Excimer laser photorefractive keratectomy

Excimer laser photorefractive keratectomy has been used for the correction of myopia, hyperopia and astigmatism. This laser removes tissue through a process termed photoablative decomposition, in which incident photon energy is sufficient to break molecular bonds. Selective removal of tissue across the anterior corneal surface results in a change in anterior corneal curvature. The surgical outcome may be influenced also by interindividual variability in wound healing and pharmacologic interventions. The nature of the excimer laser-tissue interaction, and clinical outcomes of predictability, stability and complications of surgery for myopia are discussed in detail.     

Excimer laser photorefractive keratectomy for hyperopia

Sixty consecutive patients with the obstructive sleep apnoea syndrome (53 men and seven women) were analysed by questionnaire, polysomnography, r?ntgenographic cephalometry and the Mueller manoeuvre before and 6 months after uvulopalatopharyngoplasty (UPPP), to assess the surgical outcome and the prognostic value of preoperative evaluation. Seventy-three per cent of patients reported improvement of snoring and 55% reported improvement of excessive daytime sleepiness. Thirty-five per cent showed a decrease of at least 50% in the desaturation index, and 13% had a postoperative desaturation index below 5. Although the improvement of desaturation parameters was marked in some patients, the overall change was not significant. Neither the Body Mass Index (BMI), nor any of the cephalometric variables were significantly correlated to surgical outcome. Increased difference in collapsibility between the soft palate and the base of the tongue showed a close to significant relation with the improvement of desaturation index. High desaturation index, low mean saturation and deep lowest saturation were found to be slightly predictive of improvement in nocturnal desaturation. In a multivariate analysis however no significant predictors could be identified. It is concluded that UPPP is effective in reducing snoring and daytime sleepiness over a 6-month follow-up period, but that the overall improvement in nocturnal desaturation is limited and difficult to predict. Further research is needed to evaluate the long-term efficacy of UPPP.     

Excimer laser photoastigmatic refractive keratectomy: eighteen-month follow-up

A new technique of shoulder fusion is presented using a posterior approach. After removal of the articular cartilage, a Rush pin is introduced from the spine of the scapula, through the glenoid into the medullary canal of the humerus. This is supplemented by tension-band wiring from the acromion to the neck of the humerus and a muscle pedicle graft attached to the acromion. A shoulder spica is applied for four to six weeks. Four patients with injuries to the upper brachial plexus and 14 with paralysis of the upper arm due to anterior poliomyelitis have been followed for three years. One of the 18 patients developed nonunion; she had removed her own cast prematurely. This method of fixation provides high shear resistance and low axial stiffness without deforming plastically. It does not affect bone growth in young patients, is effective in patients with osteoporosis, and gives a high rate of union.     

Bacterial keratitis following phototherapeutic keratectomy

Traumatic brain injury (TBI) induces astrocytic and microglial activation and proliferation and augmented production of the cytokine interleukin-1 beta (IL-1 beta) and nerve growth factor (NGF). The increase in NGF temporally follows the increase in IL-1 beta, suggesting that the IL-1 beta up-regulation after trauma directly induces the increase in NGF. We examined the effect of IL-1 receptor antagonist protein (IL-1ra) on microglial proliferation and NGF production in rat cortex, following two different models of TBI. Rabbit fibroblasts infected with a retroviral vector containing the human IL-1ra gene were implanted into the wound cavity immediately following a cortical stab wound or 6 hours after a weight drop-induced trauma. Both microglial proliferation and NGF up-regulation were decreased significantly in animals receiving IL-1ra-expressing cells compared with animals receiving naive (untransfected) fibroblasts. These data demonstrate that the increase in NGF after central nervous system trauma is directly mediated through IL-1 beta and that blocking IL-1 beta following brain injury leads to suppression of an NGF-mediated reparative response. Such blockade of inflammation, however, may prove to be of significant therapeutic benefit in human brain injury and other inflammatory states.     

Wessely-type immune ring following phototherapeutic keratectomy

Immune rings following photorefractive keratectomy (PRK) have been reported but have not been described in detail. This case report describes an immune ring after phototherapeutic keratectomy (PTK) in a patient with long-standing superficial corneal scars. A dense white ring formed in the peripheral cornea on the fourth day following surgery. The patient was treated with antibiotics until negative cultures were reported 48 hours later. A biopsy was taken and examined by light microscopy using hematoxylin-eosin and Mason's trichrome staining. The stroma showed focal keratocyte depopulation with nuclear fragments, occasional polymorphonuclear leucocytes, and an active fibroblastic reaction. No lymphocytes or plasma cells were seen. Clinically, the immune ring faded slowly and was still apparent 9 months after the PTK. Studies of similar cases are required to clarify the mechanisms responsible for this phenomenon.     

