Experimental circular keratotomy for correction of corneal astigmatism.

PURPOSE: To investigate the effect of circular keratotomy depth and diameter on corneal astigmatism. METHODS: High astigmatism was induced in 25 human donor eyes by an anterior radial 7-0 silk suture across the corneoscleral limbus. With a 6.0, 6.5, 7.0, or 7.5 mm trephine, a 0.3 mm deep circular incision was made in 20 donor eyes. In 5 donor eyes 5 circular incisions were made with a diamond knife set at 0.1, 0.2, 0.3, 0.4, and 0.5 mm depths. RESULTS: The reduction of astigmatism between the 4 groups in which different trephination diameters were used showed no statistically significant difference (P > .1). The relationship between incision depth and reduction of astigmatism was statistically significant (P < .001). CONCLUSION: Artificially induced corneal astigmatism was reduced by a circular keratotomy in this donor eye model. Deeper incisions showed a greater effect.

Scar tissue orientation in unsutured and sutured corneal wound healing.

AIMS: This study aimed to evaluate stromal wound healing morphology in short term unsutured compared with sutured corneal wounds, to define regional variation in healing within radial keratotomy wounds. METHODS: Stromal scar tissue orientation (fibroblast and collagen fibre orientation) was analysed in unsutured and adjacent sutured keratotomy wounds in monkeys, 2 to 9 weeks after surgery, using light and transmission electron microscopy. RESULTS: At 2 to 4 weeks, scar tissue orientation was transverse to the wound edge in unsutured wounds, but sagittal in sutured wounds. At 5 to 9 weeks, a reorientation of scar tissue sagittal to the wound was seen in the unsutured wounds, proceeding from the posterior to anterior wound regions. In sutured wounds, a scar tissue reorientation transverse to the wound was seen, proceeding from the anterior wound region in a posterior direction. CONCLUSIONS: Within the same cornea, sutured and unsutured wounds showed opposite patterns of healing. Sutured wounds initially healed more slowly, but obtained pseudolamellar continuity over time. In contrast, healing of unsutured wounds was characterised by an early approximation towards lamellar repair that was followed by an ineffective reorganisation of the scar. This latter pattern of healing, that may be associated with a variable weakening of the wound, may relate to the clinical findings of unpredictability and/or progression of refractive effect following radial keratotomy.

Healing of reopened-and-sutured radial keratotomy wounds.

We designed a study to evaluate healing in reopened-and-sutured (RAS) keratotomy wounds to determine the efficacy of reoperations in treating radial keratotomy overcorrections. Using light and transmission electron microscopy, we compared stromal scar tissue organization (transverse fibroblast orientation and collagen fiber continuity across the wound) in RAS wounds and in sutured and unsutured control wounds in 18 monkey eyes one to nine weeks after surgery. Wound healing morphology of RAS wounds varied with the interval between reoperation and termination of the experiment. Scar tissue organization was sagittal at one week postoperatively, transverse in the anterior and mid regions after four weeks, and transverse over the entire wound after nine weeks. Sutured wounds showed a similar pattern of healing, although transverse scar tissue organization was restricted to the anterior and mid regions in the late healing phases. In contrast, unsutured wounds showed a temporary, transverse scar tissue organization over the entire wound depth at two to four weeks and a progressive reorientation of the mid and posterior scar tissue sagittal to the wound at later intervals. The results suggest that reopening and suturing keratotomy incisions to treat radial keratotomy overcorrections may be effective through a myopic shift induced by sutured wound apposition and long-term wound remodeling, contraction, or both.

Effect of blade configuration, knife action, and intraocular pressure on keratotomy incision depth and shape.

