Publications by authors named "Majid Moshirfar"

335 Publications

Phakic intraocular lenses: an update and review for the treatment of myopia and myopic astigmatism in the United States.

Curr Opin Ophthalmol 2022 Sep 27;33(5):453-463. Epub 2022 Jun 27.

Hoopes Vision Research Center, Hoopes Vision, Draper.

Purpose Of Review: To review all phakic intraocular lenses (pIOLs) available in the United States for the correction of myopia or myopic astigmatism and offer a clinical approach to their proper use, postoperative follow-up, and analysis of visual and adverse outcomes.

Recent Findings: In March 2022, the FDA approved the EVO/EVO+ Visian ICL for widespread use, adding this lens to the two others available (Verisyse, Visian ICL). Cataract formation, endothelial cell loss (ECL) and surgical reintervention remain the most common adverse events. There are discrepancies between studies on ECL following implantation with pIOLs, although trends can be deduced with meta-analysis. Posterior Chamber-pIOLs (PC-pIOLs), especially the EVO/EVO+, have an overall lower mean adverse effect and subjective patient symptom profile when compared to Iris Fixated-pIOLS (IF-pIOLs). Advancements in PC-pIOL sizing have provided a noticeable difference in visual and safety outcomes.

Summary: All pIOLs available in the United States provide high-quality visual correction of moderate to high myopia and/or myopia with astigmatism. Proper follow-up for ECL and cataract formation is warranted.
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http://dx.doi.org/10.1097/ICU.0000000000000870DOI Listing
September 2022

Assessing Patients with Alpha-1 Antitrypsin Deficiency for Corneal Refractive Surgery: A Review and Clinical Experience.

J Clin Med 2022 Jul 19;11(14). Epub 2022 Jul 19.

Hoopes Vision Research Center, Hoopes Vision, 11820 S. State St. #200, Draper, UT 84020, USA.

Alpha-1 Antitrypsin Deficiency (AATD) is an autosomal inheritable disorder that impairs the protease inhibitor alpha-1 antitrypsin. This disorder presents with various systemic effects, including liver cirrhosis, centrilobular emphysema, and ocular manifestations. Performing corneal refractive surgery in patients with AATD raises concerns regarding the increased rates of corneal erosions, corneal ulcerations, potential developing descemetoceles, and other ocular manifestations. Patient outcomes for laser-assisted in situ keratomileuses (LASIK), photorefractive keratectomy (PRK), small incision lenticule extraction (SMILE), and other ocular corrective surgeries are lacking in this population. This article provides experiences performing corneal refractive surgery, discusses the current understanding of AATD, including its ocular manifestations, and explores factors to consider when evaluating patients for corneal procedures. The aim of this paper is to address the manifestations of AATD prior to performing corrective vision surgery.
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http://dx.doi.org/10.3390/jcm11144175DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9317581PMC
July 2022

Corneal Refractive Surgery Considerations in Patients on Dupilumab.

J Clin Med 2022 Jun 8;11(12). Epub 2022 Jun 8.

Hoopes Vision Research Center, Hoopes Vision, 11820 S. State St., Ste. 200, Draper, UT 84020, USA.

Dupilumab is a biologic approved by the United States Food and Drug Administration (US FDA) for the treatment of atopic dermatitis. While it is an effective medication for eczema, ocular side effects are common in patients receiving dupilumab therapy. Greater consideration is needed when evaluating these individuals for corneal refractive surgery. Dupilumab patients may suffer from atopy, a condition that also merits consideration in those desiring refractive surgery. Additional testing and careful consideration are needed, as these patients have an increased risk of dry eye syndrome, keratoconus, cataracts, diffuse lamellar keratitis, viral keratitis, and perioperative infection. This commentary discusses the current understanding of dupilumab ocular side effects and investigates factors to consider when evaluating these patients for corneal refractive surgery.
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http://dx.doi.org/10.3390/jcm11123273DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9225227PMC
June 2022

Charcot-Marie-Tooth Disease and Implications on Corneal Refractive Surgery.

Ophthalmol Ther 2022 Aug 11;11(4):1301-1307. Epub 2022 Jun 11.

Hoopes Vision Research Center, Hoopes Vision, 11820 S. State Street Suite #200, Draper, UT, 84020, USA.

Charcot-Marie-Tooth (CMT) disease is the most common inherited polyneuropathy, with a characteristic phenotype of distal muscle weakness, atrophy, and sensory loss. Variable ocular involvement has been documented in patients with CMT, with optic atrophy as the most frequently reported symptom. Although the Charcot-Marie-Tooth Association has generally deemed laser-assisted in situ keratomileuses (LASIK) a safe option for patients with CMT, reports of corneal refractive surgery are lacking in this patient population. This commentary discusses the current understanding of CMT, including its ocular manifestations, and additional specific testing to consider when evaluating these patients for corneal refractive surgery.
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http://dx.doi.org/10.1007/s40123-022-00524-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9253221PMC
August 2022

Cataract extraction after inadvertent Nd:YAG laser capsulotomy in a phakic eye.

SAGE Open Med Case Rep 2022 18;10:2050313X221097775. Epub 2022 May 18.

University of Arizona College of Medicine Phoenix, Phoenix, AZ, USA.

