Conjunctival-limbal autograft.

PURPOSE OF REVIEW: To provide an overview of conjunctival-limbal autografting (CLAU) for ocular surface rehabilitation with emphasis on more recent literature detailing outcomes of the procedure over the last 2 decades as well as technique variations and adjuvant techniques. RECENT FINDINGS: Limbal autografting initially described in 1964 by Barraquer and Strampelli and later popularized by Kenyon and Tseng is considered the best option for restoration of corneal phenotype in unilateral limbal stem-cell deficiency. Although there have been developments in alternative limbal epithelial stem-cell techniques including ex-vivo tissue engineering methods, because of the benefit of immunohistocompatability, this procedure still provides better long-term outcomes. As autograft donor tissue is valuable, optimization of the recipient eye preoperatively with good lid closure and reduction of inflammation is vital for success as is close postoperative follow-up. Variations in the technique described have included the modified Cincinnati technique combining CLAU with cadaveric keratolimbal allograft to avoid conjunctivalization. In addition, simple limbal epithelial autograft transplantation, a less-invasive technique combined with amniotic membrane transplantation, has shown promise. SUMMARY: In spite of the development of new epithelial transplant techniques, in unilateral limbal stem-cell deficiency, CLAU from a healthy unaffected fellow eye remains the best option available for restoration of corneal phenotype.

Femtosecond laser-assisted lamellar keratoplasty (FSLK) for anterior corneal stromal diseases.

Our objective was to study the outcome of femtosecond-assisted lamellar keratoplasty (FSLK) in stromal corneal diseases. This is a retrospective chart review of 17 patients (20 eyes) who underwent FSLK for anterior corneal pathologies. Main outcome measures were refractive results following FSLK, complications, and graft survival. Mean follow-up time was 42 ± 15 (7-58) months. Preoperative best spectacle-corrected visual acuity (BSCVA) was ≤20/40 in 17 eyes. Postoperative BSCVA ≥ 20/40 was achieved in 12/14 at 12 months, 11/12 at 24 months, and 10/12 eyes at 36 months; postoperative BSCVA ≥ 20/25 was achieved in 8/14, 8/12, and 5/12 eyes at 12, 24, and 36 months, respectively. One eye had vertical gas break through the epithelium during the FSLK. One eye had postoperative epithelial rejection and two eyes had stromal rejection treated successfully with topical steroids. Another eye had epithelial ingrowth that was not progressive; however, the same eye developed bacterial keratitis and scarred graft 32 months post-FSLK. One eye had graft dehiscence and one eye developed excessive interface fibrosis. Five out of 20 grafts failed due to the recurrence of the original disease (3), corneal scarring (1), and excessive interface fibrosis (1). FSLK provides many advantages over conventional PK and DALK, with faster visual rehabilitation and emmetropization of the manifest refraction rather than inducing ametropia and irregular astigmatism.

Immediate Sequential Bilateral Implantable Collamer Lens Surgery Is Safe and Effective.

PURPOSE: To assess the clinical outcomes and safety profiles of patients who underwent immediate sequential bilateral phakic lens surgery. METHODS: This retrospective multicenter study included 254 consecutive patients (508 eyes) who underwent bilateral same-day Implantable Collamer Lens (ICL) (STAAR Surgical) surgery. The authors focused on 1-year postoperative clinical outcomes and adverse events. RESULTS: In the initial cohort, 176 patients (352 eyes) met inclusion criteria. Of these, 335 eyes underwent myopic ICL placement, and 17 eyes received a hyperopic ICL. Notably, 87% of eyes achieved ±0.50 diopters (D) and 95% achieved ±1.00 D of the intended refraction. One year postoperatively, 78% of eyes demonstrated optimal vaulting (250 to 750 µm), with a significant 19% reduction in vaulting observed over the 12 months (P < .001). Only minor adverse events, including early cataract formation (1 case), secondary toric ICL rotation (3 cases), and ICL exchange due to inappropriate vaulting (6 cases), were noted. CONCLUSIONS: The findings corroborate the safety and efficacy of immediate sequential bilateral phakic lens surgery and indicate its potential as a treatment option. The low incidence of minor adverse events further reinforces its favorable safety profile. [J Refract Surg. 2024;40(5):e313-e320.].

