Ocular Pain after Refractive Surgery: Interim Analysis of Frequency and Risk Factors.

PURPOSE: To examine the frequency and risk factors for ocular pain after laser assisted in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK). DESIGN: Prospective study of individuals undergoing refractive surgery at 2 different centers. PARTICIPANTS: One hundred nine individuals undergoing refractive surgery: 87% LASIK and 13% PRK. METHODS: Participants rated ocular pain on a numerical rating scale (NRS) of 0 to 10 before surgery and 1 day, 3 months, and 6 months after surgery. A clinical examination focused on ocular surface health was performed 3 and 6 months after surgery. Persistent ocular pain was defined as an NRS score of 3 or more at both 3 and 6 months after surgery (patients), and this group was compared with individuals with NRS scores of < 3 at both time points (control participants). MAIN OUTCOME MEASURES: Individuals with persistent ocular pain after refractive surgery. RESULTS: The 109 patients who underwent refractive surgery were followed up for 6 months after surgery. Mean age was 34 ± 8 years (range, 23-57 years); 62% self-identified as female, 81% as White, and 33% as Hispanic. Eight patients (7%) reported ocular pain (NRS score ≥ 3) before surgery, with the frequency of ocular pain increasing after surgery to 23% (n = 25) at 3 months and 24% (n = 26) at 6 months. Twelve patients (11%) reported an NRS score of 3 or more at both time points and constituted the persistent pain group. Factors that predicted persistent pain after surgery in a multivariable analysis were (1) ocular pain before surgery predicated persistent pain after surgery (odds ratio [OR], 1.87; 95% confidence interval [CI], 1.06-3.31), (2) symptom report of depression before surgery (Patient Health Questionnaire-9: OR, 1.3; 95% CI, 1.1-1.6; P = 0.01), (3) use of an oral antiallergy medication before surgery (OR, 13.6; 95% CI, 2.1-89.3; P = 0.007), and (4) pain intensity day 1 after surgery (OR, 1.6; 95% CI, 1.2-2.2; P = 0.005). There were no significant associations between ocular surface signs of tear dysfunction and ocular pain, P > 0.05 for all ocular surface signs. Most individuals (> 90%) were completely or somewhat satisfied with their vision at 3 and 6 months. CONCLUSIONS: Eleven percent of individuals reported persistent ocular pain after refractive surgery, with several preoperative and perioperative factors predicting pain after surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Experimental design considerations for studies of human tear proteins.

PURPOSE: Human tears contain abundant, diverse sets of proteins that may serve as biomarkers of ocular surface health. There is a need for reproducible methods that consider multiple factors influencing the tear proteome, in addition to the variable of interest. Here we examined a workflow for proteomic analysis of tear proteins without the need to pool tear samples from multiple individuals, thus allowing for analyses based on individual factors, and increasing opportunities for protein biomarker discovery. METHODS: Tears were collected by Schirmer strip following topical ocular anesthetic application then individually stored at -80 °C prior to processing for proteomics. Tear proteins were extracted from Schirmer strips, digested using suspension trapping spin columns (S-Trap), and labeled with high multiplicity tandem mass tags (TMT). Peptide digests were then extensively fractionated by two-dimensional chromatography and analyzed by mass spectrometry to identify and measure changes in protein abundance in each sample. Analysis of select samples was performed to test protocols and to compare the impact of clinically relevant parameters. To facilitate comparison of separate TMT experiments, common pool samples were included in each TMT instrument run and internal reference scaling (IRS) was performed. RESULTS: Differences in subsets of tear proteins were noted for: geographic site of tear collection, contact lens use, and differences in tear fluid volume among individuals. CONCLUSION: These findings demonstrate that proteomic analysis of human tear proteins can be performed without the need to pool samples, and that development of analytic workflows must consider factors that may affect outcomes in studies focused on diverse clinical samples.

Human MPox (Monkeypox) Virus Membranous Keratoconjunctivitis With Transient Corneal Hypoesthesia and Late Symblepharon Formation: A Novel Case and Clinical Implications.

