Analysis of pre-operative factors affecting range of optimal vaulting after implantation of 12.6-mm V4c implantable collamer lens in myopic eyes.

BACKGROUND: To evaluate clinical factors affecting postoperative vaulting in eyes that had achieved optimal vaulting within the range of 250-750 µm following implantation of 12.6-mm V4c implantable collamer lenses (ICL). METHODS: A total of 236 eyes of 236 patients that had achieved optimal vaulting following implantation of a 12.6-mm V4c ICL were retrospectively analyzed. Associations between postoperative vaulting and age, preoperative anterior chamber depth (ACD), preoperative axial length (AL), preoperative white-to-white diameter, preoperative pupil size, preoperative sulcus-to-sulcus diameter, and preoperative manifest refraction spherical equivalent were investigated using simple regression, stepwise multiple regression, and multinomial logistic regression analyses. RESULTS: Mean central vaulting at the 6-month follow-up was 519.0 ± 112.8 µm. Variables relevant to postoperative vaulting were, in order of influence, preoperative ACD (ß = 0.305, p <  0.001), preoperative pupil size (ß = 0.218, p <  0.001), and preoperative AL (ß = 0.171, p = 0.006). Low preoperative pupil size was associated with low optimal vaulting (250 to 450 µm), relative to that observed in the mid optimal vaulting group (451 to 550 µm) (odds ratio = 0.532, P = 0.021). Increasing preoperative ACD was associated with high optimal vaulting (551 and 750 µm), relative to that observed the mid optimal vaulting group (odds ratio = 6.340, P = 0.034). CONCLUSIONS: Myopic eyes with greater preoperative ACD, larger pupil size, and longer AL are predisposed to higher postoperative vaulting following 12.6-mm V4c ICL implantation. Therefore, the extremes of these parameters should be considered when choosing V4c ICL size.

Comparison between Wavefront-optimized and corneal Wavefront-guided Transepithelial photorefractive keratectomy in moderate to high astigmatism.

BACKGROUND: To compare the clinical outcomes of wavefront-optimized (WFO) transepithelial photorefractive keratectomy (trans-PRK) and corneal wavefront-guided (CWFG) trans-PRK for myopic eyes with moderate to high astigmatism. METHODS: One hundred ninety-six eyes (196 patients) with moderate to high astigmatism (≥ 1.75 D) treated with WFO or CWFG trans-PRK (101 and 95 eyes, respectively) were retrospectively registered. Safety, efficacy, predictability, vector analysis, and corneal aberrations were compared between groups preoperatively and at 6 months postoperatively. RESULTS: At postoperative 6 months, the mean logMAR uncorrected distance visual acuity was similar in the WFO (- 0.07 ± 0.08) and CWFG (- 0.07 ± 0.07) groups. Safety, efficacy, and predictability of refractive and visual outcomes were also similar. The correction indices were 1.02 ± 0.14 and 1.03 ± 0.13 in the WFO and CWFG groups, respectively, with no significant difference. The absolute values of the angle of error were significantly higher in the WFO group (2.28 ± 2.44 vs. 1.40 ± 1.40; P = 0.002). Corneal total root mean square higher-order aberrations and corneal spherical aberrations increased postoperatively in both groups; however, the change was smaller in the CWFG group. Corneal coma showed a significant increase postoperatively only in the WFO group. CONCLUSIONS: WFO and CWFG trans-PRK are safe and effective for correcting moderate to high astigmatism. However, CWFG trans-PRK provides a more predictable astigmatism correction axis and fewer induced corneal aberrations.

Visual rehabilitation in moderate keratoconus: combined corneal wavefront-guided transepithelial photorefractive keratectomy and high-fluence accelerated corneal collagen cross-linking after intracorneal ring segment implantation.