Inadvertent neodymium: yttrium-aluminum-garnet (Nd:YAG) capsulotomies are rare, with only one incident reported in the literature prior to the present case. We discuss the management of a phakic patient with a dense posterior subcapsular cataract who underwent yttrium-aluminum-garnet (YAG) capsulotomy for presumed posterior capsular opacification. Operative course involved cataract surgery with anterior vitrectomy for prolapsed lens fragments due to the disrupted posterior capsule. This patient experienced excellent visual outcomes postoperatively, with ultimate best-corrected visual acuity of 20/20. This case underscores the importance of thorough preoperative time out, including confirmation of patient's understanding of the intended procedure.
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http://dx.doi.org/10.1177/2050313X221097775DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9121449PMC
May 2022

Repeatability and reproducibility of the galilei G6 and its agreement with the pentacam® AXL in optical biometry and corneal tomography.

Expert Rev Med Devices 2022 Apr 19;19(4):375-383. Epub 2022 May 19.

Zeimer Ophthalmic Systems AG, Port, Switzerland.

Objectives: To assess the repeatability and reproducibility of corneal measurements performed by the Galilei G6 and determine its agreement with the Pentacam® AXL.

Methods: 105 eyes underwent examination by both devices, measuring nine parameters. Paired t-tests, Deming Regression, and Bland-Altman plots were used to determine agreement. Analysis of Variance was used to determine repeatability and reproducibility.

Results: Measurements showed no clinically significant differences between the two devices. On average, the Galilei G6 measured axial length longer than the Pentacam® AXL by 0.05 mm ± 0.03 mm (p < 0.001), just 0.2% of the mean value and therefore clinically insignificant. It measured central corneal thickness and anterior chamber depth 3.77 μm ± 7.71 μm longer (p < 0.001) and 0.04 mm ± 0.07 μm shorter (p < 0.001), respectively. They are also clinically insignificant, constituting just 0.7% and 1% of the mean values. The results showed evidence of repeatability and reproducibility. Only measurements of corneal cylinder showed some clinically significant variance.

Conclusions: The Galilei G6 and Pentacam® AXL measurements show evidence of repeatability, reproducibility, and agreement for examined parameters. Certain caution needs to be applied in cases with moderate or severe corneal cylinder, due to discrepancies in repeatability and reproducibility of corneal cylinder measurements with the Galilei G6.
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http://dx.doi.org/10.1080/17434440.2022.2075725DOI Listing
April 2022

Potential Risks of Corneal Refractive Surgery in Patients with Ectodermal Dysplasia.

Ophthalmol Ther 2022 Aug 9;11(4):1281-1289. Epub 2022 May 9.

Hoopes Vision Research Center, Hoopes Vision, 11820 S. State St. #200, Draper, UT, 84020, USA.

Ectodermal dysplasia (ED) involves the aberrant development of at least two ectodermal derivatives, such as skin, teeth, hair, sweat glands, and ocular tissue. The group of over 200 conditions is commonly classified into two major types: hypohidrotic/anhidrotic ED, in which sweat glands are either absent or significantly reduced, and hidrotic ED, in which sweat glands are normal. Ocular manifestations pertinent to patients undergoing corneal vision correction surgery include multifaceted dry eye syndrome, corneal pathology, such as recurrent erosions, scars, neovascularization, and limbal stem cell deficiency, and early-onset cataracts and glaucoma. In this article we discuss the current understanding of ED and offer factors to consider when these patients are seeking corneal refractive surgery.
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http://dx.doi.org/10.1007/s40123-022-00515-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9253218PMC
August 2022

Ocular adverse effects of therapeutic biologics.

Ther Adv Ophthalmol 2022 Jan-Dec;14:25158414211070878. Epub 2022 Apr 26.

Hoopes Research Center, 11820 South State Street, Suite 200, Draper, UT 84020, USA.

Biological drugs, termed biologics, are medications that contain or are derived from a living organism (human, animal, or microorganism). With new biological agents being approved by the Food and Drug Administration (FDA) every year, clinicians need to know potential ocular adverse effects that are associated with these drugs. This review provides an overview of ocular adverse effects of biological medications used to treat both ophthalmic and non-ophthalmic diseases. We searched PubMed for relevant case reports, case series, reviews, and clinical trials reporting ocular adverse effects caused by biologics. This review was conducted in June 2021 and investigated the drugs listed in the most updated (April 2021) FDA Purple Book Database of Licensed Biological Products. This review focuses on monoclonal antibodies, interleukins, and receptor fusion proteins. We explore ocular side effects of 33 biological drugs, stating whether they are frequent, common, or rare.
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http://dx.doi.org/10.1177/25158414211070878DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9047051PMC
April 2022

Implications of Corneal Refractive Surgery in Patients with Fabry Disease.

Ophthalmol Ther 2022 Jun 16;11(3):925-929. Epub 2022 Apr 16.

Hoopes Vision Research Center, Hoopes Vision, 11820 S. State Street Suite #200, Draper, UT, 84020, USA.

Fabry disease is an X-linked lysosomal storage disorder involving abnormal metabolism of glycosphingolipids, resulting in a range of multisystem organ dysfunction and ocular manifestations. Reports of laser-assisted in situ keratomileuses (LASIK) and photorefractive keratectomy (PRK) are lacking in this patient population. Proceeding with corneal refractive surgery in patients with Fabry disease raises concerns regarding the pre-existing corneal manifestations, reduced mesopic visual acuity, the potential for conjunctival lymphangiectasia, and predisposition to dry eye syndrome. This commentary discusses the current understanding of Fabry disease, including its ocular manifestations, and explores factors to consider when evaluating these patients for LASIK or PRK.
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http://dx.doi.org/10.1007/s40123-022-00503-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9114174PMC
June 2022

Thygeson Superficial Punctate Keratitis: A Clinical and Immunologic Review.

Eye Contact Lens 2022 Jun 15;48(6):232-238. Epub 2022 Mar 15.

