The latest medical research on Neuro Ophthalmology
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Request AccessChanges in the prognosis of CADASIL over time: a 23-year study in 555 individuals.
Neurology, Neurosurgery and PsychiatryCerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is the most common monogenic form of stroke and is associated with early-onset stroke and dementia. Whether its clinical phenotype is becoming milder with better risk factor treatments and other care improvements is unknown. In a large longitudinal CADASIL cohort, we determined whether the prognosis has changed over 23 years.
Patients were identified from the Cambridge CADASIL register and the UK Familial stroke study. Change in age at stroke over the time of recruitment was determined using linear mixed-effects model, and the impact of genetic and vascular risk factors on stroke and dementia risk was further evaluated using Cox proportional hazard regression.
A total of 555 patients with CADASIL were recruited between 2001 and 2023. The age of stroke onset significantly increased over time (p<0.001), with the mean age of stroke onset for patients recruited before 2016 (n=265) at 46.7±9.2 years and 51.6±9.5 years for those recruited since 2016 (n=290). Patients recruited since 2016 had lower risks of both stroke (HR 0.36, 95% CI 0.26 to 0.50, p<0.001) and dementia (HR 0.43, 95% CI 0.19 to 0.99, p=0.046) after adjusting for sex, hypertension history, smoking status, epidermal growth factor-like repeat position and calendar effect.
The clinical phenotype of CADASIL is improving. While this may be partly explained by reduced vascular risk factors such as smoking and the identification of milder cases, differences persisted after controlling for risk factors and mutation sites. These updated risk estimates should be used when counselling patients with CADASIL on prognosis.
Corneal Allogenic Intrastromal Ring Segments (CAIRS) Versus Synthetic Segments: A Single Segment Comparative Analysis Using Propensity Score Matching.
Refractive SurgeryTo compare and assess the visual, refractive, and tomographic results of patients with corneal ectasia treated with either corneal allogenic intrastromal ring segments (CAIRS) or synthetic intrastromal corneal ring segments (ICRS) without concomitant corneal cross-linking.
In this retrospective cohort study, 34 eyes with CAIRS were matched to 34 eyes with ICRS using the propensity score matching technique. Each group was matched on a oneto-one basis using multiple parameters such as central corneal thickness, vertical and horizontal coma, maximum anterior keratometry, steepest keratometry, and age. Visual, refractive, topographic, and aberrometric data were measured at baseline, 1 week, 1 month, 3 months, and 1 year postoperatively.
Initial preoperative parameters were similar between the two groups. Both groups showed significant improvement at last follow-up time in corrected distance visual acuity (CDVA) (0.52 ± 0.23 to 0.16 ± 0.18 logarithm of the minimum angle of resolution [logMAR], P < .001; 0.44 ± 0.27 to 0.17 ± 0.21 logMAR, P < .001), topographic astigmatism (4.45 ± 2.75 to 3.14 ± 1.93 diopters [D], P = .001; 3.66 ± 2.22 to 2.36 ± 1.46 D, P = .007), maximum anterior keratometry (55.85 ± 7.53 to 50.69 ± 6.38 D, P < .001; 54.59 ± 6.95 to 50.71 ± 4.51 D, P = .003), and vertical coma (1.49 ± 1.02 to 0.38 ± 0.65 D, P < .001; 1.22 ± 0.75 to 0.52 ± 0.57 D, P < .001) for CAIRS and ICRS, respectively. The improvements observed in both groups at the last follow-up visit were comparable; however, the CAIRS group demonstrated a higher percentage of eyes gaining two or more Snellen lines of CDVA (60% vs 31.58%, P = .04), and a greater magnitude of reduction in vertical coma compared to the ICRS group, although this difference did not reach statistical significance. No major complications were observed with both groups, and one eye lost one CDVA line in the ICRS group. The mean thickness of the CAIRS segments at the last follow-up visit was 401.06 ± 100.12 µm, compared to 435.29 ± 26.19 µm for ICRS. Both CAIRS and ICRS demonstrated significant compression of stromal thickness above the segment (36.19% and 32.00%, respectively).
When adequately matched for preoperative disease type and severity, eyes with CAIRS had a similar and notable clinical improvement compared to ICRS, with possibly better improvement in vertical coma and CDVA. [J Refract Surg. 2024;40(11):e863-e876.].
Visual Outcomes After Cataract Surgery With the Light Adjustable Lens in Japanese Patients With and Without Prior Corneal Refractive Surgery.
