Multi-component adjustable intraocular lenses: a new concept in pediatric cataract surgery.

PURPOSE: The multi-component intraocular lens (IOL) (IVO; SAS, Strasbourg, France) is a novel approach to the treatment of pediatric cataract. Because the refractive requirements for pediatric eyes often change over time, current IOL technology does not easily allow refractive adjustments after the primary surgical intervention. The multi-component IOL concept allows easy, surgical refractive adjustments to the initial surgical implantation at any postoperative time period. Thus, both surgical implantation and enhancement surgery have been successfully accomplished in adult patients. METHODS: A novel surgical approach to pediatric cataract surgery is described. At the time of the primary surgery, a two component IOL was implanted. At any postoperative time period, the front lens component, located in front of the capsular bag, could be easily surgically exchanged because the dioptric power requirements of the pediatric eye changed over time. RESULTS: Both primary and enhancement surgeries have been done in adult patients with good results. Implantations have occurred uneventfully in all cases with no intraoperative or postoperative complications. There was no statistically significant difference in the endothelial cell density, anterior chamber depth, and pachymetry readings preoperatively and 2 years postoperatively. There was no interlenticular fibrosis present. CONCLUSION: The multi-component IOL should provide a unique and greatly needed surgically adjustable approach to the treatment of pediatric cataract.

Corneal collagen cross-linking (CXL) combined with refractive procedures for the treatment of corneal ectatic disorders: CXL plus.

PURPOSE: To discuss current combined corneal collagen cross-linking (CXL) and refractive surgical techniques (herein termed "CXL plus") for the treatment of corneal ectatic disorders to improve functional visual acuity in addition to corneal stability from CXL alone. METHODS: Literature review. RESULTS: Efficacious combined treatments with CXL include: photorefractive keratectomy, transepithelial phototherapeutic keratectomy, intrastromal corneal ring segments implantation, phakic intraocular lens implantation, and multiple combined procedures. Some uncertainty remains as to the optimal strategies for each patient. A decision tree is proposed to facilitate optimal patient management. CONCLUSIONS: With multiple adjuvant techniques, CXL plus is likely to benefit many patients with corneal ectatic disorders. The appropriate combined procedure will depend on multiple factors, such as refraction, corneal thickness, and degree of irregular astigmatism.

Outcomes after accommodative bioanalogic intraocular lens implantation.

PURPOSE: To evaluate the outcomes after Wichterle Intraocular Lens-Continuous Focus (Medicem, Kamenné Zehrovice, Czech Republic) accommodative bioanalogic intraocular lens implantation. METHODS: In this prospective case series, 50 eyes of 25 patients (mean age: 65.3 ± 8.4 years; range: 53 to 83 years) were included. All patients underwent routine cataract surgery and Wichterle Intraocular Lens-Continuous Focus implantation. RESULTS: Mean follow-up was 11.44 ± 2.46 months (range: 9 to 17 months). Both monocular uncorrected and corrected distance visual acuity statistically and significantly (P < .05) improved from 0.31 ± 0.17 (20/63 Snellen) (range: counting fingers to 0.7) to 0.74 ± 0.19 (20/25 Snellen) (range: 0.2 to 1) and from 0.61 ± 0.19 (20/32 Snellen) (range: 0.2 to 1) to 0.82 ± 0.13 (20/25 Snellen) (range: 0.4 to 1), respectively. Target postoperative refraction was -0.5 diopters (D) and preoperative and 1-year postoperative spherical equivalent refraction were 0.72 ± 2.71 D (range: -7.25 to 2.37 D) and -0.24 ± 0.65 D (range: -1.0 to 1.0 D), respectively. No eyes lost lines of corrected distance visual acuity during the follow-up period, whereas 88% of patients gained one or more lines of corrected distance visual acuity. Uncorrected intermediate and near visual acuity were J2 (Snellen 20/25) or better in 72% of patients. No complications occurred intraoperatively or postoperatively. The evaluation of the mean values of root mean square of third and fourth order higher-order aberrations at 1 year postoperatively revealed a mean negative spherical aberration of -0.18 ± 0.13 µm. CONCLUSIONS: Wichterle Intraocular Lens-Continuous Focus accommodative bioanalogic IOL implantation provides satisfactory visual acuity for far, intermediate, and near distances and the promising results remain stable throughout the follow-up period.

