Evaluation and treatment of thoracic outlet syndrome during the global pandemic due to SARS-CoV-2 and COVID-19.

The global SARS-CoV-2/COVID-19 pandemic has required a reduction in nonemergency treatment for a variety of disorders. This report summarizes conclusions of an international multidisciplinary consensus group assembled to address evaluation and treatment of patients with thoracic outlet syndrome (TOS), a group of conditions characterized by extrinsic compression of the neurovascular structures serving the upper extremity. The following recommendations were developed in relation to the three defined types of TOS (neurogenic, venous, and arterial) and three phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources). • In-person evaluation and treatment for neurogenic TOS (interventional or surgical) are generally postponed during all pandemic phases, with telephone/telemedicine visits and at-home physical therapy exercises recommended when feasible. • Venous TOS presenting with acute upper extremity deep venous thrombosis (Paget-Schroetter syndrome) is managed primarily with anticoagulation, with percutaneous interventions for venous TOS (thrombolysis) considered in early phases (I and II) and surgical treatment delayed until pandemic conditions resolve. Catheter-based interventions may also be considered for selected patients with central subclavian vein obstruction and threatened hemodialysis access in all pandemic phases, with definitive surgical treatment postponed. • Evaluation and surgical treatment for arterial TOS should be reserved for limb-threatening situations, such as acute upper extremity ischemia or acute digital embolization, in all phases of pandemic response. In late pandemic phases, surgery should be restricted to thrombolysis or brachial artery thromboembolectomy, with more definitive treatment delayed until pandemic conditions resolve.

Donation of discarded ocular tissue in patients undergoing SMILE laser refractive surgery: developing appropriate guidelines.

Tissue Biobanks represent an invaluable resource. Despite the majority of people supporting tissue donation, the actual rate remains low overall. Tissue discarded from surgical procedures represents a further avenue for collection for use in research. We aim to understand the information and consent requirements in a cohort of healthy, post-ophthalmic surgical subjects to optimise future tissue collection in living donors. Patients attending an ophthalmic clinic following refractive surgery for myopia (SMILE) were identified. Patient consent was implied with the completion of the provided survey. The questionnaire included gender, age range and education status. The majority of 31 subjects identified a benefit for future patients as the main motive for potential donation of discarded tissue (71%). Payment for the discarded tissue would not influence their decision in 77.4%. Explanation of the potential benefits of research was the most important information to consider before making a decision to donate. Only 12.9% of patients would have refused to include further information. Almost half of patients felt that the Biobank became the owner of tissue following donation. Current surgical patients may be more inclined to participate in research than the general public because of a sense of duty or an increased understanding of the role of research in evolving treatment. Despite minor uncertainty about the eventual use of the tissue and data, most subjects were positive to donation of discarded ocular tissue and de-identified information. Consent and education processes should be revised within an ophthalmic practice to minimise future patient anxiety.

Femtosecond laser cataract surgery: technology and clinical practice.

The recent introduction of femtosecond lasers to cataract surgery has generated much interest among ophthalmologists around the world. Laser cataract surgery integrates high-resolution anterior segment imaging systems with a femtosecond laser, allowing key steps of the procedure, including the primary and side-port corneal incisions, the anterior capsulotomy and fragmentation of the lens nucleus, to be performed with computer-guided laser precision. There is emerging evidence of reduced phacoemulsification time, better wound architecture and a more stable refractive result with femtosecond cataract surgery, as well as reports documenting an initial learning curve. This article will review the current state of technology and discuss our clinical experience.

High-Fidelity sEMG Signals Recorded by an on-Skin Electrode Based on AgNWs for Hand Gesture Classification Using Machine Learning.

