Update on Keratophakia

Visual results are reported for 23 cases of keratophakia for the correction of surgical aphakia followed from 12 to 48 months. Seventeen of the 23 patients had final visual acuities of 20/40 or better. The average residual visual overrefraction was 1.87 ± 1.79 diopters (mean ± SE), with an increase of postoperative astigmatism of 1.70 ± 1.33 diopters. Complications included interface deposits and peripheral epithelial deposits that did not interfere with vision. One patient had an anterior chamber penetration and subsequent penetrating keratoplasty, and two patients had lenticules removed because of corneal edema secondary to increased intraocular pressure. The major disadvantages of keratophakia are the complexity of the procedure and the time required (4 to 6 months) to achieve best-corrected spectacle visual acuity. However, because this procedure is extraocular, it is a better choice than secondary intraocular lens implantation for patients who are unilaterally aphakic and for the young patient.     

Epikeratoplasty. The surgical correction of aphakia, myopia, and keratoconus

Thirty-five patients have had 39 consecutive epikeratoplasty procedures (12 adult aphakic, 9 pediatric aphakic, 12 myopic, and 6 keratoconic eyes) by the same surgeon, using commercially prepared lenticules. The lenticule remained totally clear in 85% of eyes. Two lenticules were removed due to infection and scarring; four lenticules had minimal scarring and did not require removal. Spectacle-corrected acuity was worse than one line from the preoperative spectacle-corrected acuity in 58% of the adult aphakic eyes; however, 75% were 20/50 or better postoperatively. Fifty percent were within 2 diopters (D) of emmetropia and 92% within 3 D. All pediatric aphakic patients showed an improvement in best-corrected acuity, and 83% of eyes at 6 months were within 2 D of emmetropia; by 1 year a 3.4-D average myopic shift had occurred. Two of the six eyes (33%) using the original myopia technique were within 2 D of emmetropia, whereas five of the six eyes (83%) with the current technique are within this range. Spectacle-corrected acuity in the entire current myopia group has either improved by one or more lines or has remained unchanged. Five of the six keratoconic eyes had 20/40 or better spectacle-corrected and 20/25 contact lens-corrected acuity postoperatively; average corneal flattening was 6 D. Persistent epithelial defect and irregular astigmatism were the principal factors in delay in visual recovery.     

Congenital cataract and intraocular lenses

We implanted nine intraocular lenses for the aphakic correction of congenital monocular cataracts in eight children (eight eyes). During follow-up periods ranging from 18 to 50 months in six children, there were no major complications connected to the surgery. Parental cooperation with treatment for amblyopia was satisfactory in all cases. The degree of strabismus, the fixation pattern, and the optokinetic nystagmus responses improved postoperatively in all six. Three children old enough to cooperate during visual testing had visual acuities better than 20/200 and two of these had visual acuities of 20/40. In all six children the sound eye is still patched for three to six hours a day. All six attend regular kindergartens and participate in their normal activities without difficulty.     

Epikeratophakia: the surgical correction of aphakia. Update: 1982

Sixty-five epikeratophakia procedures have been performed in 63 patients; visual acuity data have been tabulated on 31 patients with 4 to 30 months follow-up. Patients with more than a year of follow-up showed stable keratometry readings. Early patients achieved 70% of the predicted dioptric correction; more recent patients have achieved 87% with improvements in the lathing procedure, tissue handling, and surgical technique. Visual acuities improve with time. At any given time after surgery, acuities measured with a hard contact lens are better than those measured with spectacles; the decrease in spectacle acuity is probably a result of irregular refraction at the graft surface. The gap between contact lens and spectacle acuity decreases with time. A number of patients achieve postoperative visual acuities better than their preoperative acuities, and most achieve final spectacle acuities within a line or two of their preoperative acuities.     

Aphakic extended-wear contact lenses after penetrating keratoplasty

Fifteen aphakic eyes in 15 selected patients who underwent penetrating keratoplasty were successfully fitted with extended-wear contact lenses three to 42 months postoperatively. After an average follow-up of 17 months, there was no graft edema, no microbial corneal ulcers, and no episode of graft rejection. Three eyes developed minor (1 to 2 mm) graft neovascularization; the neovascularization was stable and did not require discontinuation of the contact lenses. Fourteen of the 15 patients had postoperative visual acuities of 20/70 or better; the one patient whose visual acuity was worse than 20/70 had a clear graft but also had senile macular degeneration.     

