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1 CLINICL SCIENCES Keratoconus Managed With Intacs One-Year Results Samuel Levinger, MD; Russell Pokroy, MD Objectives: To describe the visual outcome of keratoconus managed with Intacs implantation (ddition Technology Inc, Fremont, Calif) and to define criteria that predict good outcome. Methods: This retrospective, nonrandomized, comparative, consecutive case series studied 58 eyes of 43 patients with keratoconus managed by Intacs implantation. The outcome measures were analyzed pre-intacs and 1 year post-intacs. parameters were correlated with outcome. Main Outcome Measures: Uncorrected visual acuity (UCV), best spectacle-corrected visual acuity (SCV), manifest refraction, videokeratography, and patient questionnaires. Results: Intacs were implanted in all eyes with no intraoperative complications. Six eyes underwent additional Intacs surgery. Post-Intacs, the mean±sd UCV improved from less than 2/2±.1 line to 2/ 5 3 ±3.1 lines, the mean±sd SCV was unchanged at 2/32±2. lines, the mean±sd spherical equivalent improved from 3.88±1.64 to 1.4±1.51 diopters (D), and the mean±sd astigmatism improved from 3.34±2.23 to 1.97±1.51 D. Twenty-five eyes had a good outcome (UCV 2/4). Multiple regression selected SCV, astigmatism, and spherical myopia as the preoperative predictors of outcome. Conclusions: Intacs improve myopia and regular astigmatism in keratoconus. Milder keratoconus (SCV 2/ 32 2 and astigmatism 3.5 D) and significant spherical myopia ( 1.75) predict better outcome. rch Ophthalmol. 25;123: uthor ffiliations: Enaim Refractive Surgery Center, Jerusalem, Israel (Drs Levinger and Pokroy); and Department of Ophthalmology, Kaplan Medical Center, Rehovot, Israel, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem (Dr Pokroy). CLSSICLLY, THERPEUTIC options for keratoconus with clear corneas are limited to spectacles and contact lenses. Penetrating keratoplasty is indicated in central corneal scarring and contact lens intolerance. ecause most cases of keratoconus are young adults with clear corneas and penetrating keratoplasty has significant risks, an additional treatment to improve uncorrected visual acuity (UCV) in contact lens intolerance would be useful. Recently, intrastromal corneal ring segments (Intacs; ddition Technology Inc, Fremont, Calif) have been reported to improve the refractive defect in keratoconus 1-4 and in post laser-assisted in situ keratomileusis keratectasia. 5-9 Colin et al 1,2 in 1 eyes and oxer Wachler et al 3 in 74 eyes, in an attempt to treat the inferior ectasia characteristic of keratoconus, used an asymmetric technique, implanting an inferior.45-mm segment and a superior.25-mm segment through a temporal incision. In 33 keratoconic eyes, Siganos et al 4 used a symmetric technique, implanting 2 same-thickness segments in a technique similar to that used to correct low myopia. lthough these studies reported encouraging results, crucial questions remain unanswered. These include the long-term corneal stability post-intacs and which preoperative refractive parameters predict a good outcome. In an attempt to answer these questions, we present our experience with a large number of keratoconic eyes 1 year after Intacs implantation. METHODS PTIENTS We retrospectively reviewed patient records of keratoconus cases consecutively managed by Intacs surgery between March 21 and ugust 22 at our center. Keratoconus of varying severity was included. Definite keratoconus was diagnosed by slitlamp signs (localized corneal thinning, Vogt striae, Fleisher ring) or 138
