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PURPOSE: To report the French refractive surgeons' real-life practices for preventing infection after corneal refractive surgery (photorefractive keratotomy [PRK], laser in situ keratomileusis [LASIK], and small-incision lenticule extraction). SETTING: French refractive surgeons. DESIGN: Anonymous practice survey. METHODS: The questionnaire was sent in a single email invitation to 400 declared refractive surgeons. The following information was recorded between December 2019 and April 2020, before the coronavirus pandemic: demographics data, preoperative evaluation and preparation of the patient, surgical management, immediate and postoperative protocol, and infections reported after corneal refractive surgery. RESULTS: Eighty-three 83 of 400 surgeons (20.75%) responded to the questionnaire; 55 (66.0%) performed more than 50 corneal refractive surgeries a year, and 25 (30.1%) performed more than 200 procedures a year. Thirty-six (43.4%) surgeons wore 3 protective items, 37 (44.6%) 2, 5 (6.0%) 1, and 5 (6.0%) zero. Seventy-seven (92.8%) surgeons used povidone-iodine for skin area disinfection and 54 (65%) for conjunctival fornix disinfection. The contact time of povidone-iodine was less than 3 minutes for 71 (85.0%) surgeons. Twenty surgeons (24.1%) reported at least 1 post-refractive surgery infection. Twenty percent of surgeons who wore sterile gloves for PRK reported post-operative infections compared with 62.5% for those who did not (p=0.008). These figures were, respectively, 8.7% and 66.7% for the use of sterile gloves during LASIK (p=0.002); 8.9% of surgeons who wore surgical masks for LASIK reported postoperative infections compared with 50.0% for those who did not (p=0.01). CONCLUSION: Practices are variable among French refractive surgeons. Wearing a surgical mask and sterile gloves during corneal refractive surgery appears to be advisable.

Unilateral corneal ectasia developed after small-incision lenticule extraction for mild myopia in a 43-year-old man with preoperative asymmetric astigmatism. The ectasia was diagnosed 4 years postoperatively. Preoperative data showed asymmetric astigmatism with no signs of forme fruste keratoconus. Inferior anterior curvature steepening exceeded 2.00 diopters without bulging of the posterior curvature, and pachymetric thickness exceeded 515 μm. Corneal ectasia can occur after small-incision lenticule extraction in patients older than 40 years with preoperative asymmetric astigmatism.

We report the clinical features and management of a patient with severe bilateral infectious keratitis developing after simultaneous bilateral small-incision lenticule extraction. A 39-year-old man was referred to our emergency department 2 days after a small-incision lenticule extraction procedure for moderate myopia. He reported decreased vision, photophobia, and pain bilaterally. Visual acuity was counting fingers in the right eye and hand motion in the left eye. Slitlamp examination showed multiple white corneal infiltrates at the corneal cap–stromal bed interface. The interface was first rinsed with povidone–iodine 10.0% and then with vancomycin (50 mg/mL). Fortified antibiotics eyedrops administration was initiated. Cultures showed Streptococcus pneumonia. Anterior segment spectral-domain optical coherence tomography scans were performed daily. Once the infection was controlled 4 days later, corticosteroids eyedrops were begun. Three months postoperatively, the patient had a corrected distance visual acuity of 20/32 in the right eye and 20/25 in the left eye. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

The KAMRA small-aperture corneal inlay can compensate for presbyopia. A small number of complications have been reported, including glare, halos, decentration, iron deposition, compromised distance and night vision, infectious keratitis and reversal corneal haze. We describe a case of corneal fibrosis after small-aperture corneal inlay implantation and its persistence after late explantation. The postoperative period was uneventful, with good uncorrected near and distance visual acuities. Six years after implantation, the patient reported vision loss in the left eye. A slitlamp evaluation and optical coherence tomography showed stromal opacity and a stromal hyperreflective signal at the level of the small-aperture corneal inlay. The corneal inlay was removed, but persistent decreased visual acuity and fibrosis were observed even 8 months after explantation and did not respond to steroids. Long-term monitoring with multimodal imaging methods is important to detect late adverse events after small-aperture corneal inlay implantation.

