Femtosecond laser-assisted Bowman layer transplantation for advanced keratoconus.

BACKGROUND/AIMS: To assess the technical feasibility and outcomes of femtosecond laser-assisted Bowman layer transplantation (FLABOLT) in stabilizing progressive, advanced keratoconus, which is ineligible for corneal crosslinking. METHODS: This single-center retrospective study included 50 eyes of 49 patients with progressive advanced keratoconus, ineligible for corneal crosslinking, that underwent FLABOLT with both the donor graft and recipient mid-stromal pocket using a femtosecond laser. RESULTS: The mean follow-up was 13.2 ± 4.9 months (range 7-35 months). Donor graft preparation and accurate dissection of the recipient mid-stromal pocket were successful in 96% and 100% of cases, respectively. The mean maximum keratometry decreased by 1.93 D at 6 months after surgery and there was no change in the mean preoperative best contact lens-corrected visual acuity (BCLVA). Three eyes developed hydrops postoperatively and recovered after clinical treatment. One eye that achieved useful BCLVA postoperatively, worsened 2 years after the surgery due to progressive corneal scarring and required corneal transplantation for visual rehabilitation. Preoperative corneal scarring was a risk factor for BCLVA loss. All other eyes remained stable (92%), and no other procedure was required until the last follow-up. CONCLUSION: In this series, FLABOLT was successfully performed as an alternative to stabilize advanced progressive keratoconus. This technique is highly reproducible for graft preparation and recipient pocket dissection when assisted by femtosecond laser. Despite promising initial results, more studies with longer follow-up periods are needed to evaluate the effectiveness of FLABOLT in stabilizing advanced progressive keratoconus.

Pre-Descemet's endothelial keratoplasty: a simple, Descemet's membrane scoring technique for successful graft preparation.

PURPOSE: Pre-Descemet's endothelial keratoplasty (PDEK) donor tissue preparation involves the intrastromal injection of air to create a type 1 big bubble (BB) and avoidance of the creation of a type 2 BB. The purpose of this study was to design and test a technique to consistently creates a type 1 BB without risk of creating a type 2 BB. METHODS: A prospective matched study with 64 human donor sclerocorneal discs, which were not suitable for corneal transplantation, was conducted. The corneas were divided into two groups, of which 32 were subjected to the standard technique of preparing the PDEK donor tissue (group 1, control) and 32 new technique, where in the donor Descemet's membrane was scored with a Sinskey hook. Frequency of occurrence of different types of BB was compared and statistically analysed. RESULTS: With the standard technique (group 1), type 1 BB occurred in 53.1%, type 2 BB in 34.4% and mixed BB in 12.5% of samples. With the scoring technique (group 2), a type 1 BB occurred in 100% of the samples. No type 2 or mixed BB occurred in any case in group 2. The difference in creation of a type 1BB between the two groups was statistically significant (p=0.00). CONCLUSION: The scoring technique is a simple, inexpensive and reproducible option to consistently achieve a type 1 BB to prepare PDEK graft tissue. The next step would be to study the clinical outcomes of PDEK performed with tissue obtained by the scoring technique.

Trends in Corneal Transplantation in a Tertiary Hospital in Brazil.

PURPOSE: The purpose of this study was to analyze the evolving trends of surgical techniques and indications of corneal transplantation (CT) at a tertiary hospital in Brazil. METHODS: The medical records of all patients who underwent CT at the Hospital Oftalmológico de Sorocaba (Sorocaba Eye Hospital) from the Banco de Olhos de Sorocaba (Sorocaba Eye Bank) group in Sorocaba, Brazil, from January 1, 2012, to December 31, 2019, were analyzed. Data regarding age, sex, transplant indication, and surgical technique were collected. RESULTS: A total of 16,250 CTs were performed. There was a statistically significant decreasing trend of keratoconus-related CT ( P < 0.0001), with rates dropping from 41.7% among all CTs in 2012 to 25.5% in 2019. Penetrating keratoplasty, anterior lamellar keratoplasty, and endothelial keratoplasty (EK) accounted for 59.3%, 27.1%, and 7.8% of the CTs performed in 2012 and 33.3%, 16.4%, and 39.9% in 2019, respectively. A statistically significant decreasing trend was observed for penetrating keratoplasty ( P < 0.0001) and anterior lamellar keratoplasty ( P < 0.0001), whereas EK showed a statistically significant increasing trend during the period ( P < 0.0001). Among EKs, Descemet membrane EK increased statistically significantly from 12.8% in 2012 to 74.4% in 2019 ( P < 0.0001). CONCLUSIONS: This study shows relevant evolving trends in indications and preferred CT techniques in a tertiary hospital in Brazil.