BACKGROUND: To investigate the effects of combined corneal wavefront-guided transepithelial photorefractive keratectomy (tPRK) and accelerated corneal collagen cross-linking (CXL) after intracorneal ring segment (ICRS) implantation in patients with moderate keratoconus. METHODS: Medical records of 23 eyes of 23 patients undergoing combined tPRK and CXL after ICRS implantation were retrospectively analyzed. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction spherical equivalent (MRSE), corneal indices based on Scheimpflug tomography, higher-order aberrations (HOAs), and corneal biomechanical properties were evaluated before and after ICRS implantation, and at 1, 3, and 6 months after combined tPRK and CXL. RESULTS: There were significant improvements in final logMAR UDVA and logMAR CDVA, and reductions in sphere, MRSE, and all corneal indices from baseline. Significant improvements in logMAR UDVA and reductions in sphere, MRSE, maximal keratometry, keratometry at the apex, mean keratometry, and keratoconus index were noted after ICRS implantation. After tPRK and CXL, significant improvements in logMAR UDVA and logMAR CDVA, and reductions in cylinder and all corneal indices were observed. There were significant improvements in final root mean square HOAs and coma aberrations from baseline, but no changes from baseline after ICRS implantation. Significant reductions in final radius and deformation amplitude from baseline were noted. CONCLUSIONS: Combined tPRK and accelerated CXL after ICRS implantation in moderate keratoconus appears to be a safe and effective treatment, providing an improvement in visual acuity, corneal indices, and HOAs. TRIAL REGISTRATION: retrospectively registered (identification no. NCT03355430 ). Date registered: 28/11/2017.

Changes in posterior corneal elevations after combined transepithelial photorefractive keratectomy and accelerated corneal collagen cross-linking: retrospective, comparative observational case series.

BACKGROUND: To compare the changes in anterior and posterior corneal elevations after combined transepithelial photorefractive keratectomy (PRK) and accelerated corneal collagen cross-linking (CXL) and after PRK. METHODS: Medical records of 82 eyes of 44 patients undergoing either combined transepithelial PRK and CXL (PRK-CXL group) or transepithelial PRK (PRK group) were examined retrospectively. Changes in anterior and posterior corneal elevations were calculated by fitting an 8.0-mm diameter best-fit sphere and best-fit toric ellipsoid (BFTE) to the corneal shape with a fixed eccentricity of 0.4 using Scheimpflug tomography (Pentacam HR; Oculus Optikgeräte GmbH, Wetzlar, Germany) preoperatively and 6 months postoperatively. RESULTS: In anterior corneal elevation, both groups demonstrated a similar trend of a forward displacement of peripheral anterior corneal surface and a backward displacement of central anterior corneal surface. In posterior corneal elevation, a forward displacement of peripheral posterior corneal surface was induced in both groups, along with a backward displacement of central posterior corneal surface, regardless of the calculation method. The magnitudes of displacement of peripheral and central posterior corneal surfaces were significantly smaller in the PRK-CXL group than in the PRK group. Moreover, the PRK-CXL group showed a backward displacement of posterior corneal surface at maximum corneal elevations when the BFTE was used as the reference surface. CONCLUSIONS: Transepithelial PRK combined with prophylactic CXL significantly reduced the magnitudes of displacement of peripheral and central posterior corneal surfaces, with the radius of the BFTE was set to 8.0-mm on the Scheimpflug tomography system.

Optimized Artificial Intelligence for Enhanced Ectasia Detection Using Scheimpflug-Based Corneal Tomography and Biomechanical Data.

PURPOSE: To optimize artificial intelligence (AI) algorithms to integrate Scheimpflug-based corneal tomography and biomechanics to enhance ectasia detection. DESIGN: Multicenter cross-sectional case-control retrospective study. METHODS: A total of 3886 unoperated eyes from 3412 patients had Pentacam and Corvis ST (Oculus Optikgeräte GmbH) examinations. The database included 1 eye randomly selected from 1680 normal patients (N) and from 1181 "bilateral" keratoconus (KC) patients, along with 551 normal topography eyes from patients with very asymmetric ectasia (VAE-NT), and their 474 unoperated ectatic (VAE-E) eyes. The current TBIv1 (tomographic-biomechanical index) was tested, and an optimized AI algorithm was developed for augmenting accuracy. RESULTS: The area under the receiver operating characteristic curve (AUC) of the TBIv1 for discriminating clinical ectasia (KC and VAE-E) was 0.999 (98.5% sensitivity; 98.6% specificity [cutoff: 0.5]), and for VAE-NT, 0.899 (76% sensitivity; 89.1% specificity [cutoff: 0.29]). A novel random forest algorithm (TBIv2), developed with 18 features in 156 trees using 10-fold cross-validation, had a significantly higher AUC (0.945; DeLong, P < .0001) for detecting VAE-NT (84.4% sensitivity and 90.1% specificity; cutoff: 0.43; DeLong, P < .0001) and a similar AUC for clinical ectasia (0.999; DeLong, P = .818; 98.7% sensitivity; 99.2% specificity [cutoff: 0.8]). Considering all cases, the TBIv2 had a higher AUC (0.985) than TBIv1 (0.974; DeLong, P < .0001). CONCLUSIONS: AI optimization to integrate Scheimpflug-based corneal tomography and biomechanical assessments augments accuracy for ectasia detection, characterizing ectasia susceptibility in the diverse VAE-NT group. Some patients with VAE may have true unilateral ectasia. Machine learning considering additional data, including epithelial thickness or other parameters from multimodal refractive imaging, will continuously enhance accuracy. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Comparison of Clinical and Biomechanical Outcomes of Small Incision Lenticule Extraction With 120- and 140-µm Cap Thickness.

