A growing number of patients with prior refractive surgery are now presenting for cataract surgery. Surgeons face a number of unique challenges in this patient population that tends to be highly ...motivated to retain or regain functional uncorrected acuity postoperatively. Primary challenges include recognition of the specific type of prior surgery, use of appropriate intraocular lens (IOL) power calculation formulas, matching IOL style with spherical aberration profile, the recognition of corneal imaging patterns that are and are not compatible with toric and/or presbyopia-correcting lens implantation, and surgical technique modifications, which are particularly relevant in eyes with prior radial keratotomy or phakic IOL implantation. Despite advancements in IOL power formulae, corneal imaging, and IOL options that have improved our ability to achieve targeted postoperative refractive outcomes, accuracy and predictability remain inferior to eyes that undergo cataract surgery without a history of corneal refractive surgery. Thus, preoperative evaluation of patients who will and will not be candidates for postoperative refractive surgical enhancements is also paramount. We provide an overview of the specific challenges in this population and offer evidence-based strategies and considerations for optimizing surgical outcomes.
This study aimed to evaluate the visual and refractive outcomes in eyes with a history of laser corneal refractive surgery implanted with the second-generation light-adjustable lens (LAL).
Private ...Practice, Sioux Falls, South Dakota, US.
Retrospective, consecutive case series.
Eyes with a history of prior corneal refractive surgery that underwent cataract surgery with implantation of the LAL and were targeted for plano were included. Data on the type and number of prior refractive surgeries were collected, in addition to the timing and number of postoperative adjustments. The primary outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and the percentage (%) of eyes within ±0.25 diopter (D), ±0.50D, and ±1.00 D of their refractive target.
76 eyes from 70 patients were included. A total of 45 eyes with a history of one prior refractive surgery and 31 eyes with a history of ≥2 refractive surgeries were included. 74% (n=56) of all eyes achieved UDVA of 20/20 or better, 88% (n=67) achieved 20/25 UDVA or better and 93% (n=71) were correctable to 20/20 or better postoperatively. For refractive outcomes, 66% of eyes (n=50) were within ±0.25 D and 86% (n=65) were within ±0.50 D of refractive target.
Patients with a history of laser corneal refractive surgery achieved favorable visual and refractive outcomes with the LAL. This intraocular lens (IOL), which affords postoperative adjustability, is a promising option for patients with a history of corneal refractive surgery who maintain high expectations for functional uncorrected acuity following cataract surgery.
PURPOSE:
To describe the evaluation and management of irregular astigmatism induced by persistent irregular epithelial remodeling in the absence of persistent underlying stromal curvature ...irregularity following photorefractive keratectomy (PRK) re-treatment after remote myopic laser in situ keratomileusis (LASIK) with subsequent conductive keratoplasty (CK) and transepithelial corneal cross-linking (CXL).
METHODS:
Case report.
RESULTS:
A 41-year-old woman presented for evaluation 1 year after developing blurred vision. She had irregular astigmatism in her right eye following PRK re-treatment for regression after remote myopic LASIK, with a subsequent combined CK and modified transepithelial CXL procedure 1 month after PRK. Scheimpflug tomography demonstrated a post-myopic ablation pattern with an apparent decentered optical zone. Anterior segment optical coherence tomography (AS-OCT) revealed an irregular epithelial thickness pattern, with an asymmetric focal region of epithelial thickness para-centrally temporally. Superficial keratectomy was performed. Following the procedure, the patient's uncorrected distance visual acuity improved by two lines to 20/20, and her subjective blur symptoms resolved and remained stable during 12 months of follow-up. Repeat AS-OCT demonstrated a more uniform epithelial thickness pattern. Scheimpflug tomography showed resolution of the optical zone decentration, confirming that the irregular epithelial remodeling caused the curvature irregularity, and the underlying stromal curvature was not significantly irregular at the time of treatment.
CONCLUSIONS:
Although uncommon, irregular epithelial remodeling can occur without permanent underlying stromal irregularity. The authors surmise that a temporary induced stromal curvature change from combined CK and transepithelial CXL regressed, but epithelial remodeling did not return to the anticipated regular postoperative pattern. This phenomenon would be unrecognizable in the absence of epithelial mapping and highlights the need for thorough evaluation and targeted management strategies to improve epithelial regularization.
Journal of Refractive Surgery Case Reports
. 2021;1(2):e23–e30.
Purpose To evaluate the safety and efficacy of a trabecular microbypass stent (iStent) combined with cataract surgery in patients with pseudoexfoliation glaucoma (PXG). Setting Vance Thompson Vision, ...Sioux Falls, South Dakota, USA. Design Retrospective case series. Methods Eyes with PXG had implantation of 1 stent. Data were collected preoperatively and postoperatively through 24 months. Data included intraocular pressure (IOP), number of glaucoma medications, the incidence of postoperative IOP pressure spikes of 15 mm Hg or higher at any timepoint, and the need for additional surgery. Results The series included 115 eyes. The mean preoperative IOP was 20.00 mm Hg ± 6.95 (SD). One year postoperatively, the mean IOP was 15.54 ± 3.83 mm Hg ( P < .01). At 2 years, the mean IOP was 14.51 ± 2.79 ( P < .01). The mean number of glaucoma medications was 1.41 ± 1.04 preoperatively and 0.71 ± 0.94 2 years postoperatively ( P < .01), indicating a 50% reduction in medication use. Postoperatively, 7 eyes (6%) had an IOP spike of 15 mm Hg or higher above the baseline IOP; the spikes responded to topical therapy. Ninety-eight percent of patients with an IOP of 20 mm Hg or higher achieved a reduction in IOP at the last follow-up. Conclusion Trabecular microbypass stent implantation during cataract surgery safely and effectively lowered IOP and medication use in patients with mild to severe PXG.
