Search

Introduction: Clear corneal incision (CCI) architecture in modern microincision cataract surgery (MICS) plays an undeniable role in postoperative refraction. The goal of this study was to evaluate the effect of hinge incision prior to two-step CCI on postoperative refractive astigmatism after cataract surgery and to demonstrate the schematic presentation of these postoperative astigmatic changes via double-angle polar plots. Methods: this study involved a consecutive case series of patients who had MICS. The first incision was performed as a two-step CCI, whereas the second was made as a hinge incision prior to 2-step CCI. The preoperative corneal and postoperative refractive astigmatism and surgically induced astigmatism (SIA) were calculated by vectorial analysis. Hotelling’s T2 test was performed to compare the centroid values of preoperative and postoperative corneal astigmatism. Results: a total of 63 eyes from 57 subjects were evaluated. Group I consisted of 27 eyes with the two-step CCI, and Group II included 36 eyes with the hinge incision prior to two-step CCI. No significant difference was found between the groups in terms of age, sex, axial length, keratometry readings, implanted intraocular lens power, and postoperative spherical equivalent. The centroids of corneal astigmatism postoperatively increased to 0.21 D at 87.6°±0.61 with no significance in Group I (p=0.525) and to 0.70 D at 90.6°±0.47 with significance in Group II (p=0.032). The difference in postoperative centroids between the two groups was also significantly different (p=0.043). Finally, the centroids of SIA were 0.12 D at 85.5°±0.50 and 0.22 D at 91.1°±0.49 for Group I and Group II, respectively, with no significance. Discussion and conclusion: A hinge incision did not have an unfavorable effect on postoperative refractive astigmatism; therefore, it may be preferred for controlled entrance to the anterior chamber, NA

Introduction: this study analyses if a translated version of the CatInfo tool increases the knowledge of Serbian-and Turkish-speaking patients about cataract surgery. Methods: in total, 61 cataract patients, literate in Serbian or Turkish, were randomly allocated into two groups. Via an interactive computer-based tool (""CatInfo""), patients either saw a detailed audio-visual presentation about cataract surgery (study group) or a ""placebo""video (control group). Afterwards, all participants had a face-to-face discussion with an ophthalmologist. Immediately after the interview and on the day of surgery, all patients had to fill out a questionnaire including knowledge and demographic questions. Patients in the study group were further asked about their satisfaction with the CatInfo tool and the usefulness of such a device before other interventions. Results: patients in the study group answered significantly more questions correctly compared to the control group, and this information gain remained stable over a 1-week period. There was a significant low negative correlation between educational level and the test results, whereas age and computer habits of the participants did not have an influence on correct answers. Satisfaction with the CatInfo tool was high in the Serbian and the Turkish group (96% and 84%, respectively), and 92% of Serbian patients as well as 62% of the Turkish patients rated that they could imagine to use such a device before any other surgery. Discussion/Conclusion: the translated version of the CatInfo tool improved patients' knowledge, and this information gain remained stable until the day of the surgery., NA

Purpose: diagnose keratoconus by establishing an effective logistic regression model from the data obtained with a Scheimpflug-Placido cornea topographer. Methods: topographical parameters of 125 eyes of 70 patients diagnosed with keratoconus by clinical or topographical findings were compared with 120 eyes of 63 patients who were defined as keratorefractive surgery candidates. The receiver operating character (ROC) curve analysis was performed to determine the diagnostic ability of the topographic parameters. The data set of parameters with an AUROC (area under the ROC curve) value greater than 0.9 was analyzed with logistic regression analysis (LRA) to determine the most predictive model that could diagnose keratoconus. A logit formula of the model was built, and the logit values of every eye in the study were calculated according to this formula. Then, an ROC analysis of the logit values was done. Results: Baiocchi Calossi Versaci front index (BCVf) had the highest AUROC value (0.976) in the study. The LRA model, which had the highest prediction ability, had 97.5% accuracy, 96.8% sensitivity, and 99.2% specificity. The most significant parameters were found to be BCVf (p=0.001), BCVb (Baiocchi Calossi Versaci back) (p=0.002), posterior rf (apical radius of the flattest meridian of the aspherotoric surface in 4.5 mm diameter of the cornea) (p=0.005), central corneal thickness (p=0.072), and minimum corneal thickness (p=0.494). Conclusions: the LRA model can distinguish keratoconus corneas from normal ones with high accuracy without the need for complex computer algorithms., NA

It has been established that many chemotherapeutic agents are associated with a variety of ocular side effects. As an antineoplastic agent, 5-fluorouracil (5-FU) is the chemotherapeutic agent that is frequently linked with cicatricial ectropion. Capecitabine is a prodrug of 5-FU and has a more favorable side effect profile than 5-FU. Frequent side effects of capecitabine include gastrointestinal events and hand-foot-mouth syndrome; cicatricial ectropion is rather uncommon. Enzyme deficiencies affecting the capecitabine metabolism have been reported to be associated with exaggerated generalized systemic and cutaneous side effects; however, there are no cases in the literature reporting capecitabine-induced isolated bilateral-progressive ectropion. Although cessation of the agent is frequently sufficient for the treatment of ectropion, close follow-up is indicated in such patients as permanent damage may occur if the problem is left untreated. We report a case of capecitabine-induced bilateral cicatricial ectropion refractory to treatment cessation, ultimately requiring surgical treatment., NA

PURPOSE To analyze the changes in anterior and posterior corneal surfaces and aberrations in patients who underwent intracorneal ring segment (ICRS) implantation for the treatment of keratoconus. METHODS Eighty-nine eyes of 59 patients with keratoconus who underwent ICRS implantation were analyzed. All eyes were evaluated using a tomography system combining a Placido disc and Scheimpflug photography before and at least 6 months after surgery. Total, anterior, and posterior corneal aberrations, anterior and posterior sagittal and tangential anterior and posterior curve analysis, keratometry (K), minimum corneal thickness, and anterior chamber depth were analyzed before and after surgery. RESULTS Flattening with a decrease in the cone shape on the anterior corneal surface and steepening in the paracentral area with persistence of cone appearance on the posterior corneal surface were noted in all cases after ICRS implantation. The total corneal higher-order aberrations (HOAs) significantly decreased from 1.09 ± 0.43 to 0.71 ± 0.32 μm, and anterior corneal HOAs significantly decreased from 0.98 ± 0.46 to 0.81 ± 0.37 μm, whereas the posterior corneal HOAs increased from 0.53 ± 0.29 to 0.66 ± 0.25 μm after ICRS implantation (P < 0.05). There was a significant decrease in anterior maximum keratometry, but there was a significant increase in posterior maximum keratometry after ICRS implantation (P < 0.05). CONCLUSIONS The cone shape persists on the posterior corneal surface despite its correction on the anterior corneal surface, leading to a decrease in anterior corneal aberrations and an increase in posterior corneal aberrations after ICRS implantation in eyes with keratoconus.

INTRODUCTION[|]This study is an analysis of the cosmetic and functional results of patients who underwent keratopigmentation (KTP).[¤]METHODS[|]Sixteen eyes of 16 patients, 7 females (43.75%) and 9 males (56.25%) were included in the study. Intrastromal and superficial manual KTP were performed under general anesthesia. Patients with no light perception or with only light perception but total corneal opacification, prosthetic contact lens intolerance, or unwillingness to use a contact lens were studied. The main outcomes were postoperative patient's satisfaction, cosmetic results, pigment stabilization and surgical complications. A grading system (0-5 points) was used to assess patient satisfaction and the cosmetic results.[¤]RESULTS[|]The mean age of the patients was 30.5+-12.06 years (range: 16-53 years). Black pigment was used in 10 patients (62.5%), a brownish color in 5 patients (31.25%) and a greenish, yellow, blue, and black color pigmentation was used for 1 patient (6.25%). The mean follow-up was 29.31+-15.45 months (range: 8-52 months). In 2 of 16 patients, mild to moderate pigment loss was seen 12 months after the surgery and superficial KTP was repeated. Minimal pigment loss was seen in 5 patients, but the cosmetic results were satisfactory and no secondary surgical procedure was required. Pigment leakage underneath the conjunctiva was seen in only 1 patient. Otherwise, there were no complications associated with keratopigmentation. The postoperative mean patient satisfaction score was 4.18+-0.75 points (range: 3-5 points).[¤]DISCUSSION AND CONCLUSION[|]KTP is a safe surgical procedure that is easy to learn and perform, does not require expensive materials, and avoids more extensive and invasive reconstructive ocular procedures. Corneal KTP may have a great impact on future ophthalmic surgical practice from both therapeutic and cosmetic perspectives.[¤]

