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Aim To evaluate the changes in higher order aberrations (HOAs) after implantable collamer lens (ICL; Staar Surgical, Nidau, Switzerland) implantation. Methods Totally 30 eyes of 18 patients with myopia were included in this study with an average age of 25.77y (min: 21, max: 40). Refraction, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), HOAs (entire, corneal and internal) were evaluated preoperatively and three months postoperatively. Ocular aberrations were measured by using iTrace (Tracey Technology, Houston, Texas, USA). SPSS (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp) was used for the statistical analysis and the interpretation of the data. P values of less than 0.05 were considered statistically significant. Results The preoperative mean spherical power was -9.01 D (min: -5.00, max: -13.00) and the mean cylindrical error was -2.40 D (min: -0.50, max: -4.75). The postoperative mean residual spherical power was -0.73 D (min: -0.20, max: -1.75) and the mean cylindrical error was -0.89 D (min: -0.18, max: -2.09). Analyses were made on root mean square (RMS) values of total HOAs (tHOAs), spherical aberration, coma and trefoil as entire, corneal and internal components. The differences in entire tHOAs and in internal tHOAs were significant. There was no significant change found in spherical aberrations. The differences in entire coma and in internal coma were significant. There was no significant change found in corneal coma. With respect to trefoil, the only significant difference was in internal trefoil. Conclusion The ICL implantation corrects the refractive error successfully and changes entire and internal HOAs of the eye.

The tuck-and-pull technique was developed for practical and safe explantations of posterior chamber phakic intraocular lenses (PCPIOLs). In this technique, after the creation of a side port, viscoelastic (or OVD [ophthalmic viscosurgical device]) is initially injected behind the PCPIOL to widen the space between PCPIOL and the crystalline lens. The old incisions can be used after recent implantations rendering the enlargement of the main incision unnecessary. After additional OVD over and under the PCPIOL, the haptic is tucked by a chopper and pulled through the main incision with a single maneuver. The haptic is grasped by two suture forceps and explanted with a "hand-to-hand" maneuver. The tuck-and-pull technique provided high protection of the corneal endothelium, crystalline lens, anterior chamber structures, and the PCPIOL itself. This technique is a practical, easy, and safe approach for explantations of all PCPIOL types, whatever the reason for its explantation may be.

To evaluate one-year visual, refractive, and topographic outcomes of 58 eyes of 53 keratoconus patients who underwent surgery with a progressive thickness intrastromal corneal ring segment (ICRS). This multi-center, retrospective, observational study evaluates the one-year effects of progressive thickness ICRS implanted in keratoconus patients meeting the inclusion criteria. One or two progressive ICRS were implanted in the selected eyes after creating an intrastromal tunnel with a femtosecond laser. Pre- and postoperative uncorrected distance visual acuity, best-corrected distance visual acuity, manifest refraction (both spherical equivalent and cylindrical refractions), corneal astigmatism, maximum keratometry, corneal thickness, and corneal topography measurements and indices were evaluated. In this retrospective case series, 58 eyes of 53 keratoconus patients were included with a follow-up of 12 months. The mean age was 30.89 ± 11.90 years. There were improvements postoperatively in mean values of visual acuities, both uncorrected from 0.71 (preoperatively) to 0.28 (log MAR), and best-corrected from 0.28 to 0.10 (log MAR), mean cylindrical refraction from − 2.35 ± 1.51 to − 4.15 ± 2.23 D, and mean spherical equivalent from − 2.10 ± 2.25 to − 4.64 ± 3.2 D. There was also a reduction in maximal keratometry from 54.21 D preoperatively to 50.93 D postoperatively. The implantation of the progressive thickness ICRS is an effective and safe method to improve the vision of keratoconic eyes. Corneal stability was maintained at the 12-month mark.

