Comparative Study of Primary SMILE, SMILE Enhancement, and Femtosecond Laser-Assisted LASIK on Higher Order Aberrations and Corneal Densitometry.

PURPOSE: To compare differences in corneal densitometry (CD) and higher order aberrations (HOAs) in eyes that underwent small incision lenticule extraction (SMILE) and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) for the treatment of myopia and myopic astigmatism at postoperative months 3, 6, and 12, and to evaluate their changes in a separate cohort of eyes after SMILE enhancement. METHODS: In this prospective, randomized, paired-eye clinical trial, consecutive eligible participants were randomized to undergo SMILE or FS-LASIK in either eye. Main outcome measures were CD and HOAs preoperatively and at 3, 6, and 12 months postoperatively. A separate cohort of consecutive patients who had SMILE and underwent enhancement were also included for comparison. RESULTS: For CD, no significant differences were found between SMILE and FS-LASIK up to month 12. For HOA measured by wavefront aberrometry, both SMILE and FS-LASIK had an increase in total root mean square (RMS) HOAs, spherical aberration (SA), and vertical coma up to month 12. SMILE had an additional increase in vertical quatrefoil, and FS-LASIK had an increase in horizontal coma at month 12. FS-LASIK had higher SA than SMILE, whereas SMILE had higher vertical quatrefoil than FS-LASIK at month 12. Central and posterior zone CD had significantly decreased after SMILE enhancement compared to after primary SMILE up to 2 years after enhancement. RMS HOAs, lower order aberrations, and SA were all increased after SMILE enhancement compared to after primary SMILE. CONCLUSIONS: SMILE induced lower SA but higher vertical quatrefoil than FS-LASIK at 1 year. Both SMILE and FS-LASIK had similar increases in RMS HOAs and vertical coma up to 1 year. There were no differences in CD between both groups. SMILE enhancement additionally had decreased central and posterior CD but greater RMS HOAs and SA compared to primary SMILE. [J Refract Surg. 2024;40(5):e291-e303.].

Effect of anti-VEGF on retinal blood flow in diabetic mice using laser speckle flowgraphy.

PURPOSE: To assess intra- (repeatability) and inter-observer (reproducibility) variability of laser speckle flowgraphy (LSFG) for retinal blood flow (RBF) measurement in 20 eyes of wild type (C57BL/6J) mice and effect of intravitreal Aflibercept on RBF in optic nerve head (ONH) region of 10 eyes of Ins2 (Akita) diabetic mice. METHODS: 'Mean blur rate (MBR)' was measured for all quadrants of tissue area (MT), vessel (MV) and total area (MA) of ONH region. Changes in MT were analysed at each timepoint. Repeatability was evaluated by measuring MBR variability without changing mouse head position, and reproducibility after resetting mouse head position by another operator. Coefficient of repeatability (CR) through Bland-Altman plot method coefficient of variation (COV) and Intraclass correlation coefficient (ICC) was calculated. Intravitreal Aflibercept (1 µg) was administered to Akita eyes and intraocular pressure (IOP) was measured using a tonometer at baseline, day 7, 14, 21 and 28 post-injection. Hurvich and Tsai's criterion was used. RESULTS: Coefficient of repeatability values of repeatability and reproducibility for all quadrants were within limits of agreement. Reliability was excellent (ICC 0.98-0.99) and reproducibility was moderate to excellent (ICC 0.64-0.96). There was a non-significant IOP increase in all Akita eyes at Day 28 (p > 0.05), and significant increase in MT in all quadrants at Day 21 and superior, inferior and temporal quadrants at Day 28 (p < 0.05). CONCLUSION: Laser speckle flowgraphy demonstrates excellent repeatability and moderate to excellent reproducibility in measuring RBF. Intravitreal Aflibercept injection results in a significant increase in MT up to 28 days post-injection without significant increase in IOP.

The Effects of High Energy Capsulotomy on Aqueous Cytokine Profiles and Pupil Size During Femtosecond Laser-Assisted Cataract Surgery.

