Preoperative Best Spectacle-corrected Visual Acuity Research Articles

EndoArt®: results in patients with glaucoma drainage devices

EndoArt® (Eye Yon Medical, Ness Ziona, Israel) is anovel artificial corneal inner layer transplant and an innovative treatment alternative for patients at high risk for graft failure after posterior lamellar corneal transplantation (EK). We present the initial results of the EndoArt® implantation in patients with glaucoma drainage devices (GDD). In this study 12eyes with GDD were retrospectively evaluated. All had ahigh risk of transplant rejection in cases of EK (previous other glaucoma surgery in addition to GDD, n = 8, condition following Descemet membrane endothelial keratoplasty, DMEK, n = 9, uveitis, n = 2, or synechiae, n = 2). The EndoArt® was secured with agas bubble and one to three holding sutures. The preoperative and postoperative best spectacle-corrected visual acuity (BSCVA) and central corneal thickness (CCT) were determined. The need for additional gas injections (rebubbling) was analyzed. Octafluoropropane (C3F8) 12% was used in nine patients and sulfur hexafluoride (SF6) 20% in three patients as anterior chamber tamponade to ensure adhesion of the EndoArt®. At least one rebubbling was necessary in four eyes. The preoperative BSCVA was 1.6 (± 0.5) logMAR and significantly improved to 1.1 (± 0.6) logMAR after 12weeks (p = 0.028). The preoperative CCT was 719 µm ± 145.7, which significantly decreased to 622.4 µm ± 174.9 after six weeks (p = 0.004) and to 591.7 µm ± 190.8 after 12weeks (p = 0.096). In one eye, the prosthesis was explanted due to a suspected fibrotic remodelling of the cornea following multiple previous DMEKs. EndoArt® led to asignificant improvement in BSCVA and reduction in CCT; however, there was ahigh rebubbling rate in patients with GDD. In high-risk patients, the use of EndoArt® may be advantageous in avoiding graft failure after EK.

Postoperative, but not preoperative, central corneal thickness correlates with the postoperative visual outcomes of Descemet membrane endothelial keratoplasty.

Descemet membrane endothelial keratoplasty (DMEK) restores visual acuity in patients with progressive corneal endothelial diseases such as Fuchs endothelial corneal dystrophy (FECD). However, patients often prefer to delay the surgery as long as possible, even though outcomes are poorer in advanced FECD. A recent study proposed that preoperative central corneal thickness (CCT) of ≥625 μm associated with worse best spectacle-corrected visual acuity (BSCVA) after DMEK for FECD. Since this threshold could signal to both surgeons and patients when to perform DMEK, we further explored the relationship between CCT and BSCVA with a retrospective cohort study. The cohort consisted of all patients with FECD who underwent DMEK in a tertiary-care hospital in 2015-2020 and were followed for 12 months. Extremely decompensated corneas were not included. Relationships between preoperative CCT and BSCVA on days 8 and 15 and months 1, 3, 6, and 12 were examined with Pearson correlation analyses. Eyes with preoperative CCT <625 or ≥625 μm were also compared in terms of postoperative BSCVA. Relationships between postoperative CCT and final BSCVA were also explored. The cohort consisted of 124 first-operated eyes. Preoperative CCT did not correlate with postoperative BSCVA at any timepoint. Eye subgroups did not differ in postoperative BSCVA. However, postoperative CCT at 1-12 months correlated significantly with 12-month BSCVA (r = 0.29-0.49, p = 0.020-0.001). Thus, postoperative, but not preoperative, CCT correlated with postoperative BSCVA. This phenomenon may reflect factors that distort preoperative CCT measurements but disappear after surgery. This observation and our analysis of the literature suggest that while there is a relationship between CCT and post-DMEK visual acuity, preoperative CCT measurements may not always adequately reflect that relationship and may therefore not be a reliable predictor of DMEK visual outcomes.

Long-term Outcomes of Collagen Crosslinking for Early Keratoconus.

