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Refractive lensectomy and accommodating lens implantation in a case of hyperopia.

We present a 39-year-old woman with high hyperopia who developed an intolerance to contact lenses due to dry-eye syndrome and Grave's disease. Refractive lensectomy with implantation of a custom-made +31.00 diopter (D) accommodating intraocular lens (IOL) (1CU, HumanOptics) was performed in both eyes. This foldable IOL has modified haptics with transmission elements that allow axial movement of the IOL optic and capsular bag secondary to contraction of the ciliary muscle. The calculated pseudophakic accommodation induced by the anterior shift of a +31.00 D IOL is 2.20 D per millimeter of axial displacement. After 6 months, the accommodative range determined by defocusing was 3.00 D. The subjective near point with best distance correction was 32.00 cm. Refractive lensectomy and implantation of an accommodating IOL based on focus shift may be a refractive solution in eyes with high hyperopia and a short axial length.

Accommodation, Ocular↗

Laser in situ keratomileusis for hyperopia with the LADARVision 4000 with centration on the coaxially sighted corneal light reflex.

PURPOSE: To analyze the visual acuity, contrast sensitivity, and target deviations in patients who had laser in situ keratomileusis (LASIK) for primary hyperopia with the ablation centered on the coaxially sighted corneal light reflex. SETTING: University-based refractive surgery practice. METHODS: Retrospective review comprised 37 consecutive patients (61 eyes) who had LASIK for hyperopia with the LADARVision 4000 excimer laser (Alcon Laboratories). Preoperative and 3-month postoperative visual acuity and contrast sensitivity, as well as the target deviation, were assessed for each eye. The change in best spectacle-corrected visual acuity (BSCVA), best spectacle-corrected contrast sensitivity (BSCCS), and target deviation from the intended correction were analyzed. RESULTS: Postoperatively, the uncorrected visual acuity (UCVA) was 20/20 or better in 44.4% of eyes. The mean deviation from target was +0.25 diopter (D) +/- 0.82 (SD), with 65.6% of eyes within +/-0.50 D of target. None eye lost 2 or more lines of BSCVA. A loss of 3 or more patches of BSCCS were seen in 6.6% of the eyes and a loss of 4 or more patches, in 1.6%. CONCLUSION: Hyperopic LASIK with LADARVision 4000 with the ablation zone centered on the coaxially sighted corneal light reflex did not adversely affect BSCVA and BSCCS.

Adult↗

Laser in situ keratomileusis for primary hyperopia.

PURPOSE: To evaluate the efficacy, predictability, stability, and safety of hyperopic laser in situ keratomileusis (H-LASIK) over a 24-month period and analyze topographic changes after H-LASIK to assess topographic pseudokeratectasia (TPKE) following H-LASIK. SETTING: Eye Institute of Utah, Salt Lake City, Utah, USA. METHODS: This prospective study included 139 eyes of 77 patients having H-LASIK for primary hyperopia. The mean follow-up was 15.6 months +/- 7.6 (SD) (range 6 to 48 months). One hundred twenty-two eyes (88%) were followed at 1 year and 36 eyes (26%) at 24 months. Topographic pseudokeratectasia was defined as 1 or more positive keratoconus screening findings in an eye with topographic central or inferior steepening detected by the Topography Modeling System but without corneal thinning or progressive change. RESULTS: The mean spherical equivalent manifest refraction was +2.39 +/- 0.99 diopter (D) preoperatively and -0.05 +/- 0.61 D at the last visit. Ninety-one percent of eyes were within +/-1.00 D of emmetropia and 71% of the eyes were within +/-0.50 D. Uncorrected visual acuity of 20/20 or better was present in 42%, 20/25 in 63%, and 20/40 or better in 93% of eyes. Loss of 2 lines of BSCVA occurred in 2 eyes (1.4%). In 1 eye, ischemic optic neuropathy occurred, and in another, choroidal neovascularization developed postoperatively. Topographic pseudokeratectasia was detected in 28% to 56% of eyes postoperatively. No significant difference between postoperative visual and refractive outcome, regression, or irregularity was found between the eyes with or without TPKE. CONCLUSION: Hyperopic LASIK appears to be an effective, predictable, and safe procedure to correct low to moderate primary hyperopia. Topographic pseudokeratectasia, which was observed after H-LASIK with a keratoconus-like topographic pattern in otherwise normal eyes, may represent a relatively static condition.