The Impact of the COVID-19 Pandemic on Corneal Transplantation in Brazil.

PURPOSE: The purpose of this study was to evaluate the impact of the coronavirus disease 2019 pandemic on corneal transplantation (CT) in Brazil. METHODS: Data from patients who underwent CT at the Hospital Oftalmológico de Sorocaba (HOS), Brazil, were analyzed. National and state numbers of keratoplasties, patients added to the CT waiting list, and total patients on the waiting list were also obtained. Baseline prepandemic (from January 1, 2019, to March 31, 2020) data were compared with 2 time frames of the coronavirus disease 2019 pandemic: elective CT suspension period (between April 1, 2020, and September 31, 2020) and after elective CT resumption (between October 1, 2020, and April 30, 2021). RESULTS: Despite elective CT resumption after the moratorium, the monthly CT rates did not return to baseline at HOS (-14.7%, P = 0.007), São Paulo state (-19.1%, P = 0.001), or Brazil (-30.1%, P < 0.001). The waiting list increased significantly regionally (P < 0.001) and nationally (P < 0.001). Among optical keratoplasties performed at HOS after resuming elective CTs, the proportion of endothelial keratoplasties declined from 38.2% to 30.0% (P < 0.001), whereas penetrating keratoplasties increased from 33.2% to 39.5% (P < 0.001) when comparing with prepandemic data. CONCLUSIONS: Keratoplasty numbers dropped significantly locally, regionally, and nationally. Hence, the CT waiting lists had a progressive increase, with significant long-term implications. An estimated increment on monthly CT rates of approximately 34% in São Paulo state, and 91% in Brazil, is required for the CT waiting list to get back to prepandemic numbers over the next 2 years.

Toric intraocular lens misalignment inducing astigmatism after refractive surgery.

PURPOSE: To report the unexpected induction of astigmatism after phacoemulsification and toric intraocular lens (IOL) implantation in an eye with previous corneal refractive surgery. METHODS: Case report of a 46-year-old man with bilateral nuclear cataract and previous photorefractive keratectomy. Because corneal topography identified regular corneal astigmatism at the central optical zone, phacoemulsification and implantation of a one-piece hydrophobic acrylic toric IOL were performed. RESULTS: Unexpected induction of astigmatism occurred in the first operated eye despite proper alignment of the IOL according to the preoperative calculations using simulated K values to determine toric IOL power and alignment. A retrospective qualitative analysis of corneal topography showed mismatching of the steepest meridian, leading to an off-axis IOL. Secondary IOL rotation improved both uncorrected and corrected distance visual acuity. CONCLUSIONS: Qualitative analysis of the corneal topography is mandatory during the assessment of toric IOL alignment in eyes with previous corneal refractive surgery to identify the actual location of the steepest meridian.

Partial-Thickness Intrastromal Lamellar Keratoplasty for Corneal Pellucid Marginal Degeneration.

