Phacoemulsification with implantation of a trifocal intraocular lens in eyes with asteroid hyalosis and synchysis scintillans.

PURPOSE: To compare the visual outcomes in both eyes of patients who undergo phacoemulsification and trifocal intraocular lens (IOL) implantation and have asteroid hyalosis (AH) or synchysis scintillans (SS) in only one eye. METHODS: A retrospective comparative case series was performed. We evaluated uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), uncorrected intermediate visual acuity (UIVA), uncorrected near visual acuity (UNVA), predictability, safety, efficacy, and satisfaction after implantation of the same model of trifocal IOL in both eyes (PhysIOL FineVision Pod-F and Micro-F and Rayner RayOne Trifocal). RESULTS: A total of 164 eyes of 82 patients (41 females, 50%) met the inclusion criteria. There were no statistically significant differences in sphere, cylinder, spherical equivalent, UDVA, UIVA, or UNVA between the groups. Postoperative CDVA was slightly better in the control group (logMAR 0.03) than in the AH/SS group (logMAR 0.04) (P: 0.014). There were no statistically significant differences in predictability, safety index, or efficacy index between the groups. Overall subjective satisfaction was good (98.2%). CONCLUSIONS: Visual outcomes and satisfaction are good after implantation of trifocal IOLs in eyes with AH or SS. Therefore, trifocal IOLs should not be ruled out in these patients when no other vitreoretinal disorder is present.

Visual outcomes of combined use of implantable collamer lens implantation and laser corneal visual correction for myopia over -18.00 diopters.

PURPOSE: To explore visual outcomes in patients with extreme myopia receiving an implantable collamer lens (ICL) at -18.00 diopters (D), with central port, followed by bioptics by laser vision correction (laser in situ keratomileusis [LASIK] or photorefractive keratectomy [PRK]) to address residual myopia or myopic astigmatism. SETTING: Clínica Baviera (Aier Eye Hospital Group), Bilbao, Spain. DESIGN: Retrospective analysis of cases. METHODS: The study assessed uncorrected distance visual acuity, corrected distance visual acuity (CDVA), predictability, safety, efficacy, and patient satisfaction after implantation of the ICL and bioptics. The model implanted was V4c and EVO, with a correction of -18.00 D. Bioptics were performed at least 3 months after implantation, and patients were followed up for at least 3 months after LASIK or PRK. RESULTS: The analysis included 125 eyes from 90 patients. Of these, 51.2% underwent LASIK and 48.8% PRK. Mean time from implantation to bioptics was 5.9 ± 9.4 months. Patients were followed up for a mean of 40.2 ± 37.9 months after bioptics. Median manifest refractive spherical equivalent was -2.89 D before bioptics and -0.49 D after. Median CDVA was 0.18 logMAR before bioptics and 0.17 after. The mean safety and efficacy indices were 2.22 ± 1.88 and 2.06 ± 1.85, respectively. CONCLUSIONS: Visual outcomes and safety indices after ICL implantation and subsequent LASIK or PRK in patients with extreme myopia are excellent.

Laser corneal enhancement after trifocal intraocular lens implantation in eyes that previously had photoablative corneal refractive surgery.

