Poor intraoperative visibility and postoperative astigmatism associated with trabecular micro-bypass stent for corneal dystrophy: A case report.

RATIONALE: There are reports of safe cataract surgery in eyes with posterior polymorphous corneal dystrophy (PPCD); however, to our knowledge, there are no reports of minimally invasive glaucoma surgery (MIGS) in eyes with PPCD. Herein, we report a case of poor intraoperative visibility with gonioscopy, postoperative corneal edema, and corneal astigmatism in eyes with PPCD treated with trabecular micro-bypass stent combined with cataract surgery. PATIENT CONCERNS/DIAGNOSIS: A 78-year-old man was referred to our hospital for MIGS. He presented with bilateral corneal endothelial vesicular changes and band lesions. Endothelial cell density was 2983/2871 cells/mm2 (right/left eye), central corneal thickness was 581 µm/572 µm, best-corrected visual acuity values (Snellen equivalent) were 20/32 (right) and 20/100 (left), and corneal astigmatism was -2.7D in the right eye and -2.5D in the left eye. INTERVENSIONS/ OUTCOMS: After phacoemulsification and aspiration with intraocular lens implantation with a 2.4-mm corneal incision in both eyes, trabecular micro-bypass stents were inserted successfully despite the poor intraoperative visibility with gonioscopy. One week after surgery, the central corneal thickness was 614 µm/609 µm, and Descemet's membrane folds and mild corneal edema were observed. Best-corrected decimal visual acuity was 20/40 for the right eye and 20/50 for the left eye. In the left eye, total corneal astigmatism increased from -2.5D to -5.5D. Corneal astigmatism and edema showed gradual improvement. LESSONS: Although reports have shown that cataract surgery can be safely performed in eyes with PPCD, MIGS in eyes with PPCD may require caution regarding intraoperative visibility with gonioscopy and visual function in the early postoperative period.

Posterior corneal surface stability after femtosecond laser-assisted in situ keratomileusis in patients with myopia and myopic astigmatism.

PURPOSE: To evaluate the variation and stability of the posterior cornea surface parameters (posterior cornea curvature [PCC], posterior cornea astigmatism [PCA], and posterior cornea elevation [PCE]) after femtosecond laser-assisted in situ keratomileusis (LASIK) in patients with myopia and myopic astigmatism over a period of 6 months or longer. METHODS: This retrospective study comprised 284 right eyes. Patients aged 18 years or older with myopia up to -12.00 D and/or astigmatism up to -6.00 DC and who underwent femtosecond LASIK were recruited. Patients were divided into three subgroups: low myopia (-0.50 to -3.00 D), moderate myopia (>-3.00 to ≤-6.00 D), and high myopia (>-6.00 D), according to their pre-LASIK spherical equivalent (SE). The variables included for analysis were PCC (central 0-3.0 mm, pericentral 3.0-6.0 mm, and peripheral region 6.0-9.0 mm), PCE, PCA, internal anterior chamber depth, intraocular pressure, and central cornea thickness at the pre- and post-LASIK stages. RESULTS: The central PCC remained unchanged across all three myopia subgroups at 1 month when compared to the pre-LASIK stage and remained stable at 6 months. The pericentral regions became flatter across all myopia subgroups at 1 month postsurgery (P < 0.001) and remained unchanged at 6 months. This trend was not seen in the peripheral cornea regions, which remained unchanged at 1 and 6 months post-LASIK when compared to pre-LASIK mean readings. There were minimal changes in post-LASIK posterior cornea astigmatism throughout follow-up. There was no incidence of post-LASIK surgery ectasia in this study population. CONCLUSION: Post-LASIK, the different cornea subregions behaved differently. Overall, the posterior cornea surface remained stable post-LASIK across all myopia subgroups throughout follow-up.

Visual outcomes following bilateral implantation of a non-diffractive extended depth of focus toric intraocular lens using a mini-monovision approach.

