Publications by authors named "Mohammed Ziaei"

42 Publications

The Aotearoa Research Into Keratoconus Study: Geographic Distribution, Demographics, and Clinical Characteristics of Keratoconus in New Zealand.

Cornea 2021 Feb 24. Epub 2021 Feb 24.

Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

Purpose: To investigate the epidemiologic, demographic, and basic clinical characteristics of individuals with keratoconus managed by optometrists in New Zealand (NZ)/Aotearoa.

Methods: A prospective, longitudinal, nationwide, survey protocol was completed for every patient with keratoconus who underwent a consultation with participating optometrists in a 2-year period. Data for each patient included date of birth, sex, self-reported ethnicity, new or previous diagnosis, uncorrected (UCVA) and best-corrected visual acuity (BCVA), type of refractive correction required to obtain BCVA and keratometric readings obtained using keratometry or computerized topography.

Results: One thousand eight hundred sixty-nine cases were identified, with a mean age of 41.0 ± 15.7 years, 56.4% being men, and 87.3% with previous diagnosis. The distribution of cases was skewed toward Auckland (41.6%), Waikato (21.3%), Wellington (16.8%), and Bay of Plenty (13.3%). Self-reported ethnicities were predominantly NZ European (54.4%), Māori (24.7%), and Pacific Peoples (15.5%), disproportionate to the general population profile (74.0%, 14.9%, and 7.4% respectively). Most eyes (64.3%) were managed with rigid contact lenses (corneal lens in 34.2%). The mean K-mean was 49.0 ± 5.7 D. The mean UCVA was 6/42 and BCVA was 6/9. Māori and Pacific Peoples had both the highest K-mean and proportions of eyes graded stage IV on the Amsler-Krumeich scale.

Conclusions: The results indicate that keratoconus is relatively common in NZ with at least 1869 patients managed by optometrists in 2 years. Most eyes had mild to moderate disease; however, Māori and Pacific Peoples seem to have greater disease severity. An ethnic predilection is apparent, with Māori and Pacific Peoples overrepresented relative to their population proportions, reinforcing a long-held clinical suspicion.
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http://dx.doi.org/10.1097/ICO.0000000000002672DOI Listing
February 2021

Corneal Biomechanical Properties in Varying Severities of Myopia.

Front Bioeng Biotechnol 2020 21;8:595330. Epub 2021 Jan 21.

Department of Optometry, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran.

To investigate corneal biomechanical response parameters in varying degrees of myopia and their correlation with corneal geometrical parameters and axial length. In this prospective cross-sectional study, 172 eyes of 172 subjects, the severity degree of myopia was categorized into mild, moderate, severe, and extreme myopia. Cycloplegic refraction, corneal tomography using Pentacam HR, corneal biomechanical assessment using Corvis ST and Ocular Response Analyser (ORA), and ocular biometry using IOLMaster 700 were performed for all subjects. A general linear model was used to compare biomechanical parameters in various degrees of myopia, while central corneal thickness (CCT) and biomechanically corrected intraocular pressure (bIOP) were considered as covariates. Multiple linear regression was used to investigate the relationship between corneal biomechanical parameters with spherical equivalent (SE), axial length (AXL), bIOP, mean keratometry (Mean KR), and CCT. Corneal biomechanical parameters assessed by Corvis ST that showed significant differences among the groups were second applanation length (AL2, = 0.035), highest concavity radius (HCR, < 0.001), deformation amplitude (DA, < 0.001), peak distance (PD, = 0.022), integrated inverse radius (IR, < 0.001) and DA ratio (DAR, = 0.004), while there were no significant differences in the means of pressure-derived parameters of ORA between groups. Multiple regression analysis showed all parameters of Corvis ST have significant relationships with level of myopia (SE, AXL, Mean KR), except AL1 and AL2. Significant biomechanical parameters showed progressive reduction in corneal stiffness with increasing myopia (either with greater negative SE or greater AXL), independent of IOP and CCT. Also, corneal hysteresis (CH) or ability to dissipate energy from the ORA decreased with increasing level of myopia. Dynamic corneal response assessed by Corvis ST shows evidence of biomechanical changes consistent with decreasing stiffness with increasing levels of myopia in multiple parameters. The strongest correlations were with highest concavity parameters where the sclera influence is maximal.
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http://dx.doi.org/10.3389/fbioe.2020.595330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859342PMC
January 2021

Case Report: Successful Corneal Crosslinking in a Patient with Corneal Ectasia Associated with Stevens-Johnson Syndrome.

Optom Vis Sci 2021 Jan;98(1):13-17

Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

Significance: Corneal ectasia can be a complication of Stevens-Johnson syndrome. When detected in a timely manner, corneal crosslinking can be a safe treatment. This is an important association to highlight that early diagnosis and treatment can prevent the need for invasive surgical procedures such as keratoplasty.

Purpose: This study aimed to report a successful accelerated epithelium-off corneal crosslinking in a rare case of corneal ectasia secondary to Stevens-Johnson syndrome.

Case Report: A 25-year-old Indian man presented with a progressive visual acuity decline 5 years after an acute episode of Stevens-Johnson syndrome secondary to penicillin ingestion. Serial tomography scans confirmed the diagnosis of corneal ectasia. After the preparation of the ocular surface, which was deemed to have a mild degree of limbal stem cell deficiency, with frequent preservative-free lubrication and steroid use, accelerated epithelium-off crosslinking was performed with 4 minutes of continuous ultraviolet-A exposure at 30 mW/cm2 and a total energy dose of 7.2 J/cm2. Complete re-epithelialization was observed at 72 hours after crosslinking with no complications. Corneal tomography 15 months after treatment showed stabilization of ectasia, with improvement in visual acuity.

