Five-Year Follow-up of 399 Phakic Artisan–Verisyse Implantation for Myopia, Hyperopia, and/or Astigmatism

Comparison of the Biometric Characteristics After Long-term Implantation of Iris-fixated Phakic Intraocular Lens in Explanted and Nonexplanted Groups of Eyes

PURPOSE

To evaluate and compare the biometric characteristics of the anterior chamber of a group of patients with significant endothelial cell loss (ECL) who required phakic intraocular lens (pIOL) explantation and a group of patients who did not fulfill the explantation criteria related to corneal decompensation.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

The study included all consecutive patients receiving a pIOL implantation at Oftalmosalud Instituto de Ojos, Lima, Peru, between 2001 and 2012. The explanted group (E group) consisted of eyes in which the pIOLs were explanted due to ECL, and the nonexplanted group (NE group) consisted of eyes randomly selected in which the pIOL was not explanted with a minimum follow-up time of 8 years. Slit-lamp biomicroscopy, visual acuity, refraction, endothelial cell count, and anterior segment optical coherence tomography were assessed at the preoperative evaluation for both groups and before explantation in the E group and 8 years post-implantation in the NE group.

RESULTS

pIOLs were implanted in 265 eyes. The annual percentage of ECL was 1.47% and 5.55% in the NE group and E group, respectively (P < .001). The mean minimum endothelial lens distance (ELD) was 1.44 ± 0.22 mm and 1.05 ± 0.23 mm in the NE group and E group, respectively (P < 0.001). The mean time for explantation was 12.58 ± 3.79 years for the E group. Annual ECL could accurately discriminate between the NE group and E group; a cutoff point of 3.5 (%/year) or 86.5 (cells/years) had a 100% sensitivity and specificity. A cutoff of 1.21 mm in the minimum ELD has a 91% sensitivity and 79% specificity to discriminate between the E group and NE group.

CONCLUSIONS

pIOL explantation due to ECL occurs in eyes with a significantly postoperative lower minimum ELD. Annual ECL and minimum ELC can effectively discriminate between the E and NE groups.

Visual Prognosis Following Cataract Surgery in Highly Myopic Patients with Prior History of Verisyse Phakic Intraocular Lens Implantation

Background/Objectives: This study aimed to evaluate the visual outcomes and prognosis after cataract surgery in patients with prior history of Verisyse phakic intraocular lens (pIOL) implantation. Methods: A retrospective cohort study involving 215 Verisyse pIOL implantations and 17 explantations was conducted. The Verisyse pIOL was disenclaved and removed through a superior scleral tunnel incision. Cataract extraction with phacoemulsification was then performed through a temporal clear corneal incision. Results: An occurrence rate of 7.9% of eyes with cataract formation was found. Both uncorrected (UDVA) and corrected visual acuity (CDVA) three months after cataract surgery were significantly improved (0.24 ± 0.30 vs. 0.73 ± 0.48; p < 0.001 and 0.10 ± 0.14 vs. 0.30 ± 0.31; p = 0.004, respectively). The UDVA was 20/20 or better in 41% of eyes and 20/40 or better in 65% of eyes. The CDVA was 20/20 or better in 53% of eyes and 20/40 or better in 88% of eyes. The safety and efficacy indices were 1.96 ± 1.68 and 1.60 ± 1.36, respectively. Conclusions: Various complications including cataracts may develop in these patients. Verisyse pIOLs have a lower incidence of cataract formation and are more likely to lead to age-related cataracts rather than the anterior subcapsular cataracts commonly seen in implantable collamer lens (ICL) patients. Patients with a prior history of Verisyse pIOL can expect to have a good visual prognosis after cataract extraction.

Endothelial Cell Loss in Patients with Phakic Intraocular Lenses

Although the safety of phakic intraocular lenses (pIOLs) has been continuously improved over 70-years of development, high endothelial cell losses can occur even with current pIOL models. Numerous studies have demonstrated that the distance of a pIOL to the corneal endothelium plays a crucial role in the extent of endothelial cell loss. For this reason alone, higher endothelial cell loss tends to be observed with anterior chamber lenses than with posterior chamber lenses. Adequate preoperative anterior chamber depth is essential, at least for iris-fixed pIOLs, in order to ensure a safe distance from the endothelium. However, the anterior chamber becomes shallower with age and therefore it may be useful to consider patient age in the safety criteria. Although endothelial cell loss is generally low with current pIOL models, regular monitoring of the endothelial cell density remains essential due to large interindividual differences in patients with pIOLs. If the endothelial cell loss is greater than expected and the follow-up visits confirm the trend, the pIOL should be explanted without delay. The endothelial reserve should be considered on an individual basis by taking into account patient age, physiological endothelial cell loss, and loss due to further surgery. With careful indication and long-term patient care, pIOLs remain a safe treatment option.

Diagnostic Techniques to Increase the Safety of Phakic Intraocular Lenses

Preoperative and postoperative diagnostics play an important role in ensuring the safety of patients with phakic intraocular lenses (pIOLs). The risk of endothelial cell loss can be addressed by regularly measuring the endothelial cell density using specular microscopy and considering the endothelial cell loss rate and the endothelial reserve in accordance with the patient's age when deciding whether to explant a pIOL. The anterior chamber morphometrics, including the anterior chamber depth and the distance between the pIOL and the endothelium, measured using Scheimpflug tomography and anterior segment optical coherence tomography (AS-OCT), can help to assess the risk of the endothelial cell loss. In patients undergoing posterior chamber pIOL implantation, accurate prediction of the vault and its postoperative measurements using AS-OCT or Scheimpflug tomography are important when assessing the risk of anterior subcapsular cataract and secondary glaucoma. Novel approaches based on ultrasound biomicroscopy and AS-OCT have been proposed to increase the vault prediction accuracy and to identify eyes in which prediction errors are more likely. Careful patient selection and regular postoperative follow-up visits can reduce the complication risk and enable early intervention if a complication occurs.

Impact of Ocular Conditions and Improvements After Refractive Surgery in Quality of Life for Children With Neurodevelopmental Disorders

PURPOSE

This study aims to characterize the eye-related quality of life of children with neurodevelopmental and ocular disorders at baseline and after refractive surgery.

DESIGN

Prospective interventional case series.

METHODS

We enrolled children and adolescents 5 to 18 of age with neurodevelopmental disorders undergoing refractive surgery (6 for pre-/postsurgical assessment and 14 for baseline analysis). Eye-related quality of life was measured using the Pediatric Eye Questionnaire (PedEyeQ). Baseline levels of adaptive functioning and social behaviors were measured using the Adaptive Behavioral Assessment System (ABAS-3) and Social Responsiveness Scale (SRS-2). We assessed the correlation between baseline PedEyeQ scores, number of ocular comorbidities, magnitude of refractive error, and ABAS-3 and SRS-2 scores.

RESULTS

At baseline, 14 patients demonstrated decreased median eye-related quality of life (<60/100) in 5 of 9 PedEyeQ domains, moderate deficiencies in social behaviors (SRS-2 median 71, range 49-90), and low adaptive functioning (ABAS-3 median percentile for age of 0.100). Baseline PedEyeQ scores did not correlate with magnitude of refractive error or adaptive functioning scores but did correlate with number of ocular comorbidities and social behavior scores. Six patients have undergone refractive surgery without complication. Postoperatively, 11 of 11 eyes were within ±1.5 diopters spherical equivalent. Four of 6 patients exhibited clinically significant improvements in PedEyeQ scores after surgery.

CONCLUSIONS

Even in the presence of significant social and adaptive impairments, quality of life in children with neurodevelopmental disorders is decreased by ocular disorders. Refractive surgery is associated with clinically significant improvements in eye-related quality of life.

