Long-term results after surgical basal cell carcinoma excision in the eyelid region: revisited.

The aim of the study was to readdress basal cell carcinoma (BCC) in the periocular region to prove the efficacy of histologically controlled surgical treatment and to identify high-risk characteristics.Retrospective analysis of 451 microscopically controlled BCC excisions in the periocular region. Tumor location, tumor size, AJCC 7 classification, and histological results were recorded. The same procedure was followed for recurrences.A recurrence rate of 5.0% was observed after the first microscopically controlled excision. Recurrent BCCs show a shift from nodular to sclerosing BCC as the primary histological type as well as a change in primary location from lower eyelid to medial canthus. The frequency of BCC with deep extension increased from 7.3% to 24.7%, and 57.1% after the second and third operations, respectively. The recurrence rate increased to 9.5% and 42.9%, after the second and third operations, respectively.In conclusion, we are facing the same challenges in surgical BCC treatment as 30 years ago. The distribution of periocular BCC location, histologic subtype and recurrence rates mirror the literature und the general consensus. The recurrence rate increases with every operation needed. Sclerosing BCCs with deep extension at the medial canthus bear the greatest risk for recurrence. In such cases, centers of expertise should be consulted and additional treatment options should be considered.

FACE-Q Patient Report-Assisted Subjective and Objective Evaluation of Blepharoplasty Outcomes Using Two Different Suturing Techniques: A Randomized and Patient-Blinded Pilot Study.

BACKGROUND: /Objectives To compare two suturing techniques in patients undergoing upper eyelid blepharoplasty by using the FACE-Q™ Eye Module questionnaire to assess patient-reported outcomes and by blinded Likert-scale gradings of two experienced surgeons. METHODS: 90 patients undergoing bilateral blepharoplasty were randomly assigned to a suturing technique (running cutaneous or subcuticular closure) using Prolene 6.0. Patients completed the FACE-Q eye module questionnaire before surgery and 7 days and 3 months after surgery. Further, two trained oculoplastic surgeons assessed the outcome. FACE-Q ratings were RASCH-transformed, and linear models were fitted for appraisal and satisfaction results. Intraclass correlation coefficient (ICC) was calculated to assess the surgeons' rating agreement. RESULTS: There was no statistically significantly difference in patients' FACE-Q self-assessments regarding satisfaction with eyes and appraisal of upper eyelids between the two suturing techniques investigated, both 7 days and 3 months after blepharoplasty. The more content the patient at baseline, the less the increase in satisfaction after 3 months. There was good agreement between blinded graders in outcome assessment expressed by an ICC of 0.86. Dry-eye symptoms increased after surgery, independent of the suturing technique, patient age or sex. CONCLUSION: In conclusion, this study shows that post operative patient satisfaction is independent of suturing technique, but depends on baseline FACE-Q reports. These findings are valuable in patient communication and selection and are in line with observer-based assessments. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Long-term changes in posterior chamber phakic intraocular collamer lens vaulting in myopic patients.

