Visual Performance and Quality of Life after Femtosecond Laser-Assisted Cataract Surgery with Trifocal IOLs Implantation.

PURPOSE: To assess visual performance and quality of life after implantation of diffractive trifocal IOLs with enhanced depth of focus (Acriva Reviol Tri-ED) compared to monofocal IOLs. SETTING: Ophthalmology Clinic, Department of Medicine and Science of Ageing, University "G. d'Annunzio" Chieti-Pescara, Italy. DESIGN: Prospective clinical study. METHODS: This study comprised 36 eyes of 18 patients with senile cataract candidates for phacoemulsification and implantation of the Acriva Reviol Tri-ED (Group 1-18 eyes) and the AcrySof IQ Monofocal IOL SN60WF (Group 2-18 eyes). The main outcome measures, over a 6-month follow-up period, were uncorrected and corrected visual acuity at different distances (40, 60 cm and 4 m), defocus curve, contrast sensitivity and wavefront error. Patient satisfaction was evaluated by means of the NEI-RQL-42 questionnaire. RESULTS: At 180 days postoperatively, the difference of the UCDVA and CDVA between the groups was not statistically significant (p = 0.888 and p = 0.843, respectively). The difference between the groups was statistically significant for UCIVA (p = 0.019) and UCNVA (p = 0.036). The mean values of contrast sensitivity under photopic and mesopic conditions were not significantly different between the groups. The RMS of spherical aberration was significantly lower in Group 1 compared to Group 2. The NEI-RQL-42 questionnaire showed statistically significant differences between the groups for the dependence on correction (p < 0.001). CONCLUSIONS: The diffractive trifocal IOL with enhanced depth of focus Acriva Reviol Tri-ED was effective in improving functional capacity for intermediate and near vision compared to monofocal IOLs and provided a good quality of vision due to a significant reduction in spherical aberration.

In Vivo Confocal Microscopy of Stromal Lenticule Addition Keratoplasty for Advanced Keratoconus.

PURPOSE: To investigate the in vivo corneal microscopic changes after femtosecond laser-assisted stromal lenticule addition keratoplasty in keratoconus by means of in vivo confocal microscopy. METHODS: Patients affected by advanced keratoconus were included in the study. Negative meniscus-shaped stromal lenticules, produced with a femtosecond laser (VisuMax; Carl Zeiss Meditec) from eye bank corneas were transplanted into a stromal pocket dissected in the recipient cornea at a depth of 120 µm. In vivo confocal microscopy was performed during the 12-month follow-up to investigate changes of the corneal and lenticule structure. RESULTS: Ten patients were enrolled in the study. No changes of the dendritic cell population were documented during the follow-up period. Mild edema and stromal keratocyte activation gradually decreased during the first month. Subbasal nerve density returned to preoperative values after 6 months. Donor-recipient interfaces appeared hyperreflective but gradually improved over time with significantly reduced reflectivity after 3 months. No evidence of stromal inflammatory cell migration or matrix opacification was observed. Endothelial and keratocyte density remained stable over time. A variable degree of stromal radially distributed folds, not visible on biomicroscopy, was observed in the lenticule and in the posterior recipient stroma. CONCLUSIONS: Stromal lenticule addition keratoplasty produces transitory nerve plexus density reduction and minor inflammatory reaction that rapidly decreases during the first month. Donor-recipient interface reflectivity is comparable to a femtosecond laser refractive procedure with no sign of stromal opacification or stromal rejection in 1 year of follow-up. [J Refract Surg. 2020;36(8):544-550.].

Tear Meniscus Imaging by Anterior Segment-Optical Coherence Tomography in Medically Controlled Glaucoma.

PURPOSE: The purpose of this study was to investigate the tear meniscus in medically controlled glaucoma patients (MCGP) using anterior segment-optical coherence tomography (AS-OCT). MATERIALS AND METHODS: Fifty-six MCGP, 24 patients with evaporative dry eye (EDE), and 30 healthy subjects (controls), were enrolled. MCGP were divided into group 1 (14 eyes): ß-blockers; group 2 (14 eyes): prostaglandin analogs; group 3 (28 eyes) ≥2 drugs. Ocular Surface Disease Index (OSDI) questionnaire, tear film break-up time, corneal fluorescein staining, Schirmer Test I, and tear meniscus height (lower and upper: L-TMH, U-TMH) and area (L-TMA, U-TMA) using AS-OCT, were performed. RESULTS: OSDI score was higher (P<0.05) in patients with EDE and in group 3 compared with groups 1, 2, and controls. No significant differences were found between group 3 and patients with EDE for all clinical parameters. L-TMA was significantly lower in groups 1 to 3 (P<0.05) and in EDE patients (P<0.001) compared with controls, and it was lower in group 3 and in EDE patients compared with groups 1 and 2 (P<0.05). L-TMH was lower in groups 1 to 3 and in EDE patients compared with controls (P<0.001), and in EDE patients and in group 3 compared with groups 1 and 2 (P<0.05). U-TMA was lower in EDE and MCGP groups compared with controls (P<0.05). L-TMA and L-TMH negatively correlated with OSDI score (P<0.01, r=-0.379 and P<0.01, r=-0.352, respectively). CONCLUSIONS: AS-OCT permits a noninvasive and reliable tear meniscus imaging in medically controlled glaucoma, depicting the glaucoma-related ocular surface disease as a dry eye disease-like condition. Thus, reduced values of TMH and TMA can be proposed as structural indicators of glaucoma therapy-related ocular surface disease.