Purpose: to compare the functional outcomes and astigmatic tolerability after implantation of multifocal intraocular lenses (IOLs) with a +2.5, +3.0, and +3.75 diopter (D) addition power. Methods: this study included 122 eyes of 61 patients who had bilateral cataract extraction and implantation of diffractive aspheric multifocal acrylic IOLs with +2.5 D (+2.5 group), +3.0 D (+3.0 group), and +3.75 D (+3.75 group) addition powers. 1-year after surgery, distance corrected near (DNVA) and intermediate (DIVA) visual acuities at 32, 40, 45, 50, 55, and 60 cm; and contrast sensitivity measurements under photopic, mesopic and mesopic with glare conditions; spherical and astigmatic defocus testing; distance-intermediate-near vision patient satisfaction levels; spectacle dependance; patient-reported outcomes were assessed binocularly. Results: the +2.50 D group had better DIVA than both +3.0 group and +3.75 groups at 45 cm, 50 cm, 55 cm, and 60 cm (p < 0.05). The +3.75 group had better DNVA than both +2.5 and +3.0 IOL groups at 32 cm (p < 0.05). There was no significant difference in mean contrast values at all frequencies between three IOL groups (p > 0.05). The +2.50 D group showed better astigmatic tolerability than +3.00 group (at 2.00 D) and +3.75 group (at 1.50 D, and at 2.00 D) (p < 0.05). Conclusion: multifocal IOLs with +2.5 add power have better intermediate vision, but worse near vision compared to multifocal IOLs with +3.00 D and +3.75 D add power. Multifocal IOLs with +2.50 D add power tend to have better astigmatic defocus tolerability than multifocal IOLs with +3.00 D and +3.75 D add powers., NA

Purpose: To evaluate the topographic, refractive, and pachymetric changes after ethanol-assisted transepithelial corneal cross-linking (CXL) to stabilize progression of keratoconus (KC). Patients and methods: This study retrospectively evaluated the long-term topographic, refractive, and pachymetric changes in patients diagnosed with KC who underwent corneal cross-linking and/or intrastromal corneal ring segment (ICRS) implantation. The subjects were divided into three groups, corresponding to eyes treated with CXL alone (group 1), CXL and ICRS at the same time (group 2), and CXL after ICRS implantation (group 3). Corrected visual acuity and refraction, steep keratometry (SteepK) values, steepest keratometry reading on sagittal curvature map, and corneal thickness were recorded preoperatively and at each visit. Changes between measurements were assessed during follow-up. Results: Corrected distant visual acuity (CDVA) values improved in all groups compared with baseline, but the differences were not statistically significant except for the first year (p > 0.05). In groups 1 and 3, SteepK values did not change statistically significantly during the entire follow-up (p > 0.05). In group 2, SteepK values statistically significantly decreased at all follow-up examinations compared with baseline, determined as the first month after ICRS implantation (p

Yunus Karabela,1 Orkun Muftuoglu,2 Faruk Kaya1 1Department of Ophthalmology, Medipol University, 2Department of Ophthalmology, Vehbi Koç Vakfi Amerikan Hospital, Istanbul, Turkey Purpose: This study aimed to evaluate the accuracy and consistency of corneal flap thickness in laser-assisted in situ keratomileusis (LASIK) with the Moria M2 single-use head 90 microkeratome. Methods: The central corneal thickness of 72 (37 right, 35 left) eyes of 37 patients was measured by ultrasonic pachymetry preoperatively and intraoperatively after flap cut. The Moria M2 single-use head 90 microkeratome was used to create a superior hinged flap in all eyes. The right eyes were always operated on before the left eyes in each patient, using the same blade in all bilateral cases. All patients underwent LASIK for myopia and/or myopic astigmatism using VISX Star S4 platform. Results: The mean preoperative spherical equivalent refraction was -3.55±2.30D (range: -0.625 to -11.00D), preoperative central corneal thickness by ultrasonic pachymetry was 541±26.82µm (490–600µm) and steepest K was 44.08±1.49D (40–46.75D) in all eyes. The mean flap thickness was 136.97±20.07µm (106–192µm), 131.2±19.5µm (91–192µm), and 134.16±19.85µm (91–192µm) in the right, left, and both eyes, respectively. A positive significant relationship was found between flap thickness and preoperative ultrasonic pachymetry thickness. No significant relationship was found between flap thickness and the age, preoperative spherical equivalent, and preoperative steepest K. The difference between the first and second eyes was not significant. There were no major intraoperative and postoperative complications in all eyes. Conclusion: The Moria M2 single-use head 90 microkeratome cut relatively thicker flaps than were intended. The flap thickness range was quite wide. This was a disadvantage for the accuracy and consistency of corneal flap thickness. Keywords: flap thickness, laser-assisted in situ keratomileusis, LASIK, microkeratome, Moria M2 single-use head

WOS: 000331530700001 PubMed ID: 24452211 Purpose:The aim of this study was to evaluate the clinical efficacy and safety of sulfur hexafluoride (SF6) as a tamponading agent after donor placement during Descemet stripping endothelial keratoplasty (DSEK) surgery and to compare the outcomes with those of air.Methods:Forty-four eyes of 44 consecutive patients who underwent DSEK were included in the study. Air was used in 22 eyes of 22 patients (air group), and SF6 was used in 22 eyes of 22 patients (SF6 group) to attach the donor lenticule. The complications, corrected visual acuity (CVA), and the endothelial cell density (ECD) results were compared between these 2 groups.Results:Six eyes had graft dislocation in the air group that underwent successful rebubbling on postoperative day 1. There was no graft dislocation in the SF6 group. There was no other complication observed in both the groups. The mean increase in the CVA was 1.09 0.36 logarithm of the minimum angle of resolution in the air group, whereas it was 0.80 +/- 0.57 logarithm of the minimum angle of resolution in the SF6 group. The mean increase in the CVA was not statistically different between the 2 groups (P = 0.060). Compared with the mean ECD in donor grafts, the mean decrease in the ECD was 222 +/- 86 (44%) cells per square millimeter in the air group and 178 +/- 52 (39%) cells per square millimeter in the SF6 group at the 1-year follow-up. The mean decrease in the ECD was statistically significantly higher in the air group compared with that in the SF6 group (P = 0.049).Conclusions:SF6 is comparable to air for attaching the donor graft as a tamponading agent in DSEK surgery.

Purpose The purpose of this study was to describe a new modification for big-bubble deep anterior lamellar keratoplasty (DALK) using pneumatic pressure to detach Descemet membrane (DM) via air injection followed by ophthalmic viscoelastic device (OVD) injection. Methods After failure of big-bubble formation after air injection, OVD was injected from a different site other than the previous air injection using a 27-gauge cannula to detach DM, called air-visco bubble (AVB) DALK technique. The technique was used in 7 human corneoscleral rims that were investigated with anterior segment optical coherence tomography and histopathology and in 69 eyes that underwent DALK surgeries. Results Big-bubble formation was noted in 4 of 7 of the donor corneoscleral rims. The anterior segment optical coherence tomography showed big-bubble formations together with intrastromal OVD accumulation. The histology of the donor corneas showed microdetachments at the DM in the periphery, deep intrastromal separation, and big-bubble formation filled with OVD. One hundred forty-one of 210 eyes (67%) underwent successful DALK with only air injection, and 69 of 210 eyes (33%) underwent AVB technique when a big bubble was not achieved with only air injection. All the corneas showed a clear interface with good wound healing when DM was bared with the AVB DALK technique. Conclusions Additional OVD injection to detach DM may be useful in cases where air injection fails. Also, creating small DM detachments with air injection may facilitate the formation of a big bubble with further OVD injection.

