Showing papers in "Journal of Cataract and Refractive Surgery in 2012"
TL;DR: Selecting toric intraocular lenses based on anterior corneal measurements could lead to overcor correction in eyes that have with‐the‐rule astigmatism and undercorrection in eyes which have against‐the-ruleAstigmatism.
Abstract: Purpose To determine the contribution of posterior corneal astigmatism to total corneal astigmatism and the error in estimating total corneal astigmatism from anterior corneal measurements only using a dual-Scheimpflug analyzer. Setting Cullen Eye Institute, Baylor College of Medicine, Houston, Texas, USA. Design Case series. Methods Total corneal astigmatism was calculated using ray tracing, corneal astigmatism from simulated keratometry, anterior corneal astigmatism, and posterior corneal astigmatism, and the changes with age were analyzed. Vector analysis was used to assess the error produced by estimating total corneal astigmatism from anterior corneal measurements only. Results The study analyzed 715 corneas of 435 consecutive patients. The mean magnitude of posterior corneal astigmatism was −0.30 diopter (D). The steep corneal meridian was aligned vertically (60 to 120 degrees) in 51.9% of eyes for the anterior surface and in 86.6% for the posterior surface. With increasing age, the steep anterior corneal meridian tended to change from vertical to horizontal, while the steep posterior corneal meridian did not change. The magnitudes of anterior and posterior corneal astigmatism were correlated when the steeper anterior meridian was aligned vertically but not when it was aligned horizontally. Anterior corneal measurements underestimated total corneal astigmatism by 0.22 @ 180 and exceeded 0.50 D in 5% of eyes. Conclusions Ignoring posterior corneal astigmatism may yield incorrect estimation of total corneal astigmatism. Selecting toric intraocular lenses based on anterior corneal measurements could lead to overcorrection in eyes that have with-the-rule astigmatism and undercorrection in eyes that have against-the-rule astigmatism. Financial Disclosure The authors received research support from Ziemer Group. In addition, Dr. Koch has a financial interest with Alcon Laboratories, Inc., Abbott Medical Optics, Inc., Calhoun Vision, Inc., NuLens, and Optimedica Corp.
431 citations
TL;DR: Patients with combined single trabecular micro‐bypass stent and cataract surgery had significantly better IOP control on no medication through 24 months than patients having cataracts surgery alone.
Abstract: Purpose To assess the long-term safety and efficacy of a single trabecular micro-bypass stent with concomitant cataract surgery versus cataract surgery alone for mild to moderate open-angle glaucoma. Setting Twenty-nine investigational sites, United States. Design Prospective randomized controlled multicenter clinical trial. Methods Eyes with mild to moderate glaucoma with an unmedicated intraocular pressure (IOP) of 22 mm Hg or higher and 36 mm Hg or lower were randomly assigned to have cataract surgery with iStent trabecular micro-bypass stent implantation (stent group) or cataract surgery alone (control group). Patients were followed for 24 months postoperatively. Results The incidence of adverse events was low in both groups through 24 months of follow-up. At 24 months, the proportion of patients with an IOP of 21 mm Hg or lower without ocular hypotensive medications was significantly higher in the stent group than in the control group ( P =.036). Overall, the mean IOP was stable between 12 months and 24 months (17.0 mm Hg ± 2.8 [SD] and 17.1 ± 2.9 mm Hg, respectively) in the stent group but increased (17.0 ± 3.1 mm Hg to 17.8 ± 3.3 mm Hg, respectively) in the control group. Ocular hypotensive medication was statistically significantly lower in the stent group at 12 months; it was also lower at 24 months, although the difference was no longer statistically significant. Conclusions Patients with combined single trabecular micro-bypass stent and cataract surgery had significantly better IOP control on no medication through 24 months than patients having cataract surgery alone. Both groups had a similar favorable long-term safety profile. Financial Disclosure Dr. Craven was an investigator in the clinical trial of the iStent. Dr. Katz is a consultant to Glaukos and was the medical monitor for the clinical trial of the iStent. Dr. Katz is a stockholder in Glaukos. Mr. Wells and Ms. Giamporcaro are employees of Glaukos.
286 citations
TL;DR: Tansepithelial CXL treatment appeared to halt keratoconus progression, with a statistically significant improvement in visual and topographic parameters, and its noninvasive nature makes it potentially useful in cases in which epithelial debridement is ideally avoided.
Abstract: Purpose To evaluate the efficacy of transepithelial collagen crosslinking (CXL) in patients with bilateral progressive keratoconus. Setting Outpatient ophthalmic clinic. Design Cohort study. Methods Patients with a history of bilateral progressive keratoconus were recruited. The worst eye was treated with transepithelial CXL, while the fellow eye was left untreated as a control. Transepithelial CXL was performed by applying an enhanced riboflavin solution (riboflavin 0.1%, dextrane T500 with trometamol [Tris-hydroxymethyl aminomethane] and EDTA [ethylenediaminetetraacetic] sodium salt) on the intact corneal epithelium for 30 minutes before irradiation with ultraviolet A (370 nm at 3 mW/cm2) for 30 minutes. Follow-up was 18 months in all eyes. Results The study enrolled 20 patients. Transient hyperemia and mild foreign-body sensation occurred in 8 eyes (40%) after treatment; both resolved after 24 hours. In treated eyes, there were statistically significant improvements in uncorrected and corrected visual acuity and topography-derived keratometry, cone apex power, and higher-order aberrations (P Conclusions Transepithelial CXL treatment appeared to halt keratoconus progression, with a statistically significant improvement in visual and topographic parameters. The treatment was safe and well tolerated. Its noninvasive nature makes it potentially useful in cases in which epithelial debridement is ideally avoided, such as pediatric cases, uncooperative patients, and thin corneas with thicknesses nearing 380 μm. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
232 citations
TL;DR: The refractive predictability, safety, and patient satisfaction 3 months after small‐incision lenticule extraction were high and comparable to results in previous studies of femtosecond laser–assisted techniques.