PURPOSE: To assess whether aqueous cytokine profiles and pupil size are altered when high capsulotomy energy is used in eyes undergoing femtosecond laser-assisted cataract surgery (FLACS), and if preoperative use of a topical non-steroidal anti-inflammatory drug (NSAID) has an effect on this. METHODS: This prospective study recruited 83 eyes (63 patients) that were allocated to four treatment groups: conventional phacoemulsification (n = 20 eyes); FLACS with 90% capsulotomy energy without NSAID pretreatment (n = 20 eyes); FLACS with 90% capsulotomy energy with NSAID pre-treatment (n = 21 eyes); and FLACS with 150% capsulotomy energy with NSAID pretreatment (n = 22 eyes). Aqueous humor was collected before and after phacoemulsification to assess cytokine profiles. Pupil size was measured before and after laser capsulotomy. RESULTS: FLACS increased aqueous concentrations of pros-taglandin E2 (PGE2), interferon γ (IFN-γ), and interleukin 6 (IL-6) compared to conventional phacoemulsification. However, when increasing capsulotomy energy from 90% to 150% (with topical NSAID pretreatment), there was no significant increase in aqueous concentrations of PGE2 (37.7 ± 21.7 vs 33.6 ± 27.6 pg/mL, P = .99), IFN-γ (3.6 ± 1.1 vs 3.6 ± 0.8 pg/mL, P = .99), or IL-6 (7.1 ± 2.9 vs 6.3 ± 2.4 pg/mL, P = .99). For 90% and 150% capsulotomy energy, there was significant miosis following laser capsulotomy. Increased PGE2 concentration was significantly correlated with a reduction in pupil area (r = -0.58, P < .001) and pupil diameter (r = -0.57, P < .001). However, when a topical NSAID was given preoperatively, there was no difference in the degree of miosis between the 90% and 150% capsulotomy energy groups. CONCLUSIONS: Pretreatment with a topical NSAID prevented a rise in PGE2, IFN-γ, and IL-6 levels and excessive miosis when a higher capsulotomy energy was used. When a topical NSAID is used preoperatively, it is safe to use higher capsulotomy energy settings (with a low pulse energy femtosecond laser system) to achieve a satisfactory capsulotomy. [J Refract Surg. 2022;38(9):587-594.].

Effect of corneal stromal lenticule customization on neurite distribution and excitatory property.

Introduction: Refractive stromal lenticules from Small Incision Lenticule Extraction (SMILE), though usually discarded, hold a potential for various ophthalmic applications, including refractive correction, stromal volume expansion, and biomechanical strengthening of the cornea. Objectives: To investigate the effect of lenticule customization on lenticule neurite length profile and the excitatory response (calcium signaling) and the potential of reinnervation. Methods: Human and porcine stromal lenticules were treated by (1) excimer laser reshaping, (2) ultraviolet A-riboflavin crosslinking (CXL), and (3) decellularization by sodium dodecyl sulfate (SDS), respectively. The overall neurite scaffold immuno-positive to TuJ1 (neuron-specific class III ß-tubulin) expression and population of active neurite fragments with calcium response revealed by L-glutamate-induced Fluo-4-acetoxymethyl ester reaction were captured by wide-field laser-scanning confocal microscopy, followed by z-stack image construction. The NeuronJ plugin was used to measure neurite lengths for TuJ1 (NL-TuJ1) and calcium signal (NL-Ca). Reinnervation of lenticules was examined by the ex vivo grafting of chick dorsal root ganglia (DRG) to the decellularized human lenticules. Differences between groups and controls were analyzed with ANOVA and Mann-Whitney U test. Results: The customization methods significantly eliminated neurites inside the lenticules. NL-TuJ1 was significantly reduced by 84% after excimer laser reshaping, 54% after CXL, and 96% after decellularization. The neurite remnants from reshaping and CXL exhibited calcium signaling, indicative of residual excitatory response. Re-innervation occurred in the decellularized lenticules upon stimulation of the grafted chick embryo DRG with nerve growth factor (NGF 2.5S). Conclusion: All of the lenticule customization procedures reduced lenticule neurites, but the residual neurites still showed excitatory potential. Even though these neurite remnants seemed minimal, they could be advantageous to reinnervation with axon growth and guidance after lenticule reimplantation for refractive and volume restoration of the cornea.

Outcomes of combined single-use dual blade goniotomy and cataract surgery.

