Vision-Related Quality of Life after Cataract Surgery in West Africa

PURPOSE

To study vision related quality of life (VRQoL) before and after a massive cataract campaign in West Africa and the relationship with visual indicators.

METHODS

All the patients who received cataract surgery in Burkina Faso during a blindness prevention campaign were examined. VRQoL was assessed using a modified version of the WHO/PBD VF20. The questionnaire was changed to reflect the socioeconomic and local culture. Patients were interviewed by local interviewers before and three months after surgery. A quality of life related to vision index (QoL-RVI) was calculated.

RESULTS

A total of 305 patients underwent cataract extraction in at least one eye, of these, a total of 196 (64%) completed the study. Mean age was 61.97 ± 14.39 years. The majority of eyes had poor visual acuity (VA<20/200, log MAR: 1.0) preoperatively (88.70%) with a mean VA of logMAR 2.17 ± 0.70 (20/2000) which improved to 0.86 ± 0.64 LogMAR (20/150) 3 months after cataract surgery. QoL-RVI improved postoperatively in 90.2% of patients, did not change in 3.1% and was worse in 6.7%. Statistically significant differences were detected (Wilcoxon test p <0.05) for all items tested before and after surgeries. Correlations for the patients after operations showed that there was a statistically significant relation between a global estimated QoL-RVI and the VA previous to the surgery (-0.196 p=0.014), regarding the same index and the VA after the procedures (-0,35 p=0,00018).

CONCLUSION

Cataract surgery increases the quality of life of patients living in a developing country such as Burkina Faso and the improvement correlates with the recovery of the visual acuity.

Retinal detachment after phacoemulsification in refractive surgery clinics: a large series analysis with variable follow-up during 16 years

PURPOSE

To determine the long-term incidence of pseudophakic retinal detachment (PRD) after phacoemulsification and the weight of the main risk factors in the appearance of such complication in a large sample. To implement a customized formula and a software calculation program able to quantify the risk of suffering PRD applicable to all lens extraction patients.

METHODS

Retrospective cumulative risk analysis conducted on 178,515 eyes operated under similar conditions in a group of refractive surgery clinics (Clínica Baviera SL) located in a relatively limited geographical area (Spain). A survival analysis was performed and the data were modelled using the Weibull regression to determine the risk over a period of 16 years and to estimate the association of different risk factors: sex, age, axial length (AXL) of the eye, intraoperative posterior capsule rents (PCR), and YAG laser capsulotomies. The resulting estimates were translated into a predictive equation for hazard rates and survival probabilities. Later, an application was developed to make prediction available for the clinical community in order to estimate the potential risk of any hypothetical case before lens surgery.

RESULTS

Globally, 1521 (0.85%) cases of PRD were diagnosed during the period. The risk for PRD was significantly greater in males (5.48 [2.94-10.2]; p < 0.001), in long eyes (1.24 [1.21-1.26]; p < 0.001), and also after posterior capsule rents (13.97 [11.61-16.82]; p < 0.001). Posterior capsule rupture increased the risk of PRD up to fourteen times.

CONCLUSIONS

From weaker to stronger impact, age, axial length, sex, and intraoperative posterior capsule rent were significant risk factors for the appearance of PRD after lens extraction.

Cataract surgery in surgical camps: outcomes in a rural area of Cameroon

AIM

To assess the complications and visual outcomes of cataract surgery during an outreach eye camp in Cameroon in which two foreign ophthalmologists operate alongside a local one.

MATERIALS AND METHODS

This is a retrospective and comparative cohort study. The patients were consecutively assigned to three groups depending on the ophthalmologist who performed the cataract surgeries. All eyes underwent manual sutureless incision cataract surgery with posterior chamber intraocular lens (PCIOL) implantation under peribulbar anesthesia. Postoperative visits were scheduled for the first day, first week and second month after the procedures. Intra- and postoperative complications, best-corrected visual acuity and also refractive errors were assessed.

RESULTS

A total of 263 eyes underwent cataract extraction with PCIOL implantation. The percentage of eyes in which two or more lines of corrected distance visual acuity decreased were 2.4%, 2.7% and 0% for groups A, B and C, respectively. The percentage of eyes with good visual outcome (uncorrected distance visual acuity UDVA > 20/60) were, respectively, 82.09%, 81.43% and 80.82% for the three groups. Similar results were found between the three groups regarding complications. Ocular hypertension, transient corneal edema and hyphema were the incidences registered at the first postoperative control performed 24 h after surgery. The most common complication observed 2 months after surgery was posterior capsular opacity (2.6%).

CONCLUSION

High-volume cataract surgery in low- and middle-income countries may have good visual outcomes and a low rate of complications when the procedures are performed by either foreign or local ophthalmologists.

SYNOPSIS

A program of high-volume cataract surgery carried out in a rural environment with few resources can give good visual outcomes in the hands of both foreign and local experienced ophthalmologists.

Safety and Efficacy of the Transition from Extracapsular Cataract Extraction to Manual Small Incision Cataract Surgery in Prevention of Blindness Campaigns

PURPOSE

To compare the safety and the visual outcomes of two experienced cataract surgeons who converted from extracapsular cataract extraction (ECCE) to manual small incision cataract surgery (MSICS) during a campaign for the prevention of blindness.

METHODS

Two surgeons used the ECCE technique (ECCE group) during a campaign in Burkina Faso on 93 consecutive cataract patients with a corrected distance visual acuity (CDVA) <20/80 in the best eye. Both surgeons used MSICS for the first time on 98 consecutive cases in another campaign in Kenya after theoretical instructional courses.

RESULTS

There were no significant differences in CDVA at 3 months postoperatively. There were 69% of eyes with uncorrected distance visual acuity ≥20/60 in the MSICS group and 49% eyes in the ECCE group. Spherical equivalents ranged between -1D and +1D in 55% of the MSICS group versus 43% in the ECCE group. There were significant differences in the changes in the vertical component of astigmatism (J45) but not the horizontal (J0) component. There were no significant differences in the intraoperative complications. The most common postoperative complication was corneal edema on the first day in 40.86% and 19.38% of the ECCE and MSICS groups, respectively.