Femtosecond LASIK retreatment using side cutting only.

PURPOSE: To present visual and refractive outcomes in 11 eyes that underwent femtosecond LASIK and subsequent retreatment with flap lifting using only side cutting. METHODS: Seven patients (11 eyes) with a mean age of 30.55±5.42 years (range: 24 to 39 years) underwent retreatment 18.18±5.41 months (range: 12 to 26 months) after primary LASIK treatment with side cutting only using a femtosecond laser for the correction of residual refractive error. RESULTS: Mean follow-up after retreatment was 7.72±1.48 months (range: 6 to 10 months). No intra- or postoperative complications were found after LASIK retreatment. Uncorrected distance visual acuity (UDVA) improved in all patients. Mean UDVA improved from 0.54±0.12 (decimal scale) (range: 0.4 to 0.7) preoperatively to 0.99±0.03 (range: 0.9 to 1.0) after retreatment. No patient lost lines of corrected distance visual acuity. CONCLUSIONS: Retreatment using a femtosecond laser to create only a side cut is an effective modality to treat residual refractive errors in postoperative LASIK patients.

Visual outcomes and safety of a small diameter intrastromal refractive inlay for the corneal compensation of presbyopia.

PURPOSE: To investigate the outcomes and safety of an intrastromal refractive inlay (Invue Lens, Biovision AG) for the corneal compensation of presbyopia. METHODS: This prospective, noncomparative, interventional clinical study comprised 45 emmetropic presbyopes with a mean age of 52.3 ± 3.3 years (range: 47 to 58 years). The refractive inlay was inserted in the non-dominant eye within a corneal pocket that was created using a mechanical microkeratome. Last follow-up was 12 months in all patients and examinations were scheduled at 1 week and 1, 3, 6, and 12 months after surgery. Visual, wavefront, contrast sensitivity, and topographic outcomes as well as structural corneal alteration were evaluated. RESULTS: Twelve months after surgery, uncorrected near visual acuity was 20/32 or better in 98% of operated eyes and binocularly, whereas uncorrected distance visual acuity was 20/40 or better in 93% of operated eyes and 20/25 or better in all patients binocularly. Three patients lost one line of corrected distance visual acuity in the operated eye. Overall, higher order aberrations were increased and contrast sensitivity was decreased in the operated eye. No tissue alterations were found using corneal confocal microscopy. No intra- or postoperative complications occurred. CONCLUSIONS: The intracorneal refractive inlay (Invue Lens) seems to be an effective surgical method for the corneal compensation of presbyopia in emmetropes aged between 45 and 60 years.

Long-term results of phakic refractive lens implantation in eyes with high myopia.

PURPOSE: To evaluate the long-term results of phakic refractive lens (PRL; Carl Zeiss Meditec) implantation in eyes with high myopia. METHODS: In this retrospective, noncomparative, interventional case series, 143 myopic eyes of 82 patients were treated for high myopia with the implantation of the silicone PRL in the posterior chamber. RESULTS: Mean follow-up was 3.8±1.7 years (range: 1 to 6 years). Six years postoperatively (n=34), a statistically significant reduction was noted in the cycloplegic spherical equivalent from -14.08±4.00 diopters (D) (range: -24.88 to -4.75 D) before PRL implantation to -0.45±0.62 D (range: -1.00 to 1.00 D) (P<.001). At 6 years, 67.6% (23 eyes) and 91.2% (31 eyes) were within ±0.50 and ±1.00 D of target refraction, respectively. Mean logMAR uncorrected and corrected distance visual acuity improved significantly (P<.001) (counting fingers preoperatively in all eyes to 0.17±0.15 [range: 0.54 to -0.06] and 0.19±0.19 [1.00 to -0.08] to 0.07±0.10 [range: 0.30 to -0.10], respectively). Complications included anterior capsule damage (3 eyes), temporary intraocular pressure increase (14 eyes), pigment dispersion (1 eye), and PRL decentration (1 eye). No eyes presented any signs of cataract up to 6 years postoperatively. CONCLUSIONS: Long-term results show that PRL implantation is an effective and safe method for treating high myopia.

