Abstract: PURPOSE: To analyze the 2-year topographic response of the cornea to deep lamellar endothelial keratoplasty (DLEK). METHODS: The Orbscan topographies of 24 eyes that underwent DLEK for corneal decompensation were retrospectively analyzed. Twelve eyes received a large-incision DLEK technique and 12 eyes received a small-incision DLEK. All the preoperative and postoperative corneal raw data were imported into a custom software program, which computed the average composite corneal maps and difference maps for both study groups to evaluate the corneal response to the surgery. The software delineated 2 concentric zones of the cornea to characterize the regional response after the surgery: the central and peripheral regions. RESULTS: At 2 years after surgery, no significant changes (<0.41 diopters; analysis of variance, P > 0.05) in the central topography configuration were measured in comparison with the preoperative state after DLEK procedures. On the other hand, a significant increase (P < 0.01) in the mean tangential curvature and astigmatic power of the anterior corneal periphery was measured after surgery, with higher changes after large-incision DLEK. No significant differences in the average curvature profile of the posterior corneal interface were measured after DLEK procedures (<0.40, P > 0.05) in comparison with the preoperative state. CONCLUSIONS: DLEK provides stable central corneal topography, with minimal changes in curvature and astigmatic power in the years after surgery. Moreover, the donor posterior cornea shows to maintain its vitality and integrity in the long-term postoperative period, with curvature values similar to the original posterior corneal interface.

Abstract: During the past decade, there has been a remarkable expansion of the application of wavefront-related technologies to the human eye. The ability to measure the wavefront aberrations (WA) of an individual eye has greatly improved our understanding on the optical properties of the human eye. The development of wavefront sensors has further generated an intensive effort to revise methods to correct vision. Wavefront sensors have offered the promise of a new generation of visual correction methods that can correct high order aberrations beyond defocus and astigmatism, that is, the wavefront-guided excimer laser platforms and adaptive optics, thus improving visual performance or fundus imaging at unprecedented spatial resolution. On the other hand, current wavefront technologies suffer from some inaccuracies that may limit a wider expansion in the clinical environment. Several innovative approaches have been developed to overcome the limits of standard wavefront sensing techniques. Curvature sensing, pyramid sensing and interferometry currently represent the most reliable methods to revise and improve the measurement and reconstruction of the WA of human eyes. This review describes advantages and disadvantages of current wavefront sensing technologies and provides recent knowledge on innovative methods for sensing the WA of human eyes. In the near future, we expect to benefit from these new wavefront sensor elements, including their application in the personalised correction of optical aberrations and adaptive optics imaging of the eye.

Abstract: High-order coreal wavefront analysis was performed in a population of 60 myopic eyes that underwent photorefractive keratectomy. Corneal aberration data over 3, 5, and 7 mm pupils were collected for up to three years after surgery. The optical performance of the anterior cornea was characterized by estimation of the modulation transfer function (MTF) and the point-spread function. The high-order corneal wavefront aberrations were shown to stabilize one year after surgery. Over photopic pupils, after an early slight increase, corneal RMS-high-order aberrations (HOA) tended to decrease toward preoperative values. On the other hand, over mid- and large-pupil sizes, corneal HOA significantly increased compared with the preoperative state, while the optical performance of the cornea was diminished. The MTF ratio showed a distinct decline in the optical quality of postoperative corneas at low and middle spatial frequencies over larger pupils in the range between 6 and 19 c/deg, especially for deeper ablations.

Abstract: We showed the capabilities and accuracy of atomic force microscopy (AFM) techniques for imaging and analyzing the corneal epithelium and the photoablated corneal stroma. Eight normal porcine corneas, half of which were ablated using a scanning-spot excimer laser, were examined. All the corneas were imaged in balanced salt solution after fixation in glutaraldehyde. In the normal untreated corneas we observed the epithelial surface showing the typical polygonal cells and presenting numerous microprojections. The superficial epithelial cells were classified in three types as a result of the anterior-surface roughness measurements. AFM images of the photoablated corneal specimens showed undulations and granule-like features on the ablated stromal surface, specific to 193-nm ArF laser irradiation. Nevertheless, the quantitative analysis confirmed the precision of excimer laser surgery in removing sub-micrometric amounts of tissue. AFM showed to be a high-resolved imaging tool for the scanning of both native as well as photoablated corneal specimens. Also, this technique permits precise topographic analysis of the corneal plane, in the nanometric scale, of which smoothness is an important physical characteristic and necessary to achieve an optimal optical quality of the eye.

