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Fard AM, Patel SP, Nader ND. The efficacy of 2 different phakic intraocular lens implant in keratoconus as an isolated procedure or combined with collagen crosslinking and intra-stromal corneal ring segments: a systematic review and meta-analysis. Int Ophthalmol 2023; 43:4383-4393. [PMID: 37470861 DOI: 10.1007/s10792-023-02813-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
PURPOSE To compare the efficacy of phakic intra-ocular lenses in isolation or in combination with corneal crosslinking (CXL) and/or intra-stromal corneal ring segments (ICRS) in keratoconus. METHODS Data extracted from the publications meeting the selection. The outcome parameters included mean pre- and post-operative uncorrected distance visual acuity, corrected distance visual acuity (CDVA), sphere and cylinder of refraction and complications. Available data analyzed with Cochrane Review Manager. RESULTS A total of 23 studies including 464 eyes were included. All the parameters showed significant improvement in all subgroups other than CDVA in ACPIOL + CXL subgroup and cylinder in PIOL + CXL subgroups. There was not a significant difference between PCPIOL and ACPIOL in the outcomes, exception was more improvement of CDVA in "ACPIOL only" than" PCPIOL only" subgroup. CONCLUSION Both PCPIOLs and ACPIOLs are comparably safe and efficient options in management of KCN and their efficacy significantly improves when combined with CXL/ICRS.
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Affiliation(s)
- Ali Mahdavi Fard
- Department of Ophthalmology, Ross Eye Institute, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
- Department of Ophthalmology, Doheny Eye Center of UCLA, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sangita P Patel
- Department of Ophthalmology, Ross Eye Institute, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
- Research and Ophthalmology Services, Veterans Administration of Western New York Healthcare System, Buffalo, NY, USA
| | - Nader D Nader
- Department of Anesthesiology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA.
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2
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Singh C, Joshi VP. Cataract surgery in Keratoconus revisited - An update on preoperative and intraoperative considerations and postoperative outcomes. Semin Ophthalmol 2023; 38:57-64. [PMID: 35996343 DOI: 10.1080/08820538.2022.2112702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE This review aims to evaluate and simplify the recent literature on preoperative surgical planning, intraoperative considerations, postoperative surprises, and their management in patients with keratoconus undergoing cataract surgery. METHODS A review of the literature was done to analyze all the pertinent articles on Keratoconus and cataract surgery. RESULTS The surgical planning of cataracts in eyes with keratoconus needs a multifaceted approach. Preoperatively, techniques such as cross-linking or the use of intra-corneal rings help stabilize the progression. Unreliable biometric measurements are a significant problem in keratoconus patients, especially in an advanced stage of the disease. It is better to consider actual K readings if the K value is less than 55D but for a K value, more than 55D using standard K values will prevent postoperative refractive surprises. For calculation of K values, an elevation-based device like pentacam gives better repeatability in mild to moderate cases whereas for advanced keratoconus none of the keratometers is reliable. Recently, the Kane keratoconus formula performed better in all stages of disease whereas previous studies showed good results with SRK/T formula is a mild and moderate disease. Monofocal intraocular lenses are a better choice in these patients. Toric lenses can be used in mild and stable keratoconus. Intraoperatively, the use of a customized RGP lens can overcome the challenge of image distortion and loss of visual perspective. Despite taking necessary measures, postoperative refractive surprise can occur and can be managed with IOL exchange or Secondary IOLs. CONCLUSION There is a spectrum of challenges in managing cataracts in keratoconus which makes thorough preoperative planning important for good surgical outcomes. Despite the measures, there might be post-operative surprises and the patients need to be informed regarding the same.
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Affiliation(s)
- Charul Singh
- Academy of Eye Care Education, L V Prasad Eye Institute, Hyderabad, India.,The Cornea Institute, L V Prasad Eye Institute, Hyderabad, India
| | - Vineet P Joshi
- The Cornea Institute, L V Prasad Eye Institute, Hyderabad, India.,Centre for Innovation, L V Prasad Eye Institute, Hyderabad, India
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Sakla HF, Altroudi W, Sakla YFR, Muñoz G, Pineza C. Visual and Refractive Outcomes of Toric Implantable Collamer Lens Implantation in Stable Keratoconus After Combined Topography-Guided PRK and CXL. J Refract Surg 2021; 37:824-829. [PMID: 34914551 DOI: 10.3928/1081597x-20210920-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of toric implantable Collamer lens (ICL) (STAAR Surgical) implanted at least 6 months after combined topography-guided photorefractive keratotomy (TG-PRK) and corneal cross-linking (CXL) in keratoconus. METHODS This retrospective study included 46 eyes with keratoconus of 31 patients who underwent toric ICL implantation after previous TG-PRK+CXL. Patients were examined for uncorrected (UDVA) and corrected (CDVA) distance visual acuity, flat and steep keratometry, and manifest refraction spherical equivalent preoperatively and 12 months postoperatively. RESULTS At 12 months postoperatively, there was a statistically significant improvement in visual and refractive outcomes (all P < .001). Mean UDVA improved to 0.17 ± 0.14 logMAR (vs 1.00 ± 0.38 logMAR preoperatively) and mean manifest refraction spherical equivalent improved to -0.32 ± 1.42 diopters (D) (vs -7.35 ± 5.20 D preoperatively). At 12 months, 63% of eyes achieved UDVA of 20/32 or better and 60.9% of eyes were within ±0.50 D of manifest refraction spherical equivalent. Mean refractive astigmatism improved from -2.90 ± 2.21 D preoperatively to -1.47 ± 1.46 D at postoperative 12 months (P < .001), with 30.4% and 45.7% of eyes having a postoperative astigmatic error within ±0.50 and ±1.00 D, respectively. No complications were observed. CONCLUSIONS Toric ICL implantation was found to be safe and effective for the correction of myopia and myopic astigmatism in patients with stable keratoconus who had undergone TG-PRK+CXL, as revealed by the statistically significant improvement in visual and refractive outcomes at 12 months after toric ICL implantation. [J Refract Surg. 2021;37(12):824-829.].
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4
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Moshirfar M, Barke MR, Huynh R, Waite AJ, Ply B, Ronquillo YC, Hoopes PC. Controversy and Consideration of Refractive Surgery in Patients with Heritable Disorders of Connective Tissue. J Clin Med 2021; 10:3769. [PMID: 34501218 PMCID: PMC8432249 DOI: 10.3390/jcm10173769] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Majid Moshirfar
- Hoopes Vision Research Center, Hoopes Vision, Draper, UT 84020, USA; (B.P.); (Y.C.R.); (P.C.H.)
- John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, UT 84132, USA
- Utah Lions Eye Bank, Murray, UT 84107, USA
| | - Matthew R. Barke
- McGovern Medical School at the University of Texas Health Science Center, Houston, TX 77030, USA;
| | - Rachel Huynh
- University of Utah School of Medicine, Salt Lake City, UT 84132, USA;
| | - Austin J. Waite
- A.T. Still University College of Osteopathic Medicine in Arizona, Mesa, AZ 85206, USA;
| | - Briana Ply
- Hoopes Vision Research Center, Hoopes Vision, Draper, UT 84020, USA; (B.P.); (Y.C.R.); (P.C.H.)
| | - Yasmyne C. Ronquillo
- Hoopes Vision Research Center, Hoopes Vision, Draper, UT 84020, USA; (B.P.); (Y.C.R.); (P.C.H.)
| | - Phillip C. Hoopes
- Hoopes Vision Research Center, Hoopes Vision, Draper, UT 84020, USA; (B.P.); (Y.C.R.); (P.C.H.)