PURPOSE: Pellucid marginal degeneration (PMD) is a bilateral corneal ectatic disorder, characterized by thinning of the inferior cornea. Numerous surgical procedures have been described in the literature, and there is a lack of consensus regarding the best available surgical management. Recently, full-thickness intrastromal lamellar keratoplasty (ILK) was described as an option for treating PMD and emerged as a promising technique. However, ILK results in an irregular surface, leading to a significant residual against-therule (ATR) astigmatism. METHODS: This study describes a variation of the ILK technique, using a partial-thickness graft to treat 2 cases of PMD. RESULTS: At the final follow-up, both patients improved visual acuity and had their mean simulated keratometry flattened, although a residual ATR astigmatism remained. CONCLUSIONS: The ILK technique modification might lead to a more regular thickness pattern, although it did not seem efficient in reducing the ATR astigmatism.

Influence of upper blepharoplasty on intraocular lens calculation.

PURPOSE: To determine the effect of upper blepharoplasty on corneal topography and intraocular lens power calculation using Galilei and IOLMaster. METHODS: Thirty patients submitted to upper blepharoplasty from May 2014 to March 2017 at the Hospital Oftalmológico de Sorocaba (São Paulo, Brazil) were included in this observational case series. All patients underwent imaging sessions with Galilei and IOLMaster preoperatively (baseline) and at 1 and 6 months postoperatively. Primary outcome measures using both devices included flattest, average, and steepest corneal curvature, corneal astigmatism, and blepharoplasty-induced corneal astigmatism. Determination of axial length and lens power calculation were performed using only IOLMaster (Holladay formula). Paired t-test and vectorial analysis were used for statistical analysis. RESULTS: Sixty eyes from 30 patients were prospectively included. Vectorial analysis showed that 6 months after surgery, blepharoplasty induced on average 0.39 D and 0.31 D of corneal astigmatism, as measured with Galilei and IOLMaster, respectively. IOLMaster measurements showed that average corneal curvature (44.56 vs 44.64 D, p=0.01), steepest corneal curvature (45.17 vs 45.31, p=0.01) and corneal astigmatism (1.22 vs 1.34, p=0.03) were higher 6 months after surgery. IOLMaster measurements also showed that intraocular lens power was significantly smaller 6 months after surgery (22.07 vs 21.93, p=0.004). All other parameters showed no change for comparisons between baseline and 6 months (p>0.05 for all comparisons). CONCLUSION: Upper eyelid blepharoplasty influenced intraocular lens calculation using the IOLMaster. However, the influence was not clinically significant. No topographic changes were found using Galilei.

Descemet Membrane Endothelial Keratoplasty in Children.

PURPOSE: To describe the outcomes of Descemet membrane endothelial keratoplasty (DMEK) performed in amblyopic aged (younger than 8 years) children. METHODS: This is a single-center retrospective study, including 11 eyes (7 congenital hereditary endothelial dystrophy and 4 congenital glaucoma) of 6 children in amblyopic age undergoing DMEK by a single surgeon (N.C.P.) at Sorocaba Eye Hospital from December 2015 to November 2017. Best spectacle-corrected visual acuity, biomicroscopy, pachymetry, endothelial cell density, and complications were evaluated. RESULTS: No intraoperative complications occurred. Graft detachment occurred in 1 eye (9.1%) and was successfully managed with rebubbling. No primary graft failure or pupillary block was observed. All pachymetric measurements improved, and the corneal edema clinically resolved in all eyes within 2 weeks after the procedure. At the last follow-up (mean 30 months), best spectacle-corrected visual acuity was ≥20/40 in 7 (77.8%) of 9 eyes from patients cooperative enough to assess vision. All children began visual stimulation therapy and amblyopic treatment within 1 month of surgery, and all grafts remained clear until the last follow-up. The mean preoperative donor endothelial cell density was 2588 ± 236 cells/mm, which decreased to 1726 ± 292 cells/mm 2 years after surgery, yielding a 33% reduction (P < 0.001). No immunologic graft reaction, secondary graft failure, or cataracts were observed during the follow-up period. CONCLUSIONS: In this series, DMEK was performed to successfully treat endothelial dysfunction in children. However, the procedure is more challenging, and more studies with more patients and longer follow-up are needed to confirm the superiority of DMEK in treating endothelial dysfunction in children.

