Journal of Refractive Surgery

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ISSN / EISSN : 1081-597X / 1938-2391
Published by: SLACK, Inc. (10.3928)
Total articles ≅ 5,837
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Md Dan Z. Reinstein, MA(Oxon) Timothy J. Archer, Od Ryan S. Vida, Bsc(Optom) Vimal Piparia, BMedSc Joseph G. Potter
Published: 1 May 2022
Journal of Refractive Surgery, Volume 38, pp 272-279;

To identify parameters influencing the postoperative vault of the Implantable Collamer Lens (ICL) (STAAR Surgical) using the Artemis Insight 100 very high-frequency (VHF) digital ultrasound robotic scanner (ArcScan, Inc) and develop a model to improve lens vault prediction. This was a retrospective analysis of 147 consecutive V4c EVO and EVO+ ICL implantation procedures performed over three phases in myopic eyes. In the initial phase, lens size was defined by published sulcus-to-sulcus and crystalline lens rise measurements (Kojima formula) from VHF digital ultrasound biometry. From these data, a stepwise multivariate regression analysis was performed to develop a model for predicting central vault including the following variables: ICL size, ICL power, sulcus-to-sulcus (STS), ciliary body inner diameter (CBID), zonule-to-zonule, STS lens rise (STSL), ACD, anterior chamber angle, scotopic pupil diameter (SPD), angle-to-angle, and white-to-white diameter. The resulting regression model was used in coordination with the Kojima formula to select the lens size for the next series of eyes. The regression analysis was then repeated and a further series were treated. The postoperative achieved vault at 1 month was compared to the target vault predicted by the formula. A comparison analysis of the new model was made to previously published lens sizing formulas. Statistically significant variables were ICL size, ICL power, CBID, STSL, and SPD. The primary 42 eyes (Kojima formula) achieved a mean vault of 506 ± 233 µm, a range of 810 µm (114 to 924 µm), and an interquartile range (IQR) of 391 µm. Using the Reinstein formula v1.0 for the next 36 eyes, the mean vault relative to target was +7 ± 123 µm, range of 569 µm (−278 to +291 µm), and IQR of 169 µm. Using the Reinstein formula v2.0 for the next 69 eyes, the mean vault relative to target was +67 ± 121 µm, range of 573 µm (−219 to +354 µm), and IQR of 131 µm. The achieved vault was within ±100, ±200, and ±300 µm of target in 33%, 50%, and 74% of eyes, respectively, for the training group, 58%, 89%, and 100% for the Reinstein formula v1.0 group, and 62%, 84%, and 94% for the Reinstein formula v2.0 group. This is the first report describing the ciliary body inner diameter, which proved to be more highly correlated with vault than STS, and thus CIBD supersedes STS from the previous widely accepted improvement over WTW sizing. The new model also found scotopic pupil size to be a significant predictor, which has not been a part of any previously published model. The significant improvement in vault predictability afforded by these parameters and the new model enables charting attempted versus achieved vault outcomes for the first time. [J Refract Surg. 2022;38(5):272–279.]
Michael D. Greenwood, Jake W. Hutchison, Richard A. Gorham, Brent A. Kramer
Published: 1 May 2022
Journal of Refractive Surgery, Volume 38, pp 304-309;

