SMILE after DALK to reduce residual refraction: two-year results.

PURPOSE: To determine the two-year results of small incision lenticule extraction (SMILE) for correcting post-keratoplasty myopia and myopic astigmatism. METHODS: In this case-series study, 10 eyes of 10 patients with a 6- to 10-year history of successful deep lamellar keratoplasty (DALK) underwent SMILE using the VisuMax laser platform. Ophthalmologic examinations and visual acuity and refraction measurement were taken pre- and 1, 3, 6, 12, and 24 months postoperatively. The Pentacam and Sirius imaging were done in the first and last follow-up sessions. RESULTS: The mean age of the patients was 39.60 ± 7.86 years. Six subjects were male. Two years after SMILE, the mean improvement in UDVA and CDVA was 3.60 ± 1.84 (P < 0.001) and 1.60 ± 2.91 (P = 0.231) LogMAR, respectively. The mean decrease in spherical equivalent, spherical error, and cylinder power was 1.92 ± 1.96 diopter (D) (P = 0.013), 0.70 ± 3.05D (P = 0.213), and 2.42 ± 2.91D (P = 0.024), respectively. The vector mean target-induced astigmatism, surgical-induced astigmatism, and difference vector were 1.30D@44˚, 1.11D@24˚, and 0.86D@73˚, respectively. Two years after SMILE, vertical coma, horizontal coma, and spherical aberration increased by 0.44 ± 0.51, 0.23 ± 0.32, and 0.02 ± 0.16 µm, respectively, (all P > 0.05) while trefoil reduced by 0.29 ± 0.75 µm (P = 0.428). CONCLUSION: SMILE can be an effective procedure for reducing refraction and astigmatism after DALK in patients with moderate myopia and moderate to severe astigmatism and improves the visual acuity in these patients. Axis rotation during surgery may result in under-correction of astigmatism. Refinement of SMILE treatment nomogram for post-DALK cases seems necessary.

Biocompatibility improvement of artificial cornea using chitosan-dextran nanoparticles containing bioactive macromolecules obtained from human amniotic membrane.

Corneal transplantation, by which the damaged cornea is replaced by a new one, suffers from limited access to HLA-compatible-donors and high maintenance and surgical costs. Therefore, artificial corneas are considered as alternative tools with promising prospects. In our previous study, a two-part-polymeric artificial cornea was composed of enhanced hydrophilic surface electrospun poly(ε-caprolactone) nanofibrous scaffold that is thermally connected to a polyvinyl alcohol-based hydrogel disk was prepared. Characterization tests revealed the prepared artificial cornea had similar biocompatible and structural characteristics regarding the natural cornea. In current study, human amniotic membrane extract containing growth factors, cytokines, anti-inflammatory factors, and anti-angiogenic factors was prepared, nano-encapsulated in chitosan-dextran nanoparticles, and physically decorated on the poly(ε-caprolactone)-polyvinyl-alcohol artificial cornea. Physicochemical and biological characterizations revealed the nano-decorated artificial cornea has more biocompatibility than the unmodified one. Our study demonstrated the bioactive macromolecules loaded on chitosan-dextran nanoparticles enhanced the anti-angiogenic property of artificial cornea through the sustained release of anti-angiogenic factors such as thrombospondin-1, endostatin, and heparin sulfate proteoglycan. Real-time-PCR and flow-cytometry assessments elucidated the vascularization was inhibited through a decrease in the expression of cluster of differentiation 31 and von-Willebrand-Factor. Our study proposed the use of biocompatible artificial cornea could be a promising strategy in corneal transplantation.

Application of polycaprolactone nanofibers as patch graft in ophthalmology.

PURPOSE: The purpose of the study was to evaluate tissue reaction to polycaprolactone (PCL) nanofiber patches in the cornea, conjunctiva, and anterior chamber (AC) in rabbit eyes and to assess their biocompatibility for use as patch grafts. METHODS: Two 100 µ PCL patches were implanted under the conjunctiva and in the corneal stroma of one albino New Zealand rabbit, and pathologic evaluation was done after 3 weeks. In the next step, two PCL patches were implanted; one in the corneal stroma and the other in the AC of two rabbits followed by pathologic evaluation after 3 months. RESULTS: On slit-lamp examination, there was minimum inflammation in all cases. Pathologic examination showed that the contact and probably merging between the host tissue and PCL fibers were achieved with minimal tissue reaction. CONCLUSION: As a biocompatible material, PCL nanofibers seem to be a promising modality for the repair of different tissue defects including melting, thinning, and perforation. They may also be a suitable material for manufacturing keratoprostheses.

Photopic, Mesopic, and Scotopic Visual Acuity After 18 mW/cm2 Accelerated Corneal Cross-Linking.

