Small Incision Lenticule Extraction for Hyperopia: 3-Month Refractive and Visual Outcomes

PURPOSE

To evaluate visual and refractive outcomes of small incision lenticule extraction (SMILE) for hyperopia.

METHODS

This prospective study of vertex-centered hyperopic SMILE used the VisuMax femtosecond laser (Carl Zeiss Meditec, Jena, Germany). Inclusion criteria were maximum attempted hyperopic meridian of between +1.00 and +7.00 diopters (D) and corrected distance visual acuity (CDVA) of 20/40 or better. Lenticule parameters were 6.3- to 6.7-mm diameter, 2-mm transition zone, 30-µm minimum thickness, and 120-µm cap thickness. Standard outcomes analysis was performed for the 3-month data, including contrast sensitivity using the Functional Vision Analyzer.

RESULTS

For 93 eyes treated, 3-month data were available for 82 (88%). Attempted spherical equivalent refraction was +5.62 ± 1.20 D (range: +1.00 to +6.90 D) and cylinder was -0.91 ± 0.68 D (range: 0.00 to -3.50 D). For eyes targeted for emmetropia (n = 36), uncorrected distance visual acuity was 20/40 or better in 89%. Spherical equivalent refraction relative to target was -0.17 ± 0.85 D (range: -2.20 to +3.00 D), with 59% within ±0.50 D and 76% within ±1.00 D. There was one line loss of CDVA in 17% of eyes, and one eye lost three lines (1.2%) but recovered to one line lost at 9 months. There was no clinically significant change in contrast sensitivity.

CONCLUSIONS

Refractive and visual outcomes 3 months after SMILE for hyperopia were promising, given the high degree of hyperopia corrected and relatively reduced CDVA in this population. Undercorrection of more than 1.00 D in 5 eyes might be partly explained by latent hyperopia in these young patients. [J Refract Surg. 2019;35(1):24-30.].

Three-year results from the Retro-IDEAL study: Real-world data from diabetic macular edema (DME) patients treated with ILUVIEN® (0.19 mg fluocinolone acetonide implant)

INTRODUCTION

The Retro-IDEAL (ILUVIEN Implant for chronic DiabEtic MAcuLar edema) study is a retrospective study designed to assess real-world outcomes achieved with the ILUVIEN® (0.19 mg fluocinolone acetonide (FAc)) in patients with chronic diabetic macular edema (DME) in clinical practices in Germany.

METHODS

This study was conducted across 16 sites in Germany and involved 81 eyes (63 patients) with persistent or recurrent DME and a prior suboptimal response to a first-line intravitreal therapy (primarily anti-VEGF intravitreal therapies).

RESULTS

Patients were followed-up for 30.8 ± 11.3 months (mean ± standard deviation) and had a mean age of 68.0 ± 10.4 years. Best-recorded visual acuity (BRVA) improved by +5.5 letters at month 9 (P ⩽ 0.005, n=56; from a baseline of 49 letters) and this was maintained through to month 30 (P ⩽ 0.05, n = 42). There was a concurrent improvement in central macular thickness with a reduction from 502 µm at baseline to 338 µm at year 1 (P ⩽ 0.0001, n = 43). This effect was sustained to year 3 (i.e. 318 µm; P ⩽ 0.0001, n = 29). Mean intraocular pressure (IOP) remained constant between baseline and year 3 with a peak change of 1.9 mm Hg occurring at year 1. Elevated IOP was observed in a similar percentage of patients prior to (22.2% of cases) and following (27.2%) treatment with the FAc implant. In the majority of cases, these elevations were managed effectively with IOP medications.

CONCLUSIONS

Despite substantial amounts of prior intravitreal treatments - primarily with anti-vascular endothelial growth factor (VEGF) drugs - this real-world study showed that sustained structural and functional improvements can last for up to 3 years with a single FAc implant.

Flushing versus not flushing the interface during small-incision lenticule extraction

PURPOSE

To assess the differences in outcomes between interface flushing with a balanced salt solution after refractive lenticule removal in simultaneous uneventful bilateral small-incision lenticule extraction (SMILE).

SETTING

Six study centers in Germany.

