Prescribing patterns for paediatric hyperopia among paediatric eye care providers.

PURPOSE: To survey paediatric eye care providers to identify current patterns of prescribing for hyperopia. METHODS: Paediatric eye care providers were invited, via email, to participate in a survey to evaluate current age-based refractive error prescribing practices. Questions were designed to determine which factors may influence the survey participant's prescribing pattern (e.g., patient's age, magnitude of hyperopia, patient's symptoms, heterophoria and stereopsis) and if the providers were to prescribe, how much hyperopic correction would they prescribe (e.g., full or partial prescription). The response distributions by profession (optometry and ophthalmology) were compared using the Kolmogorov-Smirnov cumulative distribution function test. RESULTS: Responses were submitted by 738 participants regarding how they prescribe for their hyperopic patients. Most providers within each profession considered similar clinical factors when prescribing. The percentages of optometrists and ophthalmologists who reported considering the factor often differed significantly. Factors considered similarly by both optometrists and ophthalmologists were the presence of symptoms (98.0%, p = 0.14), presence of astigmatism and/or anisometropia (97.5%, p = 0.06) and the possibility of teasing (8.3%, p = 0.49). A wide range of prescribing was observed within each profession, with some providers reporting that they would prescribe for low levels of hyperopia while others reported that they would never prescribe. When prescribing for bilateral hyperopia in children with age-normal visual acuity and no manifest deviation or symptoms, the threshold for prescribing decreased with age for both professions, with ophthalmologists typically prescribing 1.5-2 D less than optometrists. The threshold for prescribing also decreased for both optometrists and ophthalmologists when children had associated clinical factors (e.g., esophoria or reduced near visual function). Optometrists and ophthalmologists most commonly prescribed based on cycloplegic refraction, although optometrists most commonly prescribed based on both the manifest and cycloplegic refraction for children ≥7 years. CONCLUSION: Prescribing patterns for paediatric hyperopia vary significantly among eye care providers.

Hyperopic LASIK Enhanced by Pharmacological Treatment of Presbyopia.

Purpose: Regression of the refractive outcome is a major concern of LASIK procedures mainly in presbyopic patients. The purpose of this study was to evaluate the long-term efficacy of the pharmacological treatment of presbyopia performed with Benozzi's method, in combination with hyperopic LASIK surgery in presbyopic population. Methods: A nonrandomized case series was developed, including presbyopic patients who underwent bilateral "Hyperopic LASIK surgery" and were pharmacologically treated with Benozzi's Method from January 2011 to August 2018, with at least 2 years of follow-up, at two private ophthalmological clinics of Argentina. Main outcomes were spherical equivalent (SE), uncorrected distance visual acuity (UDVA), and uncorrected near visual acuity (UNVA). Measurements were evaluated at baseline and postoperative at 1 month (without Benozzi's treatment), 2 months (starting with Benozzi's treatment), and 2 years. The SE stability across the time was statistically compared. Results: A total of 84 eyes of 42 patients, with a mean age at the time of the surgery of 51.07 ± 4.5 (42-59), were found following 2 years of follow-up. Patients have improved and maintained UDVA, achieving Jaeger 1 in the second postoperative month, which was maintained up to the last year of follow-up. Refractive stability across the time is observed comparing first month after surgery with the last year of follow-up, without statistical significant difference (p: 0.11). Conclusion: Hyperopic presbyopic patients that underwent LASIK surgery and 1 month after surgery started with the pharmacological treatment of presbyopia (Benozzi's method) results in excellent UNVA and UDVA that is stable over time without refractive regression.

Enhanced S-Cone Syndrome Masquerading as TORCH in an Infant and a Toddler.

PURPOSE: To report two cases masquerading as TORCH but eventually diagnosed with Enhanced S-cone Syndrome (ESCS). METHODS: Descriptive case report. RESULTS: Case 1: A ten-month-old boy presented with high hypermetropia, strabismus and bilateral chorioretinal pigmented scars with a history of cat scratch of his mother during pregnancy. He was treated for suspected toxoplasma retinitis. Choroidal neovascular membranes (CNV) were diagnosed bilaterally and treated with intravitreal bevacizumab. Genetic testing showed homozygote mutation in NR2E3 gene. Case 2: A two-year old girl presented with bilateral high hypermetropia and strabismus. Funduscopy revealed extrafoveal chorioretinal lesions and surrounding subretinal fibrosis. An elevated titer of anti-toxocara IgG antibodies was detected and managed accordingly. LE CNV was diagnosed and treated with intravitreal bevacizumab. Genetic testing disclosed homozygote mutation in NR2E3. CONCLUSION: Ocular manifestations in ESCS can be reminiscent to TORCH. CNV may develop with an incidence of 15%. We report the youngest patient with ESCS-associated CNV.