PURPOSE: To evaluate the visual and refractive outcomes of laser corneal enhancement after trifocal intraocular lens (IOL) implantation in eyes previously treated with myopic/hyperopic laser corneal refractive surgery (LCRS). SETTING: Clinica Baviera-AIER-Eye Group, Spain. DESIGN: Retrospective comparative case series. METHODS: Patients were divided by primary LCRS into myopic and hyperopic groups. The outcomes evaluated were uncorrected distance (UDVA), corrected distance (CDVA), uncorrected intermediate (UIVA), and uncorrected near visual acuity (UNVA), and predictability, safety, efficacy, and satisfaction after implantation of 2 trifocal IOL models (Physiol-FineVision and Zeiss-ATLisa 839) and subsequent laser enhancement. RESULTS: 186 eyes (89 myopic and 97 hyperopic eyes) from 146 patients were assessed. At the last visit, refractive outcomes were better in myopic than those in hyperopic eyes, with statistically significant differences for sphere ( P < .001), cylinder ( P < .001), manifest refraction spherical equivalent (MRSE) ( P = .003), CDVA ( P = .005), UDVA ( P = .047), and UNVA ( P = .003) but not for UIVA ( P = .580), binocular UIVA ( P = .660), or binocular UNVA ( P = .836). Predictability differences were nonsignificant between groups for a final MRSE of ±0.5 diopters (D) and ±1.0 D (P = .167 and .502, respectively). Efficacy and safety were similar in both groups ( P = .235 and P = .080). A greater myopic MRSE was present after trifocal implantation in myopic than in hyperopic eyes (MRSE = -0.93 vs -0.69 D, P = .013), and the statistically significant differences were maintained after enhancement between both groups (MRSE -0.00 vs 0.00 D, P = .003). Overall satisfaction was similar in both groups ( P > .05 all items). CONCLUSIONS: Corneal laser enhancement after implantation of a trifocal IOL in eyes previously treated for myopia or hyperopia with LCRS was safe, effective, predictable, and highly satisfactory.

Dynamic assessment of variations in pupil diameter using swept-source anterior segment optical coherence tomography after phakic collamer lens implantation.

PURPOSE: To dynamically assess variations in pupil diameter induced by changes in brightness in myopic eyes implanted with an implantable collamer lens (ICL, STAAR Surgical) with a central port. METHODS: This prospective, observational single-center case series study comprised 65 eyes from 65 consecutive patients undergoing ICL implant. A modified commercially available swept-source Fourier-domain anterior segment optical coherence tomography (AS-OCT) device was used for imaging and performing dynamic pupillometry under changing light conditions before and after a mean follow-up interval of four months after surgery. RESULTS: Preoperative mean pupil size under photopic conditions was 3.38 ± 0.64 mm; after surgery, this increased to 3.48 ± 0.61 mm. Mean pupil size under scotopic light conditions was 5.72 ± 0.79 mm before surgery and 5.84 ± 0.77 mm postoperatively. The differences between preoperative and postoperative pupil diameter in miosis and mydriasis were 0.10 ± 0.44 mm (P = 0.078) and 0.12 ± 0.58 mm (P = 0.098), respectively. The scotopic pupil exceeded the optic zone of the implanted lens in 39 eyes (60%). The mean central vault value was 412 ± 177 µm under maximum miosis and 506 ± 190 µm under maximum mydriasis. We found a positive correlation between vault and differences in pupil diameter under all light conditions (P < 0.05). CONCLUSION: Dynamic AS-OCT enables a very precise determination of the pupillary diameter in the iris plane. The changes in the pupil diameter under different light conditions after the implantation of an ICL are related to the postoperative vault.

Case Report: Double Intrastromal Corneal Ring Segment and Posterior Chamber Phakic Intraocular Lens Implantation.

SIGNIFICANCE: Keratoconus can manifest asymmetrically, affecting binocularity and becoming a refractive problem that is sometimes complex to solve. We propose a therapeutic approach for correction of keratoconus based on parallel implantation of a second intrastromal corneal ring segment (ICRS). PURPOSE: This study aimed to improve the refractive status of a patient affected with advanced bilateral keratoconus using implantation of a second ICRS and a phakic intraocular lens. CASE REPORT: A 44-year-old man came to our clinic requesting a refractive solution for his visual impairment. He had been diagnosed with bilateral severe keratoconus categorized by the Amsler-Krumeich classification scale as grade III (right eye) and grade II (left eye). He had previously undergone corneal cross-linking and implantation of ICRS (Intacs) in both eyes. Significant anisometropia was present between the eyes, and the patient also complained of poor quality of vision. We decided to implant a posterior chamber phakic collamer lens in his right eye and to insert a new ICRS (Keraring) deep and parallel to the previous one in his left eye. We aimed to prevent anisometropia in his right eye and to further regularize the affected cornea in his left eye. Refractive symmetry was achieved, and vision was optimized after surgery. CONCLUSIONS: In a patient with keratoconus, refractive surgery should be performed from a bilateral perspective. Specific cases of keratoconus can be managed by parallel implantation of a second ICRS.