Refractive SurgeryTo describe Light Adjustable Lens (RxSight, Inc) (LAL) visual and refractive outcomes in a Japanese patient population with and without prior refractive surgery.
In this retrospective chart review of patients with cataract in a private eye clinic, 34 eyes from 21 patients underwent cataract surgery with LAL implantation. Eyes underwent light treatment to adjust the patients' refraction after implantation to meet individual visual goals. Standard visual and refractive outcomes were collected. Contrast sensitivity (to assess quality of vision), clinical defocus and vergence curves (to assess range of vision), and patient satisfaction were also collected.
The mean prediction error of the light adjustment was -0.04 ± -0.48. Thirty-one eyes (91%) and 33 eyes (97%) were within ±0.25 and ±0.50 diopters (D) of manifest spherical equivalent target, respectively. Thirty-two eyes (94%) had residual refractive cylinder of 0.50 D or less. The full depth of focus was 3.68 D. Monocular contrast sensitivity shows frequencies equivalent to a normal population aged 50 to 60 years. The mean satisfaction score was 8.8 (scale: 1 to 10). There were no adverse events and no eyes lost corrected distance visual acuity from the light treatment.
LALs in cataract refractive surgery hold great promise, including for the Japanese population, which have unique ocular biometrics. By providing a safe procedure and the ability for postoperative adjustments, the LAL provided a tailored approach to vision correction, ultimately improving patient outcomes and satisfaction. [J Refract Surg. 2024;40(11):e854-e862.].
Comparison of Subjective and Wavefront-Measured Refractions by InnovEyes Platform in Myopic Patients.
Refractive SurgeryTo compare the subjective refraction and Innov-Eyes (Alcon Laboratories, Inc) wavefront-measured refraction in patients with myopia and astigmatism before refractive surgery.
Consecutive myopic patients planning to receive refractive surgery with ages between 18 and 50 years old were retrospectively enrolled. The subjective and wavefront-measured refraction (InnovEyes platform) were compared, and the influential factors for the measurement difference were analyzed.
Of the 500 eyes enrolled, the mean age was 29.3 ± 6.8 years. Mean wavefront-measured refraction was 0.58 ± 0.62 diopters (D) more myopic and 0.10 ± 0.27 D more astigmatic than subjective refraction (P < .001). Wavefront-measured refraction exhibited excellent consistency and significant correlation with subjective refraction. Linear regression demonstrated that age (P = .008) and wavefront-measured sphere standard deviation (P < .001) were positively correlated with spherical measurement difference, and total quality score (P < .001) and accommodative response (binocular cross-cylinder) (P = .011) demonstrated a negative correlation with spherical and cylindrical measurement difference. The patients with low wavefront measurement quality had significantly greater spherical differences than those with high-quality measurement (P < .001). The patients with accommodative lead had greater spherical equivalent differences than other participants (P = .047).
Wavefront-measured refraction had excellent consistency with subjective refraction, although it measured more myopia and astigmatism than subjective refraction. The spherical measurement difference was greater in older patients and those with accommodative lead. More stable and higher quality repeated measurements will yield closer results between wavefront-measured and subjective refraction. [J Refract Surg. 2024;40(11):e836-e844.].
Clinical Comparison of a Small-Aperture Intraocular Lens Versus a Monofocal Control.
Refractive SurgeryTo evaluate range of visual acuity, visual quality, and safety of the IC-8 small-aperture (SA) intraocular lens (IOL) (Apthera; Bausch & Lomb, Inc) in patients with cataract.
This was a prospective, multicenter, open-label, parallel-group, non-randomized, examiner-masked, 12-month clinical study conducted at 21 sites in the United States. Included patients (N = 453) received either the SA IOL (targeted to -0.75 diopters) in one eye and a monofocal or monofocal toric IOL (targeted to plano) in the fellow eye (SA IOL group, n = 343) or bilateral monofocal/monofocal toric IOLs (control group, n = 110).
At 6 months, the SA IOL group achieved superior binocular uncorrected intermediate and near visual acuity (P < .0001) and equivalent binocular uncorrected distance visual acuity versus the control group. In SA IOL eyes, 99.1% achieved monocular corrected distance visual acuity of 0.3 logarithm of the minimum angle of resolution or better. The SA IOL and control groups had comparable binocular photopic and mesopic contrast sensitivities at 6 months both with and without glare. The SA IOL group reported few visual symptoms overall, although at higher rates than in the control group.