Descemet Membrane Endothelial Keratoplasty Outcomes During the Initial Learning Curve of Cornea Fellows.

PURPOSE: To describe the outcomes of Descemet membrane endothelial keratoplasty (DMEK) performed by cornea fellows during their initial learning curve. METHODS: This prospective study included the first consecutive series of 53 DMEK surgeries performed by 14 corneal fellows at Sorocaba's Ophthalmological Hospital. Best spectacle-corrected visual acuity, endothelial cell density (ECD), and complications were evaluated. RESULTS: Of the eyes without ocular comorbidities and with complete visual acuity measurements, 97% of 33 eyes achieved a best spectacle-corrected visual acuity of ≥20/40 in 6 months. The mean (SD) preoperative donor ECD was 2453 (361) cells/mm, and at 6 months postoperatively, the in vivo mean ECD (SD) was found to be 1300 (587) cells/mm, an average loss of 47%. Preparation of the DMEK graft by the cornea fellows was successful in all cases. There were 9 eyes (17%) that experienced partial graft detachment requiring rebubbling. A total of 3 eyes (5.7%) failed to clear the cornea, all of which were managed with successful secondary endothelial keratoplasty. None of the eyes experienced pupillary block. CONCLUSIONS: Establishing DMEK in a fellowship program was successful with the supervision of an experienced DMEK surgeon. Even without the facility of a prestripped DMEK graft by an eye bank and with no backup tissue, no surgery was canceled because of graft preparation failure. Good visual outcomes were achieved with satisfactory ECD at 6-month follow-up, with an acceptable complication rate. Even the 3 eyes that failed to clear the cornea evolved well after secondary endothelial keratoplasty by the cornea fellows.

Descemet's membrane endothelial keratoplasty with a simplified technique and low complication rate: the samba technique.

PURPOSE: We report a simplified Descemet's membrane endothelial keratoplasty (DMEK) technique that involves safe and effective preparation and introduction, correct orientation, and easy unfolding of the donor graft inside the recipient anterior chamber. METHODS: In this retrospective study, we assessed the surgical outcomes of 26 eyes of 23 consecutive patients (mean age, 61.2 ± 11.4 yr; range, 39-82 yr) with Fuchs endothelial corneal dystrophy (n=19) or bullous keratopathy (n=7) who underwent the Samba technique, a simplified DMEK method, at the Sorocaba Ophthalmology Hospital, Sorocaba Eye Bank, Sorocaba, Brazil, between August 2011 and July 2012. RESULTS: Of the 26 operated eyes, only two (7.7%) experienced partial graft detachment requiring rebubbling, and in those eyes, the graft was reattached successfully with one air bubble. There were no cases of primary graft failure, tissue loss, or pupillary block. All patients with good visual potential achieved a best-corrected visual acuity of 20/30 or better at 6 months, and 82.6% achieved a best-corrected visual acuity of 20/30 or better 1 month postoperatively. CONCLUSION: In this retrospective study, the Samba technique, a simplified DMEK procedure, was safe and effective, with an acceptably low rebubbling rate and no incidence of primary graft failure or pupillary block. Moreover, rapid and nearly complete visual recovery was achieved. This simplified DMEK technique can be adopted by corneal surgeons worldwide as a primary treatment for endothelial dysfunction with a less steep learning curve and low rate of postoperative complications.

Endothelial assessment of donated tectonic corneas: a viable option for posterior lamellar transplantation.

