Confocal microscopy analysis of corneal changes after photorefractive keratectomy plus cross-linking for keratoconus: 4-year follow-up.

PURPOSE: To analyze corneal confocal microscopy changes after combined photorefractive keratectomy (PRK) plus the cross linking (CXL) procedure. DESIGN: Prospective interventional case series. METHODS: At the Department of Basic Medical Sciences, Neuroscience, and Sense Organs of the University of Bari, Bari, Italy, 17 eyes of 17 patients with progressive keratoconus underwent confocal microscopy examination before and after 1, 3, 6, 12, 18, and 48 months following PRK plus the CXL procedure. The main outcome measures were mean superficial epithelial cell density; mean basal epithelial cell density; mean anterior, mid and posterior keratocyte density; qualitative analysis of stromal backscatter; sub-basal and stromal nerve density parameters; and mean endothelial cell density. RESULTS: During the 4-year follow-up, the mean superficial epithelial cell density, mean basal epithelial cell density and mean endothelial cell density remained unchanged (P > 0.05). The anterior mid-stromal keratocyte density showed a significant decrease (P < 0.05) as compared with preoperative values, and the posterior stromal keratocyte density showed a significant increase at 1 and 3 months of follow-up. Sub-basal and stromal nerve density parameters were significantly decreased until postoperative month 6 (P < 0.05 at 1, 3, and 6 months) and then tended to increase up to preoperative values by the 18th postoperative month. CONCLUSION: Corneal changes after the PRK plus CXL procedures seem to be pronounced and long lasting as far as keratocyte density of the anterior and mid stroma is concerned. Sub-basal nerve densities tend to reach preoperative values 6 months after surgery.

Intravitreal dexamethasone implant for refractory macular edema secondary to vitrectomy for macular pucker.

PURPOSE: To study the efficacy of a single 0.7 mg dexamethasone intravitreal implant in vitrectomized eyes with refractory macular edema secondary to combined cataract extraction and macular pucker removal. METHODS: In 8 eyes of 8 consecutive patients with refractory macular edema secondary to combined cataract extraction and 25-gauge vitrectomy with internal limiting membrane peeling for macular pucker removal, the injection of the 0.7 mg dexamethasone implant was performed. Best-corrected visual acuity, central retinal thickness measured by spectral domain optical coherence tomography, and intraocular pressure were evaluated at baseline, 1 month, and 6 months. RESULTS: After a mean follow-up of 6.75 ± 0.71 months, best-corrected visual acuity was significantly increased (P < 0.0001) from 20/50 to 20/23 (P < 0.0001), mean central retinal thickness decreased significantly from 439 ± 45 µm to 296 ± 49 µm (P < 0.0001), and intraocular pressure changed significantly (P = 0.02) from 14.63 ± 1.19 to 16 ± 0.93. In no case postoperative hypotony or other complication was observed. CONCLUSION: A single injection of the 0.7 mg dexamethasone intravitreal implant resulted effective in the treatment of refractory macular edema secondary to combined cataract extraction and vitrectomy for macular pucker removal allowing a stable visual acuity recovery.

Intravitreal dexamethasone implant for macular edema following uncomplicated phacoemulsification.

PURPOSE: To retrospectively study the efficacy of a single 0.7-mg dexamethasone intravitreal implant in eyes with refractory macular edema secondary to uncomplicated phacoemulsification and intraocular lens implant. METHODS: In 11 eyes of 11 consecutive patients with persistent refractory macular edema, secondary uncomplicated cataract extraction, and intraocular lens implant, the injection of 0.7-mg dexamethasone implant was performed at the Clinica Oculistica, University of Bari, Italy. Best-corrected visual acuity (BCVA), central retinal thickness measured by spectral-domain optical coherence tomography, and intraocular pressure (IOP) was evaluated at baseline, 1 month, and 6 months. RESULTS: After a mean follow-up of 6.27 ± 0.47 months, BCVA was significantly increased from 20/40 to 20/22 (p<0.0001), mean central retinal thickness decreased significantly from 462 ± 100 to 276 ± 8 µm (p<0.0001), and IOP did not change significantly (p = 0.053). In no case were postoperative complications observed. CONCLUSIONS: A single injection of 0.7-mg dexamethasone intravitreal implant was effective in the treatment of persistent refractory macular edema secondary to uneventful phacoemulsification and in-bag lens implant.

