Long-Term Outcomes of Upper Eyelid Loading with Platinum Segment Chains for Lagophthalmos: An Adjustable Approach.

PURPOSE: This article reports the outcomes of a 5-year series of individually sutured platinum segment chains for upper eyelid loading. DESIGN: Consecutive case series. METHODS: Platinum segments of 0.4 and 0.2 g were assembled to create the desired weight and were placed in a supratarsal location after levator aponeurosis recession. Primary outcome measures included lagophthalmos on blink, gentle and forced eyelid closure, upper eyelid margin-to-reflex distance (MRD1), corneal staining, static and dynamic validated scoring for facial palsy patients, and complications. Secondary outcome measures were visual acuity, occurrence of induced ptosis, need for further surgery, cosmesis, and quality of life evaluation. RESULTS: During 2013-2018, a total of 122 upper eyelids of 117 patients received platinum segment chains (mean weight, 1.2 ± 0.2 g; range, 0.8-1.6 g) for lagophthalmos. Median follow-up was 17.4 months. All grades of lagophthalmos were reduced (P < 0.001), with mean reductions of 3.6, 2.5, and 1.5 mm on blink, gentle, and forced closures, respectively. Mean MRD1 was reduced by 1.4 mm (P < 0.001). Overall, 36 eyelids (29.5%) underwent revision surgery at 9.1 ± 9.2 months after implantation. Of those, 6 eyelids (5.0%) required 2 or more procedures. No platinum allergy occurred. The chain was graded as having no prominence in 77.5% of eyelids; the eyelids were graded as having a normal contour in 70.8% of cases. CONCLUSIONS: Platinum segments are US Food and Drug Administration approved and provide benefits of platinum chains with the additional advantages of allowing postoperative adjustability, reduced health care costs, and less likelihood of inducing allergy than gold. Platinum segments are an ideal first-line loading implant for lagophthalmos.

State of the art of robotic surgery related to vision: brain and eye applications of newly available devices.

BACKGROUND: Robot-assisted surgery has revolutionized many surgical subspecialties, mainly where procedures have to be performed in confined, difficult to visualize spaces. Despite advances in general surgery and neurosurgery, in vivo application of robotics to ocular surgery is still in its infancy, owing to the particular complexities of microsurgery. The use of robotic assistance and feedback guidance on surgical maneuvers could improve the technical performance of expert surgeons during the initial phase of the learning curve. EVIDENCE ACQUISITION: We analyzed the advantages and disadvantages of surgical robots, as well as the present applications and future outlook of robotics in neurosurgery in brain areas related to vision and ophthalmology. DISCUSSION: Limitations to robotic assistance remain, that need to be overcome before it can be more widely applied in ocular surgery. CONCLUSION: There is heightened interest in studies documenting computerized systems that filter out hand tremor and optimize speed of movement, control of force, and direction and range of movement. Further research is still needed to validate robot-assisted procedures.

Placido disk-based topography versus high-resolution rotating Scheimpflug camera for corneal power measurements in keratoconic and post-LASIK eyes: reliability and agreement.

AIM: To compare the repeatability/reproducibility of measurement by high-resolution Placido disk-based topography with that of a high-resolution rotating Scheimpflug camera and assess the agreement between the two instruments in measuring corneal power in eyes with keratoconus and post-laser in situ keratomileusis (LASIK). METHODS: One eye each of 36 keratoconic patients and 20 subjects who had undergone LASIK was included in this prospective observational study. Two independent examiners worked in a random order to take three measurements of each eye with both instruments. Four parameters were measured on the anterior cornea: steep keratometry (Ks), flat keratometry (Kf), mean keratometry (Km), and astigmatism (Ks-Kf). Intra-examiner repeatability and inter-examiner reproducibility were evaluated by calculating the within-subject standard deviation (Sw) the coefficient of repeatability (R), the coefficient of variation (CoV), and the intraclass correlation coefficient (ICC). Agreement between instruments was tested with the Bland-Altman method by calculating the 95% limits of agreement (95% LoA). RESULTS: In keratoconic eyes, the intra-examiner and inter-examiner ICC were >0.95. As compared with measurement by high-resolution Placido disk-based topography, the intra-examiner R of the high-resolution rotating Scheimpflug camera was lower for Kf (0.32 vs 0.88), Ks (0.61 vs 0.88), and Km (0.32 vs 0.84) but higher for Ks-Kf (0.70 vs 0.57). Inter-examiner R values were lower for all parameters measured using the high-resolution rotating Scheimpflug camera. The 95% LoA were -1.28 to +0.55 for Kf, -1.36 to +0.99 for Ks, -1.08 to +0.50 for Km, and -1.11 to +1.48 for Ks-Kf. In the post-LASIK eyes, the intra-examiner and inter-examiner ICC were >0.87 for all parameters. The intra-examiner and inter-examiner R were lower for all parameters measured using the high-resolution rotating Scheimpflug camera. The intra-examiner R was 0.17 vs 0.88 for Kf, 0.21 vs 0.88 for Ks, 0.17 vs 0.86 for Km, and 0.28 vs 0.33 for Ks-Kf. The inter-examiner R was 0.09 vs 0.64 for Kf, 0.15 vs 0.56 for Ks, 0.09 vs 0.59 for Km, and 0.18 vs 0.23 for Ks-Kf. The 95% LoA were -0.54 to +0.58 for Kf, -0.51 to +0.53 for Ks and Km, and -0.28 to +0.27 for Ks-Kf. CONCLUSION: As compared with Placido disk-based topography, the high-resolution rotating Scheimpflug camera provides more repeatable and reproducible measurements of Ks, Kf and Ks in keratoconic and post-LASIK eyes. Agreement between instruments is fair in keratoconus and very good in post-LASIK eyes.

