U.S. military implantable collamer lens surgical outcomes: 11-year retrospective review.

PURPOSE: To examine the long-term efficacy and safety of myopic implantable collamer lens (ICL) implantation in active duty personnel of U.S. military. SETTING: Hospital practice. DESIGN: Retrospective longitudinal observational study. METHODS: 1485 patients (median age 25, interquartile range 22 to 29) underwent ICL surgery. Patients received a preoperative examination including uncorrected distance visual acuity (UDVA), intraocular pressure (IOP), manifest refraction measuring corrected distance visual acuity (CDVA), corneal topography and tomography, qualitative grading of perceived ectatic risk, ophthalmic biometry, and baseline endothelial cell counts (ECCs). Outcome measures included UDVA, IOP, vault size, manifest refraction, CDVA, and ECCs. The long-term follow-up data ware drawn from the U.S. military medical record system. RESULTS: A total of 3105 eyes were evaluated. Patients received ICLs because of either abnormal topography (2111 eyes [68%]) or high myopia (994 eyes [32%]). 94 eyes (80%) maintained UDVA of 20/25 or better up to 8 years postoperatively. The rate of achieving the desired refractive correction was 97% (503 eyes) at 1 year and 90% (81 eyes) at 8 years. Stability of these outcomes was also shown by minimal change in manifest refraction. Documented mean ECC loss was 22% at postoperative year 5. The overall rate of adverse events was 1.2% (36 eyes) including visually significant cataract formation, glaucoma, retinal detachment, and traumatic incision opening. A removal or replacement rate of 4.5% (135 eyes) was observed. CONCLUSIONS: ICL implantation was found to be effective and safe. Vault sizes decreased over time, suggesting an increased risk of cataract formation after 7 years. Further study is necessary to assess long-term clinical significance of ECC decline.

Gamma-Irradiated Cornea in Combat-related Ocular Trauma.

Corneal injury is a known risk for deployed troops worldwide. To the authors' knowledge, there has been no reported use of gamma-irradiated corneas in the setting of severe corneal trauma. Our report highlights the case of a 36-year-old active duty solider who sustained bilateral penetrating ocular trauma from a nearby ordnance explosion. We propose that ocular surgeons should consider utilizing gamma-irradiated corneas in (1) a situation where the corneal tissue is so damaged that it would be challenging to accomplish an adequate repair while providing the opportunity for future visual rehabilitation and (2) remote and/or deployed environments where storage of fresh donor tissue is limited. The long shelf life of gamma-irradiated corneas reduces the need for specialized storage equipment and the need for continuous resupply, both potentially leading to significant cost savings for the Military Health System.

Corneal and Corneoscleral Injury in Combat Ocular Trauma from Operations Iraqi Freedom and Enduring Freedom.

OBJECTIVES: To examine the incidence and the etiology of corneal and corneoscleral injuries in the setting of combat ocular trauma, and to determine what effect these injuries have on overall visual impairment from combat ocular trauma. METHODS: Retrospective, noncomparative, interventional case series, analyzing U.S. service members who were evacuated to the former Walter Reed Army Medical Center (WRAMC). Primary outcome measures were types of corneal injuries, length of follow-up at WRAMC, globe survival, and anatomical causes of blindness. Secondary outcome measures included surgical procedures performed, use of eye protection, source of injury, and visual outcomes. RESULTS: Between 2001 and 2011, there were 184 eyes of 134 patients with corneal or corneoscleral injuries. The average age was 26 years (range, 18-50); 99.3% were male, 31.9% had documented use of eye protection. The average follow-up was 428.2 days (3-2,421). There were 98 right-eye and 86 left-eye injuries. There were 169 open-globe and 15 closed-globe injuries with corneal lacerations occurring in 73 eyes with injuries to Zone I. Most injuries were attributable to an intraocular foreign body (IOFB; 48%), followed by penetrating (19.6%) and perforating (16.3%) injuries. The most common presenting visual acuity was hand motion/light perception (45.7%), yet, at the end of the study, visual acuity improved to 20/40 or better (40.8%). The majority of injuries in eyes with visual acuity worse than 20/200 involved the cornea and retina (58%). Injuries solely to the cornea accounted for only 19% of all injuries sustained. CONCLUSIONS: Ocular injuries in military combat have led to significant damage to ocular structures with a wide range of visual outcomes. The authors describe corneal and corneoscleral injuries in combat ocular trauma by classifying injuries by the anatomical site involved and identifying the main source of decreased visual acuity. In combat ocular trauma, corneal or corneoscleral injuries are not the sole etiology for poor vision. A cohesive approach among multiple ophthalmic subspecialties is needed when treating combat ocular trauma.

The Efficacy of Two Trabecular Bypass Stents Compared to One in the Management of Open-Angle Glaucoma.

