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• W2009314897 abstract "Purpose: To retrospectively evaluate the visual and refractive outcome of visually impaired adults treated with refractive surgery (photorefractive keratectomy or laser-assisted in situ keratomileusis). Methods: We searched a refractive surgery database comprising 1716 mildly visually impaired patients [best spectacle-corrected visual acuity (BSCVA) on a logMAR scale ≤ −0.1 (Snellen ≤ 0.8)] who had undergone either PRK or LASIK (n = 96). PRK patients who had visits at 5–7, 8–13 and 14–24 months postoperatively were selected. Eleven patients and nine PRK control myopic patients were found (cohort 1). From the same database, 41 visually impaired patients and 54 controls who had a postoperative control at 14–24 months postoperatively were chosen. These patients formed cohort 2. Results: Preoperatively, in cohort 1, the mean BSCVA on a logMAR scale was −0.15 ± 0.13 (Snellen 0.73 ± 0.16) in visually impaired patients and 0.04 ± 0.02 (Snellen 1.11 ± 0.17) in myopic controls. At 14–24 months postoperatively, the mean BSCVA improved to 0.05 ± 0.04 (Snellen 1.13 ± 0.10) in visually impaired patients and 0.05 ± 0.08 (Snellen 1.13 ± 0.21) in control patients. In cohort 2, preoperatively the mean BSCVA on a logMAR scale was −0.15 ± 0.12 (Snellen 0.74 ± 0.14) in visually impaired patients and 0.01 ± 0.03 (Snellen 1.04 ± 0.10) in myopic controls. At 14–24 months postoperatively, the mean BSCVA improved to 0.02 ± 0.07 (Snellen 1.06 ± 0.16) in visually impaired patients and 0.06 ± 0.06 (Snellen 1.15 ± 0.16) in control patients. Conclusion: Refractive surgery improves BSCVA in visually impaired patients, possibly through plastic changes in the visual cortex. Consequently, refractive surgery may be used successfully for the treatment of visually impaired adults to enhance their visual acuity. Amblyopia is a unilateral or bilateral reduction of best spectacle-corrected visual acuity (BSCVA) in an eye that is otherwise physically normal (Attebo et al. 1998). Conditions that predispose to amblyopia include strabismus, anisometropia, stimulus deprivation, high refractive error and media opacification causing reduction in image quality. The reported prevalence of amblyopia varies between 1% and 3% depending on the study population (Attebo et al. 1998; Brown et al. 2000; Eibschitz-Tsimhoni et al. 2000; Williams et al. 2003). Correction of refractive errors by spectacles or contact lenses and/or occlusion therapy with a patching of the dominant eye or atropine penalization of the healthy eye can be used to treat juvenile amblyopia (Wu & Hunter 2006). Unfortunately, the results of these conventional treatment methods may not always be permanent (Moseley et al. 1997; Holmes et al. 2004; Bhola et al. 2006; Holmes et al. 2007). Even after successful conventional treatment, the recurrence of amblyopia is about 25% (Holmes et al. 2007). When occlusion therapy is halted, the visual input to the visual cortex may return to its original state whereby the better eye dominates and suppresses the non-dominant eye. Recently, studies concerning the efficacy of refractive surgery for anisometropic amblyopia in children have yielded somewhat encouraging results (Autrata & Rehurek 2004; Paysse et al. 2006). The visual deficiencies are thought to be irreversible after the first decade of life, and this is believed to be because of the termination of the developmental maturation window. In amblyopic patients it seems that neuronal networks in primary visual cortex are functionally abnormal (Polat 1999). Repetition of certain visual tasks has provided evidence that perceptual learning can improve the adult visual system (Polat et al. 2004). Previously, we studied the improvement of visual acuity in myopic and anisometropic adult patients after refractive surgery. Visual acuity improvement was significantly slower in the anisometropic group, suggesting that some plastic changes for anisometropic adults in the visual cortex might have taken place (Vuori et al. 2007). Because of the suspected permanency of visual impairment after the first decade of life, there have been only minor efforts to find efficient ways to treat visually impaired adults. The findings indicating plasticity in the adult visual cortex (Chino et al. 1992; Gilbert & Wiesel 1992; Levi & Polat 1996) support the idea that the visual impairment of amblyopic patients may be partly reversible in adulthood if the optical deprivation is removed. If significantly ametropic, refractive surgery for visually impaired adult