Microbial keratitis after intrastromal corneal ring segment implantation.

PURPOSE: To evaluate the incidence of acute microbial keratitis after intrastromal corneal ring segment implantation and to investigate whether microbial keratitis is related to the intrastromal corneal ring type or surgical technique. METHODS: Intrastromal corneal ring segments were implanted in 212 eyes of 149 patients. Two different types of intrastromal corneal ring segments were used during the study, Intacs and Ferrara rings, and two surgical techniques were used for intrastromal corneal ring segment implantation, manual and femtosecond laser. RESULTS: One hundred thirty-four eyes (63.2%) underwent Intacs implantation and 78 (36.8%) eyes received Ferrara rings. Corneal tunnels were created using the manual technique in 119 (56.1%) eyes and by femtosecond laser in 93 (43.9%) eyes. Three cases (1.4%) of acute microbial keratitis were clinically identified. Cultures were positive in 2 eyes and negative in 1 eye, and polymerase chain reaction was positive in all 3 cases. The microorganisms isolated from cultures were Streptococcus mitis and Staphylococcus aureus. In 2 cases, the femtosecond laser technique was used (1 eye Intacs, 1 eye Ferrara), and in 1 case, the manual technique was used (Intacs). No statistically significant difference was noted between techniques (P=.582) or segment type (P=1.000). In all cases, intrastromal corneal ring segments were explanted and intensive topical antibiotics were used with clinical success. CONCLUSIONS: Acute microbial keratitis incidence after intrastromal corneal ring segment implantation was 1.4%. Gram-positive cocci were the organisms isolated more frequently. Proper management of this condition requires intrastromal corneal ring segment explantation and intensive topical antibiotics.

Hydrogel intracorneal inlays for the correction of hyperopia: outcomes and complications after 5 years of follow-up.

PURPOSE: To evaluate safety and efficacy of an intracorneal inlay for the correction of hyperopia. DESIGN: A prospective, nonrandomized, noncomparative, 2-center study. PARTICIPANTS: Thirty-four hyperopic eyes were implanted with a hydrogel intracorneal inlay (Permavision, Anamed, Lake Forest, CA). Preoperative hyperopia was +3.9 diopter (D; range, +2 to +7). Uncorrected visual acuity (UCVA) was the logarithm of the minimum angle of resolution (logMAR; the decimal logarithm of decimal visual acuity with a minus sign) 0.6 +/- logMAR 1, and best-corrected visual acuity (BCVA) was logMAR 0.1 +/- 0.7. METHODS: Corneal flaps were created with a mechanical microkeratome (M2 [Moria, Anthony, France] or Amadeus [Advanced Medical Optics Inc, Santa Ana, CA]; 180 microm), followed by inlay implantation onto the stromal bed over the pupillary center and covered by the corneal flap. Follow-up was 5 years. MAIN OUTCOME MEASURES: We measured UCVA and BCVA; patients underwent, slit-lamp examination, pachymetry, and confocal microscopy. The follow-up was up to 6 years. RESULTS: The UCVA improved during 3 months and was stable for up to 2 years. There was a loss of > or =2 lines of spectacle-corrected visual acuity in 35% of eyes at 2 years, and a loss of > or =2 lines in 55.5% of the eyes at 5 years. Refractive predictability was poor, with 60% of the eyes having +/-3.00 D of emmetropia. A decentration of the inlay occurred in 29.4%, progressive perilenticular deposits were observed in 88.2%, haze was seen in 73.5%, and the inlay was explanted in 58.8%, with a cumulative survival rate of 58.4%. CONCLUSIONS: An intracorneal inlay may be an option to treat hyperopia, but the tested inlay caused significant visual loss and scarring and had to be explanted in the majority of cases.

Polymerase chain reaction and DNA typing for diagnosis of infectious crystalline keratopathy.