Adult↗

Angle-supported phakic intraocular lenses in hyperopia.

PURPOSE: To evaluate the efficacy and safety of angle-supported phakic intraocular lenses (PIOLs) in hyperopia. SETTING: Private practice, Siena, Italy. METHODS: A prospective noncomparative single-surgeon interventional case series comprised 42 consecutive hyperopic eyes of 22 patients having implantation of a type PIOL (Morcher) through a sclero-corneal 5.5 mm x 3.0 mm tunnel along the steepest meridian, with surgical iridectomy. The mean preoperative defocus equivalent (DEQ) was 7.30 diopters (D) +/- 1.89 (SD). The mean spherical equivalent (SE) was 6.61 +/- 1.47 D (range 4.0 to 10.5 D), and the mean refractive astigmatism was 1.51 +/- 1.33 D (range 0 to 5 D). The mean age was 29.9 +/- 6.0 years (range 22 to 42 years). Thirteen patients (59%) were men. RESULTS: Postoperative mean SE was 0.38 +/- 0.52 D (range 0 to 2 D); mean DEQ 0.93 +/- 0.98 D; mean astigmatism 0.95 +/- 1.17 D; mean surgically induced astigmatism (vector analysis) 0.67 +/- 0.58 D (95% confidence interval, 0.49-0.85); 38 eyes (90%) were within +/-2 D of DEQ, 34 eyes (81%) within +/-1 D, and 24 eyes (57%) within +/-0.5 D. Safety index was 1.05; efficacy index 0.85. Complications were night halos 10%; pupil ovalization 7%; pupillary block reversed by neodymium:YAG laser 7%; monocular anterior subcapsular opacity 5%; monocular iridocyclitis 5%; and intraocular pressure rise due to topical steroids 2%. Endothelial cell loss at 12 month was 6% (range +2.5% to -11%). CONCLUSION: High hyperopia was corrected safely and predictably by an angle-supported PIOL with limited complications.

Adult↗

Early-onset autosomal dominant retinitis pigmentosa with severe hyperopia.

We studied a four-generation family with early-onset autosomal dominant retinitis pigmentosa, severe hyperopia, and axial eye lengths of less than 20 mm. The affected members had decreased vision, night blindness, typical peripheral retinal pigmentary changes, and electroretinographic abnormalities characteristic of retinitis pigmentosa. This pedigree suggests there is another variant of retinitis pigmentosa associated with hyperopia besides Leber's congenital amaurosis and preserved para-arteriole retinal pigment epithelium.

Adolescent↗

Flicker parameters are different for suppression of myopia and hyperopia.

Axial eye growth rates in the chicken are controlled by local retinal image-processing circuits. These circuits quantify the loss of contrast for different spatial frequencies and promote axial eye growth rates in correlation with the amount of retinal image degradation ("deprivation myopia"). They also distinguish whether the plane of focus lies in front of or behind the retina. How the sign of defocus is detected still remains unclear. Cues from chromatic aberration are not important. In an attempt to isolate retinal circuits controlling the development of myopia or hyperopia, young chickens were raised in flickering light of different frequencies (12 and 6 Hz) and duty cycles (4-75%) produced by rotating chopper disks. The effects of flickering light on refractive errors and change in axial growth rates induced by translucent occluders or defocusing lenses were measured by infrared retinoscopy and A-scan ultrasound, respectively. Retinal electrical activity was evaluated by flicker ERG after matching flicker parameters and stimulation brightness at retinal surface. Changes in retinal and vitreal dopamine content caused by flicker in occluded and normal eyes were determined by HPLC-ECD. Strikingly, suppression of myopia occurred for similar flicker parameters, whether induced by translucent occluders ("deprivation") or negative lenses ("defocus"). The degree to which myopia was suppressed was correlated with the duration of flicker dark phase and with the ERG amplitude. In contrast, suppression of hyperopia did not correlate with these parameters. We conclude that two different retinal circuits with different temporal characteristics are involved in the processing of hyperopic defocus/deprivation and of myopic defocus, the first one dependent on flicker ERG amplitude. However, we did not find any correlation between the rate of dopamine release and the degree of inhibition of deprivation myopia in flickering light.

