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PURPOSE To compare the visual outcomes in both eyes of patients who undergo phacoemulsification and trifocal intraocular lens (IOL) implantation and have asteroid hyalosis (AH) or synchysis scintillans (SS) in only 1 eye. METHODS This retrospective comparative cases series study evaluated uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), uncorrected intermediate visual acuity (UIVA), uncorrected near visual acuity (UNVA), predictability, safety, efficacy, and satisfaction after implantation of the same model of trifocal IOL in both eyes (PhysIOL FineVision Pod-F and Micro-F and Rayner RayOne Trifocal). RESULTS A total of 164 eyes from 82 patients (41 females, 50%) met the inclusion criteria. There were no statistically significant differences in sphere, cylinder, spherical equivalent, UDVA, UIVA, and UNVA between the groups. Postoperative CDVA was slightly better in the control group (logMAR 0.03) than in the AH/SS group (logMAR 0.04) (p: 0.014). There were no statistically significant differences in predictability, safety index, and efficacy index between the groups. Overall subjective satisfaction was good (98.2%). CONCLUSIONS Visual outcomes and satisfaction are good after implantation of trifocal IOLs in eyes with AH or SS. Therefore, trifocal IOLs should not be ruled out in these patients when no other vitreoretinal disorder is present.

To determine the long-term incidence of pseudophakic retinal detachment (PRD) after phacoemulsification and the weight of the main risk factors in the appearance of such complication in a large sample. To implement a customized formula and a software calculation program able to quantify the risk of suffering PRD applicable to all lens extraction patients. Retrospective cumulative risk analysis conducted on 178,515 eyes operated under similar conditions in a group of refractive surgery clinics (Clinica Baviera SL) located in a relatively limited geographical area (Spain). A survival analysis was performed and the data were modelled using the Weibull regression to determine the risk over a period of 16 years and to estimate the association of different risk factors: sex, age, axial length (AXL) of the eye, intraoperative posterior capsule rents (PCR), and YAG laser capsulotomies. The resulting estimates were translated into a predictive equation for hazard rates and survival probabilities. Later, an application was developed to make prediction available for the clinical community in order to estimate the potential risk of any hypothetical case before lens surgery. Globally, 1521 (0.85%) cases of PRD were diagnosed during the period. The risk for PRD was significantly greater in males (5.48 [2.94–10.2]; p < 0.001), in long eyes (1.24 [1.21–1.26]; p < 0.001), and also after posterior capsule rents (13.97 [11.61–16.82]; p < 0.001). Posterior capsule rupture increased the risk of PRD up to fourteen times. From weaker to stronger impact, age, axial length, sex, and intraoperative posterior capsule rent were significant risk factors for the appearance of PRD after lens extraction.

PURPOSE: To analyze corneal aberrations and factors affecting visual outcomes after implantation of a trifocal intraocular lens (IOL) in eyes previously treated with laser corneal refractive surgery. METHODS: This retrospective case series included 222 consecutive eyes implanted with the trifocal FineVision Micro-F IOL (PhysIOL) after laser corneal refractive surgery. The series was divided into two groups according to safety outcomes after lensectomy: eyes with loss of one or more lines of corrected distance visual acuity (CDVA) [n = 59, 26.5%]) (failed eyes group) and eyes with no loss or gain in CDVA lines (n = 163, 73.4%]) (successful eyes group). Distribution of tomographic corneal aberrations (spherical aberration [Z 4 0 ], comatic and root mean square of higher order aberrations [RMS-HOA]), laser corneal refractive surgery error, kappa angle, and CDVA after laser corneal refractive surgery were compared among both groups. RESULTS: Mean CDVA after lensectomy was 0.15 ± 0.07 logMAR (range: 0.05 to 0.30 logMAR) versus 0.03 ± 0.04 logMAR (range: 0.00 to 0.15 logMAR) in the failed and successful eyes groups, respectively ( P < .001). Comparison of both groups showed that failed eyes had a statistically significantly higher grade of hyperopic laser corneal refractive surgery than successful eyes measured as mean sphere (+0.71 ± 3.10 diopters [D] [range: −7.75 to +6.00 D] vs −0.46 ± 3.70 D [range: −10.75 to +6.00 D], P < .01), spherical equivalent (+0.27 ± 3.10 D [range: −8.00 to +5.50 D] vs −0.97 ± 3.60 D [range: −12.50 to +4.90 D], P < .05), and percentage of hyperopic laser corneal refractive surgery (64% vs 43.5%, P < .05). Corneal aberration analysis showed that mean Z 4 0 values were significantly more negative in the failed eyes group than in the successful eyes group (+0.07 ± 0.40 mm [range: −0.82 to +0.65 mm] vs +0.18 ± 0.37 mm [range: −0.79 to +0.87 mm], P < .05). Laser corneal refractive surgery cylinder was distributed homogeneously between both groups, as well as coma and RMS-HOA, kappa angle, and CDVA after laser corneal refractive surgery that were not statistically significant. CONCLUSIONS: Surgeons should consider tomographic corneal spherical aberration after implantation of a trifocal IOL in eyes after keratorefractive surgery, particularly in eyes previously treated with hyperopic laser corneal refractive surgery, to prevent loss of lines of visual acuity after lensectomy. [ J Refract Surg . 2022:38(4):222–228.]