Purpose To analyze the modifications to the vitreous body after femtosecond laser–assisted laser in situ keratomileusis (LASIK) for myopia. Setting Centre Hospitalier National Des Quinze-Vingts, Paris, France. Design Case series. Methods B-scan ultrasonography of the posterior ocular segment was performed the day before and 48 hours after femtosecond LASIK for myopia. Posterior vitreous detachment (PVD) was diagnosed by the presence of a low-reflected mobile echogenic membrane partially or completely detached from the retina. Eyes with signs of partial or total PVD on preoperative examination were excluded. Occurrence of total or partial PVD after surgery was the main outcome measure. Results Thirty-one eyes of 18 patients (10 women; mean age 28 years ± 5 [SD]) were included in the study. The mean preoperative spherical equivalent was −4.38 diopters (D) (range −2.88 to −6.75 D). After surgery, 5 eyes (16%) developed partial or total PVD. The remaining 26 eyes had no signs of PVD postoperatively. Conclusion Although less vacuum is required to create a corneal flap with a femtosecond laser than with a conventional microkeratome, the incidence of PVD after femtosecond laser–assisted LASIK was similar to that reported for microkeratome-assisted LASIK. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

To report the results of correction of post-keratoplasty astigmatism by arcuate keratotomy performed with the Hanna arcitome (Moria).Service 5, Hôpital des 15-20, Paris VI University, Paris, France.Forty eyes operated on for post-keratoplasty astigmatism using the Hanna arcitome were retrospectively studied. Paired symmetrical arcuate keratotomies were performed on the graft button. Mean follow-up was 10.8 months +/- 11.2 (SD). Outcome measures included uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), and subjective refraction. For statistical analysis, visual acuity data were transformed into logMAR units. The refractive data were analyzed using the Alpins method.By a mean of 10.8 +/- 11.2 months after surgery, the UCVA had improved a mean of 0.28 +/- 0.46 lines, which was significant (P = .013). The BSCVA remained stable. The mean subjective cylinder was 8.84 +/- 3.00 diopters (D) preoperatively and 4.88 +/- 2.50 D postoperatively (P.001). The changes in postoperative subjective cylinder values correlated with preoperative cylinder values (r(s) = 0.584; P.0001). The subjective axis was modified by 20 degrees or less in 27 eyes (67.5%). The mean surgically induced astigmatism was 8.07 +/- 3.83 D and the mean correction index, 0.96 +/- 0.46. One microperforation occurred and required suturing. Incisions were off center in 1 case, and 2 patients had an allograft rejection after the procedure.Arcuate keratotomy performed with the Hanna arcitome was effective in reducing post-keratoplasty astigmatism. The device enabled safer, easier arcuate incisions than with manual techniques. However, predictability and efficacy could be improved by a more accurate nomogram.

Purpose To report long-term results of Artisan phakic intraocular lens (pIOL) to correct myopia and to propose a model predicting endothelial cell loss after pIOL implantation. Setting Quinze-Vingts National Ophthalmology Hospital, Paris, France. Design Retrospective, interventional case series. Methods Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and central endothelial cell count (ECC) were determined before and at yearly intervals up to 5 years after pIOL implantation. Linear model analysis was performed to present a model that describes endothelial cell loss as a linear decrease and an additional decrease depending on postoperative loss. Results A total of 49 patients (68 eyes) implanted with pIOLs from January 2000 to January 2009 were evaluated. The mean preoperative and final spherical equivalent (SE) were −13 ± 4.10 and −0.75 ± 0.74 diopters (D), respectively. The mean preoperative and final central ECC were 2629 ± 366 and 2250 ± 454 cells/mm 2 , respectively. There were no intraoperative complications for any of the eyes. One eye required surgery for repositioning the pIOL, and 1 eye required pIOL exchange for postoperative refractive error. The model predicted that for patients with preoperative ECC of 3000, 2500, and 2000 cells/mm 2 , a critical ECC of 1500 cells/mm 2 will be reached at 39, 28, and 15 years after implantation, respectively. Conclusions Implantation of the pIOL was an effective and stable procedure after 5 years of follow-up. The presented model predicted EC loss after pIOL implantation, which can assist ophthalmologists in patient selection and follow-up. Financial disclosure The authors report no conflict of interest.

A 70-year-old man was referred to us with a 2-year, progressive, painless decrease in visual acuity in the right eye. Ocular history included extraction of a traumatic cataract with a transclerally fixated posterior chamber intraocular lens. Slitlamp examination showed a raised, white, vascularized mass covering the cornea. The lesion was removed by superficial lamellar keratectomy. Light microscopy examination confirmed the diagnosis of corneal keloid. These uncommon lesions usually develop in adults after corneal traumas, surgery, or inflammatory processes. They have also been described in children with Lowe's syndrome, Rubinstein-Taybi syndrome, and other ocular developmental disorders.

