Journal of refractive surgery最新文献

Purpose: To evaluate the long-term safety and efficacy of simultaneous total corneal wavefront-guided transepithelial photorefractive keratectomy (TCWG-TransPRK) with accelerated corneal cross-linking (CXL) in mild to moderate keratoconus, incorporating corneal biomechanics as objective markers of structural stability.

Methods: This prospective, interventional, single-center study included patients with mild to moderate keratoconus. All underwent TCWG-TransPRK (maximum planned stromal ablation: 55 µm) followed by accelerated CXL (30 mW/cm² for 3 minutes; total fluence: 5.4 J/cm²). Follow-up was conducted at 24 hours, 1 week, and 1, 3, 6, and 12 months. Primary outcomes were safety and efficacy, with stress-strain index version 2 (SSI v2) proposed as a key objective marker of biomechanical stability. Additionally, refractive accuracy, tomography, and epithelial remodeling were evaluated.

Results: Thirty-eight eyes from 19 patients were analyzed. At 12 months, uncorrected distance visual acuity improved from 0.80 ± 0.36 to -0.03 ± 0.10 logarithm of the minimum angle of resolution (P < .0001), with 87% achieving 20/20 and all 20/40 or better. Corrected distance visual acuity improved (P < .0001), with no Snellen line loss. Refractive accuracy was high (89% within ±1.00 diopter). SSI v2 increased significantly (P < .0001), indicating enhanced intrinsic stiffness. No keratoconus progression was observed. Epithelial thickness increased nasally and temporally, correlating with changes in spherical aberration and vertical trefoil.

Conclusions: Despite the use of accelerated CXL parameters, TCWG-TransPRK with CXL improved vision and enhanced biomechanical stability, as evidenced by a significant increase in SSI v2. This provides an objective structural marker for monitoring and customizing keratoconus care. These findings support the procedure as a safe and effective option for non-progressive mild to moderate keratoconus.

Purpose: To systematically evaluate the effect of different centration methods on postoperative visual quality in patients with refractive error undergoing corneal refractive surgery.

Methods: Overall, 3,140 eyes from 65,604 records were retrieved through a comprehensive search of eight databases. Thirteen studies were included in the meta-analysis to evaluate the impact of centration methods on visual quality outcomes.

Results: Postoperative decentration was significantly lower in the coaxially sighted corneal light reflex (CSCLR)-centered group than in the entrance pupil center (EPC)-centered group (P < .05). The proportion of spherical equivalent (SE) within ±0.50 diopters (D) were significantly better in the CSCLR-centered group (P = .001). However, no significant differences were found in postoperative uncorrected distance visual acuity (UDVA), postoperative corrected distance visual acuity (CDVA), the proportion of eyes achieving 20/20 or better UDVA, loss of two or more lines of CDVA, or astigmatism (all P > .05). Induced coma was significantly lower in the CSCLR-centered group (P < .00001), with no significant difference in sphere or other higher order aberrations (HOAs). Significant differences in HOAs were observed between angle kappa of 0.2 mm or greater and angle kappa less than 0.2 mm groups (P = .03), although no significant differences were found in postoperative UDVA, SE, sphere, or horizontal coma/vertical coma (all P > .05).

Conclusions: CSCLR centration ablation might have a potential advantage over EPC centration in achieving better postoperative outcomes (SE residuals, and induced coma) after corneal refractive surgery according to the currently available low-quality evidence. When the preoperative angle kappa is large, an angle kappa adjustment is suggested. More high-quality trials are required in future research.

Purpose: To determine the visual outcomes and patient satisfaction in patients undergoing cataract surgery who had previous corneal refractive surgery with implantation of enhanced monofocal intraocular lenses (IOLs).

Methods: This was an ambispective, comparative pilot study conducted at Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, Delhi, India. Thirty-two eyes of 21 patients with a history of prior corneal refractive surgery presenting with cataract in one or both eyes were included in the study. Sixteen eyes were included in each group: enhanced monofocal IOL and standard monofocal IOL. They were evaluated at postoperative 1 day, 1 week, 1 month, and 3 months. The uncorrected and corrected distance (UDVA and CDVA), intermediate (UIVA and CIVA), and near (UNVA and CNVA) visual acuity, contrast sensitivity (CS), and subjective quality of vision were compared between the two groups.

