Use of true net power in intraocular lens power calculations in eyes with prior myopic laser refractive surgery.

Intraocular lens (IOL) power calculation following laser refractive surgery is still one of the most challenging aspects in cataract surgery. This study was initiated to investigate the application of true net power (TNP; Pentacam, software version 6.02r10, Oculus, Germany) in IOL power calculations in eyes with prior laser refractive surgery. Our data contribute to the notion that the TNP of the Pentacam is a reliable alternative to determine the IOL power in cases where the historical data are missing. Based on our data, we recommend implementing the TNP to obtain the true corneal power and thus, reliable IOL power calculations.

Use of In Vivo Corneal Confocal Microscopy to Guide Excimer Laser With Adjunctive Mitomycin C for Treatment of Recalcitrant Acanthamoeba Keratitis.

PURPOSE: The aim of this study was to describe 3 cases of recalcitrant Acanthamoeba keratitis (AK) that were successfully treated using in vivo corneal confocal microscopy (IVCM) to guide excimer laser ablation depth with adjunctive mitomycin C 0.02%. METHODS: Three patients diagnosed with AK did not respond to several weeks of intensive topical therapy with antiamoebic agents. The patient underwent phototherapeutic keratectomy with topical mitomycin C 0.02% application. The maximum stromal depth of cysts measured by IVCM was 80 µm, 100 µm, and 240 µm, and the stromal ablation depths were 80 µm, 100 µm, and 100 µm, respectively. RESULTS: In all 3 eyes, AK resolved after a single excimer laser application, and topical treatment was gradually discontinued within 6 weeks afterward. In 1 eye, penetrating corneal transplantation was performed 6 weeks after phototherapeutic keratectomy because of ongoing severe corneal pain. IVCM and histology of the corneal transplant did not reveal any Acanthamoeba cysts within the excised corneal button. No recurrence was observed during the follow-up period of 19 to 34 months. CONCLUSIONS: IVCM-guided phototherapeutic keratectomy with mitomycin C 0.02% seems to be a safe and successful approach for the treatment of AK, especially in cases of resistance to topical treatment. Corneal IVCM should be performed before laser application to measure cyst depth, determine ablation depth, and assess postoperative treatment success.

[Combined transepithelial PTK and topography-guided PRK for treatment of trauma-related corneal scarring]. / Kombinierte transepitheliale PTK und topografiegesteuerte PRK zur Behandlung von traumatisch bedingten Hornhautnarben.

BACKGROUND: Corneal scars can severely impair visual performance and treatment can be challenging. The study aimed to evaluate a promising minimally invasive option in the treatment of corneal scars using transepithelial topography-guided ablation. METHODS: This retrospective interventional study involved four eyes of four patients who developed corneal scarring and irregular surfaces due to trauma and were treated with topography-guided photorefractive keratectomy (TG-PRK) between 2017 and 2020. The ablation profile was calculated in all four cases using CRS-Master (Zeiss, Jena, Germany). The main outcome measures were uncorrected and best-corrected distance visual acuity, manifest refraction and corneal regularity by topographic images. The mean age was 34.75 ± 15.39 years and the follow-up time was 6 months for all patients. RESULTS: In three cases full subjective refraction was corrected in one session and one patient had a refractive error of +0.5 D. Only corneal surface smoothing without additional refractive correction was performed in this case. All four patients showed improvement in uncorrected (2-3 Snellen lines) and corrected (3 Snellen lines) distance visual acuity. No complications occurred during or after the treatment and there was no reduction of visual acuity in any case. CONCLUSION: The use of TG-PRK in patients with corneal scarring improves visual acuity in selected cases. In myopic patients most of the refractive error can also be corrected in a single session.

Altered Regulation of mRNA and miRNA Expression in Epithelial and Stromal Tissue of Keratoconus Corneas.

