Visual and Refractive Outcomes of Toric Implantable Collamer Lens Implantation in Stable Keratoconus After Combined Topography-Guided PRK and CXL.

PURPOSE: To evaluate the safety and efficacy of toric implantable Collamer lens (ICL) (STAAR Surgical) implanted at least 6 months after combined topography-guided photorefractive keratotomy (TG-PRK) and corneal cross-linking (CXL) in keratoconus. METHODS: This retrospective study included 46 eyes with keratoconus of 31 patients who underwent toric ICL implantation after previous TG-PRK+CXL. Patients were examined for uncorrected (UDVA) and corrected (CDVA) distance visual acuity, flat and steep keratometry, and manifest refraction spherical equivalent preoperatively and 12 months postoperatively. RESULTS: At 12 months postoperatively, there was a statistically significant improvement in visual and refractive outcomes (all P < .001). Mean UDVA improved to 0.17 ± 0.14 logMAR (vs 1.00 ± 0.38 logMAR preoperatively) and mean manifest refraction spherical equivalent improved to -0.32 ± 1.42 diopters (D) (vs -7.35 ± 5.20 D preoperatively). At 12 months, 63% of eyes achieved UDVA of 20/32 or better and 60.9% of eyes were within ±0.50 D of manifest refraction spherical equivalent. Mean refractive astigmatism improved from -2.90 ± 2.21 D preoperatively to -1.47 ± 1.46 D at postoperative 12 months (P < .001), with 30.4% and 45.7% of eyes having a postoperative astigmatic error within ±0.50 and ±1.00 D, respectively. No complications were observed. CONCLUSIONS: Toric ICL implantation was found to be safe and effective for the correction of myopia and myopic astigmatism in patients with stable keratoconus who had undergone TG-PRK+CXL, as revealed by the statistically significant improvement in visual and refractive outcomes at 12 months after toric ICL implantation. [J Refract Surg. 2021;37(12):824-829.].

Pinhole iris-fixated intraocular lens for dysphotopsia and photophobia.

UNLABELLED: We present the pinhole iris-fixated diaphragm intraocular lens (IOL), which is a 1-piece black polycarbonate IOL with rigid iris-fixated haptics, an 8.5 mm overall length, a 6.0 mm diameter optic, and a central opening, the pinhole. The IOL was implanted in a 36-year-old man who had a history of debilitating dysphotopsia (star burst, halos, glare, and ghosting) and severe light sensitivity in his right eye following several interventions for keratoconus. The diameter of the central opening of the pinhole IOL, 2.0 mm, was based on the patient's corneal aberration profile. Postoperatively, the dysphotopic symptoms and photophobia markedly improved. We recommend the use of the pinhole iris-fixated IOL in patients with severe photophobia or dysphotopsia refractory to other treatment modalities. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Combining zonal refractive and diffractive aspheric multifocal intraocular lenses.

PURPOSE: To assess visual performance with the combination of a zonal refractive aspheric multifocal intraocular lens (MIOL) (Lentis Mplus, Oculentis GmbH) and a diffractive aspheric MIOL (Acri.Lisa 366, Acri.Tech GmbH). METHODS: This prospective interventional cohort study comprised 80 eyes from 40 cataract patients (mean age: 65.5±7.3 years) who underwent implantation of the Lentis Mplus MIOL in one eye and Acri.Lisa 366 MIOL in the fellow eye. The main outcome measures were refraction; monocular and binocular uncorrected and corrected distance, intermediate, and near visual acuities; monocular and binocular defocus curves; binocular photopic contrast sensitivity function compared to a monofocal intraocular lens (IOL) control group (40 age-matched pseudophakic patients implanted with the AR-40e [Abbott Medical Optics]); and quality of vision questionnaire. RESULTS: Binocular uncorrected visual acuities were 0.12 logMAR (0.76 decimal) or better at all distances measured between 6 m and 33 cm. The Lentis Mplus provided statistically significant better vision than the Acri.Lisa at distances between 2 m and 40 cm, and the Acri.Lisa provided statistically significant better vision than the Lentis Mplus at 33 cm. Binocular defocus curve showed little drop-off at intermediate distances. Photopic contrast sensitivity function for distance and near were similar to the monofocal IOL control group except for higher frequencies. Moderate glare (15%), night vision problems (12.5%), and halos (10%) were reported. Complete independence of spectacles was achieved by 92.5% of patients. CONCLUSIONS: The combination of zonal refractive aspheric and diffractive aspheric MIOLs resulted in excellent uncorrected binocular distance, intermediate, and near vision, with low incidence of significant photic phenomena and high patient satisfaction.

