Evaluation of a Device for Standardized Measurements of Reading Performance in a Prepresbyopic Population.

PURPOSE: Automated measurements of reading performance are required for clinical trials involving presbyopia-correcting surgery options. Repeatability of a testing device for reading (Salzburg Reading Desk) was evaluated in a prepresbyopic population. METHODS: Subjective reading performance of 50 subjects divided into 2 age groups (23-30 years and 38-49 years) with distance-corrected eyes was investigated with different log-scaled reading charts. At study entry, refractive parameters were measured and distance visual acuity assessed. Two standardized binocular measurements were performed for each subject (32.24 ± 9.87 days apart [mean ± SD]). The repeatability of the tests was estimated using correlation coefficients, Wilcoxon signed-rank test, and Bland-Altman method. RESULTS: The test parameters at both maximum reading rate (MRR) measurements demonstrate a strong relationship of age group 2 subjects (correlation coefficient [r] = 0.74 p = 10-4) and of younger subjects (age group 1: r = 0.69, p = 10-4). Prepresbyopic subjects of age group 2 showed moderate results for near reading distance (r = 0.67, p = 10-4); by contrast, younger subjects had poorer results (r = 0.55, p = 10-3). The Wilcoxon signed-rank test revealed agreement between measurements and Bland-Altman plots showed a wide data spread for MRR and near reading distance in both groups. CONCLUSIONS: The device measures repeatedly selected reading performance parameters of near real world conditions, such as MRR, in prepresbyopic populations if several factors are taken into account. The option to choose preferred distance leads to more variance in measuring repeated reading performance. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) registration reference number: DRKS00000784.

Repeatability of topographic and aberrometric measurements at different accommodative states using a combined topographer and open-view aberrometer.

PURPOSE: To evaluate the repeatability of corneal first-surface aberrations and aberrometric measurements of a combined aberrometer-topographer (iTrace Visual Function Analyzer) for 5 accommodative stimuli. SETTING: Department of Ophthalmology, Goethe-University, Frankfurt, Germany. DESIGN: Prospective case series. METHODS: Eyes of young adults with low to moderate myopia or hyperopia were examined in 2 measurement series comprising 3 corneal topography measurements and wavefront measurements focusing on targets at 5 distances (0.4, 0.5, 0.6, 1.0, and 4.0 m). Repeatability was analyzed using the standard deviation (SD) within 6 measurements and the coefficient of repeatability (CoR) by Bland-Altman analysis of the means of the 2 measurement series. RESULTS: Fifty eyes (50 subjects) were evaluated. The lowest calculated mean SD/CoR measurements using the aberrometer function at 5 target distances were 0.07 µm/0.14 µm for total ocular aberrations root mean square (RMS), 0.07 µm/0.16 µm for lower-order aberrations (LOAs) RMS, 0.03 µm/0.66 µm for higher-order aberrations (HOAs) RMS, 0.10 diopter (D)/0.22 D for sphere, 0.08 D/0.13 D for cylinder, and 0.09 D/0.21 D for the spherical equivalent (SE). Repeatability of the total RMS, LOAs RMS, sphere, and SE measurements improved with increasing target distance (P < .01 for aberrometric values; P < .03 for refractive values). Measurement reproducibility using the corneal topographer showed mean SDs/CoRs of 0.19 µm/0.41 µm for total RMS, 0.19 µm/0.39 µm for LOAs RMS, and 0.08 µm/0.23 µm for HOAs RMS. CONCLUSION: The aberrometer showed satisfactory results for measurement repeatability at all target distances and declining repeatability with increasing accommodation effort. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Objective classification of glistenings in implanted intraocular lenses using Scheimpflug tomography.

