Assessment for Macular Thickness after Uncomplicated Phacoemulsification Using Optical Coherence Tomography

Purpose@#Macular edema including cystoid macular edema is one of the main causes of unfavorable visual outcomes after cataract surgery. The macular thickness and the occurrence of macular edema after uncomplicated cataract surgery was evaluated using optical coherence tomography (OCT) in this study. @*Methods@#Macular map images were taken by OCT before surgery and at 1 week, 1 month, and 2 months postsurgery. The subjects were classified into two groups (group 1, patients with no macular edema; group 2, patients with macular edema). Group 2 was defined as increase in central macular thickness (CMT) by 30% compared with that before surgery. The risk factors for macular edema were evaluated. Group 2 was divided into two subgroups: subclinical macular edema (group 2A) and cystoid macular edema (group 2B) and they were assessed in terms of the clinical course of best-corrected visual acuity and CMT. @*Results@#A total of 376 patients were enrolled in this study, of which 36 (9.57%, group 2) showed macular edema measured by OCT after the surgery. Univariate analysis for group 1 and 2 revealed that intracameral injection of epinephrine during phacoemulsification was associated with the development of macular edema. In group 2, five patients (1.33%) developed cystoid macular edema. Statistically significant differences in the clinical course of CMT were observed at 2 months (201.2 ± 23.1, 250.0 ± 29.8, and 371.0 ± 160.3 in group 1, group 2A, and group 2B, respectively; p 0.2 with CMT in the normal range. @*Conclusions@#The intracameral injection of epinephrine may cause macular edema after uncomplicated cataract surgery. Examination of CMT using OCT is recommended for the early detection of macular edema.

Comparison of Penetrating Keratoplasty and Descemet Stripping Automated Endothelial Keratoplasty in Eyes with Glaucoma Ahmed Valve implants

Purpose@#To compare the clinical outcomes of penetrating keratoplasty (PKP) and Descemet stripping automated endothelial keratoplasty (DSAEK) in eyes with Glaucoma Ahmed Valve implants. @*Methods@#The charts of 11 patients who underwent PKP and 11 who underwent DSAEK between February 2016 and June 2018 were retrospectively reviewed; all patients previously underwent Ahmed valve implant surgery. The best corrected visual acuity, intraocular pressure, and endothelial cell count were compared 1, 3, and 6 months after surgery. Graft rejection and graft failure were also evaluated during follow-up. The survival rates were compared using Kaplan–Meier survival analysis. @*Results@#The difference in graft survival rates of the PKP and DSAEK groups was not significant (p = 0.295); however, graft failure occurred earlier in the PKP group (12.9 ± 10.1 vs. 18.8 ± 5.3 months). The postoperative best corrected visual acuity of the PKP group had improved at 1 (p = 0.027) and 3 (p = 0.017) months, while the DSAEK group showed significant improvement at 1, 3, and 6 months (all p = 0.005). Intergroup analysis showed better visual prognosis of the DSAEK group at 1, 3, and 6 months after surgery (p = 0.023, p = 0.007, and p = 0.004, respectively). @*Conclusions@#In our study, the two corneal transplantation methods did not have significantly different graft survival rates; however, graft failure occured later in the DSAEK group and the postoperative visual acuity was better than in the PKP group. Although further study is needed, performing DSAEK in patients with an Ahmed valve implant seems to be a good alternative to PKP.

Association with Corneal Remodeling Related Genes, ALDH3A1, LOX, and SPARC Genes Variations in Korean Keratoconus Patients