PURPOSE: To evaluate the clinical outcomes following bilateral implantation of the AcrySof™ IQ Vivity™ toric extended depth of focus (EDOF) intraocular lens (IOL). DESIGN: Prospective interventional case series. METHODS: Patients with bilateral significant cataracts and pre-existing corneal astigmatism underwent cataract surgery and implantation with the AcrySof™ IQ Vivity™ toric IOL. Dominant eyes were targeted at emmetropia and non-dominant eyes at -0.50D. Primary endpoints were binocular uncorrected distance (UDVA), intermediate (UIVA at 66 cm) and near (UNVA at 40 cm) acuities at 3 months. Secondary outcomes were corrected distance (CDVA), distance corrected intermediate (DCIVA) and distance corrected near (DCNVA), refractive predictability, rotational stability, binocular defocus curve, contrast sensitivity, Questionnaire for Visual Disturbances (QUVID) and Visual Function Index (VF-14) questionnaire scores. All visual acuities were converted to logarithm of minimum angle of resolution (logMAR) for analysis. RESULTS: 30 patients underwent uneventful phacoemulsification. The mean binocular UDVA, UIVA and UNVA were 0.06 ± 0.12, 0.11 ± 0.10 and 0.26 ± 0.10 respectively. The mean refractive spherical equivalent (MRSE) for dominant and non-dominant eyes were - 0.07D ± 0.27 and - 0.12D ± 0.54 respectively. 92.4% of dominant eyes and 84.6% of non-dominant eyes within 0.50D of target. The mean IOL rotation was 3.85° ± 5.09 with 86.7% of eyes with less than 5° of rotation. 26.7%, 20% and 36.7% of patients reported starbursts, haloes and glare respectively. The mean VF-14 score was 91.77. CONCLUSION: Bilateral implantation of the AcrySof™ IQ Vivity™ Toric IOL resulted in very good unaided visual acuities for far and intermediate distance with functional near vision. Dysphotopsias were reported but despite this, a high level of visual function was achieved.

Rotational Stability, Footplate Position, and Visual Outcomes of Toric Implantable Collamer Lenses in Eyes With Low Vault.

PURPOSE: To evaluate the clinical outcomes, rotational stability, and footplate position of the toric Implantable Collamer Lens (TICL) (STAAR Surgical) in eyes with low vault and analyze factors related to rotational stability. METHODS: This prospective observational study included 59 eyes of 59 patients with insufficient vault (< 250 µm). Postoperative rotation was defined as the difference between the achieved angle and the intraoperative fixation angle, and assessed with a digital anterior segment photograph after full mydriasis at 1 week and 1, 3, and 6 months postoperatively. Ultrasound biomicroscopy was used to determine the ciliary body morphology and position of the footplate. Correlation analysis was employed to identify the risk factors associated with TICL rotation at 6 months postoperatively. RESULTS: At 6 months postoperatively, the mean central vault was 137.4 ± 61.0 µm (range: 40 to 236 µm), and the mean efficacy and safety indices were 1.04 and 1.15, respectively. The mean manifest refractive astigmatism decreased from -1.67 ± 0.82 diopters (D) preoperatively to -0.43 ± 0.33 D postoperatively, and the mean absolute rotation was 4.50 ± 3.08 degrees (range: 0 to 12.50 degrees). The angle of rotation was correlated with the preoperative spherical power (r = -0.318, P = .014), the average value of TICL footplates position (r = 0.284, P = .029), and postoperative astigmatism (r = -.469, P⩽ .001). CONCLUSIONS: TICL implantation is predictable, safe, and effective in correcting myopic astigmatism in eyes with low vault. The rotational stability was acceptable and related to the malposition of the footplate and preoperative spherical power. [J Refract Surg. 2024;40(7):e460-e467.].

Outcomes of Corneal Compound Hyperopic Astigmatism With Presbyopia by Zeiss PRESBYOND Laser Blended Vision LASIK Using Default Custom Refractive Software Master Target Refractions for Reduced Anisometropia.

