Comparison of Intraocular Lens Power Prediction Accuracy Between 2 Swept-Source Optical Coherence Tomography Biometry Devices.

PURPOSE: To compare intraocular lens (IOL) power prediction accuracy of the Eyestar 900 (EyeS900) and the IOLMaster 700 (IOLM700) based on estimated and measured posterior corneal power. DESIGN: Retrospective, interinstrument reliability study. METHODS: Setting: Institutional. PARTICIPANTS: Two hundred twenty-five eyes of 225 cataract surgery patients. MEASUREMENTS: Patients underwent measurements by both devices preoperatively. MAIN OUTCOME MEASURES: Spherical Equivalent Prediction Error (SEQ-PE), spread of the SEQ-PE (precision) and the absolute SEQ-PE (accuracy) of each device using Barrett Universal II (BUII) formula with either estimated posterior keratometry (E-PK) or measured posterior keratometry (M-PK). RESULTS: Trimmed mean SEQ-PEs of EyeS900 E-PK, EyeS900 M-PK, IOLM700 E-PK, and IOLM700 M-PK were 0.03, 0.08, 0.02, and 0.09 D, respectively with no significant differences between EyeS900 E-PK and IOLM700 E-PK (P = 0.31) as well as between EyeS900 M-PK and IOLM700 M-PK (P = 0.31). Statistically significant SEQ-PE differences were found when E-PK and M-PK were compared, regardless of the device used, showing hyperopic SEQ-PE in M-PK calculations. Excellent correlation and agreement in SEQ-PE were found between the devices for both E-PK (P < 0.001, r = 0.848, mean bias: +0.01 D, 95% LOA of -0.32 to +0.34 D) and M-PK (P < 0.001, r = 0.776, mean bias: -0.01 D, 95% LOA of -0.42 to +0.39 D). No significant differences were found comparing absolute SEQ-PE and precision of the devices. CONCLUSION: The Eyestar 900 and the IOLMaster 700 show comparable IOL power prediction accuracy by the BUII formula using either estimated or measured posterior keratometry. An adjusted lens factor may be required for BUII when utilizing measured posterior keratometry in both devices.

Type 1 and type 2 diabetes predisposed to higher Nd:YAG capsulotomy rates following cataract surgery: analysis of 53,471 consecutive cases.

OBJECTIVE: To assess the effect of diabetes type on Nd:YAG capsulotomy rates following cataract surgery. DESIGN: A retrospective cohort study. METHODS: All patients who underwent cataract extraction at the Department of Ophthalmology, Bristol Eye Hospital, Bristol, UK, between 2003 and 2017 were included. The Nd:YAG capsulotomy rate following cataract surgery was assessed and compared between nondiabetic, type 1 diabetes (T1D), and type 2 diabetes (T2D) patients. Multivariate Cox regression analysis controlling for age and sex was used to estimate hazard ratios for Nd:YAG laser capsulotomies. RESULTS: Included were 53,471 consecutive cataract surgeries. Overall, 42,651 eyes (79.8%) were in nondiabetic patients, 823 eyes (1.5%) were in T1D patients, and 9,997 eyes (18.7%) were in T2D patients. The mean follow-up time was 6.8 ± 4.2 years. In univariate analysis, the eyes of T1D patients (p < 0.001) and T2D patients (p = 0.003) had significantly higher Nd:YAG laser capsulotomy rates than the eyes of nondiabetic patients. In Cox regression analysis adjusted for the patient's age and sex, DM1 (HR 1.692, 95%CI 1.390-2.059, P<0.001) and DM2 (HR 1.157, 95%CI 1.075-1.244, P<0.001) remained significantly predictive for higher Nd:YAG laser capsulotomy rates. CONCLUSION: In our large cohort study, patients with T1D and T2D were predisposed to high risk for Nd:YAG capsulotomy following cataract surgery. This study may be beneficial and raise awareness regarding the assessment of posterior capsular opacification development in pseudophakic diabetic patients, particularly those with T1D. The significance of ophthalmology screening for diabetes individuals is further supported by this issue.

Factors Predicting the Need for Re-treatment After Laser Refractive Surgery in Patients With Mixed Astigmatism.

