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Marjan Farid,1 Sheri L Rowen,2 Majid Moshirfar,3 Derek Cunningham,4 Ian B Gaddie,5 Gerard Smits,6 Teresa Ignacio,6 Preeya K Gupta7 1UCI Health, Irvine, CA, USA; 2NVISION Eye Centers, Newport Beach, CA, USA; 3Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 4Dell Laser Consultants, Austin, TX, USA; 5Gaddie Eye Centers, Louisville, KY, USA; 6Orasis Pharmaceuticals, Ponte Vedra, FL, USA; 7Triangle Eye Consultants, Raleigh, NC, USACorrespondence: Marjan Farid, UCI Health, 850 Health Sciences Road, Irvine, CA, 92617, USA, Tel +1-949-824-2020, Fax +1-855-376-5057, Email mfarid@hs.uci.eduPurpose: To evaluate the efficacy of 0.2% and 0.4% pilocarpine HCl (CSF-1) for the treatment of presbyopia and to determine the contributions of pilocarpine HCl and diclofenac sodium on the efficacy of fixed-dose combination (FDC) formulations.Patients and Methods: This was a Phase 2b, multicenter, randomized, double-masked, parallel-group clinical trial. Adults (45– 64 years) with presbyopia were randomized 1:1:1 to 3 arms (Pilo arm: pilocarpine HCl; Pilo-Diclo FDC arm: pilocarpine HCl with 0.006% diclofenac sodium; Control arm: 0.006% diclofenac sodium). Participants in Pilo and Pilo-Diclo FDC arms received 0.2% pilocarpine HCl (0.2% Pilo or 0.2% Pilo FDC, respectively) from days 1– 8, and 0.4% pilocarpine HCl (CSF-1 or CSF-1-FDC, respectively) from days 8– 15. Primary efficacy endpoint was achievement of ≥ 3-line (15-letter) gain in mesopic, monocular distance-corrected near visual acuity (DCNVA) at 40 cm, 1 hour post-treatment of the study eye on days 8 and 15 in the per protocol (PP) population. Safety endpoints were assessed.Results: One hundred and sixty-six participants were randomized (intent-to-treat, N = 166; PP, n = 160). There were no statistical differences between 0.2% Pilo or 0.2% Pilo FDC versus Control at 1 hour post-treatment on day 8. On day 15, 43.1% and 46.9% of participants receiving CSF-1-FDC (0.4% Pilo FDC) or CSF-1 (0.4% Pilo), respectively, achieved ≥ 3-line gain at 1 hour post-treatment in mesopic DCNVA compared with 16.1% of Control group in the PP population, meeting the primary endpoint (P = 0.0015 and P = 0.0002, respectively). All formulations were well tolerated.Conclusion: CSF-1 demonstrated significant improvements in mesopic DCNVA and favorable safety. Pilocarpine HCl as a single active ingredient, at the concentration of 0.4% (CSF-1), provided a transient, therapeutic effect for presbyopia.Keywords: pilocarpine hydrochloride, presbyopia, minimum effective concentration

Majid Moshirfar,1– 3 Alex H Brown,4 Garrett N Manion,5 Kayvon A Moin,1 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4Department of Ophthalmology, University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA; 5Department of Ophthalmology, Creighton University School of Medicine, Omaha, NE, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, 11820 S State St #200, Draper, UT, 84020, USA, Tel +1 801-568-0200, Fax +1 801-563-0200, Email cornea2020@me.comAbstract: Posterior capsular opacification (PCO), also known as “secondary cataract”, is a common complication following cataract surgery that can significantly impair visual acuity. The incidence of PCO varies widely in the literature, influenced by intraocular lens (IOL) type and patient risk factors. Neodymium-doped yttrium-aluminum-garnet (YAG) laser posterior capsulotomy is the standard treatment for PCO-related visual impairment. Recurrence of PCO after initial treatment with YAG capsulotomy, though more common in children, is rare in adults. Its underlying pathophysiological mechanisms are similar to that of primary PCO, which includes proliferation, migration, and/or clustering of lens epithelial cells (LECs), with subsequent reclosure of the posterior aperture. Potential risk factors for PCO recurrence that have been speculated through a comprehensive search of the current literature include younger age, female sex, high myopia, diabetes, vitrectomized status, uveitis, low-diopter IOLs, and certain IOL types with higher water content. We present a case of recurrent PCO in a highly myopic 48-year-old male following cataract surgery and implantable collamer lens (ICL) explantation who received a hydrophobic acrylic lens with 4% water content. Surgical techniques that may reduce recurrent PCO occurrence and appropriate postoperative care are emphasized to assist surgeons in their approach to patients at high-risk for this complication.Keywords: recurrent posterior capsule opacification, recurrent PCO, implantable collamer lens, ICL, repeat neodymium-doped yttrium-aluminum-garnet, repeat Nd:YAG, cataract surgery, posterior capsule reclosure, posterior capsule re-opacification, intraocular lens water content, IOL water content

Majid Moshirfar,1– 3 Azraa Ayesha,4 Muhammad Jaafar,5 Kenneth Han,5 Soroush Omidvarnia,6 Amal Altaf,5 Isabella M Stoakes,1,7 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, John A. Moran Eye Center, Murray, UT, USA; 4Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA; 5University of Arizona- Phoenix College of Medicine, Phoenix, AZ, USA; 6Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX, USA; 7Pacific Northwest University of Health Science School of Medicine, Yakima, WA, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, 11820 South State Street #200, Draper, UT, 84020, USA, Tel +1 801-568-0200, Fax +1 801-563-0200, Email cornea2020@me.comPurpose: This study aimed to evaluate the accuracy of 12 intraocular lens (IOL) power calculation formulae for eyes that have undergone both radial keratotomy (RK) and laser assisted in situ keratomileusis (LASIK) surgery to determine the efficacy of various IOL calculations for this unique patient group. Currently, research on this surgical topic is limited.Methods: In this retrospective study, 11 eyes from 7 individuals with a history of RK and LASIK who underwent cataract surgery at Hoopes Vision were analyzed. Preoperative biometric and corneal topographic measurements were performed. Subjective refraction was obtained postoperatively. Twelve different intraocular lens (IOL) power calculations were used: Barrett True K No History, Barrett True K (prior LASIK, Prior RK history), Barrett Universal 2, Camellin-Calossi-Camellin (3C), Double K-Modified Holladay, Haigis-L, Galilei, OCT, PEARL-DGS, Potvin-Hill, Panacea, and Shammas.Results: The rankings of mean arithmetic error (MAE), from least to greatest, were as follows: 3C (0.088), Haigis-L-L (− 0.508), Shammas (− 0.516), OCT Average (− 0.538), Barrett True K (− 0.557), OCT RK (− 0.563), Galilei (− 0.570), IOL Master (− 0.571), OCT LASIK (− 0.583), Barrett True K No History (− 0.597), Pearl-DGS (− 0.606), Potvin-Hill SF (− 0.770), Potvin-Hill TNP (− 0.778), Panacea (− 0.876), and Barrett Universal 2 (− 1.522). The 3C formula achieved the greatest percentage of eyes within ± 0.25 D of target range (91%), while Haigis-L, Shammas, Galilei, Potvin Hill, Barrett True K, IOL Master, PEARL-DGS, and OCT formulae performed similarly, achieving 45% of eyes within ± 0.75D of target refraction.Conclusion: This study demonstrates the accuracy of the lesser known 3C formula in IOL calculation, particularly for patients who have undergone both RK and LASIK. Well-known formulae, such as Haigis-L, Shammas, and Galilei, which are used by the American Society of Cataract and Refractive Surgery (ASCRS), are viable options, although 3C formulae should be considered in this patient population. Furthermore, larger studies can confirm the best IOL power formulas for post-RK and LASIK cataract patients.Keywords: radial keratotomy, intraocular lens, laser assisted in situ keratomileusis, IOL power, IOL calculator, Barrett True K No History, Barrett True K, Barrett Universal 2, Camellin-Calossi-Camellin, double K-modified Holladay, Haigis-L, Galilei, OCT, PEARL-DGS, Potvin-Hill, Panacea, Shammas

Majid Moshirfar,1– 3 Shreya Pandya,4 Stephanie Zhang,5 Isabella M Stoakes,1,6 Azraa Ayesha,7 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Louisville School of Medicine, Louisville, KY, USA; 5University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA; 6Pacific Northwest University of Health Sciences, Yakima, WA, USA; 7University of Utah School of Medicine, Salt Lake City, UT, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, 11820 S. State St. #200, Draper, UT, 84020, USA, Tel +1 801-568-0200, Fax +1 801-563-0200, Email cornea2020@me.comPurpose: To determine whether the AvaGen (AG) Genetic Eye Test provided additional information for screening for the presence of keratoconus (KC) and assessing KC risk in refractive surgery candidates, as compared to the Keratoconus Severity Score (KSS) and Randleman Ectasia Risk Score System (ERSS).Methods: This retrospective study analyzed patients seeking refractive surgery at an eye clinic in the United States between January 2022 and July 2023. The inclusion criteria encompassed those with a family history of KC, positive KC indices, or both. Corneal evaluations and demographic information were recorded and analyzed. KSS and ERSS criteria were utilized to evaluate postoperative KC and ectasia risk, respectively. Patients were categorized on how the AG genetic test compared to KSS and ERSS criteria. Clinicians assessed topographic indices, criteria scoring, and AG testing to deliver a definitive surgical recommendation.Results: Among the 19 patients evaluated for ectasia risk, AG testing showed lower KC risk than ocular screening in three patients (15.8%), equal risk in three patients (15.8%), and higher risk in 13 patients (68.4%). The mean AG scores were 45.7 ± 7.0, 49.0 ± 3.46, and 61 ± 13.0 for these respective categories. The most frequently identified KC risk genes were ADAMTS18, COL2A1, and COL4A1. The AG test modified the physician’s recommendation for refractive surgery in nine cases (47.4%).Conclusion: Despite the promising application of AG testing for assessing KC risk, further research and development are needed to enhance its applicability for screening refractive surgery candidates, in addition to standard ocular screening approaches.Keywords: AvaGen, keratoconus, severity, corneal topography, Randleman, ectasia risk score system, keratoconus severity score

Majid Moshirfar,1– 3 Michael S Herron,4 David S Cha,5 Jordan M Santos,6 Levi T Miller,7 Phillip C Hoopes Sr1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, 84020, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Nevada, Reno School of Medicine, Reno, NV, USA; 5Saint Louis University School of Medicine, St. Louis, MO, USA; 6University of Arizona, Phoenix School of Medicine, Phoenix, AZ, USA; 7Utah State University, Department of Electrical and Computer Engineering, Logan, UT, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, 11820 S. State St. &num;200, Draper, UT, 84020, USA, Tel\Fax +1 801-568-0200, Email cornea2020@me.comPurpose: We assess the relationship between preoperative myopic sphere, astigmatism, and spherical equivalent and effective optical zone (EOZ) size, shape, and decentration within individual populations of post-LASIK, PRK, and SMILE patients.Patients and Methods: A retrospective chart review was conducted with 118 LASIK, 144 PRK, and 41 SMILE eyes from 179 total patients that underwent compound myopic ablation. One-year postoperative Pentacam tangential difference maps were used for EOZ data measurements. Correlational analysis between compound myopic measures [sphere, cylinder, manifest refractive spherical equivalent (MRSE)] and EOZ parameters was performed, and differences between groups of myopic sphere and cylinder within each surgery type were assessed.Results: An increase in absolute myopic sphere (and subsequent MRSE) is associated with a smaller EOZ area in SMILE (r=0.454, p=0.003) and a more circular EOZ shape in LASIK (r=0.396, p< 0.001) and PRK (r=0.563, p< 0.001). An increase in absolute myopic cylinder is associated with an increased EOZ area in all three surgery types [LASIK (r=− 0.459, p< 0.001), PRK (r=− 0.716, p< 0.001), SMILE (r=− 0.429, p=0.005)] and a more elliptical EOZ in LASIK (r=− 0.491, p< 0.001) and PRK (r=− 0.538, p< 0.001).Conclusion: While astigmatism may be correlated to EOZ size within all three refractive surgery types, myopic sphere alone is insufficient to estimate EOZ size differences for procedures with a large blend zone of ablation like LASIK or PRK. Shape is just as important a factor as size to consider when examining corneal EOZ differences; reported correlative findings likely result from inherent differences in surgical technique and abruptness of planned surgical ablation borders.Keywords: EOZ, OZ, Pentacam, tangential difference map