Visual function after bilateral implantation of a new zonal refractive aspheric multifocal intraocular lens.

PURPOSE: To evaluate visual function after bilateral implantation of a zonal refractive aspheric multifocal intraocular lens (IOL). SETTING: Private practice surgery center, Valencia, Spain. DESIGN: Cohort study. METHODS: Consecutive eyes with cataract had bilateral implantation of Lentis Mplus LS-312 multifocal IOLs. Distance, intermediate, and near visual acuities; contrast sensitivity; defocus curves; and a quality-of-vision questionnaire, including presence of halos or dysphotopsia, were evaluated 6 months postoperatively. A control group of age-matched monofocal pseudophakic patients was included to compare contrast sensitivity function. RESULTS: In the multifocal group, the mean binocular corrected distance visual acuity (logMAR) was -0.04 ± 0.07 at 6 m, 0.11 ± 0.10 at 1 m, and 0.06 ± 0.07 at 40 cm. The defocus curve showed little intermediate vision drop off. Photopic contrast sensitivity for distance was similar to the monofocal IOL contrast sensitivity function, while photopic contrast sensitivity for near and mesopic contrast sensitivity for distance with or without glare was reduced at high frequencies. The mean patient satisfaction was 8.09 ± 1.30 (scale 0 to 10); 84.4% of patients were completely independent of spectacles. Moderate halos, glare, and night-vision problems were reported by 6.2%, 12.5%, and 15.6% of patients, respectively. CONCLUSION: The new-generation multifocal IOL provided adequate distance, intermediate, and, to a lesser extent, near vision with high rates of spectacle freedom. Halos occurred, and other photic phenomena should be expected in a small percentage of patients. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Effects of LASIK on corneal endothelium using the 15-kHz IntraLase femtosecond laser.

PURPOSE: To assess the effects of LASIK with the 15-kHz IntraLase femtosecond laser on corneal endothelium. METHODS: In a prospective, single-center clinical trial, 138 patients (mean age: 32.0 ± 7.1 years [range: 21 to 42 years]) underwent femtosecond LASIK for the correction of myopia -0.75 to -9.00 diopters (D) and cylinder up to 3.25 D. Patients were divided into two groups: contact lens group (n=76) and non-contact lens group (n=62). Pre- and 12-month postoperative specular microscopy of the central corneal endothelium was performed. The integrity of the central endothelium was assessed in terms of endothelial cell density and percentage of hexagonality. RESULTS: In the contact lens group, mean endothelial cell density improved significantly from 3401 ± 292 cells/mm(2) to 3587 ± 262 cells/mm(2) (P<.001) with a mean increase of 5.5%. The percentage of hexagonal cells was statistically significantly higher after surgery (32.5 ± 4.0%) compared with preoperative data (31.0 ± 5.1%) (P=.035). No statistically significant differences were noted regarding mean endothelial cell density (P=.126) or hexagonality (P=.56) before and 1 year after femtosecond LASIK in the non-contact lens group. CONCLUSIONS: Femtosecond LASIK to correct myopia was safe for the corneal endothelium. Improvement in mean endothelial cell density and percentage of hexagonality was observed in the contact lens group.

Increased risk for flap dislocation with perioperative brimonidine use in femtosecond laser in situ keratomileusis.