Photorefractive keratectomy followed by cross-linking versus cross-linking alone for management of progressive keratoconus: two-year follow-up.

PURPOSE: To compare visual, refractive, topographic, and corneal higher-order aberration outcome at the 2-year follow-up after customized photorefractive keratectomy (PRK) followed by cross-linking (CXL) as a single procedure versus CXL alone in eyes with progressive keratoconus. DESIGN: Prospective, interventional, nonrandomized clinical trial. METHODS: Seventeen patients (34 eyes) with progressive keratoconus were assigned to 2 groups: the worse eye (17 eyes) was assigned to the PRK plus CXL group and the better eye (17 fellow eyes) was assigned to the CXL group. RESULTS: In the PRK plus CXL group, uncorrected distance acuity improved significantly, from a mean ± standard deviation of 0.63 ± 0.36 logarithm of the minimal angle of resolution (logMAR) units to 0.19 ± 0.17 logMAR units (P < .05) and best distance acuity from 0.06 ± 0.08 logMAR to 0.03 ± 0.06 logMAR (P < .05). Manifest refraction spherical equivalent and spherical and cylindrical power improved significantly (P < .05). Simulated keratometry, flattest, steepest, average, cylindrical, apex keratometry, and inferior-superior value decreased significantly (P < .05). Total and coma-like aberrations significantly decreased for all pupil diameters (P < .05). In the CXL group, uncorrected distance acuity improved, but not significantly, from 0.59 ± 0.29 logMAR units to 0.52 ± 0.29 logMAR units, and best distance acuity improved from 0.06 ± 0.11 logMAR units to 0.04 ± 0.07 logMAR units (P > .05). Manifest refraction spherical equivalent and cylindrical power improvement was not significant (P > .05), unlike spherical power (P < .05). Steepest simulated keratometry, average simulated keratometry, and inferior-superior value significantly decreased (P < .05), unlike flattest simulated keratometry, cylindrical simulated keratometry, and apex keratometry (P > .05). Total and coma-like aberrations were not decreased significantly for all pupil diameters (P > .05). No significant endothelial changes were observed in either group. CONCLUSIONS: The PRK plus CXL procedure may be a good option to reduce corneal aberrations and stabilize corneas with progressive keratoconus.

Diathermy of leaking sclerotomies after 23-gauge transconjunctival pars plana vitrectomy: a prospective study.

PURPOSE: To evaluate the efficacy of bipolar diathermy in ensuring closure of leaking sclerotomies after complete 23-gauge transconjunctival sutureless vitrectomy. METHODS: In this prospective, interventional case series, in 136 eyes of 136 patients with at least one leaking sclerotomy at the end of a complete 23-gauge transconjunctival sutureless vitrectomy, external bipolar wet-field diathermy was applied to leaking sclerotomies, including the conjunctiva and sclera. Intraoperative wound closure, and postoperatively, at 6 hours, 1 day and 3 days, sclerotomies leakage, intraocular pressure, hypotony, and hypotony-related complications were evaluated. RESULTS: Intraoperative closure was achieved in 231 of 238 leaking sclerotomies (97%) that received diathermy. One of these with postoperative leakage needed suture. Compared with baseline (14.4 ± 2.8 mmHg), mean intraocular pressure was lower at 6 hours (13.2 ± 3.8 mmHg, Tukey-Kramer P < 0.001) and not different at 24 hours or 72 hours. Hypotony (intraocular pressure <5 mmHg) was observed in 6 eyes (4.5%) at 6 hours, in 2 (1.5%) at 24 hours, and in none at 3 days. Logistic regression analysis showed that, 6 hours postoperatively, hypotony was related to younger age (≤50 years) at surgery (P = 0.031). No hypotony-related complications were recorded. CONCLUSION: Bipolar wet-field diathermy of sutureless sclerotomies is an effective method for ensuring a leaking sclerotomies closure.