Conclusions: Corneal ectasia is a rare but important complication of Stevens-Johnson syndrome. Accelerated epithelium-off crosslinking treatment can be considered in patients with a compromised ocular surface after Stevens-Johnson syndrome. Pre-operative optimization of the ocular surface and vigilant monitoring in the early post-operative period are recommended for the prevention of complications.
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http://dx.doi.org/10.1097/OPX.0000000000001623DOI Listing
January 2021

Corneal transplantation after failed grafts: Options and outcomes.

Surv Ophthalmol 2021 Jan - Feb;66(1):20-40. Epub 2020 Oct 14.

Cornea, Cataract and Refractive Surgery Unit, Vissum (Miranza Group), Alicante, Spain; Division of Ophthalmology, Universidad Miguel Hernández, Alicante, Spain.

Corneal transplantation is the most commonly performed human tissue transplantation procedure worldwide. Because of the large number of transplants, corneal graft failure has become one of the most common indications for corneal transplantation. The relatively recently developed lamellar transplant techniques have brought about specific potential complications leading to graft failure that may require different approaches to repeat transplantation other than penetrating keratoplasty. On the other hand, these new lamellar techniques also provide novel ways of rescuing failed penetrating grafts, with potential advantages over successive penetrating keratoplasties, such as reduced intraoperative risks and faster visual rehabilitation. We summarize the incidence and risk factors of graft failure for penetrating and lamellar (stromal and endothelial) corneal transplants and discuss the various surgical alternatives currently available to rescue such failed grafts, with a focus on the reported outcomes and limitations.
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http://dx.doi.org/10.1016/j.survophthal.2020.10.003DOI Listing
October 2020

Microdroplet and spatter contamination during phacoemulsification cataract surgery in the era of COVID-19.

Clin Exp Ophthalmol 2020 12 11;48(9):1168-1174. Epub 2020 Oct 11.

Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

Importance: Determine phacoemulsification cataract surgery risk in a Covid-19 era.

Background: SARS-CoV-2 (Covid-19) transmission via microdroplet and aerosol-generating procedures presents risk to medical professionals. As the most common elective surgical procedure performed globally; determining contamination risk from phacoemulsification cataract surgery may guide personal protection equipment use.

Design: Pilot study involving phacoemulsification cataract surgery on enucleated porcine eyes by experienced ophthalmologists in an ophthalmic operating theatre.

Participants: Two ophthalmic surgical teams.

Methods: Standardized phacoemulsification of porcine eyes by two ophthalmologists accompanied by an assistant. Fluorescein incorporated into phacoemulsification irrigation fluid identifying microdroplets and spatter. Contamination documented using a single-lens reflex camera with a 532 nm narrow bandpass (fluorescein) filter, in-conjunction with a wide-field blue light and flat horizontal laser beam (wavelength 532 nm). Quantitative image analysis using Image-J software.

Main Outcome Measures: Microdroplet and spatter contamination from cataract phacoemulsification.

Results: With phacoemulsification instruments fully within the eye, spatter contamination was limited to <10 cm. Insertion and removal of the phacoemulsification needle and bimanual irrigation/aspiration, with irrigation active generated spatter on the surgeons' gloves and gown extending to >16 cm below the neckline in surgeon 1 and > 5.5 cm below the neckline of surgeon 2. A small tear in the phacoemulsification irrigation sleeve, presented a worse-case scenario the greatest spatter. No contamination above the surgeons' neckline nor contamination of assistant occurred.

Conclusions And Relevance: Cataract phacoemulsification generates microdroplets and spatter. Until further studies on SARS-CoV-2 transmission via microdroplets or aerosolisation of ocular fluid are reported, this pilot study only supports standard personal protective equipment.
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http://dx.doi.org/10.1111/ceo.13861DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537193PMC
December 2020

Measurement of refractive, wavefront, topographic, and keratometric changes attributable to epithelial removal in keratoconus.

Can J Ophthalmol 2021 Feb 7;56(1):6-11. Epub 2020 Aug 7.

Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

Objective: The corneal epithelium is able to mask topographic and keratometric abnormalities of the underlying Bowman layer in keratoconus, but its contribution to refractive and wavefront parameters has not yet been studied. This study compared the refractive and aberrometric features of the corneal epithelium and Bowman layer in eyes with keratoconus before and after epithelial debridement.

Methods: Corneal refractive and wavefront variables were measured in patients with keratoconus undergoing corneal crosslinking-immediately before and after epithelial debridement using a third-generation combined corneal topographer, autorefractor, and aberrometer.

Results: After epithelial debridement, there were significant changes in spherical equivalent (-1.37 D; p < 0.01) and asphericity (-0.64; p = 0.03). The mean difference in the magnitude of epithelium-induced astigmatism in the 3rd and 5th central millimeter rings was 0.44 ± 3.20 D × 8 and 0.43 ± 2.75 D × 21 (positive cylinder), respectively. Corneal astigmatism axis shifted in the against-the-rule orientation after epithelial debridement. There were no significant changes in any corneal higher-order aberration parameter after epithelial debridement (p > 0.05).

Conclusions: In eyes with keratoconus, epithelial debridement increased the magnitude of anterior corneal prolateness and tended to increase astigmatism and shift its axis toward the against-the-rule orientation. This study supports the notion that the corneal epithelium smooths underlying Bowman layer irregularity in keratoconus.
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http://dx.doi.org/10.1016/j.jcjo.2020.06.013DOI Listing
February 2021

Biomechanics in DALK: Big bubble vs Manual lamellar dissection.

Arq Bras Oftalmol 2020 08 29;83(4):354-355. Epub 2020 Jul 29.

Haydarpasa Numune Research and Education Hospital, Istanbul, Turkey.