Purpose To evaluate the effectiveness of indices derived from the EyeSys System 2000 in detecting keratoconic corneas. Setting Department of Ophthalmology, Hopital Saint Antoine, Paris VI University, Paris, France. Methods Topographies of 208 corneas were evaluated. The corneas were from 8 groups of patients classified by the following diagnoses: normal, regular astigmatism, cataract, radial keratotomy, photorefractive keratectomy, myopic keratomileusis, penetrating keratoplasty (PKP), and keratoconus. Nine statistical indices derived from EyeSys data, 2 Holladay Diagnosis Summary indices (coefficient of uniformity and coefficient of asphericity [Asph]), and our refractive power symmetry index were studied. A training set of 104 corneas was used to determine the most efficient threshold value of each index based on sensitivity and specificity curves. Decision trees combining 2 indices were generated. Sensitivity and specificity were calculated in a validation set composed of the remaining 104 corneas. Results Based on the results of the training set, the optimum indices were SDSD (standard deviation of the standard deviations of the radii of curvature of each ring) and Asph. In the validation set, the decision tree using these indices featured 88.5% sensitivity and 94.9% specificity; the 4 false-positive cases were in corneas in the PKP group of patients. Conclusions Clinically apparent keratoconus can be detected among normal corneas and irregular corneal shape patterns using the EyeSys System 2000 data and a decision tree combining 2 indices.

To report the results of arcuate keratotomy performed with the Hanna arcitome in patients with postkeratoplasty astigmatism.Department of Ophthalmology, Saint-Antoine Hospital, Paris VI University, Paris, France.This retrospective study comprised 22 eyes (22 patients) with postkeratoplasty astigmatism. Paired symmetrical arcuate keratotomy was performed with the Hanna arcitome. Outcome measures included refraction, videokeratography, and keratometry.At 6.6 months +/- 8.9 (SD) after surgery, the mean increase in best spectacle-corrected visual acuity (BSCVA) was 2.1 +/- 2.4 lines. Thirteen eyes gained 2 lines or more of BSCVA, and 15 gained 3 lines or more of uncorrected visual acuity. Two patients had a decrease in BSCVA: 1 had lens opacification unrelated to arcuate keratotomy and 1, increased corneal irregularity. Mean refractive astigmatism was 6.94 +/- 2.11 diopters (D) preoperatively and 3.85 +/- 1.95 D postoperatively (P.01). Mean change in keratometric astigmatism was -51 +/- 36%. Astigmatism decreased in 21 eyes as measured by manifest refraction, keratometry, and videokeratography; it increased in 1 cornea with a microperforation.The results of arcuate keratotomy performed with the Hanna arcitome were comparable to those with freehand relaxing incisions. The instrument made safer and more uniform arcuate incisions than a freehand technique.

To determine whether optical coherence tomography (OCT) epithelial mapping can improve the detection of form fruste keratoconus.French National Eye Hospital, Paris 6 PierreMarie Curie University, Paris, France.Retrospective comparative study.Eyes with normal corneas, form fruste keratoconus, moderate keratoconus, or severe keratoconus were assessed using Fourier-domain OCT (RTVue 5.5), scanning-slit corneal topography (Orbscan IIz), and rotating Scheimpflug camera (Pentacam Comprehensive Eye Scanner). Several parameters provided by the software or derived from elevation maps, OCT pachymetric maps, and OCT epithelium parameters were evaluated and compared between the 4 groups.The study involved 145 eyes. There were no significant differences in the keratometry (K) value, inferior-superior value, keratoconus index, central K index, and topographic keratoconus classification indices between the form fruste keratoconus group and the control group (P .05). Form fruste keratoconic corneas had less epithelial thickness in the thinnest corneal zone than normal corneas, and greater epithelial thickness in the thinnest corneal zone than keratoconic corneas (P .005). The epithelial thickness in the thinnest corneal zone in form fruste corneas was located inferiorly (P .005) and corresponded with the zone of minimum epithelial thickness and maximum posterior elevation (P .005). The receiver operating characteristic curve analysis showed good overall predictive accuracy of the epithelial thickness in the thinnest corneal zone, with a 52 μm threshold value for discriminating form fruste keratoconic corneas from normal corneas.The epithelial thickness in the thinnest corneal zone and its location provided by the OCT epithelial mapping might be useful for the early diagnosis of form fruste keratoconus.No author has a financial or proprietary interest in any material or method mentioned.

We report a case of bacterial keratitis that occurred after implantation of intrastromal corneal ring segments (Intacs). The patient presented with decreased vision, inflammation, and stromal infiltrates localized at the extremity of an Intacs channel 3 months after surgery. Culture were positive for Clostridium perfringens and Staphylococcus epidermidis. The infiltrates progressed despite treatment with topical fortified and systemic antibiotics. The Intacs were removed. The keratitis slowly resolved, and the patient recovered a best corrected visual acuity of 20/20.

After uneventful phacoemulsification and in-the-bag implantation of an AcrySof SA60AT (Alcon) intraocular lens (IOL), a 52-year-old black man developed pigmentary glaucoma. Slitlamp examination, anterior segment optical coherence tomography, and ultrasound biomicroscopy showed that the posterior surface of the iris was being rubbed by the inferior haptic of the IOL, which was in the bag but deformed. Filtering surgery was needed to control the intraocular pressure. This type of IOL can cause IOL-induced pigmentary glaucoma.