Phototherapeutic keratectomy: current approaches and changing trends in a tertiary eye clinic / Ceratectomia fototerapêutica: abordagens atuais e tendências de mudança em uma clínica oftalmológica terciária

ABSTRACT Purpose: To examine the efficacy of phototherapeutic keratectomy as a treatment for variable pathologies with anterior corneal opacities and evaluate the distribution of phototherapeutic keratectomy indications over the past 10 years. Methods: The records of 334 eyes from 276 patients who underwent phototherapeutic keratectomy between March 2010 and 2020 were retrospectively reviewed. Etiologies of the patients who underwent phototherapeutic keratectomy were noted, and their changes were examined. Refractive and visual acuity results before and after the operation were recorded and analyzed according to etiology. Results: The mean age of the patients was 40.7 ± 16.2 years (range: 19-84). The mean follow-up was 25.5 ± 19.1 months (range: 3-96). Phototherapeutic keratectomy was most frequently applied for corneal stromal dystrophies (44%, 151 eyes from 111 patients), and granular dystrophy was the most common phototherapeutic keratectomy indication among corneal dystrophies. Unlike other indications, there has been an increase in the application of phototherapeutic keratectomy for persistent subepithelial opacities due to adenoviral conjunctivitis in the past 10 years. There was a significant increase in visual acuity in all groups except for the recurrent epithelial defect group (p<0.05). The greatest improvement in visual acuity was detected for stromal dystrophies in the granular dystrophy subgroup. Conclusion: Despite changing indication trends, phototherapeutic keratectomy remains an effective and reliable treatment for anterior corneal lesions.

RESUMO Objetivo: Examinar a eficácia da ceratectomia fo­toterapêutica para o tratamento de patologias variáveis que apresentarem opacidades anteriores da córnea, e avaliar a distribuição das indicações de ceratectomia fototerapêutica nos últimos 10 anos. Métodos: Foram revisados retrospectivamente os prontuários de 276 pacientes, com 334 olhos tratados com ceratectomia fototerapêutica entre março de 2010 e o ano de 2020. As etiologias dos pacientes submetidos à ceratectomia fototerapêutica foram anotadas e suas alterações foram examinadas. Os resultados refrativos e de acuidade visual antes e após a operação foram registrados e analisados de acordo com a etiologia. Resultados: A idade média dos pacientes foi de 40,7 ± 16,2 anos (faixa: 19-84). O tempo médio de acompanhamento foi de 25,5 ± 19,1 meses (faixa: 3-96). A ceratectomia fototerapêutica foi aplicada com mais frequência para distrofias estromais corneanas (44%, 151 olhos de 111 pacientes); entre as distrofias corneanas como um todo, a distrofia granular foi a indicação terapêutica mais comum desse procedimento. Ao contrário de outras indicações, nos últimos 10 anos houve um aumento na aplicação de ceratectomia fototerapêutica em casos de opacidade subepitelial persistente causada por conjuntivite adenoviral. Houve um aumento significativo na acuidade visual em todos os grupos, exceto para o grupo com defeito epitelial recorrente (p<0,05). A maior melhora na acuidade visual foi detectada em casos de distrofia estromal, no subgrupo das distrofias granulares. Conclusão: Apesar das mudanças nas tendências de indicação, a ceratectomia fototerapêutica continua sendo uma abordagem terapêutica eficaz e confiável para tratar lesões da córnea anterior.

Wilson Disease Combined with Keratoconus: A Case Report.

A case of Wilson disease (WD) combined with keratoconus (KC) is described. A 30-year-old male diagnosed with WD presented to Ophthalmology Department due to progressive bilateral vision loss. Biomicroscopy revealed copper depositional ring and mild central corneal ectasia in both eyes. The patient had essential tremors and mild speech disturbance. The keratometric values were K1 = 45.94 diopters (D), K2 = 49.10 D in the right eye, and K1 = 47.14 D, K2 = 51.22 D in the left eye. The maximal elevation points on the posterior elevation maps were 98 mm for the right eye and 94 mm for the left eye. The typical KC pattern was seen on corneal topography bilaterally. Based on these findings, the patient was diagnosed with KC, and corneal cross-linking treatment was recommended. WD rarely occurs in combination with KC, and only two cases have been reported; this is the third case of WD combined with KC so far.