Surgical reposition of a dislocated Ex-PRESS miniature device.

PURPOSE: To present a technique of surgical reposition of the Ex-PRESS miniature glaucoma device when dislocated in corneal limbus. METHODS: A 54-year-old woman diagnosed with glaucoma, with a 3-month history of Ex-PRESS miniature implant, was referred to our department because of progressive intraocular pressure (IOP) rise. Slit-lamp biomicroscopy showed the posterior flange of the implant located in the corneal limbus; IOP was 34 mmHg. Surgical technique consisted of reopening of the conjunctiva and the scleral flap, excision of the corneal tissue covering the flange, and stitching the implant to the sclera with polyprolene suture. RESULTS: Postoperatively, IOP rapidly reduced to 5 mmHg and was balanced to 10 mmHg in the follow-up. CONCLUSIONS: Corneal dislocation of the Ex-PRESS implant, when associated with ocular hypertension, needs surgical treatment. Before considering a trabeculectomy, it could be valuable to attempt an implant reposition.

Orbital pseudotumor in a child: diagnostic implications and treatment strategies.

Orbital pseudotumor is a benign, idiopathic, non-infectious and non-neoplastic clinical syndrome characterized by the presence of an inflammatory mass at orbital level with no identifiable cause. The disease is rarely observed in the pediatric population. This article describes a relapsing bilateral orbital pseudotumor in a young girl. The diagnostic implications and treatment strategies are discussed.

Excimer laser-assisted lamellar keratoplasty and the corneal endothelium.

PURPOSE: To evaluate endothelial changes after excimer laser-assisted lamellar keratoplasty. DESIGN: Retrospective, interventional case series. METHODS: Seven eyes of 7 keratoconus patients were evaluated for 1 year after pachymetry-guided lamellar keratoplasty, performed using the iRES Laser (Ligi Tecnologie Medicali S.p.A.), with the Corneal Lamellar Ablation for Transplantation software (Ligi Tecnologie Medicali S.p.A.) procedure. Both anterior segment optical coherence tomography (Visante OCT; Carl Zeiss Meditec, Inc) and in vivo confocal microscopy (Corneal Confocal Microscope CS4; NIDEK Technologies) images were collected. RESULTS: Changes in morphologic features were investigated and the endothelium was assessed quantitatively in all 7 patients. In 6 eyes, we measured a mean residual bed thickness of 151.3 +/- 5.46 microm, and a mean endothelial cell density loss of 5.38% at 1 year after surgery, as compared with preoperative values. The mean percentage hexagonality change was 15.67%, and the mean coefficient of variation change was -21.11%. In 1 eye, a residual bed thickness of 72 microm was found and endothelial loss after 1 year was 72.26%; assessment of the coefficient of variation and percentage hexagonality by manual Confoscan4 software (NIDEK Technologies) was not practicable in this case. CONCLUSIONS: Our results showed that the Corneal Lamellar Ablation for Transplantation procedure induced mild changes to the endothelium in corneas with a mean residual bed thickness of 151.3 +/- 5.46 microm, but serious damage in one eye with a residual bed thickness of 72 microm.

Ex-PRESS miniature glaucoma device in vitrectomized eyes.

PURPOSE: To evaluate the clinical efficacy and safety of the Ex-PRESS miniature glaucoma device placed under scleral flap for the treatment of ocular hypertension in eyes that underwent vitreoretinal surgery. METHODS: Vitrectomized patients who required glaucoma surgery for persistent ocular hypertension were included. The Ex-PRESS miniature glaucoma device was implanted under scleral flap. Postsurgical clinical outcomes and intraocular pressure (IOP) was monitored for 6 months after surgery. RESULTS: At 6 months, all the patients had an IOP lower than 18 mmHg, 3 of them without topical therapy. CONCLUSIONS: The use of the Ex-PRESS implant under scleral flap in eyes that underwent vitreoretinal surgery was effective for lowering IOP.