Abstract: The interocular symmetry of the high-order corneal wavefront aberration (WA) in a population of myopic eyes was analyzed before and after photorefractive keratectomy (PRK). The preoperative and one-year postoperative corneal aberration data (from third to seventh Zernike orders) for 4- and 7-mm pupils from right and left eyes were averaged after correcting for the effects of enantiomorphism to test for mirror symmetry. Also, the mean corneal point-spread function (PSF) for right and left eyes was calculated. Preoperatively, a moderate and high degree of correlation in the high-order corneal WA between eyes was found for 4- and 7-mm pupils, respectively. Myopic PRK did not significantly change the interocular symmetry of corneal high-order aberrations. No discernible differences in the orientation PSF between eyes were observed one year after surgery in comparison with the preoperative state over the two analyzed pupils.

Abstract: PURPOSE: To analyze the influence of specific combinations of corneal high order aberrations on the optical image quality of the cornea before and after photorefractive keratectomy (PRK) for low to high myopia and myopic astigmatism. METHODS: Corneal topography was obtained for 80 eyes that underwent PRK using a scanning-spot excimer laser. The eyes were subdivided into three groups according to the preoperative refraction. The topographical data were imported into a custom software program that combined the Zernike high order terms having the same sign and angular frequency up to seventh order for 4-mm and 6-mm pupils, ie, coma and spherical aberrations, and midperipheral and peripheral high order aberrations. RESULTS: Photorefractive keratectomy induced a significant amount of the root-mean-square (RMS) values of the combinations of midperipheral and peripheral high order aberrations over the smaller pupil size for deeper myopic ablations (P<.05). Over the larger pupil, spherical myopic ablations showed a significant increase (P<.05) of the RMS values of coma and spherical aberrations. In the astigmatism group, the combination of terms having higher angular frequency increased significantly (P<.05) after surgery both over 4-mm and 6-mm pupils. CONCLUSIONS: After surface ablation, ablation depth and profile significantly influence the distribution and contribution of determined combinations of high order aberrations to the overall high order corneal wavefront aberration. Terms having high angular frequency were increased following large myopic correction and wide treatment zone. Quality of the whole corneal optics will be enhanced by designing future ablation profiles to compensate for peripheral high order optical aberrations.

Abstract: PURPOSE: To analyze the surface optics of 4 currently available intraocular lenses (IOLs) with atomic force microscopy. SETTING: Licryl Laboratory, University of Calabria, Rende, Italy. METHODS: The surface roughness and topography of poly(methyl methacrylate) (PMMA), silicone, hydrophobic, and hydrophilic acrylic IOLs were evaluated with atomic force microscopy in contact mode. The analysis was performed in a liquid environment using cantilevers with a 0.01 Newtonw/meter nominal elastic constant. Measurements were made over areas of 10 microm2 on different locations of the posterior optic surface of the IOL. RESULTS: Atomic force microscopy permitted high-resolution imaging of IOL optic surface characteristics. Surface topography showed different features with respect to the lens biomaterial. The root-mean-square roughness of the IOL optic surface was significantly different between lenses of various materials (P < .001). The hydrophobic acrylic and silicone IOLs had the lowest mean surface roughness, 3.8 nm +/- 0.2 (SD) and 4.0 +/- 0.5 nm, respectively, and the 2 PMMA IOLs had the highest mean surface roughness, 6.6 +/- 0.3 nm and 7.0 +/- 0.6 nm. CONCLUSIONS: Atomic force microscopy was effective and accurate in analyzing IOL optics. The surface topography of IOLs may vary with different manufacturing processes.

