Journal of refractive surgery最新文献

Purpose: To establish a diagnostic index for keratoconus based on spectral-domain optical coherence tomography (SD-OCT) and to compare it with existing parameters.

Methods: SD-OCT and Scheimpflug-based tomography were conducted on normal and keratoconic eyes. Multiple SD-OCT machine-derived parameters were assessed for the whole cornea, stroma, and epithelium. Receiver operating characteristic (ROC) curves were performed to determine area under the curve (AUC), sensitivity, and specificity. Principal component analysis and multinomial logistic regression after features selection established a new diagnostic index (Whole Information of Stroma and Epithelium [WISE]). The WISE index was compared with existing Scheimpflug-based diagnostic parameters.

Results: A total of 306 healthy control, 101 forme fruste keratoconus (FFKC), 86 early keratoconus (EKC), and 161 advanced keratoconus eyes were included for training and internal validation, as well as 52 normal, 31 FFKC, and 36 EKC eyes as a test dataset. The highest-ranked SD-OCT parameters to discriminate FFKC and EKC from normal eyes were Pachymetry_9mm_N (AUC = 0.65) and Epithelium_5mm_SN-IT (AUC = 0.77). In the internal validation and test datasets, the proposed WISE index demonstrated AUC = 0.76 and 0.83 for FFKC, and = 0.92 and 0.94 for EKC, respectively, comparable to Belin-Ambrósio Deviation and Pentacam Random Forest Index, as confirmed by De-Long's test (All P > .10).

Conclusions: Individual OCT-based machine-derived parameters lack sufficient power to discriminate FFKC and EKC from normal corneas, but this can be improved by combining OCT-based information from stroma and epithelium as in this new index. The discrimination accuracy of the WISE index was comparable to existing Scheimpflug-based indices.

Purpose: To explore the correlation between epithelial behavior markers derived from optical coherence tomography (OCT) and topographic inferior-superior asymmetry (I-S), and to compare these epithelial values across different I-S subgroups.

Methods: In this prospective observational study, 526 eyes undergoing refractive surgery evaluation were randomly selected. Each patient underwent imaging examinations, including Placido-disk corneal topography and OCT. Four epithelial parameters-minimum (thinnest), maximum (thickest), difference between minimum and maximum, and standard deviation-were analyzed. Analysis of variance and Kruskal-Wallis tests compared these parameters across I-S subgroups, whereas Pearson correlation assessed the relationship between continuous I-S values and each epithelial parameter. Multiple linear regression evaluated the I-S predictive effect on epithelial metrics. Correlations were investigated considering the entire I-S spectrum and in two separate I-S subgroups (below and above 1.4).

Results: Higher I-S values (I-S > 1.4) corresponded to significantly greater epithelial variability (difference between minimum and maximum, and standard deviation, P < .0001) compared to lower I-S groups. Across all I-S values, moderate, significant correlations were found between I-S and epithelial variability (difference, r = 0.57; standard deviation, r = 0.59; P < .0001). Subgroup analysis indicated that significant correlations between I-S and epithelial variability measures were present only in the high-asymmetry group (I-S > 1.4). Multiple linear regression confirmed that I-S significantly predicts epithelial variability, particularly in this subgroup.

Conclusions: A moderate correlation exists between I-S and epithelial thickness variability, particularly in eyes with high asymmetry, as supported by regression analysis, indicating the predictive value of I-S. However, these epithelial markers are less useful in eyes with low asymmetry.

Purpose: To review the reported outcomes for correction of astigmatism using excimer laser-based corneal refractive surgery techniques and to present distinctly the intricacies of the different ablation profiles.

Methods: Keywords such as "refractive correction," "excimer lasers," "ablation profiles," and "astigmatism" were used for literature research. Inclusion criteria were strict relevance and adequacy to the clinical questions under research, and availability of the abstract in the English language.

Results: Bitoric, cross-cylinder, and custom wavefront-optimized (aberration-neutral) or wavefront-guided treatments are used in modern laser systems to correct astigmatism. From scientific literature reviewed in this article, laser ablation to correct astigmatism was found to produce satisfactory visual outcomes in terms of safety, efficacy, and predictability. Custom ablation respecting postoperative corneal curvature gradient, correcting true corneal astigmatism after eliminating the higher order aberrations, and accurately compensating for possible cyclotorsion will result in patient satisfaction.