OBJECTIVES: One-year changes in uncorrected (UDVA) and corrected (CDVA) distance visual acuity under different lighting conditions after accelerated cross-linking (CXL) in patients with progressive keratoconus in comparison with nontreated cases. METHODS: In this nonrandomized clinical trial, the sample included 50 eyes in the CXL group and 40 eyes in the control group. Visual acuity was tested under photopic (100 lux), mesopic (20 lux), and scotopic (0.5 lux) lighting conditions at 6 months and 1 year. RESULTS: Changes in all studied variables were similar in the two groups (all P>0.05) after adjusting for age, but the 0.02±0.17 logMAR reduction in scotopic UDVA in the CXL group showed a difference of marginal significance compared with the control group (P=0.061). In cases with baseline UDVA≤20/40, 1-year adjusted results in the CXL and control groups were, respectively, 0.61±0.34 and 0.83±0.35 logMAR for photopic UDVA (P=0.021), 0.48±0.22 and 0.68±0.27 logMAR for mesopic UDVA (P=0.033), and 0.21±0.14 and 0.26±0.07 logMAR for mesopic CDVA (P=0.056). In those with baseline UDVA greater than 20/40, 1-year adjusted results in the CXL and control groups were, respectively, 0.12±0.20 and 0.06±0.10 logMAR for mesopic UDVA (P=0.034) and 0.15±0.18 and 0.07±0.06 logMAR for scotopic UDVA (P=0.024). Other vision indices showed no significant intergroup differences (all P>0.05). CONCLUSION: Poor vision (UDVA≤20/40) keratoconus cases are more likely to achieve improved vision or a halt in its deterioration after CXL. In cases with good vision (UDVA>20/40), however, although further photopic vision impairment is halted, they may experience worse vision under mesopic and scotopic conditions.

Scotopic contrast sensitivity and glare after accelerated corneal cross-linking.

BACKGROUND: The aim was to assess one-year changes in uncorrected and corrected contrast sensitivity (CS) and glare under scotopic conditions after accelerated cross-linking (CXL) using the 18 mW/cm2 protocol for the treatment of progressive keratoconus and compare results with unoperated controls. METHODS: In this non-randomised clinical trial, 30 eyes were enrolled in the CXL group and 30 were assigned to the control group. Scotopic CS at spatial frequencies (SFs) of 0.5, 1.1, 2.2, 3.4, 7.1 and 15 cycles per degree (cpd) were assessed using the MonCv3System (Metrovision, Pérenchies, France) under scotopic conditions (0.5 lux) at baseline and at six and 12 months. RESULTS: The mean ages of the participants in the CXL and control groups were 24.32 ± 5.17 and 30.93 ± 7.43 years, respectively (p < 0.001). After adjusting for age, changes in uncorrected and corrected CS and glare were similar in the two groups (all p > 0.05) except for corrected CS at SF 7.1 cpd (1.45 ± 4.31 versus 3.21 ± 4.69 dB, p = 0.010) and 15 cpd (1.12 ± 4.63 versus 3.03 ± 5.48 dB, p = 0.007), which were reduced as an effect of CXL. Based on covariate analyses, among corrected CS indices, corrected CS7.1 and CS15 were related to CXL and their baseline values (all p < 0.050). Uncorrected CS in all SFs and uncorrected and corrected glare were related to their pre-operative values (all p < 0.001). CONCLUSION: Accelerated CXL can reduce scotopic corrected CS at SFs higher than 7.0 cpd in cases with better baseline values of these parameters. Changes in uncorrected CS and glare are only a factor of baseline values and the indices reduce in cases with better baseline values after one year.

Intracorneal ring segment depth in keratoconus patients: a long-term follow-up study.

PURPOSE: To compare the actual depth of the tunnel created with femtosecond laser for intracorneal ring segment (ICRS) implantation with the target depth in keratoconus patients. METHODS: In this mix design study, eligible keratoconus patients were identified through chart review. The inclusion criterion was a history of ICRS implantation with femtosecond laser more than 6 months prior to enrollment. Participants underwent anterior segment optical coherence tomography using Spectralis (Heidelberg Engineering GmbH, Heidelberg, Germany) for depth measurement defined as the distance from the anterior corneal surface to anterior rim of the ring. RESULTS: The mean age of the 30 participants was 31.4 ± 7.9 years, and 58.6% were male. Mean follow-up time after ring implantation was 25.8 ± 10.0 (range 7-41) months. Mean actual depth was 59.9% (42.4-86.8%), and the target depth was 85.0% (74.8-90.0%) (P < 0.001). The ring was at a depth of less than 70% in 25 eyes of the 30 (83.3%) studied eyes. CONCLUSION: The mean 26 months after implantation, ring segments are placed at a shallower depth than originally intended. Therefore, although femtosecond laser technology is an acceptable method for the surgeon, it is necessary to revisit the depth calculator of the device.

Amniotic Membrane Extract Preparation: What is the Best Method?

PURPOSE: To compare different preparation methods for a suitable amniotic membrane (AM) extract containing a given amount of growth factors. METHODS: In this interventional case series, we dissected the AM from eight placentas within 24 hours after delivery, under clean conditions. After washing and mixing, AM extracts (AMEs) were prepared using pulverization and homogenization methods, and different processing and storing conditions. Main outcome measures were the amount of added protease inhibitor (PI), the relative centrifugal force (g), in-process temperature, repeated extraction times, drying percentage, repeated pulverization times, and the effect of filtering with 0.2 µm filters. Extract samples were preserved at different temperature and time parameters, and analyzed for hepatic growth factor (HGF) and total protein using ELISA and calorimetric methods, respectively. RESULTS: The extracted HGF was 20% higher with pulverization as compared to homogenization, and increased by increasing the PI to 5.0 µl/g of dried AM. Repeating centrifugation up to 3 times almost doubled the extracted HGF and protein. Storing the AME at -170° for 6 months caused a 50% drop in the level of HGF and protein. Other studied parameters showed no significant effect on the extracted amount of HGF or total protein. CONCLUSION: Appropriate extraction methods with an adequate amount of PI increases the level of extractable components from harvested AMs. To achieve the maximal therapeutic effects of AMEs, it is necessary to consider the half-life of its bioactive components.