[Preexisting astigmatism correction combined with cataract surgery: corneal relaxing incisions or toric intraocular lenses?]. / La chirurgie du cristallin combinée à la chirurgie de l'astigmatisme, incisions ou implants?

Corneal relaxing incisions combined with microincisions cataract surgery allow correction of preexisting congenital astigmatism. Limbal relaxing incisions and opposite clear corneal incisions were the main surgical techniques in use during last decade. However, corneal wound healing variations particularly at epithelial level are associated with poor refractive results predictability. New generations of toric intraocular lenses have a good stability in the capsular bag with less risks of secondary rotation. Well positioned in the right axis, toric intraocular lenses have potentially better accuracy and predictability than relaxing corneal surgery to correct preexisting congenital astigmatism. Combined corneal surgery progressively lost its indications for a simple refractive microincision cataract surgery with implantation of toric intraocular lenses.

[Quality of life after Lasik: part I. Validation of the French translation of the NEI-RQL-42 scale]. / Qualité de vie après Lasik : partie I. Validation de la traduction française de l'échelle NEI-RQL-42.

INTRODUCTION: The objective of this study was to bring some validation elements to a French adaptation of an American refraction-related quality of life scale, as applied to a population of Lasik patients. METHODS: The NEI-RQL-42 scale was developed in 2003 in the United States. It comprises 42 questions and 13 scores exploring quality of vision, functional symptoms, influence of refraction on daily activities and psychological impact. The authors propose here a French adaptation and elements for its validation (internal consistency, discriminating validity and external validity). These were assessed through an observational cross-sectional study, performed in one center on all patients consecutively treated with Lasik between January and March 2008. RESULTS: The study sample (307 patients) has the expected characteristics of Lasik-treated patients. The French adaptation of the NEI-RQL-42 has a good internal consistency with Cronbach's coefficients greater or equal to 0.7 for 10 scores out of 12. The discriminating validity of the scale was shown though the reference groups techniques: quality of life is generally lower in severe hyperopes compared with non-severe myopes. The scale's external validity is confirmed by the comparison of its results to those of a satisfaction questionnaire that was simultaneously sent to patients. CONCLUSION: The results obtained are favorable arguments for the validity of the proposed French adaptation of the NEI-RQL-42. This is the first scale available in French to assess refraction-related quality of life.

[Quality of life after LASIK: part II. Quality of life and satisfaction of a population of patients treated with LASIK]. / Qualité de vie après LASIK : partie II. Qualité de vie et satisfaction d'une population de patients opérée par LASIK.

INTRODUCTION: The objective of this study was to assess the refraction-related quality of life and patients' satisfaction in a LASIK-treated sample. METHODS: The French adaptation of the NEI-RQL-42 scale and a satisfaction questionnaire were sent to all patients consecutively treated with LASIK (all ages, all indications) in a same center between January and March 2008. The 13 scores of the NEI-RQL-42 were described. The scores "satisfaction with correction" and "glare" have been further analyzed using multivariate logistic regression. Answers to the satisfaction questionnaire were also described. RESULTS: The study sample (307 patients) has the expected characteristics of LASIK-treated patients. Quality of life scores are generally high (>70/100), except for the "glare" (65/100) and "expectations" (42/100) scores. Most of the scores are higher in myopes than in hyperopes. A lower "satisfaction with correction" score was associated with hyperopia (P<0.001) and with a lower "glare" score. A lower "glare" score was associated with ametropia severity (P=0.002), secondary surgery (P=0.02) and to the use of a non-customized treatment (P=0.047). Satisfaction rate was 95%. CONCLUSIONS: Quality of life scores and satisfaction rate are high in this sample, and suggesting how the refractive results impact patients' lives. They also show the importance of glare and other visual symptoms.

[Presbyopia surgery: principles and current indications]. / Chirurgie de la presbytie: principes et orientation des indications.

