Long-term results of phakic refractive lens implantation in eyes with high myopia.

PURPOSE: To evaluate the long-term results of phakic refractive lens (PRL; Carl Zeiss Meditec) implantation in eyes with high myopia. METHODS: In this retrospective, noncomparative, interventional case series, 143 myopic eyes of 82 patients were treated for high myopia with the implantation of the silicone PRL in the posterior chamber. RESULTS: Mean follow-up was 3.8±1.7 years (range: 1 to 6 years). Six years postoperatively (n=34), a statistically significant reduction was noted in the cycloplegic spherical equivalent from -14.08±4.00 diopters (D) (range: -24.88 to -4.75 D) before PRL implantation to -0.45±0.62 D (range: -1.00 to 1.00 D) (P<.001). At 6 years, 67.6% (23 eyes) and 91.2% (31 eyes) were within ±0.50 and ±1.00 D of target refraction, respectively. Mean logMAR uncorrected and corrected distance visual acuity improved significantly (P<.001) (counting fingers preoperatively in all eyes to 0.17±0.15 [range: 0.54 to -0.06] and 0.19±0.19 [1.00 to -0.08] to 0.07±0.10 [range: 0.30 to -0.10], respectively). Complications included anterior capsule damage (3 eyes), temporary intraocular pressure increase (14 eyes), pigment dispersion (1 eye), and PRL decentration (1 eye). No eyes presented any signs of cataract up to 6 years postoperatively. CONCLUSIONS: Long-term results show that PRL implantation is an effective and safe method for treating high myopia.

Fifteen-year follow-up after anterior chamber phakic intraocular lens implantation in one and LASIK in the fellow eye.

PURPOSE: To report a patient fifteen years after anterior chamber phakic intraocular lens (AC-PIOL) implantation in one and laser in situ keratomileusis (LASIK) in the fellow eye. METHODS: Case report. RESULTS: A 56-year-old male underwent AC-PIOL implantation in one eye and LASIK in the fellow eye fifteen years ago. Preoperative uncorrected visual acuity (UCVA) was finger count in both eyes. Preoperative best spectacle-corrected visual acuity (BSCVA) was 20/25 (-16.75 -0.50 x 40) in the LASIK eye and 20/32 (-24.50 -0.50 x 90) in the AC-PIOL eye. Fifteen years postoperatively, UCVA was finger count in the LASIK eye and 20/200 in the AC-PIOL eye, while BSCVA was 20/32 and 20/25, respectively. Endothelial cell density (ECD) was 2020+/-47 in the LASIK eye and 945+/-22 in the AC-PIOL eye. CONCLUSION: Both procedures had similar visual outcomes. Furthermore, lower ECD was found in the AC-PIOL eye in comparison to the LASIK eye.

Comparison of Epi-LASIK and off-flap Epi-LASIK for the treatment of low and moderate myopia.

