Changes in visual outcomes and ocular morphometrics after foldable myopic and toric intraocular lens implantation: 5-year results.

PURPOSE: To evaluate the refractive, visual, and morphometric changes after implantation with a foldable iris-fixated phakic intraocular lens (pIOL) to correct myopia or astigmatism. SETTING: University Eye Clinic Maastricht, the Netherlands. DESIGN: Prospective case series. METHODS: We evaluated patients implanted with the Artiflex Myopia Toric (Ophtec B.V.) iris-fixated pIOL as of January 2004. Measurements were performed annually and reported after 1 and 5 years. RESULTS: The study included 481 eyes (277 patients; age 39.8 ± 10.9 years [SD]). 5 years postoperatively, 91% of eyes were within ±1.0 diopter (D) of target, and the mean myopization over a 5-year period was 0.22 D (P < .001). The logMAR corrected distance visual acuity (CDVA) increased by a mean 0.015 (P = .015) over 5 years; 88% of eyes had a CDVA of 20/20 or better, and 5.5% lost 2 or more lines of CDVA. Mean uncorrected distance visual acuity (UDVA) increased by 0.045 logMAR over 5 years (P < .001); 96% reached an UDVA of 20/40 or more. Anterior chamber depth (ACD) decreased by 0.04 mm (P < .001), and axial length (AL) increased by 0.23 mm (P < .001) over 5 years. Chronic endothelial cell loss showed a 5-year decline of 320 cells/mm2 in the myopic and 310 cells/mm2 in the toric subgroups (P < .001). Cataract resulted in pIOL explantation in 4.0% of eyes (mean survival 59.0 ± 40.0 months); higher preoperative age (hazard ratio [HR], 1.13; P < .001) and smaller ACD (HR, 6.80; P = .035) were risk factors for shorter survival due to cataract formation. CONCLUSIONS: Over 5 years, logMAR CDVA and UDVA decreased significantly due to myopization caused by lenticular changes and AL elongation.

Excimer laser-assisted corneal epithelial pattern ablation for corneal cross-linking.

PURPOSE: To determine corneal cross-linking (CXL) efficacy and chromophore penetration after excimer laser-assisted patterned de-epithelialization. METHODS: Two-hundred-twenty porcine eyes were de-epithelialized ex vivo, either fully (mechanical; n = 88) or patterned (excimer laser; n = 132). Consecutively, corneas were impregnated with hypo- or hyperosmolar riboflavin (RF; n = 20, RF-D; n = 40, respectively) or water-soluble taurine (WST11; n = 40, and WST-D; n = 40, respectively), or kept unimpregnated (n = 80). Sixty corneas were subsequently irradiated, inducing CXL, with paired contralateral eyes serving as controls. Outcome measurements included strip extensiometry to assess CXL efficacy, and spectrophotometry and fluorescence microscopy to determine stromal chromophore penetration. RESULTS: All tested chromophores induced significant CXL (p < 0.001), ranging from 7.6% to 14.6%, with similar stiffening for all formulations (p = 0.60) and both de-epithelialization methods (p = 0.56). Light transmittance was significantly lower (p < 0.001) after full compared with patterned de-epithelialization. Stromal chromophore penetration was comparable between fully and patterned de-epithelialized samples, with full penetration in RD and RF-D samples and penetration depths measuring 591.7 ± 42.8 µm and 592.9 ± 63.5 µm for WST11 (p = 0.963) and 504.2 ± 43.2 µm and 488.8 ± 93.1 µm for WST-D (p = 0.669), respectively. CONCLUSIONS: Excimer laser-assisted patterned de-epithelialization allows for effective CXL. Stromal chromophore concentration is, however, reduced, which may have safety implications given the need for sufficient UVA attenuation in RF/UVA CXL. The different safety profile of near-infrared (NIR) may allow safe WST11/NIR CXL even with reduced stromal chromophore concentration values. In vivo studies are needed to evaluate the benefits and further assess safety of excimer laser-assisted patterned de-epithelialization for corneal CXL.

Phakic intraocular lenses: An overview.

Phakic intraocular lenses (pIOLs) are a common solution for the surgical correction of high myopia and myopia in thin corneas. Global trends result in increasing rates of patients with high myopia which will result in increased rates of pIOL implantation. Three types of lenses can be distinguished: anterior chamber angle-supported, anterior chamber iris-fixated, and posterior chamber phakic IOLs. The efficacy of phakic intraocular lenses is generally very good, but pIOLs have undergone many changes over the years to improve the safety profile and decrease pIOL-related complications such as endothelial cell loss, corneal decompensation and cataract formation. This article describes the efficacy and safety profiles of the most recent pIOLs, as well as suggests gaps of knowledge that are deserve additional research to optimize the results of pIOLs.

