Late approach for LASIK flap striae.

A 24-year-old man was referred for postrefractive surgery evaluation. The patient had a history of uneventful laser in situ keratomileusis (LASIK) in both eyes 3 months previously. According to the surgeon who originally performed the surgery, on slitlamp examination, only microstriae in the left eye was detected on postoperative day 1 and a more conservative follow-up approach was adopted without further immediate intervention. The patient returned only 3 months after surgery, complaining of low vision in the left eye that, according to the patient, had been present since postoperative week 2. The patient was then referred for examination and surgical procedure with a diagnosis of significant postoperative striae. The slitlamp examination revealed a LASIK flap with striae, epithelial filling, and a wrinkled appearance (Figure 1JOURNAL/jcrs/04.03/02158034-202312000-00017/figure1/v/2023-11-20T151558Z/r/image-tiff). There were no signs of infection or inflammation. Originally, the LASIK flap was programmed to be 110 µm. Preoperative manifest refraction in the right eye was -5.25 (20/20) and in the left eye was -5.25 (20/20). Assuming it is a case of late-approach LASIK flap striae, how would you proceed? Would you try to hydrate and lift the flap and just reposition it? Would you avoid lifting and associate phototherapeutic keratectomy (PTK) with excimer laser on top of the flap? Would you consider topo-guided surgery with regularization of the visual axis or even amputation of the flap?

Interface Fluid Syndrome After Descemet Membrane Endothelial Keratoplasty in Patients With History of LASIK.

PURPOSE: The aim of this study was to evaluate the visual, pachymetric, tomographic, and biomicroscopic findings in a series of cases with laser in situ keratomileusis (LASIK) flap interface fluid syndrome (IFS) after Descemet membrane endothelial keratoplasty (DMEK). METHODS: Six cases were included in this study; all patients had a history of LASIK and underwent DMEK for the treatment of bullous keratopathy. After uneventful surgery, all patients presented with corneal edema and IFS under the LASIK flap, which was demonstrated with anterior segment optical coherence tomography (AS-OCT). Visual acuity, clinical findings, pachymetry, endothelial cell count, and AS-OCT were documented during the management of these cases. RESULTS: IFS appears 2.33 days (±1.03) after DMEK. One case improved with conservative treatment. In 5 cases, the LASIK flap was lifted, the fluid was drained, and the flap was replaced. The mean best-corrected visual acuity after fluid drainage was 0.44 logMAR (range 0.18-1.0) and mean central corneal thickness was 538 µm ± 160. Total resolution of the IFS was achieved at 14.5 days (range 4-30) after DMEK. AS-OCT showed resolution of the flap interface in 5 of 6 cases, while 1 patient required second DMEK due to reaccumulation of the interface fluid. CONCLUSIONS: IFS can occur after DMEK in patients with previous LASIK. AS-OCT is a valuable tool for monitoring these cases preoperatively and postoperatively. Early surgical management is often needed to achieve resolution.

Argument for Prompt Corneal Cross-Linking on Diagnosis of Keratoconus in a Pediatric Patient.

ABSTRACT: Strong evidence suggests that corneal crosslinking is a safe procedure capable of stopping or slowing down the progression of keratoconus, avoiding visual loss associated with progression, and delaying or preventing the need for corneal transplantation. The progressive and chronic nature of the disease makes the option for prompt crosslinking upon keratoconus diagnosis in a pediatric patient valid.

Comparing the vision quality using double-pass technique in eyes with corrected refractive errors and emmetropic eyes / Comparação da qualidade óptica usando a técnica de dupla passagem em olhos com erros de refração corrigidos e olhos emetrópicos