The human forearm is one of the most densely distributed parts of the human body, with the most irregular spatial distribution of muscles. A number of specific forearm muscles control hand motions. Acquiring high-fidelity sEMG signals from human forearm muscles is vital for human-machine interface (HMI) applications based on gesture recognition. Currently, the most commonly used commercial electrodes for detecting sEMG or other electrophysiological signals have a rigid nature without stretchability and cannot maintain conformal contact with the human skin during deformation, and the adhesive hydrogel used in them to reduce skin-electrode impedance may shrink and cause skin inflammation after long-term use. Therefore, developing elastic electrodes with stretchability and biocompatibility for sEMG signal recording is essential for developing HMI. Here, we fabricated a nanocomposite hybrid on-skin electrode by infiltrating silver nanowires (AgNWs), a one-dimensional (1D) nano metal material with conductivity, into polydimethylsiloxane (PDMS), a silicone elastomer with a similar Young's modulus to that of the human skin. The AgNW on-skin electrode has a thickness of 300 µm and low sheet resistance of 0.481 ± 0.014 Ω/sq and can withstand the mechanical strain of up to 54% and maintain a sheet resistance lower than 1 Ω/sq after 1000 dynamic strain cycles. The AgNW on-skin electrode can record high signal-to-noise ratio (SNR) sEMG signals from forearm muscles and can reflect various force levels of muscles by sEMG signals. Besides, four typical hand gestures were recognized by the multichannel AgNW on-skin electrodes with a recognition accuracy of 92.3% using machine learning method. The AgNW on-skin electrode proposed in this study has great potential and promise in various HMI applications that employ sEMG signals as control signals.

Outcomes of femtosecond laser cataract surgery with a diffractive multifocal intraocular lens.

PURPOSE: To report the visual and refractive outcomes in an initial series of eyes undergoing femtosecond laser cataract surgery with implantation of a diffractive multi-focal intraocular lens (IOL). METHODS: The first 61 consecutive eyes undergoing femtosecond laser cataract surgery and ReSTOR (Alcon Laboratories Inc) +3.00-diopter (D) add IOL implantation between May and July 2011 were enrolled in the study (LCS group). The control group consisted of a retrospective consecutive cohort of 29 eyes that underwent manual phacoemulsification cataract surgery and ReSTOR +3.00-D add IOL implantation (MCS group) between December 2010 and April 2011. Visual and refractive parameters were collected pre- and postoperatively at 1 and 3 months. RESULTS: Mean postoperative spherical equivalent refraction was -0.01±0.35 D and -0.06±0.30 D in the LCS and MCS groups, respectively (P=.492). Mean absolute refractive prediction error (PE) was 0.26±0.25 D for the LCS group and 0.23±0.16 D for the MCS group (P=.489). Mean arithmetic refractive PE was 0.06±0.44 D and -0.02±0.30 D for the LCS and MCS groups, respectively (P=.388). No significant difference was noted in mean postoperative uncorrected distance visual acuity or uncorrected near visual acuity between groups. No eyes in either group had surgical complications or loss of corrected distance visual acuity in the follow-up period. CONCLUSIONS: Mean spherical equivalent refraction and visual acuity of our initial group of patients undergoing laser cataract surgery are comparable to the manual phacoemulsification cohort for the AcrySof ReSTOR +3.00-D add IOL.

An integrin-contactin complex regulates CNS myelination by differential Fyn phosphorylation.

The understanding of how adhesion molecules mediate the axon-glial interactions in the CNS that ensure target-dependent survival of oligodendrocytes and initiate myelination remains incomplete. Here, we investigate how signals from adhesion molecules can be integrated to regulate these initial steps of myelination. We first demonstrate that the Ig superfamily molecule contactin is associated in oligodendrocytes with integrins, extracellular matrix receptors that regulate target-dependent survival by amplification of growth factor signaling. This amplification is inhibited by small interfering RNA-mediated knockdown of contactin in oligodendrocytes. In contrast, the presence of L1-Fc, the extracellular portion of a contactin ligand expressed on axons, enhanced survival and additionally promoted myelination in cocultures of neurons and oligodendrocytes. We further demonstrate that the signals from contactin and integrin are integrated by differential phosphorylation of the Src family kinase Fyn. Integrin induced dephosphorylation of the inhibitory Tyr-531, whereas contactin increased phosphorylation of both Tyr-531 and the activating Tyr-420. The combined effect is an enhanced activity of Fyn and also a dynamic regulation of the phosphorylation/dephosphorylation balance of Fyn, as required for normal cell adhesion and spreading. We conclude, therefore, that a novel integrin/contactin complex coordinates signals from extracellular matrix and the axonal surface to regulate both oligodendrocyte survival and myelination by controlling Fyn activity.

Do changes in gastro-intestinal blood flow explain high-altitude anorexia?

