Risk factors for keratoconus progression after treatment by accelerated cross-linking (A-CXL): A prospective 24-month study.

PURPOSE: Identification of potential predictive factors for keratoconus progression after treatment by accelerated Cross-linking (A-CXL) SECONDARY OBJECTIVES: Evaluation of clinical and topographic outcomes for two years following accelerated cross-linking treatment for progressive keratoconus including: best spectacle corrected visual acuity (BSCVA), thinnest pachymetry, maximum keratometry (Kmax), cylinder. STUDY: Prospective, interventional, monocentric study. SITE: Metz-Thionville Regional Medical Center, Lorraine University, Mercy Hospital, Metz, France. PATIENTS AND METHODS: We included 82 eyes of 60 patients between March 2014 and June 2016 who underwent accelerated corneal cross-linking (A-CXL) with epithelial debridement for progressive keratoconus, with a minimum follow-up of 2 years. A complete clinical evaluation and corneal topography were performed before cross-linking, and subsequently at 6, 12 and 24 months post-procedure. The following parameters were monitored during follow-up: best spectacle corrected visual acuity (BSCVA), minimal pachymetry, maximum keratometry (Kmax), mean anterior and posterior curvatures, maximum posterior curvature, presence of optical aberrations, subdivided into spherical aberration, coma, astigmatism, higher order optical aberrations and residual optical aberrations. After a 2-year follow-up, two groups, defined as "responders" and "non-responders" to treatment, were separated for analysis, and their initial characteristics were compared. RESULTS: Data for 82 eyes of 60 patients with progressive keratoconus with a mean age of 24±7 years were studied. Fourteen eyes (17.1%) showed signs of progression after treatment by A-CXL (non-responders), and 68 eyes (82.9%) showed stabilization of the disease (responders). Characteristics of non-responding eyes after A-CXL included a younger mean age (20±5 vs. 25±7 years) (P=0.04) and a lower initial mean BCVA for non-responders of 0.44±0.16 logMAR vs. 0.29±0.19 logMAR (P=0.03). Non-responders also had a higher mean maximal posterior curvature (AKB) of -10.84±1.72D vs. -9.46± 1.12D (P=0.03). They also showed more higher order optical aberrations (3.84±1.72D vs. 2.4±1.02D; P=0.01), including coma (3.85±1.81D vs. 2.1±1.01D; P=0.03) and more residual aberrations than responders (1.05±0.44D vs. 0.45±0.6D; P=0.005). No significant differences were found between responders and non-responders for the other parameters in our study. CONCLUSION: Eyes with progressive keratoconus who did not respond to A-CXL treatment were the most aggressive cases in the youngest patients, with highest maximum corneal curvatures and most pronounced optical aberrations. These patients should be informed in advance of the high risk of non-response to A-CXL treatment, and of the potential need for additional treatment in the future.

Evaluation of ostium size following endoscopic dacryocystorhinostomy as a predictive factor of outcome: A prospective study.

INTRODUCTION: Endonasal dacryocystorhinostomy (DCR) is a surgical procedure that aims to increase tear drainage to treat epiphora caused by nasolacrimal obstruction by creating a bypass through the bone between the lacrimal sac and the nasal cavity. A silicone stent is temporarily put in place for 2 months to avoid early obstruction of the rhinostomy. One of the causes of surgical failure is related to progressive stenosis of intranasal ostium, due to fibrosis and new bone growth, inducing a relapse of epiphora and/or dacryocystitis. Few studies have described changes in the size of the intranasal ostium on direct post-DCR measurement or kinetics of its shrinkage. The purpose of this study is to determine whether changes in the size of intranasal ostium might be a predictor of final functional efficacy. MATERIALS AND METHODS: A prospective cohort of eighteen consecutive patients undergoing endonasal DCR for chronic epiphora or chronic dacryocystitis between January 2017 and April 2018 was analyzed. Eight patients who underwent bilateral DCR, and twenty-six intranasal ostia were finally analyzed. Follow-up took place every two months for 1 year, with the silicone tube removed at 2 months. Functional success was defined as absence of recurrent epiphora or dacryocystitis. Ostium size was systematically measured on photos taken during intranasal endoscopy performed every 2 months for 1 year. RESULTS: At 2 months after endonasal DCR, 23 of the 26 ostia (88.5%) were functional, but only 19 (73.1%) of them were directly measurable. The mean horizontal diameter at 2 months was 1.44 (SD 0.61) mm, and the mean vertical diameter was 0.86 (SD 0.37) mm, which corresponded to a mean area of 10 (SD 0.84)mm2. We noted a statistically significant decrease in ostium size and area between 2 and 4 months after the procedure (P -0.001), followed by a stabilization period with no statistical correlation between the size of the ostium and its final functional efficacy. At 6 months after DCR, of the 7 ostia that were not initially measurable, 3 were immediately non-functional at 2 months, 3 had a relapse of epiphora at 4 months, and 1 had a relapse of dacryocystitis at 6 months, i.e., 100% clinical failures at 6 months. The other procedures all remained functional after 1 year of follow-up. CONCLUSION: The intranasal ostium of an endonasal DCR shrinks significantly within the 2 months after removal of the silicone tube and remains stable thereafter. There is no correlation between the size or area of intranasal ostium and its final functional efficacy. However, when the ostium is not measurable at the time of 2-month stent removal, all patients experienced a relapse of epiphora or dacryocystitis within 6 months.