Limited macular translocation for the management of subfoveal choroidal neovascularization after photodynamic therapy

PURPOSE: To report our initial experience of limited macular translocation in patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration following photodynamic therapy with verteporfin. DESIGN: Interventional case series. METHODS: Retrospective review of four eyes of four consecutive patients with subfoveal choroidal neovascularization secondary to age-related macular degeneration who underwent effective limited macular translocation following photodynamic therapy. The mean logarithm of minimal angle of resolution preoperative best-corrected visual acuity was 20/190 (range, 20/150 to 20/200), and in all eyes the visual acuity was 20/150 or worse. The major outcome measures were postoperative visual acuity and complications related to the surgery. RESULTS: The mean postoperative follow-up was 6.75 months (range, 6-8 months). Postoperative best-corrected visual acuity improved by 2 or more Snellen lines of visual acuity in three of four eyes (75%) and remained within 1 line in one of four eyes (25%). The mean postoperative best-corrected visual acuity was 20/100 (range, 20/40 to 20/150), and in two of the four eyes (50%) the visual acuity achieved was 20/100 or better. No complication was observed. CONCLUSIONS: Limited macular translocation may be a viable option in patients who have previously undergone photodynamic therapy.     

Progression of visual acuity after penetrating keratoplasty

A consecutive series of 721 eyes was followed for visual acuity changes after keratoplasty in four groups: keratoconus, Fuchs' dystrophy, pseudophakic bullous keratopathy with retained intraocular lenses, and aphakic/pseudophakic bullous keratopathy with secondary implants during keratoplasty. Follow-up ranged from 12 to 84 months. Keratoconus eyes showed the quickest recovery of visual acuity: by 12 months, 91% attained a best-corrected vision of 20/40, and the mean lines of visual acuity for the group plateaued thereafter. The other three groups showed continuing improvement in vision through 24 months. From 3 months through 3 years after keratoplasty, the keratoconus and Fuchs' groups consistently showed better visual acuity levels than either the retained or the secondary implant groups (P less than 0.0001). Reporting changes in visual acuity over time offers multiple advantages compared with providing best-attained or last-recorded visual acuities after keratoplasty.     

The relationship between indoor and outdoor Snellen visual acuity in cataract patients

One hundred six cataractous eyes of 78 patients were evaluated to examine the relationship between indoor and outdoor Snellen visual acuity. While 81 of all cataractous eyes (76.4%) had Snellen visual acuities of 20/40 or better when tested indoors, only 33 eyes (31.2%) had 20/40 or better Snellen visual acuities when tested outdoors facing the sun. When tested indoors, only three eyes (2.8%) had Snellen visual acuities worse than 20/80, while 31 eyes (29.2%) had outdoor Snellen visual acuities worse than 20/80. Ten eyes (9.4%) had outdoor Snellen visual acuities worse than 20/200. Seventy-four eyes (69.8%) had outdoor visual acuities that were at least two Snellen lines worse than those measured indoors and 23 eyes (21.7%) had outdoor visual acuities that were at least five Snellen lines worse. The median difference between indoor and outdoor visual acuity was three Snellen lines. The need for increased precision in the ability to assess outdoor "real world" vision while in the ophthalmologist's examination room is discussed. Clearly, indoor Snellen visual acuity alone is insufficient to evaluate functional visual impairment in cataract patients.     

Indications for and outcomes of repeat penetrating keratoplasty

We reviewed data on 150 repeat corneal transplants performed between 1983 and 1988 at Wills Eye Hospital. Minimal postoperative follow-up was six months. The most common diagnoses before regraft were pseudophakic bullous keratopathy (29 of 150), aphakic bullous keratopathy (28 of 150), Fuchs' dystrophy (21 of 150), failed graft (17 of 150), and keratoconus (14 of 150). Herpes simplex keratitis, interstitial keratitis, chemical burns, traumatic scars, and corneal dystrophies accounted for most of the remaining regrafts. Of the 150 regrafts, 39 (26%) failed during the study period. Almost half of the regraft failures occurred within six months, and over four fifths occurred within 18 months. Of the 111 eyes with clear grafts, final visual acuity data were available for 68 eyes (minimal follow-up, two years; mean, 3.3 years). A best-corrected visual acuity of 20/20 to 20/40 (22 of 68) or 20/50 to 20/100 (27 of 68) was achieved in most patients.     

Epikeratophakia—The Surgical Correction of Aphakia: Update 1981

Epikeratophakia grafts used to rehabilitate vision in adult monocular aphakic patients intolerant of contact lens correction or not candidates for IOLs were studied prospectively. Thirty-two patients who entered this study between its inception in February 1980 through February 1981 were followed for at least eight months. Patients with normal visual potential before surgery had average visual acuities with spectacle overcorrection of 20/50 at four months, 20/40 at eight months, and 20/30 at one year. Few long-term complications were seen. Empirical modification of the lathing process has decreased the undercorrection from the 5.5 diopters seen in the early patients to the 1.0 diopter seen in the more recent patients. Problems with predictability are related to the behavior of preserved corneal tissue during the lathing and the healing of these lamellar grafts. This procedure is intended for aphakic patients for whom IOL and contact lens correction is not possible.     