To compare prediction error outcomes between the Optiwave Refractive Analysis System (ORA) (Alcon Laboratories, Inc) and two modern intraocular lens (IOL) formulas (Hill-RBF2.0 [HRBF] and Barrett Universal II [BUII]), and further analyze IOL selection in scenarios of disagreement between methods. Patients with no previous history of corneal refractive surgery who underwent cataract extraction and had intraoperative aberrometry measurements between October 2016 and December 2019 were analyzed. The prediction error for the ORA, HRBF, and BUII were calculated based on the postoperative manifest refraction. Further analysis was performed evaluating prediction error for scenarios of disagreement between the three methods. After exclusions, 281 eyes were included. The mean absolute prediction errors were 0.28 diopters (D) (ORA), 0.31 D (HRBF), and 0.33 D (BUII) (P < .05). In instances when the IOL recommended by the ORA was in disagreement with what was selected preoperatively, there was no benefit when the lens recommended by the ORA was selected based on anecdotal experience. When further analyzing these instances of disagreement, selecting the ORA-recommended lens when it is higher in power results in improved refractive outcomes: the ORA resulted in more eyes within ±0.25 diopters (D) of predicted spherical error (65% ORA, 37% HRBF, 32% BUII; P = .004) and fewer hyperopic surprises (5% ORA, 15% HRBF, 24% BUII; P = .009). In normal eyes without previous corneal refractive surgery, intraoperative aberrometry is not different from to two modern preoperative IOL formulas. Placing the ORA-recommended lens when it is higher in power than that selected preoperatively results in better refractive outcomes. [J Refract Surg. 2022;38(5):304–309.]
Md Andrea Russo, Md Dan Z. Reinstein, Dmath Ottavia Filini, MA(Oxon) Timothy J. Archer, Alessandro Boldini, Od Gloria Cardin, Giulia Festa, Francesco Morescalchi, Od Chiara Salvalai, Francesco Semeraro
Published: 1 May 2022
Journal of Refractive Surgery, Volume 38, pp 288-297;

To report 6-month visual and refractive outcomes following PRESBYOND Laser Blended Vision (Carl Zeiss Meditec) treatment using non-linear aspheric micro-anisometropia laser in situ keratomileusis (LASIK) for the correction of myopic and hyperopic presbyopia. A retrospective, non-comparative study of 139 consecutive patients with a mean age of 53.13 ± 5.84 years (range: 42 to 70 years) treated with LASIK-induced micro-anisometropia using the MEL 90 excimer laser and VisuMax femtosecond laser (both Carl Zeiss Meditec). The target refraction was plano for distance eyes (dominant eye) and between −0.50 and −1.50 diopters (D) for near eyes. Patients were observed for 6 months. A total of 278 eyes (78 myopic and 200 hyperopic) from 139 patients completed the study. Mean preoperative spherical equivalent (SE) was −3.40 ± 1.83 D (range: −0.50 to −8.25 D) for myopic eyes and +1.61 ± 0.98 D (range: −1.25 to +4.63 D) for hyperopic eyes. Mean postoperative SE refraction of distance eyes was +0.20 ± 0.35 D (range: −0.38 to +1.00 D) and −0.14 ± 0.42 D (range: −1.38 to +0.88 D) for myopic and hyperopic eyes, respectively. Mean postoperative SE refraction of near eyes was −0.90 ± 0.44 D (range: −0.13 to −2.25 D) and −1.21 ± 0.48 D (range: −0.13 to −2.25 D) for myopic and hyperopic eyes, respectively. Mean binocular uncorrected near visual acuity was 0.70 ± 0.28 logMAR (range: 0.32 to 1.00 logMAR) and 0.79 ± 0.27 logMAR (range: 0.25 to 1.00 logMAR) for myopic and hyperopic eyes, respectively. Mean binocular uncorrected distance visual acuity was 1.19 ± 0.18 logMAR (range: 0.63 to 1.25 logMAR) and 1.14 ± 0.26 logMAR (range: 0.40 to 1.25 logMAR) for myopic and hyperopic eyes, respectively. Stereoacuity was better than 100 seconds of arc in 79% of myopic eyes and 85% of hyperopic eyes and all vision quality scores were greater than 90 of 100. No eyes lost two or more lines. The non-linear aspheric micro-anisometropia protocol resulted in safe and effective visual outcomes in patients with both myopic and hyperopic presbyopia. [J Refract Surg. 2022;38(5):288–297.]
Md Dan Z. Reinstein, MA(Oxon) Timothy J. Archer, Od Ryan S. Vida, Mbbch Glenn I. Carp, Julia F. R. Reinstein, Theo McChesney, BMedSc Joseph G. Potter
Published: 1 May 2022
Journal of Refractive Surgery, Volume 38, pp 262-271;