Long-term assessment of crystalline lens transparency in eyes implanted with a central-hole phakic collamer lens developing low postoperative vault.

PURPOSE: To assess long-term crystalline lens transparency in eyes implanted with phakic collamer intraocular lens (pIOL) with a central port and low postoperative vault for correction of myopia. SETTING: Clinica Baviera, Madrid, Spain. DESIGN: Retrospective cross-sectional single-center study. METHODS: Using a noninvasive Fourier-domain swept-source anterior segment optical coherence tomography system, shifts in myopic and astigmatic myopic eyes implanted with a pIOL with vaulting lower than 100 µm in miosis and more than 4 years of follow-up were dynamically evaluated. Main outcome measures were pIOL dynamic vault (vault interval and vault range [VR]), crystalline lens density, and anterior subcapsular lens opacities. Crystalline lenses were examined under slitlamp microscopy, and lens density was evaluated using quantitative Scheimpflug images. Scheimpflug images were compared with those of a control group comprising eyes that were candidates for pIOL implantation. RESULTS: The study population comprised 24 eyes from 16 patients previously implanted with a pIOL (5.82 ± 0.9 years) with central vault lower than 100 µm under photopically induced miosis. The mean vault value was 52 ± 19 µm under photopic light conditions and 113 ± 37 µm under scotopic conditions. The mean VR was 58 ± 24 µm. Anterior subcapsular lens opacities were found in only 1 eye (4.17%). The mean lens density was 7.94 ± 0.43, and no statistically significant differences were observed compared with the control group. CONCLUSIONS: Long-term low vaulting in eyes implanted with a pIOL with a central port for correction of myopia was associated with a low risk for developing anterior crystalline lens opacities.

Outcomes of Flap Lift Laser In Situ Keratomileusis Enhancements in a Large Patient Population: Does Application of a Bandage Contact Lens Affect Incidence of Epithelial Ingrowth?

PURPOSE: To compare the incidence of corneal epithelial ingrowth (EIG) and the visual outcomes of enhancement with laser in situ keratomileusis (LASIK) by flap lift when a bandage soft contact lens (CL) was fitted after the procedure and when it was not. METHODS: This is a multicenter, retrospective, interventional case series in which all patients who underwent LASIK enhancement from January 2005 to January 2015 were included consecutively. Patients were grouped depending on whether a bandage CL was fitted after re-treatment by flap lift (group 1) or not (group 2). RESULTS: A total of 16,702 eyes from 12,485 patients were included. There were statistically significant differences between the groups regarding corrected distance visual acuity (better in group 1) and safety index (better in group 2) although these were not clinically relevant. The incidence of EIG was 0.58% in group 1 and 0.55% in group 2 although, again, the difference was not statistically different. CONCLUSIONS: We found no relevant differences in LASIK enhancement between patients who received a bandage CL and those who did not regarding the incidence of EIG and visual outcomes.

Determining the Potential Role of Crystalline Lens Rise in Vaulting in Posterior Chamber Phakic Collamer Lens Surgery for Correction of Myopia.

