Dexamethasone Intravitreal Implant to Treat Persistent Full-Thickness Macular Hole.

Purpose: To describe a new technique for the secondary repair of persistent full-thickness macular holes (FTMHs). Methods: This series evaluated 3 cases of a persistent FTMH after pars plana vitrectomy, internal limiting membrane peeling, and 20% sulfur hexafluoride gas tamponade. After at least 4 weeks (mean, 36.3; range, 32-40) of unsuccessful topical treatment with nonsteroidal anti-inflammatory drugs, an intravitreal dexamethasone implant was injected. Results: The intravitreal dexamethasone implant led to anatomic closure and visual improvement in all 3 cases over a 3-month follow-up. Conclusions: An intravitreal dexamethasone implant could be considered in the management of selected cases of persistent FTMH. Further studies and a consistent number of cases are needed to fully understand the role of intravitreal dexamethasone implants in persistent FTMHs.

Routine use of filtered air as endotamponade in the management of primary rhegmatogenous retinal detachment.

PURPOSE: To evaluate the safety and efficacy of filtered air as endotamponade in the management of primary rhegmatogenous retinal detachment (RRD) treated with pars plana vitrectomy (PPV) and complete drainage of subretinal fluid. METHODS: For this retrospective study, we reviewed the medical charts of 273 patients (275 eyes) who consecutively underwent PPV, subretinal fluid drainage and filtered air tamponade to treat primary RRD between 2018 and 2022. As primary outcome we evaluated the anatomical success considered as retinal reattachment after single surgery. As secondary outcomes: final mean best corrected distance visual acuity (BCDVA), complications, and mean intraocular pressure (IOP) trends. RESULTS: The anatomical success was reached by 262 (95.6%) of cases. Mean BCDVA improved from 0.73 LogMAR at baseline, to 0.21 LogMAR at the end of follow-up. As complications we recorded: 5 cases of clinically relevant macular pucker, 1 full thickness macular hole, and 1 PFO bubble under the retina. The mean IOP remained on normal values during the overall follow-up period.

Femtosecond laser-assisted deep anterior lamellar keratoplasty: A safer option in keratoconus surgery.

PURPOSE: To evaluate postoperative safety of femtosecond laser deep anterior lamellar keratoplasty performed with an innovative anvil profile in keratoconus patients. METHODS: This is a single-center, retrospective cohort study. We reviewed medical records of 89 keratoconus patients that underwent femtosecond laser deep anterior lamellar keratoplasty surgery (46 eyes) and manual deep anterior lamellar keratoplasty (47 eyes). Inclusion criteria required: age > 18 years old, best-corrected visual acuity < 0.3 LogMAR, continuous suture of the graft, postoperative immunomodulant regimen with dexamethasone 0.1% for 6 months and at least 12 months follow-up. Previous eye surgery, hydrops, and other ocular disease were excluded. The main outcome measures were postoperative events: rejections, persistent epithelial defects, and graft failures. RESULTS: During the follow-up (20 ± 6 months) graft rejection was diagnosed in 0 of femtosecond laser deep anterior lamellar keratoplasty versus 6 (17%) of manual deep anterior lamellar keratoplasty [p 0.027], persistent epithelial defect in 0 of femtosecond laser deep anterior lamellar keratoplasty versus in 4 (11%) of manual deep anterior lamellar keratoplasty [p 0.048] and graft failure occurred in 4 (11%) of manual deep anterior lamellar keratoplasty. The best-corrected visual acuity, after removal of sutures, was better in the femtosecond laser deep anterior lamellar keratoplasty group 0.09 ± 0.08 LogMAR versus 0.16 ± 0.13 LogMAR in manual deep anterior lamellar keratoplasty [p 0.035] group although refractive spherical equivalent and cylinder, topographic average keratometry and cylinder were similar. CONCLUSIONS: Anvil-shaped femtosecond laser deep anterior lamellar keratoplasty in keratoconus surgery increases safety and readiness of recovery, decreasing the incidence of corneal rejection, epithelial defects, graft failures, and producing better best-corrected visual acuity after removal of sutures.

Gender medicine in corneal transplantation: influence of sex mismatch on rejection episodes and graft survival in a prospective cohort of patients.