2 by videokeratography using the Rabinowitz indices 1 (a keratoconic topographic pattern of inferior steepening or skewed bow-tie axes, with inferior-superior [I-S] asymmetry 1.9 diopters [D], central corneal power 48.7 D, or a central corneal power difference.92 D between the 2 eyes). Forme fruste keratoconus was diagnosed as a keratoconic topographic pattern and at least 1 of the following: I-S asymmetry greater than 1.4 D, central corneal power greater than 47.2 D, 1 or fellow eye keratoconus (as earlier). Patients were intolerant to rigid contact lenses. Exclusion criteria were central corneal scarring, additional ocular pathologic abnormalities, prior ocular surgery, and follow-up time less than 1 year. Patients with large pupils ( 7. mm) were not excluded. Prior to signing a detailed consent to Intacs implantation, patients received a thorough explanation of the surgical procedure emphasizing the aims, the possible adverse effects, and the paucity of experience with Intacs in keratoconus. SURGICL TECHNIQUE Intacs surgery was performed under topical anesthesia. Two surgical techniques were used, depending on the patient s refractive problem: symmetric, that is, 2 same-thickness segments (superior or temporal incision), or asymmetric, that is, a thicker inferior segment or a single inferior segment. Our surgical nomogram depended on the manifest refraction, the patient s age (amount of presbyopia), and the site of the cone. For spherical equivalents less than 3. D, we used an asymmetric technique (usually a single inferior.45-mm-thick segment) or a symmetric technique with a temporal incision and thinner segments (.35- or.4-mm-thick segments). For spherical equivalents greater than 3.75 D (most cases), we used a symmetric technique (usually.45-mm-thick segments) with a temporal incision (segments implanted superiorlyinferiorly) for inferior cones and a superior incision (segments implanted nasally-temporally) for central cones. We allowed our patient s age and reading habits to influence the segment thickness choice (using thinner segments in presbyopes). Regarding inferior cone surgery, we attempted to place the Intacs segment where the cornea was steepest. To achieve this end, we marked the steepest meridian at the slitlamp because cyclotorsion of the eye in the operating room may lead to placement of the segment too nasally or too temporally. To prevent extrusion of the Intacs segment, the incision mark was made approximately 1.5 mm above the desired site of the proximal end of the Intacs segment. The corneal thickness at the planned site of Intacs implantation was measured using both Orbscan II (ausch & Lomb Surgical, Orbtek Inc, Salt Lake City, Utah) and Ultrasound Pachymetric nalyzer pachymetry (Model P55, Paradigm Medical Industries Inc, Salt Lake City) because Orbscan pachymetry may not be reliable. Corneal thickness of at least 45 µm along the entire site was required, to enable a channel depth of at least 37 µm to prevent superficial perforation. calibrated diamond knife with a 15 -angled blade was used to make the approximately 1.8-mm radial incision two thirds of the peripheral corneal thickness (usually ~4 µm). Incision depth was checked with a corneal thickness gauge. Using 2 Sinskey hooks and a stromal spreader, the corneal pocket was fashioned at the full depth of the incision. The inferior stromal hemichannel was created using a dissection glide and blade rotated under the suction of a vacuum-centering guide. Incisions were closed with a 1- nylon suture. Postoperatively, all eyes received antibiotic and steroid drops 4 times daily for 3 weeks, in addition to frequent use of preservative-free artificial tears. The single suture was removed 1 to 4 weeks postoperatively. VISUL CUITY Visual acuity was assessed at 2 feet and converted to the logarithm of the minimum angle of resolution (logmr) for statistical analysis and was reported as logmr or Snellen equivalents, as recommended by Holladay. 