Abstract: PURPOSE: To analyze the long-term corneal topographic changes 4 years after myopic photorefractive keratectomy (PRK). METHODS: This study comprised 15 patients (30 eyes) who had PRK surgery with a scanning-spot excimer laser (Chiron Technolas 217C; Bausch & Lomb, Dornach, Germany) and were followed up to 4 years after surgery. The eyes were subdivided into three groups according to the preoperative spherical equivalent refraction. Corneal topographic maps were obtained for all eyes with a Placido disc topographer. Preoperative and follow-up topographical data were imported into a custom software program, which computed the average composite corneal maps and difference maps for each study group to quantify the anterior corneal changes following laser ablation. The software delineated three concentric zones of the corneal surface to characterize the regional corneal remodeling following the surgery. RESULTS: A significant central corneal steepening (approximately 0.25 D, P < .001) was calculated between the 1- and 4-year postoperative maps in all study groups. A significant steepening (P < .001) of the corneal periphery was also noted for the lower myopic ablations whereas a peripheral flattening (P < .001) was observed for the deeper ablations between 1 and 4 years after surgery. CONCLUSIONS: The anterior corneal surface was observed to remodel for up to 4 years after surface ablation, steepening a mean of approximately 0.25 D.

Abstract: PURPOSE: To analyze the surface roughness of porcine corneas after excimer laser ablation with and without the smoothing procedure by means of atomic force microscopy. METHODS: Excimer laser photorefractive keratectomy (PRK) was performed on eight porcine corneas. Immediately following the procedure, smoothing was performed on four corneas using a viscous solution of 0.25% sodium hyaluronate. The corneas were examined in balanced salt solution after fixation in 2.5% glutaraldehyde solution using atomic force microscopy. Quantitative analysis of the ablated stromal surface topography was performed using the section analysis module of the atomic force microscopy software. Repeated measurements were made over small areas (< or =50 microm2) near the center of each ablation, with a vertical resolution of <1 nm. RESULTS: Images of the ablated stromal surface showed undulations and granule-like features on the ablated surface of the specimens. The specimens on which the smoothing procedure was performed (root-mean-square [RMS] rough: 0.152 +/- 0.014 microm) were more regular (P < .001) than those on which PRK alone was performed (RMS rough: 0.229 +/- 0.018 microm). CONCLUSIONS: Atomic force microscopy analysis requires a simpler preparation of the specimens with respect to that necessary for scanning electron microscopy; for this reason, atomic force microscopy techniques are more reliable for the study of biological surfaces and prove to be a feasible method to establish the differences when comparing different laser techniques. Our investigations highlight that although the laser cut of scanning-spot excimer laser systems is precise in removing even the smallest amounts of tissue, the smoothing technique may still be useful to reduce post-ablation roughness.

Abstract: PURPOSE: To characterize the velocity of epithelial migration after photorefractive keratectomy (PRK) with 3 different corneal ablation patterns. SETTING: Department of Ophthalmology, Catholic University of Rome, Rome, Italy. METHODS: Fifteen patients (30 eyes) with mild to moderate myopia and with simple to compound myopic astigmatism were enrolled for this study. The surgical procedure consisted of standardized PRK with final smoothing performed using the Technolas Keracor 217C excimer laser. The reepithelialization process was evaluated at 0 hours, 20 hours, 40 hours, and 60 hours after surgery using a digital photo camera and custom software for measurement. Digital analysis of the images was performed. Corneal topographies were taken at 1 month, 3 months, 6 months, and 12 months after PRK. RESULTS: The mean speed of radial migration in the 10 eyes (33%) in the low spherical ablation group was 0.087 mm/h +/- 0.008 (SD). This was significantly higher than that found in the 10 eyes (33%) in the high spherical ablation group (mean speed 0.078 +/- 0.007 mm/h; P<.001) and in the 10 eyes (33%) in the cross-cylinder ablation group (mean speed 0.055 +/- 0.014 mm/h; P<.001). CONCLUSION: Analysis of the data shows that epithelial migration along the photoablated corneal surface depends on the ablation pattern. The epithelial sliding is highly influenced by local variations in the curvature of the stromal surface. The data demonstrate that faster epithelial wound healing after PRK is predictive of optimal visual performance.

Abstract: PURPOSE: To examine the differences in the biomechanical response of the peripheral regions of the cornea after photorefractive keratectomy (PRK). SETTING: Department of Ophthalmology, Catholic University of Rome, Rome, Italy. METHODS: Preoperative and 1-, 3-, 6-, and 12-month postoperative corneal topographies of 70 eyes that had PRK with the Technolas 217C excimer laser (Bausch & Lomb) were obtained. The eyes were divided into 4 groups according to the preoperative spherical equivalent refraction. Preoperative and follow-up topographic data were imported into custom software that computed the average composite corneal map and difference maps in each group to scientifically evaluate the corneal response to the surgery. The software was also used to analyze regional corneal changes after the laser ablation. Corneal peripheries up to 9.0 mm were evaluated. RESULTS: The preoperative corneas had a flatter nasal periphery than temporal periphery. The corneal surfaces in the right eyes and left eyes showed a mirror symmetry. Significant differences in the regional response of the cornea were observed (P<.05), with a greater increase in the curvature of the nasal periphery than in the temporal periphery. CONCLUSIONS: To refine modeling of the cornea, the different regional anatomic features and biomechanical responses must be considered. Modifying existing ablation algorithms to compensate for the differences between nasal and temporal corneal flattening of the preoperative corneal surface and between the nasal and temporal responses may improve the postoperative corneal shape and quality of peripheral optics.