Hoopes Vision Research Center (M.M., S.M., Y.C.R., P.H.), Hoopes Vision, Draper, UT; Department of Ophthalmology and Visual Sciences (M.M.), John A. Moran Eye Center, University of Utah Health Sciences Center, Salt Lake City, UT; Utah Lions Eye Bank (M.M.), Murray, UT; Rocky Vista University College of Osteopathic Medicine (T.P., D.B.B., F.T.), Ivins, UT; University of Utah School of Medicine (E.U.), Salt Lake City, UT; and Mission Hills Eye Center (S.M.), Pleasant Hill, CA.

Abstract: Thygeson superficial punctate keratitis (TSPK) is clinically characterized by exacerbations and remissions of gray-white opacities within the corneal epithelium, most often bilateral but may be asymmetric. Symptoms typically include photophobia, tearing, blurring, and eye irritation. Although disease progression and prognosis are well described, the exact cause is unknown. Hypotheses exist implicating virus-mediated immunity as the cause of TSPK following cases of viral keratitis; however, several polymerase chain reaction studies refute the infectious process concurrently with symptomatic TSPK. This is further supported by the consistent lack of response to antiviral and antibacterial treatment. A subset of dendritic cells known as Langerhans cells (LC) found within the corneal epithelium has been positively correlated with exacerbations of TSPK. Langerhans cells proliferate to protect and mitigate the cornea's inflammatory response, but the inflammatory triggers and relapses associated with TSPK are not well understood. Several topical drugs exist to treat inflammation related to TSPK; however, drug delivery is a major barrier to treatment because of the tear film and epithelial barrier. Drug-eluting contact lenses that target intermediates of inflammation could serve as a more effective treatment modality because of the increased bioavailability of the drugs. This review is an in-depth survey of the literature regarding the relationship between the origin and pathophysiology of LC and TSPK at the immunologic level. We also discuss potential pharmacotherapeutic interventions for TSPK prevention and treatment.
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http://dx.doi.org/10.1097/ICL.0000000000000891DOI Listing
June 2022

Safety and Efficacy of AGN-190584 in Individuals With Presbyopia: The GEMINI 1 Phase 3 Randomized Clinical Trial.

JAMA Ophthalmol 2022 04;140(4):363-371

AbbVie Inc, Irvine, California.

Importance: AGN-190584 (Allergan, an AbbVie company) is an optimized topical formulation of pilocarpine hydrochloride, 1.25%, designed for managing presbyopia and enhanced with a proprietary vehicle.

Objective: To evaluate the efficacy and safety of pilocarpine hydrochloride, 1.25%, in individuals with presbyopia.

Design, Setting, And Participants: This vehicle-controlled, participant- and investigator-masked, randomized, phase 3 clinical study, GEMINI 1, enrolled individuals with presbyopia, aged 40 to 55 years, at 36 sites in the United States from December 21, 2018, to October 31, 2019. Analysis took place between February 2020 and December 2021.

Interventions: AGN-190584 or the AGN-190584 formulation vehicle was administered bilaterally, once daily for 30 days.

Main Outcomes And Measures: The proportion of participants with improvement of 3 or more lines in mesopic, high-contrast, binocular distance-corrected near visual acuity (DCNVA) at hours 3 and 6 on day 30 were the primary and key secondary efficacy end points, respectively. Safety measures included adverse events.

Results: Of 323 participants who were randomized, 235 (72.8%) were female and 292 (90.4%) were White. The mean (SD) age was 49.6 (3.5) years, and the baseline mean (SD) mesopic DCNVA was 29.2 (6.3) letters. A total of 163 individuals were randomized to AGN-190584 and 160 were randomized to vehicle. GEMINI 1 met its primary and key secondary efficacy end points. On day 30, hour 3, the percentage of participants with improvement of 3 or more lines in mesopic DCNVA was 30.7% (50 of 163) in the AGN-190584 group and 8.1% (13 of 160) in the vehicle group (difference, 22.5% [95% CI, 14.3%-30.8%]; adjusted P < .001). At hour 6, those percentages were 18.4% (30 of 163) and 8.8% (14 of 160), respectively (difference, 9.7% [95% CI, 2.3%-17.0%]; adjusted P = .01). At hour 8, the between-group difference in 3 or more lines of mesopic DCNVA gains was not statistically significant, but clinically relevant prespecified outcome measures demonstrated AGN-190584 superiority to vehicle in least-squares mean (SE) mesopic DCNVA change from baseline at hour 8 (5.4 [0.51] vs 3.6 [0.52] letters; P = .009) and photopic distance-corrected intermediate visual acuity at hour 8 (3.9 [0.44] vs 2.4 [0.45] letters; P = .01) and hour 10 (3.5 [0.46] vs 1.7 [0.47] letters; P = .004). No participants with mesopic DCNVA improvement of 3 or more lines at hour 3 had losses of more than 5 letters in mesopic, high-contrast, binocular-corrected distance visual acuity. The onset of effect was at 15 minutes. AGN-190584 demonstrated an acceptable safety and tolerability profile.

Conclusions And Relevance: AGN-190584 demonstrated superiority over vehicle in mesopic DCNVA on day 30, hours 3 and 6, with an acceptable safety profile. AGN-190584 is a safe and efficacious topical therapy for presbyopia through 30 days.

Trial Registration: ClinicalTrials.gov Identifier: NCT03804268.
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http://dx.doi.org/10.1001/jamaophthalmol.2022.0059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8895317PMC
April 2022

Refractive Outcomes After LASIK for the Treatment of Mixed Astigmatism with the Allegretto WaveLight EX500.

Ophthalmol Ther 2022 Apr 15;11(2):785-795. Epub 2022 Feb 15.

