Initial clinical outcomes of two different phakic posterior chamber IOLs for the correction of myopia and myopic astigmatism.

PURPOSE: The purpose of this study is to document clinical outcomes of 2 posterior chamber phakic intraocular lenses with a central hole, the implantable contact lens (IPCL V2.0) and the Visian implantable collamer lens V4c (ICL), in myopic and myopic-astigmatic patients. METHODS: Retrospective study comprising 111 IPCL (60 toric) and 106 ICL implantations (59 toric) with a follow-up of 3 months to 2 years. Primary outcome was uncorrected distance visual acuity (UDVA) improvement; secondary outcomes were changes in corrected distance visual acuity (CDVA), and complications. RESULTS: At 3 months postoperatively, 76% of plano targeted eyes in the IPCL group and 83% of eyes in the ICL group had a UDVA of 20/20 or better. Ninety-six percent of IPCL implanted eyes and 94% of ICL implanted eyes had a postoperative UDVA within 1 line of preoperative CDVA. One eye lost one line of CDVA after IPCL implantation, and no lines were lost after ICL implantation; 33.7% of IPCL eyes and 40.6% of ICL eyes gained at least 1 line of CDVA. Cataract extraction (none because of anterior subcapsular opacification) was performed after 4 ICL implantations, none after IPCL implantation. Endothelial cell loss was mild with both pIOLs. Mean IOP was not clinically significantly affected at 3 months or thereafter. CONCLUSIONS: We observed equally excellent (statistically not different) results with the IPCL and ICL for the correction of myopia and myopic astigmatism, at least up to 2 years post implantation. Longer follow-up is needed to determine the stability of these results especially with the IPCL.

Changes of Subjective Symptoms and Tear Film Biomarkers following Femto-LASIK.

Femtosecond laser-assisted in situ keratomileusis (Femto-LASIK) represents a common treatment modality in refractive surgery and shows excellent results in terms of safety, efficacy, predictability, and long-term stability. However, patients may be affected by dry eye symptoms. The aim of this study was to identify a potential association between subjective dry eye symptoms, objective dry eye markers, and possible changes in the tear film, which could be a target for future therapy development. Therefore, clinical (dry eye) examinations (OSDI, Schirmer test, lissamine green and fluorescein staining, BUT, visual acuity) were carried out before LASIK as well as 5 and 90 days post-OP. The dry eye marker MMP-9, cytokines (IL-1ß, IL-8), and pain markers (NGF, CGRP) were quantified in tear samples with immunoassays. In addition, correlation analyses were performed. Clinical examinations revealed an upregulated OSDI score 5 days post-OP and an increased lissamine green staining score 90 days post-OP. Downregulated CGRP levels were noted 5 days post-OP, while other protein markers were not significantly altered after Femto-LASIK. Hence, Femto-LASIK surgery induced subjective symptoms like that of dry eye which could objectively rather be classified as Femto-LASIK-related discomfort. In the future, this could possibly be better detected and treated using pain markers such as CGRP.

Influence of a Therapeutic Soft Contact Lens on Epithelial Healing, Visual Recovery, Haze, and Pain After Photorefractive Keratectomy.

OBJECTIVES: To examine the influence of a therapeutic soft contact lens (TSCL) after alcohol-assisted photorefractive keratectomy (PRK) on visual recovery, epithelial closure, pain perception, and haze formation. METHODS: Prospective, randomized, single-center, contralateral eye, patient-masked study. Same surgeon treated 15 patients with bilateral PRK using a Vidaurri Fluid Retention Ring (Katena) with 8.7 mm inner diameter to apply ethanol 18% for 30 sec. Each patient received a TSCL (Balafilcon A, PureVision, Bausch & Lomb) in a randomized fashion in one eye only. RESULTS: Without knowing which eye had a contact lens, four patients preferred the eye with TSCL so much that these patients wanted a TSCL inserted in the second eye as well. Uncorrected distance visual acuity improved postoperatively from day 1 to 3 months from 0.61 to 1.18 with TSCL and from 0.21 to 1.04 without TSCL. Uncorrected distance visual acuity was statistically significantly better on days 1 and 2 with TSCL. Epithelial defect was on average smaller with TSCL. Epithelium was closed at day 4 in all eyes except one without TSCL. Pain perception was significantly lower with TSCL on days 1 and 2. Haze levels after 3 months were significantly lower with TSCL (with 0.09/without 0.45, respectively). One eye without TSCL had haze grade 2 (Fantes). CONCLUSIONS: A TSCL had statistically significantly and clinically meaningful beneficial effects in the first days in visual recovery and pain perception and after 3 months in haze formation. Epithelial healing was slightly quicker with the use of TSCLs (not statistically, but clinically significantly).

