Visual Quality Assessment After FS-LASIK Using Customized Aspheric Ablation Profile for Age-Related Accommodation Deficiency Compensation.

PURPOSE: To evaluate clinical outcomes and visual quality 12 months after femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) performed with the Custom-Q algorithm for correction of myopia with or without astigmatism and compensate for age-related accommodation deficiency. METHODS: Patients who had Custom-Q FS-LASIK for myopia and myopic astigmatism with age-related accommodation deficiency were included in this retrospective study. Distance, intermediate, and near visual acuities, objective and subjective refractions, Q-factor, corneal higher order aberrations (HOAs), accommodation function, defocus curve, contrast sensitivity, and a subjective questionnaire assessing visual quality were evaluated 12 months postoperatively. RESULTS: Clinical data of 43 cases were analyzed. The mean age was 42.02 ± 1.85 years (range: 40 to 48 years). At the 12-month follow-up visit, there were 43 (100%), 42 (97%), and 33 (77%) patients who achieved a binocular uncorrected distance, intermediate, and near visual acuity, respectively, better than 20/20 separately. Defocus curves revealed better distance vision in the dominant eyes, and the nondominant eyes performed better at intermediate and near vergence (P < .001). The Q-value and corneal spherical aberration coefficient were more positive in the dominant eyes than those in the nondominant eyes (P < .001). The accommodative amplitude and relative accommodation improved binocularly (P < .001). The questionnaire demonstrated high patient satisfaction with near vision, and no one reported having severe visual disturbance. CONCLUSIONS: For myopic patients with age-related accommodation deficiency, the Custom-Q algorithm proved to be an effective way to achieve acceptable near vision without compromising distance vision. [J Refract Surg. 2024;40(4):e245-e252.].

Comprehensive Assessment of Posterior Corneal Asphericity Change Calculated by Tangential Radius of Curvature After FS-LASIK and SMILE.

PURPOSE: To evaluate changes in posterior corneal asphericity (ΔQ) using the tangential radius of curvature after femtosecond laser-assisted in situ keratomileusis (FS-LASIK) and small incision lenticule extraction (SMILE) procedures. METHODS: One hundred twenty right eyes of myopic patients who underwent either FS-LASIK or SMILE procedures were analyzed using Sirius 3D corneal topography for assessment. The tangential radius was employed to calculate both preoperative and postoperative posterior corneal Q-values across each semimeridian. After both surgical interventions, the ΔQ value variations across the 360° semimeridional regions of the posterior corneal surface were compared. RESULTS: A marked postoperative increase in the posterior corneal Q-value was documented. No significant differences were noted between the postoperative Q-values or ΔQ-values of the two surgical approaches. Among patients with moderate myopia, postoperative Q-value exhibited considerably lower increases and ΔQ-value significantly smaller than their counterparts with high myopia. Moreover, the fluctuation in ΔQ across semimeridional regions was less evident in patients with moderate myopia than in those with high myopia. Notably, the degree of ΔQ fluctuation across semimeridional regions was similar between both surgical categories. These data offer insights into variations in the posterior corneal surface after refractive surgeries depending on the degree of myopia, illuminating their clinical relevance. CONCLUSIONS: Both FS-LASIK and SMILE introduce notable changes to posterior corneal asphericity among patients with different myopia intensities. Furthermore, the influence on the asphericity across the entire posterior surface is similarly distributed between FS-LASIK and SMILE techniques. [J Refract Surg. 2024;40(3):e133-e141.].

Corneal remodeling after SMILE for moderate and high myopia: short-term assessment of spatial changes in corneal volume and thickness.

PURPOSE: To evaluate the early corneal remodeling and its influencing factors after Small incision lenticule extraction (SMILE) for moderate and high myopia. METHODS: This was a retrospective study. Pre- and post-operative (1 week and 1, 3, 6 months) corneal volume (CV), mean keratometry (Km), and corneal thickness (CT) were measured by Scheimpflug tomography. CT at the central, thinnest point, and on concentric circles of 2, 4, and 6 mm diameter was recorded to assess corneal thickness spatial profile (CTSP) and percentage of thickness increase (PTI) in the moderate and high myopia groups, and to explore possible influencing factors. RESULTS: After SMILE, the peripheral CT decreased in the moderate myopia group and central corneal thickness (CCT) increased in the high myopia group at 1 month compared to 1 week (all P < 0.05). The CV, Km and CT were significantly increased at 3 months compared to 1 month (all P < 0.05), but there was no significant change at 6 months compared to 3 months for both groups (all P > 0.05). Patients with high myopia showed greater corneal thickness changes (△CT) and higher PTI than moderate myopia (all P < 0.05). Regression analysis revealed that in addition to refraction, peripheral PTI was negatively correlated with CCT in the moderate myopia group (4 mm: ß = -0.023, P = 0.001; 6 mm: ß = -0.050, P < 0.001), as well as in the high myopia group (4 mm: ß = -0.038, P < 0.001; 6 mm: ß = -0.094, P < 0.001). Moreover, peripheral PTI in the moderate myopia group was negatively correlated with age (4 mm: ß = -0.071, P = 0.003; 6 mm: ß = -0.162, P < 0.001). CONCLUSIONS: After SMILE, the CV, Km, and CTSP showed dynamic changes in the early stage, which stabilized after 3 months. Compared to the moderate myopia group, the high myopia group experienced slower corneal stabilization. The change in PTI at 6 months after SMILE may be related to higher preoperative refraction, thinner CCT and younger age.

