Effects of Corneal Scars and Their Treatment With Rigid Contact Lenses on Quality of Vision.

OBJECTIVES: To study the effects of corneal scars and the treatment of these scars with rigid gas-permeable (RGP) contact lenses on quality of vision including straylight. Visual effects were related to scar characteristics such as size and grade. METHODS: Straylight and best-corrected visual acuity were measured in 23 patients with corneal scars during and after RGP contact lens wear. Contralateral eyes were used as controls, and age-normal values in case of bilateral scars. Straylight measurements were performed using the compensation comparison method of the Oculus C-Quant instrument. RESULTS: Scarred eye straylight values were 1.53 log(s) without contact lens and 1.60 log(s) with contact lens (P=0.043). Healthy eyes without contact lens had a mean straylight value of 1.13 log(s), corresponding to age-normal values. Contact lens wear increased straylight in healthy eyes to 1.26 log(s) (P<0.001). Visual acuity improved from 0.66 logarithm of minimal angle of resolution (logMAR) to 0.19 logMAR with contact lens wear in eyes with a corneal scar (P<0.001). CONCLUSIONS: Corneal scars can have a strong effect on quality of vision by diminishing visual acuity and increasing straylight. The increase in straylight from corneal scars on its own can lead to a serious visual handicap. Contact lens treatment did not improve straylight, but showed a slight worsening. As the recovery of visual acuity with contact lens wear far exceeded straylight increase, contact lenses remain a clinically useful treatment option in most patients with corneal scars.

Vernal shield ulcers treated with frequently installed topical cyclosporine 0.05% eyedrops.

PURPOSE: To report on the beneficial results of an intense regimen of 0.05% cyclosporine eye drops, eight times a day in patients with therapy resistant vernal shield ulcers. METHODS: Case cohort of four eyes of three male children with vernal keratoconjunctivitis complicated by shield ulcers, who were treated with frequent cyclosporine 0.05% eye drops and observed for up to 5 years. RESULTS: Quick resolution of the shield ulcers and complete re-epithelialization within 14-25 days was observed after adding intensive treatment with cyclosporine 0.05% to regular anti-inflammatory, histamine blocking, and surgical therapy. In one patient, additional scraping of the bottom of the ulcer was needed. CONCLUSIONS: In patients with vernal shield ulcers, frequent installation of low-concentration cyclosporine eye drops seems to have a promising therapeutical value.

Topical bevacizumab treatment in aniridia.

PURPOSE: To report the results of long-term topical treatment with bevacizumab (Avastin) 5 mg/mL eyedrops in a case of aniridia-related neovacularization of the cornea. METHODS: Interventional case report. A female patient with aniridia had a decrease in the best corrected visual acuity from 0.32 to 0.02 in the OS over the course of 4 years, secondary to central corneal neovascularization and epithelial breakdown. Vision in the OD was 0.2. In 2008, at age 28, a shared decision was made to start off-label treatment with bevacizumab eyedrops 0.5% in both eyes. After 9 years, the visual acuity in the OD remained stable, with stability of the macropannus and maintenance of central corneal clarity. In the OS, the central corneal neovascularization regressed, the epithelium regained its clarity, and after cataract surgery visual acuity was regained to 0.32. RESULTS: After 9 years of treatment with topical bevacizumab, vision acuity is comparable to the situation of 12 years previously: Visual acuity remained stable in the ODS. CONCLUSION: In a young patient with progressive corneal neovascularization secondary to aniridia, stability of central corneal neovascularization was obtained and corneal clarity was preserved by adding a daily drop of bevacizumab 5 mg/mL. No adverse events occurred. Vessel growth was inhibited, and as such, the progression of the natural history of the patient's disease was halted. More clinical study with longer follow-up is needed to investigate the applicability of treatment with topical VEGF inhibitors in aniridia.

LASIK flap breakthrough in Nd:YAG laser treatment of epithelial ingrowth.