Abstract: Purpose To present initial clinical experience with small-incision lenticule extraction for the treatment of moderate to high myopia. Setting Department of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark. Design Prospective clinical study. Methods For small-incision lenticule extraction, an intrastromal lenticule was cut with a femtosecond laser and manually extracted without creation of a flap. Patients were treated and followed for 3 months. Only 1 randomly chosen eye of each patient was used in the statistical analyses. Results The study enrolled 144 patients. The mean preoperative spherical equivalent was −7.18 diopters (D) ± 1.57 (SD). Of eyes with emmetropia as target refraction, 40% had an uncorrected distance visual acuity of 0.1 logMAR or less 1 day after surgery; this increased to 73% at 3 months. The mean corrected distance visual acuity (CDVA) improved significantly from −0.01 (logMAR) preoperatively to −0.03 3 months postoperatively. None of the 127 eyes lost 2 lines or more of CDVA and 6 eyes lost 1 line of CDVA after 3 months. In contrast, 1 eye gained 2 lines and 24 eyes gained 1 line of CDVA. The achieved refraction was a mean of −0.09 ± 0.45 D from the attempted refraction. Of the eyes, 77% were within ±0.50 D and 95% were within ±1.00 D. Ninety-five percent of the patients would recommend the procedure to others. Conclusions The refractive predictability, safety, and patient satisfaction 3 months after small-incision lenticule extraction were high and comparable to results in previous studies of femtosecond laser–assisted techniques. Financial Disclosure Drs. Hjortdal and Asp received travel reimbursement from Carl Zeiss Meditec AG, Jena, Germany. No other author has a financial or proprietary interest in any material or method mentioned.
227 citations
TL;DR: The present guidelines are based on data entered from January 1, 2009, to August 28, 2011 (523,921 cataract extractions) and include only those steps in theCataract surgery process that can be analyzed by the database.
Abstract: In March 2008, the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) commenced. This 3-year project was cofunded by the European Union (EU) and the European Society of Cataract & Refractive Surgeons (ESCRS). The ESCRS became the lead partner in the project with 11 national societies as associated partners. The aims of the project were to improve treatment and standards of care for cataract and refractive surgery and to develop evidence-based guidelines for cataract and refractive surgery across Europe. Surgeons from all participating societies contributed to the database, which contained data on 820,000 cataract surgeries in November 2011. The present guidelines are based on data entered from January 1, 2009, to August 28, 2011 (523,921 cataract extractions). The guidelines include only those steps in the cataract surgery process that can be analyzed by the database.
191 citations
TL;DR: Using multiple micro‐bypass stents with concurrent cataract surgery led to a mean postoperative intraocular pressure (IOP) of less than 15 mm Hg and allowed patients to achieve target pressure control with significantly fewer medications through 1 year.
Abstract: Purpose To evaluate the efficacy of multiple trabecular micro-bypass stents combined with cataract surgery in patients with open-angle glaucoma (OAG) and cataract. Setting Private practice, Mississauga, Ontario, Canada. Design Comparative case series. Methods Eyes with OAG had implantation of 2 or 3 micro-bypass stents with concurrent cataract surgery and follow-up through 1 year. Efficacy measures were intraocular pressure (IOP) and topical ocular hypotensive medication use. Safety assessment included complications and corrected distance visual acuity (CDVA). Results The study comprised 53 eyes (47 patients); 28 had implantation of 2 stents and 25 had implantation of 3 stents. The overall mean 1-year postoperative IOP was 14.3 mm Hg, which was significantly lower than preoperative IOP overall and in each group (P Conclusions Using multiple micro-bypass stents with concurrent cataract surgery led to a mean postoperative IOP of less than 15 mm Hg and allowed patients to achieve target pressure control with significantly fewer medications through 1 year. Financial Disclosure Dr. Ahmed is a consultant to Glaukos Corp. No other author has a financial or proprietary interest in any material or method mentioned.
166 citations
TL;DR: Ophthalmic devices for corneal analysis and diagnosis have experienced a rapid development during the past decade with the implementation of technologies such as scanning-slit topography, Scheimpflug photography, and optical coherence tomography, which are able to accurately describe not only the geometry of the anterior Corneal surface but also that of the posterior surface.
Abstract: The increasing volume of patients interested in refractive surgery and the new treatment options available for keratoconus have generated a higher interest in achieving a better characterization of this pathology. The ophthalmic devices for corneal analysis and diagnosis have experienced a rapid development during the past decade with the implementation of technologies such as the Placido-disk corneal topography and the introduction of others such as scanning-slit topography, Scheimpflug photography, and optical coherence tomography, which are able to accurately describe not only the geometry of the anterior corneal surface but also that of the posterior surface, as well as pachymetry and corneal volume. Specifically, anterior and posterior corneal elevation, corneal power, pachymetry maps, and corneal coma-like aberrometry data provide sufficient information for an accurate characterization of the cornea to avoid misleading diagnoses of patients and provide appropriate counseling of refractive surgery candidates. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
145 citations
TL;DR: For staff surgeons experienced with both phacoemulsification and manual SICS, intraoperative complication rates were comparably low, but for trainee surgeons, the complication rate was significantly higher with phacoamulsification, suggesting that manuals SICS may be a safer initial procedure to learn for inexperienced cataract surgeons in the developing world.
