Publications by authors named "Majid Moshirfar"

297 Publications

Comparison of Visual Outcome After Hyperopic LASIK Using a Wavefront-Optimized Platform Versus Other Excimer Lasers in the Past Two Decades.

Ophthalmol Ther 2021 May 19. Epub 2021 May 19.

Hoopes Vision Research Center, Draper, UT, USA.

Introduction: Laser-assisted in-situ keratomileusis (LASIK) for the correction of hyperopia and hyperopic astigmatism is challenging and has been less studied than for the correction of myopia and myopic astigmatism. The aim of this study was to analyze the refractive outcomes of LASIK in hyperopia and hyperopic astigmatic eyes using a wave-front optimized laser platform (the Allegretto EX500 laser) and perform a historical comparison with other excimer lasers within the past two decades.

Methods: A one-center (Tertiary Refractive Center, Draper, Utah), retrospective, non-comparative study was conducted on 379 eyes treated with LASIK for hyperopia and hyperopic astigmatism. The data retrieved on these eyes were analyzed using uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), and spherical equivalents. A literature search of excimer platforms in use in the past 20 years and a comparison of US Federal Drug Administration-approved platforms for hyperopia were performed.

Results: At 3 and 12 months postoperatively, 142 (66%) and 81 (69%) eyes had a UDVA of 20/20 or better and 207 (96%) and 114 (97%) eyes had a UDVA of 20/40 or better, respectively. The mean refractive spherical equivalent was - 0.52 ± 0.78 D at 3 months and - 0.46 ± 0.79 D at 12 months. At 12 months, 181 (96%) eyes achieved a spherical equivalent within ± 1.00 D of the intended target. Studies published before 2005 reported lower rates of UDVA 20/20 or better (32%) compared to those published after (68%); however, this discrepancy was less evident for UDVA 20/40 or better. A similar trend towards improved accuracy was noted in the literature with postoperative manifest refractive spherical equivalent within ± 0.50 D before and after 2005.

Conclusion: There has been significant improvement in safety, efficacy, stability, and accuracy of LASIK treatment for hyperopia and hyperopic astigmatism within the past two decades. Newer excimer lasers meet industry standards and in particular, the Allegretto EX500 used in this study exceeded industry standards.
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http://dx.doi.org/10.1007/s40123-021-00346-1DOI Listing
May 2021

EDITOR'S COMMENTS.

Authors:
Majid Moshirfar

J Cataract Refract Surg 2021 Apr;47(4):555

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http://dx.doi.org/10.1097/01.j.jcrs.0000749636.76346.f7DOI Listing
April 2021

Bilateral reticular haze and scar involving central cornea.

Authors:
Majid Moshirfar

J Cataract Refract Surg 2021 Apr;47(4):552-555

A 17-year-old girl with a few years' history of declining vision, photophobia, and dry eye symptoms was referred to our clinic. She noted that the vision in the right eye declined significantly over the past several months. On her last year examination, her uncorrected distance visual acuity (UDVA) was recorded as 20/25 in both eyes with a corrected distance visual acuity (CDVA) of 20/20 in both eyes with minimal refractive error, with a diagnosis of bilateral Salzmann nodular degeneration. The patient was given artificial tears and was encouraged to wear sunglasses. On examination now, UDVA was 20/70 in the right eye and 20/40 in the left eye. The manifest refraction was -2.00 + 1.25 × 96 in the right eye and -1.00 + 2.00× 34 in the left eye, with a CDVA of 20/50 and 20/30, respectively. Slitlamp examination revealed superficial reticular stromal scar with clear intervening spaces involving the anterior 75 μm of the stromal cornea in the central 6.0 mm optical zone (Figure 1).JOURNAL/jcrs/04.03/02158034-202104000-00021/figure1/v/2021-04-19T183640Z/r/image-tiffJOURNAL/jcrs/04.03/02158034-202104000-00021/figure2/v/2021-04-19T183640Z/r/image-tiff The rest of the anterior and posterior segment examination was completely normal and noncontributory. Anterior segment optical coherence tomography (AS-OCT) revealed subepithelial lesion involving the central aspect of the cornea in the right eye more than that in the left eye (Figure 2). Family history was significant for an older sister with a similar problem who never required medical attention. She also has mild photophobia and dry eye symptoms. What is your differential diagnosis? What diagnostic test will help you in your diagnosis and clinical decision-making? What is the most likely diagnosis in this case? Do you recommend medical and/or surgical intervention in the right eye, realizing that there has been exacerbation of her ocular condition in the most recent year? What is the long-term prognosis and future plan for a patient with this potential condition?
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http://dx.doi.org/10.1097/j.jcrs.0000000000000627DOI Listing
April 2021

The impact of vaping on ocular health: a literature review.