Tobacco smoking in crosslinked keratoconus patients.

PURPOSE: The aim of this study was to evaluate the possibly protective link of smoking in keratoconic patients treated with accelerated cross-linking. METHODS: A telephone survey was conducted among 80 KC patients treated by accelerated cross-linking (A-CXL). The questions focused on general history, possible atopy and smoking habits. Results were compared to those of the general population by indirect standardization by age and sex according to the French national INPES survey. RESULTS: Sixty-two patients with KC were analyzed. The mean age at diagnosis was 22 years (SD 5). The mean age at which A-CXL was performed was 23 years (SD 6). Daily smokers represented 19 %, occasional smokers 8 %, ex-smokers 21 % and non-smokers 52 %. The mean age at which the patients began smoking was 17 (SD 2) years. Ex-smokers quit at a mean age of 24 (SD 4) years. The observed rates and expected rates of daily smokers were 19 % and 39 % respectively at the time of the survey (P=0.01), 24 % and 35 % at the time of the A-CXL treatment (P=0.10) and 31 % and 35 % at the time of diagnosis (P=0.58). The decrease in the rate of observed daily smokers over time was significant (P=0.02). DISCUSSION: Our data does not appear to suggest a significant protective effect of smoking on the occurrence of KC. It shows a lesser proportion of smokers in KC patients after A-CXL, but this difference did not exist at the time of KC diagnosis.

Reconstruction of exenteration socket with Integra® dermal substitute and skin graft.

The authors report their experience with the use of Integra® dermal substitute, in combination with a thin skin graft, following an orbital exenteration. The clinical case described relates to a 42-year-old gentleman with an ulcerative retractile lesion of the right lower eyelid. Histopathological examination diagnosed a moderately differentiated epidermoid carcinoma infiltrating the orbit. Total exenteration was necessary as well as secondary radiation therapy and chemotherapy. Rehabilitation of the exenterated socket was performed by inserting an Integra® patch, followed by an additional thin skin graft one month later. The authors review the various available techniques for exenterations, their indications and the various possible secondary rehabilitations. Despite being less utilized, the dermal substitute technique, which is relatively new, seems to offer quicker and easier rehabilitation compared to traditional techniques. A comparative study would be necessary to define superiority among the different techniques of exenteration, with respect to the speed of rehabilitation and resistance to radiation therapy.

Supracapsular phacoemulsification: Description of the "Garde à vous" technique and comparative clinical results.

Phacoemulsification techniques can be divided into 2 categories: endocapsular and supracapsular techniques. Supracapsular techniques involve phacoemulsification of the nucleus outside and above the capsular plane. The "Garde-à-vous" technique described in this manuscript is a modified and improved version of the supracapsular procedure with up-to-date technology in micro-coaxial surgery. It maintains the known advantages of supracapsular techniques such as faster surgical times and lower rates of capsular tears and brings a standardized technique with well-defined surgical steps in order to achieve tilting of the nucleus in a vertical or oblique position in almost 100% of cases by performing a double-wave hydro-dissection. The authors also give the results of a non-randomized prospective study, comparing the "Garde-à-vous" technique and the standard "cracking" technique in 2856 cases. The results show that for the "Garde-à-vous group", the patients were significantly younger (P<0.001), the power of ultrasound used was greater (P<0.001) for lower UST (ultrasound time or average phacoemulsification time APT) and EPT (effective phacoemulsication time) (P<0.001), the duration of the procedure was shorter (P<0.001), patient discomfort was less (P<0.001), and the power of the implants used was lower (P<0.01). With regard to the gender of the patients, the percentage of topical anesthesia and the rate of intraoperative complications (posterior capsular rupture), there was no statistically significant difference.

Lateral tarsal strip versus lateral tarsal strip with three-snip punctoplasty for managing epiphora in involutional ectropion.