ABSTRACT Purpose: To evaluate the vision quality by measuring the objective light scatter index and objective optical quality parameters (Strehl Ratio and Modulation Transfer Function) in patients with emmetropia and ametropia. Methods: This prospective, cross-sectional study included 408 eyes. The ametropic group comprised of eyes with best-corrected visual acuity of 0.0 logMAR or better and present at least a refractive error of ≥0.25 D. Patients underwent slit lamp examination, visual acuity, refraction, and vision quality using the HD Analyzer. Results: The mean objective light scatter indices were 0.62 ± 0.63, 0.77 ± 0.70, 0.74 ± 0.30, 0.93 ± 0.55, and 0.85 ± 0.61, and mean Strehl Ratio and Modulation Transfer Function scores were 38.17 ± 10.4, 37.37 ± 10.06, 29.84 ± 9.71, 33.2 ± 12.11, and 33.13 ± 10.09 in emmetropes, myopia, hyperopia, spherical equivalent of ≥0, and spherical equivalent of <0, respectively. Differences in all variables were significant between emmetropic and corrected hyperopic and between spherical equivalent of ≥0, and spherical equivalent of <0 eyes (p<0.05). Conclusion: In spectacle-corrected conditions (with trial frames), emmetropic and simple myopic eyes had significantly better vision quality compared to hyperopic and astigmatic eyes. The clinical significance of these results should be investigated in further studies.

RESUMO Objetivo: Avaliar a qualidade óptica medindo o índice de dispersão objetiva de luz e os parâmetros de qualidade óptica objetiva (Razão de Strehl e Função de Transferência de Modulação) em indivíduos com emetropia e ametropia. Métodos: Estudo prospectivo, transversal, incluindo 408 olhos. O grupo ametrópico era de olhos com melhor acuidade visual corrigida de 0,0 logMAR ou melhor e apresentando, pelo menos, um erro refrativo de 0,25 D ou mais. Os pacientes foram submetidos a exame com lâmpada de fenda, acuidade visual, refração e qualidade óptica com o HD Analyzer. Resultados: O índice de dispersão objetiva de luz médio foi de 0,62 ± 0,63, 0,77 ± 0,70, 0,74 ± 0,30, 0,93 ± 0,55, 0,85 ± 0,61 e a média da Razão de Strehl e de Função de Transferência de Modulação foram 38,17 ± 10,4, 37,37 ± 10,06, 29,84 ± 9,71, 33,2 ± 12,11 e 33,13 ± 10,09 em olhos emetrópicos, míopes, hipermétropes, equivalente esférico ≥0 e equivalente esférico <0 respectivamente. Foram encontradas diferenças significativas em todas as variáveis entre olhos emetrópicos e com hipermetropia corrigida, equivalente esférico ≥ 0 e equivalente esférico <0 (p<0,05). Conclusão: Em condições com lentes corrigidas (com armações de prova), os olhos emetrópicos e com miopia simples apresentaram qualidade óptica significativamente melhor em comparação com os olhos hipermétropes e astigmáticos. O significado clínico destes resultados deve ser estudado posteriormente.

Comparison of preoperative simulated and postoperative real safety distances using anterior segment OCT in patients with phakic IOL according to iris configuration.

AIM: To compare the simulated safe distance (SSD) preoperatively versus real safe distance (RSD) postoperatively in patients with iris-claw phakic intraocular lens (pIOL) implantation according to iris configuration. METHODS: Totally 60 eyes of 60 patients underwent pIOL implantation for surgical correction of myopia. Anterior chamber depth (ACD) was measured with the IOLMaster 700, and nasal and temporal safety distances (SD) were measured pre- and postoperatively using Anterior Segment Visante-OCT. SD was defined as a line measured between the edge of the optic or its simulated image to the endothelium. Eyes were divided into 3 groups: convex, concave, and plane according to preoperatory iris configuration. Statistical analysis was performed using the R program, for the comparison of independent groups and multiple comparisons, the Kruskal-Wallis test and the Dunn test were used respectively. RESULTS: Mean difference between nasal preoperative SSD and postoperative RSD was -0.36±0.38, -0.29±0.48, and -0.18±0.30 mm in the concave, convex, and plane group, respectively. Mean difference between temporal SSD and RSD was -0.36±0.37, -0.14±0.38, and -0.24±0.33 mm in the concave, convex, and plane group, respectively. There were statistically significant differences between SSD and RSS for both nasal and temporal sides in the concave and plane group (P<0.002). CONCLUSION: Preoperative SSD and postoperative RSD for iris-claw pIOL shows significant differences in patients with concave and plane iris.

The false positive rates for detecting keratoconus and potential ectatic corneal conditions when evaluating astigmatic eyes with Scheimpflug Technology.

