Recentration of a small-aperture corneal inlay Damien Gatinel, MD, Alaa El Danasoury, MD, Stephane Rajchles, MD, Alain Saad, MD We report 2 patients implanted with a small-aperture corneal inlay to correct presbyopia. After the surgery, both patients complained of visual symptoms and poor visual acuity. The distances from the center of the inlay to the corneal vertex center were 593 mm nasally and 159 mm superiorly in Case 1 and 72 mm temporally and 17 mm superiorly in Case 2. The 2 inlays were recentered at 2 weeks and 3 weeks postoperatively, resulting in significant improvement in the visual acuity and quality of vision. Accurate centration of a small-aperture corneal inlay seems to be an impor- tant factor in obtaining a satisfactory result. Recentration is possible and improves visual acuity if proper centration was not obtained after the first surgery. Financial Disclosure: Dr. Saad is a consultant to Acufocus, Inc. Dr. Gatinel is an investigator for a clinical trial conducted with the small-aperture inlay. He does not have any financial interest in relation to this inlay. Neither of the other authors has a financial or proprietary interest in any material or method mentioned. J Cataract Refract Surg 2012; 38:2186–2191 Q 2012 ASCRS and ESCRS The Kamra small-aperture intracorneal inlay (Acufo- cus, Inc.) is designed to increase depth of field in the im- planted eye, based on the principle of small-aperture optics. The inlay restores near and intermediate visual acuity without a significant impact on the distance vision. 1–3 The 5 mm thick microperforated inlay has a 1.6 mm central aperture and measures 3.8 mm in overall diameter. Implantation can be combined with excimer ablation to simultaneously address presbyo- pia and ametropia. The inlay is implanted monocularly in a lamellar pocket or under a 200 mm femtosecond laser–created flap in the nondominant eye. As with photoablative surgery, correct centration of a corneal inlay is important to improve distance and near visual acuity and to avoid a reduction in quality of vision. The corneal intersection of the visual axis is probably the best point on which to center the inlay. The visual axis is the line joining the fixation point and the foveal image by the nodal points. The line of sight is the line joining the fixation point and the center of the entrance pupil. The position at which this line in- tercepts the cornea is called the corneal sighting center. 4 Le Grand and El Hage 5 referred to the intersection of the visual axis with the cornea as the ophthalmometric pole. However, the true position of the visual axis at the corneal plane is unknown and whether to center the correction on the entrance pupil center or on the coax- ially sighted corneal reflex has not been determined. 6–9 The coaxially sighted corneal reflex provides an easy reference to center procedures performed over the cor- neal surface. Angle kappa is the angle between the visual axis and the pupillary axis, which is perpendic- ular to the cornea through the center of the entrance pupil. Angle lambda is the angle between the line of sight and the pupillary axis; in practice, these angles can be confounded. Their estimation in angular degree is difficult without proper knowledge of the geometry and depth of the anterior chamber. Because of the an- gle kappa, the corneal reflex usually appears to be lo- cated on the nasal side of the pupil center. The position of the corneal reflex does not mark the intersection of the visual axis with the cornea (ophthalmometric pole); however, it may be the closest landmark 10 and can be used to center the placement of the inlay.We present 2 cases of decentered inlays requiring recentra- tion because pf unsatisfactory visual outcome after the first surgery. CASE REPORTS Case 1 A 56-year-old man seeking a solution for presbyopia was referred to our practice. The refraction was C1.50 diopter Submitted: January 23, 2012. Final revision submitted: May 17, 2012. Accepted: May 21, 2012. From the Rothschild Foundation (Gatinel, Rajchles, Saad) and the Center for Expertise and Research in Optics for Clinicians (Gatinel, Saad), Paris, France; Magrabi Eye Hospital (El Danasoury), Jeddah, Saudi Arabia. Corresponding author: Damien Gatinel, MD, Fondation Ophtalmolo- gique Adolphe de Rothschild, 25, Rue Manin, 75019, Paris, France. E-mail: gatinel@gmail.com. Q 2012 ASCRS and ESCRS 0886-3350/$ - see front matter Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jcrs.2012.09.009 2186 CASE REPORT