Evaluation of phakic intraocular lens power calculation using the new Linz-Homburg-Castrop formula and comparison with four conventional methods

PURPOSE

To evaluate the accuracy of phakic intraocular lens (pIOL) power calculation in a middle European patient cohort.

SETTING

EyeLaser Clinic, Linz, Austria.

DESIGN

Single-center single-surgeon retrospective consecutive case series.

METHODS

Patients were included after uneventful pIOL surgery implanting 91 nontoric and toric Visian implantable collamer lens model V4c. Online Calculation and Ordering System (OCOS) software, JPhakic software, Olsen-Feingold formula, Holladay formula, and Linz-Homburg-Castrop (LHC) formula were compared. When possible, lens constants were optimized for the patient cohort. Data of single eye per patient were included. Outcome measures were mean absolute prediction error, median absolute prediction error, mean prediction error with SD, and median prediction error, as well as the percentage of eyes with an absolute prediction error within limits of 0.25 diopters (D), 0.5 D, 0.75 D, and 1.0 D.

RESULTS

91 eyes of 91 patients were assessed. After application of the Cochran Q test, the Olsen-Feingold formula achieved a significantly lower percentage of eyes within an absolute prediction error of 1.0 D than all other methods.

CONCLUSIONS

In the patient cohort, OCOS software, JPhakic software, and Holladay and LHC formulas showed equal results and can be cross-checked. The LHC formula was not published before. A ready-to-use Excel sheet is available as an addendum.

Five-year clinical outcomes of rigid iris-fixated phakic intraocular lens in northern Chinese

PURPOSE

To investigate the 5-year clinic outcomes of rigid iris-fixated pIOL on the visual performance, complications and intraocular light scattering in northern Chinese.

METHODS

Thirty eyes implanted with iris-fixated phakic IOLs (pIOLs group) and 34 eyes with high myopia (myopia group) were involved in this study. At preoperatively, 6 months, 1, 3, and 5 years postoperatively, the uncorrected visual acuity (UCVA), best-spectacle corrected visual acuity (BSCVA), endothelial cell density (ECD), and intraocular pressure (IOP) were measured in pIOLs group. The objective scatter index (OSI), modulation transfer function cut off (MTF cut off), and Strehl ratio were measured by Optical Quality Analysis System and a pseudophakic dysphotopsia questionnaire (PDQ) was used to evaluate the subjects' satisfaction in pIOLs and myopia groups.

RESULTS

At 5 years postoperatively, an UCVA of 20/20 or better was found in 43.33% of eyes in pIOLs group. At 6 months, 1, 3, and 5 years postoperatively, the mean ECD decrease were 1.29% ± 0.45%, 2.59% ± 1.30%, 6.67% ± 2.26%, and 10.80% ± 3.48%. The value of OSI in pIOLs group was significantly higher than that in myopia group (P < 0.001). The PDQ results showed that the subjects in myopia group complained less with intolerance of bright lights than those in pIOLs group. The values of Strehl ratio and MTF cut off in pIOLs group were significantly lower than that in myopia group (P < 0.001).

CONCLUSIONS

Iris-fixated pIOL induce more intraocular light scattering. A significant decrease in ECD was observed at 5 years postoperatively. An annual evaluation of ECD is necessary for patients undergoing pIOL implantation.

DETERMINATION OF FACTORS ASSOCIATED WITH LONG-TERM ENDOTHELIAL LOSS AND REFRACTIVE RESULT IN PATIENTS WITH ARTISAN PHAKIC LENS

PURPOSE

To determine the changes in endothelial cell density, refractive results, and risk factors associated with endothelial loss in patients with irisclaw phakic intraocular lenses for myopia/myopic astigmatism (Artisan).

METHODOLOGY

Data collection was obtained from an existing database with information on patients with a phakic Artisan lens implant between 1998 and 2011 at the Virgilio Galvis Ophthalmology Centre, with at least 5 years of follow-up. As a second stage, an analysis was carried out to identify the change in endothelial cell density and its potential associated factors.

RESULTS

A total of 80 eyes with myopic errors were included with a follow-up of 11.9 + 3.48 years. The percentage of total loss of endothelial cells was greater than 25% of the preoperative density in 43.8% of the eyes. A postoperative annual loss &gt; 1.6% was found in 47.0% of the eyes with that information available. 41 eyes (51%) had final endothelial density &lt; 2000 cells/mm2, and 7 (8.8%) eyes had endothelial cell density &lt; 1000 cells/mm2. Among the variables studied, no associated factors for long-term endothelial loss were found. During the course of the study, 8 (10%) phakic intraocular lenses were explanted, including 3 with accelerated endothelial loss, and another 2 with cataract associated and a significantly low endothelial density. The last mean spherical equivalent was -0.81 (±1.01 D), and the final uncorrected distance visual acuity was 0.45 logMar (Snellen 20/56).

CONCLUSION

Artisan-type phakic lenses are a good alternative for the correction of high myopic defects, with predictable refractive results in the long term. However, there is an increased loss of endothelial cells in the long term in a high percentage of patients. Strict postoperative follow-up, including endothelial evaluation, is required, and further studies are warranted.

Controversy and Consideration of Refractive Surgery in Patients with Heritable Disorders of Connective Tissue

Heritable Disorders of Connective Tissue (HDCTs) are syndromes that disrupt connective tissue integrity. They include Osteogenesis Imperfecta (OI), Ehlers Danlos Syndrome (EDS), Marfan Syndrome (MFS), Loeys-Dietz Syndrome (LDS), Epidermolysis Bullosa (EB), Stickler Syndrome (STL), Wagner Syndrome, and Pseudoxanthoma Elasticum (PXE). Because many patients with HDCTs have ocular symptoms, commonly myopia, they will often present to the clinic seeking refractive surgery. Currently, corrective measures are limited, as the FDA contraindicates laser-assisted in-situ keratomileusis (LASIK) in EDS and discourages the procedure in OI and MFS due to a theoretically increased risk of post-LASIK ectasia, poor wound healing, poor refractive predictability, underlying keratoconus, and globe rupture. While these disorders present with a wide range of ocular manifestations that are associated with an increased risk of post-LASIK complications (e.g., thinned corneas, ocular fragility, keratoconus, glaucoma, ectopia lentis, retinal detachment, angioid streaks, and ocular surface disease), their occurrence and severity are highly variable among patients. Therefore, an HDCT diagnosis should not warrant an immediate disqualification for refractive surgery. Patients with minimal ocular manifestations can consider LASIK. In contrast, those with preoperative signs of corneal thinning and ocular fragility may find the combination of collagen cross-linking (CXL) with either photorefractive keratotomy (PRK), small incision lenticule extraction (SMILE) or a phakic intraocular lens (pIOL) implant to be more suitable options. However, evidence of refractive surgery performed on patients with HDCTs is limited, and surgeons must fully inform patients of the unknown risks and complications before proceeding. This paper serves as a guideline for future studies to evaluate refractive surgery outcomes in patients with HDCTs.

Changes in visual outcomes and ocular morphometrics after foldable myopic and toric intraocular lens implantation: 5 year results

PURPOSE

To evaluate the refractive, visual, and morphometric changes after implantation with a foldable iris-fixated phakic intraocular lens (pIOL) to correct myopia or astigmatism.

SETTING

University Eye Clinic Maastricht, the Netherlands.

DESIGN

Prospective case series.

METHODS

We evaluated patients implanted with the Artiflex Myopia (Toric) iris-fixated pIOL as of January 2004. Measurements were performed annually and reported after 1 and 5 years.

