Surface ablation outcomes in high myopia with different epithelium removal techniques.

PURPOSE: To study the outcomes of alcohol-assisted photorefractive keratectomy (PRK) when compared with transepithelial PRK (TransPRK) using 2 software programs, with or without SmartPulse Technology (SmartSurfACE), in high myopia. SETTING: Vissum Miranza, University Miguel Hernandez, Alicante, Spain. DESIGN: Retrospective, consecutive, case series. METHODS: High myopic eyes undergoing surface ablation were included. The main inclusion criteria were preoperative spherical equivalent (SE) above -5.50 diopters (D) and no other ocular surgeries. Mitomycin-C was used in all the surgeries. The outcomes were analyzed using the 6-month follow-up visit data. RESULTS: 135 eyes were included. Alcohol-assisted PRK was performed in 65 eyes, transepithelial PRK (TransPRK1) in 32 eyes, and TransPRK2 in 38 eyes. The mean all groups preoperative sphere, cylinder, and SE were -6.00 ± 0.87 D, -1.13 ± 1.03 D, and -6.57 ± 0.69 D, respectively. The mean efficacy index in the alcohol-assisted PRK group was 0.91 ± 0.18 compared with 0.98 ± 0.1 and 0.98 ± 0.12 in the TransPRK1 and TransPRK2, respectively (P = .027). The mean safety index in alcohol-assisted PRK was 0.99 ± 0.05, whereas it was 1 ± 0.06 in the TransPRK1 and 0.99 ± 0.08 in the TransPRK2 (P = .780). A final SE of ± 0.50 D was achieved in 96.9% of eyes in the TransPRK1 group and in 100% eyes in the TransPRK2 group compared with 73.8% in the alcohol-assisted PRK group (P < .001). CONCLUSIONS: Surface ablation with the Amaris 500 excimer laser with flying spot pattern and mitomycin C use showed adequate refractive outcomes in high myopia correction in the 3 groups. TransPRK with or without SmartPulse Technology achieved statistically significant better outcomes than alcohol-assisted PRK in refractive predictability and efficacy.

Twenty years of limbal epithelial therapy: an update on managing limbal stem cell deficiency.

Limbal stem cell damage after chemical injury, autoimmune disorders or iatrogenic trauma leads to corneal conjunctivalisation with new vessel formation, epithelium instability and visual loss. Limbal stem cell transplantation includes reconstructive surgical procedures to restore a corneal epithelium. The recognised options are: conjunctival limbal autograft, in which stem cells are taken from the patient's healthy eye; conjunctival limbal allograft, in which stem cells are taken from a living, related or dead donor and the keratolimbal allograft. Each of these procedures has some drawbacks; in particular, the conjunctival limbal autograft needs a relatively healthy fellow eye and needs a relatively large amount of donor tissue from the healthy eye (about one-third of the healthy limbal stem cell tissue) with potential risks to the donor eye. In the case of keratolimbal allograft transplants, the recipient needs an immunosuppressive treatment to reduce the risk of rejection with the associate possible side effects. More modern treatment options are reviewed. Cultivated oral mucosa epithelial transplantation success rate can vary between 50% and 70% at 3-4 years of follow-up. Simple limbal epithelial transplantation results show a success rate from 75.2% to 83.8% after 1 year of follow-up. Inclusion criteria for autologous cultivated limbal epithelial transplantation as approved by the National Institute of Health and Care Excellence are also shown in this paper. On the basis of these more contemporary treatment options, a stepladder approach to evaluate which procedure is most appropriate and personalised to the patient's conditions is proposed.

Intraocular Lens Explantation After Cataract Surgery: Indications, Results, and Explantation Techniques.

Intraocular lens (IOL) explantation after uneventful cataract surgery is rare but associated with a high risk of complications. In the past few years, the number of published reports about IOL explantation has grown significantly and most of them focus on explantation surgery due to spontaneous late IOL in-the-bag dislocations. This is related to the growth of the pseudophakic population, first as a result of longer lifespans, and second, because the improvements in safety and accuracy of phacoemulsification surgery have led to an increased number of phacorefractive procedures performed in younger patients. The improvement in phacoemulsification surgery goes in tandem with higher patient demands and expectations of the surgery. Therefore, incorrect lens power or patients who fail to neuroadapt to multifocal IOLs are also well­recognized indications for IOL explantation and exchange. IOL opacification, although it was an epidemic in the past especially associated with certain IOL models, is currently still occurring even with some new IOL models. The outcomes of explantation surgeries are analyzed in this review separately according to the reason for explantation. Finally, the main reported IOL explantation techniques are reviewed as well.