Long-term results of a new posterior chamber phakic intraocular lens in patients with high myopia: 5-year results.

PURPOSE: To evaluate the long-term refractive outcomes of Eyecryl posterior chamber spherical phakic intraocular lens (pIOL) implantation in high myopia and endothelial cell density (ECD) change. SETTING: Beyoglu Eye Training and Research Hospital, Istanbul, Turkey. DESIGN: Retrospective. METHODS: Eyes that were not suitable for corneal refractive surgery, had high myopia between -6.00 diopters (D) and -20.00 D, had Eyecryl posterior chamber spherical pIOL implantation, and had at least 5 years of follow-up were included. Preoperative ECD was ≥2300 cells/mm 2 and cylindrical value was ≤2.0 D in all cases. Preoperative and postoperative first, third, and fifth years of refraction, uncorrected and corrected distance visual acuity (UDVA/CDVA), and ECD were recorded. RESULTS: 36 eyes of 18 patients were examined. The mean UDVA and CDVA in postoperative fifth years were 0.24 ± 0.19 logMAR and 0.12 ± 0.18 logMAR, respectively. The safety and efficacy indices were 1.52 ± 0.54 and 1.14 ± 0.38, respectively. At 5 years, the spherical equivalent was ±0.50 D in 75% of eyes and ±1.00 D in 92% of eyes. After 5 years, the mean cumulative ECD loss was 6.91% ( P = .07). The annual ECD loss was 1.57% in the first year, 0.26% between 1 year and 3 years, and 2.38% between 3 years and 5 years. Asymptomatic anterior capsule opacity developed in 1 eye 4 years after surgery. Rhegmatogenous retinal detachment developed in 1, and myopic choroidal neovascular membrane occurred in 1 eye. CONCLUSIONS: Eyecryl posterior chamber spherical pIOL implantation is one of the effective and safe refractive surgical methods in correcting high myopia with predictable and stable refractive results over a 5-year period. Longer-term studies are needed for complications such as decreased ECD, retinal complications, and lens opacity.

Phototherapeutic keratectomy: current approaches and changing trends in a tertiary eye clinic.

PURPOSE: To examine the efficacy of phototherapeutic keratectomy as a treatment for variable pathologies with anterior corneal opacities and evaluate the distribution of phototherapeutic keratectomy indications over the past 10 years. METHODS: The records of 334 eyes from 276 patients who underwent phototherapeutic keratectomy between March 2010 and 2020 were retrospectively reviewed. Etiologies of the patients who underwent phototherapeutic keratectomy were noted, and their changes were examined. Refractive and visual acuity results before and after the operation were recorded and analyzed according to etiology. RESULTS: The mean age of the patients was 40.7 ± 16.2 years (range: 19-84). The mean follow-up was 25.5 ± 19.1 months (range: 3-96). Phototherapeutic keratectomy was most frequently applied for corneal stromal dystrophies (44%, 151 eyes from 111 patients), and granular dystrophy was the most common phototherapeutic keratectomy indication among corneal dystrophies. Unlike other indications, there has been an increase in the application of phototherapeutic keratectomy for persistent subepithelial opacities due to adenoviral conjunctivitis in the past 10 years. There was a significant increase in visual acuity in all groups except for the recurrent epithelial defect group (p<0.05). The greatest improvement in visual acuity was detected for stromal dystrophies in the granular dystrophy subgroup. CONCLUSION: Despite changing indication trends, phototherapeutic keratectomy remains an effective and reliable treatment for anterior corneal lesions.

The relationship between systemic disorders and anatomical outcomes after Descemet membrane endothelial keratoplasty / A relação entre distúrbios sistêmicos e resultados anatômicos para ceratoplastia endotelial da membrana de Descemet