BACKGROUND: Gastrointestinal symptoms are common on acute exposure to high-altitude (HA). Underlying mechanisms are not understood, but vascular shunting away from the gut could be responsible. Therefore, blood flow in the superior mesenteric artery (SMA) and hepatic portal vein (HPV) was examined at sea level (SL) and after ascent to 4392 m (HA). MATERIALS AND METHODS: Twelve subjects [eight male, mean age 40 (22-72) years] were studied following an overnight fast and a standard meal. Cross-sectional vessel area and blood velocity were measured by ultrasound, systolic and diastolic flow calculated for the SMA (HR x vessel area x velocity, cm(3) min(-1)) and mean flow for the HPV. RESULTS: All subjects experienced reduced appetite at HA. Blood flow in the SMA and HPV increased following food at SL (mean SMA systolic flow 1024 vs. 3316 cm(3) min(-1), P < 0.001; HPV 505 vs. 1789, P < 0.001) and at HA (2020 vs. 3767, P < 0.001; HPV 708 vs. 1727, P < 0.001). Pre-prandial flow in the SMA and HPV was significantly increased at HA compared with SL. The changes were due to increased vessel diameter and increased flow velocity. There was no difference in post-prandial flow between SL and HA in the HPV, although the increase in post-prandial flow was greater at SL than HA (254% increase vs. 144%). CONCLUSIONS: These results show that resting blood flow in the gastrointestinal tract is increased during exposure to high-altitude hypoxia, and that the vascular response of increased blood flow following food ingestion is maintained. Therefore, reduced flow is unlikely to cause gastrointestinal symptoms and reduced appetite at HA.

External analysis of the Randleman Ectasia Risk Factor Score System: a review of 36 cases of post LASIK ectasia.

BACKGROUND: To validate Randleman's model of ectasia risk factor scores using a large unbiased sample of unpublished cases. METHODS: Data were collected retrospectively on 36 eyes with ectasia post laser in situ keratomileusis treated by two surgeons at Vision Eye Institute. The data were then entered into Randleman's risk factor score system. Data were also collected about posterior maximum elevation (PME) and posterior maximum elevation position (PMEP); and these were compared with a control group of 50 eyes. RESULTS: Of the 36 eyes, 9 (25%) were classified as low risk, 7 (19%) as moderate risk and 20 (56%) as high risk. On average, the most points were scored in the topography and topography was abnormal in 69% of cases. Topography points also correlated the most strongly with the increasing risk scores (P < 0.0001).PME or PMEP was not significantly different between our ectasia group and the control group. CONCLUSION: Randleman's ectasia risk factor scale can miss a significant proportion of patients at risk of ectasia. Other factors must play a role in ectasia risk.Abnormal corneal topography appears to be the most important preoperative risk factor.

Corneal Cross-Linking for Keratoconus: Current Knowledge and Practice and Future Trends.

Corneal collagen cross-linking (CXL) with riboflavin is an accepted universal standard of care for our keratoconus patients with progressive disease. It has been a game changer in how we manage keratoconus. Early diagnosis and treatment is essential in paediatric patients as younger patients progress more rapidly and have poorer transplant outcomes. There is an ongoing debate around standard, accelerated, and transepithelial protocols of CXL, the role of CXL, and the combination of laser refractive surgery. Future developments will improve CXL safety and efficacy and the scope of utilization, but we must be careful not to leap too far ahead with clinical applications before publication of basic science research and good clinical results with standardized protocols.

Re-treatment in LASIK: To Flap Lift or Perform Surface Ablation.

PURPOSE: To review safety and efficacy outcomes following re-treatment for residual refractive errors in eyes with prior laser in situ keratomileusis (LASIK) and determine the most appropriate course of action for patients. METHODS: A review of all patients undergoing LASIK enhancement at a single refractive surgery center between 2012 and 2017 was undertaken. Refraction and biomicroscopy results before and after enhancement were collated and analyzed according to the method of enhancement (flap lift or surface ablation). RESULTS: A total of 108 eyes were included in the analysis; 58 eyes underwent flap lift and 50 underwent surface ablation retreatment with mean times to enhancement of 22.3 and 53.2 months, respectively. The mean spherical equivalent prior to enhancement was -0.43 ± 0.69 and -1.03 ± 1.01 diopters (D) for the flap lift and surface ablation groups, respectively. The absolute difference from intended refraction was statistically significant (lift 0.16 ± 0.24 versus surface ablation 0.31 ± 0.35 D; P = .01). The difference was more pronounced for eyes with prior hyperopia (P = .041). The incidence of haze following re-treatment was 3.4% in the flap lift group versus 10.0% in the surface ablation group, and 8.6% of the flap lift group had evidence of epithelial ingrowth, with 1 eye requiring washout. There was no correlation between time to enhancement, refraction, and incidence of complications following the enhancement procedure. CONCLUSIONS: There has been a trend toward treating residual LASIK refractive error through surface ablation. This review suggests that flap lift may result in a more accurate refractive outcome, albeit with an expected greater risk of epithelial ingrowth. [J Refract Surg. 2020;36(1):6-11.].