PURPOSE: To quantify the false positive rates for keratoconus (KC) and potential ectatic corneal conditions in highly astigmatism eyes when using published parameters/indices obtained from the Pentacam and Galilei units. SETTING: Oftalmosalud Instituto de Ojos, Lima, Peru. DESIGN: Prospective cohort study. METHODS: 67 consecutive eyes with corneal astigmatism > 1.5 D, with a minimum follow ups of 36 months after an uneventful LASIK procedure were included. Indices for KC and other potential ectatic corneal conditions (subclinical KC, forme fruste KC, suspect KC) were obtained using the Pentacam and Galilei Scheimpflug cameras. MAIN OUTCOME MEASURES: The false positive rates for KC and potential ectatic corneal conditions were measured. Cut off values provided by previous studies and company-based parameters were used to assess the rate of false positivity. RESULTS: The range of false positive rates for a KC diagnosis depending on the lowest and highest cutoff values were: index of height decentration (61% - 1%), index of surface variance (76% - 0%), Posterior elevation (55% - 0%), maximum Ambrosio Relational thickness (100% - 13%), Belin Ambrosio enhanced ectasia display total deviation value (100% - 4%), Average pachymetric progression index (69% - 3%), Pachymetry at the thinnest point (58% - 1%), CSI Center Surround Index (100%), Differential sector index (51%). CONCLUSION: The false positive rates for KC and ectatic corneal conditions vary dramatically depending on the cut-off values used. Some indexes used for diagnosis of potential ectatic corneal conditions are inaccurate in normal, highly astigmatic eyes.

Automated Keratopigmentation in Boston Type 1 Keratoprosthesis: An Aesthetic Alternative.

Two male patients, aged 64 and 55 years old, presented at the cornea department for a Boston type 1 keratoprosthesis (Kpro I) implantation after multiple corneal graft failures. After surgery, they achieved a best corrected visual acuity of 20/200 and 20/150, respectively. However, they manifested photophobia and aesthetic complaints. Both patients underwent keratopigmentation to improve the aesthetic outcome using vegetable pigments, after mechanical corneal deepithelization, with no intraoperative or postoperative incidents or adverse events. After 1-year follow-up, the patients presented the same best corrected visual acuity with improvement of the aesthetic outcome.

Accelerated Epi-On Versus Standard Epi-Off Corneal Collagen Cross-Linking for Progressive Keratoconus in Pediatric Patients: Five Years of Follow-Up.

PURPOSE: The purpose of this study was to evaluate and compare the 5-year efficacy and safety of accelerated transepithelial (A-epi-on) corneal collagen cross-linking (CXL) with standard CXL (epi-off) in children with progressive keratoconus (KC). METHODS: This prospective cohort study included 78 eyes of patients aged 18 years old or younger with progressive KC who underwent CXL at the Oftalmosalud Institute of Eyes, Lima, Peru. A-epi-on CXL was performed in 32 eyes (30' of impregnation/5' of irradiation at 18 mW/cm2) and epi-off CXL was performed in 46 eyes (30'of impregnation/30' minutes of irradiation at 3 mW/cm2). Visual acuity, refraction, and the Scheimpflug imaging parameters were evaluated preoperatively and postoperatively at 1 and 5 years. RESULTS: The best corrected visual acuity improved to 0.06 logarithm of the minimum angle of resolution (SD: 0.19, P = 0.03) and 0.09 logarithm of the minimum angle of resolution (SD: 0.13, P < 0.001) in the A-epi-on and epi-off groups, respectively. The mean flattening in the mean keratometry was 0.09 diopters (D) (SD: 0.68, P = 0.33) and 3.18 D (SD: 5.17, P < 0.001) in the A-epi-on CXL and Epi-off groups at the 5-year follow-up. Significant differences were found in the change at 1 and 5 years between the groups for cylinder reduction, flat and mean K, and pachymetry (all P < 0.05). The KC progression rate was 9.37% (3/32) in the A-epi-on CXL; no progression was found in the epi-off CXL group at the 5-year follow-up. CONCLUSIONS: Both procedures halted the progression of KC at the 5-year follow-up; however, epi-off CXL was safer and more effective when compared with A-epi-on CXL.

Corneal lenticule extraction assisted by a low-energy femtosecond laser.

