Subacute Methicillin-resistant Coagulase-Negative Staphylococcus hominis Endophthalmitis after Penetrating Keratoplasty Re-operation

Purpose@#To report a case of subacute methicillin-resistant coagulase-negative Staphylococcus hominis endophthalmitis after re-operation for penetrating keratoplasty in a patient who had a penetrating keratoplasty rejection.Case summary: A 74-year-old man with underlying diabetes and hypertension who underwent bilateral penetrating keratoplasty at another hospital underwent penetrating keratoplasty reoperation due to corneal transplant rejection in the right eye. He had a history of end-stage glaucoma in the right eye and the visual acuity was finger counting at 30 cm. About 25 days postoperatively, the corneal epithelial defect was first found. Treatment based on suspicion of herpes simplex virus infection did not result in improvement and endophthalmitis was suspected in the right eye about 35 days after surgery. Anterior chamber irrigation, pars planar vitrectomy, and intravitreal antibiotic injection were performed. Culture revealed methicillin-resistant coagulase negative Staphylococcus hominis. After 2 months of treatment, the anterior chamber and vitreous inflammation decreased and best corrected visual acuity in the right eye recovered to 0.06. @*Conclusions@#Subacute endophthalmitis caused by methicillin-resistant coagulase-negative Staphylococcus may occur after penetrating keratoplasty. Transplant failure due to infection can be avoided with vitrectomy and antibiotic treatment at the right time.

Visual Performance and Optical Quality after Implantation of a New Generation Monofocal Intraocular Lens

Purpose@#To evaluate the performance of two intraocular lenses (IOLs). The new monofocal IOL using a higher-order aspheric optic (Tecnis Eyhance ICB00) was compared to a standard monofocal IOL (Tecnis monofocal ZCB00) of the identical platform and material. @*Methods@#The medical records of the patients who had undergone cataract surgery with implantation of either the ZCB00 or the ICB00 in the dominant eye from March 2020 to August 2020 and with available data from the 3-month visit were reviewed. Subjects with ocular comorbidities or corneal astigmatism greater than 1.00 diopters were excluded. The uncorrected near, intermediate, distance visual acuity and corrected distance visual acuity were the main outcome measures. Optical quality parameters measured using an optical quality analysis system, clinical records including age, sex, laterality, ocular dominance, and information related to refractory errors was also collected. Parameters related to the refractory errors were all uniformly based on the Barrett Universal II formula. @*Results@#Of the 197 recruited patients, 111 and 86 were implanted with the ICB00 and ZCB00, respectively. No statistically significant differences in baseline parameters were observed between the two groups. While no statistically significant differences in distance visual acuity or optical quality were found between the two groups, compared to the ZCB00 group, the ICB00 group showed significantly higher intermediate visual acuity (p @*Conclusions@#ICB00 provided superior intermediate vision and comparable distance performance and photic phenomena compared to a standard monofocal IOL.

Visual Performance and Optical Quality after Implantation of a New Generation Monofocal Intraocular Lens

Purpose@#To evaluate the performance of two intraocular lenses (IOLs). The new monofocal IOL using a higher-order aspheric optic (Tecnis Eyhance ICB00) was compared to a standard monofocal IOL (Tecnis monofocal ZCB00) of the identical platform and material. @*Methods@#The medical records of the patients who had undergone cataract surgery with implantation of either the ZCB00 or the ICB00 in the dominant eye from March 2020 to August 2020 and with available data from the 3-month visit were reviewed. Subjects with ocular comorbidities or corneal astigmatism greater than 1.00 diopters were excluded. The uncorrected near, intermediate, distance visual acuity and corrected distance visual acuity were the main outcome measures. Optical quality parameters measured using an optical quality analysis system, clinical records including age, sex, laterality, ocular dominance, and information related to refractory errors was also collected. Parameters related to the refractory errors were all uniformly based on the Barrett Universal II formula. @*Results@#Of the 197 recruited patients, 111 and 86 were implanted with the ICB00 and ZCB00, respectively. No statistically significant differences in baseline parameters were observed between the two groups. While no statistically significant differences in distance visual acuity or optical quality were found between the two groups, compared to the ZCB00 group, the ICB00 group showed significantly higher intermediate visual acuity (p @*Conclusions@#ICB00 provided superior intermediate vision and comparable distance performance and photic phenomena compared to a standard monofocal IOL.