11 ecause our study subjects were interested in achieving good vision and tended to group all visual acuity less than 2/16 as not seeing, attaining reliable data in the low-vision range was difficult. Therefore, we analyzed all visual acuities less than 2/2 as 2/2. FOLLOW-UP Follow-up examinations were performed at 1 day; 1 week; and 1, 3, 6, and 12 months post Intacs implantation. Manifest refractions, UCVs, and SCVs were assessed by experienced optometrists at each visit. xial placido-based videokeratographic maps (version 4.2; EyeSys Technologies, Houston, Tex), simulated keratometry values (minimum and maximum), central corneal power, effective refractive power, and I-S asymmetry values were attained using the EyeSys software. Nine to 12 months postoperatively, patients completed a brief questionnaire that included questions on visual distortion, night vision, blurring, glare, halos, and photophobia. DDITIONL SURGERY Six cases underwent adjustment of their Intacs. This entailed removal, exchange, addition, or shifting of an Intacs segment. ecause our aim was to assess the visual outcome of keratoconic eyes managed with Intacs, the visual outcome used in the followup analysis was that attained after the Intacs adjustment surgery. STTISTICL NLYSIS etween-group mean differences were tested for significance using the 2-tailed t test for unequal variance. We used the UCV outcome to retrospectively classify cases into 1 of 3 outcome groups: poor-, fair-, and good-ucv outcome ( 2/63 [logmr poorer than.5], 2/63 but 2/4 [logmr.5-.31], and 2/4 [logmr better than.3], respectively). To define which preoperative criteria are predictive of a good visual outcome, pre-intacs refractive parameters were correlated with the postoperative UCV both simply (Pearson product moment correlation coefficient) and multiply (stepwise multiple regression using the linear regression model of the SS system 9.1, SS Institute Inc, Cary, NC). In addition, we compared the means of the preoperative parameters of the poorand good-outcome groups (2-tailed t test). RESULTS PTIENT POPULTION Fifty-eight eyes of 43 patients were studied, 25 of whom were men. Mean±SD age was 35.9±1 years (range, years). Fifty-one eyes were classified as definite keratoconus and 7 as forme fruste keratoconus. VISUL CUITY The mean±sd UCV improved from less than 2/ 2±.1 line to 2/5 3 ±3.1 lines, and the mean±sd SCV was essentially unchanged at 2/32±2. lines (Table 1). Pre-Intacs UCV was 2/2 or worse in al- 139
3 Table 1. Visual cuities, Snellen Equivalents (n = 58) Postoperative (n = 58) P Value Uncorrected visual acuity Mean ± SD 2/2 ±.1 line 2/5 3 ± 3.1 lines.1 Median (logmr) 2/2 (1.) 2/5 1 (.38) Range (logmr) 2/2-2/125 (1.-.8) 2/2-2/2 1 (1.-.2) est spectacle-corrected visual acuity Mean ± SD 2/32 1 ±.23 line 2/32 ±.18 line.75 Median (logmr) 2/32 2 (.15) 2/32 2 (.15) Range (logmr) 2/2-2/2 (1.-.) 2/1-2/2 (.7-.) bbreviation: logmr, logarithm of the minimum angle of resolution. Postoperative UCV, LogMR Poor UCV Outcome Fair UCV Outcome Good UCV Outcome N = 58 Eyes, % 2 18 N = Poor UCV Outcome Fair UCV Outcome Good UCV Outcome UCV, LogMR Gain (+) or Loss ( ) of UCV Lines. 45 Postoperative SCV, LogMR Eyes, % SCV, LogMR Gain (+) or Loss ( ) of SCV Lines Figure 1. vs 1-year postoperative logarithm of the minimum angle of resolution (logmr) uncorrected visual acuity (UCV) () and best spectacle-corrected visual acuity (SCV) (). Eyes were analyzed according to UCV outcome: poor ( 2/63), fair (2/63 to 2/4), and good ( 2/4). The preoperative SCV correlated well with the UCV outcome group. most all of the 58 eyes studied (Figure 1). The mean±sd post-intacs UCV of the poor-ucv outcome group ( 2/ 63), comprising 21 eyes, was 2/125 1 ±1.7 lines; the mean±sd fair-ucv outcome group (2/63-2/4), comprising 12 eyes, was 2/5±.6 line; and the mean±sd good-ucv outcome group ( 2/4), comprising 25 eyes, was 2/32±.9 line (P.1 for any 2 means). Most eyes with preoperative logmr SCV better than.2 (2/ Figure 2. Change in logarithm of the minimum angle of resolution (logmr) uncorrected visual acuity (UCV) () and logmr best spectacle-corrected visual acuity (SCV) () between preoperative and 1-year postoperative examinations. Note the large improvement in UCV and the largely unchanged SCV. 32) fell into the fair- or good-outcome groups (Figure 1). Figure 2 shows that 34 (6%) of 58 eyes improved their UCV by 6 or more lines, all achieving an UCV greater than or equal to 2/5, but the SCV was mostly unchanged (Figure 2). Seven eyes, mainly of the poor- UCV outcome group, improved their SCV by 2 or more lines. This gain was offset by 6 eyes, mainly of the goodoutcome group, losing 2 or 3 lines. 131
