Impact of thermo-mechanical skin treatment on refraction and keratometry in patients with dry eye disease and the implications for cataract surgery.

PURPOSE: To determine the changes in keratometry measurements and refraction in patients having the thermo-mechanical periorbital skin treatment, Tixel®, to treat dry eye disease (DED). METHODS: A multi-centre, prospective, non-masked study was conducted. DED patients were recruited in 3 international centres and were evaluated in 5 visits separated by an interval of 2 weeks except for the last visit which took place after 18 weeks from visit 1. The same clinical examination was performed at all visits: OSDI questionnaire, tear stability, keratometry, best corrected visual acuity and refraction. Tixel® treatment was applied at the first 3 visits. RESULTS: 89 participants (24 males/65 females; mean age: 55.0 ± 14.2 years) were included: 20 presented moderate DED symptoms and 69 severe DED symptoms. Significant differences were found for the spherocylindrical refraction (vector analysis) between visit 1 and visits 2 and 3. Following cumulative analysis, 11.86 % and 16.94 % of participants had more than 0.5 dioptre (D) change in mean keratometry and keratometric astigmatism, respectively, at 3 months post-treatment. A total of 5.40 % had a sphere and cylinder change greater than 0.50D and 16.21 % had the axis changed more than 10 degrees (vector analysis). These changes were particularly significant in patients with severe DED symptoms. CONCLUSIONS: Keratometry readings and refraction can change following thermo-mechanical skin treatment for DED, especially in those patients with severe DED symptoms. This should be considered as potential errors in intraocular lens calculations may be induced.

Pregnancy-induced keractesia - A case series with a review of the literature.

We report a case series of patients who developed post-laser-assisted in situ keratomileusis (LASIK) ectasia or had a progression of keractesia during pregnancy. We reviewed the medical records of 12 patients (20 eyes) who had reported deterioration of vision during their pregnancy and were diagnosed with keractesia. All 12 patients had experienced symptoms of deterioration of vision between 2 months to 1 year of onset of their pregnancies. A total of 17 eyes of 10 patients had developed post-refractive surgery keractesia. Sixteen of these had undergone LASIK and one had undergone femtosecond lenticule extraction (FLEX). Three eyes of two patients had an exacerbation of keratoconus during pregnancy while one patient had associated hypothyroidism. The results indicate that the hormonal changes that take place in pregnant women can affect the biomechanical stability of the cornea and may trigger the onset of keractesia.

Evaluation of safety and efficacy of different protocols of collagen cross linking for keratoconus.

Introduction: Collagen cross-linking is a well-established modality that could stop the keratoconus from progressing. Off late, newer protocols have been suggested for progressive keratoconus, which include the use of hypoosmolar riboflavin for thinner corneas and the use of accelerated CXL protocol to reduce the effective treatment time. Objective: To assess the safety and efficacy of different protocols of conventional CXL, hypoosmolar CXL and accelerated CXL in patients with keratoconus. Materials & methods: It was a prospective, interventional study with minimum of 12 months follow-up. Patients were divided into 3 groups; conventional CXL, CXL using hypotonic riboflavin and accelerated CXL group. Primary outcome measures - For efficacy, Sim Kmax and Sim Kmin (Progression (Kmax > +1 D), stabilization (Kmax +1 D to -1 D) and regression (Kmax > -1 D). For safety - endothelial count evaluation (decrease >10% amounted to compromise the safety of the procedure). Secondary outcome measures - BCVA and adverse events. Results: 32 eyes underwent isotonic CXL treatment. Pre-treatment and post-treatment BCVA were 0.16 +/- 0.15 and 0.10 +/- 0.11 log MAR; specular counts 2782.81 +/- 307.25 (cells/ mm2) and 2708.5 +/- 263.27 (cells/ mm2) (p=0.05); KMax values 55.31 +/- 4.12 D and 53.9 +/- 3.77 D (p=0.0001). 16 eyes underwent hypotonic CXL treatment. Pre-treatment and post-treatment BCVA were 0.15 +/- 0.13 log MAR and 0.14 +/- 0.14; specular count 2701.19 +/- 243.25 (cells/ mm2) and 2713.5 +/- 369 (cells/ mm2) (p= 1) and KMax values 54.74 +/- 7.44 D and 52.74 +/- 6.76 D (p = 0.002). 15 eyes underwent accelerated CXL treatment. Pre-treatment and post-treatment BCVA were 0.16 +/- 0.15 and 0.10 +/- 0.12 log MAR; specular counts 2967.53 +/- 356.48 and 2893.07 +/- 336.55 (cells/ mm2) (p = 0.78) and KMax values 55.19 +/- 5.46 D and 54.24 +/- 5.33 D (p = 0.337). Conclusion: All three protocols appeared safe and efficacious as therapeutic regimen for progressive keratoconus.