A lenticule of intrastromal corneal tissue was cut together with 2 small incisions of 3.0 mm using a low-energy femtosecond laser system, FEMTO LDV Z8; 1 incision led to the posterior plane and 1 to the anterior, allowing dissection of the lenticule. When needed, recentering of the treatment area was possible without repeating the docking stage. Five eyes were operated, and a complete dissection and removal of the lenticule was achieved in all cases without any intraoperative complications. In addition, at postoperative day 1, all patients had a clear cornea. In conclusion, guided lenticule extraction using a low-energy femtosecond laser was a promising and easy procedure.

A Systematic Review of Subclinical Keratoconus and Forme Fruste Keratoconus.

PURPOSE: To identify the definitions used for the terms sub-clinical keratoconus and forme fruste keratoconus in published articles. METHODS: This was a prospective, systematic literature review of the electronic database in PubMed, the Cochrane Library, and LILACS Database of all studies using the keywords "subclinical keratoconus" and/or "forme fruste keratoconus" until August 18, 2017. Two independent reviewers analyzed the data. The inclusion criteria for articles were having analyzed subclinical keratoconus or forme fruste keratoconus eyes with a sample size greater than 10 eyes; containing the definition of subclinical keratoconus or forme fruste keratoconus; and the quality of published reports was assessed using standards quality index methods. The following aspects of the selected articles were then analyzed: inclusion criteria for definition and technology used. RESULTS: A total of 198 and 95 studies, respectively, including the definition of subclinical keratoconus and forme fruste keratoconus were collected in an initial search, of which 165 and 73 studies, respectively, were excluded. Definitions for subclinical keratoconus and forme fruste keratoconus included the criteria of having keratoconus in the fellow eye in 72.72% (24 of 33) and 77.27% (17 of 22) of the articles, respectively. A total of 96.97% (32 of 33) and 90.90% (20 of 22) of the studies used more than one parameter to define subclinical keratoconus and forme fruste keratoconus, respectively. The most common extra parameters included normal slit-lamp examination and cornea on slit-lamp biomicroscopy and inferior-superior asymmetry and/or bowtie pattern with skewed radial axes. CONCLUSIONS: This review demonstrates the lack of unified criteria to define subclinical keratoconus and forme fruste keratoconus. According to the literature review, the most common subclinical keratoconus definition used refers to an eye with topographic signs of keratoconus and/or suspicious topographic findings under normal slit-lamp examination and keratoconus in the fellow eye and the most common forme fruste keratoconus definition refers to an eye with normal topography, normal slit-lamp examination, and keratoconus in the fellow eye. [J Refract Surg. 2020;36(4):270-279.].

Comparison of eye-rubbing effect in keratoconic eyes and healthy eyes using Scheimpflug analysis and a dynamic bidirectional applanation device.

PURPOSE: To compare the effect of eye rubbing on Scheimpflug imaging parameters and corneal biomechanics in eyes with keratoconus and healthy eyes. SETTING: Oftalmosalud Instituto de Ojos, Lima, Peru. DESIGN: Prospective cohort study. METHODS: The study included healthy and keratoconus patients who attended the institution between January 2017 and July 2017. Eye rubbing was performed for 1 minute followed by a 5-second break, followed by further rubbing for 1 minute. Baseline tests were performed before rubbing; post-rubbing tests were performed immediately after (0 minutes), and then again at 7 minutes and 14 minutes. Parameters related to anterior and posterior curvature and elevation, pachymetry, and corneal biomechanics obtained from tomography with a rotating Scheimpflug camera (Pentacam HR) and a dynamic bidirectional applanation device (Ocular Response Analyzer) were measured and compared between healthy and keratoconic eyes. RESULTS: The study included 30 healthy eyes and 31 keratoconic eyes. In the healthy group, the immediate mean changes in steeper anterior keratometry, posterior astigmatism, anterior chamber volume (ACV), flattest posterior keratometry, and Goldmann-correlated intraocular pressure (IOPg) after eye rubbing were 0.07 diopters (D) ± 0.15 (SD), -0.01 ± 0.08 D, 0.03 ± 7.06 mm3, -0.001 ± 0.04 mm, and -1.21 ± 1.99 mm Hg, respectively, whereas the mean changes in the keratoconus group were -0.03 ± 0.32 D, 0.14 ± 0.50 D, -5.09 ± 8.45 mm3, 0.03 ± 0.06 mm, and -1.61 ± 1.41 mm Hg, respectively. There were statistically significant differences between the preoperative and postoperative eye-rubbing values of posterior astigmatism, ACV, and IOPg in the keratoconus group (P = .03, P = .0003, and P = .001, respectively) but not in the healthy group (P = .65, P = .85, and P = .23, respectively). CONCLUSIONS: Unlike the healthy eyes group, the keratoconus group experienced significant changes in ACV, IOP, and corneal posterior astigmatism after eye rubbing.