ABSTRACT Purpose: The aim of this study was to investigate the association of anatomical outcomes and medications of patients with systemic diseases who underwent Descemet membrane endothelial keratoplasty with donor factors. Methods: Sixty nondiabetic donors of endothelial grafts and 60 patients who underwent operation by a single surgeon were included in this retrospective study. The patients' data, including the presence of diabetes mellitus and hypertension, antidiabetic-antihypertensive medications, and intracameral tamponades and anatomical outcomes, were recorded. The donor data were obtained from eye bank records. Results: Eighteen patients had type 2 diabetes mellitus (30%) and 34 had hypertension (56.6%). Among the patients with diabetes mellitus, 13 were receiving a single-agent antidiabetic drug, 4 were receiving dual oral antidiabetic therapy, and 1 was receiving insulin therapy. Among the hypertensive patients, 11 had monotherapy and 23 had dual antihypertensive therapy. Postoperatively, 35 patients (58.3%) had an endothelial attachment, 8 (13.3%) received reinjection, 7 (11.7%) required re-Descemet membrane endothelial keratoplasty, and 10 (16.7%) underwent penetrating keratoplasty. The mean donor age was 51.2 ± 14.1 years. The most common cause of donor death was cardiopulmonary arrest (36/60 cases; 60.0%). Regression analysis revealed that the presence of diabetes mellitus significantly disrupted graft attachment (p=0.034), while the presence of hypertension, antidiabetic and antihypertensive medication use, and the type of tamponade used in the patients, and the age, sex, cause of death, and specular endothelial cell count of donors were not statistically significantly associated with graft attachment (p>0.05). Conclusion: In this study, the anatomical outcomes of Descemet membrane endothelial keratoplasty surgery were affected by recipient and donor factors. The presence of diabetes mellitus in the recipient significantly negatively affected graft attachment.

RESUMO Objetivo: Investigar a associação de desfechos ana tômicos com doenças sistêmicas e medicamentos em casos submetidos à ceratoplastia endotelial da membrana de Descemet e fatores relativos aos doadores. Métodos: Foram incluídos neste estudo retrospectivo enxertos obtidos de doadores não diabéticos e 60 casos operados por um único cirurgião. Foram registrados os dados dos casos, incluindo a presença de diabetes mellitus e hipertensão, medicamentos antidiabéticos e anti-hipertensivos, tamponamentos intracamerais e desfechos anatômicos. Os dados dos doadores foram obtidos dos prontuários do banco de olhos. Resultados: Dezoito casos tinham diabetes mellitus tipo 2 (30%) e 34 tinham hipertensão (56,6%). Entre os casos de diabetes mellitus, 13 estavam em uso de uma medicação antidiabética de agente único, 4 estavam em terapia antidiabética oral dupla e 1 estava em insulinoterapia. Entre os hipertensos, 11 estavam em monoterapia e 23 em terapia anti-hipertensiva dupla. No pós-operatório, 35 pacientes (58,3%) submeteram-se a uma fixação endotelial, enquanto 8 casos (13,3%) receberam reinjeção, 7 casos (11,7%) necessitaram de ceratoplastia endotelial da membrana de Descemet e 10 casos (16,7%) foram submetidos a uma ceratoplastia penetrante. A média de idade dos doadores foi de 51,2 ± 14,1 anos. A causa mais comum de morte do doador foi parada cardiorrespiratória (36/60 casos; 60,0%). A análise de regressão revelou que a presença de diabetes mellitus causa distúrbios significativos na fixação do enxerto (p=0,034), enquanto a presença de hipertensão, o uso de medicamentos antidiabéticos e anti-hipertensivos, o tipo de tamponamento usado, a idade, o sexo, a causa da morte e a contagem de células endoteliais especulares dos doadores não demonstraram associações estatisticamente significativas com a fixação do enxerto (p>0,05). Conclusões: Os resultados anatômicos da cirurgia de ceratoplastia endotelial da membrana de Descemet são afetados por fatores do receptor e do doador. A presença de diabetes mellitus no receptor teve um significativo impacto negativo na fixação do enxerto.

Is COVID-19 Infection a Trigger for Herpetic Stromal Keratitis?

In June 2020, a 28-year-old female patient was admitted to our clinic with reduced vision in the left eye. She had systemic COVID-19 infection in May 2020 and during her treatment course, her visual complaints had begun approximately 1 week after the beginning of the COVID-19. Previously, the patient had bilateral femtosecond assisted - Laser in situ Keratomileusis in our clinic in 2018. There was no previous history of herpetic eye involvement. In her examination, the uncorrected visual acuity was 20/20 in the right and 20/32 in her left eye. Slit-lamp examination revealed interlamellar infiltration at the flap interface in the left eye. Considering herpetic activation, ganciclovir ointment 5 × 1, valacyclovir tablet 2 × 1, and prednisolone acetate 1.0% eye drops 5 times a day and artificial tear 5 × 1 were started. Two weeks later, the infiltration completely resolved and the uncorrected visual acuity increased to 20/20.