Majid Moshirfar,1– 3 Jordan M Santos,4 David S Cha,5 Michael Herron,6 Isabella M Stoakes,1,7 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA; 5Saint Louis University School of Medicine, St Louis, MO, USA; 6University of Nevada, Reno School of Medicine, Reno, NV, USA; 7Pacific Northwest University of Health Sciences, Yakima, WA, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, Hoopes Vision, 11820 S. State St. &num;200, Draper, UT, 84020, USA, Tel +1 801-568-0200, Fax +1 801-563-0200, Email cornea2020@me.comPurpose: To provide a comprehensive guide of all implantable collamer lens (ICL) sizing nomograms and the respective preoperative diagnostic devices that are required. This guide would help clinicians in choosing the appropriate ICL size for myopic patients to optimize postoperative vault height.Methods: A literature search of peer-reviewed journals describing methods and postoperative outcomes of ICL sizing was conducted. Research articles containing ICL nomograms or formulas were identified from this search. Preoperative variables necessary for these nomograms and the required diagnostic devices to measure these parameters such as topography, biometry, or ultrasound biomicroscopy (UBM) were noted. An additional search was conducted to identify artificial intelligence (AI) or machine learning (ML)-derived nomograms.Results: Eighteen ICL sizing nomograms were identified through literature search. Five of these nomograms are available for use and require topography or biometry devices. Of these, four include the manufacturer’s, optimized white-to-white (WTW), Kang, Kim, and Rocamora Nomograms. Eight of the 18 nomograms available for use require UBM. Eight of these include the Kojima, Nakamura, KS, ZZ, Dougherty, Parkhurst, Russo, and Reinstein Nomograms. Four of the 18 nomograms are ML-derived including Shen, Rocamora, Russo, and Kang Nomograms.Conclusion: ICL nomograms are a vital tool in helping clinicians select the right ICL size for myopic patients to optimize postoperative vault reducing risk of postoperative complications. Based on available diagnostic devices such as topography, biometry, or UBM clinicians can integrate specific nomograms into practice.Keywords: phakic intraocular lens, pIOL, myopia, implantable contact lens, EVO, Visian ICL, artificial intelligence, machine learning model, ICL sizing, ICL formula

Majid Moshirfar,1– 3 Stephanie Zhang,4 Shreya Pandya,5 Isabella M Stoakes,1,6 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA; 5University of Louisville School of Medicine, Louisville, KY, USA; 6Pacific Northwest University of Health Sciences, Yakima, WA, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, Hoopes Vision, 11820 S. State St., Ste. 200, Draper, UT, 84020, USA, Tel +1 801-568-0200, Fax +1 801-563-0200, Email cornea2020@me.comPurpose: To investigate the incidence and management of only epithelial-related complications following small incision lenticule extraction (SMILE).Patients and Methods: A retrospective, single-site study analyzed patients who underwent SMILE at Hoopes Vision Clinic in Draper, Utah, from June 2017 to February 2023. Demographic data and preoperative parameters were reviewed. Postoperatively, patients were assessed for visual acuity and complications at different time points. Statistical analyses were conducted between the control and complication groups.Results: Four hundred and thirty-two eyes of 220 patients received SMILE. Postoperative epithelial-related complications were indicated in 68 (15.7%) eyes, including anterior basement membrane (ABM) changes (five [1.2%]) eyes), epithelial ingrowth (nine [2.1%] eyes), erosion (two [0.5%] eyes), rough epithelium (18 [4.2%] eyes), epithelial defect (12 [2.8%] eyes), diffuse lamellar keratitis (DLK) secondary to epitheliopathy (two [0.5%] eyes), microstriae secondary to epitheliopathy (four [0.9%] eyes), interface debris (21 [4.9%] eyes), and incisional fibrosis (one [0.2%] eye). There was a statistically significant difference in age, with older patients more likely to develop epitheliopathy postoperatively (P = 0.001). Additionally, patients with epithelial-related complications were more likely to receive photorefractive keratectomy (PRK) enhancement after SMILE than the control (P = 0.001). However, there was no statistical difference in uncorrected distance visual acuity (UDVA) better than 20/20 and corrected distance visual acuity (CDVA) between the complications group and the control at the last postoperative visit (P = 0.974 and 0.310, respectively). There was no statistically significant difference in the safety and efficacy indices between the complications and control group (P = 0.281 and 0.617, respectively).Conclusion: In our study, epithelial-related complications were more prevalent in older patients and predisposed patients to require PRK enhancements after recovery from SMILE. Despite the incidence of epithelial-related complications, visual prognoses were favorable and achieved through various management strategies.Keywords: ReLEx, epithelial ingrowth, DLK, diffuse lamellar keratitis, microstriae, LASIK

Majid Moshirfar,1– 3,&ast; Christian A Sulit,4,&ast; Alex H Brown,4,&ast; Chase Irwin,4,5 Yasmyne C Ronquillo,1,&ast; Phillip C Hoopes1,&ast; 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA; 5Phoenix Veterans Affairs Health Care System, Phoenix, AZ, USA&ast;These authors contributed equally to this workCorrespondence: Majid Moshirfar, Hoopes Vision Research Center, 11820 S. State St. &num;200, Draper, UT, 84020, USA, Tel +1 801-568-0200, Fax +1 801-563-0200, Email cornea2020@me.comPurpose: To assess the accuracy of five new-generation intraocular lens (IOL) power formulas: Barrett Universal II (BUII), Emmetropia Verifying Optical (EVO) Formula, Hill-Radial Basis Function (Hill-RBF), Kane Formula, and Ladas Super Formula (LSF).Patients and Methods: This is a retrospective single-surgeon study from a refractive clinic and clinical research center in Draper, UT, USA. The primary outcome measures were mean absolute error (MAE) and median absolute error (MedAE). Secondary outcome measures were the standard deviation (SD) of each formula’s refractive prediction errors (RPE) and the percentage of eyes within ± 0.50D. Refractive predictions were compared to the postoperative spherical equivalent to determine the RPE for each formula. RPEs were optimized, and MAE, MedAE, SD of the AME, and percent of eyes achieving RPEs within the specified ranges of ± 0.125 D, ± 0.25 D, ± 0.50 D, ± 0.75 D, ± 1.0 D were calculated. Subgroup analysis between different axial lengths was attempted but yielded insufficient statistical power to draw meaningful conclusions.Results: A total of 103 eyes of 103 patients were included in our study after applying inclusion and exclusion criteria to 606 eyes from 2019 to 2021. Formulas ranked in ascending order by MAE were Kane, EVO, BUII, Hill-RBF, and LSF. The ascending rankings of MedAE were Kane, BUII, Hill-RBF, EVO, Ladas. Kane had a significantly lower MAE than Hill-RBF (p< 0.001). EVO had the lowest SD of AMEs and the highest percentage of eyes within ± 0.50 D. According to heteroscedastic testing, EVO also had a statistically significant lower SD than Hill-RBF.Conclusion: Kane was the most accurate formula in terms of MAE and MedAE. EVO and BUII achieved marginally higher MAEs than Kane, suggesting these three formulas are comparable in performance. With the exception EVO and Hill-RBF, the heteroscedastic test yielded no significant differences in SD between the formulas. Although there were multiple statistically significant differences between the formulas in terms of MAE, MedAE, and SD, these differences may not be appreciable clinically. Lastly, there were no statistically significant differences in the percent of eyes with RPEs within ± 0.50 D, suggesting similar clinical performance between formulas.Keywords: cataract surgery, refractive surgery, IOL power formulas, new generation IOL formulas, refractive lens exchange, clear lens extraction, RLE, CLE

Majid Moshirfar,1– 3 Joshua S Theis,4 David S Cha,5 Kaiden B Porter,4 Carter J Payne,1,6 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA; 5Saint Louis University School of Medicine, Saint Louis, MO, USA; 6Department of Ophthalmology, George Washington University School of Medicine and Health Sciences, Washington, DC, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, 11820 S. State St. &num;200, Draper, UT, 84020, USA, Tel +1 801 568 – 0200, Fax +1 415-476-0336, Email cornea2020@me.comPurpose: To compare 3 of the most common corneal refractive procedures; PRK, LASIK, and SMILE assessing ΔK/ΔSEQ ratio and its correlation with preoperative demographics including age, keratometry, pachymetry, cylinder value, and attempted myopic correction. The goal was to analyze the relative strength of each preoperative parameter in accounting for changes in ∆K/∆SEQ.Patients and Methods: A total of 370 eyes from 102 male and 97 female patients (173 eyes PRK, 153 LASIK, and 44 SMILE) with ages ranging from 20 to 51 underwent refractive surgery for myopia between − 0.25 and − 7.71 D manifest refraction spherical equivalent (MRSE). All surgeries were performed at a single surgery center in Draper, Utah. The Pentacam was used for all optical measurements and data were gathered pre-operatively and then again 1-year post-operatively. Only patients who achieved emmetropia at a visual acuity of 20/25 or better were included.Results: The mean ΔK/ΔSEQ ratio for LASIK (0.839 ± 0.020) was significantly greater than that of PRK (0.775 ± 0.022) and SMILE (0.709 ± 0.046). Age was found to negatively correlate with ΔK/ΔSEQ for both LASIK (r = − 0.177) and SMILE (r = − 0.451) procedures. Pre-op keratometry was found to negatively correlate with ΔK/ΔSEQ for LASIK (r = − 0.202) but not for PRK or SMILE. Pre-op pachymetry was not correlated with ΔK/ΔSEQ for any of the procedures. Attempted myopic spherical equivalent (SEQ) correction was positively correlated with ΔK/ΔSEQ for LASIK (r = 0.236), PRK (r = 0.459), and SMILE (r = 0.304). Lastly, pre-op cylinder value was found to be correlated to ΔK/ΔSEQ in SMILE (r = − 0.367), but not in LASIK or PRK.Conclusion: The ΔK/ΔSEQ ratio not only differs depending on the procedure being done but also by pre-operative factors such as age, keratometry, attempted correction, and cylinder value. Multiple linear regression analysis revealed that the attempted correction had the greatest effect on ∆K/∆SEQ out of all parameters in LASIK and PRK. For SMILE, age had the greatest predictive value of the change in ∆K/∆SEQ. While the exact effect of these parameters will vary by surgeon, all of these should be factored into a refractive surgeon’s nomograms in order to achieve optimal visual outcomes for their patients.Keywords: cornea, refractive surgery, spherical equivalent, nomogram, keratometry, pachymetry, age, cylinder

Majid Moshirfar,1– 3 Devon Hori Harvey,4 Qiancheng Wang,5 Carter J Payne,1,6 David G West,7 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4The Ohio State University College of Medicine, Columbus, OH, USA; 5Baylor College of Medicine, Houston, TX, USA; 6Department of Ophthalmology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA; 7University of Utah School of Medicine, Salt Lake City, UT, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, 11820 South State St Ste 200, Draper, UT, 84020, USA, Tel +1 801 568-0200, Fax +1 415-476-0336, Email cornea2020@me.comPurpose: To compare corneal power difference maps (∆maps) obtained from the Pentacam in patients with 1 year follow-up after LASIK, PRK, and SMILE with further stratification to low, moderate, and high myopia.Patients and methods: This retrospective study was comprised of patients who had preoperative and 1-year postoperative power maps that were obtained–front sagittal (SagF), refractive power (RP), true net power (TNP), and total corneal refractive power (TCRP)–for evaluation. Measurements were recorded and compared at the 4mm, 5mm and 6mm pupil and apex zones. Comparisons were made between each specific power ∆map and the surgically induced refractive change (SIRC). Further analysis of the ∆maps was performed based on degree of myopia (high, moderate, and low). Correlation and agreement were also assessed with regression and limits of agreement (LoA).Results: There were 172 eyes in the LASIK group, 187 eyes in the PRK group, and 46 eyes in the SMILE group. In the LASIK group, TNP ∆map at 5mm pupil zone had the least absolute mean difference with SIRC (0.007 ± 0.42D). In the PRK group, TNP ∆map at 5mm apex zone was most accurate compared to SIRC (0.066 ± 0.45D). In the SMILE group, TCRP ∆map at 4mm apex zone had the closest absolute value when compared to SIRC (0.011 ± 0.50D). There was good correlation and agreement for all three surgery groups, LASIK: r = 0.975, LoA − 0.83D to +0.83D, PRK: r = 0.96, LoA − 0.83D and +0.95D, and SMILE: r = 0.922, LoA − 0.97 D to +0.99D.Conclusion: TNP ∆maps most accurately measured corneal power in the LASIK and PRK groups while TCRP ∆maps were most accurate in the SMILE group. The degree of myopia may change which ∆map is most accurate.Keywords: corneal topography, refractive surgery, total corneal refractive power, TCRP, true net power, TNP, sagittal, SagF

