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The aim of this study was to assess Corvis ST biomechanical indices in reference to corneal enantiomorphism. In a prospective observational cohort study, 117 eyes from 63 patients with normal or keratoconus corneas were assessed by three independent observers. In the control group (n = 62), no significant differences were observed between the three observers for all indices. The best reproducibility was obtained with pachymetry and the weakest with CBI. All indices but CBI and arc length featured COV < 10%. All indices except the PD and SSI correlated with pachymetry; all but Rad correlated with IOP. The comparison of the thinnest with the thickest corneas showed no significant differences for any index except pachymetry. In the keratoconus group (n = 55), loss of corneal enantiomorphism was confirmed for all indices except the arc length, velocity, and PD. Significant differences between both groups were found for all indices, even after adjustment for pachymetry and intraocular pressure. The CBI featured the best accuracy (92%), sensitivity (91%), and graphical relevance for keratoconus diagnosis. However, its reproducibility was weak in normal corneas and was strongly dependent on corneal thickness. The SSI was independent of corneal thickness, highly reproducible, and provided the expected enantiomorphism characteristics in both groups, making it a relevant biomarker of biomechanical corneal behavior.

Purpose: To evaluate the effect of a black-and-white (BW) filter on the optimization of visualization at each stage of cataract surgery. Methods: Prospective, single-center, single-surgeon, consecutive case series of 40 patients undergoing cataract surgery with BW filter. Surgical images and videos were recorded with and without the BW filter at each stage of cataract surgery. Contrast measurements of surgical images and subjective analysis of video sequences were performed. Results: The surgeons assessed the BW filter to optimize the tissue visibility of capsulorhexis contours, hydrodissection fluid wave perception, the contrast of instruments through a nucleus during phaco-chop, and subincisional cortex contrast through the corneal edema. Despite the higher contrasts’ value obtained with BW filter images during nucleus removal, posterior capsular polishing and viscous removal, the surgeons subjectively reported no significant advantage of using a BW filter. Standard color images were found to be better for localizing the limbal area during incision and for nucleus sculpture to assess groove depth. Conclusions: In conclusion, we describe here the potential indications for BW filter use at particular stages in cataract surgery. A BW filter could be used, with caution, in cases of poor visualization.

Resume La phacoemulsification est la chirurgie la plus frequemment pratiquee dans le monde. Depuis quelques annees, cette chirurgie semble avoir atteint un plateau et qu’il n’y a plus d’innovations de rupture. Dans cet article, nous faisons le point sur les techniques alternatives, les dernieres innovations et les voies de recherche et developpement dans ce domaine.

Purpose: The aim of this study was to evaluate the efficacy of digital visualization for enhancing the visualization of iridocorneal structures during surgical gonioscopy. Methods: This was a prospective, single-center study on a series of 26 cases of trabecular stent implantation performed by the same surgeon. Images were recorded during surgical gonioscopy, and before stent implantation, with standard colors and with the optimization of various settings, principally color saturation and temperature and the use of the cyan color filter. Subjective analyses were performed by two glaucoma surgeons, and objective contrast measurements were made on iridocorneal structure images. Results: The surgeons evaluating the images considered the optimized digital settings to produce enhanced tissue visibility for both trabecular meshwork pigmentation and Schlemm’s canal in more than 65% of cases. The mean difference in the standard deviation of the pixel intensity values was 37.87 (±4.61) for the optimized filter images and 32.37 (±3.51) for the standard-color images (p < 0.001). The use of a cyan filter provided a good level of contrast for the visualization of trabecular meshwork pigmentation. Increasing the color temperature highlighted the red appearance of Schlemm’s canal. Conclusions: We report here the utility of optimized digital settings including the cyan filter and a warmer color for enhancing the visualization of iridocorneal structures during surgical gonioscopy. These settings could be used in surgical practice to enhance the visualization of the trabecular meshwork and Schlemm’s canal during minimally invasive glaucoma surgery.

Purpose: To describe the feasibility of intraoperative digital visualization and its contribution to the enhancement of macular pigmentation visualization in a prospective series of macular surgery interventions. Materials and Methods: A prospective, single-center, single-surgeon study was performed on a series of 21 consecutive cases of vitrectomy for various types of macular surgery using a 3D visualization system. Two optimized filters were applied to enhance the visualization of the macular pigment (MP). For filter 1, cyan, yellow, and magenta color saturations were increased. Filter 2 differed from filter 1 only in having a lower level of magenta saturation for the green-magenta color channel. Results: Optimized digital filters enhanced the visualization of the MP and the pigmented epiretinal tissue associated with the lamellar and macular holes. In vitreomacular traction surgery, the filters facilitated the assessment of MP integrity at the end of surgery. Filter 1 enhanced MP visualization most strongly, with the MP appearing green and slightly fluorescent. Filter 2 enhanced MP visualization less effectively but gave a clearer image of the retinal surface, facilitating safe macular peeling. Conclusion: Optimized digital filters could be used to enhance MP and pigmented epiretinal tissue visualization during macular surgery. These filters open new horizons for future research and should be evaluated in larger series and correlated with intraoperative OCT.