Topical Estrogen Therapy for Hyperopia Correction in Vivo.

Purpose: In vitro studies found that 17ß-estradiol (estrogen) modulates corneal biomechanical properties and reduces tissue stiffness. Therefore we hypothesized that topical estrogen might affect the refractive properties of the cornea, inducing a myopic shift. Methods: Twelve female New Zealand white rabbits 16 weeks old were used. The rabbits were randomly divided to either the treatment group receiving 1.5% (w/v) estrogen eye drops or a control group receiving vehicle only (n = 6 each group). Both groups were given drops (50 µL) to the right eye every 12 hours for 35 days. Ocular examination, pachymetry, intraocular pressure (IOP), keratometry ,and refraction were evaluated at baseline and on a weekly basis. Results: No significant differences were observed between the two groups at baseline in all outcome measures. Both groups displayed corneal flattening and a hyperopic shift. However, the change rate was slower in the treatment group. Repeated measurements analysis revealed a statistically significant difference in keratometry readings between groups (P = 0.034) with steeper keratometry by up to 0.6 diopters in the treatment group. The difference between the two groups diminished and became statistically insignificant after treatment cessation. No significant changes were observed in IOP and pachymetry throughout the study period. No side effects were observed in either group. Conclusions: Estrogen eye drops induced a myopic shift in keratometry readings. These results suggest that corneal refractive power might be manipulated pharmacologically. Further studies on the physiology behind this change are warranted to facilitate a pathway for development of novel pharmacologic treatments to correct refractive errors.

Refractive Changes After Corneal Stromal Filler Injection for the Correction of Hyperopia.

PURPOSE: To evaluate a new non-ablative and adjustable procedure for laser ablative refractive corneal surgery in hyperopia using the injection of a biocompatible liquid filler material into a stromal pocket. METHODS: A total of 120 stromal pockets were created using a clinical femtosecond laser system in 96 rabbit corneoscleral discs and 24 whole globes. Pockets were cut at a depth of 120 or 250 µm below the epithelial surface. Hyaluronic acid was injected manually into the pocket. To determine the refractive changes, three-dimensional optical coherence tomography images and a specifically developed picture recognition Matlab (The Mathworks) routine were used. RESULTS: After injection, a steepening of the anterior and flattening of the posterior corneal surface was observed, which led to hyperopic correction. The two main factors determining the amount of correction were the pocket depth and the injected volume. After the pocket was homogeneously filled, an initial refractive increase was observed, followed by a linear relation between the injected volume and the refraction increase. CONCLUSIONS: This possible clinical protocol for controlled refraction correction of hyperopia suggests a potential readjustable clinical application. [J Refract Surg. 2020;36(6):406-414.].

Photorefractive intrastromal crosslinking for correction of hyperopia: 12-month results.

PURPOSE: To evaluate the efficacy of epithelium-on photorefractive intrastromal crosslinking (PiXL), a noninvasive procedure to reduce refractive error in patients with low hyperopia. SETTING: Gemini Eye Clinic, Zlin, Czech Republic. DESIGN: Prospective single-center study. METHODS: Twenty-two low hyperopic eyes were enrolled and underwent PiXL treatment according to a standardized treatment protocol. Visual acuity, subjective distance refraction, keratometry, topography, pachymetry, subjective discomfort, and endothelial cell density (ECD) were recorded during 12-month follow-up. RESULTS: In 22 eyes, the median manifest refraction decreased significantly (P < .0001) from +0.75 diopters (D) (interquartile range [IQR], +0.63 to +1.06 D), median and IQR) diopters (D) preoperatively to +0.25 D (IQR, 0.0 to +0.50 D) at 12-month follow-up and remained stable. Seventy-seven percent of eyes achieved refraction within ± 0.50 D of emmetropia by 1 month postoperatively and was stable through 12-month follow-up. ECD was stable and did not show significant changes. There was low incidence of postoperative pain and dry eye. CONCLUSIONS: PiXL is a promising alternative to conventional laser refractive surgeries for low hyperopia. Further studies are warranted to optimize treatment parameters for a wider range of refractive errors and to evaluate the potential to improve precision.