Hemorrhagic Macular Infarction After Intravitreal Bevacizumab for Central Retinal Vein Occlusion.

Intravitreal bevacizumab for macular edema secondary to central retinal vein occlusion may induce resolution of macular edema. However, the possibility of a rebound macular edema thicker than at the initial presentation after intravitreal bevacizumab injections has been reported. A case of dramatic deterioration of central retinal vein condition with hemorrhagic macular infarction 3 weeks after intravitreal injection of bevacizumab is presented.

Fundus autofluorescence and multiple evanescent white dot syndrome.

OBJECTIVE: To describe fundus autofluorescence (FAF) in a series of patients with multiple evanescent white dot syndrome. METHODS: Three eyes of three patients with multiple evanescent white dot syndrome were evaluated with indocyanine green angiography and FAF imaging to evaluate the correspondence between FAF and ICG patterns and the nature of the focal hypocyanescent spots evident with ICG. RESULTS: In the acute phase, all three eyes showed increased autofluorescence area corresponding precisely to the site of the focal hypocyanescent spots seen on ICG but less numerous. After 2 months, mean best-corrected visual acuity improved from 20/38 to 20/20 and FAF and indocyanine green angiography returned to normal pattern. DISCUSSION: FAF is an useful noninvasive diagnostic adjunct to identify multiple evanescent white dot syndrome, suggesting the inflammatory nature of the disease, probably due to perturbation of the photoreceptor-retinal pigment epithelium complex affecting the function of these cells.

Intravitreal bevacizumab for treatment-naïve subfoveal occult choroidal neovascularization in age-related macular degeneration.

PURPOSE: This study aimed to evaluate the efficacy of multiple injections of intravitreal bevacizumab for treatment-naïve subfoveal occult choroidal neovascularization (CNV) in age-related macular degeneration (AMD). METHODS: Twelve eyes of 12 patients (mean age 76 +/- 6 years) with mean best corrected visual acuity (BCVA) of 20/100 and occult subfoveal CNV at fluorescein angiography (FA), indocyanine-green (ICG) angiography and optical coherence tomography (OCT), showing intra- or subretinal fluid with or without retinal pigment epithelial detachment (PED), underwent multiple intravitreal injections (mean 2.4 +/- 0.7) of 1.25 mg (0.05 ml) bevacizumab. Visual acuity and OCT findings were assessed at the end of follow-up. RESULTS: After a mean follow-up of 5.7 +/- 2 months, BCVA improved from 20/100 (range 20/50-20/303) to 20/60 (range 20/28-20/200) (p = 0.038). Five eyes (42%) increased BCVA by > or = 3 lines, six eyes (50%) increased BCVA by < 3 lines and one eye (8%) remained stable. Macular thickness decreased from 298 +/- 71 microm to 223 +/- 72 microm (p = 0.017). No ocular or systemic side-effects were observed. CONCLUSIONS: Short-term results suggest that multiple intravitreal injections of 1.25 mg bevacizumab are well tolerated and associated with significant improvements in BCVA and decreased retinal thickness by OCT in most patients with treatment-naïve occult CNV. Further evaluation of intravitreal bevacizumab for the treatment of occult CNV is warranted.

Primary open angle glaucoma: an overview on medical therapy.

The purpose of this review is to discuss the topics relevant to the use of intraocular pressure-lowering strategies, which remains the first line in the management of glaucoma. Estimates of blindness from glaucoma and identification of risk factors remain of interest for all ophthalmologists. New functional tests offer promise for better detection and more accurate diagnosis of glaucoma. We finally discuss the impact of various glaucoma therapies, the principles of monotherapy and fixed combinations, which offer benefits of convenience, cost, and safety.