Comparison of the intermediate distance of a trifocal IOL with an extended depth-of-focus IOL: results of a prospective randomized trial.

PURPOSE: To compare visual outcomes, reading ability, and visual quality between the Symfony extended depth-of-focus intraocular lens (IOL) and the trifocal AT LISA tri 839MP IOL. SETTING: University Eye Clinic Maastricht, The Netherlands. DESIGN: Prospective randomized controlled trial. METHODS: Patients were randomly assigned to bilateral Symfony IOL or AT LISA tri 839MP IOL implantation. The primary outcome measure was uncorrected intermediate visual acuity (UIVA measured at 66 cm). Secondary outcomes included uncorrected distance visual acuity (UDVA), uncorrected near visual acuity (UNVA), reading ability, and comparison of defocus curves, contrast sensitivity, optical adverse effects, and quality of vision. RESULTS: The study enrolled 60 eyes of 30 patients. The mean UIVA was -0.02 ± 0.03 (SD) vs 0.01 ± 0.03 logarithm of the minimal angle of resolution (logMAR) in the Symfony and AT LISA tri 839MP groups, respectively (P = .047). The UDVA was 0.01 ± 0.12 and -0.05 ± 0.07 logMAR (P = .11) and the UNVA was 0.09 ± 0.05 and 0.04 ± 0.07 logMAR (P = .052) in the Symfony and AT LISA tri 839MP groups, respectively. Reading ability was similar in both groups at 40 cm and 66 cm (P = .87 and P = .14, respectively). Less than 10% of patients in both groups experienced disabling glare. Patients experienced disabling halos in the AT LISA tri 839 MP group compared to the Symfony group in 39% and 21% of cases, respectively (P = .12). The mean score for visual functioning was 88.0 ± 14.1 n the trifocal group and 88.2 ± 10.9 for the EDOF group (P = .96). CONCLUSIONS: The UIVA was better in the Symfony group than in the AT LISA tri 839MP group. No significant differences were seen in the binocular UNVA and UDVA, contrast sensitivity, reading ability, incidence of photopic phenomena, and patient satisfaction.

Long-term changes in visual outcomes and ocular morphometrics after myopic and toric phakic intraocular lens implantation: Five- and 10-year results.

PURPOSE: To evaluate the long-term refractive and visual, anterior chamber depth, and axial length (AL) changes and complications after rigid iris-fixated phakic intraocular lens (pIOL) implantation to treat myopia or astigmatism. SETTING: University Eye Clinic Maastricht, Maastricht UMC+, the Netherlands. DESIGN: Prospective case series. METHODS: The study evaluated patients who had implantation of an Artisan myopic or toric iris-fixated pIOL as of January 1998. Changes were measured annually and reported after 1, 5, and 10 years postoperatively. RESULTS: The study comprised 460 eyes (250 patients; mean age 41.1 years ± 10.7 [SD]). Over 10 years, the mean myopization was -0.79 diopters (D) (P < .001), with 52% of eyes within ±1.0 D of target. The mean increase in the logarithm of the minimum angle of resolution (logMAR) corrected distance visual acuity (CDVA) over 10 years was 0.05 (P < .001); 95% of eyes had a CDVA of 20/40 or more and 7% lost 2 or more lines of CDVA. The mean logMAR uncorrected visual acuity (UDVA) increased by 0.14 over 10 years (P < .001); 96% had a UDVA 20/40 or better. The AL increased by 1.14 mm over 10 years (P = .009). Ten percent of pIOLs were explanted because of cataract formation after a mean of 97.9 ± 34.9 months. A higher preoperative age (hazard ratio [HR], 1.08; P < .001) and longer AL (HR, 1.34; P < .001) were risk factors for shorter survival because of cataract formation. CONCLUSION: Ten years after rigid iris-fixated pIOL implantation, the CDVA and UDVA decreased significantly as a result of significant myopization caused by an increased AL unrelated to the pIOL.

The rising incidence of Acanthamoeba keratitis: A 7-year nationwide survey and clinical assessment of risk factors and functional outcomes.