Unintended epithelium-only flap creation using a femtosecond laser during LASIK.

PURPOSE: to present a patient in whom, during LASIK with the IntraLase femtosecond laser (Abbott Medical Optics), unintended epithelial (instead of anterior stromal) flaps were created in both eyes. METHODS: a 28-year-old man underwent bilateral LASIK using the IntraLase femtosecond laser programmed to create 100-microm flaps. Flap creation was performed uneventfully in both eyes but flap thickness was thinner than attempted. The flaps were easily torn during flap lift because they appeared to consist of epithelium only. Therefore, the procedure was immediately converted to photorefractive keratectomy with the use of mitomycin C. RESULTS: re-epithelialization occurred 3 days after the procedure in both eyes. Three months after treatment, uncorrected distance visual acuity was 20/25 in the right eye and 20/20 in the left eye with no signs of corneal haze on slit-lamp examination. CONCLUSIONS: despite the advantages of the IntraLase femtosecond laser in the creation of a LASIK flap, complications in terms of flap thickness may occur.

Transient peripheral edema following displaced corneal graft after descemet stripping automated endothelial keratoplasty (DSAEK): case presentation.

BACKGROUND: Descemet's Stripping with Automated Endothelial Keratoplasty (DSAEK) is constantly gaining popularity in the management of endothelial dysfunctions such as bullous keratopathy or Fuchs' dystrophy. CASE PRESENTATION: A 36 year-old man with Fuchs' dystrophy underwent combined phacoemulsification and DSAEK of the right eye. Immediately postoperatively, corneal graft displacement and peripheral corneal edema which remained stable during the first postoperative month were evident on slit lamp examination. Three months after the procedure the peripheral edema had completely resolved and the patients' subjective symptoms were improved. CONCLUSIONS: The purpose of this case presentation is to demonstrate that corneal graft displacement after DSAEK can lead to peripheral corneal edema that can resolve without further intervention such as graft repositioning or replacement.

Secondary pseudomyopia induced by amisulpride.

PURPOSE: To report a case of pseudomyopia induced by antipsychotic drug administration. METHODS: A 30-year-old woman was referred to our ophthalmology department complaining of blurred vision, especially at distance, in both eyes. The patient had been prescribed antipsychotic drugs (haloperidol and biperiden) as treatment for her schizophrenic symptoms and had recently undergone a change of treatment to amisulpride. She had a manifest refraction of -4.00/-1.00 × 180 in the OD and -3.75/-1.25 × 175 in the OS whereas her cycloplegic refraction was -1.75/-1.00 × 180 in the OD and -1.00/-1.25 × 175 in the OS, respectively. RESULTS: A diagnosis of likely drug-induced pseudomyopia was made. Therefore, the patient was advised to visit her psychiatrist, who added an extra 2 mg of biperiden, an anticholinergic agent, to the pre-existing amisulpride treatment, achieving a cessation of the visual symptoms a few days later. CONCLUSIONS: Pseudomyopia can be induced by the antipsychotic drug amisulpride. Additional treatment with anticholinergic agents can be used to eliminate this side effect.

INTACS followed by KeraRing intrastromal corneal ring segment implantation for keratoconus.