Abstract: Purpose To analyze the rate of intraoperative complications, reoperations, and endophthalmitis with phacoemulsification, manual small-incision cataract surgery (SICS), and large-incision extracapsular cataract extraction (ECCE). Setting Aravind Eye Hospital, Madurai, India. Design Retrospective cohort study. Methods This study comprised consecutive cataract surgeries performed during a 12-month period. All surgical complications and endophthalmitis cases were tabulated and analyzed for each of 4 surgeon groups (staff, fellows, residents, visiting trainees). Within each surgeon group, complication rates with phacoemulsification, manual SICS, and ECCE were compared. Results The surgical distribution was 20 438 (26%) phacoemulsification, 53 603 (67%) manual SICS, and 5736 (7%) ECCE. The overall intraoperative complication rate was 0.79% for staff, 1.19% for fellows, 2.06% for residents, and 5% for visiting trainees. Extracapsular cataract extraction had the highest overall rate of surgical complications (2.6%). The overall complication rate was 1.01% for manual SICS and 1.11% for phacoemulsification. However, the combined complication rate for trainees was significantly higher with phacoemulsification (4.8%) than with manual SICS (1.46%) ( P P Conclusions For staff surgeons experienced with both phacoemulsification and manual SICS, intraoperative complication rates were comparably low. However, for trainee surgeons, the complication rate was significantly higher with phacoemulsification, suggesting that manual SICS may be a safer initial procedure to learn for inexperienced cataract surgeons in the developing world. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
141 citations
TL;DR: Ab interno trabeculectomy using this new incisional procedure safely lowered intraocular pressure to the mid teens, with an overall greater reduction in exfoliation glaucoma and improved success when combined with cataract surgery.
Abstract: Purpose To compare outcomes in exfoliation glaucoma versus primary open-angle glaucoma (POAG) after ab interno trabeculectomy alone (Trabectome) or in combination with cataract surgery and intraocular lens (IOL) implantation. Setting Trabectome Study Group institutions. Design Prospective nonrandomized cohort study. Methods Outcomes included intraocular pressure (IOP), glaucoma medications, complications, secondary procedures, and success, defined as no secondary surgery and IOP less than 21 mm Hg and a greater than 20% reduction from baseline. Results In the ab interno trabeculectomy–alone group, the mean preoperative IOP was 29.0 mm Hg ± 7.5 (SD) in exfoliation glaucoma cases and 25.5 ± 7.9 mm Hg in POAG cases ( P P P =.02); and the cumulative probability of success was 79.1% and 62.9%, respectively ( P =.004). In the combined ab interno trabeculectomy–IOL group, the mean preoperative IOP was 21.7 ± 8.4 in exfoliation glaucoma cases and 19.9 ± 5.4 mm Hg in POAG cases ( P =.06). At 1 year, the mean decrease in IOP was −7.2 ± 7.7 and −4.1 ± 4.6, respectively ( P P =.88); and the cumulative probability of success was 86.7% and 91.0% ( P =.73), respectively. Conclusion Ab interno trabeculectomy using this new incisional procedure safely lowered IOP to the mid teens, with an overall greater reduction in exfoliation glaucoma and improved success when combined with cataract surgery. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
139 citations
TL;DR: Emmetropia is the goal in most cataract cases but was reached in only 55% of eyes planned for emmetropia, and remaining corneal astigmatism and biometry prediction errors in astigmatic and ametropic eyes were high.
Abstract: PURPOSE: To assess and analyze refractive outcome after cataract surgery in Sweden from 2008 though 2010. SETTING: Swedish cataract surgery units participating in outcome registration of National Cataract Register. DESIGN: Cohort study. METHODS: Planned and actual postoperative refractions were analyzed for cataract procedures and preoperative and postoperative corneal astigmatism for procedures performed in 2008 though 2010. Induced astigmatism was calculated with Naeser and Behrens polar coordinates. RESULTS: Postoperative refraction was analyzed for 17 056 procedures and corneal astigmatism for 7448 procedures. Emmetropia was targeted in 78.1% of eyes and achieved in 52.7%; 43.0% had less than 1.00 diopter (D) of astigmatism. "Reading myopia" of -3.5 to -1.6 D was targeted in 7.0% of eyes and achieved in 7.8%. Planned hyperopia greater than 1.0 D or myopia greater than -3.5 D was rare. The mean absolute biometry prediction error was 0.402 D +/- 0.338 (SD) in all eyes; however, astigmatic eyes and eyes planned for myopia or hyperopia had higher biometry prediction errors. Younger patients were more often astigmatic and planned for a more myopic outcome. Preoperatively, one third of eyes had more than 1.0 D of corneal astigmatism; postoperatively this figure was largely unaltered. The mean induced astigmatism was 0.525 +/- 0.804 D in all eyes. CONCLUSIONS: Emmetropia (spherical equivalent -0.5 to + 0.5 D and <1.0 D astigmatism) is the goal in most cataract cases but was reached in only 55% of eyes planned for emmetropia. Factors precluding emmetropia included remaining corneal astigmatism and biometry prediction errors in astigmatic and ametropic eyes.
136 citations
TL;DR: The retropupillary iris‐claw IOL provided good visual outcomes with a favorable complication rate and can be used for a wide range of indications in eyes without adequate capsule support.
Abstract: RESULTS: The study comprised 137 eyes (126 patients). The mean follow-up was 5 months (range 1 to 48 months). The IOLs were inserted during primary lens surgery in 10 eyes (7.3%), during an IOL exchange procedure for dislocated posterior chamber IOLs in 95 eyes (69.4%), and as a secondary procedure in 32 aphakic eyes (23.3%). The final mean corrected distance visual acuity (CDVA) (0.38 G 0.31 [SD] logMAR) was significantly better than preoperatively (0.65 G 0.58 logMAR) (P < .05). In 128 eyes (93.4%), postoperative refractive errors were within G2.00 diopters (D) of emmetropia. Complications included slight temporary pupil ovalization in 34 eyes (24.8%), cystoid macular edema in 12 eyes (8.7%), hyphema in 3 eyes (2.1%), early postoperative hypotony in 7 eyes (5.1%) and elevated intraocular pressure in 6 eyes (4.3%), chronic uveitis in 1 eye (0.7%), toxic anterior segment syndrome in 1 eye (0.7%), and endophthalmitis in 1 eye (0.7%). Iris-claw IOL disenclavation occurred in 12 eyes (8.7%); all IOLs could be easily repositioned. CONCLUSION: The retropupillary iris-claw IOL provided good visual outcomes with a favorable complication rate and can be used for a wide range of indications in eyes without adequate capsule support. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: Evaluated transepithelial CXL using proparacaine drops 0.5% preserved with BAC 0.005% was less effective than standard CXL in stabilizing progressive keratoconus and only corrected distance visual acuity showed a statistically significant improvement at 6 months and 12 months.
