Managing dissatisfaction after multifocal intraocular lens implantation through lens exchange using monofocal or alternative multifocal IOLs.

PURPOSE: To manage patient dissatisfaction following multifocal intraocular lens (MF-IOL) implantation by IOL exchange with either a monofocal or an alternative MF-IOL, and to compare outcomes in these two groups. METHODS: MF-IOL exchange was performed in 32 patients (64 eyes) with neuroadaptation failure. The MF-to-MF group involved patients who had a MF-IOL exchanged with another MF-IOL of a different optical profile and the MF-to-MO group involved patients who had a MF-IOL exchanged to a monofocal IOL. Visual outcomes and complications were analysed. The Quality of Vision (QoV) questionnaire, Visual Function Index (VF-14) and its Rasch-revised version (VF-8R) were also used to assess outcomes. RESULTS: There were no significant differences (p > 0.05) in the QoV scores between the two groups, both preoperatively and postoperatively. Preoperatively, there were no significant differences in VF-14 scores between both groups (p > 0.05). Postoperatively, there were statistically significant differences in VF-14 (total score, intermediate vision and near vision) in favour of the MF-to-MF group (p < 0.05). The postoperative VF-8R score in the MF-to-MF group was significantly better than the MF-to-MO group (p ≤ 0.001). Uncorrected and corrected near as well as corrected distance visual acuities were significantly better (p < 0.05) in the MF-to-MF group compared to the MF-to-MO group at 3 months. CONCLUSION: Patient dissatisfaction and neuroadaptation failure following MF-IOL implantation can be managed by an IOL exchange with an alternative optical design of MF-IOL or a monofocal IOL. Although, in the current study, the MF-to-MF group showed some better postoperative results, both options are feasible solutions.

Multifocal intraocular lens exchange to monofocal for the management of neuroadaptation failure.

BACKGROUND: The aim of this study was to evaluate visual, refractive, quality of vision, visual function and satisfaction of multifocal intraocular lens (MF-IOL) exchange with a monofocal IOL (MNF-IOL) in dissatisfied patients following MF-IOL implantation. METHODS: This was a retrospective case series. Bilateral IOL exchange (MF-IOL to MNF-IOL) was performed in 13 patients (26 eyes) with neuroadaptation failure. Questionnaires including the Quality of Vision (QoV), Visual Function Index (VF-14 and Rasch-revised VF-8R version), and a satisfaction questionnaire were used. RESULTS: The mean time for IOL exchange was 15 months. The corrected distance visual acuity (CDVA) improved from 20/26 to 20/23 (P = 0.028). The uncorrected near visual acuity (UNVA) worsened after exchange from 20/47 to 20/62 (P = 0.024). QoV scores improved significantly across all three subscales after exchange. Visual function for far distance improved with a change in VF-14 score from 74.2 ± 24.8 to 90.9 ± 9.1 (P = 0.03). The VF-8R score showed worsening although not statistically significant. Near vision spectacle independence was totally or partially lost in all cases. Ten patients (77%) reported they would not repeat the lens exchange. Safety and efficacy indices changed from 1.23 to 0.85, respectively, at three months to 1.24 (P = 0.871) and 0.89 (P = 0.568), respectively, at one year. CONCLUSION: IOL exchange (multifocal to monofocal) to solve neuroadaptation failure in this case series resulted in significant improvements in dysphotopsia and improved distance visual function. However, UNVA worsened and patient satisfaction after exchange remained suboptimal with 77% claiming they would not repeat the lens exchange, suggesting the value of near vision spectacle independence for these patients.

Patients' dissatisfaction with multifocal intraocular lenses managed by exchange with other multifocal lenses of different optical profiles.