PURPOSE: To evaluate whether ocular Scheimpflug tomography allows automated detection of glistenings in implanted intraocular lenses. SETTING: Department of Ophthalmology, Goethe University, Frankfurt, Germany. DESIGNS: Prospective, nonrandomized case series. METHODS: Patients who had phacoemulsification with implantation of various types of monofocal intra-ocular lenses (IOL) were examined under mydriasis for glistenings with the following 3 methods: subjective quantification with a rating scale during slitlamp examination, manual counting in slitlamp photographs, and using a purpose-written digital-image processing program for automatic counting of glistenings in Scheimpflug images. Examinations were performed by the same examiner at least 6 months after IOL implantation. Methods were tested for consistency with the Cohen κ coefficient and single-factor analysis of variance. RESULTS: The subjectively graded glistenings (n = 63 patients, 63 eyes) during slitlamp examination showed the same glistening grade as the manually counted glistenings in slitlamp photographs, with a moderate agreement (κ = 0.46). The glistening count derived from Scheimpflug images was not associated with the glistening grades determined through any of the slitlamp methods (P > .05). CONCLUSION: Subjective glistening grading score showed a moderate agreement with counted score in slitlamp images. The Scheimpflug device used in this study did not provide images of required resolution to perform an automated counting of separate glistenings and thus classification. FINANCIAL DISCLOSURES: Drs. Biwer, Schmitt, Honig, Spratte, and Baumeister have no financial or proprietory interest in any material or method mentioned. Dr. Kohnen has received travel reimbursement and lecture fees and is a consultant to Abbott, Alcon, Thieme Compliance, Hoya, Rayner, Oculus, Schwind, and Zeiss.

Repeatability of lens densitometry using Scheimpflug imaging.

PURPOSE: To evaluate the repeatability of different lens densitometry analysis modes performed with Scheimpflug imaging using the Pentacam HR device. SETTING: University eye hospital, Frankfurt am Main, Germany. DESIGN: Cross-sectional study. METHODS: Eyes were analyzed under mydriasis during 2 examinations performed by the same examiner. Three single measurements were taken to assess lens densitometry via 3 modes as follows: peak (maximum), linear (vertical axis), and 3-dimensional (3-D). Measurements were also taken using 3 cylindrical reference blocks (P) with different diameters (2.0 mm, 4.0 mm, 6.00 mm) composing the whole lens depth. Repeatability was tested using Bland-Altman analysis. As statistical parameters, the coefficient of repeatability (CoR) and the relative repeatability (RR) were applied. RESULTS: The study analyzed 105 eyes. The CoR of the peak modus was 5.6 (RR, 29.8%); of the linear modus, 0.9 (RR, 8.8%); and of the 3-D modus, 0.36 (RR, 3.6%). The values of the P mode were lower, with a CoR between 0.19 and 0.30 (RR, 2.1%-3.3%). CONCLUSIONS: Lens densitometry using Scheimpflug imaging was highly repeatable. However, repeatability was dependent on the analysis mode used. Repeatability decreased with increasing opacification.

Influence of additional astigmatism on distance-corrected near visual acuity and reading performance.

AIM: To investigate the effect of astigmatism on near vision performance. METHODS: In a consecutive case series 23 eyes of 23 participants were fogged with 0 D, -0.75 D and -1.5 D of with-the-rule (WTR) and against-the-rule (ATR) astigmatism (cylindrical lenses without spherical compensation). All subjects were cyclopleged and distance corrected. Reading acuity (RAc) and speed (RS) were measured with standardised sentences, near visual acuity (NVA) was assessed using single optotypes (Snellen E), all presented on a thin film transistor display using the Salzburg Reading Desk (SRD). Data were analysed using Wilcoxon-matched-pairs test, regression analysis and Bland-Altman analysis. RESULTS: An increasing amount of astigmatism resulted in a decreased NVA (p=0.16 for -0.75 D, p=0.005 for -1.5 D) and RAc (p=0.002 for -0.75 D, p=0.014 for -1.5 D). WTR astigmatism caused a reduced NVA, RAc and lower RS compared with ATR astigmatism (p<0.001). NVA was better than RAc with no astigmatism, -0.75 D WTR and -1.5 D WTR (p=0.03 for 0 D, p<0.001 for -0.75 D, p=0.03 for -1.5 D). There was no difference between NVA and RAc for -0.75 D ATR and -1.5 D ATR (p=0.06 for -0.75 D, p=0.5 for -1.5 D). CONCLUSIONS: WTR astigmatism results in reduced reading parameters and NVA for -0.75 D and -1.5 D astigmatism compared with corresponding ATR astigmatism and no astigmatism added. No beneficial effect of astigmatism was detected.

Advances in lens implant technology.

Cataract surgery is one of the oldest and the most frequent outpatient clinic operations in medicine performed worldwide. The clouded human crystalline lens is replaced by an artificial intraocular lens implanted into the capsular bag. During the last six decades, cataract surgery has undergone rapid development from a traumatic, manual surgical procedure with implantation of a simple lens to a minimally invasive intervention increasingly assisted by high technology and a broad variety of implants customized for each patient's individual requirements. This review discusses the major advances in this field and focuses on the main challenge remaining - the treatment of presbyopia. The demand for correction of presbyopia is increasing, reflecting the global growth of the ageing population. Pearls and pitfalls of currently applied methods to correct presbyopia and different approaches under investigation, both in lens implant technology and in surgical technology, are discussed.

