Flap Creation Research Articles

Outcomes of Conventional External Dacryocystorhinostomy with and without Mitomycin C: Experience from Eastern Nepal.

Dacryocystorhinostomy (DCR) is the commonest surgery for nasolacrimal duct obstruction. Inhibition of the scarring process within the anastomosis and rhinostomy site which has been attributed to the failure of this procedure, might improve the success rate of DCR. The objective of this study was to evaluate the outcomes of DCR with Mitomycin-C (MMC) and to compare the results of DCR with and without MMC. A hospital based, prospective study was conducted in patients with primary acquired nasolacrimal duct obstruction. Standard conventional DCR was performed upto the level of creation of flaps. Application of MMC 0.2 mg/ml in and around the ostium and underneath the created flaps for two minutes was effected with cotton pledgets. The area was thoroughly washed with normal saline after removal of the pledgets. Rest of the surgery was completed as usual. The patients were followed up on the first postoperative day, one month and three months post surgery. A total of 60 cases, 30 in each group were allocated. The success rate of DCR with MMC was found to be 96.7% compared to 86.7% (p=0.35) in the DCR group at the end of three months duration. Intraoperative application of MMC during conventional DCR surgery provides a comparatively higher success rate than DCR without MMC without posing any extra financial burden and adverse drug reaction to the patient.

CHANGES IN CORNEAL TOPOGRAPHY AFTER SMALL INCISION LENTICULAR EXTRACTION FOR MYOPIC PATIENTS

Background: SMILE does not require the creation of a flap. This reduces the risks associated with flap creation such as dry eye and traumatic flap dislocation. Objective: To assess corneal curvature changes of anterior and posterior surfaces in terms of corneal power, the radius of curvature, and asphericity following SMILE procedure for myopic patients. Patients and Methods: Thiswas A prospective comparative study which included 20 eyes of 10 myopic patients. Spherical equivalent (SE) refraction was from -3 to -8 diopters (D) and refractive astigmatism was ˂ -3 D. All patients were treated for myopia and myopic astigmatism using SMILE procedure in AL NOUR EYE HOSPITAL using (500 kHs, Visumax, Carl Zeiss, Meditec, Jena, Germany) starting from January 2018 till June 2019. Results: A statistically significant decrease in mean keratometric power in the 5 mm zones of the anterior corneal surface was detected after 1month compared with its pre- SMILE values. The mean posterior keratometry power showed insignificant change. The mean anterior corneal curvature (mean radii of curvature) showed a statistically significant increase after 1-month compared to preoperative values. The mean postoperative posterior curvature showed an insignificant change. Asphericity (Q-value) of the anterior corneal surface changed significantly 1-month postoperatively. Q-value of the posterior corneal surface showed insignificant change. A statistically significant decrease in mean spherical equivalent (SE) was detected after 1month compared with its preoperative value. Conclusion: SMILE is safe; give effective high successful refractive results, good stability and the incidence of intraoperative or postoperative complications remains minimal after one month follow up. SMILE causes significant increase in anterior corneal curvature power, Q-value and significant decrease in anterior keratometry, spherical equivalent and, central corneal thickness.