Treatment of recurrent corneal erosion using phototherapeutic keratectomy with the excimer laser

Tachyphylaxis to methacholine has been reported in nonasthmatic subjects. In a recent study on the prevalence of airway hyperresponsiveness (AHR) and atopy, we performed duplicate methacholine inhalation tests at a 60-min interval, in subjects with symptomatic asthma (n = 33), asymptomatic AHR (AAHR) (n = 72) and in a group of normal subjects (n = 130); 135/235 subjects were atopic. All subjects had a respiratory questionnaire, allergy skin prick tests, blood eosinophil counts and determination of total serum IgE level. In asthmatic subjects, PC20 just failed to be significantly higher on a second methacholine challenge (p = 0.09); when they were stratified according to severity of AHR and use of inhaled corticosteroids, we observed a significant increase in PC20 on the second test in asthmatic subjects with mild AHR not using corticosteroids (p < 0.01). In normal controls, PC20 methacholine was slightly increased on rechallenge (p < 0.01) as it was in those with AAHR (p < 0.01). There was no relationship between the magnitude of the change in PC20 and age, sex, baseline airway responsiveness, percent fall in FEV1 on the first challenge, atopic score, blood eosinophil counts and serum IgE levels. In conclusion, tachyphylaxis to methacholine is observed in normal or mild asthmatic subjects not using inhaled corticosteroids and in subjects with AAHR; however, in most subjects this change is of a small magnitude.     

Treatment of band keratopathy by excimer laser phototherapeutic keratectomy: surgical techniques and long term follow up

A series of 122 eyes with band keratopathy was treated by excimer laser phototherapeutic keratectomy (PTK), with a mean follow up of over 12.3 months (range 3 to 60 months). A single photoablation zone was used to remove the opacity over the visual axis in smooth surfaced band deposition. In eyes with reduced vision, an improvement was reported in 88% and in a series of 66 eyes mean Snellen visual acuity increased significantly (p < 0.05, t = 2.27). A reduction in glare was reported in 88% and in a series of 17 patients, visual contrast sensitivity (p < 0.01) and measurements of disability glare (p < 0.01) improved postoperatively. The mean hyperopic shift in 32 eyes at 6 months was 1.4 D (range 0-4.25 D). Multiple overlapping ablation zones, with mechanical debulking of large calcium plaques, were used to smooth the irregular corneal surface in eyes with rough bands. Ocular discomfort was improved in 95%. Band keratopathy recurred in nine eyes (8%) within 2 to 30 months (mean 12 months) of surgery, with silicone oil responsible in five eyes. Reablation was necessary in three eyes and performed successfully in all cases. Excimer laser PTK is a safe and effective outpatient treatment for band keratopathy.     

Excimer laser photorefractive keratectomy for the correction of hyperopia using an erodible mask and axicon system

PURPOSE: The purpose of the study is to evaluate photorefractive keratectomy for the correction of hyperopia using the erodible mask and Axicon system. METHODS: Forty-three patients (43 eyes) with a mean refraction (spherical equivalent) of +4.54 diopter (D) (range, +1.75 to +7.50 D) were treated using a Summit Technology "Apex Plus" excimer laser. This system uses an erodible mask to create a 6.50-mm diameter hyperopic correction over the axial cornea. An Axicon then is used to fashion a 1.50-mm "blend zone" around the correction. On the basis of preoperative refractions, patients were assigned to 3 groups: 2 groups of 14 patients underwent either "+2.00 D" or "+3.00 D" corrections and 15 patients had "+4.00 D" corrections. RESULTS: All patients had a reduction in their hyperopia with an overcorrection, especially in the first month after surgery and some stability in the refractive change at 3 to 6 months. The mean manifest refraction (n = 43) at 6 months was -0.17 D (range, +4.50 D to -3.125 D). Patient satisfaction was high. At 6 months, all eyes had an improvement in unaided near visual acuity. Unaided distance acuity was improved in 37 eyes (86%). A ring of haze 6.5 mm in diameter appeared in all eyes 1 month after surgery. Night halo measurements at 6 months showed no differences from preoperative levels. Flicker contrast sensitivity and forward light scatter (glare) measurements showed no differences after surgery. CONCLUSIONS: In this short-term study, photorefractive keratectomy for hyperopia using the erodible mask and Axicon system appeared to be a promising procedure. Visual performance, in terms of flicker contrast sensitivity, forward light scatter, and night halos, was not compromised. There was an overcorrection based on the manufacturer's algorithms. Manipulation of the treatment algorithms should improve future predictability.     