CONCLUSION

Transitioning from ECCE to MSICS for experienced cataract surgeons in surgical campaigns is safe. The rate of complications is similar for both techniques. Slightly better visual and refractive outcomes can be achieved due to the decreased induction of corneal astigmatism.

Implantable Collamer Lens for Myopia: Assessment 12 Years After Implantation

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Confocal microscopy evaluation of the corneal response following AcuFocus KAMRA inlay implantation

PURPOSE

To describe the corneal appearance on confocal microscopy after AcuFocus KAMRA Inlay (AcuFocus, Inc., Irvine, CA) implantation and evaluate the visual acuity compared to the confocal microscopy data.

METHODS

Twelve eyes of 12 patients implanted with one of three models of the AcuFocus KAMRA Inlay (ACI 7000, 7000T, and 7000PDT) were prospectively evaluated by confocal microscopy 6 months after implantation. Additionally, 4 eyes of 4 patients explanted during the follow-up period were evaluated.

RESULTS

Among the eyes implanted, mean epithelial thickness was 54.6 ± 22 μm. The subbasal nerve plexus was detected in 10 patients. The corneal nerves per unit area were 2.73 ± 2.1 sprouts/mm(2). The branch pattern was found in 8 patients. The mean keratocyte density value was 540 ± 210 cells/mm(2). A low grade of keratocyte activation was found in all patients. Among the eyes explanted, the mean wound healing opacity was 1,092.75 ± 1,877.35 μm/pixel.

CONCLUSIONS

The corneal tolerance to the KAMRA Inlay appeared to be good. The inlay modified the normal structure of the corneal layer, but it was not associated with severe complications of the eye. Keratocyte activation was the finding most associated with a negative visual outcome. Confocal microscopy can be useful to evaluate the long-term evolution of the corneal layer changes following KAMRA Inlay implantation.

Comparative outcomes of bimanual MICS and 2.2-mm coaxial phacoemulsification assisted by femtosecond technology

PURPOSE

To compare the efficacy and safety outcomes of bimanual microincision cataract surgery (MICS) versus 2.2-mm coaxial phacoemulsification assisted by Femtosecond LenSx (Alcon-LenSx Inc., Aliso Viejo, CA).

METHODS

This prospective, randomized, observational, comparative case series comprised 50 cataractous eyes of 50 patients receiving femtosecond laser refractive lens surgery followed by a bimanual MICS technique with two 1-mm incisions (25 patients) (FemtoMICS group) and a coaxial phacoemulsification technique with a 1-mm paracentesis and a 2.2-mm principal incision (25 patients) (FemtoCoaxial group). The main outcomes measures were: ultrasound power, effective phacoemulsification time, postoperative spherical equivalent, higher-order aberrations (corneal and internal), corneal thickness, endothelial cell count, macular thickness, and complications during and after surgery. Both groups were absolutely comparable for all variables preoperatively.

RESULTS

Mean ultrasound power was 1.8% ± 0.9% for MICS and 14.7% ± 4.9% for 2.2-mm incisions (P < .001). Effective phacoemulsification time values for MICS and 2.2-mm incisions were 1.5 ± 0.9 and 4.5 ± 2.9 sec, respectively (P = .002). Mean postoperative spherical equivalent was −0.26 for FemtoMICS and −0.33 for FemtoCoaxial (P > .05). The efficacy index at 1 month postoperatively was 160.2% for FemtoMICS and 149% for FemtoCoaxial. No significant differences were found in corneal thickness, endothelial cell count, and macular thickness. Complications included posterior capsule rupture (4%) and anterior capsule rupture with no posterior capsule tear (4%) for FemtoMICS and bridges due to incomplete capsulorhexis (4%) for FemtoCoaxial.

CONCLUSIONS

MICS and coaxial phacoemulsification techniques assisted by the Femtosecond LenSx achieved excellent safety and efficient outcomes. The FemtoMICS technique was surgically and statistically more efficient than the FemtoCoaxial technique.

Femtosecond laser cataract incision morphology and corneal higher-order aberration analysis

PURPOSE

Analysis of the femtosecond laser refractive lens surgery corneal incision configuration and corneal higher-order aberration (HOA) effect from the first postoperative day.

METHODS

High-resolution anterior segment optical coherence tomography was used to assess 20 eyes undergoing femtosecond laser refractive lens surgery with 2.2-mm minimal incision. The primary incision (tri-planar) actual length, cord length, surface angle, surface irregularity, and regional pachymetry values and the secondary incision (uni-planar) length, angle, surface irregularity, and pachymetry values were analyzed. Hartmann-Shack aberrometer was used to assess corneal HOAs to correlate the effect. Assessment was done preoperatively and 1 month postoperatively.

RESULTS

The actual length, cord length, and surface angle means for the primary incision in the first postoperative day and month were 1.50 ± 0.1 and 1.47 ± 0.2 mm (P = .5), 1.41 ± 0.1 and 1.42 ± 0.2 mm (P = .8), and 27° ± 4° and 23° ± 5° (P = .07), respectively. The length and surface angle for the secondary incision in the first postoperative day and month were 1.17 ± 0.01 and 1.04 ± 0.1 mm (P = .05) and 52° ± 3° and 42° ± 5° (P = .007). The regional pachymetry values for the primary and secondary incisions were significantly increased in the first postoperative day and then significantly decreased after 1 month. All irregularities occurred in the posterior surface (endothelium): 2 cases of posterior gap (first day) and 1 case of posterior retraction (first month). The HOAs had not significantly changed preoperatively and after 1 month.

CONCLUSIONS

The femtosecond laser refractive lens surgery incision is stable and does not significantly change the HOA.

Effect of platelet-rich plasma in nerve regeneration after LASIK

PURPOSE

To investigate the effect of topical eye application of platelet-rich plasma (E-PRP) on the recovery of corneal sensitivity after LASIK and the anatomical recovery of the sub-basal corneal plexus as studied by confocal microscopy.