To report a case of archipelago keratitis and its improvement as evaluated by corneal densitometry. A review of the patient's record and relevant literature. A 57-year-old man presented with blurred vision associated with photophobia and halos around lights. Slit-lamp examination revealed multiple confluent, nummular subepithelial infiltrates. The infiltrates were unresponsive to topical nonsteroidal anti-inflammatory drops. The treatment was changed to topical steroids and oral acyclovir and a diagnosis of archipelago keratitis was made. The patient showed quick response to the treatment and the infiltrates disappeared within 5 weeks. However, no clear changes were observed initially by slit-lamp but corneal densitometry allowed us to evaluate improvement as the density value decreased from 96.5 to 38.6. After 10 days of treatment all the symptoms were resolved. Archipelago keratitis responded well to topical steroids and oral acyclovir. We describe the use of corneal densitometry complementary to slit-lamp examination in the clinical observation of archipelago keratitis.

Background Recent reviews of blue light-filtering intraocular lenses (IOLs) have stated their potential risks for scotopic vision and circadian photoentrainment. Some authors have challenged the rationale for retinal photoprotection that these IOLs might provide. Our objective is to address these issues by providing an updated clinical perspective based on the results of the most recent studies. Methods This article evaluates the currently available published papers assessing the potential risks and benefits of blue light-filtering IOLs. It summarizes the results of seven clinical and two computational studies on photoreception, and several studies related to retinal photoprotection, all of which were not available in the previous reviews. These results provide a clinical risk/benefit analysis for an updated review for these IOLs. Results Most clinical studies comparing IOLs with and without the blue light-filtering feature have found no difference in clinical performance for; visual acuity, contrast sensitivity, color vision, or glare. For blue light-filtering IOLs, three comparative clinical studies have shown improved contrast sensitivity and glare reduction; but one study, while it showed satisfactory overall color perception, demonstrated some compromise in mesopic comparative blue color discrimination. Comparative results of two recent clinical studies have also shown improved performance for simulated driving under glare conditions and reduced glare disability, better heterochromatic contrast threshold, and faster recovery from photostress for blue light-filtering IOLs. Two computational and five clinical studies found no difference in performance between IOLs with or without blue light-filtration for scotopic vision performance and photo entrainment of the circadian rhythm. The rationale for protection of the pseudophakic retina against phototoxicity is discussed with supporting results of the most recent computational, in-vitro, animal, clinical, and epidemiological investigations. Conclusions This analysis provides an updated clinical perspective which suggests the selection of blue light-filtering IOLs for patients of any age, but especially for pediatric and presbyopic lens exchange patients with a longer pseudophakic life. Without clinically substantiated potential risks, these patients should experience the benefit of overall better quality of vision, reduced glare disability at least in some conditions, and better protection against retinal phototoxicity and its associated potential risk for AMD. Electronic supplementary material The online version of this article (doi:10.1007/s00417-011-1697-6) contains supplementary material, which is available to authorized users.

The purpose of this study was to evaluate the results of phacoemulsification with intravitreal bevacizumab and triamcinolone acetonide injection in patients with diabetic clinically significant macular edema and cataract.The records of 22 diabetic patients, with clinically significant macular edema and cataract who have undergone phacoemulsification with intravitreal injection of 1.25 mg bevacizumab and 2 mg triamcinolone acetonide, were retrospectively evaluated. All patients have undergone focal or modified grid argon laser photocoagulation 1 month after the surgery. All patients were evaluated by spectral OCT/OCT SLO before, 1 month, and 3 months after the surgery. The main parameters were the best-corrected visual acuity (BCVA) and central macular thickness (CMT). Paired samples t-test was used for statistical analysis.The mean initial best-corrected visual acuity was 0.15 ± 0.09 (0.05-0.3), whereas it was 0.6 ± 0.28 (SD) (0.3-0.7), 0.6 ± 0.22 (SD) (0.4-0.7) at 1 month and 3 months after the surgery, respectively. The BCVA levels recorded at 1 month and 3 months after the surgery were significantly higher than the initial BCVA (P = 0.002). The mean initial CMT was 392.2 ± 109.5 μm, whereas it was 295 ± 57.2 μm and 265.5 ± 30.3 μm at 1 month and 3 months after the surgery, respectively. The CMT values recorded at 1 month and 3 months after the surgery were significantly lower than the initial CMT (P0.001, P0.001).Phacoemulsification with intravitreal injection of bevacizumab and triamcinolone acetonide provides a decrease in CMT with a gain in BCVA in diabetic patients with clinically significant macular edema and cataract.

Keratoconus is a noninflammatory, usually bilateral, progressive disease. It is a pathology characterized by a progressive thinning and ectasia of the stroma that results in a cone-shaped cornea. In advanced keratoconus with corneal opacities, keratoplasty was regarded as the only surgical alternative. Recently, new treatment alternatives were developed in keratoconus treatment, such as intracorneal ring segments and corneal crosslinking. Intracorneal ring segments act as spacer elements between the bundles of corneal lamellae, producing a shortening of the central arc length. Corneal crosslinking treatment increases the stiffness of the cornea. Several studies reported that collagen crosslinking can delay or stop keratoconus progression and produce a better quality of vision. A combination of crosslinking and intracorneal ring segments shows a positive, synergistic effect. Keratoconus is a disease of the corneal stroma and that usually presents itself in patients at an early age, thus the endothelial cel...

To evaluate alterations in corneal power parameters after Descemet-stripping automated endothelial keratoplasty (DSAEK) using rotating Scheimpflug imaging.University of Texas, Southwestern Medical Center, Dallas, Texas, USA.Eyes that had DSAEK were evaluated with a rotating Scheimpflug imaging system (Pentacam). The outcome parameters were mean anterior and posterior keratometry (K), mean anterior radius of curvature and posterior radius of curvature, anterior and posterior astigmatism, central corneal thickness (CCT), true net power, corneal volume, keratometric power deviation, and mean zonal-equivalent K readings. These values were compared with those in a control group of age and sex-matched normal eyes.The DSAEK group comprised 32 eyes (28 patients) and the control group, 32 eyes. The mean anterior K, posterior K, and true net power were 42.53 diopters (D) +/- 1.52 (SD), -6.80 +/- 0.55 D, and 40.55 +/- 1.79 D, respectively, in the DSAEK group and 43.60 +/- 1.62 D, -6.20 +/- 0.31 D, and 42.49 +/- 1.57 D, respectively, in the control group. The posterior radius of curvature, anterior and posterior K values, and true net power were statistically significantly lower in DSAEK eyes than in control eyes (P.01). The equivalent K readings were significantly lower in all zones in DSAEK eyes than in control eyes (P.01). The mean CCT was significantly higher in DSAEK eyes than in control eyes (628 +/- 46 mum versus 553 +/- 35 mum) (P.01).The true net power of the cornea decreased significantly after DSAEK, mainly because of an increase in posterior curvature.No author has a financial or proprietary interest in any material or method mentioned.

Purpose To evaluate the visual and refractive outcomes of limbal relaxing incisions (LRIs) to reduce astigmatism at the time of apodized diffractive multifocal intraocular lens (IOL) implantation. Setting University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA. Methods This retrospective review comprised consecutive patients who had LRIs at the time of lens extraction and AcrySof ReSTOR IOL implantation. A subgroup of patients had subsequent laser in situ keratomileusis (LASIK) for residual refractive error correction. Results The study evaluated 73 eyes (59 patients); 21 eyes (28.7%) of 59 patients had further LASIK (LRI+LASIK). The mean follow-up was 13.2 months ± 6.4 (SD). The mean keratometric astigmatism decreased from 1.49 ± 0.71 diopters (D) preoperatively to 0.56 ± 0.57 D at the last follow-up ( P P = .005) and 1 month ( P = .030) and 6-months ( P = .014) postoperatively, there was no statistically significant difference between the 2 groups at the last follow-up ( P = .528). At the last follow-up, the uncorrected distance visual acuity was 20/25 or better and the uncorrected near visual acuity was J1 or better in 32 (76%) of 42 eyes in the LRI-only group and in 17 (81%) of 21 eyes in the LRI+LASIK group. Conclusion Limbal relaxing incisions at the time of apodized diffractive multifocal IOL implantation, with or without subsequent LASIK, were effective and safe in reducing astigmatism. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