PURPOSE: To compare the early postoperative course and the 1-year clinical results of off-flap Epi-LASIK and Epi-LASIK for the treatment of low and moderate myopia. DESIGN: Pilot double-masked, randomized, comparative study. PARTICIPANTS: Fifty-six patients (112 myopic eyes). METHODS: Epithelium was separated in all eyes with the use of Centurion SES epikeratome (Norwood Abbey EyeCare, Vic, Australia). The first eye treated and surgical method in the first eye were randomized. One eye of each patient underwent standard Epi-LASIK, whereas in the contralateral eye, the epithelial sheet was not retained on the photoablated stroma (off-flap Epi-LASIK eyes). Mean preoperative spherical equivalent was -3.50+/-1.22 diopters (D; range, -1.75 to -6.37 D) in Epi-LASIK eyes and -3.61+/-1.22 D (range, -1.50 to -6.50 D) in off-flap Epi-LASIK eyes (P>0.05, paired Student t test). Excimer laser corneal ablation was performed using the Allegretto 200Hz (Wavelight Laser Technologie AG, Erlangen, Germany). Patients were followed up daily until the epithelial healing was complete and at 1, 3, 6, and 12 months. MAIN OUTCOME MEASURES: Epithelial healing time, subjective pain score, and uncorrected visual acuity (UCVA) were evaluated during the first postoperative days. Uncorrected visual acuity, spherical equivalent refraction, best spectacle-corrected visual acuity, haze scores, and wavefront aberrations were recorded at all subsequent intervals. RESULTS: Time of epithelial healing did not differ significantly in Epi-LASIK and off-flap Epi-LASIK eyes (4.76+/-0.84 days in Epi-LASIK eyes vs. 4.54+/-0.93 days in off-flap Epi-LASIK eyes). No significant difference in UCVA was found after the 2 techniques during the first postoperative days. Subjective pain score was lower in off-flap Epi-LASIK eyes at 2 postoperative hours, whereas no significant difference in pain scores was noted between the 2 techniques at the other intervals. There was no significant difference in spherical equivalent, line gain or loss, haze scores, and higher-order aberrations between Epi-LASIK and off-flap Epi-LASIK eyes at any interval. Uncorrected visual acuity was significantly better in Epi-LASIK eyes only at 6 months (-0.05+/-0.08 in Epi-LASIK eyes vs. 0.00+/-0.07 in off-flap Epi-LASIK eyes). Preoperative wavefront aberrations did not change significantly 1 year after either procedure. CONCLUSIONS: Epi-LASIK and off-flap Epi-LASIK had equal visual and refractive results for the treatment of low and moderate myopia in this study. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Occlusion therapy of unilateral amblyopia with botulinum toxin induced ptosis.

In order to evaluate the role of botulinum toxin induced ptosis as an occlusion method to treat unilateral deep strabismic amblyopia in two uncooperative children, we injected 0.2 ml of diluted botulinum toxin in the levator palpaebrae; low sedation was necessary in one of the two children. In both cases a marked ptosis was achieved, which lasted about four weeks and then gradually resolved completely. The visual acuity of the ablyopic eye increased in both children, making patching easy thereafter. One child developed amblyopia in the injected eye, which was handled successfully using part-time occlusion. No other side effects were noted. Whether this new method could be a simple, safe and effective alternative method of occlusion for the treatment of deep amblyopia in uncooperative children needs to be proven with a larger series of children.

One-year clinical results after epi-LASIK for myopia.

PURPOSE: To evaluate the clinical results of epi-LASIK for the treatment of low to moderate myopia and myopic astigmatism. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Two hundred thirty-four eyes of 138 patients underwent epi-LASIK for the correction of low to moderate myopia. Mean preoperative spherical equivalent ranged from -1.0 to -7.25 diopters (D) (-3.74+/-1.46, mean+/-standard deviation [SD]) and baseline logarithm of the minimum angle of resolution (logMAR) best spectacle-corrected visual acuity (BSCVA) from 0.10 to -0.18 (mean+/-SD, 0.00+/-0.06). METHODS: All enrolled eyes underwent epi-LASIK using the Centurion SES epikeratome (Norwood Abbey EyeCare, Victoria, Australia) and the Allegretto (Wavelight Laser Technologie AG, Erlangen, Germany) laser platform. The enrolled patients were followed up daily until the epithelial healing was complete as well as at the 1-, 3-, 6-, and 12-month postoperative intervals. MAIN OUTCOME MEASURES: The main parameters assessed were subjective evaluation of postoperative pain, uncorrected visual acuity (UCVA) and BSCVA, manifest refraction, haze grade, and contrast sensitivity of the operated eyes. RESULTS: The mean epithelial healing time was 4.70+/-0.87 days (range, 3-7 days), with mean logMAR UCVA on the day of reepithelization of 0.26+/-0.14 (range, 0.7-0.0). One year after the treatment, the spherical equivalent of the treated eyes (n = 222) ranged from -1.25 to +0.625 D (mean+/-SD, -0.18+/-0.6 D), with 80.33% of the eyes within 0.5 D (96.72% within 1 D) of the attempted correction. At the same interval, 86% of the eyes had clear corneas and 14% clinically insignificant (trace) haze, whereas 60% of the eyes had a line gain of 1 or more lines of BSCVA. Mean logMAR contrast sensitivity of the treated eyes at 4 different spatial frequencies was improved or remained unchanged throughout the follow-up period. CONCLUSIONS: One-year visual and refractive results after epi-LASIK suggest that it is a safe and efficient method for the correction of low to moderate myopia and myopic astigmatism.