To report the outcomes of small incision lenticule extraction (SMILE) for high myopia between −9.00 and −14.00 diopters (D). This was a prospective study of SMILE for high myopia using the VisuMax femtosecond laser (Carl Zeiss Meditec). Inclusion criteria were attempted spherical equivalent refraction (SEQ) between −9.00 and −14.00 D, cylinder up to 7.00 D, corrected distance visual acuity (CDVA) of 20/40 or better, age 21 years or older, and suitable for SMILE. The sub-lenticule thickness was 220 µm or greater, and the total uncut stromal thickness was 300 µm or greater. Patients were to be followed up for 1 year. Standard outcomes analysis was performed using 12-month data where available or 3-month data otherwise. Of 187 eyes treated, data were available at 12 months for 181 eyes (96.8%) and 3 months for 4 eyes (2.1%), and 2 eyes (1.1%) were lost to follow-up. Mean attempted SEQ was −10.55 ± 1.00 D (range: −9.00 to −12.99 D). Mean cylinder was −1.19 ± 0.83 D (range: 0.00 to −4.00 D). Preoperative CDVA was 20/20 or better in 73% of eyes. Postoperative uncorrected distance visual acuity was 20/20 or better in 57% and 20/25 or better in 82% of eyes. Mean SEQ relative to target was −0.22 ± 0.48 D (range: −1.63 to +1.38 D), 66% ± 0.50 D and 93% ±1.00 D. Mean SEQ 12-month change was −0.08 ± 0.34 D (range: −1.75 to +0.88 D). There was loss of one line of CDVA in 4% of eyes, and no eyes lost two or more lines. Contrast sensitivity was unchanged. Patient satisfaction was 8 or more out of 10 in 94% and 6 or more in 99% of patients. Outcomes of SMILE for myopia greater than −9.00 D at 3 to 12 months showed excellent efficacy, safety, stability, and predictability, with high patient satisfaction. [J Refract Surg. 2022;38(5):262–271.]
Perry S. Binder
Published: 1 May 2022
Journal of Refractive Surgery, Volume 38, pp 260-261;

Niklas Mohr, Md Martin Dirisamer, Md Jakob Siedlecki, Md Wolfgang J. Mayer, Benedikt Schworm, Lisa Harrant, Md Siegfried G. Priglinger, Md Nikolaus Luft
Published: 1 May 2022
Journal of Refractive Surgery, Volume 38, pp 280-287;

To evaluate postoperative subjective quality of vision in patients who underwent Implantable Collamer Lens (ICL) (STAAR Surgical) implantation for correction of myopia and to identify potential predictive parameters. In this single-center cross-sectional study, a total of 162 eyes of 81 patients (58 women, 23 men) who underwent ICL implantation were analyzed. The Quality of Vision (QOV) questionnaire was used to assess patient-reported outcomes. Baseline characteristics (eg, age), treatment parameters (eg, surgical corrected refraction), and refractive (eg, residual refraction) and visual (eg, uncorrected distance visual acuity) outcomes were analyzed regarding their effect on QOV. Mean age was 33.3 ± 7.0 years (range: 21 to 51 years) and mean preoperative spherical equivalent was −8.42 ± 2.49 diopters (D) (range: −3.25 to −14.38 D). After a mean postoperative follow-up period of 19 ± 14 months (range: 6 to 54 months), the safety index score was 1.23 ± 0.21 and the efficacy index score was 1.17 ± 0.22. The mean QOV scores were 35.5 ± 11.3, 32.2 ± 11.1, and 23.3 ± 16.1 for frequency, severity, and bothersomeness, respectively. The most frequently experienced symptoms were halos (90.1%) and glare (66.7%). Halos appeared in 66.7% of the patients “occasionally” and 5 of them (6.2%) experienced them “very often.” Only 1 patient (1.2%) classified halos as “very bothersome.” Patients older than 36 years reported visual symptoms more frequently (P < .05) and showed higher bothersomeness scores (P = .01). Halos are the most commonly perceived long-term visual disturbance after myopic ICL implantation with a central hole. Visual symptoms can persist more than 6 months postoperatively, causing only minor disturbances in most cases. Older patients seem more prone to experiencing these symptoms. [J Refract Surg. 2022;38(5):280–287.]
MBChB Tony S. Chen, MBChB Benjamin R. LaHood, PhD Adrian Esterman, Frcsi(Ophth) Michael Goggin
Published: 1 May 2022
Journal of Refractive Surgery, Volume 38, pp 298-303;