Purpose: The purpose of this study was to compare the clinical outcomes and corneal biomechanical changes between 120-µm and 140-µm cap thickness after small incision lenticule extraction (SMILE). Methods: This prospective study included 150 eyes (150 patients: 91 eyes in the 120-µm group, and 59 eyes in the 140-µm group) who underwent SMILE. Enhanced correction nomograms were applied for patients according to cap thickness. Clinical outcomes, including visual acuity, refraction, and corneal wavefront aberrations, were compared between the two groups. Corneal biomechanics were evaluated using the Corvis ST (Oculus, Wetzlar, Germany). Results: The mean uncorrected-distance visual acuity, safety and efficacy indices, and refractive predictability were comparable in the 120-µm and 140-µm groups after SMILE. The postoperative total corneal root mean square higher-order aberrations (HOAs) and spherical aberrations was 0.48 ± 0.31 and 0.26 ± 0.10 in the 120-µm group, and 0.53 ± 0.16 and 0.34 ± 0.13 in the 140-µm group, which showed significant differences between the two groups (P = 0.027, and <0.001, respectively). Although corneal stiffness decreased after SMILE in both groups, the changes in the deformation amplitude ratio were significantly higher in the 140-µm group than in the 120-µm group (P = 0.022). Conclusions: SMILE with 120-µm and 140-µm cap thickness provided excellent predictable outcomes according to our enhanced correction nomogram. The amount of tissue removal required to achieve the same amount of refractive correction was greater in the thicker cap group. The induction of corneal HOAs and weakening of corneal biomechanics were less pronounced in the thin-cap group, which may be associated with the thinner cap, lesser lenticule thickness, or thicker residual stromal bed. Translational Relevance: Although SMILE with different cap thickness was effective, thicker lenticule thickness in the thick-cap group may be associated with induction of HOAs, and corneal stiffness changes.

Clinical outcomes of immediate transepithelial photorefractive keratectomy after suction loss during small-incision lenticule extraction.

PURPOSE: To investigate the surgical outcomes of immediate transepithelial photorefractive keratectomy (PRK) after suction loss during small-incision lenticule extraction (SMILE) and compare the outcomes with those of uneventful SMILE. SETTING: Eyereum Eye Clinic, Seoul, South Korea. DESIGN: Retrospective case series. METHODS: This study included 24 eyes of 12 patients who had uneventful SMILE in one eye and immediate transepithelial PRK after the development of suction loss during the lenticule cut in the contralateral eye. Visual acuity assessments, manifest refraction, and measurements of corneal wavefront aberrations were performed preoperatively and 6 months postoperatively. RESULTS: At 6 months, the mean uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and spherical equivalent were -0.04 ± 0.05, -0.09 ± 0.05, and -0.02 ± 0.24 diopter (D), respectively, in the transepithelial PRK group and -0.10 ± 0.07, -0.06 ± 0.07, and -0.04 ± 0.17 D, respectively (P = .036, P = .109, and P = .671, respectively), in the uneventful SMILE group. The 6-month Snellen UDVA was better than 20/20 for 11 (92%) and 12 (100%) of eyes in the transepithelial PRK and uneventful SMILE groups, respectively. All 24 eyes showed unchanged or improved CDVA and a significant increase in the total corneal higher-order aberrations postoperatively. Corneal spherical aberrations exhibited a significant postoperative increase only in the transepithelial PRK group. CONCLUSIONS: Immediate transepithelial PRK after early suction loss during SMILE might be safe and effective, with refractive outcomes that are comparable with those after uneventful SMILE.

Comparison of clinical outcomes between vector planning and manifest refraction planning in SMILE for myopic astigmatism.