Purpose@#To determine whether the cornea remodeling-related genes aldehyde dehydrogenase 3A1 (ALDH3A1), lysyl oxidase (LOX), and secreted protein acidic and rich in cysteine (SPARC) were potential susceptibility candidate genes for keratoconus in Korean patients, we investigated the associations of single nucleotide polymorphisms (SNPs) in these three genes in Korean patients with keratoconus. @*Methods@#Genomic DNA was extracted from blood samples of unrelated patients with keratoconus and healthy control individuals. For screening of genetic variations, all exons from the entire coding regions of the ALDH3A1, LOX, and SPARC genes were directly sequenced to determine the presence of mutations. Control individuals were selected from the general population without keratoconus. @*Results@#In this study, we detected nine SNPs in ALDH3A1, four SNPs in LOX, and 18 SNPs in SPARC. rs116992290, IVS3-62c>t, rs116962241, and rs2228100 in ALDH3A1 and rs2956540 and rs1800449 in LOX were significantly different between patient and control groups. In the SPARC gene, the distribution of the *G allele of EX10+225 T>G (p = 0.018; odds ratio, 1.869) was strongly associated with the risk of keratoconus in the Korean population. In haplotype analysis, C-G of rs2956540-rs2288393 in LOX(p = 0.046) and C-C-G and G-G-G of rs60610024-rs2228100-rs57555435 (p = 0.021 and p g - rs116962241 in ALDH3A1(p = 0.048) predisposed significantly to keratoconus. After cross-validation consistency and permutation tests, two locus model was the best SNP variations interaction pattern. @*Conclusions@#Our results suggested that genetic variations in ALDH3A1, LOX, and SPARC genes were associated with a predisposition for keratoconus in Korean individuals. Moreover, variations in ALDH3A1 and LOX may serve as strong biomarkers for keratoconus.

Association with Corneal Remodeling Related Genes, ALDH3A1, LOX, and SPARC Genes Variations in Korean Keratoconus Patients

Purpose@#To determine whether the cornea remodeling-related genes aldehyde dehydrogenase 3A1 (ALDH3A1), lysyl oxidase (LOX), and secreted protein acidic and rich in cysteine (SPARC) were potential susceptibility candidate genes for keratoconus in Korean patients, we investigated the associations of single nucleotide polymorphisms (SNPs) in these three genes in Korean patients with keratoconus. @*Methods@#Genomic DNA was extracted from blood samples of unrelated patients with keratoconus and healthy control individuals. For screening of genetic variations, all exons from the entire coding regions of the ALDH3A1, LOX, and SPARC genes were directly sequenced to determine the presence of mutations. Control individuals were selected from the general population without keratoconus. @*Results@#In this study, we detected nine SNPs in ALDH3A1, four SNPs in LOX, and 18 SNPs in SPARC. rs116992290, IVS3-62c>t, rs116962241, and rs2228100 in ALDH3A1 and rs2956540 and rs1800449 in LOX were significantly different between patient and control groups. In the SPARC gene, the distribution of the *G allele of EX10+225 T>G (p = 0.018; odds ratio, 1.869) was strongly associated with the risk of keratoconus in the Korean population. In haplotype analysis, C-G of rs2956540-rs2288393 in LOX(p = 0.046) and C-C-G and G-G-G of rs60610024-rs2228100-rs57555435 (p = 0.021 and p g - rs116962241 in ALDH3A1(p = 0.048) predisposed significantly to keratoconus. After cross-validation consistency and permutation tests, two locus model was the best SNP variations interaction pattern. @*Conclusions@#Our results suggested that genetic variations in ALDH3A1, LOX, and SPARC genes were associated with a predisposition for keratoconus in Korean individuals. Moreover, variations in ALDH3A1 and LOX may serve as strong biomarkers for keratoconus.

Comparison of the Long-term Clinical Outcomes of Penetrating Keratoplasty Using a Manual Trephine and Femtosecond-Laser Trephination

Purpose@#We compare the clinical outcomes of femtosecond-laser penetrating keratoplasty and penetrating keratoplasty performed using a manual trephine. @*Methods@#The clinical outcomes of 21 eyes that underwent penetrating keratoplasty using a manual trephine and 29 eyes that underwent femtosecond-laser penetrating keratoplasty were compared in terms of best-corrected visual acuity, refractive and corneal astigmatisms, endothelial cell counts, and graft rejection and failure. @*Results@#The best-corrected visual acuities measured 1, 3, 6, 12, and 18 months after surgery were logMAR 1.21, 1.28, 1.25, 1.14, and 1.43 for the manual trephine group and logMAR 0.82, 0.71, 0.78, 0.49, and 0.56 for the femtosecond-laser group; the latter group thus exhibited better visual acuity at all times. The refractive astigmatism values were 5.13, 6.35, 5.28, 5.18, and 6.36 diopters (D) for the manual trephine group and 6.09, 6.33, 5.14, 5.23, and 4.89 D for the femtosecond-laser group. The corneal astigmatism values were 5.40, 6.45, 6.30, 5.64, and 5.78 D for the manual trephine group and 6.17, 6.24, 5.72, 5.02, and 4.83 D for the femtosecond-laser group. The refractive astigmatism was significantly lower at 18 months after surgery and the corneal astigmatism was significantly lower at both 12 and 18 months after surgery in the femtosecond-laser group. None of endothelial cell count, graft rejection or failure rate, differed significantly between the two groups. @*Conclusions@#Femtosecond-laser-enabled keratoplasty affords better visual recovery, less refractive and corneal astigmatism, and better wound stability than does penetrating keratoplasty using a manual trephine.