Results: The UDVA was 0.20 ± 0.12 and 0.27 ± 0.10 logarithm of the minimum resolution (logMAR) (P = .08), CDVA was 0.05 ± 0.07 and 0.11 ± 0.10 logMAR (P = .07), UIVA was 0.20 ± 0.13 and 0.31 ± 0.17 logMAR (P = .08), CIVA was 0.10 ± 0.11 and 0.18 ± 0.13 logMAR (P = .05), UNVA was 0.32 ± 0.22 and 0.41 ± 0.13 logMAR (P = .08), and CNVA was 0.06 ± 0.07 and 0.11 ± 0.10 logMAR (P = .09) in the enhanced and standard monofocal IOL groups, respectively. The contrast sensitivity was significantly better in the enhanced monofocal IOL group (1.41 ± 0.18) as compared to the standard monofocal IOL group (1.27 ± 0.16; P = .03). The overall patient satisfaction was higher in the enhanced monofocal IOL group (P = .02).

Conclusions: Implantation of enhanced monofocal IOLs in patients with cataract and previous corneal refractive surgery provided better contrast sensitivity and overall higher patient satisfaction with comparable uncorrected distance, intermediate, and near visual acuity as compared to the standard monofocal IOL group.

Purpose: To compare the efficacy of topical nepafenac alone versus nepafenac combined with cyclopentolate for pain management after photorefractive keratectomy (PRK) through a comprehensive evaluation of pain intensity, stinging, tearing, light sensitivity, analgesic use, and sleep disturbance.

Methods: This was a retrospective comparative study using data from a randomized controlled trial registry. A total of 160 patients undergoing PRK were analyzed. Patients were randomized to receive a standard nepafenac regimen either alone or with the addition of perioperative cyclopentolate 1%. Pain, stinging, tearing, and light sensitivity were rated on a visual analog scale (0 to 10) twice daily for 5 postoperative days. Sleep disturbance and analgesic use were also recorded.

Results: The nepafenac-only group reported significantly lower pain score means over the 5 days compared to the nepafenac + cyclopentolate group (3.48 ± 2.25 vs 5.42 ± 3.20, P < .001). Secondary outcomes also favored the nepafenac-only group with lower reported levels of stinging sensation (1.72 ± 1.88 vs 5.86 ± 3.36, P < .001), tearing (4.43 ± 3.32 vs 5.45 ± 3.60, P < .001), and light sensitivity (3.75 ± 3.32 vs. 4.47 ± 3.60, P < .001). Moreover, sleep disturbance was less frequent in the nepafenac-only group during the first two postoperative nights (P < 0.01).

Conclusions: Contrary to theoretical expectations, adding cyclopentolate to nepafenac therapy worsened postoperative pain outcomes after PRK. For optimal pain management, a regimen of nepafenac alone appears superior to the combination therapy approach.

Purpose: To compare the predicted and actual corneal ablation depth in wavefront-guided laser in situ keratomileusis (WFG LASIK) and keratorefractive lenticule extraction (KLEx).

Methods: This prospective, randomized, contralateral eye study included 26 patients 22 years or older with sphere between -0.75 to -8.00 diopters and 3.00 diopters of cylinder or less undergoing WFG LASIK and KLEx performed by a single surgeon at a large academic hospital. Actual ablation depth was calculated from preoperative and postoperative central corneal thickness. The iDesign aberrometer (Johnson & Johnson Vision) and VisuMax 500 femtosecond laser (Carl Zeiss Meditec AG) were used to derive predicted ablation depth for WFG LASIK and KLEx, respectively. Analyses included t-tests and mixed-effects linear regression.

Results: Actual ablation depth was greater than predicted (66.5 ± 27.0 vs 56.3 ± 22.9 µm, P < .001) for WFG LASIK and less than predicted (69.0 ± 25.0 vs 73.6 ± 24.3 µm, P = .04) for KLEx. The difference between actual and predicted ablation depth was -4.6 ± 10.6 µm in KLEx and 10.2 ± 14.8 µm in WFG LASIK (P < .001). Postoperative spherical equivalent was not significantly different between WFG LASIK and KLEx eyes (P = .53). LASIK was independently associated with a greater absolute difference between actual and predicted ablation depth compared to KLEx (β: 6.2; 95% CI: 1.7 to 10.7; P = .02).

