Algorithm for Correcting the Keratometric Error in the Estimation of the Corneal Power in Eyes With Previous Myopic Laser Refractive Surgery

Purpose: To calculate theoretically the errors in the estimation of corneal power when using the keratometric index (nk) in eyes that underwent laser refractive surgery for the correction of myopia and to define and validate clinically an algorithm for minimizing such errors. Methods: Differences between corneal power estimation by using the classical nk and by using the Gaussian equation in eyes that underwent laser myopic refractive surgery were simulated and evaluated theoretically. Additionally, an adjusted keratometric index (nkadj) model dependent on r1c was developed for minimizing these differences. The model was validated clinically by retrospectively using the data from 32 myopic eyes [range, −1.00 to −6.00 diopters (D)] that had undergone laser in situ keratomileusis using a solid-state laser platform. The agreement between Gaussian (PGaussc) and adjusted keratometric (Pkadj) corneal powers in such eyes was evaluated. Results: It was found that overestimations of corneal power up to 3.5 D were possible for nk = 1.3375 according to our simulations. The nk value to avoid the keratometric error ranged between 1.2984 and 1.3297. The following nkadj models were obtained: nkadj= −0.0064286r1c + 1.37688 (Gullstrand eye model) and nkadj = −0.0063804r1c + 1.37806 (Le Grand). The mean difference between Pkadj and PGaussc was 0.00 D, with limits of agreement of −0.45 and +0.46 D. This difference correlated significantly with the posterior corneal radius (r = −0.94, P < 0.01). Conclusions: The use of a single nk for estimating the corneal power in eyes that underwent a laser myopic refractive surgery can lead to significant errors. These errors can be minimized by using a variable nk dependent on r1c.

New-Generation Hybrid Contact Lens for the Management of Extreme Irregularity in a Thin Cornea After Unsuccessful Excimer Laser Refractive Surgery

Purpose: To report a very successful outcome obtained with the fitting of a new-generation hybrid contact lens of reverse geometry in a thin cornea with extreme irregularity due to the presence of a central island after unsuccessful myopic excimer laser refractive surgery. Methods: A 32-year-old man attended to our clinic complaining of very poor vision in his right eye after bilateral laser in situ keratomileusis (treatment or surgery) for myopia correction and some additional retreatments afterward. After a comprehensive ocular evaluation, contact lens fitting with a reverse geometry hybrid contact lens (SynergEyes PS, SynergEyes, Carlsbad, CA) was proposed as a solution for this case. Visual, refractive, and ocular aberrometric outcomes with the contact lens were evaluated. Results: Distance visual acuity improved from a prefitting uncorrected value of 20/200 to a postfitting corrected value of 20/16. Prefitting manifest refraction was +6.00 sphere and −3.00 cylinder at 70°, with a corrected distance visual acuity of 20/40. Higher order root mean square for a 5-mm pupil changed from a prefitting value of 1.45 to 0.34 µm with the contact lens. The contact lens wearing was reported as comfortable, and the patient was very satisfied with this solution. Conclusions: The SynergEyes PS contact lens seems to be an excellent option for the visual rehabilitation of corneas with extreme irregularity after myopic excimer laser surgery, minimizing the level of higher order aberrations and providing an excellent visual outcome.

Clinical Validation of Adjusted Corneal Power in Patients with Previous Myopic Lasik Surgery

Purpose. To validate clinically a new method for estimating the corneal power (P,) using a variable keratometric index (nkadj) in eyes with previous laser refractive surgery. Setting. University of Alicante and Medimar International Hospital (Oftalmar), Alicante, (Spain). Design. Retrospective case series. Methods. This retrospective study comprised 62 eyes of 62 patients that had undergone myopic LASIK surgery. An algorithm for the calculation of 11kadj was used for the estimation of the adjusted keratometric corneal power (Pkadj). This value was compared with the classical keratometric corneal power (Pk), the True Net Power (TNP), and the Gaussian corneal power (PcGauss). Likewise, Pkadj was compared with other previously described methods. Results. Differences between PcGauss and P, values obtained with all methods evaluated were statistically significant (p < 0.01). Differences between Pkadj and PcGauss were in the limit of clinical significance (p < 0.01, loA [ - 0.33,0.60] D). Differences between Pkadj and TNP were not statistically and clinically significant (p = 0.319, loA [- 0.50,0.44] D). Differences between Pkadj and previously described methods were statistically significant (p < 0.01), except with PcHaigisL (p = 0.09, loA [ - 0.37,0.29] D). Conclusion. The use of the adjusted keratometric index (nkadj) is a valid method to estimate the central corneal power in corneas with previous myopic laser refractive surgery, providing results comparable to PcHaigisL.