Purpose: Evaluation of mRNA and microRNA (miRNA) expression in epithelium and stroma of patients with keratoconus. Methods: The epithelium and stroma of eight corneas of eight patients with keratoconus and eight corneas of eight non-keratoconus healthy controls were studied separately. RNA was extracted, and mRNA and miRNA analyses were performed using microarrays. Differentially expressed mRNAs and miRNAs in epithelial and stromal keratoconus samples compared to healthy controls were identified. Selected genes and miRNAs were further validated using RT-qPCR. Results: We discovered 170 epithelial and 1498 stromal deregulated protein-coding mRNAs in KC samples. In addition, in epithelial samples 180 miRNAs and in stromal samples 379 miRNAs were significantly deregulated more than twofold compared to controls. Pathway analysis revealed enrichment of metabolic and axon guidance pathways for epithelial cells and enrichment of metabolic, mitogen-activated protein kinase (MAPK), and focal adhesion pathways for stromal cells. Conclusions: This study demonstrates significant differences in the expression and regulation of mRNAs and miRNAs in the epithelium and stroma of Patients with KC. Also, in addition to the well-known target candidates, we were able to identify further genes and miRNAs that may be associated with keratoconus. Signaling pathways influencing metabolic changes and cell contacts are affected in epithelial and stromal cells of patients with keratoconus.

[Excimer laser-assisted DALK: a case report from the Homburg Keratoconus Center (HKC)]. / Excimerlaser-gestützte DALK: Ein Fallbericht aus dem Homburger Keratokonus Center (HKC).

INDICATIONS: The aim of excimer laser-assisted deep anterior lamellar keratoplasty (excimer-DALK) is, as in mechanical DALK, the treatment of keratectasia (keratoconus and pellucid marginal degeneration), stromal scars or stromal corneal dystrophy. A prerequisite for surgery is the absence of (pre­) Descemet's scars and an intact endothelium. SURGICAL TECHNIQUE: After excimer laser-assisted trephination to 80% of the corneal thickness at the trephination site, intrastromal air injection (so-called big bubble) and lamellar corneal preparation, a lamellar anterior transplantation of the endothelium-free donor tissue is performed. The technique combines the advantages of DALK and excimer laser trephination. We describe the steps of an excimer-DALK from the Homburg Keratoconus Center (HKC). CONCLUSION: Excimer-DALK is a viable treatment option for patients with intact endothelium. In cases of intraoperative perforation, conversion to excimer-perforating keratoplasty (PKP) with all the advantages of excimer laser trephination remains feasible.

Efficacy, safety, and predictability of transepithelial photorefractive keratectomy: meta-analysis.

PURPOSE: To evaluate the efficacy, safety, and predictability of transepithelial photorefractive keratectomy (TransPRK) for correcting myopia, astigmatism, and hyperopia. SETTING: Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar, Germany. DESIGN: Meta-analysis of retrospective or prospective studies. METHODS: Relevant studies were collected from Medline and included when meeting the following predefined criteria: randomized controlled trials, at least 1 of the main outcome measures as efficacy, safety, or predictability, and 1 common TransPRK laser (Schwind Amaris). The parameters estimates and 95% CI were derived from random-effects meta-analysis to account for possible heterogeneity. RESULTS: Because hyperopia studies did not meet the inclusion criteria, the results are centered on myopia and astigmatism. Sixteen studies with a total of 1924 treated eyes were included in the meta-analysis. The mean efficacy, safety, and predictability had a probability of 94% (CI, 0.86-0.97), 0% (CI, 0.00-0.03), and 89% (CI, 0.82-0.93), respectively. The mean correction index, difference vector, and index of success had a value of 1.01 (CI, 1.01-1.02), 0.20 (CI, 0.06-0.34), and 0.12 (CI, 0.07-0.18), respectively. CONCLUSIONS: This summary estimate showed that TransPRK was highly effective, safe, and predictable in correcting myopia and/or astigmatism.

Impact of a Displaced Corneal Apex in Small Incision Lenticule Extraction.