Introduction
The purpose of this study is to evaluate the use of a varenicline solution nasal spray (VNS) for reducing the signs and symptoms of dry eye following laser in situ keratomileusis ...(LASIK).
Methods
Subjects electing to undergo LASIK were randomized to VNS (study group) or placebo/vehicle (control group) and initiated treatment with the nasal spray twice daily 28 days prior to surgery with continued treatment for 84 days following LASIK. After initiation of treatment, subjects were seen on the day of surgery and postoperatively on Days 1, 7, 28, 84 (3 months) and 168 (6 months). The primary outcome measure was the mean change in NEI-VFQ-25, a 25-item dry eye questionnaire, from baseline to 3 months. The second primary outcome measure was the mean change in corneal fluorescein staining. Secondary outcome measures included evaluation of tear break-up time, Schirmer testing, tear osmolarity and eye dryness score (EDS).
Results
Twenty subjects were enrolled in each group and successfully underwent LASIK. Both groups demonstrated an improvement in the National Eye Institute Visual Function Questionnaire (NEI-VFQ) at 3 months. The study group demonstrated improved corneal staining scores at months 1 and 3. Similarly, the study group demonstrated improvement in tear osmolarity scores versus the placebo group at the same time points. Although the study group was numerically greater than placebo for each time point for both corneal staining and tear osmolarity, the differences were not statistically significant for any primary or secondary outcome measures.
Conclusion
VNS is a dry eye treatment option for patients following LASIK and may have potential benefit for patients hoping to avoid additional topical medications. The results were not statistically significant compared to placebo in this trial, and further investigation of the use of VNS following LASIK in a larger trial would be beneficial.
Plain Language Summary
Laser in situ keratomileusis (LASIK) is a very successful refractive surgery option for patients hoping to reduce or eliminate their need for spectacles. Signs and symptoms of dry eye disease are very common after LASIK owing to the transection of corneal nerves that occurs during the procedure, and many patients are advised to manage it with frequent instillation of artificial tears. This study evaluated the use of a varenicline solution nasal spray, a recently introduced pharmacologic option that stimulates natural tear production through activation of the trigeminal nerve pathway. This is the first study to evaluate the use of the varenicline solution nasal spray in patients after refractive surgery and demonstrates that it could represent a favorable, ocular surface-sparing option for patients to minimize the signs and symptoms of dry eye following LASIK, a procedure known to trigger symptoms of dry eye disease.
Purpose: To report the successful treatment of 3 cases of recalcitrant fungal keratitis (FK) with high-dose oral posaconazole. Methods: This is a series of 3 patients from a single academic center ...with a culture-positive FK who were treated with oral posaconazole after failing to respond to conventional treatments. Results: All 3 patients had a history of contact lens wear. Two of the 3 cases were culture positive for Fusarium and the other for Paecilomyces . The infections of all 3 failed to respond to conventional antifungal therapies including varying combinations of topical, systemic, and intraocular antifungal therapies. All 3 cases rapidly responded to high-dose oral posaconazole ranging from 500 to 600 mg once daily. In 1 case, multiple courses of high-dose therapy were required to treat delayed recurrences of a latent infection. There were no significant adverse effects with the elevated dose, and treatment was administered with the guidance of an infectious disease specialist. Conclusions: In cases of recalcitrant FK failing to respond to conventional therapies, high-dose posaconazole, in the delayed-release tablet formulation, can be an effective treatment option.
Cenegermin, (OXERVATE) a recently Food and Drug Administration-approved topical formulation of recombinant human nerve growth factor, has been used for the treatment of neurotrophic keratopathy (NK). ...Corneal deposits have been previously reported as a potential adverse effect; however, the clinical characteristics, visual significance, and treatment options have not been fully described. The purpose of this article is to better characterize corneal deposits occurring during treatment with cenegermin for neurotrophic keratopathy.
This was a retrospective, multicenter consecutive case series.
We identified 5 patients from 3 institutions who developed a white opacity in varying layers of the cornea, consistent with calcium deposition, during treatment with cenegermin. In all cases, the opacity occurred rapidly over the course of a few weeks after initiation of treatment. Histopathologic examination of the cornea from one corneal patient demonstrated extensive calcification of the stroma extending to 90% depth. Before treatment, all patients had stage 2 or 3 NK (Mackie classification). The deposits were visually significant in all patients and did not resolve after cessation of cenegermin. There were no differences in age, sex, etiology of the NK, corneal transplant status, or concurrent medications between the patients who developed a deposit and 15 other patients with stage 2 or 3 NK who did not. One patient was successfully treated with superficial keratectomy with ethylenediaminetetraacetic acid chelation, one patient underwent penetrating keratoplasty, and one patient received a Boston keratoprosthesis.