Effectiveness of Intrastromal Corneal Ring Implantation in the Treatment of Adult Patients With Keratoconus: A Systematic Review.

PURPOSE: To evaluate the available evidence on the effectiveness of intrastromal corneal rings (ICRs) in the treatment of adults with keratoconus. METHODS: A systematic review of electronic databases was completed through July 30, 2017. All primary research articles in which adults with keratoconus were treated with ICRs were included. Two independent reviewers assessed methodological quality and classified the studies into high, low, or undefined risk of bias. The measured variables assessed were visual acuity, refraction, keratometry, ring type, and complications. RESULTS: The initial search yielded 442 scientific articles, 62 articles were read extensively, and 18 articles were assessed for eligibility and included for statistical analysis and quality assessment. A total of 1,325 eyes were analyzed, and the results were evaluated preoperatively and at 12 months of follow-up. Uncorrected distance visual acuity (UDVA) improved 0.23 ± 0.28 logMAR and corrected distance visual acuity (CDVA) improved 0.06 ± 0.21 logMAR. Sphere improved 2.81 ± 1.54 diopters (D), cylinder improved 1.49 ± 0.83 D, and mean keratometry improved 3.41 ± 2.13 D within 12 months of follow-up. ICR implantation combined with corneal crosslinking improved UDVA, refraction, and keratometry to a greater degree than ICR implantation alone. CONCLUSIONS: The studies analyzed demonstrate refractive and visual improvement of patients treated with the ICR implantation technique. However, description of the methodological process necessary to evaluate the bias effectively is insufficient. [J Refract Surg. 2019;35(3):191-200.].

Consensus on the management of astigmatism in cataract surgery.

This project was aimed at achieving consensus on the management of astigmatism during cataract surgery by ophthalmologists from Latin America using modified Delphi technique. Relevant peer-reviewed literature was identified, and 21 clinical research questions associated with the definition, classification, measurement, and treatment of astigmatism during cataract surgery were formulated. Twenty participants were divided into seven groups, and each group was assigned three questions to which they had to respond in written form, after thoroughly reviewing the literature. The assigned questions with corresponding responses by each group were discussed with other participants in round 4 - presentation of findings. The consensus was achieved if approval was obtained from at least 80% of participants. The present paper provides several agreements and recommendations for management of astigmatism during cataract surgery, which could potentially minimize the variability in practice patterns and help ophthalmologists adopt optimal practices for cataract patients with astigmatism and improve patient satisfaction.

Long-term efficacy and safety after corneal collagen crosslinking in pediatric patients: Three-year follow-up.

PURPOSE: To evaluate the effectiveness of standard corneal collagen crosslinking for children with progressive keratoconus. METHODS: Prospective study including 26 eyes of 26 patients younger than 18 years old with progressive keratoconus at Oftalmosalud Instituto de Ojos, Lima, Peru. Standard epi-off corneal crosslinking was performed in all eyes between January 2012 and January 2013. Pre- and postoperative evaluation (at 3 years) included uncorrected and best-corrected visual acuity and Scheimpflug analysis. Crosslinking failure was defined as an increase in maximum keratometry (Kmax) of more than 1 diopter after 1 year or more. RESULTS: Mean uncorrected visual acuity improvement was 0.24 LogMAR (p = 0.07) and mean best-corrected visual acuity improvement was 0.18 LogMAR (p = 0.01). None of the eyes lost more than one line in the best-corrected visual acuity. Four eyes (15.38%) lost two lines in the uncorrected visual acuity at 3 years postoperative. Mean steeper keratometry improvement was 1.14 diopters (p = 0.60). Progression rate was 23.07%. CONCLUSION: Standard epi-off corneal collagen crosslinking is safe and effective to halt the progression of the keratoconus with significant improvement in the best-corrected visual acuity at 3-year follow-up.

Accelerated Epi-On Versus Standard Epi-Off Corneal Collagen Cross-Linking for Progressive Keratoconus in Pediatric Patients.