Excimer laser angioplasty

Increased expression of interleukin-1 (IL-1) in skin elicits a variety of responses, including inflammation and epidermal hyperplasia, which are also characteristic events elicited by tumor promoters. The goal of this study was to investigate whether various classes of tumor promoters increase expression of IL-1 alpha and whether phorbol ester-induced IL-1 alpha expression can be blocked by antitumor promoters. Northern analysis of mRNA isolated from the dorsal skins of SENCAR mice treated with 1 microgram of 4 beta-12-O-tetradecanoylphorbol-13-acetate (TPA) showed that a single application of TPA produced a significant increase in IL-1 alpha mRNA at 6 h that decreased by 24 h after treatment. Two treatments of TPA at 48-h intervals induced, at 6 h, twice as much IL-1 alpha mRNA as one treatment. Of the other promoters tested, anthralin (22.6 micrograms), mezerein (2 micrograms), calcium ionophore A23187 (120 micrograms), and benzoyl peroxide (20 mg) induced IL-1 alpha mRNA with different kinetics and to different extents. On the other hand, the non-tumor promoting phorbol ester analogue 4 alpha-12-O-tetradecanoylphorbol-13-acetate had little effect on the expression of IL-1 alpha mRNA. The effects of various antitumor promoters on TPA-induced IL-1 alpha mRNA expression were also assessed. Fluocinolone acetonide, mepacrine, and 5,8,11,14-eicosatetraynoic acid were the most effective inhibitors, and each produced about 80% inhibition. Other antitumor promoters such as retinoic acid, N-tosyl-L-phenylalanine chloromethyl ketone, and butylated hydroxytoluene inhibited approximately 35%, 65%, and 50% of TPA-induced IL-1 alpha mRNA expression, respectively. Therefore, this study suggests a possible role of IL-1 alpha in the promotion stage of skin carcinogenesis.     

Trial of new intraocular lens power calculation following phototherapeutic keratectomy]

Thirty-one men (age range, 46-76 years; mean age, 64.8 years) with intrathoracic masses suggesting possible malignancy on the basis of chest radiography or CT underwent preoperative Tc-99m MIBI SPECT examinations. Diagnosis was confirmed on pathologic examinations of samples obtained either at thoracotomy, esophagectomy, or by biopsy. Twenty-five patients had primary lung cancer, including squamous cell carcinoma, large cell carcinoma, adenocarcinoma, and small cell carcinoma. Two patients had lymphomas with spread to the mediastinum, and three patients had extrathoracic primary cancers (one squamous cell carcinoma of esophagus, one squamous cell carcinoma originating from a head and neck tumor, and one metastatic mediastinal leiomyosarcoma). One patient with a tuberculoma had negative results of the Tc-99m MIBI examination. Tc-99m MIBI had a 86.7% sensitivity rate, a 0% false-positive rate, and a 100% positive predictive value to detect malignant intrathoracic masses. There was a 13% false-negative rate, however, suggesting that MIBI-SPECT may underdiagnose malignant lesions. SPECT findings of these 31 patients can be classified as 1) mass with increased uptake, n = 23; 2) ring-like appearance of increased uptake, n = 3; 3) mass with absent uptake, n = 4; and 4) photon-deficient mass, n = 1. Absent uptake in patients with mass lesions could be explained by necrosis of the lesion (caseation necrosis or massive tumor necrosis with or without bleeding). Most malignant intrathoracic masses are Tc-99m MIBI avid and may be detected with a high degree of sensitivity and with an excellent positive predictive value. A positive MIBI scan may help in the clinical diagnosis of malignancy. The use of Tc-99m MIBI could serve not only as a tumor imaging agent, but also may be used to determine the extent of spread and potentially the chemotherapeutic responsiveness of a tumor.     