CHANGES IN CORNEAL TOPOGRAPHY AFTER SMALL INCISION LENTICULAR EXTRACTION FOR MYOPIC PATIENTS

Background: SMILE does not require the creation of a flap. This reduces the risks associated with flap creation such as dry eye and traumatic flap dislocation. Objective: To assess corneal curvature changes of anterior and posterior surfaces in terms of corneal power, the radius of curvature, and asphericity following SMILE procedure for myopic patients. Patients and Methods: Thiswas A prospective comparative study which included 20 eyes of 10 myopic patients. Spherical equivalent (SE) refraction was from -3 to -8 diopters (D) and refractive astigmatism was ˂ -3 D. All patients were treated for myopia and myopic astigmatism using SMILE procedure in AL NOUR EYE HOSPITAL using (500 kHs, Visumax, Carl Zeiss, Meditec, Jena, Germany) starting from January 2018 till June 2019. Results: A statistically significant decrease in mean keratometric power in the 5 mm zones of the anterior corneal surface was detected after 1month compared with its pre- SMILE values. The mean posterior keratometry power showed insignificant change. The mean anterior corneal curvature (mean radii of curvature) showed a statistically significant increase after 1-month compared to preoperative values. The mean postoperative posterior curvature showed an insignificant change. Asphericity (Q-value) of the anterior corneal surface changed significantly 1-month postoperatively. Q-value of the posterior corneal surface showed insignificant change. A statistically significant decrease in mean spherical equivalent (SE) was detected after 1month compared with its preoperative value. Conclusion: SMILE is safe; give effective high successful refractive results, good stability and the incidence of intraoperative or postoperative complications remains minimal after one month follow up. SMILE causes significant increase in anterior corneal curvature power, Q-value and significant decrease in anterior keratometry, spherical equivalent and, central corneal thickness.

Clinical analysis of robot-assisted laparoscopic transabdominal preperitoneal inguinal hernia repair

Objective: To explore the clinical value of robot-assisted laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. Methods: We performed a retrospective review of 23 consecutive patients who underwent robotic inguinal hernia repair from January 2018 to December 2019 at Beijing United Family hospital. The patients were all male with mean age 48.8 (17-72) years and BMI 25.8 (21.2-32.6)kg/m(2). Data examined included perioperative bleeding, operative times, length of stay, pain scale ratings and postoperative complication. Results: There were no major complications during the surgeries including no significant intraoperative bleeding, injury to the vas deferens or major vascular structures. There were no conversions to open. No patients received prophylactic antibiotics according to our hospital policy. No surgical site infections were found. All patients were discharged home within the 24-hour postoperative period. The mean operating time of 13 cases of unilateral hernia was 121 (82-165) min, and that of 10 cases of bilateral hernia was 166 (100-315) min. The mean intraoperative blood loss was 13.3 ml (5-25 ml). The average pain score in recovery was 0.96 (0-3). The total length of stay was 28.4 (24.2-37.5) h. During a follow-up period of 3-18 months, none of the patients experienced a recurrent hernia. None experienced chronic pain or discomfort in the operative field. Conclusions: The robotic surgical platform facilitates a new safe, minimally invasive approach to groin hernia. Because of improved ergonomics, visualization and wristed instrumentation, the robotic approach enabled creation of larger peritoneal flaps and had the potential for less injuries. The major advantage to the patient is a shorter hospital stay, and more rapid postoperative recovery and decreased postoperative pain, lower complications and recurrences.

Pedicle internal limiting membrane flap technique for very large macular holes: a preliminary report

BackgroundConventional vitrectomy technique for macular hole surgery has a good outcome in small and medium macular holes, but for very large macular holes (minimum linear diameter higher than 700 μm) other techniques were developed aiming to achieve greater rates of closure and visual acuity gain. The purpose of this article is to report the anatomical and functional outcomes of four very large macular hole (MH) cases which have undergone vitrectomy with the pedicle internal limiting membrane (ILM) flap technique.MethodsThis is a retrospective series of four patients with large MH who were treated with vitrectomy and the pedicle ILM flap technique. Comprehensive ophthalmologic evaluation was performed before surgery and included ETDRS best-corrected visual acuity (BCVA) and spectral domain optical coherence tomography (SD-OCT) for MH measures: height, minimum linear diameter (MLD) and external base diameter. The particular detail of this technique is related to ILM flap creation. During the peeling, the ILM was not removed completely from the retina but was left attached to the edges of the macular hole and subsequently trimmed with the vitrectomy probe using the scissors mode.ResultsFour patients with very large MH underwent PPV and the pedicle ILM flap technique was used to pursue macular closure. Median preoperative BCVA was 20/400 (range: 20/320 to 20/400) and median postoperative BCVA was 20/200 (range: 20/320 to 20/200). Of the 4 cases reported, 3 obtained anatomical closure (75%), and also presented BCVA improvement after surgery, considering the last follow-up visit of each case. No additional procedures were performed in either case. One patient demonstrated no anatomic and functional improvement.ConclusionThe present study describes the first Brazilian case series of very large MH treated by the inverted pedicle ILM flap technique. This technique was associated with anatomic and visual improvement in most cases, and represents an alternative therapeutic approach for large macular holes.Trial Registration Project registered in Plataforma Brasil with CAAE number 30163520.0.0000.5440 and approved in ethics committee from Ribeirão Preto Medical School Clinics Hospital, University of São Paulo—Ribeirão Preto, São Paulo, Brazil (appreciation number 3.948.426 gave the approval).