PURPOSE: To determine whether brimonidine 0.2% minimizes the occurrence of subconjunctival hemorrhages without inducing postoperative flap complications in femtosecond laser in situ keratomileusis (LASIK). SETTING: Centro Oftalmológico Marqués de Sotelo and Hospital NISA Virgen del Consuelo, Valencia, Spain. METHODS: This prospective contralateral-eye interventional study evaluated consecutive patients who had bilateral simultaneous femtosecond LASIK for myopia (spherical equivalent [SE] range -1.00 to -8.00 diopters) performed with an IntraLase femtosecond laser and a Visx Star 2 excimer laser. One eye of each patient received a single drop of brimonidine tartrate 0.2% (brimonidine group) and the other eye, a single drop of a balanced salt solution (control group). RESULTS: The study evaluated 136 eyes (68 patients). The difference in the incidence of subconjunctival hemorrhages was statistically significantly lower in the brimonidine group (mean score 2.24 +/- 1.96 [SD]) than in the control group (mean score 7.61 +/- 2.72) (P<.001). However, no eye in the control group and 7 eyes (10.4%) in the brimonidine group had a dislocated flap with folds on the first postoperative day (P = .016). All eyes with dislocated flaps required surgical intervention. At 6 months, there was no significant difference between groups in the percentage of eyes achieving 20/20 or better uncorrected distance visual acuity, in the mean SE, or in the enhancement rate. CONCLUSIONS: Brimonidine prevented the formation of subconjunctival hemorrhages after femtosecond LASIK but increased the risk for flap dislocation. Thus, surgeons are cautioned against the use of perioperative brimonidine to decrease hemorrhagic complications in femtosecond LASIK.

Validity of autorefraction after cataract surgery with multifocal ReZoom intraocular lens implantation.

PURPOSE: To evaluate the clinical utility of spherocylindrical automated refraction (AR) compared with subjective manifest refraction (MR) after cataract surgery with implantation of ReZoom refractive multifocal intraocular lenses (IOLs) (Advanced Medical Optics, Inc.). SETTING: Private Practice. METHODS: This prospective nonrandomized interventional study consisted of 72 patients with bilateral cataract and a potential visual acuity of at least 20/40. Patients had bilateral nonsimultaneous cataract surgery and implantation of a ReZoom IOL. Manifest refraction was performed in all patients followed by 3 consecutive measurements using the Topcon KR-8000 autorefractor with nondilated and dilated pupils. Assessment of repeatability of multiple consecutive ARs and comparison of the AR and MR using power vector analysis were performed at the 6-month follow-up. The main outcome measures were the correlation between AR and MR with sphere, spherical equivalent, and astigmatism as well as the repeatability of AR before and after dilation with phenylephrine 10%. RESULTS: Repeatability analysis showed that the initial nondilated AR was not significantly different from the mean of the 3 refractions for nondilated and dilated measurements. The mean difference between the initial AR and the MR was -0.84 +/- 0.62 diopters (D) for sphere (SD), -1.00 +/- 0.61 D for spherical equivalent, and -0.06 +/- 0.19 D and -0.01 +/- 0.17 D, respectively, for J(0) and J(45), the 2 components of astigmatism. Linear regression of AR versus MR data showed poor correlation for sphere (R(2) = 0.4852) and spherical equivalent (R(2) = 0.5529), whereas the correlation for the 2 astigmatic components of vector analysis was excellent (J(0), R(2) = 0.8881; J(45), R(2) = 0.8640). Correlation was better when the MR residual refractive defect was higher. CONCLUSIONS: Although autorefraction showed excellent agreement with subjective refractive astigmatism, correlation with spherical values was poor, with a trend toward more negative values. Autorefraction after ReZoom IOL implantation can be used as a good starting point for subjective refraction of astigmatism; however, spherical values should be underestimated.

Femtosecond laser in situ keratomileusis for consecutive hyperopia after radial keratotomy.