PURPOSE: To identify risk factors that increase the likelihood of re-treatment following refractive surgery in patients with mixed astigmatism. METHODS: This was a retrospective study including patients who underwent either laser in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) between 2000 and 2019 and had mixed astigmatism (spherical error of +0.50 D or greater and spherical equivalent of less than 0.00 diopters [D]). Patients were divided into two groups according to whether they underwent re-treatments during the study period. RESULTS: Overall, 785 eyes (785 patients) were included. In total, 5.2% of the eyes (n = 41) underwent re-treatment. The re-treatment group was more likely to have preoperative high astigmatism (80.5% vs 48.3%, P < .001), moderate to high hyperopia (36.6% vs 22.3%, P = .035), and to have undergone surgery earlier during the study period (P < .001). They were also more likely to have undergone surgery using the Wave-Light EX200 rather than the EX500 laser platform (Alcon Laboratories, Inc) (P < .001), have a treated optical zone of 6 mm rather than 6.5 mm (P < .001 for both), and their maximum ablation depth was greater (P < .001). There was no difference between the re-treatment and control groups regarding procedure type (PRK vs LASIK). Binary logistic regression found preoperative high astigmatism (odds ratio = 3.97, P < .001) and the type of laser platform used (EX200, odds ratio = 7.78, P < .001) as the only independent factors associated with re-treatment. CONCLUSIONS: Re-treatment rates following correction of mixed astigmatism were 5.2% over 20 years. Use of a sixth-generation laser platform significantly reduced the risk of re-treatment. Presence of high astigmatism is a significant risk factor for re-treatment. There was no difference in retreatment risk between PRK and LASIK. [J Refract Surg. 2024;40(2):e73-e78.].

Femtosecond LASER-Assisted Double Intraocular Lens Exchange in Nanophthalmic Eyes.

Introduction: Though patients with nanophthalmos frequently endure decreased quality of vision with contact lenses or spectacles, refractive surgery is generally an inadequate alternative due to the associated high refractive error. A refractive lens exchange (RLE) is an alternative option but is technically challenging, requiring accuracy in biometry measurements and procedures. Case Presentation: This case discusses a 27-year-old female with nanophthalmos (axial lengths 17.6 mm and 17.4 mm, right and left eyes, respectively) who underwent a femtosecond laser-assisted (FLA) RLE with simultaneous implantation of a monofocal and a Sulcoflex trifocal (Rayner, Britain) lens in each eye. Preoperative cycloplegic refraction was +11.50/-0.75 × 145 and +12.00/-1.00 × 35 in the RE and LE, respectively. Best-corrected visual acuity (BCVA) at distance and near in the RE and LE was 6/7.5 and J1, 6/8.5 and J2, respectively. Uncorrected visual acuity (UCVA) was >6/120 and >J14 for each eye. FLA RLE was performed in the RE, then in the LE 2 weeks later. In each eye, a monofocal (44.0 D, RE, and LE) and a Sulcoflex trifocal lens (both implants, Rayner, Britain) were implanted in one procedure. Distance and near UCVA measured 6 weeks post-op RE and 1-month post-op LE at 6/8.5 and J1 in the RE, 6/10 and J1 in the LE. The RE and LE refraction and BCVA were +0.50/-1.00 × 115, 6/7.5, and plano/-1.00 × 55, 6/8.5, respectively. The post-op outcomes were uneventful. Conclusion: A single procedure concurrently implanting a monofocal and Sulcoflex trifocal intraocular lens in nanophthalmic eyes resulted in an excellent UCVA. This procedure can be considered esthetic and reconstructive as it significantly improves patient appearance and function.

Photorefractive keratectomy in flat, normal, and steep corneas.