patients might remove this deprivation and increase visual performance. The purpose of this study was to extend our previous study (Vuori et al. 2007) by evaluating the visual and refractive outcome of myopic, mildly visually impaired adult patients treated with refractive surgery. The Ethical Review Committee of Helsinki University Eye Hospital approved the research plan. The study followed the tenets of the Declaration of Helsinki, and patients and controls gave informed consent before entering the study. All patients and controls were operated on at the Helsinki University Eye Hospital between May 1996 and September 2002. Patients and controls were treated by either photorefractive keratectomy (PRK) or laser-assisted in situ keratomileusis (LASIK). PRK and LASIK surgeries were performed as described previously (Vuori et al. 2007). Only one eye of each patient and control was analysed. In this retrospective study, a patient was considered visually impaired if the preoperative BSCVA on a logMAR scale was ≤ −0.1 (Snellen ≤ 0.80). The study scheme is shown in Fig. 1. In the first part of this study (Fig. 1A), we searched our database (n = 1716) for myopic patients who had undergone refractive surgery and who presented with a preoperative BSCVA of ≤ −0.1 (Snellen ≤ 0.80) Altogether, 96 visually impaired patients were found. From these 96 patients we selected those patients who were operated on using PRK and who had follow-up visits preoperatively and at 5–7 months, 8–13 months and 14–24 months (n = 11). One hundred and seventy-four control patients who had a preoperative BSCVA > −0.1 (Snellen > 0.80) were chosen randomly from the same database. Out of these 174 controls, nine myopic PRK patients had the same follow-up visits. These 11 visually impaired patients and nine control patients formed cohort 1. The study scheme representing the first (A) and second (B) parts of the study. VA, visual acuity. In the second part of this study (Fig. 1B), all of those 96 visually impaired patients (BSCVA ≤ −0.1) who had a follow-up visit at 14–24 months were selected (n = 41). Similarly, from the 174 myopic controls all of those patients who had a follow-up 14–24 months postoperatively were taken as the control group (n = 54). These 41 visually impaired patients and 54 myopic controls formed cohort 2. Preoperative and postoperative evaluations included assessment of uncorrected visual acuity (UCVA) and BSCVA using the Snellen E-chart test, cycloplaegic refraction, slit-lamp biomicroscopy and applanation tonometry. All patients and controls were treated with PRK (three patients by NIDEK EC5000, six by VisX 20/20B, one by VisX star and one by VisX star S2; three controls were treated by NIDEK EC5000, three by VisX 20/20B and three by VisX star S2). Five of the patients and four of the controls were male. Seven of the visually impaired eyes and five of the control eyes analysed were left eyes. Thirty-eight of the visually impaired patients were treated with PRK (13 patients by NIDEK EC5000, 18 by VisX 20/20B, five by VisX star and two by VisX star S2) and three with LASIK (two patients by VisX star and one by VisX star S2). Thirty-one of the control patients were treated with PRK (nine controls by NIDEK EC5000, eight by VisX 20/20B, three by VisX star and 11 by VisX star S2) and 23 by LASIK (two controls by NIDEK EC5000, two by VisX star and 19 by VisX star S2). Seventeen of the patients and 16 of the controls were male. Twenty-one of the visually impaired eyes and 29 of the control eyes analysed were left eyes. Statistical calculations were performed using Statview (Version 5.0.1; SAS Institute Inc., Cary, NC, USA). In the first part of this study (cohort 1), anova with Bonferroni adjustment for repeated measures was carried out first followed by analysis with two-tailed paired t-test corrected for repeated measurements. In the second part of this study (cohort 2), the data of visually impaired and control patients were compared using the unpaired two-tailed t-test. For t-test analysis, the level of significance was set at p < 0.05. The mean preoperative spherical equivalent (SE) was −6.8 ± 1.6 D (range −9.4 to −4.3) for visually impaired patients and −5.9 ± 1.3 D (range −8.8 to −4.8) for myopic control patients. Attempted correction ranged between 4.0 and 9.3 D (mean 6.5 ± 1.5 D) in visually impaired patients and between 4.8 and 8.8 D among controls (mean 5.8 ± 1.2 D). At 14−24 months postoperatively, the mean SEs were −0.8 ± 0.9 D (range −2.5 to 0.5) and −0.1 ± 0.5 D (range −0.8 to 0.5) in the visually impaired and control