The relationship between systemic disorders and anatomical outcomes after Descemet membrane endothelial keratoplasty.

PURPOSE: The aim of this study was to investigate the association of anatomical outcomes and medications of patients with systemic diseases who underwent Descemet membrane endothelial keratoplasty with donor factors. METHODS: Sixty nondiabetic donors of endothelial grafts and 60 patients who underwent operation by a single surgeon were included in this retrospective study. The patients' data, including the presence of diabetes mellitus and hypertension, antidiabetic-antihypertensive medications, and intracameral tamponades and anatomical outcomes, were recorded. The donor data were obtained from eye bank records. RESULTS: Eighteen patients had type 2 diabetes mellitus (30%) and 34 had hypertension (56.6%). Among the patients with diabetes mellitus, 13 were receiving a single-agent antidiabetic drug, 4 were receiving dual oral antidiabetic therapy, and 1 was receiving insulin therapy. Among the hypertensive patients, 11 had monotherapy and 23 had dual antihypertensive therapy. Postoperatively, 35 patients (58.3%) had an endothelial attachment, 8 (13.3%) received reinjection, 7 (11.7%) required re-Descemet membrane endothelial keratoplasty, and 10 (16.7%) underwent penetrating keratoplasty. The mean donor age was 51.2 ± 14.1 years. The most common cause of donor death was cardiopulmonary arrest (36/60 cases; 60.0%). Regression analysis revealed that the presence of diabetes mellitus significantly disrupted graft attachment (p=0.034), while the presence of hypertension, antidiabetic and antihypertensive medication use, and the type of tamponade used in the patients, and the age, sex, cause of death, and specular endothelial cell count of donors were not statistically significantly associated with graft attachment (p>0.05). CONCLUSION: In this study, the anatomical outcomes of Descemet membrane endothelial keratoplasty surgery were affected by recipient and donor factors. The presence of diabetes mellitus in the recipient significantly negatively affected graft attachment.

Evaluation of peripapillary - macular microvascularity and choroidal vascularity index after refractive surgery.

BACKGROUND: To evaluate the microvascularity and choroidal vascularity index (CVI) using optical coherence tomography angiography (OCTA) and OCT following femtosecond laser-assisted in-situ keratomileusis (FS-LASIK) and small incision lenticule extraction (SMILE) procedures. METHODS: Patients with myopia (<-6.0D sphere) or myopic astigmatism (<-4.0D astigmatism) were enroled. The percentage of vessel density and foveal avascular zone (FAZ) size, optic disc flux index and perfusion were noted and the CVI was calculated before and after surgery. RESULTS: Twenty-nine eyes of 16 patients in the FS-LASIK group and 30 eyes of 16 patients in the SMILE group were enroled. Macular vessel density, FAZ size, and optic disc flux index were significantly higher on postoperative 1st day compared to preoperative day (p = 0.001, p = 0.007, and p < 0.001, respectively). There was no significant difference in terms of macular and peripapillary CVI between postoperative 1st day and preoperative day (p > 0.05). All microvascular parameters were similar on postoperative 7th day and preoperative day (p > 0.05). CONCLUSIONS: It was detected that there is a transient alteration in macular and peripapillary microvascularity after FS-LASIK/SMILE, whereas choroidal circularity is not significantly affected by these refractive surgeries.

Graft survival and clinical outcomes of Descemet membrane endothelial keratoplasty: long-term results.

PURPOSE: The aim is to report long-term graft survival rates and clinical outcomes of Descemet membrane endothelial keratoplasty (DMEK). METHODS: In this study 150 eyes that underwent DMEK whether for Fuchs endothelial corneal dystrophy (FECD) or for bullous keratopathy (BK) surveilled for 7 years at 6 time points to evaluate graft survival rates and clinical outcomes of post-corneal transplantation. RESULTS: Overall, the estimated survival probability of 95% confidence interval at 7 years of post-DMEK was 0.58 (0.72-0.77), and the survival probabilities of eyes operated for FECD (0.53) were higher than eyes operated for BK (0.42) (log rank 26.87, [p = 0.197]). Post-transplant eyes with FECD achieved better visual acuity levels than eyes with BK (p = 0.006). Primary graft failure occurred in 11.3% eyes. Secondary graft failure rate was 9.3%, and allograft rejection rate was 4.7%. CONCLUSION: Although DMEK is effective and safe in long term, visual results and graft survival rates are better in cases with FECD.

