Intracanalicular antibiotic ointment loading as a management option for canaliculitis.

AIM: The aim of the study is to describe intracanalicular antibiotic ointment loading as a treatment option for canaliculitis. MATERIAL AND METHODS: It was an interventional prospective study. The study was conducted over a 3 year period from June 2015 to June 2018. All patients of canaliculitis managed with intracanalicular antibiotic ointment loading and with a minimum follow up of 3 months were included in the study. The antibiotic ointment was loaded into the canaliculus based on the antibiotic sensitivity of the material expressed out from the canaliculus. Patients' demographics, clinical details, microbiological profile and management outcomes were evaluated. RESULTS: A total of 24 patients were included in the study. Mean age at presentation was 58.41 ± 9.4 years. The right eye was involved in 15 (62.5%, p = .0424) cases. The incidence of lower canaliculus involvement (14, 58.33%, p = .022) was significantly higher as compared to the upper canaliculus (8, 33.33%). Staphylococcus epidermidis and Actinomyces israelii (6, 25%) were the most commonly isolated organisms. Mean number of intracanalicular antibiotic loading sessions required was 4.21 ± 1.69 (range 2-8). Complete resolution of canaliculitis was seen in all (100%) cases. CONCLUSION: Canalicular antibiotic ointment loading is a minimally invasive, safe, and effective procedure. It preserves the anatomy and function of the punctum and canaliculus and can be considered as one of the management options for canaliculitis.

Comparison of efficacy of trehalose-based eye drops versus topical 0.1% Hyaluronic Acid for management of clinically significant dry eye using non-invasive investigational modalities.

PURPOSE: To compare the efficacy of trehalose-HA eye drops versus 0.1% hyaluronic acid for the treatment of dry eye. METHODS: This prospective, comparative, contralateral eye study included sixty eligible patients (mean age 44.13 ± 14.53 years). Patients having a SPEED questionnaire score of 16 or above, objective scatter index (OSI) > 1 and non-invasive tear break up time (NIBUT) of 10 s or less were included in the study. Eyes were randomized to receive 0.1% hyaluronic acid (HA) in one eye and trehalose-HA eye drops in the contralateral eye. At baseline, 1- and 3-month follow-ups, OSI, NIBUT, MG loss, tear meniscus height (TMH) and tear film osmolarity (TFO) were evaluated using non-invasive modalities RESULTS: There was a statistically significant improvement in NIBUT, TMH, OSI, SPEED questionnaire score in the trehalose-HA compared to the 0.1% HA group at both 1- and 3-month visits (p < 0.05). In both the study groups, compared to the baseline, the mean values of TFO, MG loss, OSI and SPEED questionnaire score significantly reduced at 3 months (p < 0.05). The mean values of NIBUT and tear meniscus height on the other hand showed a significant increase compared to the baseline values (p < 0.05). Both drugs were well tolerated by the study participants without any significant ocular side effects. CONCLUSION: Trehalose-HA was found to be more effective than 0.1% HA eye drops in the management of symptomatic dry eye, as shown by significant reduction in NIBUT, TMH and OSI, when evaluated using non-invasive modalities of dry eye evaluation.

A comparison of safety and clinical outcomes of 100 µ versus 160 µ cap in patients undergoing ReLEx-Small Incision Lenticule Extraction (SMILE).

PURPOSE: To determine the safety, efficacy and clinical outcomes of 100 µ versus 160 µ cap in patients undergoing ReLEx-Small Incision Lenticule Extraction (SMILE). METHODS: This prospective, comparative, non-randomized clinical trial included hundred eyes from 50 patients, undergoing bilateral ReLEx SMILE for myopia ranging from - 1 to - 6 D spherical equivalent. Twenty-five patients received treatment with standard 100 µ cap thickness, while the remaining 25 patients underwent the same procedure but with a 160 µ cap thickness in both eyes. Manifest refraction, UDVA, CDVA, contrast sensitivity, aberrations and dry eye were evaluated along with a subjective questionnaire at 2 weeks and 3 months post-operatively. Mean follow-up was 90 ± 15 days. RESULTS: At two weeks and 3 months post-operative, compared to the preoperative values, the mean log-MAR UDVA, CDVA, spherical equivalent, contrast sensitivity higher order aberrations did not show statistically significant differences (p > .05) between the two study groups. However, significant reduction in Schirmer's II and TBUT scores was observed compared to preoperative scores at 3 months in 100 µ group (p > .05) but not in160 µ group. Patients did not report significant subjective complaints in either groups treated, when leading questions were asked through a subjective questionnaire. CONCLUSION: ReLEx SMILE with 160 µ cap thickness was equally safe and efficacious as 100 µ cap, with no unique complications observed by keeping a thicker cap. Post-operative dry eye was significantly less in 160 µ group, suggesting an advantage in patients with pre existing dryness or contact lens users. TRIAL REGISTRATION NUMBER: CTRI/2014/09/005,005.