Detecting Keratoconus in Adolescents with Anterior Segment Optical Coherence Tomography.

Purpose: Assessing the applicability of an algorithm developed for keratoconus detection in adolescents. This algorithm relies on optical coherence tomography (OCT) and incorporates features related to corneal pachymetric and epithelial thickness alterations. Methods: We retrospectively reviewed charts of patients under the age of 18 and divided them into four groups according to the Belin-Ambrosio display (Pentacam): normal, manifest, and subclinical keratoconus, as well as very asymmetric eye with normal topography and tomography (VAE-NTT). Corneal and epithelial thickness maps (Cirrus 5000 HD-OCT, Carl Zeiss Meditec, Germany) were evaluated by a human grader. In the first step, if at least one of four parameters (pachymetry minimum (pachy min), pachy minimum-median (min-med), pachy superonasal-inferotemporal (SN-IT), or epithelial (epi SN-IT)) exceeded its cut-off value, the eye was considered as suspect. In the second step, the combined presence of coincident thinning of total cornea and epithelium as well as concentric epithelial thinning lead to the diagnosis of keratoconus. Receiver operating characteristic (ROC) curves were generated to determine area under the curve (AUC), sensitivity, and specificity for the parameters. Results: The study involved 19 pediatric patients diagnosed with keratoconus, comprising 29 manifest keratoconic eyes, 3 eyes with subclinical keratoconus, and 5 VAE-NTT eyes. In addition, 22 eyes from 11 normal adolescents were included in the analysis. The AUC values of parameters in step 1 were 0.889 for pachy min, 0.997 for pachy min-med, 0.893 for pachy SN-IT, and 0.998 for epi SN-IT. When both steps were performed, this algorithm captured all manifest and subclinical pediatric keratoconic eyes. When all eyes of the keratoconus patients were combined, step 1 had 97.3% sensitivity and step 2 had 100% specificity. Conclusion: Using this OCT-based approach in adolescents yielded a high level of agreement with the current gold standard, tomography. Using them together, potentially also with other examinations may improve the diagnostic accuracy of KC in the pediatric population. Integration of this approach into the software of the device to facilitate automated evaluations is desired.

Effect of Corneal Allogenic Intrastromal Ring Segment (CAIRS) Implantation Surgery in Patients With Keratoconus According to Prior Corneal Cross-linking Status.

PURPOSE: To compare the effects of corneal allogenic intrastromal ring segment (CAIRS) implantation on topographical measurements and visual outcomes of patients with keratoconus with and without corneal cross-linking (CXL) prior to the time of implantation. METHODS: Sixty-seven eyes with corneal allograft intrastromal ring segment implantation (KeraNatural; Lions VisionGift) due to advanced keratoconus were included in the study. Thirty-seven eyes had no CXL and 30 eyes had had CXL before being referred to the authors. The changes in spherical equivalent (SE), uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), steep keratometry (K1), flat keratometry (K2), mean keratometry (Kmean), maximum keratometry (Kmax), and thinnest pachymetry were retrospectively analyzed 6 months after the implantation. RESULTS: The median age was 29 years in the CXL group and 24.0 years in the non-CXL group (P > .05), respectively. All topographical and visual parameters before implantation were similar in both groups (P > .05 for all parameters). At 6 months, CDVA, K1, and Kmean showed higher improvement in the non-CXL group than the CXL group (P = .030, .018, and .039, respectively). CONCLUSIONS: CAIRS surgery has a flattening effect on both the corneas with and without CXL. The cornea with prior CXL treatment had less flattening effect due to the stiffening effect of prior CXL. [J Refract Surg. 2024;40(6):e392-e397.].