METHODS

This was a randomized, consecutive, controlled, prospective and masked study on 108 myopic eyes receiving LASIK. The main variables of the study were the increase in corneal sensitivity (Cochet-Bonet aesthesiometer; Luneau, Paris, France) and the aspect of the sub-basal nerve plexus (confocal microscope). Additionally, a biomicroscopic study of the epithelial status of the cornea and a subjective questionnaire were completed. Each eye of each patient was assigned to one of two groups: 54 eyes treated with balanced saline solution and 54 fellow eyes receiving PRP drops for 3 months.

RESULTS

No significant differences were detected when the corneal sensitivity thresholds were compared at any postoperative visit in both groups (P > .05 for all comparisons). Almost identical sub-basal fiber densities were estimated for both groups before LASIK (t test, P = .66). However, the type and severity of staining detected during the slit-lamp examinations at the first and third month postoperatively were significantly less evident in the E-PRP treatment group (Wilcoxon test, P < .05).

CONCLUSIONS

PRP drops have beneficial effects for promoting epithelial status after LASIK but have no positive effect on recovery of corneal sensitivity, probably due to the limited bioavailability of growth factors in corneal stroma when the substance is topically administered.

Outcome analysis of intracorneal ring segments for the treatment of keratoconus based on visual, refractive, and aberrometric impairment

PURPOSE

To analyze the outcomes of intracorneal ring segment (ICRS) implantation for the treatment of keratoconus based on preoperative visual impairment.

DESIGN

Multicenter, retrospective, nonrandomized study.

METHODS

A total of 611 eyes of 361 keratoconic patients were evaluated. Subjects were classified according to their preoperative corrected distance visual acuity (CDVA) into 5 different groups: grade I, CDVA of 0.90 or better; grade II, CDVA equal to or better than 0.60 and worse than 0.90; grade III, CDVA equal to or better than 0.40 and worse than 0.60; grade IV, CDVA equal to or better than 0.20 and worse than 0.40; and grade plus, CDVA worse than 0.20. Success and failure indices were defined based on visual, refractive, corneal topographic, and aberrometric data and evaluated in each group 6 months after ICRS implantation.

RESULTS

Significant improvement after the procedure was observed regarding uncorrected distance visual acuity in all grades (P < .05). CDVA significantly decreased in grade I (P < .01) but significantly increased in all other grades (P < .05). A total of 37.9% of patients with preoperative CDVA 0.6 or better gained 1 or more lines of CDVA, whereas 82.8% of patients with preoperative CDVA 0.4 or worse gained 1 or more lines of CDVA (P < .01). Spherical equivalent and keratometry readings showed a significant reduction in all grades (P ≤ .02). Corneal higher-order aberrations did not change after the procedure (P ≥ .05).

CONCLUSIONS

Based on preoperative visual impairment, ICRS implantation provides significantly better results in patients with a severe form of the disease. A notable loss of CDVA lines can be expected in patients with a milder form of keratoconus.

Comparative analysis of the relationship between anterior and posterior corneal shape analyzed by Scheimpflug photography in normal and keratoconus eyes

BACKGROUND

To analyze and compare the relationship between anterior and posterior corneal shape evaluated by a tomographic system combining the Scheimpflug photography and Placido-disc in keratoconus and normal healthy eyes, as well as to evaluate its potential diagnostic value.

METHODS

Comparative case series including a sample of 161 eyes of 161 subjects with ages ranging from 7 to 66 years and divided into two groups: normal group including 100 healthy eyes of 100 subjects, and keratoconus group including 61 keratoconus eyes of 61 patients. All eyes received a comprehensive ophthalmologic examination including an anterior segment analysis with the Sirius system (CSO). Antero-posterior ratios for corneal curvature (k ratio) and shape factor (p ratio) were calculated. Logistic regression analysis was used to evaluate if some antero-posterior ratios combined with other clinical parameters were predictors of the presence of keratoconus.

RESULTS

No statistically significant differences between groups were found in the antero-posterior k ratios for 3-, 5- and 7-mm diameter corneal areas (p ≥ 0.09). The antero-posterior p ratio for 4.5- and 8-mm diameter corneal areas was significantly higher in the normal group than in the keratoconus group (p<0.01). The k ratio for 3, 5, and 7 mm was significantly higher in the keratoconus grade IV subgroup than in the normal group (p<0.01). Furthermore, significant differences were found in the p ratio between the normal group and the keratoconus grade II subgroup (p ≤ 0.01). Finally, the logistic regression analysis identified as significant independent predictors of the presence of keratoconus (p<0.01) the 8-mm anterior shape factor, the anterior chamber depth, and the minimal corneal thickness.

CONCLUSIONS

The antero-posterior k and p ratios are parameters with poor prediction ability for keratoconus, in spite of the trend to the presence of more prolate posterior corneal surfaces compared to the anterior in keratoconus eyes.

Scheimpflug photography-based clinical characterization of the correlation of the corneal shape between the anterior and posterior corneal surfaces in the normal human eye

PURPOSE

To evaluate the correlation of the mean curvature and shape factors between both corneal surfaces for different corneal diameters measured with a Scheimpflug photography-based system.

SETTING

Vissum Corporation, Alicante, Spain.

DESIGN

Case series.

METHODS

Randomly selected healthy normal eyes had a comprehensive ophthalmologic examination including anterior segment analysis with the Sirius system as follows: anterior and posterior mean corneal radius for 3.0 mm, 5.0 mm, and 7.0 mm; anterior and posterior mean shape factor for 4.5 mm and 8.0 mm; central (CCT) and minimum corneal thickness; and anterior chamber depth (ACD).

RESULTS

The study enrolled 117 eyes (117 subjects; aged 7 to 80 years). The mean anterior mean corneal radius:posterior mean corneal radius ratio was 1.19 (range 1.12 to 1.27) for all corneal diameters (P = .86). The correlation coefficient between the anterior and posterior mean corneal radius was 0.85 or more for all corneal diameters. The anterior mean shape factor:posterior mean shape factor ratio for the 2 corneal diameters analyzed was approximately 1 (range 0.45 to 4.03). The correlations between anterior and posterior mean shape factors were extremely poor and not significant. Multiple regression analysis showed that the central posterior mean corneal radius was significantly correlated with the anterior mean corneal radius, CCT, and spherical equivalent (R(2) = 0.77, P<.01).