PURPOSE: To evaluate the efficacy, predictability, safety, and intraoperative and postoperative complications of laser in situ keratomileusis (LASIK) retreatment in myopic eyes using wavefront-guided ablation with iris registration (IR). METHODS: Retrospective analysis was used to evaluate wavefront-guided retreatment with IR in a consecutive cohort of 77 eyes (57 patients) after LASIK. The eyes were divided into two groups: no previous retreatment group (group 1) (n = 63) and previous LASIK retreatment group (group 2) (n = 14). The primary outcome variables assessed postoperatively at 1, 3, and 6 months were uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), and pre- and postretreatment changes in manifest refraction. RESULTS: The mean preretreatment spherical equivalent in group 1 was reduced from -0.5 +/- 1.0 diopter (D) (range -3 to 2.4) to 0.06 +/- 0.3 (range -0.9 to 0.6) (P < 0.002) at 6 months. In group 2, the mean preretreatment spherical equivalent was reduced from -0.9 +/- 1.24D (range -3.1 to -0.5) to 0.04 +/- 0.5 (range -1.0 to 1.1) (P < 0.049) at 6 months. At 6 months, UCVA was 20/20 or better in 92% in group 1 and 64% in group 2, of patients, respectively. No eyes lost more than one line of BCVA in group 1 and one eye (7%) lost two lines of BCVA in group 2. CONCLUSION: Wavefront-guided LASIK retreatment with IR after LASIK is an effective, predictable, and safe procedure in cases requiring a single retreatment. In contrast, eyes with previous retreatments showed less predictability and lower percentage of eyes with postoperative 20/20 UCVA.

To report the clinical and histopathologic findings of 2 patients who developed epithelial downgrowth after Descemet stripping automated endothelial keratoplasty (DSAEK).A 64-year-old woman (case 1) underwent DSAEK for corneal edema secondary to Fuchs endothelial dystrophy in left eye. However, the graft failed to attach, and a repeat DSAEK was performed 3 weeks later. After 4 months, the patient developed herpes simplex virus keratitis that resulted in anterior stromal scarring. A penetrating keratoplasty was performed 15 months after the initial DSAEK. Our second patient (case 2) was an 87-year-old female who underwent DSAEK for corneal edema secondary to Fuchs endothelial dystrophy in left eye. Six months later, she had an episode of graft rejection and developed secondary glaucoma. At 14 months postoperatively, a retrocorneal membrane was seen involving the temporal half of the endothelial surface of the graft. The retrocorneal membrane extended from the inferior thickened edge of the endothelial keratoplasty graft to the iris stromal surface. An Ahmed shunt implantation followed by repeat DSAEK were then performed. The excised corneal buttons were examined.Histopathologic evaluation showed multilayered epithelium on the interface and attenuated endothelium in the endothelial graft in case 1. The host cornea showed diffuse stromal scarring. Case 2 showed multilayered epithelium with early cyst formation at the edge of the graft. The epithelium extended to involve the endothelial surface without involvement of interface surface. Significant scar formation was observed between the edge of the endothelial keratoplasty graft and thickened host Descemet membrane. Some pigmented cells were present within the epithelial downgrowth. The epithelium stained positively with cytokeratin A1/A3 in both cases.Although rare, epithelial downgrowth can occur after DSAEK and can be associated with graft failure. Early recognition and surgical treatment of epithelial downgrowth is crucial in treating the complications of corneal decompensation and glaucoma.

Purpose To evaluate the visual and refractive outcomes of laser in situ keratomileusis (LASIK) to correct residual refractive error after apodized diffractive multifocal intraocular lens (IOL) implantation. Setting University of Texas Southwestern Medical Center, Dallas, Texas, USA. Methods This retrospective study reviewed eyes of consecutive patients who had LASIK using the IntraLase FS60 femtosecond laser and Visx Star S4 excimer laser to correct residual refractive error after AcrySof ReSTOR IOL implantation. Results The review comprised 85 eyes of 59 patients. Thirty-six eyes (42.3%) had myopic correction, 35 (41.2%) had mixed astigmatic correction, and 14 (16.5%) had hyperopic correction; 45 eyes (52.9%) also had neodymium:YAG (Nd:YAG) capsulotomy. Six months after LASIK, 91.8% of eyes had an uncorrected distance visual acuity (UCVA) of 20/25 or better, 92.9% had an uncorrected near visual acuity (UCNVA) of J1 or better, and 85.9% had 20/25 or better UCVA concurrent with J1 or better UCNVA. No eye lost more than 1 line of best spectacle-corrected visual acuity; 2 eyes (2.4%) lost 1 line. Ninety-nine percent of eyes were within ±1.00 diopter (D) of emmetropia, and 98% of eyes were within ±1.00 D cylinder. There was no significant difference in postoperative UCVA or UCNVA between the 3 refraction groups (P >.05) or between eyes that had Nd:YAG capsulotomy and those that did not (P >.05). Conclusion Laser in situ keratomileusis for residual ametropia after apodized diffractive multifocal IOL implantation was predictable, effective, and safe.

To evaluate topographic findings, manifest refraction in keratoconic cases, and compare those parameters with respect to age and gender.Four hundred eighty-two eyes of 248 patients (153 male and 95 female) with keratoconus were separated into 3 groups based on their ages (group 1:21 years, group 2: 21-40 years, group 3:40 years). Groups 1, 2, and 3 included 83, 362, and 37 eyes, respectively. All patients underwent full ocular examination and Pentacam (Oculus Optikgerate GmbH) measurement. K values (mean, steepest, and flattest), and central corneal thickness using Pentacam, and manifest refraction were analyzed by comparing the results with respect to patients' gender and ages.The distribution ratios of keratoconic eyes in younger, middle, and older age groups were 17.2%, 75.3%, and 7.5%, respectively, and the distribution ratios of those of patients according to their genders were 37.8% for women and 62.2% for men.The present study demonstrates a clear inverse correlation between age and severity of keratoconus.

Keratoconus is a corneal ectatic disease that is characterized by noninflammatory progressive thinning. Since the utilization of penetrating keratoplasty and rigid contact lenses, there was no improvement for the visual rehabilitation of the keratoconus. Recently, intracorneal ring segments have been investigated to correct ectatic corneal diseases. The aim of implanting intracorneal ring segments is not to treat or eliminate the existing disease, rather a surgical alternative to decrease the astigmatism and corneal abnormality and thus increase the visual acuity to acceptable limits, aiming to at least delay, if not eliminate, the need of corneal grafting. Since its release, intracorneal ring segment implantation for keratoconus seems to be an effective and, most of all, reversible treatment with minimal complications. Conversely, long-term results should be analyzed regarding stability, predictability and the need for further corneal transplantation in the long term.

To compare the thickness of the ciliary bodies of eyes with unilateral high axial myopia with their relatively normal fellow eyes.A total of 19 patients with unilateral high axial length (AL) were included in the study. Mean patient age was 28.4+/-10.4 (11-44) years. All eyes underwent ultrasound biometry to measure the AL, and ultrasound biomicroscopy to measure the anterior chamber depth, ciliary body thickness (CBT), and ciliary process thickness (CPT), ciliary muscle thickness (CMT). The results were compared between each subject's high myopic eye and relatively normal fellow eye.The mean AL was 27.24+/-1.52 mm (range: 25.16-30.21 mm) in high myopic eyes and 23.64+/-0.86 mm (range: 22.47-25.10 mm) in normal fellow eyes. The median +/-95% confidence interval of CBT, CPT, and CMT was 1.350+/-0.034, 0.626+/-0.072, and 0.698+/-0.057 mm, respectively, in high myopic eyes and 1.211+/-0.050, 0.535+/-0.064, and 0.644+/-0.065 mm, respectively, in normal fellow eyes. The anterior chamber depth, CBT, CPT, and CMT were significantly higher in myopic eyes compared with their relatively normal fellow eyes (P0.05). CMT significantly increased with age in both groups (P0.05). There was no significant correlation between age and CBT in both the groups (P0.05).The CBT, CMT, and CPT are significantly higher in eyes with unilateral high axial myopia than in their relatively normal fellow eyes.