groups, respectively. The SE correction achieved at 14–24 months was between 3.4 and 7.8 D (mean 6.0 ± 1.4 D) in visually impaired patients and between 4.1 and 8.0 D (mean 5.8 ± 1.1 D) among controls. Figure 2A shows the attempted versus achieved correction 14–24 months postoperatively. Nine of 11 visually impaired patients and all control patients were within ±1 D of the attempted correction 14–24 months postoperatively. Deviation from attempted spherical equivalent refractive correction 14–24 months after refractive surgery performed for visually impaired patients () and myopic control patients (○). (A) Cohort 1; (B) cohort 2. Preoperatively, the mean BSCVA on a logMAR scale was −0.15 ± 0.13 (Snellen 0.73 ± 0.16), range −0.52 to −0.10 (Snellen 0.30–0.80) in visually impaired patients and 0.04 ± 0.02 (Snellen 1.11 ± 0.17), range 0.00–0.18 (Snellen 1.00–1.50) in myopic controls. At 14–24 months postoperatively, the mean BSCVA was 0.05 ± 0.04 (Snellen 1.13 ± 0.10), range 0.00–0.08 (Snellen 1.0–1.2) in the visually impaired group and 0.05 ± 0.08 (Snellen 1.13 ± 0.21), range −0.05 to 0.18 (Snellen 0.9–1.5) in the control group. The development of mean BSCVA in both visually impaired patients and myopic patients is shown in Fig. 3. For visually impaired patients, a significant improvement in BSCVA was evident at the first follow-up visit 5–7 months postoperatively; this improvement remained significant throughout the follow-up period (p < 0.001). For myopic controls, no statistically significant improvement in BSCVA was evident at any visit (p > 0.2). As shown in Fig. 3, the difference in mean BSCVA between controls and patients became smaller over time, and at 14–24 months postoperatively the mean BSCVA of the patients and controls was found to be equal. In statistical analysis the BSCVA of controls was found to be significantly better preoperatively (p < 0.0001), but after that the difference in BSCVA between these two study groups became statistically insignificant. Gain or loss of BSCVA was analysed subsequently; these data are depicted in Fig. 4A–B. None of the visually impaired patients lost any lines 5–7, 8–13 or 14–24 months postoperatively (see Fig. 4A). Fourteen to 24 months postoperatively, all visually impaired patients had gained lines: three gained one line, seven gained two lines and one gained six lines. Among controls, none had gained more than one line 14–24 months postoperatively (see Fig. 4B). The mean best spectacle-corrected visual acuity preoperatively and at 5–7, 8–13 and 14–24 months postoperatively among visually impaired patients () and myopic controls (○) from cohort 1. The error bars depict standard deviation. Changes in Snellen lines of best spectacle-corrected visual acuity following refractive surgery 5–7, 8–13 and 14–24 months postoperatively in visually impaired patients (A) and myopic control patients (B) from cohort 1. (C) Change (Snellen lines) in best spectacle-corrected visual acuity for patients and controls from cohort 2 14–24 months postoperatively; the number of patients/controls is shown in parentheses above the bars. Forty-one patients and 54 myopic controls had a follow-up visit at 14–24 months after refractive surgery. In Cohort 2 the mean preoperative SE was −6.6 ± 2.0 D (range −10.5 to −2.3) for visually impaired patients and −6.6 ± 1.9 D (range −13.4 to −3.3) for myopic controls. Attempted correction ranged between 2.3 and 10.5 D (mean 6.3 ± 2.1 D) in visually impaired patients and between 3.3 and 12.9 D (mean 6.5 ± 1.9 D) among controls. At 14–24 months postoperatively the mean SEs were −0.5 ± 0.8 D (range −2.5 to 2.3) and −0.3 ± 0.6 D (range −2.0 to 0.5) in the visually impaired and control groups, respectively. The SE correction achieved at 14–24 months was between 2.3 and 9.9 D (mean 6.1 ± 2.0 D) in visually impaired patients and between 3.0 and 11.8 D (mean 6.2 ± 1.8 D) among controls. Figure 2B shows the attempted versus achieved correction 14–24 months postoperatively. Thirty-two of 41 (78%) visually impaired patients and 47 of 52 (90%) control patients were within ± 1 D of their attempted correction 14–24 months postoperatively. Preoperatively, the mean BSCVA on a logMAR scale was −0.15 ± 0.12 (Snellen 0.74 ± 0.14), range −0.70 to −0.10 (Snellen 0.20–0.80) in visually impaired patients and 0.01 ± 0.03 (Snellen 1.04 ± 0.10), range −0.05 to 0.18 (Snellen 0.90–1.50) in myopic controls. At 14–24 months postoperatively, the mean BSCVA was 0.02 ± 0.07 (Snellen 1.06 ± 0.16), range −0.22 to 0.18 (Snellen 0.6–1.5) in the visually impaired group and 0.06 ± 0.06 (Snellen 1.15 ± 0.16), range −0.05 to 0.18 (Snellen 0.9–1.5) in the control group. The improvement in BSCVA was found to be statistically significant among both visually impaired patients and controls (p < 0.0001). The BSCVA was found to be better both preoperatively and 14–24 months postoperatively among controls, although the statistical significance of it became weaker. In cohort 2, at 14–24 months postoperatively 16 visually impaired patients (39%) and two controls (4%) had gained two lines (see Fig. 4C). Fourteen to 24 months postoperatively, none of the control patients had gained three or more lines whereas in the visually impaired group five (12%) had done so and one patient had even gained seven lines. We aimed to define a minimum preoperative BSCVA under which the use of refractive surgery would not improve BSCVA, but this limit was not found in this cohort. The most visually impaired patient in cohort 2 had a preoperative BSCVA of −0.7 on a logMAR scale (Snellen 0.20); this patient gained seven Snellen lines. Furthermore, one patient had a preoperative BSCVA of −0.5 on a logMAR scale (Snellen 0.30) and his BSCVA improved by six Snellen lines. One patient had a preoperative BSCVA of −0.4 on a logMAR scale (Snellen 0.40) and gained four Snellen lines. We have examined the visual and refractive outcome of adult visually impaired patients treated with PRK or LASIK. We have shown that refractive surgery improves the visual acuity of these patients much more than expected on the basis of image enlargement (Applegate & Howland 1993). More significantly, the mean improvement of BSCVA in visually impaired patients was nearly two Snellen lines in both cohorts 1 and 2 14–24 months postoperatively; this finding is probably clinically significant and the quality of life of these patients is likely to be improved. Because of the suspected permanency of amblyopia after the first decade of life, most of the reports concerning the use of refractive surgery to treat amblyopia are performed in paediatric populations. For example, Paysse et al. (2006) reported a 3-year follow-up study of 11 children with anisometropic amblyopia who were treated with PRK. Their data demonstrated improvement in UCVA and BSCVA in most children. We found only three studies concerning the use of laser refractive surgery for adult amblyopic patients with a follow-up time > 5 months. None of these studies had a control group. Barequet et al. (2004) analysed retrospectively eight eyes of seven patients 6 months after LASIK. The amblyopic eyes showed a mean improvement of three Snellen lines (range 2–4 lines) in UCVA at 2 months compared with the preoperative BSCVA. Lanza et al. (2005) reported 38 amblyopic eyes of 36 adult patients who had undergone PRK. Six months after PRK the mean BSCVA was improved by one Snellen line. The report by Roszkowska et al. (2006) was the only one that had a relatively large number of patients. The authors studied 68 amblyopic eyes treated with PRK; 18 adults with bilateral refractive amblyopia and 32 adults with unilateral anisometropic amblyopia. Approximately four out of five eyes improved their BSCVA by one or more lines of Snellen visual acuity. Our data showing improvement in BSCVA are consistent with these previously published reports and extend these studies further by demonstrating in more detail the dynamics of visual acuity improvement. As shown in 3, 5, the BSCVA of visually impaired patients improved during follow-up but the improvement slowed down during the follow-up period. Among myopic controls in cohort 1, no statistically significant improvement in BSCVA was evident at any visit (p > 0.2). However, in cohort 2, a statistically significant (albeit probably clinically insignificant) improvement in BSCVA was observed. The mean best spectacle-corrected visual acuity preoperatively and at 1, 3, 5–7, 8–13 and 14–24 months postoperatively in anisometropic patients (Vuori et al. 2007) (□) and visually impaired patients (). Finally, we analysed all of those 96 visually impaired patients who had been followed up for a minimum of 5–7 months (n = 76) and compared their results with the anisometropic adult patients (n = 57) of our previous study (Vuori et al. 2007). In this analysis, BSCVA was measured before PRK/LASIK [76 (100%) visually impaired patients and 57 (100%) anisometropic patients] and 1 month (66% of the visually impaired patients and 65% of the anisometropic patients), 3 months (55% of the visually impaired patients and 79% of the anisometropic patients), 5–7 months (53% of the visually impaired