Submacular surgery to remove choroidal neovascularization associated with central serous chorioretinopathy

PURPOSE: To report the results of submacular surgery for removal of choroidal neovascularization associated with central serous chorioretinopathy. METHODS: Ten eyes of nine consecutive patients with central serous chorioretinopathy and subfoveal or juxtafoveal choroidal neovascularization underwent pars plana vitrectomy with removal of the choroidal neovascular membrane between January 1994 and January 1999.RESULTS: All 10 eyes (nine patients) were followed postoperatively for at least 6 months. The mean postoperative follow-up was 23 months (range, 6 to 56.5 months). The patients were followed for an average of 6.2 months from the time of symptoms to the removal of the choroidal neovascularization. Preoperative mean best-corrected visual acuity was 20/100 (range, 20/25 to 20/400), and postoperative best-corrected mean visual acuity was 20/60 + 2 (range, 20/20 to 20/400). Seven eyes had improved postoperative visual acuity, with an average of 3.4 lines gained. Of the three eyes that had worse acuity, an average of 1.3 lines of visual acuity was lost; final mean postoperative visual acuity was 20/80 + 1 (range, 20/25 to 20/400). Of the six eyes with symptoms of less than 3 months' duration, four had a final visual acuity of 20/50 or better. All three eyes with 20/300 or worse final visual acuity had loss of foveal retinal pigment epithelium after surgery; the remaining eyes had preserved retinal pigment epithelium with a visual acuity of 20/70 or better. Two eyes had intraoperative peripheral retinal tears, and two eyes had recurrence of the choroidal neovascular complex. CONCLUSIONS: The anatomic and visual results in eyes with choroidal neovascularization associated with central serous chorioretinopathy are modestly encouraging and suggest that submacular surgery for choroidal neovascularization in patients with central serous chorioretinopathy is a treatment option that may salvage good macular function in some eyes.     

Fine lattice lines on the corneal surface after laser in situ keratomileusis (LASIK)

PURPOSE: To present an example of a pattern of lines resembling fine lattice on the corneal surface subsequent to laser in situ keratomileusis (LASIK). This subtle phenomenon may be relatively common and may affect visual outcome. METHOD :Case report. RESULTS: A 41-year-old year old man with high myopia and best-corrected visual acuity of 20/20 +2 in each eye underwent laser in situ keratomileusis (LASIK). No operative or postoperative complications occurred. No striae were evident on slit-lamp examination with direct illumination and retroillumination at the time of surgery or in the postoperative period. Postoperative uncorrected visual acuity was 20/25 with a best-corrected spectacle correction of 20/25 in both eyes. Fine lines in a lattice pattern were seen only with fluorescein dye in the precorneal tear film as areas of "negative stain" within the LASIK flap. With tear film supplementation, the lines were less evident and visual acuity improved. One year postoperatively, his uncorrected visual acuity was 20/25 in both eyes. The best-corrected spectacle visual acuity was RE: 20/20 -2, LE: 20/25. The fine lines were still present within the flap. A soft contact lens improved visual acuity to 20/20 in both eyes. Although all four puncta were occluded, he had no epiphora. CONCLUSION: Fine lines in a lattice pattern that may represent folds in the epithelium or Bowman layer may be present within the flap after LASIK and may adversely affect visual acuity. They may be visible as areas of negative stain with fluorescein dye in the precorneal tear film in the absence of any striae visible in the flap. These superficial lines have been seen more in patients with high degrees of correction and in patients with dry eye. If visual acuity is affected, it may be improved with punctal occlusion, tear supplements, or a contact lens.     

Vitreous surgery for traumatic macular holes.