PURPOSE: The aim of this study was to describe a case of corneal involvement as an early manifestation of ocular disease in the 2022 human mpox (monkeypox) virus outbreak. METHODS: This is a single case report with longitudinal care. RESULTS: A 47-year-old immunocompetent man presented with viral conjunctivitis before development of skin lesions or systemic symptoms. Subsequently, he developed membranous keratoconjunctivitis and a corneal epithelial defect. Orthopoxvirus-positive polymerase chain reaction test from his ocular surface was positive. The epithelial defect did not heal with conservative treatment but was successfully treated with amniotic membrane transplantation over 8 days. Reduced corneal sensation was noted after epithelial healing, and polymerase chain reaction from the ocular surface remained positive at 17 days from symptom onset, with slowly recovering conjunctivitis at 21 days. Continued membrane formation required repeated removal but significantly improved with topical corticosteroid treatment after epithelial healing by 29 days of symptom onset. Corneal sensation normalized by 87 days from symptom onset at which time symblepharon were noted but PCR testing from the ocular surface was negative. CONCLUSIONS: Early corneal involvement of human monkeypox virus is possible. Transient corneal hypoesthesia may be due to acute inflammation. Chronic inflammatory changes can result in symblepharon. These findings have potential implications in patient care and corneal donation.

Early Complications With Preloaded Descemet Membrane Endothelial Keratoplasty Are Not Dependent on Optisol-GS Washout or Trypan Blue Restaining.

PURPOSE: To describe the intraoperative and early postoperative complications using preloaded Descemet membrane endothelial keratoplasty (DMEK) grafts with intraocular injection of the graft in Optisol-GS and omission of trypan blue restaining. METHODS: This is a retrospective case series of 132 consecutive eyes with Fuchs endothelial dystrophy or endothelial failure who underwent DMEK using preloaded donor tissue prepared as previously described. The graft was not restained with trypan blue by the surgeon, and Optisol-GS was injected with the graft into the eye instead of being rinsed from the injector. Early postoperative complications (0-8 wk) including intraoperative fibrin formation, intraocular inflammation, elevated intraocular pressure, partial graft detachment requiring rebubble, and early graft failure were recorded. RESULTS: No eyes developed intraoperative fibrin formation or postoperative inflammation (such as toxic anterior segment syndrome) or elevated intraocular pressure. For eyes with Fuchs corneal dystrophy, our rebubble rate was 21% (22/106 eyes). Early graft failure was noted in 2% (3/132 eyes), which is similar to previous reports. CONCLUSIONS: Our results suggest that injection of Optisol-GS into the anterior chamber during DMEK graft injection does not lead to increases in intraoperative or early postoperative complications. Trypan blue restaining is not necessary for intraoperative visualization. This simplification can reduce graft manipulation and save time and resources for this procedure.

Contrast Sensitivity After Wavefront-Guided and Wavefront-Optimized PRK and LASIK for Myopia and Myopic Astigmatism.

PURPOSE: To compare contrast sensitivity among participants undergoing wavefront-guided or wavefront-optimized photorefractive keratectomy (PRK) or LASIK for the treatment of myopia or myopic astigmatism 12 months after surgery. METHODS: In a prospective, randomized clinical trial, 215 participants with myopia ranging from -0.50 to -7.25 diopters (D) and less than -3.50 D of manifest astigmatism electing to undergo either LASIK or PRK were randomized to receive wavefront-guided or wavefront-optimized treatment. Corrected Super Vision Test (Precision Vision, La Salle, IL) high contrast and small letter contrast sensitivity, uncorrected postoperative contrast sensitivity function, and uncorrected and corrected distance visual acuity were measured preoperatively and at 1, 3, 6, and 12 months postoperatively. RESULTS: There was a significant difference within each of the four groups over time when measuring high contrast visual acuity (P < .001) and small letter contrast sensitivity (P < .001), with the most significant decrease occurring 1 month postoperatively. However, there were no significant differences when comparing the four groups for high contrast sensitivity (P = .22) or small letter contrast sensitivity (P = .06). The area under the logarithm of contrast sensitivity function did not differ significantly over time (P = .09) or between groups (P = .16). A pairwise comparison of preoperative to 12-month CDVA showed a significant improvement in all groups (P < .017). The change in CDVA was also significantly different between groups as determined by one-way analysis of variance (P = .003). CONCLUSIONS: Wavefront-guided and wavefront-optimized PRK and LASIK procedures maintained high contrast, small letter contrast sensitivity, and contrast sensitivity function 12 months postoperatively. Although the recovery period for visual performance was longer for PRK versus LASIK, there was no significant difference in treatment type or treatment profile at 12 months postoperatively. [J Refract Surg. 2018;34(9):590-596.].