Clinical outcomes, predictability and rotational stability following implantation of Eyecryl toric versus TECNIS toric intraocular lenses-A comparative study.

PURPOSE: To compare the visual outcomes, predictability and rotational stability following implantation of Eyecryl toric versus TECNIS toric intraocular lenses. METHODS: This retrospective study included 100 eyes of 78 eligible patients who underwent phacoemulsification followed by implantation of either Eyecryl Toric IOL or TECNIS Toric IOL (n = 50 eyes in each group), using an intraoperative image-guided marker less system. All toric IOL implantations were performed under balanced salt solution. At 2 weeks, 3 months and 6 months, uncorrected (UDVA) and corrected distance visual acuity (CDVA), spherical equivalent refraction, residual astigmatism, and rotational stability of the toric IOL was evaluated and compared. Rotational stability was assessed using ray tracing. RESULTS: Mean age of the participants was 67.8 ± 9.26 years in Eyecryl toric group and 64 ± 11 years in TECNIS toric group. The mean pre-op corneal astigmatism was 1.75 ± 0.62 D and 2.00 ± 0.71 D in the Eyecryl and TECNIS group, respectively (p = 0.07). At 2 weeks and at 6 months post-op, there was no statistically significant difference between the UDVA, CDVA, and residual astigmatism between the two groups (p < 0.05). Mean post-operative toric IOL rotation was 3.94 ± 2.27 degrees in the Eyecryl Toric group, and 4.44 ± 2.77 degrees, in the TECNIS Toric group, respectively, the difference was not statistically significant (p = 0.32). One IOL in the Eyecryl group and two IOLs in the TECNIS group required re-positioning for significant post-op rotation at 1 week post-op. CONCLUSION: At 6 months, both Eyecryl toric and TECNIS toric IOLs showed comparable post-operative outcomes in terms of UDVA, CDVA, residual astigmatism and rotational stability.

Comparison of ReLEx SMILE and PRK in terms of visual and refractive outcomes for the correction of low myopia.

PURPOSE: To compare the objective and subjective quality of vision after femtosecond laser-assisted small incision lenticule extraction (SMILE) and photorefractive keratectomy (PRK) for low myopia. METHODS: One hundred and twenty eyes from 60 patients (34 females, 26 males) undergoing bilateral correction of low myopia (≤-4 D SE) with either ReLEx SMILE or PRK were included. Visual acuity, contrast sensitivity and higher-order aberrations were recorded preoperatively and compared postoperatively. A quality of vision questionnaire was scored and analyzed 3 months postoperatively. RESULTS: At 3 months, the SMILE group had significantly better uncorrected and corrected distant visual acuity (CDVA), compared to PRK group (p = 0.01). Post-op spherical equivalent (SE) was comparable in both groups (SMILE = -0.15 ± 0.19 D, PRK = -0.14 ± 0.23 D, p = 0.72). However, SE predictability was better in SMILE group with 97% eyes within ±0.05 D compared to 93% eyes in the PRK group. Total higher-order aberrations (HOAs) were significantly higher in PRK compared to the SMILE group (p = 0.022). The SMILE group demonstrated slightly better contrast sensitivity, which was significant at spatial frequency of 12 cpd (p = 0.03). Four eyes in the PRK group had loss of CDVA by one line due to mild haze. CONCLUSIONS: Both SMILE and PRK were effective procedures for correction of low myopia. However, SMILE offered superior quality of vision and patient satisfaction due to better postoperative comfort and lower induction of aberrations at 3 months.

Jellyfish sign for intraoperative identification of posterior lenticonus.

Posterior lenticonus is a rare progressive disease characterized by protrusion of posterior lens capsule along with lens cortex into the vitreous cavity. It may be associated with local thinning or absence of posterior lens capsule. It generally occurs sporadically, but familial cases have also been reported. If visually significant or if amblyopia is present, lens removal is indicated. Treatment consists of clear or cataractous lens extraction, optical correction along with prompt amblyopia therapy. In this case, we propose a "jellyfish sign" seen intraoperatively, which is referred to the characteristic movement of the posterior capsular cataractous material on injection of balanced salt solution in the capsular bag.