Purpose Our objectives were to determine the anatomical and functional (visual and refractive) outcomes of corneal refractive surgery during breastfeeding and to compare the results with those of women who stopped breastfeeding at least 3 months before the procedure. We also evaluated predictability, safety, and efficacy indexes; number of retreatments; and adverse effects reported in babies. Methods We performed a multicenter, retrospective, interventional case series review of patients who were breastfeeding and who underwent laser in situ keratomileusis or surface ablation (photorefractive keratectomy) from September 11, 2002 to December 12, 2017 (group 1, n = 142 eyes in the case group). Patients were compared with women who stopped breastfeeding at least 3 months before the procedure from September 11, 2002 to December 12, 2017 (group 2, n = 95 eyes in the control group). A total of 168 women (237 eyes) were included. Patients were incorporated consecutively. Functional (visual and refractive) and anatomical outcomes are described. Results No significant intraoperative or postoperative complications were recorded. There were no significant differences between the groups in visual acuity, postoperative spherical equivalent, efficacy index, predictability, safety index, or retreatments. No infants experienced adverse effects. Conclusions In our experience, laser in situ keratomileusis and photorefractive keratectomy can be performed effectively and safely in breastfeeding women.

Purpose: To evaluate the effect on visual outcomes of a diffractive trifocal intraocular lens (IOL) in pars plana vitrectomy (PPV) for removal of epiretinal membrane (ERM) in pseudophakic eyes. Methods: This is retrospective case-series study on 20 eyes with a single model of trifocal IOL that underwent PPV for removal of ERM between January 2015 and September 2018 in our clinics. Follow up was at least 1 year. Primary outcome measure was mean change in visual acuity. Other outcome measures were mean change in central macular thickness (CMT), recovery of the external retinal layers, and change in spherical equivalent (SE). Results: Mean corrected distance visual acuity (CDVA) was 0.03±0.03 logMAR after phacoemulsification; this worsened to 0.23±0.10 logMAR with ERM, improving to 0.10±0.04 log MAR 12 months after PPV (p=0.001). Mean uncorrected near visual acuity (UNVA) was Jaeger 2.62±0.51 after lensectomy. This worsened to Jaeger 5.46±1.67 with ERM and improved to the initial Jaeger 2.69±0.84 after PPV (p=0.005). CMT decreased significantly, from 380.15 ±60.50 µm with the ERM to 313.70 ±36.98 µm after PPV. Mean SE after lensectomy was -0.18 ±0.38 D, which minimally changed to – 0.18±0.47 D after PPV (p=0.99). The only complication recorded after PPV was a case of cystoid macular edema. No difficulties in visualization due to IOL design were reported during PPV. Conclusion: PPV for ERM in eyes with this trifocal IOL is safe and effective, and allows recovery of the loss of UNVA.

Seminario web “Periodismo de Soluciones. ¿Cómo cubrir el coronavirus más allá de la desesperanza? Por Liza Gross en el marco del Proyecto “Periodismo de Soluciones en América Latina” organizado por Fundación Gabo (Colombia) y la Red de Periodismo de Soluciones. Liza Gross es periodista, experta en medios y representante del Solutiones Journalism Network. Fue editora The Miami Herald y Directora Ejecutiva de Internacional Women ́s Media Foundation. En este seminario web, reflexionó sobre cómo cubrir los temas del Covid-19, no solo investigando las consecuencias y llevando un registro del caos, sino también sobre posibles guías para pensar y exponer posibles soluciones para la actual crisis., Facultad de Periodismo y Comunicación Social

Purpose To compare the incidence of corneal epithelial ingrowth (EIG) and the visual outcomes of enhancement with laser in situ keratomileusis (LASIK) by flap lift when a bandage soft contact lens (CL) was fitted after the procedure and when it was not. Methods This is a multicenter, retrospective, interventional case series in which all patients who underwent LASIK enhancement from January 2005 to January 2015 were included consecutively. Patients were grouped depending on whether a bandage CL was fitted after re-treatment by flap lift (group 1) or not (group 2). Results A total of 16,702 eyes from 12,485 patients were included. There were statistically significant differences between the groups regarding corrected distance visual acuity (better in group 1) and safety index (better in group 2) although these were not clinically relevant. The incidence of EIG was 0.58% in group 1 and 0.55% in group 2 although, again, the difference was not statistically different. Conclusions We found no relevant differences in LASIK enhancement between patients who received a bandage CL and those who did not regarding the incidence of EIG and visual outcomes.

Mohammad Reza Djodeyre,1 Jaime Beltran,2 Julio Ortega-Usobiaga,3 Felix Gonzalez-Lopez,4 Ana Isabel Ruiz-Rizaldos,1 Julio Baviera2 1Department of Refractive Surgery, Clinica Baviera, Zaragoza, 2Department of Refractive Surgery, Clinica Baviera, Valencia, 3Department of Research and Development, Clinica Baviera, Bilbao, 4Department of Refractive Surgery, Clinica Baviera, Madrid, Spain Purpose: To study long-term refractive and visual outcomes of laser in situ keratomileusis (LASIK) in eyes with a postoperative thin central cornea. Methods: In this retrospective observational case series, we studied 282 myopic eyes with a normal preoperative topographic pattern and postoperative thin corneas (275 µm. Keywords: LASIK, thin, cornea, ectasia, myopia, pachymetry, topography