BACKGROUND: The aim of the study was to evaluate the outcomes of dissatisfied patients reporting poor visual quality following implantation of multifocal intraocular lenses (MF-IOLs), managed by IOL exchange with another multifocal optical profile. METHODS: This is a retrospective series of cases. MF-IOL exchange was done in 15 dissatisfied patients (30 eyes) with the perception of poor visual quality for far distance affected by neuroadaptation failure. Patients underwent a bilateral exchange of a MF-IOL with another MF-IOL of a different optical profile. Visual outcomes and complications were analyzed. Questionnaires including Quality of Vision (QoV), Visual Function Index-14 (VF-14) and its Rasch-revised version (VF-8R) and a satisfaction questionnaire were also used for outcome evaluation. RESULTS: The mean elapsed time from implantation to explantation-reimplantation was 11.8 months. The QoV scores improved significantly across all the three subscales. Visual function improved with a change in VF-14 score from 60.41 ± 24.81 to 90.16 ± 10.91 (P < 0.001). The VF-8R score improved as well. The uncorrected distance visual acuity improved from 0.24 to 0.12 logMAR after exchange (P < 0.001) and corrected distance visual acuity improved from 0.15 to 0.04 logMAR (P < 0.001). Safety and efficacy indexes reached 1.46 and 1.16, respectively. Concerning patients' satisfaction following MF-IOL exchange, 80% of the patients reported they would have the MF-IOL reimplantation procedure again. CONCLUSIONS: Patient dissatisfaction with neuroadaptation failure following MF-IOL implantation can be managed in 80% of our cases by MF-IOL exchange with a different MF-IOL optical profile.

Corneal transplantation outcomes after the extrusion of an intrastromal keratoprosthesis: a pilot study.

This short report includes 5 eyes of 5 patients (mean age 63.2 ± 12 years) who underwent a tectonic keratoplasty [deep anterior lamellar keratoplasty (DALK) or penetrating keratoplasty (PK)] in order to rehabilitate the eye after the extrusion of the non-perforating keratoprosthesis (Kpro) KeraKlear (KeraMed, USA). The non-perforating Kpro was extruded after a mean period of 21.4 ± 21.8 months due to melting. In two cases, the keratoplasty was performed the same day of the non-perforating Kpro removal due to a severe melting, while in the other three cases it was performed one to 3 months later. Two eyes received a DALK, but in 3 eyes a macroscopic Descemet membrane perforation forced the conversion into a PK. The mean follow-up period after the keratoplasty was 16.8 ± 6.6 months. No cases of rejection were recorded. All the 5 eyes achieved "anatomical success" (transparent graft, with no signs of infection or inflammation). Two eyes showed limited "functional success" because the achievement of the best visual potential was prevented by the development of glaucomatous optic atrophy during the follow-up period. In conclusion, this short report presents an unexpected success of a keratoplasty performed with a tectonic purpose after the extrusion of the non-perforating Kpro because the corneal graft remained transparent, without neovascularization or scarring during the follow-up period. This initial evidence shows some encouraging results regarding graft survival rate and the achievement of a useful visual rehabilitation with keratoplasty after a non-perforating Kpro failure instead of repeating the Kpro implantation.

Keratopigmentation combined with strabismus surgery to restore cosmesis in eyes with disabling corneal scarring and squint.

BACKGROUND: Therapeutic corneal pigmentation has modernly evolved into different sophisticated techniques to camouflage cosmetically disabling corneal opacities and scars with good reported outcomes. Blind eyes frequently suffer from strabismus which further deteriorates the cosmesis of the patient. Combined keratopigmentation (KTPG) with strabismus surgery may be an option for these patients. METHODS: A total of 72 consecutive patients were retrospectively reviewed in this investigation. Main outcome measures were postoperative residual squint, and cosmesis evaluated by an independent observer, patient satisfaction, reoperation rates for KTPG and squint, and complications. RESULTS: A total of 72 consecutive patients and 73 eyes that underwent KTPG and strabismus surgery were included in this study. Mean follow-up time was 2.5±3 years. Patient age ranged from 5 to 83 years, with 93% having visual acuity worse than 0.1. 14 eyes (24.5%) underwent repeated KTPG, 24 (42.1%) had repeated strabismus surgery. 14 patients (19.4%) had a repeat muscle surgery, although 55 (76.4%) of the 72 patients achieved orthotropia or had deviations within 10 prism dioptres at the end of the follow-up period. Corneal microperforation was encountered in two (2.8%) patients and conjunctival staining in 10 eyes. Cosmesis was good for all patients. Patients who required repeat KTPG or strabismus surgery, or those in whom orthotropia was not totally restored, considered their cosmetic appearance sufficiently improved. CONCLUSION: Corneal KTPG combined with strabismus surgery provides good cosmesis for patients with corneal scarring and strabismus with minimal complications. Reoperation rates are relatively high in the short term to accomplish an optimal cosmetic result.

Punctiform and Polychromatic Pre-Descemet Corneal Dystrophy: Clinical Evaluation and Identification of the Genetic Basis.

