Safety and Efficacy of Repeated Corneal Collagen Crosslinking in Progressive Keratoconus.

PURPOSE: Keratoconus is a progressive visually impairing disorder. Despite the beneficial effects of epithelial off-crosslinking (CXL) on the stabilization of keratoconus, progression may still occur. We report the efficacy and safety of a repeated CXL for significant progression of keratoconus after a single CXL procedure. METHODS: This retrospective study includes patients diagnosed with progressive keratoconus who were previously treated with CXL and underwent repeated CXL. Demographic, clinical, and surgical data were retrieved and analyzed. RESULTS: Ten consecutive eyes of nine patients who developed progressive keratoconus after CXL were identified. The mean age at diagnosis of keratoconus was 20.2 ± 6.0 years. The post-repeated CXL follow-up period was 2.1 ± 1.3 years. The mean best corrected visual acuity (BCVA) remained stable throughout the follow-up period. The mean Kmax at baseline was 60.4 ± 3.6 D. Before the repeated CXL, Kmax progressed significantly ( P = 0.018) and was 62.2 ± 6.3 D, and at the last follow-up, the value decreased significantly ( P = 0.037) and was 60.3 ± 6.4 D. The mean minimal pachymetry was 464.0 ± 27.0 µ at base line. Before the repeated CXL, minimal pachymetry was significantly lower ( P = 0.018), and after the repeated CXL, the minimal pachymetry was stable ( P = 0.2). No intra- or postoperative complications were noted. CONCLUSIONS: Repeated CXL is a safe and effective treatment option when failure of the initial CXL is diagnosed, even in young patients. This procedure may prevent visual deterioration and a potential need for keratoplasty.

Changes in Refraction and Visual Acuity after Upper Eyelid Blepharoplasty versus Posterior Approach Ptosis Procedures.

PURPOSE: To evaluate surgically induced refractive changes (SIRC) and visual acuity (VA) changes after blepharoplasty combined with posterior approach ptosis surgery (Müller's muscle-conjunctival resection [MMCR]) versus upper eyelid blepharoplasty alone. METHODS: In this prospective, comparative, clinical study on patients undergoing MMCR and blepharoplasty, comprehensive ophthalmic examinations were performed preoperatively and 3 months postoperatively. SIRC were calculated with the 10-step Holladay method. RESULTS: Fifty-six patients participated in the study, 31 in the blepharoplasty group and 25 in the ptosis group. logMAR VA improved significantly after surgery in both groups (p < 0.001). In both groups, most patients showed significant changes in SIRC sphere and spherical equivalent of >0.5 D (blepharoplasty group: 61.29 and 67.74%; ptosis group: 72.72 and 72.72%, respectively). Patients undergoing combined blepharoplasty ptosis surgery showed the greatest SIRC cylinder. CONCLUSIONS: Upper eyelid blepharoplasty with or without MMCR is associated with significant SIRC 3 months postoperatively. This may affect decision-making for all patients, especially for those who intend to seek refractive correction in addition to the index upper eyelid surgery.

The Effect of a Ptosis Procedure Compared to an Upper Blepharoplasty on Dry Eye Syndrome.

PURPOSE: To examine the effect of combined blepharoplasty and Müller muscle-conjunctival resection (MMCR) compared to an upper blepharoplasty on dry eye syndrome. DESIGN: Prospective, comparative clinical study. METHODS: This is prospective, comparative case series. Two groups of patients participated in this study: the blepharoplasty group included adult patients with dermatochalasis and the ptosis group consisted of adult patients with dermatochalasis and ptosis that showed significant improvement after phenylephrine 10% instillation. The following parameters were compared for all patients before the procedure (baseline) and on postoperative day 90: MRD1, Ocular-Surface-Disease-Index (OSDI), Schirmer test 2, tear break-up time (TBUT), fluorescein staining, Lissamine-green staining (LG). RESULTS: Fifty-four patients participated in this study (blepharoplasty group: 23 patients, ptosis group 31 patients). There were significant increases in the postoperative LG scores and in fluorescein staining post ptosis surgery compared with the preoperative values (paired t test, P = .05 and P = .02, respectively). The postoperative OSDI score was significantly higher post ptosis surgery compared with the preoperative score (25.38 vs 17.24, respectively, paired t test, P < .01). There were no significant differences, in the blepharoplasty group, between the postoperative and preoperative objective and subjective dry eye tests. CONCLUSIONS: MMCR surgery causes an increase in the subjective feeling of dry eye as well as an increase of signs of dry eye. This increase was not noticed after blepharoplasty surgery. Physicians should be aware of the risk of dry eye after ptosis surgery and discuss dry eye as a complication of MMCR surgery with their patients before surgery. Those patients should be examined carefully and treated for dry eye during follow-up.

Epithelial ingrowth after late traumatic femtosecond laser-assisted laser in situ keratomileusis flap dislocation.

Traumatic flap displacement and epithelial ingrowth after microkeratome-assisted laser in situ keratomileusis (LASIK) is a widely described potentially sight-threatening complication. However, this complication is rare when a femtosecond laser is used to create the LASIK flap. We present a case of epithelial ingrowth after late traumatic femtosecond-assisted LASIK flap dislocation. A 25-year-old woman presented to our emergency department after being scratched in the right eye by her cat. The patient had bilateral myopic femtosecond-assisted LASIK surgery 5 years previously with good postoperative visual acuity. Ocular examination showed nasal dislocation of the flap. Follow-up examinations showed epithelial ingrowth. She was referred for reconstructive surgery in which the epithelial ingrowth was removed and the flap repositioned. Follow-up examinations showed an excellent result.

Müller's muscle-conjunctival resection for upper eyelid ptosis: correlation between amount of resected tissue and outcome.

AIMS: To explore the relationship between the amount of resected Müller's muscle-conjunctiva (MMCR) and clinical outcome in patients undergoing upper eyelid ptosis surgery. METHODS: 49 patients underwent 87 MMCR surgeries. The total areas of the specimen and of MM were measured in pixels. RESULTS: The average percentage of muscle tissue in relation to total excised tissue was 21%. Intraoperative MMC tissue measurements and postoperative improvement in eyelid position (delta marginal reflex distance 1 (MRD1)) were positively correlated (R=0.427, p=0.09). There was a weak correlation between total areas measured on the histological slides and the intraoperative MMCR values (R=0.3, p=0.057). Total histological areas did not correlate with the delta change in eyelid position or with the amount and percentage of resected muscle tissue and the extent of improvement in eyelid position (delta MRD1) or final eyelid position (postoperative MRD1). CONCLUSIONS: Post-MMCR improvement in eyelid positions did not correlate with the percentage of MM in the excised tissue. We believe that the mechanism responsible for surgical outcome is plication or scarring of the posterior lamella and not the amount of resected MM. More lift in eyelid position can be anticipated when more tissue is excised by MMCR, and not when more muscle is excised.