Comparison of visual and refractive outcomes following femtosecond laser- assisted lasik with smile in patients with myopia or myopic astigmatism.

PURPOSE: To compare the visual and refractive out-comes of femtosecond laser-assisted LASIK with small-incision lenticule extraction (SMILE) in terms of visual acuity, contrast sensitivity, aberrations, and dry eye. METHODS: A single-center prospective randomized study in which patients diagnosed as having myopia presenting for refractive correction were allocated to either a LASIK or SMILE group. The primary outcome measures were refractive efficacy, predictability, and safety, postoperative contrast sensitivity, aberrations, and dry eye status. Patients were followed up at days 1 and 15 and 3 months; postoperative uncorrected visual acuity (UCVA), aberrations, dry eye, and contrast sensitivity were recorded and compared to preoperative data. Two postoperative subjective questionnaires were used to assess pain, pricking sensation, redness, glare, and overall patient satisfaction. RESULTS: At day 1 postoperatively, 48 (96%) of 50 eyes in the SMILE group achieved a UCVA of 20/20 compared with 46 (92%) of 50 eyes in the LASIK group. At day 15 postoperatively, contrast sensitivity was similar in the two groups (P = .15), but by 3 months, it was better in the SMILE group than the LASIK group at all spatial frequencies (P < .0001). At 3 months postoperatively, 42 (84%) eyes in each group achieved a UCVA of 20/20, with 6 (12%) eyes in the SMILE group and 2 (4%) eyes in the LASIK group achieving 20/15. Higher-order aberrations at 3 months postoperatively were significantly higher in the LASIK group (0.437 + 0.103 pm) than in the SMILE group (0.267 + 0.07 pm; P < .001). Postoperative dry eye and glare were significantly more common following LASIK (P < .001). CONCLUSIONS: Three-month results demonstrate that refractive accuracy, dry eye, contrast, and induced aberrations are better following SMILE rather than LASIK.

Clinical outcomes and rotational stability after implantation of a monofocal toric intraocular lens with textured haptics in normal vs high axial lengths.

PURPOSE: To compare the clinical outcomes and rotational stability after implantation of a toric intraocular lens (IOL) with textured haptics in eyes with normal vs high axial lengths (ALs). SETTING: Nethradhama Superspeciality Eye Hospital, Bangalore, India. DESIGN: 2-arm, retrospective comparative study. METHODS: This retrospective study included 114 eyes of 114 patients who underwent femtolaser cataract surgery followed by implantation of the HOYA Vivinex Toric monofocal IOL (Model XY1A-SP), of which 62 and 52 eyes belonged to normal (≤23.9 mm) and high (≥24 mm) AL groups, respectively. 1 week and 3 months postoperatively, clinical outcomes and rotational stability of the toric IOL was evaluated. RESULTS: 3 months postoperatively, % eyes achieving refractive astigmatism accuracy within ≤0.50 diopter, was 100% (n = 62) in the normal vs 94% (n = 49) in the high AL group. All eyes that is, 100% (n = 62) in the normal and 96.15% (n = 50) eyes in the high myopia group were <5 degrees of the intended axis. The mean change in postoperative rotation from 1 week to 3 months was 0.28 ± 0.09 degrees in the normal, and 0.30 ± 1.11 degrees in the high AL group ( P = .80). No significant correlation was observed between AL and white-to-white diameter with 1-week postoperative rotation values. No eye required repositioning of toric IOL for significant misalignment. CONCLUSIONS: No significant differences were observed for clinical outcomes and postoperative rotational stability between eyes with normal and high ALs, suggesting excellent rotational stability of the Vivinex Toric IOL with textured haptics in all eyes, irrespective of the preoperative AL measurements.

Lamellar surgeries with SMILE-derived lenticules.