Wyatt M Corbin,1 Carter J Payne,2,3 Hamed Momeni-Moghaddam,4 Yasmyne C Ronquillo,2 Phillip C Hoopes Snr,2 Majid Moshirfar2,5,6 1Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA; 2Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 3Case Western Reserve University School of Medicine, Cleveland, OH, USA; 4Rehabilitation Sciences Research Center, Zahedan University of Medical Sciences, Zahedan, Iran; 5Moran Eye Center, University of Utah, Salt Lake City, UT, USA; 6Utah Lion’s Eye Bank, Murray, UT, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, Hoopes Vision, 11820 S. State St. Ste. 200, Draper, UT, 84020, USA, Tel +1 801 568-0200, Fax +1 801 563-0200, Email cornea2020@me.comAbstract: Increasing popularity and utility of epithelial thickness mapping (ETM) in keratorefractive surgery screening may begin to inappropriately devalue the use of tomography. An increasing body of research suggests that the interpretation of ETM based solely on the corneal resurfacing function may be insufficient to screen and select patients for refractive surgery. ETM and tomography are complementary and, when used together, may provide the safest and most optimal tools for keratorefractive surgery screening.Keywords: corneal tomography, corneal topography, corneal epithelial map, SMILE, LASIK, PRK

Majid Moshirfar,1– 3 Noor F Basharat,4 Tanner S Seitz,5 Christian M Peterson,6 Seth R Stapley,5 Melody Ziari,7 Nour Bundogji,2 Yasmyne C Ronquillo,1 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, 84020, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA; 5Midwestern University Arizona College of Osteopathic Medicine, Glendale, AZ, USA; 6University of Utah School of Medicine, Salt Lake City, Utah, USA; 7University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, 11820 S, State Street Suite &num;200, Draper, UT, 84020, Tel +1-801-568-0200, Fax +1-801-563-0200, Email cornea2020@me.comPurpose: To analyze refractive changes after neodymium: yttrium-aluminum-garnet (Nd:YAG) posterior capsulotomy in pseudophakic eyes.Patients and Methods: Patients who underwent Nd:YAG capsulotomy after cataract surgery from January 2013 to April 2022 were included in this retrospective study. Sphere, cylinder, spherical equivalent (SE), axis, and corrected distance visual acuity (CDVA) were compared pre- and postoperatively in 683 eyes of 548 patients at one month (n = 605 eyes) and one year (n = 211 eyes). Patients with both one-month and one-year follow-ups (n = 133) were also compared. Eyes were stratified into single-piece (n = 330), three-piece (n = 30), and light adjustable lenses (LALs) (n = 16). Pre- and postoperative measurements were analyzed within each group.Results: Cylinder was significantly decreased at one-month (difference: 0.042± 0.448 D, p = 0.006) and one-year (difference: 0.101± 0.455 D, p = 0.003) compared to preoperative measurements. No significant change in sphere or axis was observed at follow-up visits (p > 0.05). CDVA significantly improved at both time points (p < 0.05). No significant change in any parameters between the one-month and one-year groups was observed (p > 0.05). There was significant improvement in CDVA in the single and three-piece lens groups (p < 0.0001 and p = 0.026, respectively), with no change in the LAL group (p > 0.05).Conclusion: There were no changes in sphere, axis, or spherical equivalent after Nd:YAG capsulotomy. However, cylindrical error and CDVA were significantly better after the procedure. Lens type did not impact refractive parameters postoperatively.Keywords: PCO, posterior capsular opacification, cataract, light adjustable lenses, LAL

Majid Moshirfar,1– 3 Alex H Brown,4 Christian A Sulit,4 Wyatt M Corbin,5 Yasmyne C Ronquillo,1 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA; 5Loyola University Chicago Stritch School of Medicine, Maywood, IL, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, 11820 S. State St. &num;200, Draper, UT, 84020, USA, Tel +1 801-568-0200, Fax +1 801-563-0200, Email cornea2020@me.comAbstract: This article discusses common ocular manifestations of cystic fibrosis (CF) and cystic fibrosis transmembrane conductance regulator-related disorders (CFTR-RD). A structured approach for assessing and treating patients with CF/CFTR-RD seeking corneal refractive surgery is proposed, as well as a novel surgical risk scoring system. We also report two patients with various manifestations of CFTR dysfunction who presented for refractive surgery and the outcomes of the procedures. Surgeons seeking to perform refractive surgery on patients with CF/CFTR-RD should be aware of mild to severe clinical manifestations of CFTR dysfunction. Specific systemic and ocular manifestations of CF include chronic obstructive pulmonary disease (COPD), bronchiectasis, recurrent pulmonary infections, CF-related diabetes and liver disease, pancreatic insufficiency, conjunctival xerosis, night blindness, meibomian gland dysfunction (MGD), and blepharitis. Corneal manifestations include dry eye disease (DED), punctate keratitis (PK), filamentary keratitis (FK), xerophthalmia, and decreased endothelial cell density and central corneal thickness. Utilization of the appropriate review of systems (ROS) and screening tests will assist in determining if the patient is a suitable candidate for refractive surgery, as CF/CFTR-RD can impact the health of the cornea. Collaboration with other medical professionals who care for these patients is encouraged to ensure that their CF/CFTR-RD symptoms are best controlled via systemic and other treatment options. This will assist in reducing the severity of their ocular manifestations before and after surgery.Keywords: cystic fibrosis, CF, cystic fibrosis transmembrane conductance regulator, CFTR, cystic fibrosis transmembrane conductance regulator-related disorder, CFTR-RD, cornea, refractive surgery

Majid Moshirfar,1– 3 Chap-Kay Lau,4 Nicholas A Chartrand,4 Mark T Parsons,4 Seth Stapley,5 Nour Bundogji,2 Yasmyne C Ronquillo,1 Steven H Linn,1 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Arizona, College of Medicine-Phoenix, Phoenix, AZ, USA; 5Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ, USACorrespondence: Majid Moshirfar, Medical Director Hoopes Vision Research Center, Hoopes Vision Research Center, 11820 S. State St. &num;200, Draper, UT, 84020, USA, Tel +1 801-568-0200, Fax +1 801-563-0200, Email cornea2020@me.comPurpose: To evaluate 10 years of KAMRA corneal inlay explantation and associated visual outcomes.Patients and Methods: Single-site retrospective chart review of 22 cases of AcuFocus KAMRA Inlay (ACI7000PDT) explantation (range 1 week– 1 year). Uncorrected distance visual acuity (UDVA), uncorrected near visual acuity (UNVA), corrected distance visual acuity (CDVA), and manifest refraction at 1 day, 1 week, 1 month, 3 months, 6 months, and 1 year post-explantation were reviewed.Results: The explantation rate was 8.2% across 10 years. All patients underwent KAMRA explantation due to dissatisfaction with their vision including blurry near vision, impaired night vision, decreased vision in dim lighting, streaks or halos, haze, and double vision. Mean UDVA pre-implant was − 0.01± 0.13 logMAR (logarithm of the minimal angle of resolution), 0.30± 0.22 logMAR pre-explant, and 0.16± 0.15 logMAR post-explant (n=20). Mean UNVA pre-implant was 0.37± 0.09 logMAR, 0.38± 0.13 logMAR pre-explant, and 0.42± 0.21 logMAR post-explant (n=20). Mean CDVA pre-implant was − 0.01± 0.04 logMAR and 0.05± 0.11 logMAR post-explant (n=17). Mean CDVA pre-explant was 0.04± 0.07 logMAR and 0.04± 0.11 logMAR post-explant (n=19). Significant differences were observed between pre-implant and post-explant UDVA (p=0.009), and between pre-explant and post-explant UDVA (p=0.02). All patients (100%) had 20/20 or better CDVA pre-implant but decreased to 73.7% post-explant. Sixty percent (12/20) of the patients lost UDVA Snellen acuity lines post-explant. MRSE was − 0.31± 0.29 D pre-implant and +0.26± 0.77 D post-explant (p=0.007) with note of a hyperopic shift. The hyperopic shift in 31.6% (6/19) of patients did not resolve after explantation. Post-explant residual corneal haze occurred in 72.7% (16/22) of patients.Conclusion: Although the KAMRA corneal inlay is a removable device, patients may experience residual corneal haze, hyperopic shift, and deficits in UDVA after explantation compared to pre-implantation UDVA.Keywords: presbyopia, cornea, small aperture inlay, KAMRA, explantation

Eric J Kim,1 Arjun Ganga,1 Chaerim Kang,2 William Elnemer,3 James Y Lee,4 Yasmyne C Ronquillo,5 Phillip C Hoopes,5 Majid Moshirfar5– 7 1Division of Ophthalmology, Warren Alpert Medical School at Brown University, Providence, RI, USA; 2Program in Liberal Medical Education, Brown University, Providence, RI, USA; 3Johns Hopkins School of Medicine, Baltimore, MD, USA; 4Brown University, Providence, RI, USA; 5Hoopes Vision Research Center, Draper, UT, USA; 6John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 7Utah Lions Eye Bank, Murray, UT, USACorrespondence: Eric J Kim, Division of Ophthalmology, Warren Alpert Medical School at Brown University, Providence, RI, USA, Tel +1 978-289-0659, Email eric_kim2@brown.eduPurpose: Motorcycle-related injuries involving the eye and orbit are not well characterized, with a paucity of prospective studies focusing specifically on motorcycle-associated eye injuries nor literature reviews having been conducted on the subject. To better understand the injury types and descriptive characteristics of patients experiencing motorcycle-associated eye injuries, we sought to conduct a narrative review.Methods: The research team utilized the following databases: PubMed, EMBASE, and Web of Science to query for English articles from peer-reviewed journals that provided some patient data regarding eye injury due to motorcycle or moped accidents or usage.Results: A total of 65 studies were included in our qualitative synthesis. Of these studies, 40 (61.5%) were case reports, 20 retrospective case series (30.8%), and five (7.69%) were observational prospective studies. Among the 25 retrospective and prospective studies, 12 (48.0%) of these studies primarily focused on motorcycle-associated injuries. These 65 studies described a wide variety of motorcycle-associated eye injuries, including but not limited to orbital fractures and associated sequelae, foreign bodies, vitreoretinal trauma, neuro-ophthalmic trauma, corneal injuries, open globe injuries, lacerations, and globe avulsions.Conclusion: The current state of the literature indicates that knowledge regarding the ocular manifestations of motorcycle accidents is limited to mostly case reports and few retrospective cohort studies focused specifically on motorcycle-associated eye injuries. However, it is evident that the types of motorcycle-associated eye injuries are legion and predominantly seen in adult males, potentially leading to severe injuries and loss of vision and blindness.Keywords: motorcycle, ocular injury, eye, trauma, orbital fracture, ruptured globe, corneal injury, vitreoretinal damage, vehicular accidents

Majid Moshirfar,1–3 Joshua S Theis,4 David S Cha,5 Kaiden B Porter,4 Carter J Payne,1,6 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah, School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA; 5Saint Louis University, School of Medicine, Saint Louis, MO, USA; 6Department of Ophthalmology, George Washington University School of Medicine and Health Sciences, Washington, DC, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, 11820 S. State St. &num;200, Draper, UT, 84020, USA, Tel +1 801 568 – 0200, Fax +1 415-476-0336, Email cornea2020@me.com

Majid Moshirfar,1– 3 Mark T Parsons,4 Nicholas A Chartrand,4 Chap-Kay Lau,4 Seth Stapley,5 Nour Bundogji,2 Yasmyne C Ronquillo,1 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Arizona College of Medicine – Phoenix, Phoenix, AZ, USA; 5Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, 11820 S. State Street Suite #200, Draper, UT, 84020, USA, Tel +1 801-568-0200, Fax +1 801-563-0200, Email cornea2020@me.comPurpose: To determine rates of enhancement and visual prognosis following photorefractive keratectomy (PRK) enhancement of small-incision lenticule extraction (SMILE).Patients and Methods: This retrospective, single-site study reviewed all cases of primary SMILE at Hoopes Vision in Draper, Utah between March 14, 2017 and April 8, 2022 to identify any cases that required follow-up enhancement. Primary SMILE was performed using Visumax 500 kHz femtosecond laser (Carl Zeiss Meditec, Jena, Germany). All enhancements were performed with alcohol-assisted PRK, using a WaveLight EX500 excimer laser (Alcon Laboratories, Inc., Fort Worth, TX).Results: Four hundred and five eyes underwent primary SMILE, of which 15 later underwent PRK enhancement (enhancement rate of 3.7%). No significant difference in pre-SMILE data was identified between the enhancement and non-enhancement groups. The average age of those who underwent PRK enhancement was 33.8± 6.3 years old and ranged from 25 to 45. Following primary SMILE, 13 eyes (87%) had an uncorrected distance visual acuity (UDVA) of 20/40 or better, and none had a UDVA of 20/20 or better. After one year of post-enhancement follow-up, all eyes had a UDVA of 20/40 or better, and 13 eyes (87%) had a UDVA of 20/20 or better (Figure 1). All were within one diopter of target spherical equivalent (SEQ), 13 (87%) were within 0.50 D, and 10 (67%) were within 0.25 D. Of those with 12-month follow-up data, none had UDVA worse than corrected distance visual acuity (CDVA), and none had lost lines of CDVA. Efficacy and safety indices were 1.03 and 0.99, respectively.Conclusion: Following SMILE, ophthalmologists may anticipate an enhancement rate of one to seven percent. In these cases, PRK is a safe and effective procedure for enhancement of SMILE.Keywords: retreatment, LASIK, refractive surgery, myopia, astigmatism, SMILE