To examine the accuracy of the cylinder power choice for toric intraocular lenses (IOLs) using the Goggin Nomogram, which adjusts anterior keratometric astigmatic power values for the likely effect of posterior corneal and non-corneal, non-lenticular astigmatism. A consecutive, retrospective case series was based at the Queen Elizabeth Hospital and Ashford Advanced Eye Care in Adelaide, Australia. A total of 586 consecutive eyes of 586 patients underwent phacoemulsification surgery with implantation of a Zeiss AT TORBI 709MP or AT LISA Tri Toric 939 MP toric IOL, calculated using the Goggin Nomogram. The median absolute magnitude of error and geometric mean astigmatic correction index in consecutive eyes with toric IOL cylinder powers of 1.00 to 3.00 diopters (D) were analyzed. Overall, all eyes receiving IOL cylinder powers of 1.00 to 3.00 D inclusive had a median magnitude of error value of 0.19 D (IQR: 0.31) and astigmatic correction index value of 1.03 (IQR: 0.33). For eyes with with-the-rule, against-the-rule, and oblique astigmatism, the median magnitude of error was 0.18 D (interquartile range [IQR]: 0.29), 0.19 D (IQR: 0.31), and 0.17 D (IQR: 0.39), respectively, and the astigmatic correction index was 1.06 (IQR: 0.28), 1.01 (IQR: 0.35) and 1.08 (IQR: 0.32), respectively. Goggin Nomogram adjusted keratometry provided optimal refractive astigmatic outcome in IOL cylinder powers of 1.00 to 3.00 D in eyes with with-the-rule, against-the-rule, and oblique astigmatism. Goggin Nomogram adjusted keratometry compensates for both posterior corneal astigmatism and any other source of ocular astigmatism. [J Refract Surg. 2022;38(5):298–303.]
Lara Asroui, Samir A. Dagher, Ahmed Elsheikh, Md Bernardo T. Lopes, Cynthia J. Roberts, Bme Marc Assouad, Shady T. Awwad
Published: 1 May 2022
Journal of Refractive Surgery, Volume 38, pp 318-325;

To determine the effectiveness of parameters and indices based on biomechanical measures at discriminating fellow eyes with topographically and tomographically normal corneas in patients with keratoconus from normal control corneas. The study included 47 keratoconus suspect eyes, defined as the topographically and tomographically normal fellow eyes of patients with frank keratoconus in the other eye. Eyes were imaged using the Pentacam HR and Corvis ST (both Oculus Optikgeräte GmbH). Fellow eyes were then categorized as topographically/tomographically normal fellow eyes (TNF) and topographically/tomographically borderline fellow eyes (TBF). The ability of each of the Corvis Biomechanical Index (CBI), Tomographic and Biomechanical Index (TBI), stiffness parameter at applanation 1 (SP-A1), and stress-strain index (SSI) at discriminating between normal controls and keratoconus suspects was assessed. The TBI had the best discriminative ability with the greatest area under the receiver operating characteristic (AUROC) curve value of 0.946 for normal controls versus TBF eyes, and 0.824 for normal controls versus TNF eyes. Compared to the TBI AUROC curves, SP-A1 and CBI had AUROC curve values of 0.833 (P = .09) and 0.822 (P = .01) for normal controls versus TBF eyes, respectively, and AUROC curve values of 0.822 (P = .96) and 0.550 (P = .0002) for normal controls versus TNF eyes, respectively. The TBI had the best positive predictive value for TNF and TBF eyes, followed by CBI and SP-A1. The TBI and the purely biomechanical parameter SP-A1 were of moderate utility in distinguishing between normal and keratoconus suspect eyes. In the absence of topographic/tomographic evidence of keratectasia, an independently abnormal biomechanical parameter may suggest an increased risk of ectasia. [J Refract Surg. 2022;38(5):318–325.]
Md Zahra Ashena, Bsc Shaira Doherty, Boptom (Hons) Akilesh Gokul, PhD Charles N.H. McGhee, Md Mohammed Ziaei, Do Mayank A. Nanavaty
Published: 1 May 2022
Journal of Refractive Surgery, Volume 38, pp 310-316;

