Jesper Hjortdal

Purpose: To evaluate visual and refractive outcomes of keratorefractive lenticle extraction (KLEx) for the treatment of moderate and high myopia, defined by an attempted spherical equivalent (SEQ) correction between −6.0 diopters (D) and −8.0 D (moderate myopia) and from −8.0 to −10.0 D (high myopia), respectively. Setting: Cornea and Refractive Surgery Unit, Department of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark. Design: Prospective longitudinal quality control study. Methods: Prospective analysis of 1530 right eyes consecutively treated with KLEx for myopia correction between January 2011 and December 2023. Exclusion criteria included SEQ less than −6.0 D, refractive astigmatism larger than 2.0 D, or presence of other ocular diseases. Preoperative and 3-month evaluation included manifest refraction and uncorrected distance visual acuity (UDVA) and corrected distance visual acuity. Results: Attempted SEQ refraction was −7.03 ± 0.50 D and −8.71 ± 0.56 D in the moderate and high myopia groups, respectively. 62% (n = 586) and 52% (n = 239) of moderate and high myopia eyes achieved postoperative UDVA ≥20/20, P < .001, respectively. Efficacy index was 0.86 ± 0.26 and 0.83 ± 0.28 ( P = .044) for moderate and high myopia, respectively. 81% (n = 825) and 71% (n = 360) of moderate and high myopes were within ±0.50 D of intended refraction, P < .001, respectively. Safety index was 1.07 ± 0.20 and 1.09 ± 0.19 for moderate and high myopia ( P = .056), respectively. Conclusions: The safety of KLEx for moderate and high myopia was similar in this large cohort. Predictability and efficacy were slightly better when treating moderate myopia and lower astigmatism. Nomogram adjustment for the correction of high myopia is suggested.

Purpose: To investigate how transplant thickness and transplant asymmetry may influence best-corrected visual acuity (BCVA) after ultra-thin Descemet stripping automated endothelial keratoplasty (UT-DSAEK) procedure by using data from a controlled trial investigating BCVA after UT-DSAEK. Methods: Participants with Fuchs endothelial dystrophy underwent UT-DSAEK with eye bank prepared grafts. Twelve months postoperatively, follow-up evaluations, including BCVA, were conducted. From Optical Coherence Tomography images of the prepared donor grafts, transplant thickness was measured centrally and 1, 2, 3, and 4 mm from the center in both directions along 4 meridians to assess the entire graft. Regression analyses were used to analyze the relation between BCVA and the 2 variables: thickness at the thinnest point of the transplant and transplant asymmetry estimated by the standard deviation of thickness variation. Results: Among 33 grafts implanted in 33 patients, the mean BCVA at 12 months was 80.4 early treatment diabetic retinopathy study letters. Mean thickness at the thinnest point was 74.1 μm (range: 32–114, SD = 22.6). Thickness at the thinnest point was significantly correlated with better BCVA at 12 months ( P = <0.001), whereas transplant asymmetry was not significantly correlated with BCVA. Conclusions: This study emphasizes that transplant thickness, particularly at the thinnest point, significantly affects BCVA after UT-DSAEK. Transplant asymmetry had no significant impact on BCVA. These findings underscore the critical role of minimizing transplant thickness in optimizing visual acuity even in patients undergoing UT-DSAEK.

By Jesper Hjortdal. EuCornea has decided to put the Journal on hold and make the homepage of EuCornea more active with a newsletter with case reports, highlights on innovation and well-illustrated review articles.

Keratoconus (KC) is a multifactorial, ectatic corneal disease. Metabolic changes in the corneal stroma with alterations in collagen fibril stability, oxidative stress, and urea cycle, have previously been reported as key players in KC pathobiology. Recently, corneal collagen cross-linking (CXL) has been introduced as a treatment that can address the progressive nature of KC. While the treatment has been successful in the early days, it is not without clinical ramifications. In this study, we investigated the alterations in KC metabolic profiles due to CXL. Primary human corneal fibroblasts (HCFs) from healthy donors and human KC fibroblasts (HKCs) from KC donor patients were plated on transwell polycarbonate membranes and stimulated by a stable vitamin C. At 4 weeks, riboflavin was added to the cultures followed by UVA irradiation (365 nm). Using mass spectrometry, we measured the major differences in metabolites in HKCs compared to HCFs pre- and post CXL. The analysis of 276 metabolites in HCFs and HKCs revealed that the most affected metabolites due to CXL were glutathione disulfide, ascorbic acid, proline, and lysine. A significant decrease in the pro-inflammatory biomarkers (myo-inositol and histidine) was also observed. Furthermore, a significant downregulation of many amino acids, lactate levels, and other water-soluble metabolites was noted in HKCs following CXL. CXL is a KC treatment available to patients within certain criteria. Surprisingly, the cellular and molecular mechanisms are considerably understudied limiting our ability for more precise and targeted CXL treatments. In this study, for the first time, we report the effects of CXL on KC metabolism.

