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Asaf Achiron,1 Tal Yahalomi,2 Amit Biran,1 Eliya Levinger,1 Eyal Cohen,1 Uri Elbaz,3 Asim Ali,4,5 Kamiar Mireskandari,4,5 Raimo Tuuminen,6,7 Oleksiy V Voytsekhivskyy8 1Tel Aviv Sourasky Medical Center, Tel Aviv, Israel and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; 2Department of Ophthalmology, Samson Assuta Ashdod Hospital and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Be’er Sheva, Israel; 3Department of Ophthalmology, Rabin Medical Center, Petach-Tikva and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; 4Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada; 5Department of Ophthalmology and Vision Sciences, the Hospital for Sick Children, Toronto, Ontario, Canada; 6Helsinki Retina Research Group, Faculty of Medicine, University of Helsinki, Helsinki, Finland; 7Department of Ophthalmology, Kymenlaakso Central Hospital, Kotka, Finland; 8Kyiv Clinical Ophthalmology Hospital Eye Microsurgery Center, Kyiv, UkraineCorrespondence: Oleksiy V Voytsekhivskyy, Kyiv Clinical Ophthalmology Hospital Eye Microsurgery Center, Komarov Ave. 3, Medical City, Kyiv, 03680, Ukraine, Tel +38067-584-28-11, Email iolpower@ukr.netPurpose: To compare the accuracy of 16 intraocular lens (IOL) power calculation formulas in pediatric cataract eyes.Patients and Methods: The data records of pediatric patients who had been implanted with three IOL models (SA60AT, MA60AC, and enVista-MX60) between 2012 and 2018 were analyzed. The accuracy of 16 IOL power calculation methods was evaluated: Barrett Universal II (BUII), Castrop, EVO 2.0, Haigis, Hill-RBF 3.0, Hoffer Q, Hoffer QST, Holladay 1, Kane, LSF AI, Naeser 2, Pearl-DGS, SRK/T, T2, VRF, and VRF-G. The non-optimized (ULIB/IOLcon) and optimized constants were used for IOL power calculation. The mean prediction error (PE), Performance Index (FPI), and all descriptive statistics were calculated.Results: Ninety-seven eyes of 97 pediatric patients aged 13.2 (IQR 11.2– 17.1) were included. No statistically significant difference (HS-test) was observed (p > 0.818) except for the Hoffer Q, and Naeser 2 (P = 0.014). With optimized lens constants, the best FPI indices were obtained by Hoffer Q (0.256) and VRF-G (0.251) formulas, followed by Hill-RBF 3.0 and BUII, with an index of 0.248. The highest FPI indices with non-optimized constants showed SRK/T and T2 formulas (0.246 and 0.245, respectively), followed by VRF-G and Holladay 1, with an index of 0.244. The best median absolute error values (MedAE) were achieved by Hoffer Q (0.50 D), VRF-G (0.53 D), and Hill-RBF 3.0 (0.54 D), all P ≥ 0.074.Conclusion: Our results place the Hoffer Q, VRF-G, Hill-RBF 3.0, and BUII formulas as more accurate predictors of postoperative refraction in pediatric cataract surgery.Keywords: IOL power, formulas, pediatric eyes, calculation, axial length

Introduction: The study aimed to compare postoperative pain between alcohol-assisted and transepithelial photorefractive keratectomy in patients who received the novel analgesic preoperative nepafenac treatment 2 days preoperatively and 3 days postoperatively. Pain, stinging, tearing, light sensitivity, and stress levels were evaluated., Methods: The study included a retrospective analysis of 55 patients divided into two groups: bilateral alcohol-assisted photorefractive keratectomy (aa-PRK) and transepithelial photorefractive keratectomy (transepithelial-PRK). Nepafenac was administered for pain control for all patients, with patients receiving four drops for 2 days before the surgery and 3 days postoperatively per clinical instructions. Patients completed questionnaires on the day of the surgery and for the first 5 days postoperatively. Statistical analysis was performed using XLSTAT (version 2023.1.2). t-Test was used to analyze and compare pain and symptom levels and Fisher's exact test for categorical data. p-Values less than 0.05 were considered statistically significant., Results: The study examined 55 patients (49% female) with a mean age of 25.11 ± 6.81 years who had undergone bilateral surface refractive surgery to correct myopic errors. The mean baseline standard error (SE) was -3.16 ± 2.20 D. Among these patients, 27 patients underwent aa-PRK and 28 patients underwent transepithelial-PRK. Higher levels of pain were significant in the aa-PRK group (p = 0.003). However, there was no significant difference between the groups in the average levels of stinging, tearing, or light sensation. Additionally, stress levels decreased over time in both groups, with levels becoming almost equal after 5 days, and there was no significant difference in the average stress levels between the two groups., Conclusions: The study found that patients who underwent the transepithelial-PRK procedure had significantly lower pain levels compared with those who underwent aa-PRK after being treated with nepafenac per protocol. However, there was no significant difference between the two groups in terms of stinging, tearing, light sensation, and stress levels., Competing Interests: Declarations Conflict of Interest Nir Gomel, Nadav Shemesh, Nir Sorkin, Nadav Levinger, Shmuel Levinger, Ami Hirsch, Asaf Achiron, and Eliya Levinger have nothing to disclose. Ethical Approval All data for the study were collected and analyzed in accordance with the policies and tenets outlined in the Declaration of Helsinki. This study received approval by the Institutional Review Board of the TLV-0689-17 Medical Center. As the study data was deidentified and the study was retrospective, informed consent was not required., (© 2024. The Author(s).)