OBJECTIVES: To compare the outcomes of combined cataract surgery with two trabecular microbypass stents compared to one in patients with open-angle glaucoma. METHODS: Patients with primary open-angle glaucoma were included. Primary outcome measures were intraocular pressure (IOP), postoperative medications, and postoperative adverse events. RESULTS: The average patient age was 73.2 years. Thirty-nine eyes had phacoemulsification and one stent implanted (Group 1); 30 eyes had phacoemulsification and two stents implanted (Group 2). A significant reduction in mean IOP from baseline to 12 months was noted for both Group 1 (16.67 ± 4.1 mm Hg to 14.45 ± 3.8 mm Hg; p < 0.0251) and Group 2 (18.33 ± 3.99 mm Hg to 14.31 ± 1.8 mm Hg; p < 0.0014). Group 2 had a greater percent decrease in IOP at 12 months than Group 1, but this difference was not statistically significant. Only Group 2 demonstrated a statistically significant reduction in medication burden at 12 months. There were no serious complications in either group thought to be caused by the microbypass stents. CONCLUSIONS: Both groups demonstrated a significant reduction in IOP at 12 months. Group 2 showed a greater percent decrease in IOP; however, it was not statistically significant. Only Group 2 demonstrated a statistically significant reduction in medication burden.

Sutureless cryopreserved amniotic membrane graft and wound healing after photorefractive keratectomy.

PURPOSE: To evaluate the effect of sutureless cryopreserved amniotic membrane (Prokera) on corneal wound healing after photorefractive keratectomy (PRK). SETTING: Center for Refractive Surgery, Walter Reed Army Medical Center, Washington, DC, USA. DESIGN: Prospective nonrandomized control trial. METHODS: Patients had PRK for myopia with or without astigmatism. A 20% ethanol solution was used to create a standard 9.0 mm epithelial defect followed by photoablation with the Allegretto Wave Eye-Q 400 Hz laser. After surgery, a high-oxygen-transmissible bandage contact lens (Acuvue Oasys) was applied on the dominant eye and cryopreserved amniotic membrane on the nondominant eye. The postoperative regimen was otherwise identical for both eyes. Postoperatively, patients were evaluated daily until complete corneal reepithelialization occurred in both eyes and then at 2 weeks and 1, 3, 6, and 12 months. Reepithelialization was assessed daily with slitlamp examination, fluorescein staining, and photography. Secondary outcome measures included adverse effects, ocular comfort, visual outcomes, and corneal haze. RESULTS: Forty patients were enrolled. The amniotic membrane graft sped corneal reepithelialization 1 day after PRK but was not better than the bandage contact lens in hastening complete reepithelialization of the cornea. Visual outcomes, corneal clarity, and optical quality of the cornea were comparable between the amniotic membrane graft eyes and bandage contact lens eyes. CONCLUSION: Although the amniotic membrane graft was reasonably well tolerated with few significant adverse effects, the role of amniotic membrane in modulating wound healing after PRK remains speculative.

Causes of combat ocular trauma-related blindness from Operation Iraqi Freedom and Enduring Freedom.

BACKGROUND: The incidence of eye injuries in military service members is high in the combat setting. This is the first study that identifies the primary reason for poor visual acuity (worse than 20/200). METHODS: This is a retrospective, noncomparative, interventional case series analyzing US Operation Iraqi and Enduring Freedom members who were evacuated from the theater of operations to Walter Reed Army Medical Center from 2001 through 2011. Primary outcome measures were the length of follow-up, globe survival, and anatomic causes of blindness. Secondary outcome measures included surgical procedures performed, use of eye protection, nonocular injuries, incidence of traumatic brain injury, source of injury, visual outcomes, and predictability of Ocular Trauma Score (OTS) on visual outcome. Univariate analysis was performed using χ and Fisher's exact test. A p < 0.01 was considered significant because of the multiple hypotheses tested. RESULTS: There were 265 eyes of 239 patients who had final best-corrected visual acuity of worse than 20/200. The average age was 27.4 years (range, 19-53 years). Of the patients, 97.5% were male, and 28.9% had documented use of eye protection. The average follow-up was 350.19 days (range, 3-2,421 days). There were 128 right-eye and 133 left-eye injuries, with a total of 26 bilateral injuries. There were 206 open-globe and 56 closed-globe injuries, which were further subdivided into zones. Open-globe Zone III injuries (81.6%) were the number one cause of blindness, and most injuries were caused by improvised explosive devices (64.2%). Enucleation was the most common surgery performed (40.6%) and therefore the leading cause of blindness, followed by a multifactorial cause and direct traumatic optic neuropathy. CONCLUSION: Ocular trauma is common among combat injuries. Close to a third of service members that experience an ocular trauma become legally blind. Further research is needed to focus on strategies to prevent injury and improve visual outcomes. LEVEL OF EVIDENCE: Prognostic/epidemiologic study, level V.