Refractive error after cataract surgery combined with descemet stripping automated endothelial keratoplasty.

PURPOSE: To assess refractive error after cataract surgery combined with Descemet stripping automated endothelial keratoplasty using adjusted keratometric (K) readings to calculate intraocular lens (IOL) power. DESIGN: Prospective, interventional case series. METHODS: One eye of 39 consecutive patients with Fuchs endothelial dystrophy and cataract were included. To calculate IOL power before surgery, the Javal steep and flat K readings (Haag-Streeit) were adjusted by reducing their value by -1.19 diopters (D); the axial length was measured by immersion biometry, and the standard A-constant was used. Surgery included phacoemulsification, IOL (Acrysof SN60AT; Alcon) implantation within the capsular bag, and Descemet stripping automated endothelial keratoplasty using posterior lamella prepared with a 300-µm head microkeratome (Moria). The absolute prediction error (absolute difference between predicted and achieved refraction) was assessed 6 months after surgery. RESULTS: The mean power of the implanted IOL was 23.22 ± 2.90 D. The mean predicted and achieved refractions were -0.27 ± 0.26 D and -0.23 ± 0.73 D, respectively. The mean absolute prediction error was 0.59 ± 0.42 D (range, 0.05 to -1.52 D). The postoperative spherical equivalent fell within ±0.50 D, ±1.00 D, and ±2.00 D of the predicted refraction in 55.5%, 83.3%, and 100% of cases, respectively. Had the IOL power been calculated without adjusting the K readings, the mean absolute prediction error would have been significantly higher (0.86 ± 0.62 D; P = .04). CONCLUSIONS: In this study, in which posterior lamellae were prepared using a 300-µm head microkeratome, adjusting preoperative K readings by -1.19 D led to accurate IOL power calculation and highly predictable refractive error after cataract surgery combined with Descemet stripping automated endothelial keratoplasty.

Diagnosis of subclinical keratoconus using posterior elevation measured with 2 different methods.

PURPOSE: To compare the efficacy of posterior corneal elevation, measured by 2 methods, in discriminating subclinical keratoconus from normal corneas. METHODS: In 30 consecutive patients with subclinical keratoconus, and 37 candidates for refractive surgery, posterior corneal elevation was measured using Pentacam's rotating Scheimpflug camera (Oculus, Wetzlar, Germany) with the standard method [maximal elevation above the best fit sphere (BFS)] and with the enhanced-BFS (E-BFS) method (difference in elevation measured above the E-BFS and that measured above the BFS). Using cutoff points selected a priori (≥ 29 and ≥ 12 µm, respectively, for the standard and E-BFS methods) the sensitivity, specificity, and overall accuracy, determined through the area under the receiver operating characteristic curves, were assessed for each method and then compared. RESULTS: Mean posterior elevation values were statistically higher (P < 0.001) in corneas with subclinical keratoconus than in normal corneas, using either the standard (38 ± 15.9 µm vs. 20.3 ± 7.1 µm) or the E-BFS (15 ± 9.5 µm vs. 7.8 ± 5.5 µm) methods. Sensitivity and specificity rates were slightly higher with the standard method than with the E-BFS method (sensitivity, 73.3% vs. 60%; specificity, 86.5% vs. 83.8%), but neither difference was statistically significant (P > 0.05). The overall accuracy of the tests was similar (P = 0.19): the area under the curve was 0.80 for the standard and 0.72 for the E-BFS method. CONCLUSIONS: Posterior corneal elevation measured using either standard or E-BFS method has similar efficacy in discriminating corneas with subclinical keratoconus from normal corneas. As a single parameter, posterior elevation can be considered quite effective with either method, but it cannot be used alone to identify patients with subclinical keratoconus.

Wave-like opacities at the interface after descemet stripping automated endothelial keratoplasty.

PURPOSE: To describe a peculiar postoperative complication of Descemet stripping automated endothelial keratoplasty (DSAEK), characterized by wave-like opacities at the donor-recipient interface. METHODS: Wave-like opacities at the interface were observed a few days after surgery, in 1 eye of 2 patients who had undergone uneventful DSAEK for Fuchs endothelial dystrophy. DSAEK was performed using microkeratome-prepared lamellar grafts obtained from organ culture-preserved corneas. In the recipient, the 8.50-mm graft was inserted using a pull-through technique. Postoperative follow-up was 12 months in case 1 and 6 months in case 2. RESULTS: The wave-like opacities were whitish and involved the central cornea in both cases; in case 2, they were associated with hyperreflective dots. Despite intensive topical therapy with dexamethasone 0.2%, the opacities at the interface persisted during follow-up. However, visual acuity progressively improved; at last examination, uncorrected and corrected distance visual acuity were, respectively, 20/40 and 20/25 in case 1 and 20/30 and 20/20 in case 2. Optical coherence tomography showed that the interface reflectivity was slightly higher than it was in DSAEK cases without opacities. The central thickness of the whole cornea and the lamella were 563 and 93 µm in case 1 and 603 and 140 µm in case 2. Postoperative endothelial cell loss was 37% in case 1 and 24% in case 2. CONCLUSIONS: Wave-like opacities at the donor-recipient interface are a rare complication of DSAEK surgery of unclear origin. Although interface opacities involve the central cornea and persist after surgery, good postoperative visual recovery can be achieved.