To describe the visual, refractive, topographic and aberrometric outcomes of six different accelerated cross-linking (ACXL) protocols in progressive keratoconus (KC) at 12 months.
This observational retrospective study included 62 eyes of 49 patients with progressive KC that received one of the following accelerated cross-linking protocols: Group I (8 patients, 5.4 J/cm2, 15mWx12min, pulsed), Group II (11 patients, 5.4 J/cm2, 6mWx15min, continuous), Group III (16 patients, 5.4 J/cm2, 9mWx10min, continuous), Group IV (13 patients, 5.4 J/cm2, 30mWx6min, pulsed), Group V (8 patients, 7.2 J/cm2, 15mWx16min, pulsed) and Group VI (6 patients, 7.2 J/cm2, 30mWx8min, pulsed). Best corrected visual acuity (BCVA), sphere, refractive cylinder, spherical equivalent (SE), maximum keratometry (Kmax), mean keratometry (Km), flat keratometry (K1), steep keratometry (K2), thinnest pachymetry, total aberrations, high order aberrations (RMS-HOA), spherical aberration, coma and trefoil were studied previously and at 12 months. Intragroup and intergroup statistical analysis was performed. Postoperative complications were noted.
11 patients were females(22,45%) and 38 males(77,55%). Improvement in the BCVA was observed in all groups (P > 0.05). Kmax reduced in all patients and was statistically significant in groups II (p = 0.041), III (p = 0.017), IV (p = 0.018) and V (p = 0.018). Flattening of the Km was significant in groups II (p = 0.028), IV (p = 0.008) and V (p = 0.028), as well as the K1 in groups IV(p = 0.01) and V(p = 0.028) and K2 in group IV(p = 0.036). There was no significant difference in the thinnest pachymetry in any of the groups. Total aberrations, RMS-HOA, spherical aberration and coma reduced in all groups with statistical significance in Group V (P = 0.016). Two patients in Group I had anterior stromal scarring and one patient in Group V presented an unexpected overflattening. Progression was noticed in one patient in Group II.
Accelerated CXL protocols included in this study can be considered effective and safe procedures in stopping the progression of keratoconus at 12 months. Improvement in BCVA and wavefront analysis is observed, but results are limited by the number of patients. Caution should be taken when applying high radiance and long duration protocols to prevent undesirable events.
To describe four cases of herpetic keratitis after cultivated limbal stem-cell transplantation (CLET).
Four patients affected by limbal stem cell deficiency (LSCD) caused by alkali burns received CLET. During regular follow-up, epithelial defects were detected and corneal scraping was performed to identify active viral keratitis.
Herpetic epithelial keratitis was successfully diagnosed by corneal scraping and polymerase chain reaction of HSV-1 DNA in all four patients affected by epithelial defects. The defects resolved after appropriate therapy with topical and/or systemic antiviral drugs.
Epithelial defects due to herpetic keratitis after cultivated limbal stem-cell transplantation may mimic chronic stem-cell deficiency. A low-threshold for corneal scraping can yield rapid identification of herpetic viral DNA allowing for appropriate treatment.
To evaluate the outcomes of implantable collamer lenses (ICL), femtosecond-assisted laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) for treatment of hyperopia.
Tertiary eye center.
Case series.
All patients with hyperopia managed by ICL (Gr 1), LASIK (Gr 2) and PRK (Gr 3) in 2014 to 2019 were reviewed for safety and efficiency, predictability and spherical equivalent (SE) pre-operatively then at one and 12 months after surgery.
Total of 99 hyperopic eyes, management Gr 1, Gr 2 and Gr 3 included 26, 57 and 16 eyes respectively. The mean pre-operative manifest refraction spherical equivalent (MRSE) was +5.13D, +3.15D D, +2.39D for Gr 1, Gr 2 and Gr 3 respectively. One year after surgery, the mean MRSE was −0.23D, +0.34D and +0.08D respectively (p = 0.065). The safety index was 1.0 and efficacy index was 0.89 in all groups. The predictability for achieving ±1.0 D SE was 95.8%, 92%, and 93.3% in Gr 1, Gr 2 and Gr 3 respectively. Peripheral faint corneal haze was noticed in PRK group (P = 0.05).
All three procedures had excellent visual gain and stable refraction at one year after surgeries with low complication rates. They seem to be safe, efficient and predictable procedures.
To evaluate the efficacy and safety of topography-guided custom ablation photorefractive keratectomy (TCAT) in treating residual refractive error and astigmatism after keratoplasty.