PURPOSE: To evaluate the effectiveness, safety, and stability of a modified PRESBYOND Laser Blended Vision protocol (Carl Zeiss Meditec AG) for correcting hyperopic astigmatism and presbyopia, using Custom Refractive Software Master (CRSM) targeting over a 6-month period. METHODS: A total of 636 eyes of 318 patients with a mean age of 51.05 ± 4.71 years (range: 40 to 60 years) met the inclusion and exclusion criteria. All patients completed a 6-month follow-up. CRSM software was used to generate ablation profiles for the MEL90 excimer laser (Carl Zeiss Meditec AG). The target refraction was emmetropic for the dominant eyes and between -0.75 and -1.12 diopters (D) for the near eyes. RESULTS: Visual and refractive results were studied separately by the dominant and non-dominant eyes. The mean attempt to correct for spherical equivalent refraction was +2.17 ± 1.16 D (range: -1.00 to +5.37 D). The mean attempted cylinder was -0.60 ± 0.75 D (range: -4.00 to 0.00 D). All eyes monocularly achieved uncorrected distance visual acuity (UDVA) of 20/25 or better after refractive treatment and 88% achieved 20/20. Binocularly all eyes achieved UDVA of 20/25 or better and 96.54% achieved 20/20. Ninety-eight percent of the patients maintained their corrected distance visual acuity before surgery and UDVA 6 months after surgery. CONCLUSIONS: This hyperopic micro-anisometropia protocol with PRESBYOND Laser Blended Vision was an effective, safe, and well-tolerated refractive treatment. It was an effective procedure with excellent results for UDVA and uncorrected near visual acuity and demonstrates that binocular summation exists. [ J Refract Surg. 2024;40(7):e480-e489.].

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.].

Custom-Made Artificial Iris and Toric-Intraocular Lens Intrascleral Flange Fixation: A Case Report.

Different techniques for artificial iris implantation with or without an intraocular lens, depending on lens status, are described in the literature. We describe a surgical technique for a custom-made artificial iris and toric-intraocular lens intrascleral flange fixation. We modified the "Backpack" artificial iris implantation surgical technique to facilitate an accurate alignment of the toric-intraocular lens in a patient with aphakia, aniridia, and high asymmetric astigmatism secondary to blunt trauma. Two months after the surgery, uncorrected visual acuity was 20/30, corrected to 20/25 with a refraction of -2.00 in the diopter sphere with no residual astigmatism. The artificial iris implant and toric-intraocular lens were well-centered. The patient was satisfied with the visual and cosmetic outcomes. This procedure, however, is not complication-free as our patient developed uveitis and increased intraocular pressure during the postoperative period, which was treated successfully.

Feasibility study of treatment of mixed astigmatism with small-incision lenticule extraction (SMILE) by using research software.

PURPOSE: To report the preliminary experience and initial clinical results following SMILE for the treatment of mixed astigmatism. METHODS: Thirteen eyes of nine patients with a mean age of 27 ± 4.36 years were included in the series. In 8/13 eyes, myopic SMILE license and in 4/13 eyes, hyperopic SMILE license (available as part of an open/research software) was used for the treatment. The mean follow-up was 9.5 ± 8.7 (0.5-24) months, and the median follow-up was 6 months. SETTING: Nethradhama Superspeciality Eye Hospital, Bangalore, India. DESIGN: Exploratory study. RESULTS: The mean preoperative sphere, cylinder, and spherical equivalent (SE) were 1.44 ± 1.63, -2.70 ± 2.30, and -0.24 ± 1.14 D, which changed to -0.03 ± 0.30, -0.28 ± 0.48, and -0.18 ± 0.49 D, respectively, 6 months postoperatively. Furthermore, 85% (11/13) eyes were within ± 0.50 D, 92% (12/13) eyes were within ± 1.00 D, while all eyes were within ± 1.50 D of SE correction. All eyes were within ± 1.00 D of cylinder correction. In addition, 92% (12/13) eyes had UDVA better than 20/32, with 54% (7/13) eyes having UDVA 20/20 or better. Safety and efficacy indices were 1.08 and 0.92, respectively. No eyes lost more than 1 line of CDVA. The mean corneal higher order aberrations (HOA) increased from 0.111 ± 0.048 to 0.209 ± 0.056 (P < 0.001). The mean objective scatter index (OSI) did not show a significant change (pre = 0.71 ± 0.69, 6 months = 0.89 ± 0.20; P = 0.35). CONCLUSION: Early experience showed that SMILE was feasible for the management of eyes with mixed astigmatism, without any intraoperative complications, unique to the procedure.