PURPOSE: To evaluate the possible impact of a displaced corneal apex (point of maximum curvature) on visual results and tomographic parameters after small incision lenticule extraction (SMILE). METHODS: In this retrospective evaluation, eyes with uncomplicated SMILE for myopia correction were classified in two groups based on their preoperative distance between the corneal apex and corneal vertex (corneal intercept with the patient's line of sight) of 1 mm or greater (large A-V distance) or less than 1 mm (small A-V distance). All surgeries were performed during the early learning curve of two surgeons. Visual outcome parameters included uncorrected (UDVA) and corrected (CDVA) distance visual acuity, manifest refractive spherical equivalent (MRSE), and refractive astigmatism 3 months postoperatively. Scheimpflug-derived tomographic outcome parameters included mean keratometry value, root mean square higher order aberrations (RMS HOAs), and optical zone decentration. RESULTS: The study comprised 94 eyes of 48 patients: 44 eyes in the large A-V distance group and 50 eyes in the small A-V distance group. Preoperative and postoperative RMS HOAs were significantly higher in the large A-V distance group than in the small A-V distance group (P = .002 and .008, respectively). Postoperative CDVA was significantly better in the small A-V distance group (P = .014). There were no statistically significant differences in postoperative UDVA, MRSE, refractive astigmatism, mean keratometry value, and optical zone decentration. CONCLUSIONS: After SMILE, CDVA was significantly worse in eyes with a preoperatively displaced corneal apex compared to eyes with a more central corneal apex. However, good visual results were achieved in both groups. [J Refract Surg. 2018;34(7):460-465.].

Quality of vision and graft thickness in deep anterior lamellar and penetrating corneal allografts.

PURPOSE: To compare visual function after deep anterior lamellar keratoplasty (DALK) with visual function after penetrating keratoplasty (PK) for keratoconus and correlate this with corneal thickness. DESIGN: Retrospective case series. METHODS: Twenty-three patients (32 eyes) with unilateral or bilateral DALK or PK for keratoconus were analyzed for visual quality after suture removal. Evaluation included measurement of visual acuity, contrast sensitivity, and higher order aberrations (HOAs) (WaveScan; Visx, Santa Clara, California, USA). Readings were performed with both spectacle and rigid contact lens correction of refractive error. Total and residual stromal thickness after DALK was measured using optical coherence tomography (OCT) and correlated to visual quality. RESULTS: Eyes after PK had better visual acuity than eyes after DALK (P = .018). Subgroup analysis of DALK eyes revealed that the level of visual acuity was related to the thickness of residual recipient corneal stroma. Eyes with a recipient corneal bed thickness of <20 microm had visual acuities similar to eyes with a PK, whereas those with a recipient thickness of >80 microm had a significantly reduced visual acuity (P = .0009). Contrast sensitivity was similar in DALK and PK eyes. There was no significant difference in HOAs between eyes with DALK or PK. CONCLUSIONS: These data suggest that the main parameter for good visual function after DALK for keratoconus is the thickness of residual recipient stromal bed. An eye with a DALK with a residual bed of <20 microm can achieve a similar visual result as a PK.

Depth of focus after implantation of spherical or aspheric intraocular lenses in hyperopic and emmetropic patients.

PURPOSE: To evaluate whether hyperopic patients with short axial length and high dioptric intraocular lens (IOL) power can achieve a higher depth of focus after implantation of a monofocal spherical or aspheric IOL than emmetropic patients. SETTING: Department of Ophthalmology, Medical University Graz, Graz, Austria. DESIGN: Prospective case series. METHODS: Patients presenting for cataract surgery were divided by calculated IOL power into a hyperopic (≥22.0 diopters [D]) or emmetropic (18.0 to 21.5 D) groups and received an aspheric (Tecnis ZA9003) or a spherical IOL (Sensar AR40e). Postoperative measurements included corrected (CDVA) and uncorrected (UDVA) distance visual acuities, distance-corrected intermediate (DCIVA) and near (DCNVA) visual acuities, root-mean-square values of corneal and total eye higher-order aberrations and spherical aberrations, and photopic and mesopic contrast sensitivity. RESULTS: Sixty-two eyes of 62 patients were enrolled in this study, 34 eyes (15 hyperopic, 19 emmetropic) in the aspheric IOL group and 28 eyes (14 hyperopic, 14 emmetropic) in the spherical IOL group. The UDVA, CDVA, and contrast sensitivity did not differ significantly between the 2 IOL groups, whereas the DCIVA and DCNVA were significantly better in the spherical IOL group (P = .004 and P = .001, respectively). No significant differences were found in DCIVA and DCNVA between hyperopic patients and emmetropic patients with aspheric or spherical IOLs. CONCLUSIONS: Implantation of a monofocal spherical IOL resulted in an increased depth of focus without significant degradation of distance visual acuity or contrast sensitivity. There were no differences in the depth of focus between hyperopic eyes and emmetropic eyes.