International audience; PurposeTo describe the early topography of corneal swelling occurring after cataract surgery and to evaluate the impact of the three-dimensional (3D) digital visualization system in minimizing corneal oedema.MethodsProspective observational, single-centre, consecutive case series of 134 patients undergoing cataract surgery performed by the same surgeon, with either 3D or conventional visualization systems. Eyes were assigned to two groups based on their anterior chamber depth (group ACD ≤3 mm and group ACD >3 mm). Optical coherence tomography was performed to evaluate postoperative corneal swelling.ResultsThree corneal swelling profiles were identified on the first postoperative day type 1, limited corneal oedema near peripheral corneal incisions; type 2, dome-shaped corneal swelling spreading from the principal corneal incision and reaching the paracentral cornea; type 3, continuous oedema spreading from the principal incision to central cornea, with a generalized oedema predominating in the upper part of the cornea.On the first day after surgery, in group ACD ≤3 mm, visual acuity was significantly better in patients undergoing surgery with 3D visualization (0.023 vs 0.072 logMar, p = 0.014) with reduced central corneal thickening 17.3 µm (±3.2) in comparison with conventional visualization 44.0 µm (±9.3) (p = 0.0082). In group ACD >3 mm, no significant association was found between the use of the 3D system and pachymetry changes and early visual rehabilitation. On day 21 after surgery, no significant differences in corneal pachymetry values were observed between the two surgical approaches in both groups.ConclusionsWe describe early postoperative corneal map profiles providing insight into the pathogenesis of postoperative corneal swelling and possible prevention strategies. By improving visualization of the narrow surgical space in patients with shallow anterior chambers, the 3D system could help to minimize postoperative corneal oedema.

PURPOSE: To evaluate and compare epithelial remodeling after standard corneal cross-linking (S-CXL) and iontophoresis-assisted CXL (I-CXL) in eyes with keratoconus by anterior segment optical coherence tomography (AS-OCT). METHODS: In this prospective, observational study, AS-OCT and corneal topography were performed before and 1, 3, and 6 months after surgery. Corneal pachymetry was performed and epithelial and stromal thicknesses (central and 16 points on the 6-mm central zone) and the maximum simulated keratometry value (Kmax) were measured. RESULTS: Two groups of 30 patients (60 eyes total) with progressive keratoconus underwent S-CXL or I-CXL. Before surgery, both groups of patients presented with an irregular epithelial thickness profile. At 6 months postoperatively, localized corneal epithelial thinning was observed in the superior ( P = .026), inferior ( P = .034), inferonasal ( P = .024), and nasal ( P = .035) areas at 3 mm and in the superior ( P = .039), nasal ( P = .043), and inferior ( P = .01) areas at 6 mm in the SCXL group. Localized corneal epithelial thinning was observed at 3 ( P = .04) and 6 ( P = .01) mm in the inferior area in the I-CXL group. No significant stromal changes were observed for either group. Kmax was stable in both groups at 6 months. CONCLUSIONS: Significant epithelial remodeling occurs after S-CXL, resulting in a thinner, more regular thickness profile than after I-CXL. Epithelial thickness profile measurements after I-CXL could be used as an adjunctive follow-up tool for monitoring the efficacy of CXL in progressive keratoconus. [ J Refract Surg. 2018;34(8):551–558.]

Purpose: To assess the utility of the 3D viewing system in tilted microscope positions for the performance of cataract surgery in challenging positions, for patients with difficulty remaining supine. Methods: Prospective, single-center, single-surgeon, consecutive case series of patients undergoing surgery in an inclined position. Results: 21 eyes of 15 patients who had undergone surgery at inclined positions at angles of 20° to 80°, with a mean angle of 47.62°. Surgeon comfort was considered to be globally good. The surgeon rated red reflex perception and the impression of depth as good and stable in all cases. The operating time was slightly longer for patients inclined at angles of more than 50°. On the first day after surgery, BSCVA was 20/25 or better in all cases. No ocular complications occurred in any of the interventions. Conclusions: Due to the ocular-free design of the 3D system, the surgical procedure and the positioning of the surgeon remained almost identical to that for patients undergoing surgery in a supine position, maintaining the safety of the standard surgical approach.

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

PURPOSE To determine the anatomic criteria for diagnosing keratoconus progression by corneal optical coherence tomography (OCT). SETTING Quinze-Vingts National Ophthalmology Hospital, Paris, France. DESIGN Prospective case series. METHODS Scanning-slit corneal topography (Orbscan II) and Fourier-domain corneal OCT (RTVue) were performed in eyes with mild to moderate keratoconus (progressive or nonprogressive [stable] ectasia) at each examination to assess the keratoconus. Disease progression was defined as an increase of at least 1.0 diopter (D) in the steepest keratometry (K) measurement over 6 months. RESULTS Of the 134 eyes of 134 patients with mild to moderate keratoconus, 98 had had progressive ectasia and 36 nonprogressive ectasia. The mean maximum K increased significantly in the progressive group (2.1 D ± 1.2 [SD], P

