Topographic Keratoconus Incidence in Greece Diagnosed in Routine Consecutive Cataract Procedures: A Consecutive Case Series of 1250 Cases over 5 Years.

Background: Scheimpflug tomography has for many years been an integral part of our pre-operative assessment in cataract extraction. We retrospectively reviewed the incidence of topographic keratoconus and keratoconus suspicion in our routine cataract surgery population over 5 years. Setting: The Laservision Clinical and Research Institute, Athens, Greece. Methods: In 1250 consecutive cataract surgery cases in otherwise naïve eyes, accounting for years 2017 to 2021, we retrospectively evaluated preoperative Pentacam HR imaging. The cases already classified as keratoconus were included in group A. The residual cases were assessed by five different experienced evaluators (two ophthalmic surgeons and three optometrists) for topographic and tomographic keratoconus suspicion based on irregular pachymetry distribution, astigmatism truncation, and/or astigmatic imaging irregularity and included in group B. Regular corneas, by this assessment, were included in group C; irregular corneas, as determined by the evaluators but unrelated to keratoconus, were included in group D. Results: Based on the above, 138 cases (11.08%) were classified by Pentacam tomography as keratoconus and by default were included in group A. Of the residual cases, 314 or 25.12% were classified as suspect keratoconus and included in group B; 725 cases (58%) were classified as normal and non-keratoconus and included in group C; and 73 cases or 5.84% were placed in group D as non-keratoconus but abnormal. There was no disagreement between the five evaluators over any of the cases in groups C and D, and little variance among them for cases included in group B (less than 5% by ANOVA). Conclusions: The incidence of keratoconus and corneas suspicious for keratoconus in Greece appears to be much higher than respective reports from other regions: one in ten Greeks appear to have topographic keratoconus, most not diagnosed even by the age of cataract surgery, and almost an additional one in four may have suspicious corneal imaging for keratoconus. These data strongly imply that routine screening for disease should be promoted among Greeks, especially during puberty, to halt possible progression; moreover, careful screening should be performed when laser vision correction is being considered.

International Multicenter, Myopic and Myopic Astigmatism Femto LASIK, Customized by Automated Ray-Tracing Ablation Profile Calculation: A Postmarket Study.

Purpose: To assess the safety and efficacy of a customized ablation treatment (InnovEyes) to correct myopia and myopic astigmatism with femtosecond laser-assisted in situ keratomileusis (Femto LASIK). Patients and Methods: In this prospective, nonrandomized, multicenter study, 113 patients (225 eyes) with preoperative myopia less than -9.0 diopters (D) and astigmatism 0 to -4.0 D (based on InnovEyes refraction) underwent wavefront, tomography, and biometry assessment using a single diagnostic device (InnovEyes sightmap). These data were imported and used unmodified by the InnovEyes algorithm to automatically calculate and optimize correction of lower- and higher­order aberrations (HOAs) treated by the EX500 ablation profile. Visual acuity, refractive error, HOAs, and patient satisfaction were evaluated over 3 months. Results: A total of 106 patients (212 eyes) completed the study and were included in the analysis. Mean preoperative manifest refraction spherical equivalent (MRSE) was -3.38±1.76 D. At Month 3, uncorrected distance visual acuity was 20/20 or better in 208/212 (98.1%) eyes, and it was the same as, or better than, the preoperative best-corrected distance visual acuity (CDVA) in 162/212 (76.4%) eyes; 76/212 (35.8%) eyes gained ≥1 line of CDVA. MRSE was within ±0.5 D in 195/212 (92.0%) eyes. Additionally, 201/209 (96.2%) eyes had no change (defined as a change between -0.1 µm and 0.1 µm, inclusive) in HOAs, and 105/106 (99.1%) patients reported to be satisfied with the results. Conclusion: Customizing ray-tracing Femto LASIK with this platform appeared safe and effective in correcting myopic astigmatism and also achieved a significant percentage of eyes gaining lines of vision, potentially by addressing HOAs, along with a consistently high level of patient satisfaction.

Ray-Tracing Customization in Myopic and Myopic Astigmatism LASIK Treatments for Low and High Order Aberrations Treatment: 2-Year Visual Function and Psychometric Value Outcomes of a Consecutive Case Series.