Comparison of the predictability of refractive cylinder correction by laser in situ keratomileusis in eyes with low or high ocular residual astigmatism

Purpose: To compare the manifest refractive cylinder (MRC) predictability of myopic astigmatism laser in situ keratomileusis (LASIK) between eyes with low and high ocular residual astigmatism (ORA). Setting: London Vision Clinic, London, United Kingdom. Design: Retrospective case study. Methods: The ORA was considered the vector difference between the MRC and the corneal astigmatism. The index of success (IoS), difference vector ÷ MRC, was analyzed for different groups as follows: stage 1, low ORA (ORA ÷ MRC <1), high ORA (ORA ÷ MRC ≥1); stage 2, low ORA group reduced to match the high ORA group for MRC; stage 3, grouped by ORA magnitude with low ORA (<0.50 diopters [D]), mid ORA (0.50 to 1.24 D), and high ORA (≥1.25 D); stage 4, high ORA group subdivided into low (<0.75 D) and high (≥0.75 D) corneal astigmatism. Results: For stage 1, the mean preoperative MRC and mean IoS were −1.32 D ± 0.65 (SD) (range −0.55 to −3.77 D) and 0.27, respectively, for low ORA and −0.79 ± 0.20 D (range −0.56 to −2.05 D) and 0.37, respectively, for high ORA. For stage 2, the mean IoS increased to 0.32 for low ORA. For stage 3, the mean IoS was 0.28, 0.29, and 0.31 for low ORA, mid ORA, and high ORA, respectively. For stage 4, the mean IoS was 0.20 for high ORA/low corneal astigmatism and 0.35 for high ORA/high corneal astigmatism. Conclusions: The MRC predictability was slightly worse in eyes with high ORA when grouped by the ORA ÷ MRC. Matching for the MRC and grouping by ORA magnitude resulted in similar predictability; however, eyes with high ORA and high corneal astigmatism were less predictable.

Wavefront-Guided Laser Treatment Using a High-Resolution Aberrometer to Measure Irregular Corneas: A Pilot Study

PURPOSE: To evaluate in a pilot study the visual, refractive, corneal topographic, and aberrometric changes after wavefront-guided LASIK or photorefractive keratectomy (PRK) using a high-resolution aberrometer to calculate the treatment for aberrated eyes. METHODS: Twenty aberrated eyes of 18 patients undergoing wavefront-guided LASIK or PRK using the VISX STARS4IR excimer laser and the iDesign aberrometer (Abbott Medical Optics, Inc., Santa Ana, CA) were enrolled in this prospective study. Three groups were differentiated: keratoconus post-CXL group including 11 keratoconic eyes (10 patients), post-LASIK group including 5 eyes (5 patients) with previous decentered LASIK treatments, and post-RK group including 4 eyes (3 patients) with previous radial keratotomy. Visual, refractive, contrast sensitivity, corneal topographic, and ocular aberrometric changes were evaluated during a 6-month follow-up. RESULTS: An improvement in uncorrected (UDVA) and corrected visual acuity (CDVA) associated with a reduction in the spherical equivalent was observed in the three groups, but was only statistically significant in the keratoconus post-CXL and post-LASIK groups (P ≤ .04). All eyes gained one or more lines of CDVA after surgery. Improvements in contrast sensitivity were observed in the three groups, but they were only statistically significant in the keratoconus post-CXL and post-LASIK groups (P ≤ .04). Regarding aberrations, a reduction was observed in trefoil aberrations in the keratoconus post-CXL group (P = .05) and significant reductions in higher-order and primary coma aberrations in the post-LASIK group (P = .04). CONCLUSIONS: Wavefront-guided laser enhancements using the evaluated platform seem to be safe and effective to restore the visual function in aberrated eyes.