CONCLUSIONS

Central posterior corneal curvature could be predicted from the anterior corneal curvature, pachymetry, and the refractive status of the eye but not from the corneal shape factor.

FINANCIAL DISCLOSURE

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

Visual outcomes with a single-optic accommodating intraocular lens and a low-addition-power rotational asymmetric multifocal intraocular lens

PURPOSE

To compare the visual outcomes and intraocular optical quality in patients with a low-addition (add) power multifocal refractive intraocular lens (IOL) with rotational asymmetry and a single-optic accommodating IOL.

SETTING

Vissum Instituto Oftalmológico de Alicante, Miguel Hérnandez University, Alicante, Spain.

DESIGN

Prospective comparative nonrandomized consecutive case series.

METHODS

Consecutive cataract patients had implantation of a low-add-power refractive multifocal IOL with rotational asymmetry (Lentis-Mplus LS-312 MF15) (multifocal group) or a single-optic accommodating IOL (Crystalens HD) (accommodating group). Distance and near visual acuities were evaluated. Ocular optical quality, intraocular aberrations, defocus curve, and contrast sensitivity were evaluated postoperatively.

RESULTS

Of the 66 eyes (40 patients; age 61 to 81 years), 31 were in the multifocal group and 35 were in the accommodating group. Postoperatively, both groups had a significant improvement in the uncorrected and corrected distance visual acuities and uncorrected (UNVA) and corrected near (CNVA) near visual acuities (P <.01). Distance-corrected near visual acuity was significantly better in the multifocal group postoperatively (P ≤.04). No significant differences in UNVA and CNVA were detected postoperatively (P ≥.09). In the defocus curve, the multifocal group had significantly better visual acuities at several defocus levels. The accommodating group had better contrast sensitivity under photopic conditions at all spatial frequencies (P ≤.04). The multifocal group had significantly higher postoperative intraocular tilt (P <.01).

CONCLUSIONS

Both IOLs restored distance vision. The refractive multifocal IOL provided better near visual rehabilitation.

Refractive outcomes and quality of vision related to an outbreak of diffuse lamellar keratitis

PURPOSE

To report the impact on visual function and corneal aberrations during an epidemic of diffuse lamellar keratitis (DLK).

METHODS

A retrospective, comparative, and consecutive case-control study was performed, involving 418 eyes operated between March and October 2007 in the refractive surgery unit of one center. Eyes were separated into groups: group 1 (DLK group) included 209 eyes that presented with DLK after LASIK and group 2 (control group) included 209 unaffected, consecutive eyes operated from the beginning of the outbreak. Refractive variables and corneal aberrations were compared between the two groups.

RESULTS

Visual outcomes were significantly different when comparing control eyes and eyes with DLK grades 3 and 4, but not for eyes with DLK grades 1 and 2. Uncorrected distance visual acuity (UDVA) significantly improved from the third month after DLK was diagnosed (Kruskal-Wallis, P=.02). Corrected distance visual acuity (CDVA) did not decrease significantly with DLK grades 1 and 2 (preoperative CDVA vs 1, 3, and 6 months after diagnosis; Mann-Whitney, P>.05, respectively). At the end of follow-up, UDVA and CDVA were not significantly different between the two groups. Eyes suffering from DLK had significantly increased corneal aberrations, except for spherical and astigmatism aberrations, 3 months after being diagnosed (Kruskal-Wallis, P<.05); however, corneal aberrations were not significantly different between the DLK and control groups (Mann-Whitney, P>.05).

CONCLUSIONS

The outbreak of DLK did not induce a significant decrease in global visual outcomes, except in severe cases, and postoperative corneal aberrations were not affected.

Visual and optical performance with two different diffractive multifocal intraocular lenses compared to a monofocal lens

PURPOSE

To compare the visual acuity outcomes as well as the ocular optical performance of eyes implanted with either a monofocal or one of two diffractive multifocal intraocular lenses (IOLs).

METHODS

One hundred two consecutive eyes of 51 bilateral cataract patients (age 49 to 80 years) were divided into three groups: 22 eyes were implanted with a monofocal IOL (monofocal group), 40 eyes with the Acrysof ReSTOR SN6AD3 IOL (ReSTOR group), and 40 eyes with the Acri.Lisa 366D IOL (Acri.Lisa group). Visual acuity and contrast sensitivity were evaluated pre- and postoperatively. Additionally, ocular optical quality and intraocular aberrations were evaluated postoperatively.

RESULTS

Significant improvement after surgery in uncorrected and corrected distance and near visual acuity was observed in all three groups (P≤.05). Uncorrected near visual acuity was significantly better in eyes from the ReSTOR and Acri.Lisa groups compared to the monofocal group (P≤.01). Photopic contrast sensitivity was significantly better for the spatial frequency of 3 cycles/degree in the monofocal group (P<.01). Significantly higher values of the ocular Strehl ratio and cutoff modulation transfer function spatial frequency were also found in the Acri.Lisa group (P=.01). An acceptable range of vision between near and distance peaks was observed in the defocus curves of the ReSTOR and Acri.Lisa groups.

CONCLUSIONS

The AcrySof ReSTOR and Acri.Lisa 366D IOLs are able to successfully restore near and intermediate visual function after cataract surgery; however, the Acri.Lisa design seems to provide better optical performance. These results need to be confirmed in a randomized, prospective trial.

Inhibition of corneal neovascularization by topical bevacizumab (Anti-VEGF) and Sunitinib (Anti-VEGF and Anti-PDGF) in an animal model

PURPOSE

To evaluate the effects of topically applied bevacizumab and sunitinib on experimentally induced corneal neovascularization.

DESIGN

Experimental animal study.

METHODS

Thirty-six New Zealand rabbits were involved. One eye per rabbit was used. Corneal neovascularization was induced by placing 5 silk sutures in the upper cornea. Rabbits were randomized to 1 of 3 groups (12 rabbits each): Group 1 received saline 0.9%, Group 2 bevacizumab 5 mg/mL, and Group 3 sunitinib 0.5 mg/mL. All treatments were administered 3 times daily for 14 days. Photographs were taken on a slit lamp on days 7 and 14, and angiographic photographs were taken on day 14. The area of neovascularization was measured in mm(2), percentage of the total corneal area, and percentage of the corneal surface covered by sutures.