Purpose: The safety and long-term efficacy of automated ray-tracing customized myopic and myopic astigmatic femtosecond laser-assisted LASIK. Methods: This consecutive case series retrospective analysis, of 20 subjects (40 eyes) treated with automated raytracing named Wavelight Plus, to include low and high order aberrations based on a three-dimensional custom virtual eye for each case-calculated from interferometry data-obtained from a single diagnostic device that also provides Hartman-Shack Wavefront and Scheimpflug tomography data. We evaluated before and after the customized LASIK procedure: visual acuity, refractive error, high order aberrations, contrast sensitivity, and psychometric post-operative visual function data. Results: At 24 months, the comparison of the pre-operative to the post-operative refractive and visual function value changes in average were: subjective manifest refraction from -4.38 ± 2.54 diopters (D) (range -9.75 to -1.25 D) to +0.11 ± 0.19 D; subjective manifest refractive astigmatism from -0.76 ± 0.91 D (range -2.75 to 0 D) to -0.13 ± 0.16 D, corneal astigmatism from -1.16 ± 0.64 D (range -0.2 to -2.8) to -0.47 ± 0.11 D. 65% of the eyes studied demonstrated an increase of at least one line of vision, while from the same group 38% demonstrated 2 lines of increase. High order aberrations, contrast sensitivity as well as the subjective psychometric input based on the VFQ-25 questionnaire demonstrated actual improvement. Conclusion: This longer-term follow-up, single-arm retrospective consecutive case series documents LASIK treatment customization that appears to be safe and effective in the correction of myopia and myopic astigmatism. Markedly improved objective and subjective visual function post-operatively, underlying the potential importance of simultaneously attempting to correct high order aberrations and improving the spatial alignment of total, measured human eye optics.

Combined Photorefractive Keratectomy and Corneal Cross-Linking for Keratoconus and Ectasia: The Athens Protocol.

ABSTRACT: Customized photorefractive keratectomy with minimal tissue ablation combined with corneal cross-linking seems to be a long-term safe and effective strategy for anatomical and visual management of keratoconus, postsurgical ectasia, and other ectasia management. Multiple published studies, many with long-term follow-up, have supported the Athens Protocol and its various forms as a means to manage corneal ectatic disorders, which not only stabilize corneal shapes but also improve functional vision.

Effect of selective percutaneous myofascial lengthening and functional physiotherapy on walking in children with cerebral palsy: Three-dimensional gait analysis assessment.

BACKGROUND: Walking is the most affected motor function in children with cerebral palsy (CP). Orthopaedic surgery is regularly used to improve ambulation in children with CP. Selective Percutaneous Myofascial Lengthening (SPML) is considered the state-of-the art technique for surgical lengthening of spastic/contracted muscles in CP. The purpose of this study was to investigate the effect of combined SPML surgery and postoperative functional physiotherapy on gait function and characteristics of children with spastic cerebral palsy (CP). METHODS: Twenty-six children with spastic CP, aged 5-7 years, Gross Motor Function Classification System (GMFCS) levels II (n = 6), III (n = 12) and IV (n = 8) participated in a quasi-experimental one-group pretest-posttest study with a 9-month follow-up. The Global Motion Graph Deviation Index (MGDI) (including MGDI sub-indices of each joint in each plane of motion) and spatiotemporal parameters of a three-dimensional kinematic gait analysis were used to assess the gait function and characteristics, respectively. RESULTS: Nine months following SPML and functional physiotherapy, statistically significant improvements (p < 0.05) were noted in the Global MGDI, the MGDIs of sagittal plane knee and ankle motion analysis graphs, and the four most common spatiotemporal measures of gait: walking velocity, stride length, step length, and cadence. CONCLUSION: Children with spastic CP seem to gain better overall gait function following SPML procedure and functional physiotherapy, by achieving higher walking velocity, longer stride length and step length, and faster cadence. Further studies with control group and longer follow-up three-dimensional gait analyses are warranted to validate these positive results.