Quantitative Assessment of Gait Characteristics in Degenerative Cervical Myelopathy: A Prospective Clinical Study.

It is challenging to discriminate the early presentation of Degenerative Cervical Myelopathy (DCM) as well as sensitively and accurately distinguishing between mild, moderate, and severe levels of impairment. As gait dysfunction is one of the cardinal symptoms of DCM, we hypothesized that spatiotemporal gait parameters, including the enhanced gait variability index (eGVI), could be used to sensitively discriminate between different severities of DCM. A total of 153 patients recently diagnosed with DCM were recruited and stratified on the basis of DCM severity grades, as measured using the modified Japanese Orthopedic Association (mJOA) scale. Demographic information and neurological status were collected. Gait assessments were performed using an 8 m walkway. Spearman rank correlation was used to identify relationships between gait parameters and mJOA values as well as the mJOA lower extremity (LE) subscore. Kruskal-Wallis H test was performed to evaluate differences between severity groups, as defined by mJOA classification. A significant and relatively strong correlation was found between the mJOA score and eGVI, as well as between the LE subscore of the mJOA and eGVI. Significant differences in the eGVI (X2(2, N = 153) = 55.04, p < 0.0001, ε2 = 0.36) were found between all groups of DCM severity, with a significant increase in the eGVI as DCM progressed from mild to moderate. The eGVI was the most discriminative gait parameter, which facilitated objective differentiation between varying severities of DCM. Quantitative gait assessments show promise as an accurate and objective tool to diagnose and classify DCM, as well as to potentially evaluate the impact of therapeutic interventions.

Defining the needs and preferences of patients with dry eye disease.

OBJECTIVE: Dry eye disease is a multifactorial chronic disease, leading to ocular discomfort and visual disturbance with a substantial impact on quality of life. Therefore, the patient's perspective should be taken into account early in the drug development process. We have developed a step-by-step methodology based on the self-explicated conjoint approach to assess the needs and preferences of patients with moderate-to-severe dry eye disease. METHODS AND ANALYSIS: Following a literature review and social media listening (step 0), qualitative phone call interviews were conducted with 12 patients (step 1). Patients' responses underwent content analysis and were coded, quantified and displayed as charts. Based on the emerging trends and attributes identified as relevant in steps 0 and 1, a quantitative online questionnaire was designed and conducted with 160 patients across four countries (step 2). RESULTS: The online questionnaire was rated as easy/very easy to understand by 60% of respondents, 62% rated the survey as easy/very easy to complete and 71% rated it as interesting/very interesting. Treatment satisfaction was the most important aspect for patients, and the three most relevant attributes were as follows (with the most important indexed to 100%): 'treatment effectiveness on symptoms of dry eyes' (100%), 'frequency of treatment use' (96%) and 'how the treatment works' (95%). CONCLUSION: Our methodology was well received by patients, and the results will help inform future clinical trial development and discussions with health technology assessment bodies and regulators on unmet needs and product attributes that are of most value to patients with dry eye disease.

Comparing the needs and preferences of patients with moderate and severe dry eye symptoms across four countries.