PURPOSE: Donated corneas are classified as tectonic if there are defects within any layers of the cornea which would prevent a satisfactory visual outcome after transplantation. This study aimed to evaluate whether some tectonic corneas have sufficient endothelial characteristics to allow their use in posterior lamellar keratoplasty, and explored their reclassification for use in this sight-improving procedure. METHODS: A retrospective review of all corneal tissues preserved by the Sorocaba Eye Bank from January to April of 2014 was performed. All donated corneas classified as tectonic were included. Endothelial tissue was defined as healthy and viable for posterior lamellar keratoplasty if endothelial cell density was ≥2000 cells/mm2. Additional parameters analyzed included Descemet folds and stretch marks, loss of endothelial cells, corneal endothelial polymegathism/ pleomorphism, pseudo-guttata, and reflectivity. RESULTS: During the study period, 2,847 corneas were preserved, of which 423 (14.85%) were classified as tectonic. Of these, 87 (20.56%) were reported as having endothelial viability and were included in the posterior lamellar keratoplasty group. Average corneal endothelial cell density of this group was 2,471 SD ± 256 cells/mm2 (range 2012-2967 cells/mm2). CONCLUSION: A significant number of corneas classified as tectonic showed endothelial viability and were included in the posterior lamellar keratoplasty group (20.56%). Despite stromal and/or epithelial alterations, these corneas could have been potentially distributed for posterior lamellar transplantation to improve vision, thus reducing the corneal transplantation waiting period. This study highlights how corneal tissue reclassification could increase the potential amount of corneal tissue available for optical transplantation.

Descemet membrane endothelial keratoplasty in multifocal pseudophakic eyes.

PURPOSE: This report describes the use of Descemet membrane endothelial keratoplasty for the management of endothelial decompensation after multifocal intraocular lens implantation. METHODS: In this retrospective study, we reviewed and assessed the surgical outcomes of 9 patients (9 eyes) who underwent Descemet membrane endothelial keratoplasty after multifocal intraocular lens implantation. RESULTS: Corneal edema occurred due to Fuchs endothelial corneal dystrophy (n=3), pseudophakic bullous keratopathy (n=3), Descemet's membrane detachment (n=2), and toxic anterior segment syndrome (n=1). The Descemet membrane endothelial keratoplasty surgeries were uneventful in all eyes, but rebubbling procedures were necessary in 2 eyes. One month after the surgery, all the corneas were clear. After 6 months, excluding 1 eye with amblyopia, the mean distance corrected visual acuity was 0.10 logMAR, with all eyes achieving 0.18 logMAR or better. CONCLUSIONS: This is the first report of Descemet membrane endothelial keratoplasty after multifocal intraocular lens implantation, and it suggests that good results can be achieved without multifocal intraocular lens exchange.

Thickness and immunohistochemistry of LASIK flaps created by different femtosecond lasers in eye-bank corneas.

PURPOSE: The aim of this study was to compare the corneal cell viability and thickness of LASIK flaps created by 3 femtosecond lasers in eye-bank human corneas. METHODS: Forty-five eye-bank human sclerocorneal buttons (15 corneas in each group) were examined after the creation of 120 mm-thick laser-assisted keratomileusis (LASIK) flaps with 150kHz iFS In-traLase™ (IL), Z6 Femto LDV™ (LDV), or 200kHz Wavelight™ FS200 (FS200). The thickness of the flaps was measured using anterior segment optical coherence tomography (AS-OCT; Visante™). Cell viability was blindly evaluated with immunohistochemistry for keratocyte apoptosis using anti-caspase 3 antibodies. RESULTS: The standard deviation from the intended flap thickness was less than 10 mm in all the groups. There was a statistically significant difference in corneas treated with LDV and IL with regard to the flap thickness horizontally at +3.00 mm (p=0.0124), -0.5 mm (p=0.0082), and -1.00 mm (p=0.0425) from the corneal vertex and +0.5 mm from the flap edge (p=0.0240), and those treated with LDV and FS200 with regard to the flap thickness horizontally at -0.5 mm from the corneal vertex (p=0.0082). The mean keratocyte apoptosis numbers were 13.09 ± 1.10, 15.59 ± 3.28, and 17.72 ± 1.49 in corneas treated with IL, FS200, and LDV, respectively (p<0.001). CONCLUSION: All 3 assessed femtosecond lasers provided predictable LASIK flap thickness. The mean stromal keratocyte apoptosis number was low in all groups.

Corneal suture for the correction of hyperopia following radial keratotomy.