Int Ophthalmol 2021 Apr 16. Epub 2021 Apr 16.

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

Purpose: Vaping, or the use of electronic cigarettes, was initially introduced as a step toward smoking cessation, but has become an increasingly popular option for smokers. Though advertised as safer than conventional cigarettes, these devices have been found to contain carcinogenic chemicals, air pollutants, and heavy metals. The purpose of this article is to shed light on the known effects of vaping on the ocular setting and raise the discussion about additional potential effects that may call for further investigation.

Methods: A comprehensive literature search was conducted for publications pertaining to the effects of vaping on the eye. Relevant studies and findings were summarized in this article.

Results: It was found that aldehydes and free radicals present in electronic cigarettes may induce a disturbance in tear film stability, and vape flavorings may damage the lipid layer through peroxidation. Corneal staining has been shown to appear following exposure to e-cigarette vapor, with nicotine and acrolein potentially inducing an inflammatory response in corneal epithelial cells. In addition, nicotine has been shown to induce nystagmus, exert vasoconstrictive effects on ocular blood flow, and may interfere with retinal light-adapted vision. Vape-related explosions, though unpredictable, may also result in decreased visual acuity along with long-term ocular trauma.

Conclusion: Research discussing both the short-term and long-term effects of vaping on the eye is limited. However, the potential harms of substances such as nicotine and aldehydes warrant additional investigation and increased education about the detriment that electronic cigarettes may inflict on sensitive organs.
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http://dx.doi.org/10.1007/s10792-021-01842-wDOI Listing
April 2021

PRK Enhancement for Residual Refractive Error After Primary PRK: A Retrospective Study.

Ophthalmol Ther 2021 Mar 30;10(1):175-185. Epub 2021 Jan 30.

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

Introduction: The efficacy and safety of photorefractive keratectomy (PRK) has been well documented, but outcomes of PRK enhancement following PRK remain understudied. This study aimed to evaluate the safety, efficacy, and predictability of PRK enhancement in patients with residual refractive error after primary PRK and compare these results to prior studies as well as Food and Drug Administration (FDA) safety and efficacy clinical endpoints.

Methods: This non-randomized, retrospective chart analysis included eyes with a history of PRK that underwent PRK enhancement at a single center. Post-enhancement data were documented at 3-month and 1-year visits. Patient characteristics between the study group and a control group who underwent primary PRK only were compared. Safety and efficacy measures included change in uncorrected distance visual acuity (UDVA), change in corrected distance visual acuity (CDVA), manifest refraction spherical equivalent (MRSE), amount of induced astigmatism, and presence of serious adverse events.

Results: A total of 188 eyes from 141 patients were included. When compared to the control group, women underwent PRK enhancement at a higher rate than men (P = 0.004). The group undergoing PRK enhancement had a higher sphere (P = 0.013) and spherical equivalent (P = 0.004) than the control group at the time of primary PRK. MRSE was reduced to - 0.97 ± 0.72 D (- 2.25 to + 2.13 D) from pre-enhancement values of - 0.98 ± 0.66 D (- 2.75 to + 1.75 D) and stable over 12-month visits with 86% and 98% of eyes within ± 0.50 D and ± 1.00 D of target, respectively. UDVA of 20/20 or better was achieved in 75% of eyes. The UDVA of 75% of eyes remained the same or improved by 1 or more Snellen lines compared with pre-enhancement CDVA.

Conclusion: Our results demonstrate that, when compared with previous studies, modern PRK enhancement after PRK has improved visual acuity and refractive outcomes. Though PRK enhancement is not an FDA approved procedure, we show that it meets or exceeds the FDA criteria for the correction of refractive error.
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http://dx.doi.org/10.1007/s40123-021-00331-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7886917PMC
March 2021

Coral Keratitis: Case Report and Review of Mechanisms of Action, Clinical Management and Prognosis of Ocular Exposure to Palytoxin.

Clin Ophthalmol 2021 12;15:141-156. Epub 2021 Jan 12.