Animals↗

Refractive lensectomy for hyperopia.

PURPOSE: The purpose of this study was to evaluate refractive lensectomy as a surgical procedure for the treatment of hyperopia. DESIGN: A retrospective noncomparative case series. PARTICIPANTS: Twenty-nine patients were included in the study. Fifty eyes underwent extraction of the crystalline lens and intraocular lens implantation. METHODS: Operations were performed by the same surgeon with the patient under general anesthetic. All lenses were removed by phacoemulsification with insertion of lens implants singly or as piggyback lenses. The Holladay2 formula was used to calculate lens powers. Results are compared with other methods of treating hyperopia. MAIN OUTCOME MEASURES: The main parameters assessed were safety, efficacy, predictability, stability, and complications. RESULTS: Eyes were divided into group A (n = 26), with an average preoperative spherical equivalent (SE) of +2.26 +/- 0.94, and group B (n = 24), with an average preoperative SE of +6.32 +/- 1.32. In group A, after refractive lensectomy, 80.7% had no change in best-corrected visual acuity (BCVA) or gained a line, whereas 11.5% lost one line; 88.5% had an uncorrected visual acuity (UCVA) of 20/40 or better, and 88.5% were within 1 diopter (D) of intended postoperative SE. In group B, 70.9% of eyes had no change or gained a line in BCVA, whereas 29.2% lost a line of BCVA; 62.5% had UCVA of 20/40 or better postoperatively, and 58.3% were within 1 D of the intended SE. In one eye the posterior capsule was breached intraoperatively. One eye had a symptomatic episode of cystoid macula edema that settled spontaneously. To date, seven eyes have required secondary refractive procedures, and three eyes have required yttrium-aluminum-garnet capsulotomy. CONCLUSIONS: In the presbyopic age group refractive lensectomy may be a realistic alternative to photorefractive keratectomy or laser in situ keratomileusis, with certain potential advantages.

Female↗

Intraocular pressure after LASIK for hyperopia.

PURPOSE: To determine whether hyperopic laser in situ keratomileusis (H-LASIK) affects Goldmann applanation tonometry measurements. DESIGN: Retrospective, comparative, self-controlled case series. PARTICIPANTS: One hundred eight eyes of 58 patients were enrolled in the study. METHODS: Baseline intraocular pressure (IOP) was measured by Goldmann applanation tonometry. These readings were compared with readings obtained at least 6 months after surgery. RESULTS: After H-LASIK, a decrease was observed in the measured IOP of treated eyes that could not be related to the degree of hyperopia treated or to the treatment zone diameter. A significant difference was observed between the IOP before and after surgery (P < 0.00001). CONCLUSIONS: The applanation tonometer underestimates the true IOP after LASIK for hyperopia.

Adult↗

Photorefractive keratectomy for hyperopia: long-term nonlinear and vector analysis of refractive outcome.

PURPOSE: To characterize the refractive changes after excimer laser photorefractive keratectomy for the correction of hyperopia over a follow-up up to 3 years and to assess refractive stability and changes in astigmatism. DESIGN: Noncomparative, nonrandomized, retrospective, interventional case series. PARTICIPANTS: Thirty-eight hyperopic eyes of 28 patients (age range, 33-62 years) with refraction in the range +1.00 to +8.00 diopters (D). Mean attempted correction was +3.33+/-0.98 D (range, +1.00 to +4.00 D). Data were compared to those from 216 eyes treated for myopia in the range -1.00 to -12.70 D. INTERVENTION: The hyperopic correction was made using an erodible mask inserted in the laser optical pathway to produce a circular ablation measuring 6.5 mm in diameter. An axicon was then used to create a blend transition zone from 6.5 mm up to 9.4 mm in diameter. Eyes were evaluated 3 to 11 times (5.5+/-2.4) over a 3- to 34-month follow-up (16.8+/-8.4 months). MAIN OUTCOME MEASURES: Vector analysis of refractive error, applying a nonlinear statistical model fitting the spherical equivalent, and the sphere component data. The fit parameters were the long-term error at stabilization (epsilon(infinity)), the amount of regression (epsilon0), being the difference of refractive errors immediately after surgery and at stabilization, and the time constant (T1/2) giving the temporal scale length by which the overcorrection halves (regression half-life). Cylinder was analyzed by a linear regression. RESULTS: The initial overcorrection was much larger after hyperopic treatments than myopic ones (epsilon0 = -3.26+/-0.35 D vs. +1.43+/-0.35 D), and it takes typically four times longer to regress (T1/2 = 3.30+/-0.91 months). Refractive stabilization is reached after more than 1 year, with a satisfactory refractive result. The hyperopic treatment induces a mean astigmatism of 1.00 D, which remains constant throughout the follow-up, and tends to be aligned along the with-the-rule meridian. CONCLUSIONS: The advantages of a reasonably well-designed algorithm to correct hyperopia (epsilon(infinity) = +0.20+/-0.23 D) are counterbalanced by the long time to refractive stabilization and by the induced astigmatism.