To evaluate internal refraction and its relation to other optical properties of the eye across a large range of refractive errors, which can provide useful information for the assessment and design of intraocular lenses and corneal ablation patterns.Cohort study.Three hundred ninety-four eyes of 197 healthy subjects with a mean age of 27+/-7 years (range, 18-42).All eyes underwent optical path difference scans to evaluate corneal topography, whole and internal ocular refraction (determined by the subtraction of corneal refraction from whole ocular refraction), and total and higher-order aberrations (HOAs) were assessed. After the conversion of any spherocylindrical refractive errors to vectorial data (sphere equivalent, blurring strength; cylinder, J(0) [power of Jackson cross cylinder at 90 degrees and 180 degrees] and J45 [power of Jackson cross cylinder at 45 degrees and 135 degrees]), the distribution of internal refraction among refraction groups (high myopes, low to moderate myopes, hyperopes, mixed astigmats, and emmetropes) and relationships between internal refraction, corneal refraction, and wavefront aberrations were analyzed. The compensation relation and its rate between corneal and internal astigmatism was assessed by the compensation factor (CF).Whole ocular power and astigmatism, corneal power and astigmatism, internal power and astigmatism, CF for astigmatic data, location of the highest internal refraction zone, and wavefront aberrations.The highest refraction zone was mostly (90%) located in the center in myopes, whereas it was located at the nasal side (71%) in hyperopes. There was a significant correlation between whole ocular and internal powers (P0.01), but no correlation was observed between corneal and internal powers (P0.05). Internal astigmatism was mostly against the rule. The mean CF J(0) was 0.63+/-3.78 and CF J(45) was 0.57+/-2.47. The magnitude of the internal astigmatism under the 3-mm zone was correlated with the magnitude of corneal astigmatism (P0.05). The distribution of astigmatic CF differed among refraction groups. There were significant correlations between internal power and spherical aberration (P0.05) and internal cylinder under the 5-mm zone and HOAs (P0.001).There is a remarkable tilt in internal refraction in hyperopes. Although there is a tendency of undercompensation of the corneal astigmatism by internal astigmatism in the entire group of eyes, the compensation differs among refraction groups.

PURPOSE To evaluate the location and shift of the pupil center relative to the coaxially sighted corneal reflex on horizontal and vertical planes under natural and pharmacologically dilated conditions. METHODS Ninety-four (64 myopic and 30 hyperopic) eyes of 47 patients underwent pupillometry with the NIDEK OPD-Scan under photopic and mesopic conditions before and after instillation of cyclopentolate 1%. Horizontal, vertical, and vectorial shift of the pupil center were calculated between each condition. RESULTS The pupil center was located temporally to the coaxially sighted corneal reflex a mean distance of 0.336±0.181, 0.345±0.195, and 0.339±0.170 mm under photopic, mesopic, and pharmacologically dilated conditions, respectively. The pupil center shifted primarily inferotemporally (44%), followed by inferonasally (22%), superotemporally (19%), and superonasally (15%) from photopic to pharmacologic dilation. Mean magnitude of pupil shift was 0.084±0.069 mm (range: 0.010 to 0.385 mm) from mesopic to photopic, 0.149±0.080 mm (range: 0.013 to 0.384 mm) from photopic to pharmacologic dilation, and 0.102±0.104 mm (range: 0 to 0.530 mm) from mesopic to pharmacologic dilation. Mean distance between the pupil center and the coaxially sighted corneal reflex was greater in hyperopes than in myopes (PP>.05). CONCLUSIONS The pupil center is located temporally and shifts in every direction, primarily inferotemporally, relative to the coaxially sighted corneal reflex with natural and pharmacologic dilation. The horizontal distance between the pupil center and the coaxially sighted corneal reflex was significantly higher in hyperopes than in myopes. [J Refract Surg. 2008;24:530-538.] ABOUT THE AUTHORS From the Department of Ophthalmology, Gülhane Military Medical School (Erdem, Gundogan, Sobaci, Bayer), and the Department of Ophthalmology, Ankara University School of Medicine (Muftuoglu), Ankara, Turkey. The authors have no proprietary interest in the materials presented herein. Correspondence: Uzeyir Erdem, MD, Gülhan Military Medical School, Goz AD 06018, Etlik, Ankara, Turkey. Tel: 90 312 304 3066; Fax: 90 312 304 5850; E-mail: erdemuzeyir@hotmail.com Received: October 11, 2006 Accepted: April 24, 2007 Posted online: September 15, 2007

PURPOSE: To determine changes in entrance pupil size and pupil center shift under low mesopic and photopic conditions of illumination in eyes with in-the-bag intraocular lens (IOL) implantation. METHODS: Entrance pupil size and pupil center shift were measured under low mesopic (0.06 lux) and photopic (60 lux) conditions of illumination in 55 patients with unilateral pseudophakia (study group) and 55 ageand sex-matched patients with bilateral cataracts (control group) using the NIDEK OPD-Scan. Pseudophakie eyes had an uncomplicated intraoperative and postoperative course and best spectacle-corrected visual acuity of 20/20. Cataractous eyes had no additional ocular or systemic problems affecting the pupil. Both groups were analyzed with respect to pupil size and shift in both conditions of illumination. RESULTS: Mean patient age was 64.2±6.8 and 63.6±4.3 years in the study and control groups, respectively (P=.45). In the study group, differences in pupil size under low mesopic (5.12±1.02 and 5.13±0.96 mm for pseudophakic and phakic eyes, respectively) and photopic (3.44±0.39 and 3.45±0.39 mm for pseudophakic and phakic eyes, respectively) conditions of illumination were not statistically significant (P=1.00 and P=.95 for pseudophakic and phakic eyes, respectively). Differences in pupil shift between pseudophakic (0.11±0.08 mm) and phakic (0.12±0.10 mm) eyes were not statistically significant (P=.83) in the study group. In the control group, differences in pupil size under low mesopic (P=.59) and photopic conditions of illumination (P=.60) in the right and left eyes as well as pupil shift (P=.71) were not statistically significant. CONCLUSIONS: Uncomplicated in-the-bag IOL implantation has no influence on pupil size and shift. [J Refract Surg. 2007;23:796-799.]

PURPOSE: To evaluate the effects of hormone replacement therapy (HRT) on refractive status, corneal topography, and aberrations of the eye in postmenopausal women. METHODS: Thirty-six healthy postmenopausal women (72 eyes) were included in the study. All patients received HRT that consisted of 0.625 mg/day conjugated estrogen and 5 mg/day medroxyprogesterone acetate in a continuous combined regimen. Schirmer Il test and tear film break-up time (BUT) were performed on all patients at the time of enrollment and 6 months after initiation of HRT. Refractive status, corneal topography, and wavefront aberrations were evaluated with the NIDEK Optical Path Difference-Scan before and 6 months after HRT was initiated. RESULTS: Mean patient age was 50.8+2.6 years (range: 47 to 57 years). The mean duration of menopause was 2.7+0.8 years (range: 1.4 to 3.5 years). The Schirmer Il test and tear film BUT measurements were significantly lower after HRT (P.05). CONCLUSIONS: Hormone replacement therapy in postmenopausal women does not significantly affect refractive status, corneal topography, and wavefront aberrations of the eye at 6-month follow-up. [J Refract Surg. 2007;23:567-572.]

To compare the photopic and scotopic contrast sensitivity with and without glare as well as blue color perception between eyes with an AcrySof SN60AT Natural intraocular lens (IOL) (Alcon Laboratories Inc.) and eyes with a conventional AcrySof SA60AT IOL.Ankara University School of Medicine, Department of Ophthalmology, Ankara, Turkey.Right eyes of 38 patients with an AcrySof Natural IOL and right eyes of 38 age-matched patients with a conventional AcrySof SA60AT IOL were included in a study. Contrast sensitivity was measured with the Functional Acuity Contrast Test under photopic conditions. Scotopic contrast sensitivity in the presence or absence of glare was measured using the Mesotest II (Oculus GmbH). Blue-green color vision was evaluated with the Moreland equation of the HMC Anomaloskop MR (Oculus GmbH).The mean age of patients was 66.6 years +/- 8.2 (SD) in the Natural IOL group and 66.4 +/- 8.0 years in the conventional IOL group. There was no statistically significant difference in photopic contrast sensitivity, scotopic contrast sensitivity with and without glare, or disability glare between the 2 groups (P.05). Photopic and scotopic contrast sensitivity with and without glare significantly decreased with age in both groups (P.01). There was no statistically significant difference in anomaloscope scores between the 2 groups (P.05). The Moreland middle match point showed a significant shift toward blue with age in both groups (P.01).The AcrySof SN60AT Natural IOL provided contrast sensitivity under photopic and scotopic conditions (with and without glare) and blue color perception comparable that obtained with the AcrySof SA60AT IOL. Scotopic vision and blue color discrimination decreased with age with both IOLs.

