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Background: We review the literature on the efficacy and safety outcomes of secondary Descemet stripping endothelial keratoplasty (DSEK) and Descemet membrane endothelial keratoplasty (DMEK). Methods: Literature search of English-written publications up to September 27, 2020 in PubMed database, using the terms "endothelial keratoplasty" in combination with keywords "secondary" or "repeat." In addition, we manually searched the references of the primary articles. Results: Twenty-seven studies (n = 651 eyes) were retained and reviewed, including 10 studies on repeat DSEK, 8 studies on repeat DMEK, 6 studies of DMEK following DSEK, and 3 studies of DSEK after failed DMEK. All studies reported significant improvement in visual acuity after secondary endothelial keratoplasty (EK). Twelve studies compared visual outcomes between primary and secondary EK, reporting conflicting findings. Sixteen studies reported endothelial cell loss rates after secondary EK, and only 1 study reported significantly increased endothelial cell loss rates compared with primary EK. Allograft rejection episodes occurred in 1.8% of eyes (range, 0%-50%). Six studies compared complication rates between primary and secondary EK eyes, and only 1 study found a higher median number of complications. However, 2 studies reported higher regraft failure rates compared with primary EK eyes. Conclusions: Secondary EK is surgically feasible and renders significant visual improvement after failed primary EK, although it is not clear whether visual outcomes and allograft survival are comparable with primary EK, raising the question of whether secondary EK eyes are "low risk" as primary EK eyes. Further larger, prospective studies are encouraged to obtain additional quality data on secondary corneal endothelial allotransplantation. info:eu-repo/semantics/publishedVersion

Purpose To analyze the clinical results of repeat Descemet membrane endothelial keratoplasty (re-DMEK) for failed primary DMEK graft at a referral center for keratoplasty in Spain. Design Retrospective, interventional, comparative case series. Methods From a single-center, single-surgeon series of 189 consecutive DMEK surgeries, 14 (7.41%) were re-DMEK eyes. The primary outcome was best-corrected visual acuity change (ΔBCVA, logarithm of minimal angle of resolution [logMAR]) from baseline (before first DMEK) to last follow-up. Secondary outcomes were ΔBCVA from baseline at 3, 6, and 12 months postoperatively, endothelial cell loss (%ECL), rebubbling rate, and re-DMEK graft failure. Outcomes were compared with an age-matched control group of 18 successful primary DMEK eyes. Results After re-DMEK (median follow-up time 14.5 [42.5] months), mean BCVA improved from 0.55 (0.42) logMAR (Snellen 20/71 [20/53]) at baseline to 0.09 (0.26) logMAR (Snellen 20/25 [20/36]; P = .037). ΔBCVA from baseline was statistically significant at months 3 (P = .028), 6 (P = .023), and 12 (P = .012), and ΔBCVA was significant observed between months 6 and 12 (P = .028). BCVA differences between patient groups were statistically nonsignificant at 3 (P = .397), 6 (P = .468), and 12 months (P = .647). Mean %ECL in re-DMEK eyes with follow-up ≥12 months was 48.2 (15.1%), and the rebubbling rate was 28.6%; differences between groups were statistically nonsignificant for both variables (P = .580 and P = .669, respectively). Three re-DMEK eyes developed graft failure, all achieving final BCVA ≤0.30 logMAR (Snellen ≥20/40) after tertiary keratoplasty. Conclusions Repeat DMEK produces significant, continuous visual improvement after failed primary DMEK. Although visual outcomes and %ECL were comparable to primary DMEK, there was a relatively high rate of graft failure after re-DMEK.

Purpose To describe visual and clinical outcomes of descemet membrane endothelial keratoplasty (DMEK) for late endothelial failure after penetrating keratoplasty (PK). # Methods Retrospective, observational study of patients who consecutively received DMEK to treat PK graft failure. Intraoperative complications were recorded. Our previously described DMEK surgical technique was used except that host descemet membrane was not stripped in any of the eyes. Corrected distance visual acuity (CDVA), and endothelial cell density (ECD) were evaluated before surgery and at regular intervals up to 24 months after the surgery. # Results Twenty-six eyes of 26 patients were included. Mean host age was 58.50 ± 12.50 years old. Mean donor age was 65.30 ± 10.49. Mean follow up after DMEK was 23.08 ± 10.27 (range 6 months–48 months). Seventeen (65.38%) eyes reached at least the 24-month follow up time point. At last follow up, 24 eyes (92.31%) presented with clear corneas. Twenty-four months postoperatively, mean Snellen CDVA in decimal fraction was 0.75 ± 0.03 (range 0.6–0.80) and mean central endothelial cell density was 1480.41 ± 320.56 cells/mm2 (range, 591–1950 cells/mm2). Mean cell loss at 6 months was 27.67 ± 16.03%. Three (11.53%) eyes had significant graft detachment that required re-bubbling. No episodes of immunological graft rejection were documented. # Conclusions Our experience shows that DMEK is a useful technique to treat endothelial graft failure following PK. Compared to repeat PK, DMEK-specific surgical complications and postsurgical management should be expected.