Innovative bulls eye drop applicator for self-instillation of eye drops.

PURPOSE: To report the role of Bulls eye drop applicator device in self-instillation of eye drops and in prevention of wastage of medicine. METHODS: A small pocket sized device "Bulls eye drop applicator" was developed, which is a simple, handy, mirror-based attachment which can be attached to any eye drop bottle to help in accurate self-instillation of the drops in the eye. The prototype of this device was tried in ten volunteer subjects (Group 1) and 15 patients (Group 2); they were asked to use lubricating eye drops (5 ml bottle) in one eye without the device (N) and in the other eye with the device (M). The numbers of attempts for the application of eye drops were noted and the residual eye drops in the returned bottles were measured for quantitative assessment. RESULTS: Ten volunteers and 11/15 patients completed the study. At the completion of the study, there were a total of 232 applications of eye drops in the Group 1 N (without device) and 1 M (with device). To achieve these 232 applications, there were 330 attempts without the device and 266 attempts of instillation were needed with the device (P < 0.0001). In Group 2, there were a total of 544 applications of eye drops; to achieve this, there were 879 attempts in Group 2 N and 685 attempts of instillation in Group 2 M (p < 0.0001). The cumulative quantity of residual drops in the returned bottles collected from Group 2 N was 5.1 ml and it was 19.7 ml in Group 2 M (p = 0.001). CONCLUSIONS: The number of attempts of instillation reduced significantly with the use of the eye drop applicator device. The use of eye drops applicator device reduced the wastage of drops from 42.2% to 14.6% in Group 1 N Vs Group 1 M and saving of about 35.7 % in Group 2 M compared to Group 2 N.

A novel technology tool to capture the clinical information of patients across rural vision centers in a three-tier eye care network in India using the eyeSmart EMR App.

INTRODUCTION: This article describes the implementation of a novel technology tool to capture demographic distribution and clinical presentation of patients in rural vision centers using the eyeSmart electronic medical record (EMR) app in a three-tier eyecare network in India. METHODS: A two-year retrospective review of all patients who presented to the rural vision centers of LV Prasad Eye Institute (LVPEI) eyecare network was performed from September 2016 to August 2018 using an in-house developed eyeSmart EMR app. RESULTS: A total of 501 771 patients were captured on the eyeSmart EMR app across the LVPEI network. The ratio of males (n=273 985, 54.60%) and females (n=227 786, 45.40%) presenting to the rural vision centers was 1.2:1. The most prevalent ocular disorder was refractive errors (n=273 720, 44.32%). CONCLUSIONS: This study details the demographic distribution and prevalence of ocular disorders in a large cohort of Indian patients and demonstrates the potential for real-time analytics through the use of EMR systems. This provides rigorous evidence for the community and eyecare providers that the use of a web application/tablet app (eyeSmart) aids in providing better eyecare services in rural areas. It helps in creating government policies and improves the treatment strategies for various preventable ocular disorders in India.

Use of a Tablet Attachment in Teleophthalmology for Real-Time Video Transmission from Rural Vision Centers in a Three-Tier Eye Care Network in India: eyeSmart Cyclops.