PURPOSE: To describe the visual and refractive outcomes in three eyes (two keratoconic patients) with previous intrastromal corneal ring segments (INTACS, Addition Technology Inc) that underwent adjuvant single KeraRing (Mediphacos) intrastromal corneal ring segment implantation. METHODS: Two keratoconic patients (three eyes) with implanted INTACS segments underwent an additional (without explanting previous INTACS) single KeraRing segment implantation. RESULTS: No intraoperative complications occurred. Six months postoperatively, uncorrected distance visual acuity improved from 20/100 and 20/200 to 20/32 and 20/40 in the right and left eyes, respectively, of patient 1, and from 20/400 to 20/50 in the treated right eye of patient 2. Corrected distance visual acuity improved from 20/50 and 20/100 to 20/30 and 20/32 in the right and left eyes, respectively, of patient 1 and from 20/200 to 20/40 in patient 2. Keratometric measurements improved from 51.00/45.70 to 47.00/44.60 diopters (D) and from 50.80/48.80 to 42.70/40.30 D in the right and left eyes, respectively, of patient 1, and from 49.30/45.70 to 45.60/44.10 D in patient 2. CONCLUSIONS: In keratoconic patients with INTACS in place, adjuvant single intrastromal corneal ring segment (KeraRing) implantation could improve visual and refractive outcome.

LASIK flap buttonhole treated immediately by PRK with mitomycin C.

PURPOSE: To describe the visual outcomes of three patients who had LASIK flap buttonhole and were treated immediately with photorefractive keratectomy (PRK) and topical mitomycin C (MMC) 0.02%. METHODS: Three patients underwent bilateral LASIK with the SCHWIND Carriazo-Pendula 90 microm head microkeratome. In all three cases, a buttonhole flap occurred in the left eye. The flap was repositioned and phototherapeutic keratectomy for 50 microm was used for epithelial removal while immediate PRK with MMC was performed to treat the buttonhole flap. RESULTS: Three months after the procedure, uncorrected distance visual acuity and corrected distance visual acuity were 20/20 with regular topographic findings. CONCLUSIONS: Using PRK with MCC immediately after the occurrence of the LASIK flap buttonhole may be an effective treatment.

Intraoperative pachymetric measurements during corneal collagen cross-linking with riboflavin and ultraviolet A irradiation.

OBJECTIVE: To study central corneal pachymetric variations during corneal collagen cross-linking (CXL) treatment with the use of riboflavin and ultraviolet A irradiation (UVA). DESIGN: Prospective, noncomparative, interventional clinical study. PARTICIPANTS: Fifteen keratoconic patients (19 eyes) were enrolled. METHODS: All patients underwent riboflavin-UVA-induced corneal CXL. Intraoperative central corneal thickness (CCT) measurements using ultrasound pachymetry were performed during the procedure. Measurements were obtained after epithelial removal, after riboflavin drop instillation, and every 5 minutes (6 interval times) during UVA irradiation (30 minutes). MAIN OUTCOME MEASURES: Central corneal thickness measurements. RESULTS: Mean patient age was 26.9+/-6.5 years (range, 17-40 years). Ten were male and 5 were female. Mean preoperative CCT was 458.5+/-21.5 microm (range, 427-494 microm; 95% confidence interval [CI], 448-467 microm) and 415.7+/-20.6 microm (range, 400-468 microm; 95% CI, 406-426 microm) before and after epithelial removal, respectively. There was a statistically significant decrease (mean, 75 microm) of CCT between the epithelial removal interval (415.7+/-20.6 microm; range, 400-468 microm) and at the end of riboflavin solution instillation (340.7+/-22.9 microm; range, 292-386 microm; P<0.001). There was no statistically significant change in CCT during irradiation (P>0.05). There was no statistically significant difference between preoperative and 1-month postoperative endothelial cell count (preoperative, 2780+/-197 to 1-month postoperative, 2713+/-116; P = 0.14). No intraoperative, early postoperative, or late postoperative complications were observed in this patient series. CONCLUSIONS: During corneal CXL with the use of riboflavin and UVA irradiation, a statistically significant decrease of CCT was demonstrated.

Thin LASIK flap creation using the SCHWIND Carriazo-Pendular microkeratome.

