Femtosecond-Assisted Mushroom Deep Anterior Lamellar Keratoplasty.

PURPOSE: The aim of this study was to describe our technique for performing femtosecond laser (FSL)-assisted mushroom configuration in deep anterior lamellar keratoplasty (DALK). METHODS: We describe our surgical technique for a mushroom-configuration DALK using a femtosecond laser (FSL) both to prepare the graft and to perform a precut of the recipient cornea, as well as the steps for the dissection of the recipient cornea and for donor cornea implantation. Moreover, we show the parameters of energy and spot separation and the external and internal diameters as well as the thickness of the external and internal keratotomy. RESULTS: We performed a retrospective case series study of 20 patients with a mean follow-up of 4.36 ± 2.54 years. The indication for surgery was leukoma in 15 cases (75%), keratoconus in 4 cases (20%), and stromal corneal dystrophy in 1 case (5%). Four cases had to be converted to penetrating keratoplasty. The overall results were as follows: The mean preoperative corrected distance visual acuity increased from 0.11 ± 0.09 (0.01-0.30) to 0.78 ± 0.22 (0.30-1.0) with spectacles and to 0.92 ± 0.13 (0.5-1.0) with a gas permeable contact lens. The mean final cylinder was 3.90 ± 1.86 (1.25-7.0). The mean endothelial cell count at 6 months was 2033.83 ± 570.53 cells/mm2 (930-3207), and the mean final spherical equivalent was -4.67 ± 2.91 (-0.25 to -9.00). CONCLUSIONS: FSL-assisted technology is useful to achieve a predictable and safe procedure when using mushroom configuration to perform DALK. Our conversion rate from DALK to penetrating keratoplasty was similar to or even lower than that reported in the literature. In the successful DALK cases, the visual and refractive results were similar to those reported in other studies using FSL-assisted DALK (with a standard or mushroom configuration).

Descemet Membrane Endothelial Keratoplasty and Descemet Stripping Only Using a 3D Visualization System.

(1) Purpose: The aim was to analyze the outcomes of Descemet's membrane endothelial keratoplasty (DMEK) and Descemet stripping only (DSO) surgeries using a glasses-assisted NGENUITY® 3D visualization system (Alcon Laboratories, Fort Worth, TX, USA). (2) Methods: Five consecutive cases of DMEK surgery and four consecutive cases of DSO were performed using the NGENUITY® system in this prospective study carried out at the Arruzafa Hospital, Córdoba, Spain. Only one eye from each patient received surgery. Best corrected distance visual acuity (CDVA) using EDTRS charts, central corneal thickness using the Casia II optical coherence tomograph (Tomey Co., Nagoya, Japan), and endothelial cell count using the Tomey EM-4000 (Tomey Co., Nagoya, Japan) for DMEK cases or the Nidek CEM-530 (Nidek Co., Ltd., Gamagori, Japan) specular microscopes for DSO cases were recorded preoperatively and at 1 and 3 months postsurgery. (3) Results: DMEK cases included one male and four female subjects, with a mean age of 73.6 ± 9.5 years. Average improvement in CDVA 3 months after surgery was 0.46 ± 0.16 decimal. Average change in cell count between 1 and 3 months postsurgery was 360.75 ± 289.38 cells/mm2. DSO cases included four female subjects, with a mean age of 64.2 ± 9.7 years. The average improvement in CDVA 3 months after surgery was 0.09 ± 0.17 decimal. All cases also had phacoemulsification carried out. He average change in cell count between 1 and 3 months after surgery was 460 ± 515.69 cells/mm2. There were no associated complications during surgery or the follow-up period in any of the cases. (4) Conclusions: In addition to the known benefits of the use of a 3D visualization system during surgery, the present study shows that the system can be successfully used in both DMEK and DSO procedures with a very short learning curve for the surgeon.

Management of low astigmatism in implantable collamer lens surgery: opposite clear corneal incisions vs toric implantable collamer lens.