For the same diamond blade extension, uphill (centripetal) radial keratotomy incision direction achieves greater depth and consequently greater refractive effect than downhill (centrifugal) incisions. To determine which factors may account for this difference, two uphill and two downhill incisions were made with a double-edged diamond blade set to 90% central pachometry in 26 human donor eyes at 15 or 60 mm Hg. Uphill incisions made with the perpendicular blade had greater mean incision depth than downhill incisions made with the oblique blade at 15 mm Hg (83.6 +/- 3.9% and 68.2 +/- 5.2%) (p < 0.0005) and at 60 mm Hg (86.3 +/- 3.1% and 79.7 +/- 1.7%) (p < 0.0005). Uphill and downhill incisions both made with the perpendicular blade had equal depth (85.4 +/- 4.9% and 83.7 +/- 3.5%) (p > 0.1). The perpendicular blade edge created a straight, and the oblique edge an S- or J-shaped, histological incision configuration. Corneal profile pictures taken during each incision showed the knife to tilt opposite of the incision direction and to move at a constant angle to the limbal plane, producing a smaller optical clear zone (OCZ) in the posterior stroma than intended with uphill incisions. Greater refractive effect with uphill incisions may be explained by the perpendicular blade being more effective in incising corneal lamellae, and the creation of a smaller posterior OCZ. Intraocular pressure variations during surgery may affect achieved incision depth of downhill, but not of uphill, incisions.

Immunohistochemical analysis of unsutured and sutured corneal wound healing.

In the unsutured partial thickness penetrating wounds of the cornea, the epithelium migrates over the wounded stromal surface prior to the onset of stromal regeneration. To determine the possible affects of the epithelial ingrowth on the organization of the stromal scar tissues, the healing of unsutured and sutured wounds was compared immunohistochemically. Immunostaining patterns for fibronectin, types III, VI and VII collagen, keratan sulfate proteoglycan (KSPG), and intermediate filament-associated protein (IFAP 130) in fibroblasts, were analyzed in unsutured and adjacent sutured keratotomy wounds in monkeys, at 2-9 weeks after surgery. At 2-4 weeks, fibronectin, type III and type VI collagen showed a lamellar interweaving pattern across unsutured wounds that was absent in sutured wounds. Type VII collagen was detected along the entire depth of regenerated stroma in unsutured wounds, but not in sutured wounds indicating that the epithelium had formerly been present in the regenerated stroma in unsutured wounds. Fibroblasts in both types of wounds expressed IFAP 130, but staining was more pronounced in sutured wounds. At 5-9 weeks, cellular re-activation, as judged from the expression for IFAP 130, was concomitant with a loss of lamellar interweaving with fibronectin, type III and type VI collagen across unsutured wounds, and proceeded in a posterior to anterior direction. In contrast, in sutured wounds, lamellar interweaving was established in anterior to posterior direction. At all postoperative times, unsutured and sutured wounds showed minimal staining for KSPG in the anterior scar.(ABSTRACT TRUNCATED AT 250 WORDS)

Intrastromal corneal ring segments (ICRs): three- and six months results.

In the period from May 1997 to November 1998 twenty-one eyes of fifteen patients with sighted eyes received Intrastromal Corneal Ring Segments (ICRS) for the surgical treatment of low myopia. The mean pre-operative refraction was -3.0 diopters (D) ranging from -1.5 D to -4.1 D. Three months results showed that 44% of the treated eyes had an uncorrected visual acuity (UCVA) of 1.0 or better while 94% had an UCVA of 0.5 or better. In 94% the postoperative refraction was within one diopter (D) of emmetropia and in 61% within 0.5 D of emmetropia. Mean induced astigmatism was 1.03 (std 0.75). The best spectacle corrected visual acuity (BSC VA) after 3 months was 1.0 or better in all patients. After six months the UCVA was 1.0 or better in 43% of the treated eyes while in 100% the UCVA was 0.5 or better. The post-operative refraction was within 1 D of emmetropia in 100% and within 0.5 D of emmetropia in 81%. Mean induced astigmatism was 1.00 (std 0.50). BSCVA was in 88% 1.0 or better and in 100% 0.9 or better. In one patient vascular ingrowth occurred due to a ring segment located under the incision. Three patients experienced a lower UCVA due to postoperative astigmatism. In only one patient in this series the ICRS were removed because of induced astigmatism. These preliminary results show that the ICRS seem to offer a safe, stable and reproducible method to correct low myopia. The operation carries a low risk but care must been taken to insert the ICRS as central as possible to prevent postoperative astigmatism.