Surgical anatomy of the orbital region, local anesthesia and general considerations.

Orbital region may be divided into four sectors: medial canthus, lateral canthus, lower lid and upper lid. A vertical section of a lid shows 5 layers: skin, subcutaneous tissue with orbicularis muscle, fibrous layer (tarsus-aponeurosis), plain fibers muscle layer (Muller's), conjunctiva. The first two layers form the "anterior lamella" and the other ones the "posterior lamella", divided by the grey line. In this review Authors describe with all details the orbital region and the eyelid layers, considering the most important concepts for surgery. Finally they resume basics of local anesthesia in ophthalmoplastic surgery.

Eyelid benign and malignant tumors: issues in classification, excision and reconstruction.

In the orbital region the variety of tumors is so vast that even an expert oculoplastic surgeon may be deceived. The various tumors may be classified as benign, precancerous and malignant. Approximately 5-10% of all skin cancers occur in the eyelids. Incidence studies indicate that basal cell carcinoma is the most frequent malignant eyelid tumor, followed by squamous cell carcinoma, sebaceous gland carcinoma and malignant melanoma. Malignant neoplasms represent the leading cause of plastic reconstruction in orbital region, followed by cicatricial retraction, post-traumatic loss of tissue, congenital colobomas. Aim of this review is to classify benign and malignant lesions; to consider the surgical removal approach to the lesion (Mohs micrographic surgery, frozen sections, biopsy, immediate removal and reconstruction with permanent sections) and finally to consider reconstruction techniques with grafts and flaps.

Ectropion, entropion, trichiasis.

Aim of this review was to describe ectropion, entropion and trichiasis and their therapy. These eyelid pathologies are characterised by common symptoms (redness, excessive tearing and irritation of the eye) and by altered balance of the anterior and posterior lamellae of the eyelids. They involve more frequently the inferior eyelid and the therapy is mainly surgical. Parasurgical therapy may play a role as a temporary measure.

Blepharoplastic: essential review.

In the periorbital the major aging changes are a drooping of the brow (brow ptosis), excessive accumulation of skin in the upper lid (dermatochalasis), and a prolapse of orbital fat, in the upper and lower lids caused by weakening of the septum and orbital connective tissues. The specific anatomical abnormalities of each individual patients should be identified and the relationship between each other should be identified in order to determine a correct surgical plan. In this review we will analyze different surgical techniques.

The effects of dorzolamide 2% and dorzolamide/timolol fixed combination on retinal and optic nerve head blood flow in primary open-angle glaucoma patients.

PURPOSE: To compare the effect of dorzolamide hydrochloride 2%, timolol maleate 0.5%, and their fixed combination on intraocular pressure (IOP)and retinal and optic nerve head haemodynamics in primary open-angle glaucoma patients. METHODS: Twenty-eight patients with early moderate glaucomatous damage treated with ß-blockers (>6 months) with IOP values ranging from 18 to 22 mmHg at trough participated in this trial. After a 4-week washout period,patients were randomised in two groups: group I started with dorzolamide 2% monotherapy and group II with timolol 0.50% monotherapy for 4 weeks. After this period, both groups switched to dorzolamide/timolol fixed combination for 4 weeks. IOP, ocular diastolic perfusion pressure, heart rate, and Scanning Laser Doppler Flowmetry measurements at the peripapillary retina and neuroretinal rim were taken at T0 (enrolment), T1 (wash out), T2(monotherapy), and T3 (dorzolamide/timolol).Data were compared between different study times. Statistical analysis was conducted using a paired t-test. RESULTS: Between T1 and T3, IOP decreased significantly in group I (-21.40%) (P<0.001)and in group II (-21.25%) (P<0.001). At the same time intervals, blood flow increased significantly at rim level for group I (+30.03%)(P<0.05) and also when all patients were considered (rim +20.81%) (P<0.05). Between T1 and T3, we also observed a significant increase of ODPP in group I (+7.24%) (P<0.01)and in group II (+6.08%) (P<0.05) and when all patients were considered (+6.71%)(P<0.001) [corrected]. CONCLUSIONS: Dorzolamide/timolol fixed combination increased blood flow significantly at the neuroretinal rim showing a combination of hypotensive and haemodynamic effects.

Cyclotorsional eye movements during a simulated PRK procedure.