PURPOSE: Single-use dual blade goniotomy (SBG) is a novel ab interno procedure that removes three to five clock hours of trabecular meshwork (TM). We analysed the reduction of intraocular pressure (IOP) and topical glaucoma medication (Meds) in eyes following combined cataract surgery and SBG (Cat-SBG). METHODS: IOP and Meds were evaluated retrospectively in 55 eyes of 38 patients. 44 eyes had high tension glaucoma (HTG) and eleven eyes had normal tension glaucoma (NTG). Complete success (no Meds) and qualified success (with Meds) for IOP levels ≤ 21, ≤ 18 , ≤ 16 mmHg or ≥ 20% IOP reduction at the two- and six-month follow-up were evaluated. RESULTS: IOP and Meds were significantly reduced from before to two months after Cat-SBG in HTG- and NTG-patients (HTG: IOP 19.4 ± 3.3 to 15.1 ± 3.3 mmHg; p < 0.001; Meds 2.1 ± 1.3 to 0.8 ± 1.3; p < 0.001; NTG: IOP 14.0 ± 2.3 to 11.5 ± 2.3 mmHg; p = 0.004; Meds 1.6 ± 0.7 to 0.3 ± 0.7; p < 0.001). IOP and Meds did not change significantly from two to six months after Cat-SBG. In HTG, complete and qualified success rates were 43% (19/44) and 93% (41/44) for IOP ≤ 18 mmHg, 36% (16/44) and 64% (28/44) for IOP ≤ 16 mmHg and 30% (13/44) and 43% (19/44) for ≥ 20% IOP reduction six months after surgery. In NTG, complete and qualified success was 81% (9/11) and 100% (11/11) for IOP ≤ 18 and ≤ 16 mmHg, and 27% (3/11) for IOP reduction ≥ 20%. IOP and Meds reduction were comparable between HTG and NTG eyes. Only minor postoperative complications occurred. CONCLUSION: Cat-SBG is an efficient method to significantly lower IOP in patients with HTG and NTG.

Outcomes of surgical bleb revision at a tertiary Singapore eye hospital.

PURPOSE: To describe the outcomes of surgical bleb revisions from a tertiary glaucoma service in Singapore. METHODS: One hundred and thirty-one eyes of 129 patients who underwent surgical bleb revisions at the Singapore National Eye Centre between 2007 and 2014 were included in the study. The indications for bleb revision were: bleb-related infection (BRI), early and late bleb leak, early and late overfiltration, and bleb dysesthesia. Regression analysis was applied to elucidate risk factors. RESULTS: The mean age of the patients was 66 years, 62.6% were male, and 88.5% were Chinese. The majority of the eyes had primary glaucoma (79.4%). The mean interval from the initial trabeculectomy or phaco-trabeculectomy to the bleb revision was 58.8 months. The overall success rate was 69.5%. By Kaplan-Meier survival analysis, the overall cumulative success range fell from 78.6% to 49.1% over 10 years. Eyes with early bleb leak had lower surgical success compared to eyes with late bleb leak, early overfiltration and late overfiltration (P = 0.026, log-rank test). The IOP improved significantly post-operatively for eyes with BRI, early bleb leak, late bleb leak, early overfiltration and overfiltration (P < 0.05). Vision improved significantly in eyes with early overfiltration, but deteriorated in eyes with BRI (P < 0.05). CONCLUSION: The overall success rate for surgical bleb revisions was good with complete resolution of the primary problem in the majority of cases. However, eyes with early bleb leak were less likely to have successful outcomes and should be monitored more closely post-operatively.

Utilization rate and usage patterns of phakic and pseudophakic donor corneas recovered by the Singapore Eye Bank.

PURPOSE: To compare the utilization rate and usage patterns of pseudophakic and phakic donor corneas recovered by the Singapore Eye Bank. METHODS: Records of local donor corneas recovered by the Singapore Eye Bank from 2012 to 2017 were examined. Corneas that were deemed suitable for clinical use were stratified into phakic and pseudophakic groups. We examined the basic demographic pattern of both groups and the initial type of surgery/ies that the corneas were suitable for based on tissue parameters such as time from harvesting, stromal clarity, the clear central corneal area, the presence of Descemet's membrane tears or defects, and endothelial cell density and quality. We also identified the types of corneal grafts that the corneas were eventually used for; Penetrating Keratoplasty (PK), Anterior Lamellar Keratoplasty (ALK), Endothelial Keratoplasty (EK). Finally, the overall utilization rates for each group were determined. RESULTS: A total of 986 corneas deemed suitable for transplant were analyzed, 908 (92%) were phakic and 78 were pseudophakic (8%). The average age of pseudophakic donor corneas was (65 ± 8 yrs. old) and there was a slight male preponderance for both groups (55%). Age adjusted analysis of pseudophakic corneas showed the endothelial cell density (ECD) (mean: 2327 ± 47.1 cells/mm2) and clear area (mean: 7.0 ± 0.7 mm) were lesser than phakic corneas. The percentage of pseudophakic corneas that were of EK standard (ECD >2500 cells/mm2) were lower compared to phakic corneas (37% and 77% respectively, p < 0.001). There was significant correlation between previous cataract surgery and the endothelial cell count of the donor corneas (p < 0.001), and regression analysis also showed a strong association of ECD with cataract surgery in reference to non-cataract surgery (-478.8 (95% CI-576.9 to -380.7). The overall utilization rate for pseudophakic corneas was 58% compared to that of phakic corneas at 83%. The most common reason for pseudophakic corneas not to be utilized was due to the presence of Descemet's membrane (DM) tears or defects under the main or side port incision created during phacoemulsification (30%). Phakic corneas were used primarily for optical grafts 84% (mainly EK) while pseudophakic corneas were used mostly for therapeutic/tectonic grafts 47% (mainly ALK or patch grafts). CONCLUSION: Compared to phakic donor corneas, pseudophakic corneas generally have lower overall tissue quality leading to lower uptake by surgeons and lower utilization rates. Eye banks must continuously refine their donor acceptance criteria and engage surgeons to optimize utilization of each recovered tissue.