PurposeTo evaluate the long-term outcomes of collagen crosslinking in early keratoconus.MethodsThirty eyes of twenty patients with early keratoconus were enrolled. Uncorrected visual acuity (UCVA), best spectacle corrected visual acuity (BSCVA), objective refraction, subjective refraction, corneal topography and pachymetry were assessed before and 3, 6, 12 months and 9 years after performing collagen crosslinking surgery.ResultsThe patients' mean age was 31.2 5.59 years at nine-year follow-up (range, 25–44 years). The means of preoperative UCVA and BSCVA were 0.57 0.34 and 0.15 0.12 logMAR, respectively, and these values remained stable at the final follow-up (P = 0.990 and P = 0.227, respectively). The mean objective spherical equivalent decreased considerably from –6.00 4.05 D preoperatively to –5.22 3.71 D at the final follow-up (P 0.05). The mean subjective spherical equivalent was –4.25 2.87 D preoperatively and this value was stable at the last follow-up (P = 0.92). No considerable difference was found between the post- and preoperative mean objective cylinder values (P = 0.34). The mean subjective cylinder value changed significantly from –4.05 1.85 D preoperatively to –3.1 1.42 D at the final follow-up (P 0.05). The mean central corneal thickness was 496.97 45.95 µm preoperatively and this value was stable at nine-year follow-up (P = 0.183). No significant difference was found between the pre- and postoperative mean maximum and mean minimum corneal curvature values (P = 0.429 and P = 0.248, respectively). There were no significant postoperative complications.ConclusionCorneal crosslinking in early keratoconus seems to be a safe procedure that can effectively stabilize UCVA, BSCVA, subjective SE and CCT, while improving objective spherical equivalent.

Techniques, Outcomes, and Complications of Preloaded, Trifolded Descemet Membrane Endothelial Keratoplasty Using the DMEK EndoGlide.

To describe 2 insertion techniques, outcomes, and complications of preloaded, trifolded Descemet membrane endothelial keratoplasty (DMEK) cases using the DMEK EndoGlide inserter. This retrospective, consecutive case series analyzed the first 35 cases using the DMEK EndoGlide performed between October 2018 and October 2019 at a single center. Preloaded, trifolded DMEK tissues were delivered through a fluid-injected or pull-through technique. To inject the tissue, a burst of fluid was delivered into the lumen of the injector with a second instrument. Postoperatively, best-spectacle corrected visual acuity (BSCVA), pachymetry, graft survival, and complications were assessed. Thirty-five eyes of 29 patients underwent DMEK alone (n = 11), with cataract surgery (n = 21), or with additional surgeries (n = 3). Of these, 19 (54.3%) grafts were injected. Video analysis revealed a median time of 3.5 minutes from graft insertion to opening for gas insertion. Median preoperative BSCVA of 0.398 logMAR improved to 0.097 logMAR (P = 0.02) at 9 months. Median pachymetry decreased from 619 μm to 551 μm (P = 0.03) at 9 months. Median donor endothelial cell count of 2890.5 cells/mm2 reduced to 2123 cells/mm2 (26.6% endothelial cell loss; P = 0.008) 6 months postoperatively. One (2.9%) graft failed due to inverted marking at the eye bank and subsequent reverse implantation. Pre-loaded, tri-folded tissues can be implanted with acceptable levels of endothelial cell loss. We describe a no-touch method of injecting pre-loaded, tri-folded tissue and highlight incorrect marking as a potential complication. This may not be identifiable intraoperatively due to lack of scroll formation.

Descemet Membrane Endothelial Keratoplasty versus Ultrathin Descemet Stripping Automated Endothelial Keratoplasty: A Multicenter Randomized Controlled Clinical Trial

To compare best spectacle-corrected visual acuity (BSCVA), endothelial cell density (ECD), refractive astigmatism, and complications after Descemet membrane endothelial keratoplasty (DMEK) and ultrathin Descemet stripping automated endothelial keratoplasty (UT-DSAEK). Prospective, multicenter randomized controlled trial. Fifty-four pseudophakic eyes of 54 patients with corneal endothelial dysfunction resulting from Fuchs endothelial corneal dystrophy were enrolled in 6 corneal centers in The Netherlands. Participants were allocated to DMEK (n= 29) or UT-DSAEK (n= 25) using minimization randomization based on preoperative BSCVA, recipient central corneal thickness, gender, age, and institution. Donor corneas were prestripped and precut for DMEK and UT-DSAEK, respectively. Six corneal surgeons participated in this study. The primary outcome measure was BSCVA at 12 months after surgery. Central graft thickness of UT-DSAEK lamellae measured 101 μm (95% confidence interval [CI], 90-112 μm). Best spectacle-corrected visual acuity did not differ significantly between DMEK and UT-DSAEK groups at 3 months (0.15 logarithm of the minimum angle of resolution [logMAR] [95% CI 0.08-0.22 logMAR] vs. 0.22 logMAR [95% CI 0.16-0.27 logMAR]; P= 0.15), 6 months (0.11 logMAR [95% CI 0.05-0.17 logMAR] vs. 0.16 logMAR[95% CI 0.12-0.21 logMAR]; P= 0.20), and 12 months (0.08 logMAR [95% CI 0.03-0.14 logMAR] vs. 0.15 logMAR [95% CI 0.10-0.19 logMAR]; P= 0.06). Twelve months after surgery, the percentage of eyes reaching 20/25 Snellen BSCVA was higher in DMEK compared with UT-DSAEK (66% vs. 33%; P= 0.02). Endothelial cell density did not differ significantly 12 months after DMEK and UT-DSAEK (1870 cells/mm2 [95% CI 1670-2069 cells/mm2] vs. 1612 cells/mm2 [95% CI 1326-1898 cells/mm2]; P= 0.12). Both techniques induced a mild hyperopic shift (12 months:+0.22 diopter [D; 95% CI -0.23 to 0.68 D] for DMEK vs.+0.58 D [95% CI 0.13-1.03 D] for UT-DSAEK; P= 0.34). Descemet membrane endothelial keratoplasty and UT-DSAEK did not differ significantly in mean BSCVA, but the percentage of eyes achieving 20/25 Snellen vision was significantly higher with DMEK. Endothelial cell loss did not differ significantly between the treatment groups, and both techniques induced a minimal hyperopic shift.