Prevalence of diabetes and diabetic macular edema in patients undergoing senile cataract surgery in Italy: The DIabetes and CATaract study.

BACKGROUND: The purpose of this study is to determine the prevalence of diabetes and diabetic macular edema in patients undergoing senile cataract surgery in Italy. METHODS: It is a prospective, multicenter, cross-sectional study. Thirteen ophthalmic units equally distributed across the Italian territory have been involved in the study. For a period of 3 months, all subjects undergoing phacoemulsification received an Optical Coherence Tompgraphy (OCT) scan and were screened for the anamnestic presence of diabetes. In addition, five selected units collected blood samples from all their patients to measure glycated hemoglobin (HbA1c) levels and detect the presence of occult diabetes (HbA1c > 6.5%). In diabetic patients, levels of retinopathy were measured and diabetic macular edema was considered significant (clinically significant macular edema) when foveal thickness was above 30% of normal levels. RESULTS: A total number of 3657 subjects have been screened. Among them, 20.4% were diabetics. Prevalence of diabetes was significantly higher in males (24.7%) than in females (17%). Levels of HbA1c were tested in a representative sample of 1216 consecutive subjects, and occult diabetes was diagnosed in 4.8% of cases. No significant differences were observed between age groups or different geographic areas. Among diabetic patients, diabetic macular edema of any kind was present in 27.5% (clinically significant macular edema (6.6%)). No significant differences were seen in the prevalence of diabetic macular edema between males and females or between age groups. Among the 745 diabetic patients, no signs of retinopathy were seen in 537 subjects (76.3%), while 101 patients (14.3%) had nonproliferative retinopathy, 13 (1.7%) had nontreated proliferative diabetic retinopathy, and 53 (7.5%) had laser-treated retinopathy. In the entire sample of 3657 subjects, a normal macula was present in 90.9% of cases, diabetic macular edema of any kind in 5.4%, and other maculopathies in 3.4%. CONCLUSION: In this large cohort study on patients undergoing cataract surgery, more than one-fourth were diabetics and more than one-fourth of these had diabetic macular edema. These high prevalences suggest the opportunity to plan an adequate preoperative assessment in all patients in order to reduce the risk of postoperative development or worsening of a sight-threatening complication such as chronic diabetic macular edema.

In vivo and in vitro results of an automated preloaded delivery system for IOL implantation in cataract surgery.

PURPOSE: To compare the corneal tissue trauma after the use of an automated preloaded injector and a manual injector and assess scanning electron microscope (SEM) and atomic force microscope (AFM) features of both injector cartridges. SETTING: Ophthalmology Clinic and Laboratory of Stem Cells and Regenerative Medicine University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy; DESIGN: Prospective randomized clinical study METHODS: Forty eyes of 40 patients for phacoemulsification were divided into two groups: implantation of intraocular lens was performed with AutonoMe automated delivery system (AutonoMe group: 20 eyes) and Monarch III injector system (Monarch group: 20 eyes). In vivo confocal microscopy (IVCM) and anterior segment optical coherence tomography (AS-OCT) were performed before surgery, at 1 h, 1 day and 1 month post-operatively. In addition, SEM and AFM were performed on cartridges of both injector systems after injection of the IOL. RESULTS: A greater increase in central corneal thickness and corneal thickness at the incision site were observed in Monarch group versus AutonoMe group 1 h and 1 day post-operatively (p < 0.05). Endothelial cell count loss was significantly higher in Monarch group compared with AutonoMe group (p < 0.05) at 1 and 24 h. AS-OCT showed less endothelial misalignment at 30 days (p < 0.05), and IVCM showed less tunnel inflammation at all time points (p < 0.05) in AutonoMe group compared with Monarch group; roughness analysis at AFM of the AutonoMe cartridge was significantly lower compared to Monarch D cartridge (p < 0.05). CONCLUSIONS: The AutonoMe injector provided less corneal tissue trauma compared with Monarch III injector. The AutonoMe cartridge showed lower roughness at AFM compared to the Monarch D cartridge.