Steady-State Pattern Electroretinography in Eyes with Glaucoma and High Myopia.

PURPOSE: To investigate features of the steady-state pattern electroretinogram (ssPERG) in subjects with glaucoma (G), high myopia (HM; spherical equivalent ≤-6D) and glaucoma with high myopia (GHM). PATIENTS AND METHODS: Our study included 48 participants divided into 3 groups (G, HM, and GHM) who each underwent monocular ssPERG testing with Diopsys NOVA PERG protocols. The ConStim protocol detects distinct topographic patterns of dysfunction 16° and 24° around the central macula. MagD is the amplitude of the average signal and MagD/Mag ratio indicates the consistency of the response. ssPERG indices were compared between groups and correlated with functional (ie, visual field mean deviation (VFMD)) and structural (ie, average retinal nerve fibre layer (RNFL) thickness; Cirrus optical coherence tomography) features. RESULTS: Participants had an average age of 59.4±7.6 years. Mean Humphrey VFMD was -14.22 ± 2.88dB, -2.62 ± 1.18dB and -12.80 ± 2.60dB for G, HM and GHM groups, respectively. Mean RNFL thickness was 63.0 ± 8.20µm, 69.5 ± 15.7µm and 60.6 ± 5.0µm for G, HM and GHM groups, respectively. For the 24° setting, no significant differences were noted for any of the parameters. For the 16° setting, MagD was lower in the GHM group compared to the HM group (0.29µV vs 0.52µV; p = 0.02). Significant differences were noted for the MagD/Mag ratio between HM and G groups (0.58 vs 0.40; p = 0.02) and between HM and GHM groups (0.58 vs 0.35; p = 0.002). There were positive correlations between both MagD 16° and MagD/Mag ratio 16° with VFMD (correlation coefficient [r]=0.37, p = 0.009; and r = 0.44, p = 0.002, respectively) and RNFL (r = 0.43, p = 0.002; and r = 0.48, p = 0.001, respectively). CONCLUSION: MagD/Mag ratio at 16° was significantly lower in glaucomatous eyes (with or without high myopia) compared to those with high myopia without glaucoma, suggesting that glaucoma has a distinct impact on MagD/Mag ratio at 16° irrespective of the presence of myopia.

Assessment of the Macular Microvasculature in High Myopes With Swept Source Optical Coherence Tomographic Angiography.

Background: The risk of pathologic myopia (PM) increases with worsening myopia and may be related to retinal microvasculature alterations. To evaluate this, we analyzed the macular microvasculature of myopes with swept source-optical coherence tomographic angiography (SS-OCTA) in adolescent and young adult Singaporeans. Methods: This is a prevalent case-control study including 93 young Chinese from the Strabismus, Amblyopia and Refractive error in Singaporean children (STARS, N = 45) study and the Singapore Cohort Study of Risk Factors for Myopia (SCORM, N = 48) studies. Macular vessel density (VD) measurements were obtained from 3 × 3 mm SS-OCTA scans and independently assessed using ImageJ. These measurements were compared between individuals with non-high myopia [non-HM, N = 40; SE >-5.0 diopter (D)] and HM (SE ≤-5.0D, N = 53). Results: The mean macular VD was 40.9 ± 0.6% and 38.2 ± 0.5% in the non-HM and HM, groups, respectively (p = 0.01 adjusted for age and gender). Mean FAZ area in the superficial layer was 0.22 ± 0.02 mm2 in the HM group, which was smaller compared to non-HM group (0.32 ± 0.03 mm2, p = 0.04). Mean deep FAZ area was similar between the two groups (0.45 ± 0.03 mm2 and 0.48 ± 0.04 mm2 in the HM and non-HM groups, respectively, p = 0.70). Conclusions: VD was lower and superficial FAZ area was smaller, in adolescents and young adults with HM compared to non-HM. These findings require validation in prospective studies to assess their impact on the subsequent development of PM.