Purpose: To investigate whether the Pentacam HR could accurately predict the surgically induced refractive change in patients operated with small‐incision lenticule extraction ( SMILE ) for myopia or femto‐second laser in situ keratomileusis ( FS ‐ LASIK ) for myopia or hyperopic astigmatism. Methods: Data from three groups consisting of (1) 410 myopic eyes of 410 patients operated with SMILE , (2) 111 myopic eyes of 111 patients operated with FS ‐ LASIK , and (3) 40 eyes of 40 patients with hyperopic astigmatism operated with FS ‐ LASIK were retrospectively analysed. The change in manifest refraction due to surgery was compared with the objectively measured change in corneal power by the Pentacam HR in three different ways: Sagittal Power (calculated as for placido topographers), True Net Power (calculated by a Gaussian optics formula), and Total Corneal Refractive Power (calculated by ray tracing). Multiple linear regression analysis was performed to investigate which parameters influenced the Pentacam HR 's prediction of the change in subjective refraction due to surgery. Results: The Total Corneal Refractive Power Apex, Zone calculation in a diameter of 4.0 mm effectively predicted the surgically induced refractive change for all three patient groups. The spherical equivalent was predicted with an error of 0.08 ± 0.41 D for the SMILE eyes, 0.05 ± 0.61 D for the myopic eyes operated with FS ‐ LASIK , and −0.15 ± 0.49 D for the hyperopic astigmatic eyes treated with FS ‐ LASIK . Regression showed that preoperative refractive error had a significant impact on the prediction error of the Pentacam HR . Conclusions: Ray tracing calculations based on Scheimpflug imaging accurately assessed the change in manifest refraction due to corneal laser surgery.

The aim of the present systematic review was to examine the benefits and harms associated with immediate sequential bilateral cataract surgery (ISBCS) with specific emphasis on the rate of complications, postoperative anisometropia, and subjective visual function in order to formulate evidence-based national Danish guidelines for cataract surgery. A systematic literature review in PubMed, Embase, and Cochrane central databases identified three randomized controlled trials that compared outcome in patients randomized to ISBCS or bilateral cataract surgery on two different dates. Meta-analyses were performed using the Cochrane Review Manager software. The quality of the evidence was assessed using the GRADE method (Grading of Recommendation, Assessment, Development, and Evaluation). We did not find any difference in the risk of complications or visual outcome in patients randomized to ISBCS or surgery on two different dates. The quality of evidence was rated as low to very low. None of the studies reported the prevalence of postoperative anisometropia. In conclusion, we cannot provide evidence-based recommendations on the use of ISBCS due to the lack of high quality evidence. Therefore, the decision to perform ISBCS should be taken after careful discussion between the surgeon and the patient.