Fundus autofluorescence, optical coherence tomography and visual acuity in adult-onset foveomacular dystrophy.

AIM: We investigated fundus autofluorescence (FA) patterns and tomographic retinal changes by means of optical coherence tomography (OCT 3) in adult-onset foveomacular vitelliform dystrophy (AOFVD) and their possible correlation with best-corrected visual acuity (BCVA). METHODS: Eighteen eyes of 15 consecutive patients (mean age: 73.73 +/- 9.5 years) presented to our observation with a diagnosis of AOFVD underwent BCVA measurement, evaluation of FA distribution by means of a confocal laser scanning ophthalmoscope and OCT 3 tomography. RESULTS: The mean BCVA was 20/40 (range: 20/20-20/100). The FA pattern was patchy in 9 eyes (50%), ring-like in 5 (27.7%), focal in 3 (16.6%) and linear in 1 (5.5%). No correlation between FA patterns and BCVA was found. OCT 3 showed accumulation of highly reflective material between the neurosensory retina and retinal pigment epithelium (RPE) in 12 eyes (66.6%) with an evident overlying photoreceptor layer (PRL). In 5 eyes the highly reflective material was built up between the neurosensory retina and RPE without evidence of PRL (27.7%). Only in 1 eye was the subretinal accumulation site not well defined (5.5%). The mean thickness of the deposit was 135.52 +/- 47.53 microm, while the residual neurosensory retina thickness was 103.94 +/- 24.21 microm. The relationship between BCVA and the thickness of the neurosensory retina over the lesion was not significant (p = 0.016, r = 0.33), while the correlation between BCVA and the material deposit thickness (p = 0.017, r = 0.12) was significant. CONCLUSIONS: In AOFVD, FA presented different patterns, while OCT usually shows a well-defined material accumulation with a generally reduced neurosensory thickness between PRL and RPE. FA imaging and OCT are useful and safe for the diagnosis and follow-up of AOFVD.

Oxane HD vs silicone oil and scleral buckle in retinal detachment with proliferative vitreoretinopathy and inferior retinal breaks.

BACKGROUND: To compare pars plana vitrectomy (PPV) with 1300 cs silicone oil and scleral buckle (SB) vs PPV with Oxane HD tamponade for rhegmatogenous retinal detachment (RRD) with inferior retinal breaks (IRB). METHODS: Twenty eyes of 20 consecutive patients with primary inferior RRD and PVR >or=CP2 were alternatively assigned to PPV and 1300 cs silicone oil and segmental SB in the inferior periphery (group 1, n = 10) or PPV with Oxane HD (group 2, n = 10) in order of presentation. Silicone oil/Oxane HD removal was performed 12 weeks after surgery. Subjects were followed up for 6 months from oil removal. RESULTS: Operative time was lower in Oxane HD group (P = 0.012). In both groups, the retina was primary reattached at the third month after oil removal in nine eyes (90%). At the end of follow-up, retina was reattached in nine eyes (90%) in group 1 (including one eye with oil in situ), and in eight eyes (80%) in group 2 (P > 0.05). CONCLUSIONS: Silicone oil+SB and Oxane HD appear equal for primary RRD with IRB, but a large multi-centre study is required. Oxane HD permitted a reduced operative time.

In vivo evidence of hypotrophic ciliary body in ocular ischemic syndrome by ultrasound biomicroscopy.

In ocular ischemic syndrome, the ischemic condition is due to markedly reduced blood flow and increased vascular resistance of retrobulbar circulation, as in the central retina and posterior ciliary arteries. Chronic hypoxia affects even the iris and ciliary body. The hypoperfusion of the ciliary body leads to a relative hypotony, presumably related to decreased aqueous humor production. Histopathologic study has demonstrated ciliary body atrophy on an ischemic basis. The authors used ultrasound biomicroscopy to demonstrate in vivo the hypotrophic condition of the ciliary body in ocular ischemic syndrome.