PURPOSE To perform a paired-eye comparison of secondary iris-claw intraocular lens (IOL) implantation for aphakia. METHODS Retrospective, comparative, nonrandomized interventional case series of aphakic eyes, which underwent secondary iris-claw Artisan IOL (Ophtec BV) implantation for aphakia in one eye and no surgery (group 1) or cataract surgery (group 2) in the fellow eye. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent, central endothelial cell count (cECC), and complications were evaluated before surgery, and at yearly intervals up to 5 years. RESULTS Thirty aphakic eyes implanted with the Artisan were included, and the fellow eyes served as controls. In group 1, postoperative logMAR UDVA and CDVA was significantly higher in the Artisan-implanted eyes (P < 0.01). In group 2, no differences were found in postoperative UDVA and postoperative CDVA between the Artisan-implanted eyes and the eyes that underwent cataract surgery throughout the follow-up (P ≥ 0.05). No statistically significant differences were found in postoperative spherical equivalent between the Artisan-implanted eyes and unoperated eyes or eyes that underwent cataract surgery (P ≥ 0.05). In group 1, cECC was significantly lower in the Artisan-implanted eyes [1973 ± 822 vs. 2616 ± 481 cells per square millimeter at 2 years (P < 0.01)] throughout the follow-up (P < 0.01). In group 2, cECC was not significantly lower in the Artisan-implanted eyes (P ≥ 0.05) [1934 ± 689 vs. 2058 ± 818 cells per square millimeter at 2 years (P = 0.67)]. CONCLUSIONS Visual rehabilitation with secondary iris-claw IOL implantation in aphakic eyes without capsular support seems to be an effective and safe procedure. As expected, uncomplicated cataract surgery with posterior chamber IOL implantation showed lower endothelial cell count loss. Close monitoring of the corneal endothelium is mandatory.

Boston Keratoprosthesis (K-Pro) type 1 is the most widely used artificial cornea. K-Pro eyes require life-long follow-up by a multidisciplinary team involving a corneal specialist, a glaucoma specialist, and a retinal specialist. A deep understanding of potential complications and how to manage them is the key in achieving good outcomes. Complications may be related to the K-Pro itself or to other comorbidities frequently encountered in such complex eyes. The introduction of accurate protocols for preoperative planning, surgical technique, and postoperative follow-up has resulted in improved outcomes. Specifically, endophthalmitis prophylaxis and intraocular pressure management are some of the key aspects. This review constitutes a comprehensive overview of the most significant complications through the eyes of cornea, glaucoma, and retinal specialists with extensive experience in K-Pro surgery. The extensive preclinical and clinical research on Boston K-Pro 1 has shed light on the potential complications and their adequate prevention and management. Patients should be informed of the benefits and risks of the procedure, and the need of close follow-up throughout life.

Keratoconus (KC) is a noninflammatory progressive corneal ectasia. It is characterized by the irregular astigmatism produced by both central and peripheral corneal stromal thinning. It is a relatively common pathology of unknown etiology. Many patients with mild or moderate KC can improve their best-corrected visual acuity (BCVA) by wearing glasses or hard contact lenses. Keratoplasty is indicated in advanced KC cases when the vision does not improve after optical correction or when there is corneal scarring that alters the transparency of the cornea.

Francisco Bandeira,1 Merce Morral,2 Daniel Elies,2,3 Sergio Eguiza,2 Spyridoula Souki,2 Felicidad Manero,2 Jose L Güell2–4 1Cornea and External Disease Department, Federal University of São Paulo, São Paulo, Brazil; 2Cornea and Refractive Surgery Unit, Instituto Microcirugia Ocular, Barcelona, Spain; 3European School for Advanced Studies in Ophthalmology (ESASO), Lugano, Switzerland; 4Ophthalmology, Universitat Autonoma de Barcelona (UAB), Barcelona, Spain Synopsis: Transitional toric intraocular lens (IOL) was developed to improve refractive outcomes in cataract surgery. We report refractive, vectorial outcomes, and stability of spherical equivalent over 12months after implantation of this IOL.Purpose: To evaluate visual and refractive outcomes of a transitional conic toric intraocular lens (IOL) (Precizon®) for the correction of corneal astigmatism in patients undergoing cataract surgery.Setting: The Ocular Microsurgery Institute (IMO), a private practice in Barcelona, Spain.Design: This is a retrospective, non-randomized study.Methods: Retrospective chart review of 156 patients with preoperative regular corneal astigmatism >0.75 diopters (D) who underwent consecutive phacoemulsification and Precizon toric IOL implantation between January 2014 and December 2015 was performed. Two groups were divided according to attempted residual refraction: group 1 with emmetropia and group 2 with mild myopia for monovision. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and manifest refraction were analyzed preoperatively and 3, 6, and 12months postoperatively.Results: Precizon toric IOL was implanted in 97 eyes of 61 patients. Six months postoperatively, none of the eyes lost any line of CDVA. In all, 98% of the eyes were within ±1.00D of attempted spherical correction. The mean preoperative keratometric cylinder was 1.92 ± 1.04D (range 0.75–6.78), and the mean postoperative refractive cylinder was 0.77 ± 0.50D (range 0–2.25), with 81% of the eyes with ≤1.00D of residual cylinder. Two IOLs required realignment due to intraoperative positioning error. Eleven eyes required enhancement with corneal refractive surgery.Conclusion: Preexisting regular corneal astigmatism was effectively and safely corrected by the implantation of the transitional conic toric IOL in patients undergoing cataract surgery. Keywords: corneal astigmatism, refractive astigmatism, keratometry, cataract surgery, toric intraocular lens, biometry, phacoemulsification