Abstract: Purpose To evaluate the effect of benzalkonium chloride–assisted (BAC) transepithelial collagen crosslinking (CXL) in eyes with progressive keratoconus and a minimum follow-up of 6 months. Setting Department of Ophthalmology, Antwerp University Hospital, Antwerp, Belgium. Design Cohort study. Methods Eyes with progressive keratoconus had CXL treatment without epithelial debridement. The standard CXL irradiation was preceded by instillation of proparacaine drops 0.5% preserved with BAC 0.005% every 5 minutes for 30 minutes. Selected parameters of refraction assessed by Placido disk (Eyesys) and Scheimpflug (Pentacam) examinations were compared before CXL and after CXL at 6, 12, and 18 months. Results The study enrolled 53 eyes of 38 patients. Sphere, cylinder, as well as maximum keratometry (K max) simulated K values (steep, flat, astigmatism), and refractive power values (steep, flat, astigmatism) measured using the Placido disk device remained stable over the 18-month follow-up. Only corrected distance visual acuity showed a statistically significant improvement at 6 months and 12 months. The Scheimpflug device measurements of maximum K and pachymetry at the thinnest point showed statistically significant progression throughout the study. No patient developed corneal haze or other complications. Conclusion Transepithelial CXL using proparacaine drops 0.5% preserved with BAC 0.005% was less effective than standard CXL in stabilizing progressive keratoconus. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: Evaluating the repeatability and reliability of a recently introduced swept‐source Fourier‐domain anterior segment optical coherence tomography (AS‐OCT) system and a high‐resolution Scheimpflug camera found repeatability was better in healthy eyes than in keratoconic eyes with both instruments.
Abstract: Purpose To evaluate the repeatability and reliability of a recently introduced swept-source Fourier-domain anterior segment optical coherence tomography (AS-OCT) system and a high-resolution Scheimpflug camera and to assess the agreement between the 2 instruments when measuring healthy eyes and eyes with keratoconus. Setting Department of Ophthalmology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary. Design Evaluation of diagnostic test or technology. Methods Three consecutive series of anterior segment images were taken with AS-OCT (Casia SS-1000) followed by rotating Scheimpflug imaging (Pentacam high resolution). Axial keratometry in the steep and flat meridians and astigmatism values were recorded. Pachymetry in the apex, center, and the thinnest position and anterior chamber depth (ACD) measurements were also taken. Results This study enrolled 57 healthy volunteers (57 eyes) and 56 patients (84 eyes) with keratoconus. Significant difference was found in all measured anterior segment parameters between normal eyes and keratoconic eyes ( P Conclusions Significant differences in keratometry, pachymetry, and ACD results were found between AS-OCT and Scheimpflug imaging. However, the repeatability of the measurements was comparable. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: Toric IOL rotation was greater in eyes with a longer AL and in‐the‐bag IOL alignment had no influence on rotation, and rotational stability was measured using purpose‐designed software.
Abstract: Purpose To evaluate the rotational stability of a toric intraocular lens (IOL) using purpose-designed software and to determine the influence of axial length (AL) and in-the-bag IOL alignment on IOL rotation. Setting Iladevi Cataract & IOL Research Centre, Ahmedabad, India. Design Prospective observational case series. Methods This study enrolled eyes that had AcrySof toric IOL implantation. The AL was measured using optical coherence biometry or immersion A-scan biometry. Corneal astigmatism was determined by manual keratometry and topography. The IOL alignment was vertical, horizontal, or oblique. Rotational stability was measured using the purpose-designed software, and the mean absolute difference was determined. The effect of AL and IOL alignment on rotational stability was determined 6 months postoperatively. Results The study evaluated 168 eyes (168 patients). The mean AL was 23.86 mm ± 1.63 (SD), (range 19.50 to 29.03 mm). The median IOL rotation was 0.3 degree from baseline to 1 week, 1.0 degree from 1 week to 1 month, 0.2 degree from 1 to 3 months, and 0.1 degree from 3 to 6 months. The maximum rotation occurred between 1 week and 1 month. There was a strong correlation between AL and IOL rotation at 6 months ( r = 0.93, P P =.102, analysis of variance). Conclusions Toric IOL rotation was greater in eyes with a longer AL. Alignment of the IOL in the capsular bag had no influence on rotation. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: The single‐ Camera device was more precise for curvature, astigmatism, and corneal wavefront error measurements and the dual‐camera device for pachymetry measurements and repeatability and reproducibility were good for all parameters.
Abstract: Purpose To assess the repeatability, reproducibility, and agreement of the Pentacam HR single-camera and Galilei G2 dual-camera Scheimpflug devices in anterior segment analysis. Setting Begitek Clinica Oftalmologica, San Sebastian, Spain. Design Prospective randomized observational study. Methods Healthy young individuals had 3 consecutive tests by 2 examiners. Analyzed parameters were anterior and posterior cornea simulated keratometry (K), K flat, K steep, astigmatism magnitude and axis, J0 and J45 vectors, asphericity, total corneal higher-order wavefront aberrations (root mean square [RMS], coma, trefoil, spherical aberration), central cornea and thinnest-point thicknesses, and anterior chamber depth. Repeatability and reproducibility were evaluated by calculating the within-subject standard deviation (Sw), some derived coefficients, and the intraclass correlation coefficient. Agreement was assessed with the Bland-Altman method. Results The single-camera device reproducibility (Sw) was simulated K, 0.04 diopter (D); J0, 0.03 D; J45, 0.04 D; total power, 0.04 D; spherical aberration, 0.02 μm; higher-order aberrations (HOAs), 0.02 μm; central corneal thickness (CCT), 3.39 μm. The dual-camera device Sw was simulated K, 0.07 D; J0, 0.13 D; J45, 0.04 D; total power, 0.08 D; spherical aberration, 0.02 μm; HOAs, 0.11 μm; CCT, 1.36 μm. Agreement was good for most parameters except total corneal power (mean difference 1.58 D ± 0.22 (SD) and HOA RMS (mean difference 0.48 ± 0.19 μm) (both P Conclusions Repeatability and reproducibility were good for all parameters. The single-camera device was more precise for curvature, astigmatism, and corneal wavefront error measurements and the dual-camera device for pachymetry measurements. Agreement was good with some relevant exceptions. Financial Disclosure Dr. Aramberri is consultant to Costruzione Strumenti Oftalmici, Firenze, Italy. No other author has a financial or proprietary interest in any material or method mentioned.