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http://dx.doi.org/10.5935/0004-2749.20200076DOI Listing
August 2020

Peripheral Cornea Crosslinking Before Deep Anterior Lamellar Keratoplasty.

Med Hypothesis Discov Innov Ophthalmol 2020 27;9(2):127-134. Epub 2020 Mar 27.

Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical & Health Sciences, University of Auckland, New Zealand.

Since Cornea crosslinking (CXL) has been proven to halt progression and biomechanically stabilize keratoconus, we hypothesized that CXL of the corneal periphery 3 months prior to corneal transplantation can reduce the incidence of recurrent ectasia by strengthening the peripheral corneal tissue and causing apoptosis of diseased peripheral host keratocytes. Thus, the aim of this case-report was to propose a novel peripheral CXL technique prior to keratoplasty and evaluate its safety. A 22-year-old woman was admitted with advanced right keratoconus and corrected distance visual acuities of 20/30 in the right eye and 20/200 in the left eye with a manifest refraction of -3.00D/ -8.00D × 36° and -17.00D/ -11.50D × 90°, respectively. The proposed treatment involved crosslinking of peripheral corneal tissue (6.5-9.5mm), sparing the central cornea and limbus, three months prior to corneal transplantation as a means of biomechanically strengthening the peripheral cornea tissue. This procedure was feasible and safe with repopulation of the peripheral cornea with keratocytes, no significant endothelial cell loss and a routine postoperative course following CXL and DALK. This method might reduce or eliminate the need for repeat corneal transplantation in patients with recurrent ectasia. Further studies are needed to confirm the results.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7134244PMC
March 2020

Prospective Clinical Study of Keratoconus Progression in Patients Awaiting Corneal Cross-linking.

Cornea 2020 Oct;39(10):1256-1260

Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; and.

Purpose: Keratoconus progression should be treated with corneal cross-linking (CXL) in a timely manner. This study aimed to investigate patient factors associated with keratoconus progression between time of listing and at time of CXL.

Methods: Prospective observational study at a tertiary center. Ninety-six eyes of 96 patients with keratoconus. Demographic, clinical, and tomographic parameters were analyzed to determine the risk factors for keratoconus progression. Analyzed tomographic indices included steepest keratometry, average keratometry, cornea thinnest point, index of surface variance, index of vertical asymmetry, keratoconus index, center keratoconus index, index of height asymmetry, and index of height decentration.

Results: A total of 38 eyes (39.6%) were found to have keratoconus progression during an average waiting time of 153 ± 101 days. There were significant differences in preoperative tomographic parameters such as index of surface variance (111.3 ± 36.6 vs. 88.3 ± 31.8; P = 0.002), index of vertical asymmetry (1.1 ± 0.4 vs. 0.9 ± 0.4; P = 0.005), keratoconus index (1.31 ± 0.12 vs. 1.22 ± 0.11; P < 0.001), and index of height decentration (0.16 ± 0.07 vs. 0.11 ± 0.06; P = 0.015) between eyes that progressed and those that remained stable. There were no significant differences in steepest keratometry, average keratometry, cornea thinnest point, and center keratoconus index. Multivariate analysis did not reveal age, presence of atopy/atopic keratoconjunctivitis, eye rubbing, or waiting time to be a significant risk factor for progression; however, Maori ethnicity was a risk factor (odds ratio = 3.89; P = 0.02).

Conclusions: A significant proportion of eyes were found to be progressing while waiting for CXL. A risk stratification score for patients awaiting CXL may reduce the risk of progression.
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http://dx.doi.org/10.1097/ICO.0000000000002376DOI Listing
October 2020

Measurement of In Vivo Biomechanical Changes Attributable to Epithelial Removal in Keratoconus Using a Noncontact Tonometer.

Cornea 2020 Aug;39(8):946-951

Purpose: To compare the biomechanical properties of the cornea after epithelial removal in eyes with keratoconus undergoing corneal cross-linking.

Methods: Prospective interventional case series at a university hospital tertiary referral center. Corneal biomechanical properties were measured in patients with keratoconus undergoing corneal cross-linking, immediately before and after epithelial debridement by using a dynamic ultrahigh-speed Scheimpflug camera equipped with a noncontact tonometer.

Results: The study comprised 45 eyes of 45 patients with a mean age of 19.6 ± 4.9 years (range 14-34). The cornea was found to be 23.7 ± 15.7 μm thinner after epithelial removal (P < 0.01). Corneal stiffness was reduced after epithelial removal as demonstrated by a significant decrease of parameters such as stiffness parameter A1 (12.31, P < 0.01), stiffness parameter-highest concavity (2.25, P < 0.01), A1 length (0.13 mm, P = 0.04), highest concavity radius of curvature (0.26 mm, P = 0.01), highest concavity time (0.22 ms, P = 0.04) and an increase in A1 velocity (-0.01 m/s, P = 0.01), A1 deformation amplitude (-0.03 mm, P ≤ 0.01), A1 deflection length (-0.32 mm, P < 0.01), A2 deformation amplitude (-0.03 mm, P = 0.01), and A2 deflection length (-1.00 mm, P < 0.01). There were no significant differences in biomechanical intraocular pressure (0.15 mm Hg, P = 0.78), deformation amplitude (0.03, P = 0.54), maximum inverse radius (-0.01 mm, P = 0.57), and whole eye movement length (-0.02 mm, P = 0.12).

Conclusions: Dynamic ultrahigh-speed Scheimpflug camera equipped with a noncontact tonometer offers an alternative method for in vivo measurements of the epithelial layer's contribution to corneal biomechanical properties. Our results suggest that corneal epithelium may play a more significant role in corneal biomechanical properties in patients with keratoconus than previously described.
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http://dx.doi.org/10.1097/ICO.0000000000002344DOI Listing
August 2020

Prospective two year study of changes in corneal density following transepithelial pulsed, epithelium-off continuous and epithelium-off pulsed, corneal crosslinking for keratoconus.