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5
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Kalra N, Asif MI, Bafna RK, Sharma N, Sinha R. Posterior Chamber Phakic Intraocular Lens Implantation for Refractive Correction in Corneal Ectatic Disorders: A Review. J Refract Surg 2021; 37:351-359. [PMID: 34044697 DOI: 10.3928/1081597x-20210115-03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To summarize the indications and outcomes of posterior chamber phakic intraocular lens (PIOL) implantation in corneal ectasias including keratoconus, pellucid marginal degeneration (PMD), post-refractive surgery, and post-keratoplasty ectasias. METHODS A review of the literature was conducted using the relevant keywords from various databases up to August 15, 2020. All pertinent studies were reviewed, and the relevant articles were studied in detail for efficacy, stability, predictability, and safety outcomes. In addition, visual quality, corneal biomechanical outcomes, complications, the role of posterior chamber PIOL in combination treatment, and comparison of posterior chamber PIOL with other PIOLs for ectasias were also evaluated. RESULTS A total of 30 relevant studies (13 prospective, 13 retrospective, 4 case reports) on the subject were studied and summarized. All studies showed a favorable refractive outcome. Quality of vision remained unaffected and no significant complications were reported in any of the studies. CONCLUSIONS Posterior chamber PIOLs represent a viable option in the treatment of mild to moderate and stable corneal ectasia in patients with contact lens intolerance who have low irregular astigmatism, a clear central cornea, and good preoperative corrected distance visual acuity. [J Refract Surg. 2021;37(5):351-359.].
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6
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Hashemian SJ, Saiepoor N, Ghiasian L, Aghai H, Jafari ME, Alemzadeh SP, Hashemian MS, Hashemian SM. Long‐term outcomes of posterior chamber phakic intraocular lens implantation in keratoconus. Clin Exp Optom 2021; 101:652-658. [DOI: 10.1111/cxo.12671] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 11/29/2017] [Accepted: 12/20/2017] [Indexed: 12/01/2022] Open
Affiliation(s)
- Seyed Javad Hashemian
- Department of Ophthalmology, Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,
| | - Nahid Saiepoor
- Department of Ophthalmology, Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,
| | - Leila Ghiasian
- Department of Ophthalmology, Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,
| | - Hossein Aghai
- Department of Ophthalmology, Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,
| | - Mohammad Ebrahim Jafari
- Department of Ophthalmology, Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,
| | - Sayyed Pooya Alemzadeh
- Department of Ophthalmology, Eye Research Center, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran,
| | - Mahsa Sadat Hashemian
- Department of Ophthalmology, School of Pharmacy, International Campus, Tehran University of Medical Sciences, Tehran, Iran,
| | - Seyed Mahyar Hashemian
- Department of Ophthalmology, Shahid Beheshti University of Medical Sciences, Tehran, Iran,
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7
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Fairaq R, Almutlak M, Almazyad E, Badawi AH, Ahad MA. Outcomes and complications of implantable collamer lens for mild to advance keratoconus. Int Ophthalmol 2021; 41:2609-2618. [PMID: 33772698 DOI: 10.1007/s10792-021-01820-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 03/16/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the outcome and safety of implantable collamer lens (ICL; (Visian, STAAR Surgical, Monrovia, CA, USA) in mild to advance keratoconus patients with myopia and myopic astigmatism. METHODS This retrospective study evaluated all patients who underwent ICL implantation for the management of keratoconus at a tertiary care eye hospital from January 2012 to January 2018. The mean duration of follow-up was 15.3 months (range, 3.13 to 38.97 months). Data were collected on preoperative and postoperative uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA), refraction was compared, and adverse effects were evaluated. RESULTS Thirty-two eyes (32 patients) were evaluated. The median CDVA was 20/30 preoperatively and 20/20 at last follow-up. The median UDVA was 20/25 at last follow-up. Thirteen patients (40.6%) had 20/20 UDVA in comparison to none at baseline. The median spherical equivalent in diopters (D) was -7.875 D (-4.125 to -10.0 D) preoperatively and decreased to -0.3125 D at last follow-up. The median manifest refractive cylinder was 3.00 D (2.25 to 5.25 D) preoperatively and decreased to 1.125 D postoperatively. Cylinder axis rotation of 10° or greater occurred in 3 eyes (9.375%) and required repositioning of the ICL. One patient (3%) developed nonvisually significant anterior subcapsular cataract. One ICL (3.125%) had to be explanted due to residual refractive error and unsatisfactory vision. CONCLUSION ICLs are a suitable refractive option for the correction of refractive error associated with stable, nonprogressive keratoconus even in advance cases. However, the risk of ICL rotation and subsequent repositioning remain. Careful patient selection is necessary for achieving good outcomes and mitigating intraoperative and postoperative complications.
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Affiliation(s)
- Rafah Fairaq
- Ophthalmology Department, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia.,Cornea and Anterior Segment Division, King Khaled Eye Specialist Hospital, Umm AlHamam AlGharbi, AlUrubah road, Riyadh, Saudi Arabia
| | - Mohammed Almutlak
- Cornea and Anterior Segment Division, King Khaled Eye Specialist Hospital, Umm AlHamam AlGharbi, AlUrubah road, Riyadh, Saudi Arabia
| | - Enmar Almazyad
- Cornea and Anterior Segment Division, King Khaled Eye Specialist Hospital, Umm AlHamam AlGharbi, AlUrubah road, Riyadh, Saudi Arabia
| | - Abdulrahman H Badawi
- Cornea and Anterior Segment Division, King Khaled Eye Specialist Hospital, Umm AlHamam AlGharbi, AlUrubah road, Riyadh, Saudi Arabia
| | - Muhammad Ali Ahad
- Cornea and Anterior Segment Division, King Khaled Eye Specialist Hospital, Umm AlHamam AlGharbi, AlUrubah road, Riyadh, Saudi Arabia.
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8
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Martínez-Plaza E, López-Miguel A, Holgueras A, Barraquer RI, Alió JL, Maldonado MJ. Phakic intraocular lenses: Recent advances and innovations. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2020; 95:178-187. [PMID: 32156485 DOI: 10.1016/j.oftal.2020.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/02/2020] [Accepted: 02/04/2020] [Indexed: 06/10/2023]
Abstract
Phakic intraocular lenses (pIOL) are recommended when counselling refractive surgery candidates presenting with high ametropia or ocular surface and/or corneal conditions that contraindicate corneal refractive surgery. This review aims to present the state-of-the-art regarding pIOL models currently available in Europe, addressing their newer indications and recent design innovations. These include, in the case of posterior chamber pIOLs, the addition of a central hole to improve aqueous humour circulation, the availability of larger optical zones, and multifocal optics for the compensation of presbyopia. The review also highlights their good safety and efficacy results, as well as the role of patient education to ensure adequate outcomes in the medium-long term. The indications of pIOLs in special situations, as well as bi-lensectomy, a procedure that most pIOL patients may eventually require as they age and develop cataracts, are also addressed.
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Affiliation(s)
- E Martínez-Plaza
- Instituto de Oftalmobiología Aplicada (IOBA), Universidad de Valladolid, Valladolid, España; Red Temática de Investigación Colaborativa en Oftalmología (OftaRed), Instituto de Salud Carlos III, Madrid, España
| | - A López-Miguel
- Instituto de Oftalmobiología Aplicada (IOBA), Universidad de Valladolid, Valladolid, España; Red Temática de Investigación Colaborativa en Oftalmología (OftaRed), Instituto de Salud Carlos III, Madrid, España
| | - A Holgueras
- Instituto de Oftalmobiología Aplicada (IOBA), Universidad de Valladolid, Valladolid, España
| | - R I Barraquer
- Institut Universitari Barraquer, Universitat Autònoma de Barcelona, Universitat Internacional de Catalunya, Barcelona, España; Red Temática de Investigación Colaborativa en Oftalmología (OftaRed), Instituto de Salud Carlos III, Madrid, España
| | - J L Alió
- Vissum Instituto Oftalmológico de Alicante, Alicante, España; Red Temática de Investigación Colaborativa en Oftalmología (OftaRed), Instituto de Salud Carlos III, Madrid, España
| | - M J Maldonado
- Instituto de Oftalmobiología Aplicada (IOBA), Universidad de Valladolid, Valladolid, España; Red Temática de Investigación Colaborativa en Oftalmología (OftaRed), Instituto de Salud Carlos III, Madrid, España.