Adult↗

Correction of hyperopia with intracorneal implants.

PURPOSE: To evaluate the safety and efficacy of intracorneal lenses as a surgical alternative for the correction of hyperopia. SETTING: Al-Azhar University, Cairo, Egypt, and Louisiana State University Eye Center, New Orleans, Louisiana, USA. METHODS: PermaVision lenses (Anamed Inc.) were implanted in the left eye of 20 albino rabbits that were followed for 6 months by confocal microscopy. The lenses are made of a highly permeable hydrogel with 70% water content and a refractive index close to that of corneal tissue (1.376). The Carriazo-Barraquer microkeratome (Moria) was used to create a 150 microm corneal flap with a diameter of 8.5 mm or larger. The intracorneal lens was placed under the flap after minimal interface irrigation. RESULTS: At 3 days, confocal microscopy showed interface edema that resolved after 1 week. No flap melting or excursion of the lens was noted. In 1 eye, a deep lamellar keratitis was seen. At 6 months, the edge of the lens showed excellent compatibility, with no keratocytic activity or intrastromal fibrosis. CONCLUSIONS: Intracorneal hydrogel lenses were well tolerated by stromal tissue in rabbits. They are potentially safe and can be considered as an alternative for the correction of hyperopia. Further clinical studies are required to confirm their safety in humans.

Animals↗

Conductive keratoplasty to correct residual hyperopia after corneal surgery.

Conductive keratoplasty (CK) is an electrical-current-based technique for steepening the central cornea to reduce low to moderate hyperopia. We report 4 patients who had CK to correct hyperopia after laser in situ keratomileusis (LASIK) and were followed for at least 6 months. An overcorrection was noted after the CK procedure in all patients, but no sight-threatening complications arose. Conductive keratoplasty appears to be safe and well tolerated after LASIK. However, the algorithms should be modified to increase the predictability of the CK procedure in previously treated eyes.

Cornea↗

Laser in situ keratomileusis for consecutive hyperopia after myopic LASIK and radial keratotomy.

PURPOSE: To evaluate and compare the efficacy, predictability, and safety of hyperopic laser in situ keratomileusis (H-LASIK) for the correction of consecutive hyperopia after myopic-LASIK (M-LASIK) and radial keratotomy (RK). SETTING: The Eye Institute of Utah, Salt Lake City, Utah, USA. METHODS: Seventy-seven eyes of 64 patients were studied. The eyes were divided into 2 groups based on the prior refractive procedures: in Group A (n = 34), H-LASIK was performed for overcorrection after M-LASIK and in Group B (n = 43), for overcorrection after RK. All eyes were included in the analysis of intraoperative and postoperative complications. Only eyes with a minimum follow-up of 6 months were included in the analysis of visual and refractive results. Among these 66 eyes, 30 were in Group A and 36 were in Group B. The mean follow-up in these eyes was 12.34 months +/- 5.95 (SD) (range 6 to 33 months). RESULTS: Overall, the mean spherical equivalent (SE) was +1.88 +/- 0.91 diopters (D) preoperatively and -0.37 +/- 0.65 D at the last visit. Eighty-three percent of eyes were within +/-1.00 D of emmetropia, and 66% were within +/-0.50 D. The uncorrected visual acuity (UCVA) was 20/20 in 39% of eyes and 20/40 or better in 92% of eyes. The preoperative SE was +1.43 +/- 0.59 D in Group A and +2.26 +/- 0.96 D in Group B; the difference in the preoperative SE was significant (P=.001). However, there was no statistically significant between-group difference in postoperative refraction and UCVA. One eye in Group B (3%) lost 2 or more lines of best corrected visual acuity. Corneal ectasia developed in 1 eye in Group B 11 months after H-LASIK. A sliver occurred in 1 eye in Group A after the flap was recut. CONCLUSION: Hyperopic LASIK was equally effective and predictable in treating consecutive hyperopia after overcorrected M-LASIK and overcorrected RK. The safety of the procedure in the RK group appeared to be inferior to that in the M-LASIK group. Although vision-threatening complications are rare after H-LASIK retreatment, corneal ectasia developed in 1 eye in the RK group.