Outcomes of pseudophakic toric intraocular lens implantation in Keratoconic eyes with cataract.

PURPOSE: To evaluate the outcomes of pseudophakic toric intraocular lens (IOL) implantation in eyes with stable keratoconus and cataract. METHODS: Retrospective, noncomparative, case series of 12 eyes from 9 patients (mean age: 63.4±3.5 years) with stable mild to moderate keratoconus and cataract who underwent pseudophakic toric IOL implantation (AT TORBI 709M, AcriTec). Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction, keratometric findings, adverse events, and postoperative complications were recorded for all eyes. RESULTS: Mean postoperative follow-up was 9.0+8.8 months. At last postoperative follow-up, UDVA was 20/40 or better in 75% and CDVA was 20/40 or better in 83.3% of eyes. Postoperative mean refractive sphere (pre- vs postoperative: -4.80±5.60 vs 0.30±0.50 diopters [D]) and cylinder (pre- vs postoperative: 3.00+1.00 D vs 0.70+0.80 D) were significantly better (P<.01 for both). No intra- or postoperative complications occurred. No eyes had progression of keratoconus or significant IOL rotation at postoperative follow-up. CONCLUSIONS: Pseudophakic toric IOLs are an effective option and provide good vision in eyes with stable mild to moderate keratoconus and cataract.

Refractive lens exchange versus phakic intraocular lenses.

PURPOSE OF REVIEW: To review the evidential basis of current practice in refractive lens exchange (RLE) vs. phakic intraocular lens (pIOL). RECENT FINDINGS: Visual outcomes after pIOLs are better than RLE. With RLE, there still remain risks of retinal detachment, cystoid macular oedema, glare, halos and posterior capsule opacification. With pIOLs, risks include pigment dispersion, cataract formation, glaucoma and inflammation. The decision to choose between either is broadly based on age and type of refractive error, and the choice follows thorough evaluation and counselling taking into consideration patient's needs and expectations. SUMMARY: With advancing technology, newer IOL models for RLE and phakic correction are becoming available. pIOLs provide better visual outcomes for distance correction and currently do not provide near-vision correction possible with RLE.

OC-01 (Varenicline Solution) Nasal Spray Demonstrates Consistency of Effect Regardless of Age, Race, Ethnicity, and Artificial Tear Use.

Purpose: To evaluate OC-01 [varenicline solution nasal spray (VNS)] tear production and symptom outcomes in patients with dry eye disease by age, gender, race, ethnicity, and artificial tear use status. Patients and Methods: Adults ≥22 years of age diagnosed with dry eye disease, with Ocular Surface Disease Index score ≥23, corneal fluorescein staining score ≥2 in ≥1 region or ≥4 for all regions, and baseline Schirmer Test Score (STS) ≤10 mm, with no restrictions on eye dryness score (EDS). Efficacy was assessed using integrated data from ONSET-1 and ONSET-2 [vehicle control (VC), n=294; OC-01 VNS 0.03 mg, n=308]. Subgroups included age (≤55, 56-65, >65 years), gender (male, female), race (White, Black or African American), ethnicity (Hispanic or Latino, Not Hispanic or Latino), and artificial tear use (yes, no). Analysis of covariance models, with the covariates treatment, study site, and baseline severity measures, were used to calculate treatment-VC differences. Consistency of effect among subgroups was evaluated by conducting interaction tests. Results: Consistency of treatment effect across subgroups was observed for all endpoints, with P value for all treatment-subgroup interaction terms >0.05. For % of patients with ≥10mm improvement in STS and least squares (LS) mean change from baseline in STS and EDS, there was improvement in tear production across demographic group categories. Artificial tear use did not change STS or EDS outcomes with OC-01 VNS. Conclusion: OC-01 VNS improved tear production and patient-reported symptom outcomes across a broad range of patients by age, gender, race, and ethnicity, and regardless of artificial tear use status at baseline. OC-01 VNS demonstrated a consistent benefit across an extensive range of patients with dry eye disease.