Eric J Kim,1,2 Arjun Ganga,1 Viren K Rana,1 Joshua R Tanzer,1 Yasmyne C Ronquillo,2 Majid Moshirfar2– 4 1Warren Alpert Medical School at Brown University, Providence, RI, USA; 2Hoopes Vision Research Center, Draper, UT, USA; 3John A Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 4Utah Lions Eye Bank, Murray, UT, USACorrespondence: Eric J Kim, Warren Alpert Medical School at Brown University, 70 Ship Street, Providence, RI, 02903, USA, Tel +978-289-0659, Email eric_kim2@brown.eduPurpose: The insertion-limbus distances of the extraocular muscles are clinically relevant in the preoperative planning of strabismus surgeries, especially in reoperations when information regarding insertion sites is not accessible to the surgeon. In this systematic review, we assess the reliability of time-domain anterior segment optical coherence tomography (TD AS-OCT) in determining insertion-limbus distances preoperatively by investigating prior studies that compare preoperative TD AS-OCT measurements of the insertion-limbus distances to those of calipers, which are assumed to be the gold standard.Methods: Systematically reviewing EMBASE, PubMed, Google Scholar, Science Direct, and Web of Science, 2 members screened for studies that compared preoperative TD AS-OCT measurements to those of intraoperative calipers, the gold standard. To assess the risk of bias for individual studies, the reviewers utilized the ROBINS-I tool, a Cochrane’s collaboration tool used to assess bias in studies that are not randomized. For the meta-analysis, parallel forms reliability was examined and estimated as the Pearson product-moment correlation between TD AS-OCT measurements and surgical caliper measurements.Results: Six out of the seven eligible studies provided measures of reliability that were > 0.7. These six records were eligible for meta-analysis. There was no evidence of a difference between means of TD AS-OCT and caliper measurements ( = 6.81, 95% CI [6.41, 7.22]; = 6.73, 95% CI [6.18, 7.29]; = 0.08, 95% CI [− 0.44, 0.61]). Reliability was estimated to be good ( = 0.91) though the lower limit was slightly below the recommended minimum acceptable level of 0.70 (95% CI [0.65, > 0.99]).Conclusion: In the setting of primary surgeries, TD AS-OCT has an acceptable reliability. However, there is insufficient data to conclude whether TD AS-OCT has an acceptable reliability in the setting of reoperations.Keywords: time domain AS-OCT, strabismus, limbus, extraocular rectus muscle, reliability, validity

Majid Moshirfar,1– 3 Marshall K Henrie,4 Carter J Payne,5 Briana K Ply,1 Yasmyne C Ronquillo,1 Steven H Linn,1 Phillip C Hoopes1 1HDR Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Utah School of Medicine, Salt Lake City, UT, USA; 5Case Western Reserve University School of Medicine, Cleveland, OH, USACorrespondence: Majid Moshirfar, HDR Research Center, Hoopes Vision, 11820 State St, Draper, UT, USA, Email cornea2020@icloud.comAbstract: Presbyopia may represent the largest segment of refractive errors that is without an established and effective refractive surgery treatment. Corneal Inlays are materials (synthetic or allogenic) implanted in the stroma of patients’ corneas to improve presbyopia. These inlays, introduced into the United States in 2015 via the small-aperture corneal inlay (KAMRATM, SightLife Surgical/CorneaGen, Seattle, Washington, United States), were met with an initial wave of enthusiasm. Subsequent models like the shape-changing corneal inlay (RAINDROPTM, Revision Optics, Lake Forest, California, United States) offered excellent results for patients, but longer-term research raised questions about patient safety. At the time of this article, no synthetic corneal inlays are available in the United States for the correction of presbyopia. Other options for presbyopia correction include allograft corneal inlays, trifocal synthetic corneal inlays, pharmacologic therapies, scleral incisions or additive techniques and PresbyLASIK. Presently, allograft inlays consist of corneal lenticules removed from patients undergoing Small Incision Lenticule Extraction (SMILE). We will review corneal inlays and other alternative procedures that may provide effective and predictable treatments for patients with presbyopia.Keywords: corneal inlay, corneal onlay, SMILE, PEARL, PresbyLASIK, refractive surgery, KAMRA, raindrop, flexivue, corneal allografts, presbyopic allogenic refractive lenticule

Majid Moshirfar,1– 3 Court R Webster,4 Tanner S Seitz,5 Yasmyne C Ronquillo,1 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4Michigan State University College of Osteopathic Medicine, East Lansing, MI, USA; 5Midwestern University, Glendale, AZ, USACorrespondence: Majid Moshirfar, Hoopes Vision Research Center, Hoopes Vision Research Center, Draper, UT, USA, Tel +1-801-568-0200, Fax +1-801-563-0200, Email cornea2020@me.comAbstract: Myotonic dystrophy is the most common inherited muscular dystrophy in adults and presents as two forms, type 1, and type 2. Ocular manifestations such as premature cataract formation, may be the first diagnostic sign or symptom of the disease, offering ophthalmologists a unique diagnostic role. Fuchs’ endothelial corneal dystrophy, ptosis and ocular melanoma are other possible findings. Systemic features can help providers better understand the disease and any accommodations to be made in clinical or surgical settings. Some patients with this disease may request evaluation of certain cataract or corneal refractive procedures. This article focuses on pertinent information for clinicians to utilize when evaluating and treating patients with myotonic dystrophy and specific surgical perspectives to consider prior to any ocular interventions. Hydrophobic intraocular lenses are still recommended in these patients with careful observation of capsular phimosis and posterior capsular opacities.Keywords: corneal endothelium, intraocular lens, IOL, laser assisted in situ keratomileusis, LASIK, small incision lenticule extraction, SMILE, yttrium aluminum garnet, YAG, capsulotomy

Majid Moshirfar,1– 3 Austin J Waite,4 James H Ellis,5 Rachel Huynh,5 John Placide,6 Matthew R Barke,6 Shannon E McCabe,1,7 Yasmyne C Ronquillo,1 Phillip C Hoopes Jr,1 Michael J Bradley,1 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4A.T. Still University College of Osteopathic Medicine in Arizona, Mesa, AZ, USA; 5University of Utah School of Medicine, Salt Lake City, UT, USA; 6McGovern Medical School at the University of Texas Health Science Center, Houston, TX, USA; 7Mission Hills Eye Center, Pleasant Hill, CA, USACorrespondence: Majid MoshirfarHoopes Vision Research Center, 11820 S. State Street Suite #200, Draper, UT, 84020, USATel +1 801-568-0200Fax +1 801-563-0200Email cornea2020@me.comPurpose: To assess visual outcomes over time of femtosecond laser-assisted cataract surgery compared to standard phacoemulsification cataract surgery.Design: A retrospective, single-center comparative study.Methods: Patient data including demographics, ocular biometry, pre- and postoperative visual acuity, postoperative complications, primary (uncorrected distance visual acuity over time) and secondary visual outcomes (uncorrected near visual acuity, best distance visual acuity, patient complaints, satisfaction, and postoperative surgery) were gathered and statistically analyzed. Demographic differences between patients receiving femtosecond-laser assisted cataract surgery (FLACS) versus standard phacoemulsification cataract surgery (PCS) were corrected for outcome comparison. Safety, efficacy, predictability, and stability were analyzed for each procedure and compared.Results: A total of 155 eyes in PCS and 143 eyes in FLACS were analyzed at 1 week, 3 months, and 1 year using odds ratio. The odds ratio of being 20/20 or better and 20/40 or better at the specified time periods were similar and statistically insignificant at all time periods analyzed except 20/20 or better for uncorrected distance visual acuity (UDVA) at 1 year (p=0.0001) and uncorrected near visual acuity (UNVA) at 1 week (p=0.02). In both cases, the odds of being 20/20 or better favored FLACS. Mean UDVA, UNVA, and best distance visual acuity (BDVA) were all similar and statistically insignificant between the two groups. Postoperative patient complaints, safety, efficacy, predictability, and stability between the two groups showed no statistical significance.Conclusion: Despite the odds ratio of being 20/20 or better favoring FLACS for UDVA at 1 year and UNVA at 1 week, the mean logMAR UDVA, BDVA, and UNVA were similar and statistically insignificant between the FLACS and PCS groups at 1 week, 3 months, and 1 year. Differences in visual acuity were likely due to differences other than surgical approaches. While both FLACS and PCS are appropriate approaches to cataract surgery, one does not appear to be superior when assessing longitudinal markers for visual acuity, safety, efficacy, predictability and stability.Keywords: cataract surgery, cataracts, femtosecond-laser assisted cataract surgery, phacoemulsification cataract surgery, uncorrected distance visual acuity, best distance visual acuity, uncorrected near visual acuity

Majid Moshirfar,1– 3 William B West Jr,4 Dallin C Milner,5 Shannon E McCabe,1 Yasmyne C Ronquillo,1 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, 84020, USA; 2John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT, 84132, USA; 3Utah Lions Eye Bank, Murray, UT, 84107, USA; 4University of Utah School of Medicine, Salt Lake City, UT, 84132, USA; 5University of Colorado School of Medicine, Aurora, CO, 80045, USACorrespondence: Majid Moshirfar Tel +1-801-568-0200Fax +1-801-563-0200Email cornea2020@me.comAbstract: We report an unusual presentation of presumed mitomycin C toxicity with possible subsequent hypersensitization to other medication toxicities. A 50-year-old female presented three months after photorefractive keratectomy with intraoperative mitomycin C for the management of persistent epithelial defects, corneal haze, and edema. She was found to have used an expansive and rapidly changing medical regimen which may have caused additional toxicity. These medications included besifloxacin, bromfenac, and ketotifen. Additives such as benzalkonium chloride and DuraSite® may have also contributed. Intraoperative mitomycin C can result in longstanding corneal haze, edema, and delayed epithelial healing in the setting of corneal refractive surgery. These may leave the cornea more susceptible to additional subsequent medication toxicities during the postoperative period. This report describes a case of mitomycin C exposure leading to a prolonged sensitivity to other medication toxicities, which has not been discussed elsewhere in the literature.Keywords: polypharmacy, corneal toxicity, surface ablation, hypersensitivity, medication toxicity, mitomycin corneal toxicity, photorefractive keratectomy

Majid Moshirfar,1– 3 Varshini S Odayar,4 Shannon E McCabe,1,5 Yasmyne C Ronquillo1 1Hoopes Vision Research Center, Draper, UT, 84020, USA; 2John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT, 84132, USA; 3Utah Lions Eye Bank, Murray, UT, 84107, USA; 4Department of Molecular and Cellular Biology, Harvard University, Cambridge, MA, USA; 5Mission Hills Eye Center, Pleasant Hill, CA, 94523, USACorrespondence: Majid MoshirfarHoopes Vision Research Center, 11820 State Street, Draper, UT, 84020, USATel +1 801-568-0200Email Cornea2020@me.comPurpose: This review aims to outline current practices and guidelines of corneal donation and eye banking, describes the implications of COVID-19 and emerging diseases on the corneal donor pool, and discusses future trends to improve and increase the efficiency of the processes involved in corneal donation and eye banking.Summary: Corneal screening, preservation, corneal storage, and prevention of systemic disease transmission from donor to recipient have been crucial in shaping the policies of the FDA and eye banks across the world. Eye banks globally have developed varying guidelines and criteria for evaluating the viability of donor corneas. Variables such as the age of the donor, medical history, and potential disease transmission are important screening parameters. While known infectious diseases may be transmissible through the cornea, emerging infectious diseases that are not well studied may be more transmissible than other infections. In particular, coronavirus has impacted corneal transplantation as SARS-CoV-2 expression has been detected in corneal tissue and conjunctiva. In recent years, partial-thickness corneal transplantations have been introduced. Lamellar grafts and other corneal layers are now utilized for transplantation of the specific areas that are damaged.Keywords: donor cornea, eye bank, COVID-19, cornea transplant, keratoplasty, donor recipient