A randomized clinical trial using atropine, cyclopentolate, and tropicamide to compare refractive outcome in hypermetropic children with a dark iris; skin pigmentation and crying as significant factors for hypermetropic outcome.

Purpose: To evaluate the refractive outcome and influencing factors following atropine 0.5% eye-drops applied twice daily during 2 ½ days at home and two drops of cyclopentolate 1% (C+C) and one drop of cyclopentolate 1% and one drop of tropicamide 1% (C+T) applied in an outpatient clinic, in hypermetropic children with a dark iris. Methods: Double-blind randomized study including 67 3-6-year-old children receiving C+C in one eye and C+T in the other eye. Two weeks later followed by atropine 0.5% in both eyes. Primary outcome measures were: spherical equivalent (SEQ) following C+C, C+T and atropine, and secondarily SEQ with respect to sex, ethnicity, skin pigmentation (light, medium, dark) and crying. Data on atropine are divided in those with C+C (CC) or C+T (CT) as a first intervention. Results: Mean SEQ±SD for C+C, C+T, atropine-(CC) and atropine-(CT) was +1.74 ± 1.35, +1.77 ± 1.34, +2.15 ± 1.43 and +2.10 ± 1.38 diopter (D). Atropine 0.5% revealed significantly more hypermetropia than C+C and C+T; +0.41 ± 0.43, 95%CI +0.31 to +0.52D and +0.33 ± 0.39, 95%CI +0.24 to +0.34D. No significant difference was present between C+C and C+T; -0.03 ± 0.56, 95%CI -0.16 to +0.11D. Ethnicity and skin-color were strongly associated (r = 0.84, p < .001). Sex was not affecting outcomes (p = .101). Ethnicity was borderline significant (p = .049). Skin-color was a highly significant factor (p = .002). A statistical model combining intervention and skin-color, with light-pigmented subjects receiving atropine-(CC) as reference group (mean SEQ +2.61 ± 1.46D), indicated borderline significantly less hypermetropia in atropine-(CC)-dark: mean decrease (95%CI): -0.81 (-1.66 to +0.05)D and atropine-(CT)-dark -0.87 (-1.70 to -0.03)D, furthermore significantly less hypermetropia in C+C-dark: -1.15 (-1.97 to -0.32)D; C+T-dark: -1.21 (-2.03 to -0.39)D, C+C-medium: -1.02 (-1.81 to -0.24)D and C+T-medium: -0.86 (-1.64 to -0.08)D. Adding crying to the model significantly less hypermetropia was found for subjects crying in all interventions; -0.53 (-0.98 to -0.09)D. Within the interventions, with light-pigmented non-crying subjects as reference group (mean SEQ in atropine, C+C, respectively, C+T: +2.62 ± 1.41, +2.33 ± 1.20 and +2.32 ± 1.20D), showed significantly less hypermetropia in dark-pigmented crying subjects in each individual intervention: atropine -1.10 (-2.01 to -0.19), C+C -1.28 (-2.14 to -0.42) and C+T -1.34 (-2.20 to -0.48)D. For medium pigmented crying subjects this was present in atropine: -0.82 (-1.61 to -0.03)D and C+C: -0.86 (-1.68 to -0.04)D, but not in C+T: -0.58 (-1.25 to +0.09)D. Conclusions: Atropine 0.5% revealed a slight significantly higher hypermetropia. A dark-pigmented skin, especially when crying upon application, resulted in lower hypermetropia in all interventions. C+T provided clinically better results in medium pigmented crying subjects compared to C+C, and equal results compared to atropine 0.5%.

The interaction between homatropine and optical blur on choroidal thickness.