PURPOSE: To compare 2 techniques to correct low astigmatism during implantable collamer lens (ICL) surgery: astigmatic opposite clear corneal incisions (OCCIs) and toric ICL (T-ICL). SETTING: Arruzafa Ophthalmological Hospital, Cordoba, Spain. DESIGN: Randomized prospective comparative study. METHODS: The study comprised 152 myopic eyes undergoing ICL surgery. Patients were separated into 2 groups: Group 1 (57 patients; 76 eyes) received a spherical ICL with OCCIs and Group 2 (53 patients; 76 eyes) received a T-ICL. The inclusion criteria were refractive astigmatism up to 1.50 diopters (D), regular corneal astigmatism up to 2.00 D (Sim K, Pentacam), and agreement between the refractive and topographic corneal cylinders (discrepancies less than 30 degrees axis or 0.50 D). The outcomes were evaluated after a 1-month follow-up. RESULTS: The T-ICL group achieved a mean postoperative spherical equivalent refraction and refractive astigmatism of -0.04 ± 0.17 D and -0.03 ± 0.12 D, respectively, vs -0.14 ± 0.33 D and -0.20 ± 0.36 D, in the OCCI group ( P < .001). Postoperative refractive astigmatism of less than 0.25 D was achieved in 94.74% of cases in the T-ICL group vs 73.68% in the OCCI group. Undercorrection of corneal astigmatism occurred in the OCCI group with a surgically induced astigmatism of 0.48 ± 0.24 D and correction index = 0.46. CONCLUSIONS: Both the T-ICL and OCCI techniques provided excellent results in terms of safety and efficacy. T-ICL surgery was shown to be more predictable and accurate for correcting low astigmatism with a lower postoperative spherical equivalent and less residual astigmatism compared to incisional management.

Complications of Small Aperture Intracorneal Inlays: A Literature Review.

Presbyopia can be defined as the refractive state of the eye in which, due to a physiological decrease in the ability to accommodate, it is not possible to sustain vision without fatigue in a prolonged manner, along with difficulty focusing near vision. It is estimated that its prevalence in 2030 will be approximately 2.1 billion people. Corneal inlays are an alternative in the correction of presbyopia. They are implanted beneath a laser-assisted in situ keratomileusis (LASIK) flap or in a pocket in the center of the cornea of the non-dominant eye. The purpose of this review is to provide information about intraoperative and postoperative KAMRA inlay complications in the available scientific literature. A search was conducted on PubMed, Web of Science, and Scopus with the following search strategy: ("KAMRA inlay" OR "KAMRA" OR "corneal inlay pinhole" OR "pinhole effect intracorneal" OR "SAICI" OR "small aperture intracorneal inlay") AND ("complication" OR "explantation" OR "explanted" OR "retired"). The bibliography consulted shows that the insertion of a KAMRA inlay is an effective procedure that improves near vision with a slight decrease in distance vision. However, postoperative complications such as corneal fibrosis, epithelial iron deposits, and stromal haze are described.

Surgical correction of corneal opacity and aniridia with penetrating keratoplasty and a new iris prosthesis implant.

PURPOSE: This study is to describe the clinical outcome of penetrating keratoplasty combined with implantation of a novel intraocular lens with an artificial iris, aided by continuous vitreous chamber infusion, in patients with severe aniridia and corneal alterations. METHODS: This was a prospective single-center case series study involving five patients with corneal alterations and aniridia. All subjects underwent simultaneous penetrating keratoplasty and implantation of a new intraocular lens with an artificial iris with the assistance of infusion into the vitreous chamber to regulate intraocular pressure during the surgical procedure. Visual acuity, corneal endothelial cell density, and intraocular pressure assessments were performed in the postoperative period. The final cosmetic outcome of the iris prosthesis placement was also evaluated. RESULTS: In all cases, increased visual acuity and a good aesthetic result were observed in all affected eyes except one in which, despite the excellent aesthetic outcome, the eye was very hypotonic as it had high myopia and had undergone several previous surgeries. CONCLUSION: The single surgical procedure combining implantation of an intraocular lens-iris prosthesis with penetrating keratoplasty is an effective technique for the simultaneous treatment of aphakia and aniridia. However, larger series with longer-term follow-up are needed to definitively establish the benefits of this technique.