RESULTS

The study included 481 eyes (277 patients; age 39.8±10.9 years [SD]). Five years postoperatively 91% of eyes were within ±1.0 D of target, and the mean myopisation over a 5 year period was 0.22 diopters (p<0.001). The logMAR CDVA increased by a mean 0.015 (p=0.015) over 5 years; 88% of eyes had a CDVA of 20/20 or better and 5.5% lost 2 or more lines of CDVA. Mean UDVA increased by 0.045 logMAR over 5 years (p<0.001); 96% reached an UDVA of 20/40 or more. Anterior chamber depth (ACD) decreased by 0.04 mm (p<0.001), and axial length (AXL) increased by 0.23 mm (p<0.001) over 5 years. Chronic endothelial cell loss showed a 5-year decline of 320 cells/mm2 in the myopic and 310 cells/mm2 in the toric subgroups (p<0.001). Cataract resulted in pIOL explantation in 4.0% of eyes (mean survival 59.0±40.0 months); higher preoperative age (hazard ratio [HR], 1.13; p<0.001) and smaller ACD (HR, 6.80; p= 0.035) were risk factors for shorter survival due to cataract formation.

CONCLUSION

Over 5 years logMAR CDVA and UDVA decreased significantly due to myopisation caused by lenticular changes and AXL elongation.

Eight-year follow-up of Artiflex and Artiflex Toric phakic intraocular lens

PURPOSE

To analyse long-term efficacy, safety, visual and refractive stability and physiological changes of Artiflex Myopia and Toric phakic intraocular lenses (pIOL) separately throughout an 8-year follow-up.

DESIGN

Retrospective cohort study.

METHODS

A total of 67 eyes of 37 patients underwent Artiflex Myopia (47 eyes) or Artiflex Toric (20 eyes) implantation for correcting myopia and/or astigmatism. Follow-up evaluations were performed 1, 3, 5 and 8 years after surgery. Preoperative and postoperative data included corrected (CDVA) and uncorrected distance visual acuity (UDVA), manifest refraction, endothelial cell density (ECD) and intraocular pressure (IOP) assessments. Efficacy and safety indexes were analysed. The vectorial analysis was performed using the Thibos method.

RESULTS

Mean CDVA and UDVA of both pIOLs significantly improved from preoperative to 1 year after implantation, and then it remained stable over the 8-year follow-up. The efficacy and safety indexes after 8 years were 0.94 ± 0.16 and 1.07 ± 0.18 for Artiflex Myopia and 1.00 ± 0.11 and 1.10 ± 0.15 for Artiflex Toric, respectively. The spherical equivalent (SE) significantly improved after surgery. J0, J45 and SE refractive components showed no changes between postoperative visits. A total ECD loss of 4.8% (p < 0.001) and 10.4% (p = 0.005) was found after 8 years for Artiflex Myopia and Toric, respectively.

CONCLUSIONS

Artiflex Myopia and Toric pIOLs are a safe, efficient and predictable option for the correction of myopia and/or astigmatism. The vectorial analysis showed excellent rotation stability for the toric version.

Comparison of the visual performance of iris-fixated phakic lens and implantable collamer lens to correct high myopia

Background

To compare visual performance between the iris-fixated phakic intraocular len (pIOL) and implantable collamer len (ICL) to correct high myopia.

Methods

Twenty-four eyes underwent iris-fixated pIOL implantation and 24 eyes underwent ICL implantation. At the 6-month follow-up, the best-corrected visual acuity (BCVA) and uncorrected distance visual acuity (UDVA) were compared between the iris-fixated pIOL and ICL groups. The objective scatter index (OSI), modulation transfer function (MTF) cutoff, and ocular aberrations were performed to evaluate postoperative visual quality between the two groups.

Results

No significant difference was found in UDVA, BCVA, and spherical equivalent between the iris-fixated pIOL and ICL groups (P > 0.05). Six months after surgery, the following values were significantly higher in the ICL group than in the iris-fixated pIOL group: MTF cutoff, strehl ratio and optical quality analysis system values at contrasts of 9 %, 20 %, and 100 % (P < 0.01). The OSI in the iris-fixated pIOL group was higher than in the ICL group 6 months after surgery (P < 0.01). All high-order aberrations were slightly more severe in the iris-fixated pIOL group than in the ICL group 6 months after surgery, although only trefoil (P = 0.023) differed significantly in this regard.

Conclusions

Both iris-fixated lenses and ICLs can provide good visual acuity. ICLs confer better visual performance in MTF-associated parameters and induce less intraocular light scattering than iris-fixated pIOLs.

Implantation of an iris-fixated phakic intraocular lens for the correction of hyperopia: 15-year follow-up

PURPOSE

To assess the predictability, efficacy, stability, and safety of implantation of an Artisan iris-fixated phakic intraocular lens (IF-pIOL) for the correction of hyperopia with a follow-up of up to 15 years.

SETTING

Leiden University Medical Center, the Netherlands.

METHODS

Patients operated by a single surgeon up to 2007 were identified, and data on refraction, corrected distance visual acuity (CDVA), uncorrected distance visual acuity, endothelial cell (EC) density, and complications were collected.

RESULTS

A total of 61 eyes (32 patients) were analysed. The mean spherical equivalent decreased from +6.43 ± 1.78 diopters (D) preimplantation to -0.22 ± 0.57 D at 1 year postimplantation and remained stable throughout follow-up. A stable CDVA with safety indices ranging from 0.91 to 1.10 and efficacy indices between 0.43 and 0.86 were observed. Follow-up time had a significant effect on EC density with an estimated annual decline of 58 cells/mm2 after IF-pIOL implantation. IF-pIOL explantation was performed in a 10 eyes (16.4%) after 8.13 ± 5.11 years. The main reason for IF-pIOL explantation was EC loss (4 eyes [6.6%]). Pigment dispersion was the most encountered complication, observed in 9 eyes (14.8%).

CONCLUSIONS

Visual and refractive results after implantation of an IF-pIOL to correct hyperopia show favorable and stable results with long-term follow-up. Lifelong monitoring of EC counts is mandatory. Pigment dispersion might be a problem in hyperopic eyes implanted with an IF-pIOL; a shallower anterior chamber depth and a convex iris configuration might be predisposing factors.

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

PURPOSE

Evaluating efficacy and safety of iris-supported phakic lenses (Verisyse) for high myopia treatment.

METHODS

Patients treated with Verisyse (Abbott Medical Optics, Santa Ana, CA, USA) intraocular lens (IOL) implants were evaluated retrospectively. Patients with follow-up periods of more than 5 years were included in the study. Pre- and postoperative fifth-year spheric equivalent (SE) of manifest refraction values, uncorrected and corrected distance visual acuities (UDVA and CDVA, respectively), and endothelial cell density (ECD) values were recorded. Complications were evaluated.

RESULTS

Forty-seven eyes of 31 patients were included in the study. Pre- and postoperative fifth year mean SE was - 12.50 ± 3.51D and - 0.72 ± 0.40D, respectively. Pre- and postoperative fifth-year UDVA was 1.56 ± 0.22 and 0.33 ± 0.18 logMAR (p < 0.001), respectively. The safety index (pre- and postoperative CDVA) was 1.39 ± 0.63 at the 5-year follow-up (p > 0,05). The efficacy index (ratio of mean postoperative UDVA to mean preoperative CDVA) of the patients was 1.14 ± 0.60. The mean postoperative endothelial cell loss at 5 years was -7.42%. None of the patients had lost 25% of their preoperative endothelial cells at 5-year follow-up. The mean postoperative endothelial cell loss was -3.05% at 1 year, -1.23% between years one and three, -1.02% between the third and fifth years.