Objective: To assess the effect of diabetes type on Nd:YAG capsulotomy rates following cataract surgery., Design: A retrospective cohort study., Methods: All patients who underwent cataract extraction at the Department of Ophthalmology, Bristol Eye Hospital, Bristol, UK, between 2003 and 2017 were included. The Nd:YAG capsulotomy rate following cataract surgery was assessed and compared between nondiabetic, type 1 diabetes (T1D), and type 2 diabetes (T2D) patients. Multivariate Cox regression analysis controlling for age and sex was used to estimate hazard ratios for Nd:YAG laser capsulotomies., Results: Included were 53,471 consecutive cataract surgeries. Overall, 42,651 eyes (79.8%) were in nondiabetic patients, 823 eyes (1.5%) were in T1D patients, and 9,997 eyes (18.7%) were in T2D patients. The mean follow-up time was 6.8 ± 4.2 years. In univariate analysis, the eyes of T1D patients (p < 0.001) and T2D patients (p = 0.003) had significantly higher Nd:YAG laser capsulotomy rates than the eyes of nondiabetic patients. In Cox regression analysis adjusted for the patient's age and sex, DM1 (HR 1.692, 95%CI 1.390-2.059, P<0.001) and DM2 (HR 1.157, 95%CI 1.075-1.244, P<0.001) remained significantly predictive for higher Nd:YAG laser capsulotomy rates., Conclusion: In our large cohort study, patients with T1D and T2D were predisposed to high risk for Nd:YAG capsulotomy following cataract surgery. This study may be beneficial and raise awareness regarding the assessment of posterior capsular opacification development in pseudophakic diabetic patients, particularly those with T1D. The significance of ophthalmology screening for diabetes individuals is further supported by this issue., Competing Interests: Footnotes and Disclosures Raimo Tuuminen and Asaf Achiron made equal contributions to this paper. The authors have no proprietary or commercial interest in any materials discussed in this article. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2024 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess the risk for pseudophakic cystoid macular oedema (PCME) and posterior capsular opacification (PCO) associated with combined cataract surgery and trabeculectomy compared to cataract surgery alone., Methods: Data analysis of subjects who underwent routine cataract surgery without and with concomitant trabeculectomy at the Department of Ophthalmology, Bristol Eye Hospital, the UK, between January 2008 and December 2017. Odds ratios (ORs) for PCME between the types of surgeries were calculated using univariate and multivariate regression analysis. Multivariate Cox regression controlling for age and gender was used to estimate the hazard ratio (HR) for neodymium-doped yttrium aluminium garnet (Nd:YAG) laser capsulotomies., Results: This study included 56 973 cataract surgeries without and 288 with concomitant trabeculectomy (phaco-trab) with a mean follow-up time of 6.9 ± 4.2 years. Baseline variables (age and gender, diabetes, pseudoexfoliation, use of pupil expansion device and postoperative follow-up time) were comparable between the groups. Postoperative rates of PCME remained non-significant between the cataract surgery and phaco-trabe groups both in uni- and multi-variate analysis (OR 0.347, 95%CI 0.049-2.477, p = 0.291). Furthermore, in Cox regression analysis adjusted for the patients' age and gender, Nd:YAG laser capsulotomy rates remained non-significant between the cataract surgery and phaco-trabe groups (HR 1.250, 95%CI 0.883-1.769, p = 0.209)., Conclusions: In our large cohort study, combining trabeculectomy with cataract surgery did not predispose to an increased PCME or Nd:YAG laser capsulotomy rates., (© 2024 The Author(s). Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Purpose: To compare laser-assisted in situ keratomileusis (LASIK) outcomes in patients with different corneal curvatures., Methods: This is a retrospective comparative chart review. Patients included in this study underwent wavefront-optimized myopic LASIK between January 2013 and December 2022 at Care-Vision Laser Center, Tel-Aviv, Israel. Patients were divided into 3 groups based on the steepness of the cornea (steep keratometry) (flat: <42 diopters [D], normal: 42-46 D, and steep: >46 D). Case-by-case matching was performed to verify that baseline parameters (age, preoperative visual acuity, and refractive error) were similar between groups. Primary outcome measures were postoperative corrected/uncorrected distance visual acuity, efficacy index, safety index, spherical equivalence, and astigmatism., Results: After matching, 300 eyes were included in each group, which were similar in baseline parameters. There were no significant postoperative differences between flat, normal, and steep corneas regarding safety index (1.01 vs. 1.02 vs. 1.01, P = 0.95), efficacy index (1.03 vs. 1.02 vs. 1.02, P = 0.94), logarithm of the minimum angle of resolution corrected distance visual acuity (0.01 vs. 0.01 vs. 0.01, P = 0.17), logarithm of the minimum angle of resolution uncorrected distance visual acuity (0.02 vs. 0.03 vs. 0.02, P = 0.65), proportion of patients with spherical equivalence within 0.50 D (73.0% vs. 73.7% vs. 69.3%, P = 0.45) or 1.00 D (93.3% vs. 94.7% vs. 91.7%, P = 0.34) of the target, and proportion of patients with astigmatism within 0.50 D (86.7% vs. 82.3% vs. 80.3%, P = 0.11) or 1.00 D (98.7% vs. 98.7% vs. 99.0%, P = 0.91) of the target. Longer term follow-up of a smaller set of patients revealed similar results., Conclusions: No significant differences were found between flat, normal, and steep corneas following wavefront-optimized myopic LASIK. Thus, this procedure may be safely and effectively performed across a wide range of corneal curvatures., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To compare intraocular lens (IOL) power prediction accuracy of the Eyestar 900 (EyeS900) and the IOLMaster 700 (IOLM700) based on estimated and measured posterior corneal power., Design: Retrospective, interinstrument reliability study., Methods: Setting: Institutional., Participants: Two hundred twenty-five eyes of 225 cataract surgery patients., Measurements: Patients underwent measurements by both devices preoperatively., Main Outcome Measures: Spherical Equivalent Prediction Error (SEQ-PE), spread of the SEQ-PE (precision) and the absolute SEQ-PE (accuracy) of each device using Barrett Universal II (BUII) formula with either estimated posterior keratometry (E-PK) or measured posterior keratometry (M-PK)., Results: Trimmed mean SEQ-PEs of EyeS900 E-PK, EyeS900 M-PK, IOLM700 E-PK, and IOLM700 M-PK were 0.03, 0.08, 0.02, and 0.09 D, respectively with no significant differences between EyeS900 E-PK and IOLM700 E-PK (P = 0.31) as well as between EyeS900 M-PK and IOLM700 M-PK (P = 0.31). Statistically significant SEQ-PE differences were found when E-PK and M-PK were compared, regardless of the device used, showing hyperopic SEQ-PE in M-PK calculations. Excellent correlation and agreement in SEQ-PE were found between the devices for both E-PK (P < 0.001, r = 0.848, mean bias: +0.01 D, 95% LOA of -0.32 to +0.34 D) and M-PK (P < 0.001, r = 0.776, mean bias: -0.01 D, 95% LOA of -0.42 to +0.39 D). No significant differences were found comparing absolute SEQ-PE and precision of the devices., Conclusion: The Eyestar 900 and the IOLMaster 700 show comparable IOL power prediction accuracy by the BUII formula using either estimated or measured posterior keratometry. An adjusted lens factor may be required for BUII when utilizing measured posterior keratometry in both devices., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: In this case report, we demonstrate the application of an aspheric macular lens (Grieshaber, Alcon) for conducting posterior segment procedures after a posterior capsular rupture (PCR) occurrence during cataract surgery., Case Presentation: During a cataract surgery on a 70-year-old female patient, a PCR was identified, accompanied by the descent of the lens into the vitreous, and prompted subsequent interventions. This involved performing posterior-assisted levitation, anterior segment phacoemulsification, and anterior segment vitrectomy. Subsequently, due to the absence of a BIOM posterior viewing system in the operating room, an aspheric macular lens (Grieshaber, Alcon) was positioned on the patient's eye. Subsequently, pars plana vitrectomy was performed, along with the extraction of residual lens cortical remnants. The procedure concluded with gradually inserting a 3-piece intraocular lens into the sulcus., Conclusion: When managing posterior capsular rupture, using an aspheric macular lens, such as the Grieshaber (Alcon), can be beneficial., Competing Interests: The authors have no conflicts of interest to declare., (© 2024 The Author(s). Published by S. Karger AG, Basel.)

Purpose: To evaluate the intraoperative central corneal epithelial thickness (ET) as measured by optical coherence pachymetry (OCP) in myopic eyes undergoing alcohol-assisted photorefractive keratectomy (PRK)., Methods: A retrospective review of patients who underwent alcohol-assisted PRK was performed. Data were abstracted on age, gender, contact lens (CL) wear, preoperative refractive errors, keratometry, topographic and ultrasonic pachymetry, and intraoperative OCP measurements before and after epithelium removal. The central ET was calculated by subtracting OCP measurement after epithelium removal from the OCP measurement prior to epithelium removal., Results: The study comprised of 162 consecutive eyes from 81 patients. Mean age was 26.73 ± 6.47 years, 50.6% were males. CL was used in 92 eyes (56.8%). The mean sphere and spherical equivalent were -3.60 ± 1.84 D and -3.26 ± 1.85D, respectively. The mean intraoperative ET was 58.22 ± 17.53 µm (range, 15-121µm). Fifty-five percent of the eyes had an ET measurement above or below the range of 40-60µm. ET was significantly higher in the second operated eye compared to the first operated eye (p = 0.006), and an association was found to CL-wear (p = 0.03). There was no significant difference in thickness between genders (p = 0.62), and no correlation to patient age (p = 0.45, r p  = 0.06), refractive errors (p > 0.30,r p= -0.07-0.08), nor keratometry(p > 0.80, r p= -0.01- (-0.02))., Conclusion: The intraoperative assessment of ET in alcohol-assisted PRK showed a high variability of the central corneal epithelium, with a significant difference between the first and second operated eyes. This difference may have implications when the epithelium is not included in the surgical planning in surface ablation., (© 2024. The Author(s).)