Accelerated Corneal Cross-Linking: Efficacy, Risk of Progression, and Characteristics Affecting Outcomes. A Large, Single-Center Prospective Study

We examined the efficacy and preoperative characteristics that affect outcomes of accelerated (9 mW/cm2 for 10minutes) corneal cross-linking (CXL). Prospective single-center observational cohort study. We enrolled 612 eyes of 391 subjects with progressive keratoconus (n= 589), pellucid marginal degeneration (n= 11), and laser insitu keratomileusis-induced ectasia (n= 12). We evaluated best spectacle-corrected visual acuity (BSCVA), topography, refraction, endothelial cell density, corneal thickness, haze, intraocular pressure, and visual function before and 12months after the CXL procedure. We tabulated the proportion of those with progression of maximum keratometry (Kmax). We included participant's race, age, sex, and the presence of preoperative apical scarring and environmental allergies in a multivariable linear regression model to determine the effect of these characteristics on outcomes. At 1 year there was no significant change in mean Kmax (n= 569). Progression of Kmax was higher in subgroups with a baseline Kmax >58 diopters (n= 191) and those 14-18 years of age (n= 53). Preoperative BSCVA, Kmax, refraction, corneal cylinder, coma, central corneal thickness, and vision function were statistically and clinically significant predictors of outcomes (P< .001). Preoperative apical scarring led to worsening haze (P= .0001), more astigmatism (P= .002), more central corneal thinning (P= .002), and was protective to the endothelium (P= .008). Race, age, and sex affected some outcomes. Mean Kmax was stable at 1 year after accelerated CXL. Younger patients and those with a higher preoperative Kmax need to be monitored closely for progression. Preoperative BSCVA, topography, refraction, CCT, and apical scarring were significant predictors of outcomes.

Descemet Membrane Endothelial Keratoplasty in Irreversible Corneal Edema Due to Herpes Simplex Virus Endotheliitis.

To report the clinical outcome and postoperative course of Descemet membrane endothelial keratoplasty (DMEK) in irreversible corneal edema due to herpes simplex virus (HSV) endotheliitis. This is a retrospective, noncomparative, interventional case series. Nineteen eyes of 19 patients underwent standard DMEK combined with cataract surgery (triple DMEK) between May 2016 and April 2018. All patients received perioperative oral acyclovir (ACV) and prednisolone. Patients were followed up on day 1, on day 7, at 1 month, and then at 3 monthly intervals. Preoperative and postoperative best spectacle-corrected visual acuity (BSCVA), graft clarity, pachymetry, and endothelial cell loss after 1 year were recorded. Postoperative complications and HSV recurrence were noted until the last follow-up visit. All eyes were phakic with variable grades of cataract with a preoperative BSCVA of 1.0 logarithm of the minimum angle of resolution or worse. The mean follow-up period was 19.3 ± 5.4 months. After 1 year, 14 (73.7%) eyes achieved a BSCVA of 0.3 or better. Seventeen (89.5%) patients had a clear graft at the last visit without any rejection episode. One graft failed after 16 months. After 3 months, the mean pachymetry reduced from 667.1 ± 62.1 to 512.8 ± 27.1 μm (P < 0.001). The mean endothelial cell loss after 1 year was 36.7 ± 13.4%. Three (15.8%) eyes had recurrence: one with recurrent endotheliitis and 2 with dendritic keratitis despite oral ACV, which responded to oral valacyclovir and ACV eye ointment. One patient had re-recurrence of endotheliitis after 20 months. DMEK in persistent corneal edema after HSV endotheliitis remains challenging but has encouraging outcomes. The postoperative course may be complicated by HSV recurrence. Prophylactic oral antivirals for 1 year or more and topical antivirals are useful for the prevention of recurrence.

Does Preoperative or Postoperative Graft Thickness Influence Postoperative Visual Acuity in Descemet Stripping Automated Endothelial Keratoplasty for Advanced Pseudophakic Bullous Keratopathy?