Comparison Between the Wavefront-Optimized and Custom-Q Aspheric Ablation Profiles in Myopic Eyes With Two Different Q-targets: A Contralateral Eye Study.

PURPOSE: To compare two aspheric ablation profiles in myopic refractive surgery using different asphericity targets. METHODS: Patients underwent laser in situ keratomileusis (LASIK) with the WaveLight EX500 laser platform (Alcon, WaveLight Laser Technologie). Asymmetric surgery was performed, programming the wavefront-optimized (WFO) ablation profile in one eye and the custom-Q (CQ) profile in the contralateral eye. The patients were divided into two groups following a systematic randomization method. The Q-target programmed for the preoperative Q group was equal to the preoperative asphericity of the CQ profile, and for the -0.6 Q-target group, the Q-target was set to -0.6. RESULTS: The study included 100 patients (200 eyes). Both groups had comparable safety and efficacy indexes greater than 1. A similar oblate shift in postoperative asphericity was seen in both groups regardless of the ablation profile and programmed Q-target. Asphericity was 0.33 ± 0.34 and 0.35 ± 0.29 (P = .18) in the preoperative Q group and 0.26 ± 0.28 and 0.26 ± 0.27 (P = .89) in the -0.6 Q-target group for WFO and CQ, respectively. A lower spherical aberration was found with CQ compared to WFO when the Q-target was set to -0.6: 0.211 ± 0.121 versus 0.144 ± 0.114 (P < .01). However, no statistically significant differences were found when the preoperative Q-target was used. CONCLUSIONS: WFO and CQ treatments are similar in terms of refractive and visual outcomes. CQ offers greater control over the increase in positive spherical aberration after myopic refractive surgery, but it does not represent an advantage over WFO in the oblate shift in postoperative asphericity regardless of the Q-target programmed. [J Refract Surg. 2022;38(11):698-707.].

Visual Performance, Satisfaction, and Spectacle Independence after Implantation of a New Hydrophobic Trifocal Intraocular Lens.

The main objective was to evaluate distance, intermediate, and near vision in patients who have undergone cataract extraction with bilateral implantation of a new trifocal diffractive intraocular lens (IOL), along with patient-reported outcomes (PRO). A total of 50 eyes from 25 patients after AsqelioTM Trifocal IOL (AST Products, Inc., Billerica MA, USA) implantation were assessed in this study. At 3 months after surgery, the photopic visual acuity (VA) at distance, intermediate, and near distances was measured. Binocular photopic defocus curves were also obtained. Three questionnaires to assess patients' visual satisfaction and spectacle dependence, among other items, were completed: the Catquest-9SF, the patient-reported spectacle independence questionnaire (PRSIQ), and the patient-reported visual symptoms questionnaire (PRVSQ). The average spherical equivalent was 0.21 ± 0.37 D at 3 months post-operation, and the average absolute tolerance to defocus was 3.64 ± 0.70 D. The mean binocular uncorrected VAs for distance, intermediate, and near vision were -0.02 ± 0.09, 0.06 ± 0.08, and 0.11 ± 0.07 logMAR, respectively. The best-corrected VA was better than 0.1 logMAR for the whole range from distance to near. PROs revealed spectacle independence and general satisfaction with vision, and the incidence of photic phenomena were low. This study shows that the new bi-aspheric diffractive trifocal IOL provides a good visual performance at different distances under photopic conditions, accompanied by patient satisfaction and spectacle independence.

Early patient-reported outcomes of cataract surgery with implantation of the trifocal liberty 677MY intraocular lens: A pilot study.