OBJECTIVE: Evaluation of central and midperipheral vaulting of the posterior chamber phakic intraocular Collamer lens (ICL; Staar Surgical Inc., Monrovia, CA) in eyes with moderate to high myopia. DESIGN: Retrospective analysis of prospectively collected data. PARTICIPANTS: Eighty-four eyes treated with the latest ICL (V4 model) and 27 eyes treated with early ICL models were examined. METHODS: After standardized ICL implantation, patients underwent complete ophthalmologic examinations before surgery and at 1 week, 1 month, 3 months, 6 months, and at yearly intervals thereafter. Central vaulting was measured using the Jaeger device (Haag-Streit, Bern, Switzerland). From 2006 onward, vaulting was measured additionally by optical coherence tomography (Visante OCT; Carl Zeiss Meditec, Jena, Germany). Using the Visante OCT, the crystalline lens rise and the midperipheral vaulting of the ICL were assessed. MAIN OUTCOME MEASURES: Central vaulting after ICL implantation. RESULTS: The mean duration of follow-up was 74.1+/-23.1 months and 96.3+/-50.2 months in eyes treated with V4 and early models, respectively. Postoperative central vaulting was 466+/-218 microm (range, 30-900 microm) in eyes treated with the V4 models and 321+/-200 microm (range, 150-900 microm) in those treated with early ICL models. From the 6-month follow-up onward, a continuous and nearly linear reduction of central vaulting was observed. At the 10-year follow-up, the mean central vaulting was reduced to 184+/-159 microm (range, 6-500 microm) and 138+/-218 microm (range, 0-820 microm) in eyes treated with V4 or early models, respectively. Eyes with total vaulting had a mean central vaulting of 407+/-202 microm (range, 180-730 microm), whereas those with midperipheral contact had a significantly lower central vaulting of 105+/-87 microm (range, 0-200 microm). CONCLUSIONS: This study revealed consistent reduction of central vaulting over a 10-year period and provides further evidence that insufficient vaulting of the ICL is responsible for the development of anterior subcapsular cataract. A minimum central vaulting of 230 microm seems to be necessary to ensure total vaulting of the ICL. If an ICL is chosen for the correction of myopia, targeting for the greatest possible postoperative central vaulting is advised to achieve safe and complete vaulting for several years.

Repeatability and reproducibility of central corneal thickness measurement with Pentacam, Orbscan, and ultrasound.

PURPOSE: The purpose of this study was to compare central corneal thickness (CCT) measurements obtained with a novel rotating Scheimpflug camera (Pentacam; Oculus) with scanning slit topography (Orbscan; Bausch & Lomb), and with ultrasound pachymetry (SP-2000; Tomey). METHODS: CCT in 30 healthy eyes was measured twice with each modality by 2 independent observers in random order. The results from scanning slit topography are given both with and without multiplication with the "acoustic correction factor" of 0.92. In addition, the displayed images from the rotating Scheimpflug camera and scanning slit topography were used to calculate the signal difference-to-noise ratios (SD/N) between cornea and background signal. RESULTS: The mean CCT values as determined with the different modalities (+/-standard deviation) were: 542+/-29 microm, 576+/-37 microm, 530+/-34 microm, and 552+/-32 microm for rotating Scheimpflug imaging, for uncorrected and for corrected scanning slit pachymetry, and for ultrasound, respectively. The differences between modalities (+/-95% limits of agreement) were -9.8+/-31 microm between rotating Scheimpflug and ultrasound, 24+/-31.2 microm between scanning slit and ultrasound, and 33+/-27 microm between scanning slit and rotating Scheimpflug imaging. The limits of agreement for within and between observer effects were within 4.2% of the absolute CCT values for scanning slit and ultrasound and within 2.2% for the rotating Scheimpflug imaging. The rotating Scheimpflug camera showed similar SD/N ratios but steeper edges of the corneal surfaces in the intensity profile plots. CONCLUSION: In the assessment of normal corneas, the Pentacam measured CCT values closer to ultrasound pachymetry and with less variability compared with Orbscan. The (interobserver) reproducibility with the Pentacam was highest of all 3 modalities.

Validity and repeatability of anterior chamber depth measurements with Pentacam and Orbscan.