Combined Phototherapeutic Keratectomy and Peripheral Anterior Stromal Puncture for the Treatment of Recurrent Corneal Erosion Syndrome

Purpose@#To investigate the efficacy of the combined phototherapeutic keratectomy (PTK) and peripheral anterior stromal puncture (ASP) compared with that of PTK alone in patients with recurrent corneal erosion syndrome (RCES). @*Methods@#The medical records of 25 patients (25 eyes) who underwent combined treatment of PTK and peripheral ASP for RCES from March 2016 to May 2017 were retrospectively reviewed. Twenty-three patients (23 eyes) treated with PTK alone from March 2015 to February 2016 served as a control group. All surgeries were performed by a single surgeon. This retrospective clinical study comprised 48 patients (48 eyes) who were followed up for more than 18 months. Clinical records of age, sex, laterality, etiology of RCES, and history of recurrence after treatment were evaluated. @*Results@#Twenty-five eyes were treated with combined PTK and ASP, and 23 eyes were treated with PTK only. The mean follow-up period was 19.63 ± 2.97 and 19.75 ± 6.83 months, respectively. There were no differences in baseline parameters between the groups. In the combined treatment group, one patient experienced recurrence 6 months after the surgery. In the single treatment group, five patients showed recurrence at 4, 7, 8, 11, and 13 months after the surgery, respectively.Compared to the single treatment group, the combined treatment group showed significantly lower recurrence rate (p < 0.05).All recurred patients required no additional treatment except temporary therapeutic contact lenses and topical lubricants. @*Conclusions@#Our findings suggest that combined treatment of PTK and peripheral ASP is effective in alleviation of symptoms and prevention of recurrence in refractory RCES compared with treatment using PTK alone.

Clinical Aspects of Phlyctenular Keratoconjunctivitis Using a Tear Film Interferometer

PURPOSE: To evaluate clinical findings in phlyctenular keratoconjunctivitis patients and assess the function and morphology of Meibomian glands using an interferometer (LipiView®, TearScience, Morrisville, NC, USA) in such patients.METHODS: This retrospective study included 19 eyes of 13 patients diagnosed with phlyctenular keratoconjunctivitis. The lipid layer thickness (LLT) and meibograph of each eye was quantified by tear interferometry. Tear film break-up time (TBUT) and corneal staining score were measured. Meibomian gland morphology (lid margin vascularity, plugging of gland orifices, lid margin irregularity, lid margin thickening, and partial glands) was evaluated based on anterior photographs and meibographs.RESULTS: The mean age was 21.3 years (8–44 years). Mean BUT and Oxford corneal staining scores were 2.6 ± 1.2 seconds and 1.9 ± 0.8, respectively. Abnormal findings of the Meibomian glands were observed in all patients. The mean LLT was 79.6 ± 27.4 µm and the incomplete eye blinking frequency was 3.8 ± 5.9 during 20 seconds. The graphs of the tear lipid layer showed various patterns such as flat, up-hill, down-hill, and mixed.CONCLUSIONS: Meibomian gland dysfunctions and changes in the tear film lipid layer were noted in patients with phlyctenular keratoconjunctivitis. These factors are to be considered for the treatment of phlyctenular keratoconjunctivitis in young patients under 10 years of age.