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9
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Vastardis I, Sagri D, Fili S, Wölfelschneider P, Kohlhaas M. Current Trends in Modern Visual Intraocular Lens Enhancement Surgery in Stable Keratoconus: A Synopsis of Do's, Don'ts and Pitfalls. Ophthalmol Ther 2019; 8:33-47. [PMID: 31605318 PMCID: PMC6789053 DOI: 10.1007/s40123-019-00212-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Indexed: 10/29/2022] Open
Abstract
Keratoconus is a relatively common ectatic, non-inflammatory corneal disorder that involves gradual visual deterioration through progressive alteration of the shape of the cornea. The corneal thinning, irregular astigmatism and higher order aberrations that occur as the disease progresses pose major challenges in the visual rehabilitation of such patients. This paper summarizes the current literature regarding the results of visual enhancement procedures in patients with stable keratoconus treated with standalone anterior or posterior chamber phakic intraocular lens implantation and monofocal, toric or multifocal toric intraocular lens implantation following phacoemulsification for age-related cataract extraction or refractive lens exchange.
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Affiliation(s)
| | | | - Sofia Fili
- St Johannes Hospital, Eye Clinic, Dortmund, Germany
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10
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Surgical Options for the Refractive Correction of Keratoconus: Myth or Reality. J Ophthalmol 2017; 2017:7589816. [PMID: 29403662 PMCID: PMC5748308 DOI: 10.1155/2017/7589816] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 11/28/2017] [Indexed: 01/14/2023] Open
Abstract
Keratoconus provides a decrease of quality of life to the patients who suffer from it. The treatment used as well as the method to correct the refractive error of these patients may influence on the impact of the disease on their quality of life. The purpose of this review is to describe the evidence about the conservative surgical treatment for keratoconus aiming to therapeutic and refractive effect. The visual rehabilitation for keratoconic corneas requires addressing three concerns: halting the ectatic process, improving corneal shape, and minimizing the residual refractive error. Cross-linking can halt the disease progression, intrastromal corneal ring segments can improve the corneal shape and hence the visual quality and reduce the refractive error, PRK can correct mild-moderate refractive error, and intraocular lenses can correct from low to high refractive error associated with keratoconus. Any of these surgical options can be performed alone or combined with the other techniques depending on what the case requires. Although it could be considered that the surgical option for the refracto-therapeutic treatment of the keratoconus is a reality, controlled, randomized studies with larger cohorts and longer follow-up periods are needed to determine which refractive procedure and/or sequence are most suitable for each case.
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11
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Doroodgar F, Niazi F, Sanginabadi A, Niazi S, Baradaran-Rafii A, Alinia C, Azargashb E, Ghoreishi M. Comparative analysis of the visual performance after implantation of the toric implantable collamer lens in stable keratoconus: a 4-year follow-up after sequential procedure (CXL+TICL implantation). BMJ Open Ophthalmol 2017; 2:e000090. [PMID: 29354720 PMCID: PMC5721648 DOI: 10.1136/bmjophth-2017-000090] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/28/2017] [Accepted: 08/24/2017] [Indexed: 11/23/2022] Open
Abstract
Aims To report on 4-year postoperative visual performance with the toric implantable collamer lens (TICL) for stable keratoconus after sequential procedure (corneal collagen crosslinking plus TICL implantation). Methods Forty eyes of 24 patients with stable keratoconus with myopia between 0.00 and −18.00 dioptres (D) and astigmatism between 1.25 and 8.00 D were evaluated in this prospective interventional study (https://clinicaltrials.gov/ct2/show/NCT02833649). We evaluated refraction, visual outcomes, astigmatic changes analysed by Alpins vector, contrast sensitivity, aberrometry, modulation transfer functions (MTFs), defocus curve, and operative and postoperative complications. Results At 4-year follow-up, 45% had 20/20 vision or better and 100% had 20/40 or better uncorrected visual acuity (UCVA). Vector analysis of refractive astigmatism shows that the surgically induced astigmatism (SIA) (3.20±1.46 D) was not significantly different from the target induced astigmatism (TIA) (3.14±1.42 D) (p=0.620). At 4 years postoperatively, none of the eyes showed a decrease in UCVA, in contrast to 24 eyes in which UCVA was increased by ≥1 lines, with contrast sensitivity and improvement in total aberrations and MTF value at 5 per degree (*p=0.004) after TICL implantation. The cumulative 4-year corneal endothelial cell loss was ≤5%. No patients reported dissatisfaction. At the end of follow-up, the vault was 658±54.33m (range, 500–711) and the intraocular pressure was 11.7±2.08 mm Hg. Occurrences of glare and night-driving troubles diminished after TICL surgery. Conclusion The results from this standardised clinical investigation support TICL implantation from clinical and optical viewpoints in patients with stable keratoconus. Trial registration number NCT02833649, Pre-results
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Affiliation(s)
- Farideh Doroodgar
- Ophthalmology Department, Eye Research Center Tehran University of Medical Sciences, Tehran, Tehran, Iran
| | - Feazollah Niazi
- Shahid Beheshti University of Medical Sciences and Health Services , Chamran Highway, Daneshjoo Street, Tehran, Iran, Thran, Tehran, Iran
| | - Azad Sanginabadi
- Ophthalmology Department, Eye Research Center Tehran University of Medical Sciences, Tehran, Tehran, Iran
| | - Sana Niazi
- Shahid Beheshti University of Medical Sciences and Health Services , Chamran Highway, Daneshjoo Street, Tehran, Iran, Tehran, Tehran, Iran
| | - Alireza Baradaran-Rafii
- Shahid Beheshti University of Medical Sciences and Health Services , Chamran Highway, Daneshjoo Street, Tehran, Iran, Tehran, Tehran, Iran
| | - Cyrus Alinia
- Department of Public Health, Urmia University of Medical Sciences, Urmia, West Azerbaijan, Iran
| | - Eznollah Azargashb
- Shahid Beheshti University of Medical Sciences and Health Services , Chamran Highway, Daneshjoo Street, Tehran, Iran, Tehran, Tehran, Iran
| | - Mohammad Ghoreishi
- Ophthalmology Department, Isfahan University of Medical Sciences, Isfahan, Isfahan, Iran
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12
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Chan AT, Zauberman NA, Chan CC, Rootman DS. Outcomes after implantable collamer lens surgery in a Canadian cohort. Can J Ophthalmol 2017; 52:150-154. [DOI: 10.1016/j.jcjo.2016.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 08/31/2016] [Indexed: 11/26/2022]
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13
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Esteve-Taboada JJ, Domínguez-Vicent A, Ferrer-Blasco T, Alfonso JF, Montés-Micó R. Posterior chamber phakic intraocular lenses to improve visual outcomes in keratoconus patients. J Cataract Refract Surg 2017; 43:115-130. [DOI: 10.1016/j.jcrs.2016.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/06/2016] [Accepted: 05/25/2016] [Indexed: 12/01/2022]
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14
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Kim B, Mun S, Choi H, Chung Y. Short-term Clinical Outcomes of Implantable Collamer Lens Implantation with Simultaneous Full Thickness Astigmatic Keratotomy. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2017. [DOI: 10.3341/jkos.2017.58.8.916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Buki Kim
- Onnuri Smile Eye Clinic, Seoul, Korea
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15
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Zhang X, Tao XC, Li ZW, Zhou WY, Ma P, Zhang CX, Wang YM, Mu GY. Combining corneal crosslinking and phakic toric Implantable Collamer Lenses for the treatment of keratectasia: A case report. Exp Ther Med 2016; 12:1495-1498. [PMID: 27602074 DOI: 10.3892/etm.2016.3481] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/05/2016] [Indexed: 11/06/2022] Open
Abstract
The present study reports the use of a phakic toric Implantable Collamer Lens (ICL) that improved the refraction correction of high myopia and astigmatism in a case of keratectasia following corneal cross-linking. A 31-year-old male was diagnosed with keratectasia 12 years after laser-assisted in situ keratomileusis (LASIK). Following LASIK, the manifest refraction was -3.50-2.25×90 [0.1 logarithmic expression (LogMAR) best corrected visual acuity (BVCA)] in the right eye and -8.00-3.50×175 (0.3 LogMAR BCVA) in the left eye, with a LogMAR uncorrected distance visual acuity (UDVA) of 0.8 and a 'counting fingers' value of 3 ft (CF @3 ft) in the left and right eyes, respectively. Riboflavin/ultraviolet A light (UVA) corneal crosslinking (CXL) was conducted on both eyes. Seven months after cross-linking, LogMAR UDVA was 0.4, the manifest refraction was -2.75-2.50×85 and LogMAR BCVA was 0.1 in the right eye. In the left eye, LogMAR UDVA was CF @3 ft, the manifest refraction was -15.00 and LogMAR BCVA was 0.3. The corneal topography was stable 7 months after CXL. Phakic toric ICL was implanted to correct the refractive error, following which the LogMAR UDVA improved to 0.1 in the right eye and 0.3 in left eye, and visual acuity remained stable for 6 months after ICL implantation. In conclusion, combining riboflavin/UVA corneal cross-linking and phakic toric ICL implantation may be an alternative in the correction of high refractive error in patients with keratectasia.