Risk Factors for Re-treatment After Keratorefractive Lenticule Extraction (KLEx) for Myopia and Myopic Astigmatism.

PURPOSE: To identify potential risk factors that increase the likelihood of re-treatment following keratorefractive lenticule extraction (KLEx) for myopia and myopic astigmatism. METHODS: This was a retrospective study of patients with myopia and myopic astigmatism who underwent KLEx using the VisuMax 500 laser (Carl Zeiss Meditec) between April 2015 and December 2020. Patients were assigned to one of two groups: the control group and the re-treatment group (if they had additional refractive surgery within 2 years of the primary treatment). The effect of different preoperative, intraoperative, and postoperative parameters on the re-treatment rate was analyzed. RESULTS: Overall 1,822 eyes of 938 patients were analyzed. In total, 2.96% of eyes (n = 54) underwent re-treatment. The re-treated patients were more likely to be women and have high myopia, high astigmatism, steep corneas, higher ocular residual astigmatism, and residual myopic and/or astigmatic refractive error. In contrast, no significant correlation was found between re-treatment rate and age, chord µ, type of astigmatism, and corneal thickness. CONCLUSIONS: Factors associated with higher rates of retreatment after KLEx included female gender, manifest refractive high myopia (> -5.00 diopters [D]), astigmatism (> 2.00 D), spherical equivalent (> 6.00 D), ocular residual astigmatism, steeper corneas, and postoperative residual myopic and astigmatic refractive errors. This study may help to preoperatively detect patients at risk for re-treatment, improve preoperative patient counseling, and optimize patient selection to reduce future re-treatment rates. [J Refract Surg. 2024;40(6):e362-e370.].

The Influence of Lens Position, Vault Prediction, and Posterior Cornea on Phakic Posterior Chamber Intraocular Lens Power.

BACKGROUND: Achieving precise refractive outcomes in phakic posterior chamber intraocular lens (pIOL) implantation is crucial for patient satisfaction. This study investigates factors affecting pIOL power calculations, focusing on myopic eyes, and evaluates the potential benefits of advanced predictive models. DESIGN: Retrospective, single-center, algorithm improvement study. METHODS: Various variations with different effective lens position (ELP) algorithms were analyzed. The algorithms included a fixed constant model, and a multiple linear regression model and were tested with and without incorporation of the posterior corneal curvature (Rcp). Furthermore, the impact of inserting the postoperative vault, the space between the pIOL and the crystalline lens, into the ELP algorithm was examined, and a simple vault prediction model was assessed. RESULTS: Integrating Rcp and the measured vault into pIOL calculations did not significantly improve accuracy. Transitioning from constant model approaches to ELP concepts based on linear regression models significantly improved pIOL power calculations. Linear regression models outperformed constant models, enhancing refractive outcomes for both ICL and IPCL pIOL platforms. CONCLUSIONS: This study underscores the utility of implementing ELP concepts based on linear regression models into pIOL power calculation. Linear regression based ELP models offered substantial advantages for achieving desired refractive outcomes, especially in lower to medium power pIOL models. For pIOL power calculations in both pIOL platforms we tested with preoperative measurements from a Scheimpflug device, we found improved results with the LION 1ICL formula and LION 1IPCL formula. Further research is needed to explore the applicability of these findings to a broader range of pIOL designs and measurement devices.

Keratectasia after treating presbyopia with INTRACOR followed by SUPRACOR enhancement.

