Corneal Endothelial Cell Cultures from Organotypic Preservation of Older Donor Corneas Are Suitable for Advanced Cell Therapy.

INTRODUCTION: The purpose of this work was to evaluate the in vitro growth capacity and functionality of human corneal endothelial cells (hCEC) expanded from corneas of elderly (>60 years) donors that were preserved using an organotypic culture method (>15 days, 31°C) and did not meet the clinical criteria for keratoplasty. METHODS: Cell cultures were obtained from prior descemetorhexis (≥10 mm) and a controlled incubation with collagenase type I followed by recombinant trypsin. Cells were seeded on coated plates (fibronectin-albumin-collagen I) and cultures were expanded using the dual supplemented medium approach (maintenance medium and growth medium), in the presence of a 10 µm Rho-associated protein kinase inhibitor (Y-27632). Cell passages were obtained at culture confluency (∼2 weeks). A quantitative colorimetric WST-1 cell growth assay was performed at different time points of the culture. Morphometric analysis (area assessment and circularity), immunocytochemistry (ZO-1, Na+/K+-ATPase α, Ki67), and transendothelial electrical resistance (TEER) were performed on confluent monolayers. RESULTS: There was no difference between the cell growth profiles of hCEC cultures obtained from corneas older than 60 years, whether preserved cold or cultivated organotypic corneas. Primary cultures were able to maintain a certain cell circularity index (around 0.8) and morphology (hexagonal) similar to corneal endothelial mosaic. The ZO-1 and Na+/K+-ATPase pump markers were highly positive in confluent cell monolayers at 21 days after isolation (passage 0; P0), but significantly decreased in confluent monolayers after the first passage (P1). A weak expression of Ki67 was observed in both P0 and P1 monolayers. The P0 monolayers showed a progressive increase in TEER values between days 6 and 11 and remained stable until day 18 of culture, indicating a state of controlled permeability in monolayers. The P1 monolayers also showed some functional ability but with decreased TEER values compared to monolayers at P0. CONCLUSIONS: Our results indicate that it is possible to obtain functional hCEC cultures in eye banks, using simplified and standardized protocols, from older donor corneas (>60 years of age), previously preserved under organotypic culture conditions. This tissue is more readily available in our setting, due to the profile of the donor population or due to the low endothelial count (<2,000 cells/mm2) of the donated cornea.

Comparison of Sulfur Hexafluoride 20% versus Air Tamponade in Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To compare clinical outcomes using 20% sulfur hexafluoride (SF6) versus 100% air as a tamponade for graft attachment in Descemet membrane endothelial keratoplasty (DMEK). DESIGN: Retrospective, comparative, interventional case series. PARTICIPANTS: Pseudophakic patients with Fuchs' endothelial dystrophy or pseudophakic bullous keratopathy that underwent DMEK using either 20% SF6 (group 1; 42 eyes) or 100% air (group 2; 39 eyes) tamponade between April 2010 and August 2011. METHODS: A bimanual infusion technique was used to introduce and position the donor endothelium-Descemet membrane graft tissue. Outcome measures were analyzed at the following time points: before surgery, 3 and 6 months after surgery, and at yearly intervals up to at least 3 years. MAIN OUTCOME MEASURES: Corrected distance visual acuity (CDVA), manifest refraction, pachymetry, central endothelial cell count (cECC), complications, and rebubbling rates. RESULTS: Three years after surgery, mean CDVA improved from 0.48±0.45 logarithm of the minimum angle of resolution (logMAR) to 0.04±0.23 in group 1 (P < 0.001) and from 0.67±0.45 logMAR to 0.09±0.13 logMAR in group 2 (P < 0.001). The percentage of eyes with CDVA of 20/25 or more was 85.71% (36/42 eyes) in group 1 and 82.05% (32/39 eyes) in group 2 (P = 0.43). Mean preoperative cECCs and at last follow-up were: group 1, 2525±338 cells/mm(2) and 1758 ± 398 cells/mm(2) (mean cell loss, 30±11%; P = 0.008); and group 2, 2492±204 cells/mm(2) and 1678±373 cells/mm(2) (mean cell loss, 32±13%; P = 0.008). Endothelial cell loss was similar in both groups (P = 0.65). Intracameral air reinjection was needed in 1 patient in group 1 (2.38%) and in 5 patients in group 2 (12.8%). The rebubbling rate was significantly higher in group 2 (P = 0.004). No episodes of immunologic graft rejection were documented. CONCLUSIONS: Although clinical outcomes and corneal endothelial cell loss were similar in both groups, tamponade with 20% SF6 yielded a significantly lower incidence of graft detachments that may warrant its routine use in DMEK. Longer-term, randomized studies are needed to recommend this approach fully.