Hoopes Vision, HDR Research Center, Ophthalmology University of Utah Health Sciences Center, 11820 S. State Street Suite #200, Draper, UT, 84020, USA.

Introduction: Treatment of mixed astigmatism with laser in situ keratomileusis (LASIK) is complex as the correction requires flattening the cornea in one meridian while steepening the cornea in the other meridian. The bitoric technique has become the most popular approach and has been tested across a variety of platforms. This study is the first to evaluate the results of mixed astigmatism treatment using the Allegretto WaveLight EX500.

Methods: This study was a single-center, retrospective, noncomparative analysis of 400 eyes that underwent LASIK to correct for mixed astigmatism utilizing the EX500 excimer laser. Data on uncorrected distance visual acuity, corrected distance visual acuity, and spherical equivalent was analyzed at consecutive intervals (1, 3, 6, 9, and 12 months). Refractive measurements were used to perform a vector analysis.

Results: Three and 12 months postoperatively, 71% and 74% of eyes had an uncorrected distance visual acuity (UDVA) of 20/20 or better and 99% and 100% of eyes had a UDVA of 20/40 or better, respectively. The postoperative UDVA was within one line of the corrected distance visual acuity (CDVA) in 88% and 93% of eyes at 3 and 12 months, respectively. At 3 months, 78% of eyes achieved refractive astigmatism no greater than 0.50 diopters and at 12 months, 80% achieved this. The mean spherical equivalent refraction was - 0.36 ± 0.57 D at 12 months after surgery. At the 12-month follow-up, the mean refractive cylinder was reduced by 87%, from - 2.79 to - 0.37 diopters. On vector analysis, 99% of eyes had an angle of error within ± 15° from the intended target at 3 and 12 months.

Conclusion: Treatment of mixed astigmatism using the Allegretto WaveLight EX500 laser exceeded the industry standards of safety, efficacy, stability, and accuracy.
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http://dx.doi.org/10.1007/s40123-022-00472-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8927553PMC
April 2022

Special Issue on Refractive Surgery.

J Clin Med 2022 Jan 28;11(3). Epub 2022 Jan 28.

Hoopes Vision Research Center, Draper, UT 84020, USA.

Laser in situ keratomileusis (LASIK) and photorefractive keratectomy (PRK), for the treatment of refractive errors, continues to evolve [...].
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http://dx.doi.org/10.3390/jcm11030684DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8836585PMC
January 2022

Assessing the Efficacy of Four Diagnostic Devices and Four Nomograms in Posterior Chamber Phakic Intraocular Lens Size Selection.

J Refract Surg 2022 Feb 1;38(2):106-111. Epub 2022 Feb 1.

Purpose: To assess the efficacy of different devices and nomograms in predicting the most optimal Implantable Collamer Lens (ICL) (STAAR Surgical) size.

Methods: This retrospective study includes 73 patients (142 eyes) who underwent ICL placement surgery. Anterior segment measurements were obtained by the OPD-Scan III (Marco), the Lenstar LS 900 (Haag-Streit AG/Alcon Laboratories, Inc), the Galilei G4 (Ziemer), and the VuMax ultrasound biomicroscopy device (UBM) (Sonomed Escalon). The efficacy of the four devices and four nomograms was assessed by comparing the indicated ICL sizes to the patient's postoperative vault measurements.

Results: Using white-to-white (WTW) measurements obtained by the Lenstar LS 900 and Galilei G4 coupled with the U.S. Food and Drug Administration's (FDA) (also called the manufacturer's) nomogram predicted the highest percentage (33% and 43%) of the 13.7 mm ICL sizes, respectively. Using the VuMax UBM coupled with the Dougherty nomogram indicated the highest percentage (80%) of the 12.6 mm ICL size. The ICL sizes predicted by UBM using the Parkhurst nomogram were comparable to those deemed ideal according to postoperative vault measurements.

Conclusions: The Parkhurst nomogram predicted the most appropriate ICL size. When using WTW measurements, the optimized WTW nomogram showed promising results, especially in eyes whose preoperative calculations suggest low postoperative vaults. Moreover, clinicians should use caution when using the FDA nomogram because it showed a propensity toward indicating oversized ICLs. .
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http://dx.doi.org/10.3928/1081597X-20211109-01DOI Listing
February 2022

To Amputate or Not to Amputate: Management of Iatrogenic LASIK Flap Dehiscence and Epithelial Ingrowth with Overlying Pseudopterygium.

Case Rep Ophthalmol 2021 Sep-Dec;12(3):967-974. Epub 2021 Dec 20.

Hoopes Vision Research Center, Hoopes Vision, Draper, Utah, USA.

A 73-year-old male with a history of myopic laser-assisted in situ keratomileusis (LASIK) 20 years earlier presented with a late LASIK flap dehiscence, epithelial ingrowth, conjunctivalization, and the development of a pseudopterygium in the right eye. The findings were consistent with surgical trauma, likely occurring after corneal epithelial debridement to improve visualization during pars plana vitrectomy for retinal detachment repair 3 months earlier. The patient underwent epithelial ingrowth debridement, LASIK flap reapproximation and suturing, and a conjunctival limbal autograft from the contralateral eye. The surgery was completed successfully without the need for flap amputation. Postoperatively, the patient had an uneventful course with a well-healing conjunctival graft and no interface opacity or evidence of recurrent pseudopterygium of the right eye. The graft and corneal topography remained stable after subsequent cataract surgery.
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http://dx.doi.org/10.1159/000519628DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8787494PMC
December 2021

The historical development and an overview of contemporary keratoprostheses.

Surv Ophthalmol 2022 Jul-Aug;67(4):1175-1199. Epub 2022 Jan 23.

Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA. Electronic address:

Corneal blindness is a major cause of ocular morbidity that affects 4.5 million people worldwide. Though penetrating keratoplasty is an excellent option for most patients with corneal blindness, there are various conditions for which corneal transplantation carries a low likelihood of success. In cases of multiple failed transplants, the keratoprosthesis, an artificial cornea, is a well-documented surgical option, though few models are commercially available. Keratoprostheses also provide a solution to those in developing areas of the world who do not have access to penetrating keratoplasty owing to limitations in the supply of corneal donor tissue. We summarize the history of keratoprostheses, examine the various keratoprosthesis models used across the globe, and highlight efforts to improve the accessibility and biointegration of keratoprosthesis through novel technological developments.
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http://dx.doi.org/10.1016/j.survophthal.2022.01.005DOI Listing
January 2022

Atypical presentation of acanthamoeba keratitis resembling central toxic keratopathy.

Am J Ophthalmol Case Rep 2022 Mar 16;25:101243. Epub 2021 Dec 16.

Hoopes Vision Research Center, Draper, UT, USA.

Purpose: To describe an atypical case of acanthamoeba keratitis with positive in vivo confocal microscopy in a non-contact lens user who presented with signs and symptoms suggestive of central toxic keratopathy.

Observations: The patient presented with bilateral, though sequential, decreased visual acuity with mild pain. Examination showed stromal haze with corneal flattening and thinning without epithelial defects. Optical coherence tonometry of the right eye revealed an inverse dome-shaped appearance of the opacity and in-vivo confocal imaging showed double-walled cysts consistent with acanthamoeba. Corneal haze, stromal loss, resolved and visual acuity improved over time.

Conclusion And Importance: Acanthamoeba is a rare cause of infectious keratitis that is most often associated with contact lens wear in developed countries. Typically, it presents with a unilateral decrease in visual acuity, photophobia, watering, and pain that is out of proportion to slit lamp examination findings. However, many atypical presentations have been reported in the literature. Consequently, it may be misdiagnosed, especially early in the course of the disease. This delay in diagnosis can lead to progressive ulceration and visual impairment. In addition, cyst formation can make eradication with anti-amoebic treatment especially difficult.Central toxic keratopathy is a non-inflammatory clinical syndrome of unknown etiology that is most often associated with excimer laser ablation, though other associated causes have been reported. It is characterized by a central or paracentral opacity with corneal stromal loss and resultant hyperopic shift. The opacification and stromal loss mostly resolve over the course of months with an improvement in visual acuity. This report may help physicians broaden their differential and correctly diagnose atypical presentations of amoebic infection.
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http://dx.doi.org/10.1016/j.ajoc.2021.101243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8715135PMC
March 2022

Delayed Epithelial Healing with Corneal Edema and Haze After Photorefractive Keratectomy Using Intraoperative Mitomycin C.

Int Med Case Rep J 2021 24;14:863-870. Epub 2021 Dec 24.

Hoopes Vision Research Center, Hoopes Vision, Draper, UT, 84020, USA.

We report an unusual presentation of presumed mitomycin C toxicity with possible subsequent hypersensitization to other medication toxicities. A 50-year-old female presented three months after photorefractive keratectomy with intraoperative mitomycin C for the management of persistent epithelial defects, corneal haze, and edema. She was found to have used an expansive and rapidly changing medical regimen which may have caused additional toxicity. These medications included besifloxacin, bromfenac, and ketotifen. Additives such as benzalkonium chloride and DuraSite may have also contributed. Intraoperative mitomycin C can result in longstanding corneal haze, edema, and delayed epithelial healing in the setting of corneal refractive surgery. These may leave the cornea more susceptible to additional subsequent medication toxicities during the postoperative period. This report describes a case of mitomycin C exposure leading to a prolonged sensitivity to other medication toxicities, which has not been discussed elsewhere in the literature.
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http://dx.doi.org/10.2147/IMCRJ.S342774DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8714007PMC
December 2021

A One Year Longitudinal Comparative Analysis of Visual Outcomes Between Femtosecond Laser-Assisted Cataract Surgery and Standard Phacoemulsification Cataract Surgery.

Clin Ophthalmol 2021 14;15:4667-4680. Epub 2021 Dec 14.

Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA.

Purpose: To assess visual outcomes over time of femtosecond laser-assisted cataract surgery compared to standard phacoemulsification cataract surgery.

Design: A retrospective, single-center comparative study.

Methods: Patient data including demographics, ocular biometry, pre- and postoperative visual acuity, postoperative complications, primary (uncorrected distance visual acuity over time) and secondary visual outcomes (uncorrected near visual acuity, best distance visual acuity, patient complaints, satisfaction, and postoperative surgery) were gathered and statistically analyzed. Demographic differences between patients receiving femtosecond-laser assisted cataract surgery (FLACS) versus standard phacoemulsification cataract surgery (PCS) were corrected for outcome comparison. Safety, efficacy, predictability, and stability were analyzed for each procedure and compared.

Results: A total of 155 eyes in PCS and 143 eyes in FLACS were analyzed at 1 week, 3 months, and 1 year using odds ratio. The odds ratio of being 20/20 or better and 20/40 or better at the specified time periods were similar and statistically insignificant at all time periods analyzed except 20/20 or better for uncorrected distance visual acuity (UDVA) at 1 year (p=0.0001) and uncorrected near visual acuity (UNVA) at 1 week (p=0.02). In both cases, the odds of being 20/20 or better favored FLACS. Mean UDVA, UNVA, and best distance visual acuity (BDVA) were all similar and statistically insignificant between the two groups. Postoperative patient complaints, safety, efficacy, predictability, and stability between the two groups showed no statistical significance.