PURPOSE: To compare clinical outcomes of small-incision lenticule extraction (SMILE) between manifest refraction (MR) and vector planning for myopic astigmatism with high ocular residual astigmatism (ORA). SETTING: Yonsei University College of Medicine and Eyereum Eye Clinic, Seoul, South Korea. DESIGN: Prospective, randomized, comparative case series. METHODS: Patients with myopic astigmatism and ORA of 0.75 diopters (D) or greater were randomized into the MR or vector planning group and underwent SMILE without applying any nomogram for cylinder correction. Visual acuity, MR, corneal topography, and corneal aberration were measured preoperatively and postoperatively. Outcomes at 6 months postoperatively were compared between the groups. RESULTS: The study comprised 114 patients (114 eyes): 58 eyes in MR planning and 56 eyes in vector planning. The mean uncorrected and corrected distance visual acuity, safety and efficacy indices were comparable between the 2 groups. Postoperative refractive cylinder reached statistically significant differences between the groups (-0.22 ± 0.18 D and -0.14 ± 0.16 D in the MR and vector planning groups, respectively, P = .02). Postoperative corneal toricity and ORA reached statistically significant lower in the vector planning group. CONCLUSIONS: In myopic astigmatism with high ORA, MR and vector planning in SMILE were effective with comparable visual outcomes; vector planning showed statistically significant lower postoperative refractive and corneal astigmatism and ORA. Use of vector planning may improve refractive outcomes in SMILE cases with high ORA. However, the results may have been different had a nomogram adjustment been applied, as is often used for cylinder corrections with SMILE.

Effect of Corneal Cross-linking on Epithelial Hyperplasia and Myopia Regression After Transepithelial Photorefractive Keratectomy.

PURPOSE: To investigate the effect of accelerated corneal cross-linking (CXL) on epithelial thickness change and refractive outcome after myopic transepithelial photorefractive keratectomy (TPRK). METHODS: This study compared epithelial thickness changes in 49 patients undergoing TPRK-CXL with 49 patients undergoing TPRK who were matched for age and refractive error. Corneal epithelial thickness, obtained using spectral-domain optical coherence tomography preoperatively and 12 months postoperatively, was compared between the groups. Regression analysis was performed to investigate the association between changes in epithelial thickness and keratometric power. Factors affecting myopic regression (> 0.50 diopters] were evaluated using logistic regression analysis. RESULTS: For TPRK, the mean epithelial thickness of the center (2-mm diameter), paracenter (2- to 5-mm diameter), and pericenter (5- to 6-mm diameter) increased by 6.5 ± 3.1, 7.0 ± 2.9, and 4.9 ± 2.9 µm, respectively; increases of 4.8 ± 3.0, 5.9 ± 2.8, and 4.8 ± 2.7 µm were observed following TPRK-CXL, indicating a significant difference in the center (P = .013). Epithelial thickness increased linearly to the magnitude of myopic correction and was negatively correlated with the optical zone diameter of ablation. Change in epithelial thickness showed a linear correlation with the change in keratometric power between 1 and 12 months postoperatively, indicating regression in eyes following TPRK. Corneal epithelial thickening was significantly associated with myopic regression and simultaneous CXL tended to reduce the risk of regression. CONCLUSIONS: TPRK-CXL induces less epithelial hyperplasia than does TPRK, presumably owing to the effect of CXL, and the magnitude of epithelial thickening seemed to be associated with myopic regression. [J Refract Surg. 2019;35(6):354-361.].

Adjustment of Spherical Equivalent Correction According to Cap Thickness for Myopic Small Incision Lenticule Extraction.

PURPOSE: To evaluate the amount of spherical equivalent correction for three different cap thicknesses (120, 130, and 140 µm) during myopic small incision lenticule extraction (SMILE) and determine the association between the amount of spherical equivalent correction and several variables in each cap thickness group. METHODS: In this retrospective, comparative, observational case series study, the authors compared refractive errors, keratometric values, laser setting (sphere correction, cylinder correction, spherical equivalent correction, optical zone, and cap diameter), and spherical aberration measured preoperatively and at 3 months postoperatively between three different cap thickness groups: 120 µm (n = 554), 130 µm (n = 377), and 140 µm (n = 90). Multiple linear regression analyses were used to determine the associations between the amount of spherical equivalent correction and several variables, including age, preoperative spherical equivalent, optical zone diameter, central corneal thickness, preoperative mean keratometric values, and preoperative corneal asphericity. RESULTS: According to cap thickness, attempted correction is adjusted to achieve the same refractive outcomes for different cap thicknesses. There were significant differences in the amount of sphere correction and spherical equivalent correction, as well as lenticule thickness, among subgroups. Changes in keratometric values, corneal asphericity, and spherical aberration were also significantly different among subgroups (all P < .001). Changes in keratometric values, corneal asphericity, and spherical aberration significantly increased as cap thickness increased. Preoperative spherical equivalent mainly influenced the amount of spherical equivalent correction in each group. CONCLUSIONS: Dioptric adjustment of spherical equivalent correction according to cap thickness is essential to obtain similar refractive outcomes in myopic SMILE procedures. [J Refract Surg. 2019;35(3):153-160.].