Purpose: To evaluate the difference between planned and measured central ablation depth (CAD) and compare the first and second operated eye in simultaneous bilateral myopic alcohol-assisted PRK. Methods: A retrospective review of patients was performed. Demographic and preoperative data was abstracted. Intraoperative assessment included environmental data, laser-planned algorithm of ablation (L-CAD), and optical coherence pachymetry (OCP) measurements. The true stromal ablation depth (O-CAD) was calculated by subtracting the immediate post-ablation OCP measurement from the OCP measurement before laser ablation. Deviation in pachymetry (DP) between O-CAD and L-CAD was also assessed. Results: The study comprised 140 eyes from 70 consecutive patients. The mean age was 26.91 ± 6.52 years, and 57.1% were females. O-CAD was significantly correlated to preoperative refractive errors and intraoperative laser settings. DP was not correlated to any of the pre- or intraoperative parameters. L-CAD showed a significant underestimation as compared to O-CAD (67.87 ± 25.42 µm and 77.05 ± 30.79 µm, respectively, p < 0.001), which was shown in 74.3% of the cases. A moderate agreement between the two methods was noted, with a mean deviation of 17%. This difference was maintained for each eye individually ( p < 0.001). In addition, DP was significantly higher in the first operated eye as compared to the second operated eye (11.97 ± 16.3 µm and 6.38 ± 19.3 µm respectively, p = 0.04). Conclusion: The intraoperative assessment of stromal ablation showed significantly higher central ablation depth values compared to the laser-planned ablation algorithm. The deviation in pachymetry was higher in the first, compared to the second, operated eye. Awareness is warranted as to the discrepancy between preoperative planning and intraoperative assessment.

Purpose: To identify risk factors that increase the likelihood of re-treatment following refractive surgery in patients with mixed astigmatism., Methods: This was a retrospective study including patients who underwent either laser in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) between 2000 and 2019 and had mixed astigmatism (spherical error of +0.50 D or greater and spherical equivalent of less than 0.00 diopters [D]). Patients were divided into two groups according to whether they underwent re-treatments during the study period., Results: Overall, 785 eyes (785 patients) were included. In total, 5.2% of the eyes (n = 41) underwent re-treatment. The re-treatment group was more likely to have preoperative high astigmatism (80.5% vs 48.3%, P < .001), moderate to high hyperopia (36.6% vs 22.3%, P = .035), and to have undergone surgery earlier during the study period ( P < .001). They were also more likely to have undergone surgery using the Wave-Light EX200 rather than the EX500 laser platform (Alcon Laboratories, Inc) ( P < .001), have a treated optical zone of 6 mm rather than 6.5 mm ( P < .001 for both), and their maximum ablation depth was greater ( P < .001). There was no difference between the re-treatment and control groups regarding procedure type (PRK vs LASIK). Binary logistic regression found preoperative high astigmatism (odds ratio = 3.97, P < .001) and the type of laser platform used (EX200, odds ratio = 7.78, P < .001) as the only independent factors associated with re-treatment., Conclusions: Re-treatment rates following correction of mixed astigmatism were 5.2% over 20 years. Use of a sixth-generation laser platform significantly reduced the risk of re-treatment. Presence of high astigmatism is a significant risk factor for re-treatment. There was no difference in retreatment risk between PRK and LASIK. [ J Refract Surg . 2024;40(2):e73-e78.] .

Purpose: To compare photorefractive keratectomy (PRK) outcomes in patients with different corneal steepness., Setting: Care-Vision Laser Center, Tel-Aviv, Israel., Design: Retrospective comparative chart review., Methods: Patients included in this study underwent wavefront optimized myopic PRK between January 2013 and December 2019. Patients were divided into 3 groups based on the steepness of the cornea (steep keratometry) (flat: <42 diopters [D], normal: 42 to 46 D and steep: >46 D). One to one matching was performed to verify that baseline parameters (age, preoperative visual acuity and refractive error) were similar between groups. Primary outcome measures were: postoperative corrected/uncorrected distance visual acuity (CDVA/UDVA), efficacy index (postoperative UDVA/preoperative CDVA), safety index (postoperative CDVA/preoperative CDVA), spherical equivalence (SEQ) and cylinder., Results: After matching, 650 eyes were included in each group, which were similar in baseline parameters. There were no significant postoperative differences between flat, normal, and steep corneas in terms of safety index (1.02 vs 1.03 vs 1.03, P = .28), efficacy index (1.01 vs 1.01 vs 1.02, P = .57), logMAR CDVA (0.01 vs 0.02 vs 0.01, P = .76), logMAR UDVA (0.02 vs 0.03 vs 0.02, P = .68), %SEQ within 0.50 D (73.9% vs 74.2% vs 74.6%, P = .95) or 1.00 D of target (91.9% vs 92.5% vs 92.2%, P = .92), %cylinder within 0.50 D (82.8% vs 82.2% vs 81.4%, P = .81) or 1.00 D of target (96.9% vs 97.1% vs 97.2%, P = .95)., Conclusions: No significant differences were found between flat, normal and steep corneas following wavefront-optimized myopic PRK. Thus, this procedure may be safely and effectively performed in both flat and steep corneas., (Copyright © 2023 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To assess the risk for uveitis, pseudophakic cystoid macular edema (PCME), and posterior capsular opacification (PCO) associated with the use of pupil expansion devices in cataract surgery., Design: A retrospective comparative cohort study., Participants: Patients who underwent routine cataract surgery with and without pupil expansion devices at the Department of Ophthalmology, Bristol Eye Hospital, UK, between January 2008 and December 2017., Methods: This study included 39,460 eyes operated without a pupil expansion device and 699 eyes operated with the device. Odds ratios for uveitis and PCME when using a pupil expansion device were calculated using univariate and multivariate regression analysis, having age, gender, diabetes, pseudoexfoliation, and pupil expansion device as independent variables. Multivariate Cox regression controlling for age and gender was used to estimate hazard ratios (HR) for Nd : YAG laser capsulotomies., Results: Postoperative uveitis and PCME were reported in 3.9% and 2.7% of the eyes operated with a pupil expansion device compared to 2.3% and 1.3% operated without the device (p=0.005 and p=0.002, respectively). In univariate regression analysis, eyes with pupil expansion devices showed a higher risk of postoperative uveitis or PMCE after cataract surgery (OR 1.88, 95%CI 1.39-2.55, p<0.001). In multivariate regression analysis, the risk for PMCE was greater among diabetic patients and in eyes with a pupil expansion device than in those without (OR 1.50, 95%CI 1.24-1.83, P <0.001; OR 1.90, 95%CI 1.16-3.11, P =0.01). In Cox regression analysis adjusted for the patient's age and gender, the use of a pupil expansion device was associated with higher Nd : YAG laser capsulotomy rates (HR 1.316, 95%CI 1.011-1.714, P=0.041)., Conclusion: In our large cohort study, the use of pupil expansion devices in cataract surgery was associated with an increased risk of major postoperative complications. Effective anti-inflammatory treatment and follow-up are warranted in eyes operated with a pupil expansion device., Competing Interests: RT is a scientific adviser advisory board, honoraria to Alcon Laboratories, Inc., Allergan, Inc., Bayer and Novartis AG, and has received clinical trial support study medicines from Bayer AG and Laboratoires Théa. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Yahalomi, Elhaddad, Avadhanam, Tole, Darcy, Levinger, Tuuminen and Achiron.)