PURPOSE: To report a case of unilateral keratectasia after INTRACOR, which was followed by an additional excimer LASIK enhancement with a new presbyopia-correcting ablation profile. METHODS: The non-dominant eye of a 49-year-old man with emmetropia was treated with the INTRACOR procedure using the Technolas femtosecond laser (Technolas Perfect Vision GmbH, Munich, Germany) for presbyopia. Neither eye had risk factors for keratectasia. Two years later, a presbyopia-correcting LASIK (SUPRACOR LASIK; Technolas Perfect Vision GmbH) enhancement was performed in the same eye because of deteriorated distance and near visual acuity. RESULTS: The eye treated with INTRACOR followed by SUPRACOR LASIK developed marked keratectasia topographically limited to the area altered by INTRACOR, whereas the fellow eye remained stable and still has no signs of keratoconus. CONCLUSIONS: This case emphasizes the incomplete knowledge of the risk factors for keratectasia following INTRACOR alone and in combination with a SUPRACOR LASIK enhancement. It also suggests that the combined weakening effect of both procedures on corneal mechanical stability may be too strong even in the absence of established risk factors for LASIK surgery.

Influence of corneal cross-linking for keratoconus on several objective parameters of dry eye.

PURPOSE: To evaluate the potential influence of corneal cross-linking (CXL) with ultraviolet-A light and riboflavin in keratoconic eyes on several objective parameters of dry eye syndrome. METHODS: This prospective single center study included 30 consecutive eyes of 16 patients that underwent CXL with riboflavin and ultraviolet-A treatment (epithelial removal, 30 minutes soaking with riboflavin, 30 minutes of illumination with 365 nm, 3 mW/cm(2), 5 cm distance). Several dry eye syndrome parameters were evaluated preoperatively and 3 and 6 months after the procedure: intra-individual comparison of fluorescein and Rose bengal staining, height of tear film meniscus, and tear film break-up time. RESULTS: Pathologic staining (more than 10 point-shaped areas or diffuse staining) with fluorescein was evident before CXL in 1 eye, 3 months after CXL in 1 eye, and 6 months after CXL in 1 eye. Rose bengal staining 3 and 6 months postoperatively was comparable to preoperative staining. Tear film height was reduced in 2 eyes before CXL and in 4 eyes 3 months postoperatively, and was normal in all eyes after 6 months. The number of eyes with reduced tear film break-up time was not significantly changed. CONCLUSIONS: CXL had no significant impact on several parameters of dry eye syndrome 3 and 6 months postoperatively.

Aspheric wavefront-guided versus wavefront-guided LASIK for myopic astigmatism with the Technolas 217z100 excimer laser.

PURPOSE: To compare clinical outcomes of wavefront-guided LASIK with and without aspheric compensation in myopic eyes. METHODS: In this observational, single-center study, 134 eyes were treated using an aspheric module in combination with wavefront-guided profiles (PTA-algorithm) and compared to 146 eyes treated with the predecessor wavefront-guided software (APT) that has no aspheric compensation. All treatment plans included the Rochester nomogram that accounts for the preoperative manifest refraction and interaction of higher order aberrations. Active eye-tracking (including cyclorotational movements) was utilized during photoablation. RESULTS: Results at the 3-month follow-up: 67 % of PTA-treated eyes and 39 % of APT-treated eyes achieved an uncorrected distance visual acuity (UDVA) of 20/20 or better. Change in mean higher order aberration root-mean-square (HOA RMS) after PTA treatments was not statistically significant (p = 0.18). The increase in HOA RMS after APT treatments was statistically significant (p = 0.003). Change in mean postop spherical aberration (SA) after PTA treatments was not statistically significant (p = 0.27). The change in SA after APT treatments was statistically significant (p = 0.001). In both cohorts, mean uncorrected low-contrast visual acuity was statistically not different to preoperative corrected values. CONCLUSIONS: Adding an aspheric compensation to wavefront-guided myopic LASIK statistically improved clinical results in terms of visual acuity and refractive outcomes. Low-contrast visual acuity was not negatively affected in either group. While in APT-treated eyes mean HOA RMS and mean SA were significantly increased postoperatively, PTA-treated eyes showed neither induced HOA RMS nor induced SA.