PURPOSE: To evaluate a four-stage combined treatment for keratoconus including intrastromal corneal ring segment (ICRS) implantation followed by corneal cross-linking (CXL), toric phakic intraocular lens (IOL) implantation, and topography-guided photorefractive keratectomy (TG-PRK). METHODS: In this retrospective interventional case series, 11 eyes of 7 patients with progressive keratoconus were treated with a four-stage procedure including the following: Keraring ICRS (Mediphacos Ltda, Belo Horizonte, Brazil) implantation followed by CXL, phakic IOL implantation, and TG-PRK (minimum 6 months between each stage). Minimum follow-up was 12 months after TG-PRK. RESULTS: Both mean uncorrected distance visual acuity and corrected distance visual acuity (CDVA) improved from 0.025 decimal (20/800 Snellen) and 0.093 decimal (20/215 Snellen) preoperatively to 0.68 decimal (20/30 Snellen) and 0.73 decimal (20/27 Snellen), respectively, after the combined treatment ( P < .0001). Mean postoperative CDVA of 0.73 decimal (20/27 Snellen) was similar to preoperative contact lens CDVA of 0.72 decimal (20/28 Snellen). Mean manifest refraction spherical equivalent reduced from 16.78 ± 3.58 to 0.59 ± 0.89 diopters ( P < .0001) and mean refractive astigmatism reduced from 5.16 ± 1.86 to 0.82 ± 0.28 diopters ( P < .0001). CONCLUSIONS: This four-stage procedure appears to be an effective and safe approach for corneal stabilization and improvement of functional vision in patients with keratoconus. Larger case series with a longer follow-up are required to thoroughly evaluate the efficacy, safety, and stability of this combined approach. [ J Refract Surg. 2017;33(10):683–689.]

In the original publication, the Results paragraph of the abstract was published incorrectly. The correct version should read as follows.

PURPOSE: To analyze 1-week, 1-month, and 12-month postoperative refractive outcomes of eyes that under-went ICL implantation to correct hyperopic astigmatism. METHODS: The study enrolled 20 eyes of patients with an average age of 32 years (range: 21 to 40 years). The outcomes of spherical and cylindrical refraction, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), vault, and angle parameters were evaluated 1 week, 1 month, and 12 months postoperatively. RESULTS: The preoperative mean UDVA was 0.15 ± 0.11 (decimal) (20/133 Snellen) and increased to 0.74 ± 0.25 (20/27 Snellen) postoperatively, with a change of 0.59 (decimal) (20/33.9 Snellen) ( P < .0001), which was statistically significant. The preoperative mean CDVA was 0.74 ± 0.25 (decimal) (20/27 Snellen) and increased to 0.78 ± 0.21 (20/25 Snellen), with a change of 0.03 (decimal) (20/666 Snellen) ( P < .052), which was not statistically significant. The mean preoperative sphere was 6.86 ± 1.77 diopters (D) and the mean preoperative cylinder was −1.44 ± 0.88 D. The mean 12-month postoperative sphere decreased to 0.46 ± 0.89 D ( P < .001) and cylinder decreased to −0.61 ± 0.46 D ( P < .001), with a change of 6.40 D, both of which were statistically significant. The mean 1-month postoperative vault was 0.65 ± 0.13 mm and decreased to 0.613 ± 0.10 mm at 1 year postoperatively, with a change of 0.44 mm ( P < .003). The preoperative/12-month and 1-month/12-month trabecular–iris angle (TIA), trabecular–iris space area 500 mm from the scleral spur (TISA500), and angle opening distance 500 mm from the scleral spur (AOD500) values were analyzed nasally, temporally, and inferiorly. All differences were statistically significant between preoperative/12-month analysis. The only differences between 1- and 12-month analysis were on TISA500 inferior ( P < .002) and AOD500 nasal (0.031) values. CONCLUSIONS: ICL hyperopic toric implantation is a safe method and provides stable refractive outcomes in patients with high hyperopia (up to 10.00 D) and astigmatism (up to 6.00 D). [ J Refract Surg. 2017;33(9):604–609.]

Director, Refractive Surgery Department Dunya Eye Hospital Istanbul, Turkey. Laser Focus-Centre for Eye Microsurgery, 1KBC Zvezdara, Belgrade, Serbia. 3 Clinical Research Associate Refractive Surgery Department Dunya Eye Hospital Istanbul, Turkey. Chairman, Department of Ophthalmology, University Hospitals of Geneva, Switzerland. The first clinical results of collagen cross-linking in keratoconus were reported by a research group from Dresden University in 2003. In this study, 23 eyes of 22 patients with keratoconus were included and only one eye of each patient was treated except one case that was treated bilaterally. The follow-up period was from 3 to 47 (23,2 ± 12,9) months. The BCVA improved in 65% of the patients by an average of 1.26 lines. The refractive correction improved by an average of 1.14D. In 70% of the patients, maximum K was flattened by an average of 2.01D. K value remained stable in 5 patients and in 1 patient an increase of 0.28D was present. In 22% of the fellow control eyes, however maximum K value increased by an average of 1.48D. The same research group later published their long-term results in 2008 on 153 eyes of 111 patients. The minimal follow-up time was 12 months and the maximum follow-up was 7,5 years.