Hoopes Vision Research Center, Draper, UT, USA.

Palytoxin is one of the most lethal natural toxins ever discovered. This molecule has been isolated from various marine animals, including zoanthid corals. This popular organism is commonly found in many home saltwater aquariums due to its beauty and survivability. As a result of an increase in popularity, an increased number of individuals are at risk for exposure to this potentially deadly toxin. Affected patients may experience various symptoms based on the route of exposure (ie, cutaneous contact, inhalation of aerosolized toxin, ocular exposure, or ingestion). Ocular exposure can occur in various ways (eg, contact with contaminated water, rubbing the eye with a dirtied hand, or direct spraying into the eye), and incidence rates have dramatically risen in recent years. In this review, we discuss a case of systemic toxicity from inhalation and ocular exposure to presumed palytoxin on a zoanthid coral which resulted in an intensive care unit (ICU) stay, and corneal perforation which required a corneal transplant. Additionally, we review what is known about the mechanism of action of this toxin, propose a comprehensive hypothesis of its effects on corneal cells, and discuss the prognosis and clinical management of patients with systemic symptoms secondary to other routes of exposure.
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http://dx.doi.org/10.2147/OPTH.S290455DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811479PMC
January 2021

Five-Year Occurrence and Management of Central Toxic Keratopathy After Femtosecond Laser-Assisted LASIK.

J Refract Surg 2021 Jan;37(1):25-31

Purpose: To report the 5-year occurrence, management, and outcomes of 12 eyes diagnosed as having central toxic keratopathy (CTK) after femtosecond laser-assisted in situ keratomileusis (FS-LASIK).

Methods: A retrospective chart review was conducted on 20,622 FS-LASIK procedures performed at a single site from January 2015 to December 2019 to identify patients diagnosed as having central toxic keratopathy. Preoperative and postoperative visual acuity, refraction, and imaging were recorded and analyzed.

Results: CTK occurred in 12 eyes of 8 patients after FSLASIK. A total of 75% of eyes were diagnosed during an outbreak that happened over 2 months and the remaining 25% were considered sporadic. Five eyes were treated with flap lift and irrigation and 7 eyes were treated non-surgically. The average time to resolution of CTK in eyes that underwent flap lift and irrigation was 53 days compared to 33 days in eyes treated non-surgically. All 5 eyes treated with flap lift and irrigation ultimately achieved uncorrected distance visual acuity of 0.1 logMAR or better, whereas only 3 of 7 eyes treated non-surgically achieved the same. At the final postoperative visit, the eyes treated with flap lift and irrigation measured on average 14 µm thinner and 1.60 diopters (D) flatter than the expected postoperative pachymetry and keratometry, respectively. Those treated non-surgically were on average 28 µm thinner and 1.70 D flatter than expected.

Conclusions: CTK is a rare complication of FS-LASIK but can occur in clusters. Although management of CTK is debated, flap lift and irrigation may lead to better visual acuity and refractive and anatomic outcomes in some cases. [J Refract Surg. 2021;37(1):25-31.].
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http://dx.doi.org/10.3928/1081597X-20201030-01DOI Listing
January 2021

Marginal Keratitis with Secondary Diffuse Lamellar Keratitis After Small Incision Lenticule Extraction (SMILE) After Initiation of Continuous Positive Airway Pressure (CPAP) Therapy.

Int Med Case Rep J 2020 10;13:685-689. Epub 2020 Dec 10.

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

Marginal keratitis, also known as catarrhal infiltrates, is a common, self-limiting condition characterized by inflammation at the peripheral aspect of the cornea. This non-infectious process is most typically a reaction to bacteria such as , and results from a cell-mediated immune response to the bacterial antigens. This hypersensitivity reaction leads to the formation of stromal infiltrates that run parallel to the limbus. These infiltrates may extend around the limbal edge and can lead to the formation of marginal ulcers. Often the patient will have associated blepharoconjunctivitis. Both marginal keratitis and blepharoconjunctivitis are treated with topical steroids, with or without antibiotics, and good lid hygiene. We report a case of a patient who previously underwent small incision lenticule extraction (SMILE) who presented with marginal keratitis and secondary diffuse lamellar keratitis (DLK) in the right eye following recent initiation of continuous positive airway pressure (CPAP) therapy. There was no antecedent ocular trauma. With the initiation of steroid therapy, the patient returned to baseline visual acuity within one week. Though recurrence may be common in cases of marginal keratitis, our patient has not had any recurrence of symptoms or disease. DLK has previously been reported in the literature; however, there has been no reported case of marginal keratitis with secondary DLK after initiation of CPAP therapy to date.
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http://dx.doi.org/10.2147/IMCRJ.S285625DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7735781PMC
December 2020

Visual Outcomes After Sequential Posterior Chamber Phakic IOL with Corneal Refractive Surgery (Bioptics) for the Treatment of Myopic Astigmatism.