A 63-year-old man developed infectious crystalline keratopathy (ICK) in his right eye 1 year after phacoemulsification. The white peripheral lesion was adjacent to the corneal phacoemulsification incision. Infiltrates in the form of creamy-white, midstromal branching, needle-like opacities without evidence of inflammatory cells were noted. A corneal biopsy by double lamellar flap was done and studied by 3 techniques: microbiological culture, stain, and polymerase chain reaction (PCR). Fungal and bacterial PCR were positive. A second sample was necessary to obtain a positive stain and culture. The DNA sequence analysis showed Candida parapsilosis and Staphylococcus aureus as the causal agents of the crystalline keratopathy. Treatment was started with amphotericin B 1% and cefazolin 6 times a day, and systemic voriconazole was recommended. This is the first reported case of ICK after cataract surgery. Polymerase chain reaction amplification and subsequent DNA typing were useful tools in detecting and identifying the ocular pathogens involved in this case.

Artisan toric phakic intraocular lens for correction of astigmatism.

PURPOSE: To assess the safety and efficacy of implanting Artisan toric phakic intraocular lenses (PIOLs) (Ophtec BV, Groningen, The Netherlands) in eyes with high degrees of compound myopic, hyperopic, and mixed astigmatism. METHODS: Twenty-five eyes (20 patients) presenting with high astigmatism were implanted with Artisan toric PIOLs and followed for 1 year. Group 1 included 8 eyes (myopic astigmatism), group 2 included 9 eyes (hyperopic astigmatism), and group 3 included 8 eyes (mixed astigmatism). RESULTS: In the myopic astigmatism group, 8 (100%) of 8 eyes had preoperative uncorrected visual acuity (UCVA) of < or = 20/50, and at 6-month follow-up, 5 (62.5%) of 8 eyes had UCVA of > or = 20/40 (P = .005). In this group, 75% of eyes were within +/- 1.00 diopter (D) of the intended correction. In the hyperopic astigmatism group, 8 (88.9%) of 9 eyes had preoperative UCVA of < or = 20/40, and at 6-month follow-up, 6 (66.6%) of 9 eyes had UCVA of > or = 20/32 (P = .199). Approximately 77.8% of eyes were within +/- 1.00 D of the intended correction. In the mixed astigmatism group, 8 (100%) of 8 eyes had preoperative UCVA of < or = 20/50, and at 6-month follow-up, 6 (87.5%) of 8 eyes had UCVA of > or = 20/40 (P = .007). In this group, 87.5% of eyes were within +/- 1.00 D of the intended correction. The safety index of the procedure was 1.6, 1.3, and 1.3 in the myopic, hyperopic, and mixed astigmatism groups, respectively. The efficacy index of the procedure was 1.2, 1.0, and 1.0 in the myopic, hyperopic, and mixed astigmatism groups, respectively. CONCLUSIONS: Artisan toric PIOLs are safe for the correction of high degrees of astigmatism associated with myopic or hyperopic spherical refractive defect.

Presbyopia correction with an anterior chamber phakic multifocal intraocular lens.

PURPOSE: To investigate in a pilot study the potential of an anterior chamber phakic refractive multifocal intraocular lens (IOL) prototype for the correction of near and far vision in those with myopic and hyperopic presbyopia. DESIGN: A multicenter, open-label, prospective, noncomparative pilot evaluation. PARTICIPANTS: There were 17 patients (34 eyes), 16 women and 1 man, with a mean age of 52+/-3.94 years (range, 46-62 years). Six eyes were myopic (mean spherical equivalent [SE], -9.3+/-3.83 diopters (D)) and 28 were hyperopic (mean SE, +2.3+/-0.77 D), with astigmatism less than 1.5 D. METHODS: The prototype multifocal phakic IOL was implanted through a 6.5-mm temporal incision. The dominant eye was targeted for emmetropia and the nondominant eye for -1.0 D. MAIN OUTCOME MEASURES: The efficacy of the implant was assessed after surgery by measuring monocular and binocular uncorrected and distance-corrected visual acuity (VA) at distance, intermediate, and near, and distance-corrected near VA with near add. Distance-corrected distance and near VA also were determined in low contrast (25%). The safety index and efficacy index were calculated, and patient satisfaction questionnaires also were administered. Follow-up was at 1-3 days, 5-9 days, 21 days, 3 months, 6 months, and 1 year after surgery. RESULTS: Spherical equivalent refraction ranged from -11.75 to +4.25 D before surgery, and from -2.0 to +1.85 D 1 year after surgery. The binocular efficacy index was 0.68 (near) and 1.0 (distance), and the binocular safety index was 1.0 for both near and distance. Mean binocular uncorrected distance VA improved from 20/59 (+/-4 lines) before surgery to 20/18 (+/-1 line) 1 year after surgery. Mean binocular uncorrected intermediate VA improved from 20/125 (+/-10 lines) to 20/21 (+/-1 line), and mean binocular uncorrected near VA improved from 20/78 (+/-5 lines) to 20/32 (+/-1 line). Binocular uncorrected visual acuity was at least 20/40 (distance and intermediate) and Jaeger 3 in 88.2% of patients, and it was at least 20/40 and Jaeger 5 in 100% of patients. Patient satisfaction was very good in 88% of patients (15 of 17); the remaining 2 patients reported moderate satisfaction. CONCLUSIONS: Promising results were obtained with the refractive multifocal phakic IOL prototype investigated in this pilot study for near and far visual correction in presbyopia associated with myopia and hyperopia. Multifocal phakic intraocular optics may be an option for presbyopia correction.