PURPOSE: To present visual and refractive outcomes in 11 eyes that underwent femtosecond LASIK and subsequent retreatment with flap lifting using only side cutting. METHODS: Seven patients (11 eyes) with a mean age of 30.55±5.42 years (range: 24 to 39 years) underwent retreatment 18.18±5.41 months (range: 12 to 26 months) after primary LASIK treatment with side cutting only using a femtosecond laser for the correction of residual refractive error. RESULTS: Mean follow-up after retreatment was 7.72±1.48 months (range: 6 to 10 months). No intra- or postoperative complications were found after LASIK retreatment. Uncorrected distance visual acuity (UDVA) improved in all patients. Mean UDVA improved from 0.54±0.12 (decimal scale) (range: 0.4 to 0.7) preoperatively to 0.99±0.03 (range: 0.9 to 1.0) after retreatment. No patient lost lines of corrected distance visual acuity. CONCLUSIONS: Retreatment using a femtosecond laser to create only a side cut is an effective modality to treat residual refractive errors in postoperative LASIK patients.

A thirty-nine year old man was referred to our institute due to progressive decreased visual acuity five years after bilateral Laser in situ Keratomileusis (LASIK). Topography revealed signs of post - LASIK ectasia. Patients' left eye was treated with simultaneous Topography Guided Photorefractive Keratectomy (PRK) followed by Corneal Collagen Cross Linking (CXL). Twelve months after the combined procedure both uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) showed significant improvement while topographic findings revealed an improvement of the astigmatic pattern. All higher order aberrations showed a significant decrease twelve months postoperatively. Combined topography guided PRK and corneal cross linking could represent an alternative treatment for post - LASIK ectasia.

PURPOSE: To describe the visual and refractive outcomes in three eyes (two keratoconic patients) with previous intrastromal corneal ring segments (INTACS, Addition Technology Inc) that underwent adjuvant single KeraRing (Mediphacos) intrastromal corneal ring segment implantation. METHODS: Two keratoconic patients (three eyes) with implanted INTACS segments underwent an additional (without explanting previous INTACS) single KeraRing segment implantation. RESULTS: No intraoperative complications occurred. Six months postoperatively, uncorrected distance visual acuity improved from 20/100 and 20/200 to 20/32 and 20/40 in the right and left eyes, respectively, of patient 1, and from 20/400 to 20/50 in the treated right eye of patient 2. Corrected distance visual acuity improved from 20/50 and 20/100 to 20/30 and 20/32 in the right and left eyes, respectively, of patient 1 and from 20/200 to 20/40 in patient 2. Keratometric measurements improved from 51.00/45.70 to 47.00/44.60 diopters (D) and from 50.80/48.80 to 42.70/40.30 D in the right and left eyes, respectively, of patient 1, and from 49.30/45.70 to 45.60/44.10 D in patient 2. CONCLUSIONS: In keratoconic patients with INTACS in place, adjuvant single intrastromal corneal ring segment (KeraRing) implantation could improve visual and refractive outcome. [ J Refract Surg . 2010;26:371–374.]