PURPOSE: This study reports the clinical features and genetic bases of 3 previously unreported families with punctiform and polychromatic pre-Descemet corneal dystrophy (PPPCD). DESIGN: Observational case series. METHODS: Full ophthalmic assessment was performed for members of 3 unreported families with PPPCD. Structural and biomechanical alterations of the cornea were screened. Whole exome sequencing (WES) was performed in the first family. Novel or rare variants that segregated with the affected status were screened in the other 2 families using Sanger sequencing. Identified variants that segregated with the affected status in all families were characterized by using in silico prediction tools and/or in vitro splice assays. Additionally, 2 previously reported PPPCD families were screened for variants identified in the 3 unreported PPPCD families. RESULTS: PPPCD was diagnosed in 12 of the 21 examined members of the 3 unreported families. The only refractive, topographic, or biomechanical abnormality associated with PPPCD was a significantly increased corneal stiffness. WES and Sanger sequencing identified 2 variants that segregated with the affected status in all 3 families: a rare intronic PDZD8 c.872+10A>T variant and a novel missense PRDX3 c.568G>C (p.Asp190His) variant. The same PRDX3 variant was identified in the previously reported PPPCD family expressing the common PPPCD phenotype and was predicted by in silico prediction tools to be damaging to protein function. CONCLUSIONS: PPPCD is associated with an alteration of corneal biomechanics and a novel missense variant in PRDX3. Screening of additional families will determine whether all families demonstrate a PRDX3 variant or whether locus heterogeneity may exist for PPPCD.

Superficial Keratopigmentation: An Alternative Solution for Patients With Cosmetically or Functionally Impaired Eyes.

PURPOSE: To report the use of different superficial keratopigmentation (KTP) techniques for restoring or enhancing cosmetic appearance of eyes impaired for several reasons. METHODS: This is a retrospective, consecutive, noncomparative interventional series of cases, in which 136 cosmetically disabled eyes (due to different corneal abnormalities) of 130 patients were included. A total of 222 procedures of superficial manual KTP and superficial automated KTP were performed. The procedures were divided into 2 groups: first and second-stage procedures. The patients' cosmetic appearance and satisfaction were evaluated and graded as excellent, good, or poor. RESULTS: A total of 222 procedures were performed, 57.2% were superficial automated KTP, 22.5% were superficial manual KTP, and 20.3% included the combination of superficial KTP with other KTP techniques. Six procedures were purely cosmetic, 16 therapeutic functional, and 200 therapeutic cosmetic. Superficial KTP, as a second-stage procedure, was performed in 13 eyes that were previously pigmented by intrastromal techniques. Superficial KTP as an initial indication (first-stage procedure) alone or in combination with another KTP technique in the same surgery was performed in 123 eyes, in which 44.7% of them were reoperated once or more. Best-corrected visual acuity changed insignificantly, and the intraocular pressure decreased significantly in all the studied groups. No intraoperative complications were observed, 11.2% of eyes with a follow-up time of more than 3 months developed postoperative complications. Most of the patients (98.5%) were satisfied. CONCLUSIONS: The modern superficial KTP procedure provides the possibility to improve the cosmetic appearance of impaired eyes, as an alternative to evisceration, enucleation, prosthetic contact lenses, or keratoplasty.

Clinical outcomes with a diffractive trifocal intraocular lens.

PURPOSE: To evaluate clinical and visual outcomes, quality of near vision, and intraocular optical quality of patients bilaterally implanted with a trifocal PanOptix intraocular lens. METHODS: In this prospective consecutive case-series study, 52 eyes of 26 bilateral patients (mean age, 60.2 ± 7.4 years) were implanted with the AcrySof IQ Panoptix intraocular lens. Visual acuity, defocus curve, contrast sensitivity (Pelli-Robson test), near activity visual questionnaire, and internal aberrations with Osiris were evaluated. A prototype light-distortion analyzer was used to quantify the postoperative light-distortion indices. The follow-up was 6 months after surgery. RESULTS: Uncorrected, corrected distance, and uncorrected near visual acuities improved with the surgery (p ≤ 0.02). Distance corrected near visual acuity was 0.13 ± 0.10, 0.13 ± 0.13, and 0.13 ± 0.08 at 1, 3, and 6 months after surgery, respectively (p = 0.82). Distance corrected intermediate visual acuities were 0.09 ± 0.13, 0.13 ± 0.15, and 0.12 ± 0.12 at 1, 3, and 6 months, postoperatively. Binocular contrast sensitivity was 1.86 ± 0.15 Log Units. Defocus curve provided a visual acuity equal or better to 0.30 LogMAR between defocus levels of +0.50 to -3.00 D. The near activity visual questionnaire scores improved significantly with the surgery (p < 0.01). CONCLUSION: The AcrySof IQ Panoptix intraocular lens is able to restore visual function with an acceptable intermediate and near vision after cataract surgery with good contrast sensitivity and an improvement in the near activity visual questionnaire.

