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PURPOSE:To compare the long-term outcomes of corneal cross-linking (CXL) for the treatment of keratoconus using two different techniques for epithelial removal: transepithelial phototherapeutic keratectomy (t-PTK) and mechanical epithelial debridement.METHODS:In this prospective, comparative, interventional case series, 26 patients (30 eyes) with progressive keratoconus underwent CXL treatment. Fifteen eyes (13 patients) underwent epithelial removal with t-PTK (Cretan protocol) and 15 eyes (13 patients) underwent mechanical epithelial debridement (Dresden protocol) during CXL. Visual, refractive, and keratometric outcomes were evaluated preoperatively and at 1, 2, 3, and 4 years postoperatively.RESULTS:No intraoperative or postoperative complications were observed in any of the patients. In the Cretan protocol group, mean uncorrected (UDVA) and corrected (CDVA) visual acuity improved from 0.99 ± 0.42 and 0.33 ± 0.28 logMAR preoperatively to 0.75 ± 0.32 (No intraoperative or postoperative complications were observed in any of the patients. In the Cretan protocol group, mean uncorrected (UDVA) and corrected (CDVA) visual acuity improved from 0.99 ± 0.42 and 0.33 ± 0.28 logMAR preoperatively to 0.75 ± 0.32 (P= .018) and 0.21 ± 0.16 (P= .024) logMAR at 4 years postoperatively, respectively. In the Dresden protocol group, mean UDVA improved from 0.83 ± 0.47 logMAR preoperatively to 0.63 ± 0.40 logMAR (P= .033) at 4 years postoperatively, whereas mean CDVA did not demonstrate a statistically significant improvement postoperatively (P> .05). In the Cretan protocol group, mean corneal astigmatism improved from −6.19 ± 4.54 diopters (D) preoperatively to −4.68 ± 3.10 D (P= .041) at last follow-up, whereas in the Dresden protocol group there was no statistically significant difference postoperatively (P> .05).CONCLUSIONS:Epithelial removal with t-PTK during CXL (Cretan protocol) resulted in better visual, refractive, and keratometric outcomes compared with mechanical epithelial debridement over a long-term follow-up.[[J Refract Surg. 2019;35(10):650–655.]

PURPOSE:To compare clinical outcomes of three different techniques of combined cataract and Presbia Flexivue Microlens refractive corneal inlay (Presbia Coöperatief U.A., Amsterdam, Netherlands) implantation surgery for presbyopia compensation over a 12-month follow-up.METHODS:In this comparative pilot study, 15 patients with bilateral cataract were allocated to one of three groups with a different combination of surgical steps (cataract surgery, intrastromal pocket creation, and inlay implantation). In the three-step group, the intracorneal pocket was created in the non-dominant eye, bilateral cataract surgery was performed 3 months later, and the intracorneal inlay was inserted 3 months after that. In the two-step at 3 days group, bilateral cataract surgery was performed 3 days after pocket creation and inlay implantation in the non-dominant eye. In the two-step at 3 months group, the pocket creation and the inlay implantation were performed in the non-dominant eye 3 months after bilateral cataract surgery. Visual, refractive, and contrast sensitivity outcomes were evaluated and compared between the three groups.RESULTS:Twelve months after the inlay implantation, mean monocular uncorrected distance visual acuity was 20/32 in the three-step group, 20/32 in the two-step at 3 days group, and 20/25 in the two-step at 3 months group. Achieved mean monocular uncorrected near visual acuity was similar in the three groups (20/25). The visual and refractive outcomes did not show significant differences between groups. Contrast sensitivity was similar between groups under mesopic and photopic conditions. No intraoperative or postoperative complications were observed.CONCLUSIONS:Clinical outcomes of three different techniques of combined cataract surgery and refractive corneal inlay implantation had no apparent differences between them. The corneal inlay provided excellent near vision acuity, with high patient satisfaction and a high spectacle independence rate after cataract surgery.[[J Refract Surg.2016;32(5):318–325.]