PURPOSE: To present two cases with complications after Nd:YAG laser treatment of epithelial ingrowth. METHODS: Case reports. RESULTS: Dense central recurrent epithelial ingrowth was treated with a Nd:YAG laser directed at the epithelial nests in the LASIK flap interface in one case. Misalignment of the aiming beam after movement resulted in perforation of the LASIK flap, followed by renewed epithelial ingrowth through the new defect. The epithelial ingrowth receded and became more translucent as a result of the treatment, but the area of the perforation remained irregular. In another case, use of the Nd:YAG laser to treat recurrent epithelial ingrowth adjacent to the flap edge created a cavitation bubble that broke through the flap edge, creating a new epithelial channel through which ingrowth recurred. CONCLUSIONS: Surface breakthrough and renewed epithelial ingrowth is a possible complication of Nd:YAG laser treatment of epithelial ingrowth.

Indications for and outcomes of tertiary referrals in refractive surgery.

PURPOSE: To review the spectrum of disease, symptomatology, and management offered to patients referred for a second opinion after refractive surgery. METHODS: A prospective cohort study was done on all patients referred from October 1, 2006, to September 30, 2011, to a tertiary eye clinic after refractive surgery of any kind (ie, corneal laser surgery, conductive keratoplasty, radial keratotomy, phakic implants, refractive lens exchanges, or any combination thereof). Data analysis was performed on all demographic and clinical aspects of this cohort, including the initial complaint, type of referral, number of complaints, procedure previously performed, diagnosis at our center, type of advice given, and rate and type of surgical intervention. RESULTS: One hundred thirty-one eyes (69 patients) were included. Corneal refractive surgery was performed in 82% (108 eyes), and 11% (14 eyes) were seen after phakic intraocular lens (PIOL) implantation and 7% (9 eyes) after refractive lens exchange. The most common diagnoses were tear film dysfunction (30 eyes, 23%), residual refractive error (25 eyes, 19%), and cataract (20 eyes, 15%). Most patients (42 patients, 61%) were treated conservatively. In 27 patients (39%), 36 eyes (28%) were managed surgically. Severe visual loss was seen in 1 eye. CONCLUSIONS: No major problems were found in most second opinions after refractive surgery referral. Dry eyes, small residual refractive error, or higher-order aberrations were the most common complaints. Surgical intervention was needed in 36 eyes (28%), almost half of which were cataract extractions. Severe visual loss was seen in 1 eye with a PIOL. There was no incidence of severe visual loss in keratorefractive and refractive lens exchange procedures.

Intraocular pressure after descemet stripping endothelial keratoplasty (DSEK).

To assess the incidence of elevated intraocular pressure (IOP) after descemet stripping endothelial keratoplasty (DSEK). Retrospective case series. From the start of the technique in our hospital in 2003 until the middle of 2010, 73 eyes underwent DSEK, of which 66 (90.5 %) had a clear graft 1 year after surgery. IOP data pre- and postoperatively were analyzed. Follow-up was 1-5 years (mean 3.8, SD 1.3). Mean age was 71 years (SD 11, range 43-89). Three eyes (4.5 %) had a history of glaucoma before DSEK. Mean pre-operative IOP was 12.4 mmHg (SD ± 4.3). Mean IOP 1 day post-operatively was 16.4 mmHg (±9.2). Mean IOP after 1 and 6 months, and 1, 3, and 5 years were, respectively, 13.9 (±5.3), 14.7 (±5.6), 14.2 (±5.4), 13.8 (±3.7), and 12.6 (±3.5). Seventeen percent (11 eyes) had a postoperative rise in IOP which needed medical or surgical intervention: 8 % (5 eyes) had a rise in IOP 1 day after DSEK, of which 1 underwent a trabeculectomy 7 months after DSEK surgery; 6 % (4 eyes) had a rise in IOP later in the postoperative period, which could all be managed medically; and 3 % (2 eyes) had increased IOP 1 day after DSEK and later in the postoperative period, both eyes underwent a trabeculectomy 5 and 24 months, respectively, after DSEK surgery. An increase in IOP was encountered in 17 % of DSEK patients. Checking the IOP in the short and long postoperative period is necessary.

Allogeneic Serum Eye Drops: A Randomized Clinical Trial to Evaluate the Clinical Effectiveness of Two Drop Sizes.