4 Table 2. Refractive Outcomes (n = 58) Postoperative (n = 58) P Value Manifest spherical equivalent, D Mean ± SD 3.88 ± ± Median Range 8.5 to.5 6. to 2.5 Manifest spherical correction, D Mean ± SD 2.21 ± ± Median Range 6. to to 3.25 Manifest astigmatic correction, D Mean ± SD 3.34 ± ± Median Range 8. to. 7. to. bbreviation: D, diopters. Table 3. Keratometry by Videokeratography (n = 58) Postoperative (n = 56) P Value Maximum simulated keratometry, D Mean ± SD 48.6 ± ± Median Range Minimum simulated keratometry, D Mean ± SD ± ± Median Range Central corneal power, D Mean ± SD 47.4 ± ± Median Range Effective refractive power, D Mean ± SD 47.1 ± ± Median Range Postoperative Spherical Correction, D Postoperative stigmatic Correction, D Poor UCV Outcome Fair UCV Outcome Good UCV Outcome Spherical Correction, D N = stigmatic Correction, D bbreviation: D, diopters. Table 2 presents that the mean manifest spherical equivalent, spherical correction, and astigmatic correction all improved significantly (P.1). lthough Intacs surgery reduced the mean spherical correction to almost, a significant mean astigmatic correction of 1.97 D remained. Figure 3 shows that preoperatively, the poor-outcome group had a wide range of spherical correction (Figure 3), usually with high astigmatic correction (Figure 3). ly, 1 pooroutcome eyes had little spherical myopia ( 1.75 D); 9 of these had severe astigmatism ( 5. D). Only 3 poor-outcome eyes had less than 3. D of astigmatism preoperatively. KERTOMETRY Keratometry by videokeratography improved significantly (Table 3). The mean±sd preoperative I-S asymmetry was 4.34±3.91 D (range,.91 to D). Fortyone (8%) of 52 of the preoperative I-S values attained were greater than 1.9 D. PTIENT QUESTIONNIRES Out of the 54 patient questionnaires completed, 39 reported significant improvement and 15 reported no improvement. Five cases, although satisfied with their improved UCV, reported a slight loss of SCV. Many patients mildly complained of decreased near vision and intermittently seeing the ring. Figure 3. vs 1-year postoperative manifest spherical correction () and manifest astigmatic correction (). Note that preoperatively, many poor-outcome eyes had low or positive spherical correction and high astigmatic correction ( 3.5 diopters [D]). UCV indicates uncorrected visual acuity. REFRCTIVE OUTCOME PREOPERTIVE PRMETERS S PREDICTORS OF OUTCOME Table 4 presents correlations between preoperative parameters and the UCV outcome. The preoperative SCV and astigmatic correction had the strongest correlations, with keratographic parameters showing significant correlations. Table 5 summarizes the multiple regression analysis of the respective preoperative param- 1311
5 Table 4. Correlations etween Parameters and Postoperative UCV Parameter Pearson Correlation Coefficient No. of Eyes UCV.8 58 SCV.51* 58 Spherical equivalent Spherical correction.2 58 stigmatic correction.47* 58 Central corneal power.44* 58 Effective refractive power.46* 55 Inferior-superior asymmetry.36* 52 Minimum simulated keratometry Maximum simulated keratometry.43* 58 bbreviations: SCV, best spectacle-corrected visual acuity; UCV, uncorrected visual acuity. *Correlation coefficient values significantly different from, 2-tailed test, P.1. Table 5. Multiple Regression of Parameters gainst Postoperative UCV* Step Parameter Entered Partial R 2 Model R 2 F Value eters contribution to the UCV outcome. Only 3 variables met the.15 significance level for entry into the regression model. The SCV accounted for most of the variance of the UCV outcome, with the astigmatism and the spherical correction making smaller yet significant contributions. Table 6 compares the preoperative parameters of the poor- and good-ucv outcome groups. The SCV and astigmatism had the lowest P values, with videokeratographic parameters also showing significant differences between the 2 groups. SURGICL