The SA IOL group exhibited improved intermediate and near vision, comparable distance vision and binocular contrast sensitivities, and few visual symptoms or adverse events versus the bilateral monofocal/monofocal toric IOL group, suggesting that the SA IOL is an effective option for presbyopia correction at the time of cataract surgery. [J Refract Surg. 2024;40(11):e824-e835.].
Evaluation of Long-term Rotational Stability and Functional Performance of Two Toric Multifocal IOL Models Beyond 5 Years.
Refractive SurgeryTo assess visual outcomes and stability of lens alignment more than 3 years after implanting either the AT Lisa Tri Toric (Carl Zeiss Meditec) or the Acrysof IQ Restor Toric (Alcon Laboratories, Inc) intraocular lens (IOL).
Patients who had received either the AT Lisa Tri Toric or the Acrysof IQ Restor Toric IOL were included in the study. The average follow-up period was 5.4 years for the AT Lisa Tri Toric group and 7.9 years for the Acrysof IQ Restor group. The examinations covered included: subjective refraction, monocular and binocular corrected and uncorrected visual acuity at far (4 m), intermediate (75 cm), and near (40 cm) distances, binocular best-corrected defocus curve analysis (4 m), contrast sensitivity evaluation, assessment of IOL axial position, and presence of positive dysphotopsia.
A total of 42 eyes were evaluated. Both groups exhibited good long-term lens axial stability. The AT Lisa Tri Toric group had a mean misalignment of 4.8 ± 3.2° from the preoperatively determined axis, whereas the Acrysof IQ Restor Toric group had an average misalignment of 5.4 ± 4.5° (no statistically significant difference, P = .578). Mean achieved spherical equivalent was -0.19 ± 0.36 diopters (D) for the AT Lisa Tri Toric group and 0.15 ± 0.39 D for the Acrysof IQ Restor Toric group. In the AT Lisa Tri Toric group, 18 eyes (72%) achieved an uncorrected distance visual acuity of 0.10 logarithm of the minimum angle of resolution (20/25 Snellen) or better, compared to 15 eyes (88%) in the Acrysof IQ Restor Toric group. Overall, 21 eyes (84%) in the AT Lisa Tri Toric group and 14 eyes (83%) in the Acrysof IQ Restor Toric group achieved a postoperative spherical equivalent refraction between -0.50 and +0.50 D.
Both the AT Lisa Tri Toric and the Acrysof IQ Restor Toric IOLs showed good long-term stability and functional outcomes. They proved to be effective options for restoring vision at far, intermediate, and near distances, providing a viable solution for presbyopia correction even several years after implantation. [J Refract Surg. 2024;40(11):e845-e853.].
Reasons for Re-treatment Following Monovision Laser Refractive Surgery.
Refractive SurgeryTo assess the incidence and causes for re-treatment following monovision laser refractive surgery in a large data study spanning a decade.
The setting for this retrospective comparative study was Care Vision Laser Center, Tel Aviv, Israel. This study included patients aged 36 to 60 years who underwent monovision laser vision correction at the Care Vision Laser Centers, Israel, from January 2012 to December 2022. Demographic, preoperative, and postoperative data were retrieved for analysis.
Overall, 3,674 eyes of 1,847 patients were included. Re-treatment was performed in 1.28% (n = 47) of eyes, 0.84% (n = 31) distance-targeted and 0.44% (n = 16) near-targeted. Monovision reversal in near-targeted eyes occurred due to overcorrection (37.5%, n = 6 of 16), despite being on target (25%, n = 4 of 16), insufficient myopia (18.8%, n = 3 of 16), and de novo astigmatism (12.5%, n = 2 of 16). One eye was targeted for near vision due to de novo astigmatism. Re-treatment in distance-targeted eyes was due to myopic undercorrection (45.2%, n = 14 of 31), myopic regression (19.4%, n = 6 of 31), myopic overcorrection (12.9%, n = 4 of 31), hyperopic regression (6.5%, n = 2 of 31), astigmatism undercorrection (6.5%, n = 2 of 31), de novo astigmatism (6.5%, n = 2 of 31), and astigmatism regression (3.2%, n = 1 of 31). Re-treatment was more likely in distance targeted eyes of patients with monovision compared to near-targeted eyes (P = .025) and patients without monovision (P < .001).