What Happens 20 to 30 years After Radial Keratotomy? Case Series.

ABSTRACT: Radial keratotomy (RK) was commonly performed in the 1980s and 1990s. We aimed to clarify the current status of post-RK refractive correction and treatment. We retrospectively reviewed the charts of 70 patients with a history of RK. Of the 70 patients, 44 were identified for clinical outcomes. Refractive or therapeutic intervention (rigid gas-permeable contact lens fit, spectacle prescription, corneal surgery, and use of pilocarpine hydrochloride for photophobia) was possible in 59% of patients with postoperative visual deterioration after RK; in the remaining 41%, therapeutic intervention was not possible. Rigid gas-permeable contact lens fit for corneal irregular astigmatism was the most common refractive intervention and was effective in 36% of cases in the university hospital.

Investigating the topographic effect of epithelium in myopic eyes with subtle topographic preoperative abnormalities.

PURPOSE: To explore the topographic effect of the epithelium in keratoconus suspected (KCS) and in normal Placido classified corneas. SETTING: Rothschild Foundation, Paris, France. DESIGN: Prospective interventional case series. METHODS: Anterior corneal specular Placido topography using OPD-Scan II was performed in 97 eyes of 67 patients undergoing photorefractive keratectomy for myopia, before and after epithelium removal. The differences in axial keratometry, asphericity, and astigmatism were computed. RESULTS: After epithelial peeling, some Placido-normal classified corneas became KCS. Therefore, we have subdivided this group into 2 groups: one of normal classified corneas which stayed normal after epithelium removal (Group NN) and another of corneas that became KCS classified (Group NK). The mean difference in axial mean keratometry in the third central millimeter rings was +0.50 ± 0.24 diopters (D), 0.69 ± 0.31 D, and 0.49 ± 0.35 D and the mean difference in the magnitude of epithelial-induced astigmatism in the first central millimeter ring was 0.37 D × 89 degrees (positive cylinder), 0.54 D 86 degrees, and 0.52 D 86 degrees, respectively, in Group NN, NK, and KK (KCS corneas that stayed KCS). These differences were significant ( P < .0001). Preoperative keratometry was the only predictive factor differentiating Group NN from NK ( P < .001). CONCLUSIONS: The epithelial layer tended to reduce the magnitude of the Bowman layer's astigmatism, prolateness, and keratometry, more importantly in Group NK. In the KK group, we found a similar trend as in normal eyes (Group NN). The epithelium would be able to mask Bowman layer's irregularities until a certain degree of severity.

Central toxic keratopathy leading to epithelial ingrowth following femtosecond LASIK.

We report a case of a woman in her 30s who underwent femtosecond LASIK (laser-assisted in situ keratomileusis) in both eyes to correct her simple myopic astigmatism. After the surgery, both eyes developed diffuse lamellar keratitis, and intensive topical steroids were initiated to control the same. Subsequently, central toxic keratopathy (CTK) developed bilaterally. Three weeks after the surgery, the right eye showed signs of progressive epithelial ingrowth involving the pupillary area. Surgical intervention in the form of flap relift followed by debridement of the epithelial cells and an alcohol interface wash were performed to treat the same. This is the first report of an epithelial ingrowth following CTK after femtosecond LASIK.