PURPOSE: This study describes the development of an attachment for a smart tablet to stream live video information of an eye examination through the slit lamp. METHODS: A tablet attachment was developed that enables the live streaming of video from the slit lamp from the rural vision centers of the LVPEI network. A video streaming solution like Skype Lite was used to transmit the same. The eyeSmart app was utilized for the documentation of the clinical information of the patients. RESULTS: A tablet attachment of eyeSmart Cyclops was developed and piloted in 3 vision centers of the LVPEI network. CONCLUSION: The use of real-time video transmission illustrates a novel teleophthalmology solution in low resource settings to screen rural populations. The ability to transmit live video enables gathering more information than static images.

Contact lens fitting after corneal collagen cross-linking.

BACKGROUND: Contact lenses (CLs) remain the mainstay in improving vision in patients having keratoconus. With corneal collagen cross-linking (CXL) performed worldwide, whether the same CLs can be used or needs replacement needed to be assessed and considered. AIMS: The aim of this study was to evaluate the changes in CL fitting following CXL. SETTINGS AND DESIGN: This is a retrospective study conducted at a tertiary center. SUBJECTS AND METHODS: We analyzed the medical records of patients who underwent CXL and used CL. Data collected included demographics, pre- and post-CXL refraction, corneal topography, anterior-segment examination, and CL [rigid gas permeable(RGP)] fitting details and duration between CXL and RGP fitting. STATISTICAL ANALYSIS: Descriptive analysis and paired t-test were used to compare the pre- and post-CXL data on refraction, visual acuity, and CL parameters. The statistical significance was kept at P < 0.05. RESULTS: Thirty-four eyes (keratoconus = 32, pellucid marginal degeneration = 1, and post-LASIK ectasia = 1) of 27 patients who used CL before and after undergoing CXL were analyzed. Mean duration between CXL and RGP lens use was 2.53 months. Mean sphere and cylinder post-CXL was -4.11 ± 4.32 D and -3.54 ± 2.51 D, respectively. A mean change of 0.75 ± 3.72 D sphere and 0.71 ± 3.39 D cylinder was noted post-CXL. The post-CXL best spectacle-corrected visual acuity (CVA) was 0.52 ± 0.36 and with RGP lens it was 0.09 ± 0.18. There was no significant difference in pre- and post-CXL RGP lens CVA (0.07 ± 0.09 and 0.09 ± 0.18, respectively; P = 0.556). Pre-CXL, 3-point-touch fitting was in 24 eyes (70.59%) and central fluorescein pooling was in 10 eyes (29.41%). Post-CXL, 30 eyes (88.24%) had 3-point-touch and central fluorescein pooling was found in four eyes (11.76%). One patient had CL intolerance after CXL. Of the 32 keratoconus eyes, 62.5% (n = 20 eyes) were prescribed new lenses; 37.5% (n = 12 eyes) continued using own lenses. CONCLUSIONS: There was no significant difference in refraction, topography indices, and RGP lens parameters pre- and post-CXL. However, changes in RGP lens fitting characteristics suggest a possible change in shape or apex location of the cornea after CXL. RGP lenses remain the best option to improve visual acuity after CXL in corneal ectasia.

Micrococcus keratitis following microkeratome-assisted laser in situ keratomileusis.

We hereby report a case of infectious keratitis after laser in situ keratomileusis (LASIK) caused by Micrococcus luteus, a commensal, managed successfully in a nonimmunocompromised individual. A 25-year-old healthy male underwent uneventful bilateral simultaneous LASIK for myopia using disposable blades. Postoperatively, topical antibiotic and steroids were advised; he discontinued antibiotic on his own after using for a day. On the 5th postoperative day, he had pain, redness, decreased vision, and white spot in the left eye (LE) for 1-day duration. Uncorrected visual acuity (UCVA) of LE reduced to 20/80 from postoperative 20/20. Slit-lamp biomicroscopy revealed tiny infiltrate in the interface with reticular haze in the flap and stroma. Gram-positive cocci in pairs and tetrads were found on corneal smears that were collected after lifting the flap from infiltrate, stromal bed, and undersurface of the flap. M. luteus was isolated on culture. The infiltrate resolved with scarring with intensive topical antibiotics. UCVA was 20/25. To the best of our knowledge, this is a first case report of post-LASIK infectious keratitis caused by M. luteus.