Cont Lens Anterior Eye 2020 10 22;43(5):458-464. Epub 2020 Mar 22.

Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.

Purpose: To compare the corneal densitometry changes after transepithelial pulsed (t-ACXL), epithelium-off continuous (c-ACXL) and epithelium-off pulsed (p-ACXL), accelerated corneal crosslinking for patients with progressive keratoconus.

Methods: Prospective, interventional case series at a university hospital tertiary referral center. Forty eyes received t-ACXL, 40 eyes received c-ACXL, and 40 eyes received p-ACXL. Corneal tomography, densitometry and visual acuity were evaluated preoperatively and at 1, 3, 6, 12 and 24 months postoperatively.

Results: Total densitometry values of the total layer over the annular diameters 0-12 mm expressed in grayscale units (GSU) showed no significant change after t-ACXL and p-ACXL but increased significantly after c-ACXL at 1 month (16.76 ± 2.38, P value < 0.01) and 3 months (16.12 ± 2.22, P value 0.04), returning to baseline levels at month 6 (14.97 ± 2.13, P value 0.99) and remained stable until final follow-up. At 1 month, the mean change in total densitometry value of the t-ACXL group (-0.53 ± 2.08) was significantly lower than the p-ACXL (0.70 ± 1.96 P value 0.04) and c-ACXL (1.97 ± 2.65 P value < 0.01). There was no statistical difference in the mean change in total densitometry between the three groups from 6 to 24 months. In the c-ACXL group, a higher degree of CXL-induced corneal haze at 1 month was observed in patients with steeper preoperative keratometry readings and in individuals where a greater flattening effect was achieved at 24 months.

Conclusions: Continuous epithelium-off accelerated cornea crosslinking appears to induce more corneal haze than pulsed epithelium-off and transepithelial pulsed cornea crosslinking in the early postoperative period. Differences resolve by six-months.
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http://dx.doi.org/10.1016/j.clae.2020.03.004DOI Listing
October 2020

Outcomes in randomised controlled trials of multifocal lenses in cataract surgery: the case for development of a core outcome set.

Br J Ophthalmol 2020 10 20;104(10):1345-1349. Epub 2020 Jan 20.

Department of Ophthalmology, The Royal Berkshire NHS Foundation Trust, Reading, UK.

Background/aims: To describe and summarise the outcomes reported in randomised controlled trials of multifocal versus monofocal intraocular lenses in cataract surgery.

Methods: We identified all randomised controlled trials of multifocal versus monofocal lenses in a Cochrane review (last search date June 2016). We extracted and summarised data on all outcomes reported using the framework of domain, measurement, metric and method of aggregation.

Results: All studies collected data on distance and near visual acuity but there was considerable variation in the measures used and whether these outcomes were unaided or best corrected. Most studies reported final value measurements, rather than change from baseline. Approximately half of the studies reported data as a continuous measure only, one-third reported both continuous and categorical measures and a minority reported categorical measures only. There was little consensus as to cut-points. Although a majority of studies included one or more patient-reported outcome measures, none of the studies reported patient involvement in the choice of outcomes.

Conclusion: The collection and analysis of data on outcome measures in studies of multifocal intraocular lenses in cataract surgery are complicated. As a result, there is considerable heterogeneity in collection and reporting in the medical literature. This makes it difficult to synthesise such data to provide robust estimates of effect and is a potential source of research waste. Investigators in this field must produce a core outcome set that is informed by patients' views and we propose an initial set of outcomes on which these could be based.
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http://dx.doi.org/10.1136/bjophthalmol-2019-315410DOI Listing
October 2020

Comparison of corneal biomechanical properties following penetrating keratoplasty and deep anterior lamellar keratoplasty for keratoconus.

Clin Exp Ophthalmol 2020 03 27;48(2):174-182. Epub 2019 Nov 27.

Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand.

Importance: Keratoplasty is a surgical procedure to create a more regular optical surface following biomechanical weakening of the cornea in keratoconus. The ideal keratoplasty procedure should also restore corneal biomechanics to that of the healthy cornea.

Background: This study aimed to evaluate and compare the biomechanical properties of corneas following penetrating keratoplasty (PKP) and predescematic deep anterior lamellar keratoplasty (DALK) to those of healthy eyes.

Design: Prospective cross-sectional study.

Participants: Two cohorts of post-keratoplasty eyes (42 eyes with PKP and 27 eyes with DALK) with each other, and with a cohort of 152 healthy eyes.

Methods: All eyes were examined by slit-lamp biomicroscopy, tomography, anterior segment-OCT and non-contact tonometry CorVis ST (CST).

Main Outcome Measures: CST biomechanical parameters, maximum corneal deformation (MCD) and corneal energy dissipation were compared between keratoplasty techniques, and with healthy eyes.

Results: The mean age of participants with PKP and DALK were 35 ± 13.7 and 36.1 ± 12.6 years, respectively. None of the CST parameters were significantly different between PKP and DALK eyes. However, when compared to healthy corneas, numerous parameters were significantly different for both keratoplasty techniques. Of note, MCD was significantly higher in PKP compared to DALK and healthy corneas, after controlling for co-factors.

Conclusions And Relevance: Neither type of keratoplasty technique utilized in keratoconus completely restored corneal biomechanical properties to that of healthy corneas. However, PKP resulted in a greater number of parameters significantly different to healthy corneas, compared to DALK.
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http://dx.doi.org/10.1111/ceo.13677DOI Listing
March 2020

Assessing and managing an anomalous vascular lesion of the iris.

Clin Exp Ophthalmol 2019 Dec 10;47(9):1220-1222. Epub 2019 Oct 10.

Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

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http://dx.doi.org/10.1111/ceo.13646DOI Listing
December 2019

Prospective 2-year study of accelerated pulsed transepithelial corneal crosslinking outcomes for Keratoconus.

Eye (Lond) 2019 12 4;33(12):1897-1903. Epub 2019 Jul 4.

Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142, New Zealand.

Aims: To report 2-year outcomes of transepithelial, accelerated, pulsed, corneal crosslinking (t-ACXL) for patients with progressive keratoconus.

Methods: Prospective, interventional case series at a university hospital tertiary referral centre. Forty eyes with progressive keratoconus undergoing t-ACXL were included. Treatment was performed with pulsed illumination (1 s on/1 s off) using 45 mW/cm for 5 min and 20 s, for a surface dose of 7.2 J cm. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction spherical equivalent (MRSE), corneal tomography, anterior segment optical coherence tomography (OCT) and confocal microscopy were evaluated preoperatively and at 12 and 24 months postoperatively.

Results: The mean patient age was 23.32 ± 5.18 years (SD) (range 14-42 years). The mean CDVA significantly improved from 0.38 ± 0.32 logMAR at baseline to 0.30 ± 0.21 logMAR at 24 months (P < 0.01). There was no significant difference in UDVA, MRSE, asymmetry indices, tomographic parameters and endothelial density. The improvement in visual acuity was inversely correlated with preoperative CDVA and preoperative K. No complications were encountered.

Conclusions: In this prospective study, t-ACXL appeared safe and effective in halting progression of keratoconus within a follow-up period of 24 months.
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http://dx.doi.org/10.1038/s41433-019-0502-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7002515PMC
December 2019

Prospective two-year study of clinical outcomes following epithelium-off pulsed versus continuous accelerated corneal crosslinking for keratoconus.

Clin Exp Ophthalmol 2019 Nov 27;47(8):980-986. Epub 2019 Jun 27.

Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand.

Importance: Keratoconus is a debilitating condition with a disproportionately high impact on health resources and vision-specific quality of life.

Background: This study aimed to compare 2-year outcomes of epithelium-off pulsed (p-ACXL) and epithelium-off continuous (c-ACXL) accelerated corneal crosslinking in progressive keratoconus.

Design: Prospective, interventional case series.

Participants: Eighty eyes of 80 patients were included.

Methods: The visual, refractive and tomographic results of the two crosslinking protocols were compared.

Main Outcome Measures: Uncorrected distance visual acuity, corrected distance visual acuity (CDVA), manifest refraction spherical equivalent (MRSE) and maximum keratometry (K ) on corneal tomography assessment.

Results: The mean patient age was 22.51 ± 6.12 years (SD) and 22.08 ± 5.72 years in the p-ACXL and c-ACXL groups, respectively. The mean CDVA significantly improved from 0.30 ± 0.16 logMAR at baseline to 0.23 ± 0.17 logMAR at 24 months (P = .04) in the p-ACXL group and from 0.36 ± 0.22 logMAR to 0.26 ± 0.27 logMAR (P = .02) in the c-ACXL group. The mean induced change in MRSE (+1.79 ± 2.30 D vs +0.27 ± 3.19 D, P = .04) and K (-1.75 ± 1.80 D vs -0.39 ± 1.95 D, P = .04) were superior in the c-ACXL group compared to the p-ACXL group at 24 months. No complications were encountered.

Conclusions And Relevance: In this prospective study, both p-ACXL and c-ACXL treatments were safe methods to halt the progression of keratoconus within a follow-up period of 24 months. c-ACXL appeared to offer superior refractive and tomographic outcomes when compared to p-ACXL but this did not translate into better visual outcomes.
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http://dx.doi.org/10.1111/ceo.13567DOI Listing
November 2019

Descemet membrane endothelial keratoplasty for treatment of iridocorneal endothelial syndrome.

Can J Ophthalmol 2018 12 4;53(6):e226-e229. Epub 2018 Apr 4.

Department of Ophthalmology, New Zealand National Eye Centre, New Zealand.

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http://dx.doi.org/10.1016/j.jcjo.2018.02.011DOI Listing
December 2018

Direct measurement of anterior corneal curvature changes attributable to epithelial removal in keratoconus.

J Cataract Refract Surg 2018 01;44(1):71-77

From the Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand.

Purpose: To compare the tomography of the corneal epithelium and Bowman layer in eyes with moderate to severe keratoconus before and after epithelial debridement.

Setting: University hospital tertiary referral center.

Design: Prospective case series.

Methods: Dual-channel Scheimpflug combined with Placido-disk tomography was used to measure the corneal variables in eyes with keratoconus having corneal crosslinking immediately before and after epithelial debridement. The differences in pachymetry, axial keratometry, astigmatism magnitude, asphericity, total corneal power, and spherical aberrations were computed.

Results: The study comprised 30 eyes of 30 patients. After epithelial removal, the central (0.0 to 4.0 mm) and midperipheral (4.0 to 7.0 mm) corneal zones were significantly thinner mean (21 μm ± 14 [SD] and 35 ± 44 μm, respectively). The mean anterior axial flat keratometry (K) (+1.71 diopters [D]), steep K (+2.14 D), maximum K (+2.13 D), corneal astigmatism (+1.11 D), asphericity (-0.31), and total corneal power changes (+2.03 D) were significantly different after epithelial debridement. There were no significant changes in posterior corneal flat K or steep K, posterior corneal astigmatism, or posterior asphericity. There were no significant differences in the mean astigmatic axis (anterior or posterior corneal surface) or spherical aberration after epithelial debridement.