In monovision laser vision correction, retreatment in the near-targeted eye is rare when the ideal near target (-1.50 to -1.25 diopters) is achieved. However, the distance-targeted eye is more likely to require re-treatment. Surgeons can plan monovision surgery and advise patients accordingly. [J Refract Surg. 2024;40(11):e892-e897.].
Reading Performance Following Contralateral Implantation of an Extended Depth of Focus (EDOF) IOL and a Hybrid EDOF Multifocal IOL.
Refractive SurgeryTo assess objective reading performance at intermediate and near distances using the Salzberg Reading Desk (SRD) (SRD Vision) in patients with cataract who underwent the implantation of a diffractive extended depth of focus intraocular lens (EDOF IOL) in the dominant eye and a hybrid multifocal EDOF IOL in the non-dominant eye.
This prospective, non-comparative, interventional study included 46 eyes of 23 patients with cataract who underwent bilateral cataract surgery with implantation of the DFR00V Tecnis Synergy IOL (Johnson & Johnson Surgical Vision) in the non-dominant eye and the DXR00V Tecnis Symfony OptiBlue IOL (Johnson & Johnson Surgical Vision) in the dominant eye. At postoperative 6 months, the Salzburg Reading Desk was used to assess distance-corrected reading performance at near and intermediate distances.
Although the monocular reading acuity at the preferred intermediate distance was statistically significantly better in the eyes implanted with the DXR00V IOL, it was better with the DFR00V IOL at preferred near distances. The mean binocular distance-corrected preferred intermediate and near reading acuity was 0.07 ± 0.09 (20/23) and 0.13 ± 0.09 (20/27) logarithm of the minimum angle of resolution, respectively. Other parameters of reading performance, such as reading speed, reading distance, reading time, and smallest scale log print size, were similar between the two IOL groups when assessed monocularly.
Implanting a DFR00V IOL in the non-dominant eye and a diffractive DXR00V IOL in the dominant eye resulted in excellent binocular reading acuity and speed at intermediate and near distances. [J Refract Surg. 2024;40(11):e778-e782.].
Keratorefractive Lenticule Extraction Using the Ziemer FEMTO LDV Z8 Platform (CLEAR): One-Year Results.
Refractive SurgeryTo present the outcomes and detail the surgical procedure employed in the initial 102 eyes treated with keratorefractive lenticule extraction (KLEx) using the FEMTO LDV Z8 platform (Ziemer Ophthalmic Systems).
This was a retrospective analysis of 102 eyes of 53 patients treated with KLEx at the American University of Beirut Medical Center. Visual, refractive, topographic, and aberrometric parameters were evaluated 1 week and 1, 3, 6, and 12 months postoperatively.
Mean preoperative spherical equivalent refraction (SEQ) was -4.11 ± 1.82 diopters (D) (range: -10.00 to -1.625 D) and mean preoperative cylinder was -0.75 ± 0.65 D (range: -3.00 to 0.00 D). Postoperatively, the mean SEQ was 0.06 ± 0.54 D (range: -2.88 to +1.00 D) at 1 week and -0.04 ± 0.26 D at 12 months and was within ±0.50 D in 95.6% and ±1.00 D in 100% of eyes. A total of 96.7% of eyes had an uncorrected distance visual acuity (UDVA) of 20/20 at 12 months postoperatively. Fifty percent gained one or more lines of corrected distance visual acuity (CDVA), 5 eyes (5.4%) lost one line, and none lost two or more lines. No suction losses were encountered and all extracted lenticules were intact without tears.
The application of KLEx using the FEMTO LDV Z8 platform yields safe and effective outcomes, aligning comparably with established modes of lenticule extraction and femtosecond laser-assisted laser in situ keratomileusis procedures previously employed and accepted within the field of refractive surgery. [J Refract Surg. 2024;40(11):e898-e905.].
Visual Quality, Patient Satisfaction, and Photic Phenomena With a Diffractive Intraocular Lens and Its New Evolved Materials Version.
Refractive SurgeryTo assess the visual quality, patient satisfaction, and photic phenomena 3 and 12 months after the implantation of two similar diffractive intraocular lenses (IOLs) manufactured with different materials.
This retrospective observational study included patients with the AcrySof PanOptix IOL or the Clareon Pan-Optix IOL (both Alcon Laboratories, Inc). Three and 12 months after the surgery, binocular contrast sensitivity under photopic conditions was measured. The presence of dysphotopsias and difficulties when driving in dim light conditions was also reported. Patient satisfaction was assessed through the Catquest 9-SF questionnaire and patients also reported the need for additional spectacles at different distances. Twelve months after the surgery, the presence of posterior capsule opacification and glistening was reported.