Purpose To define the optical coherence tomography (OCT) corneal changes predisposing to acute corneal hydrops among patients with advanced keratoconus. Design Retrospective cohort study. Participants A total of 191 advanced keratoconic eyes from 191 patients with advanced keratoconus cases were studied. Methods Data collected from patients with advanced keratoconus cases were studied during a minimum period of 24 months of follow-up. High-resolution Fourier-domain corneal OCT (5 μm of axial resolution) and corneal topography were performed every 4 months during the follow-up. Several anatomic features at the keratoconus cone were analyzed with OCT, including epithelial and stromal thicknesses, the aspect of Bowman's layer, the presence of Vogt's striae, and stromal opacities. A comparative analysis between anatomic corneal features in eyes that developed corneal hydrops and those that did not develop this complication during the follow-up was performed. Main Outcome Measures Evaluation of anatomic corneal changes at risk of developing a corneal hydrops on the basis of OCT findings. Results Eleven cases of corneal hydrops (5.8%) occurred in our series during a mean follow-up of 30 months (24–36 months). All of these patients were male and younger (23.7±5.9 years) than patients with no acute keratoconus (32.7±11.3 years). Increased epithelial thickening with stromal thinning at the conus and the presence of anterior hyperreflectives at the Bowman's layer level were significantly associated with corneal hydrops, whereas the presence of corneal scarring was a preventive factor. At the healing stage, a pan-stromal scar occurs, with a significant stromal thickening and cornea flattening. Conclusions Increased epithelial thickening, stromal thinning at the keratoconus cone, anterior hyperreflectives at the Bowman's layer level, and the absence of stromal scarring are associated with a high risk of developing corneal hydrops. These aspects should be taken into account by the clinician in the evaluation of keratoconus eyes and in the planning of corneal keratoplasty.

Corneal collagen crosslinking (CXL) is, at present, the only treatment that can slow or even stop the progression of keratoconus. It uses riboflavin and ultraviolet A (UVA) to create covalent bonds ("crosslinks") between collagen fibrils thus increasing corneal rigidity. Although to date there has been no direct evidence of intrastromal corneal crosslinking, several studies have reported the safety and efficacy of the conventional CXL protocol. This protocol is indicated for progressive keratoconus with a minimal corneal thickness (without the epithelium) of at least 400 μm. It should be performed as early as possible in patients under 18 years with keratoconus or with post-LASIK ectasia. Because of the epithelial debridement, it may rarely induce complications such as infectious keratitis or stromal scars. A variety of new protocols is under investigation and may reduce the rate of these complications. In addition, combination of CXL with other surgical treatments (intracorneal ring segments or photorefractive keratectomy) may improve visual outcomes in patients with keratoconus. Finally, the antimicrobial and anti-edematous properties of CXL have been shown, suggesting new therapeutic indications of this procedure such as infectious keratitis or stromal edema in the future.

Resume Objectif Comparer a l’aide de l’Orbscan et de la pachymetrie ultrasonique les caracteristiques de la cornee dans un groupe de myopes forts et dans un groupe sans ametropie spherique. Methodes La pachymetrie ultrasonique et l’Orbscan ont ete prospectivement realises sur 105 myopes forts (longueur axiale superieure a 26 mm) et sur 105 patients sans ametropie spherique (equivalent spherique inferieur a 1,25D en valeur absolue, independamment du cylindre). Les donnees de l’astigmatisme ont ete transformees en coordonnees rectangulaires dans un plan dioptrique. L’axe a ete decompose en 2 composantes (directe/inverse et oblique) analysees par les fonctions trigonometriques (Cos2axe et Sin2axe). L’enantiomorphisme (symetrie en miroir) des 2 yeux d’un patient a ete quantifie par une distance euclidienne pour la localisation du point le plus fin et par la difference (en valeur absolue) entre la somme des 2 axes et 180° pour l’astigmatisme. Resultats Dans le groupe myope, la longueur axiale etait de 27,82 mm (±2,14 ; 26,00 a 34,06) et l’equivalent spherique subjectif de −9,00D (±3,46 ; −4,71 a −19,82). L’astigmatisme corneen moyen etait de +0,92D × 91,3° pour les myopes et de +0,65D × 89,3° pour l’autre groupe. Le cylindre corneen etait significativement plus eleve chez les myopes (1,44D contre 0,91D ; p p = 0,03) contrairement a la keratometrie moyenne et a la keratometrie minimale qui ne presentaient pas de difference. Aucune difference significative entre les 2 groupes n’a ete retrouvee pour l’epaisseur centrale (myopes : 540,2 μm versus 546,9 μm ; p = 0,10), l’epaisseur peripherique, le diametre corneen, l’irregularite corneenne, l’asphericite ou l’astigmatisme irregulier. Le degre d’enantiomorphisme ne presentait aucune difference entre les 2 groupes. Dans le groupe myope, la correlation avec la longueur axiale etait uniquement significative pour l’equivalent spherique ( r = −0,86 ; p r = 0,16 ; p = 0,04). Conclusion A l’exception de la toricite, la cornee des myopes forts est similaire a la cornee des yeux sans ametropie spherique. Contrairement a l’elongation du segment posterieur, le developpement de la myopie forte ne semble pas concerner la cornee. En perturbant le mecanisme d’emmetropisation de l’œil, la toricite de la cornee pourrait etre un facteur favorisant l’evolution vers la myopie forte.