Arthritis remission with partial cartilage restoration in a 9-year-old female with hip chondrolysis following treatment with adalimumab.

Hip chondrolysis is observed primarily or secondary to other diseases and is a rare but yet debilitating disease, characterised by loss of cartilage of the femoral epiphysis and significant restriction of motion. We present the case of a 9-year-old female diagnosed with hip chondrolysis associated with probable juvenile psoriatic arthritis. Avoidance of weight-bearing activities and treatment with corticosteroids, methotrexate, and adalimumab followed by aquatic therapy resulted in clinical and radiographic improvement as well as partial cartilage regeneration.

Presbyopic Corneal Inlay Extrusion Consequent to Sterile Keratolysis: Surgical Revision and Long-Term Management.

PURPOSE: The purpose of this study was to report a serious complication of early sterile keratolysis associated with a presbyopia inlay implantation combined with hyperopic laser in situ keratomileusis (LASIK). METHODS: A 55-year-old hyperopic man underwent uneventful topography-guided bilateral femtosecond laser-assisted hyperopic LASIK, combined with same-day polymer refractive inlay implantation in the nondominant eye for additional presbyopia correction. Within 2 months, anterior sterile keratolysis and partial extrusion required surgical explantation of the inlay, and long-term medical management over 9 years achieved effective visual rehabilitation documented also with corneal imaging. RESULTS: Immediate postoperative results were binocular 20/20 uncorrected distance visual acuity and J1 uncorrected near visual acuity. The early progressive anterior sterile keratolysis and partial extrusion necessitated surgical explantation at 2 months, severe anterior scarring of the perforated flap area and severe focal flattening of the cornea of over 10 diopters, developed despite aggressive topical corticosteroid use. The uncorrected distance visual acuity in the OS dropped from 20/25 to 20/400. The LASIK flap portion that underwent keratolysis and perforated, remodeled long-term from a scarred, epithelial plug with early significant surface concavity to evidently a mild subepithelial localized hazy area with regularized curvature over a period of 9 years. CONCLUSIONS: Some refractive synthetic corneal inlays have been recalled because they may result in significant corneal haze. We present herein a case of severe keratolysis that necessitated surgical explantation and further document long-term care for eventual visual rehabilitation.

Translation, reliability and validity of the Greek functional mobility scale (FMS) for children with cerebral palsy.

PURPOSE: To translate and investigate the reliability and validity of the Greek version of the Functional Mobility Scale (FMS). METHODS: FMS was translated into Greek. Test-retest reliability (Cohen's weighted kappa coefficient, κw) and concurrent validity (Spearman's rank correlation coefficient, rs) of the Greek version of FMS were assessed in children with Cerebral Palsy (CP). Sixty children (mean age 7.82 ± 3.20 years) were recruited. Physical therapists administered the FMS by interviewing parents about their children's mobility status. The Gross Motor Function Classification System (GMFCS) was additionally used for testing concurrent validity. RESULTS: The translation of the FMS was deemed easy to understand and administer. The Greek FMS was demonstrated to have almost perfect test-retest reliability (κw=0.98-1.00), and very strong correlation with the GMFCS (-0.85 ≤ rs ≤ -0.89, p < 0.001). CONCLUSIONS: The Greek version of the FMS was shown to be a reliable and valid classification system for CP and can be used with confidence by Greek physical therapists.Implications for rehabilitationThe FMS provides a very simple and practical outcome measure of functional mobility in children with CP.The use of the reliable and valid Greek FMS will enhance the physical therapy assessment process in the Greek population, by offering the feasibility to detect the motor performance changes in children with CP as they grow or following interventions.The current study renders the Greek FMS available for utilization by physical therapists in order to quantify the independent mobility in children with CP.

Concordance of keratoconus in monozygotic twins before and after combined corneal crosslinking/photorefractive keratectomy (Athens Protocol) using Scheimpflug and OCT tomography.