A Clinical Decision Tree to Support Keratoconus Patients Considering Corneal Cross-Linking Combined with Refractive Treatment.

BACKGROUND: To develop a fast and frugal decision tree to identify keratoconus patients most likely to benefit visually from the combination of corneal cross-linking (CXL) with topography-guided photorefractive keratectomy ("CXL plus"). PATIENTS AND METHODS: The outcome of interest was an improvement in uncorrected distance visual acuity (UDVA) by at least two lines at the 12-month follow-up. Preoperative and 12-month follow-up data from patients who received CXL plus (n = 96) and CXL only (n = 96) were used in a recursive partitioning approach to construct a frugal tree with three variables (corneal thickness [>/< 430 um], patient interest in CXL plus [yes/no], and tomographic cylinder [ 3 D]). In addition, we estimated the probability of the outcome from a multivariate logistic regression model for each combination of variables used in the decision tree. RESULTS: In the complete sample, 101/192 (52.6%) patients improved by at least two lines at the 12-month follow-up. Patients affirmative in all three answers had a 75.6% (34/45) probability of gaining at least two lines of improvement in UDVA by CXL plus. The statistical model estimated a 66.0% probability for a successful outcome. CONCLUSION: A fast and frugal tree consisting of three variables can be used to select a patient group with a high likelihood to benefit from CXL plus. The tree is useful in the preoperative counseling of keratoconus patients contemplating the CXL plus option, an intervention that is not fully covered by many health insurances.

Assessment of Refractive Outcome of Photo Refractive Keratectomy in Myopia and Myopic Astigmatism.

OBJECTIVES: To determine the refractive outcomes of wavefront optimized photo refractive keratectomy (PRK) in patients having myopia and myopic astigmatism in terms of efficacy, safety, accuracy, stability and predictability of the procedure. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Refractive Surgical Unit, Armed Forces Institute of Ophthalmology, National University of Medical Sciences, Rawalpindi, Pakistan, from October 2013 to August 2018. METHODOLOGY: Patients having myopia and myopic astigmatism, consented to be a part of the study, underwent meticulous screening consisting of detailed medical history, ocular examination and investigations. Each case was compiled and evaluated. Those who satisfied the criteria for refractive surgery were subjected to PRK procedure. Postoperative follow-up was carried out and parameters were recorded at designated intervals of 1 week, 1, 3, 6 and 12 months. RESULTS: This study included 208 eyes of 106 patients with mean age of 25.33 + 5.196 years. At the end of one year, 97% (202 out of 208) eyes had uncorrected distance visual acuity (UDVA) better than 20/25 with efficacy index of 1.009 ± 0.132 and safety index of 1.019 ± 0.126. None of the eyes lost two or more lines. In this study, 207 out of 208 eyes remained within + 0.50 diopter (D) of intended spherical equivalent (SEQ). Results showed 100% accuracy of procedure since all the study patients achieved SEQ within + 1D. CONCLUSION: PRK is an effective, predictable, and safe treatment procedure for correcting myopia and myopic astigmatism. Key Words: Photorefractive keratectomy, Myopia, Refractive surgery, Myopic astigmatism, Uncorrected distance visual acuity.

Láser ó luz excimer 308nm en pacientes con vitíligo / 308-nm Excimer Laser or 308-nm Excimer Light for Patients with Vitiligo