Conclusions: Corneal ablations were deeper than predicted after WFG LASIK and shallower than predicted after KLEx. WFG LASIK was independently associated with greater ablation depth inaccuracy, but there was no difference in postoperative spherical equivalent between WFG LASIK and KLEx.

Purpose: To evaluate visual, refractive, and quality-of-vision outcomes after cataract surgery with a low-addition rotationally asymmetric refractive multifocal intraocular lens (Lentis Comfort Mplus LS-313 MF15; Teleon) in eyes with prior hyperopic corneal laser refractive surgery.

Methods: This was a retrospective observational study of 26 eyes (26 patients) implanted with the LENTIS Comfort Mplus LS-313 MF15 after uneventful surgery. Distance, intermediate, and near visual acuity, manifest refraction, ocular/corneal wavefront aberrations, contrast sensitivity, and defocus curves were assessed preoperatively and at 1, 3, and 6 months and at the final visit. Subjective quality was measured with the Quality of Vision (QoV) questionnaire.

Results: At 6 months and the final visit, uncorrected (UDVA), corrected (CDVA), uncorrected near (UNVA), and corrected near (CNVA) visual acuity improved to 0.10 ± 0.14, 0.05 ± 0.06, 0.27 ± 0.22, and 0.08 ± 0.10 logarithm of the minimum angle of resolution (logMAR), respectively (all P < .05). UIVA and CDIVA were 0.12 ± 0.07 and 0.10 ± 0.09 logMAR, respectively. Refractive cylinder decreased to -0.40 ± 0.38 diopters (D) (P < .05); mean spherical equivalent at 6 months was 0.00 ± 0.70 D. Ocular root mean square for total, astigmatism, coma, asymmetry, HOAs, spherical-like, and coma-like aberrations were 0.59 ± 0.36, 0.42 ± 0.28, 0.20 ± 0.12, 0.05 ± 0.03, 0.39 ± 0.28, 0.16 ± 0.12, and 0.30 ± 0.20 µm, respectively. Defocus showed 0.05 ± 0.01 logMAR at 0.00 D, 0.13 ± 0.01 at -1.50 D, and 0.27 ± 0.20 at -2.50 D; contrast sensitivity remained within normal limits. QoV scores were 32.97 ± 24.31 (frequency), 30.47 ± 22.19 (severity), and 28.59 ± 21.32 (bothersomeness). Corneal higher order aberrations (HOAs) and angle kappa correlated with postoperative uncorrected acuity, especially at intermediate and near.

Conclusions: The aberration-neutral, rotationally asymmetric LENTIS Comfort Mplus LS-313 MF15 provided safe, predictable rehabilitation in eyes after hyperopic corneal surgery, with high-quality distance/intermediate vision and low photic phenomena. Preoperative HOAs and angle kappa significantly influenced postoperative uncorrected vision.

Purpose: To evaluate the clinical outcomes of ray-tracing-guided femtosecond laser-assisted laser in situ keratomileusis (FS-LASIK) in the patients with a difference of greater than 0.50 diopters (D) between subjective and wavefront refractions at the corneal plane.

Methods: This retrospective study included 80 eyes (45 patients). The wavefront refraction was measured by InnovEyes sightmap (Alcon Laboratories, Inc). All patients underwent ray-tracing-guided FS-LASIK with the customized ablation profile following ray-tracing calculation adjusted by Mi optimized strategies. Visual acuity and refractive error were evaluated over 3 months, postoperatively.

Results: The mean preoperative spherical equivalent (SEQ), subjective sphere diopter, and cylinder diopter of the included eyes were -6.82 ± 1.64, -6.15 ± 1.81, and -1.34 ± 1.01 D, respectively. At the 3-month postoperative follow-up visit, 98% of eyes achieved the uncorrected visual acuity (UDVA) of 20/20 and the mean UDVA was -0.08 ± 0.05 logarithm of the minimum angle of resolution. None of the treated eyes had a worse corrected distance visual acuity (CDVA). The R² value was 0.972 in the linear regression analysis of SEQ. The SEQ of 99% of eyes was within 1.00 D. The postoperative astigmatism in 88% of eyes was within 0.25 D. The mean difference vector was 0.04 D@81°. The arithmetic and geometric means of correction index were 1.08 and 1.05, respectively.