SmartSight Correction of Compound Myopic Astigmatism Treatments With Preoperative Astigmatism > 1.00 Diopter Using the SCHWIND ATOS: A Retrospective Case Series.

PURPOSE: To evaluate moderate to high astigmatism corrections on the outcomes of SmartSight lenticule extraction for myopic astigmatism with a new femtosecond laser system. METHODS: Two hundred ninety-two eyes consecutively treated for myopic astigmatism with astigmatism magnitude greater than 1.00 diopter (D) were evaluated at the 6-month follow-up visit. The mean age of the patients was 29 ± 6 years with a mean spherical equivalent of -5.06 ± 2.20 diopters (D) and a mean magnitude of refractive astigmatism of 1.74 ± 0.61 D. RESULTS: At 6 months, astigmatism was 0.10 ± 0.20 D. Uncorrected and corrected distance visual acuities (UDVA and CDVA, respectively) were both 0.0 ± 0.1 logMAR. Differences between postoperative UDVA and preoperative CDVA and the change in CDVA were both +0.4 ± 0.7 lines better than preoperatively (P < .0003). CONCLUSIONS: Lenticule extraction treatment using Smart-Sight is safe and efficacious at 6 months. Findings suggest that moderate to high astigmatism improves after SmartSight lenticule extraction in the treatment of myopic astigmatism. [J Refract Surg. 2024;40(5):e328-e335.].

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

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

Femtosecond laser-assisted in situ keratomileusis versus small-incision lenticule extraction: current approach based on evidence.

PURPOSE OF REVIEW: Laser keratorefractive surgery achieves excellent visual outcomes for refractive error correction. With femtosecond laser, small incision lenticule extraction (SMILE) is an increasingly viable alternative to laser-assisted in situ keratomileusis (LASIK). Comparative studies demonstrate similar efficacy and predictability between SMILE and LASIK, making it difficult for clinicians to choose which to use. This review thus compares femtosecond-LASIK (FS-LASK) and SMILE in various scenarios, to assist clinicians in deciding which refractive surgery procedure to recommend. RECENT FINDINGS: SMILE may be superior for highly myopic eyes due to a smaller decrease in functional optical zone. SMILE further induces less spherical aberration and less overall higher order aberrations in mesopic conditions. SMIILE also has less postoperative dry eye, making it suitable those with preexisting dry eye. For low to moderate myopic astigmatism correction, FS-LASIK has less undercorrection compared to SMILE. Lastly, SMILE has not yet received Food and Drug Administration or Conformité Européenne approval for hyperopic correction, rendering FS-LASIK the choice of procedure for hyperopic correction. SUMMARY: Both FS-LASIK and SMILE demonstrate good efficacy and predictability. Understanding specific clinical scenarios where one may be superior to the other will aid clinicians in choosing the most suitable procedure for personalized care.

Effectiveness of toric intraocular lens implantation for correcting irregular corneal astigmatism in cataract eyes.

A retrospective cohort study was conducted to observe the correction effect of Toric intraocular lens (IOL) implantation in cataract eyes with specific types of irregular corneal astigmatism. Thirty-four eyes with either the "asymmetric bow-tie" pattern (Type I) or the "angled bow-tie" pattern (Type II) were included. Corneal topography was assessed using Pentacam HR, and changes in preoperative corneal astigmatism, visual acuity, manifest refraction, and objective visual quality were measured and compared. The average uncorrected distance visual acuity improved significantly from 0.86 ± 0.40 logMAR to 0.22 ± 0.15 logMAR (P < 0.001). Preoperative corneal astigmatism of 2.05 ± 0.90 D was corrected to a postoperative residual astigmatism of 0.78 ± 0.57 D (P < 0.001), with 32% of eyes within 0.50 D. The residual astigmatism prediction errors in Type I and Type II cases were (0.97 ± 0.68 D) and (0.66 ± 0.37 D), respectively (P = 0.100). The mean spherical equivalent prediction error in Type II cases (0.07 ± 0.36 D) was significantly smaller than that in Type I cases (- 0.29 ± 0.52 D) (P = 0.030). This study concludes that Toric IOL implantation effectively corrects specific types of irregular corneal astigmatism in cataract surgery. Eyes with the "angled bow-tie" pattern show higher accuracy in refractive predictions compared to eyes with the "asymmetric bow-tie" pattern.