To assess the visual outcomes and ocular safety when implanting diffractive trifocal intraocular lenses in a population of high myopic eyes.This is a retrospective cumulative clinical study. Two hundred five myopic eyes consecutively operated in the hospitals of Clínica Baviera, Spain, were included. All eyes presented an axial length equal or greater than 26 mm and were treated and examined following the same methodology for at least 2 years. Refractive and visual outcomes and also intraoperative or postoperative complications were tabulated for later analysis. Furthermore, a subjective questionnaire was completed by all patients at the end of the follow-up period.The percentage of eyes that lost two or more lines of corrected distance visual acuity (CDVA) was 5.9%, 11.5% and 10.7% 3, 12 and 48 months after surgeries respectively. However, 33% of eyes gained two or more lines of CDVA 2 years after implantation. Excimer laser correction of residual refractive error was performed after implants in 29.75% of eyes. Uncorrected distance visual acuities (UDVAs) were significantly better 1 year (0.10 ± 0.3 logMAR) and 2 years after the surgeries (0.10 ± 0.14 logMAR) compared with those estimated 3 months postoperatively (0.14 ± 0.15 logMAR; Kruskal-Wallis; p 0.001). Mean near and intermediate uncorrected visual acuities remained stable from the first to the last postoperative visit (Kruskal-Wallis; p 0.05 for all comparisons). Of the eyes, 27.31% were diagnosed and treated with yttrium aluminum garnet (YAG) laser after being diagnosed as having posterior capsular opacification. Retinal detachment (RD) was diagnosed in six eyes (2.92%).Diffractive trifocal IOLs have good efficacy and predictability in high myopic eyes. Retinal concerns should lead the surgeons to explore other alternatives for refractive surgery in young patients without cataracts.

The aim of this paper is to show the results obtained and the methodology used to achieve better logistic organization of Mediterranean ports and logistics areas. Recently, we introduced a new methodology in the ports of Naples and Algeciras Bay in order to improve their logistics processes. This methodology was implemented as a part of the INTE-TRANSIT project, cofinanced by the MED Program with the aim to improve logistic processes and increase technological integration in Mediterranean ports. The methodology used in the ports of Naples and Algeciras Bay consists of four parts, two of which include a tool called VSM. VSM stands for “Value Stream Mapping”, a tool to analyze and understand the flow of material and information that allow a deep knowledge of a process and identify the wastes. “Waste” in this context, is defined as something anything that adds cost to a product or service without adding value. The use of this methodology has allowed us to identify in detail the problems in both the information flow and material flow. It was detected that the acquisition of new technologies could facilitate and expedite the process of receiving, the location, the internal movements and the vessel loading.

To assess visual acuity and refractive correction in moderately myopic adult eyes with suboptimal preoperative corrected distance visual acuity (CDVA) after laser in situ keratomileusis (LASIK) or insertion of a posterior chamber Implantable Collamer Lens phakic intraocular lens (pIOL).Clínica Baviera, Instituto Oftalmológico Europeo, Torrevieja Hospital, Madrid, Spain.Retrospective study.The study sample included 1310 eyes that had LASIK and 94 that had insertion of a pIOL from July 2002 to September 2013. Suboptimal preoperative CDVA was defined as equal to logMAR 0.15 or below and moderate myopia as a spherical equivalent of -5.0 to -10.0 diopters (D).The preoperative mean CDVA was 0.22 logMAR ± 0.09 (SD) in the LASIK group and 0.23 ± 0.09 logMAR in the pIOL group. Postoperative uncorrected distance visual acuity (UDVA) was 0.13 ± 0.12 logMAR in the laser group and 0.12 ± 0.09 logMAR in the pIOL group, with a postoperative CDVA of 0.11 ± 0.10 logMAR and 0.08 ± 0.07 logMAR, respectively.Compared with preoperative values, amblyopic eyes with moderate myopia having LASIK or implantation of a pIOL demonstrated a statistically significant improvement in UDVA and CDVA (P.001). The pIOL group performed significantly better than the LASIK group in terms of safety and efficiency.No author has a financial or proprietary interest in any material or method mentioned.

To assess the incidence, culture results, and visual outcomes of infectious keratitis after laser in situ keratomileusis (LASIK) and surface ablation when topical moxifloxacin was added to postoperative prophylaxis with tobramycin.Clínica Baviera, Instituto Oftalmológico Europeo, Bilbao, Spain.Retrospective case series review.The medical records of 55 255 patients (108 014 eyes) who had LASIK and surface ablation were reviewed to identify cases of infectious keratitis. The incidence, risk factors, clinical course, days to diagnosis, treatment, and final visual outcomes were recorded. These data were compared with previously published data of 221 437 eyes that received postoperative tobramycin alone.Post-LASIK infectious keratitis was diagnosed in 10 eyes (9 patients) and post-surface ablation infectious keratitis in 11 eyes (10 patients). The onset of infection was early in 40.00% of cases after LASIK and in 36.36% after surface ablation. Cultures were positive in 2 cases after surface ablation. Immediate flap lifting and irrigation with antibiotics were performed in all eyes after LASIK. The final corrected distance visual acuity was 20/20 or better in 7 cases after LASIK (70.00%) and 7 cases after surface ablation (63.64%) and 20/40 or better in all cases after LASIK or surface ablation.The incidence of infectious keratitis decreased from 0.025% to 0.011% (P.001) per procedure after LASIK and from 0.200% to 0.066% (P.001) after surface ablation. Infectious keratitis was less frequent after LASIK than after surface ablation. The frequency of infection, mainly early-onset infection, was lower when the postoperative treatment was tobramycin and moxifloxacin rather than tobramycin alone.No author has a financial or proprietary interest in any material or method mentioned.