PURPOSE: To describe the concordance of keratoconus (KC) expression in 2 pairs of monozygotic twins before and after a combined corneal crosslinking (CXL)/photorefractive keratectomy (PRK) procedure. SETTING: Private ambulatory eye surgery unit. DESIGN: Retrospective interventional twin study. METHODS: Two pairs of male monozygotic twins with KC were studied retrospectively. Improvement of flattest (K1) and steepest (K2) keratometry, index of height decentration (IHD), and corneal thickness at the thinnest point and corneal epithelial thickness measured by anterior segment optical coherence tomography and Scheimpflug tomography was compared between respective eyes of monozygotic twin siblings 1 to 5 years after the application of combined CXL and topography-guided PRK of part of the refractive error (the Athens Protocol). RESULTS: Significant improvement was noted in all the keratometric indices of all 8 eyes after the combined CXL/PRK procedure. The difference in K1, K2, IHD, corneal thickness at the thinnest point, and corneal epithelial thickness percentage improvement between the right eyes of each pair of twins was statistically significant 1 year and 5 years postoperatively (P < .05). Statistically significant discordance in the aforementioned parameters percentage improvement was similarly observed between the left eyes of each pair of twins (P < .05). CONCLUSIONS: Although a genetic predisposition in KC is well documented, the discordance in keratometric indices improvement after a CXL/PRK procedure between respective eyes of monozygotic twins suggests that environmental influences may contribute to the disease expression as well. Variable degree of synergy in a combined CXL/PRK procedure may also explain the aforementioned discordant improvement.

Effects of minimally invasive surgery and functional physiotherapy on motor function of children with cerebral palsy: A non-randomised controlled trial.

PURPOSE: This non-randomised controlled trial investigated whether a combined programme of functional physiotherapy and minimally invasive orthopaedic surgery improves the level and degree of capacity and performance of gross motor function in children with spastic cerebral palsy (CP). METHODS: Fifty-two children with spastic CP aged 5-7 years, Gross Motor Function Classification System (GMFCS) levels II-IV, were allocated to two equal groups: experimental group (selective percutaneous myofascial lengthening [SPML] procedure and 9-month functional strengthening physiotherapy programme) and control (standard physiotherapy) groups. At baseline and at the end of the 9-month intervention, the capacity and performance of gross motor function were assessed with the Gross Motor Function Measure (GMFM) D and E subcategories and Functional Mobility Scale (FMS), respectively. The level of gross motor function was measured with the GMFCS. RESULTS: There was a statistically significant difference in the post-intervention improvements in the GMFM D (experimental mean difference = 19.63 ± 10.46; control mean difference = 2.40 ± 4.62) and E (experimental mean difference = 19.33 ± 11.82; control mean difference = 4.20 ± 6.26) between experimental and control group (p < 0.001). There was a significant improvement in the GMFCS level and each FMS distance for the experimental group (p < 0.001), but not for the control group (p > 0.05). CONCLUSION: SPML procedure combined with functional physiotherapy improves gross motor function in children with spastic CP, by raising the degree and level of motor independence.

Comparison of Planned Versus Achieved Central Stromal Thickness Reduction in LASIK Versus SMILE: A Contralateral Eye Study.

PURPOSE: To compare attempted versus achieved corneal stromal thickness reduction in a consecutive case series of patients undergoing laser in situ keratomileusis (LASIK) in one eye and small incision lenticule extraction (SMILE) in the other eye. METHODS: This prospective, randomized, contralateral eye study included 22 consecutive patients (44 eyes), one eye randomized to have myopic LASIK and the contralateral eye to have SMILE. Anterior segment optical coherence tomography was performed preoperatively and at 3 months postoperatively. For each of the treatment groups, the achieved maximum stromal thickness reduction was compared to the planned/attempted thickness. The deviation of planned versus achieved stromal thickness reduction was then compared between the two groups. RESULTS: At 3 months postoperatively, LASIK had a lower difference between planned versus attempted stromal thickness reduction compared to SMILE (13.72 ± 14.45 vs 24.00 ± 19.45 µm, P = .03). Graphical analysis revealed this deviation to be exaggerated in higher myopic errors, when a higher maximum stromal reduction was planned. The mean stromal reduction thickness was 83.40 ± 29.52 µm achieved versus 97.13 ± 25.69 µm mean planned ablation depth in the LASIK group (P < .001) compared to 76.45 ± 29.69 µm achieved versus 100.45 ± 26.56 µm planned ablation depth in the SMILE group (P < .001). CONCLUSIONS: LASIK had a significantly lower difference between planned versus achieved stromal thickness reduction when compared to SMILE (P = .03). This difference was more apparent in higher myopic corrections. [J Refract Surg. 2021;37(7):454-459.].