The ocular surface after successful glaucoma filtration surgery: a clinical, in vivo confocal microscopy, and immune-cytology study.

We investigated the ocular surface (OS) system modifications after completely successful glaucoma surgery in thirty-eight patients undergoing trabeculectomy (surgical group), using laser scanning confocal microscopy (LSCM) and impression cytology (IC). Twenty-six medically controlled glaucomatous patients served as controls (medical group). LSCM, IC, and the ocular surface disease index (OSDI) and National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25) questionnaires, were performed at baseline and after six months. The main outcomes were: goblet cell density (GCD), limbal dendritic cell density (LDCD), subbasal corneal nerve inhomogeneity (SCNI), Meibomian gland density and inhomogeneity (MGD, MGI), and HLA-DR positivity. There were no significant baseline differences between groups. At the sixth month, the surgical group showed a GCD increase (p < 0.001), and a LDCD, SCNI, MGI, HLA-DR (p < 0.001), OSDI and NEI VFQ-25 scores decrease (p < 0.05). The medical group did not show significant OS modifications, showing LSCM and IC parameters significantly worse compared to the surgical group (p < 0.001). The OSDI score correlated with GCD, MGI, SCNI, LDCD, and HLA-DR (p < 0.001; p < 0.05; p < 0.01). The present study found that the whole OS system objectively improved after completely successful glaucoma filtration surgery. These changes positively affected the OSDI score, but not the NEI VFQ-25 score.

Immunohistochemical study of corneal inflammation after femtosecond laser clear corneal incisions or manual surgery.

PURPOSE: To use immunohistochemical staining to evaluate corneal inflammation and apoptosis induced after femtosecond laser incisions or manual incisions. SETTING: Ophthalmology Clinic, University G. d'Annunzio, Chieti, Italy. DESIGN: Experimental study. METHODS: Ninety human cadaver corneas were cut manually or with the femtosecond laser at different energies and analyzed by immunohistochemistry after 5 minutes or 4 hours. The corneas were divided into 5 groups: untreated (Group 1), cut manually (Group 2), and treated with the femtosecond laser with increasing energies (Groups 3 to 5; 3.0 µJ, 6.0 µJ, and 15.0 µJ, respectively). RESULTS: At 5 minutes, increased expression of interleukin (IL)-18 was observed in the femtosecond laser groups compared with the manual group (P < .01). Interferon gamma (IFNγ) positivity was significantly higher in Groups 4 and 5 than in Group 2 and between Groups 3 and 4 (P < .05). The terminal uridine deoxynucleotidyl nick end-labeling (TUNEL) positivity increased with higher energy (Group 2 versus Group 4 and Group 2 versus Group 5; P < .05). After 4 hours, IFNγ positivity was higher in Group 5 than in Group 2 (P = .0021) and between Group 5 and Groups 3 and 4 (P < .05). No sign of IL-18 positivity was found after 4 hours in any sample. Group 5 showed significant higher TUNEL positivity than all other groups (P < .0001). CONCLUSION: The femtosecond laser technique at high energies induced a higher corneal inflammatory response and a higher corneal cell apoptosis than the manual technique. FINANCIAL DISCLOSURE: None of the authors has a financial or proprietary interest in any material or method mentioned.

Astigmatism correction with toric IOL: analysis of visual performance, position, and wavefront error.

PURPOSE: To evaluate astigmatism correction, visual performance, intraocular lens (IOL) position, and wavefront error after implantation of toric IOLs in patients with cataract. METHODS: This prospective study comprised 30 eyes of 30 patients with cataract who were candidates for phacoemulsification and implantation of the AcrySof toric IOL (Alcon Laboratories, Inc., Fort Worth, TX). Mean preoperative corneal keratometric and subjective refractive cylinder were 2.10 ± 0.47 and 2.17 ± 0.41 diopters (D), respectively. RESULTS: The refractive cylinder decreased significantly from 2.17 ± 0.41 to 0.73 ± 0.45 D (P = .001) at 180 days postoperatively. The difference between preoperative corneal astigmatism and postoperative refractive astigmatism was statistically significant (P < .05). At 180 days postoperatively, the uncorrected distance visual acuity was 0.20 logMAR (Snellen 20/32) in 100% of patients and 0.0 logMAR (Snellen 20/20) in 64% of patients. The root mean square of internal coma and trefoil aberrations showed a trend toward reduction; internal spherical aberration significantly decreased, whereas corneal trefoil aberration significantly increased (P < .05). A low amount of IOL decentration and tilt were detected at 30 and 180 days postoperatively, respectively. CONCLUSIONS: Toric IOL implantation is an effective procedure for correction of preexisting corneal astigmatism, improving visual performance, and inducing a low amount of higher-order aberrations. Moreover, the toric IOLs is well positioned early after surgery and stable over time.