INTRODUCTION: Allogeneic serum from blood donors is starting to be used to treat patients with dry eye disease (DED). However, the optimal dose is not known. We therefore aimed to evaluate the clinical efficaciousness and user-friendliness of micro-sized versus conventional-sized allogeneic serum eye drops (SEDs). METHODS: In a randomized trial, patients with DED first receive micro-sized SEDs (7 µl/unit) for 1 month, followed by a 1-month washout, before receiving conventional-sized SEDs (50 µl/unit) for 1 month; or vice versa. The primary endpoint was the Ocular Surface Disease Index (OSDI) score. Secondary endpoints were tear break-up time (TBT), tear production (TP), and presence of corneal punctate lesions (CP). The user-friendliness of both application systems was also compared. A linear mixed model for cross-over design was applied to compare both treatments. RESULTS: Forty-nine patients completed the trial. The mean OSDI score significantly improved from 52 ± 3 to 41 ± 3 for micro-sized SEDs, and from 54 ± 3 to 45 ± 3 for conventional-sized SEDs. Non-inferiority (margin = 6) of micro-sized SEDs was established. We demonstrate a significant improvement for TBT in case of conventional-sized SEDs and for CP in both treatment groups. TP trended towards an improvement in both treatment groups. The user-friendliness of the conventional drop system was significantly higher. CONCLUSIONS: For the first time, non-inferiority of micro-sized allogeneic SEDs was established. The beneficial effect of both SED volumes was similar as measured by the OSDI score. Although user-friendliness of the micro drop system was significantly lower, it is an attractive alternative as it saves valuable donor serum. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03539159).

Effect of Nd:YAG laser capsulotomy on refraction in multifocal apodized diffractive pseudophakia.

PURPOSE: To evaluate the effect on refraction of neodymium:YAG (Nd:YAG) laser posterior capsulotomy for posterior capsule opacification (PCO), and to evaluate the correlation between automated and subjective refraction in multifocal apodized diffractive pseudophakia. METHODS: A retrospective study of 75 pseudophakic eyes (50 patients) with multifocal apodized diffractive pseudophakia, treated for PCO with Nd:YAG laser posterior capsulotomy, was performed. Pre- and postintervention values of refractive and visual parameters were compared. The outcomes of autorefraction and subjective refraction were also compared. RESULTS: Uncorrected and corrected distance visual acuity improved significantly after Nd:YAG capsulotomy (P<.001). No significant changes were noted in defocus equivalent, astigmatic power vectors J(0) and J(45), and overall blurring strength in subjective refraction and autorefraction. Spherical equivalent changed significantly in autorefraction (P=.008), but not in subjective refraction. Autorefraction and subjective refraction were highly correlated in spherical equivalent, defocus equivalent, and blurring strength (r(2)>0.59). In approximately 7% of eyes, a change of more than 0.50 diopters in spherical equivalent in subjective refraction occurred. CONCLUSIONS: In most cases, Nd:YAG laser capsulotomy in patients with multifocal pseudophakia did not result in a change in refraction. However, 7% of eyes experienced a significant change in subjective refraction. Autorefraction correlated well with subjective refraction in apodized diffractive multifocal IOLs.

Grey Filter Contact Lens as Therapeutic Option for Acquired Reduced Binocular Visual Performance.

Disturbing binocular problems can be too complex to be treated in such a way that comfortable binocular single vision is restored. The grey filter contact lens could offer a safe and clinically useful way to help these patients. BACKGROUND: In unilateral acquired reduced visual performance or intractable diplopia the binocular performance often is less than the performance of the better eye, possibly leading to complaints of binocular visual functioning. The hypothesis is to use a grey filter contact lens on the affected eye to obtain more binocular visual comfort. The grey filter changes the binocular central visual image in the brain through delaying the image of the affected eye and has minimal effect on the peripheral vision. The purpose of this study was to evaluate the effect of the grey filter contact lens on the reduction of patients' binocular complaints in daily life. METHODS: In 19 consecutive patients with unilateral acquired reduced visual performance or intractable diplopia a grey filter contact lens was fitted. The contact lens was chosen from six available filters with different transmissions, based on patient preference. The chosen filter contact lens was fitted according to the normal practice of contact lens fitting. RESULTS: The results of 18 patients are reported, one patient was lost to follow-up. Twelve patients (67%) reported good results when wearing the grey filter contact lens. Five patients (28%) discontinued wear of the grey filter contact lens because their binocular visual complaints disappeared during filter contact lens wear and remained absent after contact lens wear was terminated. CONCLUSION: The grey filter contact lens is a clinically useful, safe, and easily reversible treatment option for patients with binocular visual complaints due to an acquired monocular reduction in visual quality.

