Long-term results of accelerated corneal collagen crosslinking in paediatric patients with progressive keratoconus: 10-year follow-up.

OBJECTIVES: To evaluate the 10-year visual, refractive, and tomographic outcomes of epithelium-off accelerated corneal collagen cross-linking (ACCL) in paediatric patients with progressive keratoconus (KC) and to compare the stages in terms of re-progression. METHODS: Patients under 18 years of age with progressive KC who underwent ACCL between 2010 and 2012 and completed at least 10 years of follow-up were included in this retrospective study. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refractive errors, and corneal tomography parameters were evaluated preoperatively and at 1, 5, and 10 years postoperatively. The effect of stage and age on re-progression was analysed. RESULTS: The study included 175 eyes of 97 patients (mean age: 14.46 ± 2.17 years). Improvement in UDVA and CDVA was observed in all postoperative periods compared to the preoperative period (each p-value < 0.05). The increase in spherical equivalent (SE), flattening of keratometry values, and decrease in thinnest corneal thickness (TCT) were statistically significant in the tenth year compared to preoperatively (each p-value < 0.05). Re-progression was observed in 16 eyes (9.14%). Haze was observed in 13 eyes (7.43%), 4 of which were permanent. Deep anterior lamellar keratoplasty was performed in 3 eyes (1.7%) and a second ACCL in 3 eyes (1.7%). CONCLUSIONS: ACCL is an effective and safe long-term strategy to prevent progression of KC in paediatric patients. In the light of this study with a 10-year follow-up re-progression rate of 9.14%, long-term follow-up of patients after ACCL for possible re-progression and the need for re-CCL or keratoplasty may be recommended.

Comparison of three techniques for simultaneous intraocular lens implantation in subluxated cataract surgery: Transconjunctival intrascleral, Z-suture knotless transscleral, and Cionni capsular tension ring assisted.

PURPOSE: To evaluate and compare the clinical outcomes of three different methods of intraocular lens (IOL) implantation in the surgery of subluxated cataracts. METHODS: In this retrospective, comparative, clinical interventional study, the medical records of patients who underwent IOL implantation with sutureless 27-gauge needle-assisted transconjunctival intrascleral (Group 1), Z-suture knotless transscleral (Group 2), and Cionni capsular tension ring (Cionni-CTR) assisted (Group 3) simultaneously with subluxated cataract extraction between June 2010 and June 2022 were evaluated. Demographic characteristics, follow-up times, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical and cylindrical refractive values, and spherical equivalent (SE) values of three groups were compared. Intraoperative and postoperative complications were recorded. RESULTS: There were 20 eyes in Group 1, 35 eyes in Group 2, and 40 eyes in Group 3. In all groups, statistically significant improvement was observed in postoperative UDVA and CDVA compared to preoperative values (each p < 0.05). There was no statistical difference between the groups in postoperative UDVA and CDVA values. (p = 0.130, p = 0.167 respectively). No significant difference was observed between the groups in terms of postoperative spherical, cylindrical, and SE values (each p > 0.05). CONCLUSION: The study suggests that three different IOL implantation techniques for simultaneous IOL implantation in subluxated cataract surgery have similar effects on visual and refractive outcomes.

Effect of Keratoconus Stage and Classification Parameters on Deep Anterior Lamellar Keratoplasty Outcomes.