RESULTS

On day 14, corneal neovascularization area in Group 1 (25.92 ± 5.08 mm(2), 18.78% ± 3.5% of corneal surface, 105.59% ± 18.9% of corneal surface with sutures) was larger than in Groups 2 (18.52 ± 7.94 mm(2), 13.67% ± 5.8%, 76.35% ± 33.2%) (1-way analysis of variance, P = .041) and 3 (4.57 ± 2.32 mm(2), 3.40% ± 1.7%, 18.94% ± 9.2%)(P < .001). Neovascularization in Group 2 was larger than in Group 3 (P < .001). Compared to saline, corneal neovascularization was inhibited 28.5% by bevacizumab and 82.3% by sunitinib. Sunitinib settled on the iris.

CONCLUSIONS

Topical administration of both bevacizumab and sunitinib inhibits corneal neovascularization in rabbits. But vascular endothelial growth factor (VEGF) pathway blockade by bevacizumab was not sufficient for a profound inhibition. Blocking both VEGF and platelet-derived growth factor pathways using sunitinib was 3-fold more effective.

Increased risk for flap dislocation with perioperative brimonidine use in femtosecond laser in situ keratomileusis

PURPOSE

To determine whether brimonidine 0.2% minimizes the occurrence of subconjunctival hemorrhages without inducing postoperative flap complications in femtosecond laser in situ keratomileusis (LASIK).

SETTING

Centro Oftalmológico Marqués de Sotelo and Hospital NISA Virgen del Consuelo, Valencia, Spain.

METHODS

This prospective contralateral-eye interventional study evaluated consecutive patients who had bilateral simultaneous femtosecond LASIK for myopia (spherical equivalent [SE] range -1.00 to -8.00 diopters) performed with an IntraLase femtosecond laser and a Visx Star 2 excimer laser. One eye of each patient received a single drop of brimonidine tartrate 0.2% (brimonidine group) and the other eye, a single drop of a balanced salt solution (control group).

RESULTS

The study evaluated 136 eyes (68 patients). The difference in the incidence of subconjunctival hemorrhages was statistically significantly lower in the brimonidine group (mean score 2.24 +/- 1.96 [SD]) than in the control group (mean score 7.61 +/- 2.72) (P<.001). However, no eye in the control group and 7 eyes (10.4%) in the brimonidine group had a dislocated flap with folds on the first postoperative day (P = .016). All eyes with dislocated flaps required surgical intervention. At 6 months, there was no significant difference between groups in the percentage of eyes achieving 20/20 or better uncorrected distance visual acuity, in the mean SE, or in the enhancement rate.

CONCLUSIONS

Brimonidine prevented the formation of subconjunctival hemorrhages after femtosecond LASIK but increased the risk for flap dislocation. Thus, surgeons are cautioned against the use of perioperative brimonidine to decrease hemorrhagic complications in femtosecond LASIK.

Femtosecond laser in situ keratomileusis for consecutive hyperopia after radial keratotomy

PURPOSE

To assess the use of the femtosecond laser for laser in situ keratomileusis (LASIK) in eyes with consecutive hyperopia after radial keratotomy (RK).

SETTING

Private ambulatory surgical center, Valencia, Spain.

METHODS

This prospective noncomparative interventional case series study included 13 eyes of 9 patients with secondary hyperopia after previous RK. The patients were operated on with the IntraLase femtosecond laser (IntraLase Corp.) and the Star S2 excimer laser (Visx, Inc.). Postoperative uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), manifest refraction, flap thickness, flap diameter, and complications were evaluated at 6 months.

RESULTS

The mean spherical equivalent (SE) decreased from 2.00 diopters (D)+/-0.40 (SD) to -0.41+/-0.61 D, with 8 eyes (61.5%) within+/-0.50 D of the targeted refraction. Twelve eyes (92.3%) had a UCVA of 20/40 or better, and 3 eyes (23.1%) lost 1 line of BSCVA. A mean change in SE of 0.10 D was observed at the 6-month follow-up. The mean flap thickness and diameter were 117+/-14 microm and 9.18+/-0.12 mm, respectively. Most complications were in eyes with more than 8 RK incisions than in eyes with 8 RK incisions. These complications were multiple intraoperative incision openings (100% versus 28.6%, respectively), interface inflammation (66.6% versus 0%, respectively), haze (83.3% versus 14.3%, respectively), and loss of BSCVA (50% versus 0%, respectively).

CONCLUSIONS

The femtosecond laser provided large, thin corneal flaps for hyperopic LASIK. However, the procedure should be avoided in eyes with more than 8 RK incisions because of the increased risk for multiple intraoperative incision openings, interface inflammation, haze, and loss of BSCVA.

Confocal Microscopy and Histopathological Examination of Diffuse Lamellar Keratitis in an Experimental Animal Model

PURPOSE

To investigate the cell populations and structural alterations of the cornea in an experimental model of diffuse lamellar keratitis (DLK) using confocal microscopy and histopathology.

METHODS

A corneal flap was cut in 22 eyes of 11 New Zealand rabbits and the stromal interface was exposed to balanced salt solution (BSS, BSS group) and Pseudomonas aeruginosa lipopolysaccharide (LPS) endotoxin (5 mg/mL) (LPS 5 mg/mL group) and (3.5 mg/mL) (LPS 3.5 mg/mL group). Postoperatively, eyes were examined with a slit-lamp microscope (DLK grading) and confocal microscopy. Animals were sacrificed on day 3 (BSS group and LPS 5 mg/mL group) and day 4 (LPS 3.5 mg/mL group). Corneoscleral buttons were excised and processed for histopathologic examination.