Purpose: To compare the frequency of rejection and graft failure after Descemet's stripping automated endothelial keratoplasty (DSAEK) and penetrating keratoplasty (PK) for secondary endothelial failure.Methods: Seventy‐eight eyes undergoing DSAEK from 2006 to 2013 and 80 eyes undergoing PK from 1998 to 2013 were included. Indications were endothelial failure due to pseudophakic bullous keratopathy (82%), previous eye trauma (8%), uveitis (4%) or other causes (6%). Rejection episodes and graft failure were recorded, together with preoperative risk factors (glaucoma, neovascularization and active inflammation). Kaplan–Meier survival curves with up to 4 years follow‐up were used to compare DSAEK with PK, as well as low‐risk with high‐risk eyes.Results: During follow‐up, 15% of the PK‐treated eyes and 4% of the DSAEK‐treated eyes experienced rejection. Graft failure occurred in 8% of the PK‐treated eyes and in 7% of the DSAEK‐treated eyes. No significant differences were found in the rate of rejection (p = 0.11), graft failure (p = 0.29) or rejection‐related graft failure (p = 0.30) between DSAEK and PK in low‐risk eyes. In DSAEK, high‐risk eyes (mainly with glaucoma) experienced significantly more rejection episodes (p = 0.01), graft failures (p = 0.04) and rejection‐related graft failures (p = 0.04) compared with low‐risk eyes. No differences were seen between high‐risk and low‐risk PK‐treated eyes (p > 0.40).Conclusion: In the present, relatively small study, no differences in rejection rate or graft failure were found between DSAEK and PK in low‐risk eyes. However, glaucoma seems to increase the risk of graft complications after DSAEK for secondary endothelial failure. Long‐term studies of larger samples sizes are needed to confirm this.

PURPOSE: To report the outcome of topography-guided photorefractive keratectomy (PRK) after complicated small incision lenticule extraction (SMILE). METHODS: Retrospective case series of 5 eyes with irregular topography and ghost images after complicated SMILE. All eyes received transepithelial topography-guided PRK. Two eyes were treated with 0.02% mitomycin C. Patients were examined after a minimum of 3 months with evaluation of uncorrected (UDVA) and corrected (CDVA) distance visual acuity, Pentacam tomography (Oculus Optikgeräte, Wetzlar, Germany), and whole-eye aberrometry. RESULTS: In 3 eyes, subjective symptoms were diminished and UDVA, CDVA, topography, and corneal wavefront aberrations were improved. The remaining 2 eyes developed significant haze with worsened topography and wavefront aberrations. One eye experienced a two-line reduction in CDVA. Eyes with haze development had not been treated with mitomycin C. CONCLUSIONS: Transepithelial topography-guided PRK may reduce visual symptoms after complicated SMILE if postoperative haze can be controlled. To reduce the risk of haze development, application of mitomycin C may be considered. [ J Refract Surg. 2014;30(6):429–432.]

Purpose: Introducing a simple image grading system to support the interpretation of in vivo confocal microscopy (IVCM) images in filamentous fungal keratitis. Setting: Clinical and confocal studies took place at the Department of Ophthalmology, Aarhus University Hospital, Denmark. Histopathological analysis was performed at the Eye Pathology Institute, Department of Neuroscience and Pharmacology, University of Copenhagen, Denmark. Methods: A recent series of consecutive patients with filamentous fungal keratitis is presented to demonstrate the results from in-house IVCM. Based upon our experience with IVCM and previously published images, we composed a grading system for interpreting IVCM images of filamentous fungal keratitis. Results: A recent case series of filamentous fungal keratitis from 2011 to 2012 was examined. There were 3 male and 3 female patients. Mean age was 44.5 years (range 12-69), 6 out of 17 (35%) cultures were positive and a total of 6/7 (86%) IVCM scans were positive. Three different categories of IVCM results for the grading of diagnostic certainty were formed. Conclusion: IVCM is a valuable tool for diagnosing filamentous fungal keratitis. In order to improve the reliability of IVCM, we suggest implementing a simple and clinically applicable grading system for aiding the interpretation of IVCM images of filamentous fungal keratitis.

: Purpose:  To evaluate indications for paediatric keratoplasty in recipients aged ≤16 years and assess long‐term clinical outcome.Method:  Recipients were identified from records of the Danish Cornea Bank. Data were collected from patient journals, clinical follow‐up examinations and questionnaires and stratified into pre‐, peri‐ and postoperative variables. Diagnoses were classified into acquired traumatic, acquired nontraumatic and congenital groups. Recipients were divided into groups of Results:  Thirty‐three out of sixty identified recipients (73 keratoplasties in 63 eyes) were invited. Twenty‐four accepted, seven still attended follow‐up in our clinic. Follow‐up data reached 95% of the eligible recipients (median follow‐up 11 years). Twenty‐three per cent were Conclusion:  Paediatric keratoplasty was successful regarding indication. Graft survival was best in the acquired nontraumatic group and poorest in the congenital group. Vascularization and/or combined risk factors, additional surgeries and young recipient age influenced negatively on graft survival.