PURPOSE: To review the anatomic and visual outcomes of a series of patients with traumatic macular holes who underwent vitreous surgery without adjunctive therapy. METHODS: We performed a retrospective chart review of 23 patients who underwent vitrectomy, fluid-gas exchange, and sulfur hexafluoride gas tamponade for traumatic macular holes. Anatomic success rate and final visual improvement after the surgery were studied. RESULTS: Medical records of 23 patients (23 eyes) who underwent this procedure were reviewed. Closure of the macular hole was achieved in 16 (70%) eyes with one surgery and in 22 (96%) of the 23 eyes with two surgeries. The mean best-corrected preoperative visual acuity was 20/160, and postoperative visual acuity was 20/60 with a mean (+/- standard deviation) follow-up of 23+/-13 months (range 3-56 months). Fourteen (61 %) of the 23 eyes achieved a best-corrected postoperative visual acuity of 20/60 or better, and 11 (48%) of the 23 eyes achieved 20/40 or better. Twenty (87%) of the 23 eyes achieved at least two lines of visual improvement. CONCLUSIONS: Vitreous surgery without adjunctive therapy for traumatic macular holes can lead to anatomic success and visual acuity improvement in most eyes.     

Natural course of choroidal neovascular membranes within the foveal avascular zone in senile macular degeneration

We divided 96 eyes (93 patients) with senile macular degeneration and choroidal neovascular membranes into two groups--those with juxtafoveal membranes (1 to 250 mu from the center of the foveal avascular zone) and those with subfoveal membranes (0 mu from the center of the zone). After an average follow-up period of 21 months, one of 38 eyes in the juxtafoveal group (3%) had improved two or more lines on the Snellen chart, three eyes (8%) had remained the same, and 34 eyes (89%) had lost two or more lines on the Snellen chart. Although 35 of the 38 eyes (92%) had had initial visual acuities of 6/30 (20/100) or better, 27 eyes (71%) had become legally blind. Of the 58 eyes in the subfoveal group, 18 (31%) had remained the same or improved and 40 (69%) had lost two or more lines on the Snellen chart; 41 (70%) had final visual acuities of 6/60 (20/20) or worse. Of the 26 eyes in the subfoveal group that had had initial visual acuities of 6/60 (20/100) or better (45%). four (15%) had stayed the same and 22 (85%) had lost two or more lines on the Snellen chart. Fourteen of the 26 eyes (54%) had final visual acuities of 6/60 (20/200) or worse. Exudative maculopathy developed in the second eye in 13% of patients who initially had unilateral choroidal neovascularization after 12 months, in 22% after 24 months, and in 29% after 36 months, using life table analysis.     

ReSTOR+3D多焦点人工晶状体临床效果观察

目的：观察ReSTOR+3D多焦点人工晶状体的临床效果。 方法：选取40例80眼年龄相关性白内障患者,按同一标准分为两组,其中双眼非同期植入ReSTOR+3D多焦点人工晶状体者20例设为MIOL组;双眼非同期植入蓝光滤过型单焦点人工晶状体者20例设为SIOL组。均行透明角膜切口超声乳化白内障摘除联合人工晶状体植入术。术后1d观察术眼的裸眼远、近视力;术后1mo观察术眼的裸眼远、近视力,矫正远、近视力,最佳远矫下近视力,对比敏感度,问卷调查视觉质量、各视觉功能区满意度及脱镜率。 结果：两组患者术后均有良好的远视力;MIOL 组患者同时获得良好的近、中程视力。术后对比敏感度MIOL组较SIOL组有所下降,但无功能性意义。MIOL 组视近脱镜率85%。 结论：ReSTOR+3D多焦点人工晶状体植入可为患者提供良好的全程视力,安全有效,满意度高。     

Treatment of bilateral refractive amblyopia in children three to less than 10 years of age

PURPOSE: To determine the amount and time course of binocular visual acuity improvement during treatment of bilateral refractive amblyopia in children three to less than 10 years of age. DESIGN: Prospective, multicenter, noncomparative intervention. METHODS: One hundred and thirteen children (mean age, 5.1 years) with previously untreated bilateral refractive amblyopia were enrolled at 27 community- and university-based sites and were provided with optimal spectacle correction. Bilateral refractive amblyopia was defined as 20/40 to 20/400 best-corrected binocular visual acuity in the presence of 4.00 diopters (D) or more of hypermetropia by spherical equivalent, 2.00 D or more of astigmatism, or both in each eye. Best-corrected binocular and monocular visual acuities were measured at baseline and at five, 13, 26, and 52 weeks. The primary study outcome was binocular acuity at one year. RESULTS: Mean binocular visual acuity improved from 0.50 logarithm of the minimum angle of resolution (logMAR) units (20/63) at baseline to 0.11 logMAR units (20/25) at one year (mean improvement, 3.9 lines; 95% confidence interval [CI], 3.5 to 4.2). Mean improvement at one year for the 84 children with baseline binocular acuity of 20/40 to 20/80 was 3.4 lines (95% CI, 3.2 to 3.7) and for the 16 children with baseline binocular acuity of 20/100 to 20/320 was 6.3 lines (95% CI, 5.1 to 7.5). The cumulative probability of binocular visual acuity of 20/25 or better was 21% at five weeks, 46% at 13 weeks, 59% at 26 weeks, and 74% at 52 weeks. CONCLUSIONS: Treatment of bilateral refractive amblyopia with spectacle correction improves binocular visual acuity in children three to less than 10 years of age, with most improving to 20/25 or better within one year.     