The Effect of Secondary Intraocular Lens Implantation Time on Visual Prognosis in Aphakia Cases after Open Globe Injury.

PURPOSE: We investigated the effect of the time of secondary intraocular lens (IOL) implantation on final visual acuity and other causes affecting visual prognosis in cases left aphakic after open globe injury. METHODS: The study included 62 eyes of 62 patients left aphakic after the repair of open globe injury between 2012 and 2019. Demographic characteristics, trauma zone, ocular trauma score, type of injury, time of secondary IOL implantation, final best-corrected visual acuity (BCVA), and complications were recorded for each patient. RESULTS: The mean follow-up time of 62 patients was 25.05 ± 12.59 months. The preoperative BCVA was found to be 2.40 ± 0.86 logarithm of the minimum angle of resolution (logMAR), while the postoperative final BCVA was found to be 0.53 ± 0.70 logMAR (p < 0.01). The mean interval timing of secondary sulcus foldable IOL implantation was determined to be 3.79 ± 4.04 months. No correlation was observed between secondary IOL implantation time and final BCVA (r = 0.140, p = 0.319). Furthermore, when only pediatric patients were taken, an excellent positive correlation was found between the secondary IOL implantation time and final BCVA logMAR (r = 0.895, p < 0.01). Multiple linear regression on final BCVA with age, revealed a significant model explaining 48.0% of the variability with younger age and better final BCVA with as significant coefficients (p = 0.007). CONCLUSIONS: Although time interval between primary repair and secondary IOL implantation to correct aphakia does not effect final BCVA in adult patients, earlier surgery should be considered for amblyopia management in pediatric patients.

Efficacy and safety of iris-supported phakic lenses (Verisyse) for the treatment of high myopia: 5-year results.

PURPOSE: Evaluating efficacy and safety of iris-supported phakic lenses (Verisyse) for high myopia treatment. METHODS: Patients treated with Verisyse (Abbott Medical Optics, Santa Ana, CA, USA) intraocular lens (IOL) implants were evaluated retrospectively. Patients with follow-up periods of more than 5 years were included in the study. Pre- and postoperative fifth-year spheric equivalent (SE) of manifest refraction values, uncorrected and corrected distance visual acuities (UDVA and CDVA, respectively), and endothelial cell density (ECD) values were recorded. Complications were evaluated. RESULTS: Forty-seven eyes of 31 patients were included in the study. Pre- and postoperative fifth year mean SE was - 12.50 ± 3.51D and - 0.72 ± 0.40D, respectively. Pre- and postoperative fifth-year UDVA was 1.56 ± 0.22 and 0.33 ± 0.18 logMAR (p < 0.001), respectively. The safety index (pre- and postoperative CDVA) was 1.39 ± 0.63 at the 5-year follow-up (p > 0,05). The efficacy index (ratio of mean postoperative UDVA to mean preoperative CDVA) of the patients was 1.14 ± 0.60. The mean postoperative endothelial cell loss at 5 years was -7.42%. None of the patients had lost 25% of their preoperative endothelial cells at 5-year follow-up. The mean postoperative endothelial cell loss was -3.05% at 1 year, -1.23% between years one and three, -1.02% between the third and fifth years. CONCLUSION: Verisyse IOL implantation is an effective and safe for high myopia surgical treatment. However, the 5-year follow-up period is not sufficient to evaluate the safety profiles in terms of endothelial cells.

Comparison of Adult Refractive Disorder Measurements Using HandyRef-K, Retinomax, Plusoptix, and Table-top Autorefractometer Devices.