Intracorneal hydrogel lenses and corneal aberrations.

PURPOSE: To investigate the optical performance of the cornea based on corneal aberrometry following intracorneal hydrogel lens implantation. METHODS: A retrospective, nonconsecutive, observational study of the anterior corneal surface aberration profile of four hyperopic eyes previously implanted with an intracorneal hydrogel lens were studied by videokeratographic elevation maps before and 6 months after surgery. RESULTS: Intracorneal hydrogel lenses reduced the optical performance in all four eyes by increasing the spherical aberrations by a mean factor of 1.87 and 1.95, coma aberrations by a mean factor of 2.98 and 3.01, and total higher order aberrations by a mean factor of 2.6 and 2.17 at 3.0-mm and 6.5-mm pupils, respectively (P<.005). CONCLUSIONS: Intracorneal hydrogel lenses decreased the optical performance of the cornea by significantly increasing spherical, coma, and total higher order aberrations.

Intracorneal inlay complicated by intrastromal epithelial opacification.

OBJECTIVE: To report epithelial perilenticular opacity as a new complication of intracorneal inlay implantation for the correction of hyperopia. DESIGN: Prospective observational case series. PARTICIPANTS: Eleven eyes of 7 patients underwent intracorneal inlay implantation for the correction of hyperopia. METHODS: Intracorneal inlays were implanted onto the stromal bed by using a microkeratome cut to create an inferior hinged corneal flap. MAIN OUTCOME MEASURES: Postoperative complication occurrence of intracorneal perilenticular opacity, microbiological laboratory analysis, histopathological analysis, and confocal microscopy study. RESULTS: Of 11 implanted eyes, 5 showed diffuse perilenticular opacity of varying intensity that was unresponsive to steroid use following intracorneal inlay implantation. All patients had moderate to severe loss of best-corrected visual acuity. The inlays showed deposits at the edge and on the surface. Confocal microscopy in all eyes produced images compatible with the confocal morphologic features of epithelial cells. Explantation of inlays was performed in 5 eyes. The histopathologic study showed the presence of epithelial cells, and microbiological analysis and cultures were negative for bacteria, fungi, and mycobacteria. CONCLUSION: Epithelial perilenticular opacity is a new and serious complication in patients with intracorneal inlay implantation for the correction of hyperopia.

Evaluation of a new bioadhesive copolymer (ADAL) to seal corneal incisions.

OBJECTIVE: To evaluate the efficacy and clinical tolerance of a new acrylic copolymer tissue adhesive, ADAL, in corneal surgery. METHODS: Corneal incisions were performed on 24 New Zealand albino rabbits. The incision was either sealed with ADAL bioadhesive, hydrated with balanced salt solution, or closed with 10-0 nylon surgical sutures. The incisions underwent weekly tensile strength testing and clinical, histopathologic, and confocal microscopy evaluations. RESULTS: Clinical evaluation revealed good sealing and no incision leakage in any group. There was no anterior chamber reaction in any case. Compared with the hydrated group, there was somewhat more incisional vascularization and localized corneal opacity in the ADAL group, but there were no cases of severe corneal opacity or neovascularization. On histologic analysis, a slightly larger inflammatory reaction was noted in the ADAL group compared with the hydrated group. Tensile strength during the first week was statistically significantly greater in the ADAL group (2.93 Newtons) than in the control groups (1.40 Newtons, hydrated group; 1.43 Newtons, sutured group) (P < 0.001). Confocal microscopy study revealed a unique dendritic keratocyte shape and structure resembling shiny crystalline particles after disappearance of the adhesive from the cornea. CONCLUSIONS: Corneal surgical incisions sealed with ADAL adhesive have superior tensile strength in the first postoperative week compared with incisions closed with sutures or hydrated with salt solution. Thereafter, findings in both groups became similar. The use of ADAL adhesive was not associated with any deleterious effects during the corneal incision-healing process compared with hydration or sutures.