RESULTS

Seven eyes were excluded. Slit-lamp microscopy revealed no cellular infiltration in the BSS group (five eyes). In the LPS groups, all eyes developed DLK, with iritis only observed in grade III eyes. In the LPS 5 mg/mL group, four eyes had DLK grade III, with iritis in three eyes. In the LPS 3.5 mg/mL group, three eyes had grade II and three eyes had grade III with iritis. On confocal microscopy, the BSS group had no cellular infiltration. Dense accumulation of inflammatory cells at the interface was noted in both LPS groups. Histopathology in the BSS group had a normal appearance. In the LPS groups, an inflammatory infiltrate was present at the interface that consisted of three cell populations--eosinophils, neutrophils, and lymphocytes.

CONCLUSIONS

Lipopolysaccharide endotoxin induced DLK in all exposed eyes, with iritis in a considerable proportion of eyes. The infiltrate consisted of three cell populations. Confocal microscopy showed the infiltrate in all affected eyes. Histopathological and confocal microscopic findings correlated well with the clinical appearance.

Outcomes of ZB5M Angle-supported Anterior Chamber Phakic Intraocular Lenses at 12 Years

PURPOSE

To evaluate the visual and refractive stability and the potential long-term risks associated with ZB5M phakic intraocular lens (PIOL) implantation.

METHODS

A retrospective, non-randomized, cumulative clinical study was performed over 12 years in a consecutive group of 225 eyes implanted with the ZB5M PIOL. The main analyzed variables were visual and refractive outcomes (best spectacle-corrected visual acuity [BSCVA], uncorrected visual acuity [UCVA], and spherical equivalent), endothelial cell density, and postoperative complications.

RESULTS

Mean preoperative spherical equivalent refraction was -17.23 +/- 7.69 diopters (D) and 12 years postoperatively it was -1.80 +/- 0.80 D. Mean BSCVA at 1- and 12-year follow-up was 0.38 +/- 0.19 and 0.57 +/- 0.18, respectively (Wilcoxon test, P < .001). At 12 years postoperatively, 3.5% of eyes lost > or = 2 lines of BSCVA. An initial 10.6% reduction in endothelial cell density was noted in the first year, followed by a mean annual rate of decrease of 1.78%. The cumulative incidence of pupil ovalization was 34.7% (78 eyes), and there was no statistical correlation with endothelial cell impairment. Bilateral hypertensive uveitis was diagnosed in 3 (1.33%) eyes.

CONCLUSIONS

The ZB5M PIOL offers good refractive outcomes and stability in the long-term; however, endothelial cell loss increases over 12 years, requiring annual endothelial cell counts.

Confocal Microscopy Comparison of IntraLase Femtosecond Laser and Moria M2 Microkeratome in LASIK

PURPOSE

To analyze the quality of LASIK flaps created using a femtosecond laser or a mechanical microkeratome.

METHODS

A prospective study of consecutive bilateral LASIK flaps (100 patients) created with a 15 kHz femtosecond laser (IntraLase) or with a mechanical microkeratome (Moria M2) was performed. Outcome measures included visual and refractive outcomes, flap dimensions, and intraoperative complications. The first consecutive ten patients (20 eyes) were examined using confocal microscopy 1 and 3 months following surgery.

RESULTS

No significant differences were noted in the visual outcomes between groups (t test, P > .05 for all comparisons). Analysis of superficial measurements revealed more round flaps and greater predictability in surface dimensions for the femtosecond laser group (t test, P = .016). Mean deviation of flap thickness from target was the same for both instruments, 10 microm, with greater variability for the mechanical microkeratome. The incidence of diffuse lamellar keratitis was significantly greater in the femtosecond laser group (17%) than in the mechanical group (0%) (chi-square test, P < .001). Confocal microscopy revealed a higher wound healing opacity index in the femtosecond laser group.

CONCLUSIONS

Although the clinical results are similar, the femtosecond laser produces LASIK flaps with more accurate dimensions compared to the mechanical microkeratome.

Transient light-sensitivity syndrome after laser in situ keratomileusis with the femtosecond laser

PURPOSE

To describe the incidence of transient light-sensitivity syndrome (TLSS) after laser in situ keratomileusis (LASIK) with the femtosecond laser and to identify preventive strategies.

SETTING

Hospital NISA Virgen del Consuelo, Valencia, Spain.

METHODS

The first 765 eyes operated on with the 15 KHz femtosecond laser were prospectively analyzed for subjective complaints and clinical findings compatible with TLSS. Intraoperative settings, postoperative treatment, and development of complications were analyzed.

RESULTS

Overall, TLSS developed in 10 eyes (incidence 1.3%). However, the incidence decreased from 2.8% to 0.4% when aggressive topical steroids were used during the first 3 postoperative days. Postoperative interface inflammation and postoperative use of a low-dose topical steroid regimen were associated with a higher incidence of TLSS.

CONCLUSIONS

Transient light-sensitivity syndrome is a relatively uncommon complication related to the use of the femtosecond laser. Postoperative interface inflammation may increase the probability of developing TLSS, whereas an aggressive postoperative steroid regimen seemed to provide protection against it.

Angle-Supported Anterior Chamber Phakic Intraocular Lens ExplantationCauses and Outcome

PURPOSE

To investigate the reasons for explantation of angle-supported phakic intraocular lenses (IOLs) as well as the outcome and safety of the explantation procedure.

DESIGN

Consecutive retrospective series.

PARTICIPANTS

One hundred eyes of 66 patients who underwent phakic angle-supported IOL explantation.

INTERVENTION

Surgical explantation of anterior chamber angle-supported phakic IOLs.

MAIN OUTCOME MEASURES

Visual acuity, refraction, and endothelial cell density.

RESULTS

The main causes of explantation were cataract development (64 cases [64%]), progressive endothelial cell loss (24 cases [24%]), and pupil ovalization (10 cases [10%]). According to the reason for phakic IOL explantation and the condition of the eye at time of explantation, 92 cases underwent bilensectomy (phakic IOL explantation followed by phacoemulsification of the crystalline lens), 2 cases underwent phakic IOL exchange, 4 cases underwent concomitant phakic IOL explantation and penetrating keratoplasty, and 2 cases underwent simple explantation of a phakic IOL. The mean time between phakic anterior chamber IOL implantation and explantation due to cataract was 10.04+/-3.66 years (range, 2-14). The mean time between implantation and secondary intervention due to progressive endothelial cell loss was 8.97+/-2.21 years (range, 2-14), and most of these cases were related to a specific model of angle-supported phakic IOL.