A 21-year-old man, with bilateral posterior amorphous corneal dystrophy, was studied by biomicroscopy, corneal topography and in vivo confocal microscopy. The best-corrected visual acuity was 6/21 in the right eye and 6/6.9 in the left eye. Biomicroscopy revealed bilateral, asymmetric, sheet-like opacification at the deep posterior stromal layer. The corneal topography displayed asymmetric against-the-rule astigmatism in the right eye and prominent steepening at the inferior paracentral cornea in both eyes. In vivo confocal microscopy of the corneas demonstrated microfolds and hyper-reflective layer at the posterior stroma just adjacent to the endothelial layer. The epithelium, Bowman’s membrane, anterior stroma and the endothelial layer were normal. In vivo confocal microscopy is useful in evaluating the corneal dystrophies.

Purpose To compare the multimetric D index and other keratoconus-screening parameters in patients with clinical keratoconus in 1 eye and subclinical keratoconus in the fellow eye. Setting Medipol University Hospital and Birinci Eye Hospital, Istanbul, Turkey. Design Retrospective case-control study. Methods Patients with clinical keratoconus in 1 eye and subclinical keratoconus in the fellow eye and eyes of normal subjects were evaluated with a rotating Scheimpflug imaging system (Pentacam). Parameters included anterior curve analysis, keratometry (K) values, minimum corneal thickness, pachymetric progression index, Ambrósio relational thickness, posterior elevation, back difference elevation, and D-index values. The receiver operating characteristic (ROC) curves were analyzed to evaluate the area under curve (AUC), sensitivity, and specificity of each parameter. Results Forty-five patients and 67 normal subjects were evaluated. The pachymetric progression indices, posterior elevation, and the D-index measurements were statistically significantly higher whereas corneal thickness and Ambrósio relational thickness measurements were significantly lower in eyes with keratoconus or subclinical keratoconus than in eyes of normal subjects (P

Purpose : To describe the deposition rate of tamoxifen in the cornea and observe its impact on the cornea with confocal microscopy. Methods : Forty-four eyes of 22 women receiving tamoxifen at a dosage of 20 mg/day for at least 6 months for the adjuvant treatment of breast cancer and 30 eyes of 15 healthy age-matched women were examined for corneal drug deposition by slitlamp after pupil dilation. Ultrasound pachymetry, specular microscopy, in vivo confocal microscopy, and Schirmer tear test were also performed in all patients. Results : The mean duration of tamoxifen intake was 21.6 +/- 7.9 months (range, 13-44 months), and the mean cumulative dose was 12.9 +/- 4.7 g (range, 7.8-26.4 g). Drug depositions in the inferior paracentral cornea were identified in 32 (72%) eyes at pupil-dilated slitlamp examination. There were no significant differences between eyes with keratopathy, those without keratopathy, and control eyes in regard to the mean Schirmer test scores, mean central corneal thickness, mean endothelial cell count, mean basal epithelium cell density, mean anterior and posterior stromal keratocyte density, and mean endothelial cell density (P > 0.05). No pathologic alteration of structure was observed with in vivo confocal microscopy at any corneal level in patients receiving tamoxifen. Conclusions : Low-dose tamoxifen use was associated with corneal depositions in 72% of patients. Slitlamp examination performed with pupil dilation was helpful in detection of subtle tamoxifen-related deposits. Amelioration of in vivo confocal microscopy systems may be helpful in accurate imaging of the paracentral and peripheral cornea.

Purpose To evaluate the clinical features, treatment, and prognosis in patients with metastatic retinoblastoma. Design Retrospective interventional case series. Participants Eighteen consecutive patients with metastatic retinoblastoma who were diagnosed and managed at the Oncology Service of Ankara University, Turkey, between January 1999 and January 2005. Methods All patients underwent magnetic resonance imaging (MRI) of the orbit and brain, lumbar puncture, bone marrow aspiration, and bone scintigraphy for metastatic evaluation. Histopathologic confirmation of retinoblastoma via enucleation, exenteration, or orbital biopsy was obtained in each patient. The status of extraocular spread (optic nerve, extrascleral extension, or both) was assessed based on histopathologic or MRI results. Systemic treatment for metastatic retinoblastoma consisted of chemotherapy and radiotherapy (craniospinal, orbital, or both), if necessary. Main Outcome Measures Status of extraocular spread, site of metastasis, and survival from metastatic retinoblastoma. Results At presentation, the mean patient age was 45 months (range, 13–86). Ten patients had unilateral retinoblastoma, 7 had bilateral retinoblastoma, and 1 had trilateral retinoblastoma. All patients with metastatic retinoblastoma had histopathologic or MRI evidence of unilateral extraocular disease characterized by optic nerve involvement, extrascleral extension, or both. Nine of 18 patients experienced central nervous system (CNS) involvement, 5 patients had distant and CNS metastasis, and 4 patients had distant metastasis only. Fourteen patients underwent craniospinal irradiation and 12 had orbital irradiation. At a mean follow-up of 24 months (range, 4–62), all patients with CNS and concurrent distant and CNS metastasis were deceased. Four patients who had distant metastasis only were alive at a follow-up ranging from 9 to 62 months. Conclusions The prognosis for metastatic retinoblastoma is dismal and the presence of CNS involvement may portend an even worse outcome.

WOS: 000343672300009 PubMed ID: 25255132 Purpose: The aim of this study was to evaluate the differences in tear osmolarity and tear film parameters between pterygium-affected and healthy fellow eyes. Methods: The study enrolled 65 patients with unilateral pterygium. Tear osmolarity, tear film break-up time (TBUT), Schirmer I test measurements, fluorescein corneal staining, and conjunctival redness were evaluated. The results were compared between pterygium-affected eyes and healthy fellow eyes of the same patient (controls). The pterygium thickness was measured using optical coherence tomography. We also evaluated the relationship between pterygium thickness and tear osmolarity and between TBUT and Schirmer I test results in eyes with pterygium. Results: The mean tear osmolarity was 307 mOsm/L in pterygium-affected eyes and 294 mOsm/L in control eyes. The mean values of TBUT, Schirmer I test, corneal staining, and conjunctival redness scores were 10.3 +/- 3.4 seconds, 14.8 +/- 9.2 mm, 1.2 +/- 1.1, and 0.9 +/- 0.9 in the pterygium group, whereas the mean values were 12.3 +/- 4.4 seconds, 16.2 +/- 7.2 mm, 0.4 +/- 0.8, and 0.4 +/- 0.7 in the control group, respectively. Eyes with pterygium had significantly higher tear osmolarity levels, corneal staining, and conjunctival redness scores; and lower tear film TBUT and Schirmer I test values than eyes without pterygium (Wilcoxon signed rank test, P < 0.05). There was no significant correlation between pterygium thickness versus tear osmolarity, TBUT, and Schirmer I test values in eyes with pterygium (r = 0.159, 0.738, 0.321, respectively; P > 0.05). Conclusions: This study showed that pterygium is associated with tear hyperosmolarity and abnormal tear film function.

A 64-year-old man underwent anterior lamellar keratoplasty using the Melles technique for corneal scar secondary to healed bacterial keratitis in the left eye. Two months postoperatively, the patient presented with blurry vision in the left eye after a fall in the bathroom. The uncorrected visual acuity was 20/400 in the left eye, and the external examination showed periorbital swelling with ecchymosis. Slit-lamp examination revealed an absent graft, a circular crater in the center, and a fragment of suture on the temporal edge of the crater. The Seidel test was negative, and there was no sign of infection. The anterior segment optical coherence tomography showed intact residual stroma with slight forward protrusion. The patient underwent repeat anterior lamellar corneal transplantation with improvement in uncorrected visual acuity of 20/100 and best spectacle-corrected visual acuity of 20/70 in the left eye 3 months postoperatively.