Presbyopia surgery is not yet a corrective option that can restore effective accommodation, but a compensation option which aims at creating depth of field. Monovision preserves a good close-vision quality for myopes. Multifocality is well tolerated by hyperopes if it is compatible with good far-vision quality. Monovision and multifocality can be applied to surgery by using corneal or intraocular implantation techniques. Presby LASIK and Presbyopic Lens Exchange (PRELEX) are the most effective techniques but they are still controversial. Indications depend on preoperative ametropia and patient age.

[ISO 9001-2000 certification for refractive laser treatment]. / Certification ISO 9001-2000 des traitements réfractifs par laser cornéen.

PURPOSE: To obtain ISO 9001-2000 certification for laser corneal refractive treatment, never before sought in Europe. MATERIAL AND METHODS: The consulting firm Veritas led the certification process with the clinic's staff manager. This ISO norm is dedicated to the implementation of a quality management system. We assessed and optimized all necessary resources, evaluating customer satisfaction using patient and referring-physician surveys. We started quality rounds including surgeons, nurses, and technicians. Based on this preparation, we redefined and explained all processes including staff responsibilities and necessary resources in the quality manual. The procedure lasted 14 months with substantial involvement on the part of the management. RESULTS: Unconditional ISO 9001-2000 certification was granted by the independent audit firm, BVQI, in december 2003 for refractive laser treatment. CONCLUSION: The 2000 version of the new ISO 9001-2000 seeks to meet the demand for improving health care delivery in this field, most particularly by establishing a clear procedural orientation. Such certification enhances team work, stabilizes methodologies, and reinforces cohesion and self-audit. Patients notice that the center follows a consistent quality policy and are assured that the clinic respects rules and regulations. Certification is an advantageous alternative when accreditation cannot be considered. Our article discusses the steps taken in upper management, quality management, procedural guidance, as well as customer and staff counselling. It also discusses the project's cost/benefit ratio for the organization.

[Lasik, PRK and quality of vision: a study of prognostic factors and a satisfaction survey]. / Lasik, photokéractectomie réfractive et qualité de vision: étude des facteurs pronostiques et enquête de satisfaction.

PURPOSE: To confirm the clinical interest of pupillary diameter measurement for selecting indications and determining surgical protocols, to look for clinical factors predisposing to night vision symptoms, and to the assess patient satisfaction level for photoablation techniques not based on aberrometry. METHODS: This retrospective study was conducted on 111 consecutive myopic patients (219 eyes, with a mean spherical equivalent of -4.25+/-1.84 D); they underwent Lasik (91.3% of cases) or photorefractive keratectomy, after having their pupillary diameter measured by the Colvard pupillometer. Clinical data were collected from medical files, and an anonymous questionnaire was sent in order to assess quality of vision and postoperative satisfaction. RESULTS: Preoperative aims were reached (r=0.41, p<0.0001). The response rate for the questionnaire was 81.1%. Daytime vision was the same or better for 91.1% of the patients, but 25.6% had worse night vision than before. Night vision symptoms were mentioned by 46.7% of the patients, and the most frequent complaint was halos. However, 97.8% of the patients declared themselves as satisfied and would recommend such surgery to their family and friends. A preoperative myopia greater than 4.50D (RR=1.52, p<0.05) and a postoperative keratometry greater than 8.44 mm (RR=1.62, p<0.05) were risk factors for having night vision symptoms, but pupillary diameter was not a risk factor. CONCLUSION: This survey gives an indirect confirmation of the interest of scotopic pupillary diameter measurement and taking it into account in photoablation protocols. However, night vision symptoms remain frequent but do not influence patient satisfaction. Knowledge of risk factors and technical progress should provide a better quality of vision after Lasik.

[Limbal dermoid and Goldenhar syndrome. Report of an anatomoclinical study]. / Dermoïde du limbe et syndrome de Goldenhar. A propos d'une observation anatomo-clinique.