To evaluate the effect of donor-to-recipient sex mismatched (male donor corneas to female recipients) on the incidence of rejection episodes and failures up to 1 year after corneal transplantation. Prospective observational cohort study, with donor corneas randomly assigned and surgeons blind to the sex of donor. A unique eye bank retrieved and selected the donor corneas transplanted in 4 ophthalmic units in patients with clinical indication for primary or repeated keratoplasty for optical reasons, perforating or lamellar, either anterior or posterior. Rejection episode defined as any reversible or irreversible endothelial, epithelial or stromal sign, with or without development of corneal edema, and graft failure as a permanently cloudy graft or a regraft for any reason detected or acknowledged during a postoperative ophthalmic visit at any time up to 1 year after surgery were recorded.156 (28.6%) patients resulted donor-to-recipient gender mismatched for H-Y antigen (male donor to female recipient). During the 12 months follow-up, 83 (14.7%, 95% CI 12.0-17.9) grafts showed at least 1 rejection episode and 17 (3.2%, 95% CI 2.0-5.0) failed after immune rejection, among 54 (9.6%, 95% CI 7.4-12.3) grafts failed for all causes. No significant differences between matched and mismatched patients were found for cumulative incidence of both rejection episodes (15.2% and 13.5%) and graft failures following rejection (3.2% and 2.6%), respectively. Multivariable analyses showed that H-Y matching either is not a predictive factor for rejection or graft failure nor seems to influence incidence of failures on respect to patient's risk category. The lack of influence of donor-to-recipient mismatched on the rate of rejections and graft failures resulting from this study do not support the adoption of donor-recipient matching in the allocation of corneas for transplantation.

A Conservative Surgical Approach to the Treatment of Optic Disc Pit Maculopathy: Four Case Reports.

The purpose of this report is to present the outcomes of surgical interventions in 4 patients with maculopathy associated with optic disc pit (ODP). We report 4 cases of patients affected by ODP maculopathy and treated by core vitrectomy with induction of posterior vitreous detachment and peeling of the internal limiting membrane restricted to the interpapillary macular zone without laser treatment and gas tamponade. The patients had rapid resolution of the multilayer inner retinoschisis-like separation and progressive slow reabsorption of the macular intraretinal and subretinal fluid up to complete retinal reattachment. Currently, there are still no widely accepted guidelines related to the best technique in the management of the maculopathy associated with ODP. We used a conservative approach, without the adoption of intravitreal gas injection or laser.

Fungal keratitis following deep lamellar keratoplasty.

A young man affected from keratoconus was submitted to deep lamellar keratoplasty (DLK). The day after, the presence of pseudochamber between the donor and the recipient cornea was observed by the slit-lamp and the patient was submitted to the injection of an air bubble into the anterior chamber. Approximately six days later, multiple, whitish patches mostly located in the centre of the lamellar interface were noticed. Medical treatment was started immediately but no improvement was observed and penetrating keratoplasty was performed. Although this organism has been described as a microbial pathogen in blepharitis, conjunctivitis, keratitis, canaliculitis, dacryocystitis, and endophthalmitis, to the best of our knowledge, this is the first case report of keratitis after DLK caused by Actinomyces species.

Vitrectomy for vitreous opacities and macular pucker in Gaucher disease.

PURPOSE: To report significant surgical results in an uncommon ophthalmologic complication of a rare disease. METHODS: Interventional case report. RESULTS: A 16-year-old girl with type III Gaucher disease experienced visual loss in both eyes. Ophthalmologic examination revealed dense whitish vitreous opacities and macular pucker OU. Visual acuity (VA) OD was 20/63 and OS was 20/25. She underwent 25-gauge vitrectomy with removal of the vitreous core, posterior vitreous cortex, and indocyanine green?stained internal limiting membrane OD. Visual acuity improved, reaching 20/25 1 year after surgery despite the appearance of small preretinal flecks. Visual acuity OS decreased some time later and vitrectomy was performed when VA OS was 20/100. Three years after surgery, BCVA was 20/25 OD and 20/20 OS 1 year after surgery. CONCLUSIONS: We describe a young patient with Gaucher disease with severe bilateral vitreous opacities and macular pucker. After surgery, vitreous opacities partially and progressively recurred, but the overall favorable outcome strongly supports a surgical approach in cases of this kind.

Intravitreal bevacizumab (Avastin) for choroidal neovascularization in angioid streaks: a case series.