TECHNIQUE We compared the 2 techniques of symmetric Intacs implantation. In 26 eyes, the segments were implanted superiorly-inferiorly through a temporal incision and in 18, nasally-temporally through a superior incision. There were no significant differences in UCV, SCV, refraction, corneal topography, and patient satisfaction between the 2 techniques of same-thickness Intacs implantation (Table 7). DDITIONL INTCS SURGERY Probability Greater Than F 1 SCV stigmatic correction Spherical correction bbreviations: SCV, best spectacle-corrected visual acuity; UCV, uncorrected visual acuity. *The independent variables (preoperative parameters) were entered into the model using the stepwise method. Only 3 variables contributed enough to the R 2 (variance in the UCV outcome) to enter the regression model. Table 6. Comparison etween Poor- and Good-UCV Outcome Groups Parameter UCV, mean ± SD, Snellen equivalent SCV, mean ± SD, Snellen equivalent Spherical equivalent, Spherical correction, stigmatic correction, Central corneal power, Effective refractive power, Inferior-superior asymmetry, * Minimum simulated keratometry, Maximum simulated keratometry, Poor-UCV Outcome (n = 21) Six eyes underwent additional Intacs surgery. In 4 cases, the patient s visual function worsened because of increased astigmatism after the initial Intacs implantation. This surgically induced astigmatism was managed by removing the superior segment in all 4 cases, with shifting of the lower segment in 1 case. Two of these eyes attained UCV of 2/4 and 2 remained close to 2/16. The fifth patient had surgically induced hyperopia. This was managed by removing the superior segment, yielding UCV of 2/5 2. The sixth patient had received a single inferior segment and remained myopic. He was treated by implanting a.25-mm superior segment, yielding UCV 2/4. COMMENT Good-UCV Outcome (n = 25) P Value 2/2 ±. lines 2/2 ±.2 lines.33 2/5 ± 2.9 lines 2/25 1 ± 1.1 lines ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± bbreviations: SCV, best spectacle-corrected visual acuity; D, diopters; UCV, uncorrected visual acuity. *Each UCV outcome group had 2 missing values. Twenty-five of 58 eyes of this study achieved an UCV greater than or equal to 2/4, 1 year post-intacs. We expect that selecting patients for Intacs surgery using the criteria recommended by this study will further improve this good result. good outcome may be expected in the patient with keratoconus with a preoperative SCV greater than 2/32 2 and secondarily with an astigmatic correction less than 3.5 D and a spherical correction more myopic than 1.75 D. We received these values by adding 1 standard deviation to the mean of the good-ucv outcome group in Table 6 (SCV) and, regarding astigmatism and spherical correction, by the watershed values on the respective scattergrams (Figure 3). Siganos et al 4 also attempted, albeit to a limited extent, to define preoperative criteria that are predictive of 1312
6 Table 7. Comparison etween Temporal and Superior Incision Surgery Techniques Variable Temporal Incision (n = 26) Superior Incision (n = 18) P Value UCV, mean ± SD, logmr 1. ±.4 1. ±..19 Postoperative UCV, mean ± SD, logmr.5 ±.35.5 ± SCV, mean ± SD, logmr.2 ±.16.3 ±.3.48 Postoperative SCV, mean ± SD, logmr.2 ±.21.2 ± spherical equivalent, * 3.6 ± ± Postoperative spherical equivalent,.9 ± ± astigmatic correction, 3.7 ± ± Postoperative astigmatic correction, 1.7 ± ± central corneal power, 47.1 ± ± Postoperative central corneal power, 45.4 ± ± effective corneal power, 47.1 ± ± Postoperative effective corneal power, 45. ± ± maximum simulated keratometry, 48. ± ± Postoperative maximum simulated keratometry, 44.4 ± ± bbreviations: SCV, best spectacle-corrected visual acuity; D, diopters; logmr, logarithm of the minimum angle of resolution; UCV, uncorrected visual acuity. *Our surgical approach selected the more myopic eyes for superior-incision surgery. a good outcome. They found higher spherical equivalent, astigmatism, and keratometry were associated with