Dysembryoplastic neoplasm, the limbal dermoid is a benign congenital tumor involving the outer coat of the eye. This congenital tumor affected the right eye of a 6-year-old girl. The lesion was typically hemispheric, covered with pink skin, located in the inferior and temporal part of the cornea, and devoid of any major consequences except the cosmetic appearance of the eye. There were no other major abnormalities in the clinical examination but a single skin tag could be observed at the homolateral preauricular area without any visible cutaneous fistula next to it. This additional change allowed us to establish the diagnosis of a minor form of Goldenhar syndrome. This malformative syndrome typically includes several changes: dermoid and/or dermolipoma, preauricular tags and/or cutaneous fistulas in the same area, vertebral abnormalities etc. These findings may be limited to dermoid and cutaneous tags, as in our report. Such changes must be looked for in all limbal dermoids.

[Therapeutic photokeratectomy for the treatment of band keratopathy]. / La photokératectomie thérapeutique dans le traitement de la kératopathie en bandelettes.

PURPOSE: This retrospective study was designed to investigate the therapeutic potential of phototherapeutic keratectomy (PTK) for the treatment of band keratopathy. PATIENTS AND METHODS: PTK was performed with the Excimed UV 200, (Summit Technology, Inc) on 27 eyes of 22 patients and with the Nidek EC5000 on 11 eyes of 10 patients with band keratopathy. Mean patient age was 57 years. The mean follow-up period was 19 months (ranged from 4 to 54 months). When possible, the change in best corrected visual acuity and spherical equivalent was evaluated at 6, 12, 18 and 24 months. RESULTS: Almost 90% of patients with smooth bands achieved visual improvement and 85% of patients with rough bands improved ocular discomfort. The mean hyperopic shift caused by tissue ablation was less than +2.0D after one year, for smooth bands. CONCLUSION: Excimer laser PTK is a safe and effective outpatient treatment and should be used as initial treatment for band keratopathy.

[Cataract surgery after refractive surgery. Part I: practical surgical consequences]. / Chirurgie de la cataracte après chirurgie réfractive. Première partie: conséquences chirurgicales pratiques.

Prior refractive surgery has little incidence on the phako-exeresis technique. Most of the precautions taken are based more on theoretical considerations rather than extensive clinical experience. Excepting cases of high myopy corrected with IOL where early opacification may have occurred, mo st of the population undergoing refractive surgery has not yet reached the age of cataracts. In case of prior corneal surgery (radial keratotomy, PKR, Lasik or intracorneal ring segments) the incision tunnel must remain behind or away from the anatomically modified sectors. In case of prior refractory surgery, explantation must always precede the procedure. A large diameter (6mm or more) lens is always chosen in order to ava avoid optical consequences of modifications induced by the aspheric cornea.

[Cataract surgery after refractive surgery: Part II: the problem of implant calculation]. / Chirurgie de la cataracte après chirurgie réfractive. Part II: le problème du calcul d'implant.

Refractive surgery is a growing technique in a selected population of young patients who no longer want to wear corrective lenses. As this population becomes older and reaches an age where cataracts may develop, we decided to examine the problems encountered in calculating the IOL. Certain techniques may perturb keratometry oe measurement of axis length, two elements essential for calculating the implant. In certain cases where no solution is currently available for making these measurements, we propose archiving keratometry and axial length measurements for candidates for refractive surgery.

[Phototherapeutic keratectomy in the treatment of Groenouw's type I corneal dystrophy]. / La photokératectomie thérapeutique dans le traitement de la dystrophie de Groenouw I.

PURPOSE: This study was designed to investigate the therapeutic potential of phototherapeutic keratectomy (PTK) for the treatment of corneal granular dystrophy. PATIENTS AND METHODS: PTK was performed with the Excimed UV 200, (Summit Technology, Inc) on a series of 27 eyes of 22 patients with corneal granular dystrophy. Mean patients' age was 34.6 years. The mean follow-up period was 31 months (ranged from 6 to 52 months). The changes in best corrected visual acuity and spherical equivalent were evaluated at 6, 12, 18 and 24 months. RESULTS: All of patients achieved visual improvement. Mean preoperative best corrected visual acuity (BCVA) was 20/100 and mean postoperative BCVA was 20/30 at one year. The mean hyperopic shift caused by tissue ablation was +/- 2.8 D after one year. CONCLUSION: Corneal grafting was the standard treatment for visually disabling granular dystrophy, but PTK has significant advantages over this procedure and must now be the standard method of managing corneal granular dystrophy when intervention is required.