Decentration measurements using Placido corneal tangential curvature topography and Scheimpflug tomography pachymetry difference maps after small-incision lenticule extraction.

PURPOSE: To assess the agreement of decentration measurements between tangential curvature topography and tomography pachymetry difference maps after a small-incision lenticule extraction (SMILE) procedure. SETTING: Yonsei University College of Medicine and Eyereum Eye Clinic, Seoul, South Korea. DESIGN: Retrospective case series. METHODS: Decentrations and pupillary offset (angle κ) were analyzed and compared using two different methods. A difference map of the tangential curvature was generated with a Placido corneal topographer (Keratron Scout) and a pachymetry difference map was generated with a Scheimpflug tomographer (Pentacam) for each eye, using preoperative and 3-month postoperative scans. Decentrations were also compared using a vector difference plot for the two maps. RESULTS: The study comprised 155 eyes (155 patients). The magnitude of decentration was 0.27 mm ± 0.17 (SD) (range 0.02 to 0.88 mm) with the tangential curvature difference maps and 0.26 ± 0.20 mm (range 0.00 to 0.91 mm) with the pachymetry difference maps, showing no significant difference in the arithmetic values of decentration (P = .124). However, the vector difference in pupillary offset between preoperative and postoperative measurements from the pachymetry difference map significantly correlated with the magnitude of vector differences of decentration between the two maps (P = .007). The vector difference plot also showed a wide distribution spread to all 4 quadrants, demonstrating a lack of agreement. CONCLUSIONS: Although there was no significant difference between the scalar magnitude of decentration with the tangential topography difference maps and tomography pachymetry difference maps, the vector differences did not agree and increasing error was present with increasing differences in pupillary offset in the pachymetry difference maps.

Relationship Between Decentration and Induced Corneal Higher-Order Aberrations Following Small-Incision Lenticule Extraction Procedure.

Purpose: To investigate the amount of lenticule decentration following small-incision lenticule extraction (SMILE) by using the Keratron Scout tangential topography difference map, and the relationship between the magnitudes of total decentration and induced corneal higher-order aberrations (HOAs). Methods: This retrospective observational case series study analyzed decentration values obtained from the Keratron Scout tangential topography difference map of 360 eyes (360 patients) that underwent SMILE. Root mean square total HOAs, third order coma aberration, fourth order spherical aberration, as well as individual coefficients for vertical and horizontal coma were measured preoperatively and 3-months postoperatively. Simple linear regression analysis and piecewise regression models were used to determine the relationship between the magnitudes of total decentration and induced corneal HOAs. Results: The mean total decentration distance from the corneal vertex was 0.36 ± 0.22 mm (range, 0.02-1.27 mm). There were significant differences in total HOAs, coma, vertical and horizontal comas, and spherical aberration between preoperative and 3-month postoperative assessments. Significant relationships between the magnitudes of total decentration and induced corneal HOAs were noted. Subgroup analysis according to the degree of total decentration (group I, total decentered displacement ≤0.335 mm; and group II, total decentered displacement >0.335 mm) revealed that induced changes in total HOAs, coma, vertical coma, and spherical aberration were significantly larger in group II than in group I. Conclusions: A minimal degree of decentration was closely related to a smaller induction of corneal HOAs. Efforts to optimize centration are critical for achieving better surgical outcomes in SMILE.

Clinical Outcomes of Transepithelial Photorefractive Keratectomy According to Epithelial Thickness.

PURPOSE: To investigate the clinical outcomes, vector parameters, and corneal aberrations of corneal wavefront-guided (CWFG) transepithelial photorefractive keratectomy (PRK), according to epithelial thickness. METHODS: This retrospective, comparative case series study included 91 eyes (91 patients) that underwent CWFG transepithelial PRK for myopic astigmatism. Epithelial thickness was less than 50 µm in 48 patients and 60 µm or greater in 43 patients. Clinical outcomes, including visual acuity, manifest refraction, vector parameters, and corneal wavefront aberration, were compared between the two groups. RESULTS: The mean uncorrected distance visual acuity, safety and efficacy indices, and aberrometric values were comparable between the two groups at 6 months after transepithelial PRK. The postoperative spherical equivalent was significantly different between the two groups: 0.05 ± 0.19 diopters (D) in the less than 50 µm group and -0.05 ± 0.18 D in the 60 µm or greater group (P = .009). The difference between the two groups was 0.10 D, which is less than the theoretical difference because the epithelial remodeling pattern was different. There was a slight difference in slope between target induced astigmatism vector and surgically induced astigmatism vector (0.9979 in the less than 50 µm group and 0.9145 in the 60 µm or greater group; P = .025). CONCLUSIONS: Transepithelial PRK is an effective and safe treatment modality regardless of epithelial thickness. However, a difference in postoperative refraction is present between the two groups, and astigmatic correction may be less in patients with thick epithelium; hence, a new algorithm is needed that can be tailored in accordance with individual epithelial thickness. [J Refract Surg. 2018;34(8):533-540.].