PURPOSE: Eye alignment is a serious concern when performing corneal surface ablation. Although several excimer lasers monitor horizontal and vertical movements, little is known about the potential impact of cyclotorsional movements. Dynamic cyclotorsions have been measured on 10 emmetropic subjects during a simulated PRK treatment. METHODS: Cyclotorsional eye movements were measured using a 3D videoculographic system (SMI) in 10 emmetropic subjects in upright and supine position. The subjects were wearing an eyelid speculum and were asked to fixate on a 1 degrees red spot. The fixation target was either in focus or optically degraded by electronic filters. Data were collected at the University Eye Clinic, Torino, Italy, and the different setting measurements were compared using Student's t-test for paired data. RESULTS: Cyclotorsions were significantly higher when subjects were fixating an optically degraded stimulus (upright: P=0.04; supine: P=0.0002). The cyclotorsional movements ranged from -13 to 17 degrees. A significant difference in eye orientation was present when changing from the upright to the supine position (P=0.03). Even when correcting for this positional error, significantly higher cyclotorsional movements were detected in the supine position (in focus: P=0.0043; optically degraded: P=0.0008). The torsional range was from -14.85 to 14.55 degrees. CONCLUSIONS: The high range of cyclotorsional eye movements during a simulated PRK procedure suggests that 3D tracking could improve surface ablation results when treating high astigmatism or when wavefront guided.

Hypertensive retinopathy revisited: some answers, more questions.

Hypertension is associated with cardiovascular risk and systemic target organ damage. Retinopathy is considered one of the indicators of target organ damage. This review focuses on recent studies on hypertensive retinopathy and their implications for clinical care. Early recognition of hypertensive retinopathy signs remains an important step in the risk stratification of hypertensive patients.

Transpupillary thermotherapy of juxtafoveal recurrent choroidal neovascularization.

PURPOSE: To evaluate the effectiveness of low power transpupillary thermotherapy (TTT) in treating juxtafoveal recurrent choroidal neovascularization (CNV) after laser photocoagulation in patients with age-related macular degeneration (ARMD). METHODS: Eight eyes of eight patients with ARMD and juxtafoveal recurrent CNV were treated with low power TTT, delivered using an 810-nm diode laser with 350 mW, 2.0 mm spot, and 1-minute duration. Visual acuity (VA) ranged from 20/100 to 20/50. Treatment effect was evaluated by fluorescein angiography, indocyanine green angiography, and VA measurements (Early Treatment Diabetic Retinopathy Study) at 1-week, 2-week, and monthly follow-up visits. RESULTS: No retinal damage was visible ophthalmoscopically during treatment. At the first follow-up visit, seven eyes had obliteration of CNV and one eye required a second TTT application. VA was unchanged in six eyes, improved in one eye, and worsened in one eye. Recurrences occurred in all eyes between 1 and 7 months after TTT and were treated with photodynamic therapy (PDT). More than two PDT treatments were performed in each eye in the year after recurrence. CONCLUSIONS: Low power TTT is as able to close juxtafoveal recurrent CNV as is high power conventional laser photocoagulation but does not prevent recurrences. Further intervention with TTT in order to treat recurrences is under investigation.

Long-term refractive and phoric changes in visual display unit (VDU) operators.

PURPOSE: This study assessed the phoric and refractive changes possibly caused by visual display unit (VDU) activity. METHODS: In a longitudinal trial nearly 6000 VDU operators received two ophthalmological examinations at intervals ranging from 34 to 43 months. The findings from the two examinations were correlated to VDU work (hours daily and years of VDU work), age and sex. RESULTS: Changes in the refractive state seemed to be mainly age-related. There was a slight tendency toward hyperopia (imbalance of latent hyperopia). CONCLUSIONS: In the analysis of ocular motility, the results show no worsening capable of causing a definitive change from heterophoria to heterotropia. Heterophoric subjects, however, tend to improve both with regular office work and with additional VDU activity.

Evaluation of serotonin levels in human aqueous humor.

PURPOSE: Serotonin is biochemically present in the iris and ciliary body of animals and humans. Controversial findings are reported about the concentrations of serotonin in aqueous humor with respect to plasma in humans. The aim of this study was to evaluate the levels of serotonin both in aqueous humor and plasma in human subjects. METHODS: In 50 patients with glaucoma or cataract, plasma and aqueous humor serotonin levels were measured by HPLC with electrochemical detection. Serotonin plasma levels were also measured in 25 healthy subjects as controls. RESULTS: In all patients with cataract or glaucoma, the aqueous humor serotonin concentration is significantly lower than that in plasma [1.14+/-0.29 (SEM) vs. 5.33+/-1.03 ng/ml, p<0.01]. Furthermore, in the same patients and in 25 healthy controls, serotonin plasma levels were similar. CONCLUSION: Our study shows that serotonin is present in human aqueous humor and its concentration is 4 times lower than in plasma.