Comparison of effective corneal refractive centration to the visual axis: LASIK vs SMILE, a contralateral eye digitized comparison of the postoperative result.

PURPOSE: To define and compare the centration of the ablation effect in laser in situ keratomileusis (LASIK) with the corresponding effect in small-incision lenticule extraction (SMILE), in myopic laser vision correction to possibly explain the refractive performance differences noted between the two procedures in a contralateral eye study. SETTING: Private ambulatory eye surgery unit. DESIGN: Prospective randomized contralateral eye study. METHODS: In 22 consecutive patients (44 eyes), 1 eye was prospectively randomized to undergo myopic topography-guided LASIK treatment and the contralateral eye to undergo SMILE; digital image analysis of the achieved centration to the aimed corneal vertex was assessed for both procedures on perioperative Scheimpflug tangential curvature maps, using a proprietary digitized methodology. RESULTS: The radial displacement measured in micrometers in the above treated 44 eyes, between the attempted centration point on the corneal vertex vs the center of the measured effective anterior corneal curvature flattening was on average 130 ± 62 mm in the 22 eyes of LASIK group and 313 ± 144 mm in the 22 contralateral eyes of the SMILE group (P < .001). CONCLUSIONS: In this contralateral eye study, topography-guided myopic LASIK was found to achieve significantly better effective centration compared with myopic SMILE, in regard to digitally measured decentration of the effective refractive change achieved in the anterior corneal curvature from the corneal vertex. This may explain the previously reported superior visual outcomes in the LASIK group eyes when compared with the contralateral SMILE group eyes.

Keratoconus Management With Customized Photorefractive Keratectomy by Artificial Intelligence Ray-Tracing Optimization Combined With Higher Fluence Corneal Crosslinking: The Ray-Tracing Athens Protocol.

PURPOSE: The aim of this study was to report novel ray-tracing customization of surface excimer laser ablation combined with higher fluence corneal crosslinking (CXL) in the stabilization and normalization of ectasia and visual rehabilitation of progressive keratoconus. METHODS: A 28-year-old man with bilateral progressive keratoconus was treated with Athens protocol: CXL combined with photorefractive surface ablation customized by a novel artificial intelligence platform calculating lower- and higher-order aberrations based on wavefront, Scheimpflug tomography, and interferometry axial length data from a single diagnostic device. Visual acuity, refractive error, keratometry, optical coherence tomography and Scheimpflug tomography, and endothelial cell density were evaluated over 12 months. RESULTS: Keratoconus stabilized in both eyes. Uncorrected distance visual acuity changed from 20/80 to 20/20 in the OD and from 20/40 to 20/25 in the OS at 12 months. Keratometry changes were as follows: from 40.7 and 42.7 at 165.1 degrees to 41.4 and 43.1 at 169.3 degrees in the OD and from 40.9 and 42.6 at 15.9 degrees to 44.1 and 44.7 at 9.8 degrees in the OS. Corneal surface normalization was as follows: index of height decentration from 0.115 to 0.099 and index of surface variance from 77 to 67 in the OD and index of height decentration from 0.066 to 0.014 and index of surface variance from 49 to 31 in the OS. CONCLUSIONS: We introduced in this study the management of progressive keratoconus with CXL combined with novel excimer laser customization using several independent up-to-now diagnostics calculated by software, evaluating bidirectional theoretical ray tracing. It bears the potential advantage of addressing more accurately normalization of the distorted human eye optics associated with corneal ectasia, compared with using anterior corneal surface data or wavefront data alone.

The orthopaedic aspect of spastic cerebral palsy.