Damage control hip disarticulation: two-stage operation with index creation of a large medial flap for the septic hip

BackgroundAlthough rarely performed, hip disarticulation (HD) is usually used for the patient with a non-viable leg who is also in extremis. HD was first used for trauma and infection; however, the technique was perfected during the age of hindquarter amputation for osteosarcomas. The operation performed by most surgeons today is still based on the oncological principles of high vessel control and ligation. When this approach has been used in the overwhelmingly infected or mangled extremity, it has resulted in high mortality rates. During the last 20 years, the concept of damage control operation has been embraced by emergency surgeons in all fields. We sought to extrapolate this concept and to apply it to the non-viable lower extremity.MethodsWe describe a new concept of damage control HD, review the technique and discuss our consecutive series of nine patients who underwent the procedure for trauma or necrotizing infection without flap dehiscence or mortality.ResultsAll patients survived to hospital discharge. At time of discharge or at follow-up, six of the nine patients were able to transfer to a wheelchair.DiscussionProper disarticulations for infection need to address these two operative and postoperative issues: damage control debridement with creation of sufficient flap size and thorough postoperative wound care.Level IV

Two-year successful results of femto-LASIK in steep and opacified corneas


 Background: Flap creation is the most critical step of laser in situ keratomileusis (LASIK). The introduction of the femtosecond laser with its uniform flaps, which enhance the accuracy of LASIK, has decreased the risk of flap-related complications like buttonholes and incomplete flaps. We recommended femtosecond laser-assisted LASIK (FS-LASIK) in the presence of superficial corneal opacities.
 Case Presentation: We report a case of a 31-year-old female who reported to the Cornea clinic of the Sohag Center for LASIK and Corneal Surgeries, Sohag, Egypt, complaining of bilateral decreased vision due to refractive error. The uncorrected distance visual acuity (UDVA) and corrected distance visual acuity (CDVA) were 0.01 and 0.7 with a refractive correction of -3.50Ds/ –3.00Dc x 172° in the right eye and 0.01 and 0.6 with a refractive correction of -1.75 Ds/-6.00Dc x164° in the left eye, respectively. Slit-lamp examination of the anterior segment showed bilateral superior vascularized corneal scars and a linear superior conjunctival scar suggestive of old trachoma. Corneal tomographic imaging with a Scheimpflug based tomography device (Oculus Inc., Wetzlar, Germany) revealed a symmetrical bow tie with a very steep cornea without other ectatic changes. The patient underwent bilateral FS-LASIK with an excimer laser. No intraoperative complications occurred. She was followed up for two years with serial corneal topographies and stable post-LASIK results and visual outcomes.
 Conclusions: FS-LASIK, in the presence of superficial corneal opacities, was safe and effective and induced no complications with special precautions. However, these findings are yet to be confirmed using well‐designed clinical studies with larger samples and longer follow-ups.

Incidence and predisposing factors of anterior chamber gas bubbles during femtosecond laser flap creation.