A prospective multicenter trial of excimer laser phototherapeutic keratectomy for corneal vision loss. The Summit Phototherapeutic Keratectomy Study Group

PURPOSE: The 193-nm argon fluoride excimer laser can remove corneal scars and smooth corneal irregularities, obviating corneal transplantation. We conducted a prospective multicenter trial of excimer laser phototherapeutic keratectomy for corneal vision loss as a basis for Food and Drug Administration premarket approval. METHODS: We treated 232 eyes of 211 patients with corneal vision loss. All had corneal pathology in the anterior 100 microns of the stroma. Mean postoperative follow-up was 10 +/- 8 months. The primary outcome variable was change in best spectacle-corrected visual acuity. RESULTS: At postoperative month 12, best spectacle-corrected visual acuity improved in 46 (45%) of 103 eyes and worsened in nine (9%) of 103 eyes by 2 or more Snellen lines. Best spectacle-corrected visual acuity improved by a mean of 1.6 +/- 2.8 Snellen lines (95% confidence interval, 1.1 to 2.1 lines). Every postoperative visit confirmed statistically significant improvement of mean best spectacle-corrected acuity. At month 12, treated eyes had a mean hyperopic shift in refraction of 0.87 diopter and a mean reduction in astigmatism of 0.36 diopter. Treatment appeared most effective in eyes with hereditary corneal dystrophies, Salzmann's nodular degeneration, and corneal scars, and least effective in eyes with calcific band keratopathy. Complications included recurrence of underlying pathology, corneal graft rejection, and bacterial keratitis. CONCLUSIONS: Argon fluoride excimer laser phototherapeutic keratectomy is effective, with relatively few complications, for treating vision loss from corneal opacification or irregularity. Efficacy, however, varies widely depending upon individual eyes and underlying diagnoses.     

Topical interferon alpha 2b for corneal haze after excimer laser photorefractive keratectomy. The Melbourne Excimer Laser Group

PURPOSE: To determine whether topical interferon alpha 2b (IFN-alpha) prevents corneal haze after excimer laser photorefractive keratectomy (PRK). SETTING: Tertiary referral ophthalmic hospital. METHOD: A prospective, double-blind, placebo-controlled, randomized study of 31 patients was undertaken. After surgery in a single institution, patients received a drop of either a placebo or IFN-alpha (5 x 10(6) IU/ml) four times daily for 4 weeks. The main outcome measures were corneal haze, refraction, and visual acuity. RESULTS: The major side effect of interferon alpha treatment was a significant delay in epithelial healing by a mean of 2 days. The means of the average post-treatment clinical scores for haze in all patients up to 12 months after surgery were 0.46 +/- 0.25 for the IFN-alpha group and 0.64 +/- 0.43 for the placebo group (P = .20). Of patients with a correction of greater than 5.00 diopters (D), the IFN-alpha group had significantly less haze over the course of the study (0.39 +/- 0.23 versus 0.98 +/- 0.50; P = .03). After 12 months, the mean absolute spherical equivalent in the two groups was not significantly different (1.02 +/- 1.13 D versus 1.44 +/- 2.64 D). There was a tendency toward better uncorrected visual acuity in the INF-alpha group (P < .10, Kolmogorov-Smirnov). CONCLUSION: Topical IFN-alpha may merit further investigation as a treatment to reduce corneal haze after excimer laser PRK for corrections greater than 5.00 D.     

Excimer laser treatment of hyperopia

In a previous study we demonstrated that human vaginal mucosa was as permeable to water as was buccal mucosa. Water, however, is a very small molecule with a molecular weight of 18 d. To further explore similarities between these two types of mucosa with respect to permeability, it was decided to investigate the passage of two large, hydrophilic molecules across these epithelia. Specimens of fresh, clinically healthy human vaginal and buccal mucosa were taken from excised tissue obtained during vaginal hysterectomies and various oral surgical procedures. Seven biopsy materials from each specimen were mounted in flow-through diffusion cells (exposed area, 0.039 cm2), and their permeability to 4.4- and 12-kd fluorescein-isothiocyanate-labeled dextrans was determined through use of a continuous flow-through perfusion system. Dextran was detected by means of a fluorospectrophotometric method at excitation and emission wave lengths of 498 and 520 nm, respectively. Specimens were examined histologically before and after permeability experiments, and similarities between vaginal and buccal tissues were verified. No statistically significant differences between the flux values of the 4.4-kd dextran across vaginal and buccal mucosa were found. However, for the 12-kd dextran the flux rate across buccal mucosa was significantly higher than the rate across vaginal mucosa. These results demonstrate that human vaginal mucosa is for practical purposes as permeable as buccal mucosa to 4.4-kd hydrophilic molecules. This further supports the hypothesis that vaginal mucosa may be a useful model for studying the passage across buccal mucosa of chemical compounds and therapeutic agents that are less than approximately 4.4 kd in molecular mass. For a 12-kd dextran the flux rate across buccal mucosa is significantly higher than the flux rate across vaginal mucosa, and the model becomes inaccurate.     