BACKGROUND/AIMS: Understanding patients' perspectives of their disease can inform drug development and treatment decisions. In this study, we compared the preferences and needs of patients with moderate and severe dry eye symptoms from four different countries. METHODS: A quantitative questionnaire was developed based on the self-explicated conjoint methodology and was administered to 160 patients with moderate or severe dry eye disease (DED) from Australia, Germany, UK and the USA. RESULTS: Patients with moderate dry eye symptoms ranked 'treatment satisfaction' as the most important aspect, whereas 'symptom bother' was more relevant for those in the severe group. Both the moderate and severe groups classified treatment effectiveness as the most important treatment attribute. This result was consistent across the four countries, although US patients gave significantly higher scores than patients from other countries (p<0.001). Furthermore, patients from Australia ranked 'treatment experience' as significantly more important than the concern of side effects, whereas respondents from Germany exhibited the opposite trend (p<0.05 for both). The health burden of DED is reflected in the average European Quality of Life-5 Dimensions 5-level (EQ-5D) scores of 0.764 and 0.658 for patients with moderate and severe disease, respectively. CONCLUSION: Our results confirm that across the countries in the study, moderate and severe DED has a major impact on patients' quality of life and daily activities. By providing insight into the patient perspective of DED, our study helps identify outcomes that are important to patients and may guide future drug development and clinical decision-making.

The graded redefined assessment of strength sensibility and prehension version 2 (GV2): Psychometric properties.

Context: GRASSP Version 1 (GV1) was developed in 2010, is an upper extremity measure specifically designed to assess recovery after traumatic tetraplegia. A second version was developed to reduce length of the test and refine instructions/standardization. The purpose of this post hoc analysis was to calculate psychometric properties of GRASSP Version 2 (GV2). Design/Setting: A post-hoc analysis of datasets for the GRASSP cross-sectional (n = 72 chronic,) and longitudinal (n = 127 acute) studies was conducted. Reliability, validity and MDD were calculated from the chronic sample and responsiveness was re-calculated from the longitudinal sample. Both studies were observational. Participants: A chronic sample (n = 72) and acute longitudinal sample (n = 127) of individuals with traumatic tetraplegia (AIS A to D, NLI C2 to C8) were studied. Outcome Measures: GV1, the Spinal Cord Independence Measure III (SCIM), International Standards of Neurological Classification of Spinal Cord Injury (ISNCSCI) were administered in both studies at all centers and the Capabilities of the Upper Extremity Questionnaire (CUE-Q) was administered in North American sites only. GRASSP-Palmar Sensation, GRASSP-Prehension Performance subtest items included in GV2 were re-analyzed for reliability; validity, MDD and responsiveness. Results: Inter-rater and test-retest reliability for all subtests ranged between 0.849-0.971 and 0.950-0.971 respectively. Concurrent validity between domains of GV2 were positively and moderately (0.530-0.830, P < 0.0001) correlated to SCIM, SCIM self-care subscore (SS) and CUE-Q. MDD values were 4 and 3 points for sensation and prehension performance (single side). Responsiveness values were .84-.88 for GR-Sens and .93-1.22 for GR-PP respectively. Conclusions: GV2 retains excellent psychometric properties as does GV1.

Comparison of the effects of LASIK retreatment techniques on epithelial ingrowth rates.

PURPOSE: To compare the incidence of postoperative epithelial ingrowth using 3 different surgical LASIK retreatment techniques. DESIGN: Retrospective consecutive case series. PARTICIPANTS AND CONTROLS: Thirty consecutive eyes that underwent LASIK retreatments by a single surgeon. METHODS: The first 10 eyes underwent LASIK retreatment using the surgeon's routine surgical technique (forceps lift group), the next 10 retreated eyes had a bandage contact lens placed after surgery and removed the following day (contact lens group), and the next 10 patients had retreatment performed using a Pinelli spatula to cleave the circumference of the flap edge before lifting the flap and no contact lens placed after surgery (spatula cleaving group). The retreatment technique did not vary apart from these modifications. MAIN OUTCOME MEASURES: Incidence of postoperative epithelial ingrowth. RESULTS: The incidence of epithelial ingrowth was 40% in the contact lens group, 20% in the forceps lift group, and 10% in the spatula cleaving group. There was a trend toward a significant difference between the contact lens and spatula cleaving groups (P = 0.12). The patients with epithelial ingrowth showed a trend toward being older, with a mean age of 53+/-8.5 years compared with a mean age of 44+/-13 years for the patients without epithelial ingrowth (P = 0.07). Incidence of ingrowth was not related to the preoperative spherical equivalent. CONCLUSIONS: There was an increased incidence of epithelial ingrowth with use of an overnight bandage contact lens in our series. The Pinelli spatula may reduce trauma to the epithelium at the flap edge. The incidence of epithelial ingrowth was not related to the preoperative spherical equivalent. Increasing age may be a risk factor for epithelial ingrowth, but further study is warranted.