OBJECTIVES: This study was conducted to compare refractive error measurements recorded using the Nidek HandyRef-K handheld autorefractometer (HDY; Nidek Co. Ltd., Tokyo, Japan), Plusoptix A09 photorefractor (PO; Plusoptix GmbH, Nuremberg, Germany), Retinomax K-plus 3 (RTX; Right Mfg. Co. Ltd., Tokyo, Japan), and a table-mounted autorefractometer/keratometer (TTR; URK 800, Unicos Co. Ltd., Daejeon, Republic of Korea). METHODS: Patients aged ≥18 years underwent measurement of refraction without cycloplegia using 4 devices and the spherical power (SP), cylindrical power (CP), and spherical equivalent (SE) values were analyzed and compared. RESULTS: A total of 181 eyes of 181 patients were enrolled in the study. The mean age of the patients was 33.08±0.95 years (range: 18-79 years). There was a significantly significant difference in the SP, CP, and SE values determined by the devices (p<0.001). The SP and SE values of the RTX and the HDY were similar, while the other device results were different (Wilcoxon signed-rank test, p=0.004). The CP values of the PO and the TTR, the HDY and the TTR were also comparable. CONCLUSION: The HDY, RTX, and the PO are suitable for screening in clinical practice, but the findings strongly suggest that they should be used with caution.

Detection of Subclinical Corneal Ectasia after Laser in Situ Keratomileusis: Corvis ST.

Described herein are the cases of 2 patients who underwent bilateral femtosecond-assisted laser in situ keratomileusis (FS LASIK) surgery and subsequently developed unilateral postLASIK ectasia. The fellow eye of both patients was topographically normal, their visual acuity was 20/20, and the patients had no visual symptoms. However, a biomechanical assessment using the Corvis ST tonometer (Oculus Optikgerate GmbH; Wetzlar, Germany) revealed remarkable weakness not only in the ectatic eyes, but also in the fellow eye. Arrangements were made to perform corneal crosslinking for the eyes with manifest ectasia and close follow-up of the fellow eyes.

The Effect of Cone Localization on Higher Order Aberrations After Corneal Crosslinking for Keratoconus.

OBJECTIVES: This study was designed to evaluate the effects of corneal collagen cross-linking (CXL) on topographic parameters, visual acuity, and corneal high-order aberrations according to the preoperative cone location in keratoconus. METHODS: This retrospective study assessed patients with keratoconus who underwent CXL between March 2016 and February 2019. Patients with a history of corneal surgery, corneal hydrops, corneal scar tissue, delayed epithelial healing, and a corneal thickness of <400 µm were excluded. The included eyes were divided into 2 groups according to the preoperative cone location: maximum K in the central 3-mm optical zone (group 1) or the central 3-mm to 5-mm optical zone (group 2). The preoperative and postoperative 24-month, best-corrected visual acuity (BCVA), intraocular pressure, K max, symmetry index front, corneal thickness, and high order aberration findings were recorded. RESULTS: The study included 67 eyes of 67 patients with keratoconus: 39 in group 1, and 28 in group 2. There were statistically significant differences between the groups in the preoperative BCVA values (p=0.04). There was no significant difference between the preoperative and postoperative mean K max between the 2 groups (p=0.08). The mean difference in corneal thickness between preoperative and postoperative measurements was significantly lower in group 2 than in group 1 (p=0.03). The preoperative and postoperative mean spherical aberration was significantly higher in group 1 than in group 2 (p=0.001 and p=0.005, respectively). CONCLUSION: The preoperative cone location in keratoconus may affect CXL outcomes. At the end of the second year, CXL was found to have a similar efficacy on visual acuity and keratometry parameters in the central and paracentral cone groups, and the recovery in terms of a spherical aberration among high-order aberrations after CXL in the central cone group was better than that of the paracentral cone group.

Five-year outcomes of small-incision lenticule extraction vs femtosecond laser-assisted laser in situ keratomileusis: a contralateral eye study.

PURPOSE: To compare the long-term refractive and visual outcomes and the corneal higher-order aberrations of contralateral eyes of patients who received small-incision lenticule extraction (SMILE) in one eye and femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) in the other eye. SETTING: Refractive Surgery Clinic of the University of Health Sciences Beyoglu Eye Training and Research Hospital, Istanbul, Turkey. DESIGN: Retrospective case series. METHODS: The medical files of patients who received SMILE in one eye and FS-LASIK in the contralateral eye for myopia and myopic astigmatism were reviewed. Postoperative examinations at 1 year, 3 years, and 5 years were evaluated. The main outcome measures were the comparison of the refractive and visual outcomes and the effect on corneal higher-order aberrations between the procedures. RESULTS: This study included 44 eyes from 22 patients. At the 5-year follow-up, the mean uncorrected distance visual acuity improved to 0.03 ± 0.06 and 0.02 ± 0.05 logarithm of the minimum angle of resolution (range 0.15 to -0.08 and 0.10 to -0.08) for SMILE and FS-LASIK groups, respectively. There was no statistically significant difference between the groups (P = .572). At 5 years, all eyes in both groups were within ±1.00 diopter of attempted spherical equivalent refraction, and no statistically significant difference was found between the intended and achieved correction comparing the groups at any time points. None of the aberrations showed a difference between the groups at any time. CONCLUSIONS: Both SMILE and FS-LASIK were safe and similar in terms of efficacy and predictability at long-term follow-up for the correction of myopia and myopic astigmatism.