Femtosecond thin-flap laser assisted in situ keratomileusis for correction of post-penetrating keratoplasty ametropia: long-term outcome.

PURPOSE: To evaluate the long-term clinical outcomes of femtosecond thin-flap LASIK (femto-LASIK) for correction of refractive error after penetrating keratoplasty in keratoconus-affected eyes. SETTING: a private ophthalmology clinic. DESIGN: Prospective interventional case series. METHODS: This prospective interventional case series enrolled 22 eyes of 22 patients who underwent femto-LASIK for the management of post-penetrating keratoplasty ametropia. The refractive error, uncorrected (UDVA), and corrected (CDVA) distance visual acuities and vector analysis were reported in short-term and long-term period after surgery. RESULTS: The mean age was 32.7 ± 7.5 years (range, 23 to 47 years) at the surgery time. The average time between PK and femto-LASIK was 42.5 ± 31.7 months. The average follow-up duration after femto-LASIK was 81.2 ± 18.6 months. The mean preoperative UDVA significantly improved from 0.47 ± 0.15 logMAR to 0.35 ± 0.14 logMAR at 12 months (P = 0.048) and 0.4 ± 0.17 at final follow-up exam (P = 0.007). CDVA was 0.22 ± 0.1 at baseline which improved to 0.18 ± 0.15 and 0.15 ± 0.1 logMAR at 12 and 81 months, respectively. (Ps = 0.027, 0.014). The mean cylinder before surgery was - 5.04 ± 1.4D which significantly decreased to -1.5 ± 0.8 D at 12 months postoperatively. (P < 0.001). There was a significant increase in refractive astigmatism from 12 months to 81 months postoperatively (-3.1 ± 2.0, P = 0.002). At the final visit, the efficacy index was 0.83, and the safety index was 1.16. CONCLUSIONS: Despite the short-term outcome indicated that femo-LASIK was effective for correction of post-keratoplasty ametropia during short-term period, a notable regression in its effect was observed in the long-term follow-up. Therefore, the predictability of this technique might decrease in the long-term.

Evaluation of visual outcomes with toric intraocular lens implantation using digital marker during cataract surgery.

Objectives: To assess the visual improvement and mean residual astigmatism in patients who underwent cataract surgery with toric intraocular lens. METHODS: The retrospective, observational study was conducted at the Department of Ophthalmology, Aga Khan University Hospital, Karachi, and comprised data from January 1, 2018, to December 31, 2020, related to adult patients who had regular astigmatism of at least 0.75D and underwent cataract surgery with toric intraocular lens implantation using a digital marker. The patients were followed up on post-operative days 1, 7, 30, 90 and 180. Along with age, the degree of astigmatism was noted. The visual acuity was calculated pre- and post-operatively. The mean residual astigmatism was then noted for all patients post-operatively. Data was analysed using SPSS 22. RESULTS: The sample comprised 240 eyes of 177 patients; 99(55.9%) males and 78(44.1%) females. The mean age of the sample was 62.5±10.6 years. The mean unaided visual acuity improved post-operatively from 0.57±0.38 to 0.07±0.22 at 90 days. At the 30-day follow-up, mean residual astigmatism had reduced from 1.52±0.84 to 0.01±0.09 (p<0.001). The mean intraocular lens rotation from the intended axis was 0.73°±0.92° on day 30. CONCLUSIONS: Toric intraocular lens implantation using a digital marker could effectively reduce the post-operative cylinder, and improve the unaided visual acuity following cataract surgery.