To describe the evolution of best spectacle-corrected visual acuity (BSCVA) after Descemet stripping automated endothelial keratoplasty (DSAEK) for very advanced pseudophakic bullous keratopathy (PBK) and to determine whether the thickness of corneal grafts in DSAEK surgery for advanced PBK correlates with BSCVA 6 months postoperatively. In a prospective, single-center, observational study, 141 eyes treated with DSAEK surgery were studied, from patients requiring posterior lamellar transplantation for advanced PBK. Graft thickness was measured during the surgery and in vivo 6 months later. The primary end point was BSCVA in LogMAR at 6 months. BSCVA 6 months after surgery was slightly correlated with 6 months graft thickness (r = 0.24, P = 0.01), but not with preoperative graft thickness (r = 0.01, P = 0.93). After adjusting for preoperative BSCVA, a better 6 months BSCVA was best associated with thinner grafts at 6 months (P < 0.01), but not with preoperative graft thickness (P = 0.80). BSCVA after DSAEK was significantly related to graft thickness measured 6 months after surgery, suggesting that better BSCVA after DSAEK is related to a decrease in graft thickness after surgery and not to the use of a thinner graft during surgery. This decrease may be because of the good health of the endothelium, but this result may be biased because of the intrastromal scars inherent in severe PBK. This study shows that DSAEK is a good option for advanced PBK but has low visual acuity potential recovery because of stromal scarring. Therefore, a penetrating keratoplasty may be indicated to obtain maximal recovery of visual acuity or for monocular patients.

Résultats réfractifs et facteurs pronostiques de succès du traitement du kératocône par anneaux intracornéens : étude rétrospective sur 75 yeux

To define the prognostic factors for success and to evaluate the predictability of intracorneal ring segments (ICRS) in the treatment of keratoconus. In this retrospective study conducted at the University Hospital of Nantes, Keraring ICRS were implanted in 75 eyes of 65 patients with keratoconus. Best spectacle corrected visual acuity (BSCVA), manifest refraction and corneal topography were analysed. To define prognostic factors, we compared the results of 2 groups: "IMP" (gain of at least 2 lines of BSCVA) and "ROS" (the others). We evaluated the predictability of the nomogram with a mathematical model proposed by Pena-Garcia et al. (IOVS 2012). At 3 months, BSCVA improved from 0.3 to 0.2 logMAR (P<0.05). A total of 61% of the patients experienced a gain of at least 1 line of BSCVA. Spherical equivalent decreased by 2.32 diopters (D), cylinder decreased by 2.47 D, and maximal keratometry by 2.62D (P<0.05 for each compared with preoperative values). A total of 90% of the patients whose BSCVA did not improve achieved a significant refractive improvement. A preoperative BSCVA>0.3 logMAR is a prognostic factor for gain of at least 2 lines of BSCVA (P=1.6E-3). Predictability was fair: only 43% had a±1D difference from the spherical equivalent predicted by the nomogram. There was no statistically significative difference between gain or loss of BSCVA predicted by the mathematical model and the postoperative results. ICRS are visually and refractively effective. Predictability could be improved by using mathematical models and knowledge of prognostic factors for success, allowing for better patient selection.

Prediction of Descemet Membrane Perforation During Deep Anterior Lamellar Keratoplasty in Patients With Keratoconus With Stromal Scar.

To report big-bubble deep anterior lamellar keratoplasty (DALK) in patients with keratoconus with corneal stromal scar, and to investigate factors that can influence intraoperative Descemet membrane (DM) perforation. A retrospective study included patients with keratoconus with central stromal scar that underwent DALK using the big-bubble technique. Best spectacle-corrected visual acuity (BSCVA), keratometry, minimum corneal thickness (MCT), stromal scar depth, and endothelial cell density (ECD) were recorded. Receiver operating characteristic (ROC) curves were analyzed to predict an intraoperative perforation related to stromal scar. Thirty-eight eyes of 38 patients with keratoconus (mean age: 30.0±9.2 years) were included in this study. Thirty-four eyes had successful DALK; in four eyes, the procedure was converted to penetrating keratoplasty because of DM macroperforations. Successful big-bubble formation was achieved in 24 of 38 (63.2%) eyes, whereas in 10 eyes, manual dissection was used to complete the DALK. Mean preoperative and postoperative second year BSCVA were 1.3 (±0.4) and 0.5 (±0.2) logarithm of the minimum angle of resolution (P<0.001), keratometry values were 65.5±7.4 and 42.8±7.8 diopters (P<0.001), and ECD were 2,740±359 and 2,279±452 cells/mm (P<0.001), respectively. Using ROC analysis, the area under curve value to predict DM perforation was found to be 0.792 (scar/MCT ratio, P=0.04) and the best cutoff point for scar depth/MCT ratio was 53%. Big-bubble DALK is effective in patients with keratoconus with stromal scars. Scar depth/MCT ratio seems to predict the DM perforation.