PURPOSE: The purpose of this study was to determine the validity and repeatability of anterior chamber depth (ACD) measurements obtained with a novel rotating Scheimpflug camera (Pentacam; Oculus Optikgeräte GmbH, Wetzlar, Germany) to scanning slit topography (Orbscan; Bausch & Lomb, Rochester, NY). METHODS: ACD in 60 healthy eyes was measured twice by two independent observers with each modality in random order. A total of eight measurements was performed on each eye. The mean differences between measurements, between observers, and between modalities were calculated, and 95% limits of agreement (LoA) were given as mean +/- 1.96 * standard deviation (SD) of the mean. RESULTS: The mean ACD values as determined with the different modalities (+/- SD) were 3.18 +/- 0.38 mm for Pentacam imaging and 3.23 +/- 0.40 for Orbscan. The mean difference between the two modalities was 0.047 mm (LoA: 0.176 to -0.081 mm). Within each modality, the limits of agreement of the differences between individual measurements and between different observers were within 0.073 mm or 4% of total ACD. The total variance in the observed data was 0.145. The variance resulting from interindividual differences in ACD was 85%, as a result of the two different modalities 15%, as a result of different observers 0.007%, and as a result of different measurements 0.007%. CONCLUSIONS: In the assessment of normal eyes, the differences of ACD values measured with Orbscan and Pentacam were within clinically acceptable levels, and inter- and intraobserver variability was considerably below clinically significant levels. Thus, these two modalities can be regarded as interchangeable.

Long-term results of implantation of phakic posterior chamber intraocular lenses.

PURPOSE: To study the incidence and progression of lens opacification after implantation of phakic posterior chamber intraocular lenses for myopia and its correlation with vaulting and endothelial cell density (ECD). SETTING: Department of Ophthalmology, University of Vienna Medical School, Vienna, Austria. METHODS: An implantable contact lens (ICL V4, Staar Surgical Inc.) was inserted in 76 myopic eyes. Patients were prospectively followed preoperatively and at 1, 3, 6, 12, 24, and 36 months. The uncorrected visual acuity and best corrected visual acuity (BCVA) were determined. Vaulting was measured optically with a Jaeger II pachymeter, and the crystalline lens was examined at the slitlamp for the presence and characteristics of opacification. Endothelial cell morphometry was performed by specular microscopy, and the ECD was calculated. Eyes in which lens opacification developed were followed for at least 12 months to determine the degree and course of visual impairment. RESULTS: Lens opacification occurred in 11 eyes (14.5%). Opacification was correlated with intraoperative trauma to the crystalline lens, age older than 50 years, and decreased ECD values throughout the observation period. Vaulting of the ICL did not correlate with the risk for lens opacification. After onset of lens opacification, 6 eyes (55%) had a stable BCVA within +/-0.5 lines and 5 eyes had progressive opacification, losing between 3.5 lines and 0.5 lines (mean 1.8 lines +/- 1.1 [SD]). Three eyes (3.9%) in the progressive group had a 1- to 2-line loss of BCVA over preoperative values and subsequently had cataract surgery. CONCLUSIONS: Risk factors for lens opacification after implantation of the model V4 ICL included intraoperative trauma to the crystalline lens and older age. Decreased ECD in eyes with opacification suggests ongoing inflammation as a cause. Patients younger than 45 years may have a significantly lower incidence of opacification.

Influence of spectacle-related changes in retinal image size on contrast sensitivity function after laser in situ keratomileusis.

PURPOSE: To evaluate changes in contrast sensitivity after laser in situ keratomileusis (LASIK) for the correction of myopia using a monitor-based method and considering the preoperative minification effect of high-diopter spectacles. SETTING: Department of Ophthalmology, University of Vienna Medical School, Vienna, Austria. METHODS: Fifteen eyes of 11 patients had LASIK to correct myopia. The best corrected visual acuity (BCVA) and contrast sensitivity function (CSF) were measured preoperatively and 1, 3, and 6 months postoperatively using the AcuityMax (Science 2020) computer program. The error in contrast sensitivity measurement due to different angular sizes of the test figures deriving from the spectacle refractions before and after LASIK were considered. RESULTS: Preoperatively, and at 1, 3, and 6 months, the mean Snellen BCVA was 0.93 +/- 0.19 (SD), 0.80 +/- 0.26, 0.85 +/- 0.21, and 0.84 +/- 0.27, respectively. The best mean CS (measured at 1.1 logMAR) was 1.17 +/- 0.05, 1.12 +/- 0.07, 1.13 +/- 0.08, and 1.18 +/- 0.04, respectively. The strongest CS changes were observed at 0.7 logMAR (6 cycles per degree), where CS was 1.10 +/- 0.07 preoperatively and 1.06 +/- 0.09, 1.07 +/- 0.12, and 1.14 +/- 0.07, at 1 month, 3 months, and 6 months, respectively. With correction for the spectacle effect, the preoperative CS was approximately 3% higher and CS at 3 months for intermediate optotype sizes was significantly inferior to preoperatively. CONCLUSIONS: With correction of different retinal image sizes before and after LASIK (due to different spectacle refraction), the CS was significantly below the preoperative values at 1 and 3 months and approached the preoperative values at 6 months. The proposed method is potentially capable of quality monitoring and method comparisons after photorefractive surgery.