Polymorphisms within the tumor necrosis factor-alpha promoter region in patients with HLA-B27-associated uveitis: association with susceptibility and clinical manifestations.

PURPOSE: The existence of genetic variations in a number of cytokines has been considered to influence susceptibility or relate to disease severity in various autoimmune diseases. Among these, single-nucleotide polymorphisms (SNPs) of the tumor necrosis factor alpha (TNF-alpha) promoter at nucleotides -308 and -238 are considered to be protective against inflammation in HLA-B27-positive individuals, whereas the SNP at position -857 has been associated with disease development in anterior uveitis. We investigate a hypothesized association between the TNF-alpha -857 C-to-T, -308 G-to-A, and the TNF-alpha -238 G-to-A SNPs and the presence of HLA-B27-associated uveitis. DESIGN: Retrospective case-control study. PARTICIPANTS: One hundred fourteen Caucasian patients with HLA-B27-associated uveitis were studied. Mean age of patients was 44.9+/-14 years (range, 16-81), and mean duration of HLA-B27-associated uveitis was 115.6+/-104 months (range, 6 months-51 years). Eighty-six patients (75.4%) suffered from an additional systemic manifestation of the disease. Sixty-three unrelated healthy HLA-B27-positive blood donors and 88 unrelated healthy HLA-B27-negative individuals served as controls. METHODS: Genotypes were determined by polymerase chain reaction. MAIN OUTCOME PARAMETERS: Association of genotypes at positions -857, -308, and -238 of the TNF-alpha gene with disease development. RESULTS: Frequencies of the TNF-alpha -308GA and TNF-alpha -238GA genotypes were significantly lower in patients with HLA-B27-associated uveitis (6.1% and 0%, respectively) when compared with the HLA-B27-negative control group, 23% at -308 (P = 0.003), and 7.9% at -238 (P = 0.0003). When compared with healthy HLA-B27-positive controls, a significantly lower frequency of the TNF-alpha -238GA genotype was found among patients (6.3%, P = 0.015). The frequency of the TNF-alpha -308GA genotype was also found to be lower in patients than among HLA-B27-positive control subjects, without, however, reaching statistical significance (6.1%, P = 0.07). No difference in frequencies was seen among the different groups for the SNPs at position -857. CONCLUSION: Our data suggest that HLA-B27-positive individuals show a higher susceptibility towards development of an intraocular inflammation in the presence of an A allele at nucleotide -238 and, to a lesser degree, at nucleotide -308 of the TNF-alpha gene promoter.

Keratitis after intracorneal ring segment insertion for keratoconus.

We report a case of sterile keratitis after Ferrara intracorneal ring (Ferrara Ophthalmics) implantation into the right cornea of a keratoconus patient who also suffered from atopic blepharoconjunctivitis. The keratitis resolved within a few days after removal of the Ferrara rings. Ocular atopy with sterile keratitis should be considered in the differential diagnosis of keratitis after the insertion of intracorneal ring segments, which can be easily treated by ring removal.

Role of the CCL2/MCP-1 -2518A>G gene polymorphism in HLA-B27 associated uveitis.