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Affiliation(s)
- Xiao Zhang
- Department of Ophthalmology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, P.R. China
| | - Xiang-Chen Tao
- Department of Ophthalmology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, P.R. China
| | - Zhi-Wei Li
- Department of Ophthalmology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, P.R. China
| | - Wei-Yan Zhou
- Department of Ophthalmology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, P.R. China
| | - Ping Ma
- Department of Ophthalmology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, P.R. China
| | - Chun-Xiao Zhang
- Department of Ophthalmology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, P.R. China
| | - Yu-Meng Wang
- Department of Ophthalmology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, P.R. China
| | - Guo-Ying Mu
- Department of Ophthalmology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250000, P.R. China
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Kamiya K, Shimizu K, Kobashi H, Igarashi A, Komatsu M, Nakamura A, Kojima T, Nakamura T. Three-year follow-up of posterior chamber toric phakic intraocular lens implantation for the correction of high myopic astigmatism in eyes with keratoconus. Br J Ophthalmol 2014; 99:177-83. [PMID: 25147365 DOI: 10.1136/bjophthalmol-2014-305612] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIM To assess the clinical outcomes following the use of toric implantable collamer lenses (toric ICL, STAAR Surgical) for the correction of high myopic astigmatism with keratoconus. METHODS This retrospective study evaluated 21 eyes of 11 patients with spherical equivalents of -9.70±2.33 D (mean±SD) and astigmatism of -3.21±1.56 D who underwent toric ICL implantation for keratoconus. Preoperatively, and at 1, 3 and 6 months and 1, 2 and 3 years postoperatively, we assessed the safety, efficacy, predictability, stability and adverse events of the surgery. RESULTS The logarithm of the minimum angle of resolution (logMAR) uncorrected distance visual acuity (UDVA) and the logMAR corrected distance visual acuity (CDVA) were -0.06±0.11 and -0.12±0.09, respectively, at 3 years postoperatively. At 3 years, 67% and 86% of the eyes were within ±0.5 and ±1.0 D, respectively, of the targeted correction. Manifest refraction changes of 0.04±0.33 D occurred from 1 month to 3 years postoperatively. No significant change in manifest refraction (analysis of variance, p=0.989) or keratometry (p=0.951), or vision-threatening complications occurred during the observation period. CONCLUSIONS Toric ICL implantation is beneficial according to measures of safety, efficacy, predictability and stability for the correction of refractive errors for keratoconus during a 3-year observation period. The disease did not progress even in the late-postoperative period, suggesting the viability of this procedure as a surgical option for the treatment of such eyes.
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Affiliation(s)
- Kazutaka Kamiya
- Department of Ophthalmology, University of Kitasato School of Medicine, Kanagawa, Japan
| | - Kimiya Shimizu
- Department of Ophthalmology, University of Kitasato School of Medicine, Kanagawa, Japan
| | - Hidenaga Kobashi
- Department of Ophthalmology, University of Kitasato School of Medicine, Kanagawa, Japan
| | - Akihito Igarashi
- Department of Ophthalmology, University of Kitasato School of Medicine, Kanagawa, Japan
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Moshirfar M, Edmonds JN, Behunin NL, Christiansen SM. Current Options in the Management of Pellucid Marginal Degeneration. J Refract Surg 2014; 30:474-85. [DOI: 10.3928/1081597x-20140429-02] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 03/11/2014] [Indexed: 11/20/2022]
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Kummelil MK, Hemamalini MS, Bhagali R, Sargod K, Nagappa S, Shetty R, Shetty BK. Toric implantable collamer lens for keratoconus. Indian J Ophthalmol 2014; 61:456-60. [PMID: 23925337 PMCID: PMC3775087 DOI: 10.4103/0301-4738.116064] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Keratoconus is a progressive non-inflammatory thinning of the cornea that induces myopia and irregular astigmatism and decreases the quality of vision due to monocular diplopia, halos, or ghost images. Keratoconus patients unfit for corneal procedures and intolerant to refractive correction by spectacles or contact lenses have been implanted toric posterior chamber phakic intraocular lenses (PC pIOLs) alone or combined with other surgical procedures to correct the refractive errors associated with keratoconus as an off label procedure with special informed consent from the patients. Several reports attest to the safety and efficacy of the procedure, though the associated corneal higher order aberrations would have an impact on the final visual quality.
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Affiliation(s)
- Mathew Kurian Kummelil
- Cataract and Refractive Lens Surgery Services, Narayana Nethralaya, Post-Graduate Institute of Ophthalmology, Bangalore, Karnataka, India
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Evaluation of a Toric Implantable Collamer Lens After Corneal Collagen Crosslinking in Treatment of Early-Stage Keratoconus. Cornea 2014; 33:475-80. [DOI: 10.1097/ico.0000000000000094] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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Clinical Evaluation of Corneal Biomechanical Parameters After Posterior Chamber Phakic Intraocular Lens Implantation. Cornea 2014; 33:470-4. [DOI: 10.1097/ico.0000000000000088] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Comparison of iris-claw and posterior chamber collagen copolymer phakic intraocular lenses in keratoconus. J Cataract Refract Surg 2014; 40:383-94. [DOI: 10.1016/j.jcrs.2013.07.052] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 07/25/2013] [Accepted: 07/30/2013] [Indexed: 02/07/2023]
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Shuber HS. Implantable Collamer Lens for Correction of Refractive Errors in Patients with Keratoconus following Collagen Cross-Linking: One Year Follow-up. ACTA ACUST UNITED AC 2014. [DOI: 10.5005/jp-journals-10025-1074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
ABSTRACT
Objective
The purpose of this study is to assess the predictability, safety, efficacy and stability of correction of refractive errors in patients with keratoconus using Visian implantable collamer lens (ICL) following collagen cross-linking.