Changes in Higher-order Aberrations after Superior-incision Cataract Surgery in Patients with Positive Vertical Coma

PURPOSE: The purpose of this study was to compare changes in higher-order aberrations after superior-incision cataract surgery between eyes with a within-the-rule (WTR) astigmatism and an against-the-rule (ATR) astigmatism in patients with positive vertical coma. METHODS: This study included patients who presented with positive vertical coma and who underwent cataract surgery through a 2.5 mm superior clear corneal incision. The eyes included in this study were divided into two groups (37 eyes with WTR astigmatism and 33 eyes with ATR astigmatism), and uncorrected visual acuity, best corrected visual acuity, and corneal astigmatism were measured before and after surgery. In addition, anterior, posterior, and total aberrations (i.e., oblique trefoil, horizontal trefoil, vertical coma, horizontal coma, spherical aberration, and total higher-order aberrations) were measured using a Pentacam. RESULTS: In the WTR astigmatism group, anterior/posterior corneal aberrations and total aberrations were significantly decreased after surgery (p < 0.05). However, in the ATR astigmatism group, a significant decrease in the posterior vertical coma (p = 0.008) was observed, although there was no change in total vertical coma. A significant increase in oblique trefoil was observed in both groups, while a significant decrease in horizontal trefoil was found in the ATR astigmatism group (all p < 0.05). For spherical aberration, the ATR astigmatism group showed a significant decrease in anterior cornea aberrations (p < 0.001). For total higher-order aberrations, the WTR astigmatism group showed a significant increase in anterior and posterior aberrations, while the ATR astigmatism group showed a significant increase in posterior aberrations (p < 0.05, p = 0.001, respectively). In the case of horizontal coma and corneal astigmatism, both groups exhibited no significant changes after surgery. CONCLUSIONS: When superior-incision cataract surgery was performed, vertical coma was affected by the axis of astigmatism, resulting in a significant decrease in the WTR astigmatism group. However, no significant changes in corneal astigmatism were observed before and after surgery.

Effectiveness of Toric Orthokeratology in the Treatment of Patients with Combined Myopia and Astigmatism

PURPOSE: The purpose of this multi-institute, single-group clinical trial was to evaluate the effectiveness and safety of toric orthokeratology lenses for the treatment of patients with combined myopia and astigmatism. METHODS: A total of 44 patients were included in this clinical trial. The patients ranged in age from 7 to 49 years, with myopia of -0.75 to -6.0 diopters (D) and astigmatism of 1.25 to 4.0 D. After excluding 21 subjects, 23 subjects (39 eyes) were analyzed after toric orthokeratology lens use. The subjects underwent ophthalmologic examination after 1 day and 1, 2, 3, and 4 weeks of wearing overnight toric orthokeratology lenses. RESULTS: A total of 19 subjects (31 eyes) completed the trial after five subjects (eight eyes) dropped out. In the patients who completed the study by wearing lenses for 4 weeks, the myopic refractive error decreased significantly by 2.60 ± 2.21 D (p < 0.001), from -3.65 ± 1.62 to -1.05 ± 1.64 D. The astigmatic refractive error were also significantly decreased by 0.63 ± 0.98 D (p = 0.001), from 2.07 ± 0.83 to 1.44 ± 0.99 D. The mean uncorrected and corrected visual acuities before wearing the lenses were 2.14 ± 0.80 logarithm of the logMAR (logMAR) and 0.05 ± 0.13 logMAR, respectively, which changed to 0.12 ± 0.30 logarithm of the logMAR (p < 0.001) and 0.01 ± 0.04 logMAR (p = 0.156) after 4 weeks. No serious adverse reactions were reported during the clinical trial. CONCLUSIONS: Our results suggest that toric orthokeratology is an effective and safe treatment for correcting visual acuity in patients with combined myopia and astigmatism.