Medical records of all patients who underwent TCAT from 2013 to 2017 for residual refractive error and irregular astigmatism after keratoplasty were reviewed. Data were collected on patient demographics, surgical details and preoperative and 6 months postoperative refraction, corrected distance visual acuity (CDVA), uncorrected distance visual acuity (UDVA) and keratometry indices. The procedure was comprised of two stages where stage-1 was aimed at decreasing the irregular astigmatism and stage-2 at correcting the refractive error. Stage 2 was only performed if the corneal parameters including residual stromal bed were within acceptable limits.
Forty-six eyes of 46 patients were included. Nineteen eyes underwent stage-1 TCAT treatment only (Group-1). Nine eyes underwent stage-2 TCAT six months after the stage 1 (Group-2) and 18 eyes underwent a simultaneous stage 1 and 2 procedure (Group-3).
Six months following TCAT, CDVA improved in 69.6% This success rate was 63.2% in Group-1, 44.4% in Group-2 and 88.9% in Group-3.
Median spherical equivalent (SE) decreased from −4.5D preoperatively to −2.5D postoperatively and the median cylinder decreased from 3.25D preoperatively to 2.43D postoperatively. Comparing to Group-2, eyes in Group-3 experienced larger reduction in SE and astigmatism.
Treatment of patients with post-keratoplasty residual refractive error and astigmatism with TCAT resulted in successful outcomes with improvements CDVA and UDVA. Performing a simultaneous two-stage TCAT procedure appeared to be more effective in reducing the refractive error.
Femtosecond laser technology has evolved as an alternative method to make surgical incisions in keratoplasty. The use of this approach has a number of purported advantages that may lead to superior clinical outcomes. However, there remains a low uptake of the femtolaser-assisted keratoplasty within public healthcare, and incongruity remains between perceived expert opinion on the presence and significance of superior clinical outcomes based on available data.
This review is registered publicly on the Open Science Framework registry and aims to evaluate the evidence base on femtolaser-assisted keratoplasty and its comparison with manual trephination in intraoperative and postoperative outcomes. Over 2000 studies were screened and critically appraised in the field of keratoplasty, using multiple databases. 17 studies were included via predetermined criteria for full analysis. The studies covered interventional research into penetrating keratoplasty (PK), deep anterior lamellar keratoplasty (DALK), and posterior lamellar keratoplasty (PLK).
The results of this review show that PK studies shared a trend of improved visual outcomes with the femtolaser, and evidence for earlier suture removal. Complication rates were similar. When used for DALK, studies showed some evidence of improved visual outcomes with the femtolaser, and evidence for earlier suture removal, reduced intraoperative complications and increased wound healing activity. The use in Descemet’s membrane endothelial keratoplasty (DMEK) showed reduced graft detachment whereas in Descemet’s stripping automated endothelial keratoplasty (DSAEK) the results were limited.
Overall, this review shows a trend that the use of the femtolaser may improve clinical outcomes in PK, DALK and DMEK. However, it was also clear that in order to corroborate the superiority of femtolaser-assisted keratoplasty versus manual methods, further research is required.
Deep anterior lamellar keratoplasty (DALK) has become a safe and standardized technique for the treatment of corneal diseases. The use of femtosecond lasers for corneal trephination in DALK allows for a precise and controlled corneal trephination very close to Descemet’s membrane (DM) which is important for a successful pneumatic dissection and results in separation of Pre-Descemet’s layer (Dua’s layer, PDL) and/or DM from the stroma. However, even with newer curved contact interfaces the cornea becomes massively warped during trephination causing irregular trephination patterns which results in high postoperative astigmatism. Here we present a novel technique of Femto-DALK using a non-contact liquid interface where the cornea keeps its natural curvature during the complete laser process.
Case series of two patients, which underwent femtosecondlaser-assistant deep anterior lamellar keratoplasty by using a non-contact liquid interface. The laser device (Ziemer LDV Z8, Ziemer Ophthalmic Systems AG, Port, Switzerland) was used for trephination of the donor and recipient cornea. In one patient Femto-DALK was combined with femtolaser-assisted cataract surgery (Femto-Phaco). Read-out parameters were the feasibility of the technique and postoperative outcome.
Trephination was successful in both cases leading to a circular trephination very close to the recipients’ Descemet’s membrane. In both patients a big bubble type 1 was induced successfully.
Femtosecondlaser-assisted DALK using a liquid interface is a novel procedure representing an alternative to manual DALK or Femto-DALK with a contact interface. Future studies need to evaluate outcomes and complication rates in comparison to manual DALK and microscope-integrated Optical Coherence Tomography-aided DALK.
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