Abstract: PURPOSE: To assess the efficacy, predictability, stability, and safety of a smoothing technique in patients with myopia immediately after photorefractive keratectomy (PRK) using a scanning-spot excimer laser. METHODS: Using the Technolas 217C excimer laser, PRK was performed on 100 eyes of 54 patients. Ablation zone diameter was 6.0 mm and transition zone diameter was 9.0 mm. The eyes were randomized into two groups: in 50 eyes PRK alone was performed and in the other 50 eyes, a smoothing technique was performed after the initial ablation. Preoperative mean spherical equivalent refraction was -4.98 +/- 1.71 D in the PRK only group (range -2.25 to -8.60 D) and -4.82 +/- 1.61 D in the smoothing group (range -2.00 to -8.00 D). Follow-up was 12 months for all patients. RESULTS: At 1 year after surgery, mean manifest spherical equivalent refraction was -0.61 +/- 0.50 D (range -2.25 to +0.62 D) in the PRK only group and in the smoothing group, +0.02 +/- 0.32 D (range -0.75 to +0.75 D). Postoperative regularity topographic indices were lower in the smoothing group than in the PRK group (P<.001). CONCLUSIONS: Smoothing after PRK for correction of myopia up to -6.50 D increased surface regularity, as expressed by lower topography surface regularity indices, and reduced the incidence and severity of postoperative haze. We observed higher predictability throughout follow-up in the smoothing group, which may be addressed by a nomogram adjustment in the PRK only group.

Abstract: PURPOSE: To demonstrate efficacy of a smoothing technique to increase regularity of the anterior corneal surface after photorefractive keratectomy (PRK), using two different excimer lasers. METHODS: Spherical ablations of -10.00 D were performed on 11 fresh porcine corneas using either the Technolas Keracor 217C scanning-spot or the Nidek EC-5000 scanning-slit beam excimer laser. Following the procedure, we performed a phototherapeutic keratectomy treatment (smoothing technique) on half of the corneal surface. The smoothing technique was performed using a viscous solution of 0.25% sodium hyaluronate, which was spread on the cornea prior to the procedure. The ablation zone was 6 mm in diameter and the transition zone extended to 3 mm. The ablation depth was set at 10 microm. Corneas were then examined with scanning electron microscopy. RESULTS: Smoother treatment zones were apparent in porcine corneas in which smoothing was performed following PRK, with both laser systems. Results from the two lasers were not directly compared. CONCLUSIONS: The smoothing procedure performed following PRK using a viscous 0.25% sodium hyaluronate masking solution and a scanning laser system rendered the porcine corneal surface more regular.

Abstract: PURPOSE: To assess whether a smoother stromal surface and a faster epithelium regeneration after excimer laser photorefractive keratectomy (PRK) may lead to better visual results. METHODS: Ten patients had unilateral PRK and contralateral PRK plus smoothing. The operative outcome was checked by means of digital standardized photographs taken at 0, 20, 40, and 60 hours after surgery. Complete clinical examinations were performed before and 1 and 3 months after surgery. RESULTS: Between 20 and 40 hours after surgery, the average velocity of radial epithelial migration in eyes in which smoothing was performed was 0.083 +/- 0.008 mm/h. This was faster than that (0.064 +/- 0.007 mm/h [P<.01]) observed in the eyes without smoothing. The corneal regularity index at 1 and 3 months was worse in the PRK alone group compared to the PRK plus smoothing group (P=.1). At 3 months, better visual outcome and less haze were observed in the PRK plus smoothing group. CONCLUSION: When using a flying spot laser, PRK plus smoothing improved the visual results and diminished regression and haze at 3 months, but gave rise to a slight hyperopic shift.