Rotational Stability After Implantation of Two Different Phakic Toric Intraocular Lenses.

PURPOSE: To compare clinical outcomes and rotational stability of the toric implantable Collamer lens (TICL) and toric implantable phakic contact lens (TIPCL). METHODS: Charts were reviewed from January 2011 to January 2023 to identify all TICLs and TIPCLs implanted by a single surgeon. Implant size was generally chosen according to the manufacturer's recommendation, but 15 TIPCLs 0.25 mm larger than recommended to increase vaulting were included. RESULTS: Eighty-four TICLs and 98 TIPCLs were identified and yielded excellent refractive and visual results in eyes with high myopic astigmatism at the last follow-up visit. No case of acute glaucoma or cataract induction was observed. In total, 15 (8.2%) rotated lenses were recorded; 2 (2.4%) TICLs and 13 (13.3%) TIPCLs (P = .013). Eyes in both groups were similar in preoperative spherical equivalent, cylinder, white-to-white distance, anterior chamber depth (ACD), anterior chamber angle, and mean follow-up times (P = .925, .673, .822, .794, .358, and .873, respectively). Average TICL size was larger than TIPCL size (P < .001). Rotation of the lenses was positively correlated with cylinder and negatively correlated with ACD but not with vaulting (P = .001, r = 0.253; P = .011, r = -0.193; P = .488, r = -0.057; respectively). Vaulting was positively correlated with preoperative ACD (P ≤ .001, r = .329). In eyes with a rotated TIPCL, preoperative cylinder was higher and ACD was shallower than in eyes with a stable TIPCL (P = .001 and .007, respectively). Increasing the implant size had no significant effect on rotation rate (P = .685). CONCLUSIONS: Although both implants were safe and effective in highly myopic eyes, TICL rotated less frequently than TIPCL and required fewer secondary interventions. Rotation was correlated with preoperative cylinder and ACD but not lens vaulting. [J Refract Surg. 2023;39(7):463-472.].

Increasing depth of focus with allogeneic presbyopic inlays: 3-year results.

PURPOSE: To demonstrate the safety and efficacy of allogenic corneal inlays designed to increase the depth of focus (DoF) in treated eyes. SETTINGS: Medipol University Hospital, Istanbul, Turkey. DESIGN: Prospective case series. METHODS: This study includes 50 eyes of 25 patients with a follow-up of 3 years. Emmetropic patients with presbyopia had implantation of allogenic corneal inlays in the nondominant eye. The uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and uncorrected near visual acuity (UNVA) were evaluated in all eyes. A subjective visual acuity test system (Multifocal Lens Analyzer 3.0 application) was used to analyze the DoF by measuring the defocus curves. RESULTS: No significant difference between the treated and fellow eyes in UDVA and CDVA was found, whereas UNVA was significantly better in the treated eyes ( P = .20, P = .07, P < .01, respectively). Comparing to the preoperative CDVA, there was a 1-line decrease in CDVA in 6 (%24) patients. The mean defocus curves reveal a DoF of 1.1 diopters (D) for the untreated eye at the logMAR = 0.2 threshold. By contrast, the mean DoF of the treated eye and binocularly was 2.8 D. The areas under the curve were significantly better in the near, intermediate, and total distances in the treated eyes, whereas it was better for the far distances in the untreated eyes. All values were significant ( P = .023 total, P < .01 others). CONCLUSIONS: Allogenic presbyopic inlay implantation may be safe and provided a clinically and statistically significant increase in the DoF leading to good far, intermediate, and near-visual acuity in emmetropic presbyopic patients.

Changes of Subjective Symptoms and Tear Film Biomarkers Following Lenticule Extraction.