poorer UCV outcome and concluded that Intacs are more effective in early keratoconus. lthough in severe keratoconus the prognosis for successful Intacs surgery is poorer, some of our severe cases, and others, 3,4 did well with Intacs. Two techniques of Intacs surgery for keratoconus have been reported. Colin et al 1,2 and oxer Wachler et al 3 used an asymmetric technique in which a thicker segment is implanted inferiorly. This technique aims to treat the inferior steepening seen in most keratoconic and keratectatic eyes. The same-thickness segment implantation technique used by Siganos et al 4 and our study aims to reduce the myopia and astigmatism by symmetrically flattening and supporting the central cornea. We also used an asymmetric technique in certain cases where the spherical equivalent was less than 3. D. It seems that both techniques are effective in keratoconus. Our approach, as described in the Methods section, is to tailor the technique to each specific patient, the spherical equivalent being the most decisive factor. dditional study will determine the optimal surgical technique. ecause the greatest improvement was seen in the cases with astigmatism less than 3.5 D and spherical correction greater than 1.75 D, it seems that the main mechanism of Intacs improving the refractive outcome is improving the spherical error. lthough astigmatism is also improved (regular astigmatism manifesting as a decrease in the manifest astigmatic correction and irregular astigmatism manifesting as an increase in the SCV), this effect appears more limited. Therefore, in selecting patients for Intacs implantation, the surgeon should consider that the patient with greater myopia would probably be more satisfied than the patient with high astigmatism and little spherical myopia. Intacs implantation in keratoconus appears safe. We had no superficial corneal buttonholing because we were careful to dissect the entire length of the Intacs channel at least 37 µm deep. Likewise, we had no segment extrusion because the proximal end of the segment was implanted at least 1 mm into the channel. Ectatic corneas are thinner, less rigid, and less symmetric than normal corneas, making buttonholing and segment extrusion more likely if the preceding precautions are not taken. Eight eyes, mostly of the good-ucv outcome group, had postoperative loss of 2 or more lines of SCV. Two of these eyes, having little UCV improvement, underwent additional Intacs surgery (removal of superior segment). oth eyes greatly improved their UCV and recovered their lost SCV. Others 3,4 also reported loss of SCV post-intacs in a small number of keratoconic eyes. lthough Intacs are easily removed, which reverses the refractive effect, loss of SCV is a cause for concern and requires further study. Six eyes underwent additional Intacs surgery; 3 achieved a good visual outcome and 1 a fair outcome. dditional Intacs surgery carries a negligible risk of complication, often requiring simple explantation of the superior segment. lthough Siganos et al 4 and our study show the visual outcome to be similar in both temporal and superior incision same-segment Intacs surgery, an advantage of the temporal incision is that it allows the option of easy removal of the superior segment, if necessary. Others 3,4 respectively describe 2 cases of superior Intacs segment removal that achieved satisfactory results. ecause keratoconus differs in severity and patterns of presentation, studies on keratoconus, including ours, are limited. oxer Wachler et al 3 included cases of forme fruste keratoconus as well as advanced cases of keratoconus with corneal scarring. lthough they showed the ability of Intacs to significantly improve the UCV and SCV in severe keratoconus, few of the cornealscarring cases achieved an UCV greater than or equal to 2/4. Colin et al, 1,2 Siganos et al, 4 and we excluded cases of corneal scarring. This variation in the severity of keratoconus in the patient cohort studied makes comparing studies difficult. We stress the need for standard- 1313
