Fresh Human Myopic Lenticule Intrastromal Implantation for Keratoconus Using SMILE Surgery in a Long-term Follow-up Study: Ultrastructural Analysis by Transmission Electron Microscopy.

PURPOSE: To investigate new intrastromal histological structures that develop after myopic human lenticular implantation in keratoconus with femtosecond laser-assisted small incision lenticule extraction (SMILE) surgery using transmission electron microscopy. METHODS: Sixty eyes with advanced keratoconus indicated for corneal transplantation were included in this study. Fresh myopic lenticular implants were placed in all eyes through SMILE surgery. Lenticular implants were extracted from patients with myopic refractive errors of the cornea, untreated keratoconus, and treated keratoconus following 1, 2, and 3 years of surgery. These five lenticular samples were examined under the electron microscope and compared. RESULTS: Disorganized and thinned collagen fibers were observed in the stroma with degenerative stromal cells (telocyte-like cells and keratocytes) in the keratoconic cornea. Apoptotic bodies and cell debris were easily observed near the disorganized fibers. In contrast, the myopic refractive error of the control and treatment groups demonstrated well-organized parallel lamellar structures. Healthy keratocytes and telocyte-like cells were observed in samples obtained 1, 2, and 3 years after lenticular implantation. Thus, telocyte-like cells may be activated by appropriate stimuli, such as stem cells, and be involved in stromal regeneration. CONCLUSIONS: Fresh myopic intrastromal lenticular implantation is a safe, economical, and reliable technique that leads to increased corneal thickness, improved visual acuity, and the regeneration of healthy keratocytes and telocyte-like cells that are involved in stromal regeneration. [J Refract Surg. 2022;38(8):520-528.].

SMILE for the Treatment of Residual Refractive Error After Cataract Surgery.

INTRODUCTION: In the context of managing patients' expectations and satisfaction regarding visual acuity after cataract surgery, we aimed to investigate the improvement in visual acuity and patient satisfaction after small-incision lenticule extraction (SMILE) in pseudophakic (trifocal intraocular lens, IOL) patients with residual myopic refraction after cataract surgery. METHODS: Seventy-six patients (82 eyes) who underwent cataract surgery with ZEISS AT LISA tri 839MP IOL implantation were included in this retrospective study. The included patients were 56-79 years old, wanted spectacle independence, and had preoperative myopic refraction between - 1.0 and - 2.25 diopters (D) and astigmatism between - 0.75 and - 1.75 D. The treatment status of these patients was defined as trifocal IOL (n = 82). SMILE was performed in patients who were dissatisfied after cataract surgery, and these patients were followed up for 1 year on average. We evaluated visual acuity and satisfaction and further examined laser vision correction and satisfaction levels in patients who were dissatisfied after trifocal IOL implantation. RESULTS: The possible reasons for patient dissatisfaction were reading books, using a computer, and driving at night. After SMILE, the residual myopic refractive error (spherical) decreased significantly from - 2.08 ± 0.28 [- 2.25 to - 1.0] preoperatively to - 0.25 ± 0.20 - 0.5 to 0] 1 year postoperatively (p < 0.001). Additionally, the uncorrected distance visual acuity increased from 0.65 ± 0.08 [0.52-0.7] logMAR preoperatively to 0.09 ± 0.02 [0.05-0.1] logMAR at 1 month postoperatively (p < 0.001), 0.09 ± 0.02 [0.05-0.1] logMAR at 6 months postoperatively, and 0.06 ± 0.02 [0.05-0.1] logMAR at 12 months postoperatively (p < 0.001). Patient satisfaction measures after SMILE (reading, night driving, and using a computer) were significantly improved. CONCLUSION: SMILE is a reliable method for treating residual refraction after cataract surgery, as it provides results in the shortest time without complications and increases patient satisfaction. TRIAL REGISTRATION: The protocol was registered on clinicaltrials.gov (NCT04693663).

Perception of Trifocal IOL Performance in Young Adults with High Astigmatism and Hyperopia and its Improvement Using Small Incision Lenticule Extraction.