Objective To study corneal morphologic changes in a large keratoconic population and to establish a structural optical coherence tomography (OCT) classification. Design Cross-sectional, observational study. Participants A total of 218 keratoconic eyes from 218 patients and 34 eyes from 34 normal subjects. Methods A Fourier-domain OCT system with 5-μm axial resolution was used. For each patient, 3 high-resolution scans were made across the keratoconus cone. All scans were analyzed by keratoconus specialists who were not given access to patients' clinical and topographic data, and who established an OCT classification. The reproducibility of the classification and its correlation with clinical and paraclinical characteristics of patients with keratoconus were evaluated. The OCT examinations were performed every 4 months to follow up structural corneal changes. Main Outcome Measures Evaluation of the structural corneal changes occurring in keratoconus cases with various stages of severity based on OCT findings. Results Fourier-domain OCT classification containing 5 distinct keratoconus stages is proposed. Stage 1 demonstrates thinning of apparently normal epithelial and stromal layers at the conus. Stage 2 demonstrates hyperreflective anomalies occurring at the Bowman's layer level with epithelial thickening at the conus. Stage 3 demonstrates posterior displacement of the hyperreflective structures occurring at the Bowman's layer level with increased epithelial thickening and stromal thinning. Stage 4 demonstrates pan-stromal scar. Stage 5 demonstrates hydrops; 5a, acute onset: Descemet's membrane rupture and dilaceration of collagen lamellae with large fluid-filled intrastromal cysts; 5b, healing stage: pan-stromal scarring with a remaining aspect of Descemet's membrane rupture. The reproducibility of the classification was very high between the corneal specialist observers. Clinical and paraclinical characteristics of keratoconus, including visual acuity, corneal epithelium and stromal thickness changes, corneal topography, biomechanical corneal characteristics, and microstructural changes observed on confocal microscopy, were concordant with our OCT grading. Conclusions Optical coherence tomography provides an accurate assessment of structural changes occurring in keratoconus eyes. These changes were correlated with clinical and paraclinical characteristics of patients. The established classification not only allows structural follow-up of patients with keratoconus but also provides insight into the pathogenesis of keratoconus and treatment strategies for future research. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Background To evaluate the incidence, evolution, clinical characteristics, possible risk factors or preventive factors, and visual outcomes of epiretinal membrane (ERM) recurrence. Methods Retrospective study of 440 consecutive patients (440 eyes) who underwent pars plana vitrectomy for ERM. The internal limiting membrane (ILM) was peeled in 266 cases, with the help of indocyanine green in 27 cases and brilliant blue in 45 cases. Cases of symptomatic ERM recurrence were reoperated. Results The incidence of ERM recurrence was 5% (22/440), and 2% of the patients were reoperated (9/440). Epiretinal membrane recurrence was symptomatic in 9 cases (41%) and asymptomatic in 13 cases (59%). ILM peeling was the only factor preventing ERM recurrence (adjusted odds ratio = 0.33, P = 0.026). The use of staining dyes did not prevent recurrence (adjusted odds ratio = 0.35, P = 0.338). In the case of ERM reproliferation, the absence of ILM peeling, the existence of ERM on the fellow eye, and poor visual acuity before surgery seemed to be associated with a high risk of symptomatic recurrence and reoperation. The mean duration for follow-up was 3.5 ± 1.7 years. Conclusion ILM peeling not only reduces the likelihood of reproliferation of ERM but also seems to improve the visual prognosis of recurrent ERMs. The use of dyes did not reduce the rate of recurrence compared with when ILM was peeled without dyes.

A 48-year-old woman with no significant past history underwent bilateral simultaneous laser in situ keratomileusis for correction of her myopia. On the tenth postoperative day, the patient complained of visual decrease and photophobia. Slit lamp exam showed corneal epithelial irregularities. Confocal microscopy was performed and revealed a characteristic appearance of epithelial basement membrane dystrophy (EBMD). The patient was successfully treated with artificial tears and autologous serum eyedrops. EBMD may be missed before LASIK surgery, even after a careful pre-operative examination. Exacerbation of EBMD after LASIK surgery is rare. It should be considered when unexplained corneal epithelial defects or irregularities occur following LASIK. Confocal microscopy is very useful to confirm the diagnosis.

PURPOSE To assess the influence of donor characteristics on the outcome of anterior lamellar keratoplasty (ALK) and to evaluate whether corneal donor tissue considered unsuitable for penetrating or posterior lamellar keratoplasty due to poor endothelial condition may be safely used for ALK. METHODS Institutional setting. One hundred sixty-six consecutive ALK (166 patients) performed for optical indication in eyes with corneal diseases not involving the corneal endothelium. The main outcome measures were graft survival, early (0-12 months postoperatively) and late (after 12 months) annual endothelial cell loss, and postoperative logarithm of the minimum angle of resolution visual acuity. RESULTS The average and extreme values of donor tissue characteristics were: donor age, 70.6 years (range, 28-88 years); organ culture time, 20.9 days (range, 12-35 days); graft endothelial cell density before transplantation, 2047 cells per millimeters (range, 100-3300 cells/mm2); and deswelling time, 2.0 days (range, 1-4 days). The average follow-up time of patients was 48.1 ± 24.8 months (mean ± SD). None of the donor characteristics significantly influenced graft survival or postoperative endothelial cell loss (early and late phase). Donor age >80 years was associated with lower postoperative visual acuity at all postoperative points in time (P < 0.05). At 3 years, the mean logarithm of the minimum angle of resolution visual acuity was 0.44 (20/55) for grafts from donors older than 80 years and 0.25 (20/35) for younger donors. This result was shown to be significant both in univariate and in multivariate analysis. CONCLUSIONS Grafts from elderly donors should be discarded before ALK. Conversely, donor tissue with poor endothelial cell density (