Comparing Clinical Outcomes of Descemet's Membrane Stripping Automated Endothelial Keratoplasty Between Graft Insertion Methods

PURPOSE: To compare clinical outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) between different graft insertion methods. METHODS: The clinical records of 32 eyes of 30 DSAEK patients were retrospectively analyzed. Patients were divided into 2 groups according to graft insertion method. Group A: Taco-folding, group B: Tan-endoglide. The best corrected visual acuities (BCVA), intraocular pressures, astigmatism, endothelial cell count, central corneal thickness and complications were evaluated pre and post-operatively. RESULTS: The average follow-up period was 19 months (range 1-67). Postoperative log MAR visual acuity had significantly improved both from 1.63 (log MAR) to 0.69 and 0.53 at 12 months in each group (p = 0.035, p = 0.000). Mean endothelial cell survival of each group at 1 month postoperative were 75.8% (range 62.7-88.6) and 87.7% (range 70.2-97.9), respectively (p = 0.012). The differences of BCVA improvement and endothelial cell survival between the groups at 12 months were not significant (p = 0.393, p = 0.544). CONCLUSIONS: Both methods showed fast visual recovery. Using Tan-endoglide insertion resulted less endothelial cell loss at early post-operative period and showed less post-operative complication and graft failure.

Effects of Axial Length and Vitrectomy on Refractive Error after Cataract Surgery Using SRK/T Formula

PURPOSE: To investigate the error tendency between preoperative target diopter and postoperative manifest refraction in cataract surgery cases and the effect of axial length and vitrectomy on refractive error (RE). METHODS: We retrospectively studied 90 eyes of 90 patients who underwent cataract surgery. The power of intraocular lens (IOL) was calculated by SRK/T formula. Patients were devided into four groups based on axial length (AXL) and the past history of vitrectomy. RESULTS: The mean of RE showed no significant difference between groups. But an increasing AXL was associated with increased myopic shift with normal range AXL (24.4 mm) (r = 0.718, p < 0.001). In vitrectomized eyes, it showed no significant refractive shift with both normal range and long AXL. CONCLUSIONS: When determining IOL power using SRK/T formula in nonvitrectomized eyes, postoperative refractive shift based on axial length should be considered.

Usefulness of Open Ring Guider for Continuous Curvilinear Capsulorrhexis

PURPOSE: To compare the size, circularity and repeatability between the conventional manual technique and the open-ring guided continuous curvilinear capsulorrhexis (CCC) technique in cataract surgery. METHODS: The present study comprised 120 eyes divided into two equal groups. In the first group (group A), CCC was performed using a 5.3-mm open ring-shaped caliper and in the second group (group B), CCC was performed using the conventional manual technique. Photographs were taken after each surgical step (CCC, phacoemulsification, Intraocular lens insertion and corneal stromal hydration). The diameter, area and circularity of the anterior capsule were compared between the two groups. RESULTS: The anterior capsule diameter was 5.32 +/- 0.26 mm for group A (coefficient of variation 0.049) and 5.14 +/- 0.64 mm for group B (coefficient of variation 0.125); the area was 22.9 +/- 0.71 mm2 for group A (coefficient of variation 0.031) and 21.40 +/- 1.37 mm2 for group B (coefficient of variation 0.064). Circularity was 0.93 +/- 0.24 for group A (coefficient of variation 0.258) and 0.86 +/- 0.78 for group B (coefficient of variation 0.907). CONCLUSIONS: The open ring-guided CCC technique resulted in an increase of diameter and capsulorrhexis area. This method showed superior circularity and repeatability compared to conventional manual technique and can be useful in cataract surgery.