Purpose The aim was to study the visual and refractive results in patients with epithelization in the corneal interface after laser in situ keratomileusis (LASIK) who were treated by cleaning the corneal interface (epithelial cyst extraction) and suturing the corneal flap. Methods This is a retrospective, noncomparative interventional case series. The main outcome measures were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), refractive cylinder (CYL), spherical equivalent (SE), recurrence of epithelial ingrowth, and complications. Results From a total of 7520 LASIK refractive eyes, 13 eyes with epithelial ingrowth were treated. The mean age was 46.9 years. The mean preoperative logMAR UDVA was 0.34 (SD, 0.19). At 2 months, the mean postoperative logMAR UDVA was 0.18 (SD, 0.17) and at 1 year was 0.12 (SD, 0.18) (P = 0.01). The mean logMAR CDVA before surgery was 0.16 (SD, 0.16). Two months and 1 year postoperatively, the mean logMAR CDVA was 0.05 (SD, 0.08) and 0.03 (SD, 0.06), respectively (P = 0.03). The mean SE before surgery was 0.30 D (SD, 1.09). The mean SE 2 months and 1 year after surgery was -0.07 (SD, 0.53) and -0.004 (SD, 0.18), respectively (P = 0.04). The mean CYL before surgery was -0.92 D (SD, 1.09); and the mean CYL 2 months and 1 year after surgery was -0.60 (SD, 0.84) and -0.18 (SD, 0.75), respectively (P = 0.26). No epithelial ingrowth recurrence was observed up to 1 year after epithelial removal. Conclusions Cleaning the corneal interface and suturing the corneal flap was effective and appeared safe in treating epithelial ingrowth after LASIK, with an extremely low rate of regrowth. However, further prospective controlled studies with a longer follow-up are needed.

Purpose To compare the achieved refractive accuracy of laser in situ keratomileusis (LASIK) performed based on manifest refraction with the predicted accuracy that would have been achieved using WASCA aberrometric refraction with and without Seidel correction factor for sphere. Setting London Vision Clinic, London, United Kingdom. Design Comparative case series. Methods Myopic eyes and hyperopic eyes had LASIK based on manifest refraction. Two aberrometric refractions were obtained preoperatively: Seidel, which includes spherical aberration in the sphere calculation, and non-Seidel. Bland-Altman plots were used to show the agreement between aberrometric and manifest refractions. Predicted LASIK outcomes had aberrometric refraction been used were modeled by shifting the postoperative manifest refraction by the vector difference between the preoperative manifest and aberrometric refractions. Results This study included 869 myopic eyes and 413 hyperopic eyes. The mean differences (manifest minus aberrometric) in spherical equivalent were +0.03 diopters (D) ± 0.48 (SD) (Seidel aberrometric) and +0.45 ± 0.42 D (non-Seidel aberrometric) for myopia and −0.20 ± 0.39 D and +0.39 ± 0.34 D, respectively, for hyperopia. The mean differences in cylinder magnitude were −0.10 ± 0.27 D and 0.00 ± 0.25 D, respectively. The percentage of eyes within ±0.50 D of the attempted correction was 81% (manifest), 70% (Seidel), and 67% (non-Seidel) for myopia and 71% (manifest), 61% (Seidel), and 64% (non-Seidel) for hyperopia. Conclusions The achieved refractive accuracy by manifest refraction was better than the predicted accuracy had Seidel or non-Seidel aberrometric refractions been used for surgical planning. Using the Seidel method improved the accuracy in myopic eyes but not in hyperopic eyes. Financial Disclosure Dr. Reinstein is a consultant to Carl Zeiss Meditec AG and has a proprietary interest in the Artemis technology (Arcscan Inc., Morrison, Colorado, USA) through patents administered by the Cornell Center for Technology Enterprise and Commercialization, Ithaca, New York. No other author has a financial or proprietary interest in any material or method mentioned.