PURPOSE: To compare photorefractive keratectomy (PRK) outcomes in patients with different corneal steepness. SETTING: Care-Vision Laser Center, Tel-Aviv, Israel. DESIGN: Retrospective comparative chart review. METHODS: Patients included in this study underwent wavefront optimized myopic PRK between January 2013 and December 2019. Patients were divided into 3 groups based on the steepness of the cornea (steep keratometry) (flat: <42 diopters [D], normal: 42 to 46 D and steep: >46 D). One to one matching was performed to verify that baseline parameters (age, preoperative visual acuity and refractive error) were similar between groups. Primary outcome measures were: postoperative corrected/uncorrected distance visual acuity (CDVA/UDVA), efficacy index (postoperative UDVA/preoperative CDVA), safety index (postoperative CDVA/preoperative CDVA), spherical equivalence (SEQ) and cylinder. RESULTS: After matching, 650 eyes were included in each group, which were similar in baseline parameters. There were no significant postoperative differences between flat, normal, and steep corneas in terms of safety index (1.02 vs 1.03 vs 1.03, P = .28), efficacy index (1.01 vs 1.01 vs 1.02, P = .57), logMAR CDVA (0.01 vs 0.02 vs 0.01, P = .76), logMAR UDVA (0.02 vs 0.03 vs 0.02, P = .68), %SEQ within 0.50 D (73.9% vs 74.2% vs 74.6%, P = .95) or 1.00 D of target (91.9% vs 92.5% vs 92.2%, P = .92), %cylinder within 0.50 D (82.8% vs 82.2% vs 81.4%, P = .81) or 1.00 D of target (96.9% vs 97.1% vs 97.2%, P = .95). CONCLUSIONS: No significant differences were found between flat, normal and steep corneas following wavefront-optimized myopic PRK. Thus, this procedure may be safely and effectively performed in both flat and steep corneas.

Use of a three-dimensional head-mounted digital visualization platform in cataract surgery.

OBJECTIVE: To report preliminary experience using the BeyeonicsOne (Beyeonics Vision, Haifa, Israel) digital visualization platform and the utilization of its three-dimensional (3D) head-mounted display (HMD) in cataract surgery. METHODS: An interventional case series including patients who underwent cataract surgery using the 3D HMD platform at the Tel Aviv Medical Center. The system uses the HMD unit to display high-resolution real-time 3D surgical field images. Collected data included patient demographics, ocular comorbidities, risk factors for complex cataract surgery, cataract grading, preoperative and postoperative best-corrected visual acuity (BCVA), and intra- and postoperative complications. RESULTS: In total, 60 eyes of 60 subjects (mean age 73.1 ± 8.4 years) were included. Mean preoperative BCVA was 0.40 ± 0.30 logMAR (Snellen equivalent ~20/50) and improved to 0.10 ± 0.10 logMAR (Snellen equivalent ~20/25, p < 0.001). None of the patients suffered BCVA loss. All procedures and follow-ups were uneventful except for one case of a posterior capsular tear and one case of post-surgical cystoid macular edema. CONCLUSION: The visualization platform and its embedded 3D head-mounted display can be easily used in routine cataract surgery with the added benefits of improved ergonomics, high picture quality and enhanced image control.

Clinical comparison of manual and laser-cut corneal tunnel for intrastromal air injection in femtosecond laser-assisted deep anterior lamellar keratoplasty (DALK).

PURPOSE: The most crucial step in deep anterior lamellar keratoplasty (DALK) is to achieve a bare Descemet's membrane. We aimed to assess a new femtosecond laser software that allows for a precise intrastromal tunnel creation for big bubble (BB) air injection using a real-time microscope-integrated optical coherence tomography. MATERIALS AND METHODS: A retrospective review of 61 eyes of 61 patients with keratoconus. Before introducing the new software update, DALK was performed using a partial-assisted femtosecond laser (partial-thickness circular cut followed by a lamellar cut) with manual intrastromal tunnel creation (partial FS-DALK group). After the software update, the femtosecond laser created the intrastromal tunnel (full FS-DALK group). RESULTS: In the full FS-DALK group, the BB's formation was significantly higher (64.3% vs. 36.4%, p = 0.04), and surgery time was shorter (21.8 ± 5.1 vs. 25.6 ± 6.8 min, p = 0.025) than in the partial FS-DALK. Penetrating keratoplasty conversion rate (7.1% vs. 15.1%, p = 0.432) was similar between the groups. Both groups showed statistically significant improvement in uncorrected and corrected distance visual acuity, central corneal thickness, surface asymmetry, and regularity indices. Endothelial cell density loss at 12 and 18 months was lower in the full compared with the partial FS-DALK group (12 months:10.0% vs. 16; 18 months: 10.7 vs. 16.5%, p < 0.001 for both comparisons). CONCLUSIONS: Creating the intrastromal guiding tunnel using FS laser for air injection resulted in a higher rate of BB formation, reduced long-term endothelial cell loss, and operating room time.

Use of a Novel Three-dimensional Head-mounted Digital Visualization Platform in Corneal Endothelial Transplantation.