DESIGN

Prospective case series.

METHODS

Patients with myopia or myopic astigmatism of similar magnitude in both eyes with a spherical equivalent less than or equal to 10.0 diopters (D), preoperative corrected distance visual acuity (CDVA) of 0.80 decimal or better, and anisometropia less than or equal to 2.0 D were enrolled and followed for 3 months. One eye of each patient was treated with interface flushing after dry extraction of the lenticule. Flushing was performed with 1.0 cc balanced salt solution using a single-use 27-gauge cannula. The uncorrected distance visual acuity (UDVA) at 1 day, 1 week, and 3 months; the CDVA at 3 months; and postoperative differences at the slitlamp examination were recorded. Statistical analyses were performed with logarithm of the minimum angle of resolution values using paired t tests. The P value for significance was less than 0.05.

RESULTS

The study analyzed 470 eyes. One day postoperatively, the mean UDVA was 0.81 in the non-flush group and 0.83 in the flush group (P = .110). At the last visit 3 months postoperatively, the mean UDVA was 1.04 and 1.05, respectively (P = .172). No significant differences in the rate of postoperative complications were found.

CONCLUSION

Interface irrigation with 1.0 cc of balanced salt solution after the removal of the refractive lenticule has neither advantages nor disadvantages in terms of visual recovery, postoperative complications, or final visual acuity.

Biomechanical Properties of Human Cornea Tested by Two-Dimensional Extensiometry Ex Vivo in Fellow Eyes: Femtosecond Laser-Assisted LASIK Versus SMILE

PURPOSE

To investigate the biomechanical properties of the ex vivo human cornea after flap-based versus cap-based laser refractive surgery in the same donor.

METHODS

In this experimental study, 11 pairs of human corneas unsuitable for transplantation were equally divided into two groups. Corneas from the right eye were treated with femtosecond laser-assisted LASIK (FSLASIK) and corneas from the left eye with small incision lenticule extraction (SMILE). Pachymetry was measured in each eye directly before laser refractive surgery. All corneas were subjected to a refractive correction of -10.00 diopters (D) sphere and -0.75 D cylinder at 0° with a 7-mm zone, using either a 110-μm flap (FS-LASIK) or 130-μm cap (SMILE). For two-dimensional biomechanical measurements, corneoscleral buttons underwent two testing cycles (preconditioning stress-strain curve from 0.03 to 9.0 N and stress-relaxation at 9.0 N during 120 sec) to analyze the elastic and viscoelastic material properties. The effective elastic modulus was calculated. Statistical analysis was performed with a confidence interval of 95%.

RESULTS

In stress-strain measurements, the effective elastic modulus was 1.47 times higher (P = .003) after SMILE (median = 8.22 [interquartile range = 4.76] MPa) compared to FS-LASIK (median = 5.59 [inter-quartile range = 2.77] MPa). The effect size was large (r = 0.83). No significant differences (P = .658) were observed among stress-relaxation measurements, with a mean remaining stress of 181 ± 31 kPa after SMILE and 177 ± 26 kPa after FS-LASIK after relaxation.

CONCLUSIONS

Compared to a flap-based procedure such as FS-LASIK, the SMILE technique can be considered superior in terms of biomechanical stability, when measured experimentally in ex vivo human fellow eye corneas. [J Refract Surg. 2018;34(6):419-423.].

Early visual outcomes and optical quality after femtosecond laser small-incision lenticule extraction for myopia and myopic astigmatism correction of over -10 dioptres

PURPOSE

To investigate early visual and refractive outcomes, corneal stability and optical quality after femtosecond laser small-incision lenticule extraction (SMILE) for treating myopia and myopic astigmatism over -10 D.

METHODS

Thirty eyes (30 patients) with myopia and myopic astigmatism of over -10 D were treated with VisuMax^® femtosecond laser (version 3.0; Carl Zeiss Meditec AG, Jena, Germany). Six months postoperative safety, efficacy and predictability were evaluated. Corneal Scheimpflug topography was measured preoperatively, 1 day, 3 months and 6 months postoperatively. Wavefront aberrations were measured preoperatively, 3 months and 6 months postoperatively.