Corneal impairment in a patient with type 2 distal arthrogryposis.

OBJECTIVE: Case report of a 7-year-old male patient, diagnosed with idiopathic progressive corneal alteration developed within a period of 6 months. METHODS: Description of type 2 distal arthrogryposis affecting hands and feet, a bilateral, congenital hearing loss, alterations such as keloid-like scarring, congenital heart disease, and cryptorchidism with no relevant family history. RESULTS: Corrected visual acuity in the right eye (RE) was 0.5 and in the left eye was 1 and, in addition to that, a bilateral corneal subepithelial fibrosis that was denser in the RE without neovessels and no signs of inflammatory activity. CONCLUSION: This is the first publication relating arthrogryposis with corneal affectation, probably because of a collagen anomaly characteristic in these patients.

Late onset of a persistent, deep stromal scarring after PRK and corneal cross-linking in a patient with forme fruste keratoconus.

PURPOSE: To present a case of a late, deep stromal scar in a 22-year-old patient with forme fruste keratoconus who underwent combined corneal cross-linking and photorefractive keratectomy (PRK). METHODS: Topography-guided corneal cross-linking combined with corneal PRK (without complications) was performed in both eyes with a delay of 2 weeks between each eye. RESULTS: At the 5-month postoperative examination of the right eye, a localized corneal haze was circumscribed to the posterior deep stroma, signifying a decrease of visual acuity. However, this improved partially and temporarily when treated with topical corticoids during 2 years of follow-up and then reoccurred, affecting the corrected distance visual acuity. CONCLUSIONS: To the authors' knowledge, this is the first documented, clinical case presenting a deep stromal affectation without endothelial decompensation and visual acuity affectation as a postoperative complication following topography-guided PRK and corneal cross-linking.

Long-term efficacy and safety profiles of iris-fixated foldable anterior chamber phakic intraocular lens implantation in eyes with more than 10 years of follow-up.

PURPOSE: To evaluate the long-term efficacy, safety, predictability, and stability of a foldable anterior chamber phakic intraocular lens (pIOL) (Artiflex) implantation in eyes with more than 10 years of follow-up. SETTING: Instituto de Microcirugía Ocular, Barcelona, Spain. DESIGN: Retrospective study. METHODS: Patients who underwent Artiflex pIOL implantation during 2008 to 2011 and with more than 10 years of follow-up were included. Variables analyzed were as follows: uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction, spherical equivalent (SE), endothelial cell count (ECC), and intraocular pressure (IOP) preoperatively and at 1 month, 1 year, 5 years, and the final follow-up. Descriptive statistics were performed and results reported following the Standard for Reporting Refractive Surgery Outcomes. RESULTS: 76 eyes (40 patients) were analyzed, and the mean follow-up was 10.67 ± 0.64 years. The mean preoperative SE was -8.26 ± 2.47 diopters (D), and the mean preoperative cylinder was -0.95 ± 0.86 D. At the final follow-up, efficacy and safety indices were 0.82 and 1.11, respectively. In total, 58 eyes (76%) achieved a UDVA of ≥20/40. 30 eyes (39%) gained ≥1 line of CDVA, and no eye lost ≥2 lines of CDVA. At the final follow-up, 46 (61%) and 58 (76%) eyes were within ±0.50 D and ±1.00 D of attempted SE correction, respectively. 72 eyes (95%) had ≤1.00 D of postoperative astigmatism, and 46 eyes (61%) were within ±15 degrees from the intended correction axis. At the last visit, a statistically significant myopic progression of -0.56 ± 0.83 D was observed ( P = .01). The mean ECC loss at the final follow-up was 12.2 ± 12.5%. IOP remained stable. Two eyes (2.63%) developed cataract after 10.3 years. CONCLUSIONS: Long-term results demonstrated that Artiflex pIOL implantation was effective, predictable, stable, and safe.

