 logMAR equivalents preoperatively to 0.25 logMAR equivalents postoperatively (P < .001). Mean (SD) graft thickness of the series was 97 (25) (range, 39-145) μm. After excluding patients with vision-limiting comorbidities, visual gain significantly correlated with graft thickness (r = -0.35 [P = .02]). This correlation was strongest in patients with pseudophakic bullous keratopathy (r = -0.62 [P = .01]). Graft thickness significantly correlated with graft asymmetry in the 4- and 6-mm zones (r = 0.32 [P = .007] and r = 0.32 [P = .006], respectively), which in turn correlated with all but spherical PC HOAs. CONCLUSIONS AND RELEVANCE After DSAEK, visual gain shows a significant correlation with graft thickness in patients without vision-limiting comorbidities. This relationship is strongest in patients with pseudophakic bullous keratopathy. Graft thickness also correlates with graft asymmetry, which in turn correlates with all but spherical PC HOAs. These findings may assist surgeons in choosing DSAEK graft thickness and shape, particularly in eyes without vision-limiting comorbidities. Further randomized trials are needed to investigate the relationship between graft thickness and visual gain after DSAEK.

Economic Evaluation of Deep Anterior Lamellar Keratoplasty Versus Penetrating Keratoplasty in The Netherlands

PURPOSE To evaluate the cost effectiveness of deep anterior lamellar keratoplasty (DALK) versus penetrating keratoplasty (PK) in The Netherlands. DESIGN Cost-effectiveness analysis alongside a randomized, multicenter clinical trial. METHODS Fifty-three patients with corneal stromal pathologic features not affecting the endothelium were included with 28 patients in the DALK group and 25 in the PK group. Quality of life was measured before surgery and 3, 6, and 12 months after surgery. The main outcome measures were incremental cost-effectiveness ratios per clinically improved patient on the 25-item National Eye Institute Visual Functioning Questionnaire and per patient with endothelial cell loss of maximally 20% within the first year. RESULTS Mean total bootstrapped costs per patient were €7607 (US

Economic Evaluation of Endothelial Keratoplasty Techniques and Penetrating Keratoplasty in The Netherlands

10,498) in the DALK group and €6552 (US

Femtosecond-laser–assisted Descemet's stripping endothelial keratoplasty

9042) in the PK group. The incremental cost-effectiveness ratios were €9977 (US

Three-Year Follow-up Analysis of Artisan Toric Lens Implantation for Correction of Postkeratoplasty Ametropia in Phakic and Pseudophakic Eyes

13,768) per clinically improved patient on the 25-item National Eye Institute Visual Functioning Questionnaire and €6900 (US