Comparison of the Long-term Clinical Outcomes of Penetrating Keratoplasty Using a Manual Trephine and Femtosecond-Laser Trephination

Purpose@#We compare the clinical outcomes of femtosecond-laser penetrating keratoplasty and penetrating keratoplasty performed using a manual trephine. @*Methods@#The clinical outcomes of 21 eyes that underwent penetrating keratoplasty using a manual trephine and 29 eyes that underwent femtosecond-laser penetrating keratoplasty were compared in terms of best-corrected visual acuity, refractive and corneal astigmatisms, endothelial cell counts, and graft rejection and failure. @*Results@#The best-corrected visual acuities measured 1, 3, 6, 12, and 18 months after surgery were logMAR 1.21, 1.28, 1.25, 1.14, and 1.43 for the manual trephine group and logMAR 0.82, 0.71, 0.78, 0.49, and 0.56 for the femtosecond-laser group; the latter group thus exhibited better visual acuity at all times. The refractive astigmatism values were 5.13, 6.35, 5.28, 5.18, and 6.36 diopters (D) for the manual trephine group and 6.09, 6.33, 5.14, 5.23, and 4.89 D for the femtosecond-laser group. The corneal astigmatism values were 5.40, 6.45, 6.30, 5.64, and 5.78 D for the manual trephine group and 6.17, 6.24, 5.72, 5.02, and 4.83 D for the femtosecond-laser group. The refractive astigmatism was significantly lower at 18 months after surgery and the corneal astigmatism was significantly lower at both 12 and 18 months after surgery in the femtosecond-laser group. None of endothelial cell count, graft rejection or failure rate, differed significantly between the two groups. @*Conclusions@#Femtosecond-laser-enabled keratoplasty affords better visual recovery, less refractive and corneal astigmatism, and better wound stability than does penetrating keratoplasty using a manual trephine.

Accuracy of Predicting Refractive Outcomes Using Swept-source Optical Coherence Tomography in Nuclear Cataracts

PURPOSE: To evaluate the accuracy of predicting refractive outcomes of swept-source optical coherence tomography based biometry (ARGOS; Movu Inc., Santa Clara, CA, USA) in nuclear cataracts. METHODS: A total of 107 eyes (107 nuclear cataract patients) were analyzed. Subjects were divided into three groups according to the maximum nuclear density of Pentacam HR (A, lower tertile; B, medium tertile; C, upper tertile). The keratometry and axial length measured by IOLMaster (Carl Zeiss Meditec, Jena, Germany) and ARGOS systems were compared for each group. The correlation between maximum nuclear density and axial length difference readings from the two instruments was evaluated. The mean absolute error between the predicted refraction and 2-month post-operative refraction was compared. RESULTS: The maximum nuclear densities were 28.31 ± 7.30, 51.37 ± 7.82, and 88.63 ± 11.23 for groups A, B, and C, respectively. The axial length measured by ARGOS was significantly longer than that obtained using IOLMaster for groups B and C (respectively, p = 0.035, p < 0.001). A significantly positive correlation was found between the maximum nuclear density and axial length difference of the two devices (p < 0.001). Mean absolute errors were not significantly different between IOLMaster and ARGOS in group A. However, in groups B and C, the mean absolute error using ARGOS (0.31 ± 0.22 D and 0.32 ± 0.20 D, respectively) was significantly lower than that of IOLMaster (0.43 ± 0.21 D and 0.50 ± 0.26 D, respectively) (Group B, p = 0.027; Group C, p = 0.001). CONCLUSIONS: Even in dense nuclear cataracts, accurate refractive outcome prediction was possible using swept-source optical coherence tomography based biometry.