Adult↗

Bilateral high hyperopia after radial keratotomy.

A patient with myopia and astigmatism in the ideal range for correction by radial keratotomy had surgery on both eyes. Postoperatively, she developed bilateral high hyperopia, with a +9.00 diopter refractive error (OD) and a spherical equivalent of +8.75 diopters (OS). Her best corrected visual acuity dropped one line and hyperopia increased during the follow-up.

Adult↗

Radial and staggered treatment patterns to correct hyperopia using noncontact holmium:YAG laser thermal keratoplasty.

PURPOSE: To compare the effects of two treatment patterns in the correction of hyperopia by noncontact holmium:YAG laser thermal keratoplasty (LTK). SETTING: Divisione Oculistica, Ospedale S. Gerardo, Monza, Italy. METHODS: Using two treatment patterns, we performed noncontact LTK in one session in 16 eyes of 8 patients with isometropic hyperopic refractive errors; mean preoperative subjective cycloplegic refraction was +4.90 diopters (D) +/- 1.17 (SD). The treatment consisted of 24 spots in three concentric rings of eight spots each; ring diameters were 6.0, 7.0, and 8.0 mm, respectively. Each spot received seven pulses of laser energy at 30 mJ/pulse. We treated one eye of each patient with a radial pattern (the spots of the three rings aligned on the eight semimeridians) and the fellow eye with a staggered pattern (the spots of the contiguous rings at 22.5 degrees from each other). Follow-up at 1, 15, 30, 90, 180, and 360 days included subjective cycloplegic refraction, uncorrected (UCVA) and spectacle-corrected visual acuity (SCVA), computerized videokeratography (CVK), and Scheimpflug camera examination. RESULTS: One year postoperatively, the mean subjective cycloplegic refraction was +2.75 +/- 1.6 D in the eyes treated with the radial pattern and +3.40 +/- 1.6 D in those treated with the staggered pattern; the mean change in subjective cycloplegic refraction was 2.15 and 1.50 D, respectively. Mean UCVA improved by five lines in the radial group and by four lines in the staggered group. Mean SCVA returned to preoperative levels by day 15 in the radial group and at 1 year in the staggered group; at 1 year, SCVA improved by one line in the radial group and remained unchanged in the staggered group. No eye lost one or more lines of SCVA. Refractive astigmatism was essentially unchanged in both groups. Scheimpflug photography and CVK indicated larger and more uniform corrected zones in the radial group. CONCLUSIONS: Radial and staggered patterns effectively corrected low hyperopia, although both were subject to a certain amount of regression. The radial pattern produced faster postoperative recovery of SCVA and demonstrated greater refractive stability.

Adult↗

Epithelial debridement for secondary hyperopia following myopic excimer laser photorefractive keratectomy.

BACKGROUND: To evaluate epithelial debridement for the treatment of persistent hyperopia in eyes that had photorefractive keratectomy (PRK). SETTING: Optimax Laser Eye Clinics, Manchester, London, Bristol, England. METHODS: Epithelial debridement was performed on 46 eyes to reduce the hypermetropia following excimer laser PRK. RESULTS: Mean age of the patients was 43 years +/- 9.7 (SD). Mean refractive change was -0.51 diopter (D) +/- 0.76 (range +0.75 to -2.50 D). Mean change in best corrected visual acuity (BCVA) was 0.00 Logmar units (range +0.40 to -0.20 units), although 33% of eyes lost one line or more of Logmar BCVA. Mean follow-up after debridement was 61.0 +/- 26.9 weeks (range 26 to 140 weeks). CONCLUSIONS: Epithelial debridement is an unpredictable procedure to treat secondary hyperopia after PRK, producing a small mean change in spherical equivalent with a wide range of results. A significant number of eyes lost one line or more of Logmar BCVA. We therefore do not advocate epithelial debridement after PRK.