Biomechanical Properties of the Cornea Using a Dynamic Scheimpflug Analyzer in Healthy Eyes.

PURPOSE: To investigate biomechanical properties of the cornea using a dynamic Scheimpflug analyzer according to age. MATERIALS AND METHODS: In this prospective, cross-sectional, observational study, participants underwent ophthalmic investigations including corneal biomechanical properties, keratometric values, intraocular pressure (IOP), and manifest refraction spherical equivalent (MRSE). We determined the relationship of biomechanical parameters and ocular/systemic variables (participant's age, MRSE, IOP, and mean keratometric values) by piecewise regression analysis, association of biomechanical parameters with variables by Spearman's correlation and stepwise multiple regression analyses, and reference intervals (RI) by the bootstrap method. RESULTS: This study included 217 eyes of 118 participants (20-81 years of age). Piecewise regression analysis between Corvis-central corneal thickness (CCT) and participant's age revealed that the optimal cut-off value of age was 45 years. No clear breakpoints were detected between the corneal biomechanical parameters and MRSE, IOP, and mean keratometric values. Corneal velocity, deformation amplitude, radius, maximal concave power, Corvis-CCT, and Corvis-IOP exhibited correlations with IOP, regardless of age (all ages, 20-44 years, and over 44 years). With smaller deformation amplitude and corneal velocity as well as increased Corvis-IOP and Corvis-CCT, IOP became significantly increased. We provided the results of determination of confidence interval from RI data using bootstrap method in three separate age groups (all ages, 20-44 years, and over 44 years). CONCLUSION: We demonstrated multiple corneal biomechanical parameters according to age, and reported that the corneal biomechanical parameters are influenced by IOP.

Clinical Outcomes of SMILE With a Triple Centration Technique and Corneal Wavefront-Guided Transepithelial PRK in High Astigmatism.

PURPOSE: To comparatively investigate the clinical outcomes, vector parameters, and corneal aberrations of small incision lenticule extraction (SMILE) with a triple centration technique and corneal wavefront-guided transepithelial photorefractive keratectomy (PRK) for the correction of high astigmatism. METHODS: This retrospective, comparative case series study included 89 eyes (89 patients) that received treatment for myopia with high astigmatism (≥ 2.50 diopters) using SMILE with a triple centration technique (SMILE group; 45 eyes) and corneal wavefront-guided transepithelial PRK (transepithelial PRK group; 44 eyes). Visual acuity measurement, manifest refraction, slit-lamp examination, autokeratometry, corneal topography, and evaluation of corneal wavefront aberration were performed preoperatively and at 1, 3, and 6 months after surgery. The safety, efficacy, vector parameters, and corneal aberrations at 6 months after surgery were compared between the two groups. RESULTS: At 6 months after surgery, the transepithelial PRK and SMILE groups exhibited comparable mean uncorrected distance visual acuities (-0.06 ± 0.07 and -0.05 ± 0.07 logMAR, respectively), safety, efficacy, and predictability of refractive and visual outcomes. There was a slight but statistically significant difference in the correction index between the transepithelial PRK and SMILE groups (0.96 ± 0.11 and 0.91 ± 0.10, respectively). Whereas the transepithelial PRK group exhibited increased corneal spherical aberration and significantly reduced corneal coma and trefoil, no changes in aberrometric values were noted in the SMILE group. CONCLUSIONS: Both SMILE with a triple centration technique and corneal wavefront-guided transepithelial PRK are effective and provide predictable outcomes for the correction of high myopic astigmatism, although slight undercorrection was observed in the SMILE group. The triple centration technique was helpful in astigmatism correction by SMILE. [J Refract Surg. 2018;34(3):156-163.].

Comparison of the Distribution of Lenticule Decentration Following SMILE by Subjective Patient Fixation or Triple Marking Centration.