To investigate the incidence and the predisposing factors of anterior chamber (AC) gas bubbles during femtosecond laser (FS) flap creation for laser in situ keratomileusis (LASIK). All patients who underwent FS-LASIK surgery at CMU LASIK Center between January 2013 and May 2016 were retrospective reviewed. Preoperative and intraoperative data including keratometry, white-to-white (WTW) corneal diameter, flap parameters (diameter, thickness, hinge position, and tunnel length) and pulse energy were reviewed and compared between incident group and control group. To determine the risk factors, univariate and multivariate conditional logistic regression were used; the eye was unit of analysis. The incidence of AC gas bubbles was 1.6% (22 out of 1378 eyes). The median WTW in the AC bubbles group was 11.5 mm (range 11.1-12.1), which was significantly different from the control group (11.7 mm, range 10.5-12.8, P=0.021). The result of the median WTW minus the flap diameter in the AC bubbles group was 2.5 mm (range 2.1-3.2), which was statistically different to the control group (2.7 mm, range 1.5-3.8, P=0.008). The logistic regression analysis showed that the result of the WTW minus the flap diameter in the AC bubbles group had an adjusted odds ratio of 0.204 (95%CI; 0.056-0.747, P=0.016). Development of AC gas bubbles during FS flap creation is not an uncommon event in Asian eyes which typically have a small WTW. The flap diameter when adjusted relatively to the WTW is a predisposing factor to the possibility of AC gas bubbles occurrence.

Management of interface irregularity due to high energy after uneventful SMILE

A 48-year-old man was referred for the management of suboptimal vision after an uneventful bilateral small-incision lenticule extraction (SMILE) procedure, performed 6 weeks previously. His corrected distance visual acuity (CDVA) was 6/9p and 6/12 in the right eye and the left eye, respectively. Corneal topography was regular, and higher-order aberrations were within the acceptable range. Clinical photographs in retroillumination revealed rough and irregular interface in both eyes, probably because of the use of a relatively high-energy cut index of 40 (200 nJ) to perform SMILE. The case was managed by CIRCLE software–enabled flap creation with phototherapeutic keratectomy (PTK), followed by enhancement with flap relift and topography-guided LASIK 3 months later in both eyes, which resulted in improvement in the CDVA to 6/4.5 in the right eye and 6/9p in the left eye. CIRCLE software–enabled flap creation and PTK might result in satisfactory visual outcomes in cases of interface irregularity after SMILE.

Modified deep anterior lamellar dissection for corneal opacity during vitrectomy: case reports

BackgroundTo introduce a modified deep anterior lamellar dissection technique to improve visibility during surgery for vitreoretinal diseases with coexisting corneal opacity.Case presentationTwo patients with retinal detachment and coexisting corneal blood staining or corneal decompensation underwent modified deep anterior lamellar dissections followed by vitrectomy. The modified deep anterior lamellar dissection techniques, unlike the dissection and removal of corneal lamellar in a typical deep anterior lamellar keratoplasty, included the creation and preservation of a deep lamellar corneal flap, the retroillumination to visualize and easily remove the remaining opaque stroma on the Descemet membrane, and the big air bubble technique in the eye with endothelial decompensation. The patient’s own cornea flap was sutured back after vitrectomy was done. The modified dissection techniques provided adequate fundus view during vitrectomy while removing as less corneal tissue as possible and decreasing the surgical complications and the requirement of a fresh cornea. Postoperatively, in case 1, the corneal blood staining was gradually absorbed and the vision improved from light perception to counting fingers. In case 2, even though the cornea remained cloudy and the vision was poor, the cornea endothelial decompensation was stable and asymptomatic. Both retinas were attached after silicone oil removal at 6-month follow-up.ConclusionsThis modified and limited deep anterior lamellar corneal dissection procedure appears to be a useful alternative to penetrating keratoplasty, ophthalmic endoscope and temporary keratoprosthesis during the vitrectomy with coexisting corneal opacity.

Biomechanical Changes to the Cornea from LASIK Flap Creation Resulting in Inaccurate Ablations and Suboptimal Refractive Outcomes with Topographic-Guided Ablation.