CONCLUSION

Verisyse IOL implantation is an effective and safe for high myopia surgical treatment. However, the 5-year follow-up period is not sufficient to evaluate the safety profiles in terms of endothelial cells.

[Refractive surgery for hyperopia]

Hyperopia is a refractive error in which light is focused behind, instead of on, the retina. Clear vision can be obtained by accommodation, but in the long run, this results in eye strain. Hyperopia can be classified as low [≤2.00 diopters (D)], moderate (2.00-4.00 D) and high (>4.00 D). Detailed preoperative evaluation is necessary and essential to obtain good postoperative results. Various surgical techniques can be proposed to correct this ametropia. The main techniques used act either by modifying the corneal curvature with the Excimer laser or by implanting a phakic intraocular lens. The anatomical peculiarities of the hyperopic eye (small corneal diameter, short axial length, narrow anterior chamber or large kappa angle) make refractive surgery for hyperopia a considerable challenge. Large optical ablation zones now allow correction of high hyperopia by reducing the risks of optical aberrations and regression. The patient must be informed and understand the postoperative course, which differs from that of surgery for myopia.

Middle- and long-term results after iris-fixated phakic intraocular lens implantation in myopic and hyperopic patients: a meta-analysis

The iris-fixated phakic intraocular lens (pIOL) has been available for over 25 years. To provide a clear picture of outcomes and risks, for this systematic review and meta-analysis, the literature was searched for reports on middle- and long-term effects. The iris-fixated phakic intraocular lens (pIOL) has been available for over 25 years. To provide a clear picture of outcomes and risks, for this systematic review and meta-analysis, the literature was searched for reports on middle- and long-term effects of iris-fixated pIOLs on myopic and hyperopic eyes with a follow-up of at least 2 to 4 years. Visual and refractive results after implantation for correction of myopia are positive and the complication rate is low. Endothelial cell loss appears to be at an acceptable rate, although the range of endothelial cell change is too wide to draw firm conclusions. Care should be taken when considering an iris-fixated pIOL for hyperopic eyes because complication rates, particularly pigment dispersion, might be higher than those in myopic eyes. More well-designed, long-term studies are needed, especially in hyperopic eyes. The authors advocate for standardized reporting of refractive surgery data. Initiatives proposed by journal authors and editors to achieve uniformity should be supported.

Micro/nanodevices for assessment and treatment in stomatology and ophthalmology

Micro/nanodevices have been widely applied for the real-time monitoring of intracellular activities and the delivery of exogenous substances in the past few years. This review focuses on miniaturized micro/nanodevices for assessment and treatment in stomatology and ophthalmology. We first summarize the recent progress in this field by examining the available materials and fabrication techniques, device design principles, mechanisms, and biosafety aspects of micro/nanodevices. Following a discussion of biochemical sensing technology from the cellular level to the tissue level for disease assessment, we then summarize the use of microneedles and other micro/nanodevices in the treatment of oral and ocular diseases and conditions, including oral cancer, eye wrinkles, keratitis, and infections. Along with the identified key challenges, this review concludes with future directions as a small fraction of vast opportunities, calling for joint efforts between clinicians and engineers with diverse backgrounds to help facilitate the rapid development of this burgeoning field in stomatology and ophthalmology.

Toric phakic IOLs in keratoconus-evaluation of preoperative parameters on the outcome of phakic anterior chamber lens implantation in patients with keratoconus

Purpose

To evaluate the influence of the type of the keratectasia and preoperative keratometry readings on the efficacy of implantation of iris-fixated phakic anterior chamber intraocular lenses (pIOL) in patients with keratoconus.

Methods

In this retrospective study, iris-fixated pIOLs (Artisan/Artiflex (Ophtec®), Verisyse/Veriflex (AMO®)) were implanted in 38 eyes of 22 patients with stable keratoconus. Thirty-six eyes underwent corneal crosslinking (CXL) prior to the lens implantation. The refractive outcome was evaluated 6 weeks postoperatively and the influence of preoperative refraction and topo- and tomographical factors were analyzed.

Results

The mean postoperative uncorrected distance visual acuity (UDVA_post) was 0.25 ± 0.15 logMAR and was not statistically different from the mean preoperative corrected distance visual acuity (CDVA_pre), which was 0.24 ± 0.13 logMAR. Twenty-seven eyes (71%) reached UDVA_post/CDVA_pre ≥ 1 (efficacy index), whereas patients with PMD-like ectasia (n = 14) showed significantly (p = 0.003) higher efficacy index (100%) than patients diagnosed with keratoconus (n = 24) (54%). Higher eccentricity of the maximum posterior elevation showed a significant beneficial influence on the efficacy index (p = 0.021). Furthermore, a higher Amsler-Krumeich stage and preoperative MAE were correlated with a worse UDVA_post. The mean absolute spherical equivalent was significantly decreased from 5.71 ± 4.96 D to 1.25 ± 1.20 D (p < 0.001). No significant difference was found in endothelial cell count.

Conclusion

The results indicate that the implantation of phakic iris-fixated anterior chamber IOLs is a reasonable refractive option for patients with keratoconus. Keratoconus patients with a pellucidal marginal degeneration (PMD)-like appearance ectasia seem to benefit most from such procedures.

Phakic intraocular lenses: An overview

Phakic intraocular lenses (pIOLs) are a common solution for the surgical correction of high myopia and myopia in thin corneas. Global trends result in increasing rates of patients with high myopia which will result in increased rates of pIOL implantation. Three types of lenses can be distinguished: anterior chamber angle-supported, anterior chamber iris-fixated, and posterior chamber phakic IOLs. The efficacy of phakic intraocular lenses is generally very good, but pIOLs have undergone many changes over the years to improve the safety profile and decrease pIOL-related complications such as endothelial cell loss, corneal decompensation and cataract formation. This article describes the efficacy and safety profiles of the most recent pIOLs, as well as suggests gaps of knowledge that are deserve additional research to optimize the results of pIOLs.

Long-term changes in visual outcomes and ocular morphometrics after myopic and toric phakic intraocular lens implantation: Five- and 10-year results

PURPOSE

To evaluate the long-term refractive and visual, anterior chamber depth, and axial length (AL) changes and complications after rigid iris-fixated phakic intraocular lens (pIOL) implantation to treat myopia or astigmatism.

SETTING

University Eye Clinic Maastricht, Maastricht UMC+, the Netherlands.

DESIGN

Prospective case series.

METHODS

The study evaluated patients who had implantation of an Artisan myopic or toric iris-fixated pIOL as of January 1998. Changes were measured annually and reported after 1, 5, and 10 years postoperatively.

RESULTS

The study comprised 460 eyes (250 patients; mean age 41.1 years ± 10.7 [SD]). Over 10 years, the mean myopization was -0.79 diopters (D) (P < .001), with 52% of eyes within ±1.0 D of target. The mean increase in the logarithm of the minimum angle of resolution (logMAR) corrected distance visual acuity (CDVA) over 10 years was 0.05 (P < .001); 95% of eyes had a CDVA of 20/40 or more and 7% lost 2 or more lines of CDVA. The mean logMAR uncorrected visual acuity (UDVA) increased by 0.14 over 10 years (P < .001); 96% had a UDVA 20/40 or better. The AL increased by 1.14 mm over 10 years (P = .009). Ten percent of pIOLs were explanted because of cataract formation after a mean of 97.9 ± 34.9 months. A higher preoperative age (hazard ratio [HR], 1.08; P < .001) and longer AL (HR, 1.34; P < .001) were risk factors for shorter survival because of cataract formation.

CONCLUSION

Ten years after rigid iris-fixated pIOL implantation, the CDVA and UDVA decreased significantly as a result of significant myopization caused by an increased AL unrelated to the pIOL.