Conclusions: Integrating subjective and objective assessment of astigmatism effectively to optimize treatment outcomes is complex, particularly across a wide range of refractive errors. Properly determining how much astigmatism should be incorporated into the treatment is critical. Ignoring ocular residual astigmatism and sculpting the cornea based only on manifest refraction has the penalty that the entire ocular residual astigmatism remains as postoperative surgical residual astigmatism, also resulting in induction of spherical aberrations. Centration, optical zone sizes, cyclotorsion compensation, and use of appropriate treatment algorithms are of prime importance in obtaining favorable outcomes in correction of astigmatism.

Purpose: To evaluate the effectiveness of keratorefractive lenticule extraction (KLEx) in providing superior ocular surface protection compared to femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK), focusing on key dry eye parameters such as tear break-up time (TBUT), Ocular Surface Disease Index (OSDI), Schirmer test, and corneal sensitivity.

Methods: A systematic search was conducted in PubMed, Scopus, Web of Science, and Embase in December 2024, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria required human studies comparing KLEx (small incision lenticule extraction [SMILE]) and FS-LASIK with outcomes related to TBUT, OSDI, Schirmer test, and corneal sensitivity. Statistical analysis was performed using RevMan 5.3, employing a random-effects model to account for clinical heterogeneity. Heterogeneity was evaluated using Higgins' I² statistic, and publication bias was assessed through funnel plots.

Results: This meta-analysis, including 18 studies, compared KLEx (SMILE) and FS-LASIK in terms of dry eye parameters. The findings indicate that KLEx provides superior tear film stability, with significantly longer TBUT at 3 months (MD = 3.267 sec, P < .0001) and 6 months (MD = 3.320 sec, P < .0001). OSDI scores were slightly lower for KLEx, but the difference was not statistically significant. Schirmer test results (MD = 0.820 mm, P = .0001) favored KLEx, suggesting better tear production. KLEx also demonstrated better corneal sensitivity preservation, with significant differences at 1 (MD = 18.48, P < .0001) and 6 (MD = 7.56, P = .02) months, indicating less nerve damage. Sensitivity analyses confirmed the reliability of these findings. These results suggest that KLEx may be the preferable option for patients at risk of postoperative dry eye disease, offering better ocular surface stability and faster recovery.

Conclusions: KLEx offers significant advantages over FS-LASIK in TBUT and corneal sensitivity, indicating better tear film stability and nerve preservation. Both procedures yielded similar results for OSDI and Schirmer test outcomes. These findings suggest that KLEx may be a preferable option for patients at higher risk of postoperative dry eye disease. Future research should focus on standardized protocols and long-term follow-up to strengthen these conclusions.

Purpose: To evaluate the efficacy of refractive lens exchange (RLE) with a trifocal intraocular lens (IOL) implantation by assessing reading performance and visual acuity at near and intermediate distances.

Methods: This was a prospective interventional case series of 27 patients (54 eyes) at a university hospital who underwent a femtosecond laser-assisted RLE with Clareon PanOptix IOL (Alcon Laboratories, Inc) implantation. Visual acuity was tested before surgery and 6 months postoperatively and reading performance was evaluated using the Salzburg Reading Desk (SRD Vision) at near and intermediate distances. With a software-based simulator, the perception of halo and glare were quantified.

Results: The uncorrected and distance-corrected near (40 cm) and intermediate (60 cm) visual acuities improved, with the mean (± standard deviation) postoperative binocular uncorrected visual acuity of 0.03 ± 0.08 logarithm of the minimum angle of resolution (logMAR) at 40 cm and -0.08 ± 0.06 logMAR at 60 cm. The surgery also improved uncorrected reading acuities, with the postoperative binocular uncorrected reading acuity of 0.05 ± 0.08 logMAR at 40 cm and 0.09 ± 0.10 logMAR at 60 cm. The postoperative uncorrected reading acuity matched the preoperative reading acuity with spectacle correction for near (0.04 ± 0.10 logMAR, P = .495). The near vision efficacy index was 0.75 ± 0.12 for conventionally measured visual acuity and 0.99 ± 0.35 for reading acuity. A total of 77.8% of patients reported halo and 14.8% reported glare, although none complained of bothersome photic phenomena.