PURPOSE: To study the outcomes of LASIK after intended thin flap creation using the SCHWIND Carriazo-Pendular microkeratome with the 90-microm head. METHODS: Forty-seven eyes of 26 patients (mean age 28.78+/-6.98 years) underwent LASIK with a superior hinge flap using the 90-microm head of the SCHWIND Carriazo-Pendular microkeratome. Evaluation included flap parameters (thickness, diameter, hinge size), complications, and visual outcome. RESULTS: No intraoperative or early postoperative complications were observed. The mean flap thickness was 79.88+/-6.94 microm (range: 70 to 93 microm). Mean flap diameter was 9.25+/-0.45 mm (range: 8.5 to 11 mm) whereas mean hinge size was 4.63+/-0.66 mm (range: 3 to 6.5 mm). No eye lost lines of best spectacle-corrected visual acuity, and all eyes were emmetropic within one diopter postoperatively. CONCLUSIONS: The SCHWIND Carriazo-Pendular microkeratome with the 90-microm head seems to have increased accuracy in intended creation of thin flaps.

Simultaneous topography-guided PRK followed by corneal collagen cross-linking for keratoconus.

PURPOSE: To present the results after simultaneous photorefractive keratectomy (PRK) followed by corneal collagen cross-linking (CXL) for progressive keratoconus. METHODS: Twelve patients (14 eyes) with progressive keratoconus were prospectively treated with customized topography-guided PRK with the Pulzar Z1 (wavelength 213 nm, CustomVis) immediately followed by corneal collagen CXL with the use of riboflavin and ultraviolet A irradiation. RESULTS: Mean follow-up was 10.69+/-5.95 months (range: 3 to 16 months). Mean preoperative spherical equivalent refraction (SE) was -3.03+/-3.23 diopters (D) and defocus was 4.67+/-3.29 D; at last follow-up SE and defocus were statistically significantly reduced to -1.29+/-2.05 D and 3.04+/-2.53 D, respectively (P<.01). Preoperative mean (logMAR) uncorrected visual acuity was 0.99+/-0.81 and best spectacle-corrected visual acuity was 0.21+/-0.19, which improved postoperatively to 0.16+/-0.15 and 0.11+/-0.15, respectively. The mean steepest keratometry was reduced from 48.20+/-3.40 D preoperatively to 45.13+/-1.80 D at last follow-up. CONCLUSIONS: Simultaneous PRK followed by CXL seems to be a promising treatment capable of offering functional vision in patients with keratoconus.

Anterior Chamber Sulfur Hexafluoride (SF6) Injection for the Management of Postsurgery Hypotony in Glaucoma Patients.

PURPOSE: The purpose of this article was to describe a new technique involving the injection of sulfur hexafluoride (SF6) gas in the anterior chamber (A/C) for the management of hypotony in patients with previous glaucoma surgery. MATERIALS AND METHODS: Seven patients were included in this prospective case series. All patients had advanced glaucoma that was managed surgically either by trabeculectomy (6 patients) or Ahmed valve (1 patient). All patients presented with intraocular pressure (IOP) <7 mm Ηg, shallow A/C, and ultrasound images of choroidal detachment and ciliary body detachment. Patients' hypotony was treated by 0.4 to 0.6 mL of 100% pure SF6 injection in the A/C followed by supine posture. The purpose of this injection was dual: to displace the ciliary body to its normal position and restore aqueous humor normal production, and to block aqueous humor outflow through bubble formation, causing an increase in IOP. RESULTS: Surgical technique was successful in all 7 patients with IOP normalization (>10 mm Hg) and A/C depth increase within the first week after surgery. CONCLUSION: A new surgical technique of SF6 injection in the A/C for patients with choroidal detachment and hypotony shows promising results.

Diffuse lamellar keratitis after corneal crosslinking in a patient with post-laser in situ keratomileusis corneal ectasia.