Conclusions: In eyes with moderate to severe keratoconus, the tomography of Bowman layer was significantly steeper than that of the epithelium; thus, epithelial debridement increased the magnitude of anterior corneal keratometry, astigmatism, and prolateness. These data suggest that the corneal epithelium smooths the underlying Bowman layer irregularity in keratoconus.
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http://dx.doi.org/10.1016/j.jcrs.2017.10.044DOI Listing
January 2018

The rising tide of Acanthamoeba keratitis in Auckland, New Zealand: a 7-year review of presentation, diagnosis and outcomes (2009-2016).

Clin Exp Ophthalmol 2018 08 5;46(6):600-607. Epub 2018 Mar 5.

The Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

Importance: Acanthamoeba is an increasingly prevalent cause of vision-threatening microbial keratitis.

Background: To assess the incidence, clinical presentation, diagnosis and outcomes of patients with Acanthamoeba keratitis (AK) in Auckland, New Zealand over a 7-year period.

Design: Retrospective observational consecutive case series.

Participants: Fifty-eight eyes of 52 patients diagnosed with AK.

Methods: All cases of AK were identified using a cross-referenced search of clinical, laboratory and pharmacy records from March 2009 to May 2016.

Main Outcome Measures: Demographic and clinical data were collected including age, gender, risk factors, clinical manifestations, initial diagnosis, diagnostic investigations, treatment, presenting and final visual acuity and surgical interventions.

Results: Contact lens (CL) use was noted in 96% of unilateral and 100% of bilateral cases. The mean duration of symptoms at presentation was 21 days and the mean duration from presentation to definitive diagnosis was 14 days. Initial diagnosis was recorded as CL-related keratitis in 70.6%, viral keratitis in 15.5% and AK in 12.0%. The diagnosis was confirmed with In vivo confocal microscopy (IVCM) in 67.2%, corneal scrape in 22.4%, corneal biopsy in 1.7% and clinically in 8.6%. IVCM sensitivity was 83.0%. Surgical intervention was required in four patients, all with delayed diagnosis (range 63-125 days). The incidence of AK has more than doubled when compared with the preceding 7-year period.

Conclusions And Relevance: AK is a rare vision-threatening protozoal infection with rapidly-increasing incidence in New Zealand, predominantly affecting CL users. Diagnosis is often challenging and when delayed is associated with worse outcomes. IVCM offers rapid diagnosis with high sensitivity.
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http://dx.doi.org/10.1111/ceo.13166DOI Listing
August 2018

Wound healing in the eye: Therapeutic prospects.

Adv Drug Deliv Rev 2018 02 31;126:162-176. Epub 2018 Jan 31.

University of Auckland, Department of Ophthalmology, New Zealand National Eye Centre, New Zealand. Electronic address:

In order to maintain a smooth optical surface the corneal epithelium has to continuously renew itself so as to maintain its function as a barrier to fluctuating external surroundings and various environmental insults. After trauma, the cornea typically re-epithelializes promptly thereby minimizing the risk of infection, opacification or perforation. A persistent epithelial defect (PED) is usually referred to as a non-healing epithelial lesion after approximately two weeks of treatment with standard therapies to no avail. They occur following exposure to toxic agents, mechanical injury, and ocular surface infections and are associated with significant clinical morbidity in patients, resulting in discomfort or visual loss. In the case of deeper corneal injury and corneal pathology the wound healing cascade can also extend to the corneal stroma, the layer below the epithelium. Although significant progress has been made in recent years, pharmaco-therapeutic agents that promote corneal healing remain limited. This article serves as a review of current standard therapies, recently introduced alternative therapies gaining in popularity, and a look into the newest developments into ocular wound healing.
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http://dx.doi.org/10.1016/j.addr.2018.01.006DOI Listing
February 2018

Scleral suture fixation of supplementary sulcus-based toric intraocular lenses to prevent rotational instability.

Clin Exp Ophthalmol 2018 07 22;46(5):570-573. Epub 2018 Jan 22.

Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

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http://dx.doi.org/10.1111/ceo.13125DOI Listing
July 2018

Descemet's membrane macroperforation during interface irrigation in big bubble deep anterior lamellar keratoplasty.

Oman J Ophthalmol 2017 Sep-Dec;10(3):241-243

Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

This report describes the macroperforation of descemet's membrane (DM) during irrigation of the interface following successful removal of stromal tissue in big bubble (BB) deep anterior lamellar keratoplasty (DALK). A 42-year-old woman with keratoconus underwent a BB DALK procedure. After successful formation of Type 2 bubble and removal of stromal tissue, interface irrigation was performed to remove residual viscoelastic. This led to a macroperforation of DM, and the case was converted to penetrating keratoplasty. To the best of our knowledge, this is the first report of such a complication in the literature. Recognition of a 2 bubble formation during pneumodissection should alert the surgeon to a high risk of DM rupture. We advise against the removal of DM from the donor in such cases as an added measure of safety.
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http://dx.doi.org/10.4103/ojo.OJO_66_2016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5657172PMC
November 2017

Battle-axe fold: surgical technique for in-the-bag implantation of an artificial iris implant.

Clin Exp Ophthalmol 2017 11 24;45(8):831-834. Epub 2017 May 24.

Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

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http://dx.doi.org/10.1111/ceo.12959DOI Listing
November 2017

Postoperative rotation of supplementary sulcus-supported toric intraocular lenses.

J Cataract Refract Surg 2017 02;43(2):285-288

From the Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.