Corneal Densitometry as a Predictive Diagnostic Tool for Visual Acuity Results After Descemet Membrane Endothelial Keratoplasty

We sought to investigate correlations between preoperative corneal backscatter with visual acuity results after Descemet membrane endothelial keratoplasty (DMEK) in eyes with corneal endothelial disorders. Retrospective interventional case series. The first 551 consecutive patients with DMEK at the Center of Ophthalmology, University of Cologne who had available preoperative corneal densitometry values (corneal light backscatter measured in gray scale units) measured with the Scheimpflug-based Oculus Pentacam corneal densitometry module were screened for eligibility. Best spectacle-corrected visual acuity (BSCVA) results were retrospectively correlated with densitometry data. Densitometry data were obtained in 4 corneal layers (ie, anterior, central, posterior, and total layers) and 4 annuli. Pre- and postoperative BSCVA results were correlated with densitometry data. Receiver operating characteristic analyses were performed. Four hundred twelve eyes were available for the analyses. Visual acuity results improved significantly after DMEK surgery at 3, 6, 12, and 24months of follow-up (P < .001). Corneal backscatter correlated moderately with preoperative BSCVA results. Moderate associations to postoperative BSCVA results could predominantly be found between densitometry values of the anterior and central layer more pronounced in the center of the cornea for all postoperative timepoints. The posterior layer correlated worst with postoperative gain in BSCVA. Receiver operating characteristic analyses revealed that the best predictive power of densitometry values was for the 2-6mm annular zone of the cornea. Corneal backscatter in eyes with corneal endothelial disorders correlates with postsurgical BSCVA results after DMEK surgery. Therefore, early DMEK surgery seems to have a positive impact on long-term BSCVA results.

Outcomes of Descemet Membrane Endothelial Keratoplasty in Eyes With a Previous Descemet Stripping Automated Endothelial Keratoplasty Graft.

To analyze the outcomes of Descemet membrane endothelial keratoplasty (DMEK) in eyes with previous Descemet stripping automated endothelial keratoplasty (DSAEK). This retrospective interventional case series included 26 eyes (26 patients) that underwent DMEK to replace a previous DSAEK graft with at least 6 months of follow-up. The outcome measures were indications for surgery, best spectacle-corrected visual acuity (BSCVA), endothelial cell density, rebubbling rate, rejection, and failure. Patient age was 71.9 ± 12.6 years. The average follow-up time after DMEK was 15.1 ± 10.6 months. Indications for DMEK were DSAEK graft failure (69%) and a DSAEK suboptimal visual outcome (31%). BSCVA of the entire cohort (n = 26) improved from 1.33 ± 0.78 logMAR preoperatively to 1.04 ± 0.78 and 1.06 ± 0.89 logMAR at 6 months postoperatively and at the last follow-up, respectively (P = 0.019 and P = 0.033). BSCVA among eyes without visual comorbidities (n = 13) improved from 0.84 ± 0.50 logMAR preoperatively to 0.55 ± 0.47 and 0.51 ± 0.49 logMAR at 6 months postoperatively and at final follow-up, respectively (P = 0.023 for both). Of these eyes, 84.6% had improvement in BSCVA at 6 months postoperatively and at last follow-up. In the subgroup of 8 eyes with DMEK for suboptimal visual outcomes after DSAEK, BSCVA improved from 0.81 ± 0.44 to 0.52 ± 0.35 logMAR at final follow-up (P = 0.024). When excluding eyes with visual comorbidities, BSCVA of this subgroup (n = 5) improved from 0.54 ± 0.32 to 0.36 ± 0.25 logMAR at final follow-up (P = 0.038). BSCVA of this subgroup at 6 months postoperatively was not significantly different from preoperative BSCVA, when including visual comorbidities (n = 8, 0.75 ± 0.60 logMAR, P = 0.79) and when excluding visual comorbidities (n = 5, 0.40 ± 0.28 logMAR, P = 0.621). Endothelial cell density decreased from 2753 ± 307 cells/mm to 1659 ± 655 cells/mm 6 months after surgery (39.7% loss, P = 0.005). Three eyes (11.5%) required rebubbling, and 5 eyes (19.2%) had secondary graft failure at 2 to 20 months. DMEK is effective for replacing previous DSAEK not only for graft failure but also for suboptimal visual outcomes.