Conclusion: Despite the odds ratio of being 20/20 or better favoring FLACS for UDVA at 1 year and UNVA at 1 week, the mean logMAR UDVA, BDVA, and UNVA were similar and statistically insignificant between the FLACS and PCS groups at 1 week, 3 months, and 1 year. Differences in visual acuity were likely due to differences other than surgical approaches. While both FLACS and PCS are appropriate approaches to cataract surgery, one does not appear to be superior when assessing longitudinal markers for visual acuity, safety, efficacy, predictability and stability.
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http://dx.doi.org/10.2147/OPTH.S336356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8684426PMC
December 2021

Agreement of anterior segment measurements between four diagnostic imaging devices in myopic patients.

Expert Rev Med Devices 2021 Dec 7;18(12):1235-1243. Epub 2021 Dec 7.

Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA.

Purpose: To compare the inter-device agreement of anterior chamber depth (ACD), central corneal thickness (CCT), flat keratometry (K1), steep keratometry (K2), corneal astigmatism (ΔK), and white-to-white (WTW) measurements.

Methods: This is a retrospective study with 73 myopic patients (142 eyes). We extracted and compared anterior segment measurements (ACD, CCT, K1, K2, ΔK, and WTW) of four devices (OPD-Scan III, Pentacam HR, Lenstar LS 900, and Galilei G4), and performed pairwise agreement comparisons between them.

Results: Agreement analyses revealed that the most agreement occurred: in Pentacam HR and Galilei G4 for ACD measurements, in Pentacam HR and Lenstar LS 900 for CCT measurements, in OPD-Scan III and Galilei G4 for WTW measurements, in OPD-Scan III and Pentacam HR for K1 and K2 measurements, and OPD-Scan III and Galilei G4 for ΔK measurements.

Conclusion: OPD-Scan III is interchangeable with both Galilei G4 and Lenstar LS 900 for WTW measurements. OPD-Scan III and the Pentacam-HR are interchangeable in K1, K2, and ΔK measurements. OPD-Scan III and Lenstar LS 900, and OPD-Scan III and Galilei G4 are interchangeable in K1 and ΔK measurements, respectively.
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http://dx.doi.org/10.1080/17434440.2021.2012153DOI Listing
December 2021

Cataract surgery and intraocular lens placement in patients with Fuchs corneal dystrophy: a review of the current literature.

Curr Opin Ophthalmol 2022 Jan;33(1):21-27

University of Utah School of Medicine, Salt Lake City, Utah, USA.

Purpose Of Review: Late-onset Fuchs endothelial corneal dystrophy (FECD) is seen in approximately 4% of individuals over the age of 40. With the growing population of adults over the age of 65, ophthalmologists need to be aware of the preoperative, perioperative, and postoperative considerations involved in cataract surgery in Fuchs patients.

Recent Findings: Management of cataract patients with FECD requires preoperative assessment of endothelial cell size, density, and morphology. Considerations for perioperative endothelial cell loss include patients with hyperopia and shallow anterior chambers, phacoemulsification technique, transfer of ultrasonic energy to the cornea, corneal-protective perioperative agents, as well as thermal and mechanical damage.

Summary: Ophthalmologists performing cataract surgery on patients with FECD must carefully consider the risks of endothelial cell loss during surgery and minimize the risk of corneal decompensation after surgery. Preoperative management should evaluate the severity of the FECD as well as individual factors such as cataract density, the health and thickness of the cornea, and the anterior chamber depth. Perioperative techniques, adjustments to biometry calculations, and intraocular lens (IOL) selection may help optimize visual outcomes and recovery time.
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http://dx.doi.org/10.1097/ICU.0000000000000816DOI Listing
January 2022

Delayed Perforation of an Intrastromal Corneal Ring Segment into the Anterior Chamber: A Case Report and Review of the Literature.

Case Rep Ophthalmol 2021 Sep-Dec;12(3):740-748. Epub 2021 Sep 9.

Hoopes Vision Research Center, Hoopes Vision, Draper, Utah, USA.

Intrastromal corneal ring segments (ICRSs) are an effective treatment for stabilizing and normalizing corneal shape in patients with keratoconus and other corneal ectasias. Intraoperative segment perforation through the corneal endothelium into the anterior chamber (AC) is an uncommon but known complication. However, perforation into the AC postoperatively is an exceedingly rare complication with only 3 reported cases in the literature. One case was due to Descemet membrane detachment and another due to ocular trauma. In the third case, the mechanism for perforation was unclear. We present the fourth case of delayed ICRS perforation due to silent migration through the endothelium into the AC. We also present all reported cases in the literature of intraoperative and postoperative perforation into the AC.
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http://dx.doi.org/10.1159/000518012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8460883PMC
September 2021

Post-LASIK corneal epithelial irregularities October consultation #1.

J Cataract Refract Surg 2021 10;47(10):1377

Salt Lake City, Utah.