Blink lagophthalmos and dry eye keratopathy in patients with non-facial palsy: clinical features and management with upper eyelid loading.

PURPOSE: To evaluate the outcome of using upper eyelid gold weight implantation for patients with non-paralytic lagophthalmos on blink (LOB) only. We highlight the features of incomplete blink and reduced blink rate in patients with non-facial palsy as an exacerbating factor in dry eye keratopathy. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twelve patients (21 procedures) who underwent upper eyelid gold weight implantation for non-paralytic LOB only. METHODS: Retrospective case note review of patients who underwent upper eyelid loading for non-paralytic LOB only over a 5-year period at a single institution. MAIN OUTCOME MEASURES: Improvement in LOB, gentle and forced closure, increased frequency of blinking (FOB), degree of corneal staining, incidence of epithelial defects or corneal ulcer, improvement in vision, and subjective improvement in ocular discomfort. RESULTS: Twenty-one procedures in 12 patients. Nine patients underwent bilateral surgery. Mean age was 56 (range, 8-80) years. Median postoperative follow-up was 15 months, and mean follow-up was 20.38 ± 16.61 (6-58) months. Eleven of 12 patients had an improvement in LOB and increased FOB, resulting in improvement of keratopathy and reduced ocular discomfort. One patient developed superior corneal thinning and descemetocele, requiring removal of the gold weight; 1 patient required ptosis surgery; and 1 patient developed a gold allergy and underwent platinum chain exchange. CONCLUSIONS: We highlight the need to consider incomplete blink and reduced FOB as exacerbating factors for corneal-related disorders, including dry eye. Upper eyelid loading with gold weight implantation is a useful and predictive method of improving exposure-related keratopathy due to LOB in the absence of facial palsy.

Parameters affecting anterior capsulotomy tear strength and distension.

PURPOSE: To study the effects of anterior capsulotomy diameter and discontinuity on tear threshold load and distension for the technique of continuous curvilinear capsulorhexis (CCC). SETTING: Singapore National Eye Centre, Singapore, and CapsuLaser Inc., Livermore, California, USA. DESIGN: Two separate randomized pairwise cadaver eye preclinical studies. METHODS: Capsulotomies were performed in 40 cadaver eyes of 20 donors using CCC. The pairwise comparisons were divided into 2 study groups: Study A: Continuous versus discontinuous capsulotomies; Study B: Capsulotomy diameter of 5.0 mm and smaller versus diameters of 5.2 mm and larger. A shoe-tree method was used to apply load to the capsulotomy rim, and the Instron tensile stress instrument measured threshold load and distension to initiate a capsular tear. Wilcoxon matched-pairs signed-rank tests were performed to assess statistical superiority. RESULTS: In Study Group A, all pairs demonstrated that continuous capsulotomies were better than discontinuous capsulotomies for both the anterior tear threshold load and distension (P < .01). In Study Group B, 80% of the pairs demonstrated that diameters of 5.2 mm and larger were better than those of 5.0 mm and smaller diameter (P < .05). CONCLUSIONS: Anterior capsulotomies behave as nonlinear elastic (elastomeric) systems when exposed to an external load and distension. This study demonstrated that continuous circular capsulotomies were more resistant to anterior tears than discontinuous capsulotomies. A point of irregularity or a defect in a capsulotomy rim has a high probability of being the tear initiation point. Furthermore, larger diameter capsulotomies were more resistant to anterior tears than smaller capsulotomies.

Meibomian gland inversion: under-recognized entity.