Objective: To report preliminary experience using the BeyeonicsOne (Beyeonics Vision, Haifa, Israel) digital visualization platform and the utilization of its three-dimensional (3D) head-mounted display (HMD) in cataract surgery., Methods: An interventional case series including patients who underwent cataract surgery using the 3D HMD platform at the Tel Aviv Medical Center. The system uses the HMD unit to display high-resolution real-time 3D surgical field images. Collected data included patient demographics, ocular comorbidities, risk factors for complex cataract surgery, cataract grading, preoperative and postoperative best-corrected visual acuity (BCVA), and intra- and postoperative complications., Results: In total, 60 eyes of 60 subjects (mean age 73.1 ± 8.4 years) were included. Mean preoperative BCVA was 0.40 ± 0.30 logMAR (Snellen equivalent ~20/50) and improved to 0.10 ± 0.10 logMAR (Snellen equivalent ~20/25, p < 0.001). None of the patients suffered BCVA loss. All procedures and follow-ups were uneventful except for one case of a posterior capsular tear and one case of post-surgical cystoid macular edema., Conclusion: The visualization platform and its embedded 3D head-mounted display can be easily used in routine cataract surgery with the added benefits of improved ergonomics, high picture quality and enhanced image control., (© 2023. The Author(s), under exclusive licence to The Royal College of Ophthalmologists.)

Introduction: To report the first endothelial keratoplasty procedures performed using a 3D digital head-mounted ophthalmic exoscope., Methods: Three patients underwent Descemet stripping automated endothelial keratoplasty (DSAEK) using a 3D digital ophthalmic exoscope (Beyeonics One, Beyeonics Vision, Haifa, Israel) at the Tel Aviv Sourasky Medical Center, Tel Aviv, Israel., Results: All procedures were uneventful, leading to resolution of corneal edema and vision improvement. Surgeons reported excellent visualization and minimal lag, almost negligible, with the benefits of improved ergonomics and the use of head gestures to control zoom, focus, brightness, and panning. There were no postoperative complications., Conclusion: The new 3D digital ophthalmic exoscope system can be successfully used in DSAEK surgery with potential advantages in ergonomics, picture quality, and image control. Further studies can compare this system with either standard operating microscopes or 3D heads-up display systems., (© 2022. The Author(s).)

Purpose: The most crucial step in deep anterior lamellar keratoplasty (DALK) is to achieve a bare Descemet's membrane. We aimed to assess a new femtosecond laser software that allows for a precise intrastromal tunnel creation for big bubble (BB) air injection using a real-time microscope-integrated optical coherence tomography., Materials and Methods: A retrospective review of 61 eyes of 61 patients with keratoconus. Before introducing the new software update, DALK was performed using a partial-assisted femtosecond laser (partial-thickness circular cut followed by a lamellar cut) with manual intrastromal tunnel creation (partial FS-DALK group). After the software update, the femtosecond laser created the intrastromal tunnel (full FS-DALK group)., Results: In the full FS-DALK group, the BB's formation was significantly higher (64.3% vs. 36.4%, p = 0.04), and surgery time was shorter (21.8 ± 5.1 vs. 25.6 ± 6.8 min, p = 0.025) than in the partial FS-DALK. Penetrating keratoplasty conversion rate (7.1% vs. 15.1%, p = 0.432) was similar between the groups. Both groups showed statistically significant improvement in uncorrected and corrected distance visual acuity, central corneal thickness, surface asymmetry, and regularity indices. Endothelial cell density loss at 12 and 18 months was lower in the full compared with the partial FS-DALK group (12 months:10.0% vs. 16; 18 months: 10.7 vs. 16.5%, p < 0.001 for both comparisons)., Conclusions: Creating the intrastromal guiding tunnel using FS laser for air injection resulted in a higher rate of BB formation, reduced long-term endothelial cell loss, and operating room time., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Accurate intraocular lens (IOL) calculation in subjects with irregular astigmatism is challenging. This study evaluated the accuracy of using Scheimpflug-derived central 2-mm equivalent keratometry reading (EKR) values for IOL calculation in irregular astigmatism., Methods: This retrospective study included subjects (31 eyes of 30 patients) who underwent cataract surgery and IOL calculation using the 2-mm central EKR methods. We compared prediction error (PE) and absolute PE (APE) outcomes using SRK/T and Barrett Universal II formulas for keratometry data obtained from the IOLMaster 500 and Pentacam (anterior corneal sim k) devices., Results: Cataract surgery and IOL calculation using the 2-mm central EKR methods resulted in improved visual acuity (uncorrected: from 1.13 ± 0.38 to 0.65 ± 0.46 logMar, p < 0.01; best-corrected: from 0.45 ± 0.24 to 0.26 ± 0.20 logMar, p < 0.01) after surgery. The percentage of subjects with best-corrected visual acuity of 6/6 was 22%, < 6/9 was 58%, and < 6/12 was 71%. For both the SRK/T and the Barrett formulas, the PE was similar to those obtained by IOLMaster (> 0.14) but lower than those obtained by the anterior corneal sim k (p < 0.02). IOLMaster provided keratometry reading in only 23/31 (74.1%) of cases., Conclusions: The use of Scheimpflug central 2-mm EKR for IOL calculation in irregular astigmatism was beneficial in terms of visual acuity improvement. It had comparable refractive prediction performance to the IOLMaster 500 and better than the anterior corneal sim K. The 2-mm EKR method can be used when IOLMaster cannot provide a reliable reading in abnormal corneas., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To evaluate the agreement in biometry measurements and intraocular lens (IOL) power calculations between 2 integrated swept-source optical coherence tomography (SS-OCT) tomography/biometry devices: the Eyestar 900 and the Anterion., Setting: Tel Aviv Medical Center, Tel Aviv, Israel., Design: Retrospective comparative study., Methods: 113 eyes of 66 consecutive patients who were evaluated prior to cataract surgery using both devices on the same visit were included. Measurements of axial length, anterior and posterior keratometry, anterior chamber depth, corneal diameter (CD), central corneal thickness, and lens thickness were recorded from both devices and analyzed for agreement and correlation. IOL power calculations using Barrett Universal II formula were compared between the devices in addition to prediction error (PE) and the mean absolute error (MAE)., Results: The mean age was 71.6 ± 9.8 years. Clinically, the mean differences in measured variables were small. Measurement correlation and agreement between the devices were excellent for all variables, except for CD (Spearman r = 0.763, P &lt; .001, and Bland-Altman 95% limits of agreement -0.21 to +0.65 mm). Good agreement was found between the devices in IOL power calculations, PE, and MAE, and the agreement was better when using the Eyestar 900 reflective keratometry measurements than the Eyestar 900 SS-OCT keratometry measurements (IOL power agreement within ±0.5 diopter (D) in 90.5% [n = 95] and 81.0% [n = 85], respectively [ P = .076], and within ±0.25 D in 64.8% [n = 68] and 44.8% [n = 47], respectively [ P = .005])., Conclusions: The 2 integrated SS-OCT tomography/biometry devices had good agreement in biometry measurements and IOL power calculations. Agreement was better when the Eyestar 900 reflective anterior keratometry measurements were used rather than the Eyestar 900 SS-OCT anterior keratometry measurements. Measurements of CD had reduced agreement and were not interchangeable., Competing Interests: Disclosures: A. Abulafia is a consultant for Haag-Streit AG and received lecture fees from Haag-Streit AG. All other authors have no conflicts of interest., (Copyright © 2022 Published by Wolters Kluwer on behalf of ASCRS and ESCRS.)