Comparison of keratoplasty outcomes at the scar versus edema stages of keratoconus.

PURPOSE: To assess the outcomes of deep anterior lamellar keratoplasty or penetrating keratoplasty at the scar and the edema stages. METHODS: Forty-five patients (45 eyes) with keratoconus scar stage (scar group, n=26; penetrating keratoplasty a subgroup, n=7; deep anterior lamellar keratoplasty b subgroup, n=19) and keratoconus edema stage (edema group, n=19; penetrating keratoplasty c subgroup, n=12; deep anterior lamellar keratoplasty d group, n=7) who received penetrating keratoplasty or deep anterior lamellar keratoplasty from 2000 to 2022 were retrospectively studied. At 1, 6, and 12 months after surgery, the best-corrected visual acuity, astigmatism, spherical equivalent, corneal endothelial cell density, and complications were analyzed. RESULTS: The best-corrected visual acuity and average corneal endothelial cell loss rate were not significantly different between the scar and edema groups (p>0.05). At 6 and 12 months after surgery, the astigmatism and spherical equivalent in the scar group were significantly lower than those in the edema group (p<0.05). The spherical equivalent of the deep anterior lamellar keratoplasty b subgroup was lower than that of the penetrating keratoplasty a subgroup in the scar group 6 months after surgery (p<0.05). In the edema group, there was no significant difference in spherical equivalent between subgroups (p>0.05). There were no significant differences in best-corrected visual acuity and astigmatism between subgroups within the two groups (p>0.05). In comparison to the scar group, the edema group experienced more complications. According to a survival analysis, there was no statistically significant difference between the scar group and the edema group regarding the progression of vision. CONCLUSIONS: In terms of the outcomes and prognosis for vision after keratoplasty with edema stage and scar stage, deep anterior lamellar keratoplasty may be as effective as penetrating keratoplasty.

Functional Approach to IOL Selection in Eyes With Combined Cataract and Keratoconus With an Option for Refractive Lens Exchange.

PURPOSE: To evaluate spherical intraocular lens (IOL) implantation for cataracts in keratoconic eyes followed by optional refractive toric lens exchange to improve uncorrected visual acuity. METHODS: This retrospective study evaluated cataract surgery outcomes in keratoconic eyes. Eyes treated with a spherical IOL targeted for -2.00 diopters (D) either achieved acceptable manifest refraction and desired exchange with a toric IOL (Group 1); achieved satisfactory manifest refraction and chose to use spectacles or contact lenses (Group 2); or did not achieve acceptable refraction and used contact lenses (Group 3). Group 4 had single-stage toric IOL implantation with plano target. Corrected and uncorrected distance visual acuity (CDVA and UDVA) and keratometry were analyzed. RESULTS: Groups 1 to 4 had 18, 23, 18, and 26 eyes, respectively. A staged toric exchange resulted in significantly better (P = .02) UDVA (mean: 0.15 logMAR; 20/25 Snellen) than initial toric IOL implantation (0.24 logMAR; 20/30 Snellen). All toric IOL exchange eyes achieved 20/30 or better CDVA and 94% had 20/40 or better UDVA. Mean manifest cylinder significantly decreased from 3.39 D before lens exchange to 1.10 D postoperatively. CONCLUSIONS: Initial implantation of a spherical IOL in keratoconic eyes allows basing toric calculations on the manifest refraction, which may be more reliable than keratometry measurements in keratoconic eyes. UDVA after staged toric IOL exchange was significantly better than after initial toric IOL implantation. Importantly, by staging use of toric lenses, the authors avoided cases where patients required a rigid contact lens after a toric IOL was implanted. [J Refract Surg. 2024;40(4):e207-e217.].