CONCLUSION

Nuclear cataract was the most frequent reason for angle-supported phakic IOL explantation. Bilensectomy was effective and maintained the refractive benefits obtained with phakic IOL implantation. Few cases developed severe endothelial cell loss, most of them related to certain types of phakic IOLs.

Prophylactic Perioperative Antiviral Therapy for LASIK in Patients With Inactive Herpetic Keratitis

PURPOSE

To report the outcome of LASIK in patients with inactive herpetic keratitis in which perioperative antiviral prophylaxis was used to prevent the recurrence of ocular herpes.

METHODS

We report an uncontrolled series of five patients with inactive herpetic keratitis for at least 1 year before surgery in whom LASIK was successfully performed. All patients showed normal topography, pachymetry, and corneal sensitivity with no central corneal scarring. Perioperative prophylaxis was used in each case with oral valacyclovir and topical acyclovir ointment.

RESULTS

None of the eyes developed reactivation of herpetic keratitis during follow-up.

CONCLUSIONS

This study suggests that perioperative antiviral prophylaxis may protect the cornea from herpes simplex virus reactivation after LASIK.

Confocal Microscopy of Disposable and Nondisposable Heads for the Moria M2 Microkeratome

PURPOSE

To study the quality of the flap obtained with two different heads, disposable and nondisposable, and two different speeds, low and high, using the same Moria M2 microkeratome (Moria, Antony, France).

METHODS

In a prospective randomized study, 51 consecutive eyes (28 patients) underwent myopic LASIK (-4.39 +/- 2.15 diopters). The eyes were randomly assigned to four groups related to cutting head model (disposable and nondisposable) and cut speed (low and high). In all cases, the intended cut was 160 microm and the same M2 unit was used. During surgery, superficial measurements of the flap and the surgeon's opinion about the quality of the cut were recorded. One month after LASIK, the cut depth, interface particle density, and transparency of the cornea (confocal wound healing opacity index) were measured with a confocal microscope.

RESULTS

Flaps performed with a disposable cutting head and high speed were statistically significantly larger than the flaps created in the other groups (Kruskal-Wallis test; P = .041). No statistical differences were noted in cut depth, number of particles, and wound healing opacity index. The surgeon's opinion parameters were similar in all groups.

CONCLUSIONS

The Moria M2 microkeratome is safe and provided reproducible results, regardless of cutting head and speed. Disposable and nondisposable head models were similar in their outcome in the quality control model used in this study.

LASIK in Patients with Rheumatic Diseases

PURPOSE

To investigate the safety of LASIK in patients with a known history of controlled rheumatic diseases.

DESIGN

Retrospective consecutive observational clinical study.

PARTICIPANTS

Forty-two eyes (22 patients) known to have had a history of rheumatic diseases underwent LASIK. All patients had a history of controlled rheumatic diseases, including rheumatoid arthritis, systemic lupus erythematosus, dermatomyositis, scleroderma, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, arthritis, or Behçet's disease.

METHODS

Assessments were made preoperatively and at 1, 3, and 6 months postoperatively and included visual acuity (VA), refraction, keratometric readings, slit-lamp biomicroscopy, and corneal topography. All the patients underwent LASIK. Postoperative treatment included a topical steroid-antibiotic combination.

MAIN OUTCOME MEASURES

Visual acuity, refraction, keratometric readings, and slit-lamp biomicroscopy findings at 1, 3, and 6 months postoperatively.

RESULTS

LASIK was performed uneventfully on all patients. The mean pre-LASIK spherical equivalent (SE) was -5.39+/-2.25, and the sixth month postoperative SE was -0.15+/-0.38 diopters (D) (P<0.001). Uncorrected VA 6 months after the LASIK procedure was 20/25. Enhancement procedures were performed in 6 of 42 eyes (14.3%) at variable times after the primary procedure. Postoperative follow-up showed development of a moderate degree of dry eye syndrome in 4 eyes (9.5%). Corneal haze, melting, flap, or interface complications were not observed in any of the study eyes.

CONCLUSIONS

In this small series, we found good outcomes when correcting refractive errors using LASIK in selected patients with controlled rheumatic diseases. In this series, a favorable postoperative visual outcome was obtained with no operative or postoperative vision-threatening complications.

[Confocal microscopy of the cornea in photorefractive surgery]

OBJECTIVE

Corneal refractive surgery involves a range of techniques which have assumed a growing importance during the last few years. The advances of very different surgical methods and the early age of the majority of the patients subjected to surgery, limits our knowledge of the histopathologic changes in the operated corneas. For this reason, the development of any diagnostic tool which can permit us to improve our knowledge of the wound healing process would be of significant value. As we describe in our paper, confocal microscopy enables the assessment of the more important advantages for the study of corneal wound healing after refractive surgery: high magnification, harmless, and "in vivo", providing pathogenic information and lateral and axial definition not achievable with other exploration techniques.

CONCLUSION

Confocal microscopy appears to be an essential tool for creating a global concept of quality in corneal refractive surgery.

Severe anaphylactic reaction after intracameral antibiotic administration during cataract surgery

We report a severe anaphylactic reaction that occurred about 5 minutes after 1.0 mg of cefuroxime was injected into the anterior chamber after routine phacoemulsification and intraocular lens implantation. The patient was known to be allergic to penicillin. Immediate action was taken, and the patient recovered well. The presence of staff trained in resuscitation was essential in this case and raises questions about the trend to perform routine topical anesthesia cataract surgery without an anesthesiologist in the operating room.

Laser in situ keratomileusis to correct post-keratoplasty astigmatism; 1-step versus 2-step procedure

PURPOSE

To investigate the correction of post-penetrating keratoplasty (PKP) astigmatism using laser in situ keratomileusis (LASIK). Visual and refractive outcomes were evaluated after LASIK was performed in 1 step (lamellar cut and ablation in 1 procedure) or 2 steps (lamellar cut then ablation in 2 successive procedures).