Three patients presented with spontaneous myopic shift 6 weeks to 6 months after implantation of the Artiflex phakic intraocular lens (pIOL). The corrected distance visual acuity (CDVA) was maintained in all cases. Cyclopentolate drops successfully reverted the myopic shift in all cases; however, 2 cases required surgical reenclavation of the pIOL haptics to achieve long-term refractive stability. At the last follow-up, all patients had returned to emmetropia, with uncorrected distance visual acuities of 20/20. A slight decrease in objective optical quality was observed. No eye lost a line of CDVA. In 1 eye, optical coherence tomography scans showed slight posterior positioning of the pIOL. These cases show that spontaneous myopic shift is a potential complication of iris-claw pIOL implantation. That cyclopentolate drops and/or reenclavation of the haptics were effective in reverting the situation suggests a mechanical mechanism related to iris and ciliary body dynamics. Financial Disclosure Dr. Guell is a consultant to Ophtec. No author has a financial or proprietary interest in any material or method mentioned.

We describe a technique of femtosecond laser-assisted enhancement after primary LASIK with a mechanical microkeratome-created flap. The vertical side-cut incision by the femtosecond laser creates a wound configuration that decreases mechanical trauma to the epithelium and prevents epithelial cell migration. These factors may decrease the risk for post-LASIK enhancement epithelial ingrowth. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned. Additional disclosures are found in the footnotes.

The second part of a review of phakic intraocular lenses (pIOLs) addresses results and complications with current pIOL models. Phakic IOLs demonstrate reversibility, high optical quality, potential gain in visual acuity in myopic patients due to retinal magnification; correction is not limited by corneal thickness or topography. With proper anatomical conditions, pIOLs also show good results in hyperopic patients. Toric pIOL designs enable spherocylindrical correction. Complications are rare and primarily related to pIOL position and type. The main complications of anglesupported anterior chamber pIOLs are glare and halos, pupil ovalization, and corneal endothelial cell loss; of iris-fixated anterior chamber pIOLs, chronic subclinical inflammation, corneal endothelial cell loss, and dislocation or pupillary block glaucoma; and of posterior chamber pIOLs, anterior subcapsular cataract formation, pigment dispersion, and luxation or pupillary block glaucoma. No causative relationship between pIOL implantation (of any pIOL type) and retinal detachment has been established. Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.

To report the 4-year outcomes after Intacs intrastromal corneal ring segment (ICRS) implantation to correct low myopia in patients with abnormal topography.Instituto de Microcirugia Ocular, Barcelona, Spain.This retrospective consecutive interventional case series included eyes with myopia lower than -4.50 diopters (D) and abnormal topography that excluded excimer laser surgery. Evaluation was performed preoperatively and at yearly intervals up to 4 years postoperatively. The 4-year outcomes measures were uncorrected (UDVA) and corrected (CDVA) distance visual acuities, predictability and stability of refractive correction, the efficacy and safety indices, and complications.After ICRS implantation, 82.05% of 39 eyes (21 patients) were within +/-1.00 diopter (D) of emmetropia and 46.15% were within +/-0.50 D. Refractive correction improved during the first 6 months and remained stable up to 4 years. The UDVA was 20/40 or better in all eyes and 20/20 or better in 38.46% of eyes. Seven eyes (17.95%) lost 1 line of CDVA, and no eye lost 2 or more lines. No intraoperative complications occurred. The ICRS were exchanged for thicker ICRS in 7 eyes (17.9%) because of undercorrection. One patient requested ICRS removal due to unsatisfactory refractive results.The 4-year results indicate that ICRS implantation is effective and safe in the correction of low myopia in patients for whom excimer laser surgery is contraindicated because of abnormal topography, including forme fruste keratoconus. The achieved refractive correction remained stable throughout the follow-up.No author has a financial or proprietary interest in any material or method mentioned.

PURPOSE: To study the feasibility of performing myopic femtosecond small incision lenticule extraction (SMILE) with four different cap thicknesses (130, 140, 150, and 160 μ m). METHODS: In this retrospective, comparative, non-randomized clinical trial, a refractive lenticule of intrastromal corneal tissue was cut with the VisuMax femtosecond laser system (Carl Zeiss Meditec AG, Jena, Germany) using different depths of the non-refractive lenticule cut. Manifest refraction, uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and Objective Scattering Index (OSI) were evaluated. Minimum follow-up time was 1 year. RESULTS: Ninety-four eyes of 47 patients with myopia with (14 patients) and without (33 patients) astigmatism were treated. One year after the surgery, mean log-MAR UDVA, logMAR CDVA, SE, and OSI were 0.07 ± 0.12, 0.01 ± 0.37, 0.07 ± 0.57, and 0.88 ± 0.17, respectively ( P < .05). There were no significant statistical differences in logMAR UDVA, logMAR CDVA, SE, or OSI ( P > .05) variables when the different groups were compared for the same periods of time. CONCLUSIONS: No differences in visual acuity, refractive outcomes in optical visual quality, or complications were observed when using SMILE at four different depths. [ J Refract Surg. 2015;31(9):580–585.]

