Combined intracorneal ring segments and iris-fixated phakic intraocular lens for keratoconus refractive and visual improvement.

PURPOSE: To evaluate the efficacy and safety of keratoconus refractive and visual improvement by combined intracorneal ring segments (ICRS; Intacs/Intacs SK, Addition Technology Inc., Des Moines, IL) and phakic intraocular lens (PIOL; Artisan/Artiflex Toric IOL, Ophtec BV, Groningen, Holland) implantation. METHODS: This study comprised patients who had ICRS implantation followed by PIOL implantation 6 or more months later for the correction of keratoconus. Over a 12-month follow-up after PIOL implantation, the main outcome measures were uncorrected and corrected distance visual acuity (UDVA and CDVA), spherical equivalent refraction, and central endothelial cell density. Efficacy and safety indexes were calculated. RESULTS: The study included 21 eyes of 16 patients. The mean UDVA 12 months after ICRS and PIOL implantation increased from 2.0 ± 0 to 0.25 ± 0.22 logMAR (Snellen 20/2000 to 20/35) (P < .001). The mean CDVA increased from 0.31 ± 0.13 to 0.13 ± 0.13 log-MAR (Snellen 20/40 to 20/25) (P = .039). Predictability of refractive results was good, with spherical equivalent refraction within ±0.50 diopter of the attempted correction in 13 eyes (61.9%) and within ±1.00 diopter in 19 eyes (90.5%). Mean central endothelial cell density decreased from 2,513 ± 245 cells/mm(2) preoperatively to 2,312 ± 263 cells/mm(2) (P = .402). The efficacy index was 1.06 and the safety index was 1.40. CONCLUSIONS: Keratoconus visual and refractive improvement by the sequential implantation of Intacs ICRS and Artisan/Artiflex Toric IOL is a safe and predictable procedure.

Endothelial distance after phakic iris-fixated intraocular lens implantation: a new safety reference.

PURPOSE: To evaluate the distance between the endothelial surface of the cornea to the anterior edge of an Artiflex® phakic intraocular lens (IOL) implant to improve the safety profile of this implant. METHODS: This is a retrospective clinical case series of 45 patients who had Artiflex phakic IOL implantation (Artiflex p-IOL) with a follow-up period of 3 years. A Pentacam HR imaging system was used to measure the distance from various points of the anterior edge of the Artiflex IOL to the endothelial surface of the cornea, which we called endothelial-IOL (E-IOL) distance, in 45 eyes. The E-IOL distances were assessed at 1, 3, 6, 12, 24, and 36 months. Corresponding correlations of central endothelial distance to temporal and nasal edges and center of the IOL anterior surface were tabulated. RESULTS: Mean follow-up was 21.39±11.28 months. A statistically significant reduction of the E-IOL distance was observed over the follow-up period (P<0.05), with the mean annual reduction being 24.70 µm. A strong positive correlation between the E-IOL distance of the edges of the IOL and the central distance was observed (correlation coefficients nasal/central: month 1, 0.905; month 36, 0.806; temporal/central: month 1, 0.906; month 36, 0.806; P<0.001). Moderate negative correlations were found between the spherical equivalent power of the implanted IOL and the E-IOL distance (correlation coefficients -0.271 to -0.412, P>0.05). For an E-IOL distance of the IOL edge >1500 µm, the distance from the endothelium to the central point of the p-IOL optic should be a minimum of 1,700 µm to improve the safety profile for Artiflex p-IOL implantation and reduce the potential complication of accelerated endothelial cell loss. CONCLUSION: After Artiflex IOL implantation, the mean annual reduction of the E-IOL distance was 25 µm. A negative correlation existed between the spherical equivalent power of the implanted IOL and the postoperative E-IOL distance. The minimum E-IOL distance from the center of the IOL to minimize the risk of endothelial cell loss was 1.7 mm. This distance, as is the 1.5 mm initially proposed by Baikoff, is a postoperative value. We cannot make that assumption for the preoperative evaluation, as the morphometry of the anterior chamber changes with the implant.

Correlation between cataract grading by Scheimpflug imaging and phaco time in phacoemulsification using peristaltic and venturi pumps.

PURPOSE: To study the correlation among cataract grading system by Scheimpflug imaging (Oculus Pentacam® Nucleus Grading System [PNS]), effective phaco time (EPT), and surgical time (ST) using peristaltic and venturi pumps on the Whitestar Signature Phaco System (Abbott Medical Optics, Inc., Santa Ana, California, USA). 
 METHODS: Patients scheduled to have bimanual microincision phacoemulsification by the same surgeon (T.F.) had Pentacam® Scheimpflug assessment using PNS and were randomly distributed into 2 groups. In group 1, surgery was performed using peristaltic pump, and in group 2, using venturi pump. Parameters assessed in both groups included EPT and ST. 
 RESULTS: Sixty eyes that had uneventful clear cornea phacoemulsification with implantation of foldable intraocular lens (IOL) were evaluated, 30 in each group. The EPT was statistically superior with higher nuclear density grades for both groups 1 and 2 (group 1 Spearman R = 0.739, p<0.001; group 2 Spearman R = 0.924, p<0.001). The ST statistically increased with nucleus density for both groups 1 and 2 (group 1 Spearman R = 0.620, p<0.001; group 2 Spearman R = 0.643, p<0.001). Group 2 presented statistically significant reduction on median ST compared with group 1 for nucleus grading 2, 3, 4, and 5. CONCLUSIONS: The PNS is an objective and reproducible method of grading nuclear cataract density and had a correlation with EPT. Peristaltic and venturi pumps in Signature Phaco System were similar in EPT but venturi pump reduced the median ST in nucleus with higher PNS, without repercussion on complications or anterior chamber stability.

Intravitreal voriconazole as primary treatment for endogenous Aspergillus endophthalmitis.

This report describes the first case of Aspergillus endophthalmitis after heart transplantation which was successfully treated with intravitreal voriconazole. A 62-year-old man receiving immunosuppressive agents after a heart transplant presented with pain, reduced visual acuity and redness of the left eye. The patient had been diagnosed with invasive pulmonary aspergillosis and was being treated with intravenous voriconazole. Endogenous endophthalmitis was diagnosed. Aspergillus fumigatus was isolated in a vitreous sample. After five intravitreal voriconazole injections (50 µg/0.1 ml), pars plana vitrectomy, intravenous and topical voriconazole treatment, there was no ocular inflammation and the visual acuity improved from counting fingers at 50 cm to 20/20. This case report shows that intravitreal voriconazole, in addition to topical and systemic treatment, was safe and very effective in treating Aspergillus endophthalmitis. More clinical studies are needed to determine the optimal treatment for this condition.