CONTEXTO CLÍNICO: El vitíligo es un trastorno de despigmentación crónico adquirido, que se produce por pérdida de melanocitos funcionales. Afecta al 0,5-1% de la población mundial, tanto adultos como niños por igual. Aproximadamente en el 70-80% de las personas el vitíligo suele aparecen antes de los 30 años. La patogenia de la enfermedad no se conoce con exactitud, pero se estipula que es una enfermedad con predisposición genética y es multifactorial. La teoría de la autoinmunidad/autoinflamatoria es la hipótesis principal, en la que se propone que los meloncitos mueren por mecanismos de efectos autoinmunes mediados principalmente por linfocitos T citotóxicos. Las lesiones de vitíligo generalmente afectan las áreas que normalmente se encuentran más pigmentadas, como la cara, las axilas, las ingles, las mucosas (genitales, labios y encías), áreas de fricción permanente o traumatismo, como el dorso de manos, pies, codos, rodillas y tobillos. El diagnóstico del vitíligo suele realizarse con la presentación clínica, en ocasiones la lámpara de Wood puede ser útil para determinar la extensión y la actividad del vitíligo, así como para controlar la respuesta al tratamiento y la evolución de las lesiones a lo largo del tiempo. NOMBRE DE LA TÉCNICA CON PRETENDIDA FINALIDAD SANITÁRIA: Técnicas de relajación basadas en la inducción de sensaciones corporales. TECNOLOGÍA: El láser excimer, es un tipo de fototerapia, que contiene una mezcla de gas xenón y cloruro que forma "dímeros excitados" inestables, la disociación de estos dímeros produce una longitud de onda coherente monocromática ultravioleta (UV) de 308 nm. Este láser llega hasta las células epidérmicas y, en segundo lugar, a los fibroblastos. Se estipula que el mecanismo de acción es similar al de la fototerapia convencional, pero con mejores resultados, la luz ultravioleta induce la apoptosis de los linfocitos T y estimular la secreción de endotelina-1. El láser permite un tratamiento específico, menor irradiación total del cuerpo y menos efectos secundarios en la piel sana (como por ejemplo hiperpigmentación). Además, el láser excimer se considera una forma de tratamiento más segura en pacientes pediátricos debido a su campo de irradiación es más localizado.2 Se recomiendan que el tratamiento con láser excimer sea realice três veces por semana, y que se prolongue de uno a nueve meses (promedio de 12 semanas). Los efectos adversos que se han descripto son: eritema y prurito leve. La luz excimer, es también una luz ultravioleta de tipo B, monocromática, que emite luz con uma longitud de onda de 308 nm, pero es incoherente y no direccional. Tiene un campo de tratamento más amplio en comparación con el láser excimer, lo que puede permitir la irradiación de zonas más amplias y tiempos de tratamiento más cortos y ha demostrado que es eficaz para inducir la repigmentación de las lesiones de vitíligo. El mecanismo de acción, se desconoce, pero se estima que es similar al láser excimer. La Agencia Nacional de Medicamentos, Alimentos y Tecnología Médica de la Argentina (ANMAT), autorizó el uso de láser excimer para el tratamiento de condiciones dermatológicas. Así como también, la Administración de Alimentos y Medicamentos de los Estados Unidos (FDA, de su sigla en inglés: Food and Drug Administration). OBJETIVO: El objetivo del presente informe es evaluar la evidencia disponible acerca de la eficacia, seguridad y aspectos relacionados a las políticas de cobertura del uso del láser y luz excimer 308nm para pacientes con vitíligo. MÉTODOS: Se realizó una búsqueda en las principales bases de datos bibliográficas, en buscadores genéricos de internet, y financiadores de salud. Se priorizó la inclusión de revisiones sistemáticas (RS), ensayos clínicos controlados aleatorizados (ECAs), evaluaciones de tecnologías sanitarias (ETS), evaluaciones económicas, guías de práctica clínica (GPC) y políticas de cobertura de diferentes sistemas de salud. RESULTADOS: Se incluyeron dos ECAs, dos RS, cinco GPC, y siete informes de políticas de cobertura del uso de láser o luz excimer 308nm para el tratamiento del vitíligo. CONCLUSIONES: Dentro de la evidencia relevada, al evaluar el uso de láser excimer 308nm versus luz excimer 308nm, no se observaron diferencias significativas en sus beneficios netos; por este motivo, en este documento consideramos ambos dispositivos de manera conjunta para el tratamiento del vitíligo. Evidencia de baja calidad sugiere que el uso de láser o luz excimer 308nm podría mejorar la pigmentación de las lesiones por vitíligo de manera similar la terapia habitual de radiación ultravioleta B de banda ancha (UVBba), considerado uno de los tratamientos de primera línea. Sin embargo, se desconoce si la repigmentación ganada es duradera en el tiempo y si esto conlleva a uma mejoría de la calidad de vida. No se ha encontrado evidencia que compare la efectividad del láser o lámpara excimer 308nm versus otras terapias de primera línea (corticoides tópicos, inhibidores de calcineurina tópicos) o segunda línea (psoraleno más radiación ultravioleta de gran longitud de onda (PUVA), análogos de la vitamina D) de forma directa. Los estudios relevados comparan la combinación de terapéuticas tópicas asociadas a láser o luz excimer 308nm versus el uso de estos dispositivos como monoterapia, en los que se sugiere que la combinación de terapias tendría mejores resultados en la repigmentación em comparación al uso de los dispositivos en monoterapia. En pacientes pediátricos, evidencia proveniente de un estudio, mostró que el uso combinado de láser excimer 308nm asociado a otras terapias tópicas presenta mejores resultados en la repigmentación en comparación con el uso de laser como monoterapia. Al considerar el uso de luz excimer para el vitíligo facial, los resultados de un estudio sugieren que no hay diferencia en el porcentaje de repigmentación cuando se utilizó luz excimer asociado a corticoides tópicos versus luz excimer como monoterapia. Las guías de práctica clínica relevadas y los consensos de expertos, consideran el uso de laser excimer 308 nm como una opción de segunda o tercera línea de tratamiento, asociado a otras terapêuticas tópicas y principalmente para pacientes pediátricos o en aquellos pacientes que tengan lesiones pequeñas. La mayoría de las guías no mencionan la luz excimer como tratamiento. Los financiadores de salud públicos consultados de la Argentina y otros países seleccionados de América y Europa, no mencionan o no brindan cobertura a esta tecnología. Los financiadores de medicina privada relevados de los Estados Unidos, Aetna, Cigna y Healthnet, dan cobertura para el uso de laser excimer en el tratamiento de vitíligo. No se encontraron evaluaciones económicas locales, ni internacionales acerca de la costo-efectividad u otros aspectos económicos acerca del uso del láser excimer 308nm para el tratamiento del vitíligo.