To compare clinical outcomes using 20% sulfur hexafluoride (SF6) versus 100% air as a tamponade for graft attachment in Descemet membrane endothelial keratoplasty (DMEK).Retrospective, comparative, interventional case series.Pseudophakic patients with Fuchs' endothelial dystrophy or pseudophakic bullous keratopathy that underwent DMEK using either 20% SF6 (group 1; 42 eyes) or 100% air (group 2; 39 eyes) tamponade between April 2010 and August 2011.A bimanual infusion technique was used to introduce and position the donor endothelium-Descemet membrane graft tissue. Outcome measures were analyzed at the following time points: before surgery, 3 and 6 months after surgery, and at yearly intervals up to at least 3 years.Corrected distance visual acuity (CDVA), manifest refraction, pachymetry, central endothelial cell count (cECC), complications, and rebubbling rates.Three years after surgery, mean CDVA improved from 0.48±0.45 logarithm of the minimum angle of resolution (logMAR) to 0.04±0.23 in group 1 (P0.001) and from 0.67±0.45 logMAR to 0.09±0.13 logMAR in group 2 (P0.001). The percentage of eyes with CDVA of 20/25 or more was 85.71% (36/42 eyes) in group 1 and 82.05% (32/39 eyes) in group 2 (P = 0.43). Mean preoperative cECCs and at last follow-up were: group 1, 2525±338 cells/mm(2) and 1758 ± 398 cells/mm(2) (mean cell loss, 30±11%; P = 0.008); and group 2, 2492±204 cells/mm(2) and 1678±373 cells/mm(2) (mean cell loss, 32±13%; P = 0.008). Endothelial cell loss was similar in both groups (P = 0.65). Intracameral air reinjection was needed in 1 patient in group 1 (2.38%) and in 5 patients in group 2 (12.8%). The rebubbling rate was significantly higher in group 2 (P = 0.004). No episodes of immunologic graft rejection were documented.Although clinical outcomes and corneal endothelial cell loss were similar in both groups, tamponade with 20% SF6 yielded a significantly lower incidence of graft detachments that may warrant its routine use in DMEK. Longer-term, randomized studies are needed to recommend this approach fully.

The cornea remains in a state of deturgescence, maintained by the endothelial cell Na+/K+ ATPase and by tight junctions between endothelial cells that limit the entrance of fluid into the stroma. By maintaining an optimum level of corneal hydration, endothelial cells preserve the ordered arrangement of collagen fibers, which is crucial for corneal transparency. Fuchs' endothelial corneal dystrophy (FECD) was initially described by Fuchs in 1910 as a combination of epithelial and stromal edema in older patients. It manifests itself as bilateral, albeit asymmetric, central corneal guttae, corneal edema, and reduced vision. The Descemet membrane thickens and develops excrescences known histopathologically as guttae. Stromal edema develops, and the corneal thickness may increase to over 1,000 μm. When the edema is severe, the corneal epithelium can detach from its basement membrane, creating painful bullae on the anterior surface of the cornea. FECD is the most common endothelial dystrophy and is usually seen beyond the fifth decade of life, although not all cases are in the elderly. Pseudophakic bullous keratopathy is a term used to describe endothelial cell loss caused by surgical manipulations in the anterior chamber (usually due to pseudophakic intraocular lens (IOL) implantation, but it may be related to any other intraocular surgical procedure, obviously including phakic IOL implantation). If the corneal endothelium is damaged during surgery (as often occurs during cataract extraction, phakic IOL implantation and other procedures), the same spectrum of symptoms as found in FECD can develop, although the histological phenotype of both diseases is different and, usually, there is no guttata in pseudophakic bullous keratopathy. Full-thickness grafts have been the standard of care for treating medically uncontrollable endothelial disease for a significant number of years worldwide. However, although the success rate is 90% in low-risk patients, it is only 30-50% in more complex, higher-risk cases, and overall, 30% of cases have a rejection episode. Moreover, regrafting has become the most common indication for corneal transplantation in the US and in some places in Europe. The more recently developed lamellar keratoplasty techniques are designed to overcome some of the problems of corneal transplantation by leaving as much of the healthy cornea in place as possible. For example, endothelial keratoplasty procedures replace only the endothelium but leave the patient's cornea's refraction as well as most of its biomechanical properties fairly intact. In this chapter, we will review the actual techniques for endothelial transplantation and provide an update on the surgical strategy (mostly for Descemet membrane endothelial keratoplasty) and its clinical results and complications.