PURPOSE: To analyse the short-term interaction between a short period of myopic and hyperopic defocus and the muscarinic antagonist homatropine upon the choroidal thickness and ocular biometrics of healthy subjects. METHODS: Thirty young adults (15 myopes and 15 emmetropes) aged 18-35 years had subfoveal choroidal thickness (ChT) and ocular biometry measurements taken before, 30 min, and 60 min following the introduction of monocular optical blur (0.00 D, +3.00 D and -3.00 D) combined with administration of either 2% homatropine or placebo (total of six conditions). Each combination of optical blur and drug was tested on different days, 2 days apart, in randomised order. For choroidal thickness, we captured three SD OCT images (5 mm, cross scans centred at the fovea with 999 A-scans and 50 B-scans) with the Copernicus SOCT HR instrument (www.optopol.com). A masked observer manually segmented the average B-scan images to derive subfoveal choroidal thickness measurements from each measurement session. RESULTS: The choroid exhibited significant thinning after imposing hyperopic defocus (-3.00 D) combined with placebo (-11 ± 3 µm, p < 0.001). Homatropine prevented the significant choroidal thinning response with hyperopic defocus (+3 ± 2 µm), and the magnitude of ChT change was significantly different to placebo and hyperopic defocus (p < 0.001). There was a significant increase in ChT after the introduction of myopic defocus (+3.00 D) with placebo (+12 ± 3 µm, p < 0.0001) and homatropine combined with myopic defocus also caused a similar increase in ChT (+11 ± 3 µm; p < 0.001). Eyes treated with homatropine alone exhibited a significant increase in ChT (+14 ± 3 µm, p < 0.0001). There was no evidence of differences in choroidal response between refractive groups. Axial length also underwent small but significant changes (all p < 0.01 except homatropine/hyperopic blur and placebo) that were of similar magnitude, but of opposite direction to the changes in choroidal thickness. CONCLUSIONS: Homatropine appears to block the thinning effect of hyperopic defocus on choroidal thickness but did not enhance the thickening effect of myopic defocus. The changes in the choroid may relate to the different pathways in the eye's response to myopic and hyperopic blur or reflect an upper limit on the capacity of the choroid to thicken in the short-term.

Prevention of myopia by partial correction of hyperopia: a twins study.

PURPOSE: To confirm the prediction of emmetropization feedback theory that myopia can be prevented by correcting the hyperopia of a child at risk of becoming myopic. METHODS: We conducted such myopia prevention treatment with twins at risk. Their hyperopia was partially corrected by one half at age 7 and in subsequent years until age 16. RESULTS: Hyperopia progressively decreased in all eyes as expected. None of the twins developed myopia. The spherical equivalent refractions of the followed eyes were +1 and +1.25 D at age 16. Feedback theory accurately predicted these values. CONCLUSIONS: The treatment of the twins with partial correction of their hyperopia was successful. Prevention of myopia with this technique is relatively simple and powerful. The use of this myopia prevention treatment has no adverse effects. This prevention treatment is indicated in children with a hyperopic reserve at risk of developing myopia.

Increase in esodeviation under cycloplegia with 0.5% tropicamide and 0.5% phenylephrine mixed eye drops in patients with hyperopia and esotropia.

BACKGROUD: To evaluate the manifestations of increased esodeviation under cycloplegia with 0.5% tropicamide and 0.5% phenylephrine in children with hyperopia and esotropia. METHODS: We reviewed the medical record of 34 children with hyperopia and esotropia who underwent a prism alternate cover test before and after instillation of mixed eye drops containing 0.5% tropicamide and 0.5% phenylephrine between November 2014 and October 2015. Increased angle of deviation was defined as 10 prism diopters (PD) or greater deviation after cycloplegia. The factors related to increased angle of deviation were evaluated using univariable and multivariable logistic regression analysis. RESULTS: The median age was 5.0 years (interquartile range, 3.75 to 5.0) and 12 patients (35.3%) were male. The median manifested refractive (MR) was +2.13 diopters (D) (+0.92 to +4.47) and cycloplegic refractive (CR) was +3.50 D (+1.72 to +5.66). The median difference between MR and CR was +0.88 D (+0.50 to +1.28). Thirteen patients (38.2%) showed increased esodeviation under cycloplegia and all had accommodative esotropia. A larger difference between MR and CR was the only significant factor affecting increased esodeviation in both univariable (OR = 4.72, P = 0.029) and multivariable (OR = 5.22, P = 0.047) analyses. CONCLUSION: Children with hyperopia and esotropia often showed an increased angle of deviation after instillation of 0.5% tropicamide and 0.5% phenylephrine. This phenomenon reminded the clinicians that cycloplegics can have a different effect on esodeviation and suggested that increased angle of esodeviation may help to reveal the latent deviation in some patients with hyperopia and esotropia.

Cycloplegic Refraction in Hyperopic Children: Effectiveness of a 0.5% Tropicamide and 0.5% Phenylephrine Addition to 1% Cyclopentolate Regimen.