PURPOSE: Lamellar surgeries with SMILE lenticules are an evolving field of refractive surgery. This chapter intends to discuss the reported clinical results of using SMILE derived lenticules in terms of feasibility, safety and predictability; or the potential management of hyperopia, keratoconus, SMILE ectasia and presbyopia. MATERIALS AND METHODS: Donor SMILE lenticules were prepared under microscope tocreate doughnut shaped lenticules. For hyperopia, this tissue was then inserted into afemtosecond laser enabled pocket created using VisuMax FS Laser at a depth of 160µm. For ectasia induced by keratoconus and post refractive procedure (SMILE), 0.23% riboflavin dye was instilled into the interface and then lenticule was inserted followed by exposure to UV-A radiation with total energy of 6.3 J. RESULTS: Spherical equivalent (S.E.) of within ± 0.5 D was observed in 50% (n=21) eyes and within 1 D was seen in 71% eyes treated for hyperopia. A significant increase in the K mean anterior, central corneal thickness, Q-value and corneal aberrations was seen 2 weeks post-op. Clinical improvement in terms of S.E. and uncorrected distance visual acuity in eyes treated for ectasia after keratoconus and post refractive procedure (SMILE) was seen. CONCLUSION: With the ample availability of SMILE- derived lenticules, researchers are exploring the possibility of using this tissue for the treatment of various refractive and corneal conditions.

Changes in endothelial cell density after conventional phacoemulsification and FLACS in eyes with dense cataracts.

PURPOSE: To compare the safety, effectiveness, and changes in endothelial cell density (ECD) after standard phacoemulsification and femtosecond laser-assisted cataract surgery (FLACS) in dense cataracts (Lens Opacities Classification System III grade 3.0 NO and above). SETTING: Nethradhama Superspeciality Eye Hospital, Bangalore, India. DESIGN: Prospective, randomized, comparative study. METHOD: 100 eyes of 100 patients were randomly assigned to either conventional phacoemulsification surgery (CPS) or FLACS (LENSAR Laser System) using predefined patterns of nuclear fragmentations. Measured outcomes included intraoperative phacoemulsification time, irrigation fluid volume, surgical time, and complication rates. ECD was evaluated at baseline, 2 weeks, and 6 months postoperatively. RESULTS: The CPS group had significantly higher mean total phacoemulsification time (11.17 ± 6.5 seconds vs 8.03 ± 3.77 seconds), effective phacoemulsification time (6.14 ± 3.62 seconds vs 4.42 ± 2.07 seconds), and total surgical time (8.18 ± 2.36 minutes vs 7.11 ± 1.55 minutes) than the FLACS group ( P < .001). Volume of irrigation fluid was comparable between the 2 groups (CPS, 36.7 ± 12.18 mL; FLACS, 38.64 ± 13.73 mL ( P = .45). Mean corneal edema score and central corneal thickness values on postoperative day 1 were significantly higher for the CPS group. At 6 months, % ECD loss was significantly higher in the CPS group (16.08%) vs the FLACS group (12.8%) ( P < .001). 3 eyes in the CPS group had wound burns of varying severity. CONCLUSIONS: FLACS with customized nuclear fragmentation patterns resulted in significantly less intraoperative phacoemulsification time, surgical time, and endothelial cell loss compared with conventional phacoemulsification when treating dense cataracts. TRIAL REGISTRATION NUMBER: CTRI/2021/12/038887.

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

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

Interobserver agreement between central topography and Scheimpflug tomography for premium intraocular lens selection.

PURPOSE: To assess the inter-observer agreement and reliability of central topography (CT) of IOL Master 700 with that of Pentacam HR, as a screening tool for determining the suitability for premium (toric, monofocal and presbyopia correcting) intraocular lens (IOL) implants. SETTING: Nethradhama Superspeciality Eye Hospital, Bangalore, India. METHOD: 200 eyes of eligible patients undergoing unilateral or bilateral phacoemulsification with premium IOL's were included in the study. Preoperatively, IOL Master 700 CT and Pentacam scans were performed for corneal topography evaluation. 2 experienced clinicians were randomised to interpret the axial map of either of the scans at a time and their responses were then enclosed in an envelope, and forwarded to a third observer for analysis. If there was a conflict, final decision was based on the interpretation of the Pentacam scan. RESULTS: Of the total scans interpreted by the 2 observers, 77.5% (n = 155) showed agreement whereas 22.5% (n = 45) showed disagreement. The sensitivity, specificity, positive predictive value and negative predictive value (NPV) of IOL Master 700 CT in diagnosing irregular corneas when compared with Pentacam HR, was 72.73%, 78.09%, 29.09% and 95.86% respectively. The Cohen's κ inter-observer agreement value was 0.44, signifying a moderate degree of agreement, which was statistically significant (P < .00). CONCLUSIONS: High NPV of IOL Master CT suggested that the device efficiently ruled out irregular corneas, while any suspicious scan should be confirmed with Pentacam HR or a similar device for appropriate decision-making regarding premium IOL selection. TRIAL REGISTRATION NUMBER: CTRI/2021/11/038053.

