【In Press】 Phacoemulsification combined with transpupillary removal of silicone oil and intracapsular intraocular lens implantation

AIM:To evaluate phacoemulsification combined with transpupillary silicone oil removal and foldable intraocular lens (IOL) implantation through corneal incision. METHODS: Candidate patients for intraocular silicone oil removal and cataract extraction underwent combined phacoemulsi?cation and transpupillary drainage of silicone oil through a planned posterior capsulorrhexis and without the use of a pars plana infusion line. RESULTS: The surgery was successfully completed in all eyes. Best corrected visual acuity (BCVA) improved (143 eyes) or stabilized (25 eyes) in all patients at the last follow-up visit. The mean BCVA statistically improved from 20/400±0.02 to 20/100±0.15 (P<0.001) and mean postoperative IOP was 13.85±2.18 mm Hg (P=0.415). No intraoperative complications were reported. CONCLUSION: Combined phacoemulsi?cation and transpupillary drainage of silicone oil is a safe and effective technique. In general, it enables a rapid visual rehabilitation with low complication rate.     

【In Press】Clinical outcomes of a new diffractive multifocal intraocular lens

AIM: To evaluate clinical outcomes after implantation of a new diffractive aspheric multifocal intraocular lens (IOL) with +3.00 addition power. METHODS: This is a retrospective, consecutive case series of cataract patients who underwent bilateral implantation of the Optiflex MO/HF D012 (Moss Vision Inc. Ltd, London, UK) multifocal IOL. Patients followed for 6MO were included in the study. Data on distance, intermediate and near visual acuity, refractive error [manifest spherical equivalent (MSE)], contrast sensitivity, adverse events, subjective symptoms, spectacle independence and patient satisfaction (VFQ-25 questionnaire) were retrieved from electronic medical records and analyzed. RESULTS: Forty eyes of 20 patients with a mean age of 66.7±8.5Y (range: 53-82) were included in the study. Mean uncorrected distance, near and intermediate visual acuity remained stable through postoperative visits and was 0.18±0.19 logMAR, Jaeger 4 and jaeger 3 respectively at the 6mo visit. At the end of postoperative 6MO, MSE was -0.14±0.42 diopters (D) and 98% of the eyes were within 1.00 D of target refraction. Postoperative low contrast (10%) visual acuity remained stable (P=0.54) through follow up visits with a mean of 0.35±0.17 logMAR at the 6mo visit. There were no reported adverse events. None of the patients reported subjective symptoms of halo or glare. Spectacle independence rate was 90%. Mean VFQ-25 questionnaire score was 93.5±6.12. CONCLUSION: The Optiflex MO/HF-DO12 IOL was safely implanted and successfully restored distance, intermediate and near visual acuity without impairing contrast sensitivity. High levels of spectacle independence were achieved at all distances including intermediate distance.     

【In Press】 Short and long-term outcomes of angle supported phakic intraocular lens implantation in high myopic eyes

This cohort study included 36 eyes of 21 patients with high myopia treated with angle supported phakic intraocular lens (pIOL). Endothelial cell density (ECD) at baseline, 6mo and 3y were 3017±296, 2775±265 and 2558±299 cells/mm2 respectively. ECD loss at 6mo was 7.2% and annual ECD loss was 3% over three years. Corrected distance visual acuity (CDVA) at 3y was 0.4 logMAR in 32 (88%) eyes. Intraocular pressure did not change (p=0.9). No eyes developed cataract, retinal detachment or pupillary distortion. Angle supported pIOL gives good visual outcome. Endothelial cell loss should be monitored.     