TL;DR: Laser in situ keratomileusis with accelerated CXL appears to be a promising modality for future applications to prevent corneal ectasia after LASIK treatment, and results in this pilot series suggest that evaluation of a larger study cohort is warranted.
Abstract: Purpose To assess accelerated corneal collagen crosslinking (CXL) applied concurrently with laser in situ keratomileusis (LASIK) in a small group of patients. Setting Beyoglu Eye Research and Training Hospital, Istanbul, Turkey. Design Prospective pilot interventional case series. Methods In May 2010, patients had LASIK with concurrent accelerated CXL in 1 eye and LASIK only in the fellow eye to treat myopia or myopic astigmatism. The follow-up was 12 months. The attempted correction (spherical equivalent) ranged from −5.00 to −8.50 diopters (D) in the LASIK–CXL group and from −3.00 to −7.25 D in the LASIK-only group. Main outcome measures were manifest refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, and the endothelial cell count. Results Eight eyes of 3 women and 1 man (age 22 to 39 years old) were enrolled. At the 12-month follow-up, the LASIK–CXL group had a UDVA and manifest refraction equal to or better than those in the LASIK-only group. No eye lost 1 or more lines of CDVA at the final visit. The endothelial cell loss in the LASIK–CXL eye was not greater than in the fellow eye. No side effects were associated with either procedure. Conclusions Laser in situ keratomileusis with accelerated CXL appears to be a promising modality for future applications to prevent corneal ectasia after LASIK treatment. The results in this pilot series suggest that evaluation of a larger study cohort is warranted. Financial Disclosure Drs. Yilmaz and Marshall are paid consultants to Avedro, Inc. No other author has a financial or proprietary interest in any material or method mentioned.
TL;DR: These 3‐year results support the safety and efficacy of the corneal inlay to correct presbyopia in naturally emmetropic presbyopic patients.
Abstract: Purpose To report the 3-year postoperative safety and efficacy outcomes of the Acufocus corneal inlay. Setting University Eye Clinic, Paracelsus Medical University, Salzburg, Austria. Design Prospective nonrandomized noncomparative cohort study. Methods The corneal inlay was implanted in the nondominant eye of naturally emmetropic presbyopic patients. Refraction, uncorrected near (UNVA), intermediate (UIVA), and distance (UDVA) visual acuities; corrected distance visual acuity (CDVA); contrast sensitivity; visual fields; subjective patient satisfaction and symptoms; and operative and postoperative adverse events and complications were evaluated. Results The study enrolled 32 patients. The mean UNVA improved from Jaeger (J) 6 preoperatively to J1 at 3 years and the mean UIVA, from 20/40 to 20/25, respectively. At 3 years, 97% of eyes had a UNVA of J3 or better and 91% had a UIVA of 20/32 or better. The mean UDVA was 20/20, with all eyes achieving 20/32 or better. Nine eyes (28.3%) lost 1 line of CDVA, 1 eye (3.1%) lost more than 2 lines (3.8 lines), and 3 eyes (9.3%) gained 1 line. No inlay was explanted, and no inflammatory reactions were observed. At 3 years, 15.6% of patients reported severe night-vision problems and 6.3% (versus 87.5% preoperatively) reported being dependent on reading glasses. Conclusions These 3-year results support the safety and efficacy of the corneal inlay to correct presbyopia in naturally emmetropic presbyopic patients. However, despite a significant gain in UNVA and UIVA, 28.3% of patients lost 1 line of CDVA. Financial Disclosure Acufocus, Inc., California, USA, financially supports the Research Foundation for Promoting Opthhalmology, Salzburg, Austria, as the clinical research center of the University Eye Clinic, Paracelsus Medical University, Salzburg. Dr. Grabner received travel expenses from Acufocus, Inc. Dr. Riha currently works as a clinical application specialist for Acufocus, Inc. Drs. Seyeddain, Hohensinn, Nix, Ruckl, and Dexl have no financial or proprietary interest in any material or method mentioned.
TL;DR: Surgically induced AOD widening was significantly correlated with anterior chamber biometric factors and preoperative LV appears to be a significant factor in angle widening and IOP reduction after phacoemulsification.
Abstract: Purpose To evaluate anterior chamber biometric factors associated with the degree of angle widening and intraocular pressure (IOP) reduction after phacoemulsification. Setting University of California, San Francisco, California, USA. Design Case series. Methods Anterior chamber parameters obtained by anterior segment coherence tomography were compared preoperatively and 3 months postoperatively. Measurements included the angle opening distance 500 μm anterior to the scleral spur (AOD500), trabecular–iris space area 500 μm from the scleral spur (TISA500), iris curvature (I-Curv), anterior chamber angle (ACA), trabecular–iris space area, anterior chamber volume, anterior chamber width, and lens vault (LV). Results The study enrolled 73 eyes. The mean patient age was 77.45 years ± 7.84 (SD); 65.75% of patients were women. From preoperatively to 3 months postoperatively, the mean AOD500 increased significantly (0.254 ± 0.105 to 0.433 ± 0.108 mm) and the mean IOP decreased significantly (14.97 ± 3.35 to 12.62 ± 3.37 mm Hg) (P Conclusions Surgically induced AOD widening was significantly correlated with anterior chamber biometric factors. Preoperative LV appears to be a significant factor in angle widening and IOP reduction after phacoemulsification. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: Corneal and ocular HOAs decreased after CXL, suggesting an improvement in corneal shape, however, changes in HOAs were not statistically associated with a improvement in visual acuity or most subjective visual symptoms.