Purpose: To validate the effectiveness of the multi-metric D-index by Pentacam in detecting keratoconus (KC) progression., Materials and Methods: This was a retrospective study of KC patients at the Rabin Medical Center, Petah Tikva, Israel, during 2016-2018 with at least two corneal tomography examinations six months apart. Agreement between clinical diagnosis of progression (1.5D increase in mean keratometric value, 1D increase in Kmax, a 5% decrease in central corneal thickness (CCT), worsening of visual acuity by more than one line, or deterioration of manifest corneal astigmatism > 1.5D) and the D-index was evaluated. Receiver operating characteristic (ROC) analysis was used to find the D-index's optimal cutoff value to show progression., Results: We included KC eyes in the stable group (N = 7) and the progression group (N = 54). Patient demographics and tomographic parameters at baseline were similar between the groups. The D-index change was significantly higher in the progression group than in the stable group (median + 1 and 0.0, respectively, p = 0.024). Based on the ROC analysis, the optimal D-index cutoff change within at least six months was 0.32 (59.3% sensitivity and 100% specificity (area under the curve [AUC] = 0.771, Youden = 0.592). Subjects with a D-index change above this value had a 21.1-fold increase in odds for corneal ectasia progression requiring CXL (OR: 21.1, 95%CI 1.17-398.8, p = 0.038)., Conclusion: The multi-metric D-index can serve as a clinically feasible parameter to detect KC progression and guide patients' referral for further interventions., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Visual rehabilitation after a keratoplasty is often compromised due to high amounts of residual astigmatism. Femtosecond laser-assisted astigmatic keratotomy (FLAK) is gaining popularity in decreasing this astigmatism. Though one set of two incisions suffices in most cases, sometimes the treatment proves insufficient and additional treatment is required. This case series evaluates the outcomes in patients who underwent two consecutive FLAK sets to correct post-keratoplasty residual astigmatism. All repeated FLAK cases performed on post-keratoplasty eyes were reviewed in a high-volume clinic as a non-comparative retrospective case series. The data extracted include the procedure parameters, time between procedures, refraction including sphere, astigmatism, spherical equivalent (SE), and uncorrected and best-spectacle-corrected distance visual acuity (UDVA, BSDVA, respectively). Eleven eyes of eleven patients aged 25.5 ± 10 treated with more than one FLAK procedure were identified. The average follow-up time was 6 months after the first FLAK and 24 ± 10 months after the second. The second FLAK was performed six months after the first. The preoperative mean astigmatism was -9.59 ± 2.36 D. At the final follow-up, the mean astigmatism decreased to -5.38 ± 1.79 D ( p = 0.001). Repeated FLAK procedures achieved a significant and stable reduction of astigmatism in post-keratoplasty eyes. This procedure shows safety and effectivity in these complex eyes and may prevent the need for a further keratoplasty.

Background: To perform a systematic review and meta-analysis of the refractive outcomes of non-toric and toric intraocular lenses (IOLs) in keratoconus (KC) using different IOL power calculation formulas., Methods: A systematic search was conducted to identify studies that report on refractive outcomes of different IOL power calculation formulas in KC patients undergoing cataract surgery. Inclusion criteria were primary posterior chamber non-toric and toric monofocal intraocular lens implantation, data on the degree of KC, explicit mention of the formula used for each stage of KC, and the number of eyes in each category. We calculated and compared the absolute and mean prediction errors, percentage of eyes within 0.5 D and 1 D from target, and the weighted absolute prediction errors of IOL formulas, all were given for KC degrees I-III., Results: The bibliographic search yielded 582 studies published between 1996 and 2020, 14 of which (in total 456 eyes) met the criteria: three studies on non-toric IOL (98 eyes), eight studies on toric IOLs (98 eyes) and three studies of unknown separation between non-toric and toric IOLs (260 eyes). The lowest absolute prediction error (APE) for mild, moderate, and advanced KC was seen with Kane's IOL power formula with keratoconus adjustment. The APE for the top five IOL power formulas ranged 0.49-0.73 diopters (D) for mild (83-94%) of eyes within 1 D from the target), 1.08-1.21 D for moderate (51-57% within 1 D), and 1.44-2.86 D for advanced KC (12-48% within 1 D)., Conclusions: Cataract surgery in eyes with mild-to-moderate KC generally achieves satisfactory postoperative refractive results. In patients with advanced KC, a minority of the eyes achieved spherical equivalent refraction within 1 D from the target. The Kane's formula with keratoconus adjustment showed the best results in all KC stages.

Purpose: To assess the tear film thickness in healthy individuals by using a dual-Scheimpflug camera and topical 0.1% fluorescein., Methods: A prospective study on healthy individuals who underwent a bilateral tomography examination using the GALILEI dual-Scheimpflug with assessments of the thinnest and central corneal thickness (TCT and CCT, respectively), at baseline and 1 min after applying 2 and 4 µl of 0.1% fluorescein (30 min apart) under topical anesthesia with Oxybuprocaine 0.4%. Inclusion criteria were lack of dry eye disease symptoms and exclusion criteria were contact lens usage, eye drops usage, previous refractive surgery or any ocular surgery. All individuals scored zero on the ocular surface disease index (OSDI) questionnaire., Results: A total of 62 eyes of 31 participants were included in this study. The mean age was 35.3 ± 10.88 (range 18-62). The mean TCT in was 549.16 µm in the right eye (RE) and 547.84 µm in the left eye (LE). After instillation of 2 µl of 0.1% fluorescein mean TCT increase by 27.84 µm in the RE and by 26.35 µm in the LE. CCT change was 27.58 µm increase in RE and 27.23 µm increase in LE. After instillation of 4 µl of 0.1% fluorescein the mean increase in TCT and CCT were 30.09 and 30.26 µm for OD and 28.33 and 30.15 µm for OS respectively. Comparison between the post instillation of 2 and 4 µl measurements showed no significant differences., Conclusion: Combining a dual-Scheimpflug camera and 0.1% fluorescein may serve as a method to assess the pre-corneal tear film.

Purpose: The purpose of this study was to assess the results of a sulcus intraocular lens (Sulcoflex) for pseudophakic refractive errors following phacoemulsification cataract surgery., Methods: This retrospective clinical observational cohort study included consecutive eyes in which a Sulcoflex was implanted. Uncorrected distance visual acuity and corrected distance visual acuity as well as refractive outcomes were assessed. The minimum follow-up time required for inclusion was 3 months., Results: In total, 15 eyes ( n  = 15) were evaluated. The mean follow-up was 14 months (range: 3-18 months). The Sulcoflex aspheric (653L) was implanted in 13 eyes and the Sulcoflex toric (653T) in two eyes. The preoperative mean logMAR (Snellen) uncorrected distance visual acuity and corrected distance visual acuity were 0.88 (20/150) and 0.27 (20/40), respectively. The postoperative mean logMAR (Snellen) corrected distance visual acuity was 0.15 (20/30). The preoperative mean spherical equivalent was -0.22 ± 5.95 D and the postoperative mean spherical equivalent was -1.59 ± 1.45 D. There was a significant and strong correlation ( r  = 0.64, p  < 0.001) between the attempted and the achieved spherical equivalent., Conclusion: The Sulcoflex is a safe and viable option for patients with residual refractive error following cataract surgery.