Comparison of corneal sensitivity and tear function following Epi-LASIK or laser in situ keratomileusis for myopia.

PURPOSE: To compare the effect of Epi-LASIK or Laser In Situ Keratomileusis (LASIK) on corneal sensitivity and tear function. DESIGN: Prospective, non-randomized comparative clinical trial. METHODS: Seventy-nine eyes (Group A) underwent Epi-LASIK and 61 eyes underwent LASIK (Group B) for the treatment of myopia. Matching parameters between the groups were age and attempted correction. Corneal sensitivity, tear break-up time (BUT), and Schirmer test II were evaluated before and at one, three, and six months after the procedure. RESULTS: Corneal sensitivity and BUT were decreased at one month in Group A (P < .001) to be restored by the third month (P = .71 and P = .58, respectively). In Group B, corneal sensitivity and BUT were reduced postoperatively (P < .001). There was a significant difference in corneal sensitivity between the two groups at all postoperative intervals. Schirmer test II was not significantly decreased postoperatively in Group A. In Group B, it was decreased at one and three months and restored by the sixth month. CONCLUSION: Epi-LASIK-treated eyes had faster rehabilitation of corneal sensitivity and tear function than LASIK-treated eyes.

Epipolis laser in-situ keratomileusis: an evolving surface ablation procedure for refractive corrections.

PURPOSE OF REVIEW: The aim of this article is to provide an update on epipolis laser in-situ keratomileusis--an alternative surface photorefractive surgical technique for the correction of myopia. RECENT FINDINGS: In-vivo studies on animal models provide evidence that the replacement of the epithelial sheet on an ablated cornea can control corneal wound healing. Preliminary clinical data confirm that epipolis laser in-situ keratomileusis can provide excellent long-term visual and refractive results. The problems of late visual rehabilitation and postoperative pain, however, have not yet been fully addressed. SUMMARY: Being a recently introduced surgical photorefractive technique for ametropias correction, epipolis laser in-situ keratomileusis is a fast evolving area of interest for refractive surgeons.

Epi-LASIK: histological findings of separated epithelial sheets 24 hours after treatment.

PURPOSE: To report the histological findings of four eyes of three patients who underwent epi-LASIK treatment for the correction of low myopia. METHODS: The epithelial sheets were harvested either immediately after separation (one eye) or were accidentally dislocated and harvested from the operative eyes 24 hours after treatment (three eyes). All sheets underwent optical and transmission electron microscopy. RESULTS: Histological evaluation showed that the majority of the epithelial cells were morphologically normal in all examined specimens. CONCLUSIONS: Histological examination of specimens in four eyes showed that 24 hours after mechanical separation the epithelial cells' morphology was close to normal.

Epi-LASIK: preliminary clinical results of an alternative surface ablation procedure.