Macular hemorrhage after excimer laser photorefractive keratectomy

We describe three patients with high myopia, 13.0 to 20.0 diopters (D), who had typical myopic macular hemorrhages 1 to 6 months after photorefractive keratectomy (PRK). The hemorrhages eventually resolved, with resultant permanent decrease in vision and pigmentary and atrophic changes in the macula. Highly myopic eyes are predisposed to bleeding in areas of lacquer cracks and to myopic choroidal neovascularization formation. Awareness of potential retinal pathology in patients having PRK and follow-up retinal examinations are warranted.     

Complications of excimer laser photorefractive keratectomy for myopia

PURPOSE: To evaluate the safety and complication rates of excimer laser photorefractive keratectomy (PRK). SETTING: Assutah Laser Center, Tel-Aviv, Israel. METHODS: This retrospective study evaluated the complication rate after PRK in 825 consecutive patients who had PRK for myopia and had a follow-up of at least 12 months. RESULTS: At 12 months postoperatively, 4.0% of patients suffered from overcorrection and 8.6% from undercorrection. Induced astigmatism developed in 1.4% of all operated eyes. Three percent of the patients had haze, and 3.6% reported glare or halos. Twenty-three eyes (2.7%) lost one line or more of best corrected visual acuity (BCVA). Ptosis developed in 0.4% of the eyes, and 3.5% had a significant increase in intraocular pressure resulting from corticosteroid treatment. There were no complications in 678 eyes (82.5%). CONCLUSION: Eighty-two percent of eyes having PRK did not develop complications. In 18.0% one or more complication, mainly undercorrection, overcorrection, or loss of BCVA, occurred.     

Excimer laser induced bubble: dimensions, theory, and implications for laser angioplasty

BACKGROUND AND OBJECTIVE: Previous studies have demonstrated that during Xenon-Chloride excimer laser ablation of tissue, rapidly expanding and imploding bubbles (diameter < 3 mm), predominantly containing water vapor, are formed. These short lived bubbles (life time < 300 microseconds) induce mechanical damage in adjacent tissue. In the present study, a theoretical analysis of the volume of vaporized water is correlated with measured bubble volumes formed in hemoglobin solution. STUDY DESIGN/MATERIALS AND METHODS: The dimensions of the rapidly expanding and imploding vapor bubble induced by the XeCl excimer laser pulses (308 nm, 115 ns), delivered via a 300, 550, or 950 microns diameter monofiber in 16% w/v hemoglobin solution (at 37 degrees C), were measured. RESULTS: Theoretical analysis and the experimental data correlated well (correlation coefficient r = 0.97). The diameter of excimer laser induced bubbles increased with increasing pulse energy. For a given radiant exposure, the bubble size was decreased by either decreasing the fiber tip area or by decreasing the absorption coefficient of the hemoglobin solution. CONCLUSION: We conclude that, for a wide range of conditions, theory agrees well with experimental data. Thus, during delivery of excimer laser pulses in blood, bubble dimensions can be reduced by flushing with saline or by reduction of the area radiated with each laser pulse, for example, by pulse multiplexing or using a smaller multifiber catheter.     

Excimer laser surface processing of Ti-6Al-4V

We have examined the effect of surface processing in air, using excimer laser light at 248 nm wavelength, on the oxygen content, microstructure, and surface hardness of Ti-6Al-4V. Processing with a single pulse results in the transformation of theα +β material toα′ martensite. Multiple pulse processing results in rapid incorporation of oxygen in the material. Oxygen initially dissolves in the material in the liquid phase. As the concentration exceeds the solid solubility limit during solidification, TiO particles precipitate. In contrast to equilibrium oxidation processes in Ti, only TiO is observed as an oxidation product; further processing results in increased oxygen incorporation and an increased volume fraction of TiO but no other oxides of Ti. The TiO particle size is a function of the oxygen concentration and the number of pulses, with some grain growth occurring after many pulses. The effects of solution hardening by dissolved oxygen and precipitation hardening by the TiO are identifiable as functions of oxygen concentration and mean free path between particles, respectively. A maximum surface hardness almost twice that of electropolished Ti-6Al-4V is observed.