Majid Moshirfar,1– 3 Nour Bundogji,4 Alyson N Tukan,4 James H Ellis,5 Shannon E McCabe,1,6 Ayesha Patil,5 Yasmyne C Ronquillo,1 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, 84020, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA; 5University of Utah School of Medicine, Salt Lake City, UT, USA; 6Mission Hills Eye Center, Pleasant Hill, CA, USACorrespondence: Majid MoshirfarMedical Director Hoopes Vision Research Center, Hoopes Vision Research Center, 11820 S. State Street Suite #200, Draper, UT, 84020, USATel +1 801-568-0200Fax +1 801-563-0200Email cornea2020@me.comPurpose: To report visual outcomes following surgical correction of myopic astigmatism with Visian Toric implantable collamer lens (ICL) (STAAR Surgical, Monrovia, CA, USA) at a single tertiary refractive center in the United States.Patients and Methods: Toric ICL was implanted in 96 eyes (55 patients) with mean preoperative sphere of − 8.98 ± 3.04 diopters (D) and cylinder of − 2.67 ± 1.02 D from December 2018 to February 2021. Primary visual outcomes of efficacy, safety, stability, predictability of refractive correction, and astigmatic analysis were reported at three and twelve months postoperatively. Secondary subjective outcomes included patient-reported dry eye symptoms and glare/halos at postoperative visits. Other secondary outcomes were biometric data and postoperative vault over time.Results: At three and twelve months, 75 and 46 eyes were evaluated, respectively. At twelve months, the mean manifest refraction spherical equivalent (MRSE) was − 0.23 ± 0.47 D with 93% achieving within ± 1.00 D of target refraction. The manifest refractive cylinder (MRC) at twelve months was − 0.73 ± 0.51 D, with 86% within ± 1.00 D of target. Uncorrected distance visual acuity (UDVA) was 20/20 or better in 74% of eyes at twelve months. No patients lost ≥ 2 lines of corrected distance visual acuity (CDVA) at twelve months. The mean angle of error was − 0.9 ± 10.2° at three months and − 1.6 ± 12.8° at twelve months. One patient required bilateral lens rotation, four patients underwent secondary enhancement with LASIK/PRK, and seven patients underwent postoperative limbal relaxing incisions.Conclusion: This initial single-site experience finds Toric ICL implantation for myopic astigmatism to be safe and effective. Patients can achieve markedly improved UDVA in a single surgery with stable vision over time and minimal adverse subjective symptoms.Keywords: Toric ICL, visian, myopic astigmatism, visual outcomes

Majid Moshirfar,1– 3 James Ellis,4 Daniel Beesley,5 Shannon E McCabe,1,6 Adam Lewis,7 William B West Jnr,4 Yasmyne Ronquillo,1 Phillip Hoopes Snr1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Utah School of Medicine, Salt Lake City, UT, USA; 5Brigham Young University, Provo, UT, USA; 6Mission Hills Eye Center, Pleasant Hill, CA, USA; 7Kansas City University College of Osteopathic Medicine, Kansas City, MO, USACorrespondence: Majid MoshirfarHoopes Vision Research Center, Hoopes Vision, Draper, UT, USATel +1 801-568-0200Fax +1 801-563-0200Email cornea2020@me.comPurpose: To compare the visual performance of the AcrySof IQ PanOptix trifocal intraocular lens and the TECNIS Symfony extended depth-of-focus lens at near and distance visual ranges.Methods: A total of 146 patients (221 eyes) who underwent phacoemulsification and cataract extraction and received either a PanOptix or Symfony lens from January 2019 to July 2020 were included in the study (83 PanOptix non-toric, 30 PanOptix toric, 70 Symfony non-toric, and 38 Symfony toric). Uncorrected distance (UDVA), uncorrected near (UNVA), and corrected distance (CDVA) visual acuity were assessed at one-day, one-month, and three-months postoperatively. Averages of UDVA, UNVA, and CDVA were taken to evaluate which lens was superior at near and distance visual ranges. Secondary outcome measures including glare, halo, dryness, and problems with night vision were documented at each postoperative visit.Results: At one month postoperatively, the average UNVA was 0.16 ± 0.14 logMAR in the PanOptix group and 0.21 ± 0.14 logMAR in the Symfony group (P=0.007); the average UDVA for the PanOptix group was 0.09 ± 0.13 logMAR compared to the Symfony group at 0.10 ± 0.14 logMAR (P=0.67); and the average CDVA was 0.02 ± 0.05 logMAR in the PanOptix group and 0.00 ± 0.04 logMAR in the Symfony group (P=0.11). At three months postoperatively, there were no statistically significant differences in UNVA, UDVA, or CDVA between the two groups (P=0.18, 0.79, 0.68 respectively). There was no statistically significant difference in secondary outcome measures at one- and three-months (P=0.49, 0.10 respectively).Conclusion: The AcrySof IQ PanOptix trifocal intraocular lens appears to afford better UNVA compared to the TECNIS Symfony extended depth-of-focus intraocular lens at one-month postoperatively, though this difference was not seen at three months postoperatively. There is no statistically significant difference in UDVA and CDVA between the two groups at postoperative day one, one-month, and three-months.Keywords: visual acuity, intraocular lens, trifocal lens, extended depth-of-focus lens

Majid Moshirfar,1– 3 Adam L Lewis,4 James H Ellis,5 Shannon E McCabe,1,6 Yasmyne C Ronquillo,1 Phillip C Hoopes Sr1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4Kansas City University, Kansas City, MO, USA; 5University of Utah School of Medicine, Salt Lake City, UT, USA; 6Mission Hills Eye Center, Pleasant Hill, CA, USACorrespondence: Majid MoshirfarMedical Director Hoopes Vision Research Center, Hoopes Vision, 11820 S. State Street Suite #200, Draper, UT, 84020, USATel +1 801-568-0200Fax +1 801-563-0200Email cornea2020@me.comIntroduction: Retained lens fragments in the anterior chamber following cataract extraction (CE) with phacoemulsification are rare but can lead to significant patient morbidity. Our study aimed to identify risk factors associated with retained lens fragments.Methods: Patients who underwent cataract surgery and subsequently identified to have retained lens fragments in the anterior segment were included. Incidence per year, patient demographics, visual acuity, ocular biometrics, surgical technique, surgeon performing CE, and outcomes were collected retrospectively and compared to a control group.Results: Twenty-four patients were identified with retained lens fragments, with an incidence of 0.10%. The mean age was 76 years ± 6.72 (60– 80) compared to 63 ± 11.41 (22– 86) in the control group (p < 0.001). Patients with UDVA 20/150 or worse experienced a greater average improvement in visual acuity compared to patients with UDVA better than 20/150 (logMAR 0.46 vs logMAR 0.05). The mean intraocular pressures before (CE), after CE but before fragment removal, and following fragment removal were 14 mmHg ± 2.59, 19 mmHg ± 8.20, and 11 mmHg ± 2.75, respectively. Twenty-two patients presented with inferiorly located fragments. Statistically significant biometrics include mean anterior chamber depth (3.1 mm ± 0.37 vs 3.33 mm ± 0.39, p = 0.01) and lens thickness (4.77 mm ± 0.44 vs 4.35 mm ± 0.44, p = < 0.001). Yearly incidence rates per surgeon ranged from 0.00% to 0.85%. In 2003 and 2004, one surgeon had significantly higher incidence rates (0.31 and 0.40%) compared to the average combined rate of all surgeons throughout the study (0.10), with p values of 0.001 and 0.003, respectively. The mean number of days between CE and fragment removal was 26 ± 40 (1– 138).Conclusion: Increased patient age, shallow anterior chamber depth, and thick lens may be risk factors for retained lens fragments. There may be additional surgeon-specific risk factors. Phacoemulsification technique (Divide-and-Conquer versus Horizontal Chop) showed no significant difference.Keywords: retained lens fragments, phacoemulsification, cataract surgery, complications of cataract surgery, refractory corneal edema

Ryan T Barrett,1 Jordan P Hastings,2 Yasmyne C Ronquillo,3 Phillip C Hoopes,3 Majid Moshirfar3– 5 1Hollingshead Eye Center, Boise, ID, USA; 2California Northstate University College of Medicine, Elk Grove, CA, USA; 3Hoopes Vision Research Center, Draper, UT, USA; 4John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 5Utah Lions Eye Bank, Murray, UT, USACorrespondence: Majid MoshirfarHDR Research Center, Hoopes Vision, 11820 S. State Street Suite #200, Draper, UT, USATel +1 801-568-0200Email Cornea2020@me.comAbstract: Palytoxin is one of the most lethal natural toxins ever discovered. This molecule has been isolated from various marine animals, including zoanthid corals. This popular organism is commonly found in many home saltwater aquariums due to its beauty and survivability. As a result of an increase in popularity, an increased number of individuals are at risk for exposure to this potentially deadly toxin. Affected patients may experience various symptoms based on the route of exposure (ie, cutaneous contact, inhalation of aerosolized toxin, ocular exposure, or ingestion). Ocular exposure can occur in various ways (eg, contact with contaminated water, rubbing the eye with a dirtied hand, or direct spraying into the eye), and incidence rates have dramatically risen in recent years. In this review, we discuss a case of systemic toxicity from inhalation and ocular exposure to presumed palytoxin on a zoanthid coral which resulted in an intensive care unit (ICU) stay, and corneal perforation which required a corneal transplant. Additionally, we review what is known about the mechanism of action of this toxin, propose a comprehensive hypothesis of its effects on corneal cells, and discuss the prognosis and clinical management of patients with systemic symptoms secondary to other routes of exposure.Keywords: coral keratitis, zoanthid, palytoxin, corneal perforation, case report

Majid Moshirfar,1– 3 Shaan N Somani,4 Mitchell T Tingey,1,5 Jordan P Hastings,6 Kathryn M Shmunes,1,7 Phillip C Hoopes1 1HDR Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4Northwestern Feinberg School of Medicine, Chicago, IL 60611, USA; 5Wake Forest School of Medicine, Winston-Salem, NC, 27101, USA; 6California Northstate University College of Medicine, Elk Grove, CA 95757, USA; 7Department of Ophthalmology, University of Florida, Gainesville, FL, USACorrespondence: Majid MoshirfarHDR Research Center, Hoopes Vision, 11820 S. State Street Suite #200, Draper, UT 84020, USATel +1 801-568-0200Email Cornea2020@me.comAbstract: Marginal keratitis, also known as catarrhal infiltrates, is a common, self-limiting condition characterized by inflammation at the peripheral aspect of the cornea. This non-infectious process is most typically a reaction to bacteria such as Staphylococcus, and results from a cell-mediated immune response to the bacterial antigens. This hypersensitivity reaction leads to the formation of stromal infiltrates that run parallel to the limbus. These infiltrates may extend around the limbal edge and can lead to the formation of marginal ulcers. Often the patient will have associated blepharoconjunctivitis. Both marginal keratitis and blepharoconjunctivitis are treated with topical steroids, with or without antibiotics, and good lid hygiene. We report a case of a patient who previously underwent small incision lenticule extraction (SMILE) who presented with marginal keratitis and secondary diffuse lamellar keratitis (DLK) in the right eye following recent initiation of continuous positive airway pressure (CPAP) therapy. There was no antecedent ocular trauma. With the initiation of steroid therapy, the patient returned to baseline visual acuity within one week. Though recurrence may be common in cases of marginal keratitis, our patient has not had any recurrence of symptoms or disease. DLK has previously been reported in the literature; however, there has been no reported case of marginal keratitis with secondary DLK after initiation of CPAP therapy to date.Keywords: marginal keratitis, diffuse lamellar keratitis, small incision lenticule extraction, continuous positive airway pressure, CPAP

