Abstract PURPOSE: To describe ultrasound biomicroscopy (UBM) features in a patient with Axenfeld-Rieger syndrome (ARS) and cataract before and after anterior segment surgery using intraocular lens (IOL) and aniridic ring implantation (Morcher Aniridia rings 50 D). METHODS: Visual acuity, subjective glare disability, intraocular pressure, endothelial cell density, and UBM imaging were reviewed over a period of 1 year. RESULTS: One month after surgery, the operated eye showed improved visual acuity and visual comfort, and UBM examination showed a well-centered IOL and well-aligned aniridic ring fins. After 8 months, UBM examination showed contraction of the capsular bag, which appeared wrinkled, fibrous, and thickened. The capsular bag comprised the aniridic ring fins, causing misalignment. The glare disability had dropped from grade 0 to 3. The same outcome was present at 1 year. CONCLUSION: Ultrasound biomicroscopy is a useful noninvasive diagnostic means to picture anatomic details before and after surgery; it suggested that capsular bag shrinking caused migration of the aniridic rings, 8 months after surgery.

Abstract PURPOSE: To analyze corneal confocal microscopy changes after combined photorefractive keratectomy (PRK) plus the cross linking (CXL) procedure. DESIGN: Prospective interventional case series. METHODS: At the Department of Basic Medical Sciences, Neuroscience, and Sense Organs of the University of Bari, Bari, Italy, 17 eyes of 17 patients with progressive keratoconus underwent confocal microscopy examination before and after 1, 3, 6, 12, 18, and 48 months following PRK plus the CXL procedure. The main outcome measures were mean superficial epithelial cell density; mean basal epithelial cell density; mean anterior, mid and posterior keratocyte density; qualitative analysis of stromal backscatter; sub-basal and stromal nerve density parameters; and mean endothelial cell density. RESULTS: During the 4-year follow-up, the mean superficial epithelial cell density, mean basal epithelial cell density and mean endothelial cell density remained unchanged (P > 0.05). The anterior mid-stromal keratocyte density showed a significant decrease (P < 0.05) as compared with preoperative values, and the posterior stromal keratocyte density showed a significant increase at 1 and 3 months of follow-up. Sub-basal and stromal nerve density parameters were significantly decreased until postoperative month 6 (P < 0.05 at 1, 3, and 6 months) and then tended to increase up to preoperative values by the 18th postoperative month. CONCLUSION: Corneal changes after the PRK plus CXL procedures seem to be pronounced and long lasting as far as keratocyte density of the anterior and mid stroma is concerned. Sub-basal nerve densities tend to reach preoperative values 6 months after surgery.

Abstract PURPOSE: To evaluate the efficacy of bipolar diathermy in ensuring closure of leaking sclerotomies after complete 23-gauge transconjunctival sutureless vitrectomy. METHODS: In this prospective, interventional case series, in 136 eyes of 136 patients with at least one leaking sclerotomy at the end of a complete 23-gauge transconjunctival sutureless vitrectomy, external bipolar wet-field diathermy was applied to leaking sclerotomies, including the conjunctiva and sclera. Intraoperative wound closure, and postoperatively, at 6 hours, 1 day and 3 days, sclerotomies leakage, intraocular pressure, hypotony, and hypotony-related complications were evaluated. RESULTS: Intraoperative closure was achieved in 231 of 238 leaking sclerotomies (97%) that received diathermy. One of these with postoperative leakage needed suture. Compared with baseline (14.4 ± 2.8 mmHg), mean intraocular pressure was lower at 6 hours (13.2 ± 3.8 mmHg, Tukey-Kramer P < 0.001) and not different at 24 hours or 72 hours. Hypotony (intraocular pressure <5 mmHg) was observed in 6 eyes (4.5%) at 6 hours, in 2 (1.5%) at 24 hours, and in none at 3 days. Logistic regression analysis showed that, 6 hours postoperatively, hypotony was related to younger age (≤50 years) at surgery (P = 0.031). No hypotony-related complications were recorded. CONCLUSION: Bipolar wet-field diathermy of sutureless sclerotomies is an effective method for ensuring a leaking sclerotomies closure.