Long-term Visual Outcomes Comparing Descemet Stripping Automated Endothelial Keratoplasty and Penetrating Keratoplasty

To compare 5-year visual acuity and refraction outcome in Descemet stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK) for Fuchs endothelial dystrophy (FED) or bullous keratopathy (BK) in Asian eyes. Prospective interventional case series. We analyzed 828 consecutive cases of DSAEK (423) or PK (405) for FED and BK from the Singapore Cornea Transplant Registry performed from 1991 to 2011. Our main outcome measures were best spectacle-corrected visual acuity (BSCVA) with astigmatism (cylinder) and spherical equivalent (SE) over 5 years of follow-up. Mean age was 67.5 ± 11.5 years (50.1% male, 49.9% female) and majority was Chinese (76.6%, n= 634) in our multiracial Asian population. DSAEK eyes had significantly better BSCVA (P < .001-.037) with lower SE (P < .001-.017) and cylinder (P < .001), independent of surgical indication, compared to PK over 5 years. DSAEK was superior to PK over 5 years (P < .001-.026) in FED, but only over 3 years in BK (P < .001-.031). DSAEK in FED eyes had significantly better BSCVA compared to BK eyes (P= .006 at 4-year follow-up). DSAEKs with preoperative BSCVA < 1.3 logMAR had significantly better visual outcomes than cases with ≥ 1.3 logMAR (P < .001-.042). PKs had significantly higher postoperative refractive correction than DSAEKs, with no significant influence of the surgery indication. In our study cohort, DSAEK provided significantly better long-term BSCVA and lower astigmatism than PK over 5 years of follow-up. Visual outcomes of DSAEK for FED were better than BK. In some analyses for years 1-3, analysis of covariance adjustment indicated that this DSAEK-associated better long-term BSCVA was independent of better preoperative vision in DSAEK eyes.

Glued intraocular lens implantation for eyes with inadequate capsular support: Analysis of the postoperative visual outcome.

Aim:The aim of this study is to analyze the postoperative visual outcomes of fibrin glue-assisted, suture-less posterior chamber (PC) intraocular lens (IOL) implantation technique in eyes with inadequate capsule support at a tertiary eye care hospital in South India.Setting and Design:This is a retrospective, nonrandomized case series.Patients and Methods:This study analyzes 94 eyes which underwent PC-IOL implantation by fibrin glue-assisted, suture-less technique. All patients who had IOL implants by the fibrin glue-assisted PC-IOL technique from August 2009 to January 2014 were included in the study. Intra- and post-operative complications were analyzed. The postoperative best spectacle-corrected visual acuity (BSCVA) was evaluated and recorded at the end of 6 months.Statistical Analysis:The data were analyzed using SPSS version 16.1 (SPSS Inc., Chicago, Illinois, USA) using two sample paired t-test and independent t-test.Results:A total of 94 eyes of 92 patients that underwent glued IOL implantation over a period of 5 years were analyzed. Out of 94 eyes, 77 eyes (84.6%) maintained or improved on their preoperative BSCVA (P = 0.012).Conclusion:We conclude that glued IOL implantation is a feasible option in rehabilitating patients with aphakia without adequate capsular support.

Preliminary Results of Femtosecond Laser-assisted Cataract Surgery in a Private Clinic in Iran.

Purpose:To report the preliminary results of femtosecond laser-assisted cataract surgery in Iranian patients.Methods:This prospective case series included 21 eyes of 21 patients with cataract. Mean patient age was 66.7 ± 10 years. The patients underwent femtosecond-laser assisted cataract surgery (VICTUS Femtosecond Laser Platform: Bausch + Lomb) and intraocular lens (IOL) implementation in Bina Eye Hospital, Tehran, Iran between May and October, 2014. Visual outcomes, intraocular pressure (IOP), and complications were evaluated three months after surgery.Results:Mean preoperative best-spectacle corrected visual acuity (BSCVA) was 0.40 ± 0.21 logMAR which significantly improved to 0.02 ± 0.03 logMAR three months postoperatively (P < 0.001). Mean preoperative IOP was 17.88 ± 2.70 mmHg which significantly decreased to 12.5 ± 1.51 mmHg three months after operation (P < 0.001). Mean duration of operation for these patients was 29.30 ± 8 minutes and mean femtosecond laser process time was 4.20 ± 2 minutes. In terms of complications, 9 patients developed fine subconjunctival hemorrhage and eye redness and 2 patients had mild corneal edema which all subsided within less than 7 days. Serious complications such as anterior or posterior capsule tears were not encountered.Conclusion:Femtosecond laser-assisted cataract surgery is a relatively new method of cataract

Evaluation of factors affecting visual acuity after Descemet stripping automated endothelial keratoplasty.