patients and 54% of the anisometropic patients), 8–13 months (65% of the visually impaired patients and 43% of the anisometropic patients) and 14–24 months (55% of the visually impaired patients and 53% of the anisometropic patients) postoperatively. The improvement of mean BSCVA in both visually impaired and anisometropic patients is shown in Fig. 5. In the visually impaired patients, a rapid increase was observed up to 3 months postoperatively; subsequently, mean BSCVA behaved very similarly in the two groups. The improvement in BSCVA continued in both groups 14–24 months postoperatively. These findings may suggest that slow plastic changes take place in the visual cortex. There are some limitations to this study. We considered a patient to be visually impaired if the BSCVA was < 0.8 Snellen equivalent. This BSCVA limit is artificial and does not anticipate that the patient is amblyopic. The use of PRK and LASIK and the variety of excimer lasers can be considered as a confounding factor. On the other hand, this provides the possibility to generalize these results to different refractive surgery procedures and equipment. Similar improvement in BSCVA was detected in both cohorts 1 and 2; cohort 1 included only PRK patients and cohort 2 consisted of both PRK and LASIK patients. We found that more visually impaired than myopic control patients were outside ± 1.0 D of the attempted correction at the end of follow-up. The likely reason is that preoperative cycloplaegic refraction of visually impaired patients is not as reliable as it is with simple myopic patients. The accuracy of our data could have been enhanced by defining the contact lens refractions as part of the preoperative and postoperative evaluation: this would have compensated for image size, at least in high myopes. Lastly, BSCVA was measured using the Snellen E-chart test. Because of crowding, this chart may not be as applicable to visually impaired patients as, for instance, the Landolt C-chart. According to the conventional definition of amblyopia, amblyopic patients suffer from irreversible distraction of visual processing, possibly because of anatomical changes in the visual cortex and lateral geniculate nucleus. This irreversibility might not exist: there is accumulating evidence that a certain degree of neural plasticity also exists in adults. In the study by Polat et al. (2004), a training procedure termed ‘perceptual learning’ resulted in a twofold improvement in contrast sensitivity among amblyopic patients. The recovery in visual function of adult amblyopic eyes following a loss of vision in the non-amblyopic eye has also been reported (Wilson 1992; El Mallah et al. 2000). About 10% of anisometropic or strabismic amblyopes show spontaneous improvement in the visual performance of the amblyopic eye if injury or disease reduces the visual acuity of the non-amblyopic healthy eye (Klaeger-Manzanell et al. 1994; Rahi et al. 2002; Chua & Mitchell 2004). In our previous study (Vuori et al. 2007), we found that anisometropic and myopic adults showed significant differences in the time needed to gain the maximum improvement in BSCVA, suggesting that plastic changes might be taking place in the visual cortex in anisometropic patients. This study offers further evidence of residual neural plasticity well beyond the accepted termination of the maturation window. These results may implicate that specific neuronal network connections may be activated by correcting optical abnormalities at the corneal plane, leading to improved visual performance. No treatment is currently available for adults with visual impairment. This study suggests that refractive surgery might be used successfully to improve visual function in visually impaired adult patients. However, larger prospective trials are needed to prove this. In an accompanying study we have prospectively examined changes in the primary visual cortex (V1) using functional magnetic resonance imaging after refractive surgery for anisometropic and myopic patients. These results will be published separately. Supported in part by grants from the Finnish Eye Foundation (Helsinki, Finland), Evald and Hilda Nissi Foundation (Espoo, Finland), the Helsinki University Central Hospital Research Fund (Helsinki, Finland) and the Instrumentarium Science Foundation (Helsinki, Finland)." @default.
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• W2009314897 title "Laser refractive correction of myopia in visually impaired patients improves visual acuity" @default.
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