Comparison of Anterior Capsule Stability Following Implantation of Three Single Piece Acrylic Intraocular Lenses with Different Haptic Design

PURPOSE: To compare the anterior capsule contraction and intraocular lens (IOL) decentration among three types of IOL to determine the influence of haptic design on anterior capsule stability. METHODS: One hundred fifty patients were enrolled in this prospective, randomized study and 260 eyes underwent implantation of one of the following IOLs: modified L-haptic IOL (n = 74), modified C-haptic IOL (n = 97), or a plate-haptic IOL (n = 89). The area of the anterior capsule opening, IOL decentration, and capsule overlap were measured using retroillumination photospot 1 day and 2 months after cataract surgery. RESULTS: The area of capsule opening at postoperative day 1 was significantly different between the three IOLs (p < 0.01). All IOLs showed reduction of the anterior capsule opening from 1 day to 2 months after surgery, and greater reduction was shown in the modified C-haptic IOL (p < 0.001). At postoperative month 2, IOL decentration was significantly different between the IOLs and showed a positive correlation with the mean area reduction during month 2. CONCLUSIONS: The degree of anterior capsule contraction and IOL decentration in modified L-haptic IOLs were less than those in modified C-haptic IOLs and comparable to those in plate-haptic IOLs.

Factors Affecting Long-term Myopic Regression after Laser In Situ Keratomileusis and Laser-assisted Subepithelial Keratectomy for Moderate Myopia

PURPOSE: High myopia is known to be a risk factor for long-term regression after laser refractive surgery. There have been few studies about the correction of moderate myopias that did not need retreatment after long-term follow-up. We evaluated 10 years of change in visual acuity and refractive power in eyes with moderate myopia after laser refractive surgery. METHODS: We included patients that had undergone laser in situ keratomileusis (LASIK) or laser-assisted subepithelial keratectomy (LASEK) to correct their myopia and that had at least 10 years of follow-up. We evaluated the stability of visual acuity in terms of safety, efficacy, and refractive changes at examinations 6 months and 1, 2, 5, 7, and 10 years after surgery. RESULTS: The study evaluated 62 eyes (36 eyes in LASIK patients and 26 eyes in LASEK patients). In both groups, the efficacy index tended to decrease, and it was consistently higher in the LASEK group compared to the LASIK group over the 10 years of follow-up. The safety index improved over 10 years and was always higher than 0.9 in both groups. The difference between the spherical equivalent at 6 months postoperatively and later periods was statistically significant after 5, 7, and 10 years in both groups (LASIK, p = 0.036, p = 0.003, and p < 0.001, respectively; LASEK, p = 0.006, p = 0.002, and p = 0.001, respectively). Ten years after surgery,26 eyes (66.7%) in the LASIK group and 19 eyes (73.1%) in the LASEK group had myopia greater than 1 diopter. In comparison with the thickness at 6 months postoperatively, central corneal thickness was significantly increased after 5, 7, and 10 years in both LASIK and LASEK groups (LASIK, p < 0.001, p < 0.001, and p < 0.001, respectively; LASEK, p = 0.01, p < 0.001, and p < 0.001, respectively). CONCLUSIONS: Moderately myopic eyes showed progressive myopic shifting and corneal thickening after LASIK and LASEK during 10 years of follow-up. We also found that early refractive regression may indicate the long-term refractive outcome.

Comparisons for Evaluation of Efficacy and Safety of Cyclosporin A 0.05% Ophthalmic Emulsion Treatment Groups

PURPOSE: To evaluate and compare the efficacy and safety of cyclosporine 0.05% (Cyporin N eye drops 0.05%) to an active comparator (Restasis®) in moderate to severe dry eye patients. METHODS: This is a multicenter, randomized, double-blind, parallel, active control, non-inferiority, phase III study. Patients had a 2-week run-in period (during the run-in period, patients used artificial tears, if applicable), and afterward 158 patients were randomly assigned treatment for 12 weeks with cyclosporine 0.05% (with artificial tears, if applicable), in which the efficacy and safety were evaluated every four weeks. RESULTS: Corneal staining tests showed that in the per protocol set group, the study group was not inferior to the control group; the results for the full analysis set analytic group were the same. The number of adverse events reported from the 158 patients was not significantly different between groups (p = 0.1107). Additionally, other evaluations, including tolerability evaluations, clinical pathology examinations, and vital signs, show that there is no difference in terms of safety between the groups. CONCLUSIONS: Cyclosporine A 0.05% (Cyporin N eye drops 0.05%) is considered to have the same efficacy and safety compared to the active comparator.