Influence of amplitude, starting point, and age on first- and second-order dynamics of Edinger-Westphal-stimulated accommodation in rhesus monkeys.

PURPOSE: In humans, accommodative and disaccommodative dynamics depend on response amplitude and starting point. The purpose of this study was to determine the influence of amplitude and starting point on open-loop accommodative dynamics in Edinger-Westphal (EW)-stimulated, anesthetized rhesus monkeys of different ages. METHODS: One eye each of two younger and two older iridectomized rhesus monkeys, (aged 6.8, 8.9, 15.0, and 16.3 years) were studied. The experiment was repeated in one eye of one younger monkey. Lens thickness changes were recorded by dynamic ultrasound biometry at 100 Hz. Stimuli used produced accommodative responses: (1) starting from baseline with increasing amplitudes; (2) from increasing starting points to maximum accommodation; and (3) from increasing starting points with a constant amplitude of 1 D. The lens thickness measurements were converted into accommodation and velocities and accelerations of the responses were determined by using a two-point difference algorithm. RESULTS: Maximum accommodative amplitudes ranged from 4.68 to 6.37 D in the older monkeys and 9.33 to 11.59 D in the younger monkeys. The peak velocity of accommodation and disaccommodation increased linearly with response amplitude. Peak velocity and peak acceleration of accommodation and disaccommodation were independent of the response starting point. Subtle variations in disaccommodative response peak velocities were found to vary with age. CONCLUSIONS: The results suggest that, in anesthetized rhesus monkeys, disaccommodative rather than accommodative dynamics may be more sensitive to age-related changes and that, unlike in conscious human subjects, the starting configuration of the accommodative plant has little influence on accommodative dynamics.

Cataract surgery with implantation of an artificial lens.

BACKGROUND: Cataract surgery, the most frequently performed operative procedure worldwide, typically concludes with the implantation of an artificial intraocular lens (IOL) to correct aphakia (absence of the crystalline lens). METHOD: Selective literature review including current regulations, guidelines and recommendations for cataract surgery. RESULTS: The main symptom of cataract is loss of visual acuity, which usually progresses slowly. It can arise in one eye or both. There is a basic distinction between congenital and acquired cataracts. The probability of developing a cataract rises with age because of biochemical aging processes. The development of a cataract becomes highly likely from the sixth decade of life onward. CONCLUSIONS: As no effective medications for cataract are available at present, its current standard treatment is the removal of the clouded lens. In industrialized countries, this is usually done with ultrasound (phacoemulsification), followed by the implantation of an IOL.

Corneal re-epithelialization following phototherapeutic keratectomy for recurrent corneal erosion as in vivo model of epithelial wound healing.

BACKGROUND: This placebo-controlled double-blind study examined the suitability of recording corneal epithelialization after phototherapeutic keratectomy (PTK) as a model of epithelial wound healing. METHODS: Eighteen patients with recurrent corneal erosion were randomized into 2 groups, and received PTK with a 7-mm ablation zone. Postoperatively, one group was treated with an ointment containing 5% dexpanthenol and the other with the ointment vehicle without dexpanthenol. The epithelial lesions were recorded by digital slit-lamp photographs with fluorescein staining at fixed intervals until epithelial closure. The size of the epithelial defect was measured, and the average time until epithelial closure was calculated. Reliability of measurements was tested by calculating Cronbach's alpha from measurements at the same point in time. RESULTS: Photographs could be taken at all scheduled examinations. The measured size of the epithelial defects showed a high reliability (Cronbach's alpha = 0.994). The average time needed for epithelial closure was 57.5 h in the treatment group and 64.8 h in the placebo group (p = 0.177). CONCLUSIONS: Planimetric measurement of slit-lamp photographs of standardized epithelial defects is an adequate method for monitoring the progress of corneal epithelial wound healing. Although wounds treated with dexpanthenol showed a slightly shorter average healing time, the difference to the placebo was not significant.

Tilt and decentration of spherical and aspheric intraocular lenses: effect on higher-order aberrations.