PURPOSE: To investigate lenticule decentration following small incision lenticule extraction (SMILE) via the subjective patient fixation method or triple marking centration method and compare inductions of corneal higher order aberrations (HOAs) between the two methods. METHODS: This study analyzed decentration values obtained from the Keratron Scout (Optikon, Rome, Italy) tangential topography difference map of 110 eyes (110 patients) undergoing SMILE with the subjective patient fixation method (n = 55) or triple marking centration method (n = 55). Root mean square values of total HOAs, 3rd order coma aberration, and 4th order spherical aberration, as well as individual coefficients for vertical and horizontal coma, were measured preoperatively and 3 months postoperatively. Relationships between the magnitudes of decentration and induced corneal HOAs were assessed. RESULTS: There were significant differences in horizontal decentered displacement (P = .048), vertical decentered displacement (P = .002), and total decentered displacement (P = .001) between the two groups. Total HOAs, coma, vertical coma, and spherical aberration significantly increased in the subjective patient fixation method (all P < .001), whereas total HOAs (P = .002) and vertical coma (P = .005) increased in the triple marking centration method. Induction of total HOAs (mean values: 0.13 vs 0.07; P = .026), coma (0.09 vs 0.03; P = .032), and spherical aberration (0.08 vs 0.02; P = .013) was significantly greater in the subjective patient fixation method than in the triple marking centration method. Association between the total decentered displacement and induced vertical coma (P = .006) or induced spherical aberration (P = .018) was significant in the subjective patient fixation method. CONCLUSIONS: SMILE with the triple marking centration method can yield improved treatment centration and smaller induction of total HOAs, coma, and spherical aberrations. [J Refract Surg. 2018;34(7):446-452.].

Rotational Stability and Visual Outcomes of V4c Toric Phakic Intraocular Lenses.

PURPOSE: To investigate the clinical outcomes and rotational stability following implantation of V4c toric implantable collamer lenses (ICLs) (STAAR Surgical Company, Monrovia, CA) and to analyze the factors that influence rotational stability. METHODS: In this prospective observational case series, the authors analyzed the visual outcomes and rotational stability in 52 eyes of 52 patients immediately and 3 and 6 months after implantation. Postoperative rotation was defined as the angle between the adjusted axis and alignment axis. Central vaulting of the ICL was measured in a non-accommodative state using Visante optical coherence tomography (Carl Zeiss Meditec, Jena, Germany). Vector analysis of refractive astigmatism was performed. Regression analysis was used to investigate the association between the degree of rotation 6 months postoperatively and the associated variables. RESULTS: The mean efficacy index and safety index 6 months postoperatively were 1.35 ± 0.19 and 1.38 ± 0.22, respectively. In vector analysis, the magnitude of error was -0.20 diopters (D), indicating slight undercorrection. Absolute degree of rotation was 2.81° ± 1.87° immediately after the operation and 3.75° ± 2.92° and 3.87° ± 3.07° at 3 and 6 months postoperatively, respectively (P = .009). Bonferroni-adjusted post-hoc comparison showed that the absolute degree of rotation immediately after the operation was significantly smaller than that after 3 (P = .043) and 6 (P = .023) months, with barely any change after 3 months. No explanatory variable relevant to the absolute degree of rotation was discovered. CONCLUSIONS: The V4c toric ICL is predictable, safe, and effective in correcting low and high levels of astigmatism, showing relatively good postoperative rotational stability. [J Refract Surg. 2018;34(7):489-496.].

Effect of accelerated corneal crosslinking combined with transepithelial photorefractive keratectomy on dynamic corneal response parameters and biomechanically corrected intraocular pressure measured with a dynamic Scheimpflug analyzer in healthy myopic patients.