Purpose To compare 2 sequences of combined intrastromal corneal ring segment (ICRS) implantation and ultraviolet/riboflavin–mediated corneal collagen crosslinking (CXL) in progressive keratoconus. Setting Dunya Eye Hospital, Istanbul, Turkey. Methods In this prospective comparative randomized consecutive study, CXL was followed by ICRS implantation (Group 1) or ICRS implantation was followed by CXL (Group 2). Uncorrected (UDVA) and corrected (CDVA) distance visual acuities, spherical equivalent (SE), manifest cylinder (cylinder), and mean keratometry (K) were compared preoperatively and postoperatively. Results The mean interval between treatments was 7 months ± 2 (SD) (mean follow-up, 13 ± 1 months). The mean UDVA and CDVA improved in both groups (UDVA: 0.07 ± 0.09 to 0.25 ± 0.12, Group 1, and 0.11 ± 0.09 to 0.32 ± 0.21, Group 2; CDVA: 0.24 ± 0.11 to 0.41 ± 0.20 and 0.22 ± 0.16 to 0.55 ± 0.2, respectively). The mean SE, cylinder, and mean K values decreased in both groups (SE: −7.13 ± 3.34 D to −2.98 ± 2.33 D, Group 1, and −7.05 ± 5.54 D to −2.81 ± 4.08 D, Group 2; cylinder: −4.38 ± 2.03 D to −2.62 ± 1.93 D and −4.68 ± 2.60 D to −2.20 ± 1.67 D, respectively; mean K: 52.47 ± 4.01 D to 48.31 ± 3.65 D and 52.06 ± 4.93 D to 48.08 ± 4.13 D, respectively). Overall, there was more improvement in CDVA, SE, and mean K in Group 2 than in Group 1. Conclusion Implantation of ICRS followed by CXL resulted in greater improvement of keratoconus.

Objective To study central corneal pachymetric variations during corneal collagen cross-linking (CXL) treatment with the use of riboflavin and ultraviolet A irradiation (UVA). Design Prospective, noncomparative, interventional clinical study. Participants Fifteen keratoconic patients (19 eyes) were enrolled. Methods All patients underwent riboflavin-UVA–induced corneal CXL. Intraoperative central corneal thickness (CCT) measurements using ultrasound pachymetry were performed during the procedure. Measurements were obtained after epithelial removal, after riboflavin drop instillation, and every 5 minutes (6 interval times) during UVA irradiation (30 minutes). Main Outcome Measures Central corneal thickness measurements. Results Mean patient age was 26.9±6.5 years (range, 17–40 years). Ten were male and 5 were female. Mean preoperative CCT was 458.5±21.5 μm (range, 427–494 μm; 95% confidence interval [CI], 448–467 μm) and 415.7±20.6 μm (range, 400–468 μm; 95% CI, 406–426 μm) before and after epithelial removal, respectively. There was a statistically significant decrease (mean, 75 μm) of CCT between the epithelial removal interval (415.7±20.6 μm; range, 400–468 μm) and at the end of riboflavin solution instillation (340.7±22.9 μm; range, 292–386 μm; P P >0.05). There was no statistically significant difference between preoperative and 1-month postoperative endothelial cell count (preoperative, 2780±197 to 1-month postoperative, 2713±116; P = 0.14). No intraoperative, early postoperative, or late postoperative complications were observed in this patient series. Conclusions During corneal CXL with the use of riboflavin and UVA irradiation, a statistically significant decrease of CCT was demonstrated. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Objective: To compare visual, refractive, and corneal aberrometric outcomes in keratoconic eyes implanted with intracorneal ring segments (ICRS) implantation using either a mechanical or a femtosecond laser-assisted procedure. Design: Retrospective, consecutive case series. Participants: A total of 146 consecutive eyes of 106 patients with the diagnosis of keratoconus (68 unilateral and 39 bilateral) were included. Two groups were created according to the surgical technique used for corneal tunnelization: Mechanical group (mechanical tunnelization, 63 eyes) and Femtosecond group (femtosecond laser-assisted tunnelization, 83 eyes). Intracorneal ring segments implantation was indicated because of the existence of reduced best spectacle-corrected visual acuity (BSCVA) or contact lens intolerance. Methods: Intracorneal ring segments implantations were performed by 6 surgeons following the same protocol except for the incision location. A total of 55 eyes were implanted with Intacs (Addition Technology, Inc, Fremont, CA) and 8 eyes were implanted with KeraRings (Mediphacos, Belo Horizonte, Brazil) in the Mechanical group, and 25 eyes were implanted with Intacs and 58 eyes were implanted with KeraRings in the Femtosecond group. Mean follow-up was 10.66±8.20 months, ranging from 1 month to 24 months. Main Outcome Measures: Uncorrected visual acuity (UCVA), BSCVA, refraction, keratometry, and root mean square (RMS) for different kinds of corneal aberrations. Results: By reporting only for statistically significant changes, UCVA improved in both groups at 6 months (P≤0.02) and BSCVA improved in the Femtosecond group (P0.63, P≤0.04). Conclusions: Intracorneal ring segments implantation using both mechanical and femtosecond laser-assisted procedures provide similar visual and refractive outcomes. A more limited aberrometric correction is observed for eyes with mechanical implantation. Supported in part by a grant of the Spanish Ministry of Health, Instituto Carlos III, Red Temática de Investigación Cooperativa en Salud “Patología ocular del envejecimiento, calidad visual y calidad de vida,” Subproyecto de Calidad Visual (RD07/0062).