【In Press】 Comparison of visual outcomes with implantation of trifocal versus bifocal intraocular lens after phacoemulsification: a Meta-analysis

AIM: To compare a trifocal intraocular lens (IOL) and a bifocal IOL implantation in improving visual function after cataract surgery. METHODS: Eligible literatures were systematically searched through EMBSE and PubMed databases. The inclusion criteria were prospective comparative clinical trials on cataract surgery comparing trifocal IOL with bifocal IOL implantation that assessed visual acuity, contrast sensitivity and subjective vision quality. The effects were computed as standardized mean differences and pooled using fixed-effect or random-effect models. RESULTS: Four prospective randomized controlled trials (RCTs) and five cohorts provided data and were included by a systematic review, comprising 265 eyes implanted with trifocal IOLs and 264 eyes implanted with bifocal IOLs. Monocular distance visual acuity (VA) showed a statistically significant but small difference that favored trifocal IOLs (MD=-0.06; 95%CI, -0.10 to -0.02; Z=2.90, P=0.004 for UDVA and MD=-0.02; 95%CI, -0.03 to -0.00; Z=2.02, P=0.04 for CDVA), but the data did not suggest that the effect of trifocal IOL implantation would clinically outperform bifocal IOL implantation. There was no significant difference in monocular near VA (MD=-0.01; 95% CI, -0.07 to 0.04; Z=0.42, P=0.68 for UNVA, and MD=-0.01; 95% CI, -0.06 to 0.03; Z=0.55, P=0.58 for DCNVA) or refraction between two groups. Contrast sensitivity and subjective visual quality had no conclusive results. CONCLUSION: All results indicate that trifocal IOL and bifocal IOL had similar levels of monocular distance and near visual acuities. Besides, contrast sensitivity and subjective visual quality have no conclusive results.     

【In Press】 Descemet stripping automated endothelial keratoplasty in phakic eyes: incision modification reducing cataract formation

AIM: To evaluate the efficacy of a technical modification to reduce the incidence of traumatic cataract induced by Descemet stripping automated endothelial keratoplasty (DSAEK) performed in phakic eyes. METHODS: A retrospective cohort study. The records of all patients with a clear crystalline lens and endothelial failure that underwent modified DSAEK at our insitution were reviewed. In this modification, in order to avoid inadvertent touch of the insertion forceps against the exposed crystalline lens while passing across the anterior chamber, the incision sites were shifted from the standard 9 and 3 o’clock positions, superiorly to the 10 and 2 o’clock position respectively. Formation of typically traumatic, anterior subcapsular cataract in these patients was compared to that observed in a cohort including all the patients with a clear crystalline lens and endothelial failure that underwent conventional DSAEK at our institution. RESULTS: The study group included 49 eyes following modified DSAEK and the control group included 35 eyes following DSAEK with conventional incision sites. Anterior subcapsular cataract occurring 4 mo or less postoperatively was identified in 2 of 49 (4%) eyes in the study group and 7 of 35 (20%) eyes in the control group. The rates of traumatic cataract were significantly higher in the control group in comparison to the study group (P=0.03, RR=4.9, 95%CI 1.08-22.1). CONCLUSION: Traumatic cataract formation following phakic DSAEK may be avoided with a simple modification to the position of the incision sites.     

【In Press】Regarding successful use of 23G cutter for anterior vitrectomy and scleral-fixated intraocular lens implantation

Comment and response     

【In Press】 Etiology and failure analysis of anterior lamellar keratoplasty

AIM: To analyze indications and reasons for failure of anterior lamellar keratoplasty (ALK). METHODS: The clinical records were retrospectively reviewed. Main outcome measures: included indications for ALK and reasons for failure of ALK. RESULTS: A total of 434 patients (462 eyes) were treated with ALK at Qindao Eye Hospital, Shandong Eye Institute from June 1, 2009 to May 31, 2016. The main indications were infectious keratitis (33.3%), keratoconus (23.6%), corneal dystrophy and degeneration(9.7%), Mooren''s ulcer(8.4%), corneal neoplasm(7.8%), viral keratitis(6.5%) and regrafting (3.7%). Fungal keratitis accounted for 73.4% in the infectious keratitis cases. ALKs were failed in 36 patients, with the major causes being recurrence of primary diseases (63.9%). The leading causes of graft failure was Mooren''s ulcer (36.1%), followed by infectious keratitis (30.6%). Recurrence of fungal keratitis accounted for 81.8% in the failed cases after ALK for infectious keratitis cases. CONCLUSION: Infectious keratitis and keratoconus are the main indications for ALK, of which fungal keratitis was the major cause of corneal infections. Recurrence of primary disease is the main reason of graft failure after ALK, in which the main primary diseases associated with graft failure are Mooren''s ulcer and fungal keratitis.     