INTRODUCTION: To report the first endothelial keratoplasty procedures performed using a 3D digital head-mounted ophthalmic exoscope. METHODS: Three patients underwent Descemet stripping automated endothelial keratoplasty (DSAEK) using a 3D digital ophthalmic exoscope (Beyeonics One, Beyeonics Vision, Haifa, Israel) at the Tel Aviv Sourasky Medical Center, Tel Aviv, Israel. RESULTS: All procedures were uneventful, leading to resolution of corneal edema and vision improvement. Surgeons reported excellent visualization and minimal lag, almost negligible, with the benefits of improved ergonomics and the use of head gestures to control zoom, focus, brightness, and panning. There were no postoperative complications. CONCLUSION: The new 3D digital ophthalmic exoscope system can be successfully used in DSAEK surgery with potential advantages in ergonomics, picture quality, and image control. Further studies can compare this system with either standard operating microscopes or 3D heads-up display systems.

Complications of pupil expansion devices: a large real-world study.

Purpose: To assess the risk for uveitis, pseudophakic cystoid macular edema (PCME), and posterior capsular opacification (PCO) associated with the use of pupil expansion devices in cataract surgery. Design: A retrospective comparative cohort study. Participants: Patients who underwent routine cataract surgery with and without pupil expansion devices at the Department of Ophthalmology, Bristol Eye Hospital, UK, between January 2008 and December 2017. Methods: This study included 39,460 eyes operated without a pupil expansion device and 699 eyes operated with the device. Odds ratios for uveitis and PCME when using a pupil expansion device were calculated using univariate and multivariate regression analysis, having age, gender, diabetes, pseudoexfoliation, and pupil expansion device as independent variables. Multivariate Cox regression controlling for age and gender was used to estimate hazard ratios (HR) for Nd : YAG laser capsulotomies. Results: Postoperative uveitis and PCME were reported in 3.9% and 2.7% of the eyes operated with a pupil expansion device compared to 2.3% and 1.3% operated without the device (p=0.005 and p=0.002, respectively). In univariate regression analysis, eyes with pupil expansion devices showed a higher risk of postoperative uveitis or PMCE after cataract surgery (OR 1.88, 95%CI 1.39-2.55, p<0.001). In multivariate regression analysis, the risk for PMCE was greater among diabetic patients and in eyes with a pupil expansion device than in those without (OR 1.50, 95%CI 1.24-1.83, P<0.001; OR 1.90, 95%CI 1.16-3.11, P=0.01). In Cox regression analysis adjusted for the patient's age and gender, the use of a pupil expansion device was associated with higher Nd : YAG laser capsulotomy rates (HR 1.316, 95%CI 1.011-1.714, P=0.041). Conclusion: In our large cohort study, the use of pupil expansion devices in cataract surgery was associated with an increased risk of major postoperative complications. Effective anti-inflammatory treatment and follow-up are warranted in eyes operated with a pupil expansion device.

Intraocular lens power calculation in patients with irregular astigmatism.

PURPOSE: Accurate intraocular lens (IOL) calculation in subjects with irregular astigmatism is challenging. This study evaluated the accuracy of using Scheimpflug-derived central 2-mm equivalent keratometry reading (EKR) values for IOL calculation in irregular astigmatism. METHODS: This retrospective study included subjects (31 eyes of 30 patients) who underwent cataract surgery and IOL calculation using the 2-mm central EKR methods. We compared prediction error (PE) and absolute PE (APE) outcomes using SRK/T and Barrett Universal II formulas for keratometry data obtained from the IOLMaster 500 and Pentacam (anterior corneal sim k) devices. RESULTS: Cataract surgery and IOL calculation using the 2-mm central EKR methods resulted in improved visual acuity (uncorrected: from 1.13 ± 0.38 to 0.65 ± 0.46 logMar, p < 0.01; best-corrected: from 0.45 ± 0.24 to 0.26 ± 0.20 logMar, p < 0.01) after surgery. The percentage of subjects with best-corrected visual acuity of 6/6 was 22%, < 6/9 was 58%, and < 6/12 was 71%. For both the SRK/T and the Barrett formulas, the PE was similar to those obtained by IOLMaster (> 0.14) but lower than those obtained by the anterior corneal sim k (p < 0.02). IOLMaster provided keratometry reading in only 23/31 (74.1%) of cases. CONCLUSIONS: The use of Scheimpflug central 2-mm EKR for IOL calculation in irregular astigmatism was beneficial in terms of visual acuity improvement. It had comparable refractive prediction performance to the IOLMaster 500 and better than the anterior corneal sim K. The 2-mm EKR method can be used when IOLMaster cannot provide a reliable reading in abnormal corneas.