Purpose: To determine the ability to differentiate between normal eyes and clinically unaffected eyes of patients with highly asymmetric keratoconus (AKC) using a Scheimpflug/Placido device., Setting: Tel Aviv Sourasky Medical Center and Enaim Medical Center, Israel., Design: Retrospective case-control., Methods: Imaging from a combined Scheimpflug/Placido device (Sirius, C.S.O.) was obtained from 26 clinically unaffected eyes of patients with frank keratoconus in the fellow eye, and 166 eyes from 166 patients with bilaterally normal corneal examinations that underwent uneventful corneal refractive surgery with at least 1 year of follow-up. Receiver operating characteristic curves were produced to calculate the area under the curve, sensitivity, and specificity of 60 metrics, and finally a logistic regression modeling was used to determine optimal variables to differentiate populations., Results: The most predictive individual metric able to differentiate between 26 eyes in the case group to 166 eye in the control group was the posterior wall inferior-superior (I-S) ratio, with an receiver operating characteristics (ROC) of 0.862. A combination model of 4 metrics (posterior wall I-S ratio in the central 3 mm, thinnest pachymetry coordinate on the x horizontal axis, posterior asymmetry and asphericity index, corneal volume) yielded an ROC of 0.936, with a sensitivity/specificity pair of 92.3%/87%. Variables related to elevation were not found significant., Conclusions: Using a combination of metrics from a combined Scheimpflug/Placido device, a practical model for discrimination between clinically normal eyes of patients with highly AKC and normal eyes was constructed. Variables related to pachymetry and posterior cornea asymmetry were the most impactful.

Purpose: To evaluate the effect of pterygium excision on the posterior corneal surface and analyze the factors associated with those changes., Methods: A prospective, interventional study including 33 eyes of 31 patients who underwent pterygium excision at the Tel Aviv Medical Center (Tel Aviv, Israel). Exclusion criteria included corneal dystrophy, pseudopterygium, corneal scarring, or previous ocular surgery in the treated eye. Data were obtained by using the Galilei dual Scheimpflug analyzer. Recorded posterior corneal data included steep keratometry, flat keratometry, mean keratometry, corneal astigmatism, best-fit sphere, and the squared eccentricity index (e). Posterior surgically induced astigmatism (SIA) was calculated to demonstrate the astigmatic effect of surgery. Anterior-segment high resolution optical coherence tomography was used to measure pterygium dimensions (depth and horizontal/vertical size)., Results: The mean age was 53.7 ± 16.7 years. Posterior corneal SIA was 0.9 ± 1.1 D (P < 0.001) and was significantly correlated with age (r = 0.568, P = 0.002), horizontal pterygium size (r = 0.387, P = 0.046), and preoperative posterior astigmatism (r = 0.688, P < 0.001). In a multivariable analysis, only age (coefficient = 0.010, P = 0.038) and preoperative posterior astigmatism (coefficient = 0.648, P = 0.002) remained significant. Pterygium dimensions were not significantly associated with SIA magnitude. Flat keratometry steepened by 0.5 ± 1.1 D (P = 0.019), mean keratometry steepened by 0.3 ±0.6 D (P = 0.035), posterior astigmatism was reduced by 0.4 ± 1.2 D (P = 0.072), and e decreased by 5.1 ± 17.3 (P = 0.021)., Conclusions: Pterygium excision has a significant astigmatic effect on the posterior corneal surface. The astigmatic effect increases with age and with higher preoperative posterior astigmatism. Pterygium depth and size are not associated with the degree of surgical astigmatic effect.

Purpose : To evaluate the visual outcome and patient satisfaction after a unilateral multifocal IOL implantation in the non-dominant eye of emmetropic patients with presbyopia. Methods : An interventional case series of consecutive patients who underwent unilateral phacoemulsification with femto-laser assisted cataract surgery (FLACS) and refractive lens exchange (RLE), followed by an implantation of a trifocal diffractive IOL (FineVision Micro F), was performed in the non-dominant eyes of emmetropic patients with presbyopia. After 6 months of follow-up, the main outcome measures were uncorrected distance visual acuity (UDVA), uncorrected intermediate visual acuity (UIVA), and uncorrected near visual acuity (UNVA). Secondary outcomes included spherical equivalent (SE), refraction, contrast sensitivity, patient questionnaire and presence of visual side effects. Results : A total of 26 eyes of 26 patients, with an average age of 53.8 ± 4.1 years, were included in this study. Preoperative mean UDVA was 0.13 ± 0.04 logMAR (Snellen 20/27), UIVA was 0.46 ± 0.12 logMAR (Snellen 20/58), and UNVA was 0.66 ± 0.17 logMAR (Snellen 20/91), in comparison to postoperative mean UDVA of 0.18 ± 0.32 logMAR (Snellen 20/30) (p = 0.32), UIVA of 0.17 ± 0.21 logMAR (Snellen 20/30) (p < 0.005), and UNVA of 0.02 ± 0.10 logMAR (Snellen 20/21) (p < 0.005). Monocular UNVA of 20/25 or better in the operated eye was achieved in 23 (88%) patients. Twenty-four (96%) patients said they would recommend this procedure to family and friends. There were no intraoperative complications and no IOL exchange was required. Conclusions : A unilateral RLE of the non-dominant eye with FLACS and a trifocal diffractive IOL (FineVision Micro F) implantation in emmetropic, presbyopic patients is provides satisfactory distance, intermediate, and near visual outcomes with no complications reported in this preliminary case series.

Purpose: To analyze the visual and refractive outcome of the bioptics procedure combining multifocal intraocular lens implantation and excimer laser surgery in young patients with high hyperopic eyes not suitable for a single surgical procedure., Methods: This retrospective case series included 10 eyes of five patients (age range 18-30 years) with high hyperopia (spherical equivalent +8.51 ± 0.85 diopters (D)). They had been treated with serial multifocal intraocular lens implantation followed 6 weeks later by laser in situ keratomileusis for residual hyperopia. Uncorrected distance visual acuity, uncorrected near visual acuity, corrected distance visual acuity, corrected near visual acuity, and manifest refraction were evaluated before surgeries, after multifocal intraocular lens implantation, and 3 months post laser in situ keratomileusis., Results: No patients were lost to follow-up (6 months). The mean spherical equivalent decreased to +2.05 ± 1.33 D after multifocal intraocular lens implantation and to -0.10 ± 0.58 D after the laser in situ keratomileusis procedure. Success of the procedures was determined by uncorrected visual acuity. LogMAR uncorrected distance visual acuity improved by a total of more than six lines from 1.05 ± 0.18 LogMAR to 0.46 ± 0.12 LogMAR post multifocal intraocular lens implantation and to 0.15 ± 0.06 LogMAR after both surgeries. The LogMAR uncorrected near visual acuity increased by 0.81 ± 0.82 LogMAR after lens implantation due to loss of accommodation, and all eyes reached a LogMAR of 0 at 1 month postoperatively following laser in situ keratomileusis., Conclusions: A bioptics approach involving multifocal intraocular lens followed 6 weeks later by a laser in situ keratomileusis procedure for the correction of very high hyperopia enabled the resolution of the residual refractive error in young very high hyperopic patients.