PURPOSE: To report the visual and refractive changes observed after double concentric corneal suture to correct hyperopic shift after radial keratotomy (RK). METHODS: This retrospective consecutive case series comprised 17 eyes (15 patients) that underwent two concentric corneal sutures (modified Grene Lasso suture) to correct hyperopic shift after RK. All surgeries were performed by the same surgeon between 2000 and 2003. RESULTS: The mean time after RK was 11.6 +/- 3.2 years. The mean follow-up was 20.3 +/- 11.3 months. The spherical equivalent refraction was reduced from a preoperative mean of +4.38 +/- 2.87 diopters (D) to -0.54 +/- 2.59 D at last postoperative follow-up (P < .001). No statistically significant difference was observed in mean refractive astigmatism before and after the corneal suture (P = .15). Before surgery, no eye presented with best spectacle-corrected visual acuity (BSCVA) > or = 20/20. At final follow-up, 3 (17.6%) eyes attained this level. Seven (41.2%) eyes improved their BSCVA by > or = 2 Snellen lines. One (5.9%) eye lost 2 Snellen lines of BSCVA. CONCLUSIONS: Corneal suture can be used to correct RK-induced hyperopia, improving the corneal asphericity in an attempt to stabilize these corneas. It appeared to be effective even for high degrees of hyperopia and in cases with associated irregular astigmatism or open incisions.

Flap-induced refraction change in LASIK after penetrating keratoplasty.

PURPOSE: To further analyze the refractive and topographic changes occurring with microkeratome lamellar keratotomy and to investigate possible factors associated in eyes with previous penetrating keratoplasty (PK). METHODS: The Hansatome microkeratome was used to create a lamellar corneal flap in 21 eyes of 19 patients after PK. The laser ablation was not performed in the first stage. Pre- and postoperative refractions and corneal topographies were compared to evaluate possible changes induced by the keratotomy. RESULTS: Twenty-one eyes were analyzed in this study. Mean time between PK and lamellar keratotomy was 36.63 +/- 28.23 months (range: 12 to 120 months). No microkeratome-related flap complications occurred. Previous to the keratotomy, the mean spherical equivalent refraction was -4.26 +/- 3.41 diopters (D), mean refractive astigmatism was -4.71 +/- 2.27 D, and mean topographic astigmatism was 5.28 +/- 2.94 D. After keratotomy, eyes showed statistically significant changes in spherical equivalent refraction from preoperative values (P = .025), with 3 eyes showing changes > 2.00 D. Average refractive and topographic astigmatism did not change significantly from before to after keratotomy. However, surgically induced astigmatism (SIA) calculated through vector analysis was > 1.01 in 11 (52.4%) eyes. A statistically significant correlation was found between the SIA values and preoperative refractive astigmatism (P = .025). CONCLUSIONS: Lamellar keratotomy as part of two-stage LASIK in eyes with prior PK led to refractive changes that justify the use of this technique, especially in eyes with high degrees of preoperative astigmatism.

Indications and visual outcomes of intrastromal corneal ring segment implantation in a large patient series.

OBJECTIVES:: To describe the indications for and visual outcomes of intrastromal corneal ring segment implantation. METHODS:: A large retrospective case-series chart-review study was conducted using Sorocaba Ophthalmological Hospital medical records. This study included 1222 eyes (1196 patients) that were surgically treated between November 2009 and December 2012. The following preoperative data were collected: age, gender, type of medical care and funding source, surgical technique, best-corrected visual acuity, manifest sphere and cylinder refractive error, maximum and minimum central keratometry, and pachymetry measurements of the cornea at the thinnest point and at the ring channel. The postoperative best-corrected visual acuity and patient satisfaction were also determined. The cases were classified into six groups: four keratoconus groups (severe, advanced, moderate and mild), a pellucid marginal degeneration group and a post-graft irregular astigmatism group. This study was approved by the Brazilian Registry of Clinical Trials (UTN number 1111-1182-6181, TRIAL RBR-6S72RF). RESULTS:: The age (mean±standard deviation) of the patients was 31.0±10.0 years. The most prevalent pathology was keratoconus (1147 eyes, 93.8%). A correlation was found between ectasia severity and medical assistance (p<0.001), and the most serious cases was treated by the Brazilian public health system. No complications were found in a total of 1155 surgeries, and after surgery, 959 patients were satisfied. Among the 164 dissatisfied patients, the majority failed to show improved best-corrected visual acuity. CONCLUSION:: Patients in the public health system underwent surgical intervention for keratoconus later than those with private sources of funding. In the vast majority of operated cases, the patients reported improvements in vision.