PURPOSE: To evaluate the effectiveness of a cycloplegic regimen using 0.5% tropicamide and 0.5% phenylephrine (Tropherine, Hanmi Pharm), in addition to 1% cyclopentolate, in hyperopic children. METHODS: The medical records of hyperopic patients below the age of 14 years who had undergone cycloplegic retinoscopy were retrospectively reviewed. Cycloplegic refractions were performed using one of two cycloplegic regimens. Regimen 1 was a Tropherine-added regimen comprising the administration of one drop of 1% cyclopentolate followed by two to three drops of Tropherine added at 15-minute intervals. Regimen 2 was a cyclopentolate-only regimen comprising the administration of three to four drops of 1% cyclopentolate at 15-minute intervals. The mean difference between noncycloplegic and cycloplegic refraction was compared between the two regimens. RESULTS: A total of 308 eyes of 308 hyperopic children were included. The mean difference (±standard deviation) in the spherical equivalent (SE) between cycloplegic and noncycloplegic refraction was significantly larger in regimen 2 than in regimen 1, with values of +1.70 ± 1.03 diopters (D) and +1.25 ± 0.89 D, respectively (p=0.001). The SE change after cycloplegia was significantly different between the two regimens only in patients aged 5 years or younger (p=0.001), particularly in those with high hyperopia with an SE ≥5 D (p=0.005) or fully accommodative esotropia (p=0.009). There was no significant difference between the two regimens in patients older than 5 years, regardless of the presence of high hyperopia or fully accommodative esotropia. CONCLUSIONS: The Tropherine-added regimen exerted a weaker cycloplegic effect than the cyclopentolate-only regimen, particularly in children under the age of 5 years with high hyperopia or fully accommodative esotropia. However, the difference in refraction between the two regimens was small. A Tropherine-added regimen can be effective in hyperopic children, with less associated discomfort than the instillation of cyclopentolate.

Effects of muscarinic agents on chick choroids in intact eyes and eyecups: evidence for a muscarinic mechanism in choroidal thinning.

PURPOSE: In chicks, ocular growth inhibition is associated with choroidal thickening and growth stimulation with choroidal thinning, suggesting a mechanistic link between the two responses. Because muscarinic antagonists inhibit the development of myopia in animal models by a non-accommodative mechanism, we tested the hypothesis that agonists would stimulate eye growth and thin the choroid. We also hypothesized that the effective growth-inhibiting antagonists would thicken the choroid. METHODS: Chicks, age 12-16 days, were used. In vivo: Agonists: Single intravitreal injections (20 µL) of oxotremorine (oxo), pilocarpine (pilo), carbachol (carb), or arecaidine (arec) were given to otherwise untreated eyes. A-scan ultrasonography was done prior to injections, and at 3, 24, 48 and 72 h. Antagonists: -10D lenses were worn on one eye for 4 days. Atropine (atro), pirenzepine (pirz), oxyphenonium (oxy) or dicyclomine (dicy) were injected (20 µL) daily into lens-wearing eyes; saline injections were done as controls. Ultrasonography was done on d1 and on d4; on d4 measurements were done before and 3 h after injections. In vitro: Paired eyecups of retinal pigment epithelium (RPE), choroid and sclera were made from 1-week old chicks. All drugs except atropine were tested on one eyecup, its pair in plain medium. Choroidal thickness was measured at various times over 48 h. RESULTS: Agonists: In vivo, oxotremorine caused an increase in the rate of axial elongation (drug vs saline: 24-72 h: 338 µm vs 250 µm; p < 0.001). All except pilocarpine caused choroidal thinning by 24 h (oxo, carb and arec vs saline: -25, -35 and -46 µm vs 3 µm). In vitro, all agonists thinned choroids by 24 h (oxo: -6 vs 111 µm; pilo: 45 vs 212 µm; carb: -58 vs 65 µm; arec: 47 vs 139 µm; p < 0.05). Antagonists: Atropine, pirenzepine and oxyphenonium inhibited the development of myopia in negative lens-wearing eyes, and also caused choroidal thickening (drug vs saline: 42, 80, 88 vs 10 µm per 3 h). In vitro, pirenzepine thickened choroids by 3 h (77 vs 2 µm, p < 0.01). CONCLUSIONS: Muscarinic agonists caused choroidal thinning in intact eyes and eyecups, supporting a role for acetylcholine in the choroidal response to hyperopic defocus or form deprivation. Only oxotremorine stimulated eye growth, which is inconsistent with a muscarinic receptor mechanism for antagonist-induced eye growth inhibition. The dissociation between choroidal thinning and ocular growth stimulation for the other agonists in vivo suggest separate pathways for the two.

Effects of intravitreal insulin and insulin signaling cascade inhibitors on emmetropization in the chick.