A 27-year-old man presented with corneal ectasia in his left eye 4 years after myopic laser in situ keratomileusis (LASIK) and was treated with riboflavin-ultraviolet-A (crosslinking). During the first post-treatment days, diffuse lamellar keratitis (DLK) (stage III) developed. The microbiology culture was negative. After intensive treatment with topical corticosteroids, the DLK resolved during the following 2 weeks. Crosslinking for post-LASIK corneal ectasia may induce DLK. Early diagnosis and appropriate treatment with intensive topical corticosteroids is essential to successfully manage this post-crosslinking complication.

Herpetic keratitis with iritis after corneal crosslinking with riboflavin and ultraviolet A for keratoconus.

A 21-year-old woman had crosslinking for keratoconus in the right eye; the left eye was scheduled for penetrating keratoplasty. Five days postoperatively, she presented with geographic epithelial keratitis and iritis. Analysis of tear samples by polymerase chain reaction confirmed the diagnosis. The patient was treated with oral steroids and acyclovir, with significant improvement. Two months postoperatively, the visual acuity was improved and there was no evidence of herpetic disease recurrence. Crosslinking can induce herpetic keratitis with iritis even in patients with no history of herpetic disease. Early diagnosis and proper treatment are essential for a favorable outcome.

Safety and efficacy of a growth factor and cytokine-containing topical product in wound healing and incision scar management after upper eyelid blepharoplasty: a prospective split-face study.

PURPOSE: To evaluate the efficacy and safety of a topical product containing a mixture of growth factors and cytokines on the incision scar following upper eyelid blepharoplasty. METHODS: This is a prospective, single-blinded, and split-face study on patients who underwent bilateral upper eyelid blepharoplasty. Two weeks after surgery, one eye of each subject was randomized to receive Lumière Bio-Restorative Eye Cream on one eyelid incision for 12 weeks and no treatment on the other eyelid. Subjects returned at the postoperative weeks 6, 10, and 14. At each visit, patients and the investigator (who was blinded to the treated eyelid) evaluated the scar through specified questionnaires. RESULTS: A total of 20 subjects with a mean age of 66.3±9.2 years completed the study. Minor side effects were noted in three subjects. At all-time points, all subjects thought eyelids treated with Lumière had a better scar and overall appearance than fellow eyelids (P<0.5); and 60% of patients strongly encouraged others to use the product. The investigator assessment of erythema and pigmentation revealed less erythema and pigmentation in treated eyes at the weeks 6 and 10, although the difference was statistically insignificant. Investigator assessment also revealed a better scar appearance at week 10 in treated eyes (P=0.04). All evaluation parameters were similar in both eyes at the last visit. CONCLUSION: Lumière eye cream shows an excellent safety profile and minimal effects on features of the incision scar following upper lid blepharoplasty. It may hasten the wound healing process considering the higher outcomes at the first weeks of application.

Current views and advances on Paediatric Virology: An update for paediatric trainees.

Paediatric Virology is a bold new scientific field, which combines Paediatrics with Virology, Epidemiology, Molecular Medicine, Evidence-based Medicine, Clinical Governance, Quality Improvement, Pharmacology and Immunology. The Workshop on Paediatric Virology, which took place on Saturday October 10, 2015 in Athens, Greece, provided an overview of recent views and advances on viral infections occurring in neonates and children. It was included in the official programme of the 20th World Congress on Advances in Oncology and the 18th International Symposium on Molecular Medicine, which attracted over 500 delegates from the five continents. During the Workshop, the topics covered included the challenges of vaccine implementation against human papillomaviruses in countries under financial crisis, strategies for eradicating poliomyelitis and its 60th vaccine anniversary, as well as the debate on the association between autism and vaccination against measles, mumps and rubella. Among the non-vaccine related topics, emphasis was given to viral infections in prematurely born infants and their long-term outcomes, new paediatric intensive care management options for bronchiolitis related to respiratory syncytial virus, the clinical implications of hepatitis B virus and cytomegalovirus genotyping, the Ebola virus threat and preparedness in Paediatric Emergency Departments, oral, oropharynx, laryngeal, nasal and ocular viral infections and Merkel cell polyomavirus as a novel emerging virus of infancy and childhood. In this review, we provide selected presentations and reports discussed at the Workshop.