BACKGROUND: Intravitreal (IV) bevacizumab (Avastin(R), Roche), initially used for the off-label treatment of neovascular age-related macular degeneration (AMD), has extended itself to treat various ocular pathologies such as choroidal neovascularization not associated to AMD. METHODS: IV bevacizumab 1,25 mg (Avastin) was used in the treatment of choroidal neovascularization (CNV) in 6 eyes of 5 patients with angioid streaks. All cases had a history of photodynamic treatment (PDT) or laser treatment and all showed progressive worsening despite the use of these therapies. RESULTS: After injection patients were followed up at nearly 2-month intervals. IV Avastin was repeated in case of recurrence. Three eyes were treated combining PDT and IV Avastin. Cases were followed up for 7-14 months. All patients needed more IV injections. Five out of 6 eyes showed an improvement of BCVA and a slight reduction of leakage and size with FA. CONCLUSION: This small series suggests that IV Avastin might be useful in the treatment of CNV due to AS.

A pilot study on ocular safety of intravitreal infliximab in a rabbit model.

PURPOSE: To determine whether infliximab may be used safely as an intraocular drug, the ocular safety of intravitreal infliximab in rabbits was studied by clinical examination, electroretinography (ERG), and histology in rabbits. METHODS: Twelve New Zealand albino rabbits were selected for this study. Different infliximab doses, namely 1.0 mg, 1.7 mg, and 3.3 mg in 0.1 mL, were injected intravitreally into one eye each of three rabbits. As a control, the vehicle solution was injected into the fellow eye of each animal. Eye clinical examination and ERG recordings were made before and 2, 6, and 12 weeks after injection. Eventually, the rabbits were humanely killed, and the retinas were examined by light microscopy. In addition, the elimination half-life of the drug in the vitreous was assessed. RESULTS: Slit lamp biomicroscopy, indirect funduscopy, and ERG evidenced no significant differences between control and infliximab-injected eyes in this rabbit model, at any of the tested doses. Histologic examination revealed no retinal abnormality in the rabbits injected with 1 mg and 1.7 mg intravitreal infliximab. In two of three eyes injected with 3.3 mg infliximab, significant edema of the nerve fibers was detected compared with the control group. The half-life of the drug was estimated to be 8.5 days. CONCLUSIONS: These results indicate that infliximab may be a safe intravitreal drug in the rabbit model at a dose of up to 1.7 mg. If proven safe and efficacious in further studies, intravitreal injection of infliximab could be considered an alternative to systemic administration in selected patients.

Optical coherence tomography versus stereoscopic fundus photography or biomicroscopy for diagnosing diabetic macular edema: a systematic review.

PURPOSE: To review systematically the sensitivity and specificity of optical coherence tomography (OCT) for diagnosing macular edema attributable to diabetic retinopathy compared with well-established gold standard tests such as fundus stereophotography or contact and noncontact fundus biomicroscopy. METHODS: Medline and Embase were searched electronically and six major ophthalmic journals from 1998 to 2006 were hand searched. Two reviewers independently assessed trial searches, studied quality with the QUADAS (Quality Assessment of Diagnostic Accuracy Studies) checklist, and extracted data. The target disease was clinically significant macular edema (CSME) according to Early Treatment of Diabetic Retinopathy Study (ETDRS) criteria. A bivariate model was used to obtain summary estimates of sensitivity and specificity and fit a summary receiver operating characteristic (ROC) curve. RESULTS: Fifteen studies were considered eligible. These studies were of good quality for most items of the QUADAS checklist, but most studies did not report masking of examiners and did not describe how withdrawals and undetermined results were treated. Seven studies included healthy control subjects, which could have artificially enhanced OCT diagnostic performance. All but one study included both eyes of the patients without taking into account the within-subject correlation in statistical analyses. Sensitivity and specificity data could be extracted from only 6 of 15 studies, because appropriate cross tabulations of index and reference tests were not reported by the others. In five of these studies, central retinal thickness cutoffs between 230 and 300 microm were adopted to define abnormal OCT results and considered the central type of CSME only, whereas in one study a complex algorithm accounting for extrafoveal CSME was used. The design of one study was case-control and was excluded from the meta-analysis. The expected operating point on the summary ROC, a pooled estimate of all studies, corresponded to a sensitivity of 0.79 (95% CI: 0.71-0.86), a specificity of 0.88 (95% CI: 0.80-0.93), a positive likelihood ratio of 6.5 (95% CI: 4.0-10.7), and a negative likelihood ratio of 0.24 (95% CI: 0.17-0.32). These values suggest a good overall performance of OCT for diagnosing CSME. CONCLUSIONS: OCT performs well compared with fundus stereophotography or biomicroscopy to diagnose diabetic macular edema. The quality of reporting of such studies should be improved, and authors should present cross tabulations of index and reference test results. Data adjusted for within-subject correlation should also be provided, although this issue represents a challenge for systematic reviewers.