Phakic intraocular lens implantation for the correction of hyperopia

The prevalence of myopia is much higher than hyperopia. Hence, there are relatively few studies investigating phakic intraocular lens (pIOL) implantation for the correction of hyperopia. This review aimed to summarize the available relevant literature on the efficacy and safety of pIOL implantation for the correction of hyperopia and hyperopic astigmatism. At present, two types of pIOLs are used to correct hyperopia and hyperopic astigmatism: anterior chamber iris-fixated pIOLs and posterior chamber implantable collamer lenses. Both have been found to be safe and effective. No serious events (eg, retinal or choroidal detachment, endophthalmitis) were reported in the reviewed articles. Implantation of pIOLs might be the optimal refractive surgery for the correction of high hyperopia.

Outcomes of sequential intracorneal ring segment and phakic intraocular lens insertion for visual rehabilitation in keratoconus

PURPOSE

To report the visual and refractive outcomes of sequential intracorneal ring segment (ICRS) and toric phakic intraocular lens (IOL) insertion for visual rehabilitation in keratoconus.

METHODS

A retrospective interventional cohort study was performed through the Corneoplastics unit and Eye Bank, Queen Victoria Hospital, East Grinstead, United Kingdom.

RESULTS

14 eyes of 12 patients had sequential ICRS and phakic IOL implantation for visual rehabilitation of keratoconus between June 2014 and February 2018. After at least 6 months follow-up, the number of eyes with an uncorrected distance visual acuity (UDVA) of 20/40 UDVA or better increased from zero (0%) to 10 (71%). 12 (85.7%) eyes achieved a post-operative UDVA equal to or better than the pre-operative corrected distance visual acuity (CDVA). The number percentage of eyes with a CDVA of 20/40 or better increased from 3 (31%) to 14 (100%). The mean final spherical equivalent improved from -4.07 to -0.17 (p ⩽ 0.001). The mean refractive astigmatism magnitude improved from 4.76D to 1.23D (p = 0.002). Seven (50%) eyes had 1.0D or less of refractive astigmatism post-operatively.

CONCLUSION

In this cohort of eyes with keratoconus, sequential ICRS and phakic IOL implantation resulted in excellent visual and refractive outcomes after at least 6 months.

Long-term results of Descemet-stripping automated endothelial keratoplasty for endothelial failure caused by phakic intraocular lenses

PURPOSE

To describe the surgical approach and long-term outcomes of Descemet-stripping automated endothelial keratoplasty (DSAEK) for endothelial failure secondary to phakic intraocular lenses (pIOL).

METHODS

Retrospective, interventional case series of 18 eyes of 13 patients who developed endothelial failure secondary to pIOL implant. Patients were submitted to pIOL explant and DSAEK for visual rehabilitation, with or without phacoemulsification plus posterior-chamber intraocular lens implant. The minimum follow-up time was 3 years and the main outcome measures were best-corrected visual acuity (BCVA), endothelial cell density (ECD) and percentage of endothelial cell loss (ECL), intraoperative and postoperative complications.

RESULTS

Patients' mean age was 47.44 (7.86) years with a mean follow-up time of 55.61 (14.13) months. Sixteen eyes (88.9%) had an angle-supported pIOL. The mean pIOL implant-to explant time was 8.17 (2.73) years. BCVA improved from 1.00 (0.36) logMAR preoperatively to 0.29 (0.36) logMAR at 1 year of follow-up (p < 0.001), remaining stable over the entire follow-up period (p > 0.05). At the last visit, all corneas were clear, with a mean ECD of 724.74 (325.57) cells/mm². During the follow-up, two eyes (11.1%) required a re-DSAEK due to early graft failure (<3 months).

CONCLUSION

Our outcomes reveal that an individualized and careful approach may result in a stable visual rehabilitation in young patients with corneal decompensation following pIOL implant.

The Influence of Decentration on Higher-Order Aberrations in Artisan Aphakic Intraocular Lens Implantation Eyes

Purpose

To characterize the influence of decentration on higher-order aberrations of Artisan aphakic intraocular lens implantation eyes. Setting. Department of Ophthalmology and Vision Science, Eye and ENT Hospital of Fudan University, Shanghai, China.

Design

Retrospective case series.

Methods

Twenty-three eyes of 18 patients were retrospectively examined. Location of the IOL was imaged using a slit-lamp, and decentration (the distance from the center of a pupil to the geometric center of the IOL) was measured using the AutoCAD 2007 software. Ocular and internal higher-order aberrations were measured using the wavefront analyzer KR-1W (Topcon) and their correlation with decentration were analyzed. Coma, spherical, 3rd-, 4th-order, trefoil, tetrafoil aberrations, ocular, and internal higher-order aberrations were calculated for a 4.0 mm pupil diameter.

Results

The mean age of patients was 33.6 ± 21.4 years (ranging from 7 to 72 years). The mean follow-up period was 28.2 ± 10.5 months (ranging from 12 to 52 months). The mean postoperative best-corrected visual acuity (BCVA) was 0.19 ± 0.19 logMAR (range −0.18–0.52). The mean decentration was 0.57 ± 0.28 mm (range 0.15–1.21 mm). There was no correlation between Artisan IOL decentration and ocular higher-order aberrations, internal higher-order aberrations, coma, spherical, 3rd-, 4th-order, trefoil, and tetrafoil aberrations, respectively. There was a positive correlation between Artisan IOL decentration and 2nd-astig aberrations when 2nd-astig aberrations were less than 0.1.

Conclusions

The position of Artisan IOLs showed slight decentration and the amounts of decentration were not large enough to influence higher-order aberrations.

[Long term postural myopic shift assessment after posterior iris-claw aphakic intraocular lens implantation]

PURPOSE

Posterior chamber iris-claw intraocular lens (IOL) is often used in aphakic eyes with inadequate capsular support. Postoperatively, patients may describe better capabilities for near reading in a face-down position. The goal was to evaluate the indications, visual outcomes and complications of this IOL and to compare postoperative spherical equivalent between the prone and the face-down position.

MATERIALS AND METHODS

Retrospective single-center case series of 31 eyes of 28 patients who underwent surgery between 2007 and 2016. Visual outcomes, early and late complications were analyzed. The refractive measurements were also assessed using a portable refractometer in prone and face-down position for each patient. The spherical equivalents were then compared.

RESULTS

The mean follow up was 29 months (3-73). The final mean corrected visual acuity (0.17±0.5 SD LogMar) was significantly better than preoperatively (0.5±0.50 SD LogMar) (P<0.05). Postoperative refractive error was within±2 diopters of emmetropia in 95 % of patients. The mean spherical equivalents in prone and face down position were different (P<0.05),-0.44 diopters (-4;+2.75) and-1.38 diopters (-5.25; 1) respectively. A mean myopic shift of-0.95 diopters (-5.25; 1.00) was observed in face down position. Cystoïd macular edema (6 %) and IOL disenclavation (9.6 %) were the main complications.

DISCUSSION

A posterior iris-claw intraocular lens appears to be an effective and relatively safe IOL to treat aphakia with poor capsular support. When the patient's head is bent forward, a mean myopic shift of 1 diopter is observed. This may support the idea that this IOL could be considered as an accommodative implant. Anterior movement of the iris-IOL complex due to gravity may be responsible for this myopic shift.

Verisyse versus Veriflex Phakic Intraocular Lenses: Refractive Outcomes and Endothelial Cell Density 5 Years after Surgery

Purpose

To compare refractive stability, central endothelial cell density (ECD), and complications between Verisyse (Abbott Medical Optics, Netherlands) and Veriflex (Abbott Medical Optics, Netherlands) phakic intraocular lenses (pIOL) over five years.