Materials and methods
This prospective, non-comparative study evaluated 20 eyes of 14 patients with keratoconus subjected to implantation of intraocular collamer lens at least 1 year following collagen cross-linking and stable refraction. Mean preoperative myopia was −8.43 ± 5.13 Diopters (D) (–3.5 to −20.0D and mean cylinder was −2.19 ± 1.28D (0.0 to −4.5D). The preoperative spherical equivalent (SE) was −9.52 ± 5.33D (–3.75 to −21.25D). During the 12 months follow-up, uncorrected visual acuity, best corrected visual acuity, refraction, intraocular pressure and vaulting are measured.
Results
At 12 months postoperatively, 90% of eye had refractive cylinder of <1.0D with (p = 0.003) and 20 (100%) eyes was within ±0.75D of sphere at 1 year (r2 = 0.99) and (p = 0.0085). The mean postoperative BCVA in decimal was 0.498 ± 0.232, while the mean preoperative BCVA was 0.484 ± 0.285. The safety index at 12 months was 1.02. The mean postoperative UCVA in decimal was 0.498 ± 0.232 and the mean preoperative BCVA is 0.484 ± 0.29 and the efficacy index at 12 months was 1.01.
Conclusion
Implantation of Visian Intraocular collamer lens is predictable, safe and effective way to correct refractive error in patients with keratoconus following collagen cross-linking.
How to cite this article
Shuber HS. Implantable Collamer Lens for Correction of Refractive Errors in Patients with Keratoconus following Collagen Cross-Linking: One Year Follow-up. Int J Kerat Ect Cor Dis 2014;3(1):29-35.
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Abstract
Keratoconus is characterized by progressive corneal protrusion and thinning, leading to irregular astigmatism and impairment in visual function. The etiology and pathogenesis of the condition are not fully understood. However, significant strides have been made in early clinical detection of the disease, as well as towards providing optimal optical and surgical correction for improving the quality of vision in affected patients. The past two decades, in particular, have seen exciting new developments promising to alter the natural history of keratoconus in a favorable way for the first time. This comprehensive review focuses on analyzing the role of advanced imaging techniques in the diagnosis and treatment of keratoconus and evaluating the evidence supporting or refuting the efficacy of therapeutic advances for keratoconus, such as newer contact lens designs, collagen crosslinking, deep anterior lamellar keratoplasty, intracorneal ring segments, photorefractive keratectomy, and phakic intraocular lenses.
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Affiliation(s)
- Jayesh Vazirani
- Cornea and Anterior Segment Services, LV Prasad Eye Institute, Hyderabad, India
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Alfonso JF, Lisa C, Cueto LFV, Belda-Salmerón L, Madrid-Costa D, Montés-Micó R. Clinical outcomes after implantation of a posterior chamber collagen copolymer phakic intraocular lens with a central hole for myopic correction. J Cataract Refract Surg 2013; 39:915-21. [DOI: 10.1016/j.jcrs.2013.01.036] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Revised: 01/04/2013] [Accepted: 01/05/2013] [Indexed: 02/02/2023]
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Abstract
Pre-2000, the clinical management of keratoconus centred on rigid contact lens fitting when spectacle corrected acuity was no longer adequate, and transplantation where contact lens wear failed. Over the last decade, outcome data have accumulated for new interventions including corneal collagen crosslinking, intracorneal ring implantation, topographic phototherapeutic keratectomy, and phakic intraocular lens implantation. We review the current evidence base for these interventions and their place in new management pathways for keratoconus under two key headings: corneal shape stabilisation and visual rehabilitation.
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Affiliation(s)
- D M Gore
- Moorfields Eye Hospital, London, UK.
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Abstract
Implantation of phakic intraocular lenses (pIOLs) is a reversible refractive procedure, preserving the patient's accommodative function with minimal induction of higher order aberrations compared with corneal photoablative procedures. Despite this, as an intraocular procedure, it has potential risks such as cataracts, chronic uveitis, pupil ovalization, corneal endothelial cell loss, pigmentary dispersion syndrome, pupillary block glaucoma, astigmatism, or endophthalmitis. Currently, only two models of posterior chamber pIOLs are commercially available, the implantable collammer lens (STAAR Surgical Co.) and the phakic refractive lens (PRL; Zeiss Meditec). The number of published reports on the latter is very low, and some concerns still remain about its long-term safety. The present article reviews the published literature on the outcomes after PRL implantation in order to provide a general overview and evaluate its real potential as a surgical refractive option.
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Hashemian SJ, Soleimani M, Foroutan A, Joshaghani M, Ghaempanah J, Jafari ME. Toric implantable collamer lens for high myopic astigmatism in keratoconic patients after six months. Clin Exp Optom 2012; 96:225-32. [PMID: 22963113 DOI: 10.1111/j.1444-0938.2012.00800.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Revised: 04/06/2012] [Accepted: 05/05/2012] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The aim was to evaluate the safety, efficacy, stability and predictability of posterior chamber collagen copolymer phakic intraocular lens (pIOL) implantation to correct myopia and myopic astigmatism associated with keratoconus. METHODS The unaided vision and visual acuity, refraction and adverse events were measured in 22 keratoconic eyes of 14 patients after using an implantable collamer lens (ICL) (STAAR Surgical Inc.) to correct refractive error. The outcome was evaluated over six months. RESULTS The mean pre-operative spherical equivalent (SE) and cylinder changed from -4.98 ± 2.63 DS and -2.77 ± 0.99 DC to -0.33 ± 0.51 DS and -1.23 ± 0.65 DC, respectively at the end of six months. Before the surgery the mean Snellen decimal visual acuity was 0.63 ± 0.20. The mean unaided vision and visual acuity changed to 0.76 ± 0.23 and 0.85 ± 0.21, respectively at the end of six months. The mean safety and efficacy indices were 1.40 ± 0.32 and 1.24 ± 0.34, respectively. No eye lost a line of visual acuity and 17 eyes (77.3 per cent) gained one or more lines. Fifteen eyes (68.2 per cent) were within 0.50 D and 20 (90.9 per cent) were within 1.00 D of the desired spherical equivalent refraction. There was a change in manifest refraction of 0.09 ± 0.21 (ranging from -0.25 to +0.75) from one week to six months after the surgery. CONCLUSION The clinical outcomes of the current study demonstrate the safety, efficacy and predictability of toric implantable collamer lens in the correction of myopia and myopic astigmatism associated with keratoconus. The patients' refractions achieved early stability and remained stable during the course of the study.
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Affiliation(s)
- Seyed Javad Hashemian
- Eye Research Center, Rassoul Akram Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Visual quality after posterior chamber phakic intraocular lens implantation in keratoconus. J Cataract Refract Surg 2012; 38:1050-7. [DOI: 10.1016/j.jcrs.2011.12.035] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Revised: 11/30/2011] [Accepted: 12/21/2011] [Indexed: 11/22/2022]
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Alfonso JF, Fernández-Vega L, Lisa C, Fernandes P, González-Meijome J, Montés-Micó R. Long-term evaluation of the central vault after phakic Collamer® lens (ICL) implantation using OCT. Graefes Arch Clin Exp Ophthalmol 2012; 250:1807-12. [PMID: 22371020 DOI: 10.1007/s00417-012-1957-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Revised: 01/07/2012] [Accepted: 01/30/2012] [Indexed: 10/28/2022] Open
Abstract
PURPOSE The aim of this work is to evaluate the changes in the central vault after using implantable Collamer® lenses (ICL) to correct myopia. METHODS This cohort study included 133 eyes; mean spherical equivalent -9.47 ± 3.71 diopters (D) (range: -2.75 to -22.25 D) who underwent ICL V4 implantation. Besides a complete ophthalmologic examination, the central vaulting was measured with Visante OCT and evaluated between different periods of follow-up (1 week, 1, 3, and 6 months, and yearly postoperatively). Post-operative time ranged from 6 to 73 months. RESULTS Within the first 6 months, the mean central vaulting dropped from 510 ± 238 μm (range 100 to 940 μm) to 439 ± 231 μm (range 90 to 910) a significant decrease by 71 ± 58 μm (range -170 to 30 μm) (p = 0.028) with a trend to a lower reduction after this period. After 36 month from ICL implantation, this variation tends to be smaller with the majority of the eyes having a mean decrease smaller than 2 μm per month. Initial vault (Spearman Rho = -0.237, p = 0.006) was the factor more significantly associated with decrease in vault; eyes presenting a reduction in vault >100 μm had an average initial vault that was 141 μm and 184 μm higher than eyes with no change or with increase in vault over time, respectively. CONCLUSIONS This study shows a continuous reduction of central vault over time. The reduction is highest during the first 6 months and tends to be lower and slow down over time. The decrease of vaulting was more pronounced in eyes with larger initial vaulting.