To compare the efficacy, safety, and microstructural corneal changes during 2 years after conventional corneal collagen cross-linking (C-CXL) and transepithelial corneal CXL by iontophoresis (I-CXL) for keratoconus.Eighty eyes of 80 patients with progressive keratoconus were treated by C-CXL (n = 40) or I-CXL (n = 40). Patients were investigated before surgery and 1, 3, 6, 12, and 24 months after treatment. We measured central corneal thickness and maximal simulated keratometry values (Kmax) and performed specular microscopy and in vivo confocal microscopy at each time point. The demarcation line was assessed 1 month after treatment.Kmax remained stable after I-CXL during the entire study period (P = 0.56), whereas the average keratometry increased by 0.2 diopter (50.9 ± 5.6-51.1 ± 5.2). Kmax significantly decreased 1 (P = 0.02) to 2 years (P0.01) after C-CXL, with an average decrease of 1.1 diopters (49.9 ± 4.5-48.8 ± 4.2). The failure rate of I-CXL was 20% and that of C-CXL 7.5%. The demarcation line was superficially visible in 35% of cases after I-CXL compared with 95% of cases after C-CXL. Endothelial cell density and central corneal thickness remained stable during the entire study period. The change in Kmax 2 years after C-CXL and I-CXL and the preoperative Kmax were negatively correlated (r = 0.14, P = 0.013, and r = 0.17, P = 0.007, respectively).I-CXL halted progression of keratoconus less efficiently than did C-CXL after 2 years of follow-up. Longer prospective studies are still needed to ensure I-CXL efficacy.

To evaluate the incidence, clinical and microbiological characteristics and risk factors of infectious keratitis in patients with limbal stem cell deficiency (LSCD).Retrospective comparative case series of 35 patients with severe LSCD.The mean follow-up time was 46 months. Infectious keratitis were mainly caused by Gram positive bacteria (94%). Only 7 infections (37%) healed under fortified adapted antibiotics. In 8 cases (42%), amniotic membrane transplantation was required and in 4 cases (21%) «à chaud» keratoplasty was performed. Significant risk factors associated with infectious keratitis were: soft contact lens extended wear, history of persistent epithelial defects, number of quadrants of corneal vascularization, re-epithelialization time after amniotic membrane or corneal transplantation, and use of corticosteroid or cyclosporin eye drops.Infectious keratitis in LSCD is frequent and severe. The restoration of the epithelial barrier integrity and a careful use of therapeutic contact lenses may help to prevent infection.

Objective To compare deep anterior lamellar keratoplasty (DALK) with penetrating keratoplasty (PK) in eyes with corneal diseases not involving the corneal endothelium (keratoconus, scars after infectious keratitis, stromal dystrophies, and trauma). Design Retrospective, comparative case series. Participants One hundred forty-two consecutive DALK (DALK group; big-bubble technique or manual lamellar dissection using a slitlamp) and 142 matched PK (PK group). Methods Three models were used to describe the postoperative outcomes of the endothelial cell density. A joint regression model was used to predict long-term graft survival. Visual acuity, ultrasound pachymetry, specular microscopy, and optical coherence tomography (OCT) findings were recorded. Main Outcome Measures Postoperative endothelial cell loss and long-term predicted graft survival. Results The average 5-year postoperative endothelial cell loss was −22.3% in the DALK group and −50.1% in the PK group ( P P P P P >0.05). Conclusions Long-term, model-predicted graft survival and endothelial densities are higher after DALK than after PK. The big-bubble technique gives better results than manual dissection and PK. Compared with PK, manual dissection provides higher survival of both the corneal endothelium and graft, but lower visual acuity. Financial Disclosure(s) The authors have no proprietary or commercial interest in any materials discussed in this article.

To describe the incidence, clinical features, and evolution of paracentral retinal holes occurring after macular surgery.A retrospective non-randomized study of 909 patients operated on for either a macular hole (MH, n = 400 patients) or an epiretinal membrane (ERM, n = 509 patients) between 2004 and 2009. Six patients (0.6%) developed a paracentral macular hole after surgery. Their clinical, auto-fluorescence, and optical coherence tomography (OCT) characteristics as well as their visual outcomes were studied.The mean age of patients was 70 years. Paracentral holes occurred approximately 5 weeks after surgery (with a range of 2-12 weeks). All patients were asymptomatic. Five patients underwent ILM peeling during initial surgery. Paracentral retinal holes were located superiorly to the fovea in three cases and temporally in the other three cases. Mean pre-operative BCVA was 20/200 and mean post-operative BCVA was 20/40. The eye where the eccentric MHs were closest to the fovea (inferior to 1 optic disc area) had the poorest final visual acuity. Autofluorescence imaging showed a bright fluorescence in paramacular holes. On OCT images, they were shown to be flat full-thickness holes. No treatment was attempted. No rhegmatogenous complications or choroidal neovascularization occurred in any of the patients. Mean follow-up was 2 years.In summary, paracentral MHs are uncommon complications which can occur at the site where ILM peeling has been initiated or completed. Except for the closest holes to fovea, they have good visual prognosis and do not require any treatment underlining the importance of initiating the ILM peeling as far as possible from the fovea.