PURPOSE: The aim of this study was to investigate the effect of the keratoconus (KC) stage according to the Amsler-Krumeich classification system and the parameters used in this classification on deep anterior lamellar keratoplasty outcomes. METHODS: The preoperative KC stage was determined, and the presence of corneal scarring was noted. The preoperative and postoperative best-corrected visual acuity (BCVA), refractive error, mean central keratometry (K mean ) readings, topographic astigmatism, and minimum corneal thickness (CT) values were recorded. Intraoperative and postoperative complications were also noted. RESULTS: One hundred thirty-seven eyes (54 eyes in stage 3-83 eyes in stage 4) were included in the study. The mean follow-up period was 42.20 ± 24.36 months. There was no statistically significant difference between stage 3 and 4 KC groups for postoperative BCVA, K mean , CT, spherical equivalent, and topographic astigmatism values (each P value >0.05). The effect of preoperative BCVA, K mean , CT, and refractive error values on postoperative BCVA could not be demonstrated ( P = 0.264). In addition, no statistically significant correlation was found between postoperative and preoperative values (each P value > 0.05). Although intraoperative Descemet membrane perforation and postoperative early suture loosening were observed more frequently in stage 4 KC than in stage 3 KC, the 2 groups were statistically similar for these and other complications (each P value >0.05). CONCLUSIONS: The preoperative KC stage and the parameters used in classification are not useful in predicting postoperative deep anterior lamellar keratoplasty outcomes. The timing of the surgery should be planned with the awareness that the progression of the disease will not have a negative effect on outcomes.

Epithelial Inoculation After Small-Incision Lenticule Extraction (SMILE): A Case Report.

Epithelial ingrowth is a rare condition that is generally seen after laser in situ keratomileusis (LASIK) and has been reported in the literature in a small number of cases after small-incision lenticule extraction (SMILE) surgery. "Epithelial inoculation" should also be considered in patients presenting with decreased vision and an appearance similar to epithelial ingrowth in the early period after SMILE surgery. A 23-year-old woman presented to our clinic with a request for refractive surgery. Her manifest refractions were -7.50 -1.00 x 180° in the right eye and -7.25 -1.00 x 150° in the left eye, and best corrected distance visual acuity was 10/10 in both eyes. The SMILE procedure was performed with the Visumax femtosecond laser (Carl Zeiss Meditec AG). Slit-lamp examination at postoperative 1 week revealed a small grayish-white intrastromal opacity resembling epithelial ingrowth in the central optic axis of the right eye. Irrigation of the interface was performed with balanced salt solution using an irrigation cannula and the epithelial cluster was removed. The patient remained clinically stable 6 months after surgery and has experienced no recurrence. When epithelial inoculation is observed early after SMILE surgery, immediate irrigation of the interface appears to be an effective and safe treatment.

Comparison of Deep Anterior Lamellar Keratoplasty and Penetrating Keratoplasty in Keratoconic Eyes With Previous Hydrops-Related Corneal Scar.

PURPOSE: This study aimed to compare the outcomes of deep anterior lamellar keratoplasty (DALK) and penetrating keratoplasty (PK) procedures in keratoconic eyes with a previous hydrops-related corneal scar. METHODS: In this retrospective study, the medical records of patients who had hydrops-related corneal scarring and underwent keratoplasty surgery were reviewed. Patients treated with DALK were classified as group 1, and patients treated with PK as group 2. Preoperative and postoperative best-corrected visual acuity, central corneal thickness, keratometry (K), and refractive error values of each group were recorded and compared. RESULTS: Seventy-eight eyes (41 in group 1 and 37 in group 2) were included in this study. The mean follow-up period of the patients was 37.7 ± 30.0 months in group 1 and 51.2 ± 29.4 months in group 2 ( P = 0.06). The preoperative and postoperative best-corrected visual acuity and central corneal thickness values were statistically similar in both groups (each P value >0.05). Keratometry values (K1 and mean keratometry) were significantly steeper in group 1 ( P1 = 0.02 and P2 = 0.03, respectively). Descemet membrane perforation was experienced in 7 (4 macroperforation and 3 microperforation; 15.6%) of 45 eyes that planned to perform DALK. These 4 eyes with macroperforation underwent PK and were excluded from the study. When all postoperative complications were assessed, although the total complication rate was 21% after DALK, it was 43% after PK ( P = 0.04). CONCLUSIONS: DALK with a big-bubble technique is a feasible surgery in eyes with corneal scarring due to previous hydrops and is comparable with PK in terms of visual and refractive outcomes. This study suggests that DALK, which is safer than PK with less postoperative complication rates, should be the primary surgical option to avoid serious complications in keratoconic eyes with hydrops-related corneal scarring.