Radiographic Analysis of Extraocular Muscle Volumetric Changes Following Orbital Decompression in Thyroid-Associated Orbitopathy: Comparison of Nunery Types 1 and 2

PURPOSE: To evaluate the radiographic volume change in extraocular muscles (EOM) following orbital wall decompression for Nunery type 1 and type 2 thyroid-associated orbitopathy (TAO). METHODS: Medical records of 31 orbits in 20 patients undergoing postoperative orbital CT after orbital decompression for TAO were retrospectively reviewed. The patients were divided according to Nunery classifications. A type 1 classification was assigned to patients who had no diplopia and essentially normal versions. A type 2 classification was assigned to patients with restrictive motility loss and diplopia within 20 degrees of the primary position. EOM volumes were determined by the summation of each EOM's cross-sectional areas in the coronal plane of the CT scans and multiplying the sum by the slice thickness. Main outcome measure was a comparison of EOM volume changes between types 1 and 2 TAO and a relationship between EOM volume and change in proptosis. RESULTS: In type 2 TAO, a significant increase in the volume of the medial rectus muscle, lateral rectus, and total EOM was detected postoperatively (p = 0.044, 0.022, 0.049), whereas no significant changes were found in the EOM's volume changes in type 1 TAO. The reduction of proptosis after orbital decompression in type 1 TAO was significantly greater than in type 2 TAO (p = 0.025). A significant positive association was observed between the preoperative EOM volumes and the reduction of proptosis following orbital wall decompression (r = 0.505). CONCLUSIONS: The postoperative EOM volumes following orbital wall decompression was significantly increased in Nunery type 2 patients who had restrictive myopathy.

Refractive Eerror According to the Anterior Chamber Depth and Corneal Refractive Power in Short Eyes

PURPOSE: To evaluate the accuracy of the chosen formula in short eyes and the effect of the anterior chamber depth (ACD) and corneal refractive power on the accuracy. METHODS: A total of 251 eyes out of 185 patients (axial length below 22.0 mm) who underwent cataract surgery in our hospital were retrospectively studied. Introcular lens (IOL) power was calculated with the Hoffer Q, SRK II, SRK-T and Holladay 1 formulas and refractive outcome was measured. Patients were divided into 2 groups based on ACD. The accuracy of the 4 formulas was compared and the errors according to the ACD were also evaluated. RESULTS: In eyes with short axial lengths, all formulas showed a tendency for hyperopic shifts. The Hoffer Q formula showed significantly high predictive accuracy. This tendency for hyperopic shifts was similar in the eyes with extremely short axial length, but a large refractive error deviation was observed. The 2 groups based on ACD showed no significant difference in the refractive error, but the group with deep ACD had a tendency for hyperopic shifts. The difference of the calculated IOL power between the 4 formulas was more pronounced in eyes with lower corneal refractive power. CONCLUSIONS: In eyes with short axial lengths, preoperative ACD and corneal refractive power had an influence on the accuracies of predicted IOL power. Therefore, these factors should be considered in IOL power determination.

Influence of Endothelial Cell Loss During Preservation on Graft Survival in Imported Donor Cornea

PURPOSE: To investigate the influence of preoperative endothelial cell loss on the outcome of keratoplasty for keratoconus in imported donor corneas. METHODS: Eighteen imported corneas used in keratoplasty for keratoconus patients were evaluated. Corneal endothelial cell density at the moment of preservation was obtained from the medical records and was measured immediately before the keratoplasty. Correlation of the endothelial cell loss count before and after keratoplasty was analyzed and postoperative endothelial cell loss count according to the range of preoperative endothelial cell loss was evaluated. RESULTS: Mean endothelial cell loss before and after keratoplasty was 258.94 +/- 128.58 cells/mm2 and 355.44 +/- 371.83 cells/mm2, respectively. There was a positive correlation between preoperative and postoperative endothelial cell loss count (r = 0.431, p = 0.074). The results showed statistically significant higher endothelial cell loss count after keratoplasty in the range above 250 cells/mm2 rather than below 250 cells/mm2 of preoperative endothelial cell loss count (p = 0.033). CONCLUSIONS: The preoperative decrease in endothelial cell density affected the endothelial cell loss after keratoplasty for keratoconus in imported donor corneas.