Advanced personalized nomogram for myopic laser surgery: first 100 eyes.

PURPOSE: To report the results in the first 100 eyes treated for myopia using a new advanced nomogram. SETTING: Private refractive surgery clinic. METHODS: This prospective interventional case series comprised 58 patients (100 eyes) consecutively treated for myopia with laser in situ keratomileusis (LASIK) or laser-assisted subepithelial keratectomy (LASEK) performed by the same surgeon. All treatments used a new nomogram for the Zyoptix 217 Z100 excimer laser. Postoperative mean sphere, cylinder, and spherical equivalent (SE) refraction were evaluated 3 months postoperatively. Safety, efficacy, and predictability were also evaluated. RESULTS: In the LASIK group (34 eyes), the mean postoperative sphere was +0.18 diopters (D) +/- 0.47 (SD), the mean postoperative cylinder was -0.10 +/- 0.23 D, and the mean postoperative SE was 0.04 +/- 0.36 D. In the LASEK group (64 eyes), the respective means were 0.10 +/- 0.22 D, -0.05 +/- 0.13 D, and +0.03 +/- 0.16 D. Hyperopic overcorrection (> or = +1.00 D) occurred in 4.1% of patients. Ninety-five percent of eyes in the LASIK group and 97% of eyes in the LASIK group had an uncorrected visual acuity of 1.0 (20/20) or better. Patient satisfaction was slightly higher than that of other laser refractive surgery patients at the clinic. CONCLUSIONS: The use of the advanced nomogram increased treatment accuracy in terms of UCVA and postoperative mean refraction and reduced the rate of hyperopic overcorrection over that in earlier studies. The need for enhancement procedures was reduced, and patient satisfaction was high.

Endothelial cell density after posterior lamellar keratoplasty: five- to seven-year follow-up.

PURPOSE: To report endothelial cell density (ECD) after posterior lamellar keratoplasty (PLK). DESIGN: Prospective, interventional case series. METHODS: In a single institution, PLK was performed in 15 eyes of 15 patients with pseudophakic bullous keratopathy (PPBK), Fuchs endothelial dystrophy (FED), or both. In 11 eyes, the donor tissue was inserted unfolded through a 9.0-mm sclerocorneal incision. In four eyes, the donor was folded and inserted through a 5.0-mm incision. The ECD measurements were performed in each patient at regular intervals until three years after surgery, and then in all patients simultaneously at 54 to 84 months after surgery. RESULTS: Three patients were not available for follow-up. One graft had decompensated. In the remaining 11 eyes, ECDs ranged from 368 to 1576 cells/mm(2). Monophasic and biphasic regression models of ECD against time were fitted for each technique separately. CONCLUSIONS: After PLK, ECD declined at a high rate. Both early- and longer-term loss rates may be related to surgical technique.

Corneal staining after treatment with topical tetracycline.

PURPOSE: The purpose of this paper is to report a case of corneal staining after treatment with topical tetracycline. METHODS: A patient with crystalline keratopathy caused by Streptococcus viridans after corneal transplantation was treated topically with tetracycline eye drops, based on results of bacterial sensitivity testing. After 3 weeks of intensive treatment, the donor cornea was stained with a brownish hue, which was ascribed to the tetracycline drops. RESULTS: One patient with crystalline keratopathy developed corneal staining after intensive treatment with topical tetracycline eye drops. After a year of follow-up, the staining of the cornea had not changed significantly. CONCLUSION: Hourly topical tetracycline eye drops may induce corneal pigmentation. To our knowledge, this is the first published case report of corneal staining caused by tetracycline eye drops.

Posterior lamellar keratoplasty using descemetorhexis and organ-cultured donor corneal tissue (Melles technique).