Refractive Outcomes of Non-Toric and Toric Intraocular Lenses in Mild, Moderate and Advanced Keratoconus: A Systematic Review and Meta-Analysis.

BACKGROUND: To perform a systematic review and meta-analysis of the refractive outcomes of non-toric and toric intraocular lenses (IOLs) in keratoconus (KC) using different IOL power calculation formulas. METHODS: A systematic search was conducted to identify studies that report on refractive outcomes of different IOL power calculation formulas in KC patients undergoing cataract surgery. Inclusion criteria were primary posterior chamber non-toric and toric monofocal intraocular lens implantation, data on the degree of KC, explicit mention of the formula used for each stage of KC, and the number of eyes in each category. We calculated and compared the absolute and mean prediction errors, percentage of eyes within 0.5 D and 1 D from target, and the weighted absolute prediction errors of IOL formulas, all were given for KC degrees I-III. RESULTS: The bibliographic search yielded 582 studies published between 1996 and 2020, 14 of which (in total 456 eyes) met the criteria: three studies on non-toric IOL (98 eyes), eight studies on toric IOLs (98 eyes) and three studies of unknown separation between non-toric and toric IOLs (260 eyes). The lowest absolute prediction error (APE) for mild, moderate, and advanced KC was seen with Kane's IOL power formula with keratoconus adjustment. The APE for the top five IOL power formulas ranged 0.49-0.73 diopters (D) for mild (83-94%) of eyes within 1 D from the target), 1.08-1.21 D for moderate (51-57% within 1 D), and 1.44-2.86 D for advanced KC (12-48% within 1 D). CONCLUSIONS: Cataract surgery in eyes with mild-to-moderate KC generally achieves satisfactory postoperative refractive results. In patients with advanced KC, a minority of the eyes achieved spherical equivalent refraction within 1 D from the target. The Kane's formula with keratoconus adjustment showed the best results in all KC stages.

Comparison of two new integrated SS-OCT tomography and biometry devices.

PURPOSE: To evaluate the agreement in biometry measurements and intraocular lens (IOL) power calculations between 2 integrated swept-source optical coherence tomography (SS-OCT) tomography/biometry devices: the Eyestar 900 and the Anterion. SETTING: Tel Aviv Medical Center, Tel Aviv, Israel. DESIGN: Retrospective comparative study. METHODS: 113 eyes of 66 consecutive patients who were evaluated prior to cataract surgery using both devices on the same visit were included. Measurements of axial length, anterior and posterior keratometry, anterior chamber depth, corneal diameter (CD), central corneal thickness, and lens thickness were recorded from both devices and analyzed for agreement and correlation. IOL power calculations using Barrett Universal II formula were compared between the devices in addition to prediction error (PE) and the mean absolute error (MAE). RESULTS: The mean age was 71.6 ± 9.8 years. Clinically, the mean differences in measured variables were small. Measurement correlation and agreement between the devices were excellent for all variables, except for CD (Spearman r = 0.763, P &lt; .001, and Bland-Altman 95% limits of agreement -0.21 to +0.65 mm). Good agreement was found between the devices in IOL power calculations, PE, and MAE, and the agreement was better when using the Eyestar 900 reflective keratometry measurements than the Eyestar 900 SS-OCT keratometry measurements (IOL power agreement within ±0.5 diopter (D) in 90.5% [n = 95] and 81.0% [n = 85], respectively [ P = .076], and within ±0.25 D in 64.8% [n = 68] and 44.8% [n = 47], respectively [ P = .005]). CONCLUSIONS: The 2 integrated SS-OCT tomography/biometry devices had good agreement in biometry measurements and IOL power calculations. Agreement was better when the Eyestar 900 reflective anterior keratometry measurements were used rather than the Eyestar 900 SS-OCT anterior keratometry measurements. Measurements of CD had reduced agreement and were not interchangeable.

Applying a dual-Scheimpflug camera to measure tear film thickness.