The Consorzio Napoletano Terminal Containers (CO.NA.TE.CO.), located in the Port of Naples, is continuously exposed to a problem of traffic congestion. A queuing model has been developed to analyze this congestion problem. The model includes part of the process of exportation. The entities represented the vehicles that access into the terminal, and the servers were the entrance gate and the process of moving the freight to the yard. According to these definitions, five models have been developed with the aim of simulating solutions to the congestion problem. The first model reproduces the current situation, and the modifications in the servers have been evaluated through the rest. Finally, it has been proved that all processes inside the terminal were strongly dependent. The study shows that the solution should consider the decreasing simultaneously the time of service in the access gate and in the yard.

Purpose – The evaluation of management systems is usually based on a series of assumptions which are never questioned. The purpose of this paper is to focus on two of these assumptions, in order to further develop a quantitative model to evaluate metrological management in companies, based on the ISO 10012:2003 standard. Design/methodology/approach – First, the paper uses structural equations to identify the underlying relations between the different variables of the model and conclude that it follows the typical continuous improvement cycle formulated by Deming. And second, the paper processes the opinion of experts using analytic hierarchy process (AHP) techniques in order to prove that not all the variables included in the model are equally relevant in metrological management. Findings – The first SME analysis validates the model itself and its integration with the other management schemes in the company, all based on the Deming cycle. The second AHP analysis leads to a reformulation of the model, assigning weights to the different variables and providing better guidelines for companies to improve their metrological management. Originality/value – This constitutes a development of the management guidelines contained in the ISO 10012:2003 standard for metrological management, establishing the appropriate evaluation procedures.

Purpose To study changes in intraocular pressure (IOP) during the early postoperative period in eyes having implantation of a posterior chamber phakic intraocular lens (pIOL) (Visian Implantable Collamer Lens V4c). Setting Clinica Baviera, Instituto Oftalmologico Europeo, Madrid, Spain. Design Case series. Methods This retrospective review included the first consecutive eyes having implantation of a spherical or toric myopic pIOL with a central hole at Clinica Baviera from December 2011 to June 2012 by the same experienced surgeon. The IOP was evaluated preoperatively and 1 day, 1 week, and 1 month postoperatively. Results The study comprised 100 eyes. The mean IOP changed from 14.6 mm Hg ± 3.4 (SD) (range 8 to 26 mm Hg) preoperatively to 14.5 ± 4.6 mm Hg (range 6 to 30 mm Hg) 1 day postoperatively, 14.2 ± 4.2 mm Hg (range 6 to 29 mm Hg) at 1 week, and 12.3 ± 3.4 mm Hg (range 9 to 24 mm Hg) at 1 month. No statistically significant changes were detected over time postoperatively ( P >.2). No perioperative complications associated with the implantation of the pIOL were recorded. No pIOLs were explanted, no toric pIOL rotation was detected, and no pupillary block or acute angle closure was observed. Conclusion The short-term clinical data for the new pIOL model with the central hole (KS-Aquaport) suggest that it is a safe and effective means for controlling postoperative IOP. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

The relation between quality management and logistics performance has been evaluated in many research works, but our concern here lies with the relation between quality management and logistics management itself, that is, with how certified quality management systems guarantee by themselves that companies are appropriately managing their underlying logistics processes. We describe an evaluation tool to estimate the maturity level of logistics management systems, according to a previous logistics management model fully integrated with the ISO 9001 standard, and show the results of its application to a sample of Spanish small and medium-sized enterprises, selected for the maximum accuracy and representativity of those results. The conclusion is that quality certifications help improve the management of logistics processes, but additional tools, possibly including a specific logistics management standard, are required.

PURPOSE: To compare Nd:YAG capsulotomy rates following implantation of two diffractive trifocal intraocular lenses (IOLs). METHODS: This multi-center retrospective analysis included patients who underwent uncomplicated lens phacoemulsification and were implanted with a diffractive trifocal IOL: FineVision MicroF (PhysIOL, Liège, Belgium) or AT Lisa tri 839MP (Carl Zeiss Meditec, Jena, Germany). All surgeries were performed during the same period. The postoperative follow-up period was at least 1 year. Chi-square and Kaplan–Meier tests analyzed non-parametric estimates for survival/failure functions. The Wilcoxon (Breslow) test compared Nd:YAG capsulotomy rates between the two groups. RESULTS: Of 5,130 eyes included, 3,387 were implanted with the FineVision MicroF IOL and 1,743 with the AT Lisa tri 839MP IOL. There were no statistical differences in age, axial length, or IOL power between groups. Nd:YAG capsulotomies were necessary in 330 eyes (9%) in the FineVision group and 408 eyes (23%) in the AT Lisa tri group ( P < .001). The probability of having Nd:YAG capsulotomy up to 9 months postoperatively was equal for both lenses. Beyond 9 months, the Nd:YAG capsulotomy rate increased significantly more in the AT Lisa tri group, reaching a probability of 35% for eyes with a follow-up of 34 to 44 months, whereas in the FineVision group the probability was 14% after a follow-up of 37 to 47 months. The differences in survival (without Nd:YAG capsulotomy)/failure (with Nd:YAG capsulotomy) functions were significant ( P < .001). CONCLUSIONS: Eyes implanted with the FineVision MicroF IOL required significantly fewer Nd:YAG laser capsulotomies than those with the AT Lisa tri 839MP IOL during the first years after implantation. The design of the IOL platforms could account for these differences. [ J Refract Surg. 2016;32(11):748–752.]