Comparison of the Cost-Effectiveness of SMILE, FS-LASIK, and PRK for Myopia in a Private Eye Center in Spain.

PURPOSE: To describe and compare the cost-effectiveness of small incision lenticule extraction (SMILE), femtosecond laser-assisted in situ keratomileusis (FS-LASIK), and photorefractive keratectomy (PRK) for treating myopia and myopic astigmatism in a private eye center. METHODS: The perspectives for this cost-effectiveness analysis were for the payer and the health care sector. For the payer's perspective, a decision tree model was made, with a time period of 30 years, and the average weighted utility values and quality-adjusted life years (QALY) were computed for each procedure. The average weighted costs were derived for each procedure and divided by the QALY to obtain the incremental cost-effectiveness ratios (ICER). For the health care sector's perspective, the direct and indirect costs of acquiring the equipment and maintaining the facilities-including consumables and personnel salaries-were obtained to compute the minimum number of patients treated per year. RESULTS: The weighted utility values were 0.8 for SMILE and PRK and 0.77 for FS-LASIK. The weighted QALYs were 24 for SMILE and PRK, and 23.1 for FS-LASIK. The average weighted costs were 335.45, 443, and 346.96€, respectively. The resulting incremental cost-effectiveness ratios were 13.98 €/QALY for SMILE, 18.46 €/QALY for PRK, and 15.02 €/QALY for FS-LASIK. There was a negative correlation between the ICER and the time (in years) after the surgery. To achieve a profit, the minimum number of patients treated per year is 155 for SMILE, 136 for PRK, and 155 for FS-LASIK. CONCLUSIONS: Laser corneal refractive surgery is cost-effective for a person desirous of refractive correction for myopia. SMILE had the lowest ICER, followed by FS-LASIK and PRK. This trend was noted at all time periods. The cost of investing in laser refractive surgery facilities is outweighed by the potential income in high-volume eye centers. [J Refract Surg. 2022;38(1):21-26.].

Assessment of Refractive Outcomes of Femtosecond-assisted Laser in Situ Keratomileusis (LASIK) for Hyperopia.

OBJECTIVE: To determine the effect of refractive treatment in terms of safety, efficacy, stability, accuracy, and predictability with Wavefront Optimized Laser-assisted in situ keratomileusis (LASIK) on hyperopia. STUDY DESIGN: Descriptive, analytical study. PLACE AND DURATION OF STUDY: Armed Forces Institute of Ophthalmology, National University of Medical Sciences, Rawalpindi, Pakistan from August 2013 to June 2018.  Methodology: Participants were selected after detailed history, careful ocular examination and meticulous relevant assessment on refractive scans. Preoperative measurements were recorded. Refractive strategy was designed, considering individual requirements for each patient. Postoperative readings were taken at 1 day, 1 week, 1, 3, 6 and 12 months. RESULTS: A total of 54 patients participated with mean age of 28.07 + 8.13 years. Out of the 54 patients, 33 (61%) were males and 21 (39%) were females. Uncorrected distance visual acuity (UDVA) and Spherical equivalent (SEQ), which is algebraic sum of sphere and half of cylinder, were recorded pre- and postoperatively. These parameters were changed significantly at 12 months (p <0.001). SEQ reduced from 2.146 + 2.027 to 0.079 ± 0.269 Diopter (D) (p <0.001). UDVA improved from 0.672 ± 0.270 (20/93) to 0.153 ± 0.182 (20/28) (p <0.001). A total of 48 (out of 54) patients had uncorrected vision better than 20/40; and 49 patients showed either same or gain of Snellen lines when pre- and postoperative corrected distance visual acuity (CDVA) was compared. Two patients showed loss of two or more lines. All the patients had postoperative SEQ within + 1.0 D range. CONCLUSION: LASIK, performed to correct hyperopia, demonstrated satisfactory outcomes in terms of safety, efficacy, stability, accuracy, and predictability. LASIK is an effective treatment option for moderate (<6 D) hyperopia. Key Words: LASIK, Refractive surgery, Hyperopia, Spherical equivalent, Uncorrected distance visual acuity.