7 ized criteria for the different severities of keratoconus. 15 Retrospective studies may be less reliable than prospective ones because of missing data. esides 6 eyes lacking preoperative I-S values and 4 eyes lacking questionnaires, our study had no missing data. To our knowledge, our study is to date the largest series of keratoconus patients managed with Intacs with 1-year follow-up. We show that Intacs surgery may achieve good 1-year stable UCV in keratoconic eyes, especially if patients are selected with attention primarily to the SCV and secondarily to the astigmatism and the spherical error. Submitted for Publication: March 12, 24; accepted March 31, 25. Correspondence: Russell Pokroy, MD, Enaim Refractive Surgery Center, Shaarey Ha ir, 216 Jaffa Rd, Jerusalem, 94383, Israel (pokroyr@yahoo.com). Financial Disclosure: None. Previous Presentation: This study was presented in part at the Refractive Surgery Conference of the Israel Ophthalmologic Society; October 29, 23; Tel viv, Israel. REFERENCES 1. Colin J, Cochener, Savary G, Malet F. Correcting keratoconus with intracorneal rings. J Cataract Refract Surg. 2;26: Colin J, Cochener, Savary G, Malet F, Holmes-Higgin D. INTCS inserts for treating keratoconus: one-year results. Ophthalmology. 21;18: oxer Wachler S, Christie JP, Chandra NS, Chou, Korn TS, Nepomuceno R. Intacs for keratoconus. Ophthalmology. 23;11: Siganos CS, Kymionis GD, Kartakis N, Theodorakis M, styrakakis N, Pallikaris IG. Management of keratoconus with Intacs. m J Ophthalmol. 23; 135: Siganos CS, Kymionis GD, styrakakis N, Pallikaris IG. Management of corneal ectasia after laser in situ keratomileusis with INTCS. J Refract Surg. 22;18: lio J, Salem T, rtola, Osman. Intracorneal rings to correct corneal ectasia after laser in situ keratomileusis. J Cataract Refract Surg. 22; 28: Kymionos GD, Siganos CS, Kounis G, styrakakis N, Kalyvianaki MI, Pallikaris IG. Management of post-lsik corneal ectasia with Intacs inserts. rch Ophthalmol. 23;121: Lovisolo CF, Fleming JF. Intracorneal ring segments for iatrogenic keratectasia after laser in situ keratomileusis or photorefractive keratectomy. J Refract Surg. 22;18: Pokroy R, Levinger S, Hirsh. Single Intacs segment for post-lsik keratectasia. J Cataract Refract Surg. 24;3: merican cademy of Ophthalmology. Corneal topography. Ophthalmology. 1999;16: Holladay JT. Visual acuity measurements. J Cataract Refract Surg. 24; 3: Chan SM, Khan HN. Reversibility and exchangeability of intrastromal corneal ring segments. J Cataract Refract Surg. 22;28: Clinch TE, Lemp M, Foulks GN, Schanzlin DJ. Removal of INTCS for myopia. Ophthalmology. 22;19: lio JL, rtola, Ruiz-Moreno JM, Hassanein, Galal, wadalla M. Changes in keratoconic corneas after intracorneal ring segment explantation and reimplantation. Ophthalmology. 24;111: Pokroy R. Children with vernal keratoconjunctivitis. Ophthalmology. 24; 111: Correction Error in Figure. In the Epidemiology article by The Eye Diseases Prevalence Research Group titled The Prevalence of Refractive Errors mong dults in the United States, Western Europe, and ustralia, published in the pril 24 issue of the RCHIVES (24;122:495-55), an error appeared in Figure 3 on page 498. In the creation of that figure, the black and white prevalence rates from the altimore Eye Survey were inadvertently reversed. The corrected figure is reprinted here with its legend. ES DES MES RS Melbourne VIP Proyecto VER (Hispanics) 2 Women Men Women Men 15 Prevalence, % ge, y ge, y Figure 3. Prevalence of myopia of 5 diopters or less in white persons () and black and Hispanic persons (). ES indicates altimore Eye Survey, altimore, Md; DES, eaver Dam Eye Study, eaver Dam, Wis; MES, lue Mountains Eye Study, Sydney, New South Wales, ustralia; RS, Rotterdam Study, Rotterdam, the Netherlands; Melbourne VIP, Melbourne Visual Impairment Project, Melbourne, Victoria, ustralia; Proyecto VER, Vision Evaluation and Research, Nogales and Tucson, riz. 1314
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