【In Press】 Bimanual microincision cataract surgery with implantation of the new Incise® MJ14 intraocular lens through a 1.4 mm incision

AIM: To analyze the visual outcomes and the posterior capsule opacification (PCO) with the new Incise MJ14 intraocular lens (IOL) implanted through a 1.4 mm clear corneal incision (CCI) in patients who underwent bimanual microincision cataract surgery (B-MICS). METHODS: Eighty eyes which underwent cataract surgery using B-MICS technique performed by the same experienced surgeon were included in the study: 40 eyes were implanted with an Incise® MJ14 IOL through a 1.4 mm CCI (group A) without enlargement of the main CCI, while 40 eyes were implanted with an Akreos® MI60 IOL with enlargement of the main CCI to 1.8 mm (group B). Best corrected visual acuity (BCVA), astigmatism and endothelial cell loss were evaluated before and after surgery at 7 and 30d and 6mo. Anterior segment-OCT (AS-OCT) of CCI was performed at 1, 3, 7 and 30d, 6 and 18mo. Posterior capsule opacification (PCO) incidence was evaluated at 18mo using EPCO 2000 Software. RESULTS: Mean BCVA improvement and endothelial cell loss were statistically significant at 18mo in both groups with no difference between the two groups; no statistically significant difference in surgically induced astigmatism (SIA) was noticed in the two groups. At AS-OCT the only significant alterations in the CCI were endothelial gaping and local detachment of Descemet’s membrane at 1 and 7d after surgery; no statistically significant alterations were found at 1, 6 and 18mo. PCO score at 18mo was 0.03±0.07 for group A and 0.08±0.18 for group B (p=0.11) with no sign of central optic plate invasion in both groups. CONCLUSION: The implant of the new Incise® MJ14 IOL through a 1.4 mm CCI and B-MICS technique appeared to be a safe and effective procedure with rapid visual recovery. PCO rate resulted very low and the CCI presented few morphological alterations which were only detectable in the first days postoperatively and achieved fast corneal healing during the long-term follow-up.     

【In Press】Comparison of optical quality after implantable collamer lens implantation and wavefront-guided laser in-situ keratomileusis