PURPOSE: Intravitreal insulin has been shown to be a powerful stimulator of myopia in chickens, in particular if the retinal image is degraded or defocused. In most tissues, the insulin receptor activates two main signaling pathways: a) the mitogen-activated protein kinase (MAPK) cascade (e.g., mitogen-activated protein kinasem kinase [MEK] and extracellular regulated kinase [ERK]) and b) the phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt) pathway. In the current study, insulin was injected, and these pathways were separately inhibited to determine which is activated when the retinal image is defocused by spectacle lenses. METHODS: Chicks were treated with either +7 D, -7 D, or no lenses. They were intravitreally injected with insulin, the MEK inhibitor U0126, the PI3K inhibitor Ly294002, or a combination of insulin and one of the inhibitors. Refractions and ocular dimension were measured at the beginning and after four days of treatment. The retinal proteins of the chicks were measured with western blots after 2 h and four days of treatment. Incubation occurred with anti-Akt1, anti-Erk1/2, anti-phospho-Akt(Thr308), and anti-phospho-Erk1/2((Thr202/Tyr204)) antibodies, and the ratio between the relative intensity of the phospho-form and the total-form was calculated. RESULTS: Chicks wearing positive lenses and injected with saline and with PI3K inhibitor compensated for the imposed defocus and became hyperopic. Insulin injections and insulin plus PI3K inhibitor injections prevented lens-induced hyperopia, whereas the MEK inhibitor alone and insulin plus MEK inhibitor had no effect. Obviously, the MEK inhibitor suppressed the effect of insulin on eye growth in the plus lens-treated animals. Chicks treated with negative lenses and injected with insulin, or with insulin plus MEK inhibitor, overcompensated for the imposed defocus. This effect of insulin was not detected in eyes injected with PI3K inhibitor plus insulin, suggesting that the PI3K inhibitor suppressed the effects of insulin in minus lens-treated animals. Insulin increased the ratio of phospho-Akt/total-Akt in animals with normal visual exposure but even more so in chicks wearing plus or minus lenses. The increase was blocked by simultaneous PI3K inhibitor injections in control eyes but not in lens-treated eyes. Insulin also increased the ratio of phospho-ERK/total-ERK in animals with normal visual exposure and in animals wearing positive lenses, compared to U0126- and Ly294002-injected eyes. In contrast, no significant activation of the MEK/ERK pathway was observed in the negative lens-treated animals. CONCLUSIONS: Intravitreal insulin promoted axial eye growth and stimulated both signaling pathways. The PI3K/Akt pathway was activated in control and plus and minus lens-treated eyes, but the MEK/ERK pathway was activated only with positive lenses or no lenses. With negative lenses, insulin did not stimulate the MEK/ERK signaling cascade. Independent of the pathway stimulated after insulin binding, the effect on insulin was always the same: an increase in eye growth.

Topography-guided hyperopic LASIK with and without high irradiance collagen cross-linking: initial comparative clinical findings in a contralateral eye study of 34 consecutive patients.

PURPOSE: To evaluate the safety and efficacy of intrastromally applied collagen cross-linking (CXL) in a comparative contralateral eye study of topography-guided femtosecond laser-assisted hyperopic LASIK. METHODS: Thirty-four consecutive patients with hyperopia and hyperopic astigmatism elected to have bilateral topography-guided LASIK and were randomized to receive a single drop of 0.1% sodium phosphate riboflavin solution under the flap followed by 3-minute exposure of 10 mW/cm2 ultraviolet A (UVA) light with the flap realigned in one eye (CXL group) and no intrastromal CXL in the contralateral eye (no CXL group). All eyes were treated with the WaveLight FS200 femtosecond laser and WaveLight EX500 excimer laser (Alcon Laboratories Inc). Refractive error and keratometric, topographic, and tomographic measurements were evaluated over mean follow-up of 23 months. RESULTS: Preoperatively, mean spherical equivalent refraction was +3.15 +/- 1.46 diopters (D) and +3.40 +/- 1.78 D with a mean cylinder of 1.20 +/- 1.18 D and 1.40 +/- 1.80 D and mean uncorrected distance visual acuity (UDVA) (decimal) of 0.1 +/- 0.26 and 0.1 +/-0.25 in the CXL and no CXL groups, respectively. At 2 years postoperatively, mean spherical equivalent refraction was -0.20 +/- 0.56 D and +0.20 +/- 0.40 D with mean cylinder of 0.65 +/- 0.56 D and 0.76 +/- 0.72 D and mean UDVA of 0.95 +/- 0.15 and 0.85 +/- 0.23 in the CXL and no CXL groups, respectively. Eyes with CXL demonstrated a mean regression from treatment of +0.22 +/- 0.31 D, whereas eyes without CXL showed a statistically significant greater regression of +0.72 +/- 0.19 D (P = .0001). CONCLUSIONS: Topography-guided hyperopic LASIK with or without intrastromal CXL is safe and effective, with greater long-term efficacy (less regression) in eyes with CXL. Our data suggest that the regression seen with hyperopic LASIK may be related to biomechanical changes in corneal shape over time.