To evaluate clinical results of intrastromal corneal ring segments (ICRS) in a large series of post-laser in situ keratomileusis (LASIK) ectasia and determine which clinical parameters were related to the success of this technique.Vissum Corporation and Clínica Baviera Group, Alicante, Spain.Case series.Intrastromal corneal ring segments were implanted to correct the spherocylindrical error and improve visual acuity. Based on a previously described grading system, the best indications for ICRS implantation to treat post-LASIK ectasia were evaluated. The variables related to favorable outcomes over a 12-month follow-up were determined.Patients who lost 2 or more lines due to post-LASIK ectasia had a mean gain of +2.89 lines of corrected distance visual acuity (CDVA) after ICRS implantation (P.001) and a mean CDVA of 0.81 (95% confidence interval, 0.74-0.88). In contrast, patients who did not lose vision after ectasia had a mean loss of -2.00 lines of CDVA after the ICRS implantation (P.001). The odds ratio of a gain of at least 1 line of CDVA was 18 times greater for those who had lost 2 or more lines of CDVA after ectasia.The best indications for ICRS were a loss of 2 or more lines of CDVA after ectasia and post-LASIK ectasia grade 4. Patients who do not have vision loss after ectasia and those classified as grade 1 should not be considered candidates for ICRS implantation.No author has a financial or proprietary interest in any material or method mentioned.

Purpose To compare long-term refractive and visual outcomes of laser in situ keratomileusis (LASIK) and laser surface ablation in eyes with corneas thinner than 470 μm. Setting Private clinics, Spain. Design Comparative case series. Methods The study comprised eyes with myopic error and corneas thinner than 470 μm that had at least 2.9 years of postoperative follow-up between September 2001 and June 2007. The main outcome measures were safety, efficacy, predictability, and complications. Results The mean central corneal thickness was 462.0 μm (range 440 to 469 μm) in the LASIK group (n = 40) and 458.1 μm (range 420 to 469 μm) in the laser surface ablation group (n = 88). All eyes had normal preoperative topography. In the LASIK group after a mean follow-up of 5.1 years ± 1.5 (SD), the safety index was 1.07, efficacy was 0.99, and predictability (±1.00 diopter [D]) was 0.93. In the laser surface ablation group after a mean follow-up of 4.8 ± 1.3 years, the safety index was 1.01, efficacy was 0.93, and predictability (±1.00 D) was 0.92. The mean residual corneal bed thickness in all eyes was 345 ± 25 μm (range 270 to 399 μm). No major complications occurred. The safety index was better in the LASIK group than in the laser surface ablation group. Conclusion Both techniques were effective, safe, and predictable in eyes with corneas thinner than 470 μm, normal preoperative topography, and a residual corneal bed thickness greater than 250 μm. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Purpose: To assess dynamic variations in vault induced by changes in brightness in eyes implanted with phakic collamer intraocular lens (pIOL) with central port for correction of myopia, defining new parameters of vaulting measurement. Methods: We used a noninvasive Fourier-domain swept-source anterior-segment optical coherence tomography (AS-OCT) system to dynamically evaluate the shifts between the pIOL and anterior chamber structures under changing light conditions. For each eye assessed, we measured vault interval (VI), which we define based on central vault values in maximum mydriasis and in maximum miosis after light-induced changes in pupil diameter, and vault range (VR), which we define as the absolute difference between the VI values. Results: The pilot study sample comprised 39 eyes (23 patients) previously implanted (mean 107 +/- 156 days) with a pIOL. A significant difference in vault value was found when maximum and minimum pupil size was assessed under changing external light conditions (P < 0.001). The mean VR from scotopic (0.5 lux) to photopic (18,500 lux) light conditions was 167 +/- 70 mu m. Conclusions: Vault is continuously affected during movements of the pupil induced by external luminance. Translational Relevance: Quantifiable dynamic parameters VR and VI obtained with this AS-OCT device describe the position of the pIOL in the posterior chamber of the eye in a more accurate and real way than static vault measurements, and may contribute to improved understanding of the behavior of the pIOL in terms of safety.

Environmental management systems based on the ISO 14001 standard rely strongly on metrological measurement and confirmation processes to certify the extent to which organizations monitor and improve their environmental behavior. Nevertheless, the literature lacks in studies that assess the influence of these metrological processes on the performance of environmental management in organizations, even now that the international standard ISO 10012 is already available to establish requisites and guidelines for the development of a metrological management system that is compatible with any other standardized management system. This work seeks to assess that influence through the development of an evaluation model for metrological management, which is then validated through an experimental analysis of the results obtained from the application of an audit process in 11 Spanish companies, all ISO-14001-certified and operating in different industrial sectors.