Therapies for Psoriasis: Clinical and Economic Comparisons.

BACKGROUND: Clinical and economic comparisons of therapies for plaque psoriasis are regularly updated following each new devel- opment in the field. With the recent availability of a novel accessory (Multi Micro DoseTM [MMD®] tip) for the 308nm excimer laser (XTRAC®, Strata Skin Sciences, Horsham, PA), which can determine and deliver an optimal therapeutic dose (OTDTM) of ultraviolet-B light in an improved protocol, the need for comparative health-economic assessment recurs. To this end, a comprehensive evaluation of treatment-related costs was undertaken from the payer perspective. Results show that outcomes are influenced by many factors; most importantly, the severity and extent of disease, treatment selection, and patient preference, as well as compliance, adherence, and persistence with care. Among study comparators, the 308nm excimer laser – XTRAC – with its latest MMD enhancement, is safe and delivers incremental clinical benefits with the potential for significant cost savings. These benefits are particularly relevant today in the context of SARS-CoV-2 virus and the COVid-19 pandemic. J Drugs Dermatol. 2020;19(11):1101-1108. doi:10.36849/JDD.2020.5510.

Suction stability management in small incision lenticule extraction: incidence and outcomes of suction loss in 4000 consecutive procedures.

PURPOSE: To report the incidence and outcomes of suction loss during small incision lenticule extraction (SMILE). METHODS: The incidence of suction loss was measured over 4000 consecutive SMILE procedures and categorized by cause, the interface in which suction was lost and management (restart/continue SMILE, re-SMILE thinner cap, convert to laser in-situ keratomileusis [LASIK]). One-year outcomes were compared to the fellow eye where no suction loss occurred. RESULTS: There were 20 cases of suction loss (0.50%): during the lenticule interface in seven eyes, lenticule side cut in one eye, cap interface in nine eyes and small incision for three eyes. Small incision lenticule extraction (SMILE) was continued in seven eyes, thinner cap SMILE in four eyes, LASIK in eight eyes, and the small incision was manually completed in one eye. Suction loss was caused by a Bell's reflex in 10 eyes, fixation light tracking in six eyes, patient anxiety in two eyes, a nociceptive reflex in one eye and false suction in one eye. There was no difference in results for suction loss and fellow eyes, respectively: uncorrected distance visual acuity was 20/20 or better in 100% in both groups, spherical equivalent was within ±0.50 D in 85% and 79%, one line loss of corrected distance visual acuity in 5% and 0%, and no eyes lost two lines. CONCLUSION: Suction loss can be managed depending on the interface during which suction is lost. Treatment was completed on the same day in all instances. Visual and refractive outcomes were unaffected compared to the fellow eye in this series.

Treatment of In-Stent Restenosis by Excimer Laser Coronary Atherectomy and Drug-Coated Balloon: Serial Assessment with Optical Coherence Tomography.

OBJECTIVES: We aimed to compare the results of neointimal modification before drug-coated balloon (DCB) treatment with excimer laser coronary atherectomy (ELCA) plus scoring balloon predilation versus scoring balloon alone in patients presenting with in-stent restenosis (ISR). BACKGROUND: Treatment of ISR with ELCA typically results in superior acute gain by neointima debulking. However, the efficacy of combination therapy of ELCA and DCB remains unknown. METHODS: A total of 42 patients (44 ISR lesions) undergoing DCB treatment with ELCA plus scoring balloon (ELCA group, n = 18) or scoring balloon alone (non-ELCA group, n = 24) were evaluated via serial assessment by optical coherence tomography (OCT) performed before, after intervention, and at 6 months. RESULTS: Although there was significantly greater frequency of diffuse restenosis and percent diameter stenosis (%DS) after intervention in the ELCA group, comparable result was shown in %DS, late lumen loss, and binary angiographic restenosis at follow-up. On OCT analysis, a decreased tendency in the minimum lumen area and a significant decrease in the minimum stent area were observed in the ELCA group between 6-month follow-up and after intervention (-0.89 ± 1.36 mm2 vs. -0.09 ± 1.25 mm2, p = 0.05, -0.49 ± 1.48 mm2 vs. 0.28 ± 0.78 mm2, p = 0.03, respectively). The changes in the neointimal area were similar between the groups, and target lesion revascularization showed comparable rates at 1 year (11.1% vs. 11.4%, p = 0.85). CONCLUSIONS: Despite greater %DS after intervention, ELCA before DCB had possible benefit for late angiographic and clinical outcome.

Long-term assessment of visual and refractive outcomes of laser in situ keratomileusis for hyperopia using the AMARIS® 750S Excimer laser.