AIM: To compare the optical quality after implantation of implantable collamer lens (ICL) and wavefront-guided laser in-situ keratomileusis (WG-LASIK). METHODS: The study included 40 eyes of 22 patients with myopia who accepted ICL implantation and 40 eyes of 20 patients with myopia who received WG-LASIK. Before surgery and three months after surgery, the objective scattering index (OSI), the values of modulation transfer function (MTF) cutoff frequency, Strehl ratio, and the optical quality analysis system (OQAS) values (OVs) were accessed. The higher order aberrations (HOAs) data including coma, trefoil, spherical, 2nd astigmatism and tetrafoil were also obtained. For patients with pupil size <6 mm, HOAs data were analyzed for 4mm-pupil diameter. For patients with pupil size ≥6 mm, HOAs data were calculated for 6mm-pupil diameter. Visual acuity, refraction, pupil size and intraocular pressures were also recorded. RESULTS: In both ICL and WG-LASIK group, significant improvements in visual acuities were found postoperatively, with a significant reduction in spherical equivalent (P<0.001). After the ICL implantation, the OSI decreased slightly from 2.34±1.92 to 2.24±1.18 with no statistical significance (P=0.62). While in WG-LASIK group, the OSI significantly increased from 0.68±0.43 preoperatively to 0.91±0.53 postoperatively (Wilcoxon Signed Ranks test, P<0.000). None of the mean MTF cutoff frequency, Strehl ratio, OVs showed statistically significant changes in both ICL and WG-LASIK groups. In the ICL group, there were no statistical differences in the total HOAs for either 4mm-pupil or 6mm-pupil. In the WG-LASIK group, the HOA parameters increased significantly at 4 mm-pupil. The total ocular HOAs, coma, spherical and 2nd astigmatism were 0.12±0.06, 0.06±0.03, 0.00±0.03, 0.02±0.01, respectively. After the operation, these values were increased into 0.16±0.07, 0.08±0.05, -0.04±0.04, 0.03±0.01 respectively (Wilcoxon Signed Ranks test, all P<0.05). At 6mm-pupil, the induction of total HOAs was not statistically significant in the WG-LASIK group. CONCLUSION: ICL implantation has a less disturbance to optical quality than WG-LASIK. The OQAS system is a valuable complementary measurement to the wavefront aberrometers in evaluating the optical quality.     

Implantation of iris-claw Artisan intraocular lens for aphakia in Fuchs’ heterochromic iridocyclitis

Implantation of iris-claw Artisan intraocular lens (IOL) is a surgical option for correction of aphakia; however, these IOLs have not been used in eyes with uveitis including Fuchs’ heterochromic iridocyclitis (FHI) due to possible risk of severe postoperative intraocular inflammation. In the case reported here, we secondarily implanted an Artisan IOL in a 28-year-old man with FHI who had aphakia with no capsular support due to a previous complicated cataract surgery. Enclavation was easily performed and no intraoperative complication was noted. Postoperative course was uneventful with no significant anterior chamber inflammation during 12 months of follow-up. Although there were few deposits on the IOL surface, the patient achieved a best-corrected visual acuity of 20/20 without developing glaucoma or other complications. Therefore, Artisan IOL may be considered for correction of aphakia in patients with FHI. However, studies on large number of patients are required to evaluate safety of the procedure.     

【In Press】 Preloaded and non-preloaded intraocular lens delivery system and characteristics: human and porcine eyes trial

AIM: To compare characteristics of preloaded and non-preloaded intraocular lens (IOL) delivery systems during IOL delivery procedures. METHODS: Total 101 human eyes were included in this prospective observational case series. Delivery characteristics of 5 types of IOLs including iSert250 NC60 (NC60), EnVista MX60 (MX60), AcryS of IQ SN60WF (SN60WF), TECNIS ZCB00 (ZCB00), and TECNIS PCB00 (PCB00) were investigated. NC60 and PCB00 were injected via preloaded delivery systems and other IOLs were injected via non-preloaded systems. In the human trial, time taken from IOL loading to completion of implantation was measured in all eyes undergoing conventional cataract surgery. Using 4 excised porcine eyes, dynamics of ophthalmic viscosurgical device (OVD) between an IOL injector and a porcine eye was analyzed using fluorescein sodium-stained OVD. RESULTS: The average time for IOL implantation was 22.0s for NC60, 43.2s for MX60, 32.3 seconds for SN60WF, 41.4s for ZCB00, and 14.6s for PCB00 respectively. The number of cases with IOL manipulation with a second instrument was 6 for MX60, 2 for ZCB00, 0 for SN60WF, NC60, and PCB00. Amount of OVD pushed into a porcine eye was smaller with a preloaded system than with non-preloaded systems. CONCLUSION: IOL delivery with preloaded systems is faster and more predictable. Moreover, a preloaded delivery system shows relatively less OVD pushed into a porcine eye than non-preloaded systems.     