PURPOSE: Acute anterior uveitis (AAU) is the most common form of uveitis. Up to 50% of patients with AAU are HLA-B27 positive. Since HLA B27 itself plays only a minor role in the overall genetic background, other genetic variants are likely to contribute to the susceptibility to AAU. The chemokine (C-C motif) ligand 2 (CCL2) gene, coding for monocyte chemoattractant protein-1 (MCP-1), a chemotactic cytokine, is involved in the induction of uveitis. A CCL2 gene polymorphism, which is characterized by an A>G substitution at nucleotide -2518 in the promoter region of CCL2 has been previously shown to affect MCP-1 synthesis. The purpose of the present study was to investigate a hypothesized association between this genetic variant and the presence of HLA-B27 associated AAU. METHODS: The study group comprised 114 patients with HLA-B27 associated AAU. One hundred and eleven healthy HLA-B27 positive individuals served as the HLA-B27 positive control group, whereas 81 healthy HLA-B27 negative individuals served as a HLA-B27 negative control group. Genotyping for the CCL2 -2518A>G polymorphism was performed by polymerase chain reaction. RESULTS: Carriers of a CCL2 -2518G allele were found significantly more often in patients with HLA-B27 associated AAU than among HLA-B27 positive controls (49.2% and 31.5%, respectively; odds ratio 2.1; 95% confidence interval 1.2-3.6; p=0.007). CONCLUSIONS: Our data suggest that the CCL2 -2518A>G polymorphism may play a role in HLA-B27 associated acute anterior uveitis.

Pupil ovalization after phakic intraocular lens implantation is associated with sectorial iris hypoperfusion.

OBJECTIVE: To investigate iris perfusion in patients with and without pupil ovalization after phakic intraocular lens implantation. METHODS: Comparative retrospective randomized case series of 6 participants, each with a regular pupil, and 6 participants with pupil ovalization after phakic intraocular lens implantation for high myopia were included in the study. Indocyanine green angiography was performed between 20 and 40 months (mean +/- SD, 26 +/- 6.1 months) after lens implantation. RESULTS: Iris perfusion defects were found in 5 of 6 patients with pupil ovalization. No perfusion deficits were noted in patients with round pupils. CONCLUSION: Iris ovalization after phakic intraocular lens implantation may be associated with a lack of iris perfusion and with secondary ischemia. Patients with these lenses and pupil ovalization should be followed regularly.

Five-year results of prognostic value of tyrosinase in peripheral blood of uveal melanoma patients.

Tyrosinase-based reverse transcriptase-polymerase chain reaction (RT-PCR) is a method for the detection of circulating melanoma cells in peripheral blood. To our knowledge, no long-term studies on the prognostic impact of tyrosinase PCR in uveal melanoma have yet been reported. In this prospective, non-randomized, observational cohort study, we included 41 patients with uveal malignant melanoma. RT-PCR for tyrosinase was performed in each patient before and after treatment. A clinical follow-up was performed for each patient for at least 5 years, including chest X-ray, serum liver enzyme determination, ultrasound of the liver and bone scintigraphy. The PCR results, age of the patients, tumour size, tumour location, tumour therapy, internal reflectivity, histology, development of distant metastasis and survival rate during follow-up were analysed. At the time of diagnosis, tyrosinase messenger RNA (mRNA) in peripheral blood, suggesting the presence of circulating melanoma cells, was detected in 16 of the 41 patients. Sixty-nine percent of the PCR samples with a positive result prior to therapy revealed a negative result after therapy. The internal reflectivity of the tumour (P=0.021) and the 5-year survival (P=0.023) showed a statistically significant association with positive PCR. It can be concluded that tyrosinase RT-PCR is a sensitive method for the detection of melanoma cells in peripheral blood. This study indicates that the presence of tumour cells in peripheral blood correlates with 5-year survival. Our results suggest a prognostic value of this method. Nevertheless, prospective analysis of a larger cohort is needed to determine the ultimate value of RT-PCR for tyrosinase in blood testing.