RESULTS

Six months postoperatively, LogMAR uncorrected and corrected distance visual acuity (CDVA) were -0.013 ± 0.086 and -0.073 ± 0.069, respectively. 73% (97%) of eyes were within 0.5 (1) D of target refraction. No eyes lost CDVA, 43% (13 eyes) gained one line and 7% (two eyes) gained two lines. Mean corneal back curvature (KMB) and posterior central elevation (PCE) did not change significantly comparing preoperative and 6 months postoperative data (p = 0.91 and 0.77, respectively). Comparing 1 day with 6 months postoperative data, central corneal thickness (CCT), mean corneal front curvature (KMF), KMB and PCE did not change significantly (p = 0.27, 0.07, 0.52, 0.71, respectively). Total higher-order aberration (HOA), spherical aberration and coma increased significantly (p < 0.01) but trefoil remained stable (p = 0.49).

CONCLUSION

Our results indicate that SMILE can correct myopia and myopic astigmatism of over -10 D predictably. No early ectasia was observed. Long-term changes in visual quality and corneal stability require further investigation.

Endothelial keratoplasty in eyes with a retained angle-supported intraocular lens

PURPOSE

To describe the outcomes of endothelial keratoplasty (EK) for bullous keratopathy in eyes with a retained angle-supported anterior chamber intraocular lens (acIOL).

METHODS

Among 263 consecutive EK procedures, 7 DMEK and 11 DSAEK procedures were identified in eyes with an acIOL and included in the present retrospective case series. Pre- and postoperative status including ocular history, anatomical outcome and complications as well as best-corrected visual acuity was evaluated.

RESULTS

Ocular history included complicated cataract surgery (n = 11), ocular trauma (n = 4) and primary intracapsular cataract extraction (n = 3). Surgery-related complications included primary graft failure (n = 1), graft detachment (n = 1), endophthalmitis (n = 1) and allograft rejection (n = 1). A clear cornea at the final examination (14 ± 4 months) was observed in 14/18 (78%), while the visual outcome was limited due to significant ocular comorbidity in 9 out of 14 uncomplicated procedures.

CONCLUSION

The presented short-term outcomes suggest that both DMEK and DSAEK are feasible in eyes with an angle-supported acIOL yielding an acceptable graft survival rate in the first postoperative year.

Lidocaine-Assisted Xylocaine Jelly Anesthesia versus one Quadrant Sub-Tenon Infiltration for Self-Sealing Sclerocorneal Incision Routine Phacoemulsification

Purpose

To compare the effect of Xylocaine jelly and intracameral lidocaine with one quadrant instant sub-Tenon infiltration for self-sealing sclerocorneal phacoemulsification.

METHODS

One hundred patients were enrolled into a prospective randomized study, receiving either a combination of topical 2% Xylocaine jelly and 0.5 ml of intracameral 1% lidocaine or sub-Tenon infiltration with 2 ml of 2% Xylocaine on the operating table. All patients underwent a standard divide and conquer phacoemulsification procedure through a superior sclerocorneal frown incision followed by implantation of a polymethylmethacrylate intraocular lens. Intraoperative pain was indicated by the patient by squeezing the bedside nurse's hand, who allocated it to particular stages of surgery on a chart. After surgery, patients assessed the pain experienced using a 10-unit visual analogue scale.

Results

Pain was indicated on 31 occasions during the operation in the sub-Tenon group (mainly the injection itself) and 67 times in the topical group. The median overall subjective pain score was 3 in the jelly group and 0 in the sub-Tenon. Five eyes (10%) had to be converted to sub-Tenon during the surgery because of intolerable pain.

CONCLUSIONS

Whereas lidocaine supported Xylocaine jelly anesthesia provided acceptable analgesia for 90% of patients operated, sub-Tenon anesthesia proved to deliver better intraoperative comfort in all patients receiving sclerocorneal incision cataract surgery.