App-Based Tele Ophthalmology: A Novel Method of Rural Eye Care Delivery Connecting Tertiary Eye Care Center and Vision Centers in India.

PURPOSE: The study aims to describe a novel method of utilization of the eyeSmart EMR (electronic medical record) app. It describes the demographic distribution, clinical presentation, query requested by the vision technician, and management advised to the patients by using "eyeSmart EMR" app from the vision centers located across a three-tier eye care network in India. METHODS: This is a retrospective review of all patients who required a tele-ophthalmology consultation from January 2017 to August 2018. The demographic, clinical details, and the impact of teleophthalmology using eyeSmart app, in the vision centers of a three-tier eye care network, was analyzed in detail. RESULTS: A total of 15,001 tele-ophthalmology consults were included which is from January 2017 to August 2018. The mean age was 38 ± 19 years and male to female ratio was 1 : 2. Video calls were performed for 6191 (41.27%) consults and the impact was measured. Additional clinical information was received in 65.61% consults through video call. Medical management was advised in 47.07% of patients and 30.30% were referred to higher centers for medical intervention and 0.59% were referred for surgical intervention, 16.23% were prescribed glasses. No intervention required for 0.69% of cases. Hence nil intervention was advised. CONCLUSION: The combination of using tablet and video calls with the help of eyeSmart EMR app is a novel method in teleophthalmology. It helps in connecting the patients at rural areas and the ophthalmologists in higher centers. The use of technology plays a vital role in the appropriate medical management of the patient.

Role of Scleral Contact Lenses in Management of Coexisting Keratoconus and Stevens-Johnson Syndrome.

PURPOSE: To report the rare coexistence of keratoconus and Stevens-Johnson syndrome (SJS) managed with scleral contact lenses (ScCLs). METHODS: This is a retrospective case series. Five patients (9 eyes) who had coexisting SJS and corneal ectasia were identified from the database during the 2-year period. Diagnosis of SJS was based on a positive history of drug reactions, signs of ocular surface disease, and the presence of keratinization of lid margins. Keratoconus was diagnosed by slit-lamp biomicroscopy. RESULTS: Five eyes of 3 patients had coexisting SJS and keratoconus and were dispensed with ScCLs (PROSE, prosthetic replacement of the ocular surface ecosystem; Boston Foundation for Sight, Needham Heights, MA). All these patients had photophobia. Visual acuity improved in all these patients with ScCL wear. Two patients (4 eyes) were excluded from this study because they had SJS with generalized corneal thinning from limbus to limbus, corneal opacification, and pannus. One patient developed deep vessels in the cornea on prolonged ScCL wear. Reduction in the ScCL wear schedule and change of material with a higher Dk resulted in regression of vascularization. Case 3 developed conjunctival congestion and was uncomfortable wearing ScCLs, although visual acuity was 20/40. He discontinued using ScCL wear. CONCLUSIONS: Keratoconus, a noninflammatory condition of the cornea coexisted with inflammatory SJS. Managing such patients with ScCLs may improve vision and comfort.

Femtosecond Laser-Assisted Anterior Lamellar Keratoplasty for Recurrence of Granular Corneal Dystrophy in Postkeratoplasty Eyes.