PURPOSE: To assess the effect of crystalline lens rise (CLR) on postoperative vault in eyes implanted with a phakic Visian Implantable Collamer Lens (ICL) (STAAR Surgical Company, Monrovia, CA) with a central port for myopic correction. METHODS: Non-invasive Fourier-domain swept-source anterior segment optical coherence tomography was used for dynamic assessment of the study eyes under changing light conditions. Phakic intraocular lens (IOL) vault, anterior chamber depth (ACD), and CLR were recorded after surgery, and intra-eye differences were analyzed under scotopic and photopic ambient light conditions. Inter-group analysis and regression analysis were performed to investigate any potential correlation between these biometric variables. RESULTS: This retrospective observational study comprised 111 eyes (65 patients) implanted with a myopic Visian ICL. The mean change in CLR from mydriasis to miosis was 59 ± 60 µm (P < .001). The sample was further divided into four groups according to the CLR value in miosis: CLR < 0, 0 to 200, 201 to 350, and > 350 µm. A significant difference in central vault values was observed between the < 0 and > 350 µm groups, the 0 to 200 and 201 to 350 µm groups, and the 0 to 200 and > 350 µm groups (P < .05). Eyes with a high vault value (> 750 µm in mydriasis) had lower CLR values (P < .001) and higher ACD values (P < .001) than eyes with a low vault value (< 100 µm in miosis). The linear correlation observed was negative between CLR and ACD, positive between postoperative vault and ACD, and negative between postoperative vault and CLR (P < .001). CONCLUSIONS: CLR significantly affected anterior chamber depth and postoperative ICL vault. [J Refract Surg. 2019;35(3):177-183.].

Dynamic Assessment of Light-Induced Vaulting Changes of Implantable Collamer Lens With Central Port by Swept-Source OCT: Pilot Study.

PURPOSE: To assess dynamic variations in vault induced by changes in brightness in eyes implanted with phakic collamer intraocular lens (pIOL) with central port for correction of myopia, defining new parameters of vaulting measurement. METHODS: We used a noninvasive Fourier-domain swept-source anterior-segment optical coherence tomography (AS-OCT) system to dynamically evaluate the shifts between the pIOL and anterior chamber structures under changing light conditions. For each eye assessed, we measured vault interval (VI), which we define based on central vault values in maximum mydriasis and in maximum miosis after light-induced changes in pupil diameter, and vault range (VR), which we define as the absolute difference between the VI values. RESULTS: The pilot study sample comprised 39 eyes (23 patients) previously implanted (mean 107 ± 156 days) with a pIOL. A significant difference in vault value was found when maximum and minimum pupil size was assessed under changing external light conditions (P < 0.001). The mean VR from scotopic (0.5 lux) to photopic (18,500 lux) light conditions was 167 ± 70 µm. CONCLUSIONS: Vault is continuously affected during movements of the pupil induced by external luminance. TRANSLATIONAL RELEVANCE: Quantifiable dynamic parameters VR and VI obtained with this AS-OCT device describe the position of the pIOL in the posterior chamber of the eye in a more accurate and real way than static vault measurements, and may contribute to improved understanding of the behavior of the pIOL in terms of safety.

Outcomes of Laser In Situ Keratomileusis and Photorefractive Keratectomy in Patients Taking Isotretinoin.

PURPOSE: To determine the functional outcomes of laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) in patients taking isotretinoin, which is contraindicated for these procedures. DESIGN: Multicenter, retrospective, interventional case series. METHODS: All patients taking isotretinoin who underwent LASIK or PRK from January 2003 to September 2017 were included (Group 1). Patients were compared with those undergoing LASIK or PRK who had taken isotretinoin previously but not in the previous 6 months (Group 2). Patients were included consecutively. RESULTS: A total of 113 patients (219 eyes) were included. No significant intraoperative or postoperative complications were found. There were no significant differences between the groups in terms of visual acuity, postoperative spherical equivalent, efficacy index, predictability, or safety index. When only PRK patients were taken into account, the efficacy index (P = .017), postoperative sphere (P = .041), and postoperative astigmatism (P < .001) were better in Group 2, although the difference was not clinically relevant. CONCLUSIONS: In our experience, LASIK and PRK can be performed effectively and safely in selected patients taking isotretinoin. The absolute exclusion of certain systemic medications should be reconsidered.