Silicone oil injection after failed primary vitreous surgery in severe ocular trauma

In 42 cases of complicated retinal detachment following trauma after failed primary vitrectomy, at six months follow-up anatomic retinal reattachment posterior to the scleral buckle was achieved in 20 of 40 eyes (50%). Of the 40 eyes, 11 (28%) had a visual acuity of 5/200 or better. Of the eyes that were completely attached posterior to the buckle at six months, 13 of the 20 (65%) remained attached at the last follow-up examination. Many patients who had visual acuities of 5/200 or better at six months experienced a progressive decrease in visual acuity over three years, primarily because of recurrent retinal detachments and corneal edema. A final visual acuity of 5/200 or better was obtained in only five of the 42 eyes (12%) at the last follow-up examination.     

Efficacy of amblyopia therapy initiated after 9 years of age

AIMS/PURPOSE: To evaluate the efficacy of occlusion therapy initiated after 9 years of age. METHODS: A total of 16 amblyopes of 9 years or older (range, 9.0-14.5 years; mean, 10.5 years) with a difference in visual acuity of over two lines between the eyes alter 4 weeks of first full-time spectacle wear were included. None of the children had undergone a previous ocular examination, had ever worn spectacles, received occlusion therapy, or had strabismus surgery. Initial worst visual acuity after 4 weeks of full-time spectacle wear was 20/100 in three patients, between 20/80 and 20/40 in 11 patients, and 20/30 in two patients. Full-time occlusion was performed in 14 patients and part-time occlusion in two patients. RESULTS: The final visual acuity of 15 out of 16 patients (94%) improved at least two lines. The final visual acuities ranged from 20/30 to 20/20 in 14 patients, 20/40 in one patient, and 20/50 in one remaining patient who began amblyopia therapy at 14.5 years of age, with the poorest compliance among the patients. CONCLUSIONS: Occlusion therapy for anisometropic and strabismic amblyopia can be successful even if initiated after the age of 9 years.     

Results of surgery for bilateral cataract associated with sensory nystagmus in children

PURPOSE: To report the outcome of cataract surgery in children with bilateral cataract and preoperative sensory nystagmus.DESIGN: Interventional case series.METHODS: Retrospective review of 95 children who underwent surgery for bilateral cataract associated with sensory nystagmus. All patients lacked other structural ocular defects or neurologic abnormalities and were old enough at last follow-up to cooperate with recognition visual acuity testing. Outcome parameters studied were best-corrected postoperative visual acuity of the better eye and postoperative reduction or elimination of nystagmus.RESULTS: Mean age at surgery +/- SD was 2.0 +/- 2.6 years (range, 1 month to 13 years). Mean follow-up was 6.1 +/- 3.4 years (range, 2 months to 15 years). Best-corrected postoperative visual acuity of the better eye ranged from 20/25 to counting fingers and was 20/60 or better in 44 (46%), between 20/60 and 20/200 in 37 (39%), and 20/200 or worse in 14 (15%). Preoperative recognition visual acuity data were available for 16 of the older patients, and 5 or more lines of visual acuity improvement occurred in 5 (31%) including children as old as 9 years at the time of surgery. Nystagmus was reduced or eliminated postoperatively in 38 (40%). Mild, as opposed to severe, preoperative nystagmus was predictive of both a better visual acuity outcome (P =.004) and reduced or eliminated nystagmus postoperatively (P =.02).CONCLUSIONS: Good or even excellent visual acuity can be achieved after cataract surgery in some children with bilateral cataract and sensory nystagmus, and the nystagmus sometimes improves postoperatively.     

Secondary intraocular lens implantation

The visual, refractive, and surgical results with 190 consecutive secondary implantations of an anterior chamber intraocular lens were studied. Best-corrected postoperative visual acuity was either better than or within 1 Snellen line of best-corrected preoperative vision in 87% of the cases. Vision worsened by more than two Snellen lines in ten cases (5%), which included three cases of retinal detachment and one case of ischemic optic neuropathy; however, in only one case (0.5%) did we feel that the visual decrease was directly attributable to the secondary implantation procedure. We believe that secondary intraocular lens implantation can improve functional visual acuity in aphakic patients, especially those unable to tolerate aphakic correction with contact lenses or spectacles.