Purpose: To evaluate the refractive and keratometric effect of arcuate keratotomy using femtosecond technology in patients with high post-keratoplasty astigmatism with a mushroom profile., Setting: Enaim Refractive Center, Tel-Aviv, Israel., Design: Noncomparative prospective interventional case series., Methods: The arcuate depth incision was set to 80% of the minimal graft thickness, with a 60-degree angle. The mean diameter was 5.79 mm ± 0.32 (SD) according to the graft size. Patient evaluation included logMAR corrected distance visual acuity (CDVA), refraction, keratometry (K), and a complete eye examination., Results: Twenty-seven eyes of 27 patients after keratoplasty surgery were included. Both uncorrected distance visual acuity and logMAR CDVA improved after surgery. The preoperative mean logMAR CDVA was 0.29 ± 0.37 (SD), which improved by 1 line (to 0.19 ± 0.10; P = .01). The mean refractive astigmatism was -8.43 ± 2.80 diopters (D) (range -4.5 to -15 D), and it declined at the 3-month postsurgical follow-up to -4.31 ± 0.23 D (P < .001) and remained stable until the end of follow-up (-3.31 ± 1.39 D; P = 1.00). The K value decreased by 1.18 D (P < .001). There were no complications or adverse effects during the follow-up period., Conclusions: Arcuate keratotomies performed with the femtosecond laser showed good results. There was a more than 50% decrease in post-mushroom profile keratoplasty astigmatism as well as stability of the results over 1 year., Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned., (Copyright © 2015 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to test the 42 parameters of the ocular response analyzer for distinguishing between the biomechanical properties of emmetropic eyes with normal topography and eyes with moderate-to-high with-the-rule astigmatism (WTA) and against-the-rule astigmatism (ATA) that have symmetric bowtie topography., Methods: This retrospective case series study included 37 patients (37 studied eyes) with WTA astigmatism and 35 patients (35 studied eyes) with ATA astigmatism. The control group consisted of 70 patients with emmetropia (70 studied eyes) with normal topography. We first tested correlations of the parameters that describe the applanation curve during ocular response analyzer measurements with the maximum keratometry values and the corneal thickness in all 3 groups. We then evaluated the significant parameters among them in search of any group differences in the biomechanical properties of the cornea., Results: Fifteen parameters correlated with Kmax reading values or corneal thickness values. The correlation coefficients (r) were low. The best correlated parameters were p1area, p2area, h1, dive1, p2area1, h11, h2, and h21. The ATA group had the highest number of parameters (n = 6) with significant differences compared with the control group. Only p2area was predictive for ATA. In contrast, the WTA group had only 1 parameter (p2area1) that was found to be significantly different compared with the control group., Conclusions: Some of the new waveform parameters can distinguish between patients with ATA and WTA and normal topography patterns and may delineate the differences in biomechanical properties between these groups that may predict the risk of corneal ectasia after laser in situ keratomileusis.

Objective: To determine the safety and efficacy of topical 0.03% tacrolimus ointment treatment for subepithelial corneal infiltrates (SEIs)., Methods: This prospective non-controlled interventional case series included patients with SEIs who had been previously treated with topical corticosteroids with either no improvement or the medication being withdrawn due to associated intraocular pressure (IOP) elevation. The patients were treated with 0.03% tacrolimus ointment twice daily for 22 weeks (including a 1-month washout). The objective data were best-corrected Snellen visual acuity (BCVA), IOP, and full ocular examination results, including SEI severity and the Schirmer test. The subjective data were the patients' responses to a questionnaire at all follow-up visits., Results: The patients consisted of five males (45%) and six females (55%) (mean age 50 ± 11 years) who were followed up for an average of 22 weeks. The mean BCVA (logarithm of the minimum angle of resolution [logMAR]) before and after treatment was 0.34 ± 0.09 and 0.08 ± 0.04 respectively (p = 0.042). All the patients evidenced significant objective clinical improvement, and none had a severe degree of SEI at the end of the treatment. The patients reported considerable reduction in the severity of their symptoms (foreign body sensation, glare, etc.). Three patients were excluded due to side-effects (one had severe dizziness and discomfort), and their data were excluded from the study., Conclusion: Topical tacrolimus 0.03% is a safe and effective alternative treatment in patients with SEIs who do not respond to other treatment modalities or have untoward side-effects from topical steroids.

Purpose: The aim of this study was to compare the outcomes of "mushroom" femtosecond laser-enabled keratoplasty (M-FLEK) with those of conventional penetrating keratoplasty (PKP) in eyes with keratoconus. The femtosecond laser-enabled "mushroom" pattern keratoplasty technique results in less postoperative astigmatism and higher endothelial cell counts compared with conventional PKP in patients with keratoconus., Methods: This was a nonrandomized retrospective, single private center clinical study. Between March 2010 and April 2012, 26 eyes underwent M-FLEK and 33 eyes underwent conventional PKP. Data on preoperative and postoperative manifest refraction, uncorrected visual acuity and best-corrected visual acuity (BCVA), endothelial cell counts, vector analysis, and complications were retrieved and analyzed., Results: At 12 months of follow-up, the mean logMAR BCVA was 0.31 ± 0.55 in the M-FLEK group and 0.32 ± 0.21 in the PKP group (P = 0.91). The mean spherical equivalent was similar between the groups. The mean manifest cylinder was significantly lower in the M-FLEK group (-2.84 ± 1.08 diopters) than in the PKP group (-3.93 ± 2.26 diopters; P = 0.03). There was a smaller mean endothelial cell loss in the M-FLEK group compared with the PKP group (32.1% vs 38.7%, respectively, P = 0.17) 1 year postoperatively. The complication rates were similar for both groups., Conclusions: M-FLEK appears to be a safe procedure that results in less astigmatism and a trend toward higher endothelial cell counts compared with conventional PKP, with similar postoperative BCVA.

Background: Topical bevacizumab is a potential treatment modality for corneal neovascularization, and several recent studies have demonstrated its efficacy. No previous study of the pharmacokinetics of topical bevacizumab has been performed in human eyes. The purpose of this study is to investigate the pharmacokinetics of topical administration of bevacizumab in human eyes, and also to compare the pharmacokinetics of intravitreal bevacizumab injections with previously reported data., Methods: Twenty-two (22 eyes) were included in this study, and divided into four groups: eight patients received topical bevacizumab and aqueous samples were obtained 1 hour later during cataract extraction surgery (group 1), eight patients received topical bevacizumab and vitreous samples were obtained 1 day later during pars-plana vitrectomy (PPV) (group 2), three patients received intravitreal bevacizumab and vitreous samples were obtained during PPV (group 3). Vitreous samples from three patients who received no bevacizumab served as controls (group 4). All samples underwent enzyme-linked immunosorbent assay to detect bevacizumab., Results: No bevacizumab was detected in the aqueous or vitreous of any topically treated eyes. The mean vitreal half-life for intravitreally injected bevacizumab was 4.9 days in four non-vitrectomized eyes and 0.66 days in one previously vitrectomized eye., Conclusions: Topically administered bevacizumab does not penetrate the cornea into the anterior chamber and vitreous cavity, indicating that topical use for treating corneal neovascularization has minimal risk of intraocular penetration and adverse events related to intraocular vascular endothelial growth factor inhibition. The half-life following intravitreal bevacizumab injection measured in this study is comparable to that of previous reports, and includes the first demonstration of a significantly reduced half-life following intravitreal injection in a previously vitrectomized eye.

Purpose: To describe our experience with monovision excimer laser correction in individuals with myopic presbyopia., Methods: This prospective interventional case series was conducted in a private refractive surgery center on 40 patients with presbyopia aged 40 years and older, who were treated with monovision refractive surgery between 2010 and 2011. The dominant eye was corrected for distance vision and the nondominant eye was corrected for near vision, with anisometropia of ≥1.00 diopters (D). All patients underwent comprehensive objective and subjective visual assessments, including a questionnaire that was filled out preoperatively and at 6 and 12 months postoperatively. The primary outcomes were preoperative and postoperative refraction, binocular visual acuity, stereopsis, contrast sensitivity, glare, and questionnaire results., Results: The 1-year follow-up was completed by 38 patients (95%). Preoperative and 1-year postoperative refraction of the distance eye spherical equivalent (SE), anisometropia SE, and uncorrected visual acuity were -4.05 ± 1.94 and -0.01 ± 0.22 D, 0.45 ± 0.50 and 1.73 ± 0.56 D, and 0.87 ± 0.2 and 0.09 ± 0.11 logMAR, respectively. Best-corrected visual acuity was unchanged. Both mean distance and near stereopsis decreased, from 52 to 142 seconds of arc and from 54 to 57 seconds of arc, respectively. Contrast sensitivity and glare decreased significantly. Patient satisfaction improved from 41.5 ± 30.4% to 85.2 ± 5.0% (range, 40 to 100%) at the 1-year follow-up., Conclusions: Monovision excimer laser correction provides both effective and satisfactory results and should be considered as an option for individuals with myopic presbyopia suitable for, and interested in, refractive surgery.