Topographic customized photorefractive keratectomy for regular and irregular astigmatism after penetrating keratoplasty using the LIGI CIPTA/LaserSight platform.

PURPOSE: To evaluate the use of a software ablation program (Corneal Interactive Programmed Topographic Ablation [CIPTA]) that provides customized photorefractive keratectomy (PRK) to correct astigmatism after keratoplasty. METHODS: In this prospective, noncomparative, consecutive case series, 44 eyes underwent CIPTA for correction of astigmatism after penetrating keratoplasty. Eighteen eyes were treated for regular astigmatism and 26 eyes were treated for irregular astigmatism after penetrating keratoplasty. Orbscan II topography (Bausch & Lomb) and a flying-spot laser (LaserScan 2000; LaserSight) were used. Epithelial debridement with alcohol was performed before PRK in 16 eyes and transepithelial PRK was performed in 28 eyes. Mean target-induced astigmatism was 8.19 +/- 2.68 diopters (D) and 7.68 +/- 4.50 D in the regular and irregular astigmatism groups, respectively. RESULTS: Mean follow-up was 25.4 +/- 13 months. At last postoperative follow-up, 13 (72.2%) and 18 (69.2%) eyes in the regular and irregular astigmatism groups, respectively, had uncorrected visual acuity (UCVA) better than 20/40. Four (22.2%) and 8 (30.7%) eyes in the regular and irregular astigmatism groups, respectively, had UCVA of 20/20. Fourteen (77.7%) and 18 (69.2%) eyes in the regular and irregular astigmatism groups, respectively, were within 1.00 D of attempted correction in spherical equivalent manifest refraction. No eye lost Snellen lines of best spectacle-corrected visual acuity. Mean surgically induced astigmatism was 7.66 +/- 2.70 D and 6.99 +/- 3.80 D for the regular and irregular astigmatism groups, respectively. Index of success of astigmatic correction was 0.138 and 0.137 for the regular and irregular astigmatism groups, respectively. Haze developed in three eyes. CONCLUSIONS: Topography-driven PRK using CIPTA software is a suitable solution for correcting regular and irregular astigmatism after penetrating keratoplasty.

The role of antimetabolites in filtration surgery for neovascular glaucoma: intermediate-term follow-up.

PURPOSE: To compare the intermediate-term efficacy of 5-fluorouracil (5-FU) and Mitomycin C (MMC) as adjunctive antimetabolites in neovascular glaucoma (NVG) filtration surgery. METHODS: Forty consecutive eyes of 40 patients with NVG refractory to medical therapy were randomized to receive antimetabolite-augmented trabeculectomy. Eighteen eyes received postoperative 5-FU (5-FU group) and 22 eyes received intraoperative, low-dose (0.2 mg/ml) MMC for 2 mins (MMC group). The main outcome measure was intraocular pressure (IOP). Surgical success was defined as IOP < 21 mmHg with topical treatment (qualified success) or without topical treatment (complete success). Surgical failure was defined as IOP > or = 21 mmHg, despite postoperative topical treatment, and by postoperative blindness. RESULTS: The mean follow-up period was 35.8 +/- 22.6 months in the 5-FU group and 18.6 +/- 17.2 months in the MMC group. This difference was not significant. Mean IOP decreased from 40.4 +/- 10.3 mmHg to 14.7 +/- 3.4 mmHg (p < 0.0001) in the 5-FU group and from 42 +/- 11.3 mmHg to 22.9 +/- 13.3 mmHg (p = 0.0006) in the MMC group; however, the difference between the 5-FU and MMC groups was not significant at any point. The success rate in the 5-FU group was 55.5% (44.4% complete, 11.1% qualified), compared with 54.5% (9.1% complete, 45.4% qualified) in the MMC group. This difference was not significant. CONCLUSIONS: The percentage of patients who achieved postoperative IOP < 21 mmHg was similar in both groups, although a larger proportion of patients treated with MMC-augmented trabeculectomy required topical treatment in comparison with the 5-FU group.