WOS: 000324014300010 PubMed ID: 23820305 To evaluate posterior corneal elevation and back difference corneal elevation in patients with keratoconus in 1 eye and forme fruste keratoconus in the fellow eye. SETTING: Kudret Eye Hospital, Ankara, Turkey. DESIGN: Case-control study. METHODS: This study retrospectively reviewed patients with keratoconus in 1 eye and forme fruste keratoconus in the fellow eye and eyes of normal subjects. All subjects were evaluated with a rotating Scheimpflug imaging system (Pentacam), including sagittal and tangential anterior curve analysis, keratometry, and posterior elevation. The back difference elevation values were extrapolated from the difference maps of the Belin-Ambrosio enhanced ectasia display of the Scheimpflug system. The receiver operating characteristic (ROC) curves were analyzed to evaluate the sensitivity and specificity of the parameters. RESULTS: The corneal power, pachymetric progression index, and posterior corneal elevation (posterior elevation and back difference elevation) measurements were statistically significantly higher in eyes with keratoconus or forme fruste keratoconus than in eyes of normal control subjects (P

PURPOSE To correlate big-bubble deep anterior lamellar keratoplasty findings in donor corneas with anterior segment optical coherence tomography (OCT) and histology. METHODS This research was conducted entirely at the University of Texas Southwestern Medical Center in Dallas, Texas. We performed deep intrastromal air injections in donor corneas on artificial chambers. Surgical patterns (big bubble, intrastromal emphysema, and perforation) were assessed by spectral domain OCT with a handheld probe and histology. RESULTS Surgical patterns were evaluated by histology using a novel embedding technique. A classic big bubble may be a Descemet membrane (DM) detachment with a few attached stromal fibrils. There were no large intra-DM separations as previously reported. The emphysematous surgical patterns result from intrastromal emphysema, which can be accompanied by microdetachments of DM. We saw indirect OCT signs of big bubble, but scatter from intrastromal emphysema limits deeper imaging. CONCLUSIONS Surgical patterns of big bubble and intrastromal emphysema correlate with characteristic histology findings. Marked scatter on OCT by intrastromal emphysema limits visualization of deeper corneal structures, but the presence of a big bubble may be inferred.

To evaluate the quality of stromal bed and the safety on endothelium in preparation of donor tissue for Descemet stripping automated endothelial keratoplasty in a masked fashion using 2 mechanical microkeratomes and a femtosecond laser.Deep anterior lamellar dissection was performed on 15 donor corneas. Central endothelial cell density was calculated using specular microscopy before and after the dissection. One cornea from each of 5 donor pairs was cut with the Moria ALTK system with the CBm microkeratome using the 300-μm head and the mate cut with the Horizon disposable 300-μm microkeratome. Five additional donor corneas were cut with the Intralase 60-kHz FS laser. The donor corneas were then bisected with half of the cornea used for Live/Dead assay to study central endothelial viability. The other halves were sent for scanning electron microscopy of the stromal bed. Qualitative surface roughness of the scanning electron microscopy images was graded by 2 masked observers, and quantitative surface roughness was assessed using roughness evaluation software.The Horizon group showed a smoother stromal bed compared with the Moria or Intralase groups by 2 masked observers. However, the Moria group had the smoothest quantitative score of all the groups when assessed by roughness evaluation software. There was no statistically significant difference among the 3 groups in the percentage change in the central endothelial cell density or percentage of viable central endothelium by Live/Dead assay after the dissection.Both mechanical microkeratomes created smoother stromal bed dissections than the femtosecond laser. All systems provided good endothelial cell viability.

Endothelial dysfunction remains the leading indication for corneal transplantation in the United States.1 Visual rehabilitation after penetrating keratoplasty (PKP) may be limited by delayed wound healing, surgically induced astigmatism, suture-related complications, and anisometropia.2,3 In contrast, endothelial keratoplasty in the form of deep lamellar endothelial keratoplasty (DLEK) or Descemet stripping automated endothelial keratoplasty (DSAEK) allows selective replacement of diseased host endothelium, more rapid visual rehabilitation, minimal induced astigmatism, and a predictable change in corneal power postoperatively.4–6 DSAEK employs stripping of the diseased host endothelium and replacement with a thin layer of donor stromal tissue and endothelium harvested with an automated microkeratome.7,8 The manual lamellar dissections required to prepare the recipient cornea and donor tissue in DLEK surgery, which are technically difficult and time consuming for the surgeon, have been eliminated in DSAEK, helping this procedure become the procedure of choice for endothelial dysfunction. Despite excellent postoperative results, the available data suggest that best-corrected visual acuity after DLEK or DSAEK surgeries is at times less than that of PKP patients.8–11 Persistent subepithelial haze and interface haze have been suggested to affect the best-corrected visual acuity after DSAEK surgery.12 The better visual outcomes after DSAEK in comparison to DLEK may be attributable to the smoother interface in DSAEK compared with the manually created DLEK interface.13 Despite several advantages of DSAEK over PKP, endothelial cell loss remains a concern with endothelial keratoplasty. Endothelial cell loss of 34% has been reported at the 6- month postoperative time period after DSAEK.14 Endothelial survival may be impacted by every step of the procedure including donor tissue preparation, folding of the donor disc, insertion site size and technique, intraoperative manipulation of the tissue to center and attach the donor disc, and the postoperative course. Donor cornea preparation requires the surgeon or the eye bank to create a deep lamellar dissection to create a thin posterior stromal lenticule with viable endothelium. “Precut” donor tissue by the eye bank has been shown to have no increased risk of tissue-related complications and may increase surgeon’s efficiency.15 In this masked study, we attempted to evaluate the quality of the stromal bed and the safety on the endothelium in the preparation of donor tissue for DSAEK using the Moria ALTK system with the mechanical CBm microkeratome, disposable Horizon mechanical microkeratome system, and Intralase FS60 femtosecond laser.

Purpose To evaluate the long-term refractive and visual outcomes of apodized diffractive multifocal intraocular lens (IOL) implantation after myopic laser in situ keratomileusis (LASIK) with or without subsequent excimer laser enhancement. Setting University of Texas Southwestern Medical Center at Dallas, Texas, USA. Design Comparative case series. Methods This study comprised consecutive patients who had implantation of an AcrySof ReSTOR multifocal IOL after previous LASIK. Included were eyes that had refractive surgery enhancement with a Visx Star S4 excimer laser for residual refractive error correction and eyes that had neodymium:YAG (Nd:YAG) capsulotomy. Results Of the 49 eyes (38 patients), 21 (42.9%) had laser enhancement and 25 (51.0%) had an Nd:YAG capsulotomy. The mean follow-up was 14.2 months ± 7.23 (SD) (range 9 to 29 months). Although the uncorrected distance visual acuity (UDVA) was significantly worse in eyes with enhancement than in those with no enhancement at 1 month and 6 months ( P P >.05). At the last follow-up, 36 (73.5%) of the 49 eyes had a UDVA of 20/25 or better and an uncorrected near visual acuity of Jaeger 1 or better concurrently; 46 eyes (93.9%) were within ±1.00 diopter (D) of emmetropia, and 41 (83.7%) were within ±0.50 D. Conclusion Apodized diffractive multifocal IOL implantation and excimer laser enhancement in eyes with previous myopic LASIK provided good results. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned. Additional disclosure is found in the footnotes.