To assess the flattening of central, paracentral, and peripheral cones following non-accelerated (non-A-CXL) and accelerated (A-CXL) epithelium-off corneal cross-linking with 10 times higher intensity. In this multicenter study of 200 eyes (100 in each group), following 10 minutes of soak time with riboflavin 0.1%, continuous CXL was performed for 30 minutes (intensity: 3 mW/cm2, fluence: 5.4 J/cm2) in the non-A-CXL group and 3 minutes (intensity: 30 mW/cm2, fluence: 5.4 J/cm2) in the A-CXL group. Anterior and posterior cone flattening were compared at 12 months. Multiple regression analysis was performed to establish correlation of age, sex, cone location, and preoperative maximum keratometry (Kmax) values with postoperative flattening at 12 months. In the non-A-CXL and A-CXL groups, central cones were the steepest, followed by paracentral and peripheral cones. Both groups showed significant flattening in central (1.54 ± 1.94 and 1.09 ± 1.79 diopters [D]) and paracentral (0.62 ± 1.59 and 0.55 ± 0.98 D) cones only. In the non-A-CXL group, there was a positive correlation between postoperative flattening and preoperative Kmax values, whereas paracentral and peripheral cone locations were negatively related. In the A-CXL group, only paracentral location was negatively correlated to postoperative flattening and showed posterior cone steepening at 12 months. Although central cones were the steepest in both groups, there was no difference in postoperative flattening between the groups for all cone locations. In the non-A-CXL group, postoperative flattening was proportional to preoperative Kmax values in central cones and was less with paracentral and peripheral locations. With A-CXL, postoperative flattening was less only with paracentral location. In the A-CXL group, significant posterior cone steepening was noticed only in paracentral cones. [J Refract Surg. 2022;38(5):310–316.]
Riccardo Vinciguerra, MD Luis Fernández-Vega-Cueto, Od Arancha Poo-Lopez, Ashkan Eliasy, Md Jesús Merayo-Lloves, Ahmed Elsheikh, David Madrid-Costa, Carlos Lisa, Md José F. Alfonso
Published: 1 April 2022
Journal of Refractive Surgery, Volume 38, pp 264-269;

To evaluate the effect of the implantation of intracorneal ring segments (ICRS) in keratoconus on the dynamic corneal response (DCR) parameters obtained with the Corvis ST (Oculus Optikgeräte GmbH). This prospective clinical study included patients who underwent ICRS implantation for keratoconus over a period of 1 year. On the day of the surgery and at least 1 month after ICRS implantation, the following measurements were made: corrected and uncorrected distance visual acuity, corneal tomography indices with the Pentacam (Oculus Optikgeräte GmbH), biomechanically corrected intraocular pressure (bIOP), Corvis ST DCR parameters, integrated inverse concave radius (1/R), deformation amplitude ratio (DA ratio), stiffness parameter at first applanation (SP-A1), stress–strain index (SSI), and highest concavity radius (HRC). Fifty-one eyes of 40 patients were included with a median follow-up time of 3 months (interquartile ratio [IQR]: 2 to 6 months). Statistical analysis showed that ICRS implantation did not affect corneal biomechanical measurements evaluated with the Corvis ST, which was demonstrated by non-significant changes in the SP-A1 (P = .637), 1/R (P = .647), HRC (P = .177), DA ratio (P = .735), and SSI (P = .501). Additionally, the results showed that bIOP measurements were not significantly affected by ICRS implantation (P = .113). ICRS implantation does not affect corneal biomechanical measurements in early follow-up. [J Refract Surg. 2022;38(4):264–269.]
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