Corneal Collagen Crosslinking in Progressive Keratoconus

PURPOSE: To report the clinical efficacy and safety of progressive keratoconic eyes in Korean patients treated with accelerated corneal cross-linking. METHODS: This retrospective study focused on progressive keratoconic eyes in Korean patients that underwent accelerated corneal cross-linking from February 2015 to October 2015. Keratoconus was diagnosed in 45 eyes in 30 patients. After accelerated corneal cross-linking with VibeX rapid solution, best corrected visual acuity, maximum keratometry, mean keratometry, corneal thickness, corneal astigmatism, and endothelial cell count were measured at the preoperative visit and post operation 1 week, 1 month, 3 months, and 6 months. RESULTS: Best corrected visual acuity (log MAR) was 0.51 ± 0.23 at pre operation and 0.51 ± 0.26 at post operation 6 months, showing no improvement. The maximum keratometry measured with Auto K, Pentacam, and Orbscan II at pre operation was 49.11 ± 4.5 D, 48.37 ± 3.31 D, and 48.98 ± 4.88 D and changed to 49.29 ± 4.34 D, 46.99 ± 3.63 D, and 47.01 ± 3.62 D postoperatively, respectively. Only Pentacam and Orbscan II measurements showed a statistically significant decrease (p < 0.05). Corneal thickness (at the thinnest area) was measured with Pentacam and Orbscan II; pre-operative and post-operative 6 month data showed changes from 485 ± 26.27 and 479.24 ± 27.89 to 471.64 ± 27.12 and 472.52 ± 25.36, respectively. Only the Pentacam method resulted in a statistically significant decrease. Endothelial cell count was measured with confocal microscopy and showed a statistically significant difference between pre-operative 2,857 ± 390.49/mm² and post-operative 6 month 2,639.21 ± 249.92/mm². CONCLUSIONS: This 6-month follow-up study of Korean keratoconus patients who underwent accelerated corneal cross-linking indicates that the method is effective in stabilizing the progression of keratoconus, according to maximum keratometry change. With regard to endothelial cell count change, further long-term evaluation is required. Other than endothelial cell count change, this procedure is expected to show long-term safety comparable to that of conventional corneal cross-linking.

Comparison of Long-term Clinical Outcomes between Descemet's Stripping Automated Endothelial Keratoplasty and Penetrating Keratoplasty in Patients with Bullous Keratopathy

PURPOSE: To compare 2-year clinical outcomes of Descemet's stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK) in patients with bullous keratopathy. METHODS: A retrospective chart review was performed to obtain 2 years of follow-up data of DSAEK or PK at a single center from March 2009 to September 2012. The study comprised 15 eyes of DSAEK and 11 eyes of PK. Outcome measures included best-corrected visual acuity (BCVA), spherical and keratometric changes, central corneal thickness, endothelial cell density, intraocular pressure, and postoperative complications. Graft survival rate was assessed by Kaplan-Meier survival analysis. RESULTS: There were no differences in patient baseline characteristics between the two groups. At postoperative 2 years, better BCVA of 0.69 ± 0.51 logarithm of the minimum angle of resolution (logMAR) was found after DSAEK compared to 0.88 ± 0.48 logMAR after PK. Refractive cylinder in DSAEK and PK was −2.60 ± 1.53 and −6.00 ± 1.05 diopters (D), respectively, and keratometric cylinder was 3.27 ± 3.70 and 6.34 ± 3.51 D, respectively, at postoperative 2 years. The difference of mean spherical equivalents between postoperative 1 month and 2 years was 0.84 D after DSAEK and 2.05 D after PK. A hyperopic shift of 1.17 D was present after 2 years of DSAEK. The mean endothelial cell density at postoperative 2 years was 1,548 ± 456 cells/mm² for DSAEK and 1,052 ± 567 cells/mm² for PK, with a cell loss of 19.96% vs. 52.38%, respectively when compared to postoperative 1 month. No significant difference in central corneal thickness was found between DSAEK and PK (592 ± 75 vs. 563 ± 90 µm, respectively). Finally, the 2-year survival rate did not differ significantly between DSAEK and PK (93.3% vs. 81.8%, respectively, p = 0.344). CONCLUSIONS: Compared to PK, DSAEK provided more stable refractive errors with better visual outcome, lower endothelial cell loss, and a lower rate of graft rejection at postoperative 2 years in patients with bullous keratopathy.