Diagnosis of epithelial ingrowth after penetrating keratoplasty with confocal microscopy.

PURPOSE: To report confocal microscopy use in the clinical diagnosis of epithelial ingrowth after penetrating keratoplasty (PKP). METHODS: A 36-year-old female patient with keratoconus developed a well-delimited posterior hazy membrane covering the inferior two thirds of the cornea 3 months after an uneventful PKP. A posterior corneal line was present resembling an endothelial graft rejection line, but with no keratic precipitates or corneal edema. Ocular hypertension was not observed. Confocal microscopy was performed to elucidate the diagnosis. RESULTS: Confocal microscopy showed epithelium and stroma with normal findings. Two distinct cellular types were presented at the endothelium layer. Enlarged endothelial cells were observed in the superior part of the cornea up to the leading edge of the hazy membrane. In the middle and inferior part of the graft, the cells were larger, with polygonal shape and easily recognizable hyperreflective nuclei, suggestive of epithelial cells. With these confocal microscopy findings, the patient was promptly submitted to another PKP. Histologic analysis confirmed the diagnosis of epithelial ingrowth. CONCLUSION: Confocal microscopy imaging technique seems to be a useful tool in the early diagnosis of epithelial ingrowth after PKP.

Descemet Membrane Detachment in Femtosecond Laser-Assisted Cataract Surgery.

PURPOSE: To report a case series of 4 patients with Descemet membrane detachment (DMD) after undergoing femtosecond laser-assisted cataract surgery incisions. METHODS: Case report. RESULTS: DMD was noted at the secondary incision (n = 2) or at the main incision (n = 2). All the secondary incision and 1 main incision DMD were resolved with intraoperative maneuvers. Delay in recognizing DMD intraoperatively at the principal incision in 1 case led to inadvertent aspiration of a part of it and persistent postoperative corneal edema. This complication was handled with Descemet membrane endothelial keratoplasty 1 month after initial surgery. CONCLUSIONS: DMD can occur after femtosecond laser-assisted cataract surgery, although it is a rare complication as it is in traditional phacoemulsification. The surgeon must be prepared to recognize it, manage it intraoperatively, and treat it postoperatively to reduce the risk of permanent damage to the eye.

Influence of upper blepharoplasty on intraocular lens calculation / A influência da blefaroplastia superior no cálculo da lente intraocular

ABSTRACT Purpose: To determine the effect of upper blepharoplasty on corneal topography and intraocular lens power calculation using Galilei and IOLMaster. Methods: Thirty patients submitted to upper blepharoplasty from May 2014 to March 2017 at the Hospital Oftalmológico de Sorocaba (São Paulo, Brazil) were included in this observational case series. All patients underwent imaging sessions with Galilei and IOLMaster preoperatively (baseline) and at 1 and 6 months postoperatively. Primary outcome measures using both devices included flattest, average, and steepest corneal curvature, corneal astigmatism, and blepharoplasty-induced corneal astigmatism. Determination of axial length and lens power calculation were performed using only IOLMaster (Holladay formula). Paired t-test and vectorial analysis were used for statistical analysis. Results: Sixty eyes from 30 patients were prospectively included. Vectorial analysis showed that 6 months after surgery, blepharoplasty induced on average 0.39 D and 0.31 D of corneal astigmatism, as measured with Galilei and IOLMaster, respectively. IOLMaster measurements showed that average corneal curvature (44.56 vs 44.64 D, p=0.01), steepest corneal curvature (45.17 vs 45.31, p=0.01) and corneal astigmatism (1.22 vs 1.34, p=0.03) were higher 6 months after surgery. IOLMaster measurements also showed that intraocular lens power was significantly smaller 6 months after surgery (22.07 vs 21.93, p=0.004). All other parameters showed no change for comparisons between baseline and 6 months (p>0.05 for all comparisons). Conclusion: Upper eyelid blepharoplasty influenced intraocular lens calculation using the IOLMaster. However, the influence was not clinically significant. No topographic changes were found using Galilei.