To elucidate the factors affecting visual acuity after Descemet stripping automated endothelial keratoplasty (DSAEK). We reviewed consecutive patients who underwent primary DSAEK for corneal endothelial dysfunction at Inouye Eye Hospital from January 2010 through January 2015 and who had a follow-up of at least 6months. Fifty-four eyes of 49 patients (24 men and 25 women) were enrolled; the mean age was 72.5±8.7years. Medical charts were retrospectively examined for best spectacle-corrected visual acuity (BSCVA), intraocular pressure, keratometric value, keratometric cylinder, grade of preoperative corneal edema, preoperative graft thickness, and endothelial cell density (ECD) before and at 1, 3, 6, 12, and 24months after surgery. A multiple regression analysis was used to evaluate the factors associated with BSCVA at 3, 6months, and 1year after surgery. Explanatory variables included age, sex, preoperative factors (BSCVA, degree of corneal edema, donor ECD, and graft thickness), and factors at each time point (keratometric value, keratometric cylinder, and intraocular pressure). The mean logarithms of the minimum angle of resolution (logMAR) BSCVA preoperatively and at 1, 3, 6, and 12months after surgery were 1.03±0.49, 0.42±0.26, 0.29±0.21, 0.24±0.20, and 0.22±0.20, respectively. Multiple regression analysis showed that preoperative BSCVA alone was significantly associated with BSCVA at 3, 6, and 12months. A better preoperative BSCVA was associated with a better BSCVA after DSAEK, which suggests that DSAEK should be considered earlier than stromal changes such as subepithelial fibrosis occurrence.

A Randomized Multicenter Clinical Trial of Ultrathin Descemet Stripping Automated Endothelial Keratoplasty (DSAEK) versus DSAEK

To compare visual acuity, refraction, endothelial cell density (ECD), and complications after Descemet stripping automated endothelial keratoplasty (DSAEK) and ultrathin DSAEK (UT-DSAEK). A multicenter, prospective, double-masked, randomized, controlled clinical trial. From 66 patients with irreversible corneal endothelial dysfunction dues to Fuchs' dystrophy who enrolled from 4 tertiary medical centers in the Netherlands, 66 eyes were studied. Participants were centrally randomized to undergo either UT-DSAEK or DSAEK, based on preoperative best spectacle-corrected visual acuity (BSCVA), recipient central corneal thickness, patient age, and recruitment center. Donor corneas were precut by a single cornea bank. Participants underwent ophthalmic examinations preoperatively and 3, 6, and 12 months after the operation, including manifest refraction, BSCVA using an Early Treatment Diabetic Retinopathy Study chart, and endothelium imaging. BSCVA 12 months postoperatively. Preoperative BSCVA did not differ between patients undergoing DSAEK (0.35 logarithm of the minimum angle of resolution [logMAR] [95% confidence interval {CI} 0.27-0.43]; n= 32) and UT-DSAEK (0.37 logMAR [95% CI 0.31-0.43]; n= 34; P= 0.8). BSCVA was significantly better after UT-DSAEK compared with that after DSAEK at 3 months (0.17 logMAR [95% CI 0.13-0.21], n= 31 vs. 0.28 logMAR [95% CI 0.23-0.33], n=31; P= 0.001), 6 months (0.14 logMAR [95% CI 0.10-0.18], n= 30 vs. 0.24 logMAR [95% CI 0.20-0.28], n=30; P= 0.002), and 12 months (0.13 logMAR [95% CI 0.09-0.17], n= 33 vs. 0.20 logMAR [95% CI 0.15-0.25], n= 29; P= 0.03). Refraction, ECD loss (40% at 3 months; P < 0.001), donor loss (DSAEK n= 2 vs. UT-DSAEK n= 3 [relative risk {RR} 1.4 {95% CI 0.24-7.5}; P= 0.7]), and graft dislocation (DSAEK n= 5 vs. UT-DSAEK n= 5 [RR 1.0 {95% CI 0.34-3.33}; P= 0.9]) did not differ between UT-DSAEK and DSAEK. Donor thickness was significantly thinner for UT-DSAEK (101 μm [95% CI 93-110 μm]; range 50-145 μm) than for DSAEK (209 μm [95% CI 196-222 μm]; range 147-289 μm; P < 0.001). This study indicates that compared with DSAEK, UT-DSAEK results in faster and better recovery of BSCVA with similar refractive outcomes, endothelial cell loss, and incidence of complications.

Influence of Early Descemet Stripping Endothelial Keratoplasty on Visual Outcomes in Pseudophakic Corneal Edema