Comparison of Anterior Segment Measurements between Dual and Single Scheimpflug Camera

PURPOSE: To assess the degree of agreement of two rotating Scheimpflug cameras, Galilei G6 and Pentacam HR, in measuring corneal refractive power (K), anterior chamber depth (ACD), and central corneal thickness (CCT). METHODS: Measurement agreement was assessed in 40 eyes of 40 outpatients at our hospital. Measurements of anterior and posterior corneal refractive power (K), ACD, and CCT were compared between the Galilei G6 and Pentacam HR. RESULTS: For Galilei G6 (4 mm), Pentacam HR (3 mm) and Pentacam HR (4 mm), the anterior corneal refractive powers (K) were 44.35 ± 1.38 D, 44.09 ± 1.32 D, and 44.12 ± 1.35 D, respectively, and the posterior corneal refractive powers (K) were 6.39 ± 0.23 D, 6.45 ± 0.23 D, 6.45 ± 0.22 D. The differences in the results were statistically significant. The average ACD measurements using Galilei G6 and Pentacam HR were 3.26 ± 0.42 mm and 3.17 ± 0.42 mm, respectively, and the average CCT measurements were 556.65 ± 30.12 µm and 553.78 ± 29.42 µm. The differences in the measurements were statistically significant. In addition, ACD 95% limits of agreement (LoA) between Galilei G6 and Pentacam HR were in the range of -0.14~0.32 mm, and CCT 95% LoA were in the range of -12.54~18.29 µm. CONCLUSIONS: There were significant differences in measurements of anterior and posterior corneal refractive power (K), ACD, and CCT between the two cameras. Agreement analysis suggests that Galilei G6 and Pentacam HR should not be used interchangeably.

Comparison of Anterior Segment Measurements between Dual and Single Scheimpflug Camera

PURPOSE: To assess the degree of agreement of two rotating Scheimpflug cameras, Galilei G6 and Pentacam HR, in measuring corneal refractive power (K), anterior chamber depth (ACD), and central corneal thickness (CCT). METHODS: Measurement agreement was assessed in 40 eyes of 40 outpatients at our hospital. Measurements of anterior and posterior corneal refractive power (K), ACD, and CCT were compared between the Galilei G6 and Pentacam HR. RESULTS: For Galilei G6 (4 mm), Pentacam HR (3 mm) and Pentacam HR (4 mm), the anterior corneal refractive powers (K) were 44.35 ± 1.38 D, 44.09 ± 1.32 D, and 44.12 ± 1.35 D, respectively, and the posterior corneal refractive powers (K) were 6.39 ± 0.23 D, 6.45 ± 0.23 D, 6.45 ± 0.22 D. The differences in the results were statistically significant. The average ACD measurements using Galilei G6 and Pentacam HR were 3.26 ± 0.42 mm and 3.17 ± 0.42 mm, respectively, and the average CCT measurements were 556.65 ± 30.12 µm and 553.78 ± 29.42 µm. The differences in the measurements were statistically significant. In addition, ACD 95% limits of agreement (LoA) between Galilei G6 and Pentacam HR were in the range of -0.14~0.32 mm, and CCT 95% LoA were in the range of -12.54~18.29 µm. CONCLUSIONS: There were significant differences in measurements of anterior and posterior corneal refractive power (K), ACD, and CCT between the two cameras. Agreement analysis suggests that Galilei G6 and Pentacam HR should not be used interchangeably.