Conclusions: The RLE surgery effectively restored good uncorrected near and intermediate vision in terms of visual acuity and reading performance. At high luminance and contrast levels, the postoperative uncorrected reading ability matched the preoperative spectacle-corrected performance for near.

Purpose: To analyze the impact of the pupil size on the prediction of the clinical monocular visual acuity (VA) with a representative pupil-dependent extended depth of focus intraocular lens (EDOF IOL).

Methods: An optical bench with a model eye was used to obtain with 2-, 3-, and 4.5-mm pupils (at the IOL plane) the through-focus area under the modulation transfer function (TF-MTFa) of the refractive EDOF AcrySof IQ Vivity (Alcon Laboratories, Inc). The TF-MTFa curve with a 3-mm pupil was correlated with the clinical VA defocus curve (R² = 0.95) of a large sample of pseudophakic patients (n = 107). This group also was split into three cohorts according to pupil size: small (< 3 mm; n = 6), medium (3 to 4 mm; n = 52), and large (> 4 mm; n = 49). Each pupil group showed a differentiated clinical VA defocus curve that was highly correlated with the 2- (R² = 0.97), 3- (R² = 0.97), and 4.5-mm (R² = 0.96) TF-MTFa, respectively. The clinical VA versus MTFa curves were fitted using the formula proposed by the American National Standards Institute to derive for each pupil a new set of fitting coefficients to transform MTFa into expected VA accordingly.

Results: Four new predictive functions of the clinical VA were obtained for the pupil-dependent refractive EDOF IOL: one for the whole sample of patients, which averages out pupillary differences between patients, and three functions that incorporate the influence of the pupil size.

Conclusions: Better prediction of the clinical VA of pseudophakic patients implanted with pupil-dependent refractive EDOF IOLs is achieved with fitting functions that take into account the pupil size.

Purpose: To evaluate the visual and refractive outcomes, retinal optical image quality, and patient satisfaction following implantation of a rotationally asymmetric refractive low addition multifocal intraocular lens (IOL) (Lentis Mplus; Te-leon) during cataract surgery in patients with prior myopic corneal laser refractive correction.

Methods: This observational, retrospective study included 35 eyes (26 patients) with previous laser corneal myopic refractive surgery that were implanted with the LENTIS Mplus (LS-313 MF15) multifocal IOL during cataract surgery. Refractive and visual outcomes were analyzed at 1, 3, and 6 months of follow-up. At the last visit (range: 7 to 130 months), monocular defocus curve and monocular contrast sensitivity were examined. Total ocular aberrometry was obtained with a pyramidal wavefront sensor (Osiris; CSO) at a 4-mm pupil diameter. Patient satisfaction was evaluated with the Quality of Vision (QoV) questionnaire and Near Activity Visual Questionnaire (NAVQ-10).

Results: A statistically significant improvement was observed in uncorrected and corrected distance visual acuity postoperatively (0.09 ± 0.12 and 0.03 ± 0.12 logarithm of the minimum angle of resolution [logMAR], respectively). Postoperative uncorrected near visual acuity remained nearly unchanged at good levels of 0.38 ± 0.23 logMAR and corrected near visual acuity was 0.09 ± 0.10 logMAR. The monocular defocus curve demonstrated high levels of visual acuity achieved at far and intermediate distances along with acceptable levels at near vision. The QoV questionnaire showed lower scores for frequency (29.12 ± 19.55), severity (29.26 ± 17.40), and bothersomeness (25.87 ± 17.42).

Conclusions: This study demonstrated efficacy and safety of a rotationally asymmetric refractive low addition multifocal IOL implanted in eyes with prior myopic corneal ablation. It provided good levels of patient satisfaction and spectacle independence.