Spastic Cerebral Palsy (CP) is the most common form of CP, comprising of 80% of all cases. Spasticity is a type of hypertonia that clinically manifests as dynamic contractures. The dynamic contracture along with the reduced level of physical activity in a child with CP leads to secondary structural and morphological changes in spastic muscle, causing real musculotendinous shortening, known as fixed contractures. When fixed muscle contractures are not treated early, progressive musculoskeletal deformities develop. As a consequence, spastic CP from a static neurological pathology becomes a progressive orthopaedic pathology which needs to be managed surgically. Orthopaedic surgical management of CP has evolved from previous "multi-event single level" procedures to a "single event multilevel" procedures, with changes in selection and execution of treatment modalities. There is increasing evidence that multilevel surgery is an integral and essential part of therapeutic management of spastic CP, but more research is needed to ensure effectiveness of this intervention on all domains of physical disability in CP.

Initial Outcomes with Customized Myopic LASIK, Guided by Automated Ray Tracing Optimization: A Novel Technique.

PURPOSE: Safety and efficacy of a novel automated ray tracing optimization in customization of excimer ablation in myopic LASIK. METHODS: In a consecutive case series, 25 patients (50 eyes) undergoing femtosecond-laser-assisted myopic LASIK were evaluated. The novel, artificial-intelligence platform initially calculates the ablation profile based on a model eye for each case, based on interferometry axial length data. Low- and high-order aberration calculation is performed by raytracing based on wavefront and Scheimpflug tomography measurements, all from a single diagnostic device. Visual acuity, refractive error, keratometry, topography, high-order aberrations and contrast sensitivity were evaluated, over six months follow-up. RESULTS: Change from pre- to 6 months post-operative: mean refractive error improved from -5.06 ± 2.54 diopters (D) (range -8.0 to -0.50 D) to -0.11 ± 0.09 D (range -0.25 to + 0.25); refractive astigmatism from -1.07 ± 0.91 D (range -4.25 to 0 D) to -0.15 ± 0.04 D (range -0.25 to 0); and topographic astigmatism from -1.65 ± 0.85 D to -0.26 ± 0.11 D (range -0.60 to 0). About 65% of eyes gained one line of vision and 38% 2 lines. Pre- to post-operative high-order aberration average: RMSh changed from 0.25 um to 0.35 um. Contrast sensitivity improved post-operatively. CONCLUSION: We report safe and effective preliminary outcomes with a novel excimer laser customization by ray tracing optimization, for myopic LASIK treatments, employing several independent up-till-now diagnostics and a customized eye model reference for each case. It bears the potential advantage through total eye aberration data and ray tracing refraction calculation to offer improved and more predictable visual outcomes.

Scheimpflug vs Scanning-Slit Corneal Tomography: Comparison of Corneal and Anterior Chamber Tomography Indices for Repeatability and Agreement in Healthy Eyes.

PURPOSE: To evaluate and compare the repeatability and agreement of Scheimpflug vs scanning-slit tomography of the cornea and the anterior chamber in terms of keratometric and tomographic indices in healthy eyes. METHODS: The 20 eyes of 10 healthy participants underwent 3 consecutive measurements using both Scheimpflug-tomography and scanning-slit tomography, diagnostic devices. Multiple corneal and anterior chamber tomographic parameters were recorded and evaluated to include corneal keratometry and its axis; corneal best-fit sphere (BFS), pachymetry mapping, angle kappa, anterior chamber depth (ACD), pupil diameter, and location. Repeatability for each device was assessed using the within each subject standard deviation of sequential exams, the coefficient variation (CV) and the intraclass correlation coefficient (ICC). Agreement between the two devices was assessed using Bland-Altman plots with 95% limits of agreement (LoA) and correlation coefficient (r). RESULTS: Both devices were found to have high repeatability (ICC>0.9) both in keratometric and other tomographic measurements. Scheimpflug tomography's repeatability though appeared superior in the average keratometry values, anterior and posterior BFS, thinnest corneal pachymetry value and location (p<0.05). Agreement: Statistically significant inter-device differences were noted in the mean values of K1, K2, BFS, ACD and thinnest corneal pachymetry (p<0.05). Despite the agreement differences noted, the two devices were well correlated (r>0.8) in respective measurements with Scheimpflug delivering consistently lower values than the scanning-slit tomography device. CONCLUSION: Scheimpflug-tomography repeatability was found to be superior to that of scanning-slit tomography in this specific study, in most parameters evaluated. Inter-device agreement evaluation suggests that reading from the two devices may not be used interchangeably in absolute values, yet they are well correlated with Scheimpflug delivering consistently lower values in most.