PURPOSE:To evaluate the outcomes after Wichterle Intraocular Lens-Continuous Focus (Medicem, Kamenné Zehrovice, Czech Republic) accommodative bioanalogic intraocular lens implantation.METHODS:In this prospective case series, 50 eyes of 25 patients (mean age: 65.3 ± 8.4 years; range: 53 to 83 years) were included. All patients underwent routine cataract surgery and Wichterle Intraocular Lens-Continuous Focus implantation.RESULTS:Mean follow-up was 11.44 ± 2.46 months (range: 9 to 17 months). Both monocular uncorrected and corrected distance visual acuity statistically and significantly (Mean follow-up was 11.44 ± 2.46 months (range: 9 to 17 months). Both monocular uncorrected and corrected distance visual acuity statistically and significantly (P< .05) improved from 0.31 ± 0.17 (20/63 Snellen) (range: counting fingers to 0.7) to 0.74 ± 0.19 (20/25 Snellen) (range: 0.2 to 1) and from 0.61 ± 0.19 (20/32 Snellen) (range: 0.2 to 1) to 0.82 ± 0.13 (20/25 Snellen) (range: 0.4 to 1), respectively. Target postoperative refraction was −0.5 diopters (D) and preoperative and 1-year postoperative spherical equivalent refraction were 0.72 ± 2.71 D (range: −7.25 to 2.37 D) and −0.24 ± 0.65 D (range: −1.0 to 1.0 D), respectively. No eyes lost lines of corrected distance visual acuity during the follow-up period, whereas 88% of patients gained one or more lines of corrected distance visual acuity. Uncorrected intermediate and near visual acuity were J2 (Snellen 20/25) or better in 72% of patients. No complications occurred intraoperatively or postoperatively. The evaluation of the mean values of root mean square of third and fourth order higher-order aberrations at 1 year postoperatively revealed a mean negative spherical aberration of −0.18 ± 0.13 μm.CONCLUSIONS:Wichterle Intraocular Lens-Continuous Focus accommodative bioanalogic IOL implantation provides satisfactory visual acuity for far, intermediate, and near distances and the promising results remain stable throughout the follow-up period.[[J Refract Surg.2014;30(6):402–406.]

PURPOSE:To present the results after simultaneous conventional photorefractive keratectomy combined with corneal collagen cross-linking for pellucid marginal corneal degeneration.METHODS:In this prospective, interventional case series, 6 patients (8 eyes) with pellucid marginal corneal degeneration were enrolled. All patients underwent simultaneous conventional photorefractive keratectomy combined with corneal collagen cross-linking; corneal epithelium was removed by transepithelial phototherapeutic keratectomy during treatment (Cretan protocol plus conventional photorefractive keratectomy). Visual and refractive outcomes were evaluated along with endothelial cell density preoperatively and at 1, 3, 6, and 12 months postoperatively.RESULTS:No intraoperative or postoperative complications were observed in any of the patients. LogMAR mean uncorrected distance visual acuity improved significantly from 1.05 ± 0.33 preoperatively to 0.41 ± 0.27 (No intraoperative or postoperative complications were observed in any of the patients. LogMAR mean uncorrected distance visual acuity improved significantly from 1.05 ± 0.33 preoperatively to 0.41 ± 0.27 (P= .018) at 12 months postoperatively. Mean corrected distance visual acuity did not change significantly (P> .05) postoperatively. Mean spherical equivalent improved significantly from −3.52 ± 2.29 diopters preoperatively to −1.57 ± 1.76 diopters (P= .028) at last follow-up. Mean corneal astigmatism was significantly reduced from −6.83 ± 2.33 diopters preoperatively to −4.71 ± 1.89 diopters (P= .018) at the last follow-up. No endothelial cell density alterations were observed throughout the follow-up period (P> .05).CONCLUSIONS:Simultaneous conventional photorefractive keratectomy combined with corneal collagen cross-linking seems to be an effective, safe, and promising treatment for the management of pellucid marginal corneal degeneration.[[J Refract Surg.2014;30(4):272–276.]