To evaluate the efficacy, predictability, safety and complications of secondary iris-claw intraocular lens (IOL) implantation in aphakic eyes without capsular support.Retrospective, non-comparative, interventional case series of 128 aphakic eyes, which consecutively underwent secondary iris-claw Artisan IOL (Ophtec BV) implantation, were included. Manifest refraction, uncorrected visual acuity, best-spectacle corrected visual acuity, biomicroscopy, tonometry, funduscopy and central endothelial cell count (cECC) were evaluated before surgery, and at yearly intervals up to 5 years. Minimum follow-up time was 1 year.One hundred twenty-eight eyes were treated. Mean age was 54.55 years (range, 1-98 years). Mean follow-up was 41.8 months (SD 23.63). Mean preoperative logarithm of the minimum angle of resolution BSCVA and spherical equivalent (SE) were 0.67 ((SD) 0.53) and 9.63 D (SD 5.50), respectively. One year postoperatively, mean logarithm of the minimum angle of resolution best-spectacle corrected visual acuity improved to 0.52 (SD 0.46) (p0.05), and remained stable up to 5 years. One year postoperatively, mean SE was -0.52 (SD 2.21) (p0.05). Mean SE progressively decreased during the 1st year, and remained stable thereafter (p0.05). Mean preoperative cECC was 2237.47 (SD 793.33) cells/mm(2). cECC showed a slight, though statistically significant, decrease over the years (p=0.05). Main complications were: 2 pupillary block; 3 transient increase in intraocular pressure; 1 IOL replacement; 2 penetrating keratoplasty and 4 cystoid macular oedema.Iris-claw IOL implantation in aphakic eyes is an effective, predictable and safe procedure in the first 5 years of follow-up. However, a longer follow-up is required to demonstrate its long-term safety.

To describe a new bimanual technique for insertion and positioning of endothelium-Descemet membrane (EDM) grafts in Descemet membrane endothelial keratoplasty (DMEK).Prospective, noncomparative, consecutive interventional case series, including 15 pseudophakic eyes of 15 patients treated with DMEK at the Instituto de Microcirugia Ocular, Barcelona, Spain. A bimanual infusion technique was used to introduce and position donor's EDM. Partial tamponade was achieved with 20% sulfur hexafluoride (SF6). Intraocular manipulation time of EDM grafts, rebubbling rate, and endothelial cell density were evaluated.Six months postoperatively, mean uncorrected visual acuity and best spectacle-corrected visual acuity (BSCVA) improved from 20/100 to 20/50 and from 20/80 to 20/25, respectively (P0.001). Six eyes (40%) had ≥ 20/20 BSCVA, and 13 (86%) eyes had ≥ 20/30 BSCVA. Mean donor cell density decreased from 2690 ± 302 to 1998 ± 621 cells per square millimeter, representing a mean cell loss of 26% ± 20%. EDM was stripped successfully in all cases. Mean intraocular manipulation time of donor's EDM (interval between main incision closure and final EDM positioning) was 4.10 ± 0.5 minutes. Intracameral air reinjection was needed in 1 case (6.6%) with a partial peripheral graft detachment. No episodes of immunologic graft rejection were documented.Insertion and positioning of EDM grafts in DMEK was successfully achieved using this bimanual infusion technique and 20% SF6 partial tamponade, with a low intraocular manipulation time and very low postoperative rebubbling rates, regardless of the preservation method and the donor's age. However, prospective comparative studies are required to demonstrate the long-term safety compared with other approaches.

Purpose To describe the ocular effects associated with the administration of the systemic epidermal growth factor receptor (EGFR) inhibitors panitumumab and erlotinib. Design Retrospective, noncomparative interventional case series. Participants Ten eyes of 5 patients in treatment with systemic EGFR inhibitors, 4 patients with erlotinib for end-stage lung carcinoma, and 1 patient with panitumumab for end-stage colorectal cancer. Methods Data collected from charts included gender, age at presentation, systemic disease, and clinical presentation in each eye. Main Outcome Measures Demographics on presentation and clinical findings. Results Multiple epithelial defects were observed in all 10 eyes, corneal melting and thinning were observed in 3 eyes of 2 patients, 2 eyes of 1 patient presented with lower lid ectropion, and 2 eyes of 2 patients presented with corneal perforation, both requiring a penetrating keratoplasty. Conclusions Severe ocular side effects, including corneal perforation, may be associated with the use of the EGFR inhibitors panitumumab and erlotinib. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