Methods

We retrospectively reviewed the medical records of patients who underwent Verisyse or Veriflex pIOL implantation for surgical correction of myopia. Patients with a 5-year follow-up period were included in the study. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent of manifest refraction (SE), and ECD were compared between the groups preoperatively and 1, 3, and 5 years postoperatively.

Results

The study included 47 eyes in the Verisyse group and 50 eyes in the Veriflex group. There was no significant difference in mean SE, UDVA, CDVA, and ECD preoperatively or postoperatively. In both groups, there was a statistically significant myopic shift between 1-year and 5-year visits (−0.25 ± 0.30 D and −0.23 ± 0.48 D in the Verisyse and Veriflex groups, respectively). There was no significant difference between the groups in terms of efficacy and safety indexes at 5 years. ECD loss was highest during the first year (3.9% loss in the Verisyse group and 3.9% loss in the Veriflex group, p=0.670). At 5 years, the mean cumulative ECD losses in the Verisyse and Veriflex groups were 7.42% and 7.64%, respectively (p=0.709). Cataracts developed in 2.1% of the eyes in the Verisyse group and in 2.0% of those in the Veriflex group. No sight-threatening complications were observed.

Conclusion

Verisyse and Veriflex pIOLs are highly effective for treating high myopia up to 5 years after surgery. Longitudinal studies with longer follow-up periods are necessary to determine the endothelial safety profile.

Dependency of endothelial cell loss on anterior chamber depth within first 4 years after implantation of iris-supported phakic intraocular lenses to treat high myopia

PURPOSE

To evaluate the effect of the anterior chamber depth (ACD) on the central corneal endothelial cell density (ECD) in eyes after implantation of an iris-fixated phakic intraocular lens (pIOL).

SETTING

Department of Ophthalmology, Goethe-University, Frankfurt, Germany.

DESIGN

Retrospective nonrandomized case series.

METHODS

An Artisan pIOL was implanted in eyes of highly myopic patients. Follow-up examinations at 1, 12, 24, 36, and 48 months included evaluation of ECD and adverse events. Three cohorts based on the ACD were established and their ECDs compared. All eyes had 1-year and 4-year postoperative ECD measurements available. Statistical analysis included linear regression analysis to evaluate the influence of ACD on ECD.

RESULTS

The study comprised 95 eyes (52 patients). Four years after surgery the mean spherical equivalent changed from -11.06 diopters (D) ± 4.77 (SD) to -0.42 ± 0.47 D. Severe adverse events were not detected. There was a significantly higher ECD loss after 4 years in patients with an ACD of less than 3.00 mm than in those with an ACD greater than 3.40 mm (-224 cells/mm²) (P < .01). There was no significant difference in ECD between eyes with an ACD of 3.00 to 3.39 mm and eyes with an ACD less than 3.00 mm (P = .23) or more than 3.40 mm (P = .08).

CONCLUSIONS

The iris-claw pIOL precisely and safely corrected high myopia. However, the loss in ECD can be considerable. Establishing stricter exclusion criteria for ACD might reduce this loss.

FINANCIAL DISCLOSURE

Proprietary or commercial disclosures are listed after the references.

Updates on Managements for Keratoconus

Purpose

Keratoconus is a progressive disease of the cornea which can lead to blindness as irregular astigmatism increases. Currently, a variety of methods are available for the treatment of keratoconus, and in certain cases, it may be difficult to choose the most appropriate option. This article reviews available treatment modalities for keratoconus to provide the practitioner with practical and useful information for selecting the most suitable option for each individual patient.

Methods

To review treatment methods for different stages of keratoconus, PubMed (United States National Library of Medicine) and Scopus (Elsevier BV) databases were searched using the keywords “keratoconus”, “contact lens”, “cross-linking”, “Intacs”, “keratoplasty”, “gene therapy”, and “irregular astigmatism”, and related articles were reviewed based on disease assessment parameters and treatment methods.

Results

Various methods are available for the treatment of keratoconus: eyeglasses and contact lenses in the early stages, cross-linking for stabilizing disease progression, intrastromal corneal ring segments (ICRS) for reducing refractive errors or flattening the cornea, and penetrating keratoplasty (PK) and deep anterior lamellar keratoplasty (DALK), conductive keratoplasty, gene therapy and more recently, bowman layer transplantation (BL transplantation) in advanced stages of the disease. To achieve optimum results, it is essential to choose the best option for each individual patient.

Conclusions

A commonality of the reviewed papers was the advancement of novel diagnostic and treatment methods in ophthalmology, which can delay the need for corneal grafting. A better understanding of keratoconus treatment options can help enhance visual rehabilitation and prevent blindness in keratoconus patients.

Long-Term Endothelial Cell Loss in Patients with Artisan Myopia and Artisan Toric Phakic Intraocular Lenses: 5- and 10-Year Results

PURPOSE

To evaluate the long-term change in endothelial cell density (ECD) after the implantation of 2 types of rigid iris-fixated phakic intraocular lenses (pIOLs) for the treatment of myopia and astigmatism.

DESIGN

Prospective, clinical cohort study.

PARTICIPANTS

A total of 507 eyes of 289 patients receiving the Artisan Myopia or Artisan Toric (Ophtec B.V., Groningen, The Netherlands) iris-fixated pIOL for the treatment of myopia or astigmatism at the University Eye Clinic Maastricht as of January 1998.

METHODS

A total of 381 myopic and 126 toric pIOLs were implanted. Five- and 10-year follow-ups were completed by 193 and 127 eyes implanted with the myopic pIOL and by 40 and 20 eyes implanted with the toric pIOL, respectively.

MAIN OUTCOME MEASURES

Chronic endothelial cell (EC) loss, percentage of eyes with a decrease of ≥25% in ECD, and percentage of eyes with an ECD <1500 cells/mm².

RESULTS

Chronic EC loss was calculated from 6 months postoperatively to the end of follow-up and showed an annual ECD decline of 48 cells/mm² (standard error, 3.14) and 61 cells/mm² (standard error, 6.30) in the myopic (P < 0.001) and toric (P < 0.001) groups, respectively, resulting in a total EC loss of 16.6% and 21.5% from 6 months to 10 years postoperatively, respectively. Ten years after implantation, ECD had decreased by ≥25% in 7.9% and 6.3%, whereas ECD was <1500 cells/mm² in 3.9% and 4.0% in the myopic and toric groups, respectively. Explantation of the pIOL occurred in 6.0% in the myopic group and 4.8% in the toric group. Risk factors for increased EC loss were a shallow anterior chamber depth (ACD) (P ≤ 0.005) and a smaller distance between the central and peripheral pIOL edge to the endothelium (P ≤ 0.005).

CONCLUSIONS

A significant linear chronic EC loss was reported after implantation with myopic or toric iris-fixated pIOLs. A smaller ACD and smaller distance between pIOL edge and endothelium were risk factors for EC loss. Modification of preoperative age-related ECD thresholds is indicated to maintain an ECD that warrants safe future combined pIOL explantation and cataract surgery.

Unilateral Iris-Claw Intraocular Lens Implantation for Aphakia: A Paired-Eye Comparison

PURPOSE

To perform a paired-eye comparison of secondary iris-claw intraocular lens (IOL) implantation for aphakia.

METHODS

Retrospective, comparative, nonrandomized interventional case series of aphakic eyes, which underwent secondary iris-claw Artisan IOL (Ophtec BV) implantation for aphakia in one eye and no surgery (group 1) or cataract surgery (group 2) in the fellow eye. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent, central endothelial cell count (cECC), and complications were evaluated before surgery, and at yearly intervals up to 5 years.