Artisan phakic iris claw intraocular lens for high primary and secondary hyperopia.

PURPOSE: To evaluate the efficacy, predictability, and safety of the Artisan iris claw phakic intraocular lens for the correction of high primary and secondary hyperopia. METHODS: Fifty-seven eyes were divided into two groups: 29 eyes had primary hyperopia (mean refraction 6.06 +/- 1.26 D, and 28 eyes had secondary hyperopia, (mean refraction 5.88 +/- 1.88 D) induced or residual following a previous corneal refractive procedure. Consecutive implantation of the Artisan iris claw phakic intraocular lens was performed. Main outcome measures recorded were BSCVA, UCVA, refraction, and astigmatic change, intraocular inflammation, and endothelial cell loss. RESULTS: Primary hyperopic group: Preoperatively, mean UCVA was 0.4 +/- 0.7 and mean BSCVA was 0.2 +/- 0.6. After implantation, mean UCVA was 0.3 +/- 0.6 and BSCVA was 0.1 +/- 0.6. Mean cycloplegic residual spherical refractive error after surgery was 0.10 +/- 0.57 D (range -1 to +2 D). Mean surgically induced astigmatism was 1.48 +/- 0.89 D. Safety index was 1.11. Efficacy index was 0.83. Secondary hyperopic group: Preoperatively, mean UCVA was 0.5 +/- 0.7 and mean BSCVA was 0.2 +/- 0.6. Postoperatively, mean UCVA was 0.4 +/- 0.7 and mean BSCVA was 0.2 +/- 0.6. Mean cycloplegic residual spherical refractive error was 0.55 +/- 1.49 D. Mean surgically induced astigmatism was 1.85 +/- 1.19 D. Safety index was 1.05. Efficacy index was 0.7. Postoperative iridocyclitis was observed in one eye (3.4%) in the primary group and in three eyes (10.7%) in the secondary group. Overall corneal endothelial cell loss at 1 year of follow-up was 9.4%. CONCLUSION: The Artisan iris claw phakic intraocular lens was reasonably safe and predictable for correcting high hyperopia.

Phacoemulsification in the anterior chamber.

PURPOSE: To evaluate anterior chamber phacoemulsification as an alternative to an endocapsular procedure. SETTING: Instituto Oftalmológico de Alicante, Alicante, Spain. METHODS: In this prospective randomized masked clinical trial, 60 eyes of 30 patients had cataract extraction by phacoemulsification. A conventional stop-and-chop technique was used in 30 eyes; the other 30 had surgery by the phaco-out technique in which the nucleus was prolapsed into the anterior chamber using extensive hydrodissection. Copious sodium hyaluronate 3.0%-chondroitin sulfate 4.0% (Viscoat) and hydroxypropyl methylcellulose were used to protect the cornea and iris. The phaco time and power, postoperative inflammation, corneal edema (clinically and by pachymetry), and endothelial cell count between groups preoperatively and postoperatively were compared. All patients completed a 3-month follow-up. Postoperative examinations were at 3 days, 2 weeks, and 1 and 3 months. RESULTS: The mean nuclear hardness was 2.67 +/- 0.61 (SD) in the stop-and-chop group and 2.65 +/- 0.71 in the phaco-out group. The power-to-time ratio was 18.47 and 18.80, respectively. The mean endothelial cell loss was 11.18% +/- 4.24% in the stop-and-chop group and 11.20% +/- 5.60% in the phaco-out group. There were no significant differences between groups in any parameter (P >.05, independent-sample t test). CONCLUSION: Phacoemulsification in the anterior chamber was as safe as endocapsular phacoemulsification using a stop-and-chop technique. This technique is fast and easier to learn than endocapsular phacoemulsification.