Changes in corneal high order aberrations and anterior chamber parameters following scleral fixated intraocular lens implantation.

BACKGROUND: To evaluate the change in corneal high order aberrations (HOAs) and anterior chamber parameters following scleral fixation in aphakic patients using the Scheimpflug camera system. METHODS: This retrospective study included patients who were aphakic after phacoemulsification surgery and underwent scleral-fixed intraocular lens (SF-IOL) implantation with Z suture technique between 2010 and 2022. Preoperative and postoperative best corrected visual acuity (BCVA), anterior segment parameters and corneal aberrations were evaluated with a combined Scheimpflug-Placido disk corneal topography device (Sirius Costruzione Strumenti Oftalmici, Florence, Italy). The following values were recorded: Simulated keratometry (SimK), flat meridian (K1), steep meridian (K2), iridocorneal angle (ICA), temporal anterior chamber angle (T-ACA), nasal anterior chamber angle (N-ACA), horizontal anterior chamber diameter (HACD), anterior chamber volume (ACV), corneal volume (CV), total Root Mean Square (RMS), high order aberrations (HOAs), spherical aberration, coma, trefoil, quadrifoil, and secondary astigmatism. RESULTS: The study included 31 eyes of 31 patients (mean age: 63.00 ± 19.41 years, 17 males/14 females). Postoperative BCVA was better than preoperative BCVA (p = 0.012). Postoperatively, there was a statistically significant increase in ACV and CV values and a statistically significant decrease in K2 (p = 0.009, p = 0.032, p = 0.015). Preoperative T-ACA and preoperative and postoperative ACV were negatively correlated with postoperative intraocular pressure (r=-0.427 p = 0.033, r=-0.406 p = 0.032 and r=-0.561 p = 0.001). There were statistically significant postoperative increases in corneal RMS, trefoil and HOAs for 3 mm pupil diameter (p = 0.0177, p = 0.001, p = 0.031) and in corneal RMS, trefoil and quadrifoil aberrations for 6 mm pupil diameter (p = 0.033, p = 0.001, p = 0.001). CONCLUSIONS: In conclusion, SF-IOL implantation with Z-suture technique used for visual rehabilitation of aphakic patients may affect visual quality by increasing corneal HOAs while improving visual acuity.

Aqueous Flare and Intraocular Pressure in the Early Period Following Panretinal Photocoagulation in Patient with Proliferative Diabetic Retinopathy.

Objectives: The aim of the study was to investigate the effect of panretinal photocoagulation (PRP) on aqueous flare and intraocular pressure (IOP) in the early period. Methods: Eighty-eight eyes of 44 patients were included in the study. The patients underwent a full ophthalmologic examination including the best corrected visual acuity, IOP measured by Goldmann applanation tonometry, biomicroscopy, and dilated fundus examination before PRP. Aqueous flare values were measured by the laser flare meter. Aqueous flare and IOP values were repeated in both eyes at the 1st and 24th h after PRP. The eyes of the patients who underwent PRP were included in the study as the study group, and the other eyes as the control group. Results: In eyes treated with PRP, 1st h (19.44 pc/ms) and 24th h (18.53 pc/ms) aqueous flare values were statistically higher than before PRP (16.66 pc/ms) (p<0.05). In the study eyes which were similar to the control eyes before PRP, the aqueous flare was higher at the 1st and 24th h after PRP compared to control eyes (p<0.05). The mean IOP at the 1st h (18.69 mmHg) after PRP in study eyes was higher than both pre-PRP (16.25 mmHg) and post-PRP 24th h (16.12 mmHg) IOP values (p<0.001). At the same time, the IOP value at the 1st h after PRP was higher than the control eyes (p=0.001). No correlation was observed between aqueous flare and IOP values. Conclusion: An increase in aqueous flare and IOP values was observed after PRP. Besides, the increase in both values starts even in the 1st h, and the values at 1st h are the highest values. At the 24th h, while IOP values return to baseline, aqueous flare values are still high. In patients who may develop severe intraocular inflammation or cannot tolerate increased IOP (such as previous uveitis, neovascular glaucoma, or severe glaucoma), control should be performed at the 1st h after PRP to prevent irreversible complications. Furthermore, the progression that may develop in diabetic retinopathy due to increased inflammation should also be kept in mind.