Influence of operator experience on the performance of ultrasound biometry compared to optical biometry before cataract surgery.

PURPOSE: To compare measurements performed with the IOLMaster (Carl Zeiss, Meditec AG) with those obtained by applanation ultrasound (US) and manual keratometry and to evaluate the effect of operator experience on US biometry. SETTING: Department of Ophthalmology, University of Vienna, Vienna, Austria. METHODS: The axial length (696 eyes) and anterior chamber depth (ACD) (462 eyes) were measured in 377 patients with cataract using the IOLMaster and applanation US. To assess the effect of operator experience on the biometric results, the operators were divided into 2 groups: experienced and less experienced in performing US biometry. The difference in measurements between the methods and the variability of the difference were compared between the 2 groups. RESULTS: Applanation US measured axial length and ACD shorter than the IOLMaster; the mean numerical difference was 0.13 mm and 0.19 mm, respectively (P<.01). For axial length, the absolute difference was smaller with experienced operators than with less experienced operators (0.15 mm versus 0.22 mm) (P<.01). For ACD, experienced operators obtained a smaller difference between measurement techniques (0.21 mm versus 0.29 mm; P<.05). CONCLUSIONS: Experienced US operators had less difference and lower variability in the difference between applanation US and IOLMaster readings for axial length and ACD measurements. The noncontact optical method, which is essentially operator independent, gave significantly more reliable biometry before cataract surgery, especially in the case of less experienced operators.

Outcome after treatment of ametropia with implantable contact lenses.

OBJECTIVE: To evaluate long-term results after insertion of implantable contact lenses (ICLs) in phakic eyes. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Seventy-five phakic eyes (65 myopic, 10 hyperopic eyes) of 45 patients aged 21.7 to 60.6 years were included. INTERVENTION: STAAR Collamer Implantable Contact Lenses (STAAR Surgical Inc., Nidau, Switzerland) were implanted for correction of high myopia and hyperopia. MAIN OUTCOME MEASURES: Uncorrected visual acuity (UCVA), best-corrected visual acuity (BCVA), and intraocular pressure (IOP) were determined. Presence of lens opacification and the distance between the ICL and the crystalline lens were assessed by slit-lamp examination before surgery and at 1, 3, 6 months, and yearly after lens implantation. RESULTS: Preoperative mean spherical equivalent was -16.23+/-5.29 diopters (D) for myopic eyes and +7.88 +/-1.46 D for hyperopic eyes. After ICL implantation, mean residual refractive error was -1.77+/-2.17 D in myopic patients and +0.44+/-0.69 D in hyperopic patients. Preoperative mean UCVA was Snellen 0.03+/-0.03 for myopic patients and Snellen 0.12+/-0.16 for hyperopic patients. Preoperative mean BCVA was Snellen 0.49+/-0.23 for myopic patients and Snellen 0.82+/-0.23 for hyperopic patients. After ICL implantation, mean UCVA up to the end of individual observation time was Snellen 0.36+/-0.36 for myopic patients and Snellen 0.58+/-0.28 for hyperopic patients. Mean BCVA was Snellen 0.73+/-0.26 for myopic and Snellen 0.80+/-0.24 for hyperopic patients. Mean preoperative IOP was 14.2+/-2.7 mmHg, and mean postoperative IOP was 13.46+/-2.1 mmHg over all follow-up investigations. The main complication was the development of subcapsular anterior opacifications of the crystalline lens in 25 eyes (33.3%), 2 of which showed direct contact to the ICL. Eleven eyes (14.7%) were stable in opacification and 14 eyes (18.7%) had progressive opacifications. The median time to opacification was 27.1 months. In 8 patients (10.7%), the subjective visual impairment mandated cataract surgery. CONCLUSIONS: The most significant long-term complication after ICL implantation is the formation of opacifications of the crystalline lens with the risk of the necessity of subsequent cataract surgery (10.7%). Old age, female gender, and contralateral opacification are independent significant risk factors for early formation of opacifications in this patient group.