Eye bank and theatre factors for positive microbiological culture of corneoscleral rim and cornea storage medium in the real-world.

OBJECTIVES: To evaluate microbiological culture rate and positivity of corneoscleral rim and cornea storage media as well as possible risk factors for contamination with real-world data. METHODS: Data of consecutive cornea donors implanted in the reference centre from January 2013 to January 2018 were reviewed. Information about cornea characteristics (donor demographic data, endothelial cell density, type of cornea conservation, days of storage, and precut vs full-thickness tissue), and microbiological culture information (corneoscleral rim vs storage sample, positive result) were statistically analysed. RESULTS: During the study period, 1369 corneas (737 donors) were implanted. Cultures were performed in 76.8% (n = 1052) of them and were positive in 3.2% of cases, mainly bacteria (84.4%). Corneas preserved in hypothermia represented 61.8% of all positive microbiology results (p < 0.001). Other analysed risk factors did not reach statistically significant association with microbiological positivity. None of the 34 cases with positive microbiological cultures reported ocular infection for the recipients in at least 6 months' follow-up. CONCLUSIONS: Microbiological tests rate in real-world practice are high despite not being compulsory. Organotypic cultured corneas showed a statistically less positivity in corneoscleral and storage medium than hypothermic ones, resulting in another advantage of this kind of cornea storage. Although precut corneas are thought to present less microbiological positivity, a statistically significant association was not found in the present study.

The Cologne rebubbling study: a reappraisal of 624 rebubblings after Descemet membrane endothelial keratoplasty.

BACKGROUND/AIMS: To analyse graft detachments prior to rebubbling, the influence of rebubbling on the postoperative outcome after Descemet membrane endothelial keratoplasty (DMEK) and the need for rebubbling on the contralateral eye. METHODS: In this retrospective cohort study, out of 1541 DMEKs, optical coherence tomography scans and clinical records of 499 eyes undergoing rebubbling after DMEK at the University Hospital of Cologne, Cologne, Germany, were examined. Main Outcome measures were (a) number, localisation and size of graft detachments; (b) influence of rebubbling/s on postoperative outcome after 12 months; and (c) rebubbling risk of the contralateral eye after DMEK. RESULTS: Mean number of detachment areas was 2.02±0.9. Mean lateral diameter of all detachments was 4534.76±1920.83 µm. Mean axial diameter was 382.53±282.02 µm. Detachments were equally distributed over all regions of the cornea. Best spectacle corrected visual acuity ( BSCVA) after 12 months was 0.197±0.23 logarithm of the minimum angle of resolution, endothelial cell density (ECD) was 1575.21±397.71 cells/mm2 and mean central corneal thickness (CCT) was 566.37±68.11 µm. BSCVA, CCT, ECD or endothelial cell loss of all rebubbled patients were not influenced by the number of rebubblings or the time between DMEK and rebubbling. Of the rebubbled patients, which received a DMEK subsequently on the other eye, 193 (58.8%) also received a rebubbling, which was significantly higher, when compared to the overall rebubbling rate of 32.3% (p=0.000). CONCLUSIONS: The overall number of rebubblings has no influence on the postoperative outcome after DMEK, if a rebubbling becomes necessary. Patients who received a rebubbling on one eye have an elevated risk for a rebubbling on the fellow eye.