Clin Ophthalmol 2020 9;14:4337-4346. Epub 2020 Dec 9.

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

Purpose: To report the outcomes of sequential posterior chamber phakic intraocular lens (PC-pIOL) with corneal refractive surgery in conventional (PC-pIOL prior to refractive surgery) and reverse (refractive surgery prior to PC-pIOL) bioptics for treating high myopic astigmatism.

Setting: Tertiary refractive center, Draper, Utah, USA.

Design: Retrospective case series.

Methods: Medical records of patients who underwent planned bioptics were reviewed. Surgery involved PC-pIOL placement using an implantable collamer lens (ICL) with preceding or subsequent LASIK or PRK. Pre- and postoperative manifest spherical equivalent (SEQ), visual acuity, and PC-pIOL vault were analyzed.

Results: Of the 51 eyes present at 12 months postoperatively, 49 eyes (96%) achieved target SEQ within ±1.00 D and an identical amount achieved refractive astigmatism ≤1.00 D. Post-bioptics eyes achieved a postoperative UDVA equal to or better than preoperative CDVA in 45 eyes (88%). Efficacy and safety indices were 1.08 ± 0.20 (41 eyes) and 1.13 ± 0.22 (44 eyes) for conventional bioptics and 0.99 ± 0.42 (7 eyes) and 1.15 ± 0.38 (7 eyes) for reverse bioptics eyes at 12 months. The maximum PC-pIOL vault of conventional bioptics eyes (27 eyes) within 6 months before and after LASIK/PRK was 385 ± 159 μm and 377 ± 135 μm, respectively (P = 0.71).

Conclusion: Bioptics for high myopic astigmatism was safe and effective. Reverse bioptics, although not as traditional, could provide similar results. Additionally, the PC-pIOL vault does not appear to be affected by LASIK/PRK.
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http://dx.doi.org/10.2147/OPTH.S285140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7734069PMC
December 2020

Anisocoria? Don't sweat it: Wipes for excessive perspiration might cause mydriasis.

J Cataract Refract Surg 2021 May;47(5):676

From the Hoopes Durrie Rivera Research Center, Hoopes Vision, Draper, Utah (Moshirfar, McCabe); John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, Utah (Moshirfar); Utah Lions Eye Bank, Murray, Utah (Moshirfar); McGovern Medical School at The University of Texas Health Science Center at Houston, Houston, Texas (Hall); University of Utah School of Medicine, Salt Lake City, Utah (West).

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http://dx.doi.org/10.1097/j.jcrs.0000000000000402DOI Listing
May 2021

Light Adjustable Intraocular Lens for Cataract Surgery After Radial Keratotomy.

J Refract Surg 2020 Dec;36(12):852-854

Purpose: To describe a case of light adjustable lens implantation after radial keratotomy.

Methods: A patient with a 30-year history of radial keratotomy subsequently underwent phacoemulsification with implantation of intraocular light adjustable lenses. Serial refractions were performed at varying hours of the day postoperatively and were repeated for 3 months. The light adjustable lenses were adjusted twice, and the refractive power of the implant was eventually locked.

Results: The patient was able to achieve uncorrected distance visual acuity of 20/25 in both eyes, improving from 20/125 in the right eye and 20/80 in the left eye, with no surgical complications.

Conclusions: The authors report the first case of light adjustable lens implantation after radial keratotomy, which has yielded promising results for mitigating intraocular lens miscalculations after radial keratotomy. [J Refract Surg. 2020;36(12):852-854.].
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http://dx.doi.org/10.3928/1081597X-20201002-01DOI Listing
December 2020

Corneal Refractive Surgery in Patients with a History of Herpes Simplex Keratitis: A Narrative Review.

Clin Ophthalmol 2020 16;14:3891-3901. Epub 2020 Nov 16.