PURPOSE: To compare the efficacy of two surgical techniques-lateral tarsal strip (canthoplasty) alone, and lateral tarsal strip with three-snip punctoplasty-in reducing epiphora arising from involutional ectropion with partial punctal stenosis. METHODS: Fourty patients with involutional ectropion and partial stenosis of the lacrimal punctum were randomly allocated to two treatment groups. Group 1 patients received lateral tarsal strip alone with only non-invasive stenting of the punctum, and group 2 patients received tarsal strip plus three-snip punctoplasty. Subjective assessment of epiphora was achieved via completion of a quality of life (QoL) questionnaire preoperatively and at postoperative month 3. Eyelid position, adverse outcomes and corneal dryness (via Oxford grading scheme) were also assessed postoperatively. Only patients with unilateral problems were included in the study. RESULTS: Forty eyes of 40 patients were included: 20 in each group. The mean ages of group 1 and group 2 patients were 79±11 and 80±9 years, respectively. All patients reported significantly reduced eye watering after surgery, with no significant intergroup difference in subjective outcomes, except that computer usage and night driving (P<0.05), improved in a more significant way in group 2. Eyelid malposition was corrected in all cases, there were no cases of postoperative punctal eversion, and no significant adverse events or complications occurred. Finally, the mean improvements in the dryness/keratitis score (using the Oxford scheme) were comparable between the 2 groups (P=0.34). CONCLUSION: The study findings indicate that treatment of involutional ectropion with partial punctal stenosis by lateral tarsal strip with three snip punctoplasty does not provide greater reduction in discomfort secondary to epiphora than conventional lateral tarsal strip alone, except for specific situations such as night driving or computer use.

[Practical assessment of DSAEK in the management of endothelial decompensation following penetrating keratoplasty]. / Évaluation pratique de la prise en charge par DSAEK des décompensations endothéliales après kératoplasties transfixiantes.

PURPOSE: To report our anatomical and functional results as well as possible complications of the first six Descemet's stripping endothelial keratoplasties (DSAEK) performed in our department for endothelial decompensation after penetrating keratoplasty (PK) METHODS: This was a retrospective and observational monocentric study of six patients with DSAEK after prior PK between January 2015 and July 2016. The data collected were: demographic characteristics (age, sex), ophthalmological comorbidities, initial indication for PK, delay between PK and DSAEK. Best corrected visual acuity (BCVA) preoperatively and at 1, 3 and 6 months postoperatively were collected in Monoyer's and Parinaud scale and converted to log MAR for statistical analysis. The central cornea and graft thickness measured on OCT as well as postoperative complications were also collected. RESULTS: Mean follow-up duration was 7.2 months [3-10]. The average time after PK was 7.7 years. The mean age of the patients was 67.5 years [32-87]. The initial indication for PK was Fuchs dystrophy (3/6), pseudophakic bullous keratopathy (1/6), corneal laceration (1/6) and other corneal dystrophy (1/6). The authors report one case a combined phaco-DSAEK surgery. The complications observed were: an early graft detachment treated by an additional air bubble injection (1/6) and cystoid macular edema in one other case. The average central corneal thickness decreased from 780µm at day 7 postoperatively to 656µm at 6 months. The average thickness of the graft decreased from 154µm at day 7 to 122µm at 6 months. The mean preoperative BCVA was 1.52 log MAR [1.0-1.7], compared to the mean postoperative BCVA which was 1.5 log MAR [1.1-2.3] at 1 month, 1.15 log MAR [0.5-1.7] at 3 months and 1.1 log MAR [0.7-1.7] at 6 months (data available for 4 patients at 6 months). The recovery of visual acuity was limited in 2 cases, despite corneal clarity restored in all our patients. DISCUSSION: Our results can be compared to those described in literature. As more penetrating keratoplasty grafts reach the end of their lives, this will allow for more powerful studies. CONCLUSION: DSAEK on eyes previously treated with PK is a good alternative to a new PK in the case of endothelial decompensation of the graft. The possibility of a posterior lamellar graft allows for faster visual recovery, with preservation of the anterior corneal power and a lower rate of complications.

Central corneal thickness assessment after phacoemulsification: Subluxation versus Divide-and-Conquer.

