Reper intraocular lens with artificial iris: implantation techniques and outcomes.

The authors describe the surgical techniques to implant a novel intraocular lens with artificial iris (Reper) in patients affected by traumatic aphakia and aniridia. Two surgical approaches are proposed: implantation by suture-loaded cartridge and "open sky" implantation combined with penetrating keratoplasty. The method of establishing the exact position of the scleral fixation points and the pre-assembly of the suture of Reper before its implantation are the main novel proposed surgical procedures. The rationale is to minimize surgical procedures in the anterior chamber and to prevent knot loosening and lens tilting. The simultaneous treatment of aphakia and aniridia with a single prosthesis, the stability of the Reper and the functional, anatomical and aesthetic outcomes obtained are the highlighted advantages in this study.

A new intraocular lens with artificial iris for treating a case of iris extrusion secondary to traumatic opening of a radial keratotomy.

PURPOSE: Traumatic globe rupture can lead to aniridia with subsequent glare, light sensitivity and psychological discomfort. The authors report the results of a sulcus implantation of a new intraocular lens with artificial iris (Reper) in an eye affected by traumatic opening of a radial keratotomy incision with total iris extrusion and subluxated cataract. METHODS: A case of 56-year-old female affected by aniridia and subluxated cataract in left eye secondary to a traumatic opening of one of 12 radial keratotomy underwent a Reper implantation with three-point transcleral fixation. The following parameters were collected at 1, 3 and 6 postoperative months: best-corrected visual acuity (BCVA), intraocular pressure (IOP), central corneal thickness (CCT), simulated keratometry (Sim K), endothelial cell count (ECC) and anterior chamber depth (ACD). Pupil spread function study was performed to evaluate the high-order aberrations and the quality of vision. RESULTS: BCVA improved from light perception to 20/20 (Snellen fraction) at 6 postoperative months. No IOP postoperative peaks were detected. CCT was 520 µm at 6 postoperative months. Corneal topography showed regularization with symmetrical flattening of the central part and a residual peripheral curvature. No significant reduction of ECC was detected. ACD was stable, superior to 3 mm at each time point of follow-up. Pupil spread function study highlighted that the quality of vision was the same in both eyes at the end of follow-up. CONCLUSION: Reper is a promising functional and cosmetic solution for the treatment of aphakia and aniridia.

Aging and corneal layers: an in vivo corneal confocal microscopy study.

PURPOSE: To describe age-related changes of different corneal layers using a quantitative analysis of in vivo corneal confocal microscopy. DESIGN: Descriptive observational cross-sectional study. METHODS: A total of 108 healthy corneas of 108 subjects, distributed in four age categories, underwent in vivo corneal confocal microscopy. The effect of aging on the main features of corneal epithelium, sub-basal nerve plexus, stroma, and endothelium was investigated. RESULTS: Mean diameter of superficial epithelial cells increases with age (0.05 µm per year; p < 0.0001). Mean cell density of basal epithelium does not change with age (p = 0.37). The sub-basal nerve plexus fiber number, density, and the number of beadings do not statistically change with age (p = 0.14, p = 0.10 and p = 0.17, respectively). Keratocyte density significantly reduces with age in each stromal layer (p < 0.0001). Endothelial cell count decreases by 10.92 cells/mm(2) per year (p < 0.0001). Endothelial polymegathism index and pleomorphism index do not change with age (p = 0.79 and p = 0.39, respectively). CONCLUSIONS: Corneal confocal microscopy allows a non-invasive examination of the living cornea, analyzing the microstructure of each corneal layer. Aging significantly influences the corneal confocal microscopy parameters of individual corneal layers, except sub-basal nerve plexus and basal epithelium.

Wavefront-optimized surface ablation with the Allegretto Wave Eye-Q excimer laser platform: 12-month visual and refractive results.

PURPOSE: To evaluate the wavefront-optimized algorithm of the Allegretto Wave Eye-Q (Wavelight AG) 400-Hz excimer laser platform. METHODS: Three hundred three eyes of 303 patients treated with advanced surface ablation were evaluated prospectively. Topical mitomycin C (MMC) was used when ablation was ≥80 µm. Efficacy, safety, and predictability at 12 months were quantified with subjective refraction, visual acuity (logMAR), and slit-lamp examination. RESULTS: Mean postoperative uncorrected distance visual acuity (UDVA) was 20/20.5 (0.01±0.05 logMAR). Postoperative UDVA was equal or better than preoperative corrected distance visual acuity (CDVA) in 94.7% of eyes. Efficacy index was 1.05. Corrected distance visual acuity was maintained (93.7%) or improved (5.9%) in 99.6% of treated eyes. No patient lost ≥2 lines. Safety index was 1.05. Haze at 12 months was grade ≤0.5 in 98% of treated eyes and grade ≤1 in 100% of treated eyes. Mean postoperative manifest refraction spherical equivalent (MRSE) was -0.03±0.15 diopters (D). Postoperative MRSE was within ±0.50 D in 99% of eyes. Overcorrection was documented in 0.66% and undercorrection in 0.33% of eyes. CONCLUSIONS: The wavefront-optimized algorithm of the Allegretto Wave Eye-Q excimer laser platform showed good efficacy, safety, and predictability in advanced surface ablation, with or without MMC intraoperative use.