Purpose To report the outcomes of laser in situ keratomileusis (LASIK) in patients with a history of ocular herpes simplex virus (HSV) or herpes zoster ophthalmicus (HZO). Setting Clinica Baviera, Instituto Oftalmologico Europeo, Madrid, Spain. Methods In this retrospective case series, the records of eyes with a history of ocular herpes that had LASIK from 2003 through 2005 were reviewed. The main outcome measure was postoperative recurrence of ocular herpes. Results Forty-nine eyes (48 patients) with a history of ocular herpes (HSV keratitis, 28 eyes; HSV eyelid lesions, 17 eyes; HZO, 4 eyes) were identified. All LASIK procedures were uneventful. Herpetic disease was inactive at the time of surgery in all eyes and for more than 1 year in 31 eyes. Perioperative antiviral systemic prophylaxis was used in 13 patients with a history of HSV keratitis. No eye developed reactivation of herpetic keratitis during the follow-up (range 1 to 28 months). Conclusions Laser in situ keratomileusis was safe in patients with a history of ocular herpes; no recurrences occurred during the follow-up period. However, candidates should be selected with caution and surgery performed only in eyes in which the herpes has been inactive for 1 year before surgery, without stromal disease, and with regular topography and pachymetry maps and normal corneal sensitivity. The most reasonable clinical strategy is perioperative systemic antiviral prophylaxis.

Innovation on the base of technologies in the operation management function is key for the competitiveness of the SMEs. This paper analyzes the learnt lessons related to the implementation of an “Operation Management System” (OMS) in a group of eight Spanish SMEs and provides guides to make it more efficient. We applied Lean Manufacturing techniques in the pre-implementation phase. Then, we reflect on specific and practical issues with the objective to ensure a successful implementation and encourage SMEs to adopt this type of technological tool. We describe the main occurred incidents and the corresponding contingency actions as well as the best practices identified in the participating SMEs. We highlight the relevance of tackling with the resistance to change through the communication and training. Regular meetings with managers are considered key for the success of the project.

PURPOSE: To evaluate the long-term refractive and visual stability and the risks related to the implantation of Implantable Collamer Lens (ICL; STAAR Surgical, Monrovia, CA) phakic intraocular lens (PIOL) for myopia. METHODS: This retrospective, consecutive, cumulative clinical study was performed in a group of 144 eyes implanted with ICL PIOL for myopia. Only the cases with clinical data available 12 years after the implantation were included in the series. Corrected distance visual acuity (CDVA), uncorrected distance visual acuity, spherical equivalent, refractive astigmatism, endothelial cell density, ICL vaulting, and postoperative complications were analyzed. RESULTS: Mean spherical equivalent refraction was −16.90 ± 4.26 diopters (D) preoperatively and −1.77 ± 1.93 D 12 years postoperatively. Mean CDVA at the first and last visit were 0.31 ± 0.19 logMAR and 0.22 ± 0.22 logMAR, respectively (Mann–Whitney U test, P < .001). Twelve years postoperatively, 8.9% of eyes had lost more than two lines of CDVA. The incidence of clinically relevant cataracts (13.88%) was significantly linked to the use of the V3 model ICL (chi-square test, P = .007). During the follow-up period, a significant reduction in PIOL vaulting was observed (Kruskal–Wallis test, P < .05), and the mean endothelial cell density decreased by 19.75%. CONCLUSIONS: The ICL PIOL provided good refractive outcomes and stability in the long term. The incidence of cataracts is low when the latest models of this PIOL are used. [ J Refract Surg. 2015;31(8):548–556.]

To evaluate and characterize the main clinical features of post-laser in situ keratomileusis (LASIK) ectasia, propose a grading system based on visual limitation, and identify predictive factors related to the degree of visual loss.Vissum Corp., Alicante, Spain.Retrospective case series.This study comprised consecutive eyes with corneal ectasia after LASIK from 1996 to 2010. Main outcomes were post-LASIK ectasia corrected distance visual acuity (CDVA), CDVA loss, spherical equivalent (SE), and the corneal bulge (delta K). These outcomes were correlated with the residual stromal bed, ablation depth, ablation ratio (ablation depth:pachymetry), corneal depth (flap + ablation depth), and corneal ratio (corneal depth:pachymetry) to characterize their role in the severity of the disease.The mean post-LASIK ectasia CDVA, CDVA loss, SE, and delta K were 0.20 logMAR ± 0.18 (SD), -0.13 ± 0.15 logMAR, -3.80 ± 3.86 diopters (D), and 4.77 ± 4.23 D, respectively. The ablation ratio had the strongest correlation with post-LASIK ectasia CDVA (ρ = 0.477 and P.001), whereas the corneal ratio had the strongest correlation with the post-LASIK ectasia SE and delta K (ρ = -0.614 and ρ = 0.453, respectively: P.001). The ablation ratio was the main predictive factor for post-LASIK ectasia CDVA loss (relative risk, 2.04; P=.049).The grading system based on visual limitation was consistently represented by differences in CDVA loss, SE, and delta K. A high amount of tissue removed by the refractive procedure was associated with greater corneal biomechanical destabilization, increased corneal steepening, and a worse prognosis.