Optical quality one month after verisyse and Veriflex phakic IOL implantation and Zeiss MEL 80 LASIK for myopia from 5.00 to 16.50 diopters.

PURPOSE: To evaluate the eye's optical quality after phakic intraocular lens (IOL) implantation and LASIK for moderate to high myopia. METHODS: The retinal image quality of 45 patients was evaluated after undergoing one of three surgical procedures (9 patients with Verisyse IOL [AMO] implants, 11 patients with Veriflex IOL [AMO] implants, and 25 patients who underwent LASIK). Patients were aged <40 years, had at least 5.00 diopters of myopia, and had preoperative best spectacle-corrected visual acuity and postoperative uncorrected visual acuity better than 20/30. The eye's optical quality was measured using the Optical Quality Analysis System (OQAS, Visiometrics S.L.), which is an instrument based on the double-pass technique. Measurements were performed before surgery and 1 day and 1 month after surgery. RESULTS: Optical quality worsened noticeably 1 day after surgery with the Verisyse IOL with a 50% to 60% loss, most likely due to the large incision and the presence of sutures in most eyes. The LASIK technique and Veriflex IOL implant did not cause as remarkable a decrease in optical quality (20% to 25% loss). One month after surgery, the optical quality of patients with IOL implants was high, although some surgically induced astigmatism remained, especially in the Verisyse patients. Conversely, LASIK patients had slightly lower optical quality, with optical parameters that represented 90% of their initial value. CONCLUSIONS: Verisyse and Veriflex phakic IOL implantation and LASIK are both safe and effective in correcting moderate to high myopia, but they involve different processes of optical quality recovery. One day after surgery, the Verisyse IOL implantation significantly reduced the eye's optical quality, mainly due to the larger incision required and the higher number of sutures used. This reduction was not as remarkable with the other two techniques. However, 1 month after surgery, patients with IOL implants recovered more optical quality than LASIK patients.

Transitional conic toric intraocular lens for the management of corneal astigmatism in cataract surgery.

SYNOPSIS: Transitional toric intraocular lens (IOL) was developed to improve refractive outcomes in cataract surgery. We report refractive, vectorial outcomes, and stability of spherical equivalent over 12 months after implantation of this IOL. PURPOSE: To evaluate visual and refractive outcomes of a transitional conic toric intraocular lens (IOL) (Precizon®) for the correction of corneal astigmatism in patients undergoing cataract surgery. SETTING: The Ocular Microsurgery Institute (IMO), a private practice in Barcelona, Spain. DESIGN: This is a retrospective, non-randomized study. METHODS: Retrospective chart review of 156 patients with preoperative regular corneal astigmatism >0.75 diopters (D) who underwent consecutive phacoemulsification and Precizon toric IOL implantation between January 2014 and December 2015 was performed. Two groups were divided according to attempted residual refraction: group 1 with emmetropia and group 2 with mild myopia for monovision. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and manifest refraction were analyzed preoperatively and 3, 6, and 12 months postoperatively. RESULTS: Precizon toric IOL was implanted in 97 eyes of 61 patients. Six months postoperatively, none of the eyes lost any line of CDVA. In all, 98% of the eyes were within ±1.00 D of attempted spherical correction. The mean preoperative keratometric cylinder was 1.92 ± 1.04 D (range 0.75-6.78), and the mean postoperative refractive cylinder was 0.77 ± 0.50 D (range 0-2.25), with 81% of the eyes with ≤1.00 D of residual cylinder. Two IOLs required realignment due to intra-operative positioning error. Eleven eyes required enhancement with corneal refractive surgery. CONCLUSION: Preexisting regular corneal astigmatism was effectively and safely corrected by the implantation of the transitional conic toric IOL in patients undergoing cataract surgery.