Mitomycin C-assisted photorefractive keratectomy in high myopia: a long-term safety study.

PURPOSE: To evaluate the long-term corneal safety of topical mitomycin C (MMC) used during photorefractive keratectomy to prevent haze formation in highly myopic eyes. METHODS: Twenty-eight patients with bilateral high myopia underwent photorefractive keratectomy. One eye was randomly assigned to intraoperative 0.02% MMC and the fellow eye to conventional treatment. Each eye was checked at baseline and at 5 years after surgery using in vivo corneal confocal microscopy. RESULTS: At baseline, the endothelial cell density was 2970 ± 295 cells per square millimeter in the MMC-treated eyes and 2839 ± 323 cells per square millimeter in the control eyes. At 5 years, it was 2803 ± 307 and 2780 ± 264 cells per square millimeter, respectively (P = 0.27). The number of corneal nerve fibers was 3.9 ± 1.6 in the MMC-treated eyes and 4.4 ± 1.3 in the control eyes. At 5 years, it was 3.0 ± 1.6 and 2.7 ± 1.3, respectively (P = 0.15). The density of corneal nerves was 9600 ± 2915 µm/mm(2) in the MMC-treated eyes and 11,352 ± 3898 µm/mm(2) in the control eyes. At 5 years, the density was higher in the MMC-treated eyes (6790 ± 2447 µm/mm(2)) than in the control eyes (6024 ± 2977 µm/mm(2)) (P = 0.003). The number of nerve beadings at baseline was 12.9 ± 1.7/100 µm in the MMC-treated eyes and 12.3 ± 2.0/100 µm in the control eyes. At 5 years, it was 9.9 ± 2.6/100 and 9.4 ± 2.9/100 µm, respectively (P = 1.00). At 5 years, corneal nerve branching and tortuosity were similar in the 2 groups (P = 0.88 and 0.54, respectively). Epithelium thickness remained statistically unchanged (P = 0.69). CONCLUSIONS: Intraoperative use of topical 0.02% MMC compared with standard treatment does not induce significant long-term corneal changes, as assessed by in vivo corneal confocal microscopy.

Confocal microscopy of corneal sub-basal nerve plexus: a quantitative and qualitative analysis in healthy and pathologic eyes.

PURPOSE: To validate corneal sub-basal nerve plexus examination by in vivo corneal confocal microscopy. METHODS: Five parameters of corneal sub-basal nerve plexus in 250 human eyes (nerve fiber length, number of fibers, number of beadings, branching pattern, fiber tortuosity) acquired using in vivo corneal confocal microscopy (Confoscan 4.0; NIDEK Co Ltd) were analyzed. The first operator repeated the parameter analysis twice, performing the 2 evaluations 4 weeks apart. The second operator analyzed the cases once. RESULTS: Intraoperator reproducibility of nerve fiber length, number of fibers, and number of beadings (intraclass correlation coefficient [ICC] = 0.96, 0.96, and 0.93, respectively) and interoperator reproducibility (ICC = 0.94, 0.95, and 0.87, respectively) were very good. Intraoperator reproducibility for branching pattern was good (ICC = 0.74), whereas interoperator reproducibility was very good (ICC = 0.81). Reproducibility of fiber tortuosity was good both at intra- and interoperator levels (ICC = 0.69 and 0.60, respectively). CONCLUSIONS: Corneal confocal microscopy with the NIDEK Confoscan 4.0 represents an in vivo, noninvasive, and reproducible diagnostic technique for the analysis of sub-basal corneal nerve plexus. Methods used to analyze quantitative and qualitative variables were highly reproducible.

Long-term effects on corneal keratocytes of mitomycin C during photorefractive keratectomy: a randomized contralateral eye confocal microscopy study.

PURPOSE: To evaluate the long-term side effects of mitomycin C (MMC) assisted photorefractive keratectomy (PRK) on corneal keratocytes of highly myopic eyes. METHODS: Twenty-eight patients with bilateral myopia from -7.00 to -14.25 diopters (D) underwent PRK on both eyes, one eye of each patient received topical application of 0.02% MMC for 2 minutes immediately after the PRK procedure. Corneal keratocyte density was quantified by corneal confocal microscopy at baseline and 5 years postoperatively. RESULTS: Photorefractive keratectomy reduced keratocyte density in the most anterior stromal layer, without a statistically significant difference between MMC and standard treated eyes. Posterior stromal layers showed no signs of keratocyte loss with either techniques. CONCLUSIONS: Phototherapeutic keratectomy with 0.02% topical MMC has no significant side effects on corneal keratocytes compared to standard PRK, as documented by in vivo corneal confocal microscopy.

LASEK and photorefractive keratectomy for myopia: clinical and confocal microscopy comparison.