PURPOSE: To evaluate the incidence of Acanthamoeba keratitis in the Netherlands between 2009 and 2015 and to analyse predicting factors for treatment outcome. METHODS: Patient characteristics, diagnostic methods, diagnostic delay, therapy prior to and after diagnosis, and visual outcome were obtained from medical files of all patients diagnosed with Acanthamoeba keratitis in the Netherlands between 2009 and 2015. A logistic regression analysis on treatment failure, defined as a best corrected visual acuity of less than 20/40 Snellen decimals (i.e. >0.3 logMAR or an approximate loss of three lines of visual acuity) and/or the need for keratoplasty, was performed to determine predicting factors. RESULTS: Two hundred and twenty-four eyes of 224 patients were included. Ninety-five percent of the patients were contact lens wearers, of whom 74% wore soft contact lenses. The number of cases increased from 16 in 2009 to 49 in 2015. This resulted in an estimated incidence of 1 in 21,000 for soft contact lens wearers in 2015. Eighty-seven eyes (39%) met the criteria for treatment failure. In a multivariable regression analysis, higher age at presentation, a higher severity stage and corticosteroid use before diagnosis were positively correlated with treatment failure. Early referral to a cornea specialist was associated with better clinical outcomes. CONCLUSIONS: Although Acanthamoeba keratitis is still a relatively uncommon disease, the incidence in soft contact lens wearers has increased to reach 1 in 21,000 in 2015. Treatment failure occurred in 39% of cases, with age, higher severity stage, corticosteroid use before diagnosis and indirect referral to a cornea specialist as important risks factors.

Risk factors for explantation of iris-fixated phakic intraocular lenses.

PURPOSE: To determine risk factors for explantation of iris-fixated phakic intraocular lenses (pIOLs) with a maximum 17-year follow-up. SETTING: University Eye Clinic Maastricht, Maastricht UMC+, the Netherlands. DESIGN: Prospective case series. METHODS: Eyes that had implantation of 1 of various iris-fixated pIOL models from 1998 to 2016 were evaluated. Primary outcome measures were the rate and proportion of pIOL explantations and the survival time (ie, time to pIOL explantation) in general and specifically as a result of cataract formation or endothelial cell loss (ECL). RESULTS: The study comprised 1037 eyes. The mean follow-up was 69.3 months ± 52.8 (SD) and the mean preoperative age, 40.2 ± 10.9 years. The overall explantation rate was 12% after a mean of 166.1 months ± 3.0 (standard error). Phakic IOL explantations were performed in 59% of eyes because of cataract formation and in 32% because of ECL. Shorter survival was seen with a higher preoperative age (hazard ratio [HR], 1.07/y; P < .001), longer axial length (AL) (HR, 1.10/mm; P = .009), and smaller anterior chamber depth (ACD) (HR, 4.47/mm; P < .001). Factors for shorter survival resulting from cataract were older preoperative age, longer AL, and larger ACD. Risk factors contributing to shorter survival resulting from ECL were a smaller ACD, lower endothelial cell density, and implantation with an Artisan hyperopia (toric) or Artiflex myopia (toric) IOL. CONCLUSIONS: The explantation rate of iris-fixated pIOLs was 12% after almost 14 years of follow-up, with 59% of pIOL explantations caused by cataract formation and 32% caused by ECL. An older preoperative age, longer AL, and smaller ACD were risk factors for a shorter survival.

Five-Year Endothelial Cell Loss After Implantation With Artiflex Myopia and Artiflex Toric Phakic Intraocular Lenses.

PURPOSE: To evaluate the long-term changes in endothelial cell density (ECD) after the implantation of 2 types of foldable iris-fixated phakic intraocular lenses (pIOLs) for the treatment of myopia and astigmatism. DESIGN: Prospective clinical cohort study. METHODS: Two-hundred and ninety-three and 188 eyes implanted with, respectively, the Artiflex Myopia and Artiflex Toric (Ophtec B.V., Groningen, The Netherlands) iris-fixated pIOL for the treatment of myopia or astigmatism at the University Eye Clinic Maastricht as of January 2004. One-hundred and forty-six eyes from the myopic and 64 eyes from the toric groups completed a 5-year follow-up. Main outcome measures were chronic endothelial cell (EC) loss, percentage of eyes with a ≥25% decrease in ECD, and the percentage of eyes with an ECD < 1500 cells/mm2. RESULTS: Chronic EC loss showed an annual decline of 64 cells/mm2 in the myopic (P < .001, standard error 3.58) and 62 cells/mm2 in the toric (P < .001, standard error 3.77) groups. Total chronic EC loss from 6 months to 5 years postoperatively was 10.5% in the myopic and 10.2% in the toric groups. After 5 years, an ECD decrease of ≥25% occurred in 4.4% and 4.3% of eyes, and an ECD < 1500 cells/mm2 was reported in 3.0% and 0.0% of eyes, respectively. Explantation of a pIOL owing to EC loss was required in 3.1% and 0% of eyes. CONCLUSION: Chronic EC loss was around 10% over a 5-year period in eyes implanted with the foldable myopic (toric) pIOL. In up to 3.1% of eyes significant EC loss resulted in subsequent pIOL explantation.