Abstract PURPOSE: To evaluate endothelial changes after excimer laser-assisted lamellar keratoplasty. DESIGN: Retrospective, interventional case series. METHODS: Seven eyes of 7 keratoconus patients were evaluated for 1 year after pachymetry-guided lamellar keratoplasty, performed using the iRES Laser (Ligi Tecnologie Medicali S.p.A.), with the Corneal Lamellar Ablation for Transplantation software (Ligi Tecnologie Medicali S.p.A.) procedure. Both anterior segment optical coherence tomography (Visante OCT; Carl Zeiss Meditec, Inc) and in vivo confocal microscopy (Corneal Confocal Microscope CS4; NIDEK Technologies) images were collected. RESULTS: Changes in morphologic features were investigated and the endothelium was assessed quantitatively in all 7 patients. In 6 eyes, we measured a mean residual bed thickness of 151.3 +/- 5.46 microm, and a mean endothelial cell density loss of 5.38% at 1 year after surgery, as compared with preoperative values. The mean percentage hexagonality change was 15.67%, and the mean coefficient of variation change was -21.11%. In 1 eye, a residual bed thickness of 72 microm was found and endothelial loss after 1 year was 72.26%; assessment of the coefficient of variation and percentage hexagonality by manual Confoscan4 software (NIDEK Technologies) was not practicable in this case. CONCLUSIONS: Our results showed that the Corneal Lamellar Ablation for Transplantation procedure induced mild changes to the endothelium in corneas with a mean residual bed thickness of 151.3 +/- 5.46 microm, but serious damage in one eye with a residual bed thickness of 72 microm.

PURPOSE: To compare visual, refractive, topographic, and corneal higher-order aberration outcome at the 2-year follow-up after customized photorefractive keratectomy (PRK) followed by cross-linking (CXL) as a single procedure versus CXL alone in eyes with progressive keratoconus. DESIGN: Prospective, interventional, nonrandomized clinical trial. METHODS: Seventeen patients (34 eyes) with progressive keratoconus were assigned to 2 groups: the worse eye (17 eyes) was assigned to the PRK plus CXL group and the better eye (17 fellow eyes) was assigned to the CXL group. RESULTS: In the PRK plus CXL group, uncorrected distance acuity improved significantly, from a mean ± standard deviation of 0.63 ± 0.36 logarithm of the minimal angle of resolution (logMAR) units to 0.19 ± 0.17 logMAR units (P < .05) and best distance acuity from 0.06 ± 0.08 logMAR to 0.03 ± 0.06 logMAR (P < .05). Manifest refraction spherical equivalent and spherical and cylindrical power improved significantly (P < .05). Simulated keratometry, flattest, steepest, average, cylindrical, apex keratometry, and inferior-superior value decreased significantly (P < .05). Total and coma-like aberrations significantly decreased for all pupil diameters (P < .05). In the CXL group, uncorrected distance acuity improved, but not significantly, from 0.59 ± 0.29 logMAR units to 0.52 ± 0.29 logMAR units, and best distance acuity improved from 0.06 ± 0.11 logMAR units to 0.04 ± 0.07 logMAR units (P > .05). Manifest refraction spherical equivalent and cylindrical power improvement was not significant (P > .05), unlike spherical power (P < .05). Steepest simulated keratometry, average simulated keratometry, and inferior-superior value significantly decreased (P < .05), unlike flattest simulated keratometry, cylindrical simulated keratometry, and apex keratometry (P > .05). Total and coma-like aberrations were not decreased significantly for all pupil diameters (P > .05). No significant endothelial changes were observed in either group. CONCLUSIONS: The PRK plus CXL procedure may be a good option to reduce corneal aberrations and stabilize corneas with progressive keratoconus.