Comparison of Optic Disc Parameters in Hyperopic and Emmetropic Eyes of Healthy Children with HRT and OCT

Purpose To investigate, through Heidelberg retina tomography II (HRT II) and RTVue-100 optical coherence tomography (OCT), normal parameters of the optic nerve head (ONH) in highly hyperopic children, and compare these with a group of children with low hyperopia and emmetropia, as fundus examination of highly hyperopic children often shows crowding of the optic disc, which may be difficult to distinguish from mild optic disc swelling.

Patients and Methods ONH of the higher hyperopic eye was examined with HRT II and the peripapillary nerve fiber layer (RNFL) with RTVue-100, in 6 to 15-year-old full-term children with normal visual acuity and spherical equivalent ≥ + 3.0 D (hyperopic group) and < + 3.0 to − 1.0 D (emmetropic group).

Results Thirty highly hyperopic children and 33 emmetropic controls had a mean spherical equivalent of + 5.1 ± 1.5 D and a mean age of 8.4 ± 2.8 years, and + 1.0 ± 1.2 D and 9.6 ± 2.6 years, respectively. There was no significant difference in OCT-assessed RNFL thickness between the two groups. Compared to the emmetropic group, following HRT parameters were significantly smaller in the hyperopic group: Disc area (1.41 vs. 1.68 mm2, p = 0.023), cup area (0.19 vs. 0.37 mm2, p = 0.0001), cup volume (0.03 vs. 0.08 mm3, p = 0.02), cup/disc area (0.13 vs. 0.20, p = 0.006), linear cup/disc (0.33 vs. 0.42, p = 0.004), and mean cup depth (0.13 vs. 0.17 mm, p = 0.019).

Conclusion In children, ONH of highly hyperopic eyes are smaller than those of emmetropic eyes. RNFL thickness and neural rim volume are similar to emmetropic eyes. They can therefore appear more crowded.

[Refractive lenticule extraction - The ReLEx/SMILE technique : Video article]

Refractive lenticule extraction (ReLEx/SMILE) is a refractive surgical method developed by the authors in stages primarily for correction of myopia and myopic astigmatism, in which a femtosecond laser is exclusively used. In the (ReLEx/SMILE) method a refractive lenticule is generated by the femtosecond laser, which is subsequently extracted through a small incision. Opening of the corneal surface with a flap and use of an excimer laser is no longer necessary. In 2013 the method was newly assessed and classified by the Joint Commisssion for Refractive Surgery (KRC) of the Professional Association of Ophthalmologists (BVA) and the German Ophthalmological Society (DOG). This article presents the individual stages of the technique in a video and possible errors and their avoidance are explained.

Retinopathy with central oedema in an INS C94Y transgenic pig model of long-term diabetes

AIMS/HYPOTHESIS

Diabetic retinopathy is a severe complication of diabetes mellitus that often leads to blindness. Because the pathophysiology of diabetic retinopathy is not fully understood and novel therapeutic interventions require testing, there is a need for reliable animal models that mimic all the complications of diabetic retinopathy. Pig eyes share important anatomical and physiological similarities with human eyes. Previous studies have demonstrated that INS ^C94Y transgenic pigs develop a stable diabetic phenotype and ocular alterations such as cataracts. The aim of this study was to conduct an in-depth analysis of pathological changes in retinas from INS ^C94Y pigs exposed to hyperglycaemia for more than 2 years, representing a chronic diabetic condition.

METHODS

Eyes from six INS ^C94Ypigs and six age-matched control littermates were analysed via histology and immunohistochemistry. For histological analyses of retinal (layer) thickness, sections were stained with H&E or Mallory's trichrome. For comparison of protein expression patterns and vessel courses, sections were stained with different antibodies in immunohistochemistry. Observed lesions were compared with reported pathologies in human diabetic retinopathy.

RESULTS

INS ^C94Ypigs developed several signs of diabetic retinopathy similar to those seen in humans, such as intraretinal microvascular abnormalities, symptoms of proliferative diabetic retinopathy and central retinal oedema in a region that is cone rich, like the human macula.

CONCLUSIONS/INTERPRETATION

The INS ^C94Ypig is an interesting model for studying the pathophysiology of diabetic retinopathy and for testing novel therapeutic strategies.