European multicenter trial of the prevention of cystoid macular edema after cataract surgery in nondiabetics: ESCRS PREMED study report 1.

PURPOSE: To compare the efficacy of a topical nonsteroidal antiinflammatory drug, topical corticosteroid, and a combination of both drugs to prevent the occurrence of cystoid macular edema (CME) after cataract surgery in nondiabetic patients. SETTING: Twelve European study centers. DESIGN: Randomized clinical trial. METHODS: Nondiabetic patients having uneventful cataract surgery were included in this study. Patients were randomized to receive topical bromfenac 0.09% twice daily for 2 weeks or dexamethasone 0.1% 4 times daily with 1 drop less per day every following week, or a combination of both. The primary outcome was the difference in central subfield mean macular thickness 6 weeks postoperatively. Secondary outcome measures included corrected distance visual acuity as well as the incidence of CME and clinically significant macular edema (CSME) within 6 weeks and 12 weeks postoperatively. RESULTS: This study comprised 914 patients. Six weeks postoperatively, the central subfield mean macular thickness was 288.3 µm, 296.0 µm, and 284.5 µm in the bromfenac group, dexamethasone group, and combination treatment group, respectively (overall P = .006). The incidence of clinically significant macular edema within 12 weeks postoperatively was 3.6%, 5.1%, and 1.5%, respectively (overall P = .043). CONCLUSION: Patients treated with a combination of topical bromfenac 0.09% and dexamethasone 0.1% had a lower risk for developing CSME after cataract surgery than patients treated with a single drug.

Suggested Guidelines for Reporting Keratoprosthesis Results: Consensus Opinion of the Cornea Society, Asia Cornea Society, EuCornea, PanCornea, and the KPRO Study Group.

PURPOSE: To propose a series of standardized guidelines for reporting keratoprosthesis (KPRO) results. METHODS: At the most recent KPRO Study Group Meeting (Barcelona, 2015), representatives of the 4 multinational corneal societies (Cornea Society, Asia Cornea Society, EuCornea, and PanCornea) and the KPRO Study Group agreed to propose consistent terminology for reporting KPRO results, especially in describing the length of follow-up and in the description of the KPRO itself. Consensus was reached for minimal reporting guidelines. RESULTS: The 4 multinational corneal societies and the KPRO Study Group agreed to standardized terminology for reporting the length of follow-up, preoperative diagnosis grouping, and data stratification based on the KPRO type used. CONCLUSIONS: Guidelines suggesting minimal reporting standards will assist in both data collection and reporting and will allow for better comparative analysis and pooling of the available data.

Paired-eye comparison of corneal endothelial cell counts after unilateral iris-claw phakic intraocular lens implantation.

PURPOSE: To compare the corneal endothelial cell density (ECD) after unilateral iris-claw phakic intraocular lens (pIOL) implantation. SETTING: Instituto de Microcirugia Ocular, Barcelona, Spain. DESIGN: Retrospective interventional nonrandomized paired-eye comparison. METHODS: Patients who had pIOL implantation in 1 eye and corneal refractive surgery (Group 1) or no surgery in the fellow eye (Group 2) between 1998 and 2010 were included. The main outcome measures were central corneal ECD and the percentage of corneal endothelial cell loss. Secondary outcome measures were uncorrected distance visual acuity, corrected distance visual acuity, manifest refraction, and complications. Outcome measures were analyzed 1, 5, and 10 years postoperatively. RESULTS: Both groups comprised 29 patients. Ten years after surgery, the mean endothelial cell loss was 6.41% ± 8.02% (SD) (Group 1, iris-claw pIOLs), 5.59% ± 5.98% (Group 1, corneal refractive surgery), 7.84% ± 6.83% (Group 2, iris-claw pIOLs), and 6.74% ± 3.97% (Group 2, no surgery). No significant endothelial cell loss was observed after pIOL implantation or corneal refractive surgery at any timepoint (P > .05). No significant differences were observed in the percentage of endothelial cell loss between the groups (P > .05). CONCLUSIONS: Iris-claw pIOL implantation did not produce significant corneal endothelial cell loss up to 10 years after surgery compared with corneal refractive surgery and unoperated eyes when strict inclusion criteria were met. FINANCIAL DISCLOSURE: Dr. Güell is a consultant to Ophtec BV and Carl Zeiss Meditec AG. No other author has a financial or proprietary interest in any material or method mentioned.