Longstanding corneal edema can lead to anterior stromal scarring that may limit visual acuity following Descemet stripping endothelial keratoplasty (DSEK). The ideal time to perform DSEK to prevent permanent changes is unclear. Our aim is to determine whether earlier DSEK is associated with improved visual outcomes. Cohort study. Setting: Institutional. Total of 120 eyes of patients who underwent DSEK for corneal edema following cataract surgery (CE); 87% of eyes had a diagnosis of Fuchs dystrophy. Post-DSEK visual acuity was compared in patients who underwent DSEK ≤6months vs >6months after CE. Linear and logistic regression were performed to assessthe relationships between DSEK timing and best spectacle-corrected visual acuity (BSCVA) while accounting for baseline preoperative patient characteristics. Postoperative best-corrected visual acuity 6months after DSEK (POM6 BSCVA). Median CE-to-DSEK time was 8.62 (interquartile range [IQR] 12.28) months (n= 120). Overall median preoperative VA and POM6 BSCVA were 0.54 (IQR 0.68) and 0.24 (IQR 0.16), respectively. Median POM6 BSCVA was better in patients with CE-to-DSEK time ≤6months (median 0.18, IQR 0.19) vs >6months (median 0.30, IQR 0.21) (P= .014). A significant relationship was found between CE-to-DSEK time and POM6 BSCVA (coefficient= 0.002, P= .033), accounting for preoperative vision and pachymetry. Patients who underwent DSEK ≤6months after CE were more likely to achieve POM6 BSCVA better than 20/40 (odds ratio= 3.73 P= .035). Performing earlier DSEK for pseudophakic corneal edema appears to be associated with improved vision. Further prospective study is warranted to determine the optimal time to perform DSEK in patients with pseudophakic corneal edema.

Visual Outcomes of Successful versus Failed Big-Bubble Deep Anterior Lamellar Keratoplasty for Keratoconus.

Purpose:To compare the visual outcomes of deep anterior lamellar keratoplasty (DALK) for keratoconus with and without successful big-bubble formation.Methods:In this retrospective comparative study, a total of 289 consecutive eyes from 257 patients underwent DALK using the big-bubble technique. In cases where the big bubble could not be accomplished, manual stromal dissection down to Descemeton membrane (DM) was performed using a crescent knife. Visual acuity and refractive outcomes were compared between the bare DM group (Group 1) and manual dissection group (Group 2).Results:A bare DM was successfully achieved in 229 (79.2%) eyes and manual dissection was performed in 60 (20.8%) eyes. The study groups were comparable in terms of age (P = 0.79), preoperative best-spectacle corrected visual acuity (BSCVA) (P = 0.15), and follow-up duration (P = 0.73). Postoperative BSCVA was significantly better in Group 1 than in Group 2 throughout follow-up (P < 0.05). In Group 2, BSCVA was significantly lower in eyes with advanced keratoconus as compared to those with moderate keratoconus (P = 0.007). At final follow-up, BSCVA ≤ 0.30 logarithm of minimum angle of resolution (logMAR) was achieved in 82.1% of eyes in Group 1 versus 54.5% of eyes in Group 2 (P < 0.001). Groups 1 and 2 were comparable in terms of postoperative spherical equivalent refractive error (P = 0.61) and keratometric astigmatism (P = 0.39).Conclusion:Retention of the posterior corneal stroma which occurs with manual dissection during failed big bubble formation in DALK is associated with lower visual acuity as compared to achieving a bare DM.

Causes that influence the detachment rate after Descemet membrane endothelial keratoplasty.

To investigate Descemet graft (DG) detachment rate after Descemet membrane endothelial keratoplasty (DMEK) in relation to DG position. A total of 175 consecutive pseudophakic eyes that underwent DMEK (175 eyes for Fuchs endothelial dystrophy) from September 2009 through February 2014 at the Tübingen Eye Hospital DG position were studied retrospectively by surgical video at the end of an operation. A group of 45 eyes showed a decentration of the DG with a stromal gap of ≥1.5mm over at least 3clock hours between the descematorhexis edge and the DG. DG detachment was documented at a mean follow-up of 13.9 ± 3.7months after surgery. DG detachment was defined as a detachment of 20% or more of the DG surface area. Various donor characteristics and patient characteristics were analyzed. The best spectacle-corrected visual acuity (BCVA) in the group of eyes with central well-positioned DG differed significantly from those of eyes with decentered DG. The preoperative BCVA in the central well-positioned DG group was 0.63 ± 0.40 logMAR, and in the decentered DG group 0.91 ± 0.51 logMAR (P < 0.001). The postoperative BCVA in the group of eyes with central well-positioned DG was 0.12 ± 0.11 logMAR, and in the group with decentered DG 0.23 ± 0.29 logMAR (P < 0.001). Endothelial cell density and patient characteristics such as age, gender, and intraocular pressure did not differ significantly between the two groups. The group of eyes with central well-positioned DG showed DG detachment in 12%; the group with decentered DG findings had DG detachment in 87% (P < 0.001)at the 12 month follow up. The present findings demonstrate the importance of central well-positioned DG and the relation of disease severity. Central well-positioned DG may reduce the incidence of DG detachment. Overlapping of the donor DG and the host Descemet membrane seems to be responsible for DG detachment. One possible way to enhance graft adhesion could be a larger descematorhexis, which avoids an overlapping. The second possible way could be not waiting too long for surgery to reduce disease severity.