A new intraocular lens marker to guide the implantation of toric intraocular lenses in small and mid-dilating pupils.

Insufficient pupillary dilatation is a significant challenge during cataract surgery, as it increases the risk of various intraoperative complications. Implantation of toric intraocular lenses (TIOL) is particularly difficult in eyes with small pupils, as the toric marks are provided in the periphery of the IOL optic, making the visualization of the same difficult for proper alignment. Attempts at visualizing these marks using a second instrument such as a dialler or iris retractor lead to additional manipulations in the anterior chamber resulting in increased chances of postoperative inflammation and intraocular pressure rise. A new intraocular lens (IOL) marker to guide the implantation of TIOLs in eyes with small pupils is described, which can potentially be beneficial in achieving accurate alignment of toric IOLs in small pupils, without the need for additional manipulations, thus improving safety, efficacy, and success rates of TIOL implantation in these eyes.

A prospective, randomized, comparative clinical study to compare the safety and efficacy of different hydrophobic aspheric monofocal intraocular lenses.

Purpose: To report the 1-year clinical outcomes related to safety, efficacy, predictability, contrast sensitivity, patient satisfaction, complications, and overall results with Optiflex Genesis and Eyecryl Plus (ASHFY 600) monofocal aspheric intraocular lenses (IOLs) and compare the same with Tecnis-1 monofocal IOL. Methods: This prospective, single-center, single-surgeon, randomized, three-arm study included 159 eyes of 140 eligible patients who underwent cataract extraction with IOL implantation with any of the three study lenses. Clinical outcomes related to safety, efficacy, predictability, contrast sensitivity, patient satisfaction, complications, and overall results were compared at a mean follow-up of 1 year (12 ± 1.20 months). Results: Preoperatively, age and baseline ocular parameters of all the three groups were matched. At 12 months post-op, no significant differences were noted among the groups in terms of mean postoperative uncorrected and corrected distance visual acuity (UDVA and CDVA, respectively) sphere, cylinder, and spherical equivalent (SE; P > 0.05 for all parameters). Eighty-nine percent eyes in the Optiflex Genesis group as against 96% eyes in the Tecnis-1 and Eyecryl Plus (ASHFY 600) groups were within ± 0.5 D, and 100% of eyes in all the three groups were within ± 1.00 D of SE accuracy. Postoperative internal higher-order aberrations (HOAs) and coma, and mesopic contrast sensitivity at all spatial frequencies were comparable across all the three groups. Two eyes in the Tecnis-1 group, two eyes in the Optiflex group, and one eye in the Eyecryl Plus (ASHFY 600) group underwent YAG capsulotomy at the last follow-up. No eye in any of the groups showed glistenings or required IOL exchange due to any reason. Conclusion: At 1-year post-op, all the three aspheric lenses showed comparable results in visual and refractive parameters, post-op aberrations, contrast sensitivity, and posterior capsule opacification (PCO) behavior. Further follow-up is needed to evaluate the long-term behavior for refractive stability and PCO rates of these lenses. Trial registry: CTRI/2019/08/020754 (www.ctri.nic.in).

The Ganesh-Grewal cystitome maker - A step in standardizing cataract surgery.

A well-centered, adequately sized continuous curvilinear capsulorhexis (CCC) is a prerequisite for successful cataract surgery. A perfect capsulorhexis ensures safe and effective performance of various steps of surgery as well as a correctly positioned intraocular lens (IOL) with optimal rotational stability. Ganesh and Grewal (GG) cystitome maker is a step toward standardizing the creation of a cystitome to reduce variations and complications associated with the crucial step of CCC in cataract surgery. We conducted a study to measure the repeatability and precision of cystitomes made by the GG cystitome maker versus those made manually with a needle holder. The results showed that the cystitomes made with GG cystitome maker had a lesser degree of variation. This indicates a more repeatable cystitome, which will inadvertently help in reducing the error caused by the instrument in making a good CCC during cataract surgery.

Central corneal distortion after small-incision lenticule extraction.

