Two-step LASIK with topography-guided ablation to correct astigmatism after penetrating keratoplasty.

PURPOSE: To assess the efficacy, predictability, stability, and safety of a two-step LASIK procedure using topography-guided ablation to correct astigmatism after penetrating keratoplasty. METHODS: Fifteen eyes of 15 patients underwent a two-step LASIK procedure at the Maggiore Hospital of Bologna, Italy. In the first step, a flap was created using the Hansatome microkeratome. In the second step, topography-guided ablation using the LaserSight LSX was planned with interactive software (CIPTA) once topographical and refractive stabilization had been obtained. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), cylindrical correction, gain of lines of BSCVA, spherical equivalent refraction, and complications were analyzed. RESULTS: Minimum follow-up was 12 months (range: 12 to 30 months). Uncorrected visual acuity improved in all 15 (100%) eyes. At the last postoperative examination, 11 (73%) eyes had UCVA > or = 20/40. Nine (60%) eyes were within 1.0 diopter (D) of the attempted correction. Mean postoperative astigmatism was -1.67 (range: -3.5 to 0; standard deviation: 1.26). Index of success of astigmatic correction was 0.26. No patient lost Snellen lines of BSCVA. Intraoperative complications included two buttonhole flaps, and postoperative complications included one flap retraction. No further laser treatment was needed. CONCLUSIONS: The two-step LASIK procedure using topography-guided ablation reduces spherical and cylindrical refractive error due to penetrating keratoplasty. Topography-guided ablation also proved to be effective in correcting irregular astigmatism.

Risk of seizures while awake in pure sleep epilepsies: a prospective study.

OBJECTIVE: To estimate the risk of seizures while awake in pure sleep epilepsies in a prospective study. METHODS: From October 1, 1992, to October 31, 1996, all patients with pure sleep epilepsy presenting at a participating center were enrolled. Children with benign rolandic epilepsy and patients with frontal lobe epilepsy were excluded. Patients were followed for at least 2 up to 6 years. The primary endpoint was the occurrence of a seizure while awake. RESULTS: The authors enrolled 161 patients (64% male). Age at the time of inclusion ranged from 11 to 83 years (mean 43.2, median 39). Eighty-five percent presented generalized tonic clonic seizures. Both sleep seizures and seizures while awake were absent for 2 years after inclusion in the study in 78% of patients. Eighteen patients presented a seizure while awake. The estimated risk of a seizure while awake during 6 years of follow-up was 13% (95% CI 7 to 18%). Multivariate analysis showed that episodes of sudden withdrawal of therapy and a higher frequency of seizures at inclusion were associated with an increased risk of seizures while awake. The estimated risk of a seizure while awake in patients with none of the above risk factors was 6.5% (95% CI 1.5 to 11.3%) during 6 years of follow-up. CONCLUSION: The clinical picture of pure sleep epilepsies is characterized by a preponderance of generalized tonic clonic seizures, low seizure frequency, and a good prognosis. The risk of occurrence of a seizure while awake is low, particularly among patients with rare seizures and good compliance with the therapy.

ICSD diagnostic criteria for narcolepsy: interobserver reliability. Intemational Classification of Sleep Disorders.

STUDY OBJECTIVES: To estimate the reliability of the diagnosis of narcolepsy after clinical interview and polysomnographic evaluation among sleep medicine doctors, before and after training in application of the International Classification of Sleep Disorders (ICSD). SETTING: Videotaped semi-structured interviews of 10 patients complaining of daytime sleepiness of different etiologies. Questions referred to ICSD criteria for narcolepsy. A further series of 10 cases of narcolepsy without cataplexy were simulated, with at least a random one to three of the ICSD polysomnographic criteria at pathological levels. PARTICIPANTS AND DESIGN: Seventeen doctors were required to classify each videotaped case as "ascertained," "possible," or "excluded" narcolepsy, in two sessions: one before and one after discussion of ICSD criteria. The observers were invited to confirm or exclude the diagnosis of narcolepsy in the 10 simulated cases, according to the given polysomnographic findings, before and after an agreed proposal of the interpretation of ICSD polysomnographic criteria. Interobserver reliability was calculated using Kappa statistics. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Interobserver reliability of clinical judgement improved from "substantial" at baseline (Kappa 0.61) to "almost perfect" after training (Kappa 0.95). Interobserver reliability of polysomnographic findings was "fair" at baseline (Kappa 0.24), unanimous after the proposed interpretation of ICSD polysomnographic criteria. CONCLUSIONS: Baseline reliability of diagnostic judgement in suspected narcolepsy was found satisfactory among Italian sleep medicine doctors. Educational training, based on discussion of ICSD criteria, further improved agreement. Diagnosis based on polysomnographic findings, not reliable at baseline, needed a strict interpretation of ICSD criteria to attain standardization.