The posterior chamber phakic refractive lens (PRL): a review

Implantation of phakic intraocular lenses (pIOLs) is a reversible refractive procedure, preserving the patient’s accommodative function with minimal induction of higher order aberrations compared with corneal photoablative procedures. Despite this, as an intraocular procedure, it has potential risks such as cataracts, chronic uveitis, pupil ovalization, corneal endothelial cell loss, pigmentary dispersion syndrome, pupillary block glaucoma, astigmatism, or endophthalmitis. Currently, only two models of posterior chamber pIOLs are commercially available, the implantable collammer lens (STAAR Surgical Co.) and the phakic refractive lens (PRL; Zeiss Meditec). The number of published reports on the latter is very low, and some concerns still remain about its long-term safety. The present article reviews the published literature on the outcomes after PRL implantation in order to provide a general overview and evaluate its real potential as a surgical refractive option.

Comparative Analysis of the Visual Performance After Cataract Surgery With Implantation of a Bifocal or Trifocal Diffractive IOL

PURPOSE: To evaluate and compare the visual, refractive, contrast sensitivity, and aberrometric outcomes with a diffractive bifocal and trifocal intraocular lens (IOL) of the same material and haptic design. METHODS: Sixty eyes of 30 patients undergoing bilateral cataract surgery were enrolled and randomly assigned to one of two groups: the bifocal group, including 30 eyes implanted with the bifocal diffractive IOL AT LISA 801 (Carl Zeiss Meditec, Jena, Germany), and the trifocal group, including eyes implanted with the trifocal diffractive IOL AT LISA tri 839 MP (Carl Zeiss Meditec). Analysis of visual and refractive outcomes, contrast sensitivity, ocular aberrations (OPD-Scan III; Nidek, Inc., Gagamori, Japan), and defocus curve were performed during a 3-month follow-up period. RESULTS: No statistically significant differences between groups were found in 3-month postoperative uncorrected and corrected distance visual acuity (P > .21). However, uncorrected, corrected, and distance-corrected near and intermediate visual acuities were significantly better in the trifocal group (P < .01). No significant differences between groups were found in postoperative spherical equivalent (P = .22). In the binocular defocus curve, the visual acuity was significantly better for defocus of -0.50 to -1.50 diopters in the trifocal group (P < .04) and -3.50 to -4.00 diopters in the bifocal group (P < .03). No statistically significant differences were found between groups in most of the postoperative corneal, internal, and ocular aberrations (P > .31), and in contrast sensitivity for most frequencies analyzed (P > .15). CONCLUSIONS: Trifocal diffractive IOLs provide significantly better intermediate vision over bifocal IOLs, with equivalent postoperative levels of visual and ocular optical quality.

Clinical validation of an algorithm to correct the error in the keratometric estimation of corneal power for normal eyes

To validate clinically an algorithm for correcting the error in the keratometric estimation of corneal power by using a variable keratometric index of refraction (nk) in a normal healthy population.

In vivo characterization of corneal biomechanics

Interest in corneal biomechanics has increased with the development of new refractive surgery techniques aimed at modifying corneal properties and a variety of surgical options for corneal ectasia management. The human cornea behaves as soft biological material. It is a viscoelastic tissue and its response to a force applied to it depends not only on the magnitude of the force, but also on the velocity of the application. There are concerns about the limitations to measuring corneal biomechanical properties in vivo. To date, 2 systems are available for clinical use: the Ocular Response Analyzer, a dynamic bidirectional applanation device, and the Corvis ST, a dynamic Scheimpflug analyzer device. These devices are useful in clinical practice, especially for planning some surgical procedures and earlier detection of ectatic conditions, but further research is needed to connect the clinical measurements obtained with these devices to the standard mechanical properties.

Intrasubject repeatability in keratoconus-eye measurements obtained with a new Scheimpflug photography–based system