PURPOSE: To assess the tear film thickness in healthy individuals by using a dual-Scheimpflug camera and topical 0.1% fluorescein. METHODS: A prospective study on healthy individuals who underwent a bilateral tomography examination using the GALILEI dual-Scheimpflug with assessments of the thinnest and central corneal thickness (TCT and CCT, respectively), at baseline and 1 min after applying 2 and 4 µl of 0.1% fluorescein (30 min apart) under topical anesthesia with Oxybuprocaine 0.4%. Inclusion criteria were lack of dry eye disease symptoms and exclusion criteria were contact lens usage, eye drops usage, previous refractive surgery or any ocular surgery. All individuals scored zero on the ocular surface disease index (OSDI) questionnaire. RESULTS: A total of 62 eyes of 31 participants were included in this study. The mean age was 35.3 ± 10.88 (range 18-62). The mean TCT in was 549.16 µm in the right eye (RE) and 547.84 µm in the left eye (LE). After instillation of 2 µl of 0.1% fluorescein mean TCT increase by 27.84 µm in the RE and by 26.35 µm in the LE. CCT change was 27.58 µm increase in RE and 27.23 µm increase in LE. After instillation of 4 µl of 0.1% fluorescein the mean increase in TCT and CCT were 30.09 and 30.26 µm for OD and 28.33 and 30.15 µm for OS respectively. Comparison between the post instillation of 2 and 4 µl measurements showed no significant differences. CONCLUSION: Combining a dual-Scheimpflug camera and 0.1% fluorescein may serve as a method to assess the pre-corneal tear film.

Acute cataract development in a 43-year-old woman after an ultrasound eyelid-tightening procedure.

PURPOSE: The purpose of this article is to describe a severe side effect presentation of a bilateral cataract after treatment with intense focused ultrasound (IFUS) and subsequent uneventful cataract surgery. OBSERVATIONS: A 43-year-old woman presented to the emergency room with decreased visual acuity several hours after undergoing an eyelid-tightening procedure using IFUS. The patient's vision was decreased (R>L), a result of an acute cataract, which had an unusual appearance and consistency. Several weeks later, visual acuity had decreased further in the right eye to 20/400 and the patient underwent uneventful laser-assisted cataract surgery with intraocular lens implantation, which resulted in full visual recovery. CONCLUSIONS AND IMPORTANCE: This case emphasizes the need for particular attention to possible side effects resulting from periocular IFUS, including severe ocular impact requiring surgical intervention.

Outcomes of refractive error correction in pseudophakic patients using a sulcus piggyback intraocular lens.

PURPOSE: The purpose of this study was to assess the results of a sulcus intraocular lens (Sulcoflex) for pseudophakic refractive errors following phacoemulsification cataract surgery. METHODS: This retrospective clinical observational cohort study included consecutive eyes in which a Sulcoflex was implanted. Uncorrected distance visual acuity and corrected distance visual acuity as well as refractive outcomes were assessed. The minimum follow-up time required for inclusion was 3 months. RESULTS: In total, 15 eyes (n = 15) were evaluated. The mean follow-up was 14 months (range: 3-18 months). The Sulcoflex aspheric (653L) was implanted in 13 eyes and the Sulcoflex toric (653T) in two eyes. The preoperative mean logMAR (Snellen) uncorrected distance visual acuity and corrected distance visual acuity were 0.88 (20/150) and 0.27 (20/40), respectively. The postoperative mean logMAR (Snellen) corrected distance visual acuity was 0.15 (20/30). The preoperative mean spherical equivalent was -0.22 ± 5.95 D and the postoperative mean spherical equivalent was -1.59 ± 1.45 D. There was a significant and strong correlation (r = 0.64, p < 0.001) between the attempted and the achieved spherical equivalent. CONCLUSION: The Sulcoflex is a safe and viable option for patients with residual refractive error following cataract surgery.

Acute Lymphoblastic Leukemia Relapse Limited to the Anterior Chamber of the Eye and Treated with Novel CAR T-Cell Therapy.