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

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

Wavefront-Guided Versus Wavefront-Optimized Photorefractive Keratectomy: Visual and Military Task Performance.

PURPOSE: To compare visual performance, marksmanship performance, and threshold target identification following wavefront-guided (WFG) versus wavefront-optimized (WFO) photorefractive keratectomy (PRK). METHODS: In this prospective, randomized clinical trial, active duty U.S. military Soldiers, age 21 or over, electing to undergo PRK were randomized to undergo WFG (n = 27) or WFO (n = 27) PRK for myopia or myopic astigmatism. Binocular visual performance was assessed preoperatively and 1, 3, and 6 months postoperatively: Super Vision Test high contrast, Super Vision Test contrast sensitivity (CS), and 25% contrast acuity with night vision goggle filter. CS function was generated testing at five spatial frequencies. Marksmanship performance in low light conditions was evaluated in a firing tunnel. Target detection and identification performance was tested for probability of identification of varying target sets and probability of detection of humans in cluttered environments. RESULTS: Visual performance, CS function, marksmanship, and threshold target identification demonstrated no statistically significant differences over time between the two treatments. Exploratory regression analysis of firing range tasks at 6 months showed no significant differences or correlations between procedures. Regression analysis of vehicle and handheld probability of identification showed a significant association with pretreatment performance. CONCLUSIONS: Both WFG and WFO PRK results translate to excellent and comparable visual and military performance.

Goblet cell response after photorefractive keratectomy and laser in situ keratomileusis.

PURPOSE: To determine whether patients without dry eye preoperatively have an altered conjunctival goblet cell density and mucin secretion postoperatively and to explore what factors affect changes in goblet cell density and mucin secretion. SETTING: The former Walter Reed Army Medical Center, Washington, DC, USA. DESIGN: Prospective nonrandomized clinical study. METHODS: Impression cytology was used to determine conjunctival goblet cell density before and 1 week, 1 month, and 3 months after photorefractive keratectomy (PRK) or laser in situ keratomileusis (LASIK). The McMonnies questionnaire, Schirmer test, tear breakup time, corneal sensitivity, rose bengal staining, and computerized videokeratoscopy were also performed to assess tear-film and ocular-surface health. RESULTS: The ratio of goblet cell to total cells changed postoperatively from baseline in both groups (P < .001). The most significant change was a median 29% decrease 1 month postoperatively. However, there were no significant differences between groups over time (P = .772). The ratio of filled goblet cell to total goblet cell did not change significantly over the same time period (P = .128), and there were no significant differences between the PRK group and the LASIK group over time (P = .282). CONCLUSIONS: Patients without apparent dry eye had an altered conjunctival goblet cell population after PRK or LASIK. The conjunctival goblet cell population tended to decrease in the early postoperative period after either surgery and was most affected by preoperative goblet cell density. The changes in the tear film and ocular surface did not seem to affect goblet cell mucin secretion after either procedure. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

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

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

Wavefront-optimized surface retreatments of refractive error following previous laser refractive surgery: a retrospective study.