Purpose: To evaluate the surgical results obtained in patients with psychiatric disorders who underwent myopic laser in situ keratomileusis. (LASIK). Methods: Retrospective study of 156 eyes of 82 patients who underwent LASIK to correct a myopic spherical equivalent (SE) at Cl´onica Baviera-Instituto Oftalmologico Europeo, Bilbao, Spain. All procedures were performed with the Technolas Keracor 217 Z excimer laser. Patients had a preoperative diagnosis of bipolar disorder (79 eyes of 42 patients), schizophrenia (61 eyes of 32 patients), or obsessive-compulsive disorder (16 eyes of 8 patients). Before surgery, the average sphere of the series was 23.92 6 2.24 D in the first group, 23.45 6 2.03 D in the second group, and 23.39 6 1.97 D in the third group. We surveyed the patients to analyze subjective assessment from the patient's perspective. Results: At the last available visit after treatment, we obtained an SE of 60.50 D in 85.71% of eyes with bipolar disorder, 88.52% of eyes with schizophrenia, and 93.75% of eyes with obsessive-compulsive disorder. The efficacy index was 1.00 6 0.20 in the first group, 1.03 6 0.21 in the second group, and 1.00 6 0.07 in the third group. No eye lost 2 lines or more of best spectacle-corrected visual acuity. Conclusions: We found that patients with compensated psychiatric disorders, of which the surgeon was aware, achieved excellent results after surgery, with no remarkable complications. Patients tolerated the procedures well and were satisfied. The aim of this study was to evaluate the results of surgery in patients with psychiatric disorders who underwent LASIK. The hypothesis was that patients with psychological illnesses would report lower levels of VA, poorer outcome, and more perioperative complications. The results are intended to provide general guidance for the refractive surgeon treating patients with psychiatric disorders.

To evaluate the incidence, culture results, risk factors, treatment strategies, and visual outcomes of infectious keratitis after surface ablation.Multicenter study in Spain.Case series.The medical records of patients who had surface ablation between January 2003 and December 2009 were reviewed to identify cases of infectious keratitis. The incidence, risk factors, clinical course, days to diagnosis, medical and surgical treatment, and visual outcome were recorded. Main outcome measures were incidence of infectious keratitis after surface ablation, culture results, response to treatment, and visual outcomes.The study reviewed the records of 9794 patients (18,651 eyes). Infectious keratitis after surface ablation was diagnosed in 39 eyes of 38 patients. The onset of infection was early (within 7 days after surgery) in 28 cases (71.79%). Cultures were positive in 13 of 27 cases in which samples were taken. The most frequently isolated microorganism was Staphylococcus species (9 cases). The final corrected distance visual acuity (CDVA) was 20/20 or better in 23 cases (58.97%), 20/40 or better in 36 cases (92.30%), and worse than 20/40 in 3 cases (7.69%).The incidence of infectious keratitis after surface ablation was 0.20%. Infectious keratitis is a potentially vision-threatening complication. Prompt and aggressive management with an intensive regimen of fortified antibiotic agents is strongly recommended. Proper management can preserve useful vision in most cases.No author has a financial or proprietary interest in any material or method mentioned.

PURPOSE: To evaluate whether patients who undergo myopic LASIK or laser epithelial keratomileusis (LASEK) with preoperative central keratometry ≥47.50 diopters (D) are at higher risk for developing corneal ectasia postoperatively. METHODS: Records of 32 patients (54 eyes) who underwent myopic LASIK or LASEK between May 2002 and July 2005 with preoperative mean central keratometry ≥47.50 D were retrospectively reviewed. Patients eligible for the study were offered free follow-up. Last follow-up was at least 3 years after surgery. All procedures were performed with the Technolas Keracor 217z excimer laser (Bausch & Lomb). RESULTS: Twenty-four patients (40 eyes) had LASIK and 8 patients (14 eyes) had LASEK. At last follow-up, no patient had developed ectasia. CONCLUSIONS: This study suggests that patients with preoperative central keratometry ≥47.50 D as the only parameter evaluated should not be excluded from corneal refractive surgery due to increased risk of postoperative ectasia. However, when this preoperative finding is accompanied by other topographic abnormalities, treatment options should be carefully evaluated.

PURPOSE: To evaluate the effect of preoperative keratometric power on the intraoperative complications in LASIK for myopia, hyperopia, and astigmatism. METHODS: In this retrospective study, the records of 34,099 eyes of 17,388 patients who underwent LASIK for myopia, hyperopia, and astigmatism using the Moria LSK One manual microkeratome and the Bausch & Lomb Technolas 217 Z excimer laser were reviewed. RESULTS: One thousand three hundred thirty-eight (3.92%) intraoperative microkeratome complications were identified in the total number of eyes: 571 (1.67%) free caps, 320 (0.93%) epithelial abrasions, 282 (0.82%) thin/irregular flaps, 126 (0.36%) incomplete flaps, and 39 (0.11%) flap buttonholes. When eyes were stratified according to preoperative keratometric power, eyes with flatter corneas usually had more free caps and incomplete flaps than eyes with steeper corneas (P CONCLUSIONS: No statistically significant relationship was found between preoperative keratometric power and incidence of flap buttonholes in this series. Eyes with flatter corneas tended to have more free caps and incomplete flaps, whereas eyes with steeper corneas tended to have more epithelial abrasions and thin/irregular flaps. [J Refract Surg. 2007;23:592-597.]