Long-Term Endothelial Cell Loss in Patients with Artisan Myopia and Artisan Toric Phakic Intraocular Lenses: 5- and 10-Year Results.

PURPOSE: To evaluate the long-term change in endothelial cell density (ECD) after the implantation of 2 types of rigid iris-fixated phakic intraocular lenses (pIOLs) for the treatment of myopia and astigmatism. DESIGN: Prospective, clinical cohort study. PARTICIPANTS: A total of 507 eyes of 289 patients receiving the Artisan Myopia or Artisan Toric (Ophtec B.V., Groningen, The Netherlands) iris-fixated pIOL for the treatment of myopia or astigmatism at the University Eye Clinic Maastricht as of January 1998. METHODS: A total of 381 myopic and 126 toric pIOLs were implanted. Five- and 10-year follow-ups were completed by 193 and 127 eyes implanted with the myopic pIOL and by 40 and 20 eyes implanted with the toric pIOL, respectively. MAIN OUTCOME MEASURES: Chronic endothelial cell (EC) loss, percentage of eyes with a decrease of ≥25% in ECD, and percentage of eyes with an ECD <1500 cells/mm2. RESULTS: Chronic EC loss was calculated from 6 months postoperatively to the end of follow-up and showed an annual ECD decline of 48 cells/mm2 (standard error, 3.14) and 61 cells/mm2 (standard error, 6.30) in the myopic (P < 0.001) and toric (P < 0.001) groups, respectively, resulting in a total EC loss of 16.6% and 21.5% from 6 months to 10 years postoperatively, respectively. Ten years after implantation, ECD had decreased by ≥25% in 7.9% and 6.3%, whereas ECD was <1500 cells/mm2 in 3.9% and 4.0% in the myopic and toric groups, respectively. Explantation of the pIOL occurred in 6.0% in the myopic group and 4.8% in the toric group. Risk factors for increased EC loss were a shallow anterior chamber depth (ACD) (P ≤ 0.005) and a smaller distance between the central and peripheral pIOL edge to the endothelium (P ≤ 0.005). CONCLUSIONS: A significant linear chronic EC loss was reported after implantation with myopic or toric iris-fixated pIOLs. A smaller ACD and smaller distance between pIOL edge and endothelium were risk factors for EC loss. Modification of preoperative age-related ECD thresholds is indicated to maintain an ECD that warrants safe future combined pIOL explantation and cataract surgery.

Refractive, topographic, and visual outcomes of same-day corneal cross-linking with Ferrara intracorneal ring segments in patients with progressive keratoconus.

PURPOSE: To report refractive, topographic, and visual outcomes 12 months after same-day treatment with corneal cross-linking (CXL) and Ferrara intracorneal ring segments (ICRS) in eyes with progressive keratoconus (KC) and contact lens intolerance. METHODS: This was a case series of 7 eyes (7 patients) with progressive mild to moderate keratoconus and contact lens intolerance undergoing implantation of Ferrara ICRS immediately followed by corneal cross-linking. Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), refractive error, pachymetry, and keratometry were evaluated at 3, 6, and 12 months of follow-up. RESULTS: Mean follow-up was 11.7 ± 3.6 months (range, 5-17 months). Mean preoperative UCVA and BSCVA were 0.10 ± 0.07 (range, 0.05-0.2) and 0.56 ± 0.08 (range, 0.5-0.7), respectively. One year after the treatment, mean UCVA and BSCVA measured 0.60 ± 0.24 (range, 0.32-0.9) and 0.82 ± 0.25 (range, 0.5-1.2), respectively. The mean spherical equivalent decreased significantly (P < 0.05) with 3.5 diopters (D). Mean K values (average keratometry of the cornea) decreased from 46.81 ± 2.13 D (range, 44-51 D) to 43.97 ± 2.22 D (range, 42-47.5 D) 1 year after the treatment. The average preoperative thinnest pachymetry measured 462 ± 46 µm (range, 410 ± 546 µm) and did not change significantly after the treatment. In patient 1, the inferior ICRS was removed 5 months postoperatively because of implant migration. CONCLUSIONS: The combined treatment of corneal cross-linking and Ferrara ICRS is a safe procedure that may be considered in patients with progressive mild to moderate KC and contact lens intolerance.