Multifocal intraocular lenses: An overview.

Multifocal intraocular lenses are increasingly used in the management of pseudophakic presbyopia. After multifocal intraocular lens implantation, most patients do not need spectacles or contact lenses and are pleased with the result. Complications, however, may affect the patient's quality of life and level of satisfaction. Common problems with multifocal lenses are blurred vision and photic phenomena associated with residual ametropia, posterior capsule opacification, large pupil size, wavefront anomalies, dry eye, and lens decentration. The main reasons for these are failure to neuroadapt, lens dislocation, residual refractive error, and lens opacification. To avoid patient dissatisfaction after multifocal intraocular lens implantation, it is important to consider preoperatively the patient's lifestyle; perform an exhaustive examination including biometry, topography, and pupil reactivity; and explain the visual expectations and possible postoperative complications.

Morphologic differences observed by scanning electron microscopy according to the reason for pseudophakic IOL explantation.

PURPOSE: To compare variations in surface morphology, as studied by scanning electron microscopy (SEM), of explanted intraocular lenses (IOLs) concerning the cause leading to the explantation surgery. METHODS: In this prospective multicenter study, explanted IOLs were analyzed by SEM and energy-dispersive X-ray spectroscopy. The IOLs were explanted in the centers of the research group from 2006 to 2012. The primary procedure was phacoemulsification in all cases. RESULTS: The study evaluated 40 IOLs. The main causes for explantation were IOL dislocation, refractive error, and IOL opacification. Those explanted due to dislocation demonstrated calcifications in 8 lenses (50%), salt precipitates in 6 cases (37.5%), and erythrocytes and fibrosis/fibroblasts in 2 cases (12.5%). In the refractive error cases, the SEM showed proteins in 5 cases (45.5%) and salt precipitates in 4 lenses (36.4%). In IOL opacification, the findings were calcifications in 2 of the 3 lenses (66.6%) and proteins in 2 lenses (66.6%). CONCLUSIONS: A marked variation in surface changes was observed by SEM. Findings did not correlate with cause for explantation. Scanning electron microscopy is a useful tool that provides exclusive information regarding the IOL biotolerance and its interactions with surrounding tissues.

Enhancements after cataract surgery.

PURPOSE OF REVIEW: To provide a review of the recent literature on the indications and results of refractive and nonrefractive enhancements after cataract surgery. RECENT FINDINGS: Laser in-situ keratomileusis proves to be the most accurate procedure to correct residual refractive error after cataract surgery. Other lens-based procedures can be used for the enhancement after cataract surgery but with lower predictability. Depending on the cause of the visual problem, these may be toric intraocular lens (IOL) rotation for excess residual cylinder and IOL exchange for unsatisfied patients with multifocal IOL or for IOL dislocation. SUMMARY: Modern lens removal techniques and advanced preoperative diagnostic methods allow most cataract patients to be spectacle-independent for distance and sometimes also for near. Refractive considerations are integrated into modern cataract surgery and these days, patients expect an adequately predicted refractive outcome. Despite such advances in cataract surgery, unsatisfactory refractive and visual outcomes occasionally occur and in these cases, the enhancement after cataract surgery is required to achieve the best final visual outcome.

Comparative outcomes of bimanual MICS and 2.2-mm coaxial phacoemulsification assisted by femtosecond technology.

PURPOSE: To compare the efficacy and safety outcomes of bimanual microincision cataract surgery (MICS) versus 2.2-mm coaxial phacoemulsification assisted by Femtosecond LenSx (Alcon-LenSx Inc., Aliso Viejo, CA). METHODS: This prospective, randomized, observational, comparative case series comprised 50 cataractous eyes of 50 patients receiving femtosecond laser refractive lens surgery followed by a bimanual MICS technique with two 1-mm incisions (25 patients) (FemtoMICS group) and a coaxial phacoemulsification technique with a 1-mm paracentesis and a 2.2-mm principal incision (25 patients) (FemtoCoaxial group). The main outcomes measures were: ultrasound power, effective phacoemulsification time, postoperative spherical equivalent, higher-order aberrations (corneal and internal), corneal thickness, endothelial cell count, macular thickness, and complications during and after surgery. Both groups were absolutely comparable for all variables preoperatively. RESULTS: Mean ultrasound power was 1.8% ± 0.9% for MICS and 14.7% ± 4.9% for 2.2-mm incisions (P < .001). Effective phacoemulsification time values for MICS and 2.2-mm incisions were 1.5 ± 0.9 and 4.5 ± 2.9 sec, respectively (P = .002). Mean postoperative spherical equivalent was −0.26 for FemtoMICS and −0.33 for FemtoCoaxial (P > .05). The efficacy index at 1 month postoperatively was 160.2% for FemtoMICS and 149% for FemtoCoaxial. No significant differences were found in corneal thickness, endothelial cell count, and macular thickness. Complications included posterior capsule rupture (4%) and anterior capsule rupture with no posterior capsule tear (4%) for FemtoMICS and bridges due to incomplete capsulorhexis (4%) for FemtoCoaxial. CONCLUSIONS: MICS and coaxial phacoemulsification techniques assisted by the Femtosecond LenSx achieved excellent safety and efficient outcomes. The FemtoMICS technique was surgically and statistically more efficient than the FemtoCoaxial technique.