PURPOSE:The multi-component intraocular lens (IOL) (IVO; SAS, Strasbourg, France) is a novel approach to the treatment of pediatric cataract. Because the refractive requirements for pediatric eyes often change over time, current IOL technology does not easily allow refractive adjustments after the primary surgical intervention. The multi-component IOL concept allows easy, surgical refractive adjustments to the initial surgical implantation at any postoperative time period. Thus, both surgical implantation and enhancement surgery have been successfully accomplished in adult patients.METHODS:A novel surgical approach to pediatric cataract surgery is described. At the time of the primary surgery, a two component IOL was implanted. At any postoperative time period, the front lens component, located in front of the capsular bag, could be easily surgically exchanged because the dioptric power requirements of the pediatric eye changed over time.RESULTS:Both primary and enhancement surgeries have been done in adult patients with good results. Implantations have occurred uneventfully in all cases with no intraoperative or postoperative complications. There was no statistically significant difference in the endothelial cell density, anterior chamber depth, and pachymetry readings preoperatively and 2 years postoperatively. There was no interlenticular fibrosis present.CONCLUSION:The multi-component IOL should provide a unique and greatly needed surgically adjustable approach to the treatment of pediatric cataract.[[J Refract Surg.2014;30(1):62–66.]

The aim of the present study was to investigate the value of pattern visual-evoked potentials (pVEP) and pattern electroretinograms (pERG) in early glaucoma diagnosis.

To compare visual acuity (VA) assessed in healthy eyes and eyes with diabetic retinopathy (DR) using three different logMAR charts: the Sloan letter European-wide chart, the tumbling E chart, and the Landolt C chart.

To assess the in vitrosusceptibility of Streptococcus pneumoniae, Staphylococcus aureusand coagulase-negative staphylococci (CoNS) ocular isolates to antibiotics, and identify changing trends in resistance over a 10-year period.

PURPOSE:To evaluate the outcomes and safety of a refractive inlay (Flexivue Micro-Lens, Presbia Coöperatief U.A.) for the corneal compensation of presbyopia.METHODS:This prospective, interventional clinical study comprised 47 emmetropic presbyopes with a mean age of 52±4 years (range: 45 to 60 years). The inlay was inserted, centered on the line of sight, inside a corneal pocket created in the patient’s nondominant eye, using a femtosecond laser. Follow-up was 12 months. Visual acuity, corneal topography, wavefront aberrometry, contrast sensitivity, structural corneal alterations, and questionnaires were evaluated.RESULTS:Twelve months after surgery, uncorrected near visual acuity was 20/32 or better in 75% of operated eyes, whereas mean uncorrected distance visual acuity (UDVA) of operated eyes was statistically significantly decreased from 0.06±0.09 logMAR (20/20) (range: −0.08 to 0.26) preoperatively to 0.38±0.15 logMAR (20/50) (range: 0.12 to 0.8) (Twelve months after surgery, uncorrected near visual acuity was 20/32 or better in 75% of operated eyes, whereas mean uncorrected distance visual acuity (UDVA) of operated eyes was statistically significantly decreased from 0.06±0.09 logMAR (20/20) (range: −0.08 to 0.26) preoperatively to 0.38±0.15 logMAR (20/50) (range: 0.12 to 0.8) (P<.001), and mean binocular UDVA was not significantly altered (P=.516). Seventeen patients lost one line of corrected distance visual acuity in the operated eye. No patient lost 2 lines in CDVA in the operated eye. Overall, higher order aberrations increased and contrast sensitivity decreased in the operated eye. No tissue alterations were found using corneal confocal microscopy. No intra- or postoperative complications occurred.CONCLUSIONS:Twelve months after implantation, the Flexivue Micro-Lens intracorneal refractive inlay seems to be an effective method for the corneal compensation of presbyopia in emmetropic presbyopes aged between 45 and 60 years old.