Effect of tenascin and fibronectin on the migration of human corneal fibroblasts.

PURPOSE: To investigate the effect of fibronectin and tenascin on the migration of corneal fibroblasts. SETTING: Department of Ophthalmology, University of Vienna, Medical School, Vienna, Austria. METHODS: Using human corneal fibroblasts, a monolayer migration assay was performed to measure corneal fibroblast movement. The migration on collagen I, fibronectin, and tenascin with and without transforming growth factor (TGF)-alpha/fibroblast growth factor (FGF)-2 stimulation and the effect of soluble tenascin and fibronectin on corneal fibroblast migration on collagen-I-coated wells were investigated. RESULTS: The cytokines TGF-alpha and FGF-2 stimulated migrational activity of corneal stromal cells in a dose-dependent manner, reaching the maximum effect at 100 ng/mL and 10 ng/mL, respectively. The migration of corneal fibroblasts on fibronectin was significantly higher (P <.05) than the migration on collagen I. Transforming growth factor-alpha and FGF-2 increased radial cell displacement independent of the provided matrix composition. Tenascin had a negative effect on corneal fibroblast adhesion/migration in this in vitro model. CONCLUSION: Fibronectin and tenascin influenced corneal fibroblast migration and adhesion, respectively, and may play a role in stromal cell movement during wound healing. The cytokines TGF-alpha and FGF-2 had an additive effect on corneal fibroblast migration on a fibronectin matrix.

Glare and halo phenomena after laser in situ keratomileusis.

PURPOSE: To simulate and measure subjectively observed glare and halos after laser in situ keratomileusis (LASIK). SETTING: University of Vienna, Medical School, Department of Ophthalmology, Vienna, Austria. METHODS: In 16 eyes of 10 patients, the best corrected visual acuity (BCVA) and subjectively observed glare and halo size under mesopic conditions were measured before LASIK and 1, 3, and 6 months postoperatively. Infrared pupillography was used to ensure that all patients had a larger ablation zone than the measured pupil size under mesopic conditions. RESULTS: Preoperatively, the mean Snellen BCVA was 0.88 +/- 0.17 (SD) and the mean glare and halo size was 1.97 +/- 1.20 square degrees (sqd) before the treatment. One month after LASIK, the BCVA was 0.83 +/- 0.29 and the mean glare and halo size, 2.61 +/- 3.14 sqd. Three months after LASIK, the mean values were 0.90 +/- 0.26 and 1.88 +/- 2.37 sqd, respectively. Six months after LASIK treatment, they were 0.85 +/- 0.28 and 1.30 +/- 1.63 sqd, respectively. The 95% confidence interval for the difference between preoperative glare and halo and glare and halo at 6 months was -1.56 to + 0.51 sqd. CONCLUSIONS: Subjectively observed glare and halo size after LASIK reached a peak after 1 month and decreased in the following postoperative period.

Comparison of visual acuities at different distances and defocus curves.