OBJECTIVE: To describe a clinical entity of upper eyelid margin and meibomian gland inversion (MGI) sequential to meibomian gland dysfunction (MGD), in the absence of eyelash ptosis, trichiasis or manifest marginal entropion. We highlight its clinical features, surgical management and outcomes. METHODS: We performed a retrospective analysis of symptomatic MGI cases refractory to conservative management who underwent surgery in our centre over a 4-year period. Anatomical correction, resolution of symptoms and possible complications are reported. RESULTS: A total of 21 eyelids of 13 patients (mean age: 68.5 ± 15.4, range: 32-88 years) were analysed. Symptomatic MGI patients were operated only if they have noted immediate comfort when we corrected the lid margin position with a cotton tip. Those with refractory superior punctate corneal staining (n = 14 eyes), blink-related discomfort (n = 8) and pseudo-blepharospasm (n = 3) reported complete postoperative resolution. Milder symptoms showed partial improvement: gritty feeling (79%), sore eye (80%) and watery eye (86%). However, symptoms of dry eye disease (DED) persisted in 88% of patients. One case recurred in 6 weeks and was offered revision surgery. Median follow-up was 5 (range: 3-12) months. CONCLUSION: Meibomian gland inversion (MGI) is a subtle clinical entity that can be easily overlooked. Symptoms are often attributed to DED or MGD alone. It is likely that MGI represents early upper lid margin anatomical changes secondary to MGD before cicatricial marginal entropion becomes clinically apparent. Recommended treatment is conservative with intensive lid hygiene and topical MGD management. However, refractory symptomatic cases who respond positively to a 'cotton-tip test' (reversal of lid margin malposition with a rolling cotton-tip) may benefit from surgical intervention with favourable anatomical and functional outcome.

Survival of cultured allogeneic limbal epithelial cells following corneal repair.

In this study a technique for determining donor cell fate following corneal grafting was evaluated. Patients treated for limbal deficiency with allogeneic cultured corneal epithelial cells were studied to determine the fate of the grafted cells. The technique was evaluated initially through the use of donor eyes and then applied to the clinical analysis of 7 patients who had received a cultured corneal epithelial allograft. Cells removed from the cornea and any retrieved tissue were analyzed via polymerase chain reaction (PCR) genotyping to determine the origin of the cells populating the patients' healed cornea. A mixture of genotypes was detected in a cornea retrieved from a patient following a fully penetrating keratoplasty who had received a mixture of allogeneic tissue. Donor cells were no longer detected on the corneal surface of all 7 cases beyond 28 weeks postgraft. At these later time points, only patient genotype could be detected. These results demonstrate that PCR genotyping can be used to determine the origin of cells populating the surface of the cornea following the grafting of cultured allogeneic cells and demonstrates that transplanted cultured limbal epithelial cells do not persist on the surface of the host cornea for more than 28 weeks.

Presence of mitomycin-C in the anterior chamber after photorefractive keratectomy.

PURPOSE: To assess the presence of mitomycin-C (MMC) in hen aqueous humor after photorefractive keratectomy (PRK). SETTING: Instituto Universitario de Oftalmobiología Aplicada, Faculty of Medicine, University of Valladolid, and Department of Analytical Chemistry, Faculty of Sciences, University of Valladolid, Valladolid, Spain. METHODS: Mitomycin-C 0.02% was applied topically for 2 minutes to a right hen's eye after PRK (Group A) and to the left eye with intact epithelium (Group B). At different time points (10, 30, 60, 360, and 720 minutes), aqueous humor was extracted and high-performance liquid chromatography was performed to detect and quantify MMC levels. RESULTS: The mean maximum drug concentration of MMC measured in the aqueous humor was 187.250 microg/L +/- 4.349 (SD) in Group A and 93.000 +/- 4.899 microg/L in Group B, both detected 10 minutes after topical application. Statistically significant differences were found between Groups A and B at 10, 30, and 60 minutes, with decreasing MMC levels in both groups but a higher concentration in Group A. After 360 minutes, MMC levels were undetectable in Group B and after 720 minutes in Group A. CONCLUSIONS: Mitomycin-C was detectable in the aqueous humor of the hen eye after topical application in PRK-treated eyes and in eyes with intact epithelium. The presence of MMC is of concern as it may lead to ocular toxicity in the long term.