Long Term Clinical Results of Penetrating Keratoplasty for Macular Corneal Dystrophy

PURPOSE: To report the long term clinical results of penetrating keratoplasty as a treatment for corneal macular dystrophy. METHODS: Retrospective review of the medical record of 46 eyes (31 indivisuals) who underwent primary PK for corneal macular dystrophy at the Seoul St. Mary's Hospital between November, 1986 and December, 2011. Data extracted preoperative and postoperative best-corrected visual acuity (BCVA), postoperative complications (including graft rejection episodes, and recurrent dystrophy), change of endothelial cell density at 1, 6, 12, 24, 36 months and yearly thereafter. RESULTS: After a mean follow-up period of 91.59 +/- 3.2 months, the mean BCVA was significantly improved after penetrating keratoplasty. Endothelial cell loss rate was marked during the 1st year after penetrating keratoplasty. Graft survival was 40 graft (89.7%) at 8yrs. There was a statistically significant increased likelihood of graft failure if the patient was older than 40 years at the time of surgery (p = 0.03). Glaucoma as postoperative complication was 17.4%. Clinically significant recurrence was 2%. CONCLUSIONS: Penetrating keratoplasty is associated with a good visual outcome and prognosis for graft survival of long-term efficacy with a low complication rate in eyes with macular corneal dystrophy.

Toxic Anterior Segment Syndrome Following Cataract Surgery

PURPOSE: To report clinical and laboratory findings of toxic anterior segment syndrome (TASS) in seven patients following cataract surgery with intraocular lens (IOL) implantation. METHODS: The medical records of seven patients who underwent cataract surgery associated with postoperative decreased visual acuity, ocular pain, anterior chamber inflammation and corneal edema between Feb 2007 and Nov 2009 were retrospectively reviewed. RESULTS: All patients were over 60 years of age, four patients had diabetes and four patients had cardiovascular disease. Five patients had received hydrophilic IOL, and six patients underwent surgery later in order. All seven patients presented with increased anterior segment inflammation, acute decreased visual acuity, and severe corneal edema an average of 10.4 days (range 1 to 15 days) after surgery. Treatment of the seven patients included intensive topical and oral steroids, and improvement was noted in all patients. CONCLUSIONS: The incidence of TASS after cataract surgery was 0.8%, and was significantly higher in cases of hydrophilic IOL insertion (5 of 284 cases, 1.76%) compared to cases of hydrophobic IOL insertion (2 of 581 cases, 0.34%) (p = 0.04). Five of the seven cases presented with TASS at postoperative day 14. Inflammation improved in all patients with steroid treatment.

Change of Strabismus Angle and Deviation After Unilateral or Bilateral Lateral Rectus Recession in Exotropia

PURPOSE: To compare the changes in strabismus angle and deviation between two groups: a bilateral lateral rectus recession (Group 1) and a unilateral lateral rectus recession in exotropia (Group 2). METHODS: A retrospective survey was conducted on 198 patients who had received exotropia surgery in our ophthalmology clinic from September 2003 to April 2007. A total of 116 patients were in Group 1, and 82 patients were in Group 2. RESULTS: The average deviations of the first postoperative month and the first postoperative year were -1.96 D +/- 4.75, 2.5 D +/- 7.82 for Group 1 and 0.77 D +/- 2.87, 5.94 D +/- 3.38 for Group 2. Revealing statistical significance between the 2 Groups: Group 1 had 30 failure cases (25.9%) and their 1 postoperative year average deviation was 5.42 D +/- 13.97, while Group 2 showed 24 failure cases (29.3%) and their 1-postoperative-year average deviation was 13.0-79 +/- 3.04. Group 1 had less strabismus angle and a greater standard deviation than Group 2, as Group 1 had more overcorrection. Among the 30 failure cases of Group 1, 9 were overcorrected and 21 were undercorrected, but all 24 failure cases in Group 2 were undercorrected. CONCLUSIONS: The strabismus angle after lateral rectus recession showed a wider variation and a larger difference in bilateral lateral rectus recession than in the unilateral lateral rectus recession.