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

The incidence of herpes simplex keratitis (HSK) in patients following corneal refractive surgery is higher than in the general population, and several case reports of ocular morbidity in HSK infection following corneal refractive surgery have been published. HSK is listed by the American Academy of Ophthalmology as a relative contraindication to corneal refractive surgery, although specifics have not been further elucidated. This review summarizes the current literature regarding reactivation of HSK following corneal refractive surgery and provides a guideline for considering corneal refractive surgery in a patient with a previous history of HSK. Based on the current literature, we recommend that corneal refractive surgery is appropriate for patients with a history of HSK without multiple recurrences who have had no evidence of disease for at least one year. In addition to a thorough history and physical examination, we also recommend these patients begin 400 mg twice daily of oral acyclovir or valacyclovir 500 mg once daily for two weeks prior to surgery and continue this regimen for at least two weeks postoperatively or while on topical steroids.
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http://dx.doi.org/10.2147/OPTH.S282070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7678688PMC
November 2020

Initial Single-Site Experience Using SMILE for the Treatment of Astigmatism in Myopic Eyes and Comparison of Astigmatic Outcomes with Existing Literature.

Clin Ophthalmol 2020 29;14:3551-3562. Epub 2020 Oct 29.

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

Purpose: To assess a single site's initial experience with SMILE for the treatment of myopic astigmatism and compare outcomes and vector analysis results with the US Food and Drug Administration (FDA) results and published literature.

Patients And Methods: Forty-eight eyes (29 patients) with mean preoperative sphere of -5.11 ± 1.31 diopters (D) and cylinder of -1.12 ± 0.60 D underwent SMILE. Visual acuity, refractive, and vector analysis outcomes as well as subjective measures were reported at three and twelve months postoperatively and compared with FDA results and the published literature between 2014 and 2020 involving treatment of patients with mean cylinders of >-0.50 to ≤-3.00 D.

Results: At three and twelve months, 43 and 32 eyes were evaluated, respectively. At twelve months, mean cylinder power was reduced to -0.38 ± 0.38 D with 78.1% achieving ≤±0.50 D. Uncorrected distance visual acuity (UDVA) ≥20/20 was achieved in 77.4% of eyes by twelve months with 100% achieving ≥20/30 UDVA. No loss of corrected distance visual acuity was observed in eyes seen at twelve months. Correction index (CI) at twelve months was 0.90 indicating overall undercorrection of 10%. Twelve-month CI was 0.96, 0.90, and 0.83 in eyes with preoperative cylinders of <-1.00 D, ≥-1.00 to <-2.00 D, and ≥-2.00 D, respectively. Mean angle of error was -1.58 ± 11.61° ranging from -24.22° to 37.75°.

Conclusion: We found SMILE to be an effective and safe means of achieving spectacle independence and improving visual acuity in patients with myopic astigmatism. SMILE has the potential for improved clinical outcomes with better nomogram guidance and advancements in technique. However, surgeons must be aware of the potential for undercorrection in with-the-rule astigmatism and at higher preoperative cylinders and as well as the potential for overcorrection in against-the-rule and lower preoperative cylinder astigmatism.
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http://dx.doi.org/10.2147/OPTH.S276899DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607143PMC
October 2020

Use of presbyopia-correcting intraocular lenses in patients with prior corneal refractive surgery.

Curr Opin Ophthalmol 2021 Jan;32(1):45-53

Hoopes Vision Research Center, Hoopes Vision, Draper.

Purpose Of Review: Corneal refractive surgery has achieved spectacle-free vision for millions of patients, but this aging population is now developing cataracts. Many of these patients may wish to avoid reliance on glasses after cataract surgery. Presbyopia-correcting intraocular lenses (IOLs) offer a solution, but corneal changes after refractive surgery may compound higher order aberrations and dysphotopic symptoms associated with these IOLs. This review aims to discuss potential factors that could aid in determining suitable postkeratorefractive candidates for presbyopia-correcting IOLs.

Recent Findings: Studies investigating which preoperative measures influence outcomes are lacking. The few studies that have examined presbyopia-correcting IOLs in postkeratorefractive patients report that satisfactory outcomes are possible. However, recommendations for preoperative thresholds appear limited to expert opinion and studies involving virgin corneas.