Purpose: To evaluate in keratoconus eyes the intrasubject repeatability of anterior and posterior corneal curvature and of other anterior segment anatomic measurements obtained with a new topography system combining Scheimpflug-photography and Placido-disk technology. Setting: Vissum Corporation, Alicante, Spain. Design: Evaluation of technology. Methods: All keratoconus eyes had a comprehensive ophthalmologic examination including analysis with the Sirius system. Three consecutive measurements were obtained to assess the intrasubject repeatability of the following parameters: anterior and posterior corneal curvature and shape factor, white-to-white (WTW) corneal diameter, central and minimum corneal thickness, and anterior chamber depth (ACD). The within-subject standard deviation (Sw) and intraclass correlation coefficient (ICC) were calculated. Results: This study comprised 61 eyes of 61 patients ranging in age from 14 to 64 years. For anterior and posterior corneal curvatures and power vector components, the Sw was 0.29 mm or less in all cases. The ICC was above 0.990 in all cases except the flattest curvature of the posterior corneal surface at 3.0 mm, which was 0.840 (moderate agreement), and the posterior power vector J0, which was 0.665 (poor agreement), 0.752, and 0.758 (moderate agreement) for 3.0 mm, 5.0 mm, and 7.0 mm, respectively. In shape factor measurements, the Sw was 0.12 or less in all cases and the ICC ranged between 0.989 and 0.999. Pachymetry, ACD, and WTW had ICC values very close to 1. Conclusion: The new topography system provided repeatable measurements of corneal shape and other anatomic parameters in eyes with keratoconus.

Minimizing the IOL Power Error Induced by Keratometric Power

Purpose. To evaluate theoretically in normal eyes the influence on IOL power (PIOL) calculation of the use of a keratometric index (nk) and to analyze and validate preliminarily the use of an adjusted keratometric index (nkadj) in the IOL power calculation (PIOLadj). Methods. A model of variable keratometric index (nkadj) for corneal power calculation (Pc) was used for IOL power calculation (named PIOLadj). Theoretical differences ($PIOL) between the new proposed formula (PIOLadj) and which is obtained through Gaussian optics (PIOL Gauss) were determined using Gullstrand and Le Grand eye models. The proposed new formula for IOL power calculation (PIOLadj) was prevalidated clinically in 81 eyes of 81 candidates for corneal refractive surgery and compared with Haigis, HofferQ, Holladay, and SRK/T formulas. Results. A theoretical PIOL underestimation greater than 0.5 diopters was present in most of the cases when nk = 1.3375 was used. If nkadj was used for Pc calculation, a maximal calculated error in $PIOL of T0.5 diopters at corneal vertex in most cases was observed independently from the eye model, r1c, and the desired postoperative refraction. The use of nkadj in IOL power calculation (PIOLadj) could be valid with effective lens position optimization nondependent of the corneal power. Conclusions. The use of a single value of nk for Pc calculation can lead to significant errors in PIOL calculation that may explain some IOL power overestimations with conventional formulas. These inaccuracies can be minimized by using the new PIOLadj based on the algorithm of nkadj.

Implantation of a diffractive trifocal intraocular lens: One-year follow-up

Purpose: To evaluate the visual, refractive, contrast-sensitivity, and aberrometric outcomes during a 1-year follow-up after implantation of a trifocal intraocular lens (IOL). Setting: Premium Clinic, Teplice, Czech Republic. Design: Prospective case series. Methods: This study included eyes of patients having cataract surgery with implantation of the trifocal IOL model AT Lisa tri 839MP. Distance, intermediate (66 and 80 cm), and near (33 and 40 cm) vision; contrast sensitivity; aberrometric outcomes; and the defocus curve were evaluated during a 12-month follow-up. The level of posterior capsule opacification (PCO) was also evaluated. Results: In 120 eyes (60 patients), 1 month postoperatively, an improvement was observed in all visual parameters (P ≤ .03) except corrected near and intermediate visual acuities (both P ≥ .05). From 1 month to 12 months postoperatively, small but statistically significant changes were observed in uncorrected and corrected distance and near visual acuities (all P ≤ .03) and in uncorrected intermediate visual acuity (P = .01). In the defocus curve, no significant differences were found between visual acuities corresponding to defocus levels of −1.0 diopter (D) and −2.0 D (P = .22). The level of ocular spherical aberration decreased statistically significantly at 6 months (P < .001). Ocular and internal higher-order aberrations increased minimally but significantly from 6 to 12 months postoperatively (P < .001). The mean 12-month PCO score was 0.32 ± 0.44 (SD). Four eyes (3.3%) required neodymium:YAG capsulotomy. Conclusion: The trifocal IOL provided complete and stable visual restoration after cataract surgery during a 12-month follow-up, with good levels of visual quality.