Purpose: To evaluate the changes in the corneal stroma after Descemet stripping automated endothelial keratoplasty (DSAEK) using tandem scanning confocal microscopy (CM). Methods: Thirteen eyes of 13 patients who underwent DSAEK without preoperative corneal haze or scar obvious at the slit lamp, any ocular disease, and postoperative complication were included in the study. All patients were examined clinically and by CM 6 months after DSAEK. Results: Six months after DSAEK, none of the eyes had clinically significant interface haze (i.e., haze affecting quantity or quality of vision) at slit lamp. The mean best spectacle corrected visual acuity was 0.18 0.12 (range 0 – 0.4) logMAR (Snellen 20/30). The CM revealed highly reflective particles in interface in six eyes, particles with mild surrounding increased reflectivity in four eyes, and no discernible interface in three eyes. The mean particles density at interface was 28.6 23.4 particles/mm 2 .N o significant keratocyte activation was seen in any case at the interface. The mean anterior stromal reflectivity was 431.2 269.1 confocal back scatter units (CBU) and the mean interface reflectivity was 65.9 46.9 CBU. The mean anterior stromal reflectivity was significantly greater than the mean interface reflectivity (P0.01). Significant keratocyte activation with high reflectivity was seen in superficial anterior stroma in 8 of 13 eyes. Conclusions: Tandem scanning CM shows the presence of highly reflective particles at the level of the DSAEK interface that are morphologically similar to a laser in situ keratomileusis interface. The stromal reflectivity is more prominent in subepithelial layers than that of interface 6 months after DSAEK. However, the areas under the mean reflectivity peaks (CBU) corresponding to the flap interface and superficial anterior stroma do not seem to correlate with best spectacle corrected visual acuity results after the procedure. (Eye & Contact Lens 2009;4: 196202)

To compare the corneal higher-order aberration (HOA) after Descemet's stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PKP), and in age-matched controls.Cross-sectional, non-comparative interventional case series.Thirty-one eyes of 28 patients who underwent DSAEK, 20 eyes of 16 patients who underwent PKP, and 31 eyes of 31 control patients.The corneal topography and HOAs of the central 4- and 6-mm zones from anterior and posterior corneal surfaces were evaluated postoperatively with the Scheimpflug rotating imaging system (Oculus Gmbh, Wetzlar, Germany).Anterior and posterior corneal HOAs.The mean anterior corneal total HOAs of the central 4 and 6 mm were 0.599+/-0.288 microm and 1.215+/-0.496 microm, respectively, in eyes that underwent DSAEK; 1.730+/-0.826 microm and 3.349+/-1.490 microm, respectively, in eyes that underwent PKP; and 0.439+/-0.163 microm and 0.921+/-0.300 microm, respectively, in controls. Although the mean anterior corneal total HOAs of the central 4 and 6 mm were significantly higher in eyes that underwent PKP than in eyes that underwent DSAEK and in controls (P0.01), there was no significant difference in anterior corneal total HOAs of the central 4 and 6 mm between eyes that underwent DSAEK and controls. The mean posterior corneal total HOAs of the central 4 and 6 mm were 3.680+/-1.586 microm and 7.142+/-3.011 microm, respectively, in eyes that underwent DSAEK; 2.957+/-1.238 microm and 5.314+/-2.095 microm, respectively, in eyes that underwent PKP; and 0.818+/-0.193 microm and 1.609+/-0.344 microm, respectively, in controls. Although there was no significant difference in posterior corneal total HOAs of the central 4 mm between the DSAEK group and the PKP group, the posterior corneal HOAs of the central 6 mm were significantly higher in the DSAEK group than in the PKP group (P0.01).Although posterior corneal HOAs are significantly higher in eyes that underwent DSAEK, anterior corneal HOAs are not significantly different in eyes that underwent DSAEK than those of age-matched controls.

Intraoperative complications and their management Early postoperative complications and their management The complications of different types of AS-PIOLs Complications that may lead to explantation of the AS-PIOLs Explantation techniques of AS-PIOLs Prevention of complications Surgical technique AS-PIOL design Anterior imaging and appropriate AS-PIOL sizing

To compare the long-term outcomes of photorefractive keratectomy (PRK) and laser in situ keratomilesis (LASIK) for myopia between -6 and -10 D.A retrospective, control-matched study including 68 eyes, 34 which underwent PRK and 34 LASIK, with myopia between -6 and -10 D, operated using the VISX 20/20 excimer laser, was performed. Optical zones of 5.5 to 6 mm were used. All PRK-treated eyes were matched with LASIK-treated eyes of the same age, spherical equivalent within +/-1.25 D, sphere within +/-1.5 D and cylinder within +/-2.5 D. All patients were evaluated 3 months, 1 year, 2 years, 5 years and 10 years after surgery. The main outcomes measures were refractive predictability and stability, safety, efficacy and re-treatment rate.At 10 years, 20 (71%) and 23 (88%) were within +/-1.00 D after PRK and LASIK respectively. The re-treatment rate was 35% and 18% respectively. No eye lost more than two lines of BSCVA in both groups. The efficacy was 0.90 for PRK and 0.95 for LASIK.Both PRK and LASIK were safe for moderate myopia. LASIK demonstrated slightly better efficacy, predictability, and less rate of re-treatment after 10 years. The technical improvements should be taken into account when comparing these results with those obtained more recently.

Purpose: To report the treatment and follow-up of a linear epithelial keratitis with a horseshoe pattern. Methods: A 21-year-old Turkish soldier, who presented with epithelial keratitis with a horseshoe pattern that did not respond to immunosuppressive and multiple anti-microbial treatment, was studied clinically. Results: No microorganism was identified with different stains, cultures, and herpes simplex virus–polymerase chain reaction. The impression cytology revealed prominent polymorphonuclear leukocyte infiltration at the keratitis line. The keratitis did not respond to different antimicrobial treatment or local and systemic corticosteroids. After a fourth scraping was perfomed deeply with a disc-knife, the lesion healed and did not recur in six months. Conclusion: Linear epitheliitis of cornea with a horseshoe pattern was not found to be associated with any microorganism or systemic disease.

To evaluate the long-term outcomes of excimer laser myopic photorefractive keratectomy (PRK) for myopia of less than -6 diopters (D).Long-term (10-year) follow-up retrospective, interventional case series.The study included 225 eyes of 138 myopic patients with spherical equivalent (SE) between 0 and -6 D treated with myopic PRK at the Instituto Oftalmológico de Alicante, Alicante, Spain, using the VISX 20/20 excimer laser (Santa Clara, California, USA). The main outcome measures were refractive predictability and stability, mean corneal keratometry, topographical cylinder, safety, efficacy, stability of visual acuity, and postoperative complications.At 10 years, 169 (75%) of 225 eyes were within +/- 1.00 D and 207 (92%) were within +/- 2.00 D. Ninety-five (42%) eyes underwent retreatments because of overcorrection, regression, or both. The mean SE slightly decreased (myopic regression) with a mean magnitude of -0.10 +/- 1.08 D over 10 years (-0.01 +/- 0.11 D per year). Forty-one (58%) of 225 eyes demonstrated increase in best spectacle-corrected visual acuity after 10 years. Only one eye lost eight lines because of significant cataract, and two eyes lost vision (one lost seven lines and the other lost four lines) because of posterior segment-related complications. The mean corneal haze score gradually decreased from 0.22 +/- 0.39 at three months to 0.01 +/- 0.09 at 10 years.Photorefractive keratectomy for myopia of less than -6 D is a safe and effective procedure in the long-term.

Purpose To evaluate the long-term outcomes of excimer laser myopic photorefractive keratectomy (PRK) for myopia higher than −6 diopters (D). Design A long-term (10-year) follow-up retrospective, interventional case series. Methods The study included 267 eyes of 191 patients with myopia with spherical equivalent (SE) of more than −6 D treated with myopic PRK at the Instituto Oftalmologico de Alicante, Alicante, Spain, using the VISX 20/20 excimer laser (Santa Clara, California, USA). All patients were evaluated three months, one year, two years, five years, and 10 years after surgery. The main outcome measures were refractive predictability and stability, mean corneal keratometry, topographical cylinder, safety, efficacy, stability of visual acuity, and postoperative complications. Results At 10 years, 156 (58%) of 267 eyes were within ± 1.00 D and 209 (78%) were within ± 2.00 D. One hundred and twenty-four eyes (46.4%) underwent retreatments because of overcorrection, regression, or both. The mean SE decreased (myopic regression) in eyes that did not undergo retreatment, with a mean magnitude of −1.33 ± 2.0 D over 10 years (−1.13 ± 0.20 D per year). One hundred and twenty-one (48.3%) of 267 eyes demonstrated increase in best spectacle-corrected visual acuity, and only eight eyes lost lines of vision because of cataract and posterior segment-related complications. The mean corneal haze score decreased gradually from 0.48 ± 0.69 at three months to 0.09 ± 0. 33 at 10 years. Conclusions PRK for myopia of more than −6 D is a safe and effective procedure in the long-term.