We describe 7 cases in which supplementary sulcus-based toric intraocular lenses (IOLs) rotated postoperatively, requiring surgical realignment. The initial rotation was identified clinically between 3 months and 36 months postoperatively. All eyes had keratoconus, with and without prior keratoplasty, and 6 had longer than average axial lengths. No preceding trauma could be identified for 5 of the eyes. One eye had 3 episodes of postoperative IOL rotation, eventually requiring suture fixation to stabilize the IOL. This series indicates that postoperative rotation of a supplementary sulcus-based toric IOL may occur in eyes with or without preceding trauma. Eyes with keratoconus are at risk for postoperative rotation of the IOL, and suture fixation may be required to obtain stability.
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http://dx.doi.org/10.1016/j.jcrs.2016.12.014DOI Listing
February 2017

Umbilical cord stem cells in the treatment of corneal disease.

Surv Ophthalmol 2017 Nov - Dec;62(6):803-815. Epub 2017 Feb 21.

Faculty of Medical and Health Sciences, Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand. Electronic address:

Stem cells are capable of giving rise to progenies with specific functional and morphological traits and, in recent years, extraordinary scientific advances have initiated an era of hope for clinical regenerative strategies and tissue engineering applications. We appraise the potential benefits of human umbilical cord-derived stem cell therapy and consider current approaches to utilize these stem cells in corneal epithelial, stromal, and endothelial disorders.
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http://dx.doi.org/10.1016/j.survophthal.2017.02.002DOI Listing
December 2017

Multifocal versus monofocal intraocular lenses after cataract extraction.

Cochrane Database Syst Rev 2016 12 12;12:CD003169. Epub 2016 Dec 12.

Royal Berkshire Hospital NHS Trust, London Road, Reading, Berkshire, UK, RG1 5AN.

Background: Good unaided distance visual acuity (VA) is now a realistic expectation following cataract surgery and intraocular lens (IOL) implantation. Near vision, however, still requires additional refractive power, usually in the form of reading glasses. Multiple optic (multifocal) IOLs are available which claim to allow good vision at a range of distances. It is unclear whether this benefit outweighs the optical compromises inherent in multifocal IOLs.

Objectives: To assess the visual effects of multifocal IOLs in comparison with the current standard treatment of monofocal lens implantation.

Search Methods: We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 5), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to June 2016), Embase (January 1980 to June 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 13 June 2016.

Selection Criteria: All randomised controlled trials comparing a multifocal IOL of any type with a monofocal IOL as control were included. Both unilateral and bilateral implantation trials were included. We also considered trials comparing multifocal IOLs with "monovision" whereby one eye is corrected for distance vision and one eye corrected for near vision.

Data Collection And Analysis: We used standard methodological procedures expected by Cochrane. We assessed the 'certainty' of the evidence using GRADE.

Main Results: We found 20 eligible trials that enrolled 2230 people with data available on 2061 people (3194 eyes). These trials were conducted in Europe (13), China (three), USA (one), Middle East (one), India (one) and one multicentre study in Europe and the USA. Most of these trials compared multifocal with monofocal lenses; two trials compared multifocal lenses with monovision. There was considerable variety in the make and model of lenses implanted. Overall we considered the trials at risk of performance and detection bias because it was difficult to mask participants and outcome assessors. It was also difficult to assess the role of reporting bias.There was moderate-certainty evidence that the distance acuity achieved with multifocal lenses was not different to that achieved with monofocal lenses (unaided VA worse than 6/6: pooled RR 0.96, 95% confidence interval (CI) 0.89 to 1.03; eyes = 682; studies = 8). People receiving multifocal lenses may achieve better near vision (RR for unaided near VA worse than J3/J4 was 0.20, 95% CI 0.07 to 0.58; eyes = 782; studies = 8). We judged this to be low-certainty evidence because of risk of bias in the included studies and high heterogeneity (I = 93%) although all included studies favoured multifocal lenses with respect to this outcome.People receiving multifocal lenses may be less spectacle dependent (RR 0.63, 95% CI 0.55 to 0.73; eyes = 1000; studies = 10). We judged this to be low-certainty evidence because of risk of bias and evidence of publication bias (skewed funnel plot). There was also high heterogeneity (I = 67%) but all studies favoured multifocal lenses. We did not additionally downgrade for this.Adverse subjective visual phenomena were more prevalent and more troublesome in participants with a multifocal IOL compared with monofocals (RR for glare 1.41, 95% CI 1.03 to 1.93; eyes = 544; studies = 7, low-certainty evidence and RR for haloes 3.58, 95% CI 1.99 to 6.46; eyes = 662; studies = 7; moderate-certainty evidence).Two studies compared multifocal lenses with monovision. There was no evidence for any important differences in distance VA between the groups (mean difference (MD) 0.02 logMAR, 95% CI -0.02 to 0.06; eyes = 186; studies = 1), unaided intermediate VA (MD 0.07 logMAR, 95% CI 0.04 to 0.10; eyes = 181; studies = 1) and unaided near VA (MD -0.04, 95% CI -0.08 to 0.00; eyes = 186; studies = 1) compared with people receiving monovision. People receiving multifocal lenses were less likely to be spectacle dependent (RR 0.40, 95% CI 0.30 to 0.53; eyes = 262; studies = 2) but more likely to report problems with glare (RR 1.41, 95% CI 1.14 to 1.73; eyes = 187; studies = 1) compared with people receiving monovision. In one study, the investigators noted that more people in the multifocal group underwent IOL exchange in the first year after surgery (6 participants with multifocal vs 0 participants with monovision).

Authors' Conclusions: Multifocal IOLs are effective at improving near vision relative to monofocal IOLs although there is uncertainty as to the size of the effect. Whether that improvement outweighs the adverse effects of multifocal IOLs, such as glare and haloes, will vary between people. Motivation to achieve spectacle independence is likely to be the deciding factor.
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http://dx.doi.org/10.1002/14651858.CD003169.pub4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6463930PMC
December 2016

Systemic cyclosporine and corneal transplantation.

Int Ophthalmol 2016 Feb;36(1):139-146

Queens Hospital, Essex, RM7 0AG, UK.