A 55-year-old man with a history of bilateral laser-assisted in situ keratomileusis (LASIK) and subsequent enhancement over 15 years ago presented to our facility to investigate refractive surgery options. The patient reported progressive blurring and fluctuation of vision and desired independence from contact lenses and spectacles. Uncorrected distance visual acuity (UDVA) was 20/30 -2.0 in the right eye and 20/400 in the left eye, corrected to 20/60 in the left eye. Manifest refraction was +0.75 -1.75 × 180 diopters (D) in the right eye and -3.50 -3.50 × 64 D in the left eye. Keratometry readings were 43.9/41.1 @ 25 in the right eye and 49.3/46.8 @ 2 in the left eye. On slitlamp examination, the patient showed diffuse subepithelial fibrosis and confluent circumferential elevation, respecting the LASIK flap margin and extending centrally into the visual axis (Figure 1JOURNAL/jcrs/04.03/02158034-202110000-00025/figure1/v/2021-09-20T141830Z/r/image-tiff). Fluorescein pooling was also observed. Anterior segment ocular coherence tomography (OCT) demonstrated subepithelial hyperreflective density in the left eye (Figure 2JOURNAL/jcrs/04.03/02158034-202110000-00025/figure2/v/2021-09-20T141830Z/r/image-tiff). Pentacam showed irregularity and inferior steepening up to 52.0 D (Figure 3JOURNAL/jcrs/04.03/02158034-202110000-00025/figure3/v/2021-09-20T141830Z/r/image-tiff). A review of the patient's records from 4 years ago revealed UDVA of 20/30 -2 in the right eye and 20/20 in the left eye with manifest refraction of +1.00 -1.50 × 30 D in the right eye and -0.25 D in the left eye. Keratometry then showed 39.52/40.91 @ 98 in the right eye and 39.85/40.42 @ 75 in the left eye. Patient's slitlamp examination revealed minimal subepithelial irregularity without endothelial changes in both eyes. At current presentation, the patient was not deemed a candidate for further refractive surgery given a low residual stromal bed after original LASIK with enhancement. The patient was seeking help and advice for his declining vision. What is the most likely diagnosis, and what other conditions are on your differential? What would be your next step? Would you request additional diagnostic workup? What medical and surgical interventions would you recommend?
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http://dx.doi.org/10.1097/j.jcrs.0000000000000799DOI Listing
October 2021

Comparison of 6.0 mm versus 6.5 mm Optical Zone on Visual Outcomes after LASIK.

J Clin Med 2021 Aug 24;10(17). Epub 2021 Aug 24.

Hoopes Vision Research Center, Hoopes Vision, Draper, UT 84020, USA.

Previous studies have demonstrated safety and efficacy using 6.0 and 6.5 mm optical zones in the WaveLight EX500 Excimer Laser System but have not evaluated if differing optical zone sizes influence refractive outcomes. This study examines visual outcomes between two study populations undergoing LASIK with either a 6.0 mm (1332 patients) or 6.5 mm (1332 patients) optical zone. Outcomes were further stratified by severity of myopia (low, moderate, and high) and astigmatism (low and high). Patients were matched by age and preoperative manifest sphere and cylinder. Postoperative measurements were then compared. The 6.5 mm group demonstrated better postoperative manifest refractive spherical equivalent (MRSE), manifest sphere, and absolute value of the difference in actual and target spherical equivalent refraction (|∆ SEQ|), within the total population, moderate myopia, and low astigmatism groups, but this did not lead to improved postoperative uncorrected distance visual acuity (UDVA) or best corrected distance visual acuity (CDVA). Though astigmatic correction and postoperative angle of error were similar between optical zone sizes, they were significantly worse with high myopia. Overall, this study demonstrates differences in visual outcomes between the 6.0 and 6.5 mm optical zone sizes that may warrant consideration; however, essentially, the results are comparable between them.
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http://dx.doi.org/10.3390/jcm10173776DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8432203PMC
August 2021

Controversy and Consideration of Refractive Surgery in Patients with Heritable Disorders of Connective Tissue.

J Clin Med 2021 Aug 24;10(17). Epub 2021 Aug 24.

Hoopes Vision Research Center, Hoopes Vision, Draper, UT 84020, USA.

Heritable Disorders of Connective Tissue (HDCTs) are syndromes that disrupt connective tissue integrity. They include Osteogenesis Imperfecta (OI), Ehlers Danlos Syndrome (EDS), Marfan Syndrome (MFS), Loeys-Dietz Syndrome (LDS), Epidermolysis Bullosa (EB), Stickler Syndrome (STL), Wagner Syndrome, and Pseudoxanthoma Elasticum (PXE). Because many patients with HDCTs have ocular symptoms, commonly myopia, they will often present to the clinic seeking refractive surgery. Currently, corrective measures are limited, as the FDA contraindicates laser-assisted in-situ keratomileusis (LASIK) in EDS and discourages the procedure in OI and MFS due to a theoretically increased risk of post-LASIK ectasia, poor wound healing, poor refractive predictability, underlying keratoconus, and globe rupture. While these disorders present with a wide range of ocular manifestations that are associated with an increased risk of post-LASIK complications (e.g., thinned corneas, ocular fragility, keratoconus, glaucoma, ectopia lentis, retinal detachment, angioid streaks, and ocular surface disease), their occurrence and severity are highly variable among patients. Therefore, an HDCT diagnosis should not warrant an immediate disqualification for refractive surgery. Patients with minimal ocular manifestations can consider LASIK. In contrast, those with preoperative signs of corneal thinning and ocular fragility may find the combination of collagen cross-linking (CXL) with either photorefractive keratotomy (PRK), small incision lenticule extraction (SMILE) or a phakic intraocular lens (pIOL) implant to be more suitable options. However, evidence of refractive surgery performed on patients with HDCTs is limited, and surgeons must fully inform patients of the unknown risks and complications before proceeding. This paper serves as a guideline for future studies to evaluate refractive surgery outcomes in patients with HDCTs.
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http://dx.doi.org/10.3390/jcm10173769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8432249PMC
August 2021

Ectasia After Corneal Refractive Surgery: A Systematic Review.

Ophthalmol Ther 2021 Dec 20;10(4):753-776. Epub 2021 Aug 20.

Hoopes Vision Research Center, Hoopes Vision, 11820 S. State Street Suite #200, Draper, UT, 84020, USA.