Management of residual refractive error after cataract surgery.

PURPOSE OF REVIEW: To provide a review of the recent literature on the management of residual refractive error after cataract surgery. RECENT FINDINGS: Laser in-situ keratomileusis (LASIK) is the most accurate procedure to correct residual refractive error after cataract surgery. Lens-based procedures, such as intraocular lens (IOL) exchange or piggyback lens implantation, are also possible alternatives in cases with extreme ametropia, corneal abnormalities, or in situations where excimer laser is not available. In this review, we found that Piggyback IOL were safer and more accurate than IOL exchange. SUMMARY: Emmetropia is our main target today in modern cataract surgery. Accurate biometric analysis, selection and calculation of the adequate IOL, and modern techniques for cataract surgery all help surgeons to move toward the goal of cataract surgery as a refractive procedure free from refractive error. However, in spite of all these inputs, residual refractive error still occasionally occurs after cataract surgery and LASIK seems to be the most accurate method for its correction.

Femtosecond laser cataract incision morphology and corneal higher-order aberration analysis.

PURPOSE: Analysis of the femtosecond laser refractive lens surgery corneal incision configuration and corneal higher-order aberration (HOA) effect from the first postoperative day. METHODS: High-resolution anterior segment optical coherence tomography was used to assess 20 eyes undergoing femtosecond laser refractive lens surgery with 2.2-mm minimal incision. The primary incision (tri-planar) actual length, cord length, surface angle, surface irregularity, and regional pachymetry values and the secondary incision (uni-planar) length, angle, surface irregularity, and pachymetry values were analyzed. Hartmann-Shack aberrometer was used to assess corneal HOAs to correlate the effect. Assessment was done preoperatively and 1 month postoperatively. RESULTS: The actual length, cord length, and surface angle means for the primary incision in the first postoperative day and month were 1.50 ± 0.1 and 1.47 ± 0.2 mm (P = .5), 1.41 ± 0.1 and 1.42 ± 0.2 mm (P = .8), and 27° ± 4° and 23° ± 5° (P = .07), respectively. The length and surface angle for the secondary incision in the first postoperative day and month were 1.17 ± 0.01 and 1.04 ± 0.1 mm (P = .05) and 52° ± 3° and 42° ± 5° (P = .007). The regional pachymetry values for the primary and secondary incisions were significantly increased in the first postoperative day and then significantly decreased after 1 month. All irregularities occurred in the posterior surface (endothelium): 2 cases of posterior gap (first day) and 1 case of posterior retraction (first month). The HOAs had not significantly changed preoperatively and after 1 month. CONCLUSIONS: The femtosecond laser refractive lens surgery incision is stable and does not significantly change the HOA.

Resolving refractive error after cataract surgery: IOL exchange, piggyback lens, or LASIK.

PURPOSE: To evaluate the efficacy, predictability, and safety of three different procedures (intraocular lens [IOL] exchange, piggyback lens implantation, and LASIK) to correct residual refractive error following cataract surgery. METHODS: A retrospective multicenter study comprised 65 eyes of 54 patients that underwent phacoemulsification, resulting in a unacceptable final refractive error. Eyes were divided into three groups: eyes that had an IOL lens exchange (17 eyes), eyes that had a piggyback lens implanted (20 eyes), and eyes that had LASIK (28 eyes). RESULTS: No differences between the IOL exchange and piggyback lens groups in the spherical equivalent, sphere, or cylinder were found (P = .072, .436, and .081, respectively). The LASIK group showed a statistically significant reduction in spherical equivalent and refractive cylinder when compared with the IOL exchange group (P < .001 and P = .001, respectively). The LASIK group showed statistically significant reduced refractive cylinder in comparison with the piggyback lens group (P = .002). The median efficacy index was 0.58 (range: 0.28 to 0.93), 0.75 (range: 0.65 to 0.92), and 0.91 (range: 0.85 to 1.14) in the IOL exchange, piggyback lens, and LASIK groups, respectively. Statistically significant differences were found between the IOL exchange and LASIK groups (P = .004) and the piggyback lens and LASIK groups (P = .003). No statistically significant differences were detected in the safety index among groups (P = .094). The predictability (±1 diopters of final spherical equivalent) was 62.5% of eyes in the IOL exchange group, 85% of eyes in the piggyback lens group, and 100% of eyes in the LASIK group. CONCLUSIONS: The three procedures were effective. The LASIK group showed the best outcomes in efficacy and predictability.