A 33-year-old woman with irregular astigmatism 6 years after radial keratotomy (RK) for keratoconus was treated with implantation of a single intrastromal corneal ring segment (Keraring) using the femtosecond laser. The segment (0.150 mm thick with a 160-degree arc) was inserted in the steepest area (inferior) with no intraoperative or postoperative complications. Six months postoperatively, the uncorrected visual acuity had improved from 20/40 to 20/25 and the best spectacle-corrected visual acuity, from 20/32 to 20/20. The mean manifest astigmatic correction decreased from -2.50 diopters (D) to -0.75 D, and corneal topography showed improved inferior steepening and less irregular astigmatism. Although the results are encouraging, the long-term effect of this approach in post-RK patients is not known.

PURPOSE To evaluate staged combined treatment for keratoconus with intrastromal corneal ring segment (ICRS) implantation followed by corneal collagen crosslinking (CXL) with riboflavin ultraviolet A (UVA) and then toric implantable collagen copolymer phakic intraocular lens (pIOL) implantation. SETTING Large private ophthalmic hospital system. DESIGN Case series. METHODS Eyes with progressive keratoconus had ICRS implantation then CXL and then pIOL implantation (minimum 6 months between procedures). RESULTS The study enrolled 14 eyes (9 patients). After the combined treatments the mean decimal uncorrected distance visual acuity (UDVA) and mean decimal corrected distance visual acuity (CDVA) were significantly improved from 0.01 and 0.14 respectively preoperatively to 0.44 and 0.57 respectively (P

PURPOSE: To present the results of topography-guided transepithelial photorefractive keratectomy (PRK) after intracorneal ring segments implantation followed by corneal collagen cross-linking (CXL) for keratoconus. METHODS: In this prospective case series, 10 patients (16 eyes) with progressive keratoconus were included. All patients underwent topography-guided transepithelial PRK after Keraring intracorneal ring segments (Mediphacos Ltda) implantation, followed by CXL treatment. The follow-up period was 6 months after the last procedure for all patients. Time interval between both intracorneal ring segments implantation and CXL and between CXL and topography-guided transepithelial PRK was 6 months. RESULTS: LogMAR mean uncorrected distance visual acuity and mean corrected distance visual acuity were significantly improved ( P P P CONCLUSIONS: Combined topography-guided transepithelial PRK with intracorneal ring segments implantation and CXL in a three-step procedure seems to be an effective, promising treatment sequence offering patients a functional visual acuity and ceasing progression of the ectatic disorder. A longer follow-up and larger case series are necessary to thoroughly evaluate safety, stability, and efficacy of this innovative procedure.

PURPOSE To report the development of posterior linear stromal haze after simultaneous photorefractive keratectomy (PRK) followed by corneal collagen cross-linking (CXL). METHODS Combined simultaneous customized PRK followed by corneal collagen cross-linking was performed in 23 patients (28 eyes) with keratoconus. Corneas were examined biomicroscopically and by means of confocal microscopy before surgery and 1, 3, 6, 9, and 12 months after surgery. RESULTS Posterior linear stromal haze was observed clinically (slit lamp biomicroscopy) one month after surgery in 13 of 28 eyes (46.42%). No corneal edema or anterior haze formation was evident. Confocal microscopy revealed in those 13 eyes a hyperreflective area at the level of the posterior stroma 1 month after combined treatment. Both slit lamp examination and corneal confocal microscopy follow-up demonstrated a gradual anterior movement and a decrease in reflectance of this finding. At 12 months this posterior linear stromal haze, despite its anterior movement and decreased density, did not completely disappear at slit lamp and confocal microscopy analysis. CONCLUSIONS Posterior linear stromal haze formation may appear after simultaneous PRK followed by CXL in patients with keratoconus. This finding seems to gradually become less dense and slowly moves toward the anterior stroma.