Intraocular pressure after Descemet’s stripping and non-Descemet’s stripping automated endothelial keratoplasty

Purpose  

To evaluate the effect on intraocular pressure (IOP) of increased corneal thickness after Descemet’s stripping automated endothelial keratoplasty (DSAEK) and of non-Descemet’s stripping automated endothelial keratoplasty (nDSAEK) as measured by four different techniques.     

Comparison of outcomes of penetrating keratoplasty versus Descemet’s stripping automated endothelial keratoplasty for penetrating keratoplasty graft failure due to corneal edema

To evaluate the outcomes of repeat corneal transplantation, either penetrating keratoplasty (PKP) or Descemet’s stripping automated endothelial keratoplasty (DSAEK), for penetrating keratoplasty grafts which failed due to corneal edema. The charts of 24 eyes with failed PKP grafts, due to corneal edema, which underwent a repeat corneal transplant (PKP in 17 eyes [Group 1] and DSAEK in seven eyes [Group 2]) between 2003 and 2007 were retrospectively reviewed. There was no statistically significant difference in the median postoperative visual acuity between the two groups at 1, 2, or 3 years. In Group 1, two (18%) eyes had a final visual acuity ≥20/40, in contrast to four (80%) eyes in Group 2, which was statistically significant (P = 0.038). Seven (41%) of the Group 1 eyes developed postoperative complications compared to only one (14%) eye in Group 2. Eleven (65%) of the Group 1 eyes and five (71%) of Group 2 eyes had clear grafts on the last examination. There was no statistically significant difference in the graft survival rate for Group 1 versus Group 2 at 3 years (57.9% vs 68.6%, P = 0.507). There was a trend towards better postoperative visual acuity, a lower postoperative complication rate, and a higher graft survival rate in eyes that underwent DSAEK rather than repeat PKP for graft failure secondary to corneal edema. Given this small, retrospective study, future studies comparing repeat PKP with DSAEK are warranted to determine which procedure allows for improved outcomes.     

Combined topical and intracameral anesthesia for Descemet’s stripping automated endothelial keratoplasty

To evaluate the use of combined topical and intracameral anesthesia for Descemet’s stripping automated keratoplasty (DSAEK). This was a retrospective comparative cohort analysis consisting of 10 eyes in 10 consecutive patients undergoing DSAEK surgery with combined topical and intracameral anesthesia. These cases were compared with 21 randomly selected controls during the same time period undergoing DSAEK surgery performed under retrobulbar anesthesia. Incidence of intraoperative and postoperative complications, and endothelial cell counts were compared. In all cases, DSAEK was completed without intraoperative complications. All patients tolerated the procedure well. There were 6 cases of postoperative graft dislocation requiring rebubbling, and no cases of primary failure or endophthalmitis. No significant difference in endothelial cell counts was found at final follow-up. Short-term results suggest that combined topical and intracameral anesthesia is as safe and effective for DSAEK in cooperative patients when compared to retrobulbar anesthesia. It may thereby be an alternative anesthetic modality for patients in whom retrobulbar or peribulbar anesthesia may be risky or contraindicated.     

【In Press】Cryopreserved limbal lamellar keratoplasty for peripheral corneal and limbal reconstruction

Abstract This study aimed to evaluate the outcomes and described the recovery process of cryopreserved limbal lamellar keratoplasty (CLLK) for peripheral corneal and limbal diseases. Thirteen eyes of 12 patients with a mean age of 41±23.9y were included. The average follow-up was 12.1±5.6mo. Stable ocular surface was achieved in all eyes at last follow-up. Epithelialization originated from both recipient and graft in 9 eyes. We conclude that CLLK compensates for the shortage of donor corneas and cryopreserved limbal grafts provide epithelialization sources in ocular surface reconstruction.     