PURPOSE: To investigate the influence of lenticule extraction on subjective symptoms and objective biomarkers of dry eye and to clarify relationships between markers and find indicators for subjective symptoms after lenticule extraction. METHODS: Right eyes of myopic patients undergoing lenticule extraction surgery (n = 35) were examined preoperatively and 5 and 90 days postoperatively using established clinical dry eye examination methods (tear film break-up time [BUT], Schirmer test, lissamine green and fluorescein staining, and Ocular Surface Disease Index (OSDI) questionnaire). A patient subset was also examined after 1 year (n = 14). Tear samples were eluted from Schirmer strips and then measured with enzyme-linked immunosorbent assays (calcitonin gene-related peptide (CGRP), interleukin-1ß, IL-6, IL-8, matrix metallopeptidase 9 [MMP-9], nerve growth factor, and tumor necrosis factor-α). Postoperatively, unpreserved ofloxacin and dexamethasone eye drops were given (four times a day for 10 days). RESULTS: BUT decreased at days 5 (P = .023) and 90 (P = .025). Lissamine green staining increased at day 90 (P = .036). OSDI values increased at day 5 (total values, vision-related function, ocular symptoms, all P < .001, but not environmental triggers) and at day 90 (vision-related function, P = .017). A downregulation of CGRP (P = .006) and MMP-9 levels (P = .042) was observed on day 5 compared to day 90. CONCLUSIONS: Due to incongruity of patient symptoms, clinical signs, and tear protein changes, no predictive indicator was found, but some patients reported increased discomfort. Changes after lenticule extraction are not exclusively due to dry eye. [J Refract Surg. 2023;39(9):597-604.].

Detecting dry eye from ocular surface videos based on deep learning.

OBJECTIVE: To assess the performance of convolutional neural networks (CNNs) for automated diagnosis of dry eye (DE) in patients undergoing video keratoscopy based on single ocular surface video frames. DESIGN: This retrospective cohort study included 244 ocular surface videos from 244 eyes of 244 subjects based on corneal topography. A total of 116 eyes were normal while 128 eyes had DE based on clinical evaluations. METHODS: We developed a deep transfer learning model to directly identify DE from ocular surface videos. We evaluated the performance of the CNN model based on objective accuracy metrics. We assessed the clinical relevance of the findings by evaluating class activations maps. MAIN OUTCOME MEASURE: Area under the receiver operating characteristics curve (AUC), accuracy, specificity, and sensitivity. RESULTS: The AUC of the model for discriminating normal eyes from eyes with DE was 0.98. Network activation maps suggested that the lower paracentral cornea was the most important region for detection of DE by the CNN model. CONCLUSIONS: Deep transfer learning achieved a high diagnostic accuracy in detecting DE based on non-invasive ocular surface videos at levels that may prove useful in clinical practice.

Efficacy and safety of intracorneal allogenic ring segment implantation in keratoconus: 1-year results.

BACKGROUND: To evaluate the safety and efficacy of corneal allogenic intrastromal ring segments in the management of keratoconus patients. METHODS: The retrospective, nonrandomized, interventional case series consisted of 65 keratoconic eyes of 49 consecutive patients who had ring segment-shaped corneal allografts (KeraNatural®) implanted in intrastromal tunnels created using a femtosecond laser. The main outcome measures were uncorrected visual acuity (UCVA), corrected distant visual acuity (CDVA), refraction, keratometry, and pachymetry. Computed tomography scans of the corneal surfaces were also performed preoperatively as well as 3, 6 and 12 months postoperatively. RESULTS: Mean age was 29.5 ± 7.3 years (median 29, range: 20-52 years). The mean UCVA improved from 0.91 ± 0.50 logMAR preoperatively to 0.40 ± 0.24 logMAR postoperatively at 6 month follow-up (p < 0.01) and the mean CDVA improved from 0.87 ± 0.20 logMAR preoperatively to 0.27 ± 0.06 logMAR postoperatively (p < 0.01). The mean spherical equivalent improved from -8.82 ± 4.57 to -3.45 ± 4.81D (p < 0.01). Average Keratometry decreased from 49.23 ± 5.22 preoperatively to 45.63 ± 4.89 D postoperatively (p < 0.01). Mean anterior and posterior maximum elevation were also decreased significantly (p < 0.01). In one patient, dislocation of the graft towards the tunnel incision site and dehiscense at the tunnel entrance were observed in the first week of the operation. Yellow-white deposits were observed in the segment tunnels in five cases after 6 months. CONCLUSION: This study demonstrated that implantation of corneal allograft ring segments is a viable alternative treatment for keratoconus with safety and good visual results.

