BCLA CLEAR Presbyopia: Management with corneal techniques

Corneal techniques for enhancing near and intermediate vision to correct presbyopia include surgical and contact lens treatment modalities. Broad approaches used independently or in combination include correcting one eye for distant and the other for near or intermediate vision, (termed monovision or mini-monovision depending on the degree of anisometropia) and/or extending the eye's depth of focus [1]. This report reviews the evidence for the treatment profile, safety, and efficacy of the current range of corneal techniques for managing presbyopia. The visual needs and expectations of the patient, their ocular characteristics, and prior history of surgery are critical considerations for patient selection and preoperative evaluation. Contraindications to refractive surgery include unstable refraction, corneal abnormalities, inadequate corneal thickness for the proposed ablation depth, ocular and systemic co-morbidities, uncontrolled mental health issues and unrealistic patient expectations. Laser refractive options for monovision include surface/stromal ablation techniques and keratorefractive lenticule extraction. Alteration of spherical aberration and multifocal ablation profiles are the primary means for increasing ocular depth of focus, using surface and non-surface laser refractive techniques. Corneal inlays use either small aperture optics to increase depth of field or modify the anterior corneal curvature to induce corneal multifocality. In presbyopia correction by conductive keratoplasty, radiofrequency energy is applied to the mid-peripheral corneal stroma, leading to mid-peripheral corneal shrinkage and central corneal steepening. Hyperopic orthokeratology lens fitting can induce spherical aberration and correct some level of presbyopia. Postoperative management, and consideration of potential complications, varies according to technique applied and the time to restore corneal stability, but a minimum of 3 months of follow-up is recommended after corneal refractive procedures. Ongoing follow-up is important in orthokeratology and longer-term follow-up may be required in the event of late complications following corneal inlay surgery.

Central Corneal Thickness of a Saudi Population in Relation to Age, Gender, Refractive Errors, and Corneal Curvature

Background In this study, we aimed to investigate the relationship between central corneal thickness (CCT) and age, gender, refractive errors, and corneal curvature in a Saudi population. Methodology In this randomized, hospital-based, retrospective study, data were collected from Dr. Sulaiman Al Habib Hospital and Imam Medical Center, Riyadh. A total of 1,005 eyes were included and recruited from patients referred to the refractive surgery clinic for Lasik assessment. The study included patients aged between 17 and 57 years with no history of any ocular pathology, eye surgeries, and systemic disease, as well as all groups with stable refractions. The identifying data were the age and gender of the patients, as well as their CCT, refraction, and corneal curvature. CCT and corneal curvature were measured by ultrasound pachymeter Pentacam. Results The distribution of CCT was 543.81 ± 34.47 μm. A significant difference in the mean CCT was observed across different refractive errors (p = 0.004). Patients with astigmatism had the lowest CCT, followed by myopic and hyperopic patients. An association between the spherical equivalent of patients with myopia and CCT (p = 0.001) was noted. Conclusions In the Saudi population, we found no significant association between mean corneal curvature and CCT in all three groups. Spherical equivalent in myopic patients was significantly associated with CCT. A significant difference in the mean CCT was observed across different refractive errors. There was a significant negative and weak correlation between age in myopic and astigmatism patients and CCT. Gender was significantly associated with CCT in patients with astigmatism.

Keratorefractive Surgery Outcomes in Keratoconus Suspect Patients

Purpose. To examine the outcomes of keratorefractive surgeries in keratoconus suspect patients. Methods. This study included 192 keratoconus suspects (351 eyes), treated with photorefractive keratectomy (PRK) (211 eyes), Lasik (96 eyes), and Femto-Lasik (44 eyes) surgeries in an eye clinic. The best spectacle-corrected visual acuity (BSCVA) and subjective refraction were evaluated preoperatively and postoperatively (three months and five years after the procedure). The Orbscan II topography system was also used preoperatively and five years after the procedure. Results. The patients’ mean age was 31.6 ± 5.49 years (range: 21–47 years) in the last follow-up. There was no significant difference between the preoperative and postoperative mean values of BSCVA in any of the surgical methods ( $P$  = 0.49). The mean spherical equivalent, cylindrical power, corneal curvature, the thinnest corneal thickness, and the central corneal thickness decreased significantly in the last follow-up ( $P$  < 0.001). Four patients (3.50%) in the PRK group and one patient (1.85%) in the Lasik group needed glasses in the last follow-up. Eleven cases of corneal ectasia were detected in the last follow-up (six eyes of four patients [2.84%] and five eyes of four patients [5.20%] in the PRK and Lasik groups, respectively). Conclusion. In the present study, the high risk of postoperative ectasia was detected in keratoconus suspects following PRK and Lasik surgeries. According to the results, it can be concluded that Femto-Lasik surgery provides better outcomes than Lasik and PRK. Overall, the surgical criteria are suggested to be evaluated case by case, and the patients must be followed up over time to assess the corneal topography and refraction stability.

