Cravit

A combination of tiletimine and zolazepam-mixed agent (Zoletil^TM, Virbac, Fort Worth, TX, USA) and xylazine (Rompun^TM, Bayer, Leverkusen, Germany) was injected intramuscularly for anesthesia (12.5 mg/kg). The corneal endothelium of rabbits was cryo-damaged according to the established protocol by Okumura et al.62 (link). In brief, a stainless steel probe with a diameter of 7 mm was immersed in liquid nitrogen tank for 3 minutes to achieve a stabilized temperature of approximately −196 °C. Thereafter, corneal endothelium was damaged by transcorneal freezing by gently touching the central corneal surface with the probe for 15 seconds as noted in Fig. 3C. The ocular surface was then irrigated using 10 mL of normal saline. Topical levofloxacin eye drops (Cravit^TM, Santen, Osaka, Japan) were applied 4 times a day for 3 days to prevent infection.

Wavefront-guided LASIK was performed with the Technolas 217z excimer laser system (Bausch & Lomb) to apply a flying spot of 1.0 or 2.0 mm in diameter with a Gaussian profile and a 120 Hz active eye tracker. The LSK-1 microkeratome (Moria, Antony, France) was utilized for creating a hinged corneal flap of 130-μm thickness. Postoperatively, steroidal (0.1% fluorometholone, Flumetholone ^TM, Santen) and antibiotic (0.3% levofloxacin, Cravit^TM, Santen) medications were topically administered 4 times daily for 2 weeks.

The patients preoperatively underwent 2 peripheral iridotomies with a neodymium-YAG laser. On the day of surgery, the patients were given dilating and cycloplegic agents. After topical anesthesia, a model V4b ICL (without a central hole) was inserted through a 3-mm clear corneal incision with the use of an injector cartridge (STAAR Surgical) after placement of a viscosurgical device (Opegan^TM; Santen, Osaka, Japan) into the anterior chamber. The ICL was placed in the posterior chamber, the remaining viscosurgical device was completely washed out from the anterior chamber with balanced salt solution, and a miotic agent was instilled. For toric ICL implantation, to control for potential cyclotorsion in a supine position, the zero horizontal axis was marked preoperatively using a slit-lamp. After the ICL had then been placed in the posterior chamber and rotated by 22.5 degrees or less using the manipulator. Postoperatively, steroidal (0.1% betamethasone, Rinderon^TM, Shionogi, Osaka, Japan) and antibiotic (0.3% levofloxacin, Cravit^TM, Santen, Osaka, Japan) medications were administered topically 4 times daily for 2 weeks, and the dose was steadily reduced thereafter.

For primary pterygium surgery, after subconjunctival injection of lidocaine-epinephrine (1:100,000) into the tissue, the pterygium head was bluntly lifted off from the cornea, and the pterygium head and body were excised at ∼4 mm from the limbus. Abnormal subconjunctival fibrous tissue was trimmed away, and abnormal scarring on the cornea was polished. A conjunctival autograft was moved from the superior bulbar conjunctiva in order to cover the defect area with 8–0 absorbable polyglycolic sutures without the use of mitomycyin C.
For cataract surgery, standard phacoemulsification was performed. The surgical technique consisted of a capsulorhexis, nucleus and cortex extraction, and a monofocal IOL (AQ-110NV, Staar Surgical, CA) implantation through a temporal 2.8-mm clear corneal incision. All surgeries were uneventfully performed by 1 experienced surgeon (K.K.) using the same technique. In 43 of 60 eyes, we selected emmetropia as the target refraction. In the remaining 17 eyes, we intentionally selected a slight myopia for near vision. Postoperatively, steroidal (0.1% betamethasone, Rinderon^TM, Shionogi, Osaka, Japan), antibiotic (0.3% levofloxacin, Cravit^TM, Santen, Osaka, Japan), diclofenac sodium (0.1% Diclod^TM, Wakamoto, Tokyo, Japan) medications were topically administered 4 times daily for 1 month, the dose being reduced gradually thereafter.

All ICL implantation surgeries were performed using a standardized method in all surgical centers. After topical anesthesia, ICL was inserted through a 3-mm clear corneal incision using an injector cartridge (STAAR Surgical) after placement of a viscosurgical device (Opegan; Santen, Osaka, Japan) into the anterior chamber. The ICL was placed in the posterior chamber, the viscosurgical device was completely washed out of the anterior chamber with a balanced salt solution, and a myotic agent was instilled. All surgeries were uneventful, and no intraoperative complication was observed. After surgery, steroids (0.1% betamethasone; Rinderon; Shionogi, Osaka, Japan) and antibiotics (0.3% levofloxacin; Cravit; Santen, Osaka, Japan) were topically administered four times daily for two weeks, and the dose was gradually reduced thereafter.