Conclusions: This study demonstrated that ray-tracing-guided FS-LASIK offers superior outcomes in myopia correction. It highlighted that the surgery was also effective, safe, and predictable for the eyes with a difference of greater than 0.50 D between subjective and wavefront refractions, suggesting that more patients can benefit from this customized surgery.

Purpose: To evaluate the safety and efficacy of accelerated corneal cross-linking (A-CXL) using hypo-osmolar riboflavin solution (HRS) in patients with keratoconus and corneal thickness (CT) thinner than 400 µm and compare outcomes based on intraoperative CT.

Methods: This retrospective, non-randomized study included 76 eyes of 69 patients with progressive keratoconus who underwent A-CXL using HRS. Patients were divided into two groups based on intraoperative CT: thinner than 400 µm and 400 µm or thicker. Endothelial cell density (ECD), visual acuity, refractive outcomes, topographic parameters, and higher order aberrations (HOAs) were assessed preoperatively and postoperatively at 3, 6, and 12 months.

Results: No significant ECD reduction was observed in either group at 12 months (P = .504, P = .695). Visual acuity improved significantly in both groups (each P < .05) without intergroup differences (uncorrected: P = .797, corrected: P = .301). Thinnest CT increased significantly from month 3 to 12 in both groups (each P < .05). The thinner than 400 µm group showed a significant reduction in maximum keratometry (P = .014), whereas the 400 µm or thicker group remained stable (P = .064). HOAs did not change significantly in both groups (each P > .05). Permanent corneal haze (grade 1 in two patients, grade 2 in two patients) developed in four patients (two per group); none required corneal transplantation.

Conclusions: A-CXL using HRS appears to be a safe and effective treatment for progressive keratoconus in thin corneas, preserving endothelial integrity. Comparable visual and topographic outcomes suggest that A-CXL remains effective even when intraoperative CT remains thinner than 400 µm.

Purpose: To evaluate the predictive utility of preoperative simulated night vision disturbance (NVD) psychological testing for postoperative visual disturbances and investigate the influence of pupil size on visual quality following bilateral keratorefractive lenticule extraction (KLEx). A prospective case-control study design was used.

Methods: A total of 121 eyes (121 patients) that underwent KLEx for myopia and myopic astigmatism at the Zhongshan Ophthalmic Center from May 2024 to July 2024 were analyzed. These patients were stratified into large and small pupil groups based on preoperative pupil diameters measured with Sirius (CSO). Participants completed a simulated NVD psychological test, preoperative questionnaire, and objective and subjective visual quality measurement. Visual quality was assessed using the Objective Scattering Index (OSI), modulation transfer function (MTF) cut-off, Strehl ratio (SR), wavefront aberrations, contrast sensitivity under four lighting conditions, and NVD survey. Follow-up visits occurred at 1 week and 1, 3, and 6 months postoperatively. Generalized estimating equations were employed to analyze changes in visual quality over time within groups and differences between groups at various time points.

Results: Simulated NVD test outcomes were predictive of postoperative NVDs in 85% of the large pupil group and 74% of the small pupil group. The large pupil group exhibited more severe NVDs at 1 and 3 months postoperatively (P = .015 and .001, respectively). Preoperative NVD severity scores were significantly higher than at any postoperative time point (P < .05), and 92% of participants deemed the preoperative test necessary. OSI, MTF cut-off, SR, and contrast sensitivity did not significantly differ between groups at any time point. MTF cut-off values returned to baseline at 1 month in the small pupil group (P = .214) and at 3 months in the large pupil group (P = .761). By 6 months, spherical aberrations increased significantly in the large pupil group (P < .01) but remained stable in the small pupil group (P = .342). At 6 months postoperatively, the small pupil group showed significant improvements in contrast sensitivity under all lighting conditions, whereas the large pupil group improved only under photopic conditions.

Conclusions: Visual quality temporarily declines after KLEx but progressively recovers, with faster recovery in patients with smaller pupils. Adaptation to NVDs is also faster in this group. Preoperative simulated NVD psychological testing is a valuable predictive tool for postoperative NVDs, although it tends to overestimate symptom severity compared to actual postoperative outcomes.