Inhibition of experimental myopia by a dopamine agonist: different effectiveness between form deprivation and hyperopic defocus in guinea pigs.

PURPOSE: The dopamine (DA) system in the retina is critical to normal visual development as lack of retinal DA signaling may contribute to myopic development. The involvement of DA in myopic development is complex and may be different between form deprivation and hyperopic defocus. This study evaluated effects of a non-selective DA receptor agonist, apomorphine (APO) on refractive development in guinea pigs treated with form deprivation or hyperopic defocus. METHODS: APO was subconjunctivally injected daily for 11 days in form-deprived (0.025 to 2.5 ng/µl) and defocused (0.025 to 250 ng/µl) eyes. Changes in ocular biometry and retinal concentration of DA and its metabolites (DOPAC) were measured in the 2 animal models to assess the level of DA involvement in each of the models (the less the change, the lower the involvement). RESULTS: Similar myopic degree was induced in both the deprived and defocused eyes (-4.06 D versus -3.64 D) at 11 days of the experiment. DA and DOPAC levels were reduced in the deprived eyes but did not change significantly in the defocused eyes compared to the fellow and normal control eyes. A subconjunctival injection of APO daily for 11 days at concentrations ranged from 0.025 to 2.5 ng/µl inhibited form deprivation myopia in a concentration-dependent manner. By contrast, the APO treatment ranged from 0.025 to 250 ng/µl did not effectively inhibit the defocus-induced myopia and the associated axial elongation. CONCLUSIONS: DA signaling may play a more critical role in form deprivation myopia than in defocus-induced myopia, raising a question whether the mechanisms of DA signaling are different under these two types of experimental myopia.

Hyperopic LASEK treatments with mitomycin C using the SCHWIND AMARIS.

PURPOSE: To investigate the outcomes of hyperopic laser epithelial keratomileusis (LASEK) with mitomycin C (MMC) using the SCHWIND AMARIS platform. METHODS: Prospective study of 28 eyes of 14 patients. Mean preoperative manifest spherical equivalent refraction was +2.71±0.72 diopters (D) (range: +1.50 to +4.50 D). All eyes underwent LASEK with an Aberration-Free™ algorithm with the SCHWIND AMARIS followed by a 35-second application of MMC with a 6.7-mm optical zone size. RESULTS: At 1 year, mean manifest spherical equivalent refraction was 0.03±0.30 D (range: -0.53 to +0.50 D), with 13 eyes within -0.13 to +0.13 D and all 28 eyes within ±0.50 D. Mean uncorrected distance visual acuity was -0.03±0.09 logMAR, and the efficacy and safety indices were 1, respectively, at 1 year. The postoperative manifest spherical equivalent refraction was stable between 1 and 3 months and 1 year. CONCLUSIONS: Hyperopic LASEK with MMC using the SCHWIND AMARIS provided good outcomes in terms of accuracy, efficacy, safety, and stability.

Acute hyperopic shift in refraction associated with posterior choroidal detachment following phacoemulsification surgery.

PURPOSE: To describe a patient who presented with hyperopic shift as an initial manifestation of choroidal detachment in the posterior pole following an uneventful phacoemulsification cataract surgery. METHODS: An 82-year-old woman with preexisting diabetes mellitus and hypertension had bilateral primary angle closure glaucoma on maximal tolerated hypotensive medication. An uneventful phacoemulsification surgery using topical anesthesia was performed in her left eye. RESULTS: On the next day, refraction was markedly increased to +7.25 -1.00 × 65 and axial length was reduced from 23.24 mm to 20.13 mm. Funduscopic examination revealed choroidal detachment in the posterior pole without involvement of the peripheral fundus. Axial length increased to 22.19 mm following corticosteroid treatment 1 month later. Six months postoperatively, axial length improved to 22.87 mm with a residual hyperopia of +1.00 -1.00 × 63. CONCLUSIONS: To our knowledge, there have been no reports of choroidal detachment in the posterior pole after phacoemulsification. Acute hyperopic shift following phacoemulsification surgery should lead one to suspect a posterior choroidal detachment. Considering axial length and refractive errors along with fundus examination may contribute to a more accurate follow-up.