PURPOSE:Toreportthelong-termresultsofcombinedcollagencrosslinking(CXL)andtoricphakic intraocular lens (pIOL) implantation to correct myopic astigmatism in patients with progressive mild to moderate keratoconus. SETTING: Instituto de Microcirugia Ocular, Barcelona, Spain. DESIGN: Case series. METHODS:From November 2006to July 2009,CXLwasperformedineyes withprovenprogressive keratoconus. Oncerefraction and topographystabilized, toricArtiflex/ArtisanpIOL implantation was performed to correct residual myopic astigmatism. A complete ophthalmologic examination, including manifest refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuities, biomicroscopy, tonometry, fundoscopy, keratometry, corneal tomography, and central endothelial cell count (ECC), was performed before each procedure and postoperatively at 3 months and at yearly intervals up to 5 years. Main outcome measures were accuracy and stability of the spherical equivalent (SE) and cylinder, keratometry, UDVA (efficacy), CDVA (safety), central ECC, and complications. RESULTS: The median follow-up in the 9 patients (17 eyes) was 36.9 months G 15.0 (SD). The median interval between CXL and pIOL implantation was 3.9 G 0.7 months. Fourteen eyes (82%) were within G0.50 diopter (D) of the attempted SE correction and 13 eyes (76%) were within G1.00 D of the attempted cylinder correction. The mean difference in simulated keratometry between preoperatively and the last follow-up was 0.17 G 0.45 D (range 0.55 to 1.45 D). The postoperative UDVA was 20/40 or better in 16 eyes (94%). No eye lost lines of CDVA. No significant decrease in central ECC occurred (P>.05). CONCLUSION: Combined CXL and toric iris-claw pIOL implantation effectively and safely corrected myopic astigmatism in progressive mild to moderate keratoconus. Financial Disclosure: Dr. G€ is a consultant to Ophtec. No other author has a financial or proprietary interest in any material or methods mentioned.

In this 2-part overview, the current status of phakic intraocular lens (pIOL) surgery to correct refractive errors is reviewed. Three types of pIOLs, categorized by their intraocular position, are included: angle-supported anterior chamber, iris-fixated anterior chamber, and posterior chamber (usually fixated in the ciliary sulcus). Part 1 reviews the main models of each pIOL type, the selection criteria, and the surgical techniques, with emphasis on currently available pIOLs. Bioptics, adjustable refractive surgery, and enhancements are addressed, and applications of the new anterior segment imaging techniques are reviewed.

To perform a dynamic study of the relationship between Verisyse (AMO) and Artiflex (Ophtec B.V.) phakic intraocular lenses (pIOLs) and anterior chamber structures during accommodation using optical coherence tomography (OCT) (Visante, Carl Zeiss Meditec, Inc.)Institutional practice.Eleven myopic patients were randomly selected to have implantation of a Verisyse pIOL in 1 eye and an Artiflex pIOL in the other. Using a 2-dimensional image, dynamic measurements of the relationship between the anterior surface of the pIOL and the corneal endothelium, the posterior surface of the pIOL and the anterior surface of the crystalline lens, and the pupil diameter were performed using Visante OCT. Physiological accommodation was stimulated by adding lenses in 1.00 diopter (D) steps from +1.00 to -7.00 D.Both groups had a significant decrease in pupil diameter (P.0001, generalized linear model [GLM]) and in the distance between the anterior surface of the pIOL and the corneal endothelium (P.0001, GLM) with accommodation. There were no statistically significant changes in the distance between the posterior surface of either pIOL and the anterior surface of the crystalline lens (P = .2845, GLM). There were no statistically significant differences between the 2 pIOLs in any measurement (P.05, GLM).The results fit with Helmholtz' theory of accommodation as forward movement of the diaphragm iris-crystalline lens was seen. There was a decrease in the distance between the pIOL and corneal endothelium and in the pupil diameter, whereas the distance between both pIOLs and the crystalline lens remained constant throughout the accommodation examination. This suggests that the risk for cataract from intermittent contact between the crystalline lens and IOL from accommodative effort is unlikely.