A Family with Axenfeld-Rieger Syndrome: Report of the Clinical and Genetic Findings

PURPOSE: To describe clinical findings in a Korean family with Axenfeld-Rieger syndrome. METHODS: A retrospective review of clinical data about patients with diagnosed Axenfeld-Rieger syndrome. Five affected members of the family underwent a complete ophthalmologic examination. We screened the forkhead box C1 gene and the pituitary homeobox 2 gene in patients. Peripheral blood leukocytes and buccal mucosal epithelial cells were obtained from seven members of a family with Axenfeld-Rieger syndrome. DNA was extracted and amplified by polymerase chain reaction, followed by direct sequencing. RESULTS: The affected members showed iris hypoplasia, iridocorneal adhesions, posterior embryotoxon, and advanced glaucoma in three generation. None had systemic anomalies. Two mutations including c.1362_1364insCGG and c.1142_1144insGGC were identified in forkhead box C1 in four affected family members. CONCLUSIONS: This study may help to understand clinical findings and prognosis for patients with Axenfeld-Rieger syndrome.

Clinical Outcomes of M-Plus Intraocular Lenses

PURPOSE: To evaluate the clinical outcomes of eyes implanted with a zonal refractive multifocal intraocular lens (IOL) with an inferior segmental near add (M-plus), and to compare the outcomes between M-plus and a diffractive-type multifocal IOL, AT LISA (366D, bifocal). METHODS: We reviewed 19 eyes from 10 patients who were implanted with M-plus and 52 eyes of 26 patients who were implanted with AT LISA. The clinical outcomes of these 2 intraocular lenses were evaluated at 1 day and 2 months postoperatively, and consisted of distant, intermediate, and near visual acuity, contrast sensitivity, degree of tilt, and decentration using anterior segment photography, depth of focus, and patient satisfaction. RESULTS: There were no statistical differences between the 2 groups with respect to distant vision, near vision, refractive error, contrast sensitivity, degree of tilt, decentration, or satisfaction score. The M-plus group demonstrated significantly better intermediate visual acuity. In the defocus curve, the M-plus group also demonstrated significantly better visual acuities for intermediate unfocused vision levels. CONCLUSIONS: The M-plus multifocal IOLs are able to provide satisfactory distant and near visual acuity and visual function. The M-plus multifocal IOLs provide better intermediate vision than the AT LISA.

A Case of Fungal Keratitis Caused by Paecilomyces lilacinus after Penetrating Keratoplasty

PURPOSE: To report a case of corneal ulcer caused by Paecilomyces lilacinus after penetrating keratoplasty. CASE SUMMARY: A 67-year-old male with a history of penetrating keratoplasty in the left eye 7 years prior and re-penetrating keratoplasty in the left eye due to graft failure in June 2013, visited our clinic for ocular pain and conjunctival injection in the left eye 3 days in duration. Corneal scrapings were performed for Gram and fungal stains and cultures. The patient was admitted to the hospital for hourly topical fortified ceftazidime and amphotericin B. Despite intensive topical therapy, no improvement was observed. Three days later, fungal culture confirmed Paecilomyces lilacinus and topical voriconazole was prepared from the intravenous formulation and was administered topically and intravenously. Despite medical therapy with voriconazole, perforation occurred requiring a tectonic keratoplasty. CONCLUSIONS: Keratitis caused by Paecilomyces lilacinus is difficult to eradicate and refractory to amphotericin B. We suggest early use of topical eyedrops, intracameral, and intravitreal injections of voriconazole may be an appropriate treatment for patients with Paecilomyces lilacinus keratitis.

Magnification Effect of the Capsulorhexis by the Cornea

PURPOSE: The purpose of this study is to measure the magnification of the capsulorhexis by the cornea using open ring guided capsulorhexis (ORGC) during cataract surgery. The study also investigated the magnification changes according to anterior chamber depth and corneal power. METHODS: The subjects comprised 40 eyes from 37 patients whose astigmatism was lower than 0.25 D and who had cataract surgery using ORGC from December 2011 to April 2012. ORGC was set on the anterior capsule and photographs were obtained using a camera connected to a surgical microscope after attaching a ruler around the limbus. The pixel number of 5 mm gradations on a ruler and the inner diameter of ORGC were measured using ImageJ. The inner diameter of ORGC was known to be 5.30 mm and the size of ORGC in the snapshot was therefore calculated by proportional expression. After corneal power and anterior chamber depth were identified, the magnification effect was evaluated. RESULTS: The 37 subjects were composed of 19 males and 21 females, and their average age was 64.8 years. The average depth of the anterior chamber was 3.28 mm, and the average corneal power was 43.534 D. The measured inner diameter of ORGC was 6.14 mm (SD: +/-0.16 mm) and the average magnification of the capsulorhexis was 115.9% (SD: +/-3.1%). The results showed that in the case of shallow anterior depth and low corneal power, the magnification was low equivalent to 110%. However, when the anterior chamber was deep and the corneal power was high, the magnification was greatly increased to 120%. CONCLUSIONS: The capsulorhexis was magnified to an average of 115.9% by the cornea during cataract surgery. In particular, it is necessary to consider capsulorhexis size in cases with deep anterior chamber and high corneal power, because the magnification will be greater in those cases.