Majid Moshirfar,1– 3 Robert J Thomson,4 William B West Jnr,5 Shannon E McCabe,1,6 Thomas M Sant,5 Margaret H Shmunes,7 Yasmyne C Ronquillo,1 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA; 5University of Utah School of Medicine, Salt Lake City, UT, USA; 6Mission Hills Eye Center, Pleasant Hill, CA, USA; 7Burrell College of Osteopathic Medicine, Las Cruses, NM, USACorrespondence: Majid MoshirfarMD Hoopes Vision Research Center, Hoopes Vision, Draper, UT 84020, USATel +1 801-568-0200Fax +1 801-563-0200Email cornea2020@me.comPurpose: To report the outcomes of sequential posterior chamber phakic intraocular lens (PC-pIOL) with corneal refractive surgery in conventional (PC-pIOL prior to refractive surgery) and reverse (refractive surgery prior to PC-pIOL) bioptics for treating high myopic astigmatism.Setting: Tertiary refractive center, Draper, Utah, USA.Design: Retrospective case series.Methods: Medical records of patients who underwent planned bioptics were reviewed. Surgery involved PC-pIOL placement using an implantable collamer lens (ICL) with preceding or subsequent LASIK or PRK. Pre- and postoperative manifest spherical equivalent (SEQ), visual acuity, and PC-pIOL vault were analyzed.Results: Of the 51 eyes present at 12 months postoperatively, 49 eyes (96%) achieved target SEQ within ± 1.00 D and an identical amount achieved refractive astigmatism ≤ 1.00 D. Post-bioptics eyes achieved a postoperative UDVA equal to or better than preoperative CDVA in 45 eyes (88%). Efficacy and safety indices were 1.08 ± 0.20 (41 eyes) and 1.13 ± 0.22 (44 eyes) for conventional bioptics and 0.99 ± 0.42 (7 eyes) and 1.15 ± 0.38 (7 eyes) for reverse bioptics eyes at 12 months. The maximum PC-pIOL vault of conventional bioptics eyes (27 eyes) within 6 months before and after LASIK/PRK was 385 ± 159 μm and 377 ± 135 μm, respectively (P = 0.71).Conclusion: Bioptics for high myopic astigmatism was safe and effective. Reverse bioptics, although not as traditional, could provide similar results. Additionally, the PC-pIOL vault does not appear to be affected by LASIK/PRK.Keywords: bioptics, LASIK, PRK, posterior chamber phakic IOL, high myopic astigmatism, visual outcomes

Majid Moshirfar,1– 3 Dallin C Milner,4 Preston A Baker,5 Shannon E McCabe,1 Yasmyne C Ronquillo,1 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4University of Colorado School of Medicine, Aurora, CO, USA; 5McGovern Medical School, University of Texas Health Science Center, Houston, TX, USACorrespondence: Majid MoshirfarHoopes Vision Research Center, Hoopes Vision, 11820 S. State Street Suite #200, Draper, UT 84020, USATel +1 801-568-0200Email Cornea2020@me.comAbstract: The incidence of herpes simplex keratitis (HSK) in patients following corneal refractive surgery is higher than in the general population, and several case reports of ocular morbidity in HSK infection following corneal refractive surgery have been published. HSK is listed by the American Academy of Ophthalmology as a relative contraindication to corneal refractive surgery, although specifics have not been further elucidated. This review summarizes the current literature regarding reactivation of HSK following corneal refractive surgery and provides a guideline for considering corneal refractive surgery in a patient with a previous history of HSK. Based on the current literature, we recommend that corneal refractive surgery is appropriate for patients with a history of HSK without multiple recurrences who have had no evidence of disease for at least one year. In addition to a thorough history and physical examination, we also recommend these patients begin 400 mg twice daily of oral acyclovir or valacyclovir 500 mg once daily for two weeks prior to surgery and continue this regimen for at least two weeks postoperatively or while on topical steroids.Keywords: herpetic keratitis, LASIK, PRK, PTK, herpes prophylaxis, SMILE, HSV, shingles, varicella zoster, cytomegalovirus, CMV

Majid Moshirfar,1– 3 Andrew C Thomson,4 William B West Jr,5 MacGregor N Hall,4 Shannon E McCabe,1 Robert J Thomson,4 Yasmyne C Ronquillo,1 Phillip C Hoopes1 1Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA; 5University of Utah School of Medicine, Salt Lake City, UT, USACorrespondence: Majid MoshirfarHoopes Vision Research Center, 11820 S. State Street Suite #200, Draper, UT 84020, USATel +1 801-568-0200Fax +1 801-563-0200Email cornea2020@me.comPurpose: To assess a single site’s initial experience with SMILE for the treatment of myopic astigmatism and compare outcomes and vector analysis results with the US Food and Drug Administration (FDA) results and published literature.Patients and Methods: Forty-eight eyes (29 patients) with mean preoperative sphere of − 5.11 ± 1.31 diopters (D) and cylinder of − 1.12 ± 0.60 D underwent SMILE. Visual acuity, refractive, and vector analysis outcomes as well as subjective measures were reported at three and twelve months postoperatively and compared with FDA results and the published literature between 2014 and 2020 involving treatment of patients with mean cylinders of >− 0.50 to ≤− 3.00 D.Results: At three and twelve months, 43 and 32 eyes were evaluated, respectively. At twelve months, mean cylinder power was reduced to − 0.38 ± 0.38 D with 78.1% achieving ≤± 0.50 D. Uncorrected distance visual acuity (UDVA) ≥ 20/20 was achieved in 77.4% of eyes by twelve months with 100% achieving ≥ 20/30 UDVA. No loss of corrected distance visual acuity was observed in eyes seen at twelve months. Correction index (CI) at twelve months was 0.90 indicating overall undercorrection of 10%. Twelve-month CI was 0.96, 0.90, and 0.83 in eyes with preoperative cylinders of

Erin Major,1 Thomas Dutson,2 Majid Moshirfar2– 4 1Southern California College of Optometry, Marshall B. Ketchum University, Fullerton, CA, USA; 2Hoopes Vision, Draper, UT, USA; 3John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 4Utah Lions Eye Bank, Murray, UT, USACorrespondence: Thomas DutsonHoopes Vision, Draper, UT, USAEmail dutson@hoopesvision.comPurpose: To determine the current scope of practice with regards to cycloplegic examinations, specifically in the pediatric population.Methods: A comprehensive literature review was conducted using PubMed, ScienceDirect, Elsevier, and Google Scholar databases using keywords such as “cyclopentolate”; “tropicamide”; “pediatric”; “cycloplegia”; “atropine”; and “cycloplegic” from inception to October 2019.Results: Atropine has the strongest cycloplegic effect and is recommended for cases of large accommodative esotropia. Because of the undesired side effects and risks from atropine, cyclopentolate has been found to offer a very effective cycloplegia even for moderate to high hyperopia and has become the standard of care for traditional pediatric cycloplegic exams. Tropicamide has also been shown to offer adequate cycloplegia with less toxicity and side effects. Of all agents, tropicamide presents the least side effects and toxicity, whereas atropine presents the greatest. Cyclopentolate is a very safe cycloplegic agent that has risk of toxicity which increases with higher doses and concentrations.Conclusion: The American Optometric Association’s current pediatric cycloplegic guidelines have proven both safe and effective, as they recommend a conservative approach of using cyclopentolate 0.5% in infants and cyclopentolate 1% in those older than one-year old to avoid undesired side effects. Topical ophthalmic drops and spray instillation have both proved equally efficacious and therefore each have their place within a clinical setting. Using Cycolmydril under six months old and cyclopentolate 1% over 6 months old as recommended by the AAO, also provides a safe and effective guideline for cycloplegic examinations within the pediatric population.Keywords: cycloplegic, cycloplegia, pediatric

R Doyle Stulting,1 Daniel S Durrie,2 Richard J Potvin,3 Steve H Linn,4 Ronald R Krueger,5 Mark C Lobanoff,6 Majid Moshirfar,4,7 Manoj V Motwani,8 Timothy P Lindquist,2 Karl G Stonecipher9 1Woolfson Eye Institute, Atlanta, GA, USA; 2DurrieVision, Kansas City, KS, USA; 3Science in Vision, Akron, NY, USA; 4Hoopes, Durrie, Rivera Research, Draper, UT, USA; 5Cleveland Clinic, Cleveland, OH, USA; 6North Suburban Eye Specialists, Minneapolis, MN, USA; 7John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA; 8Motwani LASIK Institute, San Diego, CA, USA; 9TLC Laser Centers, Greensboro, NC, USACorrespondence: R Doyle Stulting 224 Konawa LN, Loudon, TN 37774, USATel +1 770-804-1684Email ophtrds@emory.eduPurpose: To identify the laser programming strategy that will achieve optimal refractive outcomes of LASIK with a topography-guided laser for eyes with a disparity between cylinder measured by manifest refraction and cylinder measured by topography.Setting: Six surgeons at 5 clinical sites in the USA.Design: Retrospective data review.Methods: Preoperative, treatment, and postoperative data on 52 eyes that underwent topography-guided LASIK with the WaveLight EX500 Contoura® Vision excimer laser ablation profile in which the vectors representing the preoperative refractive cylinder and the cylinder measured by the WaveLight® Topolyzer™ VARIO Diagnostic Device (Vario cylinder) differed by >/= 0.50D and/or >/= 10 degrees of orientation were analyzed retrospectively. Data were contributed by six surgeons using the laser at 5 different clinical sites. Vector analysis of postoperative cylindrical refractive error and the actual laser programming strategy was used to calculate the cylindrical correction that would, theoretically, have completely eliminated postoperative refractive cylinder. This was compared to expected results using the preoperative manifest cylinder, the topographic cylinder, and the Phorcides Analytic Engine (Phorcides LLC, North Oaks MN; Phorcides). For analysis, subjects were stratified on the basis of the vector difference between Manifest and Topo cylinder (High, > 0.75 D; and Low, ≤ 0.75 D).Results: The poorest calculated theoretical outcomes were obtained with the manifest refraction (centroid: − 0.43, 0.22; mean calculated error vector: 0.56 ± 0.42 D; p=ns). Better outcomes were obtained with the topographically measured refraction (centroid: 0.37, 0.02; mean calculated error vector: 0.47 ± 0.33 D; p=ns). The best outcomes were obtained with Phorcides (centroid: − 0.15, 0.06; mean calculated error vector: 0.39 ± 0.28 D; p=ns). The mean error vector magnitude in the Phorcides Low group was significantly lower than for the Manifest and Topo Low groups (0.26 D vs 0.48 D and 0.33 D; p< 0.01). The mean error magnitude in the Phorcides High group was nearly 0.25 D lower than for the Manifest High group (0.48 D vs 0.70 D; p< 0.01), but was the same as for the Topo High group (0.48 D vs 0.48 D).Conclusion: Our study suggests that using the topographically measured cylinder or the cylinder selected by Phorcides will produce more desirable refractive outcomes than entry of the preoperative refractive cylinder as the basis for correction of myopia and myopic astigmatism with the WaveLight Contoura Vision excimer laser.Keywords: LASIK, topography, excimer, laser, PRK, astigmatism

Majid Moshirfar, 1–3 Shaan N Somani, 4 Kathryn M Shmunes, 1 Yasmyne C Ronquillo 1 1HDR Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, Murray, UT, USA; 4Northwestern Feinberg School of Medicine, Chicago, IL 60611, USACorrespondence: Majid MoshirfarHDR Research Center, Hoopes Vision, 11820 S. State Street Suite #200, Draper, UT 84020, USATel +1 801-568-0200Email Cornea2020@me.comAbstract: Eyelid myokymia, commonly referred to as “eyelid twitching”, is a common, benign condition that resolves in most individuals within hours to days; however, chronic cases can persist for several weeks to months, prompting the search for home remedies that may reduce the frequency or duration of symptoms. In this article, we discuss the proposed pathophysiologic mechanism and safety concerns surrounding tonic water as a treatment for eyelid myokymia.Keywords: myokymia, quinine, tonic water, eyelid twitching

Majid Moshirfar,1–3 Jackson L Goldberg,4 Tanner W Brown,4 William D Wagner,5 Yasmyne C Ronquillo1 1HDR Research Center, Hoopes Vision, Draper, UT, USA; 2Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, John Moran Eye Center, Murray, UT, USA; 4The University of Texas Health Science Center at Houston School of Medicine, Houston, TX, USA; 5Virginia Commonwealth University School of Medicine, Richmond, VA, USA Abstract: This article presents a fact-based, direct approach in order to evaluate the strengths and short comings of both local eye banks and larger companies that have penetrated the market of eye donation. By taking a non-biased approach to the topic, the goal of this article is to create a platform, which furthers the discussion. We focus on SightLife and CorneaGen as well as local eye banks and how their models differ in terms of tissue procurement, distribution, and surgeon partnership. Keywords: SightLife, CorneaGen, Lions Eye Bank, cornea transplant