Keratopigmentation with micronised mineral pigments: complications and outcomes in a series of 234 eyes.

AIM: To report the complications observed in a consecutive large series of cases treated with keratopigmentation (KTP). METHODS: KTP was performed in 234 eyes of 204 patients for therapeutic and cosmetic reasons. From them, 50 eyes of 29 patients suffered complications. Different KTP techniques and three generations of pigments (GP) were used. The follow-up period ranged from 4 months to 12 years. Light sensitivity (LS), visual field (VF) limitations and MRI alterations were considered functional complications. Organic complications were described as change in colour, colour fading and neovascularisation. RESULTS: The percentage of complications was 12.82%. Most patients complained of LS (49%), then colour fading and change in colour (19%). Neovascularisation, VF limitations and MRI complications constituted 7%, 4% and 2%, respectively. Organic complications were observed with the previous GP but resolved with the latest third GP with CE mark certification (Conformité Européene). Although LS remained with the corneal-specific pigments, it gradually disappeared in most of the patients (81.81%) 6 months postoperatively. CONCLUSION: To the best of our knowledge this is the first time a study systematically and comprehensively approaches and reports KTP complications. KTP with third GP provides better results and fewer complications than previous ones. It is a modern, minimally invasive technique that helps solve several functional ocular problems and improves cosmetic appearance of the patients. Dermatological pigments should not be used as they lead to complications; instead pigments specifically tested for the eye in terms of toxicity and teratogenicity should be used.

Small incision lenticule extraction (SMILE) in the correction of myopic astigmatism: outcomes and limitations - an update.

Small Incision Lenticule Extraction (SMILE) is a flap-free intrastromal technique for the correction of myopia and myopic astigmatism. To date, this technique lacks automated centration and cyclotorsion control, so several concerns have been raised regarding its capability to correct moderate or high levels of astigmatism. The objective of this paper is to review the reported SMILE outcomes for the correction of myopic astigmatism associated with a cylinder over 0.75 D, and its comparison with the outcomes reported with the excimer laser-based corneal refractive surgery techniques. A total of five studies clearly reporting SMILE astigmatic outcomes were identified. SMILE shows acceptable outcomes for the correction of myopic astigmatism, although a general agreement exists about the superiority of the excimer laser-based techniques for low to moderate levels of astigmatism. Manual correction of the static cyclotorsion should be adopted for any SMILE astigmatic correction over 0.75 D.

Femtosecond Laser-Assisted Tuck-In Penetrating Keratoplasty for Advanced Keratoglobus With Endothelial Damage.

PURPOSE: To describe the outcomes of femtosecond laser-assisted tuck-in penetrating keratoplasty as a single-step surgical procedure for visual and anatomical rehabilitation of patients with severe keratoglobus (KTG) and endothelial damage. METHODS: Two eyes of a 7-year-old patient with bilateral severe KTG and previous corneal hydrops were operated. Assisted by the femtosecond laser, both donor and recipient corneas were prepared. An 8.5-mm full-thickness donor tissue with a peripheral partial-thickness rim of 1.25 mm was sutured into an 8.5-mm recipient bed with a previously dissected intralamellar peripheral pocket up to the limbus. The graft was secured with 16 interrupted 10-0 nylon sutures and the peripheral donor rim tucked into the host stromal pocket. RESULTS: Six months after surgery, both grafts remained healthy and clear. One eye developed mild postoperative ocular hypertension. No intraoperative or other postoperative complications were observed. Corrected distance visual acuity was 20/50 in both eyes, with complete functional rehabilitation of the patient. Restoration of the peripheral corneal thickness was observed in the pachymetric map. CONCLUSIONS: Femtosecond laser-assisted tuck-in penetrating keratoplasty can provide excellent anatomical and functional rehabilitation of patients with severe KTG and endothelial damage, through a single-step surgical procedure and a single donor cornea per eye. The femtosecond laser permits accurate dissection of these already thin corneas without inadvertent perforation risk.