Carboxymethyl beta-glucan binds to corneal epithelial cells and increases cell adhesion to laminin and resistance to oxidative stress.

PURPOSE: Polysaccharides are frequently used as viscoelastic agents to improve pharmacokinetics of ophthalmic preparations. Recently, polysaccharides from yeast cell walls such as beta-glucans have emerged as bioactive molecules endowed with immunomodulatory and cytoprotective properties. In this study, we investigated the effects of carboxymethyl beta-glucan (CMG), a water-soluble derivative of yeast beta-glucan, on cultured rabbit corneal epithelial cells. METHODS: We developed a fluorescein-labeled CMG to visualize its binding to corneal cells by means of digital microscopy and image deconvolution. The effects of CMG on adhesion and survival of corneal epithelial cells exposed to noxious stimuli were also studied. RESULTS: CMG binds defined regions scattered throughout the body of corneal cells, suggesting binding specificity. Tridimensional reconstruction of fluorescence shows that binding is localized mainly at the plasma and nuclear membranes. Interestingly, CMG binding is highly represented at the level of focal adhesion of cells spreading onto laminin. Accordingly, CMG promotes adhesion of corneal epithelial cells to laminin without affecting their proliferation rate. CMG also protects cells from oxidative stress-dependent cell death, being ineffective in preventing ultraviolet B cytotoxicity. CONCLUSIONS: Data show that CMG dynamically binds to corneal epithelial cells, promoting cell adhesion and resistance to oxidative stress.

Efficacy and safety of ab interno excimer laser trabeculotomy in primary open-angle glaucoma: two years of follow-up.

Ab interno trabeculotomy was performed using the recently developed XeCl excimer laser in 21 eyes of 21 patients with primary open-angle glaucoma refractory to medical therapy. The patients were followed at the Eye Department of S. Antonio Hospital in Padova, for an average of 25.3 +/- 1.3 months. Intraocular pressure (IOP), visual acuity and ocular complications were evaluated. The laser procedure was quick and relatively easy, with minimal manipulation of tissues; complications were clinically insignificant. At the last follow-up, a marked IOP-lowering effect compared to baseline was observed (from 24.8 +/- 2.0 to 16.9 +/- 2.1 mm Hg; -31.8%, p < 0.0001). Nineteen patients (90.5%) had an IOP lowering of 20% or more; however, 8 of these eyes (38.1%) required additional IOP-lowering medical therapy. The procedure failed in 2 cases (9.5%) despite additional therapy. In conclusion ab interno excimer laser trabeculotomy seems effective to decrease IOP, serves to reduce the number of antiglaucoma medications and is relatively safe, proving to be a promising therapeutic option in glaucoma surgery.

Photodynamic therapy for choroidal neovascularization in pediatric patients.

PURPOSE: To report the use of photodynamic therapy (PDT) for choroidal neovascularization (CNV) in pediatric patients. METHODS: Five patients (age range, 7-15 years) who underwent PDT for idiopathic CNV (n = 2) or CNV secondary to macular toxoplasmic scar (n = 3) were included in this study. Follow-up ranged from 12 months to 18 months. PDT was performed according to the standard protocol. We evaluated visual acuity, fluorescein leakage from the CNV, greatest linear dimension of the lesion, and occurrence of ocular or systemic adverse events at baseline and during follow-up. RESULTS: No severe or moderate visual loss occurred in all cases during follow-up. PDT reduced CNV leakage in four cases. No serious ocular or systemic adverse events were recorded. Retinal pigment epithelium atrophic changes were observed around the regressed CNV, but they did not appear to cause visual loss. CONCLUSIONS: PDT was safe for pediatric patients, and visual acuity was substantially stable after one or few treatments. Further follow-up is needed to assess if retinal pigment epithelium atrophic changes around the regressed CNV, possibly related to PDT, could affect vision in the long term.