Refractive and visual outcomes of small incision lenticule extraction (SMILE) in eyes with thin corneas

OBJECTIVES

To report the refractive and visual outcomes of small incision lenticule extraction (SMILE) with the thinnest corneal thickness (CCT) of less than 500 µm and evaluate it in terms of safety and efficacy.

SETTING

Refractive Surgery Clinic of University of Health Sciences Beyoglu Eye Training and Research Hospital, Istanbul, Turkey.

DESIGN

Retrospective case series.

METHODS

The pre-and-postoperative examinations of all patients with thin corneas (preoperative CCT <500 µm) who underwent the SMILE procedure and had a minimum of 24 months of follow-up records were reviewed from medical files. The main outcome measures of the refractive and visual outcomes and the effect on corneal high order aberrations (HOAs) were evaluated.

RESULTS

The study included 55 eyes of 39 patients. The mean preoperative uncorrected visual acuity (UDVA) was 1.3 ± 1.5 logMAR, and the mean postoperative UDVA was significantly improved to 0.05 ± 0.80 logMAR at the last visit (p < 0.001). At the last follow-up, 84% of the eyes were within ± 0.50D, and 96% of the eyes were within ±1.00D of attempted SE refraction. The HOAs of coma (p < 0.001), secondary astigmatism (p = 0.015), spherical aberration (p < 0.001), and RMS (p < 0.001) aberrations increased significantly from the baseline to the postoperative last visit. The increase in trefoil was not significant (p = 0.32). No sight threatening complications or ectasia were observed during the follow-up time.

CONCLUSION

SMILE is a safe and effective technique with long-term stability for treatment of myopia in eyes with a thin cornea, and satisfactory results can be obtained if candidates for surgery are selected carefully with particular emphasis on normal preoperative corneal topography.

Safety and Efficacy of Myopic LASIK performed on Thin Corneas

Purpose:

The aim was to report on the visual outcomes and safety of myopic LASIK performed in patients with corneas of central thickness below average(<540μm) and normal topography.

Methods:

This is a retrospective cohort study conducted at a private practice setting on Mexican Hispanic patients who underwent myopic LASIK between January 2014 and January 2015. An analysis of records of patients >18 years-old with previous normal topography, stable refraction, corrected visual acuity ≥ 20/20 (Snellen), Central Corneal Thickness (CCT) < 540μm and at least 12 months follow up after surgery was conducted. The main outcome measures were standard visual outcomes (efficacy, safety, refractive stability) and Percent Tissue Altered (PTA) analysis was conducted.

Results:

A total of 51 patients (102 eyes) were included; 56% (n=57) were female. The mean age was 26.52 ± 8.06 (range 18-55 years) with a mean follow up of 13.9 ± 1.2 months. Preoperative CCT was 515.44 ± 17.87μm (range 452- 540μm), with a mean refractive spherical equivalent (SEQ): -4.08 ± 2.17 D (range -0.75 to -9.75 D), and mean refractive cylinder: -1.44 ± 1.29 D (range 0.00 to -6.00 D). Mean predictability of postoperative SEQ was -0.20 ± 0.40 D (range -1.25 to +1.25). Postoperative SEQ was ±0.50 D in 71%, ±1.00 D in 93% of the eyes. Postoperative uncorrected distance visual acuity was ≥20/20 in 78% and ≥20/25 in 95%. One line of CDVA was lost in 3% of the eyes, no eyes lost ≥2 lines. No ectasia cases were observed during follow-up.

Conclusion:

LASIK surgery in Mexican Hispanic patients with thinner than “normal” corneas (<540 μm) is safe, efficient and predictable at 1 year follow up for myopic refractive corrections with no evidence of postoperative keratectasia.

Evaluation of the percentage tissue altered as a risk factor for developing post-laser in situ keratomileusis ectasia

PURPOSE

To assess the currently recommended percentage tissue altered (PTA) metric for its ability to screen for ectasia after laser in situ keratomileusis (LASIK).

SETTING

Gavin Herbert Eye Institute, University of California, Irvine, California, USA, and Rothschild Foundation, Paris, France.

DESIGN

Retrospective case series.

METHODS

The study used a LASIK database created by 1 surgeon for LASIK cases with normal preoperative topography that had a minimum follow-up of 24 months with complete preoperative and intraoperative data to permit the calculation of PTA values to detect eyes at risk for developing ectasia.