Efficacy of keratometric values obtained from Sirius topographer® in nidek axial length-scan® for intraocular lens calculation after penetrating keratoplasty.

BACKGROUND: To evaluate the accuracy of keratometric values obtained from Scheimpflug (Sirius) topography using Nidek AL-Scan optical biometry (OB) for intraocular lens (IOL) power calculating after penetrating keratoplasty (PK). METHODS: Thirty eyes of 26 patients were included in this study. The demographic information, complete ophthalmic examination, IOL calculation technique, and its effect on final refractive results were evaluated. RESULTS: The mean age of the patients was 52.76 ± 16.20 years. The mean K readings using Nidek AL-Scan OB, mean simulated K (SimK) (3mm), and mean pupillary power (MPP) (4.5mm) K readings using Sirius were 41.92 ± 5.05 D, 42.99 ± 5.78 D, and 43.30±6.23 D (p= 0.515). CONCLUSIONS: Both devices correctly calculated IOL power after PK; however, Sirius SimK (3mm) gave the lowest mean absolute error (MAE) results and can be safely used for IOL power calculation.

Comparison of corneal, endothelial, and anterior segment parameters in eyes with and without pigment dispersion.

BACKGROUND: To evaluate the differences of central corneal thickness (CCT), corneal endothelial cell morphology, and biometric parameters of the anterior chamber and iridocorneal angle in pigment dispersion syndrome (PDS), pigmentary glaucoma (PG), primary open-angle glaucoma (POAG), and healthy group. METHODS: Twenty- three eyes in the PDS group, 39 eyes in the PG group, 33 eyes in the POAG group, and 45 eyes in the healthy control group were included in this cross-sectional retrospective study. Corneal endothelial cell density, the coefficient of variation in the cell area, hexagonality, and central corneal thickness (CCT) were obtained by specular microscopy (CEM 530, NIDEK, Japan). Anterior chamber depth (ACD), iridocorneal angle parameters and CCT were measured by anterior segment optical coherence tomography (AS-OCT) (Visante OCT, Carl Zeiss AG, Germany). RESULTS: The mean CCT via specular microscopy (SM-CCT) was measured at the thinnest value in the PG group (531.20 ± 34.91 µm) and the thickest in the control group (569.13 ± 37.52 µm). CV value was higher in PG (34.65 ± 6.84) and POAG group (34.27 ± 9.93) and lower in control group (28.82 ± 5.18) (p = 0,005). The mean AS-OCT-CCT was the thinnest in the PG group (513.61 ± 39.94 µm), and the thickest in the control group (547.04 ± 36.72 µm) (p = 0.001). All parameters of the iridocorneal angle were larger in the PDS and PG groups (p < 0.001). In the correlation analysis of the glaucomatous eyes, a negative correlation between the C/D ratio and SM-CCT and AS-OCT-CCT (p = 0.037, p = 0.017, respectively) and a positive correlation between the pRNFL thickness and AS-OCT- CCT (p = 0.002). CONCLUSION: CCT values obtained with both SM and AS-OCT were found to be significantly thinner in PG cases. CV, which is the measure of polymegatism, was found to be significantly higher in PG cases.

Brown Syndrome: Features and Long-term Results of Management.

OBJECTIVES: The goal of this study was to evaluate surgical techniques and outcomes in patients with Brown's syndrome. METHODS: A retrospective review was conducted of patients who underwent surgery of the superior oblique (SO) muscle between 2003 and 2011 at a referral center. RESULTS: In all, 190 patients (111 female and 79 male) with an age range of 4-50 years were included in the study. The right eye was affected in 98 patients, and the left eye in 92 patients. Abnormal head posture (AHP), ocular movement (OM), and hypotropia were assessed. The greatest improvement of AHP was seen following an SO temporal tenotomy (91%). Patients with a -4 limitation achieved full OM after a SO temporal tenotomy. CONCLUSION: Temporal tenotomy provided the best improvement in limitation of elevation in adduction.