PURPOSE: To report the clinical and visual outcome of sutureless femtosecond laser-assisted anterior lamellar keratoplasty (FALK) for recurrent granular corneal dystrophy (GCD) in patients who had previously undergone penetrating keratoplasty and phototherapeutic keratectomy (PTK) performed for recurrent dystrophy in the grafted eyes. METHODS: Four eyes of 4 patients who underwent FALK for recurrence of GCD in previously grafted eyes and underwent PTK performed for initial recurrence in the grafts were included. Patients who had undergone FALK for other indications were excluded. The patients were evaluated for preoperative and postoperative best-corrected visual acuities (BCVA), and intraoperative and postoperative complications. Visual outcomes and complications, if any, were noted. RESULTS: FALK was uneventful in all 4 eyes. At last follow-up, BCVA improved by >2 lines in all eyes. Myopic shift in the refractive error was noted in 2 eyes. None of the eyes had any intraoperative or postoperative complications. One case had dissection margins cross the graft-host junction; however, no dehiscence occurred in this case. The grafts were clear at the last follow-up examinations. CONCLUSIONS: FALK is a safe and effective technique for the management of recurrence of GCD in post-penetrating keratoplasty and post-PTK eyes. BCVA improved by >2 lines after the FALK procedure. None of the patients in this series had any intraoperative or postoperative complications, which was indicative of the safety of the procedure.

Phototherapeutic keratectomy for recurrent granular dystrophy in postpenetrating keratoplasty eyes.

PURPOSE: The purpose is to assess the clinical and visual outcome after phototherapeutic keratectomy (PTK) procedure in eyes with prior penetrating keratoplasty (PKP) for granular corneal dystrophy (GCD) and the time of performance of repeat PTK for recurrence. METHODS: PTK was performed for visually significant recurrence: A reduction in best-corrected visual acuity (BCVA) by >2 lines over BCVA before recurrence was considered as visually significant recurrence. Three eyes had amniotic membrane patch performed with PTK. The main outcome measures were a recurrence of GCD, clinical course, and visual outcome. Intervals between repeat PTK procedures were noted. RESULTS: Six patients (n = 10 eyes; males: 4, mean age 39 ± 13.97 years) underwent PTK. The mean pachymetry before first PTK was 527.1 ± 34 microns. The mean duration between PKP and first PTK was 85.1 months (range: 37-108 months). Two and three PTK procedures were done for seven and five eyes, respectively. Mean duration between first and second and second and third PTK was 62.12 ± 34.41 and 42.8 ± 13.54 months respectively. The average cut depth was 43.66 ± 19.57, 75 ± 43.30 and 39 ± 19.79 microns after the first, second and third PTK procedures, respectively. All eyes had a corneal haze. Pre first PTK mean BCVA was 20/200 and improved significantly after the first two PTK procedures to 20/40 and after the third PTK procedure to 20/32 (P < 0.001). Five eyes had hyperopia. One acute graft rejection was managed successfully at 5 months with medical therapy. CONCLUSION: Multiple PTK procedures can be performed safely with improved visual acuity in grafts without compromising graft survival.

Rose Bengal- and Riboflavin-Mediated Photodynamic Therapy to Inhibit Methicillin-Resistant Staphylococcus aureus Keratitis Isolates.

PURPOSE: To evaluate the in vitro efficacy of rose bengal- and riboflavin-mediated photodynamic therapy for inhibition of methicillin-resistant Staphylococcus aureus (MRSA) isolates. DESIGN: Experimental study. METHODS: Two different multidrug-resistant, clinical MRSA isolates were grown on nutrient agar, prepared in suspension, and adjusted to concentrations of 1.5 × 10(4) colony-forming units per milliliter. Bacterial suspensions were mixed with rose bengal, riboflavin, or water according to experimental group. Tested in triplicate, groups included: Group I, MRSA control; Group II, MRSA with 0.1% rose bengal; Group III, MRSA with 0.03% rose bengal; and Group IV, MRSA with 0.1% riboflavin. All experimental groups were exposed to 3 lighting conditions: dark, ambient room light for 30 minutes, and 5.4 J/cm(2) with either green light-emitting diode (LED) or ultraviolet-A (UV-A) irradiation. Plates were photographed at 72 hours and custom software measured bacterial growth inhibition. RESULTS: Complete growth inhibition of both MRSA strains was demonstrated (1) for both rose bengal concentrations under ambient and green LED irradiation, and (2) for the 0.1% rose bengal in the dark. The 0.03% rose bengal in dark conditions showed complete inhibition of strain 2 but incomplete inhibition of strain 1. Riboflavin showed almost complete inhibition with UV-A irradiation but demonstrated minimal inhibition for both strains in dark and ambient light conditions. CONCLUSIONS: Rose bengal- and riboflavin-mediated photodynamic therapy demonstrated complete growth inhibition in vitro of 2 multidrug-resistant MRSA strains. Rose bengal was also effective in dark and ambient conditions. These results may have implications for in vivo therapy.