Resume Introduction La pathogenie des fossettes colobomateuses compliquees de decollement sereux retinien (DSR) de la macula reste controversee. Son traitement l’est aussi. A travers cette etude, qui a la particularite de comprendre la plupart des techniques proposees, nous rapportons notre experience dans le traitement de cette pathologie. Patients et methodes C’est une etude monocentrique retrospective a propos de vingt patients presentant un DSR maculaire secondaire a une fossette colobomateuse entre 1983 et 2009. Differents traitements ont ete realises : les patients au tout debut de l’etude ont eu un traitement simple par laser peripapillaire. Puis, un traitement associant le laser peripapillaire et une injection intravitreenne de gaz (C3F8) avec positionnement tete vers le bas pendant deux semaines a ete realise apres echec du laser, puis d’emblee. Au cours des dernieres annees, les patients ont ete traites en premiere intention par une vitrectomie avec ou sans pelage de la membrane limitante interne (MLI), laser peripapillaire peroperatoire et tamponnement par gaz (C2F6). Resultats Notre serie est composee de vingt patients : Neuf hommes et 11 femmes. L’âge moyen des patients au moment du diagnostic etait de 29 ans (neuf a 60 ans). La duree moyenne entre le debut des symptomes et la prise en charge therapeutique etait de 6,1 mois. Aucun patient n’avait eu de decollement posterieur du vitre lors du diagnostic. Six patients ont ete traites par du laser peripapillaire avec succes dans deux cas. Onze patients (dont trois avaient eu un echec au laser seul) ont eu un traitement par laser associe a l’injection intravitreenne de gaz avec 72 % de succes. Huit patients (dont deux avaient eu un echec au laser gaz) ont eu une vitrectomie avec dissection de la hyaloide posterieure associee au laser gaz avec succes dans 87 % des cas sans recidive. Parmi eux, cinq ont eu un pelage de la MLI au cours de la vitrectomie. La duree de suivi moyenne globale de tous les patients etait de 60 mois allant de deux mois a dix-sept ans. Conclusion Notre etude montre qu’en cas de DSR maculaire compliquant une fossettte colobomateuse, un traitement precoce par vitrectomie, pelage de la MLI, laser peripapillaire et tamponnement par gaz s’accompagne d’un bon resultat anatomique et fonctionnel. Ce traitement est superieur aux autres traitements moins invasifs. La tomographie en coherence optique (OCT) constitue un outil important permettant le diagnostic et le suivi postoperatoire des patients.

To compare the safety and functional outcomes of 25-gauge and 23-gauge (G) micro-incision vitrectomy surgery (MIVS) instrumentation with the standard 20-G vitrectomy system in the treatment of epiretinal membranes (ERM). A retrospective comparative study of 553 consecutive cases with epiretinal membrane who underwent pars plana vitrectomy. Twenty-gauge, 25-gauge and 23-gauge vitrectomy was performed respectively in 347, 91, and 115 eyes. Surgery duration, visual acuity improvement, intraocular pressure variation, intraoperative and postoperative complications were analyzed. The mean surgical time in the 23-G group and in the 25-G group was shorter than in the 20-G group (P

We report the case of anterior chamber migration of a dexamethasone implant (Ozurdex(®)) in a 54-year-old woman with macular edema due to a central retinal vein occlusion. The patient had undergone complicated cataract surgery 5 years previously with a scleral-fixated posterior chamber lens implant. An uneventful intravitreal Ozurdex(®) implant injection was performed. One month later, the patient presented emergently with painless visual loss. Slit-lamp examination revealed the presence of discrete corneal edema associated with the implant in the anterior chamber. The implant was surgically removed from the anterior chamber 24 hours later with complete resolution of corneal edema.

To assess the effects of 360-degree laser retinopexy on human corneal subbasal nerve plexus and to investigate correlations among corneal subbasal nerve plexus density, corneal epithelial thickness, and corneal sensitivity.Prospective, observational, nonrandomized study.A total of 15 eyes of 15 patients who underwent pars plana vitrectomy (PPV) with 360-degree laser retinopexy for retinal detachment (RD) and 15 eyes of 15 patients who underwent PPV for macular hole (MH) without laser treatment.Corneal sensation, corneal epithelial thickness, and corneal subbasal nerve plexus density were assessed before surgery and 6 months after surgery via in vivo confocal microscopy, anterior segment optical coherence tomography (AS-OCT), and Cochet-Bonnet esthesiometry (Luneau Ophthalmologie, Paris, France).Corneal subbasal nerve plexus density, corneal epithelium thickness, and central corneal sensitivity.Compared with baselines values, the mean subbasal nerve density (P0.001), mean corneal epithelium thickness (P = 0.006), and mean corneal sensitivity (P0.001) in the RD group were significantly decreased 6 months after surgery by 74.3%, 4.7%, and 56.6%, respectively. Conversely, in the MH group there were no significant differences in the mean subbasal nerve density (P = 0.34), mean corneal epithelial thickness (P = 0.19), and mean corneal sensitivity (P = 0.42) between preoperative and 6-month postoperative values (0.7%, 0.4%, and 0.8%, respectively). The postoperative decrease in corneal subbasal nerve density after laser retinopexy was associated with a decrease in corneal epithelium thickness (r(2) = 0.42; P = 0.006) and a decrease in corneal sensitivity (r(2) = 0.48; P = 0.004). The postoperative decrease in corneal sensitivity poorly correlated with the decrease in corneal epithelial thickness (r(2) = 0.24; P = 0.045). Postoperative corneal nerve density decreased as total laser energy increased (r(2) = 0.51; P = 0.002).Subbasal corneal nerve plexus density decreases after 360-degree laser retinopexy and is accompanied by epithelium thinning and decreased corneal sensation. Surgeons should eschew heavy confluent retinal laser treatment, and corneal sensitivity should be assessed postoperatively to determine whether significant anesthesia has occurred. In such instances, prophylactic measures may be warranted against the development of neurotrophic ulcers.