Outcomes and DNA analysis of ex vivo expanded stem cell allograft for ocular surface reconstruction.

PURPOSE: To investigate the outcome of a new technique of ex vivo expanded stem cell allograft for limbal stem cell deficiency (LSCD), and to characterize the ocular surface genotype after surgery. DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Ten eyes of 10 patients with profound LSCD arising from ectodermal dysplasia (3 eyes), Stevens-Johnson syndrome (3 eyes), chemical injury (2 eyes), thermal injury (1 eye), and rosacea blepharoconjunctivitis (1 eye). INTERVENTION: Allogeneic corneal limbal stem cells were cultured on plastic and transplanted to the recipient eye after removal of conjunctival pannus. Amniotic membrane was applied in a bandage capacity. The procedure was combined with other reconstructive surgery in 2 cases. Nine patients received systemic cyclosporin A immunosuppression, and the DNA genotype was investigated with surface impression cytology. MAIN OUTCOME MEASURES: Parameters of LSCD, including vascularization, conjunctivalization, inflammation, epithelial defect, photophobia, and pain. RESULTS: The mean follow-up period was 28 months (range, 12-50). Seven of 10 eyes (70%) had improved parameters of LSCD at final follow-up and were considered successes. Four (40%) had improved visual acuity, including 3 having had further procedures for visual rehabilitation. Three patients failed to improve-1 with a thermal burn and lid deformity, 1 with Stevens-Johnson syndrome and severe dry eye, and 1 with ectodermal dysplasia who developed an epithelial defect at 26 months. DNA analysis of the first 7 cases showed no ex vivo donor stem cell DNA present beyond 9 months. CONCLUSIONS: Ex vivo expanded stem cell allograft is a useful technique for restoring the ocular surface in profound LSCD. The absence of donor DNA beyond 9 months suggests that ongoing immunosuppression may be unnecessary and raises questions regarding the origin of the host corneal epithelium.

Corneal wedge resection to treat progressive keratoconus in the host cornea after penetrating keratoplasty.

We present 3 cases of progressive keratoconus in the host after penetrating keratoplasty PKP that were treated with a wide crescentic excision of the diseased tissue in the host cornea guided by Orbscan II topography (Bausch & Lomb). In all cases, the procedure resulted in a more regular corneal shape with a marked reduction in astigmatism, preventing the need for repeat PKP

Unexpected flap thickness in laser in situ keratomileusis.

We report a case of an unexpected thick flap during laser in situ keratomileusis (LASIK) that led to abandonment of surgery. This report illustrates the importance of stromal bed measurements after flap creation in LASIK. A thicker-than-expected flap can lead to a thinner-than-anticipated residual cornea and subsequent ectasia or even perforation during laser ablation. It is possible that reports of ectasia in normal thickness corneas reflect thicker-than-anticipated flaps.

Reproducibility of LASIK flap thickness using the Hansatome microkeratome.

PURPOSE: To evaluate the actual versus the expected thickness of laser in situ keratomileusis (LASIK) flaps and to determine the factors that affect flap thickness. SETTING: Centre For Sight, Queen Victoria Hospital, East Grinstead, United Kingdom. METHODS: A retrospective analysis of LASIK procedures in 757 consecutive eyes was done. The surgery was performed by a single surgeon using 2 Hansatome microkeratomes (Bausch & Lomb) with 160 microm and 180 microm heads. Patient age, preoperative manifest refraction, automated keratometry, preoperative central pachymetry, and intraoperative stromal pachymetry were evaluated to determine whether they influenced the actual flap thickness. RESULTS: Bilateral LASIK was performed in 343 patients (686 eyes). The 160 microm head was used in 641 eyes (84.6%) (Group 1) and the 180 microm head, in 116 eyes (15.4%) (Group 2). The mean preoperative manifest refraction spherical equivalent (SE) was -3.9 diopters (D) +/- 4.5 (SD) (range +7.4 to -25.0 D) in Group 1 and -4.4 +/- 3.7 D (range +7.1 to -12.9 D) in Group 2. The mean preoperative keratometry reading was 43.6 +/- 1.8 D (range 36.0 to 48.6 D) and 43.6 +/- 1.8 D (range 35.9 to 47.0 D), respectively; the mean preoperative central pachymetry was 543 +/- 35 microm (range 447 to 643 microm) and 548 +/- 31 microm (range 453 to 613 microm), respectively; and the mean flap thickness was 116.4 +/- 19.8 microm and 117.3 +/- 18.0 microm, respectively. The difference between the actual and the expected flap thickness in each group was statistically significant (P<.001). There was no significant difference in the actual flap thickness between the 2 Hansatomes. The preoperative SE and central pachymetry were the only factors that influenced the actual flap thickness (P<.05); thin flaps were more common with increasing myopia and increasing corneal thickness. CONCLUSIONS: Spherical equivalent and preoperative pachymetry were the principal factors that influenced flap thickness. Preoperative keratometry values and patient age did not influence the actual flap thickness.