Scleral contact lenses in the management of pellucid marginal degeneration.

PURPOSE: To assess visual improvement with scleral lenses (PROSE, prosthetic replacement of the ocular surface ecosystem, Boston Foundation for Sightight, USA) in patients with Pellucid marginal degeneration (PMD). METHODS: This is a single-center, retrospective case-series involving patients with clinical PMD who underwent scleral lens-PROSE trial for improvement of visual acuity, from January 2009 to December 2012 at a tertiary center in India. Scleral lenses with different front surface eccentricities (FSE) were tried for improvement of visual acuity. Snellen visual acuity before and with PROSE wear was noted. Complications with PROSE wear to follow-up were noted. RESULTS: PROSE was dispensed to 12 patients (20 eyes) out of 19 patients having PMD. Location of PMD was inferior in fourteen and superior in two eyes. Four eyes had co-existing keratoconus. Nine were males and three were females. The indications for scleral lens were lens popping-out, failure of piggy-back contact lens and RGP failure. LogMAR Visual acuity improved significantly from 0.45±0.31 pre-PROSE to 0.05±0.08 post-PROSE (p=0.0001). The FSE ordered was 0.6 in 17 eyes, 0.3 in one eye and 0.8 in two eyes. Three patients had hydrops over follow-up; two patients underwent keratoplasty and one was managed conservatively with steroids and hyperosmotic agents. Seven patients did not order PROSE: reasons were - no perceived improvement in visual acuity (n=2), wanted to decide (n=2), continued glasses (n=1) and continued RGP contact lens (n=1). One patient had difficulty with self lens insertion. CONCLUSION: PROSE improves visual acuity in PMD; three patients developed hydrops over follow-up.

Scleral lens for keratoconus: technology update.

Scleral lenses are large diameter lenses which rest over the sclera, unlike the conventional contact lenses which rest on the cornea. These lenses are fitted to not touch the cornea and there is a space created between the cornea and the lens. These lenses are inserted in the eyes after filling with sterile isotonic fluid. Generally, scleral contact lenses are used for high irregular astigmatism as seen in various corneal ectatic diseases such as keratoconus, pellucid marginal degeneration, or/and as liquid bandage in ocular surface disorders. In this article, we review the new developments, that have taken place over the years, in the field of scleral contact lenses as regard to new designs, materials, manufacturing technologies, and fitting strategies particularly for keratoconus.

Keratoglobus: An experience at a tertiary eye care center in India.

CONTEXT: This study was carried out as a part of an internal audit and is the largest series of patients having keratoglobus, published in the literature. Poor visual acuity of the patients indicates the blinding nature of the disease. AIMS: We report our experience with patients having keratoglobus at a tertiary eye care center in India. SETTINGS AND DESIGN: Retrospective study. MATERIALS AND METHODS: We analyzed adults and pediatric patients (<16 years) with keratoglobus, seen during 2008-2012. The age, gender, consanguinity, presenting ocular signs, ocular and systemic associations, visual acuity, corneal topography, and surgeries were documented. RESULTS: Forty-eight patients (mean age 22 ± 15 years, 31 males) having keratoglobus were analyzed. 21 patients (42 eyes) were <16 years. Twelve eyes (16 events) had positive history of trauma. The presenting clinical signs were corneal scars/scars of tear repair (15 eyes), hydrops, healed and acute (14 eyes) and corneal or globe rupture (9 eyes). Best-corrected visual acuity was >20/40 in 6/42 (14.3%) pediatric eyes and 15/53 (28.30%) adults. Visual acuity ranging from counting of fingers to no light perception was noted in 20/53 (37.74%) adults and 21/42 (50%) pediatric patients; 13/20 (65%) with blue sclera and 8/22 eyes (36.37%) without blue sclera. Vernal keratoconjunctivitis was present in one pediatric patient. Choroidal osteoma, retinitis pigmentosa, and retinal detachment were present in adults. Surgeries performed were corneal tear repair (5 eyes), tissue adhesive application (2 eyes), descematopexy (4 eyes) and penetrating keratoplasty (PK - 8 eyes: Three had post-PK glaucoma, graft failure-one eye, 4 patients wore scleral lens - prosthetic replacement of the ocular surface ecosystem). CONCLUSIONS: About 50% of pediatric eyes (65% having blue sclera) had no functional vision. Trivial trauma was responsible for corneal rupture indicating need for protective glasses. About 50% patients had post-PK glaucoma though grafts were clear.