Photorefractive keratectomy with mitomycin-C for consecutive hyperopia after radial keratotomy.

PURPOSE: To evaluate the safety, efficacy, and stability of excimer laser photorefractive keratectomy (PRK) and mitomycin-C (MMC) 0.02% for consecutive hyperopia after radial keratotomy (RK). METHODS: A prospective, nonrandomized, noncomparative interventional case series of 35 eyes (22 patients) with consecutive hyperopia after RK. All eyes were treated with PRK, using a single intraoperative topical application of MMC 0.02% for 60 seconds. Uncorrected visual acuity, best spectacle-corrected visual acuity, refraction, slit-lamp evidence of corneal haze, and endothelial cell counts were evaluated for up to 18 months after surgery. RESULTS: Postoperative follow-up was 9.6 +/- 5.5 months (ranged from 3 to 18 months). The mean spherical equivalent was +3.36 +/- 1.94 diopters preoperatively and +0.27 +/- 1.38 diopters 12 months after surgery. The uncorrected visual acuity was > or =20/30 in 37.1% of the eyes at 1 month and 78.6% of the eyes at 12 months. At 12 months, 14% of the eyes lost up to 1 line of Snellen acuity in the best spectacle-corrected visual acuity. No corneal haze was observed and the endothelial cell counts remained unchanged postoperatively (P > 0.05). CONCLUSION: PRK with MMC 0.02% for consecutive hyperopia after RK seems to be a safe and effective procedure at least in the short-term period of 6 months.

Hyperopic photorefractive keratectomy with adjunctive topical mitomycin C for refractive error after penetrating keratoplasty for keratoconus.

OBJECTIVE: To present a case of photorefractive keratectomy (PRK) with adjunctive topical mitomycin C (MMC) in an anisometropic hyperopic patient after penetrating keratoplasty (PKP) for keratoconus. METHODS: Interventional case report, chart review, and literature review. RESULTS: A 43-year-old man with a refraction of +7.00 -4.75 x 125 in the right eye underwent PRK 10 months after PKP for keratoconus. The patient had sutures removed for 3 months and was intolerant of contact lenses. After photoablation, 0.02% MMC was applied to the corneal stromal bed. The patient was followed up daily until the epithelium closed and at 1 week, 1 month, 3 months, and 6 months postoperatively. CONCLUSIONS: To our knowledge, this represents the first reported case of the use of MMC to prevent postoperative haze after PRK for PKP in an eye with keratoconus. MMC (0.02%) applied topically to the cornea immediately after PRK is safe and effective to treat a hyperopic refractive error after PKP and prevent postoperative corneal haze formation without the risks of performing a lamellar flap into an ectatic corneal bed.

Ketorolac for the regression of myopic LASIK overcorrection.

OBJECTIVE: To determine whether ketorolac (Acular) treatment and other factors influence regression after LASIK-induced consecutive hyperopia. METHODS: Seventy-two eyes of 51 patients who had undergone LASIK for myopia and compound myopic astigmatism and who experienced consecutive hyperopia of at least +0.50 diopters within the first postoperative week were analyzed. The consenting patients were treated with ketorolac (Acular). Data were collected over a period of 2 months. Primary preoperative variables included age, eye, preoperative manifest and cycloplegic refractions, and pachymetry. Postoperative variables included presence of microstriae and treatment with ketorolac. Treatment success was measured as reduction of consecutive hyperopia. RESULTS: Thirty-seven eyes were treated, and 35 eyes were in the control group. Mean start time for treatment with ketorolac was 9 days after surgery (range 3-35 days). Mean treatment time was 24.5 days (range 10-63 days). Both groups were matched for all preoperative variables except for age, including manifest and cycloplegic refraction, eye treated, and pachymetry. Treated patients were on average 9 years older than the control group. There was no significant difference in the overall rate of regression between the 2 groups at the 1-month and 2-month periods. Thicker preoperative corneas in all eyes had a sporadic association with reduction of consecutive hyperopia. CONCLUSIONS: Ketorolac does not improve consecutive hyperopia after LASIK for myopia and compound myopic astigmatism when compared with a matched control group. Pachymetry appears to be a determining factor in the degree of regression experienced after consecutive hyperopia. This finding warrants further investigation.