PURPOSE: To evaluate and compare the effectiveness and safety of accelerated transepithelial (A-epi-on) corneal collagen cross-linking (CXL) with standard CXL (epi-off) for children with progressive keratoconus. METHODS: Prospective, cohort study including 61 eyes of 51 patients younger than 18 years with progressive keratoconus at Oftalmosalud Instituto de Ojos, Lima, Peru. A-epi-on CXL was performed for 36 eyes using 30 minutes of impregnation (0.25% riboflavin, 1.0% phosphate hydroxypropyl methylcellulose, 0.007% benzalkonium chloride) and 5 minutes of irradiation (18 mW/cm). Epi-off CXL was performed for 25 eyes using 30 minutes of impregnation (riboflavin 0.1% solution plus 20% dextran 500) and 30 minutes of irradiation (3 mW/cm). Scheimpflug imaging parameters were evaluated preoperatively and at 6 and 12 months postoperatively. RESULTS: Mean uncorrected visual acuity improvement was 0.12 logarithm of the minimum angle of resolution (logMAR) for both groups (P = 0.09 for A-epi-on and P = 0.16 for Epi-off). Mean improvements in the best-corrected visual acuity were 0.09 logMAR (P = 0.05) and 0.06 logMAR (P = 0.05) at 12 months postoperatively for the A-epi-on group and the epi-off group, respectively. Mean maximum keratometry changes were +0.1 D (P = 0.62) and -0.94 D (P = 0.11) for the A-epi-on group and the epi-off group, respectively, at 12 months postoperatively. There were no significant differences between groups regarding changes in pachymetry and posterior elevation values (P > 0.05). Keratoconus progression was observed in 5.6% and 12% of eyes in the A-epi-on group and the epi-off group, respectively. CONCLUSIONS: Accelerated epi-on CXL and standard epi-off CXL are safe and effective for stopping the progression of keratoconus at 12 months postoperatively.

New Technique of Femtosecond Laser-Assisted Intracorneal Ring Segment Implantation.

PURPOSE: To describe a new technique of femtosecond laser-assisted intracorneal ring segment implantation. METHODS: The study included 6 eyes of 5 patients. Software of the LDV Z6 femtosecond laser was modified to create a 110-degree reverse side cut between the corneal surface and incision instead of the conventional 90 degree angle (which changed the angle between the incision and tunnel from conventional 90-70 degrees) and 2 disjointed tunnels separated by 10 degrees arc length at the proximal and distal ends. RESULTS: One-year postoperatively, there were no cases of segment extrusion or touch/overlap. Anterior segment optical coherence tomography showed appropriate position of the rings in all eyes postoperatively. Improvement was also found in visual, refractive, keratometric, and asphericity parameters. CONCLUSIONS: The results of this pilot study are promising. A comparative prospective study with more eyes and longer follow-up may confirm whether this technique is better than the conventional femtosecond laser-assisted one.

Corneal collagen cross-linking before Ferrara intrastromal corneal ring implantation for the treatment of progressive keratoconus.

PURPOSE: To evaluate the safety, efficacy, and stability of sequential corneal collagen cross-linking (CXL) and Ferrara intrastromal corneal ring segment (FR) implantation in selected patients with progressive keratoconus. METHODS: This prospective study involved 9 eyes with progressive keratoconus and a preoperative cylinder value equal to or greater than 5 diopters (D) diagnosed between June 2007 and October 2008. Preoperative and postoperative (6 months after the CXL procedure and 6 months after the FR implantation) biomicroscopy examinations, distance uncorrected and best-corrected visual acuities, refractive error, and topographic maps were evaluated and compared. RESULTS: Mean uncorrected visual acuity was 1.11 logarithm of the minimal angle of resolution (logMAR) preoperatively and 0.75 logMAR at 6 months after CXL (P = 0.03) and 0.23 logMAR at 6 months after FR implantation (P < 0.001). Mean best-corrected visual acuity was 0.26 logMAR preoperatively and 0.24 logMAR at 6 months after CXL (P = 0.87) and 0.12 logMAR at 6 months after FR (P = 0.05). Statistically significant reductions in the mean spherical equivalent (4.38 D; P < 0.001) and mean maximum (5.58 D; P < 0.001) and minimum (4.17 D; P < 0.001) keratometry values were present at 6 months after FR. CONCLUSIONS: FR implantation after CXL is a safe and efficacious treatment option for managing selected patients with progressive keratoconus. Good results in terms of visual acuity, postoperative residual refractive error, and keratometry values were obtained. Longer follow-up would be valuable to confirm the stability of these results.