PURPOSE: To evaluate how visual acuities at different distances correlate with results from defocus curves. SETTING: Department of Ophthalmology and Institute of Medical Physics, University of Vienna, Medical School, Vienna, and Department of Ophthalmology, Krankenhaus St. Pölten, St. Pölten, Austria. METHODS: This study comprised 15 eyes of 14 patients with a mean age of 67.9 years +/- 9.7 (SD) with a monofocal silicone intraocular lens (911A, Pharmacia). The best corrected distance visual acuity was determined at viewing distances of 6 m, 2 m, 1 m, 67 cm, 50 cm, 40 cm, and 33 cm using logMAR charts. Defocus curves were then evaluated from -3.0 to -0.5 diopter (D) at 0.5 D increments from the best distance correction at a viewing distance of 6 m. RESULTS: The mean distance visual acuity was logMAR 0.08 +/- 0.07. The visual acuity graph from the testing at different distances was above the defocus graph at all testing points. Comparison of the visual acuity results from the 2 tests revealed statistically significant differences in the range from 2 m (-0.5 D) to 33 cm (-3.0 D). CONCLUSIONS: Results of defocus curves disregard the diminutions of minus glasses, the normally restricted viewing distance to 6 m for distance acuity determination, and in particular the physiological miosis caused by the near-point reaction.

Long-term endothelial changes in phakic eyes with posterior chamber intraocular lenses.

PURPOSE: To evaluate the long-term endothelial cell changes in phakic eyes after implantation of a posterior chamber phakic intraocular lens to correct high ametropia. SETTING: Department of Ophthalmology, University Hospital of Vienna, Vienna, Austria. METHODS: Thirty-four eyes of 21 patients having implantation of an implantable contact lens (ICL, Staar Surgical) for high myopia or hyperopia were prospectively examined. The minimum follow-up was 2 to 4 years. Preoperative and serial postoperative specular microscopy (Noncon Robo SP 8000, Konan) was performed to evaluate the long-term endothelial cell changes. RESULTS: The mean preoperative endothelial cell density was 2854 cells/mm(2). The mean endothelial cell loss from preoperatively was 1.8% at 3 months, 4.2% at 6 months, 5.5% at 12 months, 7.9% at 2 years (n = 34), 12.9% at 3 years (n = 13), and 12.3% at 4 years (n = 11). All other endothelial cell characteristics remained stable during the 4-year follow-up. CONCLUSIONS: Continuous endothelial cell loss was observed after ICL implantation during a 4-year follow-up. There was rapid cell loss until 1 year postoperatively, after which the rate of loss was no longer statistically significant. The percentage of hexagonal cells (polymorphism) and the coefficient of variation (polymegethism) remained stable during the 4-year follow-up.

Quantitative performance of bifocal and multifocal intraocular lenses in a model eye: point spread function in multifocal intraocular lenses.

OBJECTIVE: To compare the optical properties of bifocal diffractive and multifocal refractive intraocular lenses. METHODS: A model eye with a pupil 4.5 mm in diameter was used to determine the point spread function (PSF) of the distance focus and near focus of a diffractive bifocal intraocular lens (IOL) (model 811E; Pharmacia Inc, Columbus, Ohio) and of a refractive multifocal IOL (model SA40N; Allergan Optical Inc, Irvine, Calif) to compare them with PSFs of foci of corresponding monofocal lenses. For interpreting the PSFs the through focus response, the modulation transfer function, and the Strehl ratio were evaluated. RESULTS: The intensity of the distance focus of the bifocal diffractive lens reached 58.5% and the near focus attained 42.7% of the intensity of a corresponding monofocal lens. The maximal halo intensity surrounding both foci was approximately 4.5%. The distance peak of the refractive multifocal IOL was 73.4% and the near peak 25.1% of a corresponding monofocal lens. The out-of-focus image overlaying the distance focus of the refractive multifocal IOL was approximately 3% of the light intensity of the distance focus, whereas the PSF of the near focus of the multifocal IOL is substantially affected by out-of-focus images. The computed modulation transfer functions show better results for the monofocal lenses, similar results for the tested distance foci, and clear advantages for the bifocal diffractive near focus. CONCLUSIONS: Modulation transfer functions reveal comparable properties for distance vision and a superiority of the bifocal diffractive lens over the refractive multifocal lens for near vision.