Perioperative complications and clinical outcomes of intraocular lens exchange in patients with opacified lenses.

BACKGROUND: To evaluate the perioperative complications and the outcomes of intraocular lens (IOL) exchange in patients with opacified lenses. METHODS: Retrospective multicentrical consecutive series of cases that comprised 22 eyes from 21 patients who had previous phacoemulsification with implantation of an IOL in the capsular bag and developed severe late opacification of the IOL. All patients had loss of vision and reported light disturbances. The IOLs were explanted and replaced with new IOLs. The perioperative complications were evaluated. The best spectacle-corrected visual acuity (BSCVA) before and after the surgery was compared. RESULTS: The mean time lapsed between the original cataract surgery and the IOL exchange surgery was 89.1 ± 33.6 [48-216] months. The IOL exchange was uneventful in 14 eyes (63.6 %). Anterior vitrectomy was needed in seven cases (31.8 %). Other complications included zonular dehiscence in one case (4.5 %). In most of the cases, 14 eyes (63.6 %), the IOL was implanted in the sulcus. The most explanted IOL was the Hydroview H60M (Bausch & Lomb). The mean BSCVA (LogMAR) before and after the surgery were 0.57 ± 0.69 (0.10-3) and 0.18 ± 0.22 (0.0-1.10) respectively (t paired test, p < 0.001). After the operation, 20 eyes (90.9 %) achieved a BSCVA ≤ 0.3. No eye lost 1 or more lines of corrected vision after the surgery. CONCLUSIONS: IOL exchange surgery, although associated with a high incidence of complications, restores and significantly improves the visual acuity of patients with opacified IOLs.

Topical cyclosporine for atopic keratoconjunctivitis.

BACKGROUND: Atopic keratoconjunctivitis (AKC) is a chronic ocular surface non-infectious inflammatory condition that atopic dermatitis patients may suffer at any time point in the course of their dermatologic disease and is independent of its degree of severity. AKC is usually not self resolving and it poses a higher risk of corneal injuries and severe sequelae. Management of AKC should prevent or treat corneal damage. Although topical corticosteroids remain the standard treatment for patients with AKC, prolonged use may lead to complications. Topical cyclosporine A (CsA) may improve AKC signs and symptoms, and be used as a corticosteroid sparing agent. OBJECTIVES: To determine the efficacy and gather evidence on safety from randomised controlled trials (RCTs) of topical CsA in patients with AKC. SEARCH METHODS: We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2012, Issue 6), MEDLINE (January 1946 to July 2012), EMBASE (January 1980 to July 2012), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to July 2012), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (January 1937 to July 2012), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov), the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en), the IFPMA Clinical Trials Portal (http://clinicaltrials.ifpma.org/no_cache/en/myportal/index.htm) and Web of Science Conference Proceedings Citation Index- Science (CPCI-S). We did not use any date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 9 July 2012. We also handsearched the following conference proceedings: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, International Council of Opthalmology and Societas Ophthalmologica Europaea from 2005 to July 2011. SELECTION CRITERIA: We included randomised controlled trials only. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data. Due to the small number of studies and the diversity of outcome measures, interventions and participants, we presented results narratively. MAIN RESULTS: We found three RCTs with a total of 58 participants that were eligible for inclusion. There was significant variability between the trials in interventions, methodology and outcome measures and therefore we did not perform meta-analysis.One study reported on the use of 2% CsA in maize oil and two on the use of a commercial emulsion of 0.05% CsA. Of these three studies, one showed a beneficial effect of topical CsA in controlling signs and symptoms of AKC, one in controlling signs of AKC and one did not show evidence of an improvement. Only two studies analysed the effect of topical CsA in reducing topical steroid use; one showed a significant reduction in topical steroid use with CsA, but the other did not show evidence of this improvement. No serious adverse events were reported in the trials. AUTHORS' CONCLUSIONS: This systematic review highlights the relative scarcity of controlled clinical trials assessing the efficacy of topical CsA therapy in AKC and suggests that evidence on the efficacy and safety of topical CsA treatment in patients with CsA remains limited. However, the data suggest that topical CsA may provide clinical and symptomatic relief in AKC and may help to reduce topical steroid use in patients with steroid-dependent or steroid-resistant AKC. No serious adverse events were reported. Reported adverse events in patients treated with topical CsA include intense stinging and eyelid skin maceration. One patient in the placebo group developed a severe allergic response to maize antigens. However, the total number of patients in the trials was too small to assess the safety of this treatment.Additional well-designed and powered RCTs of topical CsA in AKC are needed. Ideal study designs should include adequate randomisation and concealment of allocation; masking of participants, personnel and outcome assessors; adequate follow-up periods and minimisation of attrition bias; and comparison groups with similar clinical and epidemiologic characteristics. Samples should be large enough to provide sufficient statistical power to assess the safety of CsA and to detect clinically relevant treatment effect sizes of the primary outcomes. Analyses should be appropriate to the study's design and outcome measures. Moreover, standardisation of outcome measures and follow-up periods across studies would be beneficial to maximise study comparability.