Summary: As the number of presbyopia-correcting IOLs and postkeratorefractive patients grows, continued investigation into relevant preoperative factors and appropriate IOLs is required to make evidence-based decisions. The current literature shows that with rigorous counseling and appropriate patient selection, presbyopia-correcting IOLs can provide postkeratorefractive patients with satisfactory results and spectacle independence. In addition, the development of postoperative modifiable IOLs may prove to be the preferred option.
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http://dx.doi.org/10.1097/ICU.0000000000000722DOI Listing
January 2021

Refractive enhancements for residual refractive error after cataract surgery.

Curr Opin Ophthalmol 2021 Jan;32(1):54-61

Hoopes Vision Research Center, Hoopes Vision, Draper.

Purpose Of Review: Advances in cataract surgery have allowed surgeons to achieve superior refractive outcomes but have also led to higher patient expectations. Despite ever-evolving technology, residual refractive errors still occur. Postcataract refractive enhancements may be required to deliver satisfactory visual outcomes. This review aims to discuss the potential causes of residual refractive errors and the various enhancement modalities to correct them.

Recent Findings: A thorough preoperative workup to detect and address underlying pathologic causes of impaired vision should be performed prior to enhancement or corrective procedures. Corneal-based procedures are the safest and most accurate methods of correcting mild cases of residual refractive error. Hyperopic, high myopic, and high astigmatic errors are best managed with lens-based enhancements. Piggyback intraocular lenses (IOLs) are safer and more effective compared with IOL exchange. Toric IOL rotation and IOL exchange are ideally performed in the early postoperative period.

Summary: A multitude of options exist for effective correction of residual refractive errors. The choice on how to best manage these patients depends on many factors such as the cause of refractive error, type of IOL used, ocular comorbidities, and patient preference.
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http://dx.doi.org/10.1097/ICU.0000000000000717DOI Listing
January 2021

September consultation #7.

Authors:
Majid Moshirfar

J Cataract Refract Surg 2020 10;46(10):1447

Salt Lake City, Utah, USA.

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http://dx.doi.org/10.1097/01.j.jcrs.0000721424.83983.15DOI Listing
October 2020

Recurrent gelatinous Salzmann-like nodular lesion with prior history of astigmatic keratotomy: September consultation #1.

J Cataract Refract Surg 2020 Oct;46(10):1444

A 67-year-old woman was referred to our facility with declining vision in the right eye that has been present since her cataract surgery in 2016. The patient has a history of an 8-cut radial keratotomy (RK) with 2-cut astigmatic keratotomy (AK) along the vertical meridian in both eyes since 1993. She underwent superficial keratectomy of the right eye 3 times in 3 consecutive years after her cataract extraction with toric intraocular lens (IOL) implantation. She is hoping to improve her vision in the right eye with a corrected distance visual acuity (CDVA) of 20/50 with a manifest refraction of +2.00 -5.50 × 65. Keratometry readings are 39.4 @ 87/43.3 @ 177. Slitlamp examination shows a persistent raised white gelatinous tissue overlying the inferior AK at the 6 o'clock position (, , and ). The patient had attempted several failed trials of scleral lens and rigid gas-permeable (RGP) lens-fitting after each corneal scraping with intolerance and lack of improvement in her vision. Her left eye is an asymptomatic pseudophakic eye with uncorrected distance visual acuity (UDVA) and CDVA of 20/25.(Figure is included in full-text article.)(Figure is included in full-text article.)(Figure is included in full-text article.)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.0000000000000423DOI Listing
October 2020

Lipid Keratopathy: A Review of Pathophysiology, Differential Diagnosis, and Management.

Ophthalmol Ther 2020 Dec 15;9(4):833-852. Epub 2020 Oct 15.

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

Lipid keratopathy is a disease in which fat deposits accumulate in the cornea, leading to opacification and decrease of visual acuity. This condition can be idiopathic without signs of previous corneal disease or secondary to ocular or systemic diseases. Lipid keratopathy is usually associated with abnormal vascularization of the cornea, and the lipid classically deposits adjacent to these vessels. Treatment of this condition usually aims to eliminate or prevent abnormal vessel formation, and several modalities have been described. In this review we summarize the etiology, pathophysiology, and clinical presentation of lipid keratopathy and describe current and emerging treatment regimens.
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http://dx.doi.org/10.1007/s40123-020-00309-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7708541PMC
December 2020

Case Report: Suspected Donor Transmission of Acanthamoeba Keratitis After Deep Anterior Lamellar Keratoplasty.