RESULTS

Thirty aphakic eyes implanted with the Artisan were included, and the fellow eyes served as controls. In group 1, postoperative logMAR UDVA and CDVA was significantly higher in the Artisan-implanted eyes (P < 0.01). In group 2, no differences were found in postoperative UDVA and postoperative CDVA between the Artisan-implanted eyes and the eyes that underwent cataract surgery throughout the follow-up (P ≥ 0.05). No statistically significant differences were found in postoperative spherical equivalent between the Artisan-implanted eyes and unoperated eyes or eyes that underwent cataract surgery (P ≥ 0.05). In group 1, cECC was significantly lower in the Artisan-implanted eyes [1973 ± 822 vs. 2616 ± 481 cells per square millimeter at 2 years (P < 0.01)] throughout the follow-up (P < 0.01). In group 2, cECC was not significantly lower in the Artisan-implanted eyes (P ≥ 0.05) [1934 ± 689 vs. 2058 ± 818 cells per square millimeter at 2 years (P = 0.67)].

CONCLUSIONS

Visual rehabilitation with secondary iris-claw IOL implantation in aphakic eyes without capsular support seems to be an effective and safe procedure. As expected, uncomplicated cataract surgery with posterior chamber IOL implantation showed lower endothelial cell count loss. Close monitoring of the corneal endothelium is mandatory.

Long-term Visual and Refractive Outcomes After LASIK for High Myopia and Astigmatism From -8.00 to -14.25 D

PURPOSE

To evaluate outcomes of high myopic LASIK using the MEL 80 excimer laser (Carl Zeiss Meditec, Jena, Germany).

METHODS

Retrospective analysis of 479 consecutive high myopic LASIK procedures (318 patients) using the MEL 80 excimer laser and VisuMax femtosecond laser (Carl Zeiss Meditec) in 77% of cases or zero compression Hansatome microkeratome (Bausch & Lomb, Rochester, NY) in 23% of cases. Inclusion criteria were preoperative spherical equivalent refraction (SEQ) of between -8.00 and -14.25 diopters (D) and corrected distance visual acuity (CDVA) of 20/20 or better. Patients were observed for a minimum of 1 year. Flap thickness was between 80 and 160 µm and optical zone was between 5.75 and 6.50 mm. Standard outcomes analysis was performed.

RESULTS

Mean attempted SEQ was -9.39 ± 1.22 D (range: -8.00 to -14.18 D) and mean cylinder was -1.03 ± 0.84 D (range: 0.00 to -4.50 D). Mean age was 37 ± 9 years (range: 21 to 60 years) with 54% female patients. Postoperative SEQ was ±0.50 D in 55% and ±1.00 D in 83% of eyes after primary treatment. After re-treatment, 69% of eyes were within ±0.50 D and 95% were within ±1.00 D. UDVA was 20/20 or better in 89% of eyes after final treatment. One line of CDVA was lost in 3% of eyes and no eyes lost two or more lines. Statistically significant increases (P < .001) were measured in contrast sensitivity (CSV-1000) at 12 and 18 cycles per degree.

CONCLUSIONS

The MEL 80 excimer laser was found to achieve high efficacy and safety for treatment of high myopia between -8.00 and -14.25 D and up to -4.50 D of cylinder. [J Refract Surg. 2016;32(5):290-297.].

Outcomes of Sutureless Iris-Claw Lens Implantation

Purpose. To evaluate the indications, refraction, and visual and safety outcomes of iris-claw intraocular lens implanted retropupillary with sutureless technique during primary or secondary operation. Methods. Retrospective study of case series. The Haigis formula was used to calculate intraocular lens power. In all cases the wound was closed without suturing. Results. The study comprised 47 eyes. The mean follow-up time was 15.9 months (SD 12.2). The mean preoperative CDVA was 0.25 (SD 0.21). The final mean CDVA was 0.46 (SD 0.27). No hypotony or need for wound suturing was observed postoperatively. Mean postoperative refractive error was −0.27 Dsph (−3.87 Dsph to +2.85 Dsph; median 0.0, SD 1.28). The mean postoperative astigmatism was −1.82 Dcyl (min −0.25, max −5.5; median −1.25, SD 1.07). Postoperative complications were observed in 10 eyes. The most common complication was ovalization of the iris, which was observed in 8 eyes. The mean operation time was 35.9 min (min 11 min, max 79 min; median 34, SD 15.4). Conclusion. Retropupilary iris-claw intraocular lens (IOL) implantation with sutureless wound closing is an easy and fast method, ensuring good refractive outcome and a low risk of complication. The Haigis formula proved to be predictable in postoperative refraction.

Phakic intraocular lens: Two-year results and comparison of endothelial cell loss with iris-fixated intraocular lenses

PURPOSE

To evaluate the efficacy, safety, and stability of a foldable angle-supported Acrysof Cachet phakic intraocular lens (pIOL) to correct moderate to high myopia and compare endothelial cell loss after iris-fixated Artisan and Artiflex pIOL implantation.

SETTING

University Eye Clinic Maastricht, the Netherlands.

DESIGN

Retrospective observational study.

METHODS

Foldable angle-supported pIOL implantation for myopia ranging from -6.0 to -16.5 diopters (D) was done. Uncorrected (UDVA) and corrected (CDVA) distance visual acuity, spherical equivalent (SE), and adverse events were documented preoperatively and 6 months and 1 and 2 years postoperatively. Endothelial cell loss after implantation of the foldable angle-supported pIOL and iris-fixated pIOLs was compared 6 months and 1 and 2 years postoperatively.

RESULTS

There were 158 eyes. The UDVA was equal to or more than 20/25 in 95% of eyes at 1 and 2 years postoperatively. The mean SE was -0.17 D ± 0.43 (SD) 2 years postoperatively. One patient developed pupil ovalization, resulting in explantation of the pIOL from both eyes. Acute endothelial cell loss in the foldable angle-supported pIOL group was -3.2% ± 0.7%, significantly higher than after iris-fixated pIOL implantation. Chronic endothelial cell loss from 6 to 24 months after surgery was -3.8% ± 0.7%. At the 2-year follow-up, the chronic endothelial cell loss in the foldable angle-supported pIOL group was not different than with iris-fixated pIOLs (P > .05).

CONCLUSIONS

The foldable angle-supported pIOL effectively corrected moderate to high myopia. However, acute surgical endothelial cell loss was significantly higher than with iris-fixated pIOLs.

FINANCIAL DISCLOSURE

Dr. Nuijts is a consultant to Alcon Laboratories, Inc., Théa Pharma GmbH, and ASICO LLC; he has received study grants from Acufocus, Inc., Alcon Laboratories, Inc., Carl Zeiss Meditec AG, Ophtec BV, and Physiol S.A. No other author has a financial or proprietary interest in any material or method mentioned.