PURPOSE:To evaluate the outcomes of refractive surgery in patients with topographic superior corneal steepening.METHODS:This retrospective, noncomparative, interventional, clinical study included 16 patients (29 eyes) with persistent superior corneal steepening as a variation of corneal curvature (inferior to superior topographic corneal difference of at least 1.00 diopter [D] at a 3-mm zone) not related to any underlying disease or condition who underwent corneal refractive surgery. Refractive, keratometric, and visual outcomes were evaluated preoperatively and at 1, 3, 6, 12, and 24 months postoperatively.RESULTS:Twenty-two eyes underwent photorefractive keratectomy and 7 eyes underwent LASIK. Mean follow-up was 27.38±2.37 months (range: 25 to 32 months). Mean preoperative inferior to superior keratometric difference was 1.61±0.36 D (range: 1.20 to 2.63 D). Mean preoperative spherical equivalent refraction was −4.45±1.66 D (range: −2.25 to −8.00 D), which decreased to −0.09±0.61 D (range: +0.75 to −1.38 D) (Twenty-two eyes underwent photorefractive keratectomy and 7 eyes underwent LASIK. Mean follow-up was 27.38±2.37 months (range: 25 to 32 months). Mean preoperative inferior to superior keratometric difference was 1.61±0.36 D (range: 1.20 to 2.63 D). Mean preoperative spherical equivalent refraction was −4.45±1.66 D (range: −2.25 to −8.00 D), which decreased to −0.09±0.61 D (range: +0.75 to −1.38 D) (P<.05) at last follow-up. Mean preoperative topographic corneal astigmatism was 1.44±0.79 D (range: 0.52 to 3.83 D), which decreased to 0.66±0.39 D (P<.05) 3 months postoperatively and remained stable during follow-up (P<.54). Mean preoperative uncorrected distance visual acuity and corrected distance visual acuity in logMAR units were 1.57±0.62 and 0.02±0.06, respectively, which improved at last follow-up to 0.00±0.05 and −0.02±0.04, respectively. No intra- or postoperative complications were noted; specifically, no patients developed postoperative ectasia.CONCLUSIONS:Corneal refractive surgery in patients with isolated topographic superior corneal steepening provided acceptable refractive and visual outcomes without any intra- or postoperative complications. Diligence is required to screen for the potential of ectatic corneal disorders in this population. Photorefractive keratectomy may be a safer option for these patients than LASIK.

PURPOSE:To investigate the outcomes and safety of an intrastromal refractive inlay (Invue Lens, Biovision AG) for the corneal compensation of presbyopia.METHODS:This prospective, noncomparative, interventional clinical study comprised 45 emmetropic presbyopes with a mean age of 52.3±3.3 years (range: 47 to 58 years). The refractive inlay was inserted in the non-dominant eye within a corneal pocket that was created using a mechanical microkeratome. Last follow-up was 12 months in all patients and examinations were scheduled at 1 week and 1, 3, 6, and 12 months after surgery. Visual, wavefront, contrast sensitivity, and topographic outcomes as well as structural corneal alteration were evaluated.RESULTS:Twelve months after surgery, uncorrected near visual acuity was 20/32 or better in 98% of operated eyes and binocularly, whereas uncorrected distance visual acuity was 20/40 or better in 93% of operated eyes and 20/25 or better in all patients binocularly. Three patients lost one line of corrected distance visual acuity in the operated eye. Overall, higher order aberrations were increased and contrast sensitivity was decreased in the operated eye. No tissue alterations were found using corneal confocal microscopy. No intra- or postoperative complications occurred.CONCLUSIONS:The intracorneal refractive inlay (Invue Lens) seems to be an effective surgical method for the corneal compensation of presbyopia in emmetropes aged between 45 and 60 years.

Background and Objective:Previous studies have reported changes in the intraocular pressure (IOP) of fellow eyes following unilateral trabeculectomy or selective laser trabeculoplasty. This study evaluates changes in the IOP of fellow eyes following unilateral trabeculectomy and examines correlations of findings with clinical information.Patients and Methods:Sixty-one patients who underwent unilateral uncomplicated trabeculectomy were included. The IOP of both eyes was recorded on postoperative days 2, 3, 4, 15, 30, 60, and 90. Differences between preoperative and postoperative IOP in both eyes and correlations with clinical parameters were examined.Results:The IOP of the fellow eyes was significantly reduced on the fourth postoperative day. This reduction was significantly correlated (inversely) with central corneal thickness of fellow eyes and with the level of IOP reduction to the operated eyes.Conclusion:The IOP of the fellow eyes remains largely unchanged during the first 3 months following trabeculectomy. However, a significant short-term reduction is noted on the fourth day, implying that unknown (possibly neurocrine) mechanisms may participate in the regulation of the IOP of fellow eyes.