PURPOSE: To evaluate the clinical results of epi-LASIK, a new surface ablation surgical technique for the treatment of low myopia. SETTING: Vardinoyannion Eye Institute of Crete, University of Crete, Greece. METHODS: Forty-four eyes of 31 patients had epi-LASIK for the correction of low myopia. Mean preoperative spherical equivalent was 3.71 diopters (D) +/- 1.2 (SD) (range -1.75 to -7.00 D) and the mean baseline logMAR best spectacle-corrected visual acuity was -0.01 +/- 0.06 (range 0.10 to -0.10). All the epithelial separations were performed with the Centurion epikeratome (CIBA Surgical). The enrolled patients were followed daily until the epithelial healing was complete as well as at 1- and 3-month intervals. On the operative day, patients filled out a questionnaire grading visual performance and pain score of treated eyes every 2 hours for a total of 5 records. RESULTS: The mean epithelial healing time was 4.86 +/- 0.56 days (range 3 to 5 days). The mean logMAR uncorrected visual acuity on the day of reepithelization was 0.19 +/- 0.09 (range 0.40 to 0.10). At 1 month, the mean was spherical equivalent of the treated eyes (N=44), -0.3 +/- 0.6 D (range -1.0 to 0.87 D), and at 3 months it was (N=37), -0.10 +/- 0.4 D (range -0.75 to 0.75 D); 97% of eyes had clear corneas or trace haze 3 months after treatment. CONCLUSIONS: Preliminary clinical results suggest that epi-LASIK is a safe and efficient method for the correction of low myopia. Further studies will establish this method as an alternative surface ablation procedure.

Phakic refractive lens implantation in high myopic patients: one-year results.

PURPOSE: To evaluate the efficacy and safety of implantation of a new posterior chamber phakic refractive lens (PRL, Ciba Vision Surgical) in highly myopic eyes. SETTING: Department of Ophthalmology, Medical School, University of Crete, Vardinoyannion Eye Institute of Crete, Crete, Greece. METHODS: Thirty-four myopic eyes of 19 patients were treated for high myopia with implantation of a silicone PRL in the posterior chamber. Mean patient age was 29.0 years +/- 7.9 (SD) (range 18 to 44 years). Manifest refraction in spherical equivalent (MR), uncorrected (UCVA) and best corrected (BCVA) visual acuity (decimal scale), intraocular pressure, higher-order aberrations (root-mean-square [RMS] wavefront error measured with a Shack-Hartmann wavefront sensor WASCA analyzer [Carl Zeiss, Meditec]), possible complications, and subjective symptoms were evaluated. RESULTS: Phakic refractive lenses were successfully implanted in all eyes. Mean follow-up was 17.17 +/- 3.76 months (range 12 to 24 months). There was a statistically significant reduction in the MR (from -14.70 D +/- 2.65 D [range -20.75 D to -10.50 D] to -0.61 D +/- 0.89 D [range -2.25 D to 1.00 D]) (P<.001). Twenty-seven (79%) and 15 eyes (44%) were within +/-1.00 D and +/-0.50 D of target refraction, respectively. Mean UCVA significantly improved (from counting fingers to 0.62 +/- 0.28 (range 0.08 to 1.20) (P<.001). Mean BCVA also improved from 0.70 +/- 0.24 (range 0.10 to 1.00) to 0.85 +/- 0.24 (range 0.10 to 1.20) (P<0.001). Overall, there was a mean increase in BCVA of 1.5 +/- 1.5 lines (range loss of 2 lines to gain of 5 lines). There was no statistically significant difference in higher-order aberrations after PRL implantation (pre-PRL RMS: 0.18 microm +/- 0.08 microm [range 0.09 microm to 0.38 microm]; post-PRL RMS: 0.21 microm +/- 0.08 microm; [range 0.05 microm to 0.38 microm]) (P =.12). CONCLUSION: The PRL showed encouraging results in treating high myopia. Additional patients and longer follow-up period are needed to detect the long-term efficacy and safety of this refractive lens.

Epi-LASIK: comparative histological evaluation of mechanical and alcohol-assisted epithelial separation.