Molecular basis of open-angle glaucoma in Italy.

Glaucoma is a group of ocular diseases characterized by an optic neuropathy in which degeneration of retinal ganglion cells leads to a characteristic excavation of the optic nerve head. Primary open-angle glaucoma (POAG) can be subdivided into two groups according to age of onset:- 1. the more common middle- to late-age onset, chronic open-angle glaucoma (COAG) diagnosed after the age of 40 years; 2. the rarer juvenile open-angle glaucoma (JOAG), which is diagnosed between the age of 3 years and early adulthood. Recently, the gene coding for the trabecular meshwork-induced glucocorticoid response protein (TIGR), located in chromosome 1 (1q23-25), was found mutated in patients affected by POAG. In this work we describe the clinical and molecular genetic features of several Italian families affected by autosomal dominant POAG, collected in various regions of Italy.

[Changes in adrenergic innervation of the choroid during aging]. / Modifications de l'innervation adrénergique de la choroïde pendant la sénescence.

BACKGROUND: Aging causes loss of neurons and adrenergic nerve termination in various human organism systems and apparatus. The aim of this work is the observation of qualitative and quantitative differences in the orientation and density of the human choroid adrenergic innervation in relation to age. METHODS: The choroid specimens were taken from the corresponding sectors of the eyeballs of four patients aged between 70 and 75 years and patients aged between 40 and 45 years. The glyoxilic method of Furness and Costa (1975) was used. RESULTS: The location and orientation of the adrenergic fibres was similar in the adult and aged patients. However, the fibres are clearly fewer in number, less rich in varicosity and have reduced fluorescence. In the suprachoroid lamina thickness and in the vascular layer, the adrenergic synaptic contacts with the melanocytes are fewer in number, as are also the SIF-cells (small intensely fluorescent cells). CONCLUSIONS: With age there is a significant reduction of the orthosympathetic innervation of the human choroid. This fact could explain some physiopathological aspects of the choroid circulation and blood flow and, therefore, play a part in ocular pression variations.

Fluorescence histochemical demonstration of adrenergic terminations in the human choroid.

With the existing literature on the aspects of anatomic and physiological ocular choroid membrane variables in mind, the authors verify the possibility of applying the methods of Axelsson et al and of Lindvall and Bjorklund, as simplified by Furness and Costa for fluorescent microscopy, to the study of human choroid nerve topographic distribution. The material for the study was obtained from three human eyeballs, two enucleated because of malignant melanoma of the choroid and one because of neoplasia of the ciliary body. A binocular dissecting microscope was used. A fluorescent microscope was used to observe the histological specimens and photographs were taken. The following results are presented and discussed: 1) the fluorescent paravascular nervous fibres and periarterial nervous plexuses divided into preterminal and terminal fibres; 2) in the suprachoroidal layer, there were small groups of polygonal nervous branches with or without this connection; 3) the most intervasal plexus development was in the posterior part of the vascular layer with preterminal and terminal fibres, 4) in the intervascular space, melanocytes and free adrenergic nervous terminations were observed; 5) adrenergic fibres were not observed in the choriocapillaris of the choroid membrane; 6) there were adrenergic neurons in the vascular layer.

Assessment of malingerers' visual acuity by Lotmar's visometer test.

The authors, after having mentioned several methods to detect malingering, have attempted to demonstrate the reliability of Lotmar's visometer test in assessing the real visual acuity of ten malingerers (five of whom denied bilateral vision). The authors confirmed their data with several other subjective and objective methods that demonstrated the reliability of the visometer test.

Evaluation of macular function by Lotmar's visometer test and blue-field entoptic test in patients with cataract.

The authors attempted to predict postoperative visual acuity in patients undergoing cataract extraction by comparing the results obtained using two subjective methods: Lotmar's visometer test and the blue-field entoptic (BFE) test. Both tests allow assessment of retinal visual acuity in the presence of opacities of the ocular media. Measurements were made on 60 patients before cataract extraction. These subjects were followed for three months in order to assess their postoperative visual acuity and to ascertain the reliability of the tests. Analysis of the data demonstrates the high level of reliability of both methods. Lotmar's visometer test gives a more exact assessment of macular function. However, in the presence of total lens opacity, the BFE test becomes necessary since Lotmar's test loses reliability in such cases.