Decision taking in corneal refractive surgery.

A 27-year-old woman who wants to get rid of contact lenses and spectacles was seen at our clinic. She had strabismus surgery as a child and was patched for the right eye but now shows mild nondisturbing exophoria. Infrequently, she likes to box in the sports school. Her corrected distance visual acuity at presentation in the right eye was 20/16 with -3.75 -0.75 × 50 and in the left eye 20/16 with -3.75 -1.25 × 142. Her cycloplegic refraction in the right eye was -3.75 -0.75 × 44 and in the left eye was -3.25 -1.25 × 147. The left eye is the dominant eye. The tear break-up time was 8 seconds in both eyes, and the Schirmer tear test was 7 to 10 mm in right and left eyes, respectively. Pupil sizes under mesopic conditions were 6.62 mm and 6.68 mm. The anterior chamber depth (ACD) (measured from the epithelium) in the right eye was 3.89 mm and in the left eye was 3.87 mm. The corneal thickness was 503 µm and 493 µm of the right and left eye, respectively. Corneal endothelial cell density was on average 2700 cells/mm2 for both eyes. Slitlamp biomicroscopy showed clear corneas and a normal flat iris configuration. Supplemental Figures 1 to 4 (available at http://links.lww.com/JRS/A818, http://links.lww.com/JRS/A819, http://links.lww.com/JRS/A820, and http://links.lww.com/JRS/A821) show the corneal topography and Belin-Ambrósio deviation (BAD) maps at presentation of the right eye and left eye, respectively. Would you consider this patient a candidate for corneal refractive surgery (eg, laser-assisted subepithelial keratectomy, laser in situ keratomileusis [LASIK], or small-incision lenticule extraction [SMILE] procedure)? Has your opinion changed given the recent opinion of the U.S. Food and Drug Administration (FDA) regarding LASIK?1 The patient herself is slightly favoring an implantation of a phakic intraocular lens (pIOL), as she prefers something reversible. Would you implant a pIOL, and which type of IOL, for this level of myopia? What is your diagnosis or are additional diagnostic methodologies needed to establish a diagnosis? What is your treatment advice for this patient? REFERENCES 1. U.S. Food and Drug Administration, HHS. Laser-assisted in situ keratomileusis (LASIK) lasers-patient labeling recommendations; draft guidance for industry and food and drug administration staff; availability. July 28, 2022, Federal Register; 87 FR 45334. Available at: https://www.fda.gov/regulatory-information/search-fda-guidance-documents/laser-assisted-situ-keratomileusis-lasik-lasers-patient-labeling-recommendations Accessed January 25, 2023.

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.

Influence of corneal thickness changes during active uveitis on Goldmann applanation and dynamic contour tonometry.

BACKGROUND: To compare the influence of central corneal thickness (CCT) during active anterior uveitis and after resolution on intraocular pressure (IOP) measurements by Goldmann applanation tonometry (GAT) and by dynamic contour tonometry (DCT). DESIGN: Prospective, single-center study including 30 consecutive patients with active unilateral uveitis. MAIN OUTCOME MEASURE: CCT influence on GAT and DCT in active uveitis. RESULTS: Average age of included patients (total n = 30; 16 women) was 46.5 years (range: 22.3-75.4). During activity, the cornea was thicker than on the unaffected side (645 vs. 585 µm, p = 0.0001). At the follow-up visit (inactive time point), the corneal thickness of the affected eye fell to a CCT of 581 µm (p < 0.0001). IOP measured by DCT was always higher than that measured by GAT. IOP was significantly lower during the active phase (GAT = 14.3 ± 5.8 mm Hg, DCT = 16.3 ± 5.9 mm Hg) than when disease was inactive (GAT = 17 ± 6.2 mm Hg, p = 0.016; DCT = 19.6 ± 6.9 mm Hg, p = 0.0006). The two techniques showed a high concordance, with a correlation coefficient of 0.76 (p < 0.001) in the affected eye at the active time point and when inactive 0.95 (p < 0.001). In addition, no systematic difference between these two techniques was observed according to the Bland-Altman method of comparison. No correlation between ΔIOP (GAT - DCT) and CCT could be detected at either time point. CONCLUSIONS: CCT increases during active phases of anterior uveitis. The edematous corneas lead to an additional decrease in IOP measurements by GAT and DCT. Both techniques were in good concordance in the patients, and the difference between GAT and DCT IOP readings was not influenced by CCT.