Rapid Myopic Progression in Childhood Is Associated With Teenage High Myopia.

Purpose: The purpose of this study was to evaluate the association of childhood progression of spherical equivalent (SE) with high myopia (HM) in teenagers in the Singapore Cohort of Risk factors for Myopia (SCORM). Methods: We included 928 SCORM children followed over a mean follow-up of 6.9 ± 1.0 years from baseline (6-11 years old) until their teenage years (12-19 years old). Cycloplegic autorefraction and axial length (AL) measurements were performed yearly. The outcomes in teenagers were HM (SE ≤ -5 diopter [D)], AL ≥ 25 mm, SE and AL. Three-year SE and AL progression in childhood and baseline SE and AL with outcomes were evaluated using multivariable logistic or linear regression models, with predictive performance of risk factors assessed using the area under the curve (AUC). Results: At the last visit, 9.8% of teenagers developed HM and 22.7% developed AL ≥ 25 mm. In multivariate regression analyses, every -0.3 D/year increase in 3-year SE progression and every 0.2 mm/year increase in 3-year AL progression were associated with a -1.14 D greater teenage SE and 0.52 mm greater teenage AL (P values < 0.001). The AUC (95% confidence interval [CI]) of a combination of 3-year SE progression and baseline SE for teenage HM was 0.97 (95% CI = 0.95 - 0.98). The AUC of 3-year AL progression and baseline AL for teenage AL ≥ 25 mm was 0.91 (95% CI = 0.89 - 0.94). Conclusions: Three-year myopia progression in childhood combined with baseline SE or AL were good predictors of teenage HM. Clinicians may use this combination of factors to guide timing of interventions, potentially reducing the risk of HM later in life.

Femtosecond laser-assisted stromal keratophakia for keratoconus: A systemic review and meta-analysis.

PURPOSE: Femtosecond lasers have revived the possibility of stromal keratophakia or tissue additive keratoplasty, a technique originally introduced by Prof. Jose Ignacio Barraquer in the 1960s. The surgical technique offers a unique solution to treat keratoconus. In the current study, we reviewed and performed a meta-analysis of the clinical outcomes of the femtosecond laser-assisted stromal keratophakia in the treatment of keratoconus. METHODS: This is a systematic review and meta-analysis of the estimated outcome difference between pre- and post-lenticule implantations. RESULTS: A total of related 10 studies were found in the literature. No studies reported adverse events, such as persistent haze or graft rejection, at last patients' visits. We further narrowed down the article selection in accordance to our inclusion criteria to report the composite outcomes (9 studies) and meta-analysis (4 studies). In the composite analysis, we demonstrated that lenticule implantation in keratoconus and post-LASIK ectasia patients appeared to expand the stromal volume of the thin corneas, flattened the cones, and significantly improved uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA) and spherical equivalent (SE). The meta-analysis showed that the random estimated UCVA, BCVA, SE and mean keratometry (Km) differences following the lenticule implantation was -0.214 (95% CI: -0.367 to 0.060; p = 0.006), -0.169 (-0.246 to 0.091; p < 0.001), -2.294 D (-3.750 to -0.839 D; p = 0.002), and 2.909 D (0.805 to 5.012 D; p = 0.007), respectively. CONCLUSIONS: Femtosecond laser-assisted stromal keratophakia is a feasible technique to correct the refractive aberrations, expand corneal volume and regularize corneal curvature in patients with keratoconus. However, there is a need to standardize the technique (e.g., whether to crosslink or not or to use convex or concave lenticules) and to formulate a mathematical model that accounts for the long-term epithelial thickness changes and stromal remodeling to determine the shape or profile of the lenticules, in order to improve the efficacy of the keratophakia further.