We report a patient who developed an anaphylactic reaction several minutes after intracameral injection of cefuroxime at the end of uneventful phacoemulsification and intraocular lens implantation surgery. The patient had a known allergy to penicillin but not to cefuroxime. This rare life-threatening complication was recognized and immediately treated by the surgeon. The literature on the use of intracameral cefuroxime for endophthalmitis prophylaxis and its risk for anaphylaxis is reviewed. Cataract surgeons should be aware of this potentially fatal complication and be prepared to handle it., (Copyright © 2013 ASCRS and ESCRS. Published by Elsevier Inc. All rights reserved.)

Background/aims: Bevacizumab (Avastin), an anti-vascular endothelial growth factor drug, has been successfully used in the recent years to treat ocular pathologies, mostly by intravitreal administration. The aim of the current study was to assess the off-label topical use of high-dose bevacizumab for the treatment of corneal neovascularization., Methods: Seventeen eyes of 17 patients with corneal neovascularization secondary to various pathologies were included. The patients were treated with topical bevacizumab (25 mg/ml) 4 times daily for 2 weeks. The following parameters were evaluated at baseline and on days 3, 7 and 14: visual acuity, slit-lamp examination, intraocular pressure, heart rate and blood pressure. Color photos were obtained at baseline and on day 14., Results: Eleven eyes (65%) demonstrated regression of corneal neovascularization and/or clearing of corneal opacification. Adverse ocular events were mild and transient, and included eyelid swelling/chalazion and superficial punctate keratitis., Conclusion: Treatment with high-dose topical bevacizumab (25 mg/ml) was effective for corneal neovascularization in nearly two thirds of the eyes treated. Adverse ocular side effects were mild and transient.

Purpose: To investigate the roles of CYP1B1 and MYOC mutations and characterize the phenotype of primary congenital glaucoma in Israeli patients from 3 different ethnic backgrounds., Design: Interventional case series., Methods: This institutional study included 34 Israeli primary congenital glaucoma patients (26 families) comprising 9 Jews (9 families), 17 non-Bedouin Muslim Arabs (10 families), and 8 Druze (7 families). The patients and their relatives (n = 99) were screened for CYP1B1 and MYOC mutations., Results: Mutations in the CYP1B1 gene were detected in 12 of 26 families (46%) with primary congenital glaucoma (5 Muslim Arab, 5 Druze, and 2 Jewish). The Jewish families had compound heterozygous mutations and digenic mutations (ie, an Ashkenazi family had mutations in the CYP1B1 gene [Arg368His, R48G, A119S, and L432V haplotypes] and an Ashkenazi-Sephardic family had a mutation on the CYP1B1 gene [1908delA, Sephardic] with a second missense mutation on the MYOC gene [R76K, Ashkenazi]). The Muslim Arabs and Druze tended to have a more severe phenotype than that of the Jews., Conclusion: The phenotype and spectrum of the CYP1B1 and MYOC mutation roles in the clinical characteristics of primary congenital glaucoma varied according to ethnicity. The rarity of mutations in the CYP1B1 gene among Ashkenazi primary congenital glaucoma patients indicates that a different locus may be involved in the phenotype., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: We retrospectively investigated the intraocular pressure (IOP)-lowering effects of echothiophate iodide (EI) as adjunctive treatment for pseudophakic glaucoma patients who were receiving maximal medical therapy (MMT), including the newer class of medications, i.e., prostaglandin analogs, alpha-2 agonists, and topical carbonic anhydrase inhibitors., Methods: The medical records of all pseudophakic glaucoma patients (24 eyes) under MMT who received supplementary EI 0.125% between January 2002 and December 2003 were reviewed. IOP data and number of medications before, during and after EI treatment were collected., Results: Adding EI to MMT further reduced IOP in 23 of 24 eyes. Three eyes (12.5%) showed some lowering of IOP, but not enough to be considered controlled (IOP above the target pressure). The mean baseline IOP of 30.4 +/- 8.2 mmHg (median 29 mmHg) dropped at final follow-up (11.2 +/- 3.9 months) to 16.6 +/- 4.2 mmHg (median 17 mmHg, p < 0.0001) in all eyes that had showed effective pressure reduction upon the addition of EI. Their IOP rose to 27.7 +/- 8.0 mmHg (median 28 mmHg, p < 0.001) when EI was discontinued because of commercial non-availability. IOP reduction was > or =20% in 18 (75%) eyes and > or =30% (a mean decrease of 16.7 +/- 8.3mmHg) in 15 eyes (63%). Four eyes (16.6%) required a trabeculectomy despite EI supplement. Five eyes were re-challenged with EI when a small amount was released for sale: their IOP of 26.6 +/- 7.1 mmHg after the first EI discontinuation had dropped to 16.4 +/- 4.3 mmHg (p < 0.0001) and rose to 29.6 +/- 7.1 mmHg when EI was again discontinued. The recorded EI-associated side effects were increased miosis in all eyes and headache (8/24 patients), neither of which were reasons for discontinuation of the drug in any patient., Conclusion: EI substantially decreased the IOPs in pseudophakic glaucoma eyes receiving maximal medical therapy, including the newer class of medications. This drug may be the last resort for post-cataract advanced glaucoma patients and may obviate the need for filtering surgery among the very elderly.

Purpose: To evaluate the treatment with topical 1% cyclosporine A (CsA) in patients with subepithelial corneal infiltrates (SEIs)., Methods: We retrospectively reviewed the records of 9 patients (12 eyes) before and after the treatment with CsA 1% eyedrops twice daily. All patients had been treated with topical corticosteroids previously without improvement or had to stop the medication secondary to intraocular pressure elevation. The objective data recorded included best-corrected Snellen visual acuity, intraocular pressure, number of medications in use, and evaluation of severity of SEIs (improved, stable, or worse). For their subjective evaluation, patients were asked to complete a questionnaire based on the last follow-up visit., Results: Five males (56%) and 4 females (44%), mean age of 47 +/- 13 years, were included. Mean follow-up on CsA was 13 +/- 7 months. The mean best-corrected Snellen visual acuity (logarithm of the minimum angle of resolution) before and after treatment was 0.42 +/- 0.40 and 21 +/- 0.28, respectively, with no statistically significant improvement. There was statistically significant reduction in the number of medications before and after treatment from 1.88 +/- 1.05 to 1.22 +/- 0.44, respectively (P = 0.049). Six patients (66%) showed clinical improvement, and 3 (34%) were stable during the treatment period. Patients reported statistically significant reduction in the severity of symptoms before and after the treatment. Most of the patients reported no foreign body sensation, glare, or other side effects with topical CsA treatment. Overall, patients noted an improvement in vision and satisfaction with CsA treatment., Conclusions: Topical CsA 1% is a safe and effective alternative treatment in patients with SEIs who do not respond to other treatment modalities or have unwanted side effects from topical steroids.