PURPOSE: To evaluate the long-term efficacy and safety of hyperopic laser in situ keratomileusis (LASIK) using the AMARIS® 750S (Schwind, Eye-tech-solutions, GmbH) excimer laser. METHODS: The medical records of one hundred eleven eyes of 62 patients who underwent LASIK for hyperopia using the AMARIS® 750S excimer laser were reviewed retrospectively. Patients were divided into three groups based on preoperative spherical equivalent (SE) refraction: low hyperopia (less than +2.50 diopters [D]), moderate hyperopia (+2.75D to +4.00D), and high hyperopia (over +4.00D). Uncorrected and best corrected visual acuity (BCVA), long-term stability of refraction, and complications were evaluated. RESULTS: Of the entire sample, the mean preoperative SE was +3.64D±1.22D. The mean age was 37.4±11.2 years (20-59). The mean follow-up for all eyes was 51 months. At the last visit, the mean SE was +0.85D±0.34D (SD) in the low hyperopia group, +1.09D±0.43D in the moderate hyperopia group, and +1.63D±0.47D in the high hyperopia group. (+1.15D±0.49D overall). Preoperative uncorrected visual acuity (UCVA) was 0.52±0.34 logMAR and increased to 0.18±0.15 logMAR at 4 years follow-up (P<0.01). There was no statistically significant difference between preoperative and postoperative BCVA. The UCVA was 0.30 logMAR or better in 100% of eyes in the low hyperopia group, 93.7% in the moderate hyperopia group, and 69.9% in the high hyperopia group (%89.2 overall). CONCLUSIONS: LASIK is safe and effective for correcting hyperopia in the short term; however, the efficacy of the procedure is limited in the patients with high hyperopia and longer follow-up.

Comparing wavefront-optimized, wavefront-guided and topography-guided laser vision correction: clinical outcomes using an objective decision tree.

PURPOSE OF REVIEW: This review is intended to update and educate the reader on the currently available options for laser vision correction, more specifically, laser-assisted in-situ keratomileusis (LASIK). In addition, some related clinical outcomes data from over 1000 cases performed over a 1-year are presented to highlight some differences between the various treatment profiles currently available including the rapidity of visual recovery. The cases in question were performed on the basis of a decision tree to segregate patients on the basis of anatomical, topographic and aberrometry findings; the decision tree was formulated based on the data available in some of the reviewed articles. RECENT FINDINGS: Numerous recent studies reported in the literature provide data related to the risks and benefits of LASIK; alternatives to a laser refractive procedure are also discussed. The results from these studies have been used to prepare a decision tree to assist the surgeon in choosing the best option for the patient based on the data from several standard preoperative diagnostic tests. SUMMARY: The data presented here should aid surgeons in understanding the effects of currently available LASIK treatment profiles. Surgeons should also be able to appreciate how the findings were used to create a decision tree to help choose the most appropriate treatment profile for patients. Finally, the retrospective evaluation of clinical outcomes based on the decision tree should provide surgeons with a realistic expectation for their own outcomes should they adopt such a decision tree in their own practice.

Intravascular ultrasound assessment of the effect of laser energy on the arterial wall during the treatment of femoro-popliteal lesions: a CliRpath excimer laser system to enlarge lumen openings (CELLO) registry study.

The CliRpath Excimer Laser System to Enlarge Lumen Openings (CELLO) registry included patients treated with modified excimer laser catheters for the endovascular treatment of peripheral artery disease affecting the superficial femoral artery (SFA) and proximal popliteal artery. The aim of this study was to assess, via intravascular ultrasound (IVUS) the dissections in the vessel wall following treatment with the laser catheters. IVUS grayscale images from the CELLO registry were systematically reviewed for dissections in the treated vessel segments by two investigators. Images from 33 patients; 66 pullbacks (1867 IVUS frames in 2 phases), were successfully matched frame-to-frame to evaluate identical segments of the treated vessels in the two phases; post-2 mm Turbo-Elite laser pilot channel creation and post Turbo-Booster laser atherectomy. Dissections were categorized as; (1) intimal, (2) medial, (3) intramural hematoma, and (4) adventitial according to the ACC Clinical Expert Consensus Document classification of dissections. An average of 57 frames was evaluated per pullback, giving a total of 3734 frames (1867 matched for pre-ablation (post channel creation) and post-ablation phases). Treatments with the modified Excimer laser catheters resulted in a significant increase in lumen area of 5.5 ± 3.2-mm2 (95% CI 4.3-6.8, p < 0.0001) and reduction in plaque plus media volume of -10.6 ± 36.0 mm3 (95% CI -25.8 to 4.6, p = 0.1619) whilst giving rise to mainly intramural hematoma formations post Turbo-Booster laser treatment in 55% of frames assessed and 24% medial dissections with less than 1% adventitial disruption. The Excimer laser based Turbo-Booster treatment of peripheral artery lesions resulted in significant plaque debulking and increased lumen diameter with negligible degree of adventitial layer injury.