PurposeThis study documents a biomechanical corneal change related to corneal flap creation in certain patients leading to an irregular ablation pattern and an inaccurate refractive outcome.MethodsThis retrospective study included consecutive eyes treated with primary LASIK Contoura using the LYRA Protocol. All LASIK procedures were performed on the WaveLight EX500 excimer laser. Flaps were created with either the Alcon WaveLight FS200 femtosecond laser or the Moria M2 microkeratome. Eyes that were off by greater than or equal to 0.50 diopters (D) sphere or cylinder from the targeted goal within 3 months after surgery were identified. Topographical, higher order aberration, and epithelial maps were created. Of these eyes, approximately 10% of eyes were found to have undergone a biomechanical change upon flap creation that led to an inaccurate outcome.ResultsSix representative cases are presented that demonstrate the biomechanical change, outcomes, and treatment. All patients demonstrated an elliptical, irregular ablation pattern on post-operative topography, lateralized the thinnest point of the cornea relative to the corneal apex on Pentacam pachymetry maps, and irregular corneal epithelial thickening at the periphery of the elliptical ablation.ConclusionA biomechanical change during flap creation can occur in certain types of corneas during LASIK flap creation and subsequent treatment with topographic-guided ablation leading to an irregular ablation and suboptimal refractive outcomes.

Refractive surgery beyond 2020.

Refractive surgery refers to any procedure that corrects or minimizes refractive errors. Today, refractive surgery has evolved beyond the traditional laser refractive surgery, embodied by the popular laser in situ keratomileusis or 'LASIK'. New keratorefractive techniques such as small incision lenticule extraction (SMILE) avoids corneal flap creation and uses a single laser device, while advances in surface ablation techniques have seen a resurgence in its popularity. Presbyopic treatment options have also expanded to include new ablation profiles, intracorneal implants, and phakic intraocular implants. With the improved safety and efficacy of refractive lens exchange, a wider variety of intraocular lens implants with advanced optics provide more options for refractive correction in carefully selected patients. In this review, we also discuss possible developments in refractive surgery beyond 2020, such as preoperative evaluation of refractive patients using machine learning and artificial intelligence, potential use of stromal lenticules harvested from SMILE for presbyopic treatments, and various advances in intraocular lens implants that may provide a closer to 'physiological correction' of refractive errors.

Quantitative shadowgraphy of aerosol and droplet creation during oscillatory motion of the microkeratome amid COVID-19 and other infectious diseases.

To quantify the atomization of liquid over the cornea during flap creation using microkeratome using high-speed shadowgraphy. Laboratory study. Laboratory investigational study. In an experimental setup, flap creation was performed on enucleated goat's eyes (n = 8) mounted on a stand using One Use-Plus SBK Moria microkeratome (Moria SA) to assess the spread of aerosols and droplets using high-speed shadowgraphy. Two conditions were computed. A constant airflow assumed uniform air velocity throughout the room. A decaying jet assumed that local air velocity at the site of measurements was smaller than the exit velocity from the air duct. With the advancement of the microkeratome across the wet corneal surface, the atomization of a balanced salt solution was recorded on shadowgraphy. The minimum droplet size was ∼90 μm. The maximum distance traversed was ∼1.8 m and ∼1.3 m assuming a constant airflow (setting of refractive surgery theater) and decaying jet condition (setting of an operating theater with air-handling unit), respectively. The microkeratome-assisted LASIK flap creation seemed to cause spread of droplets. The droplet diameters and velocities did not permit the formation of aerosols. Therefore, the risk of transmission of the virus to the surgeon and surgical personnel due to the microkeratome procedure seemed to be low.

Quality of life and satisfaction among physicians after wavefront-optimized vs topography-guided laser vision correction.

To assess satisfaction, quality of life, occupational impact, and clinical outcomes of physicians who have undergone laser vision correction (LVC) using either wavefront-optimized (WFO) or topography-guided (TG) excimer laser ablation profile with femtosecond laser flap creation. Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio, USA. Retrospective survey study. A 12-question survey was sent to all physicians who underwent laser in situ keratomileusis or photorefractive keratectomy at the Cole Eye Institute between 2011 and 2018 on the WaveLight Allegretto Wave Eye-Q Laser (Alcon Laboratories, Inc.). Visual outcomes were obtained from patient charts. Two hundred thirty-five physicians (454 eyes) met the study's inclusion criteria, including 181 physicians (353 eyes) who underwent WFO LVC and 54 physicians (101 eyes) who underwent TG LVC. One hundred seventeen physicians (49.8%) responded to the survey and reported an overall satisfaction rate of 98.3% among all physicians receiving LVC with 96.6% reporting they would have the procedure again. Visual outcomes showed a high level of surgical predictability, efficacy, and safety among WFO and TG eyes, with a higher percentage of eyes that received TG ablation achieving 20/10 vision (22% vs 4%, P < .0001) and 20/15 vision (87% vs 69%, P < .01) when compared with WFO eyes. Physicians who had undergone LVC with either WFO or TG excimer laser ablation reported high satisfaction and quality-of-life improvements. Both groups achieved excellent visual outcomes, with a higher percentage of TG eyes achieving 20/10 and 20/15 vision.