PURPOSE: To report our first clinical and patient-reported outcomes in the early postoperative period with a new model of trifocal diffractive intraocular lens (IOL). METHODS: Pilot prospective analysis of the results of 26 eyes of 13 patients (age, 44-79 years) undergoing cataract surgery with implantation of the trifocal diffractive IOL Liberty 677MY (Medicontur Medical Engineering Ltd., Zsámbék, Hungary). The following clinical outcomes were evaluated during the first postoperative month: measurement of distance, intermediate and near visual acuity, binocular defocus curve, and level of spectacle independence, patient satisfaction, perception of photic phenomena, and difficulty in performing several vision-related daily tasks by means of a questionnaire. RESULTS: Mean binocular LogMAR uncorrected distance, intermediate and near visual acuities were -0.03 ± 0.13, 0.21 ± 0.16, and 0.16 ± 0.09, respectively. Furthermore, 100.0%, 84.6% and 92.3% of patients achieved a binocular corrected distance, distance-corrected intermediate and distance-corrected near visual acuity of 20/32 or better, respectively. In the defocus curve, visual acuities were better than 0.2 logMAR for defocus levels between +1.00 and -3.00 D. Spectacle independence was referred by all patients, with any of them reporting dissatisfaction with the outcome of the surgery. The postoperative vision did not lead to difficulties in the daily life in 92.3% of patients. Bothersome halos, glare or starbursts were only reported by only 7.7% of patients. CONCLUSIONS: The trifocal IOL evaluated provides a successful visual rehabilitation with minimal photic phenomena associated, leading to high levels of spectacle independence and patient satisfaction.

Comparison of wound architecture in implantable collamer lens surgery: Self-sealing single-plane opposite clear corneal incision versus main surgical incision.

PURPOSE: Incision architecture can play an important role in corneal astigmatism management through peripheral corneal relaxing incisions. The aim of this study was to compare the incision architecture of single-plane opposite clear corneal incisions (OCCIs) and main surgical incisions (MSIs) in patients undergoing implantable collamer lens (ICL) surgery. METHODS: A retrospective cross-sectional tomographic analysis of MSI and OCCI architectures was performed 6 months after ICL surgery. Image acquisition was performed using spectral-domain anterior segment optical coherence tomography. RESULTS: A total of 31 OCCIs and 24 MSIs were evaluated. The mean incision angle was 42.83 ± 5.69 degrees for MSIs and 48.26 ± 6.07 degrees for OCCIs (p < 0.01), and the mean MSI and OCCI length was 1146.70 ± 150.48 µm and 976.68 ± 140.19 µm, respectively (p < 0.01). The mean increase in epithelium depth in the wound was 37.63 ± 11.91 µm in the MSI group and 47.64 ± 15.45 µm in the OCCI group (p = 0.02). Endothelial misalignment was observed in both types of incisions. However, the misalignment with MSI was greater than with OCCI, 106.67 ± 31.84 µm versus 83.75 ± 23.39 µm (p = 0.01), respectively. CONCLUSION: Both types of incisions, OCCI and MSI, were shown to be safe with complete wound sealing and healing 6 months postoperatively. The MSIs performed in the temporal position were more angled and longer, with greater endothelial retraction and minor epithelial thickening in the wound area compared with astigmatic incisions without manipulation.

Cataract surgery astigmatism incisional management. Manual relaxing incision versus femtosecond laser-assisted arcuate keratotomy. A systematic review.

PURPOSE: This systematic review aims to compare corneal astigmatism correction in cataract surgery through corneal relaxing incision, manually and femtosecond laser assisted. METHODS: The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. We used PubMed, Scopus, and Web of Science (WOS) as databases from January 2010 to March 30, 2021. Patients with keratoconus, corneal ectasia, and a previous history of eye surgery were excluded because our aim was to analyze only healthy eyes. RESULTS: A total of 1025 eyes were evaluated from 946 patients (mean age was 68.90 ± 5.12) in manual incision group articles, while 1905 eyes of 1483 patients (mean age was 65.05 ± 4.57) were evaluated in femtosecond laser arcuate keratotomy (FLAK) articles. The mean uncorrected distance visual acuity (UDVA) was 0.19 ± 0.12 and 0.15 ± 0.05 logMAR for manual incision and FLAK articles, respectively (p = 0.39). The mean correction index (CI) was similar in both groups: 0.77 ± 0.18 in manual incision and 0.79 ± 0.17 in femtosecond laser assisted incision (p = 0.70). Refractive stability was found after 3 months and no serious complications were reported during the follow-up in any group. CONCLUSION: Both techniques are safe and moderately effective in corneal astigmatism correction in cataract surgery. FLAK represents a more precise and predictable approach. However, since visual and refractive outcomes appear to be similar in both cases, the cost-benefit analysis is controversial.