PURPOSE: To report the clinical results of posterior lamellar keratoplasty (PLK) using predissected organ-cultured donor corneal tissue implanted after stripping of the Descemet membrane. METHODS: Twenty-two eyes of 22 patients in whom a PLK procedure was performed for pseudophakic bullous keratopathy and/or Fuchs endothelial dystrophy were evaluated. In all eyes, the recipient Descemet membrane was excised by performing a descemetorhexis. Just after harvesting the donor tissue, each cornea had a posterior lamellar dissection made at approximately 80% stromal depth, and each cornea was preserved in an organ culture system for 10 to 21 days. During surgery, a posterior lamellar disk was trephinated from the predissected donor cornea and inserted through a 5.0-mm scleral incision into the anterior chamber of the recipient by folding the donor. Specular microscopy was performed at 6, 12, and 18 months to measure the endothelial cell density. RESULTS: In 3 eyes (14%), the posterior donor disk did not attach to the recipient posterior stroma, so a penetrating keratoplasty was performed in a secondary procedure. The transplants in the remaining 19 eyes cleared and maintained clarity throughout the follow-up period. In these eyes, best corrected visual acuity (BCVA) ranged from 0.25 to 1.0 up to 27 months of follow-up. Postoperative astigmatism averaged 1.7 +/- 1.0 D. Endothelial cell density averaged 1650 +/- 390 cells/mm at 6 months, 1560 +/- 350 cells/mm at 12 months, and 1500 +/- 430 cells/mm at 24 months. Two eyes developed mild interface haze. CONCLUSION: PLK can be performed using an organ-cultured donor posterior disk. Visual rehabilitation may be slower than in PLK with fresh donor tissue.

Increased Straylight in Patients With Keratoconjunctivitis Sicca.

PURPOSE: (1) To qualify complaints of quality of vision in patients with (severe) keratoconjunctivitis sicca by examining straylight values and (2) to check for an effect of scleral lens wear on straylight. METHODS: Straylight was measured in 16 patients with severe keratoconjunctivitis sicca using the Oculus C-Quant. In 9 of these patients, scleral lenses were used, and straylight was measured with and without scleral lenses. Other tests included the Schirmer test, visual acuity, the van Bijsterveld score, and a straylight questionnaire. RESULTS: Patients with keratoconjunctivitis sicca had a mean straylight OD of log(s) = 1.36 ± 0.19 SD and OS of log(s) = 1.45 ± 0.17 SD. Mean age was 56 ± 9.3 SD. This was significantly higher than the mean age-matched normal value of log(s) = 1.10 (P < 0.001). Such a straylight increase is functionally significant. The difference in straylight with and without scleral lenses was 0.06 log units ± 0.02 SD, but this was not statistically significant for OD (P = 0.134) and OS (P = 0.293). No correlation was found between straylight and the van Bijsterveld score on the corneal section for OD (P = 0.326) and OS (P = 0.433). CONCLUSIONS: Keratoconjunctivitis sicca leads to increased straylight. However, this increase was not correlated to the amount of surface damage graded with the van Bijsterveld score. Further study on the cornea is necessary to determine the source of the increased straylight. Scleral lenses do not have a noteworthy influence on straylight in these patients.

Localized opacification of hydrophilic acrylic intraocular lenses after procedures using intracameral injection of air or gas.

PURPOSE: To describe clinical and laboratory findings in a series of cases of intraocular lens (IOL) opacification after procedures involving intracameral injections of air or gas. SETTING: John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, USA. DESIGN: Experimental study. METHODS: Seven hydrophilic acrylic IOLs explanted after Descemet-stripping endothelial keratoplasty (DSEK) or Descemet-stripping automated endothelial keratoplasty (DSAEK) because of a localized central optic opacification associated with decrease in visual acuity and complaints of foggy vision were analyzed. The explanted IOLs were sent to our laboratory in the dry state or in fixative by the explanting surgeons. They underwent pathological and histochemical evaluation (alizarin red and von Kossa method). Light scattering measurements were also performed on the surface of 1 explant using Scheimpflug photography. A questionnaire was sent to the surgeons to obtain information pertinent to each case. RESULTS: The 7 explanted IOLs were represented by 6 hydrophilic acrylic designs from 5 manufacturers. Gross and light microscopy showed that granular deposits were densely distributed in an overall round pattern within the margins of the capsulorhexis or the pupil on the anterior surface/subsurface of the IOLs. The granules stained positive for calcium (alizarin red and von Kossa method). Light scattering on the anterior optic surface was very high (228 versus 13 computer-compatible tapes on a control IOL). CONCLUSIONS: A localized pattern of calcification was seen on the anterior surface/subsurface of various hydrophilic acrylic IOLs. Surgeons should be aware of this phenomenon following DSEK/DSAEK procedures in pseudophakic patients with hydrophilic acrylic IOLs. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Opacification of the Intraocular Lens After Descemet Stripping Endothelial Keratoplasty.