PURPOSE: To compare the impact of two phacoemulsification techniques (subluxation versus divide-and-conquer) on postoperative corneal edema at postoperative hour 1 and day 4. DESIGN: Comparative study. METHOD: Ninety-six consecutive patients (110 eyes; 43 men and 53 women, mean age 70.9±9.8 years) with equivalent cataract grades underwent cataract surgery and were followed up for 6 months. The presence of corneal edema was determined using central corneal thickness (CCT). CCT was measured preoperatively, and at postoperative hour 1 and day 4. MAIN OUTCOME MEASURES: Ultrasound power (US %), duration of ultrasound (TPA), effective ultrasound time (TPE), surgical duration and final suture (%). RESULTS: Eyes of participants were divided into two phacoemulsification technique groups: subluxation (n=50 eyes) and divide-and-conquer (n=60 eyes). Non-inferiority analysis revealed similar CCT increases at postoperative hour 1 in both groups, with 69.9±44.9µm and 64.4±42.9µm, observed in the subluxation and divide-and-conquer groups, respectively (P=0.033). TPE was similar in both groups, taking 6.2±3.4 and 7.3±4.5seconds in the subluxation and divide-and-conquer groups, respectively (P=0.150). No correlation was seen between TPE and edema at postoperative hour 1, or between TPE and day 4 edema. Rate of final suture use was similar between the subluxation and divide and conquer groups, at 36% and 30%, respectively. CONCLUSION: The study findings suggest that cataract surgery performed using the subluxation technique does not result in greater CCT than the divide-and-conquer technique. CCT appears to normalize by postoperative day 4, regardless of the technique used.

Safety and efficacy of two ocular anesthetic methods for phacoemulsification: topical anesthesia and viscoanesthesia (VisThesia).

PURPOSE: VisThesia is a new ophthalmic viscosurgical device (OVD) which has 1% lidocaine combined with 1.5% sodium hyaluronate. This is a prospective evaluation of the safety and efficacy of VisThesia used in association with phacoemulsification. METHODS: A total of 114 eyes were divided into two groups. Fifty-nine eyes were treated with tetracaine + oxybuprocaine topical anesthesia and DuoVisc OVD and 55 eyes were treated with VisThesia, for use as both topical anesthetic and OVD. Endothelial cell counts were measured at 30 days postoperatively and compared to preoperative baseline values. Pain and discomfort was subjectively evaluated by patients using a visual analog pain scale (0-10). RESULTS: All surgeries were uneventful with no intraoperative or immediate postoperative complications. Patients receiving topical anesthesia had a mean pain score of 1.1+/-6.8 compared to a mean score of 1.3+/-4.6 for patients receiving VisThesia (p=0.59). Postoperatively, endothelial cell loss at 1 month was greater for patients receiving VisThesia (20.32%+/-43.75) than for those receiving the topical anesthetic (8.8%+/-59.6; p<0.0001). CONCLUSIONS: The results from the visual analog pain scale were comparable between groups, showing that VisThesia provides similar pain relief to topical anesthesia. Specular microscopy performed at 30 days postoperatively showed a significantly greater loss of endothelial cells with the use of VisThesia, suggesting that the 1% lidocaine concentration used in VisThesia may be toxic to corneal endothelial cells.

[Comparison of PKR and LASIK for the treatment of low myopia: statistic study of refractive and optic results]. / Comparaison de la photo-kératectomie réfractive et du LASIK pour le traitement des myopies faibles.

PATIENTS AND METHODS: We present a study which compares the refractive and optical results obtained after PKR and LASIK for the correction of low myopia without astigmatism. This retrospective study involved 729 patients. All operations performed by the same surgeon, and with the same excimer laser (a Technolas Keracor 117 C). Before operation, all patients had a spherical equivalent between -0.5 and -6.0 D and a cylinder less than -0.5 D. Two groups were formed according to the treatment used. Three postoperative examinations were done (the first between 3 and 7 days, the second between 1 and 3 months, and the third between 10 and 14 months). Refractive results: Our statisticaly study found no difference in the results obtained with the two techniques. COMPLICATIONS: The incidence of complications was similar for the two procedures, but those observed after LASIK are generally more serious. DISCUSSION: In this indication, the efficacy of PKR and LASIK is similar. CONCLUSION: PKR and LASIK are safe and efficacy for the treatment of low myopia. For these patients, the use of PKR of LASIK currently depends on the habit and preference of the surgeon.

[Retreatment after PRK for low and medium myopia. Results and study of contrast sensitivity]. / Retraitement après PKR pour myopies faibles et moyennes. Résultats et étude de la sensibilité au contraste.

PURPOSE: To examine the results of retreatment with eximer laser photorefractive keratectomy (PRK) on refraction, visual acuity, haze, and contrast sensitivity. PATIENTS AND METHODS: Excimer laser photorefractive keratectomy was performed in 18 patients, once for one eye and twice for the other eye due to undercorrection or regression. Outcome was compared between the two eyes. RESULTS: Uncorrected visual acuity was above 20/40 in 94.4% of the retreated eyes. There was no statistical difference between the two eyes for haze and contrast sensitivity. CONCLUSION: Retreatment with laser photorefractive keratectomy is a safe procedure and should be performed when regression or undercorrection occurs after the first laser excimer treatment.