Translenticular hydrodissection, lens fragmentation, and influence on ultrasound power in femtosecond laser-assisted cataract surgery and refractive lens exchange.

PURPOSE: To compare ultrasound time (UST) during femtosecond laser-assisted and conventional cataract surgery or refractive lens exchange and evaluate UST during femtosecond laser surgery with and without a new technique, translenticular hydrodissection. SETTING: Centre for Sight, East Grinstead, West Sussex, United Kingdom. DESIGN: Comparative case series. METHOD: This single-surgeon study compared consecutive femtosecond laser-assisted surgery (with and without translenticular hydrodissection to assist lens mobilization) and consecutive conventional surgery performed immediately before adoption of femtosecond laser technology. The mean US power, UST, and effective phacoemulsification time (EPT) in the 2 groups were compared. Further analysis of the femtosecond group compared translenticular hydrodissection and no translenticular hydrodissection. RESULTS: The mean US power, UST, and EPT were significantly longer in the conventional group (n = 108) than in the femtosecond group (n = 108) as follows: 7.30% ± 2.56% (SD) versus 5.32% ± 2.48% (P=.000); 9.89 ± 5.32 seconds versus 8.58 ± 4.66 seconds (P=.044); 0.87 ± 0.85 seconds versus 0.57 ± 0.51 seconds (P=.002), respectively. In the femtosecond group, parameters were significantly higher in eyes without translenticular hydrodissection (n = 27) than in eyes with translenticular hydrodissection (n = 81) as follows: 5.78% ± 2.23% versus 5.16% ± 2.56% (P=.046); 10.95 ± 4.66 seconds versus 7.78 ± 4.41 seconds (P=.046); 0.72 ± 0.26 seconds versus 0.52 ± 0.53 seconds (P=.002), respectively. CONCLUSION: Femtosecond laser capsulotomy and lens fragmentation statistically significantly reduced UST over conventional surgery. Translenticular hydrodissection further reduced UST.

Intraocular pressure control and corneal graft survival after implantation of Ahmed valve device in high-risk penetrating keratoplasty.

PURPOSE: To analyze the control of intraocular pressure (IOP) and corneal graft survival after implantation of Ahmed glaucoma device (AGD) in eyes that had high-risk penetrating keratoplasty (PK). METHODS: This is a retrospective noncomparative case series of 59 eyes that had high-risk PK and underwent AGD insertion. The primary outcome measures are the control of IOP between 6 and 21 mm Hg and corneal graft survival. The secondary outcome measures are risk factors associated with IOP control and corneal graft survival. RESULTS: The mean IOP reduced significantly after the AGD procedure (26.45 ± 6.8 mm Hg preoperatively vs. 16.85 ± 7.4 mm Hg, 16.95 ± 4.6 mm Hg, 17.97 ± 5.7 mm Hg, 15.78 ± 5.2 mm Hg, and 15.59 ± 5.5 mm Hg, at 1 month, 6 months, 1 year, 2 years, and at the last follow-up postoperatively; P < 0.0001). Over a median follow-up of 78 months (range, 9-175 months) after AGD insertion, IOP control was successful in 44 eyes (75.8%). IOP control was successful in 96% of the eyes at 1 year, 87% at 2 years, 83% at 3 years, and 83% at 5 years. The percentage of clear corneal grafts after 1, 2, 3, and 5 years following the AGD insertion were 87%, 77%, 65%, and 47%, respectively. Further surgery after AGD insertion was associated with 1.79 times greater risk of failure of IOP control. CONCLUSIONS: AGD was effective in controlling the IOP associated with high-risk PK over a 5-year period. Postvalve surgery doubles the risk of failure of IOP control.