Reduced best spectacle-corrected visual acuity from inserting a thicker Intacs above and thinner Intacs below in keratoconus.

PURPOSE: To report a case of decreased best spectacle-corrected visual acuity (BSCVA) 2 months after Intacs implantation. METHODS: A 33-year-old woman with keratoconus and contact lens intolerance underwent Intacs surgery in the left eye at another institution. Two segments were used--a thinner one (0.25 mm) below the cone and a thicker one (0.35 mm) above the cone. RESULTS: Two months postoperatively, the patient presented to our practice with BSCVA reduced from 20/20 to 20/30. The superior Intacs segment was explanted, the inferior segment was exchanged for a thicker one (0.35 mm), and collagen cross-linking with riboflavin treatment was performed. This resulted in visual, topographic, and refractive improvement with BSCVA returning to 20/20. CONCLUSIONS: Single inferior segment Intacs may be more appropriate for paracentral and peripheral cones. Collagen cross-linking may help cause further flattening. Using asymmetrical segments, with the thicker segment above the cone, may increase distortions and result in loss of BSCVA.

Higher order aberrations and relative risk of symptoms after LASIK.

PURPOSE: To understand what level of higher order aberrations increases the relative risk of visual symptoms in patients after myopic LASIK. METHODS: This study was a retrospective comparative analysis of 103 eyes of 62 patients divided in two groups, matched for age, gender, pupil size, and spherical equivalent refraction. The symptomatic group comprised 36 eyes of 24 patients after conventional LASIK with different laser systems evaluated in our referral clinic and the asymptomatic control group consisted of 67 eyes of 38 patients following LADARVision CustomCornea wavefront LASIK. Comparative analysis was performed for uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), contrast sensitivity, refractive cylinder, and higher order aberrations. Wavefront analysis was performed with the LADARWave aberrometer at 6.5-mm analysis for all eyes. RESULTS: Blurring of vision was the most common symptom (41.6%) followed by double image (19.4%), halo (16.7%), and fluctuation in vision (13.9%) in symptomatic patients. A statistically significant difference was noted in UCVA (P = .001), BSCVA (P = .001), contrast sensitivity (P < .001), and manifest cylinder (P = .001) in the two groups. The percentage difference between the symptomatic and control group mean root-mean-square (RMS) values ranged from 157% to 206% or 1.57 to 2.06 times greater. CONCLUSIONS: Patients with visual symptoms after LASIK have significantly lower visual acuity and contrast sensitivity and higher mean RMS values for higher order aberrations than patients without symptoms. Root-mean-square values of greater than two times the normal after-LASIK population for any given laser platform may increase the relative risk of symptoms.

Effect of inferior-segment Intacs with and without C3-R on keratoconus.

PURPOSE: To determine whether corneal collagen cross-linking with riboflavin (C3-R) augments the effect of inferior-segment Intacs (Addition Technology) in the treatment of keratoconus. SETTING: Private practice, Beverly Hills, California, USA. METHODS: A retrospective nonrandomized comparative case series comprised 12 eyes of 9 patients who had inferior-segment Intacs placement without C3-R (Intacs-only group) and 13 eyes of 12 patients who had inferior-segment Intacs placement combined with C3-R (Intacs with C3-R group). The 2 groups were matched preoperatively. All patients had inferior-segment Intacs placed with the incision in the steep axis of manifest refraction. Corneal collagen cross-linking with riboflavin was performed after the Intacs segments were inserted. Outcome measures were topographic keratometry values and the lower-upper (L-U) ratio, which is a topographic measure of the degree of keratoconus. Preoperative data were compared to results 1 day postoperatively and measurements at the last postoperative visit. RESULTS: The Intacs with C3-R group had a significantly greater reduction in cylinder than the Intacs-only group (P<.05). Steep and average keratometry were reduced significantly more in the Intacs with C3-R group (P<.05). There was a greater reduction in L-U ratio in the Intacs with C3-R group (P<.05). CONCLUSION: The addition of C3-R to the Intacs procedure resulted in greater keratoconus improvements than Intacs insertion alone.