BACKGROUND: Retreatments are sometimes necessary to correct residual or induced refractive errors following refractive surgery. Many different combinations of primary treatment methods and retreatment techniques have been studied, however, few studies have investigated wavefront-optimized (WFO) technology for retreatment following primary refractive surgery. This study aimed to report the outcomes of WFO photorefractive keratectomy (PRK) retreatments of refractive error following previous laser refractive surgery with PRK, laser in situ keratomileusis (LASIK), or laser-assisted subepithelial keratectomy (LASEK). METHODS: We reviewed records of patients who underwent WFO PRK retreatments using the Allegretto Wave Eye-Q 400 Hz Excimer Laser System (Alcon Surgical) between January 2008 and April 2011 at Walter Reed Army Medical Center and Madigan Army Medical Center. Outcomes were recorded in terms of uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent (MRSE), corrected distance visual acuity (CDVA), and complications at 1 month (M), 3 M, and 6 M post-op. RESULTS: Seventy-eight patients (120 eyes) underwent WFO PRK retreatment during the study period. Primary surgery was surface ablation in 87 eyes (78 PRK, 9 LASEK) and LASIK in 33 eyes. The mean spherical equivalent before retreatment was -0.79 ± 0.94 D (-3.00 to 1.88 D). UDVA was ≥ 20/20 in 69 eyes (60.0 %) at 1 M, 54 eyes (71.1 %) at 3 M, and 27 eyes (73.0 %) at 6 M follow-up. MRSE was within ±0.50 D of emmetropia in 78 eyes (67.8 %) at 1 M, 59 eyes (77.6 %) at 3 M, and 25 eyes (67.6 %) at 6 M follow-up. CDVA was maintained within ±1 line of pre-op in 113 of 115 eyes (98.3 %) at 1 M, 74 of 76 eyes (97.4 %) at 3 M, and 37 eyes (100 %) at 6 M follow-up. CONCLUSION: Although follow-up was limited beyond 3 M, WFO PRK retreatments in patients with residual refractive error may be a safe and effective procedure. Further studies are necessary to determine the long-term safety and stability of outcomes.

Wavefront-guided versus wavefront-optimized photorefractive keratectomy: Clinical outcomes and patient satisfaction.

PURPOSE: To compare visual outcomes following Visx Star S4 Customvue wavefront-guided and Allegretto Wave Eye-Q 400 Hz wavefront-optimized photorefractive keratectomy (PRK). SETTING: Warfighter Refractive Eye Surgery Program and Research Center, Fort Belvoir, Virginia, and Walter Reed National Military Medical Center, Bethesda, Maryland, USA. DESIGN: Prospective randomized clinical trial. METHODS: Active-duty United States military soldiers were randomized to have wavefront-guided (Visx Star S4 Customvue) or wavefront-optimized PRK. Participants were followed up to 12 months postoperatively. Primary outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and manifest spherical equivalent (SE). Secondary outcome measures included refractive astigmatism, higher-order aberrations (HOAs), contrast sensitivity, subjective visual complaints, and patient satisfaction. RESULTS: The study evaluated 108 soldiers (mean age 30.3 years ± 6.3 [SD]; mean manifest SE -3.51 ± 1.63 D). At 12 months postoperatively, achieved UDVA, CDVA, manifest SE, and refractive astigmatism were comparable between wavefront-guided and wavefront-optimized groups (P > .213). Spherical aberration and total HOAs significantly increased from baseline in both groups (P < .006). The change in coma, trefoil, spherical aberration, and total HOAs (P > .254) were comparable between groups. There were fewer losses of photopic low-contrast visual acuity (LCVA) at 5% contrast after wavefront-guided compared to wavefront-optimized treatment (P = .003). There was no significant difference between treatment groups in visual symptoms, overall vision expectation, and satisfaction (P > .075). CONCLUSION: Wavefront-guided treatment offered a small advantage in photopic LCVA. Refractive outcomes, HOAs, self-reported visual difficulties, overall vision expectation, and satisfaction were otherwise comparable between wavefront-guided and wavefront-optimized treatments. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Traumatic cataracts secondary to combat ocular trauma.

