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Manoj Motwani,1 Emmanuel Agu,2 Albert Xu,2 Madeline Yung2 1Motwani Lasik Institute/Cornea Revolution, San Diego, CA, USA; 2Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USACorrespondence: Madeline Yung, Email madeline.yung@ucsf.eduPurpose: To compare the outcomes of two different surgical planning strategies for topography-guided repair of post-LASIK ectasia.Methods: This is a case report of a patient presenting with post-LASIK ectasia. A retrospective chart review was used to collect details of the ophthalmic exam, as well as ocular imaging such as anterior segment optical coherence tomography and Scheimpflug corneal tomography. Treatment planning was performed initially with the Phorcides analytical engine, and then an enhancement was performed with the LYRA/San Diego Protocol. Epithelium-off corneal cross-linking was performed at 3.0 mW/cm for 30 minutes.Results: The patient initially presented with a remote history of LASIK and progressive left eye blurring. His uncorrected distance visual acuity (UDVA) was 20/40, with a corrected distance visual acuity (CDVA) of 20/25 with a manifest refraction of − 1.25 +1.75 × 180. His central corneal thickness was 529 μm, and corneal topography/tomography demonstrated inferior steepening of the left eye consistent with post-LASIK ectasia. He underwent simultaneous PRK and epithelium-off corneal cross-linking with a treatment plan by Phorcides of – 0.14 − 0.87 × 001. His vision stabilized at post-operative month 7 to a UDVA 20/40, CDVA 20/20, and manifest refraction of − 2.75 +3.50 × 005. He underwent PRK enhancement with a treatment plan by the San Diego Protocol of +0.00 – 1.15 × 094, with an outcome of UDVA 20/20, CDVA 20/20, and manifest refraction of − 1.00 +0.75 × 174.Conclusion: The LYRA/San Diego Protocol outperformed Phorcides in a case of corneal ectasia. With appropriate planning, patients with irregular corneas can achieve excellent refractive outcomes.Keywords: corneal cross-linking, post-LASIK ectasia, Phorcides, San Diego Protocol, topography-guided ablation

Importance: Development of myocardial fibrosis in patients with aortic stenosis precedes left ventricular decompensation and is associated with an adverse long-term prognosis., Objective: To investigate whether early valve intervention reduced the incidence of all-cause death or unplanned aortic stenosis-related hospitalization in asymptomatic patients with severe aortic stenosis and myocardial fibrosis., Design, Setting, and Participants: This prospective, randomized, open-label, masked end point trial was conducted between August 2017 and October 2022 at 24 cardiac centers across the UK and Australia. Asymptomatic patients with severe aortic stenosis and myocardial fibrosis were included. The final date of follow-up was July 26, 2024., Intervention: Early valve intervention with transcatheter or surgical aortic valve replacement or guideline-directed conservative management., Main Outcomes and Measures: The primary outcome was a composite of all-cause death or unplanned aortic stenosis-related hospitalization in a time-to-first-event intention-to-treat analysis. There were 9 secondary outcomes, including the components of the primary outcome and symptom status at 12 months., Results: The trial enrolled 224 eligible patients (mean [SD] age, 73 [9] years; 63 women [28%]; mean [SD] aortic valve peak velocity of 4.3 [0.5] m/s) of the originally planned sample size of 356 patients. The primary end point occurred in 20 of 113 patients (18%) in the early intervention group and 25 of 111 patients (23%) in the guideline-directed conservative management group (hazard ratio, 0.79 [95% CI, 0.44-1.43]; P = .44; between-group difference, -4.82% [95% CI, -15.31% to 5.66%]). Of 9 prespecified secondary end points, 7 showed no significant difference. All-cause death occurred in 16 of 113 patients (14%) in the early intervention group and 14 of 111 (13%) in the guideline-directed group (hazard ratio, 1.22 [95% CI, 0.59-2.51]) and unplanned aortic stenosis hospitalization occurred in 7 of 113 patients (6%) and 19 of 111 patients (17%), respectively (hazard ratio, 0.37 [95% CI, 0.16-0.88]). Early intervention was associated with a lower 12-month rate of New York Heart Association class II-IV symptoms than guideline-directed conservative management (21 [19.7%] vs 39 [37.9%]; odds ratio, 0.37 [95% CI, 0.20-0.70])., Conclusions and Relevance: In asymptomatic patients with severe aortic stenosis and myocardial fibrosis, early aortic valve intervention had no demonstrable effect on all-cause death or unplanned aortic stenosis-related hospitalization. The trial had a wide 95% CI around the primary end point, with further research needed to confirm these findings., Trial Registration: ClinicalTrials.gov Identifier: NCT03094143.