RESULTS

Of the eyes, 593 eyes had complete data and met the inclusion criteria. Based on measured flap thickness, 126 eyes (21%) had a PTA value of 40% or more (mean 44) and a percentage of that flap thickness accounted for the PTA (mean 66.7%; range 34% to 92%). The mean attempted laser ablation was 79.8 μm ± 29.2 (SD), and the mean residual bed thickness was 304.4 ± 29.2 μm (range 212 to 369 μm). No eye developed ectasia over a mean follow-up of 30 months.

CONCLUSIONS

The current PTA calculation when applied to a LASIK population with normal preoperative topography and flap thickness measured with ultrasound did not predict the risk for ectasia. Differences between study populations and assumptions might have accounted for the different outcomes obtained in the initially published PTA study.

Topographic, Tomographic, and Aberrometric Characteristics of Post-LASIK Ectasia

PURPOSE

To report the refractive, topographic, tomographic, and aberrometric characteristics of post-LASIK ectasia; to compare these characteristics with normal post-LASIK controls; and to propose a comprehensive system to grade the severity of post-LASIK ectasia.

METHODS

The refraction, corrected distance visual acuity (CDVA), magnitude, and location of the steepest and thinnest point on the cornea, the highest anterior and posterior surface elevation, the radius of best fit sphere, corneal asphericity, and corneal aberrations were measured in 50 eyes of 29 patients with post-LASIK ectasia. These were compared with corresponding parameters in 50 eyes that did not develop ectasia for more than 1 year after LASIK. A logistic regression analysis was used to create a scoring system to grade the severity.

RESULTS

Eyes with post-LASIK ectasia had significantly higher myopia with astigmatism and a lower CDVA than control eyes. Mean topographic toricity was 3.4 ± 1.9D, mean keratometry at the steepest point was 55.32 ± 6.63D, mean highest posterior elevation was 69.72 ± 3 μm, and mean coma was -2.06 ± 1.2 μm. All these parameters were significantly higher than corresponding values in the control group (p < 0.001 in all). Spherical aberration was more negative and the change in asphericity indicated significantly greater prolate shape of the cornea in eyes with post-LASIK ectasia compared to controls. Five parameters, namely, CDVA, spherical equivalent, highest posterior corneal elevation, spherical aberration, and corneal asphericity, were identified as significant predictors of post-LASIK ectasia and used to create a scoring system.

CONCLUSION

Post-LASIK ectasia is characterized by significant changes in refraction, topography, tomography, and aberrometry. The proposed scoring system may be useful in diagnosing, grading, and monitoring post-LASIK ectasia.

Long-term observation and evaluation of femtosecond laser-assisted thin-flap laser in situ keratomileusis in eyes with thin corneas but normal topography

PURPOSE

To evaluate the long-term outcomes of thin-flap laser in situ keratomileusis (LASIK) in eyes with thin corneas (central corneal thickness [CCT] <500 μm) but normal topography.

SETTING

Private center, Tokyo, Japan.

DESIGN

Retrospective randomized comparative study.

METHOD

The efficacy, safety, predictability, and topography of LASIK were evaluated in eyes with a CCT of less than 500 μm but with normal topography (thin-cornea group) to 6 years postoperatively. The LASIK outcomes in the thin-cornea group were compared with those in eyes with a CCT of 500 μm or greater (control group). Analysis was performed to determine whether there were differences between the groups at the last checkup 3 to 4 years postoperatively.

RESULTS

In the thin-cornea group (291 eyes; 146 patients), no significant differences were observed in LASIK outcomes when eyes were subdivided by the time of final checkup (3, 4, and ≥ 5 years). There was a significant difference in visual and refractive outcomes between 3 months postoperatively and the last checkup in the thin-cornea group and the control group (371 eyes; 193 patients). No significant difference in visual, refractive, or topography outcomes was observed between the 2 groups at the last checkup.

CONCLUSIONS

Laser in situ keratomileusis in eyes with thin corneas was as safe and effective as and showed similar long-term stability in eyes with a CCT of 500 μm or greater. No eye in either group had a postoperative complication.

FINANCIAL DISCLOSURE

No author has a financial or proprietary interest in any material or method mentioned.

Risk Factors in Post-LASIK Corneal Ectasia

Purpose. To evaluate the risk factors for post-laser in situ keratomileusis (LASIK) ectasia. Materials and Methods. Medical records of 42 eyes of 28 (10 women, 18 men) patients who developed corneal ectasia after LASIK were retrospectively reviewed. Topographical features and surgical parameters of those patients were evaluated. Results. The mean age of patients was 34.73 ± 6.50 (23–48) years and the mean interval from LASIK to the diagnosis of post-LASIK ectasia was 36.0 ± 16.92 (12–60) months. The following factors were determined as a risk factors: deep ablation (>75 μm) in 10 eyes, FFK (forme fruste keratoconus) in 6 eyes, steep cornea (>47 D) in 3 eyes, pellucid marginal degeneration (PMD) in 2 eyes, thin cornea (<500 μm) in 2 eyes, thin and steep cornea in 2 eyes, thin cornea and deep ablation in 5 eyes, FFK and steep cornea in 2 eyes, and FFK, steep cornea, and deep ablation in 1 eye. However no risk factor has been determined in 9 eyes (21.4%). Conclusion. The findings of our study showed that most of the patients who developed post-LASIK ectasia have a risk factor for post-LASIK ectasia. However, the most common risk factor was deep ablation.