Does Pregnancy Affect Refractive and Corneal Stability or Corneal Epithelial Remodeling After Myopic LASIK?

PURPOSE: To investigate possible refractive changes in pregnant women who have previously undergone myopic laser in situ keratomileusis (LASIK). METHODS: This prospective study included 64 pregnant women (128 eyes) who had previously undergone bilateral myopic LASIK. Uncorrected distance visual acuity (UDVA), spherical equivalent, corneal keratometry, topography and tomography, and epithelial mapping were evaluated before LASIK, 12 months after LASIK, during the third trimester of pregnancy, and 1 year postpartum. RESULTS: The average age at the time of recruitment was 32.5 ± 5 years (range: 24.5 to 39.5 years). The evaluation during pregnancy was at an average 55 months (range: 12 to 108 months) from the initial LASIK procedure. The preoperative mean refractive error was -6.72 ± 2.96 diopters (D) (range: -1.00 to -11.00 D). Comparing 12-month refractive data after the original LASIK procedure to the those within the third trimester of the subsequent pregnancy, the average UDVA was 20/18, the residual refractive error was -0.63 ± 1.00 to -0.51 ± 0.82 D, the steepest keratometry value was 40.85 ± 1.89 to 40.88 ± 2.84 D, and the central epithelial thickness was 56.4 ± 3.89 to 57.38 ± 5.04 µm, respectively. CONCLUSIONS: In this study, pregnancy did not affect the refractive stability of LASIK. Pregnancy-related changes in refractive error, corneal stability, and total corneal and epithelial thickness in women after LASIK were not found to be statistically significant. [J Refract Surg. 2022;36(2):118-122.].

Ten-Year Outcomes of Progressive Keratoconus Management With the Athens Protocol (Topography-Guided Partial-Refraction PRK Combined With CXL).

PURPOSE: To report the safety and long-term efficacy of topography-guided partial-refraction PRK combined with corneal cross-linking (CXL) (the Athens Protocol), refractive, topographic, and pachymetric changes of keratoconic eyes treated were studied. METHODS: Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refraction, keratometry, qualitative and quantitative assessment of corneal keratometric, and pachymetric properties recorded by topography and tomography were evaluated for 10 years postoperatively. RESULTS: A total of 144 eyes were followed up for a mean 128 ± 4 months (range: 120 to 146 months). Mean UDVA markedly improved at 1 year (0.19 ± 0.17 to 0.53 ± 0.21 decimal) with further improvement to 0.55 ± 0.19 decimal at 10 years. CDVA increased from 0.59 ± 0.21 to 0.80 ± 0.17 decimal at 1 year and further to 0.81 ± 0.19 decimal at 10 years. Corneal thickness decreased from 468.74 ± 35.05 to 391.14 ± 40.07 µm at 1 year (P < .01) and up to 395.42 ± 32.21 µm at 10 years. Steep keratometry decreased from 50.57 ± 2.80 to 45.87 ± 2.70 diopters (D) (P < .01) at 1 year and to 44.00 ± 3.22 D at 10 years. Maximum keratometry decreased from 53.43 ± 2.97 to 46.17 ± 1.18 D at 1 year and 44.75 ± 2.14 D at 10 years (P < .01). A total of 94.4% demonstrated ectasia stabilization and 3.5% showed progressive "overcorrection" or "hyperopic" shift. CONCLUSIONS: The Athens Protocol confirms long-term safety and efficacy for corneal ectasia and visual function. Most parameters had little change after 1 year, through year 10. [J Refract Surg. 2019;35(8):478-483.].

Long-Term Stability With the Athens Protocol (Topography-Guided Partial PRK Combined With Cross-Linking) in Pediatric Patients With Keratoconus.