Current management strategies for atypical macular holes.

This review evaluates the current surgical management options for refractory and atypical macular holes (MH) and proposes a treatment paradigm for approaching complex cases. A review of literature was performed to deliver a thorough discussion of the epidemiology and pathophysiology of MH as well as the historic evolution of surgical management strategies. With this context established, an update on recent surgical advances for management of large, chronic, and highly myopic MH is provided. New small MH may be adequately treated with pars plana vitrectomy, while those ≥300 μm should undergo internal limiting membrane (ILM) peel. For MH ≥400 μm with risk factors for failure, primary intervention should involve creation of an ILM flap and various methods of flap creation are discussed. For very large MH ≥700 μm or in refractory cases, autologous retinal transplants and other recently proposed procedures should be considered. While typical MHs enjoy high initial surgical success rates, atypical and refractory MH require additional intraoperative and postoperative considerations to maximize surgical success and optimize vision. With many techniques at the surgeon's disposal, patient selection becomes critical to improving outcomes.

Is the Anterior component separation technique sufficient for ventral hernia?

Background: Large ventral hernia continued to possess a great challenge to general surgeon. Historically a variety of permutation and combination of repair have evolved. However, no single surgical repair can meet the requirement completely. A combination of component separation accompanied with mesh repair needs to be studied and analyse. Aim: To study percentage of patients required only anterior or both (anterior and posterior) component separation. Methods: 30 Patient undergoing component separation were evaluated. Tissue repair comprises of component separation with creation of flap from rectus sheath in order to breach midline and creation of new midline. This followed by preperitoneal (retro rectus) or above the rectus muscle polypropylene soft mesh enforcement with complete cover over mesh by anterior rectus sheath. So, in our patients mesh never fixed above the rectus sheath. Results: In our study we realised that most of the large defect hernias are required more anterior compartment separation. Both compartments separation is required only in complex, and more than 10 cm defect of anterior abdominal wall hernia. Conclusion: Anterior component separation is often required and enough for abdominal wall reconstruction with good cosmetic contour without any recurrence than both component separation.

The outcome of femtosecond laser in situ keratomileusis compared to conventional laser insitu keratomileusis in myopic patients

AbstractIntroduction: This is a prospective comparative clinical study conducted to assess the safety , effectiveness, and complications of Intralase femtosecond laser (FSL) compared to Moria M2 microkeratome (MK) in high myope. Methods : This study consisted of 51 myopic eyes, divided into two groups( A & B) . Twenty-five eyes in group A in which the flap was created by Intralase FSL, while twenty-six eyes in group B in which the flap was created by Moria M2 MK. Refractive , keratometric and flap complications were compared preoperative and 6 months postoperative by using the intraoperative subtraction pachymetry . (Scheimpflug imaging (CSO, Florence, Italy). Results:No substantial difference was found as regarding postoperative manifest sphere ,astigmatic and keratometry .In group A mean postoperative actual flap thickness was98.12 ± 16.1 μm and in group B it was100.6 ± 20.1 μm with statistically significant difference P value( 0.001).Conclusion: Both the femtosecond laser and the mechanical microkeratome are safe and effective in correcting myopia, with no statistically significant difference during 6-month follow-up between the two groups. The femtosecond laser has better flap creation than the microkeratome . Key words :FSL ,Moria M2 ,Myope

Intraoperative flap-related complications in FemtoLASIK surgeries performed with Visumax® femtosecond laser: A ten-year Romanian experience.