Acute lymphoblastic leukemia (ALL) is a malignant neoplasm of the blood stem cells, characterized by increased formation of immature lymphocytes. Ocular manifestations may vary with ocular, adnexal, and orbital involvement. In this case report, we describe the first case of extramedullary relapse of ALL limited to the anterior chamber of the eye treated with the novel chimeric antigen receptor T (CAR T)-cell therapy and provide a literature review of cases of ALL relapse in the anterior chamber. A 21-year-old male with a history of B-cell ALL presented with a unilateral blurry vision in his left eye. Ocular examination revealed the presence of cells +3 in the anterior chamber and a 1.5-mm hypopyon. Anterior chamber aspiration confirmed a B-ALL relapse. The patient was successfully treated with radiotherapy of his left eye and received CTL-019 transduced T cells (tisagenlecleucel; Novartis) with cytarabine as a bridging chemotherapy treatment. On the last examination, 18 months after the first presentation, the patient presented a complete ocular remission with no systemic or CNS involvement. ALL relapse may involve the anterior chamber of the eye, and an accurate diagnosis is crucial to enable a fast and appropriate treatment. Novel CAR T-cell immunotherapy, combined with ocular irradiation, may be considered in such cases.

Differentiating highly asymmetric keratoconus eyes using a combined Scheimpflug/Placido device.

PURPOSE: To determine the ability to differentiate between normal eyes and clinically unaffected eyes of patients with highly asymmetric keratoconus (AKC) using a Scheimpflug/Placido device. SETTING: Tel Aviv Sourasky Medical Center and Enaim Medical Center, Israel. DESIGN: Retrospective case-control. METHODS: Imaging from a combined Scheimpflug/Placido device (Sirius, C.S.O.) was obtained from 26 clinically unaffected eyes of patients with frank keratoconus in the fellow eye, and 166 eyes from 166 patients with bilaterally normal corneal examinations that underwent uneventful corneal refractive surgery with at least 1 year of follow-up. Receiver operating characteristic curves were produced to calculate the area under the curve, sensitivity, and specificity of 60 metrics, and finally a logistic regression modeling was used to determine optimal variables to differentiate populations. RESULTS: The most predictive individual metric able to differentiate between 26 eyes in the case group to 166 eye in the control group was the posterior wall inferior-superior (I-S) ratio, with an receiver operating characteristics (ROC) of 0.862. A combination model of 4 metrics (posterior wall I-S ratio in the central 3 mm, thinnest pachymetry coordinate on the x horizontal axis, posterior asymmetry and asphericity index, corneal volume) yielded an ROC of 0.936, with a sensitivity/specificity pair of 92.3%/87%. Variables related to elevation were not found significant. CONCLUSIONS: Using a combination of metrics from a combined Scheimpflug/Placido device, a practical model for discrimination between clinically normal eyes of patients with highly AKC and normal eyes was constructed. Variables related to pachymetry and posterior cornea asymmetry were the most impactful.

Posterior Corneal Surface Changes After Pterygium Excision Surgery.

PURPOSE: To evaluate the effect of pterygium excision on the posterior corneal surface and analyze the factors associated with those changes. METHODS: A prospective, interventional study including 33 eyes of 31 patients who underwent pterygium excision at the Tel Aviv Medical Center (Tel Aviv, Israel). Exclusion criteria included corneal dystrophy, pseudopterygium, corneal scarring, or previous ocular surgery in the treated eye. Data were obtained by using the Galilei dual Scheimpflug analyzer. Recorded posterior corneal data included steep keratometry, flat keratometry, mean keratometry, corneal astigmatism, best-fit sphere, and the squared eccentricity index (e). Posterior surgically induced astigmatism (SIA) was calculated to demonstrate the astigmatic effect of surgery. Anterior-segment high resolution optical coherence tomography was used to measure pterygium dimensions (depth and horizontal/vertical size). RESULTS: The mean age was 53.7 ± 16.7 years. Posterior corneal SIA was 0.9 ± 1.1 D (P < 0.001) and was significantly correlated with age (r = 0.568, P = 0.002), horizontal pterygium size (r = 0.387, P = 0.046), and preoperative posterior astigmatism (r = 0.688, P < 0.001). In a multivariable analysis, only age (coefficient = 0.010, P = 0.038) and preoperative posterior astigmatism (coefficient = 0.648, P = 0.002) remained significant. Pterygium dimensions were not significantly associated with SIA magnitude. Flat keratometry steepened by 0.5 ± 1.1 D (P = 0.019), mean keratometry steepened by 0.3 ±0.6 D (P = 0.035), posterior astigmatism was reduced by 0.4 ± 1.2 D (P = 0.072), and e decreased by 5.1 ± 17.3 (P = 0.021). CONCLUSIONS: Pterygium excision has a significant astigmatic effect on the posterior corneal surface. The astigmatic effect increases with age and with higher preoperative posterior astigmatism. Pterygium depth and size are not associated with the degree of surgical astigmatic effect.