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Affiliation(s)
- Jose F Alfonso
- Fernández-Vega Ophthalmological Institute, Avda. Dres. Fernández-Vega 114, 33012, Oviedo, Spain.
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Central vault after phakic intraocular lens implantation: correlation with anterior chamber depth, white-to-white distance, spherical equivalent, and patient age. J Cataract Refract Surg 2012; 38:46-53. [PMID: 22153092 DOI: 10.1016/j.jcrs.2011.07.035] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 07/21/2011] [Accepted: 07/22/2011] [Indexed: 11/21/2022]
Abstract
PURPOSE To compare the central postoperative vault of a phakic intraocular lens (pIOL) to correct myopia, myopic astigmatism, and hyperopia and identify ocular and lens parameters that might predict the vault amount. SETTING Fernández-Vega Ophthalmological Institute, Oviedo, Spain. DESIGN Cohort study. METHODS Three months after implantation of Implantable Collamer Lens pIOLs to correct myopia, hyperopia, and myopic astigmatism, central vault was measured using optical coherence tomography. Patients were divided into groups according to the preoperative anterior chamber depth (ACD) to compare the effects of ACD, white-to-white (WTW) distance, and lens diameter on postoperative pIOL vault. RESULTS Hyperopic pIOLs had statistically significantly lower vault followed by myopic pIOLs and toric pIOLs, which had a higher mean value and narrower range (260 to 860 μm). Measured vaults had a positive correlation with preoperative ACD (r = .32, P<.001) and WTW (r = .29, P<.001) and a negative correlation with preoperative spherical equivalent (SE) (r = -0.21, P<.001) and patient age (r = -0.12, P=.025). Eyes with a vault of 250 μm or less had a shallower ACD than eyes with a vault between 250 μm and 750 μm (mean difference -0.11 mm; P=.012) and those with a vault greater than 750 μm (mean difference -0.25 mm; P<.001). CONCLUSIONS Central vaulting was lower in hyperopic eyes. Current nomograms for pIOL diameter selection based on ACD and WTW might yield ideal vault and may have to be adjusted for older patients, shallower ACD, lower WTW, and lower SE.
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Camoriano GD, Aman-Ullah M, Purba MK, Sun J, Gimbel HV. Toric collagen copolymer phakic intraocular lens to correct myopic astigmatism in eyes with pellucid marginal degeneration. J Cataract Refract Surg 2012; 38:256-61. [DOI: 10.1016/j.jcrs.2011.08.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 08/12/2011] [Accepted: 08/14/2011] [Indexed: 10/14/2022]
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Güell JL, Morral M, Malecaze F, Gris O, Elies D, Manero F. Collagen crosslinking and toric iris-claw phakic intraocular lens for myopic astigmatism in progressive mild to moderate keratoconus. J Cataract Refract Surg 2012; 38:475-84. [PMID: 22261324 DOI: 10.1016/j.jcrs.2011.10.031] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2011] [Revised: 09/28/2011] [Accepted: 10/04/2011] [Indexed: 01/06/2023]
Abstract
PURPOSE To report the long-term results of combined collagen crosslinking (CXL) and toric phakic intraocular lens (pIOL) implantation to correct myopic astigmatism in patients with progressive mild to moderate keratoconus. SETTING Instituto de Microcirugia Ocular, Barcelona, Spain. DESIGN Case series. METHODS From November 2006 to July 2009, CXL was performed in eyes with proven progressive keratoconus. Once refraction and topography stabilized, toric Artiflex/Artisan pIOL implantation was performed to correct residual myopic astigmatism. A complete ophthalmologic examination, including manifest refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, biomicroscopy, tonometry, fundoscopy, keratometry, corneal tomography, and central endothelial cell count (ECC), was performed before each procedure and postoperatively at 3 months and at yearly intervals up to 5 years. Main outcome measures were accuracy and stability of the spherical equivalent (SE) and cylinder, keratometry, UDVA (efficacy), CDVA (safety), central ECC, and complications. RESULTS The median follow-up in the 9 patients (17 eyes) was 36.9 months ± 15.0 (SD). The median interval between CXL and pIOL implantation was 3.9 ± 0.7 months. Fourteen eyes (82%) were within ± 0.50 diopter (D) of the attempted SE correction and 13 eyes (76%) were within ± 1.00 D of the attempted cylinder correction. The mean difference in simulated keratometry between preoperatively and the last follow-up was 0.17 ± 0.45 D (range -0.55 to 1.45 D). The postoperative UDVA was 20/40 or better in 16 eyes (94%). No eye lost lines of CDVA. No significant decrease in central ECC occurred (P>.05). CONCLUSION Combined CXL and toric iris-claw pIOL implantation effectively and safely corrected myopic astigmatism in progressive mild to moderate keratoconus. FINANCIAL DISCLOSURE Dr. Güell is a consultant to Ophtec. No other author has a financial or proprietary interest in any material or methods mentioned.
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Affiliation(s)
- José L Güell
- Instituto Microcirugia Ocular, Barcelona, Spain.
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Espandar L, Meyer J. Keratoconus: overview and update on treatment. Middle East Afr J Ophthalmol 2011; 17:15-20. [PMID: 20543932 PMCID: PMC2880369 DOI: 10.4103/0974-9233.61212] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Keratoconus is a non-inflammatory, progressive thinning process of the cornea. It is a relatively common disorder of unknown etiology that can involve each layer of the cornea and often leads to high myopia and astigmatism. Computer- assisted corneal topography devices are valuable diagnostic tools for the diagnosis of subclinical keratoconus and for tracking the progression of the disease. The traditional conservative management of keratoconus begins with spectacle correction and contact lenses. Several newer, more invasive, treatments are currently available, especially for contact lens-intolerant patients. Intrastromal corneal ring segments can be used to reshape the abnormal cornea to improve the topographic abnormalities and visual acuity. Phakic intraocular lenses such as iris-fixated, angle-supported, posterior chamber implantable collamer and toric lenses are additional valuable options for the correction of refractive error. Corneal cross-linking is a relatively new method of stiffening the cornea to halt the progression of the disease. The future management of keratoconus will most likely incorporate multiple treatment modalities, both simultaneous and sequential, for the prevention and treatment of this disease.