BACKGROUND: Hyperopia is a kind of refractive error in which incoming light is focused behind, instead of on, the retina wall due to insufficient accommodation by the lens. It is likely affected by ethnicity, geography, and a family history of hyperopia or accommodative esotropia and is categorized as low (≤ 2.00D), moderate (2.00-4.00 D), and high (> 4.00D). Beyond hyperopia refractive error, patients may have poor accommodative function or visual perceptual skills. OBJECTIVE: This study aimed to present the latest approaches to planning trifocal intraocular lens (IOL) and toric trifocal IOL implantation for residual refractive errors in young adults with high astigmatism and hyperopia and increase the patients' best visual outcome and satisfaction using Small Incision Lenticule Extraction (SMILE) after implantation. METHODS: Eighty eyes of 40 consecutive patients who underwent refractive lensectomy were included in this retrospective study. It included patients aged 20-45 years seeking spectacle independence with pre-operative high spherical hypermetropia of 4D or higher and astigmatism of 3D or higher. Patients' treatment status was categorized as trifocal IOL (n=40) and toric trifocal IOL (n=40).The mean patient follow-up time was six months after IOL implantation. First, we assessed visual acuity and satisfaction for both groups and then examined laser vision correction results of patients who were dissatisfied after IOL implantation (trifocal IOL group) and underwent SMILE surgery to increase satisfaction level. RESULTS: There were no statistically significant differences between trifocal IOL and toric trifocal IOL for near (UNVA), intermediate (UIVA), and distance (UDVA) uncorrected visual acuity. Comparisons related to patient satisfaction six months after IOL implantation were statistically significant for using a computer and night driving. In the trifocal IOL group, compared to pre-operative values, sphere and cylinder at six months were significantly improved. CONCLUSION: In young adults, toric trifocal and trifocal IOL provided sufficient results in visual acuity; however, patients were dissatisfied after implantation. This study reported patient satisfaction levels, including quality of life and life without glasses by using Small Incision Lenticule Extraction (SMILE) surgery.

Treatment of idiopathic macular hole with silicone oil tamponade.

PURPOSE: We analyzed the anatomical and visual outcomes after surgical treatment of idiopathic macular holes with pars plana vitrectomy, internal limiting membrane (ILM) peeling using Brilliant Blue dye, and silicone oil tamponade without postoperative posturing. METHODS: This was a retrospective interventional study of 10 eyes in eight patients who underwent surgical treatment of idiopathic macular holes using pars plana vitrectomy, ILM peeling using Brilliant Blue dye, and silicone oil tamponade without postoperative posturing. The preoperative staging of macular holes and postoperative anatomic outcomes were assessed using spectral-domain optical coherence tomography. RESULTS: All patients were women with a mean age of 66.86 ± 4.8 years. In two patients, bilateral macular holes were present and both eyes were operated on. Stage 2 macular hole was diagnosed in three eyes, three eyes had stage 3, and four eyes had stage 4 macular holes. Anatomical success and closure of the macular hole was achieved in nine eyes (90%) after one operation. In one eye, the macular hole was closed after reoperation. The preoperative mean best-corrected visual acuity (BCVA) was 0.15 decimal units (0.8 logMAR units). Until the end of the follow-up period, BCVA was 0.25 decimal units (0.6 logMAR units). Visual acuity was improved in seven patients (70%). In two patients (20%), visual acuity remained at the same level, and in one eye (10%), visual acuity decreased. Postoperatively, all patients reported a significant reduction of metamorphopsia. CONCLUSION: Initial results after 20G pars plana vitrectomy with peeling of the ILM, use of dye (Brilliant Blue), and tamponade with silicone oil without postoperative posturing gave good anatomical and functional outcome in terms of visual acuity and reduction of metamorphopsia. Taking into account the age of the patients, this method, which does not require prolonged postoperative face-down posturing, was well tolerated by the patients. Because the anatomical and visual outcome as well as the rate of postoperative complications are comparable to those when gas is used as a tamponading agent, silicone oil tamponade can also be safely used as a first option in surgery of macular holes. However, a longer period of follow-up of the operated eyes, as well as a larger group of operated eyes, will be required to identify long-term outcomes of this surgical treatment.