Long-term comparison of laser in situ keratomileusis versus laser surface ablation in corneas thinner than 470 μm

PURPOSE

To compare long-term refractive and visual outcomes of laser in situ keratomileusis (LASIK) and laser surface ablation in eyes with corneas thinner than 470 μm.

SETTING

Private clinics, Spain.

DESIGN

Comparative case series.

METHODS

The study comprised eyes with myopic error and corneas thinner than 470 μm that had at least 2.9 years of postoperative follow-up between September 2001 and June 2007. The main outcome measures were safety, efficacy, predictability, and complications.

RESULTS

The mean central corneal thickness was 462.0 μm (range 440 to 469 μm) in the LASIK group (n = 40) and 458.1 μm (range 420 to 469 μm) in the laser surface ablation group (n = 88). All eyes had normal preoperative topography. In the LASIK group after a mean follow-up of 5.1 years ± 1.5 (SD), the safety index was 1.07, efficacy was 0.99, and predictability (± 1.00 diopter [D]) was 0.93. In the laser surface ablation group after a mean follow-up of 4.8 ± 1.3 years, the safety index was 1.01, efficacy was 0.93, and predictability (± 1.00 D) was 0.92. The mean residual corneal bed thickness in all eyes was 345 ± 25 μm (range 270 to 399 μm). No major complications occurred. The safety index was better in the LASIK group than in the laser surface ablation group.

CONCLUSION

Both techniques were effective, safe, and predictable in eyes with corneas thinner than 470 μm, normal preoperative topography, and a residual corneal bed thickness greater than 250 μm.

High myopia as a risk factor for post-LASIK ectasia: a case report

Purpose

To describe the case of a patient developing corneal ectasia following LASIK for the correction of myopic astigmatism.

Materials and Methods

A 39-year-old man underwent bilateral uneventful LASIK for myopic astigmatism of -10.25 -1.75 ×040 OD and -8.00 -2.50 ×005 OS. Preoperative corneal pachymetry was 542 micrometers OD and 543 micrometers OS. Preoperative corneal topography showed bilateral oblique bow-tie patterns. Central keratometry measurements were 45.12 D @ 124 / 43.87 D @ 34 OD and 44.87 D @ 78 / 43.12 D @ 168 OS. Keratoconus or forme fruste keratoconus were not present preoperatively.

Results

The residual stromal bed was 314 micrometers OD and 295 micrometers OS. Increasing astigmatism was documented progressively after LASIK. Central keratometry and topography were performed with evidence of ectasia OD at 17 months post-operatively and early evidence of ectasia OS at last follow-up of 58 months.

Conclusion

High myopia appears to be a predisposing factor in this patient. High myopia may need to be considered as an ectasia risk factor independent of amount of ablation or residual stromal bed thickness and in the absence of forme fruste keratoconus. The possibility remains that ectasia was due to an unidentified risk factor or an intrinsic corneal problem with this patient's right eye.

Validation of the Ectasia Risk Score System for preoperative laser in situ keratomileusis screening

PURPOSE

To validate the Ectasia Risk Score System for identifying patients at high risk for developing ectasia after laser in situ keratomileusis (LASIK).

DESIGN

Retrospective case-control study.

METHODS

Fifty eyes that developed ectasia and 50 control eyes with normal postoperative courses after LASIK were analyzed and compared using the previously described Ectasia Risk Score System, which assigns points in a weighted fashion to the following variables: topographic pattern, predicted residual stromal bed (RSB) thickness, age, preoperative corneal thickness (CT), and manifest refraction spherical equivalent (MRSE).

RESULTS

In this series, 46 (92%) eyes with ectasia were correctly classified as being at high risk for the development of ectasia, while three (6%) controls were incorrectly classified as being at high risk for ectasia (P < 1 x 10(-10)). Significantly more eyes were classified as high risk by the ectasia risk score than by traditional screening parameters relying on abnormal topography or RSB thickness less than 250 micro (92% vs 50%; P < .00001). There was no difference in the sensitivity or specificity of the Ectasia Risk Score System in the population from which it was derived and this independent population of ectasia cases and controls.

CONCLUSIONS

The Ectasia Risk Score System is a valid and effective method for detecting eyes at risk for ectasia after LASIK and represents a significant improvement over previously utilized screening strategies.