[Reis-Buckler dystrophy: therapeutic photo-ablation with the excimer laser]. / Dystrophie de Reis-Buckler: photoablation thérapeutique au laser excimer.

PURPOSE: Reis-Buckler's corneal dystrophy consist of superficial reticulated opacities with recurring attacks of corneal erosion. Lamellar and penetrating keratoplasties were the traditional surgical means of improving recurrent erosions and vision but the dystrophy recurs following surgery. Phototherapeutic keratectomy (PTK) is now the standard method of managing this anterior corneal disease when intervention is required. MATERIAL AND METHODS: We have treated ten eyes with Reis-Buckler's dystrophy using Excimer laser PTK. RESULTS: All of patients achieved visual improvement (preoperative corrected visual acuity: average 0.3 +/- 0.2 SD, postoperative at one month 0.6 +/- 0.3 SD and 0.7 +/- 0.2 SD at one year. The refractive shift changed from a spherical equivalent of -0.92 D to a postoperative refraction of +1.80 D at one month and +1.65 D at one year.

Angle-fixated anterior chamber phakic intraocular lens for myopia of -7 to -19 diopters.

PURPOSE: To assess the safety and efficacy of a second generation, anterior chamber phakic intraocular lens (Baikoff Model ZB5M) in patients with high myopia. METHODS: One hundred and twenty-one patients (134 eyes) with myopia of -7.00 to -18.80 D were implanted with the ZB5M lens and followed for 18 to 52 months; the number of eyes evaluated was: 6 months (104 eyes), 1 year (91 eyes), 18 months (78 eyes), 2 years (68 eyes), and 3 years (35 eyes). RESULTS: Postoperative spherical equivalent refraction averaged -1.00 D and the error in refractive correction (achieved minus intended) averaged -0.40 D during the first 2 years, increasing -to -1.30 D refraction and -0.60 D error in refractive correction at 3 years. At 2 years, approximately 40% of eyes had a spherical equivalent refraction within +/-0.50 D, and 65% within +/-1.00 D. The uncorrected distance visual acuity was 0.048 at baseline and 0.5 at 3 years; near visual acuity was 0.21 at baseline and approximately 0.7 over the 3 years of follow-up. Spectacle-corrected distance visual acuity at baseline was 0.54; it improved to 0.7. Near visual acuity was 0.65 at baseline and it improved to approximately 0.75. Endothelial cell counts in the central and peripheral cornea were reduced by an average 3.3% at 6 months, declining an additional 1% to 2% over the remaining follow-up period. Regression analyses indicated that most of the endothelial cell loss was due to surgery. Additional complications included halos/glare in 37 of 133 eyes (27.8%) and iris retraction with pupillary ovalization in 30 of 133 eyes (22.6%). The intraocular lens was exchanged in four of 133 eyes (3.0%) and removed in three of 133 eyes (2.3%), the latter because of halos (one eye) and a flat anterior chamber with severe inflammation (two eyes). CONCLUSIONS: Implantation of the Baikoff ZB5M lens in the anterior chamber of phakic eyes significantly reduced high myopia and produced a stable refractive outcome over the 3 years, accompanied by marked improvement in uncorrected distance visual acuity and minimal, non-progressive damage to the corneal endothelium. Frequent complications included pupillary ovalization and halos/glare. Improvements in accuracy of IOL power calculations are needed.

Ultrasound biomicroscopy of Baikoff anterior chamber phakic intraocular lenses.