Unilateral Iris-Claw Intraocular Lens Implantation for Aphakia: A Paired-Eye Comparison.

PURPOSE: To perform a paired-eye comparison of secondary iris-claw intraocular lens (IOL) implantation for aphakia. METHODS: Retrospective, comparative, nonrandomized interventional case series of aphakic eyes, which underwent secondary iris-claw Artisan IOL (Ophtec BV) implantation for aphakia in one eye and no surgery (group 1) or cataract surgery (group 2) in the fellow eye. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent, central endothelial cell count (cECC), and complications were evaluated before surgery, and at yearly intervals up to 5 years. RESULTS: Thirty aphakic eyes implanted with the Artisan were included, and the fellow eyes served as controls. In group 1, postoperative logMAR UDVA and CDVA was significantly higher in the Artisan-implanted eyes (P < 0.01). In group 2, no differences were found in postoperative UDVA and postoperative CDVA between the Artisan-implanted eyes and the eyes that underwent cataract surgery throughout the follow-up (P ≥ 0.05). No statistically significant differences were found in postoperative spherical equivalent between the Artisan-implanted eyes and unoperated eyes or eyes that underwent cataract surgery (P ≥ 0.05). In group 1, cECC was significantly lower in the Artisan-implanted eyes [1973 ± 822 vs. 2616 ± 481 cells per square millimeter at 2 years (P < 0.01)] throughout the follow-up (P < 0.01). In group 2, cECC was not significantly lower in the Artisan-implanted eyes (P ≥ 0.05) [1934 ± 689 vs. 2058 ± 818 cells per square millimeter at 2 years (P = 0.67)]. CONCLUSIONS: Visual rehabilitation with secondary iris-claw IOL implantation in aphakic eyes without capsular support seems to be an effective and safe procedure. As expected, uncomplicated cataract surgery with posterior chamber IOL implantation showed lower endothelial cell count loss. Close monitoring of the corneal endothelium is mandatory.

Secondary Artisan-Verysise aphakic lens implantation.

PURPOSE: To evaluate efficacy, predictability and safety of Artisan-Verysise intraocular lens (IOL) secondary implantation for aphakia correction. SETTING: Instituto de Microcirugía Ocular, and Autonoma University of Barcelona, Barcelona, Spain. METHODS: Uncorrected visual acuity, best spectacle-corrected visual acuity (BSCVA), manifest refraction, endothelial cell count, and clinical complications were evaluated. Sixteen consecutive eyes of 14 patients with aphakia were submitted to surgery. Postoperative examinations were done at 6 weeks, 6 months, 1 year, and every year for at least 3 years. An iris-supported Artisan-Verysise IOL was implanted for aphakia correction. RESULTS: Thirty-six months after Artisan-Verysise lens implantation, BSCVA was 20/40 or better in 6 eyes (37.5%). Preoperatively, 5 eyes had the same BSCVA (31.25%). Mean postoperative spherical equivalent (SE) was 0.46 diopter (D). Mean endothelial cell loss was 10.9% 36 months postoperatively. The cell loss occurred predominantly during the first year (7.78%). Cystoid macular edema was observed in 2 cases, 1 of them associated with chronic unresponsive low intraocular pressure. No other serious complications were observed. CONCLUSION: Artisan-Verysise IOL implantation seems a safe, predictable, and effective option for aphakic eyes without capsule support.