PURPOSE: To assess the use of the femtosecond laser for laser in situ keratomileusis (LASIK) in eyes with consecutive hyperopia after radial keratotomy (RK). SETTING: Private ambulatory surgical center, Valencia, Spain. METHODS: This prospective noncomparative interventional case series study included 13 eyes of 9 patients with secondary hyperopia after previous RK. The patients were operated on with the IntraLase femtosecond laser (IntraLase Corp.) and the Star S2 excimer laser (Visx, Inc.). Postoperative uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), manifest refraction, flap thickness, flap diameter, and complications were evaluated at 6 months. RESULTS: The mean spherical equivalent (SE) decreased from 2.00 diopters (D)+/-0.40 (SD) to -0.41+/-0.61 D, with 8 eyes (61.5%) within+/-0.50 D of the targeted refraction. Twelve eyes (92.3%) had a UCVA of 20/40 or better, and 3 eyes (23.1%) lost 1 line of BSCVA. A mean change in SE of 0.10 D was observed at the 6-month follow-up. The mean flap thickness and diameter were 117+/-14 microm and 9.18+/-0.12 mm, respectively. Most complications were in eyes with more than 8 RK incisions than in eyes with 8 RK incisions. These complications were multiple intraoperative incision openings (100% versus 28.6%, respectively), interface inflammation (66.6% versus 0%, respectively), haze (83.3% versus 14.3%, respectively), and loss of BSCVA (50% versus 0%, respectively). CONCLUSIONS: The femtosecond laser provided large, thin corneal flaps for hyperopic LASIK. However, the procedure should be avoided in eyes with more than 8 RK incisions because of the increased risk for multiple intraoperative incision openings, interface inflammation, haze, and loss of BSCVA.

Transient light-sensitivity syndrome after laser in situ keratomileusis with the femtosecond laser Incidence and prevention.

PURPOSE: To describe the incidence of transient light-sensitivity syndrome (TLSS) after laser in situ keratomileusis (LASIK) with the femtosecond laser and to identify preventive strategies. SETTING: Hospital NISA Virgen del Consuelo, Valencia, Spain. METHODS: The first 765 eyes operated on with the 15 KHz femtosecond laser were prospectively analyzed for subjective complaints and clinical findings compatible with TLSS. Intraoperative settings, postoperative treatment, and development of complications were analyzed. RESULTS: Overall, TLSS developed in 10 eyes (incidence 1.3%). However, the incidence decreased from 2.8% to 0.4% when aggressive topical steroids were used during the first 3 postoperative days. Postoperative interface inflammation and postoperative use of a low-dose topical steroid regimen were associated with a higher incidence of TLSS. CONCLUSIONS: Transient light-sensitivity syndrome is a relatively uncommon complication related to the use of the femtosecond laser. Postoperative interface inflammation may increase the probability of developing TLSS, whereas an aggressive postoperative steroid regimen seemed to provide protection against it.

Femtosecond laser in situ keratomileusis after radial keratotomy.

PURPOSE: To assess the safety, efficacy, and predictability of femtosecond laser in situ keratomileusis (LASIK) in eyes with previous radial keratotomy (RK). SETTING: Hospital Virgen del Consuelo de Valencia, Valencia, and Vissum Instituto Oftalmológico de Alicante, Alicante, Spain. METHODS: This prospective study comprised 11 eyes of 7 patients with residual low myopia after previous RK who had surgery with the IntraLase femtosecond laser (IntraLase Corp.) and the Star 2 excimer laser (Visx, Inc.). Uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), defocus equivalent, refraction, flap thickness, flap diameter, and intraoperative complications were evaluated over a minimum 6-month follow-up. RESULTS: Although the RK incisions opened in all eyes when the flap was lifted, LASIK was successfully completed in all cases. Mean flap thickness was 119 microm +/- 13 (SD). There were no cases of slipped flaps, microstriae, or epithelial ingrowth. Defocus equivalent was reduced from a mean of 2.51 +/- 0.62 diopters (D) to 0.52 +/- 0.28 D; 7 eyes (63.6%) were within +/-0.50 D, and 11 eyes (100%) were within +/-1.00 D. All eyes had 20/40 or better UCVA, although 2 eyes (18.1%) lost 1 line of BSCVA. CONCLUSIONS: The femtosecond laser was safely used to create thin LASIK flaps in eyes with previous RK. An increased postoperative inflammatory response may explain the loss of BSCVA in some cases. Efficacy and predictability of the procedure were comparable to those of LASIK after RK with mechanical microkeratomes.