Background and Objective:Graft harvesting for Descemet membrane endothelial keratoplasty (DMEK) occurs manually and demonstrates surgical difficulties. In the current study, a mechanical automated technique for preparing a donor Descemet membrane (DM) carrying autologous endothelium for DMEK was evaluated.Materials and Methods:Ten rabbit corneas were placed on an artificial anterior chamber and mechanical separation of the DM was conducted using an Epi-keratome (Senturium; Norwood Abbey EyeCare, Victoria, Australia). All DM specimens were properly fixated and optical microscopy was performed.Results:DM separation was achieved in a controlled fashion in 7 of 10 eyes. As demonstrated by optical microscopy of the specimens, no corneal stroma was attached on the DM, whereas the endothelial layer was preserved in several areas.Conclusion:Automated separation of the DM can be achieved using an Epi-keratome. Additional studies and improvements of the current technique are needed to draw final conclusions.

To examine the differences between Goldmann Applanation Tonometry (GAT) and Dynamic Contour Tonometry (DCT) associated with latanoprost use.

To evaluate position and function of antiglaucomatous Ahmed and Molteno shunts using magnetic resonance imaging with head and surface coils.

External and endonasal dacryocystorhinostomy (EX-DCR and EN-DCR, respectively) affect the tear drainage mechanism. This study evaluates the preservation of “lacrimal pump” function in both procedures.

To describe a new software tool for the detailed presentation of corneal topography measurements variability by means of color-coded maps.

The aim of this article is to provide an update on epipolis laser in-situ keratomileusis – an alternative surface photorefractive surgical technique for the correction of myopia.

The reports of an increasing incidence of iatrogenic ectasia, the evolution of wavefront aberrometry, and the suggestion that the laser in situ keratomileusis flap could lead to unpredictable biomechanical corneal changes have renewed interest in surface ablation and have set the stage for the introduction of alternative photorefractive treatment modalities. The theoretical advantage of surface procedures, such as laser epithelial keratomileusis that preserve the epithelial button, stems from the repositioning of the epithelial flap over the laser-ablated corneal surface. This epithelial sheet is thought to act as a natural contact lens that decreases postoperative pain and haze formation. Epipolis laser in situ keratomileusis is an alternative modality of epithelial separation with the use of a device that features a blunt oscillating blade. This surgical approach does not require the use of alcohol for epithelial loosening.

To prospectively study and compare the effectiveness and the safety of primary deep sclerectomy with and without the use of mitomycin C in eyes with open-angle glaucoma.

Purpose To determine how refractive error, visual acuity, and high-order aberrations (3rd- and 4th-order) are affected by the formation of a lamellar corneal flap during laser in situ keratomileusis (LASIK). Setting University refractive surgery center. Methods The effect of lamellar corneal flap formation was analyzed in 15 myopic eyes (mean preoperative refraction −4.72 diopters [D] [range −1.25 to −7.25 D]). The flap was created using a 2-step procedure: (1) a nasally hinged lamellar corneal flap was created; (2) the flap was lifted and stromal ablation performed 2 months after the flap was made. A Hartmann-Shack aberrometer was used to measure the aberrations. Results There was no significant change in the refractive error (spherical equivalent pre-flap −4.72 ± 1.99 D and post-flap −4.62 ± 1.99 D [ P = .28]) or visual acuity (pre-flap uncorrected visual acuity [UCVA] 0.07 and best corrected visual acuity [BCVA] 0.96; post-flap UCVA 0.08 and BCVA 0.95 [ P = .16 and P = .33, respectively]). A statistically significant increase in total higher-order wavefront aberrations was observed following flap formation (root mean square pre-flap 0.344 ± 0.125 and post-flap 0.440 ± 0.221 [ P = .04]). Conclusion Flap formation during LASIK can modify the eye's existing natural higher-order aberrations (especially spherical and coma-like aberrations along the axis of the flap's hinge), while visual acuity and refractive error remain unaffected.