PURPOSE: To describe the characteristics, visual outcomes, and predictive value of the Ocular Trauma Score (OTS) in eyes with traumatic cataract from combat ocular trauma. SETTING: Walter Reed Army Medical Center, Washington, DC, USA. DESIGN: Retrospective case series. METHODS: Records of service members with traumatic cataract from combat ocular trauma over a 7-year period were reviewed. Visual acuity at initial presentation and visual acuity at the final follow-up were compared in addition to outcomes in closed versus open globes, by final lens status, and in eyes receiving primary versus secondary intraocular lenses (IOLs). Visual outcomes were predicted using the OTS and compared to the achieved corrected distance visual acuity (CDVA). RESULTS: A total of 181 eyes of 167 patients were included in the final analysis. Twenty-six percent of all eye injuries sustained traumatic cataract. The mean final visual outcome was 0.86 logMAR ± 1.01 (SD) with 44 no light perception (NLP) eyes and 26 light perception (LP) eyes compared with an initial visual acuity of 2.41 ± 0.88 logMAR with 27 no NLP eyes and 64 LP eyes (P ≤ .001, 2-tailed Student t test). Final CDVAs in eyes receiving primary IOLs were 0.72 ± 0.84 logMAR with 1 NLP and 1 LP eye versus 0.51 ± 0.78 logMAR with 2 LP eyes in eyes receiving a secondary IOL (P = .37, Student t test). CONCLUSION: Traumatic cataracts are frequently associated with ocular trauma. The OTS is a reliable means of predicting visual outcome. There was no difference in eyes receiving primary IOLs versus secondary IOLs. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

The U.S. Army Surface Ablation Study: comparison of PRK, MMC-PRK, and LASEK in moderate to high myopia.

PURPOSE: To compare visual outcomes following photorefractive keratectomy (PRK), PRK with mitomycin C (MMC-PRK), and LASEK in moderate and high myopia in military personnel. METHODS: This prospective, randomized contralateral eye study included 167 patients 21 years or older with manifest spherical equivalent -5.99 ± 1.40 diopters (D) (range: -3.88 to -9.38 D) randomized to either MMC-PRK or LASEK treatment in their dominant eye and conventional PRK without MMC in the fellow eye. All procedures were performed using the LADARVision 4000 Excimer Laser System (Alcon Surgical Inc., Ft. Worth, TX). High- and low-contrast visual acuities, manifest refraction, endothelial cell count, and corneal haze were evaluated up to 12 months postoperatively. RESULTS: At 12 months postoperatively, visual outcomes were comparable among the treatment groups. Corneal haze of any grade was less common in MMC-PRK compared to PRK at 1 month (21.4% vs 31.0%; P < .01) and 3 months (12.8% vs 35.9%; P = .03) postoperatively; it was also less common in MMC-PRK compared to LASEK at 1 month (21.4% vs 55.9%; P < .01), 3 months (12.8% vs 42.4%; P < .01), and 6 months (12.2% vs 36.4%; P = .03) postoperatively. Haze rate (grade 0.5 or higher) was comparable between LASEK and PRK. Clinically significant haze (grade 2 or higher) developed after PRK (4 eyes) and LASEK (2 eyes), but not after MMC-PRK. CONCLUSIONS: MMC-PRK showed some benefits in minimizing corneal haze formation. One year after surgery, there was no discernible difference in the postoperative refractive outcomes among the three methods.

Anterior segment imaging in combat ocular trauma.

Purpose. To evaluate the use of ocular imaging to enhance management and diagnosis of war-related anterior segment ocular injuries. Methods. This study was a prospective observational case series from an ongoing IRB-approved combat ocular trauma tracking study. Subjects with anterior segment ocular injury were imaged, when possible, using anterior segment optical coherence tomography (AS-OCT), confocal microscopy (CM), and slit lamp biomicroscopy. Results. Images captured from participants with combat ocular trauma on different systems provided comprehensive and alternate views of anterior segment injury to investigators. Conclusion. In combat-related trauma of the anterior segment, adjunct image acquisition enhances slit lamp examination and enables real time In vivo observation of the cornea facilitating injury characterization, progression, and management.

Residency training in refractive surgery.