Abstract: Purpose To determine changes in higher-order aberrations (HOAs) after corneal collagen crosslinking (CXL). Setting Cornea and refractive surgery practice. Design Prospective randomized controlled clinical trial. Methods Corneal and ocular HOAs were measured and analyzed using the Pentacam device and Ladarwave aberrometer, respectively, at baseline and 12 months after CXL. Results Ninety-six eyes (64 keratoconus, 32 ectasia) of 73 patients had CXL. A fellow-eye control group comprised 42 eyes. The mean preoperative total anterior corneal HOAs, total coma, 3rd-order coma, and vertical coma were 4.68 μm ± 2.33 (SD), 4.40 ± 2.32 μm, 4.36 ± 2.30 μm, and 4.04 ± 2.27 μm, respectively. At 1 year, the mean values decreased significantly to 4.27 ± 2.25 μm, 4.01 ± 2.29 μm, 3.96 ± 2.27 μm, and 3.66 ± 2.22 μm, respectively (all P Conclusion Corneal and ocular HOAs decreased after CXL, suggesting an improvement in corneal shape. Financial Disclosure Dr. Hersh is medical monitor for Avedro, Inc. No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: The use of the femtosecond laser–assisted system in cataract surgery with 350 μmGrid softening led to a statistically significant lower EPT than the 500 μm grid.
Abstract: Purpose To compare the effect of different fragmentation softening grids in femtosecond laser–assisted cataract surgery on effective phacoemulsification time (EPT). Setting Ruhr University Eye Clinic, Bochum, Germany. Design Prospective randomized clinical trial. Methods The study evaluated the feasibility of using a femtosecond laser ( Catalys Precision Laser System) to perform capsulotomy and lens fragmentation in the treatment of patients with senile cataract. Patients were evaluated preoperatively with the Lens Opacities Classification System III (LOCS III). Patients had laser refractive cataract surgery with 350 μm fragmentation grids or with 500 μm fragmentation grids. Both groups had phacoemulsification using pulsed ultrasound energy, and the EPT was evaluated. Results Eighty patients were treated with 350 μm fragmentation grids and 80 patients with 500 μm fragmentation grids. The mean preoperative LOCS III grade was 3.7 ± 0.8 (SD) in the 350 μm group and 3.5 ± 0.8 in the 500 μm group. The mean laser treatment time was 66.4 ± 14.4 seconds in the 350 μm group and 52.8 ± 11.9 seconds in the 500 μm grid group and the mean EPT, 0.03 ± 0.05 seconds and 0.21 ± 0.26 seconds, respectively. Conclusion The use of the femtosecond laser–assisted system in cataract surgery with 350 μm grid softening led to a statistically significant lower EPT than the 500 μm grid. Financial Disclosure Dr. Dick is a member of the medical advisory board of Optimedica Corp. No other author has a financial or proprietary interest in any material or method mentioned.
TL;DR: Combined ICRS and CXL treatment with intracorneal riboflavin injection was effective in keratoconic eyes and may provide more penetration without epithelial removal.
Abstract: Purpose To evaluate the effectiveness of intracorneal riboflavin injection for combined collagen crosslinking (CXL) and intrastromal corneal ring segment (ICRS) implantation. Setting Kudret Eye Hospital, Ankara, Turkey. Design Noncomparative case series. Methods Keratoconic eyes had combined ICRS (Intacs) implantation and transepithelial CXL with 20% alcohol application and riboflavin injection into the corneal channel. Outcome measures were uncorrected (UDVA) and corrected (CDVA) distance visual acuities, sphere, cylinder, and keratotomy (K) readings. Results The study enrolled 131 eyes (105 patients) with a mean follow-up of 7.07 months ± 4.66 (SD). The mean improvement was 0.26 ± 0.16 logMAR in UDVA and 0.24 ± 0.16 logMAR in CDVA (both P Conclusions Combined ICRS and CXL treatment with intracorneal riboflavin injection was effective in keratoconic eyes. Intracorneal riboflavin injection into the tunnel was safe and may provide more penetration without epithelial removal. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: Vector analysis showed comparable corneal astigmatism measurements using automated, manual, and simulated keratometry, and the SMI Reference Unit showed good interobserver variability.
Abstract: Purpose To determine the comparability and repeatability of corneal astigmatism measurements obtained with different devices and determine the interobserver variability of a new automated keratometer. Setting University Eye Clinic Maastricht, the Netherlands. Design Prospective cohort study. Methods The right eye of healthy subjects was examined with the following 6 devices: IOLMaster (automated keratometry), Lenstar (automated keratometry), SMI Reference Unit 3 (automated keratometry), Javal (manual keratometry), KR-1W (corneal topography), and Pentacam (Scheimpflug imaging). An experienced operator obtained 3 repeated measurements. An inexperienced operator obtained additional measurements with the SMI Reference Unit 3. Astigmatism vector analysis was used to determine the comparability, repeatability, and interobserver variability. Results Corneal astigmatism vectors measured by automated, manual, or simulated keratometry were comparable except for the Pentacam equivalent keratometry (K) (P Conclusions Vector analysis showed comparable corneal astigmatism measurements using automated, manual, and simulated keratometry. Pentacam equivalent K values were not comparable with those of the other keratometers. The repeatability of astigmatism magnitudes was acceptable; however, the repeatability of astigmatism meridians was moderate. The SMI Reference Unit showed good interobserver variability. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: Intracameral cefuroxime injection at the end of cataract surgery was safe and significantly decreased the incidence of endophthalmitis.