Pupillary block glaucoma secondary to central port occlusion following insertion of a phakic implantable copolymer lens.

A 28-year-old woman had uneventful implantation of a phakic intraocular lens (pIOL) in her left eye (Visian ICL, EVO+ model, 13.2, -7.50 diopters) to correct myopia. Six days after the procedure, she presented with herniation of the iris. Surgical reduction was carried out successfully through the previous peripheral corneal paracentesis. On the following day, the patient reported ocular pain and blurry vision. Examination showed a shallow anterior chamber, moderate diffuse corneal edema, and ocular hypertension. The central port of the pIOL was blocked by iris pigment. The condition resolved completely after surgical iridectomy, and the postoperative course was uneventful. To our knowledge, this is the first reported case of pupillary block after implantation of a pIOL with a central hole. This uncommon complication should be taken into consideration when the iris is manipulated excessively after pIOL insertion.

Nd:YAG Capsulotomy Rates With Two Trifocal Intraocular Lenses.

PURPOSE: To compare Nd:YAG capsulotomy rates following implantation of two diffractive trifocal intraocular lenses (IOLs). METHODS: This multi-center retrospective analysis included patients who underwent uncomplicated lens phacoemulsification and were implanted with a diffractive trifocal IOL: FineVision MicroF (PhysIOL, Liège, Belgium) or AT Lisa tri 839MP (Carl Zeiss Meditec, Jena, Germany). All surgeries were performed during the same period. The postoperative follow-up period was at least 1 year. Chi-square and Kaplan-Meier tests analyzed non-parametric estimates for survival/failure functions. The Wilcoxon (Breslow) test compared Nd:YAG capsulotomy rates between the two groups. RESULTS: Of 5,130 eyes included, 3,387 were implanted with the FineVision MicroF IOL and 1,743 with the AT Lisa tri 839MP IOL. There were no statistical differences in age, axial length, or IOL power between groups. Nd:YAG capsulotomies were necessary in 330 eyes (9%) in the FineVision group and 408 eyes (23%) in the AT Lisa tri group (P < .001). The probability of having Nd:YAG capsulotomy up to 9 months postoperatively was equal for both lenses. Beyond 9 months, the Nd:YAG capsulotomy rate increased significantly more in the AT Lisa tri group, reaching a probability of 35% for eyes with a follow-up of 34 to 44 months, whereas in the FineVision group the probability was 14% after a follow-up of 37 to 47 months. The differences in survival (without Nd:YAG capsulotomy)/failure (with Nd:YAG capsulotomy) functions were significant (P < .001). CONCLUSIONS: Eyes implanted with the FineVision MicroF IOL required significantly fewer Nd:YAG laser capsulotomies than those with the AT Lisa tri 839MP IOL during the first years after implantation. The design of the IOL platforms could account for these differences. [J Refract Surg. 2016;32(11):748-752.].

Comparison Between Mix-and-Match Implantation of Bifocal Intraocular Lenses and Bilateral Implantation of Trifocal Intraocular Lenses.