Acta Ophthalmol. 2011: 89: 54–57 Abstract. Purpose: To report complications after the implantation of intrastromal corneal ring segments (Keraring; Mediphacos, Belo Horizonte, Brazil) in keratoconic eyes using a femtosecond laser (IntraLase; Advanced Medical Optics, Santa Ana, California, USA) for channel creation. Methods: Retrospective chart review of 531 patients (850 eyes) who underwent Keraring insertion using a femtosecond laser for channel creation. Intraoperative and postoperative complications were recorded. Results: Intraoperatively, there were 22 (2.7%) cases of incomplete channel formation. The rest of the intraoperative complications were galvo lag error (system malfunction) [five eyes (0.6%)], endothelial perforation [five eyes (0.6%)] and incorrect entry of the channel [two eyes (0.2%)]. Postoperatively, there were 11 (1.3%) cases of segment migration, two (0.2%) cases of corneal melting and one (0.1%) case of mild infection. The overall complication rate was 5.7% (49 cases out of 850 eyes). Conclusion: In this study, intracorneal ring segment implantation using a femtosecond laser for channel creation was related to a number of complications. The most common complications were incomplete channel creation (intraoperatively) and segment migration (postoperatively).

Purpose: To assess the progression of keratoconus in patients treated with collagen cross-linking with riboflavin and ultraviolet A (UVA) irradiation. Methods: Thirty-eight eyes of 19 patients with progressive keratoconus were enrolled in a prospective comparative study. Average follow-up was 9±2 months (range: 5 to 12 months). The worse eye was treated with collagen cross-linking, and the fellow eye served as the control. Corneal epithelium was mechanically removed. Riboflavin 0.1% solution in dextran T-500 20% solution was applied every 2 to 3 minutes for 30 minutes throughout the irradiation. Ultraviolet A irradiation (370 nm) was performed using a commercially available UVA lamp for 30 minutes. Results: The group treated with collagen cross-linking demonstrated a mean decrease (less myopic) in spherical equivalent refraction and cylinder of 1.03±2.22 diopters (D) (range: −5.25 to +3.75 D) and 1.04±1.44 D (range: −2.00 to +4.00 D), respectively ( P P P =.06) and endothelial cell count ( P =.07). The untreated group showed no statistical difference for any of the clinical parameters, apart from UCVA and BSCVA, which decreased by 0.08±0.12 (range: −0.40 to 0.10) and 0.06±0.09 (range: −0.20 to 0.10), respectively ( P Conclusions: Riboflavin/UVA collagen cross-linking appears to be efficacious in inhibiting the progression of keratoconus by reducing the corneal curvature, spherical equivalent refraction, and refractive cylinder in eyes with progressive keratoconus at average 9-month follow-up. [ J Refract Surg . 2009;25:371–376.]

Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Purpose: To evaluate refractive, visual, and aberrometric changes in corneas with pellucid marginal degeneration (PMD) implanted with intracorneal ring segments (ICRS) during a 6-month follow-up. Design: Retrospective, consecutive case series. Participants: We included 21 consecutive eyes of 15 patients ranging in age from 21 to 73 years old and with a diagnosis of PMD. This diagnosis was made on the basis of slit-lamp (inferior corneal thinning), corneal topography (“butterfly” pattern), and refractive findings (significant against-the-rule astigmatism with best spectacle-corrected visual acuity loss). Methods: A multicenter, retrospective analysis of patients undergoing ICRS implantation for the management of PMD in 4 ophthalmologic centers was performed. Surgery was indicated in all cases because of reduced best spectacle-corrected visual acuity (BSCVA) and/or contact lens intolerance or dissatisfaction. Mechanical corneal tunnelization was performed in 7 eyes and femtosecond laser-assisted tunnelization in 14 eyes. Intacs were implanted in only 3 eyes whereas KeraRings in 18 eyes. Refractive and corneal aberrometric changes were analyzed during a 6-month follow-up. Main Outcomes Measures: Uncorrected corrected visual acuity (UCVA) and BSCVA, refraction, keratometry, and root mean square (RMS) for different kinds of corneal aberrations. Results: The UCVA did not improve at 6 months after surgery (P = 0.11). The BSCVA increased from a mean preoperative value of 0.54 to a mean postoperative value of 0.75 (P = 0.06). At 6 months, 44.44% of eyes gained ≥2 lines of BSCVA. Sphere (P = 0.02), cylinder (P