Introduction: The incidence of ectasia following refractive surgery is unclear. This review sought to determine the worldwide rates of ectasia after photorefractive keratectomy (PRK), laser-assisted in situ keratomileusis (LASIK), and small incision lenticule extraction (SMILE) based on reports in the literature.

Methods: A systematic review was conducted according to modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Publications were identified by a search of eight electronic databases for relevant terms between 1984 and 2021. Patient characteristics and preoperative values including manifest refractive spherical refractive equivalent (MRSE), central corneal thickness (CCT), anterior keratometry, postoperative residual stromal bed (RSB), and percent tissue altered (PTA) were summarized. In addition, annual rates of each refractive surgery were determined, and incidence of post-refractive ectasia for each type was calculated using the number of ectatic eyes identified in the literature.

Results: In total, 57 eyes (70 eyes including those with preoperative risk factors for ectasia) were identified to have post-PRK ectasia, while 1453 eyes (1681 eyes including risk factors) had post-LASIK ectasia, and 11 eyes (19 eyes including risk factors) had post-SMILE ectasia. Cases of refractive surgery performed annually were estimated as 283,920 for PRK, 1,608,880 for LASIK, and 96,750 for SMILE. Reported post-refractive ectasia in eyes without preoperative identifiable risk factors occurred with the following incidences: 20 per 100,000 eyes in PRK, 90 per 100,000 eyes in LASIK, and 11 per 100,000 eyes in SMILE. The rate of ectasia in LASIK was found to be 4.5 times higher than that of PRK.

Conclusion: Post-refractive ectasia occurs at lower rates in eyes undergoing PRK than LASIK. Although SMILE appears to have the lowest rate of ectasia, the number of cases already reported since its recent approval suggests that post-SMILE ectasia may become a concern. Considering that keratoconus is a spectrum of disease, pre-existing keratoconus may play a larger role in postoperative ectasia than previously accounted for in the literature.
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http://dx.doi.org/10.1007/s40123-021-00383-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8589911PMC
December 2021

Five-Year Incidence, Management, and Visual Outcomes of Diffuse Lamellar Keratitis after Femtosecond-Assisted LASIK.

J Clin Med 2021 Jul 11;10(14). Epub 2021 Jul 11.

Hoopes Vision, HDR Research Center, 11820 S. State Street Suite #200, Draper, UT 84020, USA.

Femtosecond (FS) lasers initially had a higher incidence of diffuse lamellar keratitis (DLK) compared with microkeratome flap creation. It has been theorized that higher-frequency lower-energy (HFLE) FS lasers would reduce the incidence of DLK. Our study sought to evaluate the incidence of newer HFLE FS lasers with pulse frequencies above 60 kHz. It was a retrospective case-control study evaluating the incidence of DLK following flap creation with one of three FS lasers (AMO iFs, WaveLight FS200, Zeiss VisuMax). Uncomplicated LASIK cases were included as the control group (14,348 eyes) and cases of DLK were recorded in the study group (637 eyes). Of the 637 cases of DLK, 76 developed stage II, 25 progressed to stage III, and only three developed stage IV DLK. The overall incidence rate of DLK was 4.3%; it has fallen with the invention of newer HFLE FS lasers and is approaching the DLK incidence rates of DLK with microkeratome.
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http://dx.doi.org/10.3390/jcm10143067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8304683PMC
July 2021

Comparison of the Visual Outcomes of an Extended Depth-of-Focus Lens and a Trifocal Lens.

Clin Ophthalmol 2021 16;15:3051-3063. Epub 2021 Jul 16.

Hoopes Vision Research Center, Hoopes Vision, Draper, UT, USA.

Purpose: To compare the visual performance of the AcrySof IQ PanOptix trifocal intraocular lens and the TECNIS Symfony extended depth-of-focus lens at near and distance visual ranges.

Methods: A total of 146 patients (221 eyes) who underwent phacoemulsification and cataract extraction and received either a PanOptix or Symfony lens from January 2019 to July 2020 were included in the study (83 PanOptix non-toric, 30 PanOptix toric, 70 Symfony non-toric, and 38 Symfony toric). Uncorrected distance (UDVA), uncorrected near (UNVA), and corrected distance (CDVA) visual acuity were assessed at one-day, one-month, and three-months postoperatively. Averages of UDVA, UNVA, and CDVA were taken to evaluate which lens was superior at near and distance visual ranges. Secondary outcome measures including glare, halo, dryness, and problems with night vision were documented at each postoperative visit.

Results: At one month postoperatively, the average UNVA was 0.16 ± 0.14 logMAR in the PanOptix group and 0.21 ± 0.14 logMAR in the Symfony group (P=0.007); the average UDVA for the PanOptix group was 0.09 ± 0.13 logMAR compared to the Symfony group at 0.10 ± 0.14 logMAR (P=0.67); and the average CDVA was 0.02 ± 0.05 logMAR in the PanOptix group and 0.00 ± 0.04 logMAR in the Symfony group (P=0.11). At three months postoperatively, there were no statistically significant differences in UNVA, UDVA, or CDVA between the two groups (P=0.18, 0.79, 0.68 respectively). There was no statistically significant difference in secondary outcome measures at one- and three-months (P=0.49, 0.10 respectively).

Conclusion: The AcrySof IQ PanOptix trifocal intraocular lens appears to afford better UNVA compared to the TECNIS Symfony extended depth-of-focus intraocular lens at one-month postoperatively, though this difference was not seen at three months postoperatively. There is no statistically significant difference in UDVA and CDVA between the two groups at postoperative day one, one-month, and three-months.
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http://dx.doi.org/10.2147/OPTH.S321779DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8291815PMC
July 2021
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