Cornea 2021 Jul;40(7):903-906

John A. Moran Eye Center, Department of Ophthalmology and Visual Sciences, University of Utah School of Medicine, Salt Lake City, UT.

Purpose: In our report, we present a suspected case of donor-derived Acanthamoeba keratitis after deep anterior lamellar keratoplasty. To the authors' knowledge, there have been no confirmed cases of Acanthamoeba keratitis transmission through corneal transplantation.

Methods: Deep anterior lamellar keratoplasty was performed on the right eye of a 33-year-old man with severe bilateral keratoconus and an intolerance to all forms of contact lenses. The postoperative visual acuity deteriorated, while inflammation, rising ocular pressure, increasing corneal thickness, and severe eye pain began to present. Confocal imaging revealed hyperreflective cysts and trophozoite figures representative of amoebic keratitis. Despite an additional penetrating keratoplasty, antiamoeba therapy, and corneal crosslinking, the patient's condition worsened, resulting in stromal melt and corneal perforation. Emergent combined surgery of temporary keratoprosthesis, vitrectomy, lensectomy, and iridectomy was performed, along with Ahmed valve shunt placement and another penetrating keratoplasty.

Results: The infection was resistant to aggressive antiamoeba therapy, but after the emergent combined surgery, the graft re-epithelialized quickly and has since remained clear, with no presence of keratitis.

Conclusions: Several signs led us to believe that this case was donor-derived. There was little opportunity for graft exposure to the amoeba, and deep amoebic cysts and trophozoites were present on postoperative week 1-a highly unusual time course and depth of invasion for primary amoebic infection. In addition, pathological analysis revealed cysts only within the confines of the donor tissue and none in the recipient; Acanthamoeba cysts would have been present in the recipient rim tissue if the infection originated from the patient himself.
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http://dx.doi.org/10.1097/ICO.0000000000002517DOI Listing
July 2021

Cycloplegia in Children: An Optometrist's Perspective.

Clin Optom (Auckl) 2020 25;12:129-133. Epub 2020 Aug 25.

Hoopes Vision, Draper, UT, USA.

Purpose: To determine the current scope of practice with regards to cycloplegic examinations, specifically in the pediatric population.

Methods: A comprehensive literature review was conducted using PubMed, ScienceDirect, Elsevier, and Google Scholar databases using keywords such as "cyclopentolate"; "tropicamide"; "pediatric"; "cycloplegia"; "atropine"; and "cycloplegic" from inception to October 2019.

Results: Atropine has the strongest cycloplegic effect and is recommended for cases of large accommodative esotropia. Because of the undesired side effects and risks from atropine, cyclopentolate has been found to offer a very effective cycloplegia even for moderate to high hyperopia and has become the standard of care for traditional pediatric cycloplegic exams. Tropicamide has also been shown to offer adequate cycloplegia with less toxicity and side effects. Of all agents, tropicamide presents the least side effects and toxicity, whereas atropine presents the greatest. Cyclopentolate is a very safe cycloplegic agent that has risk of toxicity which increases with higher doses and concentrations.

Conclusion: The American Optometric Association's current pediatric cycloplegic guidelines have proven both safe and effective, as they recommend a conservative approach of using cyclopentolate 0.5% in infants and cyclopentolate 1% in those older than one-year old to avoid undesired side effects. Topical ophthalmic drops and spray instillation have both proved equally efficacious and therefore each have their place within a clinical setting. Using Cycolmydril under six months old and cyclopentolate 1% over 6 months old as recommended by the AAO, also provides a safe and effective guideline for cycloplegic examinations within the pediatric population.
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http://dx.doi.org/10.2147/OPTO.S217645DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7456336PMC
August 2020

Face Mask-Associated Ocular Irritation and Dryness.

Ophthalmol Ther 2020 Sep 15;9(3):397-400. Epub 2020 Jul 15.

Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA.

During the current coronavirus disease 2019 (COVID-19) epidemic, the concern for reducing disease transmission has led to a worldwide increase in face mask utilization. During this period, we have observed a corresponding increase in ocular irritation and dryness among regular mask users. This finding has not been previously described in the literature but has important implications on eye health and infection prevention, as mask use is likely to continue for the foreseeable future.
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http://dx.doi.org/10.1007/s40123-020-00282-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7362770PMC
September 2020