Purpose To report long-term results of Artisan–Verisyse phakic intraocular lenses (PIOLs) to correct myopia, hyperopia, and/or astigmatism and the percentage of additional keratorefractive surgery to eliminate residual refractive errors. Design Retrospective, nonrandomized, interventional case series. Participants From January 1996 to January 2003, 399 Artisan–Verisyse PIOLs were consecutively implanted. To correct myopia, 101 5-mm optic Verisyse PIOLs (group 1) and 173 6-mm optic Verisyse PIOLs (group 2) were implanted. Forty-one were PIOLs for hyperopia (group 3), and 84 were toric (group 4). Methods Manifest refraction, uncorrected visual acuity (UCVA), best spectacle-corrected visual acuity (BSCVA), biomicroscopy, tonometry, funduscopy, and central endothelial cell count (ECC) were determined before surgery, at 3 months, and at yearly intervals up to 5 years. Main Outcome Measures Refraction, UCVA, BSCVA, efficacy and safety indexes, enhancements' rate with keratorefractive surgery, central ECC, and complications. Results Mean follow-up was 4.05 years. Mean preoperative spherical equivalent (SE) and that at last follow-up were, respectively, −19.8±3.23 and −0.5 ± 0.89 diopters (D) (group 1), −11.27±3.11 and −0.64±0.8 D (group 2), +4.92±1.7 and +0.02±0.51 D (group 3), and −6.82±8.69 and −0.09±0.64 D (group 4). Group 4 had a mean preoperative cylinder of −3.24±1.02 D, which decreased to −0.83±0.74 D postoperatively. Additional keratorefractive surgery was performed in 60.39% of eyes (group 1), 19.6% (group 2), 41.4% (group 3), and 5.95% (group 4). Mean preoperative central ECC and that at last follow-up were, respectively, 2836±398 and 2514±529 cells/mm 2 (group 1), 2755±362 and 2454±588 cells/mm 2 (group 2), 2735±355 and 2560±335 cells/mm 2 (group 3), and 2632±543 and 2537±615 cells/mm 2 (group 4). Main complications were 3 explantations due to an unacceptable drop in ECC, 3 lenses' repositioning (2 ocular trauma and 1 unappropriate iris capture), 3 lenses' exchange due to refractive errors, 1 macular hemorrhage, 1 retinal detachment, and 2 cataracts. Conclusions According to our experience, implantation of iris-claw PIOLs is a reversible, effective, stable, safe procedure in the first 5 years of follow-up.

We report a case of sympathetic ophthalmia with systemic findings following resection of a malignant melanoma of the iris and ciliary body, and describe the treatment and clinical outcome. A 49-year-old man underwent sector iridocyclectomy of a malignant iridociliary melanoma of the right eye. Five weeks later, he was diagnosed with sympathetic ophthalmia. Snellen’s best-corrected visual acuity, fluorescein angiography, electroretinography, cerebrospinal fluid analysis and audiometry were performed. High-dose systemic steroid and immunosuppressive (cyclosporine and azathioprine) therapy was prescribed. Two months later chorioretinitis and macular edema persisted, and intravitreous triamcinolone was injected into the right eye. Five weeks after resection of an iridociliary melanoma, our patient had reported acute bilateral vision loss. Visual acuity was hand motion in both eyes. Examination showed bilateral granulomatous uveitis, diffuse choroiditis with Dalen-Fuchs nodules, papillitis and vitritis. On fluorescein angiography multiple hyperfluorescent dots, which coalesced in areas of exudative retinal detachment, were evident. The patient presented meningismus with pleocytosis on cerebrospinal fluid analysis, and sensorineural deafness. Sympathetic ophthalmia was diagnosed. High-dose intravenous steroids followed by oral prednisone at a tapering dose and immunosuppressive agents (cyclosporine and azathioprine), topical steroids in both eyes and intravitreal steroids in the right eye were administered. Phacoemulsification and intraocular lens implantation were performed to treat a dense cataract of the right eye. After 24 months of follow-up, best-corrected visual acuity was 20/200 in the right eye and 20/25 in the left; no signs of intraocular inflammation were observed and neurological signs had resolved. Low maintenance doses of systemic steroids and immunosuppressive agents were administered up to month 18 of follow-up to avoid recurrence. Sympathetic ophthalmia is a rare, but severe disease that can occur after resection of iridociliary melanoma. High-dose steroid therapy and supplementation with immunosuppressive agents early in the course of the disease was effective in resolving the condition.

We report 2 cases of reopening of macular holes after successful neodymium:YAG (Nd:YAG) posterior capsulotomy. Both patients had surgery for closure of macular holes with recovery of visual acuity. To our knowledge, this is the first report of recurrent macular holes after Nd:YAG laser posterior capsulotomy treated successfully with surgery.

Intracorneal ring segments (ICRS) have been implanted to treat mild to moderate keratoconus (KC) to correct myopia, and improve topographic abnormalities by recentring of the corneal optical zone.1 Residual refractive errors may subsequently be corrected with contact lenses (CLs) or by implanting a phakic intraocular lens (PIOL).2 Some authors have proposed photorefractive keratectomy (PRK) with mitomycin C (MMC).3 However, the risk of unpredictable refractive results caused by the intense stromal–epithelial interaction that has been observed after surface ablations following lamellar surgery raises concern over this approach (personal communication; Intacs and Intracorneal Lenses. Refractive Surgery Subspeciality Day, AAO 2002). We present a case of reactive epithelial hyperplasia after PRK in a patient with KC who had previously been implanted with ICRS. The epithelial hyperplasia had induced high hyperopic astigmatism and was successfully managed with mechanical epithelial debridement, MMC and amniotic membrane (AM). A 27-year-old woman with KC and CL intolerance underwent two 450 μm ICRS (Intacs, KeraVision, Fremont, California) implantation in the right eye. Preoperative best-spectacle corrected visual acuity (BSCVA) was 20/25 with −3.00 −2.75 × 110°, and topography revealed grade II KC, according to the Krumeich classification.4 …