Corneal transplantation is the most commonly performed tissue transplant boasting over a century of history, science, and tradition. While favorable outcomes have been reported after penetrating keratoplasty, rejection remains a major cause of graft failure. The long-term survival rates of this relatively immunologically privileged tissue are only just comparable to those of vascularized organs. While corticosteroids treatment remains the gold standard for postoperative immunomodulation, other agents have been utilized in an ongoing effort to improve graft survival and patient outcomes. One of the most promising immunomodulatory substances whose immunosuppressive effect has revolutionized solid organ transplantation is cyclosporine (CsA). A calcineurin inhibitor, cyclosporine has been used as an immunosuppressive agent in corneal transplantation since the 1980's. Although some studies have shown beneficial effects of cyclosporine in both low- and high-risk corneal transplant patients the use of cyclosporine in rejection prophylaxis and treatment remain controversial and disputable. We herein present a literature review on the role of systemic cyclosporine in corneal transplantation.
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http://dx.doi.org/10.1007/s10792-015-0137-8DOI Listing
February 2016

Femtosecond Laser-Assisted Deep Lamellar Endothelial Keratoplasty: A New Approach to a Forgotten Technique.

Cornea 2015 Nov;34(11):1369-74

Cornea and External Disease Service, Moorfields Eye Hospital, London, United Kingdom.

Purpose: To review indications and clinical results for a hybrid deep lamellar endothelial keratoplasty (Femto-DLEK) technique combining contemporary donor tissue preparation and implantation techniques with femtosecond laser-assisted dissection of the host tissue.

Methods: A retrospective analysis of consecutive cases of Femto-DLEK performed between 2011 and 2014 at Moorfields Eye Hospital, London, was conducted. All patients underwent manifest refraction and optical coherence tomography examination at their most recent review visit. Secondary interventions, graft rejection, and graft failure were recorded alongside corrected distance visual acuity.

Results: Femto-DLEK was performed in 7 eyes of 7 cases. Mean postoperative follow-up duration was 19 months. Indications included revision of deep anterior lamellar keratoplasty (n = 4), revision of failed Descemet stripping endothelial keratoplasty in cases with an anterior chamber intraocular lens (n = 2), and primary surgery in cases of dense posterior stromal copper deposition. All corneas were recorded as clear by 6 weeks after surgery. Median (range) preoperative corrected distance visual acuity was 6/60 (6/9-1/60), which improved to 6/9 (6/6-6/24) at final review. Tissue bridges requiring significant additional manual lamellar dissection were present in all 4 cases in which deep stromal femtosecond laser lamellar dissection was performed. Femtosecond laser host dissection in the remaining cases was restricted to only a posterior side-cut.

Conclusions: Femto-DLEK is a useful alternative endothelial keratoplasty modality for a narrow range of indications. The femtolaser posterior side-cut facilitates DLEK, but further development of the Femto-DLEK technique is required to optimize the combination with deep lamellar host dissection.
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http://dx.doi.org/10.1097/ICO.0000000000000610DOI Listing
November 2015

Conjunctival diverticuli in Stevens-Johnson syndrome.

Optom Vis Sci 2015 Jun;92(6):e134-7

*MBChB(Hons), FRCOphth †MA(Cantab), MD, FRCOphth ‡MD, MA(Oxon), FRCOphth Moorfields Eye Hospital, London, United Kingdom (MZ, ST, DV); and Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Oldham, United Kingdom (FZ).

Purpose: To report a patient with a history of eye involving Stevens-Johnson syndrome (SJS) who developed chronic bilateral purulent discharge attributed to conjunctival diverticuli.

Case Report: A 75-year-old woman with SJS presented with bilateral chronic relapsing purulent conjunctivitis secondary to inferior conjunctival diverticuli. The symptoms resolved after marsupialization of the diverticuli.

Conclusions: The conjunctival scarring associated with SJS can lead to sequestration of conjunctival epithelium that may in turn lead to the formation of a diverticulum. The presence of a diverticulum should be considered in patients with a history of SJS who develop chronic relapsing purulent conjunctivitis.
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http://dx.doi.org/10.1097/OPX.0000000000000593DOI Listing
June 2015

Reshaping procedures for the surgical management of corneal ectasia.

J Cataract Refract Surg 2015 Apr;41(4):842-72

From Moorfields Eye Hospital (Ziaei), Luton and Dunstable University Hospital (Barsam), and Centre for Sight (Daya), East Grinstead, London, United Kingdom; Department of Ophthalmology (Kim), Duke University Eye Center, Durham, North Carolina, Carolina Cataract and Laser Center, Ladson, South Carolina (Vroman), Ophthalmic Consultants of Long Island (Donnenfeld), Rockville Centre, and Department of Ophthalmology (Kanellopoulos), New York University Medical School, New York, New York, Cincinnati Eye Institute (Holland), Cincinnati, Ohio, University of Pittsburgh School of Medicine (Mah), Pittsburgh, Pennsylvania, and Emory University School of Medicine (Randleman), Atlanta, Georgia; Laservision.gr Eye Institute (Kanellopoulos), Athens, Greece; Instituto de Microcirugía Ocular (Güell), Barcelona, Spain.

Unlabelled: Corneal ectasia is a progressive, degenerative, and noninflammatory thinning disorder of the cornea. Recently developed corneal reshaping techniques have expanded the treatment armamentarium available to the corneal specialist by offering effective nontransplant options. This review summarizes the current evidence base for corneal collagen crosslinking, topography-guided photorefractive keratectomy, and intrastromal corneal ring segment implantation for the treatment of corneal ectasia by analyzing the data published between the years 2000 and 2014.

Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.
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http://dx.doi.org/10.1016/j.jcrs.2015.03.010DOI Listing
April 2015