Keratopathy after ultraviolet B phototherapy.

Atopic dermatitis is the most common chronic inflammatory skin disease among children in industrialized countries. The prevalence is recorded to be up to 20% in children. Phototherapy with ultraviolet B (UVB) is an effective form of treatment with a low complication rate. Here we report on a patient with atopic dermatitis who underwent UVB treatment to the facial area including the eyelids and who developed severe keratitis with facial erythema. The symptoms diminished within a few days under topical steroid treatment. Although phototherapy seems to be a safe treatment procedure for atopic dermatitis, patients undergoing UVB treatment should be informed about possible side effects if the eyes are not fully closed during treatment. The use of protective eye shields should be considered, since UVB might induce long-term corneal damage and early onset of cataract.

Lymph node metastases arising from uveal melanoma.

Since the eye lacks lymphatic vessels, uveal melanomas primarily metastasize hematogenously. Here we report the case of a patient with ciliary body ring melanoma who developed lymph node metastases after a fistulating glaucoma operation. A 40-year-old female Caucasian patient presented with unilateral pigment dispersion. Pigment dispersion glaucoma was diagnosed and since the intraocular pressure could not be managed with topical medication, transscleral cyclophotocoagulation and two trabeculectomies had to be performed. Due to enlargement of the pigmented iris mass and cell deposits in the chamber angle, a ciliary body ring melanoma was presumed and the eye enucleated. Histology confirmed the diagnosis of "ciliary body ring melanoma". Six months after enucleation the patient presented multiple metastases including ipsilateral preauricular and submandibular lymph node metastases. The patient died two months later. Lymph node metastases arising from ciliary body melanomas are very rare. Tumor seeding through the trabeculectomy site into the bleb and then via conjunctival lymphatic vessels might be the crucial factor for this pathway of metastases. Therefore, in cases of unilateral pigment dispersion, malignancy should be excluded before fistulating operations are performed.

Endogenous endophthalmitis after carotid endarterectomy due to exudative macular degeneration.

A 78-year-old male patient with unilateral exudative macular degeneration developed endogenous endophthalmitis 11 days after carotid endarterectomy. The endophthalmitis could not be treated by intravitreal application of antibiotics. The patient underwent vitrectomy and systemic application of vancomycin. Six days later, the eye was quiet and the patient was discharged with a visual acuity of 0.9 logMAR.Patients with exudative macular degeneration have a higher risk for developing endogenous endophthalmitis after vascular surgery of the carotid arteries and prolonged postoperative application of systemic antibiotics might be considered in these patients.

Associations of Independent IL2RA Gene Variants with Intermediate Uveitis.

PURPOSE: The genetic background for the concomitance of uveitis and other autoimmune diseases remains elusive. Here the role of two IL2RA gene variants (rs11594656 and rs12722495) was investigated in intermediate uveitis and HLAB27 acute anterior uveitis. MATERIALS AND METHODS: One hundred fifty-nine patients with HLAB27 acute anterior uveitis, 85 patients with intermediate uveitis, 138 HLAB27 negative controls and 100 HLAB27 positive controls were recruited for this case-control study. Main outcome measures were genotype distribution and allelic frequencies determined by polymerase chain reaction. RESULTS: The frequencies of carriers of the minor allele at rs11594656 and rs12722495 were significantly different in patients with intermediate uveitis compared to HLAB27 positive and negative controls combined (p<0.05). For rs12722495 the minor G allele was protective (genotypic OR: 0.29 [0.12-0.69]), and for rs11594656 the minor A allele conferred risk (genotypic OR: 1.59 [1.09-2.32]). No significant differences in genotype distribution were found between patients with HLAB27 acute anterior uveitis and HLAB27 positive or negative control subjects. CONCLUSIONS: We found rs11594656 and rs12722495 to be associated with intermediate uveitis but not with HLAB27 acute anterior uveitis. The genetic heterogeneity found at the IL2RA locus could help explain patterns of concomitance with other autoimmune diseases.