Real-Life Data of Patients with Exudative Age-Related Macular Degeneration.

OBJECTIVES: The aim of this study was to examine and provide real-life data of patients with exudative-type age-related macular degeneration (AMD). METHODS: A total of 189 eyes of 160 patients with exudative AMD treated with intravitreal anti-vascular endothelial growth factor therapy (anti-VEGF) injections (ranibizumab 0.3 mg/0.05 mL, aflibercept 2 mg/0.05 mL, bevacizumab 1.25 mg/0.05 mL) were included in the study. Patient demographic characteristics, and details of the clinical examinations, number of injections, best-corrected visual acuity (BCVA) measured with the Snellen chart, optical coherence tomography, and fundus fluorescein angiography images were evaluated at the first visit and during the follow-up period. RESULTS: In the study group, 78 of the patients were female (48.8%) and 82 were male. The mean age was 72.20±8.97 years. While no treatment had been applied to 151 eyes before the first examination, 38 had previously received an intravitreal injection at another center. The mean number of patient visits was 5.83 in the first year, 4.68 in the second year, and 3.84 in the third year, and the mean number of injections was 4.70 in the first year, 2.08 in the second year, and 1.51 in the third year. The mean BCVA change between the first visit and the first, second, and third years was not statistically significant (p>0.05), and a significant change was observed in the mean central macular thickness (p<0.05). CONCLUSION: Anatomical and functional success was achieved with anti-VEGF treatment after fewer injections and visits than have been reported in randomized, controlled, clinical studies in the literature. The number of injections and visits recorded in this study was consistent with the data of other real-life studies.

Simultaneous Transepithelial Topography-Guided Photorefractive Keratectomy and Accelerated Cross-Linking in Keratoconus: 2-Year Follow-Up.

PURPOSE: To evaluate the visual, refractive, and topographic outcomes after simultaneous topography-guided transepithelial photorefractive keratectomy (transepithelial TG-PRK) using the Amaris Excimer laser platform and accelerated corneal cross-linking (CXL) in eyes with keratoconus. MATERIALS AND METHODS: Patients with 2 years of follow-up were included in this retrospective case series. Manifest refraction (MR), uncorrected (UDVA) and corrected (CDVA) distance visual acuity, corneal topography, and pachymetry were evaluated at 1, 3, 6, 12, and 24 months after surgery. The root-mean-square of total higher-order aberrations (total HOA-RMS), coma (Coma-RMS), and spherical aberration (SA-RMS) were calculated for 4- and 6-mm diameters. RESULTS: Forty-six eyes of 46 patients were included in the study. Stromal ablation was ≤50 µ in all patients. MR was -3.78±3.26 preoperatively and -1.39±1.82 postoperatively. Significant improvements were seen in the UDVA and Coma-RMS values at 1 month, CDVA and total HOA-RMS values at 3 months, and SA-RMS values at 1 year compared to preoperative levels. UDVA values further improved after 2 years, compared to the 1-year values. No patient lost two or more lines and keratoconus progression was not observed in any patient. CONCLUSION: Simultaneous transepithelial TG-PRK and accelerated CXL resulted in significant gains in CDVA without compromising CXL efficacy.

Five-year Outcomes of Ranibizumab in Neovascular Age-related Macular Degeneration: Real Life Clinical Experience.