A 50-year-old woman had implantation of intrastromal corneal ring segments for recurrent keratoconus 15 years after penetrating keratoplasty. Two segments (0.15 mm and 0.25 mm) were inserted without any intraoperative or postoperative complications, using the femtosecond laser to create the tunnels (superior and inferior). Ten months after the procedure, the uncorrected visual acuity was 20/100, compared with counting fingers preoperatively, and the best spectacle-corrected visual acuity improved from 20/63 to 20/32. Although the results are encouraging, the long-term effect of this approach for the management of post-keratoplasty patients with recurrent keratoconus is not known.

Purpose: To investigate the inciting agent, clinical features, and the efficacy of hourly steroids in the prophylaxis in a diffuse lamellar keratitis (DLK) epidemic. Methods: One hundred and five eyes of 58 patients that had DLK after LASIK were included in the study. To identify the cause of the epidemic, some interventions were made: irrigation solution was changed from BSS to Ringer lactate (week 5), wiping of the interface with a sponge was discontinued (week 6), the air conditioner in the LASIK room was checked (week 6), the routine postoperative topical regimen was changed from fluoromethalone and fluoroquinolones 4 times a day to hourly prednisolone acetate or dexamethasone sodium and fluoroquinolones (week 7), and the trademark of the drape used was changed (week 12). Results: There was no statistical difference in any of the attack rates associated with variables including BSS versus Ringer lactate (9.9 vs. 14%, p = 0.4), and air conditioner check with wiping versus not wiping the interface with the microsurgical sponge (14.0 vs. 18.2%, p = 0.6). There was a significant decrease in the attack rate from 18.2 to 5.3% with use of the hourly prophylactic topical steroids (p = 0.012). After introduction of a new trademark of the drape, the incidence of DLK was further reduced from 5.3 to 0.7% (p = 0.016). Conclusion: The cause in a particular DLK epidemic should be identified and eliminated adopting a scientific approach. Hourly steroid use for prophylaxis is recommended until the etiologic agent responsible has been identified.

Keratoconus is a condition characterized by biomechanical instability of the cornea, presenting in a progressive, asymmetric and bilateral way. Corneal collagen cross-linking with riboflavin and UVA (CXL) is a new technique of corneal tissue strengthening that combines the use of riboflavin as a photo sensitizer and UVA irradiation. The studies showed that CXL was effective in halting the progression of keratoconus over a period of up to four years. The published studies also revealed a reduction of max K readings by more than 2 D, while the postoperative SEQ was reduced by an average of more than 1 D, and refractive cylinder decreased by about 1 D. No eyes lost any line of BCDVA. Moreover, there was no significant decrease in endothelial cell density. It was also found that CXL treatment was effective with reducing corneal and total wavefront aberrations. Corneal cross-linking has also led to an arrest and/or even a partial reversal of keratectasia in the treatment of iatrogenic ectasia after excimer laser ablation. A primary intervention such as CXL should be considered to potentially increase the biomechanical stability of the corneal tissue and postpone the need of lamellar or penetrating keratoplasty.

To report the results of intrastromal corneal ring segment [ICRS] (KeraRing; Mediphacos, Belo Horizonte, Brazil) implantation using a femtosecond laser (IntraLase Corp, Irvine, California, USA) in keratoconic patients.Retrospective, noncomparative, interventional study.Thirty-two keratoconic patients (50 eyes) who underwent ICRS insertion using a femtosecond laser for channel creation and completed at least one year of follow-up were included in this study. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), refraction, topographic findings, and adverse events were assessed.No intraoperative complications were demonstrated in this series of patients. At the first postoperative day, segment migration to the incision site was seen in three eyes (6%; early postoperative complication). To avoid melting, we repositioned the migrated segment away from the incision site. Serious second migration was not seen and we did not need to reposition any segment again. At the last postoperative examination, there was a statistically significant reduction in the spherical equivalent refractive error compared with that observed at the examination before implantation (mean +/- standard deviation, -5.62 +/- 4.15 diopters [D; range, -23.62 to 0.50 D] to -2.49 +/- 2.68 D [range, -11.12 to 3.5 D]; P.001). The UCVA before implantation was 20/40 or worse in 47 eyes (94%; range, counting fingers to 20/30), whereas at the last follow-up examination, 14 (28%) of 50 eyes had a UCVA of 20/40 or better (range, counting fingers to 20/25). Nine eyes (18%) maintained the preimplantation BSCVA, whereas 39 eyes (68%) experienced a BSCVA gain of one to four lines at the last follow-up examination. Only in two eyes (4%; two patients) with advanced keratoconus (stage III) was there a decrease of up to two lines. Despite this deterioration in BSCVA, the patients did not want to remove the ICRSs, because there was an increase of UCVA. No late postoperative complications were observed during the follow-up period.ICRS (KeraRing) implantation using femtosecond laser for tunnel creation is a minimally invasive procedure for improving visual acuity (both UCVA and BSCVA) in keratoconic patients.