Purpose: To evaluate the effectiveness of a blended approach to spectacle independence after cataract surgery using a novel extended depth of focus (EDOF) lens.

Methods: This retrospective comparative study took place at Mosman Eye Centre, Australia. This was a single-site, single-surgeon study evaluating patients who underwent consecutive bilateral cataract surgery with implantation of a novel EDOF lens using a symmetrical (both eyes +1.50 diopter [D] add) or blended (dominant eye +1.50 D, non-dominant +3.00 D) approach. Endpoints included uncorrected (UDVA) and corrected (CDVA) distance visual acuity and intermediate (45 and 60 cm) and near (30 cm) visual acuity at 1 month. Additional endpoints included postoperative refraction, spectacle independence, overall satisfaction with vision, and adverse events.

Results: Overall, 148 eyes of 74 patients were included, 41 patients in the symmetrical group and 33 in the blended group. The mean age was 72.28 ± 8.18 years (range: 50 to 89 years) with 33.78% being men. Both near and distance visual acuity improved significantly for both refractive approaches (P < .001). All eyes (148/148) were within 0.18 D of emmetropia postoperatively. Comparing the two approaches, postoperative distance, intermediate, and near UDVA was significantly better for the blended approach: -0.09 ± 0.05 versus -0.03 ± 0.07 at 6 m (P = .03), 7.97 ± 2.98 N versus 9.12 ± 2.63N at 30 cm (P = .014), .47 ± 2.21 N versus 8.68 ± 2.17 N at 45 cm (P = .001) and 8.32 ± 2.48 N versus 9.12 ± 2.00 N at 60 cm (P = .03). Postoperative adverse events were comparable between the groups and similar to previous reports.

Conclusions: Blended EDOF IOL implantation using +1.50 and +3.00 D addition resulted in excellent distance, intermediate, and near vision, with a high rate of spectacle independence and low rate of reported visual disturbances. Future randomized comparative trials with a larger sample size, longer follow-up, and additional objective assessments of postoperative visual quality, such as contrast sensitivity, are needed to further validate these findings.

Purpose: To report adjustment of different corneal allogeneic intrastromal ring segments (CAIRS) parameters in a group of patients with suboptimal visual and topographic results.

Methods: Thirteen eyes of 13 patients with suboptimal first-stage outcomes in the form of a decrease or lack of improvement in uncorrected (UDVA) or corrected (CDVA) distance visual acuity or complaining of decreased visual quality together with worsening of topographic map were included in this retrospective interventional case series. Adjustment was performed for arc length, width, thickness, placement, or optical zone.

Results: Post-implantation (Intervention-1) mean improvement in UDVA and CDVA compared to preoperatively was 1.5 ± 3 (range: 6 to 3) and 0.2 ± 1.5 (range: 2.5 to 3) lines of vision, respectively. Three lines of UDVA and 0.5 to 3 lines of CDVA were lost in 2 and 5 patients, respectively. Post-adjustment (Intervention-2) mean improvement in UDVA and CDVA compared to preoperatively was 3.6 ± 3 (range: 10 to 0) and 1.15 ± 1.6 (range: 5.5 to 0) lines, respectively. No patient lost any lines of UDVA or CDVA after adjustment. All patients who lost lines after Intervention-1 regained it after adjustment. The Friedman chi-squared test showed a global difference across the three time points for UDVA, CDVA, spherical equivalent (SE), refractive astigmatism (RA), keratometry (steep [Ksteep], flat [Kflat], and mean [Kmean]) (chi-square = 11.7 to 16.8, P ≤ .003). Bonferroni-corrected Wilcoxon tests showed significant improvements for UDVA, SE, RA, Ksteep, Kflat, Kmean, and maximum keratometry (Kmax) between different time points. Before Intervention-1 to after Intervention-2 contrast yielded smaller P values than before Intervention-1 to after Intervention-1 for all parameters, thus showing larger improvements. Kmax showed a statistically significant difference but was not considered important because Kmax after CAIRS implantation is often outside the visual axis.

Conclusions: Adjustments are possible to try and improve-suboptimal results after CAIRS implantation.