Long-Term Comparison of Posterior Chamber Phakic Intraocular Lens With and Without a Central Hole (Hole ICL and Conventional ICL) Implantation for Moderate to High Myopia and Myopic Astigmatism: Consort-Compliant Article

The study shows a promising next-generation surgical option for the correction of moderate to high ametropia. Hole implantable collamer lens (ICL), STAAR Surgical, is a posterior chamber phakic intraocular lens with a central artificial hole. As yet, however, no long-term comparison of the clinical results of the implantation of ICLs with and without such a hole has hitherto been conducted. A prospective, randomized, controlled trial was carried out in order to compare the long-term clinical outcomes of the implantation, in such eyes, of ICLs with and without a central artificial hole.Examinations were conducted of the 64 eyes of 32 consecutive patients with spherical equivalents of -7.53 ± 2.39 diopters (D) (mean ± standard deviation) in whom implantation of a Hole ICL was performed in 1 eye, and that of a conventional ICL was carried out in the other, by randomized assignment. Before 1, 3, and 6 months, and 1, 3, and 5 years after surgery, the safety, efficacy, predictability, stability, intraocular pressure, endothelial cell density, and adverse events of the 2 surgical techniques were assessed and compared over time.The measurements of LogMAR uncorrected and corrected distance visual acuity 5 years postoperatively were -0.17 ± 0.14 and -0.24 ± 0.08 in the Hole ICL group, and -0.16 ± 0.10 and -0.25 ± 0.08 in the conventional ICL group. In these 2 groups, 96% and 100% of eyes, respectively, were within 1.0 D of the targeted correction 5 years postoperatively. Manifest refraction changed by -0.17 ± 0.41 D and -0.10 ± 0.26 D occurred in from 1 month to 5 years in the Hole and conventional ICL groups, respectively. Only 1 eye (3.1%), which was in the conventional ICL group, developed an asymptomatic anterior subcapsular cataract.Both Hole and conventional ICLs corrected of ametropia successfully throughout the 5-year observation period. It appears likely that the presence of the central hole does not significantly affect these visual and refractive outcomes.

TRIAL REGISTRATION

UMIN000018771.

Creeping posterior synechiae following hyperopic iris-fixated phakic implants

The purpose of this study was to report on the occurrence and management of posterior synechiae (PS) in three hyperopic eyes after iris-fixated anterior chamber phakic IOL implantation. This is a case report of a 55-year-old man and a 55-year-old lady who had undergone iris-fixated anterior chamber phakic IOL implantation to correct hyperopic astigmatism (one eye) and hyperopia (both eyes), respectively. The three eyes developed creeping PS and pigment dispersion within 4-6 weeks of surgery. Synechiolysis and pupil stretching in one eye did not work as the synechiae promptly recurred. Definitive management in the form of removal of the phakic implant and phacoemulsification with lens implant was successful in restoring normal vision in all three eyes. Although implantation of phakic intraocular lenses has been reported to be very effective for the correction of moderate to high degrees of ametropia, this complication can occur in hyperopic eyes. Pigment dispersion has been reported in myopic eyes also, but PS seem to be more an issue with hyperopic eyes. Age of the patient may also be a factor. This information is important in the selection and counselling of patients.

Iris-fixated phakic intraocular lens implantation to correct myopia and a predictive model of endothelial cell loss

PURPOSE

To report long-term results of Artisan phakic intraocular lens (pIOL) to correct myopia and to propose a model predicting endothelial cell loss after pIOL implantation.

SETTING

Quinze-Vingts National Ophthalmology Hospital, Paris, France.

DESIGN

Retrospective, interventional case series.

METHODS

Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and central endothelial cell count (ECC) were determined before and at yearly intervals up to 5 years after pIOL implantation. Linear model analysis was performed to present a model that describes endothelial cell loss as a linear decrease and an additional decrease depending on postoperative loss.

RESULTS

A total of 49 patients (68 eyes) implanted with pIOLs from January 2000 to January 2009 were evaluated. The mean preoperative and final spherical equivalent (SE) were -13 ± 4.10 and -0.75 ± 0.74 diopters (D), respectively. The mean preoperative and final central ECC were 2629 ± 366 and 2250 ± 454 cells/mm(2), respectively. There were no intraoperative complications for any of the eyes. One eye required surgery for repositioning the pIOL, and 1 eye required pIOL exchange for postoperative refractive error. The model predicted that for patients with preoperative ECC of 3000, 2500, and 2000 cells/mm(2), a critical ECC of 1500 cells/mm(2) will be reached at 39, 28, and 15 years after implantation, respectively.

CONCLUSIONS

Implantation of the pIOL was an effective and stable procedure after 5 years of follow-up. The presented model predicted EC loss after pIOL implantation, which can assist ophthalmologists in patient selection and follow-up.

FINANCIAL DISCLOSURE

The authors report no conflict of interest.

Implantable Collamer Lens for Myopia: Assessment 12 Years After Implantation

PURPOSE

To evaluate the long-term refractive and visual stability and the risks related to the implantation of Implantable Collamer Lens (ICL; STAAR Surgical, Monrovia, CA) phakic intraocular lens (PIOL) for myopia.

METHODS

This retrospective, consecutive, cumulative clinical study was performed in a group of 144 eyes implanted with ICL PIOL for myopia. Only the cases with clinical data available 12 years after the implantation were included in the series. Corrected distance visual acuity (CDVA), uncorrected distance visual acuity, spherical equivalent, refractive astigmatism, endothelial cell density, ICL vaulting, and postoperative complications were analyzed.

RESULTS

Mean spherical equivalent refraction was -16.90±4.26 diopters (D) preoperatively and -1.77±1.93 D 12 years postoperatively. Mean CDVA at the first and last visit were 0.31±0.19 logMAR and 0.22±0.22 logMAR, respectively (Mann-Whitney U test, P<.001). Twelve years postoperatively, 8.9% of eyes had lost more than two lines of CDVA. The incidence of clinically relevant cataracts (13.88%) was significantly linked to the use of the V3 model ICL (chi-square test, P=.007). During the follow-up period, a significant reduction in PIOL vaulting was observed (Kruskal-Wallis test, P<.05), and the mean endothelial cell density decreased by 19.75%.

CONCLUSIONS

The ICL PIOL provided good refractive outcomes and stability in the long term. The incidence of cataracts is low when the latest models of this PIOL are used.

Visual acuity improvement in adult amblyopic eyes with an iris-fixated phakic intraocular lens: long-term results

PURPOSE

To evaluate the effect of implantation of iris-fixated phakic intraocular lenses (pIOLs) (Artisan) in adult amblyopic eyes.

SETTING

Optical Express, London, United Kingdom.

DESIGN

Retrospective case series.

METHODS

The study analyzed data from 5 years of follow-up of amblyopic eyes that were implanted with iris-fixated pIOLs and had a preoperative corrected distance visual acuity (CDVA) of 6/15 or worse. Visual acuity, refraction, endothelial cell count, and complications were assessed.

RESULTS

Data for 103 eyes were analyzed as 2 groups. Group 1 comprised 82 eyes with myopia or myopic astigmatism, and Group 2 contained 21 eyes with hyperopia or hyperopic astigmatism. The mean preoperative sphere in Group 1 was -13.42 diopters (D) ± 5.62 (SD) with a mean cylinder of -2.35 ± 1.75 D. In Group 2, the mean sphere and cylinder were +6.77 ± 1.91 D and -2.63 ± 2.43 D, respectively. The mean CDVA improved from 0.51 ± 0.15 logMAR to 0.34 ± 0.16 logMAR (P<.001) in Group 1 and from 0.54 ± 0.17 logMAR to 0.46 ± 0.14 logMAR in Group 2 (P<.005). The safety index was 1.48 in Group 1 and 1.19 in Group 2. The efficacy index was 1.21 in Group 1 and 1.00 in Group 2. The mean gain in CDVA was statistically significantly greater in Group 1 (0.17 ± 0.14 logMAR) than in Group 2 (0.08 ± 0.11 logMAR). Two or more lines of CDVA were gained by 48.8% of eyes in Group 1 and by 19.0% of eyes in Group 2.

CONCLUSION

The iris-fixated pIOL was a safe and effective option for improving visual acuity in adult amblyopic eyes.

FINANCIAL DISCLOSURE

Dr. Schallhorn is a consultant to Abbott Medical Optics, Inc. No other author has a financial or proprietary interest in any material or method mentioned.