PURPOSE: To compare postoperative visual acuity and corneal morphology after laser epithelial keratomileusis (LASEK) versus photorefractive keratectomy (PRK) in the correction of low to moderate myopia. METHODS: In a double-blind, randomized clinical trial, 50 myopic patients (mean: -4.5 +/- 1.35 diopters) were randomized to receive LASEK in one eye and PRK in the fellow eye. No mitomycin C eye drops were used in this study. Patients were observed daily for 4 days, then at 1 month and every 3 months up to 1 year. Uncorrected and best-corrected visual acuity (UCVA and BSCVA), manifest refraction, corneal epithelium healing time, postoperative pain, and corneal haze were evaluated. Corneal wound healing was quantified with corneal confocal microscopy. RESULTS: Refractive error, UCVA, and BSCVA were not statistically different between eyes treated with LASEK and PRK. Corneal epithelium healing time was 2.52 +/- 0.99 days in the eyes treated with PRK and 2.29 +/- 0.52 days in the eyes treated with LASEK (P=.22). The postoperative pain score was 2.17 +/- 0.87 in the eyes treated with PRK and 2.62 +/- 0.60 (P=.02) in the eyes treated with LASEK. Corneal confocal microscopy showed fewer stromal activated keratocytes and less extracellular matrix deposition in the eyes treated with LASEK than in the eyes treated with PRK at 1 month postoperatively (P=.003). CONCLUSIONS: LASEK is an effective and safe procedure for low to moderate myopia, but it seems more painful until full corneal reepithelization. In the early postoperative period, the corneal wound healing process is significantly less intense in eyes treated with LASEK than in eyes treated with PRK. The role of LASEK in corneal wound healing modulation remains controversial.

Central corneal thickness: z-ring corneal confocal microscopy versus ultrasound pachymetry.

PURPOSE: To compare the repeatability and validity of corneal pachymetry by a corneal confocal microscope with a z-axis adapter (Confoscan 4.0 with z-ring adapter: z-CS4) versus ultrasound (US) pachymetry in the measurement of central corneal thickness (CCT). METHODS: CCT in 44 eyes of 44 subjects was determined with z-CS4. Z-CS4 exams were used to estimate the repeatability of thickness measurement by z-ring adapter for this confocal microscope. Intraclass Correlation Coefficient (ICC) between two different z-CS4 users was also determined. CCT in the same 44 eyes was determined with US pachymetry and measurements were compared with z-CS4 CCT. RESULTS: Z-CS4 CCT showed high intrainstrument reproducibility (ICC = 0.989; 95%CI 0.982-0.993; P < 0.0001). Mean difference among three CCT consecutive measures, in the same eye, was 0.8 +/- 11.1 microm. High correlation was found between two users (ICC = 0.896; 95%IC 0.830-0.937; P < 0.0001). Z-CS4 CCT showed high correlation with US pachymetry (ICC = 0.921; 95%CI 0.851-0.958; P < 0.0001). Mean corneal thickness determined was statistically different with the two methods (US: 512.6 +/- 65.8 microm; z-CS4: 487.8 +/- 60.1 microm; P < 0.0001). CONCLUSION: Z-CS4 seems an accurate, noninvasive and reproducible technique for CCT evaluation and confirms that central cornea is thinner when measured with confocal microscopy compared to ultrasounds.

Mitomycin C modulation of corneal wound healing after photorefractive keratectomy in highly myopic eyes.

PURPOSE: To evaluate the role of topical mitomycin C in corneal wound healing (CWH) after photorefractive keratectomy (PRK) in highly myopic eyes. DESIGN: Prospective, double-masked, randomized clinical trial. PARTICIPANTS: Seventy-two eyes of 36 patients affected by high (>7 diopters) myopia. METHODS: In each patient, one eye was randomly assigned to PRK with intraoperative topical 0.02% mitomycin C application, and the fellow eye was treated with a placebo. Postoperatively, mitomycin C-treated eyes received artificial tears (3 times daily, tapered in 3 months), whereas the fellow eye was treated with fluorometholone sodium 2% and artificial tears (3 times daily, tapered in 3 months). MAIN OUTCOME MEASURES: Uncorrected visual acuity (UCVA) and best-corrected visual acuity (BCVA), contrast sensitivity, manifest refraction, and biomicroscopy. Contrast sensitivity was determined using the Pelli-Robson chart. Corneal confocal microscopy documented CWH. RESULTS: Mean follow-up was 18 months (range, 12-36). No side effects or toxic effects were documented. At 12-month follow-up examination, UCVAs (logarithm of the minimum angle of resolution) were 0.4+/-0.48 and 0.5+/-0.53 (P = .03) in mitomycin C-treated eyes and corticosteroid-treated eyes, respectively. At 1 year, corneal haze developed in 20% of corticosteroid-treated eyes, versus 0% of mitomycin C-treated eyes. At 12, 24, and 36 months, corneal confocal microscopy showed activated keratocytes and extracellular matrix significantly more evident in untreated eyes (Ps = 0.004, 0.024, and 0.046, respectively). CONCLUSION: Topical intraoperative application of 0.02% mitomycin C can reduce haze formation in highly myopic eyes undergoing PRK.