Unilateral Refractive Lens Exchange with a Multifocal Intraocular Lens in Emmetropic Presbyopic Patients.

Purpose: To evaluate the visual outcome and patient satisfaction after a unilateral multifocal IOL implantation in the non-dominant eye of emmetropic patients with presbyopia. Methods: An interventional case series of consecutive patients who underwent unilateral phacoemulsification with femto-laser assisted cataract surgery (FLACS) and refractive lens exchange (RLE), followed by an implantation of a trifocal diffractive IOL (FineVision Micro F), was performed in the non-dominant eyes of emmetropic patients with presbyopia. After 6 months of follow-up, the main outcome measures were uncorrected distance visual acuity (UDVA), uncorrected intermediate visual acuity (UIVA), and uncorrected near visual acuity (UNVA). Secondary outcomes included spherical equivalent (SE), refraction, contrast sensitivity, patient questionnaire and presence of visual side effects. Results: A total of 26 eyes of 26 patients, with an average age of 53.8 ± 4.1 years, were included in this study. Preoperative mean UDVA was 0.13 ± 0.04 logMAR (Snellen 20/27), UIVA was 0.46 ± 0.12 logMAR (Snellen 20/58), and UNVA was 0.66 ± 0.17 logMAR (Snellen 20/91), in comparison to postoperative mean UDVA of 0.18 ± 0.32 logMAR (Snellen 20/30) (p = 0.32), UIVA of 0.17 ± 0.21 logMAR (Snellen 20/30) (p < 0.005), and UNVA of 0.02 ± 0.10 logMAR (Snellen 20/21) (p < 0.005). Monocular UNVA of 20/25 or better in the operated eye was achieved in 23 (88%) patients. Twenty-four (96%) patients said they would recommend this procedure to family and friends. There were no intraoperative complications and no IOL exchange was required. Conclusions: A unilateral RLE of the non-dominant eye with FLACS and a trifocal diffractive IOL (FineVision Micro F) implantation in emmetropic, presbyopic patients is provides satisfactory distance, intermediate, and near visual outcomes with no complications reported in this preliminary case series.

Bioptics for high hyperopia with combined multifocal intraocular lens implantation and excimer ablation in young patients.

PURPOSE: To analyze the visual and refractive outcome of the bioptics procedure combining multifocal intraocular lens implantation and excimer laser surgery in young patients with high hyperopic eyes not suitable for a single surgical procedure. METHODS: This retrospective case series included 10 eyes of five patients (age range 18-30 years) with high hyperopia (spherical equivalent +8.51 ± 0.85 diopters (D)). They had been treated with serial multifocal intraocular lens implantation followed 6 weeks later by laser in situ keratomileusis for residual hyperopia. Uncorrected distance visual acuity, uncorrected near visual acuity, corrected distance visual acuity, corrected near visual acuity, and manifest refraction were evaluated before surgeries, after multifocal intraocular lens implantation, and 3 months post laser in situ keratomileusis. RESULTS: No patients were lost to follow-up (6 months). The mean spherical equivalent decreased to +2.05 ± 1.33 D after multifocal intraocular lens implantation and to -0.10 ± 0.58 D after the laser in situ keratomileusis procedure. Success of the procedures was determined by uncorrected visual acuity. LogMAR uncorrected distance visual acuity improved by a total of more than six lines from 1.05 ± 0.18 LogMAR to 0.46 ± 0.12 LogMAR post multifocal intraocular lens implantation and to 0.15 ± 0.06 LogMAR after both surgeries. The LogMAR uncorrected near visual acuity increased by 0.81 ± 0.82 LogMAR after lens implantation due to loss of accommodation, and all eyes reached a LogMAR of 0 at 1 month postoperatively following laser in situ keratomileusis. CONCLUSIONS: A bioptics approach involving multifocal intraocular lens followed 6 weeks later by a laser in situ keratomileusis procedure for the correction of very high hyperopia enabled the resolution of the residual refractive error in young very high hyperopic patients.