The Effects of Donor-Recipient Age and Sex Compatibility in the Outcomes of Deep Anterior Lamellar Keratoplasties.

PURPOSE: Corneal transplantations are the commonest allogenic transplant surgeries performed worldwide. Transplantable grade donor cornea is a finite resource. There is thus an impetus for eye banks to optimize the use of each harvested cornea, and clinicians to minimize the risks of graft rejection and failure. With better survival and lower rejection rates, anterior lamellar keratoplasty has gained popularity as an alternative technique to full-thickness penetrating keratoplasty, for the treatment of corneal stromal diseases. This study evaluated the effects of donor-recipient age- and sex-matching on the outcomes of eyes that had undergone deep anterior lamellar keratoplasty (DALK) surgeries. DESIGN: Observational cross-sectional study (national corneal graft registry data). SUBJECTS: All DALK surgeries performed in a tertiary ophthalmic hospital over an 11-year period. METHODS: To analyse the effects of donor-recipient sex-matching, transplantations were classified as "presumed H-Y incompatible" (male donor to female recipient) or "presumed H-Y compatible" (all other donor-recipient sex combinations). For age-matching, differences in donor and recipient ages were calculated. Cox proportional hazards regressions were used to evaluate the influence of donor-recipient sex-matching and age-matching on graft failure and rejection. MAIN OUTCOME MEASURES: Rates of graft failure and rejection within each group. RESULTS: 401 eyes were included. 271 (67.6%) transplants were presumed H-Y compatible. 29 (7.2%) grafts failed and 9 (2.2%) grafts rejected. There were trends of lower hazard ratios (HRs) in graft failure and rejection in the presumed H-Y compatible group [HRs: 0.59 (95% CI 0.20-1.77, p = 0.34) and 0.93 (95% CI 0.22-3.89, p = 0.926), respectively]. Median difference in age between recipients and donors was 15.0 years (IQR -2.8-34.3). The HRs of graft failure and rejection were not influenced by donor-recipient age [HRs per 1-year increase in age difference: 0.995 (95% CI 0.98-1.01, p = 0.483) and 1.01 (95% CI 0.99-1.03, p = 0.394), respectively]. CONCLUSION: In eyes that had undergone DALK surgeries, no significant influence of donor-recipient sex- or age-matching on graft rejection and failure was observed. Without strong evidence and the limitations of obtaining sample sizes required for an adequately powered study, the benefits of sex- and age-matching of donors and recipients during graft allocation for DALK surgeries is currently inconclusive.

Comparative Study of Long-term Graft Survival Between Penetrating Keratoplasty and Deep Anterior Lamellar Keratoplasty.

PURPOSE: Endothelial failure and immunological graft rejection remain long-term complications leading to late graft failure in penetrating keratoplasty (PK). Deep anterior lamellar keratoplasty (DALK) has emerged as a viable alternative that enables preservation of the host's endothelial cells to eliminate risks of endothelial rejection and failure. The aim of this study was to compare long-term graft survival between PK and DALK. DESIGN: Retrospective clinical cohort study. METHODS: All consecutive primary grafts of DALKs (n = 362) and PKs (n = 307) performed for optical indications in a tertiary eye center from the ongoing, prospective Singapore Corneal Transplant Study. Ten-year graft survival outcomes were compared. Cases in which endothelial pathologies were diagnosed were excluded, as DALK was not performed for such cases. Main outcome measurements were mean graft survival rate. RESULTS: The survival rate for PK was 94.4%, 80.4%, and 72.0% at 1, 5, and 10 years, respectively; and 95.8%, 93.9%, and 93.9% at 1, 5, and 10 years, respectively, for DALK (P = .001). Patients who underwent PK developed more complications of glaucoma (29.3% vs. 11.6%, respectively; P < .001), allograft rejection (16.6% vs. 1.7%, respectively; P < .001), epithelial problems (10.4% vs. 5.5%, respectively; P = .018), and nonimmunological failure (7.8% vs. 1.9%, respectively; P < .001), compared to DALK. Rates of graft failure attributable to rejection (36.7% vs. 5.9%, respectively; P = .015) and endothelial failure (36.7% vs. 5.9%, respectively; P = .015) were lower in DALK. CONCLUSIONS: The 10-year graft survival for primary DALK was superior to that for PK for corneal pathologies with functional endothelium. Primary DALK resulted in fewer post-operative complications and lower rates of graft rejection and failure. This study strengthens the case in favor of performing DALK over PK when possible.