BACKGROUND: The purpose of the study was to analyze qualitatively and quantitatively anatomic relationships of anterior chamber Baikoff phakic intraocular lenses (IOL) to the cornea, angle, iris, and lens in myopic eyes. METHODS: Thirteen phakic myopic eyes (-9.00 to -15.00 diopters) corrected by minus power, angle-supported, anterior chamber intraocular lenses of the ZB5M style (Chiron-Domilens), with a mean follow-up of 25 months (range 18 to 36 months), were examined clinically and by ultrasound biomicroscopy. RESULTS: The mean distance (+/- SD) between the central cornea and the IOL was 2.05 +/- 0.18 mm (range 1.8 to 2.47 mm); mean distance between the corneal periphery and the IOL was 1.56 +/- 0.17 mm (range 1.33 to 1.95 mm); and the mean distance between the IOL and the lens was 0.58 +/- 0.12 mm (range 0.48 to 0.81 mm). IOL footplates seemed to be correctly positioned in the angle in all eyes. We observed no goniosynechiae. In six eyes, we found localized posterior indentation of the iris caused by the haptics. Four of these six eyes exhibited oval pupils associated with an oversized IOL. CONCLUSIONS: High frequency ultrasound biomicroscopy can define anatomic relationships of anterior chamber phakic IOLs, and help analyze the mechanisms of corneal and iris complications.

[The optical power of the corneal epithelium. In vivo evaluation]. / Le pouvoir optique de l'épithélium cornéen. Evaluation in vivo.

PURPOSE: The refracting power of the corneal epithelium is relatively unknown. We measured the keratometric refracting power of the cornea on 15 eyes of patients undergoing photorefractive keratectomy with and without epithelium. MATERIALS: The readings were performed with a videokeratoscope TMS-1. Three readings were averaged to obtain the mean and standard deviations. RESULTS: By removing the epithelium, there was an increase in corneal refracting power. The mean change was +1.19 D (standard deviation +/- 0.36 D) at 1 mm of the center of the cornea. On all patients the optical power of the cornea increased after epithelium removal. CONCLUSION: The curvature of the Bowman membrane is steeper than the cornea with epithelium. A change in the thickness of the epithelium is related to a modification of the optical power of the cornea. The optical role of the epithelium is to compensate surface irregularities of the Bowman membrane and could explained in part the hyperopia in the first months after excimer laser.

[Quantitative topographic detection of keratoconus in the contralateral eye in clinically unilateral keratoconus. Apropos of 5 cases]. / Dépistage topographique quantitatif du kératocône sur les yeux adelphes de kératocônes cliniquement unilatéraux. Apropos de 5 cas.

BACKGROUND: Keratoconus is generally bilateral and follows an asymmetrical course. The goal of this study was to evaluate efficiency of the automated topographic screening indices on early keratoconus by examination of the fellow eyes of clinically unilateral keratoconus. PATIENTS AND METHOD: We examined the fellow eyes of 5 cases of clinically unilateral keratoconus by videokeratography using TMS-1 Computed Anatomy device, which incorporates the keratoconus screening indices from Rabinowitz (K and I-S values) and Klyce/Maeda (KPI value and other quantitative induces as OSI, DSI and CSI). RESULTS: One case (number 1) had keratoconus detected by both Rabinowitz and Klyce/Maeda indices. Two cases (number 2 and 3) had normal keratoconus screening indices. Two cases (number 4 and 5) had keratoconus detected by Rabinowitz I-S value, with a 0% KPI value. CONCLUSIONS: Rabinowitz indices are sensitive with a poor specificity. The Klyce/Maeda indices are less sensitive but more specific. Both methods may be useful for keratoconus detection. The results must always be analysed in relation to a clinical observation of both eyes and the course of the topographic changes.

[Laser and corneal surgery: topography and preoperative evaluation]. / Laser et chirurgie cornéenne: topographie et bilan préopératoire.

The purpose of preoperative clinical examination is to determine accurately the refraction under cycloplegia. Operative techniques and protocols are chosen in relation to the degree of ametropia. Computer assisted videokeratography allows early keratoconus detection and gives reference quantitative datas for analysing postoperative changes.