The study included 59 patients. Contrast sensitivity was stable in both groups 12 months after the surgery, the proportion of patients that always perceived halos decreased approximately 15%, and difficulties when driving at night were minimized. Both groups showed high and similar rates of satisfaction with their vision and achieved spectacle independence rates greater than 85% at the two visits. The presence of posterior capsule opacification was similar for both groups, whereas 64% and 90% of the eyes were free of glistening in the AcrySof and Clareon groups, respectively.
Both diffractive IOLs offer consistent visual outcomes and high rates of patient satisfaction during the initial 12 months after surgery. The results also suggest that the novel material may better preserve the transparency of the IOL in the long term. [J Refract Surg. 2024;40(11):e877-e883.].
The Effect of Eyelid Laxity on Corneal Mapping and Corneal Topography.
Refractive SurgeryTo evaluate the effect of eyelid laxity on the structure of the cornea.
This was a retrospective study performed in one institution. Patients with and without upper and lower eyelid laxity, which were determined using the snap-back test (SBT) and the upper eyelid distraction test (LDT), were evaluated for corneal structural changes with Scheimpflug imaging corneal tomography for the keratometric readings, and cor-neal spectral domain optical coherence tomography for the epithelial thickness (ET) measurements. The ET values were obtained using the statistics report for the superior quadrant (SET), the inferior quadrant (IET) within the 2- to 7-mm region, and central thickness (CET) within the 2-mm region. The minimum corneal thickness values within the central 5-mm region (MinCT) were also included in the study. Keratometric readings (in diopters), horizontal white-to-white (HWTW) measurements, pachymetry, and ET measurements were assessed along with the presence or absence of eyelid laxity.
A total of 170 eyes from 85 patients were evaluated (50.6% with eyelid laxity, and 49.4% without eyelid laxity). There was no significant difference between the mean keratometric readings, HWTW, and the mean IET and CET values (P > .05); however, the difference was significant for the MinCT and SET (P < .05). A statistically significant negative correlation was found between the SET values and age, LDT, and SBT measurements (P < .05).
A strong association was found between decreased SET and MinCT values and eyelid laxity. The possible reason for these decreases may be inflammation, which plays a role in the pathophysiology of eyelid laxity. [J Refract Surg. 2024;40(11):e783-e791.].
Ray-tracing-Guided or Q-Value-Adjusted FS-LASIK for Correction of Myopia and Myopic Astigmatism: A Comparative Contralateral Eye Study.
Refractive SurgeryTo compare the safety and efficacy of individualized ray-tracing-guided femtosecond laser-assisted in situ keratomileusis (FS-LASIK) for correction of myopia and myopic astigmatism.
This prospective, randomized, double-blind, contralateral eye study included 68 eyes of 34 patients with myopia or myopic astigmatism requiring FS-LASIK treatment. For each patient, one eye was randomly assigned to receive the ray-tracing-guided treatment, whereas the contralateral eye underwent Q-value-adjusted ablation. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), manifest refraction spherical equivalent (MRSE), sphere, cylinder, effective optical zone (EOZ), and 6-mm corneal aberrations were measured and analyzed before operation and after a 3-month postoperative follow-up.
At 3 months postoperatively, the UDVA of 20/16 or better was measured in 94% of eyes in the ray-tracing group and 85% of eyes in the Custom-Q group (P = .064). Forty-seven percent in the ray-tracing group and 32% in the Custom-Q group gained one or more Snellen lines of CDVA (P = .043). The MRSE, refractive astigmatism, surgically induced astigmatism, and difference vector were better in the Custom-Q group (P < .05). The postoperative corneal HOAs and optical path difference were significantly better in the ray-tracing group (P = .008). The EOZs of the ray-tracing and Custom-Q groups were 5.77 and 5.43 mm (P < .001), and the average ablation depths of the ray-tracing and Custom-Q groups were 100.97 and 85.24 µm (P < .001), respectively.
Despite the overcorrection and excessive ablation of corneal tissue, ray-tracing-guided FS-LASIK in clinical practice was found to be safe and effective for myopic correction both with and without astigmatism, particularly in achieving UDVA and inducing fewer corneal HOAs and less OPD. [J Refract Surg. 2024;40(11):e804-e813.].