Abstract: Purpose To determine whether an intracameral injection of cefuroxime at the end of cataract surgery decreases the incidence of postoperative endophthalmitis. Setting Dupuytren Hospital, Ophthalmology Department, Limoges, France. Design Clinical trials. Methods Patients having cataract surgery between April 2003 and June 2008 were included in a survey of operative-site infection. Intracameral cefuroxime injections started in June 2006. Preoperative data (beta-lactam allergy, a history of endophthalmitis, age, sex), intraoperative data (use of trypan blue, use of capsular ring or iris retractors, surgical time, senior or junior surgeon, corticosteroid injection, iris retractors), and the incidence of postoperative infections at 8 days and 1 month were prospectively collected. Results During the inclusion period, 5115 patients had cataract surgery; 2289 received cefuroxime and 2826 did not. The incidence of endophthalmitis was 35 (1.238%) of 2826 patients without intracameral cefuroxime and 1 (0.044%) of 2289 patients with intracameral cefuroxime; the difference was statistically significant (P Conclusion Intracameral cefuroxime injection at the end of cataract surgery was safe and significantly decreased the incidence of endophthalmitis. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: There was a significant reduction in the rate of postoperative endophthalmitis in a multiethnic Asian population with the use of intracameral cefazolin.
Abstract: Purpose To describe the incidence of postoperative endophthalmitis after cataract surgery in a multiethnic Asian population over an 11-year period, compare the endophthalmitis rates before and after the use of intracameral antibiotic agents, and identify potential risk factors for endophthalmitis. Setting Department of Ophthalmology, Tan Tock Seng Hospital, Singapore. Design Cohort study. Methods The incidence and risk factors for postoperative endophthalmitis in patients who had cataract surgery over 11 years were reviewed. Subconjunctival antibiotic agents only were administered over 7 years; in the subsequent 4 years, intracameral cefazolin (1.0 mg/0.1 mL) was used. Results The overall incidence of postoperative endophthalmitis in 50 177 was 0.042%. Over the 7 years without intracameral antibiotics, the endophthalmitis rate was 0.064% (19/29 539). With the use of intracameral cefazolin, the incidence decreased to 0.01% (2/20 638) (multivariate odds ratio [OR], 13.6; 95% confidence interval [CI], 3.15-58.58; P P =.025) and male sex (0.06% versus 0.02%; OR, 2.96; 95% CI; 1.15-7.65; P =.025). Conclusions There was a significant reduction in the rate of postoperative endophthalmitis in a multiethnic Asian population with the use of intracameral cefazolin. Men and older patients were at a higher risk for endophthalmitis. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: Simultaneous intracorneal inlay implantation and LASIK to treat presbyopia with emmetropia, hyperopia, or myopia was clinically safe and effective, yielding improvement in distance and near visual acuity.
Abstract: Purpose To evaluate the safety and efficacy of simultaneous Kamra corneal inlay implantation and laser in situ keratomileusis (LASIK) for the treatment of presbyopia in emmetropic, hyperopic, or myopic patients. Setting Private center, Tokyo, Japan. Design Cohort study. Methods Patients had bilateral LASIK with simultaneous implantation of a corneal inlay in the nondominant eye to treat presbyopia and ametropia between September 2009 and April 2010. The efficacy and safety were determined by the spherical equivalent (SE) in the eye with the inlay. Results The study enrolled 360 eyes of 180 patients with a mean age of 52.4 years ± 5.1 (SD) (range 41 to 65 years). Sixty-four patients were available for the 6-month postoperative examination. The mean logMAR uncorrected near visual acuity in the eye with the inlay improved 7 lines in hyperopic eyes, 6 lines in emmetropic eyes, and 2 lines in myopic eyes. The mean logMAR uncorrected distance visual acuity improved by 3 lines, 1 line, and 10 lines, respectively. Conclusions Simultaneous intracorneal inlay implantation and LASIK to treat presbyopia with emmetropia, hyperopia, or myopia was clinically safe and effective, yielding improvement in distance and near visual acuity. Patients were satisfied with decreased dependence on reading glasses regardless of the preoperative SE range. However, postoperative symptoms, such as dry eyes, halo, glare, or night-vision disturbances, occurred occasionally. Financial Disclosure Dr. Waring has a financial interest in and is world surgical monitor for Acufocus. No other author has a financial or proprietary interest in any material or method mentioned.
TL;DR: The OAG patients, especially those with pseudophakic eyes, had simultaneous cytokine level increases, suggesting the aqueous humor microenvironment is altered in pseudophAKic glaucomatous eyes.
Abstract: Purpose To evaluate cytokine and growth factor levels in the aqueous humor in patients with open-angle glaucoma (OAG). Setting Kumamoto University Hospital, Kumamoto, Japan. Design Cross-sectional cohort study. Methods Aqueous humor samples were collected from cataract cases and OAG cases. Aqueous levels of cytokines and growth factors were determined by multiplex immunoassay. The data were analyzed using the Tukey-Kramer honestly-significant-difference test and multiple regression analyses. Results The study evaluated 52 cataract cases and 73 OAG cases. In the cataract cases, the mean interleukin (IL)-6, IL-8, monocyte chemotactic protein (MCP)-1, tumor necrosis factor-α, epidermal growth factor, vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF)-AA, PDGF-AB/BB, and VEGF levels (all pg/mL) were 21.4, 4.6, 829.4, 0.8, 0.5, 33.8, 1.6, and 77.9, respectively. In 23 phakic primary OAG (POAG) and 26 phakic exfoliation glaucoma cases, the corresponding values were 15.1 and 8.3, 15.2 and 12.3, 1142.5 and 1253.9, 0.3 and 0.5, 1.5 and 1.4, 57.7 and 58.0, 2.5 and 3.3, 37.4 and 59.7, respectively. In pseudophakic OAG cases, the IL-8 levels for exfoliation glaucoma ( P =.0002) and MCP-1 for POAG ( P =.0008) and exfoliation glaucoma ( P P P =.0002 and P Conclusion The OAG patients, especially those with pseudophakic eyes, had simultaneous cytokine level increases, suggesting the aqueous humor microenvironment is altered in pseudophakic glaucomatous eyes. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: In phakic eyes, DMEK may give excellent visual outcomes without an increased risk for complications, and visual acuity equal to or better than 20/13 (≥1.5) may indicate that the almost anatomic repair after DMEk is associated with near perfect optical quality of the transplanted cornea.