Prevalence, indications and management of balloon uncrossable chronic total occlusions: Insights from a contemporary multicenter US registry.

BACKGROUND: Balloon uncrossable lesions can be challenging to treat, requiring specialized techniques and equipment. METHODS: We examined the prevalence, clinical and angiographic characteristics, management and procedural outcomes of balloon uncrossable lesions in a multicenter chronic total occlusion (CTO) percutaneous coronary intervention (PCI) registry. RESULTS: Between 2012 and 2016, 718 CTO PCIs (in which the occlusion was successfully crossed with a guidewire) were performed in 701 patients at 11 US centers. Mean age was 65.6 ± 10 years and 84% of the patients were men. Balloon uncrossable lesions represented 9% of all CTOs. Balloon uncrossable CTOs had more moderate/severe calcification (82% vs. 52%, P < 0.0001), moderate/severe tortuosity (61% vs. 35% P < 0.0001) and higher J-CTO score (2.95 ± 1.32 vs. 2.43 ± 1.23, P = 0.005) as compared with the remaining lesions. Technical and procedural success was significantly lower for balloon uncrossable lesions (90.5% vs. 98.3%, P < 0.0001 and 88.9% vs. 96.6% P = 0.004), respectively, but the incidence of major adverse events was similar (1.6% vs. 2.2%, P = 0.751). Balloon uncrossable lesions required longer procedure (208 [interquartile range: 135, 258] vs. 135 [94, 194] min, P < 0.0001) and fluoroscopy (77 [52, 100] vs. 45 min [27, 75], P < 0.0001) time. Techniques used to treat balloon uncrossable lesions included balloon-assisted microdissection (23%), excimer laser atherectomy (18%), and rotational atherectomy (16%). Excimer laser atherectomy and balloon-assisted microdissection were associated with the highest technical and procedural success rates. CONCLUSIONS: Balloon uncrossable CTOs are common, are associated with high rates of technical failure, and require specialized techniques for successful treatment. © 2016 Wiley Periodicals, Inc.

Mitomycin-C in corneal surface excimer laser ablation techniques: a report by the American Academy of Ophthalmology.

OBJECTIVE: To review the published literature assessing the efficacy and safety of mitomycin-C (MMC) as an adjunctive treatment in corneal surface excimer laser ablation procedures. METHODS: Literature searches of the PubMed and Cochrane Library databases were last conducted on August 19, 2014, without language or date limitations. The searches retrieved a total of 239 references. Of these, members of the Ophthalmic Technology Assessment Committee Refractive Management/Intervention Panel selected 26 articles that were considered to be of high or medium clinical relevance, and the panel methodologist rated each article according to the strength of evidence. Ten studies were rated as level I evidence, 5 studies were rated as level II evidence, and the remaining 11 studies were rated as level III evidence. RESULTS: The majority of the articles surveyed in this report support the role of MMC as an adjunctive treatment in surface ablation procedures. When MMC is applied in the appropriate concentration and confined to the central cornea, the incidence of post-surface ablation haze is decreased. Although a minority of studies that evaluated endothelial cell density (ECD) reported an MMC-related decrease in ECD, no clinical adverse outcomes were reported. CONCLUSIONS: Over the past 15 years, the use of MMC during surgery in surface ablation has become widespread. There is good evidence of the effectiveness of MMC when used intraoperatively as prophylaxis against haze in higher myopic ablations. Although there are reports of decreased endothelial counts after the administration of MMC during surgery, the clinical significance of this finding remains uncertain, because no adverse outcomes were reported with as much as 5 years of follow-up. Optimal dosage, effectiveness as prophylaxis in lower myopic and hyperopic ablations, and long-term safety, particularly in eyes with reduced corneal endothelial cell counts from prior intraocular surgery, have yet to be established.

LASIK ablation centration: an objective digitized assessment and comparison between two generations of an excimer laser.

PURPOSE: To objectively define the effective centration of myopic femtosecond laser-assisted LASIK ablation pattern, evaluate the difference between achieved versus planned excimer laser ablation centration, and compare these results from two different generations of an excimer laser system. METHODS: The study retrospectively evaluated 280 eyes subjected to myopic LASIK. Digital image analysis was performed on Scheimpflug sagittal curvature maps (difference of preoperative to postoperative). Centration was assessed via proprietary software digital analysis of the coordinate displacement between the achieved ablation geometric center and the planned ablation center, which was the corneal vertex. Results from two different excimer laser generations (Eye-Q 400 [140 eyes] and EX500 [140 eyes]; Alcon/WaveLight, Fort Worth, TX) were compared. RESULTS: Radial displacement was on average 360 ± 220 µm (range: 0 to 1,030 µm) in the Eye-Q 400 laser group and 120 ± 110 µm (range: 0 to 580 µm) in the EX500 laser group (P < .01). The percentage of eyes with displacement of greater than 300 µm was 52% in the Eye-Q 400 laser group and 4% in the EX500 laser group. CONCLUSIONS: Displacement of ablation pattern may depend on the laser platform used. The improvement in the efficiency of centration indicates that newer generation excimer lasers with faster eye tracking and active centration control appear to achieve a significantly more accurate centration of myopic ablation patterns. The authors propose this novel, objective technique for laser refractive surgeon evaluation may point out significant outcome measures not currently used in standard metrics of refractive laser efficiency.