Causes of IOL explantation in Spain.

PURPOSE: To study the reasons and the demography of pseudophakic intraocular lens (IOL) explantation in Spain. METHODS: In this observational multicenter retrospective study, the cases studied correspond to the 15 centers that constitute the Nodo Calidad Visual y Cirugia Refractiva of the Red Tematica de Investigacion Cooperativa (RETICS) sponsored by the Spanish Ministry of Health. Clinical data from all the patients who underwent explantation were assessed. The different reasons that caused the decision of explantation were analyzed. RESULTS: A total of 257 explanted pseudophakic IOLs have been studied. Patients' mean age when explantation occurred was 67.5 years (SD 13.5 [22-99]) and 135 were female (52.5%). The main causes for explantation were dislocation/decentration in 145 cases (56.3%), incorrect lens power in 33 cases (12.8%), IOL opacification in 29 eyes (11.3%), neuroadaptation failure in 16 cases (6.2%), pseudophakic bullous keratopathy in 6 eyes (2.3%), endophthalmitis in 5 cases (1.9%), and "other causes" in 23 eyes (8.9%). Treatment after explantation was posterior chamber IOL implantation in 149 eyes (58%), anterior chamber IOL implantation in 49 eyes (19.1%), aphakia in 39 eyes (15.2%), and missing information in 20 cases (7.8%). Mean time from implantation to explantation was 3.97 (SD 4.68 [0.005-21.1]) years. CONCLUSIONS: Dislocation/decentration (most of the time with lens in the bag) is the main cause for explantation in Spain, followed by incorrect lens power (which decreased greatly over past years) and IOL opacification. Posterior chamber IOL implantation is the most elected treatment after explantation.

Comparison between phaco-deep sclerectomy and phaco-deep sclerectomy reconverted into phaco-trabeculectomy: series of fellow eyes.

BACKGROUND: To evaluate and compare the results and complications after uneventful phaco-deep sclerectomy in one eye with intended phaco-deep sclerectomy converted to phaco-trabeculectomy in the fellow eye. METHODS: In this retrospective study, we analyzed thirty-two eyes of sixteen patients in which bilateral phaco-deep sclerectomy was planned but one eye was converted to phaco-trabeculectomy after perforation of the trabeculo-Descemet's membrane. Visual acuity (VA), slit-lamp examinations, intraocular pressure (IOP), and the number of glaucoma medications were recorded preoperatively and postoperatively at 1 day, 1 week, and 1, 3, 6, 12, 18, and 24 months. The postoperative complications were recorded. Comparisons between the two groups were performed. RESULTS: The IOP was significantly lower in both groups at every postoperative visit. The postoperative IOP and VA levels did not differ significantly between the groups. However, at the last postoperative visit, eyes that underwent uneventful phaco-deep sclerectomy required fewer glaucoma medications than eyes converted to phaco-trabeculectomy (P = 0.04). At 24 months, the group that underwent uneventful phaco-deep sclerectomy had a higher complete success rate (P = 0.01). Immediate postoperative complications such as hyphema, a shallow anterior chamber, or a choroidal detachment occurred more frequently in eyes converted to phaco-trabeculectomy, although the difference did not reach significance. CONCLUSIONS: There were no differences in VA or IOP control between uneventful phaco-deep sclerectomy and phaco-deep sclerectomy converted to phaco-trabeculectomy. However, fewer drugs were needed to successfully control IOP and the rate of complications was lower if phaco-deep sclerectomy was completed uneventfully.