Long-Term Review of Penetrating Keratoplasty: A 20-Year Review in Asian Eyes.

PURPOSE: To review the long-term outcomes of optical, therapeutic and tectonic forms of penetrating keratoplasty over a 20-year period in Asian eyes. DESIGN: Prospective cohort study involving the Singapore Corneal Transplant Study (SCTS). METHODS: All penetrating keratoplasties (PK) performed at the Singapore National Eye Centre (SNEC) from January 1991 to December 2010 were analyzed using records from the computerized database of the SCTS. This database includes preoperative, intraoperative, and postoperative patient data and donor cornea data. Only primary grafts were included. Patient demographics, donor cornea source, indications for grafting, complications, graft survival rate, and causes of graft failure were analyzed. RESULTS: A total of 1,206 primary PKs were performed. The mean age of the patients was 55 years (range: <1-101 years). The overall corneal graft survival rates at 1, 5, 10, 15, and 20 years were 91%, 66.8%, 55.4%, 52%, and 44%, respectively. For optical grafts, pseudophakic bullous keratopathy, postinfectious corneal scarring and thinning and keratoconus were the most common diagnoses. Graft survival for optical grafts was significantly better than therapeutic and tectonic grafts at all time points. Multivariate analysis suggested that a younger donor cornea age and higher donor endothelial cell count are associated with better long-term graft survival for optical grafts. Irreversible allograft rejection and late endothelial failure accounted for more than 60% of graft failures. CONCLUSIONS: Graft survival decreased over time from 91% at 1 year to 44% at 20 years' follow-up. Allograft rejection and late endothelial failure accounted for more than 60% of graft failures.

Annual Myopia Progression and Subsequent 2-Year Myopia Progression in Singaporean Children.

Purpose: To investigate the association between 1-year myopia progression and subsequent 2-year myopia progression among myopic children in the Singapore Cohort Study of the Risk Factors for Myopia. Methods: This retrospective analysis included 618 myopic children (329 male), 7 to 9 years of age (mean age, 8.0 ± 0.8) at baseline with at least two annual follow-up visits. Cycloplegic autorefraction was performed at every visit. Receiver operating characteristic (ROC) curves from multiple logistic regressions were derived for future fast 2-year myopia progression. Results: Children with slow progression during the first year (slower than -0.50 diopter [D]/y) had the slowest mean subsequent 2-year myopia progression (-0.41 ± 0.33 D/y), whereas children with fast progression (faster than -1.25 D/y) in year 1 had the fastest mean subsequent 2-year myopia progression (-0.82 ± 0.30 D/y) (P for trend < 0.001). Year 1 myopia progression had the highest area under the curve (AUC) for predicting fast subsequent 2-year myopia progression (AUC = 0.77; 95% confidence interval [CI], 0.73-0.80) compared to baseline spherical equivalent (AUC = 0.70; 95% CI, 0.66-0.74) or age of myopia onset (AUC = 0.66; 95% CI, 0.61-0.70) after adjusting for confounders. Age at baseline alone had an AUC of 0.65 (95% CI, 0.61-0.69). Conclusions: One-year myopia progression and age at baseline were associated with subsequent 2-year myopia progression in children 7 to 9 years of age. Translational Relevance: Myopia progression and age at baseline may be considered by eye care practitioners as two of several factors that may be associated with future myopia progression in children.

Three-Year Outcomes of Simultaneous Accelerated Corneal Crosslinking and Femto-LASIK for the Treatment of High Myopia in Asian Eyes.

PURPOSE: To determine the long-term visual outcomes of simultaneous femtosecond laser-assisted laser in situ keratomileusis (femto-LASIK) and accelerated cross-linking (CXL) [LASIK Xtra] for the treatment of high myopia. PATIENTS AND METHODS: All 163 consecutive eyes of 85 patients who underwent LASIK Xtra for the treatment of high myopia and/or myopic astigmatism (spherical equivalent ≥ -6.00 D) in Singapore National Eye Centre from the years 2013 to 2017 were included in this retrospective case series. Post-operative follow-up was up to 3 years. RESULTS: Of the 163 eyes, 67 were followed up for 1 year (mean 12.9 months), 69 for 2 years (mean 24.0 months) and 43 for 3 years (mean 36.4 months). Overall mean follow-up was 22.8 months (9-46 months). The mean pre-operative spherical equivalent (SE) was -8.60 ± 1.47 D [range: -11.75 to -4.75] (n = 163) and mean attempted correction SE was -8.84 ± 1.41 D [range: -11.88 to -5.25]. Most eyes (>95%) maintained an uncorrected distance visual acuity of 6/12 or better over 3 years. Visual outcomes were predictable with ≥95% of eyes achieving a SE correction within ± 1D of attempted correction over 3 years. There was a mild regression in SE refraction over 3 years with a mean of -0.10 ± 0.45 D three years post-operatively (p = 0.03). The safety index was >1.05 at 3 years follow-up. There were no significant post-operative complications though 24 eyes had mild haze and 2 eyes had grade 1 diffuse lamellar keratitis that resolved within 1 month. CONCLUSION: Our 3-year LASIK Xtra results show favorable safety, efficacy, predictability and stability outcomes in Asian patients with high myopia.