PURPOSE: To evaluate resident refractive surgery caseload and surgical outcomes in an academic medical center. SETTING: Walter Reed Army Medical Center, Washington, DC, USA. DESIGN: Comparative case study. METHODS: Keratorefractive procedures performed by residents at the Walter Reed Center for Refractive Surgery between 2002 and 2010 were reviewed. Outcomes of surgeries performed by the graduating classes of 2008 to 2010 were compared with those of cases performed by staff. The uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent, corrected distance visual acuity (CDVA), and complications were analyzed. RESULTS: Between 2002 and June 2010, residents performed 1566 procedures (1414 photorefractive keratectomy [PRK], 152 laser in situ keratomileusis), for a mean of 20.2 procedures from 2002 to 2004, 51.6 from 2005 to 2007, and 99.9 from 2008 to 2010. Outcomes analysis was performed on 333 resident eyes and 977 staff eyes treated between 2008 and June 2010. Six months postoperatively, 96.1% of resident-treated eyes and 94.6% of staff-treated eyes had a UDVA 20/20 or better (P=.312) and 61.3% and 64.3%, respectively, had a UDVA 20/15 or better (P=.324). The percentage of eyes within ±0.50 diopter of emmetropia at 6 months was 94.0% for residents and 91.1% for staff (P=.105). The postoperative CDVA was within 2 lines of preoperative baseline in all resident cases and 99.8% of staff cases (P=.999). CONCLUSIONS: Resident experience grew steadily over the period studied. Overall safety and efficacy of resident-performed surgery, albeit mainly PRK based, matched that of fellowship-trained refractive surgeons. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Alcohol versus brush PRK: visual outcomes and adverse effects.

BACKGROUND AND OBJECTIVE: A smooth corneal surface prior to laser ablation is important in order to achieve a favorable refractive outcome. In this study, we compare PRK outcomes following two commonly used methods of epithelial debridement: Amoils epithelial scrubber (brush) versus 20% ethanol (alcohol). STUDY DESIGN/PATIENTS AND METHODS: We reviewed records of patients who underwent wavefront-optimized PRK for myopia or myopic astigmatism between January 2008 and June 2010. Two treatment groups (brush vs. alcohol) were compared in terms of uncorrected distance visual acuity (UDVA), manifest refraction spherical equivalent (MRSE), corrected distance visual acuity (CDVA), and complications at postoperative months 1, 3, 6, and 12. RESULTS: One thousand five hundred ninety-three eyes of 804 patients underwent PRK during the study period: 828 brush-treated eyes and 765 alcohol-treated eyes. At 6 months postoperatively UDVA was ≥20/20 in 94.7% of brush-treated eyes versus 94.4% of alcohol-treated eyes (P = 0.907). At 1 month a higher percentage of brush-treated eyes maintained or gained one or more lines CDVA compared to alcohol-treated eyes (P = 0.007), but there were no other differences in UDVA, MRSE, or CDVA at any point postoperatively. At 1 month 75.4% of brush-treated eyes versus 70.4% of alcohol-treated eyes were free of complications (P = 0.032), and there were fewer brush-treated eyes with corneal haze (4.0% vs. 6.9%, P = 0.012) and dry eye (8.9% vs. 14.4%, P = 0.001). Although corneal haze was slightly more frequent in the alcohol group, most was trace and not significant. CONCLUSIONS: Although alcohol-assisted PRK had more minor complications in the early postoperative period, including corneal haze and dry eye, results for both groups beyond 1 month were comparable.

Visual and IOP outcomes after PRK in pigment dispersion syndrome.

PURPOSE: To report the results of photorefractive keratectomy (PRK) in patients with pigment dispersion syndrome. METHODS: The pre- and postoperative records of patients with pigment dispersion syndrome who underwent PRK between January 2002 and March 2009 were reviewed. Data for analysis included gender, age, ablation depth, surgical complications, manifest refraction spherical equivalent, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), intraocular pressure (IOP), central corneal thickness (CCT), cup-to-disc (c/d) ratio, and postoperative complications. RESULTS: Thirty-seven eyes of 19 patients (17 men and 2 women) with a mean age of 37.5 ± 6.9 years were included for review. At final follow-up, mean 404.1±119.5 days postoperative, UDVA was 20/15 or better in 67.6%, 20/20 or better in 91.9%, and 20/25 or better in 100% of eyes; 94.6% of eyes were within 0.50 diopters (D) and 100% were within 1.00 D of emmetropia. Corrected distance visual acuity was unchanged from preoperative in 73% and improved by one line in 27% of eyes. No eye lost 1 or more lines of CDVA. When corrected for change in CCT and curvature, mean postoperative IOP was elevated from baseline (16.7 ± 3.8 mmHg) at 1 month (18.1 ± 4.9 mmHg, P =.044) but unchanged at any other time postoperatively. Two (11%) of 19 patients were steroid responders, requiring a single topical agent until completing the course of steroids. No significant change was noted in mean c/d ratio from baseline (0.35±0.12) to final postoperative (0.35 ± 0.13, P = .99). CONCLUSIONS: Although PRK in patients with pigment dispersion syndrome resulted in excellent UDVA, retention of CDVA, and low incidence of adverse effects 1 to 2 years after surgery, long-term safety and efficacy outcomes of PRK in this cohort remain speculative

Photorefractive keratectomy in posterior polymorphous dystrophy with vesicular and band subtypes.