Biomechanical Differences Between Femtosecond Lenticule Extraction (FLEx) and Small Incision Lenticule Extraction (SmILE) Tested by 2D-Extensometry in Ex Vivo Porcine Eyes

Purpose

To evaluate the biomechanical stability of ex vivo porcine corneas after femtosecond lenticule extraction (FLEx) and small incision lenticule extraction (SmILE) refractive surgeries.

Methods

Forty-five porcine eyes were equally divided into three groups: Groups 1 and 2 were treated with FLEx and SmILE procedure, respectively. Group 3 served as control. A refractive correction of -14 diopters (D) with a 7-mm zone using either a 160-μm flap (FLEx) or a 160-μm cap (SmILE) was performed. For two-dimensional (2D) elastic and viscoelastic biomechanical characterization, two testing cycles (preconditioning stress-strain curve from 1.27 to 12.5 N, stress-relaxation at 12.5 N during 120 seconds) were conducted. Young's modulus and Prony constants were calculated.

Results

At 0.8% of strain, FLEx (370 ± 36 kPa) could resist a significantly lower stress than SmILE (392 ± 19 kPa, P = 0.046) and the control group (402 ± 30 kPa, P = 0.013). Also, FLEx (46.1 ± 4.5 MPa) had a significantly lower Young's modulus than the control group (50.2 ± 3.4 MPa, P = 0.008). The Young's modulus of SmILE (48.6 ± 2.5 MPa) had values situated between untreated corneas and FLEx-treated corneas. When compared to untreated controls, the stress resistance decreased by 8.0% with FLEx and 2.5% with SmILE; Young's modulus decreased by 5.1% with FLEx and 1.04% with SmILE. With a cap-based procedure, both anterior cap and stromal bed carry the intraocular pressure, while in a flap-based procedure, only the stromal bed does.

Conclusions

Compared to flap-based procedures like FLEx, the cap-based technique SmILE can be considered superior in terms of biomechanical stability, when measured experimentally in ex vivo porcine corneas.

Small Incision Lenticule Extraction (SMILE) for Hyperopia: Optical Zone Centration

PURPOSE

To evaluate optical zone centration of hyperopic small incision lenticule extraction (SMILE).

METHODS

This prospective study of 60 consecutive hyperopic SMILE procedures used the VisuMax femtosecond laser and matched LASIK procedures with the VisuMax and MEL 80 excimer lasers (Carl Zeiss Meditec AG, Jena, Germany). Inclusion criteria were maximum attempted hyperopic meridian of between +1.00 and +7.00 diopters (D) and astigmatism up to 6.00 D. For SMILE, the optical zone was between 6.3 and 6.7 mm, with a 2-mm transition zone. Two LASIK control groups (6.5- and 7-mm optical zone) were generated matched for spherical equivalent treated. In SMILE, the corneal vertex of the coaxially fixating eye was aligned with the vertex of the curved contact glass. In LASIK, the treatment was centered on the coaxially sighted corneal light reflex (first Purkinje image) with the contralateral eye (Seiler method). A tangential (instantaneous) curvature preoperative to 3 months postoperative difference map was generated for each eye. A fixed grid and set of concentric circles were superimposed on the difference map to measure the offset between the optical zone center and corneal vertex (0,0), and vector analysis was used for comparative analysis.

RESULTS

Mean attempted spherical equivalent was +5.61 ± 0.96 D (range: +3.20 to +6.50 D) and mean cylinder was -0.96 ± 0.62 D (range: 0.00 to -2.75 D) in the SMILE group. Mean age was 29 ± 7 years (range: 19 to 52 years) in the SMILE group. Mean centration offset was 0.23 ± 0.15 mm (range: 0 to 0.61 mm) for the SMILE group, 0.33 ± 0.14 mm (range: 0.14 to 0.85 mm) for the 6.5-mm LASIK group, and 0.31 ± 0.19 mm (range: 0.05 to 0.85 mm) for the 7-mm LASIK group. The mean centration offset for SMILE was less than that of both LASIK groups (P < .05).

CONCLUSIONS

Optical zone centration of hyperopic SMILE was found to be similar to eye-tracker-centered hyperopic LASIK with the MEL 80 laser. [J Refract Surg. 2017;33(3):150-156.].