To determine the anatomic and functional outcomes of photorefractive surgery in patients with underlying systemic diseases that are traditionally listed as relative or absolute contraindications.Observational retrospective case-control study.The case groups were composed of 275 eyes of 141 consecutive patients who underwent a LASIK procedure with any of the following underlying conditions: autoimmune connective-tissue disorders (n = 62), psoriasis (n = 91), intestinal inflammatory diseases (n = 67), diabetes mellitus (n = 44), and history of keloid formation (n = 18). Twenty-nine patients (56 eyes) were receiving systemic immunosuppressive therapy. The control group comprised 358 eyes of 181 patients without the above-mentioned conditions who underwent LASIK.The study had 2 parts, relating to the anatomic and functional (visual and refractive) outcomes. For anatomic outcome, we compared the entire sample of both groups. For functional outcome, only myopic eyes of each group were compared. Independent comparisons were performed between each disease group and the control group.Anatomic outcomes included perioperative and postoperative epithelial, flap, and interface complications. Functional outcomes were evaluated using visual and refractive indicators, percentage of eyes undergoing enhancement, and number of postoperative visits.Mild anatomic complications were observed in the case and control groups with similar percentages, and there were no statistical differences between groups. Regarding functional outcome, the only significant finding was a worse refractive outcome in the collagen vascular diseases group compared with controls. There were no other statistical differences detected in the other systemic disease groups.In our experience, LASIK can be performed effectively and safely in selected patients with stable and controlled systemic diseases with favorable postoperative anatomic and visual outcomes. The absolute exclusion of certain systemic contraindications should be reconsidered.

To analyze refractive, visual, and contrast sensitivity outcomes of laser in situ keratomileusis (LASIK) performed under thin flaps (less than 100 microm), and compare them with those of conventional thicker flaps.Clínica Baviera, Instituto Oftalmológico Europeo, Madrid, Spain.This retrospective study comprised 280 consecutive eyes that had LASIK for myopia using the Moria LSK-One microkeratome and the Technolas 217C excimer laser. Efficacy, predictability, and contrast sensitivity indicators were compared between 3 groups of flap thickness: thin (100 microm, n = 105), medium (100 to 129 microm, n = 122), and thick (130 microm, n = 53).Refractive results were excellent and comparable between the 3 groups; however, visual outcomes-measured as efficacy, postoperative evolution of uncorrected visual acuity, and contrast sensitivity-test were significantly better in the thin flap group. Efficacy results were 92.9%, 91.0%, and 81.0% in the thin, medium, and thick flap groups, respectively (P.05), and the rate of enhancements was 0%, 2.3%, and 5.6%, respectively. With regard to contrast sensitivity, changes between preoperative and postoperative values at month 3 of follow-up, the thin flap group achieved the preoperative levels at 3 spatial frequencies (3, 6, and 18 cycles per degree), while the thicker flap groups maintained lower than preoperative levels at more than 2 spatial frequencies. When comparing contrast sensitivity values between the 3 groups, the thin flap group also obtained the best results at lower spatial frequencies.Thin flap LASIK is a safe technique to correct myopic defects since it blends the advantages of surface and lamellar procedures (minimal debilitation of corneal biomechanical architecture with the rapid and comfortable visual recovery of lamellar approaches). Moreover, it achieves excellent refractive outcomes, a lower rate of enhancements, and a good visual performance with better contrast sensitivity test results.

Objectives To determine the anatomic and functional outcomes of photorefractive surgery in patients with underlying systemic diseases that are traditionally listed as relative or absolute contraindications. Design Observational retrospective case–control study. Participants The case groups were composed of 275 eyes of 141 consecutive patients who underwent a LASIK procedure with any of the following underlying conditions: autoimmune connective-tissue disorders (n = 62), psoriasis (n = 91), intestinal inflammatory diseases (n = 67), diabetes mellitus (n = 44), and history of keloid formation (n = 18). Twenty-nine patients (56 eyes) were receiving systemic immunosuppressive therapy. The control group comprised 358 eyes of 181 patients without the above-mentioned conditions who underwent LASIK. Methods The study had 2 parts, relating to the anatomic and functional (visual and refractive) outcomes. For anatomic outcome, we compared the entire sample of both groups. For functional outcome, only myopic eyes of each group were compared. Independent comparisons were performed between each disease group and the control group. Main Outcome Measures Anatomic outcomes included perioperative and postoperative epithelial, flap, and interface complications. Functional outcomes were evaluated using visual and refractive indicators, percentage of eyes undergoing enhancement, and number of postoperative visits. Results Mild anatomic complications were observed in the case and control groups with similar percentages, and there were no statistical differences between groups. Regarding functional outcome, the only significant finding was a worse refractive outcome in the collagen vascular diseases group compared with controls. There were no other statistical differences detected in the other systemic disease groups. Conclusions In our experience, LASIK can be performed effectively and safely in selected patients with stable and controlled systemic diseases with favorable postoperative anatomic and visual outcomes. The absolute exclusion of certain systemic contraindications should be reconsidered.

PURPOSE: To evaluate factors that influence retreatment results after primary hyperopic LASIK. METHODS: Restrospective study of 86 eyes of 61 patients that underwent LASIK to correct primary hyperopic spherical equivalent refraction and a second hyperopic retreatment due to undercorrection. All procedures were performed with the Technolas Keracor 217C excimer laser, lifting the preexisting flap for the retreatment. Preoperatively, under cycloplegia, mean spherical equivalent refraction of the series was +3.05±0.99 diopters (D). RESULTS: At last follow-up, mean spherical equivalent refraction was -0.07 ±0.50 D. Efficacy of the retreatment procedure was better when the primary LASIK attempted spherical equivalent refraction correction was +1.00 D (P+4.00D(P CONCLUSIONS: Efficacy, safety, and predictability of retreatments secondary to undercorrection after primary hyperopic LASIK may be affected depending on the amount of diopters corrected in the primary procedure, in the retreatment procedure, and in both primary and retreatment procedures combined. [J Refract Surg. 2007;23:201-205.]