Comparison of Early Clinical Result of Deep Anterior Lamellar Keratoplasty Using FSlaser Versus Manual Trephine

PURPOSE: To compare outcomes of femtosecond laser-enabled deep anterior lamellar keratoplasty (IE-DALK) versus manual trephine using deep anterior lamellar keratoplasty (Manual DALK, M-DALK). METHODS: Seventeen eyes from 17 patients underwent manual deep anterior lamellar keratoplasty, and femtosecond laser-enabled deep anterior lamellar keratoplasty was performed in 13 eyes of 13 patients. Postoperative clinical outcomes such as best corrected visual acuity, refractive astigmatism, keratometric astigmatism, endothelial cell density were compared between the two groups. RESULTS: The mean log MAR best spectacle-corrected visual acuity (BSCVA) was 0.31 +/- 0.17, 0.23 +/- 0.15, 0.18 +/- 0.14 in the IE-DALK group, and 0.55 +/- 0.41, 0.45 +/- 0.28, 0.35 +/- 0.22 (p = 0.056, p = 0.025, p = 0.313) in the M-DALK group at postoperative 2, 4, and 6 months respectively. The mean keratometric cylinder was 5.35 +/- 1.57, 4.24 +/- 1.97, 3.65 +/- 1.31 in the IE-DALK, 8.32 +/- 2.75, 6.80 +/- 2.50, 4.54 +/- 1.25 (p = 0.031, p = 0.041, p = 0.370) in the M-DALK group at postoperative 2, 4, and 6 months respectively. Endothelial cell counts in the two groups did not differ significantly at postoperative 6 months. CONCLUSIONS: The IE-DALK showed better results in BSCVA and keratometric astigmatism in the early postoperative period, in comparison with the M-DALK, and can be considered as a valuable method in deep anterior lamellar keratoplasty.

Objective Clinical Evaluation of Ocular Optical Instrument According to the Type of Lens Opacity

PURPOSE: To investigate the results using the OQAS and the Pentacam in cataract patients classified according to the type of lens opacity. METHODS: The present study included 124 eyes of 92 patients who had cataract surgery at Seoul St. Mary's Hospital from December 2011 to January 2012 and were classified into nuclear, cortical, and posterior subcapsular cataract patients. The lens opacity was determined with OSI, MTF, Strehl ratio, width 10%, width 50% and the opacity of Scheimpflug image by the OQAS and the Pentacam. Additionally, the correlation between subjective cataract classification and objective opacity value was analyzed. RESULTS: The nuclear cataract group showed a 6.40 +/- 2.41 OSI value and had high opacity. The cortical cataract group showed the highest MTF cut-off value (12.02 +/- 6.19 C/deg). When evaluating Pentacam results, the posterior subcapsular cataract group had the lowest average level of lens opacity (9.12 +/- 1.08) followed by in increasing order, the cortical cataract group (9.79 +/- 1.67) and the nuclear cataract group (11.08 +/- 1.84). The results were statistically significant (p < 0.001). The OSI value of the OQAS was significantly correlated with nuclear and posterior opacity (p = 0.049, p = 0.039, respectively) except cortical opacity (p = 0.781). MTF and nuclear opacity showed statistically significant correlation and the lens opacity of Pentacam was correlated with nuclear and posterior opacities. In cortical cataract with severe peripheral opacity, the cortical opacity showed significant correlation with Maximum. CONCLUSIONS: The OQAS and Pentacam results showed high correlation with the nuclear and posterior opacities which can be useful for cataract surgery.