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Affiliation(s)
- Ladan Espandar
- Department of Ophthalmology, Tulane University, New Orleans, LA, USA
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Fernandes P, González-Méijome JM, Madrid-Costa D, Ferrer-Blasco T, Jorge J, Montés-Micó R. Implantable collamer posterior chamber intraocular lenses: a review of potential complications. J Refract Surg 2011; 27:765-76. [PMID: 21710954 DOI: 10.3928/1081597x-20110617-01] [Citation(s) in RCA: 170] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 05/27/2011] [Indexed: 01/31/2023]
Abstract
PURPOSE To review the peer-reviewed literature reporting postoperative complications of the most recent models of Visian Implantable Collamer posterior chamber intraocular lenses (ICL, STAAR Surgical Co). METHODS A literature search of the PubMed database was performed to identify all articles related to ICL complications. Articles were obtained and reviewed to identify those that reported complications using the latest ICL designs. RESULTS Cataract was the major postoperative complication reported: 136 (5.2%) in 2592 eyes. Of those, 43.4% (n=59) were reported within 1 year, 15.4% (n=21) between 1 and 3 years, and 35.3% (n=48) ≥ 3 years after ICL implantation. Twenty-one (15.4%) cataracts were reported as surgically induced, 46 (33.8%) eyes had poor vault (<200 μm), and cataract surgery was carried out in 27.9% (n=38) of eyes. Early acute intraocular pressure increase was also reported to be relatively frequent, whereas acute pupillary block was less frequent and mostly resolved with additional iridotomies. A total of 42 ICLs were explanted due to cataract and IOP. Reported endothelial cell loss varied from 9.9% at 2 years to 3.7% 4 years postoperatively. This loss was reported to be more pronounced within the first 1 to 2 years, with stability or lower progression after that time. CONCLUSIONS The majority of reported complications after ICL implantation are cataract formation. The improvements in lens geometry and more accurate nomograms applied to the selection of the lens to be implanted, in addition to the surgeon's learning curve, might be factors in the decreased occurrence of postoperative complications reported currently.
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Alfonso JF, Lisa C, Fernández-Vega L, Madrid-Costa D, Poo-López A, Montés-Micó R. Intrastromal corneal ring segments and posterior chamber phakic intraocular lens implantation for keratoconus correction. J Cataract Refract Surg 2011; 37:706-13. [PMID: 21420596 DOI: 10.1016/j.jcrs.2010.10.060] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 10/27/2010] [Accepted: 10/29/2010] [Indexed: 01/13/2023]
Abstract
PURPOSE To evaluate the efficacy, safety, and predictability of sequential implantation of Keraring intrastromal corneal ring segments (ICRS) and an Implantable Collamer Lens phakic intraocular lens (pIOL) with corneal relaxing incisions for refractive correction of keratoconus. SETTING Fernández-Vega Ophthalmological Institute, Oviedo, Spain. DESIGN Cohort study. METHODS This study comprised patients with keratoconus who had ICRS implantation followed 6 months later by pIOL implantation with corneal relaxing incisions. The uncorrected (UDVA) and corrected (CDVA) distance visual acuities and residual refractive errors, analyzed using vector analysis, were recorded preoperatively, 6 months after ICRS implantation, and 6 months after pIOL implantation. RESULTS The study enrolled 40 eyes (31 patients). The mean UDVA (decimal) was 0.11 Snellen ± 0.05 (SD) preoperatively, 0.18 ± 0.14 Snellen 6 months after ICRS implantation (P=.001), and 0.50 ± 0.27 Snellen 6 months after pIOL implantation (P<.0001). The mean CDVA was 0.56 ± 0.23 Snellen, 0.68 ± 0.25 Snellen, and 0.73 ± 0.20 Snellen, respectively (all P<.0001). Six months after pIOL implantation, the efficacy index was 0.88 and the safety index, 1.28. At 6 months, 65% of eyes were within ±1.00 diopter (D) of the desired refraction and 45% were within ±0.50 D. The mean spherical equivalent after pIOL implantation was -1.19 ± 1.33 D. CONCLUSION Sequential ICRS and pIOL implantation plus corneal relaxing incisions provided good visual and refractive outcomes, indicating that it is a predictable procedure for refractive correction of keratoconus. FINANCIAL DISCLOSURE No author has a financial or proprietary interest in any material or method mentioned.
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Affiliation(s)
- José F Alfonso
- Fernández-Vega Ophthalmological Institute, Surgery Department, School of Medicine, University of Oviedo, Oviedo, Spain.
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Alfonso JF, Baamonde B, Fernández-Vega L, Fernandes P, González-Méijome JM, Montés-Micó R. Posterior chamber collagen copolymer phakic intraocular lenses to correct myopia: Five-year follow-up. J Cataract Refract Surg 2011; 37:873-80. [DOI: 10.1016/j.jcrs.2010.11.040] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Revised: 10/21/2010] [Accepted: 11/03/2010] [Indexed: 11/30/2022]
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Mertens EL. Toric phakic implantable collamer lens for correction of astigmatism: 1-year outcomes. Clin Ophthalmol 2011; 5:369-75. [PMID: 21468348 PMCID: PMC3065582 DOI: 10.2147/opth.s7259] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Indexed: 12/04/2022] Open
Abstract
Purpose: The purpose of this study was to assess predictability, efficacy, safety and stability in patients who received a toric implantable collamer lens to correct moderate to high myopic astigmatism. Methods: Forty-three eyes of 23 patients underwent implantation of a toric implantable collamer lens (STAAR Surgical Inc) for astigmatism correction. Mean spherical refraction was −4. 98 ± 3.49 diopters (D) (range: 0 to −13 D), and mean cylinder was −2.62 ± 0.97 D (range: −1.00 to −5.00 D). Main outcomes measures evaluated during a 12-month follow-up included uncorrected visual acuity (UCVA), refraction, best-corrected visual acuity (BCVA), vault, and adverse events. Results: At 12 months the mean Snellen decimal UCVA was 0.87 ± 0.27 and mean BCVA was 0.94 ± 0.21, with an efficacy index of 1.05. More than 60% of the eyes gained ≥1 line of BCVA (17 eyes, safety index of 1.14). The treatment was highly predictable for spherical equivalent (r2 = 0.99) and astigmatic components: J0 (r2 = 0.99) and J45 (r2 = 0.90). The mean spherical equivalent dropped from −7.29 ± 3.4 D to −0.17 ± 0.40 D at 12 months. Of the attempted spherical equivalent, 76.7% of the eyes were within ±0.50 D and 97.7% eyes were within ±1.00 D, respectively. For J0 and J45, 97.7% and 83.7% were within ±0.50 D, respectively. Conclusion: The results of the present study support the safety, efficacy, and predictability of toric implantable collamer lens implantation to treat moderate to high myopic astigmatism.
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Kamiya K, Shimizu K, Kobashi H, Komatsu M, Nakamura A, Nakamura T, Ichikawa K. Clinical outcomes of posterior chamber toric phakic intraocular lens implantation for the correction of high myopic astigmatism in eyes with keratoconus: 6-month follow-up. Graefes Arch Clin Exp Ophthalmol 2010; 249:1073-80. [PMID: 20953620 DOI: 10.1007/s00417-010-1540-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2010] [Revised: 09/23/2010] [Accepted: 10/02/2010] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND To assess the early clinical outcomes of toric implantable collamer lenses (toric ICL™, STAAR Surgical) for the correction of high myopic astigmatism with keratoconus. METHODS This study evaluated 27 eyes of 14 patients with spherical equivalents of -10.11 ± 2.46 D (mean ± standard deviation) and astigmatism of -3.03 ± 1.58 D who underwent toric ICL implantation for mild keratoconus. Before, and 1, 3 and 6 months after surgery, we assessed the safety, efficacy, predictability, stability, and adverse events of the surgery. RESULTS LogMAR uncorrected visual acuity (UCVA) and LogMAR best spectacle-corrected visual acuity (BSCVA) were -0.09 ± 0.16 and -0.15 ± 0.09 respectively, 6 months after surgery. The safety and efficacy indices were 1.12 ± 0.18 and 1.01 ± 0.25. At 6 months, 85% and 96% of the eyes were within ±0.5 and ±1.0 D respectively of the targeted correction. Manifest refraction changes of 0.00 ± 0.35 D occurred from 1 week to 6 months. No vision-threatening complications occurred during the observation period. CONCLUSIONS Toric ICL implantation was good in all measures of safety, efficacy, predictability, and stability for the correction of spherical and cylindrical errors in eyes with early keratoconus throughout the 6-month follow-up period, suggesting its viability as a surgical option for the treatment of such eyes.