Majid Moshirfar,1,2 Jordan D Desautels,1,3 Brian D Walker,4 Orry C Birdsong,1 David F Skanchy,4 Tyler S Quist,5 Michael S Murri,6 Steve H Linn,1 Phillip C Hoopes Jr,1,2 Phillip C Hoopes1,2 1Hoopes, Durrie, Rivera Research Center, Hoopes Vision, Draper, UT, USA; 2John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, School of Medicine, University of Utah, Salt Lake City, UT, USA; 3The Warren Alpert Medical School, Brown University, Providence, RI, USA; 4McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA; 5Department of Ophthalmology and Visual Sciences, Carver College of Medicine, University of Iowa, Iowa City, IA, USA; 6Baylor College of Medicine, Houston, TX, USA Purpose: To assess longitudinal refractive, keratometric, and topographic changes following KAMRA small-aperture inlay implantation.Design and setting: Prospective study at a single site refractive surgery center.Methods: Fifty patients underwent KAMRA small-aperture corneal inlay implantation for the correction of presbyopia. Uncorrected near visual acuity (UNVA), uncorrected distance visual acuity, manifest refractive spherical equivalent (MRSE), mean keratometry (Km), corneal topography, and surgically induced astigmatism vector analysis assessments were performed preoperatively and at 1, 3, 6, 12, 24, and 36 months postoperatively.Results: The study comprises 50 eyes. An average shift of 0.15±0.63 D (range -1.63 to 2.00 D) occurred between preoperative baseline and 36 months. At 36 months, 54% of patients had hyperopic MRSE and 40% had myopic MRSE compared with baseline. Km was significantly elevated at all postoperative measurements compared with baseline, with the largest Km measured at 12 months. Eighty-six percent of patients had UNVA of 20/32 or better and 88% uncorrected distance visual acuity of 20/25 or better at 36 months. Longitudinal corneal topography revealed a pattern of corneal steepening over the body of the inlay and flattening over the aperture, correlating with a hyperopic shift. There was no significant surgically induced astigmatism.Conclusion: KAMRA inlay may cause an increase in Km compared with baseline. Corneal steepening may occur in a specific pattern with steepening over the inlay and flattening over the aperture. This topographic pattern causes a hyperopic shift, which may be relevant for subsequent procedures, such as cataract extraction. Keywords: presbyopia, KAMRA, wound healing, IOL calculation

Michael S Murri,1 Majid Moshirfar,1,2 Orry C Birdsong,2 Yasmyne C Ronquillo,2 Yanning Ding,2 Phillip C Hoopes2 1John A Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA; 2HDR Research Center, Hoopes Vision, Draper, UT, USA Abstract: The amniotic membrane (AM) has a long history of use in the treatment of various diseases of the ocular surface. It contains pluripotent cells, highly organized collagen, anti-fibrotic and anti-inflammatory cytokines, immune-modulators, growth factors, and matrix proteins. It is used to promote corneal healing in severely damaged eyes. Recently, AM extract and AM extract eye drops have been successfully used in clinical applications, including dry eye and chemical burns. We provide an overview on the recent progress in the preparation, mechanisms of action, and use of AM extract/AM extract eye drops for corneal and external eye diseases. Keywords: amniotic membrane, amniotic membrane extract, amniotic membrane extract eye drops, AME, AMEED, AMT, umbilical cord, amnion, Regenesol, Genesis, Regener-Eyes, corneal wound healing, amniotic membrane transplant

Eileen S Hwang,1 Brian C Stagg,1 Russell Swan,1 Carlton R Fenzl,1 Molly McFadden,2 Valliammai Muthappan,1 Luis Santiago-Caban,1 Mark D Mifflin,1 Majid Moshirfar1,3 1Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, 2Department of Internal Medicine, University of Utah, Salt Lake City, 3HDR Research Center, Hoopes Vision, Draper, UT, USA Background: The purpose of this study was to evaluate the effects of laser-assisted in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK) on corneal biomechanical properties.Methods: We used the ocular response analyzer to measure corneal hysteresis (CH) and corneal resistance factor (CRF) before and after refractive surgery.Results: In all, 230 eyes underwent LASIK and 115 eyes underwent PRK without mitomycin C (MMC). Both procedures decreased CH and CRF from baseline. When MMC was used after PRK in 20 eyes, it resulted in lower corneal biomechanical properties at 3 months when compared to the other procedures, but all three procedures had similar values at 12 months.Conclusion: Significant but similar decreases in corneal biomechanical properties after LASIK, PRK without MMC, and PRK with MMC were noted. Keywords: corneal biomechanics, photorefractive keratectomy, laser-assisted in situ keratomileusis, corneal hysteresis, corneal resistance factor, mitomycin C

Majid Moshirfar,1,2 Julio C Albarracin,3 Jordan D Desautels,1,4 Orry C Birdsong,1 Steven H Linn,1 Phillip C Hoopes Sr1 1HDR Research Center, Hoopes Vision, Draper, 2John A Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT, 3Department of Ophthalmology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, 4Department of Ophthalmology, Warren Alpert Medical School of Brown University, Providence, RI, USA Purpose: Four cases of corneal ectasia after small-incision lenticule extraction (SMILE) have been reported. In this review, we provide an overview of the published literature on corneal ectasia after SMILE and risk factors associated with this complication.Methods: Case reports were identified by a search of seven electronic databases for pertinent heading terms between 2011 and July 2017. We identified patient characteristics and surgical details including preoperative topography, central corneal thickness, and anterior keratometry (Km). Residual stromal bed (RSB) values not reported were computed using VisuMax ReLEx SMILE software Version 2.10.10. Preoperative ectasia risk was measured using the Randleman Ectasia Risk Score System (ERSS). Percent tissue alteration was calculated for each patient as described by Santhiago et al.Results: Seven eyes of four patients developed corneal ectasia post SMILE. Two patients had abnormal topography in both eyes. One patient had abnormal topography in one eye. Only one patient was noted to have normal topography in both eyes and later developed ectasia in one eye in the absence of any known risk factors. The mean Randleman ectasia risk score was 4±3 (range: 1–8). The mean calculated percent tissue altered (PTA) was 38%±6% (range: 30%–47%).Conclusion: A majority of reported ectasia cases occurred in patients with subclinical keratoconus. These conditions may be exacerbated by SMILE and should be considered absolute contraindications to the procedure. Three patients were identified to have high risk based on the ERSS, and one patient exhibited a PTA ≥40%. We formulated a modification to the current calculation of PTA that takes into account the differences in tissue altered between SMILE and laser in situ keratomileusis (LASIK). More studies are needed to fully quantify the risk of ectasia. For now, we propose adopting the same exclusion criteria used for LASIK in the SMILE procedure until more specific metrics have been validated. Keywords: SMILE, small-incision lenticule extraction, ectasia, keratoconus, percent tissue altered, Ectasia Risk Score System

Mark D Mifflin,1 Brent S Betts,1 P Adam Frederick,2 Jason M Feuerman,3 Carlton R Fenzl,4 Majid Moshirfar,1,5 Brian Zaugg1 1Department of Ophthalmology and Visual Sciences, John A Moran Eye Center, University of Utah, Salt Lake City, UT, 2The Eye Center, Huntsville, AL, 3Eye Institute of Austin, Austin, TX, 4Eye Surgeons Associates, Bettendorf, IA, 5Hoopes Vision, Draper, UT, USA Purpose: To compare the outcome of photorefractive keratectomy (PRK) and complications in patients treated with either loteprednol etabonate 0.5% gel or prednisolone acetate 1% suspension and fluorometholone (fml) 0.1% suspension.Setting: John A Moran Eye Center, University of Utah, Salt Lake City, UT, USA.Design: Prospective, randomized, partially masked trial.Methods: PRK was performed on 261 eyes of 132 participants. Patients were randomized to a postoperative corticosteroid regimen of either loteprednol etabonate 0.5% gel (loteprednol) or prednisolone 1% acetate suspension followed by fluorometholone 0.1% suspension (prednisolone/fml). Primary outcome measures included incidence and grade of postoperative corneal haze and incidence of increased intraocular pressure of 10 mmHg above baseline, or any intraocular pressure over 21 mmHg. Secondary outcome measures included uncorrected distance visual acuity, best corrected distance visual acuity, and manifest refraction spherical equivalent.Results: The incidence of haze in the first 3 months was 2.6% (3/114 eyes) in the loteprednol group and 4.8% (7/147 eyes) in the prednisolone/fml group and was not statistically significant between groups (P=0.37). The incidence of elevated intraocular pressure was 1.8% (2/114 eyes) in the loteprednol group and 4.1% (6/147 eyes) in the prednisolone/fml group, and was not statistically significant between the groups (P=0.12). The mean 3-month postoperative logMAR uncorrected visual acuity was −0.078±0.10 and −0.075±0.09 in the loteprednol and prednisolone/fml groups, respectively (P=0.83).Conclusion: Postoperative corneal haze and elevated intraocular pressure were uncommon in both treatment arms. There was no statistically significant difference between each postoperative regimen. Refractive results were similar and excellent in both treatment arms. A tapered prophylactic regimen of loteprednol 0.5% gel is equally effective to prednisolone 1%/fml 0.1% after PRK. Keywords: PRK, corticosteroid, fluorometholone, loteprednol, lotemax, wavefront optimized

Majid Moshirfar,1,2 Tirth J Shah,3 David Franklin Skanchy,4 Steven H Linn,1 Paul Kang,3 Daniel S Durrie5 1HDR Research Center, Hoopes Vision, Salt Lake City, UT, 2Department of Ophthalmology and Visual Sciences, John A Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, 3University of Arizona College of Medicine – Phoenix, Phoenix, AZ, 4McGovern Medical School, The University of Texas Health Science Center at Houston, TX, 5Durrie Vision, Kansas City, KS, USA Purpose: To compare and analyze the differences in visual outcomes between Visx iDesign Advanced WaveScan Studio™ System, Alcon Wavelight Allegro Topolyzer and Nidek EC-5000 using Final Fit™ Custom Ablation Treatment Software from the submitted summary of safety and effectiveness of the US Food and Drug Administration (FDA) data.Methods: In this retrospective comparative study, 334 eyes from Visx iDesign, 212 eyes from Alcon Contour, and 135 eyes from Nidek CATz platforms were analyzed for primary and secondary visual outcomes. These outcomes were compared via side-by-side graphical and tabular representation of the FDA data. Statistical significance was calculated when appropriate to assess differences. A P-value

Majid Moshirfar,1,2 Tyler S Quist,3 David F Skanchy,4 Ryan T Wallace,5 Steven H Linn,1 Phillip C Hoopes Jr1 1Hoopes, Durrie, Rivera Research Center, Hoopes Vision, Draper, 2Department of Ophthalmology and Visual Sciences, John A Moran Eye Center, University of Utah School of Medicine, Salt Lake City, 3University of Utah School of Medicine, Salt Lake City, UT, 4McGovern Medical School, The University of Texas Health Science Center at Houston, TX, 5Brigham Young University, Provo, UT, USA Objective: The objective of this study was to describe 6-month postoperative efficacy and safety outcomes after monocular KAMRA corneal inlay implantation in emmetropic presbyopic patients. Study design: This study followed a retrospective chart analysis. Setting: This study was performed at Hoopes Vision in Draper, UT, USA. Subjects and methods: Fifty-seven patients met the inclusion criteria of this study and underwent KAMRA corneal inlay implantation following the approval of the United States Food and Drug Association between May 2015 and April 2016 at a single site. Surgery involved femtosecond laser-created corneal pockets of various depths. Efficacy, safety, and patient satisfaction reports were analyzed at 3 and 6 months. Results: At 6 months follow-up, the monocular uncorrected near visual acuity (UNVA) was Jaeger (J) 4 (20/32), the mean uncorrected distance visual acuity was 20/25, and the mean corrected distance visual acuity was 20/20. At 6 months, 71% of patients with a pocket depth of ≥250 µm had a UNVA of 20/20 or better, whereas only 22% of patients with a shallow pocket depth of

Majid Moshirfar,1,2 Jordan D Desautels,3 Tyler S Quist,4 David F Skanchy,5 Mark T Williams,6 Ryan T Wallace7 1Department of Ophthalmology and Visual Sciences, John A Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, 2HDR Research Center, Hoopes Vision, Draper, UT, 3Tufts University School of Medicine, Boston, MA, 4University of Utah School of Medicine, Salt Lake City, UT, 5McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, 6University of California, San Francisco School of Medicine, San Francisco, CA, 7Brigham Young University, Provo, UT, USA Abstract: This article reviews the current literature pertaining to rainbow glare (RG), including incidence rate, clinical presentation, etiology, prognosis, and management. RG is a rare optical complication of femtosecond laser-assisted in situ keratomileusis that results in patients seeing an array of spectral bands surrounding point sources of light under mesopic and scotopic conditions. The mechanism is thought to be a consequence of the formation of a transmissive diffraction grating on the posterior surface of the corneal flap created by the FS laser. RG has a good prognosis and is usually self-limiting. Persistent RG with concomitant residual refractive error may warrant lifting the flap and photoablating the posterior surface of the flap. Patients with persistent RG and no residual refractive error should be considered candidates for phototherapeutic keratectomy on the posterior flap surface. Keywords: rainbow glare, femtosecond, LASIK, keratomileusis, phototherapeutic keratectomy