Incidence of cystoid macular edema after Descemet’s stripping automated endothelial keratoplasty

AIM: To determine the incidence of cystoid macular edema (CME) after Descemet’s stripping automated endothelial keratoplasty (DSAEK). METHODS: This study included all consecutive patients operated in a Spanish tertiary reference hospital over a period of four years. A total of 55 eyes from 47 patients matched the selection criteria. CME was diagnosed clinically at the slit-lamp and confirmed by optical coherence tomography. RESULTS: Six cases of CME were diagnosed postoperatively, which represented an incidence of 11%. Three patients had previously undergone DSAEK alone (7%; 3/41) and the other three, DSAEK combined with phacoemulsification (21%; 3/14). Five out of six patients with CME responded to standard therapy. CONCLUSION: CME is a possible complication after DSAEK and can be treated with standard therapy. CME appears more frequently when DSAEK is combined with phacoemulsification and posterior chamber (PC) intraocular lens (IOL) implantation. Intraoperative damage to the corneal endothelial cells might play a role in the pathogenesis of CME. As long as the causes remain unclear, we recommend administering prophylaxis when risk factors are present or when combined surgery is planned.     

Glaucoma therapy escalation in eyes with pseudophakic corneal edema after penetrating keratoplasty and Descemet’s stripping automated endothelial keratoplasty

The purpose of this study was to determine and compare the prevalence of glaucoma therapy escalation (GTE) after penetrating keratoplasty (PKP) and Descemet’s stripping automated endothelial keratoplasty (DSAEK) in eyes with a surgical indication of pseudophakic corneal edema. A retrospective review was conducted of the medical records of all patients who underwent PKP or DSAEK to treat pseudophakic corneal edema at a tertiary eye care center from January 1 2003 to December 31, 2006. Eyes that were treated with PKP from January 1, 2003 to December 31, 2004 and with DSAEK from January 1, 2005 to December 31, 2006 were included in the statistical analysis. Inclusion criteria included satisfactory preoperative control of intraocular pressure (IOP) and follow-up of at least 12 months. The main outcome measure was GTE, which was defined as a sustained requirement for escalation of topical medical therapy or the need to provide surgical intervention to maintain a satisfactory postoperative IOP. Among 54 eyes that met the inclusion criteria, GTE occurred in 7 (35.0%) of 20 eyes after PKP and in 14 (41.2%) of 34 eyes after DSAEK (P = 0.78) during a mean follow-up period of 27.6 and 28.6 months, respectively. Surgical escalation occurred in 2 (10.0%) eyes after PKP and 2 (5.9%) eyes after DSAEK (P = 0.62), and was associated with late-onset endothelial graft failure in all four eyes. Glaucoma therapy escalation is relatively common and occurs with comparable frequency in eyes with pseudophakic corneal edema after PKP and DSAEK.     

【In Press】 Clinical outcomes after implantation of a new intrastromal corneal ring with 140-degree of arc in patients with corneal ectasia

AIM: To evaluate the clinical and tomographic outcomes after implantation of a new intrastromal corneal ring segment (ICRS) with 140-degrees of arc in eyes with corneal ectasia. METHODS: We evaluated patients with corneal ectasia implanted with Ferrara 140° ICRS from April 2010 to February 2015. Outcome measures included preoperative and postoperative corrected distance visual acuity (CDVA), keratometry simulated (K) reading, tomographic astigmatism and asphericity (Q). All patients were evaluated using the Pentacam Scheimpflug system. RESULTS: The study evaluated 67 eyes. The mean follow-up was 16.81±13.96mo. The CDVA (logMAR) improved from 0.5±0.20 logMAR (20/60) to 0.3±0.21 logMAR (20/40) (P<0.01). The average K reduced from 49.8±7.01 D to 47.34±4.90 D (P<0.01). The asphericity changed from -0.60±0.86 to -0.23±0.67 (P<0.01). The mean preoperative tomographic astigmatism decreased from -8.0±3.45 D to -4.53±2.52 D (P<0.01). CONCLUSION: The new ICRS model with 140-degrees of arc effectively improved the visual acuity and reduced the high astigmatism usually found in patients with corneal ectasia.