Visual acuity and refraction with a diffractive multifocal toric intraocular lens.

PURPOSE: To evaluate clinical outcomes and optical performance of the AT Lisa 909M diffractive multifocal toric intraocular lens (IOL). SETTING: Multicenter study. DESIGN: Cohort study. METHODS: The measured outcomes included refractive error; distance, near (40 cm), and intermediate (60 cm and 80 cm) visual acuities; defocus curve; rotational stability; and monocular and binocular photopic and mesopic contrast sensitivity. Astigmatism was evaluated by Alpins vector analysis. RESULTS: The multifocal toric IOL was implanted in 284 eyes of 142 patients. At 6 months, 89.4% of eyes were within ±1.00 diopter (D) of emmetropia. The mean refractive cylinder decreased from -2.39 D ± 1.48 (SD) to -0.49 ± 0.53 D; it was lower than 1.00 D in 80.9% of eyes. The mean visual acuities (logMAR) were monocular uncorrected distance 0.16 ± 0.22, monocular corrected distance 0.04 ± 0.15, binocular corrected distance -0.00 ± 0.09; monocular uncorrected near 0.21 ± 0.22, monocular corrected near 0.08 ± 0.16, binocular distance-corrected near 0.07 ± 0.14; intermediate at 60 cm (80 cm): monocular uncorrected 0.16 ± 0.21 (0.09 ± 0.21), monocular distance corrected 0.13 ± 0.19 (0.07 ± 0.20), and binocular distance corrected 0.07 ± 0.17 (0.00 ± 0.18). At 3 months and 6 months, 95.8% of IOLs showed no rotation over 5 degrees. CONCLUSIONS: This is the largest study yet on the first commercially available diffractive multifocal toric IOL. Results confirm its efficacy, predictability, and safety in restoring distance, near, and intermediate vision and allowing patients with significant levels of corneal astigmatism to achieve spectacle independence. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Outcomes of deep anterior lamellar keratoplasty in keratoconic eyes with previous hydrops.

AIM: To evaluate outcomes of deep anterior lamellar keratoplasty (DALK) in keratoconic eyes with previous hydrops. METHODS: In this retrospective, non-comparative study, keratoconic eyes with previous hydrops that underwent DALK were included. DALK was performed using a modification of Melles's technique of optical recognition with pre-Descemet's membrane dissection. Data on preoperative and postoperative uncorrected distance visual acuity and best spectacle corrected distance visual acuity (BSCVA), postoperative spherical equivalent (SEQ); keratometry and adverse events were recorded for all eyes. RESULTS: Ten eyes (10 patients) underwent DALK in keratoconic eyes with previous hydrops. Mean follow-up was 56.4 ± 23.8 months. Preoperatively BSCVA was 6/24 or worse in all eyes. At last follow-up, 100% had BSCVA of 6/12 or better. Intraoperative microperforation at the site of previous hydrops occurred in six eyes but none required conversion to penetrating keratoplasty. At latest follow-up, mean SEQ was -2.4 ± 4.2D, keratometric astigmatism was 3.8 ± 1.6D and refractive astigmatism was 3.4 ± 2.2D. Mean postoperative keratometry was 43.7 ± 2.6 and central pachymetry 572.6 ± 65.0 µm. CONCLUSIONS: DALK in keratoconic corneas with prior hydrops is a safe and effective option that preserves host endothelium Intraoperative microperforations at the site of hydrops are common, however with good management favourable outcomes are possible.