Adult↗

Iris-claw lens in phakic eyes to correct hyperopia: preliminary study.

PURPOSE: To evaluate the results of implanting convex, iris-fixated, anterior chamber intraocular lenses (IOLs) in phakic eyes to correct high hyperopia. SETTING: Robert Koch Hospital, Hannover-Gehrden, Germany (Center A), and Dr. Daljit Singh Eye Hospital, Amritsar, India (Center B). METHOD: Two eyes at Center A and 67 at Center B had implantation of an anterior chamber, convex, iris-fixated IOL. Follow-up of the 2 eyes at Center A was 91 months. Mean follow-up at Center B was 78 months +/- 24 (SD) (range 12 to 120 months). RESULTS: At Center B, all eyes except two in one patient had clear corneas and no iritis or glaucoma at the last follow-up. The patient with complications (glaucoma and corneal degeneration in both eyes) did not return for follow-up until more than 4 years postoperatively and thus did not have adequate postoperative care. CONCLUSION: Implantation of a convex iris-claw lens into the anterior chamber of phakic eyes to correct high hyperopia was successful from a refractive aspect. The clinical risks appear tolerable. However, life-long observation by endothelial microscopy is mandatory.

Adolescent↗

Oculometric features of hyperopia in children with accommodative refractive esotropia.

PURPOSE: To determine the nature of hyperopia in children with accommodative refractive esotropia (ARE) by evaluating the relationships between corneal radius (CR), axial length (AL), age and equivalent spherical refraction (SEQ). METHODS: A total of 112 children with ARE were included in the study. The children underwent an overall ophthalmic examination including cycloplegic refraction, keratometry and ultrasonic AL measurement. RESULTS: Statistical analysis revealed a strong relationship between AL and SEQ (p < 0.001). A significant correlation was also found between AL and CR (p < 0.001). The relationship between AL and age was weak but statistically significant (p = 0.02). Multiple regression analysis, using SEQ as the dependent variable and CR, AL and age as independent variables, revealed that AL accounts for 43.5% of the variance, and the combination of CR and AL accounts for 60.9% of the variance. CONCLUSION: Hyperopia is predominantly axial in nature in children with ARE. However, other refractive components are also involved in producing hyperopic refractive errors.

Accommodation, Ocular↗

Hyperopia correction using an erodible mask excimer laser delivery system coupled to an axicon: preliminary results.

PURPOSE: This paper presents the results of the first human trial on the correction of hyperopia using an erodible mask excimer laser delivery system coupled to an axicon. METHODS: We treated 17 eyes of 17 patients (age range 34-62 years) for the correction of +3.21 +/- 1.04 D (range +1.00 to +4.00 D). The hyperopic correction was made using an erodible mask inserted on the laser optical pathway, to produce a circular ablation measuring 6.5 mm in diameter. An axicon was then used to create a blend transition zone from 6.5 mm up to 9.4 mm in diameter. Eyes were evaluated at one, three and six months after surgery. RESULTS: Reepithelization was always observed by the fifth postoperative day, despite the large area of deepithelization (diameter 9.5 mm). Mean refractive error one month after treatment was -2.44 +/- 1.59 D (range 0.00 to -6.50 D). Five eyes (29.4%) had a best corrected visual acuity loss more than two to three lines; all eyes showed mild annular haze not involving the central part of the cornea. Six months after treatment, mean refractive error was -0.88 +/- 0.99 D (range +0.50 to -3.00 D). Compared to preoperative status, 13 eyes (76.5%) showed an improvement in uncorrected distance visual acuity (1-8 lines), and 14 eyes (82.4%) showed an improvement in uncorrected vision at reading distance (3-7 lines). Two eyes (11.7%) showed a best corrected visual acuity loss of two of three lines. CONCLUSIONS: These preliminary results indicate this approach is effective in reducing hyperopia, while its predictability has still to be proved in a larger treatment group with longer follow-up. A cautious approach to this technique is still advisable, especially for higher hyperopic corrections, in view of the large best corrected visual acuity loss seen in two eyes at six months.

Adolescent↗