One-stage femtolaser-assisted lamellar keratoplasty and foreign body removal.

PURPOSE: To report the use of femtosecond laser platform to remove a glass foreign body (FB) and remove scar by performing sutureless lamellar keratoplasty. CASE REPORT: A 34-year-old man presented with a posttraumatic anterior stromal scar and retained corneal glass FB after injury to his left eye, sustained in a prior vehicular accident. Right eye examination was essentially normal. Best-corrected visual acuity of the left eye was 20/320. He underwent femtosecond laser-assisted sutureless anterior lamellar keratoplasty using the 500-kHz femtosecond laser machine. The host bed and donor lenticule diameters were 7.9 and 7.8 mm and the thickness of the lenticule was 125 and 150 µm, respectively. The recipient lenticule was obtained by placing the lamellar incision that encompassed the FB. When the recipient lenticule was lifted, partially embedded FB present in the stroma was removed after dislodging it with a 26-gauge needle. The femtosecond-dissected donor button was placed onto the stromal bed with a snug fit. No sutures were taken. Postoperatively, best-corrected visual acuity improved to 20/50 at 1 month and 20/30 at 7 months of follow-up. CONCLUSIONS: Femtosecond laser-assisted sutureless anterior lamellar keratoplasty is a promising modality for lamellar keratoplasty, and as the depth of the incision can be obtained with precision, impacted stromal FBs can be removed in a single procedure along with scars.

Measurement of consensual accommodation in vision-impaired eyes.

PURPOSE: To measure the accommodative response in unsighted or profoundly vision impaired (PVI) eyes when accommodation is elicited in the fellow, sighted eye. METHODS: Eighty-eight unilaterally PVI subjects (UPS) and 97 bilaterally sighted subjects (BSS) (10 to 45 years) were enrolled. Subjects had clear ocular media for auto-refraction and could steadily fixate targets with the sighted eye. For BSS, a long-pass filter was placed in front of one eye to simulate unilateral blindness. Both eyes were measured with a Shin-Nippon auto-refractor while fixating a 4/40 letter at 4 m and then an N8 letter at 40 cm and at 33 cm. Accommodation was calculated as the difference between distance and near refraction. RESULTS: Only subjects with repeatable alignment between measurements were included in the analyses (64 UPS, 95 BSS). Results were analyzed using t test and a generalized linear mixed model including age, sightedness, distance spherical equivalent, and accommodation as factors. The t test found no significant difference between eyes for UPS (p = 0.981 at 40 cm and p = 0.663 at 33 cm). For BSS, the sighting eye produced statistically significant but only slightly greater amounts of accommodation than the filtered eye (0.098 diopters [D], p = 0.002 at 40 cm and 0.189 D, p < 0.001 at 33 cm). The generalized linear mixed model found no difference between BSS and UPS in terms of difference in accommodation between eyes (p = 0.128 at 40 cm and p = 0.157 at 33 cm). CONCLUSIONS: The PVI eyes of unilaterally PVI individuals display similar accommodative response to their fellow, sighted eyes when accommodation is elicited by near target of up to 3 D to the fellow eye. However, the difference in accommodative response between PVI and fellow, sighted eye is related to the amount of accommodation elicited.