Purpose To evaluate the results of combined Intacs (Addition Technology, Fremont, California, USA) and posterior chamber toric implantable Collamer lens [ICLs] (Visian ICL; STAAR Surgical, Monrovia, California, USA) implantation in keratoconic patients with extreme myopia and irregular astigmatism. Design Prospective, single-center, noncomparative, interventional, consecutive case series. Methods Three eyes of two consecutive highly myopic keratoconic patients who had undergone posterior chamber toric ICLs implantation after Intacs implantation. Implantation of posterior chamber toric ICLs was performed at intervals between six and 10 months after Intacs implantation. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), refraction, topographic findings, adverse events, and postoperative complications were noted. Results No intraoperative or postoperative complications were observed. An improvement in UCVA and BSCVA was found after the Intacs and toric Visian ICL procedures in all eyes. All eyes were emmetropic within 1 diopter (D), whereas the mean manifest refractive spherical equivalent refraction reduced from −18.50 ± 2.61 D (range, −16.75 to −21.50 D) to 0.42 D (range, plano to −0.75 D). The mean difference between preoperative and last follow-up UCVA and BSCA was a gain of 6.67 ± 1.15 lines (range, gain of six to eight lines) and 4.33 ± 2.52 lines (range, gain of two to seven lines), respectively. Conclusions Combined Intacs and posterior chamber toric phakic Visian ICL implantation in a two-step procedure is an effective method for correcting keratoconic patients with extreme myopia.

PURPOSE: To determine whether the use of topical apraclonidine just before the LASIK procedure prevents subconjunctival hemorrhage and to study its effect on postoperative flap adherence. METHODS: Topical apraclonidine 0.125% was randomly applied to 1 eye of 66 myopic patients who underwent primary bilateral LASIK. Apraclonidine was instilled 1 hour prior to and 30 seconds before placing the vacuum ring of the microkeratome, whereas the other eye served as control. Thirty minutes after the operation, all patients were examined by the surgeon to evaluate hyperemia and identify flap-related complications (eg, slippage, dislocation, or flap folds). The size of subconjunctival hemorrhage was also evaluated on postoperative days 1 and 7. All 132 eyes in the study were examined after surgery to identify flap folds and/or their dislocation. RESULTS: In the apraclonidine group, 48 (72.8%) eyes had no hyperemia, 16 (24.2%) eyes had mild hyperemia, 2 (3%) eyes had moderate hyperemia, and no (0%) eyes had severe hyperemia. In the control group, 37 (56.1%) eyes had mild hyperemia, 21 (31.8%) eyes had moderate hyperemia, 1 (1.5%) eye had severe hyperemia, and 7 (10.6%) eyes had no hyperemia. In the apraclonidine group, 44 (66.7%) eyes had no subconjunctival hemorrhage (grade 0); grade 1 was present in 19 (28.8%) eyes whereas grades 2 and 3 were present in 2 (3%) eyes and 1 (1.5%) eye, respectively. In the control group, 19 (28.8%) eyes showed grade 0, 13 (19.7%) eyes had grade 1, and grades 2 and 3 were present in 20 (30.3%) eyes and 14 (21.2%) eyes, respectively. Chi-square test showed a highly significant difference between the two groups (P CONCLUSIONS: Topical apraclonidine applied before LASIK surgery may prevent immediate postoperative hyperemia and prolonged subconjunctival hemorrhage by its alpha-mimetic vasoconstrictor effect without inducing flap adherence complication. [J Refract Surg. 2006;22:585-588.]