Descemet Membrane Endothelial Keratoplasty in Asian Eyes: Intraoperative and Postoperative Complications.

PURPOSE: To describe intraoperative and postoperative complications of Descemet membrane endothelial keratoplasty (DMEK) in Asian eyes. METHODS: A: prospective comparative study of consecutive cases of DMEK cases between January 2016 and January 2018. A subgroup of consecutive patients were optimized with preoperative topical eye drops and modification of donor insertion. Main outcome measures were intraoperative complications and total surgical time. Secondary outcome measures were postoperative complications and endothelial cell loss (ECL) at the 6-month follow-up. RESULTS: We included 50 consecutive patients in this study; mean age of 66 ± 9 years old with 70% women. The indications for DMEK were Fuchs endothelial dystrophy (82%) and bullous keratopathy (18%). When compared with the standard group (n = 24 eyes), the optimized DMEK group (n = 26 eyes) was associated with a significantly reduced surgical time (33.9 ± 12.7 vs. 26.9 ± 7.6 minutes; P = 0.041), lower ECL at 6 months (27.2 ± 17.1% vs. 13.7 ± 9.7%; P = 0.012) and lower risk of high vitreous pressure causing iris prolapse (16.7% vs. 0%; P = 0.046). Multivariate analysis revealed a shorter surgical time (Odds Ratio [OR]: 0.924; 95% confidence interval: 0.858-0.995; P = 0.036) and reduced ECL (OR: 0.907; 95% confidence interval: 0.843-0.977; P = 0.01) in the optimized group. CONCLUSIONS: We observed intraoperative challenges such as difficulty with donor insertion with increased vitreous pressure in Asian eyes by performing DMEK surgery, which may be reduced with anticipated preoperative and postoperative measures.

Hybrid Descemet Membrane Endothelial Keratoplasty (H-DMEK): results of a donor insertion pull-through technique using donor stroma as carrier.

AIM: To evaluate the outcomes and complications of hybrid Descemet membrane endothelial keratoplasty (H-DMEK) using a Descemet stripping automated endothelial keratoplasty (DSAEK) pull-through donor inserter and donor stroma as carrier. METHODS: This was a retrospective interventional case series of eyes with bullous keratopathy (BK) and Fuchs endothelial corneal dystrophy (FECD), which underwent H-DMEK, performed using a bimanual pull-through technique using DSAEK-prepared donor stroma as carrier and the EndoGlide Ultrathin DSAEK donor insertion device. Complex cases with tube shunts, trabeculectomy, aphakia, aniridia, previous vitrectomy, keratoplasty or combined with intraocular lens exchange, were also included. The outcome measures were intraoperative and postoperative complications, best corrected visual acuity (BCVA) and endothelial cell loss after surgery. RESULTS: Of the 85 eyes from 79 patients, 43.5% (n=37) had BK, 28.2% (n=24) had FECD while 24.7% (n=21) had failed grafts. DMEK was performed in 37 complex eyes (43.5%). Four eyes (4.7%) required rebubbling for graft detachment and two cases of graft failure were observed. A BCVA of 20/25 or better was attained in 44.7% and 57.1% of eyes without pre-existing ocular pathology at 6 and 12 months, respectively. The overall endothelial cell loss was 32.2%±20.5% at 6 months, which improved from 37.2%±20.9% to 24.2%±17.5%, comparing the first 40 and last 45 cases (p=0.012). CONCLUSION: Hybrid DMEK offers a controlled 'pull-through' technique of donor insertion in the 'endothelium-in' configuration, which may be useful especially in complicated eyes. More studies are needed to confirm the long-term endothelial cell loss and graft survival associated with this technique.