PURPOSE: To investigate the visual outcomes between mix-and-match bifocal intraocular lenses (IOLs) (ReSTOR +2.50 and +3.00 diopters [D]; Alcon Laboratories, Inc., Fort Worth, TX) versus bilateral implantation of a trifocal IOL (FineVision; PhysIOL, Liège, Belgium). METHODS: Twenty-three patients (average age: 56.3 ± 6.9 years; range: 45 to 71 years) referred for lens phacoemulsification and IOL implantation were included in this study. Patients were randomly assigned to two groups. The FineVision group was bilaterally implanted with the FineVision trifocal IOL and the ReSTOR group was implanted with mix-and-match bifocal ReSTOR +2.50 and +3.00 D IOLs. A 3-month postoperative check was performed, and manifest refraction and logMAR uncorrected (UDVA) and corrected (CDVA) distance and near visual acuities were recorded. Monocular and binocular defocus curve testing was performed under photopic (85 cd/m2) conditions in 0.50-D defocus steps. Contrast sensitivity was measured monocularly and binocularly under mesopic conditions at spatial frequencies of 3, 6, 12, and 18 cycles per degree using the CSV-1000 contrast test (VectorVision, Greenville, OH). RESULTS: There were no reported differences in monocular distance visual acuity or refractive outcomes between groups (P > .05). Furthermore, there were no significant differences in contrast sensitivity between the three IOLs (P > .05). The FineVision group achieved better monocular and binocular near and intermediate visual acuities under defocus curve testing than the ReSTOR group (P < .05). CONCLUSIONS: Binocular implantation of the FineVision trifocal IOL provided a better range of visual acuities at near and intermediate distances than mix-and-match bifocal IOL implantation. [J Refract Surg. 2016;32(10):659-663.].

Long-term evaluation of eyes with central corneal thickness <400 µm following laser in situ keratomileusis.

PURPOSE: To study long-term refractive and visual outcomes of laser in situ keratomileusis (LASIK) in eyes with a postoperative thin central cornea. METHODS: In this retrospective observational case series, we studied 282 myopic eyes with a normal preoperative topographic pattern and postoperative thin corneas (<400 µm) that had at least 3 years of follow-up after LASIK in three private clinics. The main outcome measures were safety, efficacy, predictability, percent tissue altered, and complications. RESULTS: The mean postoperative central corneal thickness was 392.05 µm (range: 363.00-399.00 µm). After a mean follow-up of 6.89±2.35 years (standard deviation), the safety index was 1.17, the efficacy index was 0.94, and predictability (±1.00 diopter [D]) was 73.49. The mean residual stromal bed thickness was 317.34±13.75 µm (range: 275-356 µm), the mean flap thickness was 74.76±13.57 µm (range: 55-124 µm), and the mean percent tissue altered was 37.12%±3.62% (range: 27.25%-49.26%). No major complications were recorded. CONCLUSION: LASIK with a resultant central cornea thickness <400 µm seems to be effective, safe, and predictable provided that preoperative topography is normal and the residual stromal bed thickness is >275 µm.

Visual outcomes in adult amblyopic eyes with moderate myopia after corneal laser surgery versus copolymer phakic intraocular lens implant.

PURPOSE: To assess visual acuity and refractive correction in moderately myopic adult eyes with suboptimal preoperative corrected distance visual acuity (CDVA) after laser in situ keratomileusis (LASIK) or insertion of a posterior chamber Implantable Collamer Lens phakic intraocular lens (pIOL). SETTING: Clínica Baviera, Instituto Oftalmológico Europeo, Torrevieja Hospital, Madrid, Spain. DESIGN: Retrospective study. METHODS: The study sample included 1310 eyes that had LASIK and 94 that had insertion of a pIOL from July 2002 to September 2013. Suboptimal preoperative CDVA was defined as equal to logMAR 0.15 or below and moderate myopia as a spherical equivalent of -5.0 to -10.0 diopters (D). RESULTS: The preoperative mean CDVA was 0.22 logMAR ± 0.09 (SD) in the LASIK group and 0.23 ± 0.09 logMAR in the pIOL group. Postoperative uncorrected distance visual acuity (UDVA) was 0.13 ± 0.12 logMAR in the laser group and 0.12 ± 0.09 logMAR in the pIOL group, with a postoperative CDVA of 0.11 ± 0.10 logMAR and 0.08 ± 0.07 logMAR, respectively. CONCLUSIONS: Compared with preoperative values, amblyopic eyes with moderate myopia having LASIK or implantation of a pIOL demonstrated a statistically significant improvement in UDVA and CDVA (P < .001). The pIOL group performed significantly better than the LASIK group in terms of safety and efficiency. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.