PURPOSE: To determine the impact of spherical and aspheric foldable intraocular lens (IOL) tilt and decentration on optical quality after cataract surgery in an intraindividual comparative study. SETTING: Department of Ophthalmology, Goethe-University, Frankfurt am Main, Germany. METHODS: Randomized implantation of a spherical IOL (Sensar AR40e) was performed in 1 eye and of an aspheric IOL with negative spherical aberration (Tecnis Z9000) in the contralateral eye. Three to 4 months postoperatively, the wavefront was measured and higher-order aberrations (HOAs) were calculated for virtual pupil diameters of 3.5 mm and 6.0 mm. Tilt and decentration of the IOLs were measured using Scheimpflug photography. The tilt and decentration, HOAs, and best corrected visual Strehl ratio of the optical transfer function (BCVSOTF) calculated from the wavefront aberration were compared. The effect of tilt and decentration on HOAs and optical quality was assessed using multiple regression analysis. RESULTS: The mean optic tilt was 2.89 degrees +/- 1.46 (SD) for the spherical IOL and 2.85 +/- 1.36 degrees for the aspheric IOL. The mean optic decentration was 0.19 +/- 0.12 mm and 0.27 +/- 0.16 mm, respectively. No significant intergroup differences in IOL tilt or decentration were found. Tilt and decentration did not significantly affect the BCVSOTF with either IOL. CONCLUSIONS: The amounts of tilt and decentration of both IOLs were not large enough to cause deterioration of optical quality. Thus, when IOL tilt and decentration are within normal limits, they do not compromise the correction of spherical aberration by the aspheric IOL.

Edinger--Westphal stimulated accommodative dynamics in anesthetized, middle-aged rhesus monkeys.

The relationships between peak velocity and amplitude of Edinger-Westphal (EW) stimulated accommodation and disaccommodation were investigated in anesthetized, middle-aged rhesus monkeys. Accommodative responses were recorded at 30Hz with infrared photorefraction. Peak velocity of accommodation and disaccommodation increased linearly with stimulus amplitude. Peak velocities of accommodation continued to increase with stimulus amplitudes greater than required to produce the maximum response. The peak velocity of disaccommodation did not further increase with supramaximal stimulus amplitudes beyond that achieved with maximal stimulus amplitudes. Although maximum accommodative response amplitude is reduced in older rhesus monkeys, within the methodological constraints of this study, older monkeys appear to achieve accommodative and disaccommodative peak velocities similar to adolescent monkeys for the same response amplitudes.

Scheimpflug measurement of intraocular lens position after piggyback implantation of foldable intraocular lenses in eyes with high hyperopia.

PURPOSE: To investigate the position of 3-piece foldable intraocular lenses (IOLs) after piggyback implantation for high hyperopia. SETTING: University Eye Hospital, Johann Wolfgang Goethe University, Frankfurt am Main, Germany. METHODS: Eight eyes of 5 highly hyperopic patients had phacoemulsification and implantation of 2 foldable IOLs. In 3 eyes, both IOLs were implanted in the capsular bag. In 5 eyes, 1 IOL was placed in the capsular bag and the second IOL in the ciliary sulcus. Intraocular lens optic tilt and decentration, combined thickness of both IOLs, and anterior chamber depth (ACD) were measured postoperatively over a period of 18 months using Scheimpflug photography. RESULTS: All eyes with both IOLs in the capsular bag showed interpseudophakic opacification, with a mean increase in combined IOL thickness of 0.4 mm, a decrease in ACD of 0.3 mm, and a corresponding hyperopic shift of 4.00 diopters. Eyes in which the anterior IOL was placed in the ciliary sulcus showed no changes in refraction or combined IOL thickness. In these eyes, the anterior IOL had a higher mean decentration (0.49 mm +/- 0.20 [SD] after 12 months) than the posterior IOL (0.21 +/- 0.13 mm after 12 months). CONCLUSIONS: Piggyback IOL implantation with placement of 2 foldable IOLs in the capsular bag can be followed by a hyperopic shift that may be caused in part by displacement of the IOLs. Placement of the anterior IOL in the ciliary sulcus can lead to higher decentration of this IOL.

Corneal ulcer caused by a wooden foreign body in the upper eyelid 6 months after minor injury.

PURPOSE: To describe a case of a wooden foreign body in the upper eyelid that remained asymptomatic for 6 months. CASE REPORT: A 9-year-old boy was presented with moderate upper lid swelling. Medical history was positive for trauma with a wooden stick 6 months ago. At first, the condition resolved under local antibiotic treatment. Three weeks later, the inflammation recurred and a corneal ulcer developed. Examination under general anesthesia revealed a wooden foreign body which had remained in the upper eyelid since the first injury. CONCLUSION: Organic foreign bodies in the eyelid can remain asymptomatic for a long period of time and can play a role in periocular inflammation. In case of doubt, children and other less cooperative patients should be examined under general anesthesia.