Assessment of axial length before and after myopic LASIK with the IOLMaster.

PURPOSE: To assess the relationship between theoretical ablation depth and axial length change after LASIK with the IOLMaster (Carl Zeiss Meditec, Dublin, CA). METHODS: Ninety-nine eyes were examined preoperatively and 1 and 3 months after LASIK. RESULTS: Mean ± standard deviation (SD) spherical equivalent before LASIK was -4.06 ± 1.91 diopters (D). Mean ± SD ablation depth was 83.13 ± 30.31 µm. Mean ± SD postoperative axial length of 25.11 ± 0.14 mm at 1 month was significantly shorter than mean ± SD preoperative axial length of 25.20 ± 0.14 mm (P < .001) with no subsequent change thereafter (P = .450). An increase in ablation depth of 1 µm led to a decrease in axial length of 0.00118 ± 0.00005 mm. Ablation depth correlated strongly with change in axial length (adjusted R(2) = 0.9039). CONCLUSIONS: The IOLMaster showed a decrease in axial length after LASIK that correlated well with theoretical ablation depth.

Assessment of tear osmolarity and other dry eye parameters in post-LASIK eyes.

PURPOSES: To assess the tear osmolarity using the TearLab device after laser in situ keratomileusis (LASIK) and to compare the values with those obtained by traditional tear film tests before and after the procedure. METHODS: Thirty eyes of 15 refractive surgery candidates (5 men and 10 women of mean age: 30.55 ± 11.79 years) were examined. Using a special questionnaire (Ocular Surface Disease Index), subjective dry eye complaints were evaluated, and then, the tear osmolarity was measured with the TearLab system (TearLab Corporation) and conventional dry eye tests were carried out. Examinations were performed preoperatively and at 1, 30, and 60 days after the surgery. RESULTS: The mean value of tear osmolarity was 303.62 ± 12.29 mOsm/L before the surgery and 303.58 ± 20.14 mOsm/L at 60 days after the treatment (P = 0.69). Mean lid parallel conjunctival folds value was 0.68 ± 0.68 before the procedure and 0.58 ± 0.65 subsequent to surgery (P = 0.25). Meibomian gland dysfunction was not detected. No significant deviation was observed in the values of Schirmer test, corneal staining, tear break-up time, and lid parallel conjunctival folds when compared with postoperatively obtained values during the follow-up period (P > 0.05). CONCLUSIONS: During LASIK flap creation, intact corneal innervation is damaged, and the ocular surface lacrimal functional unit can be impaired. In our study, no abnormal dry eye test results were observed before or after the procedure. Based on our results, LASIK treatment is safe for dry eye involving the administration of adequate artificial tears for a minimum of 3 months.

Cool excimer laser-assisted angioplasty (CELA) and tibial balloon angioplasty (TBA) in management of infragenicular arterial occlusion in critical lower limb ischemia (CLI).

We aim to compare cool excimer laser-assisted angioplasty (CELA) versus tibial balloon angioplasty (TBA) in patients with critical limb ischemia (CLI) with tibial artery occlusive disease. The primary end point is sustained clinical improvement (SCI) and amputation-free survival (AFS). The secondary end points are binary restenosis, target extremity revascularization (TER), and cost-effectiveness. From June 2005 to October 2010, 1506 patients were referred with peripheral vascular disease and 572 with CLI. A total of 80 patients underwent 89 endovascular revascularizations (EVRs) for tibial occlusions, 47 using TBA and 42 using CELA. All patients were Rutherford category 4 to 6. Three-year SCI was enhanced with CELA (81%) compared to TBA (63.8%; P = .013). Three-year AFS significantly improved with CELA (95.2%) versus TBA (89.4%; P = .0165). Three-year freedom from TER was significantly improved with CELA (92.9%) versus 78.7% TBA (P = .026). Three-year freedom from MACE was comparable in both the groups (P = .455). Patients with CELA had significantly improved quality time without symptoms of disease or toxicity of treatment (Q-TWiST) at 3 years (10.5 months; P = .048) with incremental cost of €2073.19 per quality-adjusted life year gained. Tibial EVR provides exceptional outcome in CLI. The CELA has superior SCI, AFS, and freedom from TER, with improved Q-TWiST and cost-effectiveness.