Nomogram for single-pass automated microkeratome graft preparation for ultrathin Descemet stripping automated endothelial keratoplasty.

PURPOSE: To create a nomogram including the translational speed of the microkeratome blade, microkeratome head size and precut tissue thickness to predict the postcut thickness for Descemet stripping automated endothelial keratoplasty to obtain the thinnest possible graft. METHODS: This prospective study incorporated 48 grafts for DSAEK from March 2017 to June 2020. Corneal tissue for DSAEK was prepared by 3 experienced physicians using the Moria Evolution 3E (Moria Inc, Antony, France) microkeratome with 400, 450 and 500 µm head sizes. Precut central corneal thickness was measured with a DGH 550 handheld pachymeter (Pachette 2), taking an average of 3 readings. The microkeratome head was selected according to precut tissue thickness. The selected microkeratome head size was 150 µm less than the donor cornea thickness. Two translational speeds were used for the microkeratome cuts. One month after surgery, the central lenticular thickness was measured with a Visante® Optical Coherence Tomography caliper (Carl Zeiss Meditec Inc, Germany). A descriptive analysis was performed. RESULTS: Forty-eight donor grafts were prepared. Mean graft thickness was 97.58 ± 29.84 µm (range 39-176 µm). Of the 48 samples, central graft thickness was < 120 µm (81.3%) in 39, < 100 µm (58.3%) in 28 and < 80 µm (37.5%) in 18 at 1-month follow-up. There were no statically significant differences between translational speeds. CONCLUSIONS: A nomogram with an automated microkeratome to obtain thin grafts for DSAEK provided good graft thickness results without donor waste.

Aberrometric, Keratometric, and Visual Outcomes After Trans-Epithelial Topography-Guided Phototherapeutic Keratectomy for the Treatment of Irregular Corneas.

PURPOSE: To assess the safety, aberrometric and keratometric changes, and stability of trans-epithelial topography-guided phototherapeutic keratectomy (TE-TG-PTK) with mitomycin C (MMC) using the ALLEGRO Topolyzer platform for the treatment of irregular astigmatism. METHODS: This is a retrospective case series including 57 eyes that underwent TE-TG-PTK + MMC using the ALLEGRO Topolyzer platform for the treatment of irregular astigmatism. CDVA, manifest refraction (MR), keratometry readings, and aberrometry readings were analyzed at 1, 3, 6, and 12 months. RESULTS: Causes of corneal irregularity included non-infectious leucoma (n=23), infectious leucoma (n=7), adenoviral keratitis (n=20), corneal haze (n=2), post-penetrant keratoplasty (PKP) (n=1), and others (n=4). Overall, 76% of the eyes (n=40) gained lines of vision; patients gained 1, and 2 or more lines of vision in 76%, and 38% of cases, respectively. Only 1 patient (2%) lost 5 lines of vision. Mean preoperative CDVA (LogMAR) was 0.37 ±0.31 and improved to 0.14 ±0.18 (p<0.001) at final follow-up (12 months). CDVA remained unchanged in 10 eyes (21%). No significant changes were observed in mean keratometry (Kmean) and keratometric astigmatism readings. Regarding aberrometry, only changes in coma proved to be significant 6 months after surgery (P<0.01). No intraoperative/postoperative complications were reported. CONCLUSION: At final follow-up, significant improvements were observed in CDVA and coma. TE-TG-PTK + MMC proved to be an effective and safe procedure for the treatment of corneal irregular astigmatism due to several causes.