Majid Moshirfar,1,2 Ryan T Wallace,3 David F Skanchy,4 Jordan D Desautels,5 Steven H Linn,1 Phillip C Hoopes Jr,1 Daniel S Durrie1,6 1Hoopes, Durrie, Rivera, Research Center, Hoopes Vision, Draper, UT, 2Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, 3Brigham Young University, Provo, UT, 4McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, 5Tufts University School of Medicine, Boston, MA, 6Durrie Vision, Overland Park, KS, USA Purpose: To report the short-term results of simultaneous photorefractive keratectomy (PRK) and small-aperture cornea inlay implantation (KAMRA) surgery in treating presbyopia. Methods: Simultaneous PRK and KAMRA inlay surgery was performed on 21 patients from July 2015 to March 2016. Follow-up exams were conducted at 1, 3, and 6 months postoperatively. Our patients were also divided preoperatively into three categories: myopic, hyperopic, and emmetropic. Over the 6-month period, the main outcome measures were uncorrected near visual acuity (UNVA), changes in best-corrected distance visual acuity, and mean spherical equivalent refraction. Results: At 6-month follow-up, 83% (10/12) of patients had a monocular UNVA of 20/40 or better, and 75% had a binocular UNVA of 20/40 (J5) or better. At 6 months, the overall mean refractive spherical equivalent (MRSE) was -0.60 D (±0.42 standard deviation [SD], range: -1.38 to -0.13) with a mean change of -0.43 D (±1.19 SD, range: -1.5 to 2.63) compared to preoperative data. Overall, 91% (10/11) of patients were within a ±0.5 D range of our target -0.75 D for KAMRA use. One-hundred percent (5/5) of the hyperopes, 50% (1/2) of emmetropes, and 100% (4/4) of myopes met the targeted range. At 6 months, the MRSE for the hyperopic subgroup (n=5) was 0.33 D (±0.20 SD), the MRSE for the emmetropic subgroup (n=2) was -1.19 D (±0.19 SD), and the MRSE for the myopic subgroup (n=4) was -0.66 D (±0.36 SD). Conclusion: Based on preliminary results and a small sample size, it seems that simultaneous PRK and KAMRA is effective and predictable. There are multiple advantages in performing simultaneous PRK and KAMRA including a shorter recovery time and less steroid use than the two surgeries performed separately. Keywords: KAMRA, PRKamra, PRK, femptosecond, corneal, presbyopia

Steven H Linn,1 David F Skanchy,2 Tyler S Quist,3 Jordan D Desautels,4 Majid Moshirfar1,5 1Department of Clinical Research, HDR Research Center, Hoopes Vision, Draper, UT, 2McGovern Medical School, The University of Texas Health Science Center at Houston, TX, 3University of Utah School of Medicine, Salt Lake City, UT, 4Tufts University School of Medicine, Boston, MA, 5John A Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA Purpose: The aim of this study was to compare stereoacuity before and after KAMRA corneal inlay implantation for the correction of presbyopia.Patients and methods: This is a prospective study of 60 patients who underwent KAMRA inlay implantation. Patients were examined before and 6 months after surgery for stereoacuity, uncorrected distance visual acuity (UDVA), and uncorrected near visual acuity (UNVA).Results: The mean stereoacuity before surgery was 29.5±28.1 arcsec (range: 20–200) and at 6 months was 29.8±26.4 arcsec (range: 20–200). The decline in stereoacuity was not statistically significant. At 6 months follow-up, UDVA was 20/25 or better in all 60 patients and UNVA was J2 (20/25) or better in 51 (85%) patients.Conclusion: There is no significant change in stereoacuity following KAMRA inlay implantation. The KAMRA inlay is a good treatment option for improving near vision in presbyopic patients while preserving stereoacuity and distance vision. Keywords: KAMRA, corneal inlay, AcuFocus, stereoacuity, presbyopia

Majid Moshirfar1–31HDR Research Center, Hoopes Vision, Draper, UT, USA; 2Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, UT, USA; 3Utah Lions Eye Bank, John Moran Eye Center, Murray, UT, USAI thank Dr. Mannis for his reply to our perspective editorial concerning the Paradigm Shift in Eye Banking. As mentioned in our abstract the goal of this article is to create a platform to promote further discussions. There are indeed 14, not 11, paragraphs in this article and CorneaGen has been mentioned, not necessarily supported, in 11, not 6, of the paragraphs. This correction may seem petty, but the number of paragraphs is no way a reflection of a bias. I must start by stating that none of the authors in this manuscript has any financial interest in SightLife or CorneaGen, and we have never obtained cornea tissue from CorneaGen. I am the co-director of a local community Eye Bank and I do take my role quite seriously concerning this noble and important cause for our community. In another words, Dr. Mannis, I am on the same side with you concerning this dilemma. You are accusing us of being biased in our editorial but fail to actually specify our biased comments. What comment was erroneous and biased in your opinion? As mentioned, we simply wanted to create a platform for both sides for further dialogue without adopting a reprimanding tone or trying to state if one side is more righteous than the other. View the original paper by Moshirfar and colleagues This is in response to the Letter to the Editor

Carlton R Fenzl,1 Kyla Teramoto,2 Majid Moshirfar3 1John A Moran Eye Center, University of Utah, Salt Lake City, UT, USA; 2John A Burns School of Medicine, University of Hawai’i, Honolulu, HI, USA; 3Cornea and Refractive Surgery Division, Department of Ophthalmology, Francis I. Proctor Foundation, University of California, San Francisco, CA, USA Abstract: The mucopolysaccharidoses (MPS) are a group of lysosomal storage disorders caused by inborn errors of glycosaminoglycan (GAG) metabolism. These diseases are classified by enzyme deficiency into seven groups: type I, II, III, IV, VI, VII, and IX. GAG accumulation leads to characteristic clinical features. Some ophthalmic findings that are characteristic of MPS diseases include corneal clouding, retinal degeneration, decreased electroretinogram wave amplitude, optic atrophy, papilledema, and glaucoma. Current treatments such as hematopoietic stem cell transplantation and enzyme replacement therapy have increased the life span of many MPS patients and created the need to improve management of ocular symptoms. This article aims to provide a comprehensive review of ocular manifestations and treatment options for the various types of MPS. Keywords: MPS, glycosaminoglycan, corneal clouding

Majid Moshirfar,1 Michael V McCaughey,2 Carlton R Fenzl,3 Luis Santiago-Caban,4 Gregory D Kramer,3 Nick Mamalis3 1Department of Ophthalmology, Francis I Proctor Foundation, University of California San Francisco, San Francisco, CA, USA; 2University of New Mexico School of Medicine, Albuquerque, NM, USA; 3John A Moran Eye Center, University of Utah, Salt Lake City, UT, USA; 4Department of Ophthalmology, University of Puerto Rico School of Medicine, San Juan, PR, USA Purpose: To report a case of delayed-onset bilateral scleral thinning and calcium deposition following a cosmetic ocular-whitening procedure (I-BRITE®).Methods: A 33-year-old male patient with a history of right-sided ptosis repair and left-sided anterior uveitis had previously undergone bilateral I-BRITE treatment for chronic conjunctival hyperemia. Four years after the procedure, the patient was referred to our institution with bilateral scleral thinning and overlying calcific depositions. A literature review was performed through PubMed from 1980 through 2014 using the search terms ‘cosmetic’, ‘ocular’, ‘conjunctivectomy’, ‘regional conjunctivectomy’, ‘I-BRITE’, ‘eye-whitening’, ‘scleritis’, ‘necrotizing scleritis’, ‘anterior uveitis’, ‘mitomycin C’, ‘5-fluorouracil’, and ‘bevacizumab’, along with associated cross-referencing from relevant articles.Results: Examination of the patient revealed bilateral necrotizing scleritis within the nasal region of both eyes. Calcified plaques were also present within the areas of scleromalacia, along with epithelial defects demonstrated with fluorescein staining. Although evidence of previous intraocular inflammation was apparent within the left eye, there were no active signs of inflammation evident within either eye on initial presentation. Complication rates reported in the literature include: scleral thinning (1.8%), calcific plaque formation (2.9%), fibrovascular proliferation (13%), diplopia (1.2%), elevation of intraocular pressure (4.2%), and recurrence of conjunctival hyperemia (2.1%).Conclusion: Cosmetic ocular whitening procedures have an attendant high complication rate, and have been associated with several adverse postoperative complications, which have in turn generated several reservations regarding the veritable benefit of the procedure. Many postsurgical complications may demonstrate delayed apparition, varying from several months to several years after primary surgical intervention as in the case reported here. Keywords: necrotizing scleritis, scleromalacia, cosmetic ocular whitening

Carlton R Fenzl,1 Adam J Gess,2 Majid Moshirfar31John A Moran Eye Center, University of Utah, Salt Lake City, UT, 2Eye Doctors of Washington, Washington, DC, 3Cornea and Refractive Surgery Division, Department of Ophthalmology, Francis I Proctor Foundation, University of California San Francisco, San Francisco, CA, USABackground: The Moria single-use adjustable depth trephine is a device that allows a goal trephination depth to be set prior to the surgical procedure.Methods: Eleven fresh human cadaveric eyes were trephined using 8.0 mm Moria single-use adjustable vacuum trephines. Prior to trephination, the average corneal pachymetry in the peripheral 7–10 mm range was obtained using anterior segment optical coherence tomography. The trephination depth was set to 80% of that value. Light microscopy was used to image anteroposterior cross-sections of each corneal specimen. Digital protractor software was used to evaluate the trephination angle, depth, and length. All adequately processed specimens were included in the analysis. In addition, trephination angle data from a previous publication by Moshirfar et al were used as a comparison with those of this study.Results: Trephination analysis of depth compared with pachymetry revealed a mean of 83.7%±6.53% (95% confidence interval 79.8–87.6). Maximum and minimum trephined depths were 95.35% and 71.3%, respectively. Trephination depth compared with angular corneal thickness yielded a mean of 66.2%±4.79% (95% confidence interval 63.0–69.4). Maximum and minimum depths were 73.7% and 59.7%, respectively. Analysis of trephination angle yielded a mean of 130.2±3.57 degrees (95% confidence interval 127.8–132.61). Maximum and minimum angles were 135.5 degrees and 126 degrees, respectively. The standard deviation of the trephination angle of the Moria trephine was found to be significantly less than that of Hessburg-Barron and Hanna trephines calculated in the previous study.Conclusion: The Moria adjustable vacuum trephine is an accurate method of trephination when a specific depth is desired. Further investigation is needed to determine the relevance of this in relation to deep anterior lamellar keratoplasty.Keywords: trephine, Moria, deep anterior lamellar keratoplasty, adjustable depth, vacuum

Majid Moshirfar,1 Kasey Pierson,2,* Kamalani Hanamaikai,3,* Luis Santiago-Caban,1 Valliammai Muthappan,1 Samuel F Passi11Department of Ophthalmology, John A Moran Eye Center, University of Utah, Salt Lake City, UT, USA; 2University of Arizona College of Medicine, Phoenix, Phoenix, AZ, USA; 3A T Still University, School of Osteopathic Medicine in Arizona, Mesa, AZ, USA *These authors contributed equally to this work Abstract: Numerous brands and types of artificial tears are available on the market for the treatment of dysfunctional tear syndrome. Past literature has focused on comparing the components of these products on patient’s clinical improvement. The wide array of products on the market presents challenges to both clinicians and patients when trying to choose between available tear replacement therapies. Different formulations affect patients based on etiology and severity of disease. In order to provide an unbiased comparison between available tear replacement therapies, we conducted a literature review of existing studies and National Institutes of Health clinical trials on commercially available, brand name artificial tears. Outcomes evaluated in each study, as well as the percent of patients showing clinical and symptomatic improvement, were analyzed. Fifty-one studies evaluating different brands of artificial tears, and their efficacy were identified. Out of the 51 studies, 18 were comparison studies testing brand name artificial tears directly against each other. Nearly all formulations of artificial tears provided significant benefit to patients with dysfunctional tear syndrome, but some proved superior to others. From the study data, a recommended treatment flowchart was derived. Keywords: dry eye, tear film, dysfunctional tear syndrome, ophthalmic lubricant, artificial tears, lipid layer, tear osmolarity, TBUT, Systane®, Refresh®, Blink®, GenTeal®, Soothe®, Lacrisert®, ocular surface inflammatory disease, Sjogren’s Syndrome, HPMC, CMC, polyvinyl alcohol, liquid polyols