Systematic detection of keratoconus in OCT: corneal and epithelial thickness maps.

PURPOSE: To detect keratoconus (KC) only by analyzing the corneal and epithelial map parameters and patterns in optical coherence tomography (OCT). SETTING: Tertiary care refractive surgery center. DESIGN: Retrospective data collection. METHODS: Corneal and epithelial thickness maps of normal, manifest, and subclinical keratoconic eyes (according to the Belin-Ambrosio display, Pentacam) were evaluated using spectral-domain OCT (Zeiss Cirrus 5000 HD). A new 2-step decision tree was developed based on previous studies with another OCT device. In the first step, if at least 1 of the 4 independent parameters (pachymetry minimum, pachymetry minimum-median, pachymetry superonasal-inferotemporal, and epithelial superonasal-inferotemporal) overruns the cutoff values, the eye was suspicious for KC. In the second step, if the epithelial map showed concentric thinning and the thinnest point of the cornea and epithelium is coincident, the eye was classified as keratoconic. RESULTS: 172 manifest keratoconic eyes (108 patients), 21 subclinical keratoconic eyes (20 patients), and 172 normal eyes (90 age-matched participants) were included in this study. Step 1 captured 100% of manifest and subclinical keratoconic eyes. Step 2 ruled out all suspicious but normal cases and, falsely, 2 subclinical keratoconic eyes. Our 2-step decision tree reached 100% specificity, 100% sensitivity in manifest KC, and 90.4% sensitivity in subclinical KC. CONCLUSIONS: Pachymetric and epithelial map parameters and patterns in OCT can be used in the diagnosis of KC, including subclinical cases, yielding a high level of agreement with the commonly used diagnostic reference, the Belin-Ambrosio display. Further improvements by refining our algorithm and including an automated evaluation in the software are desirable.

[Long-term outcomes of PRK, LASIK and SMILE]. / PRK, LASIK, SMILE im Langzeitverlauf.

BACKGROUND: Patients and refractive surgeons have a legitimate interest in the long-term results of the most commonly used laser procedures for correction of ametropia. OBJECTIVE: To assess the safety, predictability, stability and late complications according to the current recommendations of the committee for refractive surgery (KRC). METHODS: Literature search in PubMed with the search term "long-term outcome" combined with either "PRK", "LASIK" or "SMILE". Articles about PRK and LASIK with a minimum follow-up of 10 years and SMILE with a minimum follow-up of 5 years were evaluated and duplications were eliminated. RESULTS: From a total of 440 articles that matched these search terms 15 articles were selected and analyzed. The results of PRK were described in 4 studies with a total of 666 eyes, 7 studies (566 eyes) described the results of LASIK and 5 studies (188 eyes) the results after SMILE. CONCLUSION: Long-term studies with follow-up periods of at least 10 years have shown that PRK and LASIK treatment carried out in the early days of medical excimer lasers have a very high level of safety and late complications occurred only rarely. The effectiveness of particularly high corrections declined over time. In contrast, there was no clinically significant regression within the indications recommended by the KRC. The results of SMILE were not inferior to those of PRK and LASIK. In direct long-term comparisons no procedure showed a clear superiority. Due to technological improvements in hardware and software for both preoperative diagnostics and lasers, treatment performed nowadays is presumably even safer, more efficient and also more stable over a long period of time.