PURPOSE: To evaluate the outcomes of 5-year ranibizumab treatment in neovascular age-related macular degeneration (nAMD) in a single center and real life clinical setting. METHODS: The records of nAMD patients who were treated with ranibizumab between January 2010 and June 2011 were retrospectively reviewed. Patients who completed 5 years of follow-up were included. Main outcome measures were change in best-corrected visual acuity, central retinal thickness, and visit and injection numbers. RESULTS: Forty-four eyes of 37 patients were included. Mean best-corrected visual acuity decreased from 0.82 ± 0.69 to 1.11 ± 0.65 logarithm of minimal angle of resolution after 5 years. Twenty-four eyes (54.5%) had visual acuity loss ≥3 lines, and 20 eyes (45.5%) had stable or improved vision (loss <3 lines, remained stable, or gained ≥1 line) at month 60. The mean total number of visits was 25.3 ± 5.8 (range, 14 to 42), and the mean total number of injections was 12.6 ± 6.4 (range, 3 to 26) at month 60. CONCLUSIONS: Half of the ranibizumab-treated nAMD patients maintained their vision during the 5 years of follow-up. Visit and injection numbers were found to be lower than in prospective studies, reflecting a real world clinical practice.

CORRELATION OF CHOROIDAL THICKNESS AND BODY MASS INDEX.

PURPOSE: To evaluate the possible changes in the microvascular structure of the choroid by measuring choroidal thickness (CT) in four different body mass index (BMI) groups of healthy individuals. METHODS: One hundred and sixty eyes of 160 healthy individuals (70 females and 90 males) were included in this cross-sectional study. Healthy individuals were divided into 4 groups according to their BMIs. Cases with BMI ≤ 18.50 formed Group 1, cases with BMI between 18.50 and 24.99 formed Group 2, cases with BMI between 25.00 and 29.99 formed Group 3, and cases with BMI between 30.00 and 34.99 formed Group 4. The CT was measured by the enhanced depth imaging technique of the spectral domain optical coherence tomography. The CT was measured at subfoveal area and at 500-µm intervals to the nasal and temporal to the fovea up to 2,000 µm. The measurements were then statistically compared among the four groups. RESULTS: The mean ages were 26.5 ± 6.9 years (range: 18-39 years) in Group 1, 27.2 ± 5.0 (range: 21-38 years) in Group 2, 28.5 ± 5.9 (range: 20-40 years) in Group 3, and 29.25 ± 5.6 (range: 20-40 years) in Group 4. The mean subfoveal CT (in micrometers) was 378 ± 86 (range: 189-563) in Group 1, 384 ± 102 (range: 225-643) in Group 2, 314 ± 66 (range: 160-455) in Group 3, and 317 ± 63 (range: 220-411) in Group 4. There was a statistically significant difference among the 4 groups in regard to CT in all locations (P < 0.05). CONCLUSION: We have demonstrated that BMI may have an influence on the CT of healthy persons. Individuals in both Group 3 and Group 4 have thinner choroids than the individuals in both Group 1 and Group 2.

Comparison of three methods of tonometry in normal subjects: Goldmann applanation tonometer, non-contact airpuff tonometer, and Tono-Pen XL.

OBJECTIVE: WE AIMED TO COMPARE INTRAOCULAR PRESSURE (IOP) MEASUREMENTS VIA THREE DIFFERENT TONOMETERS: the Goldmann applanation tonometer (GAT), the Tono-Pen(®) XL (TPXL), and a non-contact airpuff tonometer (NCT). METHODS: This was a cross-sectional study of 200 eyes from 200 patients. Right eyes of all patients were included in this study. IOP was measured via GAT, NCT, and TPXL by three physicians. Each physician used one of the tonometers. Measurements via the three devices were compared. RESULTS: The mean IOP was 15.5±2.2 mmHg (range 10-22) with the GAT, 16.1±3.0 (range 9-25) with the TPXL, and 16.1±2.8 (range 10-26) with the NCT. Bland-Altman analysis showed that the mean difference between measurements from the NCT and the GAT was 0.6±2.3 mmHg. The mean difference between the TPXL and GAT measurements was 0.7±2.5 mmHg. The mean difference between the NCT and TPXL measurements was -0.02±3.0 mmHg. There was no significant difference between the groups according to a one-way analysis of variance (ANOVA) test. P-values were 0.998 for NCT-TPXL, 0.067 for NCT-GAT, and 0.059 for TPXL-GAT. CONCLUSION: The NCT and TPXL provide IOP measurements comparable to those of the gold standard GAT in normotensive eyes.