PURPOSE: To report the incidence of opacification of the intraocular lens (IOL) after Descemet stripping endothelial keratoplasty (DSEK) in an academic ophthalmology clinic. METHODS: In this retrospective case series, all patients who underwent DSEK between 2003 and 2013 were included. In 2008, the first patient presented with reduced vision as a result of opacification of the IOL in our clinic. The period between DSEK surgery and diagnosis of IOL opacification, Snellen corrected distance visual acuity before and after the appearance of IOL opacification, IOL specifications, and incidence of IOL exchange were assessed. RESULTS: A total of 160 eyes were operated on. Opacification was seen in 8 eyes (5%) and was diagnosed between 4 and 24 months after DSEK (mean, 9.6; SD, 6.3; range, 4-24 months). The mean Snellen corrected distance visual acuity was 0.6 (SD, 0.2; range, 0.2-0.8) before opacification and 0.3 (SD, 0.2; range, 0.02-0.6) after opacification of the IOL occurred. The IOL material was hydrophilic acrylic in all patients. In 4 eyes, IOL exchange was performed. CONCLUSIONS: Opacification of the IOL can be a vision-threatening late complication after DSEK and was seen in 8 of 160 eyes.

Endothelial cell density after posterior lamellar keratoplasty (Melles techniques): 3 years follow-up.

PURPOSE: To report the midterm endothelial cell density measurements after posterior lamellar keratoplasty (Melles techniques). DESIGN: Cohort study. METHODS: Fifteen consecutive eyes of 15 patients in whom a posterior lamellar keratoplasty procedure was performed for pseudophakic bullous keratopathy or Fuchs' endothelial dystrophy were evaluated. In 11 corneas the donor tissue was inserted through a 9.0-mm sclerocorneal pocket incision (technique A); in four cases the donor was folded and inserted through a 5.0-mm incision (technique B). Specular microscopy was performed at 6, 12, 24, and 36 months after surgery, to measure the endothelial cell density. RESULTS: Mean postoperative endothelial cell density averaged 2,126 cells/mm(2) (+/-548) at 6 months, 1,859 cells/mm(2) (+/-477) at 12 months, 1,385 cells/mm(2) (+/-451) at 24 months, and 1,047 cells/mm(2) (+/-425) at 36 months. CONCLUSION: In posterior lamellar keratoplasty, the donor corneal endothelium showed a decrease in cell density similar to that after conventional full-thickness penetrating keratoplasty.

Endothelial cell density after deep anterior lamellar keratoplasty (Melles technique).

PURPOSE: To measure the recipient endothelial cell loss after the Melles technique for deep anterior lamellar keratoplasty. METHODS: In 21 eyes of 21 patients, a deep anterior lamellar keratoplasty procedure was performed. Before surgery and at 6, 12, and 24 months after surgery, specular microscopy was performed to evaluate the endothelial cell density. For each postoperative time interval, the mean endothelial cell loss relative to the preoperative value was calculated. RESULTS: Mean postoperative endothelial cell loss averaged 283 cells/mm(2) (+/- 293) at 6 months, 335 cells/mm(2) (+/- 309) at 12 months, and 421 cells/mm(2) (+/- 316) at 24 months. Estimate relative endothelial cell density losses obtained by mixed model analysis of variance were 11.1%, 2.0%, and 1.2%, respectively, each time compared with its previous measurement point. Second order comparisons showed that the loss within the first 6 months was significantly higher than after 6 months. CONCLUSION: In deep anterior lamellar keratoplasty, the recipient corneal endothelium showed a small initial drop in endothelial cell density followed by a physiologic rate of cell loss. Cell survival after lamellar keratoplasty may be expected to be better when compared with that following penetrating keratoplasty.