To compare the effect of mechanical and alcohol-assisted excision on the histological ultrastructure of epithelial disks from human corneas. Vardinoyiannion Eye Institute of Crete, University of Crete, Medical School, Crete, Greece. Ten eyes of 10 patients were deepithelialized by 1 of 2 two techniques. In 6 eyes, a customized instrument was used to mechanically separate the epithelial layer. In 4 eyes, the epithelial disks were obtained using the conventional laser-assisted subepithelial keratectomy (LASEK) technique; that is, with alcohol concentrations of 15% and 20%. All specimens were assessed by light and electron microscopy, and the histological findings of the 2 methods were compared. Transmission electron microscopy showed that when the epithelial disks were excised by mechanical separation, the lamina densa and lamina lucida were preserved and the hemidesmosomes had normal morphology along almost the entire length of the basement membrane. The basal epithelial cells of the separated epithelial disks showed minimal trauma and edema. Specimens obtained using 15% and 20% alcohol concentrations showed formation of cytoplasmic fragments of the basal epithelial cells, enlargement of the intercellular spaces, and extensive discontinuities in the basement membrane, which was excised at the level of the lamina lucida. Mechanical separation did not affect the normal cell morphology of the excised epithelial disks. Transmission electron microscopy of the specimens proved the manual technique is less invasive to epithelial integrity than LASEK using either alcohol concentration.

Advances in subepithelial excimer refractive surgery techniques: Epi-LASIK.

The reports of an increasing incidence of iatrogenic ectasia, the evolution of wavefront aberrometry, and the suggestion that the laser in situ keratomileusis flap could lead to unpredictable biomechanical corneal changes have renewed interest in surface ablation and have set the stage for the introduction of alternative photorefractive treatment modalities. The theoretical advantage of surface procedures, such as laser epithelial keratomileusis that preserve the epithelial button, stems from the repositioning of the epithelial flap over the laser-ablated corneal surface. This epithelial sheet is thought to act as a natural contact lens that decreases postoperative pain and haze formation. Epipolis laser in situ keratomileusis is an alternative modality of epithelial separation with the use of a device that features a blunt oscillating blade. This surgical approach does not require the use of alcohol for epithelial loosening.

Management of post-LASIK corneal ectasia with Intacs inserts: one-year results.

OBJECTIVE: To prospectively study the effects of the use of Intacs microthin prescription inserts (Addition Technology Inc, Fremont, Calif) for the postoperative management of corneal ectasia resulting from laser in situ keratomileusis (LASIK). METHODS: In this prospective nonrandomized clinical trial, 10 eyes of 7 patients with post-LASIK corneal ectasia (2 men and 5 women) aged 33 to 46 years (mean +/- SD, 40.67 +/- 5.99 years) were included. The follow-up ranged from 6 to 24 months (mean +/- SD, 15.0 +/- 6.5 months). Two Intacs segments of thickness depending on the residual refraction of the patients were inserted in each eye. MAIN OUTCOME MEASURES: Uncorrected visual acuity, best spectacle-corrected visual acuity, refractive outcome, and topographic findings after Intacs implantation. RESULTS: Intacs were successfully implanted in all eyes. Spherical equivalent error was statistically significantly reduced after Intacs implantation (pre-Intacs, mean +/- SD: -4.81 +/- 3.24 Diopters (D) (range, -13.75 to -2.50 D) to -0.96 +/- 2.93 D (range, -8.75 to 2.50 D) (P<.001). Pre-Intacs uncorrected visual acuity was 20/100 or worse in all eyes (range, counting fingers to 20/100) while at the last follow-up examination, 9 (90%) of 10 eyes had uncorrected visual acuity of 20/40 or better (range, counting fingers to 20/20). Three eyes maintained the pre-Intacs best spectacle-corrected visual acuity while the rest of the eyes (7) experienced a gain of 1 to 2 lines. The mean difference between pre-Intacs and last follow-up best spectacle-corrected visual acuity was a gain of 1.00 +/- 0.82 lines. CONCLUSIONS: Intracorneal ring segments implantation improved uncorrected visual acuity and best spectacle-corrected visual acuity in patients with post-LASIK ectasia. Even though the results are encouraging, concern still exists regarding the long-term effect of such an approach for the management of post-LASIK ectasia.