PURPOSE: To evaluate the safety and efficacy of photorefractive keratectomy (PRK) in patients with posterior polymorphous dystrophy (PPMD) with vesicular and band subtypes. SETTING: Walter Reed Center for Refractive Surgery, Washington, DC, USA. DESIGN: Case series. METHODS: The records of patients with PPMD who had PRK between January 2002 and May 2009 were reviewed. Data for analysis included sex, age, ablation depth, residual stromal bed thickness, manifest spherical equivalent, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, central corneal thickness (CCT), endothelial cell density (ECD), intraocular pressure (IOP), and complications. Preoperative and postoperative results were compared using the Wilcoxon signed-rank test, with P < .05 considered significant. RESULTS: Fourteen eyes of 7 men (mean age 29.1 years ± 9.1 [SD]; range 21 to 42 years) with at least a 6-month follow-up were reviewed. At the final follow-up (mean 19.5 months; range 6.3 to 58.3 months), all eyes had a UDVA of 20/15 and all eyes were within ± 0.50 diopter of emmetropia. The CDVA was unchanged from preoperatively in 71.4% of eyes and improved by 1 line in 28.6%. There were no significant complications. The IOP did not change significantly over the follow-up (P = .272). At the final visit, the mean ECD (2795.3 ± 366.0 cells/mm(2)) was unchanged from baseline (2809.1 ± 338.3 cells/mm(2)) (P = .114). CONCLUSIONS: Photorefractive keratectomy in PPMD patients with vesicular and band subtypes resulted in excellent visual outcomes and a low incidence of adverse effects. Endothelial cell densities did not change significantly in the early postoperative period. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Effect of blast trauma and corneal foreign bodies on visual performance.

PURPOSE: To evaluate the effect of non-penetrating corneal foreign bodies secondary to explosive blasts on the visual performance of soldiers. METHODS: In a prospective, non-interventional study subjective visual performance and objective optical quality of 11 injured eyes with retained corneal foreign bodies were compared with that of 11 normal controls. Visual performance measures consisted of best spectacle-corrected high-contrast visual acuity (HCVA), low-contrast (5%) visual acuity (LCVA), and contrast sensitivity (CS). LCVA was evaluated in two luminance levels (photopic and mesopic) and two glare conditions (with and without glare). Acuity measurements were scored using logMAR notation. Objective optical quality was assessed comparing total root mean square wavefront error (WFE) and percent higher order aberrations. Modulation transfer functions calculated from the wavefront maps were used to predict the results of the psychophysical contrast testing. RESULTS: HCVA of injured eyes (M = -0.03) did not differ significantly (t(20) = 1.56, p = 0.13) when compared with controls (M = -0.09). However, visual performance of injured eyes (M = 0.33) was significantly worse than control eyes (M = 0.11) on photopic LCVA (t(20) = 4.16, p < 0.001), mesopic LCVA(M = 0.44 vs. M = 0.21, t(20) = 3.85, p = 0.001), mesopic LCVA with glare (M = 0.49 vs. M = 0.21, t(20) = 3.66, p = 0.002), and small letter CS (M = 0.25 vs. M = 0.90, t(20) = -6.6, p < 0.001). For a 6-mm pupil, mean absolute WFE attributed to higher order aberrations for the injured eyes was 0.86 microm and 0.59 microm for the control eyes. This difference was significant (t(20) = -2.15, p = 0.044). CONCLUSIONS: Although HCVA was no different than the normal controls, visual performance of the injured eyes was significantly worse in terms of LCVA and CS. On average, visual performance can be broadly predicted by the modulation transfer function derived from the subjects' wavefront aberration map.