Incidence and clinical results of intraoperative flap and interface-related complications were investigated after Femtosecond-LASIK surgery, where flap creation was performed with VisuMax® femtosecond laser. A retrospective 10-year cohort study was conducted including all eyes treated for all refractive errors by Femtosecond-LASIK technique. All the flaps were made by the same refractive surgeon with the VisuMax® (Carl Zeiss Meditec) femtosecond laser. We report the intraoperative flap and interface-related complications in these eyes, also describing their management. The study included 4,032 eyes. Flap and interface-related complications were: opaque bubble layer (OBL) 21.18%, suction loss 1.29%, difficult docking 0.69%, difficult dissection of the flap 0.59%, bleeding from limbal blood vessels 0.35%, de-epithelialization of the flap 0.12%, and interface debris 0.025%. These situations were appropriately addressed, with favorable outcomes. Flap creation is an important step in LASIK surgery. The predictability and safety have improved since the flap incision is assisted by a femtosecond laser, but complications of the flap and interface can still occur during the flap creation. Refractive surgeons should be aware and properly manage any unusual situation.

Simulation of the biomechanical effects induced by laser in situ keratomileusis (LASIK) for different levels of ablation in normal corneas.

To employ a finite element (FE) stress model to simulate laser in situ keratomileusis (LASIK) surgery and its biomechanical consequences. The basic geometrical model we used for the cornea was patient-specific on which we manually incorporated seven simulations: three simulations evaluating the effect of a 120, 140 and 180 μm flap (without ablation); three simulations evaluating ablation depths of 40, 80 and 120 μm (with a 120 μm flap); and one control model, without any simulated surgical intervention. In all simulations, stress values were greatest in the centre of the cornea. Furthermore, when comparing the different treatments, stress values were highest in the cornea with the deepest ablation, and were lowest in the non-treated cornea. Specifically, peak effective stresses were 0.031, 0.028 and 0.025 MPa in 120, 80 and 40 µm ablation depths, respectively. In our model, the depth of tissue penetration using ablation or flap creation was correlated with tissue loads-the thinner the residual stromal bed is, the greater are the stresses occurring as a result of the same IOP. We based our model geometry on patient specific scans, allowing for customisation of the treatment to the patient's corneal structure.

A novel intraocular lens designed for sutureless scleral fixation: surgical series.

To report a retrospective series of patients implanted with a novel hydrophilic acrylic single-piece intraocular lens (IOL) designed for sutureless scleral fixation (FIL-SSF Carlevale lens, Soleko, Italy) injectable through a 2.2-mm incision. Seventy-eight patients with minimum 6-month follow-up were divided into 6 groups: dropped nucleus, luxated IOL, trauma, aphakia, IOL exchange, and Marfan's syndrome. Surgery included peritomy and scleral flap creation at 3 and 9 o'clock position. The IOL was then injected and grasped with 25G forceps through a hole created 2 mm posterior to the limbus underneath the sculped scleral flap. The study included 78 patients (mean age 71.9 ± 12.6 years) and average follow-up 10.2 ± 4.2 months. Average surgery duration was 69.4 ± 26.1 min and vision significantly improved from 0.86 ± 0.56 logMAR to 0.38 ± 0.42 logMAR at 6 months post-operative (p < 0.001). Intraoperative complications included corneal edema, retinal tears, and vitreous bleeding each in 2/78 patients (2.5%); 1/78 (1.3%) localized retinal detachment and 1/78 (1.3%) rupture of one T-shaped IOL harpoon. Post-operative complications included 4/78 (5.1%) cystoid macular edemas, 2/78 retinal tears, 2/78 retinal detachments, 2/78 developed ocular hypertension, and 1/78 corneal decompensation requiring DSAEK. The Carlevale lens is designed for sutureless intrascleral fixation and can be successfully used in a variety of indications including difficult trauma cases with good rehabilitation. An implant requires experience and delicate manipulation.