Tilt and decentration of three-piece foldable high-refractive silicone and hydrophobic acrylic intraocular lenses with 6-mm optics in an intraindividual comparison.

PURPOSE: Intraindividual comparison of tilt and decentration of three-piece foldable intraocular lenses (IOLs) with 6-mm optics and different edge design and material. DESIGN: Prospective randomized study. METHODS: Twenty-five patients with senile cataract (group I) received a foldable silicone, sharp optic edge IOL in one eye and a silicone, rounded optic edge IOL in the other eye. Group II (n = 28) received the foldable silicone, sharp optic edge IOL in one eye and an acrylate, sharp optic edge IOL in the other eye. Scheimpflug photography was performed after the procedure with an anterior eye segment analysis system. Tilt and decentration of the IOL optic were measured 1 week, 6 months, and 12 months after the procedure. RESULTS: In group I, the foldable silicone, sharp optic edge IOL showed a mean optic tilt of 3.03 +/- 1.79 degrees and an optic decentration of 0.24 +/- 0.13 mm; the silicone, rounded optic edge IOL showed a tilt of 3.26 +/- 1.69 degrees and a decentration of 0.23 +/- 0.13 mm. In group II, the foldable silicone, sharp optic edge IOL showed an average tilt of 2.34 +/- 1.81 degrees and a decentration of 0.29 +/- 0.21 mm after 12 months; the acrylate, sharp optic edge IOL had a tilt of 2.32 +/- 1.41 degrees and a decentration of 0.24 +/- 0.10 mm. There were no significant differences in either group. CONCLUSION: The examined IOLs showed a stable position regarding tilt and decentration in the first 12 postoperative months, independent of material and edge design. Slight deviations from the optical axis might affect the outcome in aspheric or multifocal IOLs.

Intermittent myopic shift of 4.0 diopters after implantation of an Artisan iris-supported phakic intraocular lens.

A 45-year-old man with bilateral high myopia and myopic astigmatism had uneventful implantation of a -10.5 diopters (D) Artisan iris-fixated anterior chamber phakic intraocular lens (PIOL) (Ophtec) in both eyes. In the first days after surgery, uncorrected visual acuity (UCVA) was 20/16 in the right eye and 20/16 in the left; the position of the PIOL was stable. Ten days after surgery, the left eye developed a myopic shift of 4.0 D. Further examination showed that the myopia disappeared when the pupil was medically dilated. After the pupil returned to a natural position, the myopic shift reappeared. Because there were no changes in the subsequent 4 months, we decided to exclavate the IOL, rotate it by 10 degrees, and reenclavate it with less tissue. The myopic shift did not return over the following 20 months, and the UCVA was 20/20. In rare cases, iris-fixated anterior chamber IOLs may induce refractive changes related to effects on the surrounding anatomic structures. This may be corrected by phakic IOL rotation or reenclavation of the phakic IOL with less tissue.

Position of angle-supported, iris-fixated, and ciliary sulcus-implanted myopic phakic intraocular lenses evaluated by Scheimpflug photography.

PURPOSE: To examine postoperative positional stability of myopic phakic intraocular lenses (IOLs). DESIGN: Prospective, nonrandomized clinical study. METHODS: The study included 46 eyes which received an anterior chamber angle-supported (Bausch & Lomb NuVita; 10 eyes), anterior chamber iris-fixated (Ophtec Artisan; 20 eyes) or ciliary sulcus-implanted phakic IOL (Staar ICL; 16 eyes). The distance between the phakic IOL and the crystalline lens and the cornea as well as rotation around the optical axis was evaluated using Scheimpflug photography at 1, 3 to 6, and 12 months postsurgery. RESULTS: The anterior chamber phakic IOLs showed no significant movement in anteroposterior direction. The posterior chamber phakic IOL showed a significant movement toward the crystalline lens between postoperative months 3 and 12. The median amount of rotation around the optical axis between the 3- and the 12-month evaluation was 1.9 degrees (range = 0.0-33.5 degrees) for the NuVita, 0.6 degrees (range = 0.0-3.5 degrees) for the Artisan, and 0.9 degrees (range = 0.2-2.3 degrees) for the ICL. Four NuVita IOLs rotated more than 10 degrees. CONCLUSIONS: The angle-supported anterior chamber phakic IOLs showed a generally stable position regarding distance to cornea and natural lens, but rotation was observed in four IOLs. The iris-fixated phakic IOL showed the highest overall stability. The posterior chamber phakic IOL was stable in terms of rotation but had a tendency to decrease in distance toward the crystalline lens. Intraocular lenses implanted in phakic eyes followed for 12 months demonstrate stable IOL position overall.