Corneal flap thickness and topography changes induced by flap creation during laser in situ keratomileusis.

PURPOSE: To determine the corneal flap thickness profile produced by 3 microkeratomes and the topographic changes induced by flap creation in laser in situ keratomileusis (LASIK). SETTING: Cornea and Refractive Surgery Unit, Instituto de Microcirugia Ocular de Barcelona, Autonoma University, Barcelona, Spain. METHODS: In this prospective consecutive nonrandomized comparative study, patients were divided into 2 groups. In Group 1 (75 eyes), 3 microkeratomes were used: Moria LSX One, Moria M2, and Amadeus (AMO); 25 eyes per microkeratome. Pachymetry was measured with a DGH pachymeter in the center of the cornea and 3.0 mm from the center at 4 cardinal points (superior, inferior, nasal, and temporal; 3 measurements at each point) before and after the cut. The flap thickness in each sector was calculated by subtracting the mean post-flap corneal thickness from the mean pre-flap corneal thickness. In Group 2 (33 eyes), the M2 microkeratome with a 130 microm plate was used to create a superotemporal hinged flap (9 eyes) or a superonasal hinged flap (24 eyes). The topographic change induced by the microkeratome cut was evaluated using 4 sequential data acquisitions by the Keratron Scout topographic unit (Optikon) before and immediately after the cut (before laser ablation). Cardinal and oblique astigmatism and change in the axis were calculated by vectorial analysis of the simulated keratometry. Topographic Zernike analysis was performed in a subgroup. RESULTS: With the LSX One microkeratome, the mean flap thickness was 151.7 microm centrally, 161.9 microm superiorly, 151.4 microm inferiorly, 156.1 microm temporally, and 167.5 microm nasally. There was no statistically significant difference between the areas studied (P<.05). With the M2, the mean flap thickness was 131.7 microm centrally, 155.5 microm superiorly, 146.7 microm inferiorly, 143.7 microm temporally, and 160.5 microm nasally. There was a statistically significant difference between flap thickness centrally and in the other areas (P>.05). With the Amadeus microkeratome, the mean flap thickness was 140.0 microm centrally, 152.5 superiorly, 128.5 microm inferiorly, 145.0 microm temporally, and 147.0 microm nasally. Statistically significant differences (P>.05) were found in the 4 sectors of the flap. With vectorial analysis, there was no statistically significant difference between superonasal and superotemporal hinge placement in the cardinal and oblique components but there was a statistically significant difference in the axis change with both placements (P>.05). CONCLUSIONS: The LSX One microkeratome was the most predictable. A significant difference was noted in all sectors except superiorly with the M2 and in all sectors with the Amadeus. No differences between nasal and superior hinge placement were found with the M2. Topographic Zernike analysis demonstrated a difference in the orientation of the induced coma as a function of hinge position.

Intraocular Lens Opacification After Endothelial Keratoplasty as Analyzed by Environmental Scanning Electron Microscopy.

PURPOSE: To describe a case of hydrophilic intraocular lens (IOL) opacification based on IOL analysis after Descemet stripping automated endothelial keratoplasty. METHODS: A 60-year-old woman had uneventful phacoemulsification after the implantation of a hydrophilic IOL (Akreos-Adapt; Bausch & Lomb) into both eyes. Because of postoperative corneal decompensation in the right eye, 2 Descemet stripping automated endothelial keratoplasty operations were performed within 1 year. After the second procedure, the graft was not well attached, requiring an intracameral injection of air on day 3. After 1 year, opacification was observed on the superior 2/3 of the anterior surface of the IOL, along with a significant decrease in visual acuity. The IOL was explanted 6 months after the opacification. RESULTS: Environmental scanning electron microscopy followed by x-ray microanalysis revealed an organic biofilm on the surface of the IOL. CONCLUSIONS: To our knowledge, this is the first reported case in which the material deposited on the lens is organic rather than calcific.