We report the rapid onset of a corneal opacity after initiation of treatment with cenegermin in patients with stage 2 or 3 NK, consistent with acute calcific band keratopathy. This visually significant adverse finding has not previously been described. We could not identify any risk factors for development. We recommend close monitoring of patients receiving cenegermin therapy because the opacity may be irreversible and may require keratoplasty for visual rehabilitation.
The 24-hour intraocular pressure (IOP) rhythm is of interest to clinicians but its overall impact on glaucomatous progression remains unclear. Recent evidence has implicated the translaminar pressure ...gradient (TLPG), or imbalance between IOP and intracranial pressure, in the development of glaucoma. Evidence suggests that retinal ganglion cell death occurs as a result of decreased axonal transport only after a sustained, elevated TLPG. We hypothesize that periodic normalization of the TLPG prevents glaucomatous damage by enabling temporary resumption of axonal transport. Temporary resumption of axonal transport allows for delivery of critical metabolic cargoes with concomitant removal of metabolic waste which prevents apoptosis of the retinal ganglion cell.
PURPOSE OF THE STUDY:The purpose of the study was to evaluate the safety and efficacy of the iStent Trabecular Micro-Bypass stent in pseudophakic patients with open-angle glaucoma.
...METHODS:Retrospective, consecutive case series from October 2012 to May 2015 with no exclusion criteria. The series comprised 42 pseudophakic eyes with open-angle glaucoma that were implanted with 1 iStent. Data were collected preoperatively, and postoperative data were collected at 1 day, 1 week, 1, 3 and 6 months, 1 year, 18 months and 2 years. Data included intraocular pressure (IOP), number of glaucoma medications, the incidence of postoperative IOP pressure spikes ≥15 mm Hg at any timepoint, and the need for additional surgery.
RESULTS:The mean preoperative IOP was 20.26±6.00 mm Hg. At 1 year postoperatively, the mean IOP was 16.34±3.78 mm Hg (P<0.01). At 2 years postoperatively, the mean IOP was 13.62±4.55 (P<0.01). The mean number of glaucoma medications was 1.95±1.01 preoperative and 1.69±1.28 (P>0.05) at 1 year postoperatively. Postoperatively, 3 eyes (7%) experienced an IOP increase of 15 mm Hg above their baseline IOP that responded to topical therapy. In total, 96% of patients with an IOP≥19 mm Hg achieved a reduction in IOP at their last collected follow-up.
CONCLUSIONS:The insertion of the iStent Trabecular Micro-Bypass stent effectively lowers IOP in pseudophakic patients with open-angle glaucoma. Although medication use was not significantly reduced postoperatively at 1 year, 80% of patients either experienced a reduction or no change in medication use. The safety profile appears favorable with a low rate of IOP spikes and only 1 patient requiring additional surgery.
A 75-year-old man with an ocular history of 8-cut radial keratotomy (RK) in both eyes presented for cataract surgery evaluation. He was previously correctable in spectacles in years prior despite his ...irregular corneas to 20/25 in the right eye and 20/30 in the left eye. He recently noticed a change in his overall visual function with significant nighttime glare and difficulty reading despite spectacle correction. Of note, he was unable to tolerate contact lenses and was resistant to refitting despite additional encouragement. Cataract surgery was delayed for many years, given he was correctable in spectacles and the concern of uncovering a highly aberrated cornea after removing his cataracts (Figures 1 and 2JOURNAL/jcrs/04.03/02158034-202308000-00021/figure1/v/2023-07-21T030437Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202308000-00021/figure2/v/2023-07-21T030437Z/r/image-tiff). Of note, the patient was interested in returning to the spectacle independence he enjoyed in the past. Ocular examination revealed a corrected distance visual acuity (CDVA) of 20/30 in the right eye and 20/60 in the left eye, with a manifest refraction of +4.50 -0.50 × 177 in the right eye and +5.75 -1.75 × 14 in the left eye. Glare testing was 20/50 in the right eye and 20/100 in the left eye, with retinal acuity meter testing of 20/25 in each eye. Pupils, confrontation visual fields, and intraocular pressures were normal. Pertinent slitlamp examination revealed corneal findings of 8-cut RK with nasal-gaping arcuate incisions in both eyes and lens findings of 2+ nuclear sclerosis with 2+ cortical changes in the right eye and 3+ nuclear sclerosis with 3+ cortical changes in the left eye. Cup-to-disc ratios of the optic nerves measured 0.5 with temporal sloping in the right eye and 0.6 with temporal sloping in the left eye. The dilated fundus examination was unremarkable. What intraocular lens (IOL) options would you offer this patient and how would you counsel regarding realistic expectations? What additional diagnostic testing would be helpful in your assessment? How would you calculate the IOLs?
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