Pilot study of hyperopic LASIK using the solid-state laser technology

Background To evaluate and report the visual, refractive, and aberrometric outcomes of LASIK for the correction of low to moderate hyperopia in a pilot group using a commercially available solid-state laser. Methods Prospective pilot study including 11 consecutive eyes with low to moderate hyperopia of six patients undergoing LASIK surgery using the Pulzar Z1 solid-state laser (CustomVis Laser Pty Ltd., currently CV Laser). Visual, refractive, and aberrometric changes were evaluated. Potential complications were evaluated as well. Mean follow-up time was 6.6 months (range, 3 to 11 months). Results A significant improvement in LogMAR uncorrected distance visual acuity (UDVA) was observed postoperatively (p = 0.01). No significant change was detected in LogMAR corrected distance visual acuity (CDVA) (p = 0.21). Postoperative LogMAR UDVA was 0.1 (about 20/25) or better in ten eyes (90.9 %). Mean overall efficacy and safety indices were 1.03 and 1.12. Postoperatively, no losses of lines of CDVA were observed. Postoperative spherical equivalent was within ±1.00 D in ten eyes (90.9 %). With regard to aberrations, no statistically significant changes were found in higher order and primary coma RMS postoperatively (p ≥ 0.21), and only minimal but statistically significant negativization of primary spherical aberration (p = 0.02) was observed. No severe complications were observed. Conclusion LASIK surgery using the solid-state laser technology seems to be a useful procedure for the correction of low to moderate hyperopia, with minimal induction of higher order aberrations.

Influence of the Difference Between Corneal and Refractive Astigmatism on LASIK Outcomes Using Solid-State Technology

Purpose: To evaluate the influence of the difference between preoperative corneal and refractive astigmatism [ocular residual astigmatism (ORA)] on outcomes obtained after laser in situ keratomileusis (LASIK) surgery for correction of myopic astigmatism using the solid-state laser technology. Methods: One hundred one consecutive eyes with myopia or myopic astigmatism of 55 patients undergoing LASIK surgery using the Pulzar Z1 solid-state laser (CustomVis Laser Pty Ltd, currently CV Laser) were included. Visual and refractive changes at 6 months postoperatively and changes in ORA and anterior corneal astigmatism and posterior corneal astigmatism (PCA) were analyzed. Results: Postoperatively, uncorrected distance visual acuity improved significantly (P < 0.01). Likewise, refractive cylinder magnitude and spherical equivalent were reduced significantly (P < 0.01). In contrast, no significant changes were observed in ORA magnitude (P = 0.81) and anterior corneal astigmatism (P = 0.12). The mean overall efficacy and safety indices were 0.96 and 1.01, respectively. These indices were not correlated with preoperative ORA (r = −0.15, P = 0.15). Furthermore, a significant correlation was found between ORA (r = 0.81, P < 0.01) and PCA postoperatively, but not preoperatively (r = 0.12, P = 0.25). Likewise, a significant correlation of ORA with manifest refraction was only found postoperatively (r = −0.38, P < 0.01). Conclusions: The magnitude of ORA does not seem to be a predictive factor of efficacy and safety of myopic LASIK using a solid-state laser platform. The higher relevance of PCA after surgery in some cases may explain the presence of unexpected astigmatic residual refractive errors.

Profitability analysis of a femtosecond laser system for cataract surgery using a fuzzy logic approach

AIM: To define the financial and management conditions required to introduce a femtosecond laser system for cataract surgery in a clinic using a fuzzy logic approach. METHODS: In the simulation performed in the current study, the costs associated to the acquisition and use of a commercially available femtosecond laser platform for cataract surgery (VICTUS, TECHNOLAS Perfect Vision GmbH, Bausch & Lomb, Munich, Germany) during a period of 5y were considered. A sensitivity analysis was performed considering such costs and the countable amortization of the system during this 5y period. Furthermore, a fuzzy logic analysis was used to obtain an estimation of the money income associated to each femtosecond laser-assisted cataract surgery (G). RESULTS: According to the sensitivity analysis, the femtosecond laser system under evaluation can be profitable if 1400 cataract surgeries are performed per year and if each surgery can be invoiced more than $500. In contrast, the fuzzy logic analysis confirmed that the patient had to pay more per surgery, between $661.8 and $667.4 per surgery, without considering the cost of the intraocular lens (IOL). CONCLUSION: A profitability of femtosecond laser systems for cataract surgery can be obtained after a detailed financial analysis, especially in those centers with large volumes of patients. The cost of the surgery for patients should be adapted to the real flow of patients with the ability of paying a reasonable range of cost.