Xerophthalmia: Findings from the Eye Lead to Diagnosis of a Fatal Intestinal Disease.

Vitamin A has an essential role in the maintenance of corneal and conjunctival epithelization, as well as photoreceptor transduction in the retina. A deficiency of vitamin A causes keratinization of the surface epithelium, and night blindness is often the first symptom. This report describes a case of chronic intestinal pseudo-obstruction (CIPO), a rare and potentially fatal disease, diagnosed following detection of a vitamin A deficiency in an ophthalmological examination. A 25-year-old female patient presented with a 3-month history of dryness, a burning sensation, and decreased vision, especially at night, in both eyes. She appeared cachectic and ill, and reported having lost 10 kg in the previous year. An ophthalmological examination revealed conjunctival and corneal keratinization in addition to punctate keratopathy with xerosis in both eyes, which raised the suspicion of a vitamin A deficiency. Her serum vitamin A level confirmed the diagnosis, and she was referred to the gastroenterology clinic, where she was diagnosed with CIPO and treated with parenteral multivitamin supplementation. A vitamin A deficiency should be suspected in patients with malnourishment and xerosis. Rapid diagnosis and treatment can be life-saving in cases with a severe underlying pathology.

Correction of myopic astigmatism by small incision lenticule extraction: does laterality matter?

To evaluate the outcome after astigmatic correction of small incision lenticule extraction (SMILE) and to compare the refractive results of right eyes with left eyes. Patients who underwent SMILE surgery in our clinic between 2014 and 2016 (Visumax, Carl Zeiss Meditec, Germany) were retrospectively reviewed. Preoperative and postoperative manifest refractions and corrected and uncorrected visual acuities were evaluated and changes in refractive astigmatism were evaluated by vector analysis. One hundred twenty-one eyes from 82 patients with myopic astigmatism were included. The mean preoperative spherical equivalent was - 6 ± 1.7 (range from - 9.50 to - 1.25) D and the mean cylinderical power was - 1.5 ± 0.6 (range from - 3.75 to - 1.00) D. Postoperatively 71.8% of eyes had < 0.50 D cylinder magnitude. Vector analysis results based on laterality revealed that correction index was 0.87 ± 0.3 for left eyes and 0.72 ± 0.3 for right eyes (p 0.02). This study revealed that SMILE has favorable astigmatic correction affect but left eyes have better outcomes than right eyes.

Simplified approach of Gokyigit's technique for complete cranial nerve third palsy.

PURPOSE: To evaluate a simpler approach of the medial transposition of split lateral rectus technique in patients with complete third nerve palsy. METHODS: All eyes with complet third nerve palsy were followed in our Strabismus Department between 2014 and 2016. All patients had complete oculamotor nerve palsy. All patients assed routine ophthalmologic examination. Also the ocular deviation, horizontal and vertical ocular alignments were measured at 6 m and at 1/3 m using the Krimsky corneal reflection test and alternate prism cover test with best optical correction. Same surgeon (BG) performed all procedures in general anesthesia. In this procedure, same Gokyigit's technique except upper and lower part of lateral rectus muscle was passed under the superior oblique tendon and inferior oblique tendon. Final deviation from 0 to 14 PD was considered a successful result. RESULTS: Eight patients were included in the study. The average ages were 39.4 years and male to female ratio 5:3. Patients had a preoperative horizontal deviation - 42.5 ± 2.7 PD and postoperative horizontal deviation - 1.7 ± 2.6 PD. All patients follow-up time were at least 6 months. CONCLUSIONS: Achieved to acceptable alignment in primary position, manage to diplopia and cosmetical appearance are the main aims of patients with third nerve palsy.

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.