Comparison of manual and automated methods to determine horizontal corneal diameter.

PURPOSE: To compare 2 manual methods and 2 automated devices for measuring the horizontal corneal diameter (white-to-white [WTW] distance). SETTING: Department of Ophthalmology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany. METHODS: In 100 eyes of 61 patients, the WTW distance was measured independently by 2 examiners using the following techniques: the Holladay-Godwin gauge, a measuring caliper, Zeiss IOLMaster, and Orbscan II topography system (Bausch & Lomb). The results were compared with measurements on magnified slitlamp photographs of the anterior eye segment. Statistical evaluation was performed using the Bland-Altman method for comparison of measurement techniques. RESULTS: The mean horizontal corneal diameter was 11.91 mm +/- 0.71 (SD) with the measuring caliper, 11.8 +/- 0.60 mm with the Holladay-Godwin gauge, 11.78 +/- 0.43 mm with the Orbscan II, and 12.02 +/- 0.38 mm with the IOLMaster. The coefficient of inter-rater repeatability was 1.30 for the caliper, 0.92 for the Holladay-Godwin gauge, 0.76 for the Orbscan II, 0.50 for the IOLMaster, and 1.16 for the manual measurement in anterior segment images. The results obtained with the caliper were statistically significantly different between the 2 examiners (P<.001). The measurements of examiner 2 using the caliper were significantly different from the measurements of the same examiner using the Holladay-Godwin gauge. This was not the case with the 2 automated devices. CONCLUSIONS: Automated measurement of the WTW distance provides more precise results than measurements using manual methods. The Zeiss IOLMaster had the highest reliability in measuring corneal diameter.

Scheimpflug imaging of bilateral foldable in-the-bag intraocular lens implantation assisted by a scleral-sutured capsular tension ring in Marfan's syndrome.

A 35-year-old white man with bilateral high myopia, astigmatism, subluxated crystalline lenses, and incipient cataract had phacoemulsification and implantation of a hydrophobic acrylic intraocular lens (IOL) (Alcon MA60BM) in both eyes. The subluxated capsular bag was stabilized and recentered using a scleral-fixated capsular tension ring (CTR) (type 1L, Morcher). Measured with Scheimpflug photography, the capsular bag and IOL were in a stable intraocular position during the 18-month follow-up. There were no major changes in refraction. Despite the sharp-edged IOL design, both eyes had posterior capsule opacification (PCO) 18 months after surgery that in 1 eye caused a decrease in visual acuity of more than 2 lines. High myopia and subluxated lenses may be treatable long-term with a scleral-fixated CTR and foldable IOL implantation; further evaluation of PCO is necessary.

Confocal microscopic characteristics of stage 1 to 4 diffuse lamellar keratitis after laser in situ keratomileusis.

PURPOSE: To evaluate 4 stages of diffuse lamellar keratitis (DLK) after laser in situ keratomileusis using confocal microscopy. SETTING: Department of Ophthalmology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany. METHODS: This retrospective study comprised 17 eyes (15 patients): 11 cases of stage 1 DLK, 5 cases of stage 2, 1 case of stage 3, and 2 cases of stage 4. All eyes were examined by slitlamp biomicroscopy and confocal microscopy. RESULTS: In all cases of stage 1 and 2 DLK, confocal microscopy showed infiltration of inflammatory cells into the flap stroma and the interface. The density of the infiltrates and the number of cells varied within the stage 1 corneas; all stage 2 corneas had dense infiltrates. In the eye with stage 3 DLK, an aggregation of presumed cell remnants was noticed. In the stage 4 cases, there was no active inflammation but stromal folds and numerous activated keratocytes were detected. CONCLUSIONS: Confocal microscopy showed differences in the appearances of the DLK groups. There were similarities in the features of stages 1 and 2. Only stages 1 and 2 represented active inflammation, whereas stages 3 and 4 showed the result of accumulation and decay of the inflammatory cells.