RESUMO Objetivo: Determinar o efeito da blefaroplastia superior na topografia corneana e no cálculo do poder das lentes intraoculares usando Galilei e IOLMaster. Métodos: Trinta pacientes submetidos a blefaroplastia superior de maio de 2014 a março de 2017 no Hospital Oftalmológico de Sorocaba, São Paulo, Brasil foram incluídos neste estudo de série de casos observacional. Todos os pacientes foram submetidos a sessões de imagem com Galilei e IOLMaster antes da cirurgia (exame de base) e no 1º e 6º mês pós-operatório. Os resultados primários utilizando os dois aparelhos incluíram ceratometria, astigmatismo corenano e astigmatismo corneano induzido pela blefaroplastia. O comprimento axial e o cálculo do poder da lente intraocular foram realizados unicamente com o IOLMaster (fórmula de Holladay). Teste-t pareado e análise vetorial foram usados na análise estatística. Resultados: Sessenta olhos de 30 pacientes foram incluídos prospectivamente. A análise vec­torial mostrou que após 6 meses da cirurgia, a blefaroplastia superior induziu na média 0,39 D de astigmatismo corneano medido com o Galilei e 0,31 D com IOLMaster. As medidas com o IOLMaster mostraram que a ceratometria média (44,56 vs 44,64 D, p=0,01), ceratometria máxima (45,17 vs 45,31, p=0,01) e o astigmatismo corneano (1,22 vs 1,34, p=0,03) foram maiores após 6 meses da blefaroplastia. As medidas com IOLMaster mostraram que o poder da lente intraocular foi significativamente menor 6 meses após a blefaroplastia (22,07 vs 21,93, p=0,004). Todos os outros parâmetros não mostraram mudanças entre o pré-operatório e o 6º mês da cirurgia (p>0,05 para todas as comparações). Conclusões: A blefaroplastia superior influenciou o cálculo da lente intrao­cular utilizando o IOLMaster. Contudo, a influência não foi cli­­nicamente significativa. Não foram encontradas mudanças topográficas com o Galilei.

Comparison of topographic corneal irregularity after LASIK and intrastromal corneal ring segments in the same patients.

PURPOSE: To retrospectively compare the irregularity of the corneal surfaces of 14 patients after LASIK in 1 eye and placement of intrastromal corneal ring segments (ICRS) in the other eye. METHODS: In a within-patient comparison, Orbscan corneal topography was used to retrospectively compare the corneal surface irregularity of LASIK-treated and ICRS-treated eyes at an outpatient tertiary-care ophthalmology clinic in Sao Paulo, Brazil. For the anterior corneal surface, irregularity measurements were compared for both the central and peripheral areas of the cornea. The differences between each group were analyzed for statistical significance. RESULTS: The corneal surfaces of eyes treated with ICRS were found to be more irregular than the corneal surfaces of eyes treated with LASIK, the mean irregularity being 1.91 for LASIK-treated eyes and 3.12 for ICRS-treated eyes in the anterior corneal surface and 0.51 for LASIK-treated eyes and 0.87 for ICRS-treated eyes in the posterior corneal surface. A statistically significant difference was noted only in the posterior surfaces. CONCLUSIONS: When measured with Orbscan topography, ICRS-treated eyes show more corneal surface irregularity than LASIK-treated eyes. The difference in outcome for the two types of treatment may be due to the mechanical effect of the ICRS on the shape of the cornea.