SETTING

Department of Cornea and Refractive Surgery, Vissum-Instituto Oftalmológico de Alicante, University of Miguel Hernández, Alicante, Spain.

METHODS

In this prospective observational study, 22 consecutive eyes were divided into 2 groups depending on the LASIK procedure performed to correct post-PKP astigmatism. Group 1 (1-step LASIK) included 11 eyes and Group 2 (2-step LASIK), 11 eyes. The patients were followed for 6 months.

RESULTS

A statistically significant improvement was obtained in Group 2 with a mean vector analysis result of the cylinder of -4.37 diopters (D) +/- 1.79 (SD) (P = .018). In Group 1, the mean astigmatism correction was 2.38 +/- 1.71 D. The number of reoperations and residual refractive defects were significantly better in Group 2.

CONCLUSION

The 2-step technique improved the accuracy of excimer laser correction of post-PKP astigmatism.

Automated superficial lamellar keratectomy augmented by excimer laser masked PTK in the management of severe superficial corneal opacities

AIM

To assess superficial lamellar keratectomy augmented by excimer laser smoothening with sodium hyaluronate 0.25%, for the management of superficial corneal opacities.

METHODS

Consecutive procedure performed in 14 eyes (13 patients) with an automated microkeratome and excimer laser phototherapeutic keratectomy (PTK) smoothening using sodium hyaluronate 0.25%.

MAIN OUTCOME MEASURES

UCVA, BCVA, pachymetry, degree of haze, ray tracing analysis, and complications. Mean follow up was 12 (SD 1.6) months.

RESULTS

Mean preoperative haze from previous corneal refractive surgeries was 3.5 (SD 0.5) (11/14 cases). In one case, opacity was caused by ocular trauma and in two by infectious keratitis. The mean preoperative UCVA was 0.7 logMAR (0.2 (SD 0.13) decimal value). BCVA was 0.4 logMAR (0.4 (SD 0.17) decimal value). Mean preoperative corneal pachymetry was 508 (SD 62.5) micro m and mean opacity depth measured by corneal confocal microscopy was 115.2 (SD 49.4) micro m. At 6 months, 71.4% of the eyes with previous corneal refractive surgery showed grade I haze or less. Mean postoperative corneal pachymetry at 6 months was 352.36 (SD 49.05) micro m.

CONCLUSIONS

Automated superficial lamellar keratectomy combined with excimer laser PTK smoothening assisted by sodium hyaluronate 0.25% induces a significant improvement of corneal transparency and visual acuity in cases of corneal opacity caused by previous refractive surgery, ocular trauma, and keratitis.

Comparison of Four Corneal Pachymetry Techniques in Corneal Refractive Surgery

PURPOSE

To assess the effectiveness of optical and ultrasonic pachymetry when examining corneas of patients before and after laser in situ keratomileusis (LASIK).

METHODS

We conducted a prospective study of 25 patients (50 eyes) who had LASIK for myopia or myopic astigmatism (mean spherical equivalent refraction -4.80 +/- 3.60 D; range -1.75 to -12.00 D). Corneal thickness was measured using 1) conventional ultrasonic pachymetry (20 MHz probe) in the central cornea, 2) ASL confocal microscopy (CMTF analysis), 3) Orbscan II Analyzer, and 4) ultrasound biomicroscopy (UBM) (50 MHz probe) preoperatively and 3 months postoperatively.

RESULTS

Preoperative pachymetry values measured with the Orbscan II Analyzer (551.3 +/- 27.3 microm) were almost identical to those measured with the 20 MHz ultrasonic probe (553.7 +/- 25.7 microm; t-test P = .652). The mean preoperative pachymetry for UBM was 566.7 +/- 38.8 microm and for CMTF was 553.2 +/- 15.5 microm. The optic and ultrasonic system measurements differed in operated eyes; 20 MHz ultrasonic pachymetry yielded an average 478.7 +/- 23.5 microm and the UBM, 482.4 +/- 40.3 microm. These measurements differed from the Orbscan II (Tukey test; P = .023) measurement of 461.1 +/- 37.5 microm but not from the confocal microscopy measurement of 475.2 +/- 41.8 microm. UBM registered greater values that were more variable than those obtained with ultrasonic pachymetry.

CONCLUSIONS

In non-operated eyes, corneal thickness was similar using conventional ultrasound, Orbscan II, or confocal techniques, with ultrasound biomicroscopy giving thicker readings.

Follicular conjunctivitis caused by Chlamydia trachomatis in an infant Saharan population: molecular and clinical diagnosis

AIMS

To ascertain the prevalence of acute trachoma as a supposed endemic disease among infants in the Saharan refugee camps of Tindouf (Algeria) and to evaluate the efficacy of treatment with a single dose of azithromycin.

METHODS

527 children aged between 3 and 17 were evaluated in the camp schools in October 2001. All the children were clinically and microbiologically examined, including slit lamp checks of anterior segment and two conjunctival swabs, one for the detection of membrane lipopolysaccharide by quick immunoassay test Clearview Chlamydia MF and the other for the detection of specific DNA by chlamydia plasmid specific polymerase chain reaction (PCR) assay. After examination, a single dose of azithromycin was administered to each child. One month later samples from positive children and 12 random negative children by the first PCR were taken to perform a new PCR assay.

RESULTS

Chlamydia trachomatis was suspected in 2.47% of the children, papillary hypertrophy being the most frequently seen clinical sign. Scarring changes secondary to trachoma were detected in 11.7% of the children. Only four cases (0.8%) were positive to the immunoassay test and 12 cases (2.27%) were positive by PCR. After treatment a second PCR was performed on positive children and they were negative of chlamydia DNA amplification. However, one child who was negative and received the treatment was positive in the second PCR assay.

CONCLUSION

Acute trachoma prevalence is much lower than expected among infants in this Saharan population. The possible reasons could be the recent improvements in hygiene and health care. Cicatricial trachoma is more frequent. The Clearview immunoassay test has very low sensitivity in the detection of this disease. A single dose of azithromycin is sufficient to treat chlamydial conjunctivitis. However, a programme of improvement in hygiene and health care is necessary to prevent re-infection.