A 33-year-old woman with a prior history of small-incision lenticule extraction (SMILE) presented with gradual deterioration of vision in her right eye since the surgery. She had undergone bilateral SMILE for myopic correction (-7.00 diopters [D] in the right eye and -6.00 D in the left eye) 3 weeks prior. SMILE was performed with a Zeiss VisuMax femtosecond laser system, with a cap thickness of 120 µm, a cap diameter of 7.50 mm, and a lenticule diameter of 6.50 mm. At the completion of the surgery, loose epithelium was noted at the SMILE incision bilaterally, and bandage contact lenses were placed in both eyes. On the first postoperative day, the patient's uncorrected distance visual acuity (UDVA) was 20/40 in both eyes. The bandage lenses were removed from both eyes, with the epithelium intact. At the first-week postoperative visit, her visual acuity was recorded as 20/30 in the right eye and 20/20 in the left eye. She noticed her vision in the right eye was not as sharp as that in her left eye. She denied experiencing any pain, redness, or ocular surface irritations. She was advised to return to the clinic for a 1-month postoperative visit and continue with aggressive lubrication in both eyes. However, a week later, the patient returned for an emergency visit, citing significant central visual distortion in the right eye and difficulty working on the computer. At this visit, her UDVA and corrected distance visual acuity (CDVA) was 20/50 in the right eye and 20/15 in the left eye at both near and far distances. A slitlamp examination revealed mild central changes in the right eye. She once again denied any pain, redness, or irritation. She was advised to continue with artificial tears and return to the office in 1 week for further observation of the central distortion in her right eye. Upon returning to the clinic at the third postoperative week, the patient still complained of central visual changes in the right eye, with a visual acuity of 20/70. Further slitlamp examination revealed a nonspecific central haze in the same eye, but there was no corneal staining or signs of epithelial defects. Anterior segment ocular coherence tomography (AS-OCT) and NIDEK topography were performed, showing the same central distortion in the right eye (Figures 1 and 2JOURNAL/jcrs/04.03/02158034-202311000-00016/figure1/v/2023-10-18T004638Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202311000-00016/figure2/v/2023-10-18T004638Z/r/image-tiff). Based on the examination and images provided, what is your working medical diagnosis? What other medical conditions are in your differential diagnosis? What medical and/or surgical interventions would you recommend, if any?

Femtosecond Intrastromal Lenticule Implantation (FILI) for Management of Moderate to High Hyperopia: 5-Year Outcomes.

PURPOSE: To report the long-term clinical experience following femtosecond intrastromal lenticule implantation (FILI) for the management of moderate to high hyperopia. METHODS: Eligible patients who underwent FILI for moderate to high hyperopia from July 2013 to October 2020 were included. A donor small incision lenticule extraction lenticule, matched for refractive error, was implanted into the recipient's corneal pocket created using a femtosecond laser at 160 µm depth. Visual and refractive outcomes and long-term complications were evaluated at the end of a mean follow-up of 68 ± 17.28 months (5.6 years). RESULTS: Forty-two eyes of 25 patients (mean age: 27.29 ± 5.52 years) were analyzed. The mean spherical equivalent reduced significantly from +5.50 ± 1.96 to +0.66 ± 1.17 diopters (D) at last follow-up visit. Thirty eyes (71%) were within ±1.00 D of spherical equivalent correction. Cumulative uncorrected distance visual acuity of 20/40 or better was achieved in 34 eyes (81%). Efficacy and safety indices were 0.86 ± 0.19 and 1.17 ± 0.39, respectively. There was a significant increase in mean keratometry (Kmean) anterior, central corneal thickness, Q-value, and corneal higher order aberrations and a decrease in Kmean posterior 2 weeks postoperatively, without any significant change in these parameters thereafter (P > .05). Four eyes of 3 patients underwent enhancement and another 4 eyes underwent explantation of the lenticule followed by exchange (2 eyes) and hyperopic laser in situ keratomileusis (2 eyes). No eye lost more than one line of CDVA. CONCLUSIONS: At 5 years of follow-up, FILI for moderate to high hyperopia showed good safety, efficacy, and reversibility. Modification of nomograms and surgical planning may be employed for further refinement of the outcomes. [J Refract Surg. 2022;38(6):348-354.].

Long-term Outcomes of Bowman's Membrane Relaxation for Enhancement of Femtosecond Intrastromal Lenticule Implantation Performed for the Management of High Hyperopia.