To define the optical coherence tomography (OCT) corneal changes predisposing to acute corneal hydrops among patients with advanced keratoconus.Retrospective cohort study.A total of 191 advanced keratoconic eyes from 191 patients with advanced keratoconus cases were studied.Data collected from patients with advanced keratoconus cases were studied during a minimum period of 24 months of follow-up. High-resolution Fourier-domain corneal OCT (5 μm of axial resolution) and corneal topography were performed every 4 months during the follow-up. Several anatomic features at the keratoconus cone were analyzed with OCT, including epithelial and stromal thicknesses, the aspect of Bowman's layer, the presence of Vogt's striae, and stromal opacities. A comparative analysis between anatomic corneal features in eyes that developed corneal hydrops and those that did not develop this complication during the follow-up was performed.Evaluation of anatomic corneal changes at risk of developing a corneal hydrops on the basis of OCT findings.Eleven cases of corneal hydrops (5.8%) occurred in our series during a mean follow-up of 30 months (24-36 months). All of these patients were male and younger (23.7±5.9 years) than patients with no acute keratoconus (32.7±11.3 years). Increased epithelial thickening with stromal thinning at the conus and the presence of anterior hyperreflectives at the Bowman's layer level were significantly associated with corneal hydrops, whereas the presence of corneal scarring was a preventive factor. At the healing stage, a pan-stromal scar occurs, with a significant stromal thickening and cornea flattening.Increased epithelial thickening, stromal thinning at the keratoconus cone, anterior hyperreflectives at the Bowman's layer level, and the absence of stromal scarring are associated with a high risk of developing corneal hydrops. These aspects should be taken into account by the clinician in the evaluation of keratoconus eyes and in the planning of corneal keratoplasty.

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

To compare the long-term outcomes of vitreomacular surgery in eyes with nontractional diabetic macular edema (DME) with those from eyes with tractional DME.Retrospective comparative study from 55 consecutive patients (73 eyes). Twenty eyes were operated on for tractional DME and 53 eyes for nontractional DME unresponsive to laser photocoagulation or triamcinolone intravitreal injections. The best-corrected visual acuity, the central macular thickness, and the surgical complications were analyzed.The mean follow-up duration was 5.3 ± 2.4 years for the group with traction and 4.4 ± 1.7 years for the group without traction (P = 0.13). At 3 years, the mean logarithm of the minimum angle of resolution best-corrected visual acuity had improved significantly from 0.78 to 0.58 for the group without traction and from 0.75 to 0.45 for the group with traction (P0.001). At the final visit, there was no significant difference between the 2 groups in regard to visual or central macular thickness improvement (P = 0.447 and P = 0.742, respectively). The incidence of surgical complications was not significant between the two groups. The preoperative best-corrected visual acuity was the only predictive factor for the final best-corrected visual acuity.The results of vitrectomy were not different in terms of anatomical and visual outcomes and surgical complications between eyes without tractional DME and eyes with tractional DME.

To evaluate the performance of a full-field optical coherence tomography (FF-OCT) system in the study of human donor and pathological corneas and assess its suitability for use in eye banks.Our study was carried out using an FF-OCT system developed for non-invasive imaging of tissue structures in depth with ultrahigh resolution (1 µm in all directions). Images were acquired from eight stored human donor corneas (either edematous or after deswelling) and five surgical specimens of corneas with various diseases (bullous keratopathy, lattice corneal dystrophy, stromal scar after keratitis, keratoconus and Fuchs dystrophy). They were compared with standard histology and pre-operative spectral domain OCT.The FF-OCT device enabled a precise visualization of the cells and the different structures (epithelium, basement membrane, Bowman's layer, stroma, Descemet's membrane and endothelium) in normal corneas. Specific lesions in various corneal diseases could also be easily identified, such as corneal edema, epithelium and Bowman's layer irregularities, breaks, or scars (keratoconus), stromal opacities, deposits, fibrosis (stromal corneal scar, bullous keratopathy, lattice corneal dystrophy) and Descemet's membrane thickening and guttae (Fuchs dystrophy). FF-OCT image features were comparable to the details provided by conventional histology. Higher resolution could be demonstrated with FF-OCT when compared with spectral domain OCT.FF-OCT is a powerful non-invasive imaging tool that allows detailed study of corneal structures. Images correlate well with conventional histology. Further studies should evaluate the benefit of this technique as a complement to current assessment methods of human donor corneas.

The aim of this study was to describe a novel technique combining deep intrastromal arcuate keratotomy and superficial lamellar keratotomy followed by excimer photoablation for the management of high naturally occurring or postkeratoplasty astigmatism.In this retrospective case series, the first step was deep intrastromal arcuate keratotomy and superficial lamellar keratotomy performed at 100-μm depth by femtosecond laser. Manual incisions were made for flap elevation. The second step, after 1 month, consisted of reopening the flap and using an excimer laser to correct residual ametropia.Nine eyes series were studied. The mean preoperative refractive cylinder correction was 6.11 ± 2.54 diopters (D). The mean postoperative refractive cylinder correction was 2.85 ± 1.31 D. The mean correction index was 1.07 ± 0.28 D. The mean best-corrected visual acuity improved from 20/40 to 20/22 after the 2 steps. The median follow-up was 11 (range, 9-17) months. No complications were observed and postoperative outcome was satisfactory.Permitting correction of a broader range of high astigmatism with good accuracy, this combined approach minimizes excision of corneal stromal tissue and postoperative complications.