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Affiliation(s)
- Kazutaka Kamiya
- Department of Ophthalmology, University of Kitasato School of Medicine, 1-15-1 Kitasato, Sagamihara, Kanagawa, 228-8555, Japan.
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Hafezi F, Majo F, El Danasoury AM. Effect of the Direct Application of Riboflavin and UVA on the Visian Implantable Collamer Lens. J Refract Surg 2010; 26:762-5. [DOI: 10.3928/1081597x-20100415-01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Accepted: 04/08/2010] [Indexed: 11/20/2022]
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Alfonso JF, Baamonde B, Madrid-Costa D, Fernandes P, Jorge J, Montés-Micó R. Collagen copolymer toric posterior chamber phakic intraocular lenses to correct high myopic astigmatism. J Cataract Refract Surg 2010; 36:1349-57. [PMID: 20656159 DOI: 10.1016/j.jcrs.2010.02.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Revised: 02/02/2010] [Accepted: 02/02/2010] [Indexed: 11/27/2022]
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Alfonso JF, Fernández-Vega L, Lisa C, Fernandes P, González-Méijome JM, Montés-Micó R. Collagen copolymer toric posterior chamber phakic intraocular lens in eyes with keratoconus. J Cataract Refract Surg 2010; 36:906-16. [PMID: 20494760 DOI: 10.1016/j.jcrs.2009.11.032] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 11/26/2009] [Accepted: 11/28/2009] [Indexed: 11/27/2022]
Abstract
PURPOSE To assess the safety, efficacy, stability, and predictability of collagen copolymer toric phakic intraocular lens (pIOL) implantation to correct myopia and astigmatism in eyes with keratoconus. SETTING Fernández-Vega Ophthalmological Institute, Oviedo, Spain. METHODS This prospective study comprised keratoconic eyes that had implantation of a toric Intraocular Collamer Lens. Uncorrected (UDVA) and corrected (CDVA) distance visual acuities, refraction, and postoperative complications were evaluated 1, 3, 6, and 12 months postoperatively. RESULTS Preoperatively, the mean spherical equivalent in the 30 eyes (21 patients) was -5.38 diopters (D) +/- 3.26 (SD) (range -13.50 to -0.63 D) and the mean cylinder, -3.48 +/- 1.24 D (range -1.75 to -6.00 D). At 12 months, 86.7% of the eyes were within +/-0.50 D of the attempted refraction and all eyes were within +/-1.00 D. For the astigmatic components J0 and J45, 83.3% of eyes and 86.7% of eyes, respectively, were within +/-0.50 D. The mean Snellen UDVA was 0.81 +/- 0.20 and the mean CDVA, 0.83 +/- 0.18; CDVA was 20/40 or better in 29 eyes 96.7% of eyes and 20/25 or better in 22 eyes (73.3%). No eyes lost more than 2 lines of CDVA; 29 eyes (96.7%) maintained or gained 1 or more lines. The efficacy index was 1.07 and the safety index, 1.16. There were no complications or adverse events. CONCLUSIONS The results confirm that toric ICL implantation is a predictable, effective procedure to correct ametropia in eyes with keratoconus. Predictability and stability were achieved early and remained fairly stable up to 12 months.
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Affiliation(s)
- José F Alfonso
- Fernández-Vega Ophthalmological Institute, Surgery Department, School of Medicine, University of Oviedo, Oviedo, Spain.
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Collagen copolymer toric posterior chamber phakic intraocular lens for myopic astigmatism. J Cataract Refract Surg 2010; 36:568-76. [DOI: 10.1016/j.jcrs.2009.10.052] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Revised: 10/12/2009] [Accepted: 10/31/2009] [Indexed: 11/21/2022]
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Alfonso JF, Lisa C, Abdelhamid A, Fernandes P, Jorge J, Montés-Micó R. Three-year follow-up of subjective vault following myopic implantable collamer lens implantation. Graefes Arch Clin Exp Ophthalmol 2010; 248:1827-35. [PMID: 20333528 DOI: 10.1007/s00417-010-1322-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 01/18/2010] [Accepted: 02/04/2010] [Indexed: 11/24/2022] Open
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Current world literature. Curr Opin Ophthalmol 2009; 21:81-90. [PMID: 19996895 DOI: 10.1097/icu.0b013e3283350158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Alfonso JF, Lisa C, Abdelhamid A, Montés-Micó R, Poo-López A, Ferrer-Blasco T. Posterior chamber phakic intraocular lenses after penetrating keratoplasty. J Cataract Refract Surg 2009; 35:1166-73. [DOI: 10.1016/j.jcrs.2009.02.027] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Revised: 02/16/2009] [Accepted: 02/17/2009] [Indexed: 10/20/2022]
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Alfonso JF, Lisa C, Palacios A, Fernandes P, González-Méijome JM, Montés-Micó R. Objective vs subjective vault measurement after myopic implantable collamer lens implantation. Am J Ophthalmol 2009; 147:978-983.e1. [PMID: 19285654 DOI: 10.1016/j.ajo.2009.01.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Revised: 01/11/2009] [Accepted: 01/12/2009] [Indexed: 11/17/2022]
Abstract
PURPOSE To evaluate the relationship between subjective measurements of vault and objective values measured with Visante optical coherence tomography (OCT) in eyes receiving an implantable contact lens (ICL) for myopia correction. DESIGN Observational cross-sectional study. METHODS SETTING Fernández-Vega Ophthalmological Institute, Oviedo, Spain. PATIENTS Four hundred and fifty-two eyes from 246 patients were elected to be implanted with a Visian ICL V4 (STAAR Surgical Inc, Monrovia, California, USA). OBSERVATION PROCEDURES Subjective and objective measurements of vault after implantation of ICL. MAIN OUTCOME MEASURES Subjective vault classified in 5 levels assessed using an optical section during slit-lamp examination. Objective vault was measured with Visante OCT (Carl Zeiss Meditec Inc, Dublin, California, USA). RESULTS Average values of objective and subjective vault were 414 +/- 228 microm and 2.1 +/- 1.0, respectively and both parameters were highly correlated (r = 0.82; P < .001). Differences in average objective vault were statistically significant among the 5 groups of subjective vault (P < .001). Subjective vault 0 corresponded to a mean OCT value of 62 +/- 49 microm with 99% confidence interval (CI) [38; 86] microm; eyes with vault 1 to 203 +/- 93 microm with 99% CI [176; 230] microm; eyes with vault 2 to 402 +/- 131 microm with 99% CI [378; 425] microm; eyes with vault 3 to 594 +/- 146 microm, 99% CI [554; 633] microm; and vault 4 to 794 +/- 182 microm with 99% CI [713; 875] microm. CONCLUSIONS Subjective and objective values of vault are highly correlated. In 99% of cases within the CI, objective values for eyes subjectively classified within a certain level vary within a narrow interval (+/-25 to 80 microm) around the mean value, and this interval is characteristic of each subjective level.
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Affiliation(s)
- José F Alfonso
- Fernández-Vega Ophthalmological Institute, University of Oviedo, Oviedo, Spain.
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Venter JA, Hannan SJ. A Complex Case Management System Provides Optimal Care for All Patients. J Refract Surg 2009; 25:S655-60. [DOI: 10.3928/1081597x-20090611-06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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