Artiflex phakic intraocular lens implantation after corneal collagen cross-linking in keratoconic eyes.

PURPOSE: To evaluate the safety, efficacy, and stability of the Artiflex (Ophtec BV) foldable anterior iris-claw phakic intraocular lens (PIOL) following corneal collagen cross-linking (CXL) in select cases of progressive keratoconus. METHODS: This prospective, comparative study, conducted between March 2007 and June 2008, involved 11 eyes with progressive keratoconus. Inclusion criteria were progressive keratoconus (Amsler-Krumeich classification grades I and II) with no corneal opacities, corneal thickness >450 µm, endothelial cell count >2500 cells/mm(2), anterior chamber depth >3.2 mm, spherical equivalent refraction >4.50 diopters (D) (with a cylinder component <2.00 D), and no other treatment for keratoconus other than contact lens. Each patient underwent CXL in the keratoconic eye with implantation of the Artiflex IOL 6 months thereafter. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and refraction and topographic profiles were examined at 1, 6, and 12 months after the CXL procedure. RESULTS: All eyes achieved UDVA of 0.3 logMAR or better. Final spherical and cylindrical error ranged from 0 to -1.50 D and 0 to -1.75 D, respectively. No eyes lost lines of preoperative CDVA. Statistically significant reductions in mean maximum (2.14 D, P<.001) and minimum (1.17 D, P=.02) keratometry values were present 12 months after the CXL procedure. No complications were observed. CONCLUSIONS: Combined CXL and Artiflex implantation was a safe and effective treatment in this subset of eyes with progressive keratoconus. Good results in terms of visual acuity, postoperative residual refractive error, and keratometry values were identified.

Double aspiration/single irrigation system for bimanual lens cortex removal in cataract surgery.

The authors describe a bimanual double aspiration/single irrigation system (DASIS) for cataract surgery that efficiently and safely performs aspiration of the entire cortex, including subincisional space. DASIS uses standard and common instruments such as an irrigation/aspiration handpiece in one hand and a single-aspiration handpiece in the other, joined with a short silicone tube using a three-way stopcock. DASIS allows access to 360° of the cortex without a hand exchange, reducing wound leakage and maintaining chamber stability.

Riboflavin/Ultraviolet A corneal collagen cross-linking for the treatment of keratoconus: visual outcomes and Scheimpflug analysis.

PURPOSE: To evaluate the safety and efficacy of corneal collagen cross-linking (CXL) by riboflavin/UV light for the treatment of keratoconus. METHODS: This randomized, prospective, and comparative study involved 10 eyes with keratoconus diagnosed between September 2006 and January 2008. Each patient underwent CXL in the keratoconus eye. Preoperative and postoperative (at 1, 3, 6, and 12 months) biomicroscopy examinations, distance uncorrected and best-corrected visual acuities, refractive error, endothelial cell counts, keratometry readings, ultrasound pachymetry, macular thickness, and Scheimpflug analyses were performed and compared. RESULTS: Mean uncorrected visual acuity was 1.18 logarithm of the minimum angle of resolution preoperatively and 0.46 logarithm of the minimum angle of resolution at 12 months postoperatively (P < 0.001). Statistically significant reductions in the mean maximum [2.66 diopter (D), P = 0.04] and minimum (1.61 D, P = 0.03) keratometry values were present at 12 months postoperatively, in addition there was a 2.25 D reduction in the mean spherical equivalent (P = 0.01). At the end of follow-up, 8 (80%) and 6 (60%) of the 10 eyes showed a decrease in the anterior and posterior elevation values, respectively, and the thinnest point of the cornea was statistically thinner by a mean of 13.4 µm (P = 0.03). No statistically significant differences were found between preoperative and postoperative endothelial cell counts and macular thicknesses. The improvements in visual acuity, keratometry readings, and spherical equivalent values occurred progressively during follow-up. CONCLUSIONS: CXL procedure is a safe treatment for keratoconus, yields good visual results, and reduces the progression of the disease, but long follow-up is necessary.