Purpose To prospectively compare the influence of fornix-based and limbus-based conjunctival flaps on the final outcome and complications of 2-site phacotrabeculectomy with mitomycin-C in fellow eyes of patients with bilateral open-angle glaucoma (OAG). Setting Glaucoma Unit, Department of Ophthalmology, University of Crete, Crete, Greece. Methods Twenty-two patients with bilateral primary OAG and 8 patients with bilateral exfoliative glaucoma had 2-site phacotrabeculectomy in both eyes. Eyes were randomly assigned to the fornix-based flap or limbus-based flap group by the use of random tables. Results The intraocular pressure (IOP) decreased significantly in both groups ( P &lt; .01); however, there was no statistically significant difference between the groups in the amount of IOP decrease or the number of postoperative antiglaucoma medications after a 1-year follow-up. Faster improvement in visual acuity was observed in the fornix-based group during the first week. The mean time of surgery was 3.5 minutes less in the fornix-based group. An increased incidence of fibrin exudation, pupillary membrane formation, and capsule opacification was found in eyes with exfoliative glaucoma. The early bleb leakage was 3 times more frequent in the fornix-based group. Conclusion The type of conjunctival flap in a 2-site phacotrabeculectomy did not seem to influence the final outcome. The main advantage of the fornix-based conjunctival flap is the shorter surgical time and the relatively faster improvement in vision postoperatively. The main disadvantage is more frequent early bleb leakage.

To report a case that developed hemorrhagic Descemet's membrane detachment after deep sclerectomy.

To investigate the prevalence of primary openangle glaucoma POAG in a randomized sample of the inhabitants of the island of Crete.

Purpose:To present our early experience in methodology and results of laser in situ keratomileusis (LASIK) in treating moderate and high myopia.

Purpose:To evaluate the effect of photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK) on corneal sensation.

• Using a modified microkeratome, nasally based central corneal flaps were created on six human blind eyes at a depth of 300 μm. The flaps were allowed to heal with a bandage soft contact lens, using neither sutures nor bioadhesives. The optical quality of the corneas was evaluated with biomicroscopic examination, computer-assisted topography, and optical pachometry during a 3-month follow-up period. The maintenance of transparency and lack of distortion of the corneal surface 3 months after surgery support the concept that the flap technique may be useful in laser in situ keratomileusis.

Purpose:To evaluate the advantages, disadvantages, safety, complications, and surgical applicability of an erbium:YAG laser system for maneuvers in vitreoretinal surgery.

PURPOSE:To evaluate the results after unilateral sulcus implantation of the Crystalens HD (Bausch & Lomb) accommodative intraocular lens (IOL).METHODS:This retrospective interventional case series comprised six eyes from three patients who underwent cataract surgery and bilateral Crystalens HD accommodative IOL implantation. The Crystalens HD was implanted in the bag in one eye (non-sulcus group) and, due to posterior capsule rupture, the lens was positioned in the ciliary sulcus in the fellow eye (sulcus group).RESULTS:Mean patient age was 66.3±4.9 years (range: 60 to 72 years). Mean follow-up was 14.3±3.2 months (range: 12 to 18 months) for the non-sulcus group and 14±2 months (range: 12 to 16 months) for the sulcus group. Uncorrected distance visual acuity improved from 20/100 to 20/33 in the non-sulcus group and from 20/63 to 20/32 in the sulcus group during last follow-up. Corrected distance visual acuity improved from 20/35 to 20/20 in the non-sulcus group and from 20/27 to 20/23 in the sulcus group. Regarding near vision, all eyes in the sulcus group and 66.7% of eyes in the non-sulcus group achieved J1–J2 (Birkhauser reading chart). None of the eyes had any intra- (except posterior capsule rupture in the sulcus cases) or postoperative complications.CONCLUSIONS:Based on this small series, ciliary sulcus implantation of the Crystalens HD seems to be associated with no significant morbidity and provides satisfactory visual acuity outcomes.

To examine the feasibility of monocanalicular intubation in external dacryocystorhinostomy (EX-DCR).

Purpose:To present a patient in whom, during LASIK with the IntraLase femtosecond laser (Abbott Medical Optics), unintended epithelial (instead of anterior stromal) flaps were created in both eyes.Methods:A 28-year-old man underwent bilateral LASIK using the IntraLase femtosecond laser programmed to create 100-μm flaps. Flap creation was performed uneventfully in both eyes but flap thickness was thinner than attempted. The flaps were easily torn during flap lift because they appeared to consist of epithelium only. Therefore, the procedure was immediately converted to photorefractive keratectomy with the use of mitomycin C.Results:Re-epithelialization occurred 3 days after the procedure in both eyes. Three months after treatment, uncorrected distance visual acuity was 20/25 in the right eye and 20/20 in the left eye with no signs of corneal haze on slit-lamp examination.Conclusions:Despite the advantages of the IntraLase femtosecond laser in the creation of a LASIK flap, complications in terms of flap thickness may occur.