Abstract: Purpose To determine the clinical outcomes of isolated Descemet membrane transplantation (ie, Descemet membrane endothelial keratoplasty [DMEK]) in phakic eyes. Setting Tertiary referral center. Design Cohort study. Methods Phakic eyes from a larger group of consecutive eyes that had DMEK for Fuchs endothelial dystrophy were examined. The examination included corrected distance visual acuity (CDVA), subjective and objective refractions, endothelial cell density (ECD), and intraoperative and postoperative complications at 1, 3, and 6 months. Results The study enrolled 52 phakic eyes from a group of 260 DMEK eyes. Of the phakic eyes, 69% reached a CDVA equal to or better than 20/40 (≥0.5) within 1 week and 85% reached equal to or better than 20/25 (≥0.8) at 6 months. Compared with an age-matched control group of pseudophakic eyes, phakic eyes had a similar visual rehabilitation rate, final visual outcome, mean ECD at 6 months (1660 cells/mm2 ± 470 [SD]), minor hyperopic shift (+0.74 diopter), and graft detachment rate (4%). Visual acuity equal to or better than 20/13 (≥1.5) was limited to phakic eyes, suggesting better optical quality with the crystalline lens in situ. Temporary mechanical angle-closure glaucoma due to air-bubble dislocation behind the iris was the main complication (11.5%). Two eyes (4%) required phacoemulsification after DMEK. Conclusions In phakic eyes, DMEK may give excellent visual outcomes without an increased risk for complications. Visual acuities equal to or better than 20/13 (≥1.5) may indicate that the almost anatomic repair after DMEK is associated with near perfect optical quality of the transplanted cornea. Financial Disclosure Dr. Melles is a consultant to D.O.R.C. International/Dutch Ophthalmic USA. No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: Primary optical factors required for negative dysphotopsia are a small pupil, a distance behind the pupil of 0.06 mm or more and 1.23 mm or less for acrylic, a sharp‐edged design, and functional nasal retina that extends anterior to the shadow.
Abstract: Purpose To determine the cause of negative dysphotopsia and the location, appearance, and relative intensity of such images in pseudophakic eyes. Setting Baylor College of Medicine, Houston, Texas, USA. Design Reporting available data addressing a specific clinical question. Methods Negative dysphotopsia was simulated using the Zemax optical design program. The nominal values for the pseudophakic eye model were as follows: IOL power, 20.0 diopters (D); corneal power, 43.5 D; Q value, −0.26; axial IOL depth behind pupil, 0.5 mm; external anterior chamber depth (corneal vertex to iris plane), 4.0 mm; optic diameter, 6.0 mm; pupil diameter, 2.5 mm. Results From the first ray-tracing simulation, analysis of the image for the nominal parameters showed 2 annuli (ring-shaped) shadows. The inner annulus shadow was located from a retinal visual field angle of 86.0 to 100.0 degrees (width 14.0 degrees), and the outer annular shadow was located from 105.9 to 123.3 degrees (width 17.4 degrees). Superimposing the inner annulus on the human visual field showed that the shadow would be apparent only temporally, where it is within the limits of the visual field and functional retina. The patient would perceive this as a temporal dark crescent-shaped partial shadow (penumbra). Conclusions Primary optical factors required for negative dysphotopsia are a small pupil, a distance behind the pupil of 0.06 mm or more and 1.23 mm or less for acrylic, a sharp-edged design, and functional nasal retina that extends anterior to the shadow. Secondary factors include a high index of refraction optic material, angle α, and the nasal location of the pupil relative to the eye’s optical axis. Financial Disclosure Drs. Zhao and Reisin are employees of and Dr. Holladay is a consultant to Abbott Medical Optics, Inc. No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: All marking devices showed a slight deviation to the horizontal reference meridian, which can result in a relevant reduction in the astigmatism‐reducing effect with toric intraocular lenses.
Abstract: Purpose To compare 4 devices used to mark the cornea before astigmatism-reducing surgery. Setting Hanusch Krankenhaus, Vienna, Austria. Design Randomized examiner-masked clinical trial. Methods Patients were randomly allocated to 1 of 4 groups for preoperative corneal marking in the sitting position. The 4 methods used were marking at the slitlamp with an insulin needle, a pendular marker, a bubble marker, and a tonometer marker. The marks were then documented with a standardized photographic technique, and the rotational deviation and vertical misalignment were assessed. Results The study enrolled 60 patients. The pendular-marking device showed the least rotational deviation to the reference meridian (mean 1.8 degrees). There was no statistically significant difference between slitlamp marking and pendular marking (P = .05); however, there was a significant difference between the pendular marker and the bubble marker and between the pendular marker and the tonometer marker (P = .01 and P Conclusions All marking devices showed a slight deviation to the horizontal reference meridian. Because small deviations of the meridian can result in a relevant reduction in the astigmatism-reducing effect with toric intraocular lenses, accurate marking of the cornea before surgery is critical due to the variable cyclotorsion caused by a change from the upright to the supine position. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.
TL;DR: The etiology and management of post-keratoplasty astigmatism is discussed and recommendations and tips to minimize it are provided and contact lenses or surgical intervention are provided.
Abstract: Post-keratoplasty astigmatism remains a challenge for corneorefractive surgeons. While maintaining a healthy graft is the most crucial issue in keratoplasty procedures, astigmatism is a limiting factor in the visual rehabilitation of otherwise successful corneal grafts. The management of post-keratoplasty astigmatism takes place at 2 stages: when sutures are still present at the graft–host junction and when all sutures have been removed. Excessive suture-in post-keratoplasty astigmatism is usually managed by selective suture manipulation, ie, suture adjustment and/or suture removal along the steep meridian of astigmatism. A small amount of suture-out post-keratoplasty astigmatism can be managed by spectacles. Higher magnitudes of astigmatism can be addressed by contact lenses or surgical intervention, such as relaxing and compressing procedures. Laser lamellar refractive surgery can also be used to manage post-keratoplasty astigmatism, and toric phakic intraocular lenses have recently been recommended. In this review, we discuss the etiology and management of post-keratoplasty astigmatism and provide recommendations and tips to minimize it. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.