PURPOSE: To evaluate the feasibility and report long-term outcomes with Bowman's membrane relaxation (BMR) for enhancing the residual refractive error following femtosecond intrastromal lenticule implantation (FILI). METHODS: BMR was performed using a Hessburg-Barron trephine to create a circular incision into the Bowman's membrane and anterior corneal fibers up to the depth of approximately 120 to 130 µm. After enhancement, clinical outcomes were analyzed for a mean period of 36 months (range: 14 to 57 months). RESULTS: Four eyes of 3 patients (mean age: 29 years) underwent enhancement with BMR for a significant residual refractive error of +2.25 diopters (D) spherical equivalent following FILI for high hyperopia (mean spherical equivalent: +7.00 D). After BMR, the residual refraction reduced to +0.31 D, resulting in improvement in uncorrected distance visual acuity from 0.55 to 0.33 logMAR. The mean front keratometry values increased from 46.20 to 49.30 D, and the mean back keratometry values increased from -5.90 to -6.30 D following BMR, the latter returning to the baseline (pre-FILI) value of -6.30 D. An increase in Q-value with a corresponding increase in higher order aberrations was observed. Corneal biomechanics indicated reduction of stiffness and other parameters after enhancement. No intraoperative or postoperative complications were noted. CONCLUSIONS: BMR may be an effective technique for enhancement of residual hyperopia following tissue addition techniques such as FILI. BMR may reverse the posterior curvature changes, negating the steepening effect of the anterior cornea following tissue addition, potentially aiding in the enhancement. [J Refract Surg. 2022;38(2):134-141.].

Comparison of Long-Term Outcomes and Refractive Stability following SMILE versus SMILE Combined with Accelerated Cross-Linking (SMILE XTRA).

Purpose: To compare the long-term safety, efficacy, predictability, and refractive stability following SMILE versus SMILE combined with accelerated cross-linking (SMILE XTRA), and to specifically study the regression patterns following the two procedures. Methods: This retrospective study included 54 eyes of SMILE and 54 eyes of SMILE XTRA treated for normal and borderline cases of myopia/myopic astigmatism, respectively, based on certain predefined topographic features and risk factors. Patients in both the groups were matched for age and refractive error. The mean postoperative follow-up for the SMILE group was 22.18 ± 10.41 months and the SMILE XTRA group was 21.81 ± 10.19 months. Results: At the end of follow-up, the mean sphere, cylinder, and SE reduced to -0.03, -0.09, and -0.08 D in the SMILE group and -0.06, -0.15, and -0.13 D in the SMILE XTRA group. 96% and 93% eyes remained within ±0.50 D in SMILE and SMILE XTRA groups, respectively, and 94% eyes maintained an UDVA of 20/20 or better in the SMILE as well as SMILE XTRA groups. Safety and efficacy indices for the SMILE group were 1.03 and 1.00. For the SMILE XTRA group, the safety and efficacy indices were 1.00 and 0.99. No eye in either group had postoperative ectasia or enhancement performed for significant residual refractive error. Conclusion: Both the SMILE and SMILE XTRA groups exhibited comparable visual outcomes, safety, and efficacy. Contrary to the belief, combination of prophylactic CXL with SMILE did not result in a hyperopic shift in the long term. No eye in either group encountered postoperative ectasia; however, further follow-up is suggested to establish the long-term effects on refractive and corneal stability following SMILE XTRA, as all the eyes treated in this group were borderline.

Phaco with ICL in situ in a case of high hyperopia.

PURPOSE: To describe a unique method of biometric calculation and surgical technique of phacoemulsification and posterior chamber intraocular lens (PCIOL) implantation with an implantable collamer lens (ICL) in situ; for a high hyperope with post - ICL cataract. OBSERVATIONS: A patient with high hyperopia who underwent bilateral ICL implantation later developed cataract in both eyes. He underwent phacoaspiration of the cataract with ICL in situ and a standard power PCIOL implantation in the left eye. A unique method of PCIOL power calculation was later devised for the right eye by accounting for the residual refractive error of the eye and implanted by a similar surgical technique. CONCLUSION AND IMPORTANCE: Following cataract surgery with the ICL in situ, the patient had a residual refractive error of +3.00D in the left eye however had a minimal residual refractive error in the right eye. A new surgical method of PCIOL implantation after cataract extraction with an ICL in situ as well as the biometric calculation for a PICOL to be implanted with an ICL in situ was devised.