PURPOSE: To evaluate the effect of accelerated corneal crosslinking (CXL) combined with transepithelial photorefractive keratectomy (PRK) on changes in new dynamic corneal response parameters and the biomechanically corrected intraocular pressure (IOP) measured using a dynamic Scheimpflug analyzer (Corvis ST). SETTING: Yonsei University College of Medicine and Eyereum Eye Clinic, Seoul, South Korea. DESIGN: Retrospective case series. METHODS: Medical records of eyes of healthy myopic patients having transepithelial PRK or transepithelial PRK with CXL were examined. Main outcome variables were the biomechanically corrected IOP and new dynamic corneal response parameters including the deformation amplitude ratio at 1.0 mm (DAR1) and at 2.0 mm (DAR2), stiffness at first applanation and at highest concavity, and the integrated inverse radius preoperatively and 6 months postoperatively. RESULTS: The study comprised 69 eyes (69 patients); 35 had transepithelial PRK and 34, transepithelial PRK with CXL. The DAR1, DAR2, and integrated inverse radius significantly increased, while stiffness at first applanation and at highest concavity decreased postoperatively in both groups. Changes in the DAR2 and integrated inverse radius in the transepithelial PRK group were significantly larger than in the transepithelial PRK with CXL group without and with analysis of covariance with the spherical equivalent change or corneal thickness change as a covariate. No significant differences in the biomechanically corrected IOP occurred preoperatively or postoperatively in either group. CONCLUSIONS: Results indicate that prophylactic CXL combined with transepithelial PRK has a role in reducing the change in corneal biomechanical properties. The dynamic Scheimpflug analyzer showed stable biomechanically corrected IOP measurements preoperatively and postoperatively.

Comparison of clinical outcomes between wavefront-optimized versus corneal wavefront-guided transepithelial photorefractive keratectomy for myopic astigmatism.

PURPOSE: To evaluate and compare the clinical outcomes, including visual acuity, refractive errors, and aberrations, between aberration-free transepithelial photorefractive keratectomy (PRK) and corneal wavefront-guided transepithelial PRK in eyes with myopic astigmatism. SETTING: Yonsei University College of Medicine and Eyereum Eye Clinic, Seoul, South Korea. DESIGN: Retrospective comparative case series. METHODS: Patients with myopic astigmatism were treated with aberration-free transepithelial PRK or corneal wavefront-guided transepithelial PRK using a 1050 Hz high-repetition excimer laser. The safety, efficacy, predictability, and corneal aberrations were compared preoperatively and 1, 2, 3, and 6 months postoperatively. RESULTS: The study comprised 188 patients (188 eyes); 91 eyes had aberration-free transepithelial PRK and 97 eyes corneal wavefront-guided transepithelial PRK. Six month after surgery, the mean uncorrected distance visual acuity was comparable (-0.06 logMAR ± 0.07 [SD] aberration-free group; -0.06 ± 0.06 logMAR wavefront-guided group). The safety, efficacy, and predictability of refractive and visual outcomes were also comparable between groups. Corneal total root-mean-square (RMS) higher-order aberrations (HOAs) increased after treatment in both groups, although fewer RMS HOAs were induced in the corneal wavefront-guided group than in the aberration-free group. Spherical aberration increased similarly after treatment in both groups. However, coma and trefoil increased only in the aberration-free group. CONCLUSIONS: Aberration-free transepithelial PRK and corneal wavefront-guided transepithelial PRK were safe and effective for correction of myopic astigmatism without difference in visual acuity and refractive outcomes. However, the corneal wavefront-guided profile induced fewer corneal aberrations than the aberration-free profile.

Biomechanical Properties of the Cornea Measured With the Dynamic Scheimpflug Analyzer in Young Healthy Adults.

PURPOSE: To investigate the biomechanical properties of the cornea using the dynamic Scheimpflug analyzer in young healthy adults. METHODS: This prospective cross-sectional population study included 944 eyes of 472 participants aged 20 to 40 years. Participants underwent ophthalmic investigations, including evaluation of biomechanical properties of the cornea using the dynamic Scheimpflug analyzer, manifest refraction, and measurements of keratometric values by autokeratometry, intraocular pressure (IOP) by noncontact tonometer, central corneal thickness (CCT) by ultrasound, and white-to-white distance by Scheimpflug tomography. Statistical analyses included determination of the reference interval with a bootstrapping method, linear quantile mixed-effects model, and Spearman correlation analysis between the corneal biomechanical parameters and other variables (age, manifest refraction spherical equivalent, CCT, IOP, white-to-white, and keratometric values). RESULTS: The 90% CIs of all corneal biomechanical parameters demonstrated that the ranges of the 90% CIs for the reference data were almost identical with and without bootstrapping. Quantile regression to determine the fifth, 50th, and 95th percentiles of each corneal biomechanical parameter supported the findings from the nonparametric method with the 90% CIs. Correlation analysis showed significant correlations between the parameters and variables, but there was a relatively high Spearman correlation coefficient in the case of the correlations with the CCT and IOP. CONCLUSIONS: Using data from a large population of young healthy adults, we developed a database of normal values for multiple corneal biomechanical parameters obtained from the dynamic Scheimpflug analyzer. We conclude that the biomechanical properties of the cornea are influenced by the CCT and IOP.