PURPOSE: To evaluate the safety, efficacy, and stability of topography-guided partial PRK combined with corneal cross-linking (CXL) (the Athens Protocol [AP]) in pediatric patients with keratoconus over a 4-year follow-up period. METHODS: This prospective study included 39 keratoconic eyes of 21 patients younger than 18 years with clinical and imaging evidence of keratoconus progression. Partial topography-guided excimer laser ablation in conjunction with high-fluence CXL was performed in all patients according to the AP. Uncorrected distance visual acuity, corrected distance visual acuity, refraction, keratometry, endothelial cell density, topography, and tomography using both Scheimpflug and optical coherence tomography (OCT) were evaluated for 4 years postoperatively. RESULTS: At 4 years postoperative, there was significant improvement in mean uncorrected distance visual acuity from 0.51 ± 0.31 (decimal) to 0.65 ± 0.26 (decimal; P < 0.05). Mean corrected distance visual acuity improved from 0.71 ± 0.22 (decimal) preoperatively to 0.81 ± 0.19 (decimal; P < 0.05), respectively. Mean flat keratometry (K1) and mean steep keratometry (K2) readings reduced from 44.95 ± 3.71 D and 49.32 ± 5.05 D, respectively, preoperatively to 43.14 ± 2.95 D and 46.28 ± 4.87 D, respectively, (P < 0.05) at 4 years. The mean anterior maximum keratometry (Kmax) reading reduced from 56.81 ± 2.94 D preoperatively to 48.11 ± 3.17 D at 48 months. The mean index of height decentration was 0.105 ± 0.054 µm preoperatively and 0.049 ± 0.024 (P < 0.05) at 4 years postoperative. Mean preoperative corneal thickness at the thinnest point was 436.7 ± 42.6 µm preoperatively, 392.50 ± 45.68 µm at 12 months postoperative, and 418.42 ± 17.01 µm at 4-year follow-up. Late-onset deep corneal haze, a potential intrinsic complication of this technique in pediatric patients, was encountered in 2 cases at least 1 year after the procedure. CONCLUSIONS: Long-term results of the AP seem to be safe and effective in pediatric patients, with marked improvement in visual function and keratometric symmetry indices.

Management of progressive keratoconus with partial topography-guided PRK combined with refractive, customized CXL - a novel technique: the enhanced Athens protocol.

PURPOSE: To report a novel application of partial topography-guided photorefractive keratectomy combined with topographically customized, higher fluence, and variable pattern corneal cross-linking applied on the same day of the treatment of keratoconus. METHODS: A topography-guided partial photorefractive keratectomy treatment of maximum 30 µm over the thinnest cone area was applied initially followed by a 7 mm, 50 µm phototherapeutic keratectomy treatment to address epithelial removal. 0.02% Mitomycin C was applied for 20 seconds and then the exposed stroma was soaked with 0.1% riboflavin solution for 5 minutes. The cornea was then treated with a customized, variable-pattern and 20 mW/cm2 fluence for a total of 5-10 J, and up to 15 J of energy was delivered with the KXL-II device employing an active tracker. The center of the pattern that received the 15 J was topography-matched with the thinnest area of the cone. Visual acuity, refractive error, cornea clarity, keratometry, topography, pachymetry with a multitude of modalities and endothelial cell density were evaluated over 36 months. RESULTS: Keratoconus was stabilized in all cases. The severity of keratoconus stage by Amsler- Krumeich criteria improved from an average of 3.2 (1-4) to 1.8 (0-3). Uncorrected distance visual acuity changed from preoperative 20/80 to 20/25 at 6 months. A maximum astigmatic reduction of 7.8 D (5.3-15.6), and a significant cornea surface normalization (an index of height decentration improvement from 0.155 [±0.065] to 0.045 [±0.042]) were achieved by 1 month and remained relatively stable for 36 months postoperatively. Two cases delayed full reepithelialization for up to 9 days. CONCLUSION: This paper introduces a novel technique in order to maximize the refractive normalization effect along with ectasia stabilization in young keratoconus patients. This may facilitate the use of less tissue ablation, in comparison to utilizing a homogeneous UV light beam for corneal cross-linking in Athens Protocol cases. It broadens the number of potential candidate cases that would have been limited to employ this technique due to tissue thickness limitations.