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

Purpose To analyze the influence of various factors on the post-operative refractive power after anterior lamellar keratoplasty (ALK) and penetrating keratoplasty (PK) in eyes with corneal diseases not involving the corneal endothelium. Methods Retrospective comparative case series. Two hundred and thirty-eight consecutive eyes of 238 patients with clear graft and at least one post-operative Orbscan examination performed after suture removal were retrospectively analyzed. Multivariate analysis of recipient and surgical parameters was performed by multivariate regression. Results The average Orbscan 3-mm corneal power was 47.1 D with a wide 95%-confidence interval [40.3 D; 53.9 D]. It was 47.9 D for ALKs and 46.2 D for PKs (p 0.5). Conclusion The post-operative, suture-out, corneal refractive power is higher after ALK compared with PK and it features important variability. In ALK eyes, non-oversized grafts result in post-operative corneal power close to normal values and corneal diseases associated with stromal thinning result in higher post-operative corneal power. Taking into account these parameters at the time of surgery may help decreasing the post-operative spherical refractive error.

To study corneal morphologic changes in a large keratoconic population and to establish a structural optical coherence tomography (OCT) classification.Cross-sectional, observational study.A total of 218 keratoconic eyes from 218 patients and 34 eyes from 34 normal subjects.A Fourier-domain OCT system with 5-μm axial resolution was used. For each patient, 3 high-resolution scans were made across the keratoconus cone. All scans were analyzed by keratoconus specialists who were not given access to patients' clinical and topographic data, and who established an OCT classification. The reproducibility of the classification and its correlation with clinical and paraclinical characteristics of patients with keratoconus were evaluated. The OCT examinations were performed every 4 months to follow up structural corneal changes.Evaluation of the structural corneal changes occurring in keratoconus cases with various stages of severity based on OCT findings.Fourier-domain OCT classification containing 5 distinct keratoconus stages is proposed. Stage 1 demonstrates thinning of apparently normal epithelial and stromal layers at the conus. Stage 2 demonstrates hyperreflective anomalies occurring at the Bowman's layer level with epithelial thickening at the conus. Stage 3 demonstrates posterior displacement of the hyperreflective structures occurring at the Bowman's layer level with increased epithelial thickening and stromal thinning. Stage 4 demonstrates pan-stromal scar. Stage 5 demonstrates hydrops; 5a, acute onset: Descemet's membrane rupture and dilaceration of collagen lamellae with large fluid-filled intrastromal cysts; 5b, healing stage: pan-stromal scarring with a remaining aspect of Descemet's membrane rupture. The reproducibility of the classification was very high between the corneal specialist observers. Clinical and paraclinical characteristics of keratoconus, including visual acuity, corneal epithelium and stromal thickness changes, corneal topography, biomechanical corneal characteristics, and microstructural changes observed on confocal microscopy, were concordant with our OCT grading.Optical coherence tomography provides an accurate assessment of structural changes occurring in keratoconus eyes. These changes were correlated with clinical and paraclinical characteristics of patients. The established classification not only allows structural follow-up of patients with keratoconus but also provides insight into the pathogenesis of keratoconus and treatment strategies for future research.

Purpose To assess the influence of culture time on maintenance of limbal epithelial progenitors in the explant culture system. Methods Limbal epithelial cells were cultured from 2-mm2 human limbal explants in cholera toxin-free medium with no feeders for 9-21 days. Expression of differentiation and progenitor markers was assessed by immunochemestry and RT-PCR. The clonal growth ability of cultured epithelial cells at each time of culture and with murine 3T3 feeders or human corneal stromal feeders was evaluated by determining colony forming efficiency (CFE). Results The average number of cultured cells obtained after 7, 14, and 21 days was, respectively, 500, 60489, and 195949. Expression of broad spectrum cytokeratins, CK3, CK19, vimentin, p63, and ABCG-2 was observed at all culture time points by immunocytochemistry and RT-PCR. Epithelial colonies were observed at 9, 11, 14 and 18 of culture but not at 21 days, both with murine 3T3 feeders and human corneal stromal feeders. Higher number of colonies was obtained when limbal epithelial cells were cultured with murine 3T3 feeders than with human corneal stromal feeders. The highest number of colonies was obtained at 14 days of culture with murine 3T3 feeders. The average cell Feret diameter (µm)/circularity for clones obtained from 11-, 14-, and 18-day primary cultures were, respectively, 38.4/0.76, 34.2/0.80, and 45.7/0.72 (p

Purpose The aim of the study is to report and to predict long-term endothelial cell outcomes after iris fixated phakic intraocular lens implantation for the correction of high refractive errors. Methods Retrospective, non randomized study of patient who underwent surgery between January,2000 and December,2009 in the same department in the Centre Hospitalier National d’Ophtalmologie des Quinze-Vingts. To predict long-term endothelial cell density, 2 joint regression models were fitted on ECD to individuals with at least 2 ECD measurement in time. Model-predicted parameters for endothelial cell density and survival were obtained for each patient and were used in a Kaplan-Meier method plot for predicted percentage of eyes . Results This study consisted of 78 phakic eyes including 70 myopic eyes and 8 hyperopic eyes. 73 Verisyse/Artisan and 5 foldable Artiflex were implanted. Three eyes underwent further keratorefractive surgery (Bioptic). Two eyes were lost of follow-up.The mean follow-up was 68 months. Recent studies reported an endothelial cell loss 5 years after surgery ranged from -9 to -14%, but we found a decrease of 25% for 18 eyes. Surgery trauma is partially involved but we also found a higher endothelial cell loss one year after surgery ( range from -3.5 to -9%). Conclusion Potential complications such as progressive endothelial cell loss and risk of dislocation are major concerns in operative decision. Close follow-up with regular monitoring is necessary in patients with phakic intraocular lens.